The capacity for play

  EAST MEETS WEST

This paper presents the work of renowned experts in the fields of Buddhist mindfulness and psychoanalytic and psychodynamic traditions for the purpose of looking at the possibility of implementing mindfulness into a psychodynamic framework. Mindfulness has been shown to improve psychological well-being and is used to treat a number of clinical disorders, both as stand-alone treatments and as part of integrative treatment approaches. However, the current review clearly demonstrates that there isn’t enough existing research in relation to the integration of mindfulness into a psychodynamic framework and therefore future research is needed to ensure that it is both safe and effective. The many contributors of the dialogue between the East and West have mainly focused on the many similarities and differences between the two systems while the practical application of mindfulness in the counselling room has been largely neglected. Despite the major challenges of connecting the little research done in this field, the current literature review was able to identify one very interesting area that could be a starting point. Several studies indicated that mindfulness could intensify the psychodynamic process by making repressed memories available for further exploration in a safe and facilitating environment. Future research should continue to investigate other potential beneficial applications of Buddhist mindfulness, and examine practical issues and implications concerning the delivery, implementation, and further theoretical integration.

Introduction 

 Mindfulness has enjoyed a tremendous surge in popularity in the past decade, both in the popular press and in the psychotherapy literature (Shapiro & Carlson, 2009). In the West, Kabat-Zinn (1990) formulated an operational definition of mindfulness that has become standard in psychological writing and practice: “The awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to things as they are” (p.3). An alternative and brief variant of this definition is “awareness of present experience with acceptance” (Germer, Siegel & Fulton, 2005, p.198). Leading authorities have suggested that mindfulness is a ‘common factor’ in psychodynamic and behavioural models of therapy (Germer et al., 2005: Martin, 1997). This is particularly relevant as a ‘common factor’ is a fundamental component that can account for a significant part of therapy outcomes across all types of theoretical modalities. In other words, mindfulness can be considered as a meeting point or foundation upon which integrative models of therapy can be built. Germer et al. (2005) argues that mindfulness is an essential component of psychodynamic therapy as the “system encourages greater self-awareness in the immediate moment, especially with regard to the ongoing examination of one’s thought processes, emotions, and bodily experiences” (p.5). It is suggested (Safran, 2003; Rubin, 2003) that the psychoanalytic exploration of the self and the self-discovery that occurs through mindfulness share important commonalities, which Rubin (2003) has described as “experience-near self-investigation” (p.15). The relationship between psychodynamic psychotherapy and Buddhist thought has always been of specific interest to scholars, even before they actually started to acknowledge the role of mindfulness as a significant factor (Rubin, 2003). This integration may make sense when we take a deeper look of the processes that underpin psychoanalytic and contemporary forms of psychodynamic therapies which will be discussed in the sections to follow. In fact, Germer et al. (2005) compare psychodynamic psychotherapy and mindfulness, saying they are “both introspective ventures, they assume that awareness and acceptance precede change, and they both recognise the importance of unconscious processes” (p. 21). However, De Silva (1973) points out that the difference is that Freud concerned himself with the content of the mind whereas Buddhism is ultimately about the direct experience of the nature of the mind. For the purpose of situating current developments within a bigger frame of reference, the first chapter will draw an outline of the Buddhist traditions and practices. The second chapter will provide an overview of the fundamental dialogue between East and the West, which unfolded when a cohort of influential psychoanalysts became deeply inspired by a Japanese teacher of Zen, Daisetz Teitaro Suzuki. The third chapter will present the contributions of Donald Winnicott, a British Object Relation theorist, who unwittingly seem to have laid the groundwork for a psychodynamic understanding of Buddhist thought. The fourth chapter will look at the possibility of integrating mindfulness into clinical practice in an explicit way by providing a complete overview of the experimental studies of this field, followed by a final discussion. The ultimate goal of psychoanalysis has, according to Wachtel (2011), moved away from insight and expression of unconscious fantasy to the attainment of enhanced awareness and acceptance of one’s thoughts, emotions and memories. Therefore, one may ask whether an integrative shift to mindfulness can offer positive benefits for clients while promoting psychodynamic exploration and intrapsychic change. The current literature review aims to make a valuable contribution to the ongoing dialogue between East and the West by exploring the possibility of incorporating mindfulness into a psychodynamic framework.

Mindfulness in the Buddhist Context

Buddhism is widely recognised to be a religious, philosophical and systematic psychological system brought from the northern parts of India about 2500 years ago by the mythical prince, Siddhartha Gautama, perhaps better known as Buddha (Nanamoli & Bodhi, 2010; Wallace, 1993). The first Buddhist tradition is known as the Theravāda branch, which offers a systematic practice of mindfulness, called the ‘Foundations of Mindfulness’ or in Pali language ‘Satipatṭhāna Sutta’. This ancient text is the cornerstone of Buddhist psychology and the most widespread one in both eastern and western regions of the world. It is generally regarded to be representing theoretical dialogues and instructions attributed to the Buddha himself (Goenka,1998; Nanamoli & Bodhi, 2010; Wallace, 1993). In a nutshell, the ‘Satipatṭhāna Sutta’ indicates that meditation takes you towards Nirvana, which refers to a state of transcendent peace and bliss, or in other words, the extinction of all suffering (Goenka, 1998). Although, the many different Buddhist traditions such as Mahāyāna, Vajrayāna, Tibetan, and Zen offer different perspectives of mindfulness, their core is centered on the observational stance or so-called ‘bare attention’. This view is supported by several leading authorities on the subject, (Nanamoli & Bodhi, 2010; Wallace, 1993), and is further described by Merton (1968) as a “way of being that simply sees what is right there and does not add any comment, any interpretation, any judgment or any conclusion. It just sees” (p.53). For the purpose of presenting an accurate overview of the literature, the current review will present ‘bare attention’ and its meeting with the West from different Buddhist traditions. 

Before moving on, it should be said that the ‘Satipatṭhāna Sutta’ is part of the Pāli Canon which contains some of the earliest Buddhist scriptures of Buddha’s life and teachings (Goenka,1998). Despite the many different religious doctrines within Buddhism, it seems to be a consensus that Buddha was an Enlightened being and that the crucial step in his advancement was the development of insight meditation: Vipassana (Wallace, 1993). This point is further supported by the interpretation made by Buddhist teacher Lama Surya Das (1997) who describes Enlightenment to be representing a direct realisation of the nature of reality, how things are and how things work. The Pāli Canon tells us that Enlightenment comes about when one awakens to one’s own inner Buddha nature, which always remains pure and untouched. This important aspect is elaborated upon or reiterated in multiple places throughout the Pāli Canon and is part of the main core of Buddhist traditions which consist of the Three Jewels: Buddha, Dharma (teachings) and Sangha (community). Das (1997) explains that each of the jewels represents essential principles, which have to be followed by Buddhist practitioners and that Buddha represents a state of mind that is referred to as ‘wakefulness’. Buddhists believe that everybody can come to experience this particular state by following the instructions of the ‘Satipatṭhāna Sutta', which is centered around the description of four frames of reference for anchoring mindfulness in the present moment. Briefly explained, the text promotes mindfulness to be the very first stage of the human perceptual process and a prerequisite for the possibility of noticing any given sense-object. Batchelor (1998) argues that it is considered to be the state of mind that exists prior to when one starts to think about what one is experiencing. It is described as a continuous real consciousness, which often seems to disappear when the mind starts to objectify and symbolise experience. His interpretation further explains that any phenomena can attract attention and initiate associative thinking, mental constructions and conceptualisations based on past memories and experiences. This is for the purpose of navigating experience and, according to Batchelor (1998), is the cognitive state in which people’s mental lives play out. To sum up, the mind is consistently preoccupied with abstract thinking which leaves it ‘unavailable’ for the present moment. Mindfulness brings focus on the stream of sensory data and the internal mental images and thoughts without drawing on beliefs, narratives, schemas or other conceptual maps which are automatically engaged to make sense of one’s thoughts and experiences. This view is promoted by Sills (2008) who further argues that the systematic cultivation of mindfulness through meditation practices constitutes an effective method to train and enable the mind to prolong this moment of pure awareness. 

