Yoga, Mindfulness, and Mentalization: Central Role of Attention and Compassion

Department of Psychiatry, Cooper University Hospital, and Cooper Medical School of Rowan University, Camden, NJ, USA


The faculty of voluntarily bringing back a wandering attention over and over again is the very root of judgment, character and will…..An education which should improve this faculty would be the education par excellence

–William James (Principles of Psychology, 1890; p. 424)

6.1 Attention, Empathy, and Compassion: The Key Qualities in a Meditator

Deep philosophies of Yoga and meditation are the various theories about human mind and the various ways the mind works. Yoga, mindfulness, and mentalization are three related concepts and are often used interchangeably. Both mindfulness and mentalization are metacognitive which is defined simply as reflective cognition about cognition or knowing about knowing (Koriat 2000, p. 149). As concepts, they shed light on higher human qualities like empathy and compassion as well as on a variety of psychotherapeutic phenomena, including some aspects of transference (the thoughts and feelings aroused in the patient about his/her therapist) and countertransference (the thoughts and feelings aroused in the therapist about his/her patient). It is amazing to see the progress of neural sciences exploring and explaining these concepts in an ongoing manner. Some of them, as discussed later in this chapter, are the concepts of mentalizing areas of brain and the mirror neurons (discovered by Rizzolatti et al. 1996) which can be called as the experiential neurons because they map our experiences in our brain in form of the neural impressions of the perceived actions of others as well as their meanings.

One can note that attention is the key denominator in all contemplative or metacognitive traditions (Yoga, meditation, mindfulness, mentalizations): attentive observation (of self and others) plays a key part in this. Similarly, compassion and empathy are the key qualities in a meditator. Human beings are social creatures, and empathy helps create and maintain social bonds in them by enabling people to comprehend, share, and respond appropriately to others’ emotional states (Decety and Jackson 2004). Simply put, empathy means to put oneself in others shoes in order to understand other’s experience. Compassion (Pali. karuna) is the basis of this phenomenon. Empathy involves understanding the reasons for the other’s emotions as well as mental state attribution in the sense of fully adopting the other’s perspective. This involves active and imaginative representations of shared experience. Because empathy is essentially a phenomenon of connection between two people based on shared emotional experiences, in the process of empathy, a critical task is to represent the minds of other persons within one’s own mind (otherwise called mentalization).

6.1.1 Empathy and Compassion: Phenomenology and Roots in the Four Noble Truths of Buddha

Empathizing is the drive to identify another person’s emotions and thoughts and to respond to them with an appropriate emotion. True empathy must have subject–object differentiation with respect to the emotion in question. This process involved incorporation of attention by which the attended perception of the object’s emotional state automatically activates the subject’s representation of that state (Preston and de Waal 2002, p. 4). Sympathy is a precursor of empathy but lacks the subject–object differentiation essential for true empathy. Multiple models of empathy point to three major components: (i) congruent affect with the target individual, (ii) perspective-taking (imaging oneself in other’s situation), and (iii) prosocial motivation to help the target individual (Zaki and Ochsner 2012). Because empathy is essentially a phenomenon of connection between two people based on shared emotional experiences, in the process of empathy, a critical task is to represent the minds of other persons within one’s own mind (otherwise called mentalization). We perceive the existence of mind through our thoughts, feelings, and perceptions; without them we can’t experience the existence of the mind. These thoughts, feelings, and perceptions are essentially generated in the brain which is the organ of mind. Let’s consider a situation where person A is being empathic to person B. This process is as follows: to person A, the perception of person B’s mind is introjections of person B’s brain processes into the subjective and interpersonal space of person A. The basic interactional process between these two people awakens emotional activity, both positive and negative, within each other. When the emotions and feelings generate a connection based on shared (positive) emotional experiences, the result is positive empathy. Interpreting the actions of others requires the development of explanatory constructs that define people’s behavior within the patient’s sphere of interactions. These constructs can be experiential, rational, or both. In the process of empathizing, one person understands the nature of the other person by accessing memories of similar experiences as well as by applying theoretical concepts (including philosophical concepts) about understanding people.

