Buddhist psychology, psychotherapy and the brain: a critical introduction

Buddhist psychology is increasingly informing psychotherapeutic practice in the western world. This article: (a) provides a general background to Buddhist tradition; (b) outlines the central tenets of Buddhist psychology, with particular emphasis on the practice of meditation; (c) provides an overview of research into the effects of Buddhist practice on the brain; (d) outlines the relationships between Buddhist psychology and existing forms of psychotherapy; (e) provides an overview of Buddhist approaches to specific psychiatric disorders and the psychological aspects of physical disorders; and (f) discusses the emergence of Buddhist psychotherapy in western societies and explores likely future developments. There is a need for further research into the neuroscientific correlates of Buddhist concepts of mind and the evidence-base for the use of specific techniques (e.g., meditation) in psychotherapeutic practice.     

The use of Buddhist mindfulness meditation in psychotherapy: a case report from Sri Lanka

Buddhist practices have been increasingly influencing psychotherapy. For over 20 centuries, Buddhism has been the religion of a majority of Sri Lankans. However, there is little documentation of the use of Buddhist practices in psychotherapy in Sri Lanka. This paper presents a case study in which Theravadan Buddhist mindfulness meditation and cognitive therapy practices were used in the treatment of a client with depressive disorder. The paper also summarizes the influence of Buddhist concepts and mindfulness meditation on psychotherapy and illustrate how Buddhist doctrine and practices can be considered a psychotherapeutic method.     

The use of meditation in psychotherapy: a review of the literature

This article has explored research to date concerning the efficacy of introducing meditation into the therapeutic setting. I have presented the views of proponents and critics of the relaxation model of meditation and of theories describing the cognitive changes brought about by meditation--for example, Deikman's theory of the deautomatization of consciousness and Delmonte's view that meditation may be utilized to bring about "ascendence," "descendence," and "transcendence." After summarizing psychoanalytic and Jungian arguments against meditation, the writings of several transpersonal psychologists have been cited to demonstrate the differences in how psychotherapy and meditative disciplines conceptualize personal identity, work with unconscious material, and view the experience of emptiness. I conclude that the question of whether meditation should be used in therapy can be answered only by considering what therapeutic goals are being sought in a particular instance and whether or not meditation can reasonably be expected to facilitate achievement of those goals. Meditation may, in some cases, be compatible with, and effective in, promoting the aims of psychotherapy--for example, cognitive and behavioral change, or access to the deep regions of the personal unconscious. In other cases, it may be strongly contraindicated, especially when the therapeutic goal is to strengthen ego boundaries, release powerful emotions, or work through complex relational dynamics--ends which may be more effectively reached through standard psychotherapeutic methods than through meditation. Meditation may be of great value, however, through its capacity to awaken altered states of consciousness that may profoundly reorient an individual's identity, emotional attitude, and sense of wellbeing and purpose in life.     

Culture, personality and psychotherapy

Conventional Western-model psychotherapy is based on a number of premises regarding its rationale and technique. The increasing experience in psychotherapy globally is questioning the universality of these premises, suggesting that these could be to a large extent culture-specific, having developed in a particular culture at a particular time. Hence, the need to move from a dogmatic approach to psychotherapy to a flexible approach taking into account the socio-cultural reality. The paper identifies a number of cultural variables involving the intrapsychic mechanisms (e.g. cognitive and expressive), social relatedness (e.g. autonomy, social distance) and religious-philosophical belief systems (concept of sin, and belief in fatalism and after-life/reincarnation) and discusses their role in the approach to and process of psychotherapy, illustrating it with the situation in the Indian setting.     

Learning and insight in psychotherapy.

The main objectives of this paper are: (a) an overview of therapeutic parallels and differences between psychoanalytic and behavioral psychotherapy; (b) an analysis of learning process with reference to insight taking place during psychotherapy. For attaining these objectives, the author reviews the literature and explores the cognitive and educational values inherent in the psychotherapeutic process.     

Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders

OBJECTIVE: This study compared the effectiveness of short-term dynamic psychotherapy and cognitive therapy for outpatients with cluster C personality disorders. METHOD: Patients (N=50) who met the criteria for one or more cluster C personality disorders and not for any other personality disorders were randomly assigned to receive 40 weekly sessions of short-term dynamic psychotherapy or cognitive therapy. The most common axis I disorders in the patient group were anxiety and depression diagnoses. Therapists were experienced, full-time clinicians and were receiving manual-guided supervision. Outcome variables included symptom distress, interpersonal problems, and core personality pathology. Measures were administered repeatedly during and after treatment, and change was assessed longitudinally by means of growth modeling procedures. RESULTS: The overall patient group showed, on average, statistically significant improvements on all measures during treatment and also during a 2-year follow-up period. Significant changes in symptom distress after treatment were found for the group of patients who received short-term dynamic psychotherapy but not for the cognitive therapy patients. Despite these differences in intragroup changes, no statistically significant differences between the short-term dynamic psychotherapy group and cognitive therapy group were found on any measure for any time period. Two years after treatment, 54% of the short-term dynamic psychotherapy patients and 42% of the cognitive therapy patients had recovered symptomatically, whereas approximately 40% of the patients in both groups had recovered in terms of interpersonal problems and personality functioning. CONCLUSIONS: Both short-term dynamic psychotherapy and cognitive therapy have a place in the treatment of patients with cluster C personality disorders. However, factors other than treatment modality may discriminate better between successful and poor outcomes. Such factors should be explored in future studies.     

Mindfulness and Awareness: Constructivist, Psychodynamic and Eastern Perspectives

In this paper I develop my contention that reality is experienced polymorphically at different levels along a concrete-abstract continuum. At the more abstract and psychic level the internal representations of primary reality are, to varying degrees, verbally labelled. However, for various reasons, this verbal symbolisation is rarely adequate or complete??even in adulthood, and hence the persistent recourse to somatisation, acting out, projection and other psychological strategies and defences. This paper also examines, using both constructivist and psychodynamic models, how verbalisation can be helpful in clinical practice with somatoform disorders as both models are concerned with the ??talking cure??. Drawing on our understanding of meditation and mindfulness, the role of our psychological defences in limiting our consciousness is examined, in contrast to the practice of non-verbal mindfulness which aims at expanding our awareness. Potential problems with meditation are discussed, as well as limitations to the ??talking cure????as verbalisation can also be used as a higher order defence. However, it is concluded that all awareness expanding practices, such as mindfulness and psychotherapy, reduce the need to resort to somatisation and other primitive awareness distorting strategies. In this paper constructivist (Kellian) and psychodynamic (both Freudian and post-Freudian) perspectives are employed to develop my contention that reality is experienced polymorphically at different levels of cognitive awareness along a concrete-abstract continuum. At a more abstract (or largely psychic) level the internal representations of primary reality become, to varying degrees, verbally labelled as we develop and mature from infancy. However, this verbal symbolisation is rarely sufficient or complete??even in adulthood, and hence the persistent need for somatisation, acting out, acting in, and primitive forms of communication and psychological defence, such as hysterical identification, projective identification and/or other forms of basic communication typically found at the lower levels of awareness. This paper further goes on to examine, especially using constructivist, but also psychodynamic models, how verbal symbolisation can be helpful in practice with psychosomatic and hysterical disorders. Drawing on our understanding of concentrative and mindfulness meditation the workings of our psychological defences are examined. Constructivist and psychodynamic models are used to describe the distortion of consciousness by these defences??albeit from different perspectives. Both of these psychotherapy approaches are also concerned with the issue of increased awareness via insight, and are therefore complementary to the Eastern notion of enhanced awareness through the practice of meditation and mindfulness. Potential problems with meditation are discussed, as well as limitations to the ??talking cure????as verbalisation can also be used as a higher order cognitive defence, as observed in rationalisation??as well as in the higher service of the expansion of awareness.     

An outpatient psychotherapy clinic for the elderly: Rationale,establishment and characteristics

Introduction: The purpose of this paper is to describe the factors informing the establishment of an outpatient psychotherapy clinic for the elderly, the first of its kind in Australia, and then to describe the characteristics of the first 51 patients to attend the clinic. Methods: A retrospective review of patients' files was conducted to obtain data on patient demographics, diagnoses, types of psychotherapy received, and number of sessions received. Results: A majority of patients were between the ages of 65 and 75, female, partnerless, living alone in private accommodation, and suffering from major depression. Types of psychotherapy received were psychodynamic psychotherapy, cognitive‐behavior therapy, supportive psychotherapy, grief therapy, or a combination of the above. The mean number of sessions received was 11, and one in five patients terminated prematurely. Discussion: Psychodynamic psychotherapy is suited to only a very small minority of elderly patients. Enabling factors and possible barriers to treatment are discussed. Some proposals are offered to enhance the scope and quality of the clinic.     

