Dr Marianna Szabó is a clinical psychologist at the University of Sydney who specialises in anxiety and depression, with a particular interest in worry – she wrote her PhD on the topic. She has also studied the history of psychotherapies, the wellbeing of actors and, for many years, mindfulness.
Hungarian-born Szabó's interest in mindfulness started as a teenager, when she was drawn to Eastern philosophies and yoga, and was reignited in her 30s when, while going through a difficult time, she by chance saw a monk speak and reconnected with Buddhism. Now in her early 50s, her personal interest has melded into her work life: she has a small psychological private practice where she uses mindfulness as part of some treatments, lectures on it and, as a Buddhist, meditates daily.
![The modern strain of mindfulness has its DNA in Buddhism. Illustration by Georgia Perry/Jacky Winter Group.](/web/20170413003035im_/http://www.canberratimes.com.au/content/dam/images/g/v/d/b/m/8/image.related.articleLeadwide.620x349.gvd9oe.png/1491639265766.jpg)
"It's part of my research, practice and whole life, which is what most mindfulness practitioners do," Szabó says. "You don't tend to use mindfulness in clinical therapies unless you have a good [meditation] practice yourself."
Mindfulness, which involves paying attention to the present moment in a non-judgmental way, is the latest therapy to sweep psychology. People are mindful through meditation exercises where they focus on body sensations, their breathing or how thoughts wander into their mind. They then learn to not judge what is happening. "Just be" is the mantra.
While some psychologists have adopted aspects of this concept in the therapy room, it has also become widely practised in society in general, with applications running the gamut from the serious to the trivial. Mindfulness is now incorporated into everything from therapy for addiction to leadership and even cooking classes, and taught via eight-week courses, five-minute breathing apps and 10-day retreats. Widely seen as a path to happiness, mindfulness has become, according to US religious scholar David McMahan, "one of these things that can have many meanings and many uses for different people". This has led to Dr Miles Neale, a Buddhist psychotherapist, dubbing it "McMindfulness".
The concept has spread so far that in 2014, the UK parliament set up the Mindfulness All-Party Parliamentary Group to look into it. Following a year of research and eight hearings, it released an extensive report describing mindfulness as an "important innovation in mental health".
But while mindfulness is portrayed as a panacea, to the extent that any criticism of it can feel akin to clubbing a baby seal, even enthusiasts like Szabó admit the clinical proof for its effectiveness isn't quite there yet. "As an individual, I love it, it has helped me through a number of very difficult life circumstances and has changed a lot about me as a person for the better," she says. "At the same time, as a health professional, I would be very careful [about] when to use it in my psychological practice. I am aware of the limited amount of evidence for treating some disorders. It's definitely a great thing – it can help reduce stress and anxiety in everyday life – but I'm concerned about the evidence base not being strong enough before it's packaged and sold."
For thousands of years, therapists have tried all sorts of treatments to heal mental suffering – some merely colourful, others, in retrospect, awful. In ancient Greece, physically and mentally ill patients slept in a holy temple where they were visited by the god Asclepias, who supposedly touched the sick part of their bodies. The next morning, a priest would decode the patients' dreams. In the 18th century, patients in a London hospital were bled and given medications to make them vomit. The hospital, originally known as Bethlem Royal Hospital, later became known as Bedlam, which is now used as a word for madness.
![In the 1700s, Franz Mesmer practised 'mesmerism', inducing trances, in Paris salons.](http://web.archive.org./web/20170413003035im_/http://www.smh.com.au/content/dam/images/g/v/f/a/f/w/image.imgtype.articleLeadwide.620x349.png/1491461905044.png)
In the 1700s, Franz Mesmer practised 'mesmerism', inducing trances, in Paris salons. Photo: Stefano Bianchetti/Getty Images
In 18th-century Paris salons, Franz Mesmer supposedly "mesmerised" people to better mental health by restoring their "animal magnetism", a "universal force" within all humans. At first he used magnets on patients, but later used his hands and a magnetised wand, inducing trances. Though widely considered a charlatan, Mesmer's work helped shape the development of hypnosis, which has evolved over time into a relaxation tool and a way to treat pain. In the 1930s, Italian neurologist Ugo Cerletti discovered electroshock therapy, where an electrical current is passed through the head of an anaesthetised patient. It is still sometimes used for severe depression, though it is not known how or why it works.
