Category: Opinions

What is Mindfulness?

By Michael Juberg

Table of Contents

Key Points

• No single definition of mindfulness
• Buddhist conceptualizations of mindfulness differ based on emphasis on explicit ethical framework vs. direct insight
• Buddhist non-dual conceptualizations of mindfulness inform current clinically-based mindfulness programs
• Mindfulness is commonly described as “paying attention, with intention, nonjudgmentally”

What is Mindfulness?

With the increased interest in mindfulness research, there remains a practical and theoretical need to establish a testable, operational definition of mindfulness. Part of this challenge is that the concept of mindfulness is compatible with multiple explanatory frameworks from various disciplines such as contemplative theories,¹ clinical, and neuroscientific frameworks.² Framing mindfulness in a scientific context compatible to clinical medicine and psychology is helpful in that it can be communicated directly to patients, healthcare providers, and researchers. However, this secularized perspective might critically overlook elements that contribute to the potentially transformative effects of mindfulness practice that first emerged beyond the context of medicine, psychology, and neuroscience. 

Rather than proposing a single definition, mindfulness might be better understood in relation to the phenomenology of the various contemplative traditions and practices that intend to develop mindfulness. This article will explore how early Buddhist conceptualizations of mindfulness led to varying theoretical accounts that consider how ethics,  concentration, and insight align with the concept of mindfulness.  These varying theoretical considerations will then be linked to contemporary Buddhist and modern scientific accounts of mindfulness. 

While mindfulness is understood as both a process (mindful practice) and an outcome (mindful awareness),³ important differences are amplified by the various approaches that seek to cultivate mindfulness.⁴ Broadly, the construct of mindfulness has been used to refer to a mental trait or phenomenological state, a spiritual path that reduces suffering and promotes wellness, and as a cognitive process that is capable of being enhanced through training.⁵

Buddhist Origins of Mindfulness

Mindfulness as a concept rooted in Buddhist origins goes back 2,500 years. However, many spiritual traditions, psychological, and Western philosophical schools of thought also describe its phenomenological nature.⁶ While these diverse, yet converging conceptualizations of mindfulness attempt to convey mindfulness as a universal human capacity that transcends any single culture, philosophy, or religion,³ most clinical adaptations of mindfulness have drawn from Buddhist techniques and theories. Mindfulness was first introduced in its clinical capacity by Jon Kabat-Zinn, PhD, who drew on Zen Buddhist teachings and applied them in a secular, clinical context. Mindfulness has been considered the heart of Buddhist meditation,⁸ however Buddhist scholars point to a rich history of debate that concludes that there is no single authoritative account of mindfulness.^{9, 10} Examining these original Buddhist sources provides the basis for understanding whether our contemporary approaches align with original theoretical accounts. 

Mindfulness, as it is described by Buddhist teachers, goes beyond simple practices and techniques.

For Buddhist practitioners, mindfulness might entail a commitment to a way of living and a general orientation toward experiences. This sentiment has been captured by Nyanaponika Thera, who described mindfulness as “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception.” ^{11 (p5)} Thich Nhat Hanh has similarly characterized mindfulness as “keeping one’s consciousness alive to the present reality.” ^12(p11) Buddhist scholars remind us that mindfulness practice includes motivation, goals, and often an ethical framework to live one’s life.¹⁰

Mindfulness is the focus of the practice of satipatthana.¹³ This practice derives from ‘sati’ (mindfulness) and ‘sampajanna’ (clear comprehension). While the concept of ‘sati’ originally meant ‘memory,’ it is believed that the Buddha altered its meaning for his teachings to reflect ‘lucid awareness’ of the phenomenal field or the impermanence of all bodily and mental experiences. Mindfulness practices help reduce craving and aversion by allowing the practitioner to understand the selfless nature of all objective and subjective phenomena. Greater mindfulness leads to a clearer comprehension of the nature of those arising phenomena and interprets them as transient experiences until this process becomes direct insight (vipassana) and wisdom (panna).  