The Four Noble Truths

Other important concepts to consider, in order to understand mindfulness more fully, are the teachings of the Four Noble Truths. These are: (1) Suffering is, (2) Suffering has a cause, (3) Suffering can be stopped and (4) It's a way of life that can prevent suffering (Das,1997). Epstein (2008) argues that Buddha realised that nothing is permanent, and that suffering arises when one clings to and craves illusionary impermanent phenomena. He postulated that suffering comes to an end when the mind is fully present in the moment and not compromised by clinging, aversion, expectations and desires. When this truth is realised one can let go, stop clinging and release themselves from the cycle of incessant rebirths. This is an interpretation of the doctrine endorsed by many leading authorities in this field (Batchelor, 1998; Ennenbach, 2010; Sills, 2008). Collectively, they point out that the sacred scriptures of the Pāli Canon put great emphasis on direct experience and that mindfulness is the only way to experience the impermanent and perishable nature of our consciousness. The ability to directly observe how phenomena arise, how they present themselves, and how they cease could enable the individual to develop a clear understanding of this fundamental truth of existence. This is the universal law of ‘Annica’ which, according to Sills (2008), is usually translated and referred to as the ‘law of impermanence’ in the Western literature. Buddhists believe in a unifying principle in all phenomena that can be experienced as an intimate and direct presence of other objects without any sense of separation. This is referred to as Oneness. This is the Buddhist ‘ultimate reality’ that is available for anyone and everyone who seeks it, being fully ‘awake’. This view is emphasised by Gunaratana (2015) who points out that the Four Noble Truths is an effective system for the purpose of bringing about this type of peak experience, meaning happiness in every moment and insight into the factors that lead to a joyful existence.However, before rounding off this section it is important to acknowledge that the views that have been presented here are not necessarily reflective of the truth but a selection of key concepts within Buddhist traditions. 

Buddhism Entering Psychoanalytic Therapy 

 The dialogue between Buddhist psychology and the West developed primarily in America after the World’s Parliament of Religions (Chicago, 1893) in which the Japanese delegates portrayed the Mahāyāna Buddhism as scientifically consistent. The significance of this moment is described by Young-Eisendrath and Muramoto (2002) who proclaim it to be the very entering point of Zen Buddhism into the West. According to their historical timeline of events, beginning in the 1940s and reaching a peak in the 1950s, a wave of appreciation for Eastern philosophy surfaced amongst psychoanalysts leading to the so-called ‘Zen boom of the 60s’. As pointed out by Fehige (2016), Daisetz Teitaro Suzuki, is widely recognised to be the one who introduced the West to Zen and Mahāyāna Buddhism while working at the American Institute for Psychoanalysis. It is worth noting that the climate within classic Freudian psychoanalysis at the time was that forms of contemplative or mystical experiences was nothing but the revival of infantile experience, and on that account, contained no inherent religious or spiritual quality. This view was first penned down by Freud (1929) in his book ‘Civilization and Its Discontents’ which, according to Fehige (2016), would lead to deep skepticism and disinterest towards all things Eastern and ‘mystical’ by the orthodox Freudian community. However, the foreword in one of Suzuki’s many books on the subject, ‘Introduction to Zen Buddhism’, (Suzuki 1965), is written by Carl Gustav Jung, who said, “It is no accident that it is a psychotherapist who is writing this foreword” (p.3). Despite showing interest in the subject, Jung takes the opportunity to warn Western clinicians that although it is good to get to know the spiritual practices of the East, one should not try to integrate them directly into clinical work. Jung was clearly against western cultures copying Buddhist ideas and practices, believing that it was important for each to find their own path. 

 Despite his efforts to warn about the implications of integrating the two systems, Young-Eisendrath and Muramoto (2002) argued that it is perhaps Jungian theory that has been most frequently brought into dialogue with Buddhist understanding in recent decades. The authors point out that things started to change when a group of American psychoanalysts took notice and got interested in Jung’s public affirmation of the interest and importance of Suzuki’s Zen for psychoanalytic theory. Several of Suzuki’s publications became a source of great inspiration to numerous influential thinkers such as Erich Fromm, a humanistic existentially oriented psychoanalyst and Nazi-Germany survivor. In his book on the subject, ‘Art of Loving’, Fromm (1957) argues that Zen practice expands the psychoanalytic process through a positive conceptualisation of human potential that goes far beyond addressing symptoms. Fromm, Suzuki and DeMartino later collaborated and published the book ‘Zen Buddhism and Psychoanalysis’ (1960), a collection of essays which, according to Friedman (2013), fostered a steady interest in the integration of Buddhist concepts and psychoanalytic therapy. Another contributor to this dialogue is Karen Horney, a Neo Freudian, feminist thinker, and theorist, who developed a strong interest in Zen Buddhism while forming a close bond with Suzuki. Horney’s influence and significance are well documented by Berger (1994) who provides information in relation to the historical context at the time of Horney’s theoretical advancements. He points out that it was rather unusual for a woman to make such an impact, as the field and society in general was male dominated. Nevertheless, this was exactly what she did as she left her mark on the psychoanalytic field through her pioneering work and collaborations. 

 In fact, Horney (1942) was particularly interested in the faculty of ‘attentiveness’ and its importance for doing sound analytical work. In one of her earliest publications, a book called ‘Self-Analysis’, she notes numerous similarities between Zen and psychoanalysis, in particular what she termed “wholehearted attentiveness” (p. 242) or absorption in what one is doing. This quality, she argued, is difficult to attain and something that the “Orientals have a much deeper feeling than we do and a much better training” (p.8). Westkott (1997) points out that her main purpose was to try to teach students “how to bring the therapeutic setting in the meditative attitude of mindfulness…a nonjudgmental openness to feeling” (p.84). His views echo Suzuki’s message who would often speak about a genuine acceptance of ordinary experience (Fromm, et al., 1960). Horney recommends that this mindful and analytical attunement should be a therapeutic aim for the patients and an essential dispositional stance of the therapists. She related it to Freud’s (1912) instructions of upholding an ‘’evenly hovering attention” (p.112), which was according to him very simple. Freud considered this to be of major importance and warned that if the analyst listens without this impartial attention “there is the danger of never finding anything but what is already known” (1912, pp.112). However, Rubin (1985) notes that Freud did not offer any systematic procedure or specific recommendation for the purpose of cultivating this refined capacity of listening. He argues that the question had been left unanswered and understood incompletely by Freud and subsequent psychoanalytical writers. 

 To sum up, Horney made considerable efforts towards the progression of this topic by putting forward the idea that Freud’s recommendation of optimum listening could be followed through meditative practices. Mindfulness, in Horney’s (1942) view, can be developed to the point where it happens naturally and effortlessly, providing a major influence on an individual’s experience. She believed that this quality can impact the inner lives of the clients in a most profound way as they can deeply experience the neutral and meditative posture of the therapist. This aspect was furthered developed by Harold Kelman,(1960) a close associate of Horney’s, who argued that the psychoanalytical process in itself cultivates mindfulness in both the analyst and the patient. However, despite trying to establish several parallels between the two systems, Kelman was certainly not indifferent to the potential shortcomings and dangers of mixing them in clinical practice. This is clearly demonstrated in his paper ‘Psychoanalytic Thought and Eastern Wisdom’ (1960), in which he warns that although Buddhist techniques can enrich psychoanalytic practice, their underlying theoretical principles are widely different and not compatible. Jeffrey (1996) notes that throughout his life, Kelman continued to seek out the common ground between the two systems while working to find how the theoretical differences could potentially complement each other. 

 This short review of important figures in the introduction of Eastern philosophy to Western minds would be remiss without a reference to the pioneering work of Alan Watts. He made his impact through authoring several books on the subject and continued to deliver controversial lectures throughout the sixties. In his book, East meets West (1961), Watts describes the mutually fundamental commonalities between the methods and practices of Western psychotherapies and the disciplines of Buddhism, Vedanta and Yoga. He proposes that these Eastern systems are “neither organised religions nor philosophies of life but rather the resembling of psychotherapeutic principles” (p.3). Watts’s argued that both Buddhist and psychotherapeutic systems aim to alter people’s consciousness and change the way in which they feel their own existence and how they relate to the world. However, he recognised that although they both share this common goal, psychotherapy has, for the most part, focused on the treatment of people in need of psychotherapeutic treatment. Watts explains that the difference is that Buddhism seeks to change the consciousness of “normal, socially adjusted people” (p.2) or in other words, curing what Freud would refer to as the ‘ordinary human unhappiness’. Rubin (2003) argues that this is probably the most fundamental difference between Buddhism and early classical psychoanalysis. Several leading authorities on the subject (Bollas, 2013; Engler, 1986; Epstein, 2008) have noted and explored the tendency for the two systems to diverge on some points and converge on others. 

