a metacognitive therapy for anxiety disorders: buddhist psychology applied

7 2 Toneatto

j. (1995). Meditation, melatonin, and breast/prostate cancer: Hypothesis and preliminary data. Medical Hypotheses, 44, 39-46.

McCain, N. L., Zellel; J. M., Cella, D. E, Urbanski, E A., & Novak, R. M. (1996). The influence of stress management training in HIV dis- ease. Nursing Research, 45, 246-253.

Miller, J. J., Fletcher, K., & Kabat-Zinn,J. (1995). Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen- eral Hospital Psychiatry, 17, 192-200.

Mulder, C. L., Emmelkamp, R M. G., Antoni, M. H., Muldet; J. W., Sandfort, T. G. M., & de Vries, M.J. (1994). CogIfitive-behavioral and experimental group psychotherapy for HIV-infected homo- sexual men: A comparative study. Psychosomatic Medicine, 56, 423- 431.

Perry, S., Fishman, B.,Jacobsberg, L., Young, J., & Frances, A. (1991). Effectiveness of psychoeducational interventions in reducing emotional distress after human immunodeficiency virus antibody testing. Archives of General Psychiatry, 48, 143--147.

Schulz, K. H., & Schulz, H. (1992). Overview of psychoneuroimmuno- logical stress and intervention studies in humans with emphasis on the uses of immunological parameters. Psycho-Oncology, 1, 51- 70.

Shapiro, S. L., Schwartz, G. E., & Bonnel; G. (1998). Effects of nfind- fulness-based stress reduction on medical and premedical stu- dents.Journal of Behavioral Medicine, 21, 581-599.

Solomon, G. E, & Temoshok, L. (1987). A psychoneuroimmunologic perspective on AIDS research: Questions, preliminary fndings, and suggestions. Journal of Applied Social Psychology, 17, 286-308.

Speca, M., Carlson, L E., Goodey, E., & Angen, M. (2000). A random- ized, wait-list controlled clinical trial: The effect of a mindfulness

meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 61,'4-622.

Taylor, D. N. (1995). Effects of a behavioral stress-management program on anxiety, mood, self-esteem, and T-cell count in HIV-posi- tire men. Psychologiccd Reports, 76, 451-457.

Teasdale,J. D., Segal, Z., &Williams, J. M. G. (1995). How does cognitive therapy prevent depressive relapse and why should atten- tional control (mindfulness) training help? Behavior Research and Therapy, 33, 25-39.

Valentine, E. R., & Sweet, E L. G. (1999). Meditation and attention: A comparison of the effects of concentrative and mindtulness meditation on sustained attention. Mental Health, Religion, & Culture, 2, 59-70.

Van Rood, Y. R., Bogaards, M., Goulmy, E., & van Houwelingen, H. C. (1993). The effects of stress and relaxation on the in vitro immune response in man: A meta-analytic study. Journal of Behav- ioral Medicine, 16, 163-181.

Workman, E. A., & La Via, M. E (1991). Stress and immunity: A behavioral medicine perspective. In N. Plomikoff, A. Murgo, R. Faith, & J. Wybran (Eds.), Stress and immunity (pp. 69-80). Boca Raton, FL: CRCP Press.

Address correspondence to Susan Logsdon-Conradsen, Berry College, Department of Psychology, 2277 Martha Berry Hwy., NW, Mount Berry, GA 30149; e-mail: [email protected].

Received: January 10, 2000 Acc@ted: February 20, 2001

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

A Metacognitive Therapy for Anxiety Disorders: Buddhist Psychology Applied

T o n y T o n e a t t o , University o f Toronto

Buddhist psychology and philosophy have the potential of contributing to the cognitive behavioral conceptualization and treatment of psychopathology. In this article, the relevance of Buddhism to the treatment of clinical anxiety is presented. Metacognition is viewed as a concept that can bridge Buddhist and cognitive behavioral psychology. In addition to delineating Buddhist conceptions of cognition and cognitive functioning, practical applications, in the form of mindful attention, are outlined.

Give u p all nega t ive act ions;

Always act pe r fec t ly in virtue;

Deve lop c o m p l e t e mas te ry o f your own m i n d ;

This is the t e a c h i n g o f the B u d d h a .

