A Program in Contemplative Self-Healing

LONGEVITY, REGENERATION, AND OPTIMAL HEALTH

A Program in Contemplative Self-Healing

Stress, Allostasis, and Learning in theIndo-Tibetan Tradition

Joseph Loizzo,a Mary Charlson,b and Janey Petersonc

aAssistant Professor of Clinical Psychiatry, Weill Cornell Center for Complementary andIntegrative Medicine; Adjunct Assistant Professor of Religion, Columbia University

Center for Buddhist Studies; Founder and Director, Nalanda Institute for ContemplativeScience, New York, New York, USA

bProfessor of Medicine and Professor of Complementary and Integrative Medicine,Weill Cornell Medical College, Cornell University, New York, New York, USA

cAssistant Professor of Clinical Epidemiology in Medicine, Assistant Professor of ClinicalEpidemiology in Complementary and Integrative Medicine, and Assistant Professor of

Clinical Epidemiology in Cardiothoracic Surgery, Weill Cornell Medical College,Cornell University, New York, New York, USA

This paper reviews current behavioral health interventions and introduces a self-healingprogram based on the Indo-Tibetan tradition. While most work on behavior changeemphasizes cognition and motivation, this review highlights stress-reactivity as a rate-limiting resistance to learning. Surveying cognitive-behavioral theories, it finds theselimited in modeling stress-reactivity. Reviewing current interventions that addressstress by integrating relaxation, mindfulness, imagery, or movement with cognitive-behavioral education, it attributes their limited effectiveness to the limits of their modelof stress and their strategy of eclectically mixing techniques. Next, the article exploresthe Indic model of stress-cessation and self-healing assumed by mindfulness practice,concluding that it more fully reflects current findings on stress and learning. It reviewsthe theory and practice of mindfulness and of two less known contemplative “vehi-cles” preserved in Tibet, using more advanced techniques and insights better suited tolay lifestyles and secular cultures. It suggests that the Tibetan tradition of integratingall three vehicles of contemplative insight and skill in one self-healing practice shouldmaximize coherence and effectiveness while minimizing confounding variables causedby eclecticism. Finally, the paper introduces an intervention that integrates mindful-ness with techniques of cognitive analysis, affect modulation, motivational imagery,and reinforcing breathing, tailored over centuries into a complete, threefold path ofself-healing. A pilot study of this intervention in women treated for breast and othergynecologic cancers suggests that the whole spectrum of Indo-Tibetan mind/body prac-tices can be readily mastered and effectively used by Westerners to reduce stress andenhance learning and quality of life.

Key words: mindfulness; contemplation; imagery; self-healing; health education;Indo-Tibetan

Address for correspondence: Dr. Joseph Loizzo, Center for Com-plementary and Integrative Medicine, Weill Cornell Medical Col-lege, 1300 York Avenue, Box 46, New York, NY 10065. [email protected]

Background and Significance

The purpose of this paper is twofold:to review current theories and research oncognitive-behavioral health interventions andto introduce a contemplative self-healing pro-gram based on the Indo-Tibetan mind and

Longevity, Regeneration, and Optimal Health: Ann. N.Y. Acad. Sci. 1172: 123–147 (2009).doi: 10.1111/j.1749-6632.2009.04398.x C© 2009 New York Academy of Sciences.

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124 Annals of the New York Academy of Sciences

health science tradition. It presupposes the con-vergence of several lines of research clarifyingthe mechanisms and health effects of mind-set and lifestyle, ranging from the corrosiveeffects of stress-reactive habits to the health-promoting effects of positive outlook, affectand behavior.1–4 As basic stress research showsthe pervasive impact of stress-reactivity inpromoting wear-and-tear on natural systems ofimmunity, tissue healing, regeneration, cogni-tion, motivation, and learning,5–9 clinical re-searchers and health practitioners have begunto look more seriously into techniques of stress-reduction, relaxation, positive motivation, andhealthy behavior change.10–13 This new clini-cal focus on stress-reduction and health edu-cation has been further intensified by conver-gent research in positive health, showing theunexpected effects of positive reinforcementand practice in promoting use-dependent in-creases in immunity, tissue regeneration, neu-ral plasticity, cognition,14–16 motivation, andlearning.17–23 This general shift is illustratedby this volume’s specific focus on the role ofpsychosocial variables like stress or lifestyle onthe wide variations recently observed in hu-man longevity, resilience, and quality of life.Current research in this and related fieldsis increasingly highlighting the deficiency ofconventional healthcare in mobilizing the un-tapped potential for self-healing and optimalhealth.24–32 This gives compelling support torecent efforts at developing effective psychoso-cial, behavioral, and educational interventionsin emerging fields like rehabilitation medicine,preventative medicine, complementary and in-tegrative medicine, mind/body medicine, andpositive health.33–40

This paper surveys current thinking and re-search in this promising area, specifically to ex-plain the limitations of conventional interven-tions and to introduce our efforts to overcomethose limits by adapting time-tested mind/bodytheories and methods from the Indo-Tibetanmedical tradition.41,42

While much of this work on behavior change,including our own, has focused on cognitive

and motivational factors in the adoption of newbehavior,32,43–48 recently we have begun to ex-plore the hypothesis that stress-reactivity actsas a rate-limiting resistance to learning andhealthy life-change.49 Consequently, we havealso been shifting our focus towards the studyof health interventions that include variousmethods to reduce stress and facilitate learn-ing.50 Only one of the NIH Behavior ChangeConsortium (BCC) projects addressed stress asa variable of interest. In the MediterraneanLifestyle Trial, which was designed to help post-menopausal women with type 2 diabetes re-duce cardiovascular risk, stress managementwas conceptualized as a key initial and long-term outcome of the trial. In addition to fo-cusing on eating patterns and physical activity,the Comprehensive Lifestyle Management in-tervention incorporated a stress managementcomponent that included 20 minutes of yoga,15 minutes of progressive deep relaxation tech-niques, 15 minutes of meditation, and 5 min-utes of directed or receptive imagery. However,neither this project, nor any of the other Con-sortium projects, conceptualized stress as a bar-rier to maintaining new behavior change topromote health or prevent disease. We believethat this oversight reveals an important hiddenweakness in cognitive-behavioral and motiva-tional approaches to health behavior changeand its maintenance.

This analysis and the findings of our workin the BCC suggest that addressing perceivedstress versus life learning—not the specifichealth behavior of interest—may be the rate-limiting variable in helping patients initiateand sustain behavioral change over the longterm. In other words, we believe that stress-conditioned resistance is the major barrierto initiating and sustaining health behaviorchange. Moreover, while many in the field havebegun to address this variable, by integrat-ing techniques like relaxation, mindfulness orimagery with cognitive-behavioral health edu-cation,51–57 we believe that the limited effec-tiveness of this strategy reflects the fact thatcognitive-behavioral learning models are not

Loizzo et al.: Contemplative Self-Healing 125

well designed to address the multi-factorial na-ture of stress-reactivity.58 Instead, we favor in-tegrating analytic, social-emotional and behav-ioral insights and skills based on the same Indicmodel of stress-cessation and self-healing as-sumed by mindfulness practice.