It is interesting to note that these components including their cognitive–emotive aspects are found in the basic teachings of the Buddha, including in the Four Noble Truths. In the scheme of the Four Noble Truths, compassion is developed by the realizing of the first two steps (steps a and b, as described below): (a) recognizing that suffering or pain is universal and can happen to anybody in existence, (b) other’s suffering is my suffering because everything is connected (this is based upon the Buddha’s doctrine of interdependent origination or mutual arising, which tells us that everything is dependent or conditioned on other things: nothing happens in isolation and thus there is no separately existing self in the universe), and (c) everything, including suffering, is temporary, is subject to change, and hence can be changed. At the same time pleasure is also temporary and so there is no need to cling to the pleasures in life. This third step tells that because of the non-permanence of experiences, non-compassion or non-empathic experiences can be changed too; compassion and empathy can be developed in individuals who lack them. This gives rise to the solution for non-compassion and non-empathy and that solution itself is nothing other than the fourth and final part of the Four Noble Truths. The solution (fourth Noble Truth) says that liberation [Pali: nibbana, Sanskrit: nirvana] or release from suffering is possible by ending the clinging to the false sense of self (called the misidentified self in the Upanishads) that ordinary mind usually holds. This getting rid of the clinging is otherwise called dispassion or renunciation in the Patanjalian scheme. Thus, according to Buddha and Patanjali, the solutions are embedded in the Noble Eightfold Path and in the Eight-Limbed Yoga (Sanskrit: Ashtanga), respectively.

6.2 Meditation Is Part of Yoga and Mindfulness Is a Type of Meditation

The terms Yoga and meditation are not the same. Two Google searches done by this author in March 2013 putting the search word yoga and meditation generated 383,000,000 and 146,000,000 hits, respectively. This corroborates with the scriptural notions that Yoga is much broader than meditation and as a system is inclusive of meditation. Concepts in the broad rubric of Yoga include body, mind, soul, as well as the metaphysical and cosmological expositions of the universe as a whole, whereas the concept of meditation is mostly about the individual’s (Sans. jiva) mind. In the Eight-Limbed Yoga practice (Ashtanga Yoga) of Patanjali, meditation proper are the 6th and 7th steps. Historically, it seems that the term Yoga has been used earlier than the term meditation. Meditation is fundamentally a cognitive–emotive process that involves learning to shift and focus the attention at will onto an object of choice, such as bodily feelings or an emotional experience, while disengaging from usual conditioned reactivity or elaborative processing. Broadly there are two types of meditation: (a) concentrative (centering of consciousness; Pali: samatha, Sanskrit: dharana or anchorage) type where a focused attentiveness is developed and (b) mindfulness (insight) type (Pali: satipatthana, Sanskrit: dhyana, Burmese: vipassana, Japanese: Zen) which that focuses on present and involves holding, experiencing, and monitoring the mental objects in one’s awareness, as they are, in that moment. In an important distinction, Epstein (1990, p. 164) separates concentration from mindfulness and further explains: “The concentration practices emphasize one-pointedness or absorption….. The mindfulness practices, on the other hand, require moment-to-moment attention to changing objects of awareness and lead to examination of the subjective sense of I. In dynamic terms, this can be expressed as investigation of the self-representations (in one’s mind)….” So, one can see clearly that meditation is a part of the broader system of Yoga and mindfulness is actually a type of meditation. Concentrative meditation, otherwise called the meditative absorption, serves as a prerequisite for mindfulness meditation and provides the concentrative power (directed attention in the field of awareness) to mind for the subsequent mindfulness meditation (uniformly distributed attention in the field of awareness). To practice mindfulness is to become grounded in the present moment; one’s role is simply as observer of the arising and passing away of experience. In this, one does not judge the experiences and thoughts, nor do they try to figure things out and draw conclusions, or change anything—the challenge during mindfulness is to simply register the mental events and observe them rather than elaborate them. As one can see here, Yoga, meditation, and mindfulness are three overarching circles in the broad scheme of Yoga.