- - B u d d h a S h a k y a m u n i

O NE OF THE ENDURING s t r eng ths o f cogni t ive-behav-

ioral t he r apy is its i n h e r e n t adap t iveness . No tech-

n i q u e o r s t ra tegy is e x c l u d e d as a cogni t ive-behaviora l

t e c h n i q u e if empi r i ca l e v i d e n c e is suppor t ive . As a result ,

C o g n i t i v e a n d B e h a v i o r a l P r a c t i c e 9 , 7 2 - 7 8 , 2 0 0 2

107%7229/02/72-7851.00/0 Copyright © 2002 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.

cogni t ive-behaviora l t h e r a p y c o n t i n u e s to d eve lop a wide

r a n g e o f i n t e r v e n t i o n tools sui table to an ever - increas ing

r a n g e o f clinical p h e n o m e n a a n d popu la t i ons . Its adher -

e n c e to a scientif ic m o d e l o f d e v e l o p m e n t en su re s tha t

such p ro l i f e r a t i on does n o t lead to a h a p h a z a r d re l i ance

on u n s u b s t a n t i a t e d clinical tools. Desp i t e its y o u t h as a

sc ience , it has m a d e r e m a r k a b l e advances in effectively

re l ieving h u m a n suffer ing. It is n o t su rp r i s ing tha t t h e r e

is an o p e n n e s s by r e s e a r c h e r s a n d c l in ic ians w o r k i n g

wi th in a cogni t ive-behaviora l f r a m e w o r k to the ins ights o f

the B u d d h a , wh ich da te back over 2 mi l l enn ia . T h e Bud-

d h a also e m p l o y e d a str ict empi r i ca l a p p r o a c h to devel-

o p i n g his ins ights on the n a t u r e o f h u m a n su f fe r ing a n d

its al leviat ion. H e d i s c o u r a g e d his fo l lowers f r o m accept -

Buddhism and Anxiety Disorders 73

ing his instruction without also validating them within their own experience.

As the article by Sameet Kumar (2002) has made very clear, Buddhism encompasses a wide variety of traditions and definitions that defy simple summary. Kumar pro- vides a concise summary of the key concepts c o m m o n to Buddhism and an excellent context for the articles in this series. Any application of Buddhist psychology to cognitive and behavioral practice should clarify the tradition that informs the application. In this case, the author is a practitioner of the Tibetan (Tantric) Buddhist tradition. Of course, this is not an appropriate forum for an exposi- tion of Tibetan Buddhism, and what is discussed in this article only represents one of many applications that could be made. But in keeping with the emphasis on practical aspects of Buddhist philosophy for cognitive and behavioral practice, theoretical, metaphysical, or re- ligious aspects of Tibetan Buddhism will be eschewed. In- stead, practical change strategies based on Buddhist insights about the mind and behavior will be discussed as they relate to the unders tanding and treatment of clinical anxiety disorders.

Buddhist Psychology and Metacognition

A potentially useful way of discussing Buddhist philosophy within a cognitive-behavioral framework is through the construct of metacognition. Metacognition has been defined as beliefs and attitudes held about cognition (e.g., cognition about cognition; Flavell & Ross, 1981) or an active and reflective process that is directed at one's own cognitive activity (Allen & Armour-Thomas, 1991; Kluwe, 1982). Yussen (1985) defines metacognit ion as cognitive activity for which other cognitive activities are the object o f reflection (i.e., thinking about thinking). According to Slife (1987), without metacognition, awareness of any other cognition, such as thoughts, feelings, and memories, would be impossible. Metacognitive variables have been widely used to understand how children acquire problem-solving skills, moni tor and regulate their mental processes, and acquire knowledge of their abilities (e.g., reading, academic performance; Berardi-Coletta, Buyer, Rellinger, & Dominowski, 1995). More recently, there has been increasing interest in applying metacognit ion to the understanding and treatment of psychopathology (Nel- son, Stuart, Howard, & Crowley, 1999; Rachman & Shaf- ran, 1999; Teasdale, 1999; Toneatto, 1995, 1999a, 1999b; Wells, 1997).

Metacognition may serve as a means of introducing Buddhism into cognitive and behavioral practice as both are concerned with an individual's cognitive response to his or her own cognition. In a metacognitive treatment model for anxiety disorders, the client's distorted beliefs about his or her own anxiety-related cognitions are con-

sidered to be highly important in the maintenance of the disorder. Both Buddhist psychology and metacognitive theory make a distinction between adaptive or correct metacognitions and maladaptive or erroneous metacognitions. These two sets of metacognitions are distinguished by the degree to which a statement about cognitive experience is valid (discussed below). Anxiety-related metacognitions tend to be highly exaggerated, cata- strophic, and inaccurate appraisals of what are, in actual- ity, quite ordinary (in the sense of being well within the range of human experience and typically quite common) perceptions and sensations. Both cognitive-behavioral therapy and Buddhist psychology stress the importance of correcting erroneous cognizing of the external and internal environment. As a result, Buddhism may have much to offer to the cognitive-behavioral unders tanding and treatment of psychopathology.

Prior to elucidating the contribution of Buddhist psychology to a metacognitive model of clinical anxiety, it is important to first describe how the terms cognition and anxiety will be employed throughout this article.