Psychotherapy crept into the mainstream after the two world wars to treat traumatised returning soldiers. But with so much money being spent on "talk therapy", particularly in the US, it wasn't long, according to Steven Schwartz in Classic Studies in Abnormal Psychology, before questions started being asked about its efficacy. Psychologist Hans Eysenck first raised the issue in 1952, writing: "Psychoanalysts and psychotherapists generally assert that their methods cure psychoneurotic disorders … Clearly, therefore, it is on them that the onus of proof must rest."
This call for proof eventually led to the sidelining of the work of Sigmund Freud, the great neurologist and psychoanalyst. While his theories about the unconscious, the ego and the id, fixations, sexualised dreams and unresolved baggage dominated until the 1980s, they were difficult to prove. Szabó says people could undergo analysis for years, often daily, without any way of showing that the therapy "worked". (Despite this, there are still practising psychoanalysts with some modernised and shorter psychodynamic therapies seen as having a useful impact.)
You can't dish out mindfulness as a sterile, mechanical manual ... It's not going to work.
Psychiatrist Eng-Kong Tan
As Freudian ideas flourished, behaviourism was slowly developing. First proposed in 1913 by psychologist John Watson in reaction to Freud's couch, it didn't really take off as a therapy until the 1960s. Behaviourism is based on the idea that people can change their negative behaviours through learning experiences. While Szabó says behaviourism has a "massive amount of proof" behind it and still exerts a strong influence on much modern counselling, some aspects gave the concept a bad name and are no longer used, particularly aversion therapy.
As Freud faded and behaviourism rose, a raft of other "schools" with their own styles of treatment bubbled on the side. These included humanism, which focused on love, hope and personal growth, and sociopolitical psychology, which asserted that society was to blame for mental illness. Hypnosis also re-emerged, alongside various relaxation techniques and much more radical treatments, including primal scream therapy and rebirthing breath-work.
But one treatment materialised which has come to dominate: cognitive behaviour therapy, or CBT. While other theorists had been exploring cognition, this particular revolution began in 1976 with the publication of Aaron Beck's Cognitive Therapy and the Emotional Disorders. Beck, a psychotherapist, had observed how depressed patients displayed distorted thinking habits: seeing the worst in any situation; making mountains out of molehills; thinking everything is their fault. By evaluating their thoughts, these patients were able to be more realistic about them. Now the most common psychological practice in Australia, CBT has years of evidence behind it, though not all of it is positive – in 2015, a team of researchers from Norway found that its efficacy in treating depression reduced over time.
Of course, no therapy is 100 per cent effective, not even the widely accepted CBT. The result, says Szabó, herself trained in CBT, was a search for alternatives, one of which was mindfulness. "Whereas CBT takes thoughts seriously – you have this thought and you evaluate it: is it right? Is it wrong? – mindfulness is more about distancing oneself from the thoughts. Thoughts are not a reflection of reality, they are not right or wrong."
![Clinical psychologist Dr Marianna Szabo: 'Meditation is part of my research, practice and whole life,' she says.](http://web.archive.org./web/20170413003035im_/http://www.smh.com.au/content/dam/images/g/v/d/c/0/j/image.imgtype.articleLeadwide.620x349.png/1491288516864.png)
Clinical psychologist Dr Marianna Szabo: 'Meditation is part of my research, practice and whole life,' she says. Photo: Janie Barrett
There are traditions of meditative practice within all the major religions, but the modern strain of mindfulness has its DNA in Buddhism. For centuries, however, Buddhist meditation practices, with a few exceptions, were seldom practised outside a monastery. According to religious scholar David McMahan, it was only when Buddhist countries such as Burma and Sri Lanka were colonised by European powers that monks re-evaluated the place of meditation and began offering it to the laity. "They were worried that [Buddhism] was going to be wiped out by colonisation," says McMahan, professor of religious studies at Franklin & Marshall College in Pennsylvania. "That was the first move for meditation to be widely offered outside monasteries."
Another scholar, Erik Braun, tells the story in The Birth of Insight of a charismatic monk, Ledi Sayadaw, who simplified and standardised meditation and encouraged the masses to practise it in response to the British takeover of Burma in 1885. "For the first time, serious meditation practice became plausible, appealing and even patriotic," he writes.