When practitioners of mindfulness are better at distinguishing wholesome states of mind from harmful conditions, they can engage in purposeful action that nurtures more wholesome qualities. ‘Right mindfulness’ is included as the seventh factor in the Noble 8 Fold Path (samma sati) between ‘right effort’ and ‘right concentration’ and represents the mind’s energetic application to its stilling and purification. Buddhist scholars note that different traditions promote varying approaches to mindfulness. Each prescribes techniques that align with their theoretical account about the ability to observe mental phenomena as impermanent.¹

“…mindfulness has been used to refer to a mental trait or phenomenological state, a soteriological or spiritual path that reduces suffering and promotes wellness, and as a cognitive process that is capable of being enhanced through training.”

Classical Buddhist Approaches 

A Classical Buddhist perspective links suffering with distorted cognitions that lead to maladaptive actions and mental states. Suffering occurs when one misperceives phenomena as conducive to pleasure when they are actually creating suffering, and permanent when they are actually impermanent. Therefore, Classical contemplative practices’ central goal is to cease these distortions by attaining a level of insight (vipassana) that recognizes that these sensory phenomena and conditioned aspects of the mind are impermanent, selfless, and may lead to suffering. According to the traditional Abhidharma, a Buddhist theoretical account, mindfulness confers focus that allows the practitioner to see the true nature of these phenomena. The emphasis is placed on ‘remaining in the present’ without further conceptual elaboration. 

The Classical contemplative approaches help the practitioner to see beyond distorted cognitions and prior conditioning of the mind. These approaches also call for a “heedfulness” (apramāda) of one’s ethical and spiritual intentions.¹ During formal practices, an ethical framework (śīla) encourages the practitioner to make a discernment between mental states that are wholesome and are “to be adopted” (upādeya) versus those that are unwholesome and are “to be abandoned” (heya).¹ 

Many Classical traditions hope to instill a capacity to sustain these efforts during contemplative training and beyond the context of training, thus encouraging practitioners to see beyond the dualistic notion of formal and informal practice and consistently maintain a heedful awareness of their activities. This requires a practitioner to employ judgment that explicitly connects back to an ethical framework. The Classical Buddhist style explicitly requires an intensive recollection of vows and ethics to live a mindful life. 

Buddhist Non-Dual Approaches 

Contrasting the Classical approach, a Non-Dual account of suffering is attributed to a false distinction between subject and object. A Non-Dual approach, encourages dissolving this false distinction through a non-dual experience (advaya).¹ According to the Abhidharma account, mindfulness as a concept is a mental phenomenon and can only occur if there is a subject-object duality. In essence, there is only a phenomenological presentation of an object (e.g., apple) only when there is a separate phenomenological subject (e.g., person perceiving the apple). Since duality is viewed as the primary source of delusion, mindfulness as a concept is considered to be within this subject-object illusion. 

A Non-Dual approach to contemplative practice does not encourage the practitioner to cultivate mindfulness, but rather the “non-mindfulness (asmrti),” ¹⁴ which is a “mindfulness of mere non-distraction.” ^1(p263) This philosophical position would later be advanced by the Apoha theory, which invites the perspective of experiencing mental phenomena as a form of consciousness rather than the object that it represents.¹ This theory underlies a contemplative technique known in contemporary terms as ‘decentering,’ ‘dereification,’ ‘cognitive insight,’ ‘mindfulness awareness,’ and ‘diffusion.’ Whereas Classical approaches to contemplative practices emphasize an ethical paradigm, Non-dual approaches are based on insight and therefore encourages one to abandon any paradigm during formal practice, which facilitates insight during informal settings as well. Ethical judgment is viewed as a form of conceptuality that can become an obstacle and, therefore, should be suspended as one maintains a present-centered focus.

“This process, referred to as ‘decentering’ or ‘cognitive insight,’ allows the practitioner to observe mental phenomena without over-identifying and reacting to them habitually.”