Cognition Cognition will be unders tood as those subjective expe-

riences that one can know or become aware of. Thus, cognition includes all mental or psychological states of which one can be conscious. Cognition should not be re- duced to discursive thinking (better termed cogitative or cogitation) as is commonly done in many modern versions of cognitive-behavioral therapy. Thus, cognition can include all emotion, mood, feeling, discursive thinking, imagery, memory, dreaming, sensory perception, and somatic sensation. In short, whatever can be experienced by human consciousness is cognition. Cognition should be distinguished from awareness, the latter of which refers to the ability of the human mind to distinguish cognition (e.g., feeling or thinking) f rom cognizing (e.g., to know that one is feeling or thinking).

Although several types of cognition are differentiated within Buddhist psychology (which cannot be described in detail here), it will be important to at least distinguish between perceptual cognitions and conceptual cognitions (Komito, 1987). Perceptual cognition refers to the way that events in the external environment and within our own body actually present to our awareness. Concep- tual cognition refers to the thoughts, feelings, memories, sensations, and so on that almost immediately and insep- arably arise or co-emerge with the perceptual cognition. Conceptual cognitions may be merely descriptive (e.g., "That is a sound"), analytic (e.g., "That is a loud sound"), or evaluative (e.g., "That is an unpleasant sound"). Within a Buddhist perspective, metacognitions are conceptual cognitions that have, as their object, o ther perceptual and conceptual cognitions. When the metacogni-

74 Toneatto

tion is perfect ly accurate, and without distort ion or bias, metacogni t ion is equivalent to awareness.

T h r o u g h o u t this article, terms such as cognition, cognitive experiences, cognitive states, mental even& mental phenomena, cognitive phenomena, and cognitive event.s" will be used interchangeably.

Anxiety Disorders The concept of anxiety within con tempora ry psychol-

ogy had gradual ly becoxne a retried concept . Within a metacogni t ive framework, and consistent with Buddhis t psychology, anxiety is under s tood as a subjective experience consist ing of several types of cognitive events (such as thoughts, sensations, images, feelings, and memories) . Any or all of these cognitive p h e n o m e n a may be present dur ing an episode of anxiety. What unifies this diversity of cognitive events into an exper ience of anxiety is the cogni t ion of apprehens ive feat. Thus, dur ing an episode of anxiety, thoughts have a high fear content , imagery may display scenes of fear, and the somatic sensations co> respond to those observed dur ing fear. It is impor tan t to dist inguish among these e lements of anxiety within recta- cognitive theory and Buddhis t psychology since the anxious individual does not exper ience anxiety but ra ther individual cognit ions. For example , an individual who is panicking is aware pr imari ly of highly aversive somatic symptoms; a social phobic may be part icularly sensitive to self-judgmental thoughts that they at t r ibute to others. Consequently, it is not possible to adequate ly treat anxiety if the const i tuent componen t s are not individually analyzed.

Clinical anxiety disorders can be classified into two b road categories: fear of cognit ions that have their source ostensibly in the external env i ronment (which include the phobic disorders snch as agoraphobia , social phobia , specific phobia) and the fear of cognit ions that have their source ostensihly in the internal env i ronment (which include the anxiety states such as obsessive- compulsive disorder, post t ramnat ic stress disorder, gener- alized anxiety disorder, panic disorder, acute stress disorder) . In both categories, the individual responds in an exaggerated, maladaptive, or overreactive m a n n e r to a cogni t ion that is under s tood to be, at least on an intellec- tual level, harmless. Exposure to the feared cogni t ion elicits a s t rong aversive react ion and concer ted efforts to avoid or escape. This may involve modifying one 's social relat ionships (e.g., social phobia) in o rde r to prevent the occur rence of self-critical thoughts, restr ict ing behavioral choices (e.g., agoraphobia , specific phobia) in o rde r to prevent the occur rence of aversive somatic sensations or beliefs of imminen t danger, adop t ion of rituals or com- pulsions (e.g., obsessive-compulsive disorder) in o rde r to e l iminate highly aversive discursive thoughts, seeking as- surance f rom others (e.g., post t raumat ic stress disorder,

general ized anxiety disorder) to a t tenuate frightful imagery and thoughts of dangeI: The high risk of substance abuse as a coping response is an indicat ion of the measures an individual suffering from severe anxiety may adop t in o rde r to escape fearful cognit ions (Toneatto, 1995, 1999b). It must be stressed, however, that the anxious individual is taking ext raordinary measures to escape or avoid stimuli that are, by definit ion, ne i ther harmful nor dangerous. It is this knowledge that informs and justifies efforts to help cognitive-behavioral therapies and is the key insight that Buddhis t psychology hopes to inculcate. Cognitive-behavioral t reatments for anxiety disorders seek to explicitly modi ty anxiety-specific metacognit ions th rough actual exposure to the feared cognitions (e.g., phobic stimulus), combined with a critical examinat ion of the a t t endan t cognitive processes (e.g., catastrophizat ion) . Successful t r ea tment usually results in a reappraisal of feared cognit ions (e.g., "My fast hear t rate means I am having a hear t attack") that is closer to what the average person might believe (e.g., "My fast hear t rate is unusual, but I doubt I am having a hear t attack").