 While looking at the historical influence and dialogue of these writers and their subsequent impact on the psychoanalytic field, Cooper (2010) stresses the importance of The Beats. He refers to this as a literary movement in the 50s and 60s that challenged the society’s standard narrative values and initiated a significant exploration of psychedelic, sexual experimentation and liberation. He identifies this movement to be the transitional vehicle for Buddhism into American mainstream culture. Although there were less than 50 articles and books on Zen Buddhism and psychoanalysis in the 60s, it was a significant increase as the number of publications had doubled since the previous decade (Cooper, 2010). However, these numbers demonstrate a clear preference for Zen Buddhism within the psychoanalytical community while making forays into the rich psychology of Buddhism. A relatively rare exception is London based psychoanalyst Nina Coltart, who was more engaged with the Theravādan Buddhist schools of South East Asia. She would explicitly state that her meditation practice helped her focus on what was going on in the session, and that her sessions became similar to meditations (Coltart, 1990). She points to many similarities between the way we pay attention in therapy and what she would refer to as ‘bare attention’, the distinguished characteristic of the practice of meditation. For Coltart (1990), attention was “the scaffolding for everything else we do” (p.181) and described it as “both detached and involved, both scanning and focused” (p.110). Before moving on to more contemporary views, it is worth noting that Christopher Bollas (2010), Jack Engler (1986) and Mark Epstein (2008) all working from the perspective of British Object Relations Theory, have made considerable efforts towards the dialogue in modern times. This takes us to the next chapter which will describe the further development of this field, which according to Barry Magid (Stewart, Hayes & Stricker, 2017), reflects a much more “sophisticated and challenging stage where genuine differences and conflicts are allowed to emerge and be meaningfully engaged” (p.3).

The Contributions of Donald. W. Winnicott

For many, it can perhaps come as a surprise that there is a significant number of influential authors (Black, 2012; Bollas, 2013; Epstein, 2008; Hoffer, 2015; Safran, 2003 & Unno, 2006) who have suggested that Donald. W. Winnicott, a British Object Relations analyst, is the one who laid the groundwork for a psychodynamic understanding of Buddhist thought. However, it should be said that it was never Winnicott’s intention to engage in a conversation with the ancient wisdom of the East. Epstein (2008) considers this to be a tremendous asset as Winnicott’s insights offer an unbiased view, which is mainly based on what he observed in his encounters with others. This is in stark contrast to the earlier work that had been done in this field which consisted of experienced Buddhist practitioners with a strong agenda to find ways that could do justice to both systems. Epstein argues that Winnicott’s conceptualisations present an impartial view that is rare as it escapes many of the main criticisms associated with the process of integrating Buddhist principles into the West. He explains that Winnicott did not seek to exploit the Buddhist ideas but instead seemed to be exploring some of the same principles and phenomenon that Buddha once came to acknowledge. The literature seems to reflect an overall consensus that, while Buddha and Winnicott employed the respective languages of their traditions, they both described the similar space evoked by bare attention (Hoffer, 2015; Epstein, 2008; Bollas, 2013). This is particularly intriguing as it seems that Winnicott, like the Buddha, managed to discover this space on his own, which in itself seems pretty extraordinary. A common justification for stripping mindfulness of its Buddhist context is that mindfulness is a universal state of consciousness and, is as such, not necessarily Buddhist. This view is supported by Kabat-Zinn (1990) who reminds us that even though the techniques and certain philosophical ideas may have come from Buddhism, it does not mean that other fields could not come to explore them within their own theoretical context. This seems to link with the proposal made by Hoffer, (2015); Epstein (2008) and Bollas (2013) who strongly suggest that Winnicott’s investigation of human development led him deep into Buddhist territory. In this new paradigm, Epstein (2008) frequently refers to Winnicott and his conception of the ‘third space’ suggesting that this ‘transitional space’ of bare attention, “this capacity to know things as they are, qualified by mere existence” (p.181), is what links the meditator and the psychotherapist.

He further argues that it was Winnicott’s fascination with the barely perceivable, the preverbal, the in-between, of transitional space, of formless experience and intermediate areas that led him to the discovery of the ‘third space’. Milner (1988) recalls her personal experiences with Winnicott when she observed that he had a unique capacity to tolerate and even enjoy both the formless and the search for form. Winnicott, perhaps not completely oblivious to this impression, once acknowledged that “what you get out of me, you will have to pick out of chaos” (Grolnick, 1990, p.122). Bollas (2013) argues that Winnicott drew parallels between this process and the emerging of the self in infants, which he considered to drift from unintegrated to integrated states and back again. He points out that this became one of Winnicott’s psychoanalytical principles where he would allow for periods of chaos in the sessions where no theme or thread would be followed or analysed. Winnicott considered this to be the preliminary chaos preceding the creative process which according to Bollas (2013) seems to imply an attitude of openness and acceptance similar to the characteristics of the state of mindfulness. Winnicott wrote several landmark books of twentieth-century psychology and, similar to Buddha who grew up on the fringe of entrenched orthodoxies, he reconfigured them based on his own profound personal experiences. This view is supported by Hoffer (2015) who further points out that Winnicott, like Buddha, gave new meaning to concepts that people thought they already understood, often turning things upside down. All this, while emphasising the importance of looking for oneself where he looked. He also points out that both Winnicott and Buddha stressed upon the significance of not just believing what they said but instead trying to look where they were searching in order of discover the things that they came to observe and experience. Kahr (1996) adds that heuristic metaphors, such as ‘potential space’ and ‘transitional objects’, answer scientific questions while leaving open not only the mysteries but also the space for creative explorations and future corrections.

The Lotus Flower and the Potential to Grow 

Although, Winnicott (1945) did not use the term awakening, he believed that through attentive nurturing of the creativity from the earlier years, every individual has the opportunity to live in a creative state without being forced to adapt to the needs of others. It is the interruptive flow of authentic self, the capacity to going-on-being, which according to Winnicott (1945), would flourish if nurtured by good-enough mothering and a good-enough facilitative environment. Epstein (2008) sees this to be the Western equivalent of the Buddhist analogy of the lotus flower. He explains that the lotus serves as a metaphor for enlightenment; just as the lotus flower blossoms in purity from the muddy pound, so did Buddha emerge from suffering. He further stresses that for Buddhists the lotus is a symbol of purity and represents the potential to grow given the right circumstances. The sun represents the Buddhist teachings that nourishes the mind’s natural ability to flourish if brought out from the state of reactivity (Epstein, 2008). Winnicott implies something similar in his essay, ‘On Communication’ in which he states, “the alternative to being is reacting, and reacting interrupts being and annihilates” (Winnicott 1960, p.47). The parallel to the Buddhist notion of clinging and reacting as the fundamental source of unhappiness is difficult to avoid. Winnicott (1971) places great emphasis on the role of the maternal ‘holding environment’ and explains that when a child is forced to cope prematurely with the needs of others he/she develops a reactive self, which he refers to as the ‘caretaker self’. Winnicott (1963b) saw this ‘false self’ to be an attempt to protect the true self from further psychological damage. This development would leave the child with an isolated and impenetrable world which Winnicott (1960) refers to as the ‘incommunicado element’ and considers to be the root of narcissistic pathology at best and self-fragmentation at worst.

