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t!ve skilful habits: An ethics-based mindfulness intervention

Lynette Monteirol Shannon Nuttalland Frank Musten3

Ottawa Mindfulness Clinic, ottawa, ON

Abstract

This paper introduces the ethical component of mindfulness as a behavioural-based aspect of a Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy program. In Buddhist practice, cultivation of an ethical approach to living is inseparable from cultivation of mindfulness. Teaching mindfulness skills with an exclusion of an ethical framework can result in behaviours that although intended as mindful may be misguided. The Zen monk Thich Nhat Hanh refer-

1 Lynette Monteiro is a psychologist in private practice in Ottawa Canada.

She is trained in Cognitive Behavioural Therapy and has worked with persons suffering from depression, anxiety, chronic illnesses, and pain related to personal injuries. Early in her career, she integrated meditation practices with CBT and noticed that the two approaches complemented each other, enhancing the effect of the interventions.

2 Shannon Nuttall has been affiliated with the Ottawa Mindfulness Clinic

since 2003 and is currently a teaching and research assistant with the clinic. She has a BA Honours with specialization in Psychology from the University of Ottawa.

Frank Musten is a psychologist in private practice in Ottawa Canada. He established his private practice in clinical and industrial-organizational psychology in 1979. He has worked with couples and individuals experiencing severe distress related to their relationships, their jobs, or their personal history of trauma. He has developed a protocol for assessing and treating individuals suffering from chronic pain.

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mulated the Five Mindfulness Trainings which are taught as habits in a mindfulness practice. At the Ottawa Mindfulness Clinic, the Five Mindfulness Trainings or Five Skilful Habits are taught as an integral part of the 8~week program in mindfulness-based symptom management and mindfulness-based cognitive therapy. Each week participants practice a behaviour as it relates to one of the mindfulness trainings and in the context of physical, emotional, and mental experiences.

Cinq bonnes habitudes: une intervention fondee sur une ethlque de pleine conscience

Resume

L'article porte sur l'aspect ethique de la pleine conscience en tant que composante d'un programme combine de reduction du stress a l'aide de la pleine conscience et d'une therapie cognitive fonde sur la meme approche. Selon la pratique bouddhiste, l'adoption d'un art de vivre ethique est indissociable de l'adoption de la pleine conscience. Enseigner les habiletes a pratiquer la pleine conscience en faisant d'une perspective ethique peut faire en sorte que des comportements anticipes comme etant conscients se revelent plutot inappropries. Le moine bouddhiste Thich Nhat Hanh a reformule les cinq enseignements pratiques de la pleine conscience reconnus comme etant les habitudes a adopter. A la Ottawa Mindfulness Clinic, les cinq enseignements de la pleine conscience ou cinq bonnes habitudes font partie de la formation du programme de 8 semaines concernant le traitement de symptomes a la facon de la pleine conscience et de la therapie cognitive de meme orientation. Au cours de seances hebdomadaires de formation, les participants s'exercent par des experiences physiques, emotionnels, et mentaux a l'apprentissage de la pleine conscience.

Mindfulness-based interventions (MBIs) have become a widely applied treatment modality for many psychological disorders and syndromes. In its inception as a treatment protocol, mindfulness was intended as a means to ease discomfort during treatment of psoriasis (Kabat-Zinn et al., 1998). Beginning with its popularized application as a program forstress reduction, MBIs expanded the toolbox for clinicians, counsellors, life coaches, sports coaches, as well as skills trainers. These interventions have been used as sole or adjunct treatment methods for adults with chronic pain (Kabat-Zinn, 1982; Morone, Greco & Weiner,

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2008), major depression (Segal, Williams, & Teasdale, 2002; Teasdale, Williams, Soulsby, Segal, Ridgeway, & Lau, 2000), disordered eating (Baer, Fischer & Huss, 2005; Smith, Shelley, Leahigh & Vanleit, 2006), anxiety disorders (Craigie, Rees & Marsh, 2008; Kabat-Zinn, et al., 1992) and the list goes on.