Potential Contribution of Buddhist Psychology

Consistent with the metacognit ive model of anxiety briefly descr ibed above, Buddhis t psychology stresses how humans continual ly exper ience intense suffering be- cause of their misunders tand ing of the nature of phe- n o m e n a as they present to their own awareness. Not only is their own cogni t ion misunders tood, there is little insight into this confllsion. Consequent ly and invariably, they seek to grasp at their confused cogni t ion behaviorally, emotionally, and cognitively by striving to acquire that which is be l ieved to be des i rable or p leasurab le and to e l imina te what is bel ieved to be undes i r ab le or unpleasurable .

The teachings of the Buddha not only accurately describe these h u m a n tendencies but also prescr ibe specific means for overcoming this i nhe ren t confusion and of re- alizing our highest human potential , commonly referred to as Buddha-nature . Buddhis t insights into the na ture of menta l funct ioning and the mind t ra ining that defines Buddhis t practice are highly relevant to the t rea tment of clinical anxiety disorders.

Buddhism and Cognition In o rde r to apply Buddhis t psychology to the cogni-

tive-behavioral t rea tment of anxiety disorders, it is important to briefly describe the Buddhis t perspective of cognition. With an unders tand ing of the nature of cognit ion, several practical approaches to the t rea tment of anxiety disorders can be e laborated.

Cognitive phenomena are nonveridieal. The cognitive


p h e n o m e n a of which we are aware are rarely based on an accurate or "true" descr ip t ion of the env i ronment as it presents to our six senses (the Buddha cons idered mind or consciousness to be a sense organ, with concepts, thoughts, etc., as its object) . Rather, valid percept ions are inextricably b o u n d up with our beliefs, feelings, assump- tions, and at t i tudes about that percept ion . Thus, hear ing a sound will not only lead to our audi tory nerve being s t imulated bu t also an array of concept ions about that sound (e.g., pleasant, loud, etc.). Similarly, the occur- rence of a thought will usually elicit addi t ional thoughts that e l abora t e , j udge , or t ransform it and may be accompan ied by images, memories , and somatic sensations, for example . Virtually all of our menta l activity consists of e i ther perceptua l or conceptual cognit ions. The lat ter t end to be condi t ioned , biased, and dis tor ted (whether in an adaptive or maladapt ive di rect ion) .

Cognitive phenomena are unavoidable. Humans, while alive and conscious, are cont inuously cognitively active. The ubiquity of cognitive activity is a reflection of the mind 's vast creative capacity and responsiveness. Through- out a typical day, an i nnumerab le series of sensations, thoughts, percept ions , and images pass th rough our awareness. Efforts to prevent cogni t ion are ineffectual. While pleasant cognitive p h e n o m e n a are general ly pre- ferred, unpleasan t cognitive p h e n o m e n a will regularly occur t h roughou t the lifespan of every human, despi te efforts to avoid such experiences . Within a Buddhis t perspective, p leasant and unpleasant cognit ions are often in- t imately connected . For example , when pleasant experiences cease or do no t endure for as long as we would like, then unpleasan t feelings may arise. Similarly, when unpleasant exper iences cease, often this is expe r i enced as pleasure. Thus, regardless of the initial valence of an exper ience , there is a great l ike l ihood that the opposi te valence will also occur.

The onset of cognitive activity is outside of our control. Cognitive states appea r to arise, abide, and cease within awareness without any appa ren t conscious involvement of the individual. This is most obvious with regard to the activity of our senses, which are complete ly outside of our conscious control . Even menta l events such as thoughts are rarely ini t ia ted in a de l ibera te fashion but typically simply arise within awareness. Discursive thought , for example, is not accompan ied by any awareness of the process that leads to the selection of specific words, gram- mar, or syntax. Careful examinat ion of our cogni t ion suggests that these p h e n o m e n a seem to be automatic, condi t ioned , and au tonomous . The role of the experiencing individual appears l imited to label ing of such phe- n o m e n a (e.g., "I feel anxious") and re spond ing metacog- nitively (e.g., "I hate feel ing anxious") and behaviorally (e.g., "I am going to take some medica t ion to he lp calm me down"). At tempts to prevent cogni t ion are virtually

impossible as the suppression of cogni t ion is usually difficult and ineffective. Often, the only opt ion is to a t t empt to in ter fere with such cognitive activity th rough behavioral distraction.