Playing and Reality 

In Playing and Reality, Winnicott (1971) explores a whole series of innovative concepts in connection with the importance of ‘playing’, that he sees as taking place in the ‘in-between’ area, ‘the place where we live’ and experience life. He clearly states that this intermediate area of ‘potential space’ is fundamental to development and “shall exist as an area of rest for the individual engaged in the perpetual human task of keeping inner and other reality separate yet interrelated” (p.2). Winnicott sees this area to be in direct continuity with the play area of the ordinary small child who is ‘lost in play’ and the greatest part of a small child's real life. Within this third area, one makes use of what Winnicott terms as transitional objects, or transitional phenomena, true and false self, and the good-enough mother. Winnicott (1968) believed in a specialised setting that would facilitate for the non-purposive state of formlessness in which the self is recurrently formed and found in a creative process. He saw the “overlap of two areas of playing, that of the patient and that of the therapist,” (p. 51) in much the same way that "play [is] a potential space between the mother and the baby" (Winnicott, 1971, p. 64). Epstein (1998) places great emphasis on the openness of this space, an openness that is not interfering, a space that can enable some clients to imagine new behaviours without fear of critical evaluation by an authoritative person. Winnicott believed in recreating the ‘good- enough holding environment’ within the context of psychoanalysis by trying to suspend the adaptive work of the mind in order to provide a potential space for spontaneous creativity. He wanted to create an atmosphere in which ‘two people could be alone together without trying to make sense of what was or was not happening all the time’ (p.78), or in other words, developing a capacity for ‘play’ (Eigen, 1991). Winnicott (1971) said that "playing implies trust" (p. 69) which reflects the individual's movement from a "state of omnipotence," (p. 69), meaning that the child has the illusion that it is not separated from the mother to "being alone in the presence of someone,” (p. 64). To sum up, he linked the state of unintegration to the ‘capacity to be’ and further stressed that the infant who can be, as opposed to one who can only do, has the capacity to feel real, to be present and to tolerate the fulness of his/her experience (Winnicott 1971).

 Epstein (2008) points out that this echoes the Buddhist suggestion that it can be beneficial for the mind to learn how to relax into itself, instead of being caught by all of the psychic manifestations of selfhood. Kornfield (2008) emphasises that by learning to rest in the open space of awareness, "we become unafraid of the changing conditions of life" (p.10). Hoffer (2015) argues that Winnicott would view the ‘open space of awareness’ to be an attribute of good-enough holding by the mother, and later, by the ego supportive environment of a clinical setting. Epstein (2008) implies that this is the environment that is facilitated by meditation as the mind is allowed to disintegrate and rest in the space of pure awareness, while suspending the need for control. He further argues that the temporary dissolution of ego boundaries makes the self float while giving a sense of continuity and trust that is implicit in Winnicott’s notion of what it takes to feel real. Epstein (2008) further argues that the creative impulse and discovering one's authenticity are both results of awakening in mindfulness practices and in Winnicott's understanding of living from one's true self. He further notes that Buddhism is very clear on how important it is to move in such a direction and, as such, is relentlessly optimistic. He adds that in Winnicottian psychology and that of the Buddha, one finds the discovery that the less sure we are about the self the greater our mental health. However, the difference is that from a Buddhist perspective, it is not a single ‘false self’ that is uncovered, but a bundle of such selves. This view is supported by Nanamoli and Bodhi, (2010) who further argue that once one is comfortable in a state of unintegration we can, according to Buddhism, begin to see clearly how compulsively we cling to the various images of self which present themselves in our minds. In their view, the point of meditation is seeing if it’s possible and how to be free of clinging to all such selves, be they experiential, representational or systematic. Epstein (2008) adds that both meditation and Winnicott’s style of psychoanalysis open up uncertainty not to provoke anxiety but to evoke tolerance, humility and compassion.

 Although, there have been many who have attempted to establish links between psychotherapy and Buddhist meditation practices, Epstein (2008) was the first to postulate a parallel between Winnicott’s concept of ‘formlessness’ and its potential role in Buddha’s enlightenment. His conclusion relies on the earliest description of the moment Buddha-to-be, where he was able to reach ultimate liberation while sitting in deep meditation under a Bodhi-fig tree. In this description, the Prince reflects on an early childhood memory of his time spent under a tree watching his father King Suddhodana at work. He recalls the simple pleasure, the state of joy, the "concentrated and focused state that was blissful and refreshing" (Gautama, 2015, p.10). Epstein (1998) proposes that Buddha’s tapping into the pleasure, that was his being, was enabled by what Winnicott would refer to as ‘good-enough ego coverage’. From this perspective, Buddha was able to slip into a deep natural state of relaxation by his internalisation of a holding environment in which the father’s non-interfering presence allowed him to be alone in the presence of another. Epstein (1998) argues that this state initiated Buddha’s realisation that the road to ultimate liberation from suffering was the meditative state, that Winnicott would later identify as ‘formlessness’, the ‘going-on-being state’. This state of unintegration is, in Hoffer’s (2015) view, enabled by concentration meditation, that is also the stage that Buddha had to go beyond in order to achieve his final awakening. According to Bollas (2013), the Buddha realised that there was something fearful about this sudden feeling of joy as it did not seem to depend on any gratification of desire. After a moment of reflection, he saw through his fear and realised that if pleasure is inherent to what is, there is no need to avoid or cling to different aspects of reality. Bollas (2013) further points out that this discovery enabled him to stay open and acceptive towards every moment of experience and this was ‘the ultimate truth’ that he would go on to teach with great passion for the remaining time of his life

        Mindfulness Within A Psychodynamic Framework

The most systematic evaluation of a mindfulness-based intervention as an integrated part of a psychodynamic therapy was undertaken by Kutz, et al. (1985a). Their study included twenty individuals who had been receiving psychodynamic therapy for the purpose of addressing sever mental health conditions such as anxiety and depression for an average of four years. In addition to their psychodynamic therapy the participants engaged in a ten-weeks Mindfulness Based Stress Reduction (MBSR) program organised independently of their psychotherapist. At the end of the program, both the therapist and the mindfulness instructor identified similar areas of improvements such as the development of insight and increased understanding of own behaviour and internal conflicts. Furthermore, the study showed that 80% of participants reported increased anxiety tolerance, elevated optimism about future and overall better enjoyment of life. In fact, data analysis indicated that the participants improved significantly on most sub-scales of the symptom checklist and on the profile of mood states and that levels of anxiety and depression had decreased most significantly. The psychotherapist involved linked these positive finding to the clients' ability to de-stress themselves, an aspect that seemed to increase their sense of control in regard to their anxiety, which in turn served to defuse their anxiety further. In the second paper on the subject, Kutz, Borysenko and Benson (1985b) discuss several ways in which the combination of mindfulness practice and psychodynamic therapy could be beneficial. In particular, they consider the meditator’s increased capacity to observe own thoughts and feelings to be an important factor towards gaining insight into intrapsychic conflicts and struggles. In addition, they argue that this enhanced quality is further transferred into the therapeutic sphere where it can encourage favorable clinical outcomes as clients are able to identify and acknowledge their projections and achieve a greater sense of personal responsibility. Based on the earlier findings, the researchers demonstrate a clear optimism by proposing a framework for integrating the two systems, which they see as “technically compatible and mutually reinforcing” (p.6). They consider regular meditation to be key towards empowering the client, intensifying the therapeutic process and extending the therapy beyond the psychotherapeutic sessions. To sum up, in their view, heightened consciousness, enabled in both Buddhism through meditation and mindfulness, and in psychodynamic therapy through introspection and reflection, could be a powerful combination. 

However, despite identifying psychological enhancement in participants receiving traditional insight-therapy and mindfulness practices, the researchers did not mention the exact impact made by each of the two system. Kutz et al. (1985a) do not offer any guidance related to this aspect and it is perhaps not entirely inappropriate to suggest that this is a major research issue which should not be ignored. In fact, it seems like a rather missed opportunity as the researchers could only report the pre- and post-measurements of individuals allocated to the experimental condition. This means that the empirical value of the research study is significantly diminished as the researchers did not have any reliable baseline data to compare results with. This perspective is emphasised by Berg (1982) who strongly advises against the use of such pre-experimental designs as it offers the weakest degree of experimental control. He further stresses that it is not possible to draw meaningful conclusions about the cause-and-effect of the relationship under investigation. In the future, it would perhaps be useful to employ other methods for the purpose of analysing the interconnection and impact of the two systems and not just to determine whether a psychotherapy is more effective than the simple passage of time. An alternative could be to add one inactive control group placed on a waiting list and two active control groups, one for psychodynamic therapy, and the other one for participants engaged in mindfulness meditation. This could give a more empirically detailed and textured image without having to compromise experimental control and empirical rigour. However, on a pure practical level, it would obviously take much more effort to organise, something that Kutz et al. (1985a) was perhaps not able to arrange at the time. However, since all of the participants would be receiving or waiting to receive some form of therapy it does appear to be ethically feasible. 