Cognitive-Behavioral ModelsInforming Conventional Behavioral

Interventions

Although stress appears to play an im-portant role in determining whether peopleundertake and maintain potentially impor-tant health-related behavior changes,59,60 lit-tle attention has been focused in previous re-search, including our own, on the questionof whether and how stress is a barrier tolearning and adopting new behavior follow-ing illness episodes.61 We believe this reflectsthe theory of mind/body causation assumedin cognitive-behavioral psychology and ther-apy.62–65 First, cognitive-behavioral interven-tions assume a linear, unidirectional model ofthe effects learned habits of thinking have onmood, physiology, and behavior. Typical mod-els portray habitual thinking as triggering acascade of conditioned responses that includeslearned social emotions, learned forms of be-havior, and innate physiologic responses. In-formed by this behaviorist view of mind/bodycausation, researchers exploring the complexpsychobiology of stress depicted it as a “top-down” cascade following the linear stimulus-response model of classical conditioning. Thus,the individual’s distinctive response to a chal-lenge that could cause stress has come to beviewed in cognitive-behavioral terms as a cas-cade of two or more learned habits that madeit more or less likely to trigger the physiology ofthe stress response.46,66,67

The first of these habits, cognitive appraisal,refers to the cognitive assessment of a perceivedstressor as more or less threatening, given theparallel assessment of the individual’s copingcapacity and supports. Appraisal is thought to

reflect a range of learned concepts that shapethe individual’s constructs of self and world, in-cluding age, gender, ethnicity, self-involvement,self-efficacy, socio economic status and socialsupport.68–78 The second habit, affective reaction,refers to the habitual social emotion the indi-vidual has in response to the cognitive appraisalof the stressor and his or her coping capacityand supports. Affective reactions are thought toinclude an individual’s range of learned stress-reactive emotions including anxiety, hostility,shame, helplessness, and hopelessness or de-pression. These emotions are thought to re-flect emotional memory and reaction-patternslearned in previous stressful or traumatic expe-riences, further enhancing the sense of threatand reinforcing a negative cognitive appraisalof self and stressor.70,71,79,80

Stress-reactive emotions are then thoughtto trigger a third phase, the physiological stress

response, which refers to the combinationof innate physiological responses withlearned forms of instinctive, stress-reactivebehaviors. The physiology of the stress re-sponse is thought to include a neurologicallymediated increase in sympathetic arousal inthe autonomic nervous systems, known as thefight-or-flight reaction, as well as chemicallymediated activation of the hypothalamic-pituitary-adrenal axis, leading to the releaseof catecholamines and glucocorticoids thatmobilize all mind/body systems for reflexiveaggressive and/or defensive action.73 Thefinal phase in the conventional model ofthe psychophysiology of stress, often calledadaptation, is the long-term conditioning ofmind and body to the repeated triggeringof this cascade of aversively conditionedcognition, affect, and behavior. Adapta-tion is thought to reinforce the individual’sstereotypical habits of stress-reactivity and isknown to adversely affect multiple aspects ofhealth, aging, and mind/body capacity.81,82

The model of allostatic load developed byMcEwen and colleagues serves as a labo-ratory measure the cumulative effect of thetriggering of the physiological stress response,


viewed as a failure to maintain allostasis ordynamic balance with the challenges posedby a constantly changing natural and socialenvironment.83–87

Limitations of CurrentCognitive-Behavioral Models

and Interventions

While cognitive-behavioral models providea basic framework to understand stress and thestress response, we believe they are incompletefor several reasons. First, this model framesstress reduction reactively, i.e., as a primar-ily outward-focused, problem-specific processprincipally mediated by cognitive variables andstyles. Since its development, however, therehave been major shifts in consensus within cog-nitive science and stress research, where itsconceptual and empirical foundations lie. Ac-cording to the current consensus in cognitivescience, the organization of human behavior isprimarily proactive and mediated by the hier-archical integration of cognitive, affective andbehavioral systems of memory, learning, andadaptation. In addition, stress research hasdemonstrated that stress is a nonspecific, gen-eral response that overwhelmingly represents a(short- or long-term) systems failure in adap-tation at the cognitive, affective, and/or be-havioral levels. Second, cognitive-behavioralmodels rely on a unilinear model of causalsequencing and a dualistic model of mindand body that lead to an underestimation ofthe role of predisposing variables (maladaptivehabits causing allostatic load, and consequentwear and tear) and to a significant dissociationof cognitive mediators of coping from affec-tive and physiological mediators. Third, beingdeeply influenced by the medical model of cog-nitive therapy, cognitive-behavioral models ofstress and learning emphasize the unlearningof pathological habits of stress-reactivity whileneglecting the maladaptative habits endemic inthe population, as well as the potential for pos-itive health through the enhancement of learn-

ing and adaptation above the statistically nor-mal range.

We believe the literature, taken together withour own prior research, points to the criticalrole for an integrated system of stress-reduction,self-healing, and learning enrichment, not onlyin facilitating the adoption of new health be-havior, but also in sustaining and extendinghealthy behavior change over time. Thus, ourrecent research has focused on testing whethera contemplative self-healing program of multi-factorial education designed to overcome stress-conditioned resistance and enhance learningcompetence at multiple mind/body levels ismore effective in achieving long-term behaviorchange than interventions targeted directly atchanging health behaviors from the top down.Unlike cognitive-behavioral models, the inte-grative model of stress and learning assumed byour intervention drawn from the Indo-Tibetanmind science tradition frames stress reductionas a primarily inward-focused, generalized pro-cess mediated equally by cognitive, affectiveand behavioral variables. We believe that thismodel is more consistent with current cogni-tive science and stress research in two impor-tant ways: (1) it approaches human behavioras an active, constructive process of learnedchanges meant to maintain allostatic balance(Skt. svastha) with a changing reality; and (2)it views the distress cycle (sam. sara) as a gen-eral condition of maladaptation (vikr. ti) that re-flects a (short- or long-term) systems failure oflearning and self-regulation at the cognitive, af-fective, and/or behavioral levels (i.e., a failureof allostasis). Second, the integrative model wehave been investigating relies on a reversiblefeedback-loop model of conditioning and de-conditioning sequences and a non-dualistic,circular interaction of mind/body factors (seeFigure 1). Finally, this model views the cycleof stress-reactivity as endemic to the humancondition though exacerbated in the courseof illness, aging, and dying; and it also viewsthis cycle as one of two potential modes ofhuman existence, detailing the possibility andpractical steps by which it can be unlearned


FIGURE 1. How the basic causality of stress is reversed through self-healing.

and replaced with a cycle of healing that leadsto optimal health. Taken together, these as-pects of the Indo-Tibetan model more accu-rately represent the primary role of predispos-ing variables (causing allostatic load) and themutual reinforcement of cognitive, affective,and physiological mediators of maladaptiveversus adaptive behaviors and their respectiveoutcomes.

In practice, the Indo-Tibetan model of mindand health offers not only a more completeand accurate picture of the psychobiology ofstress and healing, but is also better suited to thelearning and maintenance of healthy behaviorchange in a general population. This is in largepart because it is not illness based, but ratheraddressed to helping ordinary individuals tounderstand and face the inexorable stresses ofthe human condition. Faced with the stressfulfacts of life, including the inexorable realities ofillness, aging, and death, most humans feel se-vere stress reflecting a real inability to effectivelyunderstand and respond to such ultimate chal-lenges. This is often exacerbated by cognitive-behavioral interventions based in mainstreamWestern healthcare, which is not only illnessbased in a way that pathologizes normal hu-man experience but is also framed in a quan-titative, mechanistic language that only pro-fessionals can understand. Many women afterundergoing the ordeal of diagnosis and treat-ment of breast cancer, for instance, suffer a sub-

clinical syndrome resembling post-traumaticstress disorder (PTSD).88–93 The common in-clination of research clinicians to treat this con-dition as a disorder or comorbid feature ofan illness episode reflects the bias cognitive-behavioral and psychodynamic therapies sharewith our medical system as a whole. That is, thefailure to acknowledge illness, aging, and deathas existential features of the human condition,rather than alien intrusions to be eliminated,avoided, or denied.