McMahan explains that the next big shift in mindfulness occurred with the spread of Vipassana meditation by S.N. Goenka, a Burmese-Indian who offered the practice outside of a Buddhist context and said anybody could do it. He set up his first centre in western Indian in 1976, offering 10-day meditation retreats; the practice subsequently spread and there are now more than 170 of these retreats globally, including seven in Australia. Another trend was Zen, which was becoming popular in the West in the 1950s, influenced by the writings of Japanese philosopher D.T. Suzuki.
![University of Massachusetts emeritus professor Jon Kabat-Zinn helped bring mindfulness meditation into the mainstream.](http://web.archive.org./web/20170413003035im_/http://www.smh.com.au/content/dam/images/g/v/f/a/g/4/image.imgtype.articleLeadwide.620x349.png/1491462558658.png)
University of Massachusetts emeritus professor Jon Kabat-Zinn helped bring mindfulness meditation into the mainstream. Photo: D Dipasupil/Getty Images
The next wave began in 1979 when Jon Kabat-Zinn, a molecular biologist working at the University of Massachusetts Medical School who was trained in both Vipassana and Zen, was on a meditation retreat and experienced a 10-second vision. "Why not try to make meditation so commonsensical that anyone could be drawn to it?" he wrote of the experience in a 2011 essay in which he also talked about how he wanted to bring the dharma – generally defined as Buddha's teachings – into the mainstream.
What better place," Kabat-Zinn wrote in the essay, "than a hospital to make the dharma available to people in ways that they might possibly understand it and be inspired by a heartfelt and practical invitation to explore themselves as a complement to their more traditional medical treatment … All this to be undertaken, of course, without ever mentioning the word 'dharma'."
As McMahan says of Kabat-Zinn: "He got people to see it more as a health-related practice, a psychological practice. He did this very consciously, to try to get it more accepted in places like hospitals, to get more scientific research on it, and to get it accepted in businesses and all throughout secular society."
Kabat-Zinn soon recruited chronically ill patients to take part in an eight-week mindfulness-based stress reduction (MBSR) group course at a clinic he'd set up at the hospital. While the meditation was pitched as a secular project, the curriculum was underpinned by Buddhist thought and teachings.
MBSR has a secular equivalent in mindful-based cognitive therapy (MBCT), developed by the UK's Oxford Mindfulness Centre, and is often used in conjunction with other therapies. It has also evolved into a myriad of treatments: relapse prevention, birthing and parenting, self-compassion and elder care. In patients with chronic physical illness, MBSR and MBCT have been found to help with pain, depressive symptoms, anxiety and stress.
But researching the effectiveness of mindfulness meditation in a clinical setting, like a lot of psychology, is complicated. It's very hard to know what people are really doing when they meditate. They could be watching their thoughts or they could be doing something entirely different; teachers have varying levels of training; some patients just can't do it, or they may not be honest about how much "meditation homework" they have done. There are also different forms of meditation: while practitioners of mindfulness and Vipassana focus on one solitary thing, devotees of Transcendental Meditation, a Hindu-based form that was big in the 1970s, chant a mantra. Also, are people benefiting from the meditation or the learning in group classes?
![There is evidence of brain differences in long-term meditators compared to non-meditators.](http://web.archive.org./web/20170413003035im_/http://www.smh.com.au/content/dam/images/g/v/f/a/g/b/image.imgtype.articleLeadwide.620x349.png/1491463058244.png)
There is evidence of brain differences in long-term meditators compared to non-meditators. Photo: Getty Images
While there is a lot of fanfare about the benefits of mindfulness, burrowing into the studies reveals a mixed bag: positive findings with some conceptual and methodological flaws, scientifically sound ones with unexciting outcomes.
In 2014, researchers at Johns Hopkins University in the US looked into more than 1600 papers on the subject and ended up with 47 trials they deemed acceptable. Overall, they found that mindfulness interventions led to moderate improvements in anxiety, depression and pain but there was low evidence of improvement in stress and quality of life. There was also no evidence that meditation programs were better than taking drugs, exercising or other behavioural therapies. Closer to home, a 2016 study by Griffith University and Cancer Council Queensland showed that mindfulness had no benefit for 189 men with advanced prostate cancer.
Where it does show promise is in the area of depression. While the respected Society of Clinical Psychology in the US and the National Institute for Health and Care Excellence in the UK say there is not enough evidence for using mindfulness with most specific psychiatric disorders, the latter has recommended that MBCT be used to help prevent relapses in depression.