It should be said that despite an intense and prolonged search for scientific material related to the integration of mindfulness meditation into psychodynamic therapy, it was not possible to identify many such studies for the current literature review. While considering the history between the two systems and the rather extensive theoretical exploration that followed it seems somewhat surprising that the area is still underdeveloped and lacking in empirical research. This view is further supported by a recent review conducted by Bianco, Barilaro and Palmieri (2016) who express their concern on the matter. They did only manage to identify a relatively small number of randomised controlled trials involving the use of mindfulness meditation in a psychodynamic clinical context. However, despite their efforts, the researchers identified several studies that seem to have a rather questionable relevance. One such study investigated the effect of mindfulness and psychodynamic therapy specially designed to be delivered online (Johansson, Hesser, Ljótsson, Frederick, & Andersson, 2012). This somewhat unconventional study involved the participation of 100 individuals diagnosed with mood and anxiety disorders placed in a randomised controlled trial consisting of one active experimental condition and one control group. Participants in the experimental condition took part in a self-help programme that involved contact with an allocated psychodynamic therapist in combination with a number of text-based modules and mindfulness exercises. Post-test measurements indicated that the experimental group demonstrated not only psychological improvement but an enhanced ability to process emotional material mindfully. However, despite the beneficial results it does not necessarily mean that it is an indicator that can be taken into consideration in relation to the current research question. In fact, Bianco, Barilaro and Palmieri (2016) fail to mention that participants only received a few weekly emails in support from their therapist and that modules were based on affect-phobia therapy (APT) which is a psychodynamic therapy focused on expression and experience of affect (McCullough, Fincham, & Tsang, 2003). Therefore, it may not be unreasonable to suggest that the more traditional aspects of a psychodynamic therapy might have been lost and that the many theoretical differences diminish the relevance and significance in relation to the current discussion. 

Similarly, another study (Schussel & Miller, 2013) measured the effect of a rather unconventional treatment programme that involved the use of loving-kindness meditation, visualisation techniques, Tibetan singing bowls and individual psychodynamic therapy. This study included a very limited number of case studies which illustrated a positive effect on the psychological well-being of homeless teenage boys. Although, the results only reflect the progression of a small number of individuals and is as such not generalisable to the larger population, it does, however, show a willingness to test new unexplored territory. Taken together, these studies do not really seem to contribute much to the current debate but still they were identified by Bianco, Barilaro and Palmieri (2016) to be representing the main body of research in the last 25 year. This makes them particularly important as it certainly seems to underline that there is not much existing research that involves a straightforward investigation of mindfulness within a psychodynamic framework. The lack of empirical research in relation to the topic of the current literature review makes it necessary to draw upon the findings made in the field of Cognitive Behavioural Therapy. Shapiro (2006), a world-renowned researcher in the field of psychotherapy and mindfulness, found that mindfulness can fundamentally change a person’s perspective. The first change seemed to be the client’s ability to see that there is a difference between the events that they are observing and the thoughts one has about the event. The findings showed that while being mindful and reflective, one does not only develop the ability to self-regulate but also become significantly better at identifying own values and to find ways to act in accordance to them. Furthermore, it was demonstrated that meditating over time can develop client’s ability to identify and observe raw psychological material, become increasingly aware of dysfunctional behavioural patterns and become more preoccupied with the introspection of own thoughts and feelings. 

These findings seem to be of particular relevance as they strongly echo the earlier assumptions made by Kutz et al. (1985a) who noted that mindfulness has the potential to unlock and allow access to repressed and valuable psychic material. However, the difference is that instead of making serious attempts to initiate and uphold an observational stance in relation to these experiences, Kutz et al. (1985a) stress the importance of further in-depth exploration in a safe and non-judgmental environment. In their view, this is a highly beneficial and necessary process that would allow the clients’ emotional reaction to be fully understood, interpreted and traced back to its origin. This was identified to be a central advantage of the integration as psychodynamic methods excel in their ability to place the client’s current life and problems in a historical-developmental context. They further argued that this would enhance clients’ understanding of themselves and their experiences and help them identify the near and distant internal causes of behaviour. Epstein (1998) agrees with these assumptions and adds that while Buddhism does not place importance on the individual or on past revelation, memories are often important to attend to in order to integrate them therapeutically. Furthermore, Kutz et al. (1985a;1985b), like Shapiro (2006) views mindfulness as a process that develops within the client outside the therapy session which allows the client to continue to observe and reflect, on a daily basis, at no extra cost. In addition, Kutz et al. (1985b) proposes that the combination of mindfulness and psychodynamic therapy can influence the client’s subsequent experiences during meditation in the most beneficial way which opens up for an interesting prospect. However, for some reason the authors did not choose to take this discussion further, thus leaving the subject rather unanswered and unexplored. 

In line with other leading authorities in the field, (Epstein, 1995; Miller, 1993) the researchers suggest that mindfulness could not only increase clients’ emotional receptivity but also enhance their ability to connect previously unrelated psychological material. However, despite the potential benefits of accessing repressed material or other emotional content, there are studies which indicate that this can have potentially dangerous implications for clients engaged in a meditative process. One such study conducted by Miller (1993) found that some meditating individuals suffered significant emotional distress when they were not able to consciously integrate the unveiled material during their practice. These findings indicate that there might be difficult complications that should be taken into consideration before attempting to integrate mindfulness interventions into clinical practice. Miller (1993) suggests that appropriate interventions in such situations depend on multiple factors but should include one or more of the following options, increased contact with meditation teacher, referral to psychopharmacology, ending the process of meditation practice and acute psychiatric evaluation. However, despite the reported challenges it is important to note that all participants considered their difficulties to be an important and necessary part of their journey towards growth and healing. In fact, they all demonstrated a strong wish to continue with their mediation practice as they had an overall positive experience with it. This may indicate that meditators can benefit from psychodynamic therapy in order to process psychological material that might otherwise hinder them in pursuing meditation further. This point touches upon the views made by Kutz et al (1985b) who suggested that psychodynamic therapy can be much beneficial when a person has started meditating or have met particular challenges during practice that have made it difficult to carry on.

However, Miller’s (1993) study is relatively rare as it is one of the very few attempts that actually tries to make a straightforward investigation of the integration of meditation and psychodynamic therapy.  This qualitative study employed the use of opened-ended questions, that according to Britton (2017), is the research method that will produce the richest phenomenological data about meditation-related experiences that is relative unknown. For some reason, this case study was not mentioned by Barilaro and Palmieri’s (2016), which seems somewhat unfortunate as Miller (1993) introduces an alternative psychotherapeutic approach that would be cost-effective. This combination would require a regular meditation practice combined with a less frequent number of psychodynamic sessions that would normally be recommended. This touches on the ideas of both Shapiro (2006) and Kutz et al., (1985b), which considers the mindfulness perspective to be a powerful process, a portable therapy that continues outside the sessions at no extra cost. Miller (1996), like Kutz et al., (1985a), regards mindfulness to be a medium which intensifies the therapeutic process, increases the frequency of introspection while providing an additional means for the client to work through their challenges. He builds his alternative approach on the main findings which indicated that unconscious material is unveiled through meditation, a process that, according to him, would normally require more frequent and overall a higher number of psychodynamic sessions to achieve. He stresses that in addition to gaining access to repressed memories that have not been available before, the clients may become aware of repetitive themes that could benefit from therapeutic co-investigation. This potential vantage point further validates the findings of Kutz et al,. (1985a; 1985b) and taken together the two studies might give rise to a slight optimism in relation to a possible integration of mindfulness into a psychodynamic framework. 

Miller (1993) concludes that this kind of cost-effective model would not be appropriate for all individuals, especially those who are at high risk for significant psychological distress through meditation and mindfulness practice. This certainly seems to echo the earlier warnings of Arnold Lazarus and Albert Ellis, co-founders of Cognitive Behavioural Therapy who strongly opposed the idea that meditation is for everyone. In one of his articles, Lazarus (1976) discusses the issues of a number of patients who had suffered serious disturbances after meditating; these included depression, ongoing tension and a serious suicide attempt. He furthered stresses that psychotherapists must be aware of such adverse effects and that it is essential to know that some individuals can experience positive effect while others can be at risk. The question is then, how does one identify these individuals and what are the factors that could indicate potential dangers? These are difficult questions and while evaluating this field of research it becomes much apparent that there have not been enough efforts made as only a handful of studies have been looking into the adverse effects of mindfulness. However, several psychologists and scholars have voiced their concerns in relation to the importance and slow progression of this field; (Farias & Wikholm, 2015; Shapiro, 1992; Miller, 1993; while conducting their own research investigations. One such study, conducted by psychologists Farias and Wikholm (2015), paints a rather dark picture as the findings suggest that mindfulness researchers have consistently failed in measuring potential negative effects. This indication should be taken seriously as the quantitative procedure of meta-analysis is considered to be highly reliable and is used to seek general conclusions across studies. Britton, Lindahl, Fisher, Cooper and Rosen (2017)has now started to identify and map these more difficult experiences, which they call ‘the dark side of Dharma’. This study showed that the state of fear, anxiety ,panic,  and paranoia (82%) in novice meditators was also among the most commonly reported by experts (72%). They further argued that it is not uncommon for past trauma to reappear during meditation or the trauma, that had been buried deep into the subconsciousness, to surface for the first time. This further validates some of the points made by Kurtz et al. (1985a; 1985b), Miller (1993) and Epstein (2008) which may indicate that despite the area being somewhat scattered it might be a red thread to follow here that might be worth further investigation.