Contemporary Mindfulness

Current conceptualizations of mindfulness include a non-elaborative, non-judgmental, and present-centered awareness whereby mental phenomena, including thoughts, feelings, and sensations, are acknowledged and accepted.¹⁵ This has been most commonly defined by Jon Kabat- Zinn, PhD,  as “paying attention in a particular way, on purpose, in the present moment, and non-judgmentally.” ^16(p27) Formal training in a contemporary approach helps the practitioner develop present-centered attention to an object, most commonly the breath. Following a present-centeredness, practitioners are encouraged to monitor their awareness for distractions with a non-judgmental orientation. Practitioners are not to evaluate whether the distracting mental states are to be cultivated, abandoned, nor further analyzed. ¹ Instead, practitioners are to recognize that they are distracted and are encouraged to return to the focal object, such as the breath, without further conceptual elaboration. ¹⁶ This process, referred to as ‘decentering’ or ‘cognitive insight,’ allows the practitioner to observe mental phenomena without over-identifying and reacting to them habitually. Instead, practitioners allow space for these thoughts, and they can respond with greater intention, skill, and equanimity. 

In abandoning the explicit ethical framework central to the Classical tradition, contemporary approaches toward mindfulness align more closely with the Non-dual approaches that emphasize present-centeredness rather than ethics. Buddhist scholars note that an appeal is made to the emergence of innate capacities ¹⁶ similar to specific Non-dual traditions (e.g., Mahāmudrā);¹ however, it is clear that contemporary approaches do not necessitate explicit ethical paradigms. Mindfulness-based Stress Reduction (MBSR) programs, a common form of mindfulness training utilized in clinical practice, do not teach evaluative nor ethical frameworks as a tool for mindfulness practice. Normative and simple goals are not recommended during MBSR training. Instead, practitioners are encouraged to cultivate a present-centeredness. 

It is speculated that introducing a specific ethical code in secular clinical contexts could be problematic. A secularized format increases the accessibility of mindfulness practices and allows participants to embrace their own ethical framework that arises from their personal experience and creative appropriation.¹ Despite the absence of an explicit ethical framework, an implicit framework is arguably provided in mindfulness-based training through its pedagogy, which includes poetry by Rumi, Mary Oliver, and others. These philosophical elements might implicitly suggest an intention by which to engage with the world. Even in the absence of an explicit ethical framework, practitioners’ intentions in clinical contexts appear to develop over time spontaneously. ¹⁷ At first, practitioners intend to improve their self-regulation, whereas further in their practice, they become motivated by self-exploration, followed by self-liberation, and finally devotion to selfless service.

“…a common underlying feature is the motivation to reduce suffering.”

Scientific Approaches to Mindfulness

Attempts to operationalize mindfulness have produced colorful and varied accounts. Mindfulness as a concept has been generally reconceived through a ‘family resemblance approach’ where the various cognitive processes are contextualized through postural, aspirational, and motivational dimensions that produce recognizable states within defined phenomenological dimensions. ⁵ In essence, these elements of mindfulness practice are first recognizable and then reproducible. Although various models have emerged to capture the complexity of mindfulness, two theoretical approaches are prominent.

Two-Component Model of Mindfulness

A systematic effort to establish an operational definition has led to a Two-Component model of mindfulness.¹⁸ The first component involves the self-regulation of attention to present-moment experiences. Through the practice of present moment awareness, practitioners should enhance their ability to sustain attention, switch attention back to the object of focus, and inhibit elaborative thinking. The second component of the model involves adopting a particular orientation that is curious, open, and accepting. Practitioners are encouraged to maintain a commitment to an attitude of curiosity, non-striving, and acceptance to the various mental experiences that arise. In summary, this model conceptualizes mindfulness as a process of openly relating to experiences. 

Theoretically, this model predicts that practitioners abandon avoidance strategies over time as they progressively adopt a more open orientation to their distressing internal experiences. Mindfulness has been appropriated to psychotherapy interventions due to these shifts in metacognition. By gaining insight into the nature of their thoughts and emotions, patients can expand their repertoire of responses to uncomfortable internal experiences.¹⁹ Finally, this model considers mindfulness as a psychological process that more closely aligns with a temporary state rather than a stable trait since its evocation and maintenance depends on the active regulation of attention and a mindful orientation to experiences. 