In contrast, the basic model of mind/bodyhealth in the Indo-Tibetan tradition is explic-itly aimed at teaching the individual the skillsand insights necessary to master the humancondition of distress-prone living. Its existen-tial or positive health orientation, language,and methods typically help individuals feelthat they are being empowered to face theenormity of the challenge of resuming lifein the wake of a major illness. This proac-tive focus on the big picture as opposed tothe conventional medical focus on disease spe-cific behavior typically translates into greatersense of coherence, meaning, or calm in in-dividuals participating in contemplative in-terventions from the Indo-Tibetan tradition.Furthermore, these interventions are not justtailored to reduce general stress-reactivity thatmight impede learning, but are also proactivelyequipped with positive health skills and insightsthat facilitate and enhance learning and health.


FIGURE 2. Techniques and insights offer a gradual pathway from stress to healing.

This means that one and the same interven-tion can be designed to help carry an indi-vidual through the initial phase of overcom-ing resistances to healthy behavior change aswell as subsequent phases of maintaining andextending healthy life change into the domainof optimal health.

For most if not all diseases, behavioral and bi-ological risk factors occur simultaneously andrequire multidisciplinary research on integra-tive health, which “is key to developing anunderstanding of how health at the individualand societal level is maintained.”73,94 Integra-tive health is thus a broad framework that en-compasses complex biological, psychological,cultural, and social pathways to health and dis-ease.31,73 Because even transactional cognitive-behavioral models tend to view mind and bodyin terms of linear causal sequences, predispos-ing or synergistic variables like a history oftrauma, anxiety, depression, or addictive dis-orders are seen as more or less independentvariables whose etiology and treatment are notan integral part of an individual’s pattern ofstress-reactivity or resistance to learning andhigher development. We know of no previouswork that has demonstrated the relationshipof perceived stress, learning, and healthy be-havior change, and we know of no previouswork that has attempted to test interventionapproaches designed to influence the mainte-

nance of health behavior change by focusingon reducing the impact of perceived stress onlearning and positive adaptation. In addition,cognitive-behavioral interventions informed bythe unilinear models of conventional medicalresearch and practice tend to approach all indi-viduals with a generic diagnostic mindset andmonolithic prescription of insights and skills.However, each individual has their own pat-tern of mind/body stress-reactivity.75,95,96 Fac-tors such as history of exposure to chronic stressor trauma may condition diverse styles of psy-chophysiologic stress-response.60,76–78,97 Fur-ther, individuals vary widely in deficits and/orstrengths in cognitive and emotional and be-havioral intelligence, affecting their receptiv-ity to different modes of learning and stylesof teaching. Consequently, more effective inter-ventions will also need to integrate a range ofdiverse insights and skills suited to the range ofindividual patterns of reactivity and learning, asdoes the integrated contemplative interventionwe have been studying (see Figure 2).

Recent Mind/Body Interventionsand the Indic Contemplative

Science Tradition

Growing interest in the clinical efficacy ofstress-reducing interventions for a wide range


of medical conditions can be traced to theconvergence in the 1970s of two lines of in-vestigation begun in the 1950s.98,99 By in-tegrating pioneering stress research with thefirst physiological studies of Indian medita-tion, Herbert Benson laid the groundworkfor a new, “mind/body” approach to psy-chosomatic or behavioral medicine.100 Bensonshowed that patients with ischemic heart dis-ease and hypertension seemed to benefit fromlearning a meditation-based method of elicit-ing “the relaxation response.”101,102 Gaining abroader evidence base since the 1980s,74,103–106

mind/body medicine was recognized by theNational Institutes of Health as a promisingnew clinical research field, while meditation-based stress-reduction programs gradually dis-placed hypnosis and biofeedback as the stan-dards in psychosomatic research and prac-tice.107,108

Despite this shift and the growing researchconsensus behind it,41 the conventional wis-dom that mind/body interventions functionlike hypnosis (by simple relaxation and/orsuggestion) continues to limit understandingof meditation-based interventions and to ob-scure their relevance to the critical problemof learned health behavior.109 The clinicalconsensus emerging around the mindfulness-based stress reduction program (MBSR) de-veloped by Jon Kabat-Zinn has helped to fo-cus research into the mechanism and clinicalpotential of such interventions.110–113 Centralto this consensus is a new view of medita-tion as a discipline of attention114 and a newmodel of stress-reduction as a method of fa-cilitating healthy behavior change via the en-hancement of learning.113,115 This model isconsistent with the learning paradigms cur-rent in cognitive neuroscience116 and cog-nitive therapy,63 as well as with classicalIndo-Tibetan views of meditation as a basiceducational method with medical applicationsin self-healing, illness-prevention, and healthyaging.117–119

Conversely, a link between stress-reductionand learning competence also helps to explain

the negative correlation we have observed be-tween stress and behavior change. Individualsunder stress are less likely to risk entertain-ing new ideas or behaviors and more likely toengage in reactive patterns defensively and au-tomatically, without the benefit of higher cog-nitive assessment and innovation or higher so-cial coping behaviors.120,121 Consistent withthis negative correlation is the positive corre-lation between positive stimulation and learn-ing found in studies of the effect of enrichedenvironments on neural plasticity and learningcompetence. It now appears that the combi-nation of stress-reduction and learning enrich-ment is gaining further support from currenthypnosis research, where learning models ofhypnosis are further challenging the conven-tional wisdom that mind/body interventionswork via a placebo-like mechanism involvingrelaxation and suggestion.114,122,123 We believethat the intervention approaches most likely toyield effective reduction of stress-conditionedbehavior, and thus lead to better maintenanceof behavioral change, are those approaches thatutilize what has been learned from emergingresearch on meditation-based stress reductionthat focuses on attention variables and learningcompetence.

In order to appreciate the potential advan-tages of a contemplative approach to learnedbehavior change, we must first consider the lim-itations of previous strategies combining cogni-tive therapy with relaxation techniques and/orsupportive interventions. The new learningparadigm in stress-reduction has fueled a longassociation of mind/body interventions withcognitive therapy.124 Some have gone so faras to integrate mindfulness skills into cognitivetreatments, notably in personality and mooddisorders.51,125–127 The strategy of these inter-ventions is to use mindfulness as an active in-gredient that supports the learning and main-tenance of skills such as cognitive reframing,emotional self-regulation, and social effective-ness by building capacities for objective self-observation, affect tolerance, and presence ofmind.128


Although comparing meditation-basedmethods with cognitive therapy is a helpfulcorrective to hypnosis-based misconceptionsof mind/body methods, remembering theirdifferences is equally important.128 In partic-ular, it helps to recall that cognitive therapymay also be compared with hypnosis in that itcombines “top-down” suggestive methods likethought-replacement with relaxation and/orsupport in ways that replicate the combinationof suggestion and absorption in hypnotherapy.Underlying the surface contrast between thelearning paradigm of cognitive therapy andthe manipulative paradigm of hypnotherapyis a deeper similarity: both were developedto overcome the persistent effects of aversiveconditioning without full knowledge of howthe psychophysiology of stress reinforcessuch negatively conditioned habits at variousmind/body levels.

In contrast, the learning paradigm of Indiancontemplative therapies revolves around a con-templative model of the psychophysiology ofstress (Figure 1), which describes how stress re-inforces aversive conditioning and how heal-ing and learning critically depend on reduc-ing stress and extinguishing cognitive, affective,and behavioral stress-reactivity.129 Althoughnot fully articulated in any Western psychol-ogy,3,130 such an integrative stress-based learn-ing paradigm could account for the limitationsof mind/body interventions observed in recentstudies. One such study of behavior changein patients with heart disease (the ENRICHDtrial) used an intervention combining cognitivetherapy for depression with social support andshowed less depressive symptoms, greater socialties, but no difference in cardiac events.131,132

From the perspective of an integrated stress-learning model, the limitations of such in-terventions may be accounted for by severalfactors.