6.3 What Is Mindfulness?

Mindfulness is defined as keeping one’s consciousness alive to the present reality (Hahn 1976). As mentioned before, mindfulness is understood as an attentive observation and is regarded as one of the two traditionally identified forms of meditative practice. Kabat-Zinn (1990) operationally defines mindfulness as the intentionally focused awareness of one’s immediate experience from moment to moment, in a nonjudgmental manner, as if this is the only moment one has got in his/her life. The experience is one of a moment-by-moment attention to thoughts, emotions, physical sensations, and surroundings. Mindfulness is the process and insight is the result. So this type of meditation is also called as insight meditation (Buddhist: Vipassana). Meditation is fundamentally a cognitive process that involves learning to shift and focus the attention at will onto an object of choice, such as bodily feelings or an emotional experience, while disengaging from usual conditioned reactivity or elaborative processing. Mindfulness meditation is a cognitive processing, in which thoughts are observed as just thoughts rather than considering them as real experiences. As compared to the concentrative meditation, in mindfulness meditation, one’s attention is purposefully kept broader, utilizing a more open and fluid focus but without engaging analytical thought or analysis. Mindfulness meditation may utilize any object of attention—whether an emotion, the breath, a physical feeling, an image, or an external object—such that there is more flexibility in the object of awareness than there is in concentrative meditation and such that the object may shift from moment to moment. Mindfulness meditation involves the cultivation of flexible attention as well as moment-to-moment, nonjudgmental awareness of one’s present experience, whether narrowly or more broadly focused. The goal of these practices is to cultivate a stable and nonreactive awareness of one’s internal (e.g., cognitive–affective–sensory) and external (social–environmental) experiences. Therefore, it can be argued that it is the development of stable attention and nonjudgmental awareness that mediates the much wider range of effects, including physical relaxation, emotional balance, behavioral regulation, and changes in self-judgment, self-awareness, and relationship to others.

Mindfulness has been conceptualized in a two-component model (Bishop et al. 2004): (a) the component of attention regulation and (b) the component of acceptance and openness to one’s experience.

6.3.1 How Right Mindfulness (Satipatthana) Gives Rise to the Insights (Vipassana) and Subsequent Liberation (Nibbana)?

In discussing the technicalities of meditation, it is important to understand that during the transition points from one jhana (meditative access state) to another, mind is supple and receptive rather than reactive and thus these entry and exist points between the jhanas serve as the fertile moments for meditative insight to become ripen. In the satipatthana meditation, the mindful observations of mental events by the meditator give rise to a series of realizations about the nature and workings of human mind in his/her experience. With these realizations, mindfulness matures into insight (vipassana). The practice of insight begins at the point when mindfulness continues when the meditating mind and the object of meditation arise together in one’s filed of awareness in unbroken succession without any lag (similar to the process of knowing by fusing method in the Patanjalian samyama as described in Chap. 3). This point marked by the continuity or lack of lag in one’s experience heralds the beginning of a chain of insights about mind knowing what it is doing in a moment-to-moment manner. In the sequential process of obtaining insight, the first realization is that the mental events (the phenomena) are distinct from the mind (creator of the phenomena) contemplating them. Of note, this knowledge is not just at the verbal or intellectual level; rather the meditator knows (in the sense of realizing in one’s daily life) this: each ensuing realization is a direct experience; there may not be words for this realization. Continuing to practice the vipassana, the meditator sees the whole field of awareness in a continuous flux (rather than fragmented snap shots). The meditator realizes that the world of reality is renewed at every moment in an endless chain and that the mental phenomena or mental events, like soap bubbles, arise and pass away at each moment. Because the inherent nature of these events (both good and bad, positive, as well as negative events) is to constantly change, these cannot be the basis for any lasting satisfaction and hence not worth clinging to. This is the realization of the truth of impermanence (Pali. anicca) to develop equanimity (equal or undistorted vision to all objects in one’s awareness) which along with bare attention, mindful detachment, and phenomenological analysis of experience (in terms of aggregates) leads to the realizations that one’s private reality too is devoid of self (Pali. anatta; Sans. anatma; nonself) and is ever changing which leads to states of further detachments (and de-identification) from the world of experience. From these detached (mindfulness) perspectives, the impermanent and impersonal qualities of the meditator’s mind lead him/her to see it as a source of suffering (Pali. dukkha) which leads to further detachments and de-identifications from mind, its contents, and conditionings.