 Phenomenological Matrix

Another prominent theoretical account of mindfulness is the Phenomenological Matrix, a heuristic tool for mapping various practice styles and expertise levels of mindfulness onto a multidimensional model ⁵. This model decomposes the multiple elements of mindfulness practice into three independent dimensions, including object orientation- the awareness of a particular object, dereification- interpretation of mental phenomena as mental processes rather than depictions of reality, and meta-awareness – the mental state of noticing the current contents of consciousness. These three primary dimensions are considered the main targets for all styles of mindfulness training. 

In addition to these core dimensions, four secondary qualities are described, which account for relevant features of meditation experience influenced directly or indirectly by the specific instructions for practicing mindfulness. They include aperture, clarity, stability, and effort. Aperture describes the scope of attention. Clarity refers to the vividness of one’s experience. Stability entails the degree to which a phenomenological experience persists over time, either spontaneously or intentionally. Lastly, effort describes the amount of intention and energy to maintain a state of awareness. Together, this operationalization allows scientists to empirically examine these theoretical dimensions and communicate back their discoveries to the scientific community in a common language.

Conclusion

Historically, the concept of mindfulness has provided fertile grounds for theoretical discussion for over 2,500 years. The secularization of mindfulness as it enters the realm of science and medicine comes with mixed reviews between caution and appreciation.¹³ Despite clear differences in axiological approaches, especially in regards to the ethics of mindfulness, a common underlying feature is the motivation to reduce suffering.²⁰ As this emerging field of contemplative sciences matures, theorists ought to consider whether mindfulness can be fully adopted without the traditional elements that have led to its successful proliferation over centuries, including ethics, faith, and devotion. It poses an important consideration: does the secularization of mindfulness miss the point upon which Buddhism and other contemplative traditions have been premised? These multiple attempts to understand and operationally define mindfulness are helpful, yet as theorists continue to enter space considered sacred by ancient traditions, a scientific approach accompanied by both humility and gratitude is warranted.

References

1.  Dunne, John D. “Buddhist Styles of Mindfulness: A Heuristic Approach.” In Handbook of Mindfulness and Self-Regulation, edited by Brian D. Ostafin, Michael D. Robinson, and Brian P. Meier, 251–70. New York: Springer, 2015.
2. Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry research: neuroimaging, 191(1), 36-43.
3. Shapiro, S. L., & Carlson, L. E. (2017). Mindfulness-informed therapy.
4. Chambers, R., Gullone, E., & Allen, N. B. (2009). Mindful emotion regulation: An integrative review. Clinical psychology review, 29(6), 560-572.
5. Lutz, A., Jha, A. P., Dunne, J. D., & Saron, C. D. (2015). Investigating the phenomenological matrix of mindfulness-related practices from a neurocognitive perspective. American Psychologist, 70(7), 632.
6. Cordon, S. L., Brown, K. W., & Gibson, P. R. (2009). The role of mindfulness-based stress reduction on perceived stress: Preliminary evidence for the moderating role of attachment style. Journal of Cognitive Psychotherapy, 23(3), 258-269.
7. Kabat-Zinn, J. (2011). Some reflections on the origins of MBSR, skillful means, and the trouble with maps. Contemporary Buddhism, 12(1), 281-306.
8. Nyanaponika (Thera). (1962). The Heart of Buddhist Meditation (Satipaṭṭhāna): A Handbook of Mental Training Based on the Buddha’s Way of Mindfulness, with an Anthology of Relevant Texts Translated from the Pali and Sanskrit. Rider.
9. Gethin, R. (2011). On some definitions of mindfulness. Contemporary Buddhism, 12, 263–279
10. Sharf, R. (2014). Mindfulness and mindlessness in early chan. Philosophy East and West, 64 (4), 933–964. 
11. Thera, N. (2008). The power of mindfulness. Wheel Publication, 1-75.
12. Hanh, T. N. (2016). The miracle of mindfulness: An introduction to the practice of meditation. Beacon Press.
13. Bodhi, B. (2011). What does mindfulness really mean? A canonical perspective. Contemporary Buddhism, 12, 19–39. 
14. Higgins, D. (2006). On the development of the non-mentation (amanasikāra) doctrine in Indo-Tibetan Buddhism. Journal of the International Association of Buddhist Studies, 255-303.
15. Kabat-Zinn, Jon. Full Catastrophe Living : Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. New York, N.Y: Delacorte Press, 1990. Print.
16. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (Revised and updated ed.). New York: Bantam Books. 
17. Shapiro, D. H. (1992). A preliminary study of long term meditators: Goals, effects, religious orientation, cognitions. Journal of Transpersonal Psychology, 24(1), 23-39.
18. Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., … & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical psychology: Science and practice, 11(3), 230-241.
19. Horowitz, M. J. (2002). Self- and relational observation. Journal of Psychotherapy Integration, 12(2), 115–127. https://doi.org/10.1037/1053-0479.12.2.115
20. Wilson, J. (2014). Mindful America: Meditation and the mutual transformation of Buddhism and American culture. Oxford University Press.

