Mindfulness' "Religious Effects" and Clinical Ethics

Click here to read the first part of this post on mindfulness' religious origins and informed consent.

Last month in "Therapy and Buddhist Traditions," I explored the question of whether therapists must detail the purportedly Buddhist origins of mindfulness practices in order to obtain informed consent for their use in therapy. But, for some therapists, the real concern is that even those mindfulness-based interventions (MBIs) designed to be not-religious are actually still religious in certain ways. Psychologists like Stephen Stratton argue that this should be explicated to individuals seeking secular psychotherapy or to those who could find mindfulness training dissonant with their religious identities.

There are three main ways that therapists have viewed mindfulness practices to be religious. First, some mindfulness proponents have asserted that even secularized MBIs are, in a certain sense, still authentically Buddhist; that they have the capacity to open up transformative insights in the practitioner, an awakening they have likened to a Buddhist “enlightenment.” At times, proponents have even responded to the criticism that MBIs are a harmful secularization by arguing that they are “trojan horses” for “the dharma” (by which they largely mean essential truths about the nature of reality).

Secondly, some therapists are concerned that even those secularized mindfulness modalities developed to be completely disconnected from Buddhist frameworks still transmit ideas that should be defined as religious. Such ideas include: that sensory perceptions are neither good nor bad and should be responded to non-judgmentally; the assumption that one can gain universal knowledge about human being and reality itself through inwardly-facing practices; etc.

This relates to the third major way that therapeutic mindfulness practices have been described as religious. Mindfulness practitioners have at times self-reported transformative experiences like those mentioned above and described them as “spiritual” in nature. Some therapists have thus named these to be mindfulness’ “religious or spiritual effects” as they listen to practitioners describe major personality changes and total paradigm shifts in how they view the world and their relationship to it.

Mindfulness and Defining Religion

We have waded into an extremely complicated issue here: how to define what is and is not religious. Has someone had a “religious experience” if they say they have realized that their attachment to a permanent sense of self is illusory? Should this be classified as a “religious belief”? If so, this could seem to some a very broad definition of what is religious and, perhaps more importantly, a very narrow definition of what is secular. But if, as some claim, mindfulness training is still fundamentally grounded in a Buddhist path, then perhaps this answers the question for us. If they are Buddhist, doesn’t that mean they are religious? Of course, for those therapists who do still associate mindfulness practices with Buddhist traditions, the vast majority still do not label their practices with the term “religious.” Many deny that “Buddhism” itself is a religion (a debate that dates back to when the English word was first coined) and otherwise tend to speak of mindfulness using the language of “spirituality” which they distinguish as different from religion.

My book, Prescribing the Dharma, is an exploration of the constantly shifting definitions that contemporary communities like psychotherapists hold for terms like “religion,” “secular,” and “spiritual” and the way those definitions can shape our decisions (in this case clinical decisions) on a daily basis. Some of my fellow religious studies scholars assume the authority to adjudicate on which of our ever-expanding myriad definitions of “religion” is superior and then attempt to impose that definition on others. Aside from the fact that such efforts can never truly be successful, I argue that we can be far more helpful by explaining that our definitions of “religion” will always remain in flux because the concept is a social construction, a relatively new idea in human history invented for particular politico-economic purposes. Defining the religious/not-religious is always an expression of power that maintains or subverts certain societal power dynamics (e.g., what is allowed to enter the public sphere, what is already so embedded in the public sphere as to seem unrecognizable, etc.). So the question will always be: what dynamics of power are we reinforcing or challenging when we classify something as religious/not-religious?

Are All Psychotherapies Religious?

A bit more practically speaking, meanwhile, if we are to adopt definitions of religion that would include the worldviews held by mindfulness practitioners (such as the worldview that all living beings are interconnected), then it’s extremely important to remember that the same definitions could equally apply to all psychotherapies. Whether cognitive-behavior therapy, relational psychoanalysis, or transpersonal psychotherapy, all psychotherapies operate with values, commitments, and visions of optimal human functioning. Some may be founded on biological determinism, while others see human beings as essentially good, inclined towards growth. But all psychotherapies are grounded in worldviews about what is most important in human existence and what creates suffering in people’s lives. And psychotherapies are also intended to generate at times radical change. Whether they describe them as “spiritual” experiences or not, many people leave therapy feeling totally transformed, equipped with new meaning-making abilities and an entirely new sense of purpose for their lives.