First, while classical cognitive therapy tar-gets depressive or anxious thought patterns, itneglects self-involvement and other defensivethought patterns that promote stress-reactiveemotions like hostility and clinging.133 While

cognitive therapy teaches skills for modifyingdepressive or anxious thought patterns, it typ-ically does not teach skills for directly modu-lating anger, fear, shame or other stress affectsthemselves.125,134 Second, while social supportin general seems to counter the effects of stress,psychoanalytically oriented individual and/orgroup supports may encourage the “ventila-tion” of negative thoughts and emotions thatreinforce stress-reactivity and inhibit learning,directly or indirectly.135 Third, the variable ef-fects of unstructured social support must be ex-pected even with standard psychiatric interven-tions such as supportive-expressive therapy orclinical support groups, since any interventionsnot structured to systematically reduce stressand promote learning may overlook or unwit-tingly reinforce one or more factors of stress-reactivity and learning-resistance.136

Thus, a meditation-based approach to stressreduction and behavior change represents a sig-nificant innovation in that it offers a promis-ing alternative to the more widely practicedcognitive-behavioral treatments reported in theliterature. However, there is a need to testwhether contemplative approaches that inte-grate cognitive-affective-behavior learning aremore effective by helping to teach patients howto reduce stress-conditioned resistance and en-hance learning and behavior change than anintervention explicitly designed to motivate be-havior changes piecemeal.

A more current strategy under study by someresearchers is combining cognitive therapy withmindfulness-based stress-reduction rather thanwith relaxation or support.133 Patients learnabout the basic discipline of attention andabout impact of stress on the mind and body.Breathing exercises involving deep abdominaland slow breathing helps to deepen relaxationand facilitates receptivity to learning. Thenpatients are introduced to advanced practicesincluding cognitive reframing in order to al-ter stress reactive thinking and learn how notto identify with negative thinking or emotion.They learn not to imagine the worst, enhancingthe threat of everything. They learn to override


a stress reactive imagination. In some interven-tions, patients then learn to increase positiveemotions through imagery and visualization.

Behavioral interventions even include skills-learning programs for interpersonal effective-ness, emotion regulation, and distress toler-ance.125,137 While pilot studies so far have foundsuch hybrid interventions as or more successfulthan conventional modalities,138,139 in the ab-sence of full-scale randomized controlled trialsit is unclear to what extent they have resolvedinternal contradictions and overcome limita-tions caused by mixing conflicting paradigmsand methods.140 One such intervention basedon the pioneering work of Masha Linehan, di-alectical behavior therapy (DBT) tries to hy-bridize a biological disease model of borderlinepersonality disorder with a cognitive therapymodel of desensitization; Western philosophi-cal models of dialectical thinking with Buddhisttheories of relativity and interdependence; andmindfulness skills aimed at a general stress re-sponse with psycho-education aimed at disease-specific psychopathology.125 Another hybrid in-tervention developed by Teasdale and others,mindfulness-based cognitive therapy (MBCT)uses mindfulness to build more objective self-awareness or metacognition, enhancing the ef-fectiveness of conventional cognitive therapyfor depression. Other examples of eclectic in-terventions are common in mind/body medi-cal research and practice.52,53,126,141 As we seeit the next challenge is to develop and/or adaptinterventions whose assumptions and methodsare as coherent as possible.128 This should min-imize confounding variables internal to thoseinterventions and maximize their effectivenessand research transparency.

While it is commonly assumed that thereis a large literature on the impact of stress-management programs, in fact there is remark-ably little empirical data. Several small tri-als evaluating the impact of mindfulness-basedstress reduction techniques have shown thatdaily hassles and overall psychological distresswere significantly reduced.54,55,112,142 A sys-tematic review of studies of mindfulness-based

stress reduction demonstrated that the sample-size weighted mean effect size was 0.59. Thestandard error of the effect size estimate was0.41.128 Another of our aims in drawing on theIndo-Tibetan tradition is to build on its manyadvantages as a standardized, text-based tra-dition of academic medicine and psychology.The extensive methods of educating and train-ing expert practitioners as well as educating thegeneral public will no doubt facilitate the workof making interventions more reproducible aswell as more effective and widely applicable.

The Theory and Practice ofContemplative Self-Healing

Interventions

The contemplative self-healing program wehave been studying has been designed to meetthese challenges. Rather than mix mindfulnesspractice with Western medical techniques ofcognitive therapy, dynamic therapy, hypnother-apy, or guided imagery, our intervention inte-grates mindfulness with techniques of cogni-tive analysis, affect modulation, motivationalimagery, and reinforcing breathing that havebeen designed and tailored over thousands ofyears to complement and advance the contem-plative science of self-healing and mindfulnesspractice. Extending the work of pioneers in-fluenced by the Hindu Yoga, Theravada Bud-dhist, and Zen Buddhist traditions, it drawson the West’s more recent encounter with thecivilization of Tibet, which preserved the In-dian mind and health sciences in their mostcomplete and advanced form, as refined in theworld’s first university at Nalanda.143 Ratherthan teaching mindfulness alone or mixingit with the distinct paradigms and methodsof cognitive therapy or dynamic therapy, ourintervention exploits the fact that the Indo-Tibetan mind and health science tradition pre-serves what may be the world’s most completecontemplative system of cognitive-affective-behavioral stress-cessation and learning enrich-ment, including three complementary systems


of mind/body methods designed to overcomestress-conditioned resistances to healthy behav-ior change. While prior interventions extractedmindfulness from its niche within the con-tinuing, multidisciplinary curriculum of Indo-Tibetan health education, our interventiondraws on all three core disciplines of that cur-riculum and integrates the preliminary systemof mindfulness practice with intermediate andadvanced systems of contemplative practiceaimed at initiating and maintaining cognitive-affective-behavioral change.

The theory underlying contemplative stress-cessation, self-healing, and optimal health inthe Indo-Tibetan tradition is defined in the fournoble truths (caturaryasatya), the basic frame-work of all Buddhist learning, science, and civ-ilization.124 According to the first two truths—suffering and origin—the basic condition of hu-man life is one of preventable stress and distress(duhkha) whose origin lies in a causal cycle madeup of twelve mutually reinforcing mind/bodyfactors. The cycle is rooted in two evolution-ary predisposing factors called misknowledge(avidya) or self-involvement (atmagraha) and un-healthy emotion (akusala-samskara) or addic-tive emotion (klis. t.a-samskara). These predispos-ing factors then condition the development ofself-consciousness and perception in a way thatpromotes stress-reactive experience and moti-vation as well as stereotyped, compulsive be-havior and life. Thus, the Indo-Tibetan modelanticipates the findings of contemporary stressresearch, by distinguishing cognitive, affectiveand behavioral aspects of stress-reactivity. Itrefines and expands on current models byidentifying two key predisposing variables thatserve as root causes of stress and learningresistance. And it also breaks down each gen-eral phase into several steps, further clari-fying the multiple factors reinforcing stress-driven behavior and lifestyles. Finally, itexpands the scope of current models in boththe macroscopic and microscopic dimensions,by showing how the basic human condition ofmisknowledge-conditioned development oper-ates within three different time frames, that is:

generations, within lifetimes and from momentto moment.