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What is the present moment?
Some warnings about hanging out in it, and a new scientific theory of meditation.

Ruben Laukkonen

Ruben Laukkonen is a cognitive neuroscientist at the VU University of Amsterdam. His research focuses on sudden insight experiences and the effects of intensive meditation on the mind and brain. Using a combination of neuroimaging, machine learning, and neuro-phenomenology, Ruben is investigating some of the most rare states of consciousness accessible to human beings. He has published articles in leading journals, given talks at prestigious conferences, and has written on topics that range from artificial intelligence to psychedelics. Ruben has an eclectic contemplative background, including different meditation traditions such as Zen, Advaita, and Theravada.

“Just be here now, and all your problems will go away. You’ll be more peaceful, you’ll be happier and you’ll be kinder. Live in the present, breathe, just flow…”.

Familiar advice, isn’t it?

But from the brain’s perspective, being in the present moment is no joke. Because what concept, feeling, or experience, is not built on the foundation of time? 

For example, how do we know the taste of a good coffee, recognize our mother, or open a door without a vast history of learning based on the past? How do we drink water, instead of detergent, unless we project our knowledge all over that neutral liquid? 

We can go some (many) steps further. To truly be in the present moment is to not exist. 

Time—or rather the organization of regularities in time—is the very currency of construction within the brain. Without moulding the present based on the past, there simply is nothing meaningful to experience. Those jolts of electricity that climb your nervous system are empty of meaning, without the brain and the body’s capacity to regurgitate its own meaning.

It’s sometimes tempting to think that we’re “drinking in” in the world, like a fancy cocktail of meaningful symbols that we saturate with our past, but basically, passively swig. But in fact, the brain is doing minimal drinking and much more vomiting. The brain-body is puking out this colorful world, full of self, relationship, feeling, thought, and…. Everything. Your very perception of these squiggles on the screen and their meaning is fundamentally compositional rather than passive, and what permits this generative organ its creative power… is regularities over time… patterns that we abstract into things.

“…because what concept, feeling, or experience, is not built on the foundation of time? ” 

If this time-based construction of our subjective reality goes wrong, we can develop psychopathology. Hallucinations, delusions, forgetting, and misunderstanding—they all rely on some mistaken projection of the past onto the present two-dimensional impressions on our body. The body is also generating its own internal signals all the time like hunger, proprioception, intuition, etc., and the brain is also a thought-engine bursting with fireworks of its own. 

So, the vast majority of our experience is manifested from within. 

Not in some law-of-attraction sense, but in the sense that it’s all made up based on what we have come to know. We literally would not notice that our house was burning if it wasn’t for the wisely orchestrated projections of the past; and that of all those clever hairy ancestors of ours. And even more profoundly—and this is a tricky point to grasp—it may not even be based on the electricity of the present. It is quite possible that the whole kaleidoscope is made up based on the past, and simply tested against the present. Where the present itself —those electrical signals grounded on something external—never even make a dent on what is experienced as if it was the present.  

