Traditional versus secular
The preceding review of classification issues was drawn from the secular MM literature. Recently, there has been controversy about the extent to which definitions, practices, and descriptions of meditative states should be guided by fidelity to Buddhist teachings or whether secular MM constitutes a distinct domain that may draw upon wisdom traditions but is also guided by scientific and practical considerations. Several authors have called for fidelity to Buddhism, based on the fact that mindfulness is at the heart of Buddhist teaching, and have emphasized that MM clinicians and researchers should have mindfulness training, personal meditative attainment, and collaborations with qualified Buddhist teachers (Grossman and Van Dam 2011; Van Gordon et al. 2015). Other authors have pointed out constraints involved in scientific and clinical applications of mindfulness, such as the need to operationally define and measure key constructs and present techniques in a secular way in order to render them more broadly acceptable (Baer 2011). Kabat-Zinn (2003) takes the position that Buddhist mindfulness teachings are dharma, universal truths, like the laws of physics, and as such are not exclusively Buddhist. Thus, aside from the question of whether there should be a separate, secular mindfulness domain, this controversy raises the issue of which wisdom and secular traditions may contribute to the science and practice of mindfulness. Kabat-Zinn’s dharma perspective contends that mindfulness concerns the universal human capacity of attention, which implies that it has likely been explored by various traditions throughout the course of human history. In sum, who owns mindfulness? Is it an exclusively Buddhist practice? Is mindfulness entailed in other religious or philosophical traditions? Is there a new type of secular mindfulness, which has been drawn but yet is distinct from its historical origins? Recent commentary suggests that the distinction between secular mindfulness and traditional Buddhism is not a clear one, especially to the extent that the secular mindfulness community has equated mindfulness with Buddhism teachings (Purser 2015).
In clinical practice, the interchange between wisdom and secular traditions raises many issues, such as the sort of training required for competent clinical practice, the boundaries between one’s personal, spiritual, or religious practice (or lack thereof) and therapeutic procedures, and ethical issues about the “Trojan horse” practice of employing techniques that may seem explicitly Buddhist but are presented as though they are free from any religious connotations that may be inconsistent with clients’ own faith traditions. To the first point, although standardized MMBIs such as MBSR, MBCT, and TM have training programs, many therapists may not be using the standardized protocols in therapy. As reviewed above, MM techniques are in widespread use and there are indications that psychotherapeutic applications may be incorporated into standard psychotherapy in individualized ways. This eclecticism means that psychotherapists may see spiritual teachers as appropriate clinical trainers in the MM domain, which would distinguish it from other forms of psychotherapy practice that are generally understood to require professional training (Waelde et al. in press). Labeling mindfulness (and by extension meditation) as Buddhist also implies that these therapeutic procedures represent the integration of religion into psychotherapy, raising important issues about therapeutic boundaries, such as how to frame MM procedures for the client, whether MMBI therapists remain therapists or become meditation teachers, and whether psychotherapy clients should be invited to meditation classes in the therapist’s own dharma community (Pollak et al. 2014).
There may be several advantages to maintaining the distinction between religious and clinical practice. Fundamentally, the aims of Buddhist and clinical MM practice are different. Despite Van Gordon et al.’s (2015, p. 7) call for Buddhist and scientific communities to work together to validate interventions that are “effective according to both clinical and spiritual criteria," the aim of Buddhist meditation practice, namely experience of “the single, unchanging, and all-pervasive nature of emptiness” (Van Gordon et al. 2015, p. 4) does not seem a close match with the immediate clinical needs of psychotherapy clients. Part of the issue seems to be the conflation of the Buddhist concept of suffering, duk- kha, with the sorts of suffering clients present in psychotherapy (Lindahl 2014). Moreover, the reasoning that “the Buddha’s teachings can be likened to an allpurpose medicine” (Van Gordon et al. 2015, p. 5) reflects a mind-body dualism common in religious and philosophical teachings (Forstmann and Burgmer 2015) that would have us prescribe Buddhism in place of psychotherapeutic, but not medical, intervention.