According to the crucial third and fourthtruths—extinction and path—Shakyamunilearned that this causal cycle could bechanged/reversed into a cycle of healing andlearning in which realistic self-knowledge, pos-itive motivation, and healing virtues gradu-ally generate a life of optimal peace, freedom,longevity, and happiness. Equal in importanceyet opposite in direction to the second truth oforigin, the fourth truth of extinction describesthe fruit of his journey of contemplation: a circleof healing and learning in which the mind andbody are gradually freed of learned distress-habits as well as the innate instincts of stress andviolence underlying them. Thus the four nobletruth framework of Indic mind/body practicesrevolves around the psychobiological model ofstress-reactivity and stress-cessation spelled outin the second and third truths, which describehow distress-prone thinking, feeling, and ac-tion reinforce suffering and how healing andlearning depend on eliminating distress andpromoting health by replacing stress-reactivityand its causes with self-healing and its causes(Figure 1).

Although Figure 1 numbers each factor anddepicts the link between factors as linear andunidirectional, this is mainly for ease of pre-sentation. Both the distress cycle and the heal-ing circle are understood as highly dynamicand interactive processes which can be seenas operating in many different biological timeframes, from the intergenerational frame of re-production and development, to the one-lifeframe of individual development, and the “sub-tle” frame of moment-to-moment reinforce-ment versus plasticity and learning. Likewise,each factor is understood as involved in a dy-namic, reversible equilibrium with its neigh-bors and through them with all other factorsin the cycle. This complex dynamic process ofmind/body causality is thus not too “loose”to explain regularities but not too “tight” topreclude learning, hence its name, “dependentorigination” (pratityasamutpada). This highly


dynamic, interactive view of mind/body cau-sation is what lays the foundation for recog-nizing the binary potential of human learningand development discovered by the Shakya-muni.144 Anticipating current notions of self-regulation (yogacara) and use-dependent plas-ticity (prasrabdi), this basic model supports thelinkage between stress and learning, compul-sive reactivity and positive health, that is keyto the explanatory elegance and power of thefour truth framework. Hence, this sophisti-cated view of mind/body causation helps tomake the Indo-Tibetan model both more ac-curate and complete than current cognitive-behavioral models.

Most important to understanding the prac-tice of self-healing in this tradition is the fourthtruth of the path that links the basic condi-tion of suffering to the fruitional condition ofoptimal well-being.145 The truth of the pathspells out eight steps towards self-healing thatmay be simplified into three synergistic disci-plines of reeducation: wisdom (prajna), medita-tion (samadhi), and ethics (sila). Meditation aimsat developing conscious regulation of the work-ings of the mind, nervous system, and phys-iology through control of attention, concen-tration, breathing, and posture. Wisdom aimsat clear and objective knowledge of realitythrough analysis that helps the mind expose andreform unrealistic, self-involved views. Ethicsaims at developing skilled actions that are ef-fective in achieving personal and social aimslike well-being, freedom, and happiness. Takentogether, the third and fourth truths trans-form the basic science of the first two truthsinto a positive framework of stress-cessation,self-healing, and optimal health, by describ-ing the natural human potential for self-healingthat reverses the cycle of stress-prone living aswell as the complete gradual path of unlearn-ing and relearning that helps ordinary indi-viduals access that self-transcendent potential(tathagata-garbha).

The path is often further simplified into adual format combining wisdom or insight withcontemplative-ethical technique (upaya). Prac-

tically, the path of contemplative self-healing isnot limited to stress-reduction but specificallytargets each of the twelve factors of distress withspecific insights and techniques that systemati-cally foster the unlearning of distress factors andthe enriched learning of positive health factors.

As mapped in the global framework ofmind/body practices outlined elsewhere144 (seeTable 1), the four noble truths leading to per-sonal freedom were later enhanced by theaddition of two other “vehicles” for travelingthe contemplative path using techniques andinsights better suited to the conditions of sec-ular society and culture. The techniques andinsights of the first vehicle of practice, inte-grated in current interventions like MBSR,DBT, and MBCT, focus on mindfulness andrenunciation of personal distress and compul-sive habits. Those of the second vehicle, mini-mally addressed by current mindfulness inter-ventions, focus on self-transcendent insight andempathic skill to transform stress-driven socialperceptions and emotions. Those of the finalvehicle, only integrated in our intervention, fo-cus on developing the vision and inspirationto reshape a stress-driven cultural form of life.Key to the development of this complex cur-riculum were the monastic universities of clas-sical India exemplified by Nalanda, commit-ted to making contemplative arts and sciencesavailable to the secular and lay communities ofIndia. Tibetans adopted the Nalanda traditionof combining all three vehicles into a gradualpath (Skt. pathakrama, Tib. lam rim) tailored tothe demands of teaching contemplative self-healing to lay people in a highly active, secularculture.146

Table 1 outlines this comprehensive tradi-tion of integrating all three vehicles of practice,mapping the practices following a cross-cultural matching of the esoteric integral pro-cess (yoga tantra) map of the nervous systemwith modern triune maps developed by Freud,Panksepp, and others. In addition, it maps theway in which Indic models and methods an-ticipated and expand on the current model ofallostatic load, by describing the effects of stress


TABLE

1.

Com

para

tive

psyc

hone

ural

map

ofst

ress

-red

uctio

nan

dle

arni

ngen

rich

men

t

Prac

tice

phas

eN

eura

llev

elM

enta

llev

elB

lock

s(d

rag)

Aid

s(li

ft)M

otiv

e/In

tent

Aro

usal

/Att

entio

nSk

illle

vel

Insi

ghtl

evel

Pers

onal

care

Coa

rse/

Cor

tical

Wak

ing/

Fant

asy

Tra

umat

icFo

cus/

Ref

ocus

Rel

ief/

Rel

ease

Low

/Inc

lusi

veR

eflec

tion/

Ana

lytic

/Ges

talt

cogn

ition

Min

dful

ness

Soci

alco

ncer

nSu

btle

/Lim

bic

Day

drea

m/

Tra

umat

icD

isci

plin

eC

are/

Con

cern

Low

/Exc

lusi

veA

lert

ness

/Effo

rtIm

agin

al/V

isce

ral

Dre

amin

gaf

fect

calm

Proc

ess

inte

grity

Subt

lest

/Cor

eO

rgas

m/S

leep

Stre

ssin

stin

cts

Mas

tery

/Flo

wJo

y/M

aste

ryH

igh/

Inte

gral

Dev

otio

n/F

low

Eup

hori

c/E

csta

tic in terms of the accumulation of negative en-ergies (pran. a) and drops (bindu) and by linkingthese to the stress-reactive cognition, affect andinstincts that pose blocks (avaran. a) to learning, aswell as to the contemplative aids or powers (bala)that help overcome those blocks. Elsewhere,144

we have argued that these blocks and aids maybe conceptualized as allostatic resistance or drag

versus allostatic facilitation or lift, respectively.In terms of clinical application, our contem-

plative intervention translates the gradual pathmethods from the Nalanda tradition into a se-ries of eight skills or techniques and twelve in-sights or strategies for healthy change, all tai-lored to the needs of mainstream Westerners(Figure 2). The skill sets and insights are taughtin a 20-week contemplative learning programand range across all three phases of the con-tinuum of mind/body practices mapped in aglobal framework of mind/body practices. Theprogram introduces this comprehensive systemin two modules: 8 initial weekly group classesfocus on teaching meditative techniques or skillsets; and another 12 weekly classes focus onteaching contemplative insights and lifestyles.Outside of the structured 90 minute classes,which combine lecture and discussion with ex-periential learning exercises, homework con-sists of daily practice guided by meditation CD’sand by structured manuals. Taught in adaptedTibetan style, individuals learn insights andskills suited to various needs of daily living sothat they can use the ideas and tools best suitedto the complex and varied challenges of theirlife in the world.