However, despite the adverse effects demonstrated by these studies, there is plenty of research which has documented the healing powers of meditation. One recent meta-analysis by Goya et al., (2014) estimated the effects of meditation-based interventions and concluded that such implementations decreased symptoms of depression, anxiety and pain but not in a superior way compared to other active treatment conditions. Similarly, another meta-analysis conducted by Hofmann, Sawyer, Witt and Oh (2010), which looked at the effects of mindfulness-based therapies, found a moderate effect in relation to improving anxiety and mood disorders. Another extensive meta-analysis carried out by Sedlmeier et al., (2012) included 163 studies on the effects of mindfulness and found positive changes in emotionality and relationship issues, less strong for measures of attention, and weakest for more cognitive measures. Mindfulness has also been linked to increased emotional regulation (Siegel, 2007b), cognitive flexibility (Moore & Malinowski, 2009)and higher levels of life satisfaction (Brown& Ryan, 2003). Other studies have shown that mindfulness decreases reactivity in relation to negative events (Cahn & Polich, 2009) while increasing the ability to respond in an emotionally adaptive way (Cahn & Polich, 2006). In addition, Steward (2014) argues that mindfulness allows dynamic material to be worked with from a defused perspective that allows the patient to look “at” trauma rather than “from” trauma, and thus the material can be worked with more safely and effectively. 

Before rounding up this section of research, it would be appropriate to bring the attention back on Ron Kurtz who went on to find the Hakomi Method, which is a kind of body centered psychotherapy. The method is described by Weiss, Johanson and Monda (2010) to be a psychodynamic and experimental psychology which systematically uses mindfulness to integrate the body into the psychotherapeutic process. This is brought about “by noticing in any moment, not only the content of what is being said, but what the client is doing, how they are doing it and what they are experiencing” (p. 5). This perspective sees mindfulness to be the single most effective tool in psychodynamic psychotherapy as it allows for the deeper issues to become available for therapeutic exploration and integration (Weiss et al. 2010). These instructions seem rather helpful as they demonstrate how one can effectively incorporate mindfulness into a psychodynamic framework without having to explain the Buddhist concepts or ask clients to meditate. Epstein (2017) points out that despite the evolvement of the dialogue between East and West, there seems to be a lack of information in relation to the practical application in the counselling room. This issue is reflected in the current literature review as most of the information presented has been related to the therapeutic impact of the meditating therapist, theoretical integration and when clients have been involved with meditation outside of sessions. It was not possible to find straightforward and sufficient material to adequately provide a helpful discussion in relation to how one can bring mindfulness into the therapeutic sphere in a more explicit way. Considering the dialogues have been unfolding for quite some time it is perhaps not completely unreasonable to suggest that the contributors showed great caution and did not want to make radical changes to the therapeutic framework. This is reflected in the warnings made by Fayne (2014) who insists that all dual-roles can be potentially problematic within a psychodynamic framework and that meditation during sessions can complicate and even undermine client’s meditation experience. He stresses on the importance of the therapist’s own meditation practice and embodiment of mindfulness during sessions as these will, in his view, be available for the clients via nonverbalised and nonconceptualised internalisations.

From his perspective, this is the most natural and common way to introduce mindfulness in the therapeutic space and further suggests to find ways of incorporating Buddhist concepts without necessarily presenting them in the counselling room. This resonates with the overall view promoted by Miller (1993), Kurtz et al., (1985a;1985b) and Epstein (2008) who consider that it is best to refer clients to a good meditation teacher instead of teaching mindfulness techniques during sessions. They recognise this to be the most secure way in which the psychodynamic principles can remain intact without being compromised by the integration of mindfulness into clinical practice. Kurtz et al. (1985a;1985b) points out that this approach will not interfere with the therapeutic relationship or dilute the process of transference that refers to the transference of client’s repressed historical past onto the therapeutic relationship. A central part of psychodynamic therapy is to work through these transferences so the client is able to understand that the projections belong to them and are not necessarily reflective of the current reality (Freud, 1912). Countertransference, on the other hand, is the therapist’s reaction to the client that can affect his or her “cognition, feelings, attributions, memories and fantasies, as well as verbal and nonverbal actions” (Kiesler, 2001,p.1058). Gabbard (2001) points out that therapists are consistently being drawn into different roles during the sessions and that it is vital to be aware of such enactment of the countertransference. Epstein (2008) adds that meditating therapists develop their ability to notice when this happens, which may decrease the chances of causing damage to the therapeutic relationship. Whereas the research on the positive implications of applying mindfulness approaches to psychotherapy on clients is an area that has received considerable attention, Davis and Hayes (2011) point out that research into the impact on mindfulness on therapists is only starting to emerge. To sum up, meditation has been linked to increased empathy (Anderson, 2005) which is an essential characteristic of a strong therapeutic alliance (Bohart, Elliot, Greenberg & Watson, 2002). Similar studies have linked meditation to improved self-compassion in therapists, trainees (Shapiro, Brown, & Biegel, 2007) and health care professionals (Shapiro, Astin, Bishop, & Cordova, 2005).

Epstein (1990) proposes that Buddhist meditation and psychodynamic therapy are simply more effective when they learn from each other, that they are good for different things, but neither is good for everything. While considering his major contribution towards this field, it seems appropriate to end this section with a short glance at his latest book which seems to have taken him in a somewhat new and different direction. In this book, ‘Advice Not Given: A guide to Getting Over Yourself’, Epstein (2017) points out that he has always been very vocal about the importance of not bringing Buddhist concepts in the counselling room. He did not consider it to be an appropriate arena for the discussion of Buddhist concepts as he was afraid this would force his clients towards Buddhism. In his characteristic style, Epstein uses his own personal process and journey to explain that the death of his father has radically changed his outlook and viewpoint in relation to this matter as he now wants to share the Buddhist wisdom with his clients. In fact, his father had never shown any interest for Buddhism and it was not until he was diagnosed with a terminal illness that Epstein decided to tell him about the experiences and views of the Buddha. This gave his father great relief in his final days and so Epstein concluded that he wanted others to also benefit from the Buddhist knowledge instead of keeping the information to himself. However, it is still left to be seen what this type of integration might look like in the counselling room and perhaps it also a small indication that the dialogue is entering a new and exciting phase and that Epstein seems very much inclined to carry on. 

                Conclusions and Future Directions 

It looks like Buddhism and psychodynamic therapy share some of the same goals: the end of mental suffering, one working from a highly personal and individual perspective, the other from a more universal point of view. The current literature review has reviewed research which shows that mindfulness-based practices have been correlated with positive patient outcomes and included the reduction of psychopathological symptoms. In addition, it has been indicated that recent development in psychotherapy integration reflects a growing emphasis on the role of mindfulness as a common factor that cuts across the various sectarian schools of psychotherapy. The positive outcomes in these studies imply that mindfulness therapy techniques could be beneficial to any theoretical background, including psychodynamic therapy. However, the current review has clearly shown that there is not much existing research on the subject of integrating mindfulness into psychodynamic therapy and future research is needed to ensure that this is both effective and safe. In particular, there isn’t any research that investigates the explicit use of mindfulness techniques during sessions, instead there has been a vast exploration on the theoretical integration that, in the first round, seemed to reduce the two systems to a variation of Freud’s ‘evenly hovering attention’. It is rather strange that the explorations have not included empirical research but instead focused on the many similarities and differences between the two systems instead of the practical application. The question is then how can the vast theoretical integration and all the efforts made by contributors over the past decades be of use for the clients in the counselling room if the area cannot find ways to bring it to them? Apart from a few contributors such as Mark Epstein, Christopher Bollas and Jack Engler, the area seems to have slowed down, not really reaching the vital stage of empirical research but instead halted to a ground while nobody seems to notice. 