Much research has been conducted with meditation adepts from different religious or spiritual traditions and it is not clear what implications these studies have for clinical practice. Participants in these studies are often monastics or persons with many thousands of hours of practice time in spiritual or religious contexts. Although studies of meditation adepts have shed light on the neuroscience of advanced meditative states, there are fundamental differences from clinical applications in terms of the types of participants and the aims, types, and amount of practice. For example, Lutz and colleagues investigated the neural circuitry of compassion meditation among experts (Lutz et al. 2008). The participants in this study were selected because they were recognized as experts in Buddhist meditation, with between 10,000 and 30,000 hours of meditation practice. In contrast, participants in clinical MMBI studies are typically selected because of a diagnosed disorder or condition. Likewise, the aims of MM practice among adepts are different from clinical aims. In the Lutz et al. (2008) study, “the long-term goal of meditators undergoing such training is to weaken egocentric traits so that altruistic behaviors might arise more frequently and spontaneously” (p. 1). In contrast, psychotherapy clients typically participate in MMBI with a goal of symptom reduction. The two types of practitioners may be exposed to different types of practices, with experts typically receiving instruction from religious/spiritual teachers (rather than psychotherapists) in contexts such as retreat settings that allow for extended practice periods, in contrast to the brief meditation training usually allocated in MMBI. Although comprehensive descriptions of experts’ training experience were not provided, it seems reasonable to speculate that the experts in the Lutz et al. (2008) study had received instruction in a variety of meditation practices over the course of their training, in preparation for and flowing from the specific compassion meditation that was the focus of the investigation. Finally, there can be no doubt that psychotherapy does not involve thousands or tens of thousands of hours of meditation instruction and practice. Evidence is mounting that mechanisms of meditation may be very different for novices versus experts (Chiesa et al. 2013). As Lutz and colleagues pointed out, studies of experts are vital for understanding the long-term mechanisms and outcomes of meditation, but implications for clinical practice are not straightforward.
Given these fundamental differences between spiritual and clinical MM practice, differentiating the two would clarify matters greatly. Questions about whether MM training in clinical practice should incorporate elements of the spiritual traditions would be guided by clinical necessity and acceptability. Adaptations of traditional practices to clinical problems would be guided by a keen understanding of the match between the mechanisms and outcomes of a particular practice and the nature of the problems to be treated. Similarly, distinctions among MM practices would be guided by specifics of the techniques and their mechanisms of outcome for particular disorders or conditions, rather than by classification into broad traditions such as Buddhist and Hindu. As a very practical matter, interpretation of neuroimaging data or clinical trials outcomes must make reference to clear behavioral descriptions of meditation tasks that were employed. Breath-focused meditation among beginning practitioners may for all practical purposes be identical across traditions. Further, meditation techniques used in clinical practice may bear incomplete similarity to their wellspring traditions. Several recent reviews have criticized definitions and methods of mindfulness in clinical practice as insufficiently representing the breadth of the tradition (Chiesa 2013). It is unclear to what extent clinical and research applications of meditation with novices resemble advanced techniques and mental states described in traditional accounts. In addition, broad traditions cannot be parsed according to technique. As reviewed below, both Hindu- and Buddhist-inspired meditations include a succession of techniques that flow from FA as attention training through increasingly refined states of awareness involving nondual awareness, or suspension of the distinction between the self as the observer and the object being observed (Dass and Diffenbaugh 2013; Dunne 2011). Both broad traditions employ mantra repetition, movement techniques, and philosophical frameworks that may shape the idioms used to describe meditation experiences, so differentiating Buddhist and Hindu traditions with reference to specific techniques such as mindfulness or mantra is problematic.
Contemporary conceptualizations of MM reflect a range of techniques and resulting states of awareness, from meditation on a specific focus as a means to stabilize attention, to nonselective attention to the phenomenal field, to surrender to nondual awareness. These conceptualizations have largely been drawn from Hinduism and Buddhism, both of which are vast traditions containing diverse schools of thought. However, for the purposes of addressing the types of MM in contemporary psychotherapeutic usage, it is worth considering a few overlaps between these two broad traditions in terms of the FA/OM/NDA distinction and the developmental trajectory of meditation training.