So, here’s the warning I promised: If you’re going to hang out in the present, like really do it, then you and almost everything you know might just disappear. 

This will make more sense if I now (somewhat superficially) describe our new theory of meditation. 

I present this theory with a lot of humility. Meditation is a huge subject, and we’re obviously still figuring out how the brain works. But we know so much more about meditation today than we did twenty years ago—scientifically speaking—and we have this new understanding of the brain where it ‘predicts’ (cf. vomits) out our experience. And putting these two things together somehow felt—as the cliché goes—timely. 

In our recent paper we propose that the progression of meditation is just a journey deeper  into the present moment. And with this simple understanding, we can basically predict most of the wild things that can happen during very intensive and prolonged meditation practice. When you combine this present-centeredness with a view of the brain as a hierarchical prediction-machine that is habitually abstracting away from the present to create our experience, it all makes sense. 

When you understand the brain as a system that builds our subjective experience in each moment in layers of abstraction, where the more abstract we go in this hierarchy the more ‘conceptual’ and less ‘present moment’ experience becomes, then all that stuff about non-self, impermanence, pure consciousness, timelessness, and perhaps even transcendence, begin to seem unsurprising.

“It is quite possible that the whole kaleidoscope is made up based on the past and simply tested against the present” 

Technical detour: What are current scientific conceptualizations of the present moment? Let’s take as a starting point John Kabat-Zinn’s (2003) famous secular definition of mindfulness as the “The awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.” There are several ways that this definition—which has informed hundreds of scientific studies on mindfulness—diverges from our view of the present moment. In Kabat-Zinn’s definition, there is still ‘paying attention with purpose,’ and there is still ‘the unfolding of experience.’ But, as we have briefly argued above, experience, purpose, and directed attention are very much still constructed through predictions derived from the past. Even the very process of paying attention to the breath implies the subtle generation of a subject with intentionality and agency, a thing which is the breath, and the idea that attention can be directed towards such a thing. There is nothing wrong with this view, but it is from the brain’s perspective premature to call that ‘the present’. It is perhaps “more” present than thinking, but it is all still a time-based abstraction. It is not yet being in the present moment because that would imply that time, space, the unfolding of experience, attention, intentionality, and the very idea of meditation or a meditator, are not constructed. This more radical view of the present opens doors for new empirical work. For example, we can potentially derive measures of meditative expertise, where the depth of the meditative state can be measured based on the extent to which one is constructing abstractions away from it: Even something as subtle as a startle response, responses to linguistic structure, or any signal of surprise in the brain, implies that one is not truly present.

To illustrate: Imagine you’re a super-meditator, with a perfectly refined ability to be in the here and now. And you’ve decided you want to go from being completely not in the here and now, to totally immersed in the present. And imagine that you’re listening to a song, let’s say, ‘Beautiful World’ by Colin Hay. 

At first, being in some very ordinary state, you might be kind of hearing the song, but also partly lost in thoughts, and also making all kinds of evaluations and judgments about what you like and don’t like about the music. You might think, “it’s a bit slow, I’m bored, what should I listen to next… etc.” 

Then, you might tune in a bit. Really get your attention on the song. Now maybe you start to flow with it, really feeling into the sounds themselves… vibing with it. Perhaps your body is even subtly moving with the rhythm. You’ve dropped the ‘evaluating and judging’ abstraction. Now you’re just ‘in it,’ ‘with it,’ the sensations are what dominate. 

But you’re eager to go deeper into the present. And as you do that, suddenly the words stop making sense. Colin Hay is singing “I like drinking Irish tea”, and all you’re taking in is… pure sound. Just… sound, prior to any interpretation, before any meaning. You’re so ‘in the present’ that you’re no longer projecting anything you know about language and concepts onto the sound vibrations emerging from Colin’s mouth.  

The thing is, that the sound, and the ‘you’ that hears the sound, are also made up! Just at a level that’s a little less abstract, a little more ‘here and now’… you could say. But as with understanding language, the past plays an inevitable role. 