However, that is not to say that there are no current developments but overall the literature seems to focus on the things that have already been discussed while the need to find new ways to bring mindfulness into the therapeutic space remains largely neglected. The first stage towards a clearer and deeper understanding of the implications of integrating mindfulness into the therapeutic framework would perhaps be to draw on the existing research made within other psychotherapeutic models or studies that have investigated mindfulness as a stand-alone treatment. The effect of mindfulness in relation to other ‘common factors’ could be particularly fruitful as it would connect it to an area of research that has been well established. Another recommendation is to start mapping out the personal experiences of psychodynamic therapists who are already incorporating Buddhist principles into their sessions or of the clients who are engaged in such processes. This could be done using qualitative methods for the purpose of identifying potential areas that can be explored further through quantitative research designs which will ensure a higher level of scientific rigour. However, despite the major challenges of connecting the little research done in this field, the current literature review was able to identify one very interesting area that could be a possible starting point for further developments. This is related to the potential benefits of engaging clients in meditation outside of the therapeutic sessions and the findings made by Miler (1993), Kurtz (1985a;1985b), Britton (2017), Farias and Wikholm (2015) that showed that mindfulness can bring repressed material up to the surface. This is particularly interesting as it is one of the essential goals of psychodynamic therapy and the current review is the first to connect this research which means that the point is further validated. This implies that the alternative cost-effective model proposed by Miller could be worth investigating further as it is an approach that could have significant implications to the field considering psychotherapy is an expensive affair that many people can simply not afford. 

However, this discussion has shown that very little is known about the implications of making changes to the original framework and perhaps it is the complexity of the two systems that has demanded such an extensive theoretical investigation. Epstein (2017) touches on something deeply important that one should not force their own ideology onto the clients, which seems like a potential pitfall as many clients might have problems in regards to setting up boundaries or present what Winnicott would refer to as an adaptive self that is eager to please. However, an area that did indeed look promising is the therapeutic stance of the meditating therapist that seems to be useful in the psychotherapeutic process. This is an aspect that I have noticed myself as my meditation practice helps me to stay calm and concentrated during sessions while enabling me to enter a space of ‘play’ with my clients. As a Buddhist practitioner I was deeply inspired by Winnicott and this new knowledge of applying mindfulness in the counselling room through the lens of Winnicottian theory. However, it should be mentioned that my knowledge of Buddhist practices and traditions did not really seem to help me while writing the current literature review as it in many ways rather complicated the process. The complexity of the two systems and the difficulties of navigating an area that is extremely scattered took me from a place of positivity to a state of frustration. While starting out with a slight bias towards wanting to see a possibility of a positive integration, the frustrating process, coupled with the discouraging research findings, led me to having a more negative viewpoint towards the idea.

Although, it was always my intention to give an objective overview of the dialogue between East and the West, it is a limitation that should be taken into consideration while evaluating the current literature review. To a certain degree this issue seems to apply to the rest of the research area as it reflects a tendency for Buddhist psychotherapists to use their own personal experiences to infuse theory and to take them into new and different directions. This tendency is strongly demonstrated by Epstein (2018) who, after losing his father, wants to incorporate Buddhist principles into the counselling room which takes him far away from his initial recommendations. While this has a certain value, one cannot continue to build an entire field based on personal experiences and interpretations of the past work of others if one wishes to ensure that the therapeutic space and process remain both safe and effective. For that one needs extensive empirical research or else this area is at risk of losing its credibility which would be a shame considering the enormous efforts made by the contributors of this field. Nevertheless, there is no doubt that meditation can help significantly with keeping anxieties at bay but I would argue that it is in contact with psychodynamic therapy that anxieties can be completely understood and go away. The current literature review has demonstrated that the area is still underdeveloped which indicates that there is plenty of exploration left to do and that there is still hope in regards to making the combination available for others who seek psychological freedom. Like Buddha and Winnicott, the area remains open, which again leaves me positive about the possibility of an effective integration between Buddhist mindfulness and psychodynamic psychotherapy.

References

Anderson, D. T. (2005). Empathy, psychotherapy integration, and meditation: A Buddhist contribution to the common factors movement. Journal of Humanistic Psychology, 45, 483–502.

Batchelor, S. (1998). Buddhism without beliefs: A contemporary guide to awakening. New York: Riverhead.

Berg, J. H., & Archer, R. L. (1982). Responses to self-disclosure and interaction goals. Journal of Experimental Social Psychology,18, 501-512.

Berger, L. S. (1994). Review of C. Ratner’s Vygotsky’s sociohistorical psychology and its contemporary application. New York: Psychoanalytic Books.

 Bianco, S., Barilaro, P., & Palmieri, A. (2016). Traditional meditation, mindfulness and psychodynamic approach: An integrative perspective. Frontiers in Psychology, 7, 552-557.

Black, M. B. (2012). Psychoanalysis and religion in the 21st Century: Competitors or collaborators? New York: Routledge.

Bohart, A. C., Elliott, R., Greenberg, L. S., Watson, J. C. (2002). Empathy. In J. Norcross (Eds), Psychotherapy relationships that work (pp. 89-108). New York: Oxford University Press.

Bollas, C. (2013). China on the mind. London: Routledge.

Britton, W. B., Lindahl, J. R., Fisher, N. E., Cooper, D. J., & Rosen, R. K. (2017). The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. Plos One, 12, 5-12. 

Brown, K. W., Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84, 822–848.

Cahn, B. R., & Polich, J. (2006). Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychological Bulletin, 132, 180–211.

Cahn, B. R., & Polich, J. (2009). Meditation (Vipassana) and the P3a event-related brain potential. International Journal of Psychophysiology, 72, 51–60.

 Coltart, N. (1990). Slouching towards Bethlehem… and further psychoanalytic explorations. London: Free Associations Books.

Cooper, P. (2010). The Zen impulse and the psychoanalytic encounter. New York: Routledge.

Das, L.S. (1997) . Awakning the Buddha within: Eight steps to Enlightenment: Tibetan wisdom for the Western world. New York: Broadway Books.

Davis, D. M., & Hayes, J. A. (2011). What are the benefits of mindfulness? A practice review of psychotherapy-related research. Psychotherapy, 48, 198-208.

De Silva, M.W.P. (173).Buddhist and Freudian psychology. Colombo:Lake House Pub.

Eigen, M. (1991). The area of faith in Winnicott, Lacan, and Bion. In A. Phillips (Ed.), The electrified tightrope (pp. 109-138). Northvale, NJ: Jason Aronson.

Engler, Jack. (1986). Therapeutic aims in psychotherapy and Buddhism. In K. Wilbert, E. Engler, & D. Brown (Eds.) , In transformations of consciousness  (pp 17-52).Boston: Shambhala.

Ennenbach, M. (2010). Buddhist psychotherapy: A guide for beneficial changes. Obsterdof: Windperf.

Epstein, M. (2008). Going on being: Life at the crossroads of Buddhism and psychotherapy. Somerville, MA: Wisdom Publications.

Epstein, M. (2017). Advice not given: A guide to getting over yourself. New York: Penguin Press.

Farias, M., & Wikholm, C. (2015). The Buddha pill: Can meditation change you? London: Watkins Publishing Limited.

Fayne, M. (2014). The arrival of what’s always been: Mindfulness meets psychoanalytic psychotherapy. In J. M. Stewart (Ed.), Mindfulness, acceptance, and the psychodynamic evolution: Bringing values into treatment planning and enhancing psychodynamic work with Buddhist psychology (pp. 37-54). Oakland, CA: New Harbinger Publications.

Fehige, Yiftach. (2016). Science and religion: East and West. Mumbai: Routledge India.

Freud, S. (1912). Recommendations to physicians practising psycho-analysis: Standard edition of the complete psychological works of Sigmund Freud. London: Hogarth Press.

Freud, S. (1929). Civilization and its discontents. London: W. W. Norton & Co.

Friedman, L. J., & Schreiber, A.M. (2013). The lives of Erich Fromm: Love’s prophet. New York: Columbia University Press.

Fromm, E. (1957). The art of loving. London: George Allen & Unwin.

 Fromm, E., Suzuki, D. T., & De Martino, R. (1960). Zen Buddhism & psychoanalysis. New York: Harper.