The primary focus of MBIs is on training participants in various meditation techniques in an effort to develop mindfulness. Typically, interventions of this kind consist of 8 to 10 weekly 2.5 hour group sessions plus a full day "retreat" about half-way through the intervention (Bishop, 2002). In addition to weekly meetings, participants are asked to commit to approximately 45 minutes of homework daily. This homework consists of a variety of meditative practices such as formal mindfulness meditation (normally a period of sitting or lying meditation), mindfulness movement (e.g. mindful walking), periods of "minimeditation" throughout the day (e.g. 3 minute breathing exercise) as well as bringing mindful attention to everyday events (e.g. brushing your teeth) (Allen, Chambers & Knight, 2006).

The origins of mindfulness as a mental state lie in Buddhist philosophy (Hanh, 1998). As one of the practices along the Eight-fold Path (Hanh, 1998; Smith, 2002)4 and central to the ethical practice of a lay practitioner (Hanh, 2007), it is both outcome and process in the cultivation-of awareness of phenomena and experience. As Wallace (2008) described, the practice of mindfulness includes the cultivation of bare attention, which is a non-judgemental awareness of an object. This cultivation of bare awareness develops a clear view of mental states and action so that the cause and effect of choices can be ascertained. Intention and consequences are thus clarified leading to discernment of wholesome from unwholesome actions. In conjunction with the practice of clear seeing (right view) and transparency of desire {right intention)-two other practices along the Eight-fold Path-mindfulness becomes the means by which the practitioner engages fully with an experience.

Olendzki (2008) explains that wholesome and unwholesome mental states cannot co-exist in a single moment of awareness. Therefore, for skilful mindfulness to arise as a wholesome mental state, it cannot coexist with an emergent unwholesome mental state such as rejection, desire, or denial. Inherent in this conceptualization of mindfulness is the need to discern what is wholesome and therefore consistent with the desire for wholesomeness. It follows then that it is necessary to

4 Eight-fold path is the cultivation of clarity in views, thinking, speech,

action, livelihood, effort, mindfulness and concentration.

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cultivate mindfulness in a framework of values and values-oriented actions, thoughts, and speech.

Most MBIs describe mindfulness as paying attention, on purpose, to the present moment without judgment (Kabat-Zinn, 1990). Based on the previous discussion on the Buddhist understanding of mindfulness, this definition misses both the broader and deeper meaning as well as the intention of cultivating this mental state. In its current usage, to be mindful of the moment includes being aware of negative emotions, thoughts or actions without articulating the intention of such an awareness. Whereas that is a useful starting point, to develop clear comprehension of mindfulness, it is neither complete nor beneficial to stop there because it does not carry the skill of being mindful to its intended outcome of wholesomeness in speech, thought, and action. The Ottawa Mindfulness Clinic (OMC) has attempted to address this need for a values framework, by incorporating the ethical component of mindfulness as a behavioural-based component of their MBI.

Mindfulness Based Symptom Management

The Ottawa Mindfulness Clinic (OMC) has offered over twenty-five 8-week Mindfulness Based Symptom Management (MBSM) courses since May 2003 to persons diagnosed with physical pain resulting from injury or conjoint with medical diseases, emotionally-based disorders such as mood and anxiety disorders, grief, and work- or family-related stress reactions. Their unique program combines elements drawn from Kabat-Zinn's (1990) Mindfulness Based Stress Reduction program, Mindfulness-based cognitive therapy for the prevention of relapse of depression (Segal et al., 2002) as well as Buddhist philosophy.

The challenge of any intervention is to find the opening by which therapist and patient can enter the experience without becoming distracted or derailed by the nature of the experience itself. A mindfulness-based philosophy of treatment has been described as a paradigm shift in treatment of psychological disorders (Segal et al., 2002). The premise of mindfulness-based interventions is that meeting our experience is based in attentional and intentional choices made in each moment. It is often the case that persons diagnosed with physical and/ or psychological disorders experience their symptoms as persistent and often intense sensations which are difficult to manage. The tendency is to feel overwhelmed, to over-control the experience or to deflect and avoid the pain through distraction. These strategies inevitably fail as the cognitive process fails to stay ahead of the experiential.