As succinctly elaborated by Santina (1997), in Buddhism, the realization of nibbana is achieved through combining (joining) the meditation with the meditative insight or wisdom [Pali. panna, nanna] that is the by-product of the meditative process. To develop insight, the meditator applies the two Abhidhammic methods of analysis and synthesis: (i) analytical method (based on the doctrine of impermanence) for examination of consciousness (mind) and its object—in other words, mind and matter—and (ii) the synthetic/relational method (based on the doctrine of interdependence) by considering the causes and the conditions of our personal existence. Insight or wisdom is further developed through applying these two Abhidhammic methods by dissecting internal and external, mental, and physical phenomena and examining them in relation to their causes and conditions. Through the analytic method, one arrives at the realization that what was previously taken to be a homogeneous, unitary, and substantial phenomenon is in fact composed of individual elements, all of which are impermanent and in a constant state of flux. On the other hand, the synthetic method, by considering the causes and the conditions of our personal existence, reveals the interdependence/interrelations between the factors that causes the existence of us as psychophysical entities and thus enlightens us that nothing happens in isolation, everything is interdependent. These analytical and relational investigations reveal three interrelated, universal characteristics of existence: (i) impermanence, (ii) suffering, and (iii) nonself. Realizations of these three in one’s daily life (according to Buddha, the whole life is a meditation) leads to the three doors of liberation: (i) the door of signlessness (results from contemplating the characteristics of impermanence and thus de-identifications), (ii) the door of wishlessness or freedom from desire (results from contemplating the characteristics of suffering), and (iii) the door of emptiness/sunyata (results from contemplating the characteristics of nonself). These three doors of liberation are the culmination of meditation on the three universal characteristics. At their highest extremes, the path of concentration [Pali. samatha, bare attention) through the jhanas and the path of insight to realization of nibbana tend to meet. A meditator who could marshal enough one-pointedness to attain the formless jhanas (equivalent to Patanjalian nirbija samadhi) might easily enter the liberated state (nibbana or moksha) should he/she choose to turn his/her powerful concentration to watching his/her own mind. Subsequently one gradually progresses through the four stages of enlightenment and eventually becomes liberated from this life, from the cycle of birth and death, and is no longer reborn.

6.4 Mentalization

Mentalization is a psychological concept and simply means holding mind in mind. It is defined as the ability to attend to mental states in self and others and interpreting behavior accordingly (Fonagy et al. 2002; Fonagy and Bateman 2007). We are mentalizing whenever we’re aware of what’s going on in our minds or someone else’s mind. It has been also defined as seeing yourself from the outside and others from the inside (Allen et al. 2008, p. 3). Mentalizing is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes. The theory of mentalization is rooted in Bowlby’s attachment theory (Fonagy et al. 2002). Mentalization involves unconscious, automatic, and conscious deliberate application of one’s capacity to understand both cognitive and affective aspects of one’s own and others’ mental states. Concept of mentalization emerged in the psychoanalytic literature in the late 1960s, but diversified in the early 1990s when researchers merged it with research on neurobiological deficits that correlate with autism and schizophrenia (Baron-Cohen 1995). The theory of mind (ToM; Premack and Woodruff 1978) that came from research on chimpanzees is the theoretical construct that gave rise to the construct of mentalization. ToM focuses on cognitive development and provides a conceptual framework for mentalizing. ToM is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires, and intentions that are different from one’s own. In this, the individual first appreciates the existence of different mental states in others and then accurately identifies others’ mental states (e.g., motives, beliefs, desires, and feelings) in order to interpret their behavior. ToM is tested by the false-belief task (Wimmer and Perner 1983), which is an experimental paradigm in which children are told a character named Maxi puts a candy bar in a cupboard in the kitchen and then leaves the kitchen, after which his mother comes in and moves the candy bar to a drawer. The child is then asked where Maxi will look for the candy. A child who has developed theory of mind will understand that Maxi falsely believes the chocolate is in the cupboard. A majority of children master this task between 4 and 6 years of age.