Cognitive events are impermanent. While unavoidable and omnipresent , all cogni t ion is ephemera l and con- stantly changing. Thoughts cont inuously (and often re- peatedly) en ter our awareness, evolve into o ther thoughts or cease jus t as quickly; the senses are cont inual ly stimu- lated by the physical envi ronment , memor ies rapidly form and dissolve, moods oscillate in intensity, images cont inuously shift. Careful examina t ion of this menta l activity demons t ra tes the inhe ren t i m p e r m a n e n c e of all cognitive phe nome na . Even cognitive states that appea r to be p r o l o n g e d or long-lasting, such as pain or depres- sion, are seen to consist of discrete moments of cognitive activity that may differ slightly f rom m o m e n t to momen t . Wi thou t the t ransience of such cogni t ion, it would no t be possible to have any exper ience at all as the cessation of each cogni t ion creates the necessary condi t ion for the arising of another.

Cognitive stales are insubstantial or illusory. While the activities of our consciousness seem very real and salient, they are, nonetheless , difficult to define, locate, describe, or physically isolate. Cognitive p h e n o m e n a ne i the r appear to have any substantiality pr ior to their appea rance within our awareness nor any existence following their cessation. This is analogous to a mot ion picture, which is capable of enter ta in ing, horrifying, or educa t ing us th rough the successive display of images that otherwise have no existence pr io r to and following their appear- ance on the movie screen. Fur the rmore , the images that are displayed canno t in any way be isolated or removed from contact with the movie screen without utterly de- stroying the image. Thus, while our cogni t ion is undeni - ably presen t and obvious, its nature is inherent ly illusory and without self-sufficiency. In Buddhis t philosophy, this is an indica t ion of the empty na ture of cogni t ion insofar as such exper iences are functions of o ther processes, contexts, and condi t ions and readily dissolve when these processes, contexts, and condi t ions cease. In fact, if it were not for this ability for cognitive p h e n o m e n a to dissolve (i.e., to be empty) , it would not be possible to have cogni- t ion at all.

There is no end to the amoun t of quest ions to which you can subject a thought such as "I saw my f r iend yesterday." Where is this thought? Where d id it come from? What is it made of?. Is this thought the same shape as your f r iend and is the image of your f i i end the same as your f r iend himself?. When this thought passes, does it leave no trace like a c loud d isappear ing f rom the sky, or does it leave a footpr in t like a child walking on the beach? If you

76 Toneatto

say this thought has no qualities and cannot be found, then what about the thought that thinks that? I f a mute person cannot put his thoughts into words, does this mean he has no thoughts? By inter- rogat ing thought like this you can "question it to death." Persistent ques t ioning takes the life out of them and they will not bo the r to come so often. And when they do they will be weaker in force and not so bold. (Rinpoche, 1981, pp. 74-75)

Cognitive states have no inherent potency. Sensory perceptions, memories, thoughts, and dreams do not have the ca- pability of direct influence on behavior or on the environment. While most people can readily distinguish between cognitive states that are pleasant or unpleasant, this dis- t inction should not lead to the assumption that unpleasant cognitive states are therefore dangerous or harmful and pleasant ones harmless and helpful. While cognitive states such as horrifying memories and images, panic anxiety, and intense physical pain are undeniably unpleasant to most of those who exper ience them, in and of themselves they are incapable of inflicting harm. Again, using the mot ion picture analogy, horrific movie images do not damage the screen on which they are projected. My thought, "That wall is blue," will in no way modify a wall that is red. Of course, behavioral responses to disagree- able mental states may indeed be harmful in a very direct way (e.g., suicide, violence, intoxication, social isolation) to the individual or others. The tt-ue potency of cognit ion is in its indirect effect on behavior and the envi ronment when an individual decides to respond to cognition.

All cognitive activity has value. Cognitive states, but es- pecially unpleasant ones, more often than not are indi- cators of the need tbr significant changes in our lives. Unpleasan t cognitive states serve the same function, psy- chologically, as does pain for our physical well-being. Physical pain, while undeniab ly unpleasant , is a harmless bu t po ten t motivator to seek and resolve the source of the pain. Similarly, unpleasant cognitive states serve to moti- vate changes in our behavior, lifestyle, social relationships, in terpersonal behaviors, and so on. M1 experiences, desir- able or not, have value for increasing self-knowledge and self-understanding.

Cognitive activity is not separate from the functioning of the mind. Whatever the valence or the specific conten t attrib- u ted to cognit ion, the activities that occur within one 's awareness are an expression of the normal funct ioning of the hmnan mind. They are not foreign or alien events that require e l iminat ion, suppression, or destruction. Rather, all cogni t ion is actually a display of the power of the mind and complete ly ident if ied with it. Thus, it is in- correct to separate mental activities from consciousness itself in the same way fire and heat or water and waves cannot be separa ted except conceptually.