What could a ‘you’ be without categories, without some concept of you as a ‘thing’ consistent from one moment to the next? Even the very capacity to discriminate this from that (i.e., like, a body as separate from the chair you’re sitting on) requires an inference, an abstraction, a projection… from the past. How else could electrical signals come alive?

So now it’s really getting wild. 

As you drop even deeper into the now, the sound goes ‘poof’. The whole idea of music… is gone. The whole concept of an organism that can listen to music has vanished. 

But weren’t you just looking to ‘hang out in the present’? To be a bit more peaceful and relaxed? To reduce some stress?

Being in the present is no joke.

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Your brain is also part of your body: Contextual and contemplative approaches in physical illness

By Inês Trindade, PhD

Despite significant advances in the field of psychology due to increased research, the complete rejection of the Cartesian dualist notion of a separate and distinct body and mind, and the exponential growth of psychoneuroimmunology, the usual care of people with chronic medical conditions still often neglects the psychological issues associated with the physical dimension of the disease.

This is the unfortunate reality of some places such as Portugal, a good example of a European country with top research and medical treatment and departments– including oncology, radiotherapy, gastroenterology, or rheumatology departments – that somehow still operate without a single psychologist. This is particularly surprising and alarming especially considering the very well-known impact chronic medical conditions, which affect around a third of the world population, have on mental health and quality of life. Chronically ill people face functional impairment, decreased quality of life, and significant mental health difficulties. Moreover, the interplay between psychological processes and the nervous and immune systems, may contribute to a further decrease in psychological health, in a self-perpetuating cycle between psychological suffering and physical distress.

“…people with illness would benefit the most if they had evidence-based psychological interventions available as soon as needed, which is often from the diagnosis.”

I have the strong belief that it is in part on the hands of clinical psychology researchers to advocate for the inclusion of psychological interventions in the usual treatment of chronic medical conditions. To be able to advocate such need, research should focus on developing and improving the efficacy of and access to psychological interventions for populations in need – and this is what drives me to conduct research in this field.

The research I have conducted has aimed to contribute to a better understanding of the psychological mechanisms that influence the vulnerability and persistence of psychological, social, and physical impairment in chronic illness. It has given further support to the pertinence of contextual and contemplative approaches in behavioral medicine, particularly Acceptance and Commitment Therapy (ACT) and mindfulness- and compassion-based therapies, and their integration in the treatment of chronic medical conditions. These approaches aim to change the relationship individuals have with their internal experiences (rather than changing the content of those experiences) by stimulating willingness to be aware, open and accepting about any type of internal events, while holding a nonjudgmental and compassionate attitude towards difficulties. This is particularly relevant in illness contexts – where some thoughts about one’s disease or prognosis may very well be realistic; where, it seems more useful to learn how to deal with those thoughts instead of battling their accuracy. Further, interventions based on these approaches have been found to effectively improve functioning, mental health, and even physiological markers (e.g., inflammation) in diverse medical populations.

It can thus be argued that such contextual and contemplative-based interventions should be integrated in the usual healthcare of people with chronic illness and that all interested individuals should be able to enroll in this type of intervention, as soon as they can or want. This has actually been pointed out by a participant in the preliminary efficacy study of the Mind Programme (a mindfulness, ACT, and compassion-based group intervention for cancer we have developed and tested). A 58-year-old woman with breast cancer stated, after completing the program:

“This program made me feel emotionally stronger and more able to face life’s adversities. Learning to accept mine and other peoples’ problems is a step to recovery. After all, problems may just as well be only ghosts of our mind. I would have liked to have come in contact with this program years ago. But it’s never too late to trace the path of self-knowledge.”

Although it may be in fact accurate that it is not too late to learn new tools (in this case, contemplative-based) to improve one’s mental health and well-being, people with illness would benefit the most if they had evidence-based psychological interventions available as soon as needed, which is often from the diagnosis. Given the evidence we now have available, this should be seen as a right each chronically ill person should have. Everywhere.

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