In the first 8 weeks, three contemplativetechniques are introduced. The discipline ofcombining stable open-mindedness withheightened attention is the basic skill set ofmindfulness. This is complemented by an in-termediate level skill set of social-emotionalself-care called mind-clearing or mind-training(Skt. buddhisoddhana, Tib. blo-byong), meant tohelp participants protect their self-healing prac-tice from the social stresses of everyday life.Finally, visualization, affirmation, and deepbreathing are taught as an advanced skill


set called the action or performance process(Skt. kriya-carya-tantra, Tib. bya-spyod-rgyud ) toenrich and speed the learning of contem-plative insights and healthy lifestyle changes.In the second, 12-week module on lifelongstress-cessation and optimal learning, all threeskills are combined to speed the mastery ofcontemplative insights and lifestyles as wellas to help students integrate them througha multi-dimensional visualization-based con-templative learning practice that influencescognition, emotion, physiology, and activitysynergistically.

The techniques all involve the intensifica-tion, stabilization, and effective deploymentof attention to expose and reform automaticlearned habits of mind, body, emotion, and ac-tion as well as the innate instinctual programsunderlying them. The insights direct attentiontowards the discrimination of unhealthy habitsand the conceptual understanding and experi-ential learning of healthy alternatives.

The results of a pilot study of this interven-tion in 46 women recently treated for breastcancer and other gynecologic cancers sug-gest that the whole spectrum of Indo-Tibetanmind/body practices can be readily masteredand effectively used by contemporary Western-ers to reduce stress and optimize learning andquality of life.50 The study suggests that an in-tegrated program of contemplative self-healingmay be effective in reducing the distress and dis-ability experienced by women who have beentreated for breast or gynecologic cancer. Ourfindings indicate that the intervention improvesoverall well-being, as well as emotional well-being and function, as measured by scales de-signed to assess quality of life in cancer patients.This intervention was associated with reducedangst and increased coping using fighting spirit-positive orientation. Changes in quality of lifewere correlated with changes in biological mea-sures known to be reflective of stress, includ-ing cortisol levels, lymphocyte subtypes, andnatural killer cells. The magnitude of within-patient difference is greater than that reportedin other studies and is equaled by only one

other methodologically rigorous trial in breastcancer patients. That trial evaluated a 15-weekprogram of three times a week aerobic exerciseversus a control group. It is, however, extremelydifficult to get patients to engage in or sustainthis level of aerobic exercise; and less intensephysical activity has not been effective in im-proving quality of life in women with cancer.

Finally, although this integrated contempla-tive intervention builds on Indian and Tibetancultural traditions and practices, and teachesskills and insights based on the tradition, itdoes not require patients to adopt alien ideasor beliefs. If it did, it would have limited appli-cability. In fact the intervention was designedand refined to make the most effective methodsof contemplative learning available to lay andsecular communities. The acceptability of theintervention was clear in the qualitative com-ments of the patients who participated.

Conclusion

Given the interest we all have in recoveringfrom and preventing disease while enhancinghealth, longevity, and quality of life, the im-portance of the interventions discussed in thispaper should be obvious. Also clear from ourreview of the field is that this is a crucial timefor complementary medical research, when theimportance of behavioral health is being re-inforced by encouraging findings in many ar-eas. This paper draws attention to the possibil-ity that a promising new field may be furtheradvanced by contact with a time-tested non-Western scientific tradition of reducing stressand promoting optimal learning and health.The very fact that this may be true raises anumber of complex issues of methodology. Per-haps most crucial, it challenges our precon-ceived bias that no human system of knowledgeor expertise other than modern Western sci-ence and technology can possibly offer a com-plementary science: a coherent, reproduciblesystem of alternative theories and meth-ods that complements those of conventionalbiomedicine.42 Since these complex issues have


been more fully explored elsewhere,143 here itmust suffice to say that the distance in the-ories and methods between Western behav-ioral science and Indo-Tibetan contemplativescience is not as great as we had imagined.Growing access to a comprehensive array oftraditional methods for teaching contempla-tive theories and practices of optimal healthto experts and the general public raises thepossibility of more effective, reproducible in-terventions in complementary medicine,49–51

mind/body medicine,147–149 public health, andeducation.142 In particular, the Tibetan tradi-tion is unique in preserving what may be theworld’s most rigorous and comprehensive sys-tems for optimizing mental functioning as wellas quality of living, aging, and dying.42 Mostintriguing is the fact that these systems includeways of teaching a variety of individuals of dif-ferent inclinations and temperaments a varietyof methods suited to a variety of sustainablelifestyles.

The next steps are to establish the effective-ness of this intervention in a full randomizedbreast cancer trial as well as in other promis-ing clinical areas, such as cardiac rehabilita-tion and mood disorders. If such trials showeffectiveness, it would be enormously useful tothose who face the challenges posed by the lim-its of conventional biomedicine in rehabilita-tion, prevention, and positive health. Finally,if effectiveness and mechanism are established,this and similar contemplative interventions—integrated, manualized, and reproduced in dis-parate cultures over thousands of years—couldhelp raise research and clinical standards in apromising, emerging field in healthcare.

Appendix A: Structure and Contentof the ContemplativeSelf-Healing Program

Class Format

The intervention provides psycho-educationin a group setting. Each class is divided into thefollowing parts:

Part 1: Initial Guided Meditation Session:15-minute initial practice of the guided medi-tation of the week.

Part 2: Question and Answer Session:45 minutes of structured questions and answersbetween participants and instructor, in whicheach participant is encouraged/called on toshow their comprehension of material and toreport on homework practice.

Part 3: Lecture-Discussion Session: 30 min-utes structured lecture-discussion introducingspecific principles and practices of meditation-based behavior change, in which participantsare encouraged/called on to check comprehen-sion (syllabus below).

Part 4: Final Guided Meditation Session: 15-minute final practice of the guided meditationof the week.

First Segment: Initial 8-Week Program inBasic Meditative Techniques

The weekly syllabus of principles and prac-tices taught and exercised in the first eight-weekprogram was as follows:

Week 1: The Basic Principles and Skillsof Self-Healing

Principle: People need skills that help themface illness and stress as opportunities for self-healing

Skill: Beginning mindfulness, focused onbreath and body

Objective: Participants learn the four nobletruth framework of self-healing, as well as thedefinition of basic mindfulness practice as adiscipline of stable open-mindedness and at-tention. Regarding mindfulness, they learn thetwo main types of resistance to open-mindedattention: distraction and dullness, and how tocounteract these by exercising the “mental mus-cles” of mindfulness and alertness. The role ofattention as the rate-limiting step in exposingand overriding normally automatic habits is ex-plained to show how mindfulness lays the foun-dation of self-healing. Participants have an ini-tial and final experience of guided mindfulness


focused on breath and body, and are preparedto practice it within and between meditationsessions as homework.

Week 2: The Dependent Originationof Suffering

Principle: Recognizing the causal cycle ofdistress and how mindfulness skills help to breakit

Skills: Mindfulness and alertness, focused onsensation

Objectives: Participants review the 12 fac-tors and four phases of the distress cycle, as wellas their role in undermining healing, learning,and quality of life. They focus on the criticalthird phase where one finds the weakest linkmost readily broken by mindfulness: the link be-tween addictive craving and obsessive clinging.Regarding mindfulness, they learn how mind-fulness and alertness focused on sensation andemotion serve as keys to exposing and renounc-ing normally automatic stress-reactions drivingcompulsive behavior. They have an initial andfinal experience of guided mindfulness focusedon sensation and emotion, and are preparedto practice it within and between meditationsessions as homework.