Buddhist Formulation of Anxiety Disorders

In light of the Buddhis t view of the nature of cognitive phe nome na , individuals suffering f rom clinically significant levels of anxiety have mis in te rpre ted their anxiety- re la ted cognitions. The onset of these feelings, sensations, percept ions , and thoughts, though unpleasant and undesirable , are not cons t rued as natural , harmless, im- pe rmanen t , and illusory expressions of the creative and responsive capacity of the mind. Instead, anxiety-related cognit ions are a t t r ibuted a significance and potency that they do not inherent ly possess, thus t ransforming these cognitive states into dangerous , uncontrol lable , and aver- sire sources of psychological or physical harm. As a result, metacogni t ions of danger, discomfort , and powerlessness p redomina te . The fact that symptoms of anxiety often appear spontaneously and never intent ional ly (e.g., panic symptoms, obsessions, t raumatic memories , worries seem to arise automatically) and seem to be impervious to the individual 's efforts to e l iminate them fur ther reinforces these beliefs. It is not remarkable , given such a view, that the anxious individual develops phobias, readily ingests pharmacologica l agents, and suffers panic attacks. Meta- cognitively, anxious individuals believe that their anxiety- re la ted cognitive processes are threats to their well-being, intolerable, dangerous , and undesirable .

Implications of Buddhist Psychology for Cognitive and Behavioral Treatment

In o rde r to train your mind and overcome suffering, you must rely on the power of hearing, thinking, and meditat ing. You must first hear a correct explanat ion of the teachings, on the na ture of mind, for instance, and then think about them in o rde r to ascertain their meaning. The lat ter is like looking at the mind and subjecting it to endless questions and logical analysis. Finally, when you have reached a decision about the nature of the mind, you must medi ta te and actually exper ience it to be so. Through the he lp of your Teacher you come to recognize it from your medi ta t ion. Thus all three are needed. (Rinpoche, 1981, p. 119)

Cognitive-behavioral t r ea tment in formed by a Bud- dhist theory of cogni t ion has as its initial goal the correc- tion of metacognit ive beliefs about anxiety-related cognitive phenomena . The client is inst ructed in a mode l of cognitive funct ioning in which the symptoms of anxiety must be const rued as perfectly natural , harmless, and en- tirely t ransient events taking place within their own awareness (albeit undeniab ly unpleasant) . This is best ac- compl ished by developing a certainty about the veridical- ity of the nature of cogni t ion as taught within Buddhis t philosophy. Of course, this is not possible solely th rough


therapeut ic discourse. Nevertheless, it is in this sett ing that the cl ient should receive instruct ion about the nature of cognitive funct ioning. Wi thou t a t ho rough under- s tanding of how consciousness functions, a cl ient cannot be expec ted to learn to cope effectively with anxiety (in the same way, without a knowledge of mathematics , engi- neer ing is impossible) . Th rough appl ica t ion of this knowledge to both clinically relevant and ord inary expe- r iences (see below), the cl ient can actually exper ience the insights regard ing menta l funct ioning and verify their value as taught by Buddhism.

Once a firm insight into the na ture of their cogni t ion is achieved, the cl ient can then be ins t ructed into practical methods to apply to anxiety-related cognitive phenomena . In the active phase of t rea tment the cl ient learns to correct the metacogni t ions that have trans- fo rmed ordinary exper iences into panic feelings, en- counters with phobic stimuli, o r discursive ruminat ion , by adop t ing the most veridical metacognit ive appraisal of such exper iences that they can generate . In practice, this requires the pa t ien t to realize that the activities of the mind are inherent ly natural , illusory, impermanen t , and harmless. Within Buddhis t psychology, certain conceptual metacogni t ions are cons idered to be therapeut ic , adaptive, or l ibera t ing (e.g., "These thoughts are all tran- sient and insubstantial electrical bra in activity") while others are highly maladapt ive and incorrec t (e.g., "These thoughts will never stop").

As success in accurately exper ienc ing anxiety-related cognitive events accumulates, a natural evolution occurs in the kinds of behavioral solutions that are selected in response to such cognitions. Rather than simply avoiding or escaping (and consequent ly severely compromis ing quality of life), the individual is able to more accurately perceive his or he r ( internal or external) environment .

A m o n g the techniques that may be of benefit , the most impor tan t is the ability to apply naked or bare mind- f u l attention to the anxiety-related phenomena . Mindful a t tent ion app l ied to cognitive activity is the pr imary and most effective tool taught by the Buddha for reduc ing or correc t ing the tendency to engage in e r roneous metacognitive activity. In mindful a t tent ion the cl ient is encouraged to observe the display of cognitive events occurr ing within ordinary awareness (the everyday, un t ra ined mind) bu t refrain f rom engaging in any metacognit ive (i.e., j udgmen ta l ) activity. As Epstein (1995) has def ined this a t tent ional technique, "Pay precise attention, moment by mo~ ment, to exactly what you are experiencing, right now, separating out your reactions from the raw sensory events" (p. 110). Due to the mind ' s cond i t i oned tendency to identify with any of the myriad forms of cogni t ion that may arise, this t echn ique requires r epea t ed and pers is tent r e tu rn to this a t ten t ional stance in o r d e r to ext inguish this habit . The re are many excel lent publ ica t ions deta i l ing the ba-

sic techniques of mindfulness medi ta t ion (e.g., Kabat- Zinn, 1990).