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In a mindfulness-based paradigm, a willingness to enter that experience is cultivated and requires conceptualizing sensations of the symptoms as transient, not always responsive to tried-and-true techniques, and not specifically designed to be personally inconvenient. In Buddhist terminology, these can be recognized as the three Dharma Seals: impermanence, dissatisfaction, and the assumption of a fixed self (Hanh, 1998). However, this can be a daunting challenge especially in cases of chronic emotional or physical pain. Thus, feeling motivated to engage in and sustain behaviours that can ease the physical and psychological distress requires a road map that is intuitively congruent with wellbeing and focused on increasing the skilfulness of meeting one's experience willingly.

Because the roadmap or ethical principles that facilitate health enhancing behaviours are abstract concepts, it is necessary to define their behavioural correlates. This ensures that the direction of travel is towards the development of wellbeing and the practice required to negotiate that path is appropriately focused. The psychological rationale for including an ethical (values) framework in mindfulness-based interventions (MBIs) is supported by Positive Psychology and specifically by the work of Martin Seligman and colleagues (Peterson & Seligman, 2004). In their conceptualization, what they term character - which is similar to ethics -:- is viewed as stable & general, shaped by settings, capable of change' (increase in skilfulness), and requires enabling conditions (e.g, education, opportunity, consistent support, mentors, role models, peers) (Dahlsgaard, Peterson & Seligman, 2005). These enabling conditions are embedded in the ethical framework of the Five Mindfulness Trainings as conceptualized by Thich Nhat Hanh (2007).

The Five Mindfulness Trainings

Admittedly, it is possible to deliver a treatment program without any explicit reference to or practice of ethically-derived behaviours, however, in doing so there is a risk that mindfulness, if adopted naively, can result in unintended consequences of self-focus and neglect of the interconnectedness of all beings and their behaviours. As Roshi Joan Halifax (1993) points out, "we would not have to bother with precepts at all if we were truly aware. But, alas, most of us tend to forget. We don't see how and who we really are. So the Precepts remind us, just as the teachings on our natural wholesomeness remind us (p. 217)." That is, practicing awareness of our mortality, generosity, respect for boundaries, compassionate speech and mindful consumption (i.e. the precepts) simultaneously encourages valuing self and other, reminding us of what is healthy and cultivating wellbeing. The idea that we "for-

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get who we really are" is particularly relevant when working with those who are caught in physically and emotionally distressing circumstances, in short the participants of the intervention offered at the OMC. Because much of illness continues to carry a stigma of damage, moral and physical weakness, or a myriad of interpretations of unworthiness, it is perhaps critical to be specific in the process of cultivating behaviours that highlight the capacity for acting in a beneficial and positive manner to self and others.

The Five Mindfulness Trainings as formulated and taught by Thich Nhat Hanh (2007) provide that positive-focused approach to wellbeing.

The first training

Aware of the suffering caused by the destruction of life, I am committed to cultivating compassion and learning ways to protect the lives of people, animals, plants and minerals. I am determined not to kill, not to let others kill, and not to support any act of killing in the world, in my thinking and in my way of life.

The second training

Aware of the suffering caused by exploitation, social injustice, stealing and oppression, I am committed to cultivating loving kindness and learning ways to work for the well-being of people, animals, plants and minerals. I vow to practice generosity by sharing my time, energy, and material resources with those in real need. I am determined not to steal and not to possess anything that should belong to others. I will respect the property of others, but I will prevent others from profiting from human suffering or the suffering of other species on earth.

The third training

Aware of the suffering caused by sexual misconduct, I vow to cultivate responsibility and learn ways to protect the safety and integrity of individuals, couples, families and society. I am determined not to engage in sexual relations without love and a long-term commitment. To preserve the happiness of myself and others, I am determined to respect my commitments and the commitments of others. I will do everything in my power to protect children from sexual abuse and to prevent couples and families from being broken by sexual misconduct.

The fourth training

Aware of the suffering caused by unmindful speech and the inability to listen to others, I vow to cultivate loving speech and deep listening in

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order to bring joy and happiness to others and relieve others of suffering. Knowing that words can create happiness or suffering, I vow to learn to speak truthfully, with words that inspire self-confidence, joy and hope.l am determined not to spread news that I do not know to be certain and not to criticize or condemn things of which I am not sure. 1 will refrain from uttering words that can cause division or discord; or words that can cause the family or the community to break. I will make all efforts to reconcile and resolve all conflicts, however small.