Week 3: Our Potential for Endingthe Cycle of Suffering

Principle: Recognizing the human potentialfor freedom of mind and action, and how mind-fulness can help actualize it

Skills: Mindfulness and quiescence, focusedon mental states and processes

Objectives: Participants are introduced tothe three levels of consciousness and neu-ral process—coarse, subtle, and extremelysubtle—as well as to the gradual way mind-fulness of mind helps attention gain the stablefocus needed to influence deeper mind/bodyprocesses. In particular, they explore the waymindfulness and alertness deepens into quies-cence and transcendent insight, allowing themind to expose and analyze the perceptualand predisposing factors that anchor the dis-tress cycle. Participants have an initial and

final experience of guided mindfulness andquiescence focused on consciousness and itsprocesses, and are prepared to practice themwithin and between meditation sessions ashomework.

Week 4: The Lifelong Path ofContemplative Self-Healing

Principle: Applying mindfulness skills to fos-ter lifelong self-healing through wisdom, con-centration, and ethics

Skills: Mindfulness and concentration, fo-cused on causal elements and events

Objectives: Participants learn about thethree disciplines and phases of contemplativeself-healing as well as the three kinds of sup-port for maintaining contemplative learningand healthy life change. They are introduced tosingle-pointed and equipoised concentration asthe athletic pinnacle of attention, only possiblethrough the synergy of “natural focus” with thehighest levels of healing insight and motivation.They have an initial and final experience ofguided posture and breathing techniques (akinto Hatha yoga) that help support concentration,motivation, and wisdom, and are prepared topractice them within and between meditationsessions as homework.

Week 5: Deconstructing theDistress-Prone Personality

Principle: Recognizing the need for skills tohelp expose self-involvement and destructiveemotions

Skill: Combining self-analysis with quies-cence

Objectives: Participants learn how involve-ment with a traumatized, childhood sense ofself serves as the root of the cycle of distress-prone life, predisposing us to negative emo-tions and the compulsive personality style andlifestyle they promote. Practically, participantslearn to combine meditation with self-analysisas well as the fourfold framework for ex-posing and analyzing self-involvement alongwith the habits it supports. They have an ini-tial and final experience of guided analytic


insight meditation, and are prepared to practiceit within and between meditation sessions ashomework.

Week 6: Cultivating a Self-HealingPersonality

Principle: Recognizing the need for skills thathelp build objective self-knowledge and positivesocial emotions

Skill: Transforming social life though con-templation on empathy

Objectives: Participants learn about the roleof objective self-knowledge and positive socialemotions in transforming a distress-prone so-cial self and life into a self-healing personal-ity and lifestyle. Practically, participants learnhow combined quiescence and insight con-templation are used to transform negative so-cial emotions like attachment, anger, envy, andshame into positive emotions like love, care, joy,and peace using the fourfold framework of so-cial self-transformation. They have an initialand final experience of imagery-based social-emotional contemplation, and are prepared topractice it within and between meditation ses-sions as homework.

Week 7: Envisioning and Rehearsinga Self-Healing Life

Principle: Recognizing the need for skills tohelp deconstruct and reconstruct habitual per-ception

Skill: Transforming cultural perceptionthrough role-modeling imagery and affirma-tion

Objectives: Participants learn about the roleof affirmative imagery and recitation in trans-forming habitual distress-prone cultural per-ception of the world into a self-healing visionof better ways of being in a more ideal world.Practically, participants are shown how to crafttheir own image of an ideal healer or healthyself, as well as a self-healing affirmation. Theyhave an initial and final experience of guidedvisualization and recitation as a vehicle for envi-sioning and rehearsing a healthy vision of a bet-ter self and world, and are prepared to practice

them within and between meditation sessionsas homework.

Week 8: Energizing and Realizinga Self-Healing Life

Principle: Learning the role of skills that helptransform stress physiology through healing en-ergy and chemistry

Skill: Self-transformation through recitationand breathing

Objectives: Participants review the role ofadvanced recitation and breathing techniquesin developing conscious control over neural en-ergies (pran. a) and drops (bindu) that help ener-gize and realize a self-healing life. They learnhow visualization-guided abdominal breathingand breath-holding help access and harness thepositive energy and chemistry of healing andlearning. Practically, participants have an initialand final guided experience of deep abdominalbreathing and breath-holding exercises, and areprepared to practice them within and betweenmeditation sessions as homework.

At the end of the initial 8 weeks partici-pants are practicing an integrated meditationexercising their mindfulness, quiescence, andtranscendent insight skills within a guidedsocial-emotional visualization, enhanced byaffirmative recitation and deep breathing.

At this point, participants are familiarenough with the basic techniques of mindful-ness, social-emotional insight meditation, andvisualization to build on those skills with asequence of 12 progressive contemplations.These contemplations are meant to help in-dividuals develop healing insights and strate-gies that galvanize their break with the cy-cle of distress and foster a new self-healingoutlook, attitude, and lifestyle. Following thegradual path method of the Indo-Tibetan tra-dition, these contemplations start by prompt-ing a fresh analysis of the most basic facts oflife and build one theme at a time towardsinsights into the highest reaches of humanpotential. The method of gaining insight isone of five step contemplation, beginning


with discursive analysis, moving through an-alytic reflection on what has been learnedto analytic and focused contemplation withinmeditation sessions, finally culminating inpractical application in dialogue with one’s hu-man potential, meditatively evoked as a visual-ized encounter with an ideal healer or healthyself set in a visualized ideal healing and learningenvironment.

Second Segment: 12-Week Program inContemplative Insights and Lifestyles

The syllabus of insights reviewed in the sec-ond segment of the intervention program is asfollows:

Week 9: Recognizing the Preciousness ofHuman Life

Insight: Taking illness as an opportunity tomake life more meaningful

Practice: Correcting self-limiting views of lifethrough imagery-based insight meditation

Objective: Participants reexamine their fa-miliar view of human life, its meaning andpotential, in light of the greater freedom andresponsibility possible for those who exercisemindfulness, alertness, and other contempla-tive “muscles.” Challenging extreme views ofmind as having little or no lasting effect or assolely dependent on the will of a higher power,this session explores the possibility of a mid-dle way in which exercising the human mind’sfull potential for learning and change is seenas the real opportunity of life, the best chanceto make a deep and lasting difference in thequality of life for oneself and others. Its in-tent is to counter the stultifying forms of self-involvement, from self-indulgence to self-pityand self-righteousness.

Week 10: Facing Impermanenceand the Immanence of Death

Insight: Using the immanence of death toprompt self-healing and self-change

Practice: Breaking through denial based onignoring the immanence of death

Objective: Participants reexamine their fa-miliar view of death, its nature and meaning,in light of the greater freedom and responsibil-ity possible for those who exercise mindfulness,alertness, and other contemplative “muscles.”Challenging extreme views of death as a mo-ment of final annihilation or judgment, this ses-sion explores the possibility of a middle way inwhich death is seen as the touchstone for thehard choices that can make life more enjoy-able and meaningful; a constant reminder ofthe importance of letting go of illusions andembracing the present as it is. Its intent is tocounter negative emotions that stem from thedenial of death and other challenging facts oflife.

Week 11: Recognizing the Effectivenessof Human Action

Insight: Making a real difference for oneselfand the greater world

Practice: Seeing each act as an opportunityto change life for better or worse

Objective: Participants reexamine their fa-miliar view of human action, its nature andconsequence, in light of the greater freedomand responsibility possible for those who exer-cise mindfulness, alertness, and other contem-plative “muscles.” Challenging extreme viewsof human behavior as determined by causes be-yond our control or as predetermined by God,this session explores the possibility of a mid-dle way in which every act of body, speech, ormind has an inevitable consequence on our de-velopment, incrementally altering our lives inways that make us more or less fit for health,freedom, and happiness. Its intent is to counterthe sense of alienation and powerlessness thatcomes of minimizing human freedom andresponsibility.