6.4.1 Dimensions of Mentalization

Bateman and Fonagy (2004) identify three dimensions of mentalization: (i) the first dimension is related to two modes of functioning (i.e., implicit and explicit), (ii) the second dimension related to two objects (i.e., self and other), and (iii) the third dimension related to two aspects (i.e., cognitive and affective) of both the content and process of mentalizing. Taking turns during a conversation is an example of implicit mentalization where without deliberate reflection, individuals naturally and instinctually hold the mind of their conversation partners in mind, anticipating when the other might want to respond in turn. In contrast, the activities of a psychotherapist during psychotherapy provide an example of explicit mentalization which involves deliberately exercised and conscious imagination of the mental states of the patient. Through mentalizing two friends can come to understand a misunderstanding: this is an example of the two objects (i.e., self and other) aspects of mentalization. The third dimension of the mentalization concept relates to its cognitive and affective aspects in both the content of mentalizing activity (the intentional mental states in oneself and others) and the process of mentalizing. The integration of cognitive and affective aspects of both the process and content of understanding mental states allows individuals to better know and feel the self and objects in the fields of mentalization.

6.4.2 Clarification of Closely Related Terms

Overlaps do exist between the concepts of mentalization and its conceptual cousins: theory of mind, mindfulness, empathy, and psychological mindedness. The basic distinction between theory of mind and mentalization is that the theory of mind is focused on the cognitive aspects in others, whereas metallization is focused on cognitive aspects as well as emotional aspects in both self and others (Allen et al. 2008, p. 48).

Mentalization Versus Mindfulness

Mentalizing is conceptualized as mindfulness of mind (Allen et al. 2008, p. 53). Insight is the mental content that is the product of both the mentalizing process and mindfulness (Allen et al. 2008, p. 41). Mindfulness focuses on the present and on all aspects of one’s mind including thoughts, feelings, and perceptions. The factor analytic studies identify four skills that underpin mindfulness (Baer et al. 2004): (i) observing, (ii) describing, (iii) accepting without judgment, and (iv) acting with awareness. Mindfulness overlaps with mentalization within the observing and describing subscales. Both mindfulness and mentalization involve directing one’s attention to one’s own experience; both also emphasize the integration of cognitive and affective aspects of mental states in encouraging simultaneous recognition and participation in internal experience. However, distinctions are as follows: (i) mindfulness overlaps only with one of the two modes (explicit) and one of the two objects (self) within the mentalization concept; (ii) in mindfulness, one’s own experience involves interacting with inanimate objects too rather than just other people; (iii) the practice of mindfulness is oriented to present experience, while the process of mentalization can concern the past, present, and future; and (iv) finally, mindfulness aims at acceptance of internal experience, whereas mentalization emphasizes the construction of representation and meaning related to these experiences.

Mentalization Versus Empathy

Decety and Jackson (2004) describe empathy (to put oneself in other’s shoes in order to understand other’s experience) as a complex form of psychological inferences in which observation, memory, knowledge, and reasoning are combined to yield insights into the thoughts and feelings of others. Empathy focuses on others and emphasizes the emotional states.

Conceptually, empathy has in common is three parts: (i) an affective reaction that involves sharing of another person’s emotional state, (ii) a cognitive capacity to imagine other people’s perspective (perspective-taking), and (iii) a stable ability to maintain a self–other distinction. The concept of empathy overlaps with mentalization considerably. Both mentalization and empathy involve appreciation of mental states in others; however, empathy is more other oriented while mentalization is equally self and other oriented. Empathy can function in both implicit and explicit modes but is generally regarded in its more implicit mode. Although the process of empathy involves cognitive skill and experience of affect, its content is primarily affectively focused.

Mentalization Versus Psychological Mindedness

Psychological mindedness is understood as a person’s ability to see relationships/links among thoughts, feelings, and actions, with the goal of learning the meanings and causes of one’s own experiences and behavior (Appelbaum 1973). There are several areas of overlap between psychological mindedness and mentalization, for example, in the aspects of intuition and interest in the way minds work. However, mentalization operates both implicitly and explicitly, whereas psychological mindedness primarily concerns explicit or conscious consideration of mental states. Psychological mindedness also concerns the self and one’s own mental states more so than it considers the mental states of others.

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Dec 11, 2016 | Posted by in MUSCULOSKELETAL MEDICINE | Comments Off on Yoga, Mindfulness, and Mentalization: Central Role of Attention and Compassion
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