Gabbard, G.O. (2001). A contemporary psychoanalytic model of countertransference. J Clin Psychol, 57, 983-91.

Gautama, B. (2015). The Lotus Sutra: Saddharma-Pundarika. (H. Kern, Trans.) Vancouver: CreateSpace.

Germer, C. K., Siegel, R. D., & Fulton, P. R. (2005). Mindfulness and Psychotherapy. New York: The Guilford Press.

Goenka, S. N. (1998). Satipatthana Sutta discourses. Seattle: Vipassana Research Publications.

Goldman, D. (1993). In search of the real: The origins and originality of D.W. Winnicott. Northvale, NJ: Jason Aronson Inc. 

Goyal, M., Singh, S., Sibinga, E. M., Gould, N. F., Rowland-Seymour, A., Sharma, R., et al. (2014). Meditation programs for psychological stress and wellbeing: a systematic review and meta-analysis. JAMA Intern Med, 174, 357-368.

Gronlnick, S. A. (1990). Work and play of Winnicott. Nortvale, NJ: Jason Aronson Inc.

Gunaratana, B. (2002). Mindfulness in plain English. Boston: Wisdom Publishing. 

Guntrip, H. (1969). Schizoid phenomena, object relations and the self. London: Karnac.

Hoffer, A. (2015). Freud and the Buddha: The couch and the cushion. London: Karnac Books.

Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169-183.

Horney, K. (1942). Self-analysis. New York: Norton.

Jeffrey, B. R. (1996). Psychotherapy and Buddhism: Toward an integration. New York: Springer. 

Jeffery, R. M. (1997). Mindfulness: A proposed common factor. Journal of Psychotherapy Integration, 7, 291-298.

Johansson, R., Hesser, H., Ljótsson, B., Frederick, R. J., & Andersson, G. (2012). Transdiagnostic, affect-focused, psychodynamic, guided self-help for depression and anxiety through the internet: Study protocol for a randomised controlled trial. BMJ Open, 19, 2-6.

Kabat-Zinn, J. (1990). Full catastrophe living: How to cope with stress, pain and illness using mindfulness meditation. New York: NY: Bantam Dell.

Kahr, B. (1996). D.W. Winnicott: A biographical portrait. London: Karnac Books.

Kanter, J., Tsai, M., & Kohlenberg, R.J. (2010). The practice of functional analytic psychotherapy. New York: Springer.

Kelman, H. (1960). Psychoanalytic thought and eastern wisdom. In J. Ehrenwald (Ed.). The history of psychotherapy. (pp. 328 - 333). New York: Jason Aronson. 

Kiesler, D. J. (2001). Therapist countertransference: In search of common themes and empirical referents. J Clin Psychol, 57,1053-1063.

Kornfield, Jack. (2008). The wise heart: Buddhist psychology for the West. New York: Ebury Publishing.

Kutz, I., Leserman, J., Dorrington, C., Morrison, C. H., Borysenko, J. Z., & Benson, H. (1985a). Meditation as an adjunct to psychotherapy. An outcome study. Psychother Psychosom, 43, 209-18. 

Kutz, I., Borysenko, J. Z., & Benson, H. (1985b). Meditation and psychotherapy: a rationale for the integration of dynamic psychotherapy, the relaxation response, and mindfulness meditation. Am J Psychiatry, 142, 1-8.

Lazarus, A.A. (1976). Psychiatric problems precipitated by Transcendental Meditation: Outlined. Psychotherapy, 56,10-15.

Magid, B. (2014). Foreword. In J. M. Stewart (Ed.), Mindfulness, acceptance, and the psychodynamic evolution: Bringing values into treatment planning and enhancing psychodynamic work with Buddhist psychology (pp. 3.). Oakland, CA: New Harbinger Publications.

McCullough, M. E., Fincham, F. D., & Tsang, J. (2003). Forgiveness, forbearance, and time: The temporal unfolding of transgression-related interpersonal motivations. Journal of Personality and Social Psychology, 84, 540–557.

Merton, R. K. (1968). Social theory and social structure. New York: Free Press. 

Miller, John. J. (1993). The unveiling of traumatic memories and emotions thought mindfulness and concentration meditation: Clinical implications and three case reports. Journal of Transpersonal Psychology, 25, 169 -180.

Milner, M. (1988). D. W. Winnicott and the two-way journey. In S. A. Grolnick, M. D. & L. Barkin, M.D. (Eds.), Between reality and fantasy: Winnicott’s concepts of transitional objects and phenomena. Northvale, NJ: Jason Aronson, Inc.

Moore, A., & Malinowski, P. (2009). Meditation, mindfulness and cognitive flexibility. Consciousness and Cognition, 18, 176–186.

Nanamoli, B., & Bodhi, B. (2010). The middle length discourses of the Buddha: A translation of the Majjihima Nikaya. Somervile, MA: Wisdom Publications. 

Penney, S. (1995). Buddhism. Oxford: Heinemann Educational Publisher.

Rubin, J. B. (1985). Meditation and Psychoanalytic Listening. Psychoanalytic Review, 72, 599-612.

Rubin, J. B. (2003). A well-lived life: Psychoanalytic and Buddhist contributions. Boston: Wisdom Publications.

Safran, J. D. (2003). Psychoanalysis and Buddhism: An unfolding dialogue. Boston: Wisdom Publications.

Sedlmeier, P., Eberth, J., Schwarz, M., Zimmermann, D., Haarig, F., Jaeger, S., et al. (2012). The psychological effects of meditation: a meta-analysis. Psychol Bull, 138, 1139 –1171.

Schussel, L., & Miller, L. (2013). Best self-visualization method with high-risk youth. Journal of Clinical Psychology, 69, 836 - 845.

Shapiro, D. H. (1992). Adverse effects of meditation: a preliminary investigation of long-term meditators. Int J Psychosom, 39, 62-67.

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management,12, 164–176.

Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1, 105–115.

Shapiro, S. L., & Carlson, L.E. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. American Psychological Association, 194, 3-14.

Shapiro, S. L., Carlson, L. E., Astin, J.A., Freedman, B. (2006). Mechanisms of mindfulness. J Clin Psychology, 62, 373-86.

Siegel, D. J. (2007a). Mindfulness training and neural integration: Differentiation of distinct streams of awareness and the cultivation of well-being. Social Cognitive and Affective Neuroscience, 2, 259–263

Sills, F. (2008). Being and becoming: Psychodynamics, Buddhism and the origin of selfhood. Berkley: Atlantic Books.

Stewart, J. M., Hayes, S. C., & Stricker, G. (2014). Mindfulness, acceptance, and the psychodynamic evolution: Bringing values into treatment planning and enhancing psychodynamic work with Buddhist psychology. Oakland, CA: Context Press.

Suzuki, D. T. (1965). Introduction to Zen Buddhism. New York: Grove Press Inc.

Unno, M. (2006). Buddhism and psychotherapy across cultures: Essays on theories and practices. Boston: Wisdom Publications. 

Wachtel, P. L. (2011). Therapeutic communication: Knowing what to say when. New York, NY: Guilford Press.

Wallace, A (1993). Tibetan Buddhism from the ground up: A practical approach for modern life. Somerville, MA: Wisdom publications.

Watts, A. (1961). East meets West. New York: Pantheon Books.

Weiss, H., Johanson, G., & Monda, L. (2015). Mindfulness-centered somatic psychotherapy: A comprehensive guide to theory and practice. New York: W.W. Norton.

Westkott, M. (1997). Karen Horney’s encounter with Zen. In J. L. Jacobs, & D. Capps (Eds.), Religion, society, and psychoanalysis: readings in contemporary theory (pp. 71-89). Boulder, CO: Westview Press.

Winnicott, D. W. (1945). Primitive emotional development. International Journal of Psycho-Analysis, 26, 137-43.

Winnicott, D. W. (1963b) The development of the capacity for concern. In D.W. Winicott (1965), The maturational processes and the facilitating environment (pp.73-82). London: Karnac. 

Winnicott, D. W. (1968). Playing: its theoretical status in the clinical situation. International Journal of Psycho-Analysis, 49,591-9.

Winnicott. D.W. (1971). Playing and reality. London: Tavistock Publications Ltd.

Young-Eisendrath, P. & Muramoto, S. (2002). Awakening and insight: Zen Buddhism and psychotherapy. New York: Taylor & Francis Inc.