Emotion-focused psychotherapy for patients with panic disorder.

OBJECTIVE: Recent studies have suggested that most patients treated for panic disorder receive forms of psychotherapy other than cognitive behavior therapy, even though there is little information about the efficacy of such treatments or how they compare to proven active treatments. The authors compared one of these other forms, emotion-focused psychotherapy (given to 30 patients with panic disorder), to results obtained with recommended standard treatment (either cognitive behavior therapy [N=36] or imipramine [N=22]). The authors also compared emotion-focused psychotherapy to results obtained in subjects given pill placebo (N=24). METHOD: Subjects met DSM-IV criteria for panic disorder with no more than mild agoraphobia. Treatment consisted of approximately 3 months of weekly visits followed by 6 monthly maintenance visits. Assessments were conducted after each treatment phase and at a follow-up visit after 6 months of no treatment. RESULTS: Emotion-focused psychotherapy was less effective for symptoms of panic disorder than treatment with either cognitive behavior therapy or imipramine; results obtained with emotion-focused psychotherapy after the acute and maintenance phases were similar to those seen with placebo. Treatment expectations were not different among the different groups. Patients receiving emotion-focused psychotherapy had the highest completion rate. CONCLUSIONS: The results suggest that emotion-focused psychotherapy (a supportive form of psychotherapy) has low efficacy for the treatment of panic disorder. However, emotion-focused psychotherapy may be superior to medical management in helping patients stay in treatment.     

Remission in major depressive disorder: a comparison of pharmacotherapy,psychotherapy, and control conditions

OBJECTIVE: The aim of this study was to assess the percentages of full remission in studies of patients with major depressive disorder in which pharmacotherapy, psychotherapy, and control conditions were directly compared. METHOD: Computerized searches of the MEDLINE and PsychINFO databases up to November 2000 were used to identify six multiple-cell randomized, controlled, double-blind trials for well-defined major depressive disorder in which medications, psychotherapy, and control conditions were directly compared and for which remission percentages were reported. RESULTS: The studies included a total of 883 outpatients with mild to moderate, primarily nonmelancholic, nonpsychotic major depressive disorder. Treatment duration ranged from 10 to 34 weeks (median=16 weeks). An intent-to-treat analysis indicated that, according to measurements by independent blind raters, antidepressant medication (tricyclic antidepressants and phenelzine) and psychotherapy (primarily cognitive behavior and interpersonal therapies) were more efficacious than control conditions, but there were no differences between active treatments. The percentages of remission for all patients randomly assigned to medication, psychotherapy, and control conditions were 46.4%, 46.3%, and 24.4%, respectively. Furthermore, significantly more patients dropped out of control conditions (54.4%) than either treatment with medication (37.1%) or psychotherapy (22.2%). CONCLUSIONS: Both antidepressant medication and psychotherapy may be considered first-line treatments for mildly to moderately depressed outpatients.     

Emotion suppression,not reappraisal,predicts psychotherapy outcome

Objectives: The aim of this study was to identify whether trait emotion regulation strategies predict successful or unsuccessful psychotherapy outcomes in cognitive behaviour therapy. Methods: Three emotion regulation strategies (reappraisal, suppression, and externalizing behaviour) were assessed in 358 in- and outpatients. Patients were then grouped by therapy outcome. Emotion regulation strategies and confounding variables were entered as predictors in multinomial logistic regression analyses. Results: Emotion suppression, but not reappraisal, was found to predict therapy outcomes for in- and outpatients, with patients high in suppression experiencing worse outcomes. Externalizing behaviour was only relevant in inpatient treatment. Conclusions: High suppression might be detrimental to psychotherapy outcome and should be assessed early on. Further research should investigate the influence of suppression on the mechanisms that facilitate change in psychotherapy.     

Evidence-based psychotherapy for schizophrenia

Many patients with schizophrenia have psychological distress and receive some form of psychotherapy. Several different psychotherapeutic approaches for schizophrenia have been developed and studied. Of these approaches, cognitive behavior therapy has the strongest evidence base and has shown benefit for symptom reduction in outpatients with residual symptoms. In addition to cognitive behavior therapy, other approaches include compliance therapy, personal therapy, acceptance and commitment therapy, and supportive therapy. Although usually studied as distinct approaches, the therapies overlap with each other in their therapeutic elements. As psychotherapy for schizophrenia further evolves, it will likely be informed by other psychosocial interventions used with this clinical population. In particular, techniques of remediating cognitive deficits, teaching behavioral skills, and educating about schizophrenia may be incorporated with psychotherapy. Future research may also consider three different goals of psychotherapy with this population: to provide emotional support, to enhance skills for functional recovery, and to alter the underlying illness process.     