Within a stance of mindfu l at tent ion, cognit ions, regardless of content , are pe rmi t t ed to arise and dissolve ac- cord ing to their nature. If clients f ind that they have begun to engage in an inner dia logue about what they are exper ienc ing or have immersed themselves in a par- t icular menta l activity, they are encouraged to re turn to the initial a t tent ional posture in which they are to simply observe, nonjudgmental ly , all cognitive activity. In so doing, the natural history of cognitive p h e n o m e n a can be readily observed and gradually a dist inct ion made between menta l exper iences and the observing of these menta l experiences . Growing awareness of this space between the exper ience and the observat ion of the experience is a j unc tu re at which the i nhe ren t insubstantial nature of anxiety-related p h e n o m e n a can be observed to arise and dissolve without any effort or input necessary by the client.

If you can focus without any conceptua l thoughts or ideas, this is good. But should they arise, do no t follow them out. Just let them pass and they will disappear. If you allow a thought to grow into a train of thought , it will be an obstacle to your meditation. You must realize that thoughts are the play of the mind, like r ipples on water and l ight on leaves. They naturally dissolve. (Rinpoche, 1981, pp. 43-44)

To aid this effort, the cl ient is encouraged to ne i the r pursue cognitive p h e n o m e n a that they find pleas ing nor avoid unpleasant cognitive phe nome na . In the case of anxious individuals, the paradoxical t endency to elabo- rate and fur ther art iculate fearful images or discursive th inking is resisted. Such responses on the par t of the anxious individual in terfere with the natural course of a cognitive event, which is to arise and subside, and trans- form it into a fearful anxiogenic cogni t ion (which will, o f course, also arise and dissolve). Thus, a measure of de- t achment or psychological distance is necessary to counter the tendency to select and identify with cer tain aspects of our cognit ion.

Thoughts are the result of confusion about the t rue na ture of reality and there are many dif ferent kinds. Coarse or rough thoughts are easy to identify. For instance, if you are medi ta t ing on a cup, and the thought arises that you want to d r ink tea and then you call someone to fetch it for you, this is a coarse thought . A fine or subtle thought would be thinking, "This is a cup" or "It is made of white porcelain." But whatever type of thought arises, identify it for what it is. Recognize that it is merely a thought , the play of the mind like an image on a

78 Toneat to

mirror , and wi thou t g rasp ing at it let it pass. Have

your t hough t s con t inua l ly dissolve like a pa rade o f

charac te r s m a r c h i n g across a stage wi thou t any ever

s t and ing still. (R inpoche , 1981, p. 53)

Individuals suf fe r ing f r o m clinical anxie ty shou ld be

e n c o u r a g e d to view anxie ty- re la ted aspects o f the i r cogni-

t ion with a m e a s u r e o f to le rance , kindness , and accep-

t ance r a t h e r than aversion, re jec t ion , o r ha t red . In fact,

anxie ty is f r equen t ly a m e a n s by which one ' s m i n d is pro-

v id ing f eedback a b o u t areas o f life f u n c t i o n i n g that may

r equ i r e modi f ica t ion . In this role, anxie ty func t ions as a

source o f i n f o r m a t i o n , t r ansmi t t ing pa infu l bu t necessa W

i n f o r m a t i o n a b o u t one ' s life.

In app ly ing m i n d f u l a t t en t ion to anx ious cogni t ions ,

an a t t i tude o f pa t i ence and to l e rance toward the some-

t imes unpleasan t and aversive cognit ive activities is strongly

e n c o u r a g e d . To le r ance a n d pa t i ence r equ i r e an a t t i tude

o f accep tance , n o n i n t e r f e r e n c e , and respect . S ince indi-

viduals suf fer ing f r o m clinical anxie ty d i sorders o f ten cre-

ate an an tagonis t ic o r comba t ive re la t ionsh ip with the i r

own m e n t a l func t ion ing , they natural ly e n g a g e in efforts

to suppress , e l imina te , avoid, escape, o r re jec t the i r cog-

ni t ion. Viewing the activities o f awareness with g rea t e r

equan imi ty r educes this t e n d e n c y to e n g a g e in con t inu-

ous conf l ic t with the i r own cogni t ion .

F u r t h e r m o r e , suppose you are f ee l ing self-satisfied

and happy that t hough t s and de lus ions are no t

i n t e r r u p t i n g your med i t a t i on . T h e n all o f a s u d d e n

m a n y r o u g h t hough t s upse t you violent ly and you

c a n n o t b r i ng t h e m u n d e r con t ro l in med i t a t i on .