Many practicing therapists have absorbed this and have thus included it, indeed, in the “informed consent” material of their initial paperwork explaining that, as one generic set of paperwork states, “though psychotherapy may be very beneficial for some individuals, persons contemplating psychotherapy should realize that people frequently make significant changes in their lives in the course of their therapy experience.” My own paperwork for my private practice goes on to further explain the transformative experiences that help-seekers often undergo as a result of therapy, but it does not dictate whether or not those experiences should be defined as religious or spiritual necessarily.

Since talk therapy’s invention, clinicians have deliberated about whether psychotherapy was meant to achieve more or less expansive changes in human beings. There has always been a contingent that saw psychotherapy’s true goal to go beyond symptom reduction or curing illness to include, for example, activating individuals’ “full human potential.” At times doubling as semi-professional religious studies scholars themselves, therapists from Carl Jung to Abraham Maslow to today’s relational-cultural psychologists have compared their visions of the ultimate aims of therapy to those of religious traditions.

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In a Christian-dominant U.S. society, many conservative Christians have long discouraged psychotherapy for just these reasons, warning that it exposes them to unwanted conversion experiences – or a loss of faith that the very first talk therapist, Sigmund Freud, might have viewed as conducive to psychological health. Members of such conservative Christian communities who are still open to psychotherapy would surely want to be informed at least of the above debate about mindfulness practices before consenting to their use in treatment.

Mindfulness, Defining Religion, and Cultural Humility

Freud and those that followed him have held a multiplicity of definitions of religion, psychotherapy, and health itself. And their definitions and valuations fundamentally shape their approaches to mindfulness practices. The mindfulness researchers Shonin, Van Gordon, and Griffiths have suggested that practitioners should “decide whether their primary intention is to provide” a Buddhist or non-religious “attention-based behavioural intervention” and, if it is the former, “it should be made abundantly clear” and, if the latter, “claims that MBIs embody and teach the Dharma should be abandoned.”

But Shonin et al. are operating here with particular definitions of what should be defined as Buddhist, religious, and not-religious. And these definitions could diverge widely from an evangelical Christian’s or, for that matter, those of other psychotherapists. Meanwhile, there are therapists who, based on their own understandings of what is religious, might dismiss concerns about mindfulness and informed consent. Regardless of anyone else’s definitions, they strongly believe that their MBIs are purely secular, biomedical treatment and would be loath to insert uncertainty into the thinking of sufferers – many already prone to worry and anxiety – who otherwise could be helped by them.

Following Freud, some are even wary of triggering a religious rigidity they believe is itself an ultimate source of emotional distress and in need of treatment. Other therapists, meanwhile, would find this stance to be offensive, rife with prejudice; a stance that ignores research demonstrating religiosity’s positive psychological benefits (e.g., is a protective factor against suicidality) and elides the agency of religious help-seekers to determine for themselves what is beneficial to their lives.

What we again see here is the extent to which psychotherapy is inevitably shaped by clinicians’ worldviews and cultural assumptions when working with people from diverse backgrounds. This is why I believe that guidelines around informed consent are less useful for encapsulating the ethical issues at stake here than what is often referred to as “cultural competence” or “cultural humility.” For some decades now, psychotherapists’ various disciplinary bodies (APA, ACA, etc.) have directed clinicians to develop awareness around their own cultural location, privilege, biases, etc. in learning to work with people across areas of difference. And, as we’ve seen (and has been observed by a number of clinicians like Palitsky and Kaplan), issues of cultural humility are clearly at stake in the use of therapeutic mindfulness practices.

Many therapists imagine they adopt a value-free, neutral, and non-directive therapeutic posture driven solely by the goals of the person they are working with. But this is itself a value-laden clinical assessment about what constitutes “best care.” Leaving aside techniques like paradoxical interventions, clinicians regularly “withhold” information in sessions based on the belief that doing so has therapeutic benefit, that it is for an individual’s “own good” (e.g., diagnosing an individual as suffering from addiction, but not yet ready to awaken to this reality and, thus, waiting to disclose the assessment).

In every therapeutic encounter, clinicians prioritize and re-prioritize multiple, at times conflicting, commitments (e.g., to provide expeditious symptom relief, to be sensitive to cultural difference, etc.). I note all of this in the closing pages of Prescribing the Dharma and do not attempt to resolve the ethical quandary of how (or whether) therapists should use mindfulness practices or other elements from Buddhist traditions with individuals from diverse religion-cultural contexts because what should instead be made clear is just how complicated these multilayered matters are. I argue against making totalizing pronouncements on these issues without continual nuance; there is no universal way and truth applicable to all situations at all times.

Of course, this argument too is a values-based claim. But we should always strive to be, yes, “mindfully” aware of this, of the values and assumptions on which we base all of our clinical choices, whether we define those assumptions as religious or not.