Another challenge with the research has been the selective reporting of positive studies, says Zoltan Dienes, professor of experimental psychology at the University of Sussex. He says one explanation for all the positivity is that the people being studied know they are in a mindfulness experiment, so they expect a lot and also know what the experimenter wants. "We need more direct and exact replications of key studies which are pre-registered and guaranteed to be published regardless of outcome," he says.
Freud couldn't scan for the ego and id, but modern researchers can look at what a brain is doing during meditation. Dienes says there is evidence of brain differences in long-term meditators compared to non-meditators (though this may say more about the sort of person who becomes a meditator than the effects of meditation on the brain), as well as some confirmation that eight weeks' training in meditation changes some brain function. He points to the work of US scientist Fadel Zeidan, who has shown that mindfulness engages with a unique set of brain regions depending on how much training a person has done. (Other scientists have called for more rigorous methods to definitively link meditation to an altered brain structure.)
With all the science around mindfulness, Dr Miguel Farias and Catherine Wikholm, British psychologists and authors of The Buddha Pill: Can Meditation Change You?, question why the negatives of meditation are rarely reported. In a recent Lancet article, they point to three recent studies which show that even relatively short treatments can lead to increases in stress and depression and a resurfacing of childhood trauma. One involved 30 in-depth interviews with male meditators in London, which found while meditation was reported as good for wellbeing, a quarter of the interviewees had substantial problems ranging from troubling thoughts that were hard to manage to exacerbated mental health issues. In a few cases, meditators had psychotic episodes.
Farias and Wikholm also question why mindfulness is pitched as a natural human ability, with benefits for everybody, when the reality is that people react so differently to it: some like it, others can't do it, and there can be negative effects. Because there can be "dark nights" – damaging or disturbing meditation experiences – the pair are concerned about mindfulness being taught by those with no training in managing mental health issues.
Margaret Wilson, 82, a psychologist in Bathurst, NSW, says that in nearly 40 years in practice, mindfulness is the "best thing" she has encountered. She runs twice-yearly group meditation classes and says while most of the participants have been referred to her for mood disorders or pain problems, there are others "who just want to learn about meditation. And the changes they report are quite astounding. It makes a difference to the way people are."
Wilson, who spent two weeks training with Kabat-Zinn, believes teachers also need to be practitioners. "It's part of my world," she says. "You can practise in the shower, eating a meal, walking, anything. You can actually, intentionally, be in the moment, be aware of everything that has happened. I would say a lot of therapists don't do that."
Eng-Kong Tan, a psychiatrist at Sydney's Metta Clinic and founding president of the Australian Association of Buddhist Counsellors and Psychotherapists, says another reason mindfulness may not be working in a clinical setting is that it is more than just focusing on the breath. With "layers and layers of meaning", mindfulness also has an ethical foundation. "You can't dish out mindfulness as a sterile, mechanical manual," he says. "Unless mindfulness – call it what you like – is delivered with deep understanding of the client's pain, and attending to the pain with wisdom, compassion, it's not going to work."
Szabó also raises the issue of mindfulness being taught devoid of its philosophical and ethical contexts. "When you look at the big picture of mindfulness, we're talking about things like compassion and doing no harm. So if I teach people to concentrate and better deal with situations that are actually not very compassionate, that's problematic." These ethical concerns stretch to the use of mindfulness in military and corporate settings. At its extreme end, as documented in Brian Victoria's Zen at War, Buddhist leaders in Japan backed the military establishment in the lead-up to World War II, with one, Daiun Sogaku Harada, describing combat meditation as "the king of meditation". More recently, the STRONG Project in the US has found that mindfulness meditation may help soldiers on active duty to be better focused and more prepared for stressful combat situations.
Major corporations and institutions across the country are also offering mindfulness training to executives and staff, with "mindful leadership" particularly popular. As McMahan points out, some would question if it's right for a corporation to have a toxic work environment, where staff are expected to work long hours for no extra pay, or engage in immoral practices, and then offer mindfulness as a way of dealing with it. Then again, he says mindfulness in the workplace may allow some "ground-up resistance" and give people the psychological wherewithal to effect change.
The spread of mindfulness marches on: anecdotally, primary schools offer it to students, local councils to staff, hospitals to patients, small businesses to their workers. All of which is indicative of a society wanting to engage with this ideology and its message of calmness, compassion and peace. But it begs the question: is "just being" always the answer?