Recent developments in individual psychotherapy

Individual psychotherapy, the pivotal modality of psychiatry, has undergone a constant revolution since the inception of psychoanalysis; over the years the treatment models have shifted from dynamic to behavioral to experiential. The author discusses forces, such as economic pressures to establish cost-effectiveness, that have precipitated these changes. After reviewing comparative studies of the efficacy of psychotherapy, he examines new developments in individual psychotherapy such as brief treatment and cognitive therapy for depressive disorders. The efficacy of combined techniques, the impact of diagnostic tools and training manuals, and ethical issues, such as sexism, are also explored.     

A comparative outcome study of individual, group, and conjoint psychotherapy

Sixty-four outpatients were assigned to individual, group, or conjoint psychotherapy with experienced private clinicians. The length of the treatments ("cognitive insight" or "affective insight" therapies) averaged 26.8 sessions. To examine comparative outcomes, patients and significant others were assessed on both general outcome measures (eg, symptoms, target complaints) and mode-specific indexes (eg, private self-awareness, interpersonal functioning, and family environment). The most notable finding was the significant improvement of the sample as a whole at both termination and follow-up (average, 31 weeks). When differential outcomes did appear, they were more often attributable to differences among therapists and to interactive effects (ie, a particular fit between specific patient characteristics and a specific mode of therapy) than to main effects for any single therapy. The findings also demonstrated the importance of a systems approach to understanding fully the effects of psychotherapy because the patient's view of the family, the significant other's view of the patient, and the significant other's own adjustment tended to vary together, regardless of the mode of treatment.     

Alexithymia and psychotherapy.

Alexithymia represents a disturbance in affective and cognitive function which overlaps diagnostic categories. Emotions are not differential, and are poor verbalized. Imagination related to drive fulfillment is limited. These and other problems seriously interfere with the patients' capacity to benefit from dynamic, uncovering or "anxiety-producing" psychotherapy. In order to consider possible remediation of the problem, we must explore the nature and causes of this disturbance.     

Humanistic-existential psychotherapy competencies and the supervisory process

There has been an increasing focus in recent years on articulating foundational and functional competencies for practice in professional psychology and how a competency-based approach might inform psychology training. With the aim of contributing to the dialogue in this area, the discussion herein explores psychotherapy competencies through the lens of a humanistic-existential perspective and describes implications for psychotherapy training and supervision. Specifically, competencies pertaining to facilitating the client's experiential awareness and use of the psychotherapy relationship to engender client change are described. Next, the foundational and functional competencies within professional psychology that are particularly salient to a humanistic-existential psychotherapy framework are discussed. Finally, the ways in which a humanistic-existential supervision framework contributes to the development of psychotherapy competencies in trainees is considered. A brief vignette is presented to illustrate the supervision process. (PsycINFO Database Record (c) 2010 APA, all rights reserved).     

Psychiatry residency programs: trends in psychotherapy supervision.

The evolving dominance of psychobiologic over psychodynamic theoretical influences on education and practice presents new challenges for psychiatry. This article features selected data from the 1989 American Association of Directors of Psychiatric Residency Training annual survey (n = 215) that describe current teaching activities related to psychodynamic psychiatry, mainly psychotherapy. Results are based on a 50 percent return rate (107/215 questionnaires). Responses confirm the emergence of psychobiological (48%) over psychodynamic (40%) departmental orientations and report that the psychodynamic orientation has maintained strength as a secondary emphasis. Residents generally gain experience in a range of psychotherapy theories and modalities, including psychodynamic, cognitive, behavioral, individual, couples, family, and group therapies. Training in brief and short-term individual psychodynamic psychotherapy predominates, however. Use of video- and audiotaping in supervision is limited. Full-time faculty provide the bulk of psychotherapy instruction. This is carried out in both individual and group sessions, which are organized primarily around case reviews. Supervision-related problems include faculty availability, skill diversity, competence, theoretical flexibility, and attitudes, as well as program structure and standards.