Week 12: Committing to the Necessityof Inner Peace

Insight: Recognizing that real peace of minddepends on inner not outer conditions

Practice: Seeing peace as a choice to acceptwhat is, without illusions or violence


Objective: Participants reexamine their fa-miliar view of peace, its nature and benefits,in light of the greater freedom and responsibil-ity possible for those who exercise mindfulness,alertness, and other contemplative “muscles.”Challenging extreme views of contentment asdependent on the satisfaction of instinctiveneeds or as solely reflecting the grace of God,acceptance of others or God, this session ex-plores the possibility of a middle way in whichpeace is the developmental effect of adoptingan outlook, attitude, and lifestyle committedto facing reality without illusions or violence.Its intent is to counter the distorted perceptionthat expects true contentment to come withouteffort or from others.

Week 13: Finding Reliable Guidancetowards a Self-Healing Life

Insight: Recognizing that the path to self-healing requires reliable guidance

Practice: Identifying and trusting reliablementors, traditions, and communities

Objective: Participants reexamine their fa-miliar view of guidance, its nature, risks, andbenefits, in light of the greater freedom andresponsibility possible for those who exercisemindfulness, alertness, and other contempla-tive “muscles.” Challenging extreme suspicionof guidance as regressive or as a matter of blindfaith, this session explores the possibility of amiddle way in which identifying and trying re-liable guidance is a necessity for anyone wish-ing to replace familiar habits with healthy al-ternatives. Its intent is to counter the sense ofthe world as a cold and lonely place devoidof the refuge or support we need to heal andchange.

Week 14: Understanding the Valueof Empathy

Insight: Valuing empathy as the way to im-partial experience of the world

Practice: Exercising the potential for empa-thy through image-based contemplation

Objective: Participants reexamine their fa-miliar view of empathy, its nature, scope, and

potential, in light of the greater freedom andresponsibility possible for those who exerciseinsight, quiescence, and other contemplative“muscles.” Challenging extreme suspicion ofempathy as regressive or as solely a matter ofduty or divine grace, this session explores thepossibility of a middle way in which it figures asa powerful mental muscle that acts as the basisfor a realistic sense of ourselves and others, andthe ground of impartial, objective experienceof life and the world. Its intent is to counterthe traumatic sense of the world as a threaten-ing place where others are hostile or indifferentcompetitors.

Week 15: Facing the Cost of TraumaticSelf-Involvement

Insight: Recognizing self-involvement as theroot cause of distress-prone life

Practice: Dismantling learned and innateself-involvement in image-based contemplation

Objective: Participants reexamine their fa-miliar view of the self or person, its originand nature, in light of the more accurateself-knowledge possible for those who exerciseinsight, quiescence, and other contemplative“muscles.” Challenging extreme views of theself or person as a name for the brain or aspowerless creatures of a jealous God, this ses-sion explores the possibility of a middle wayin which the self or person is recognized as asocial contract that serves to regulate the rela-tionships between human beings and to pro-tect the freedom and responsibility each indi-vidual has for his or her action. Its intent isto counter the reactive sensitivity that mistakespleasant, painful, or neutral contact with theworld for a matter of personal favor, attack, orindifference.

Week 16: Cultivating the Benefitsof Care and Love

Insight: Identifying compassion as the mosteffective way of being with others

Practice: Cultivating love and compassionthrough image-based contemplation


Objective: Participants reexamine their fa-miliar view of love and compassion, their na-ture and benefits, in light of the greater free-dom and responsibility possible for those whoexercise insight, quiescence, and other contem-plative “muscles.” Challenging extreme viewsof love and compassion as self-interested in-stincts or as solely a matter of divine grace orduty, this session explores the possibility of amiddle way in which the social emotions oflove and compassion are recognized and nur-tured as natural muscles that can be exercisedand extended to expand the scope of proactivesocial relations. Its intent is to counter the ad-dictive craving for positive attention that blockshigher social emotions and locks humans into aregressive attachment to childish illusions andhabits.

Week 17: Claiming the Powerof Responsibility

Insight: Committing to altruism as the spiritof objectivity and social effectiveness

Practice: Cultivating a mature social selfthrough guided contemplation

Objective: Participants reexamine their fa-miliar view of altruism, its nature and benefits,in light of the greater freedom and responsibil-ity possible for those who exercise insight, qui-escence, and other contemplative “muscles.”Challenging extreme views of altruism as aform of genetic self-interest or as a mere dutyor the sole province of saints and God, this ses-sion explores the possibility of a middle way inwhich altruistic concern and resolve are rec-ognized and developed as natural muscles thatcan be exercised to power and direct a proac-tively engaged social life. Its intent is to counterthe obsessive clinging that inhibits the growthof a higher social self and locks humans ina fear-based attachment to self-defeating self-centeredness.

Week 18: Recognizing the Needfor Mentoring

Insight: Identifying qualified others as mod-els for self-transformation

Practice: Transcending familiar self-con-structs through imagery and affirmation.

Objective: Participants reexamine their fa-miliar view of mentoring, its risks and benefits,in light of the greater freedom and responsi-bility possible for those who exercise vision, in-spiration, and other contemplative “muscles.”Challenging extreme views of mentoring as aform of regressive dependency or as restrictedto blind obedience to God or his representa-tives, this session explores the possibility of amiddle way in which mentoring is recognizedand developed as the natural medium of sociallearning and self-transcendence. Its intent is tocounter a rigid mindset that blocks the humanpotential for lifelong development and locks hu-mans in a self-limiting shell of automatic habitsof mind and action.

Week 19: Practicing the Virtue of Vision

Insight: Recognizing visions of self and worldas templates for self-transformation

Practice: Transforming habitual perceptionthrough role-modeling imagery and affirma-tion

Objective: Participants reexamine their fa-miliar view of perception in light of the greaterfreedom and responsibility possible for thosewho exercise vision, inspiration, and othercontemplative “muscles.” Challenging extremeviews of human perception as mirroring realityor as a benighted shadow of divine perception,this session explores the possibility of a mid-dle way in which perception is recognized andshaped as a creative process meant to guide thecurrent action and future development of indi-viduals and societies. Its intent is to counter themindless reproduction of familiar patterns thatblocks humanity’s full potential for transform-ing self and world through creative vision andthe action it guides.

Week 20: Harnessing the Powerof Inspiration

Insight: Using recitation and breath-controlto energize self-transformation


Practice: Harnessing the energy and chem-istry of arousal through restorative breathing

Objective: Participants reexamine their fa-miliar view of mind/body states in light ofthe greater freedom and responsibility possi-ble for those who exercise vision, inspiration,and other contemplative “muscles.” Challeng-ing extreme views of mental states as deter-mined by brain processes beyond consciouscontrol or as reflecting positive input from oth-ers or God, this session explores the possibilityof a middle way in which mind/body energyand chemistry are recognized as products ofmental, verbal, and physical actions and vehi-cles to be consciously shaped to support therealization of personal and social aims. Its in-tent is to counter the experience of facts of lifelike illness, aging, and death as senseless, ran-dom events beyond our control and to harnessour full potential for altering our neurobiologyand biochemistry to best meet life’s ultimatechallenges.

Conflicts of Interest

The authors declare no conflicts of interest.

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A Program in Contemplative Self-Healing

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