You m i g h t r ega rd these t hough t s as e n e m i e s that

have arisen. Try to r ecogn ize these very t hough t s

and the na tu re o f these very thoughts . Do no t

r ega rd t h e m as faults, bu t th ink o f t h e m with kind-

ness. (p. 126, the Nin th Karmapa Wang-ch 'ug do , je ,

1981)

S u m m a r y

A c o m p l e t e e luc ida t ion o f the t e c h n i q u e s that der ive

f r o m a Buddh i s t psychology is n o t possible wi th in this ar-

ticle. Mindfu l a t t en t ion r ema ins the c o r n e r s t o n e o f Bud-

dh i sm 's c o n t r i b u t i o n to a l levia t ing h u m a n suffering.

With ins t ruc t ion in the n a t u r e o f c o g n i t i o n and prac t ice

o f m i n d f u l a t t en t ion , an i n d M d u a l with clinical anxie ty

can deve lop valid m e t a c o g n i t i o n s a b o u t anxie ty- re la ted

p h e n o m e n a . This ins ight will r e d u c e n o t only the symp-

toms specific to anxie ty bu t genera l i ze to o t h e r areas o f

life f u n c t i o n i n g as well.

Cogni t ive-behaviora l therapists , with the i r wide array

o f pract ical t echn iques , can deve lop m a n y u n i q u e inter-

ven t ions based u p o n the Buddh i s t psychology o f cogni-

t ion tha t can be o f i m m e n s e utility in t e ach ing the anx-

ious individual a m o r e adapt ive be l i e f system a b o u t the

na tu re o f the i r cogn i t ion .

R e f e r e n c e s

Allen, B. A., & Armour-Thomas, E. (1991). Construct validation of metacognition. Journal of P~ycholog% 127, 203-211.

Beck, A. T., Wright, E D., Newman, C. E, & Liese, B. S. (1993). Cognitive therapy[or substance abuse. New York: Guilford Press.

Berardi-Coletta, B., Buyer, L. S., Dominowski, R. L,, & Rellingm; E. R. (1995). Metacognition and problem-soMng: A process-oriented approach.JouTvzal of Consulting and Clinical Psycholog); 21, 205-223.

Epstein, M. (1995). Thoughts without a think~ Basic Books: New York. Flavell,J. H., & Ross, L. (1981). Social cognitive development." Frontiers and

pm~ibleJhtures. New York: Cambridge University Press. Kabat-Zinn, J. (1990). Full catastrophe living. New York: Delacorte. Komito, D. R. (1987). Nagarjuna's seventy stanzas: A Buddhist psychology

of emptiness. Ithaca, NY: Snow Lion Publications. Kluwe, R. H. (1982). Cognitive knowledge and executive control: Meta-

cognition. In D. R. Griffin (Ed.), Animal mind-human mind. Berlin: Springer-Verlag.

Kumar, S. (2002). An introduction to Buddhism for the cognitive- behavioral therapist. Cognitive and Behavioral Practice, 9, 40-43.

Nelson, T. O., Stuart, R. B., Howard, C., & Crowley, M. (1999). Meta- cognition and clinical psychology: A preliminary framework for research and practice. Clinical Psychology and Psychotherapy, 6, 73-79.

Rachman, S., & Shafran, R. (1999). Cognitive distortions: Thought- action fusion. Clinical Psycholo©, and Psychotherapy, 6, 80-85.

Rinpoche, B. (1981). (Commentary). The Mahamudra: Eliminating the darkness of ignorance, by Wang-Ch'ug Dorje. Dharamsala, India: Libral T of Tibetan Works and Archives.

Slife, B. D. (1987). Can cognitive psychology account tot metacognitive fimctions of mind? The Journal of Mind and Behavior, 8(2), 195- 208.

Teasdale, J. D. (1999), Metacognition, mindfulness and the modifica- tion of mood disorders. Clinical Psychology and Psychotherapy, 6, 146-155.

Toneatto, '17. (1995). The regulation of cognitive states: A description of a cognitive model and treatment for psychoactive substance use.Journal of Cognitive Psychotherap); 9, 93-104.

Toneatto, T. (1999a). A metacognitive analysis of craving: hnplications for treatment.Journal of Clinical Psychology, 55, 527-537.

Toneatto, T. (1999b). Metacognition and substance use. Addictive Behaviors, 24, 167-174.

Wells, A. (1997). Cognitive therapy of anxiety disorders. Wiley: Chichester. Yussen, S. R. (1985). The role of metacognition in contemporary the-

ories of cognitive development. In D. L. Forrest-Presley, G. E. MacKinnon, & T. G. Waller (Eds.), Metacog~ition, cognition, and human perfi, vnance. Orlando: Academic Press.

Address correspondence to Tony Toneatto, Ph.D., Head, Addiction Section, Clinical Research Department, Center for Addiction and Mental Health, 33 Russell St., Toronto, Canada M5S 2S1; e-mail: [email protected].

Received: Janua U 10, 2000 Accepted: February. 20, 2001

a metacognitive therapy for anxiety disorders: buddhist psychology applied

Documents