The fifth training

Aware of the suffering caused by unmindful consumption, I vow to cultivate good health, both physical and mental, for myself, my family, and my society by practicing mindful eating, drinking and consuming. I vow to ingest only items that preserve peace, well being, and joy in my body, in my consciousness, and in the collective body and consciousness of my family and society. I am determined not to use alcohol or any other intoxicant or to ingest foods or other items that contain toxins, such as certain TV programs, magazines, books, films and conversations. I am aware that to damage my body and my consciousness with these poisons is to betray my ancestors, my parents, my society and future generations. I will work to transform violence, fear, anger and confusion in myself-and in society by practicing a diet for myself and for society. I understand that a proper diet is crucial for self transformation and the transformation of society. (p, 3-5)

The five trainings emphasize that the over-arching concepts are aspirations which are guides, a kind of North Star, by which skilful means are cultivated. This concept of ethical living as a process of behaviours that can be trained to be congruent with a stated aspiration fits well with the theory and concepts of Cognitive Behavioural Therapy which are based on the idea of adaptive schemas for self, others, and the world.

MBSM and the Five Skilful Habits

The curriculum of MBSM is based on the Four Foundations of Mindfulness (Hanh, 1990) which develops mindfulness of the body, feelings, mind and concepts generated in the mind. For didactic ease, the ways to establish mindfulness are presented as practice with the body, emotions, sensations (physical and emotional), and thinking (cognitive processes). Furthermore, as part of the treatment protocol, the Five Mindfulness Trainings have been modified to reflect habits and places the emphasis on the behavioural aspect of practice.

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Thus, the Five Mindfulness Trainings transformed become the Five Skilful Habits. These habits to be fostered in the service of wellbeing are cultivating behaviours that (1) enhance physical health to reduce mortality; (2) develop appropriate generosity; (3) increase awareness of physical and emotional boundaries; (4) cultivate compassionate speech, and (5) increase discernment in consumption of physical and emotional nourishment, including use of necessary medication treatments.

The essential intention of the first, second, fourth and fifth of the Five Mindfulness Trainings has been retained with more of an emphasis on healing oneself through self-valuing behaviours. The Third Mindfulness Training, however, presented unique issues. Because it focuses specifically on sexual relations, it was considered too narrow and perhaps not as likely to resonate with a population that is primarily middle-aged, usually in committed relationships, or too physically ill to consider sexual relationships as a primary concern.

The original intent of the third precept was a prohibition against excessive sensual indulgence (Hanh, 1998). This is likely a broader and more applicable concept in the context of a treatment paradigm. Patients often refer to their difficulties in knowing when their pain threshold has been exceeded. They describe pushing themselves physically and emotionally beyond limits because of messages to "get through" or "breakthrough" the pain experience. Despite their vulnerable state, they often practice a "no pain, no gain" philosophy which only serves to exacerbate their condition or deplete their resources. It appeared that pushing the boundaries of physical and emotional tolerance was a form of over-indulgence in physical or emotional sensations and a misguided attempt at symptom management or even cure. Thus, it seemed appropriate to modify the Third Skilful Habit to reflect respect far these boundaries as a way to be more skilful in managing symptoms.

Each week participants in the program are invited to focus on one aspect of their experience (e.g. body, emotions, sensations, thinking). Folded into these four ways to establish mindfulness, the five skilful habits form a behavioural focus for the home practice. Such that, each week a different way to establish mindfulness is chosen until the four ways are integrated in the penultimate class on compassion and loving kindness. At the end of each class, practitioners are invited to identify specific behaviours, based on the five skilful habits, which they are willing to become more aware of or willing to practice over the week.

For example, if awareness of the body is the theme for the week, during class participants are guided in awareness of the physical nature of their

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experience by focusing on the parts of the body using the Body Scans as a meditation tool. Through this practice, discernment of the physical part of the body from the feeling/thinking aspects is cultivated. For instance, discerning the awareness of the knee or joint from the sensations of arthritis-related pain or awareness of the body in a lying position is cultivated in the presence of any sensations that may arise from the lying down position. As part of their homework participants select behaviours from one of the five skilful habits, respect for mortality, generosity, respect of limits, compassionate speech and mindful consumption, related to facilitating physical health. Examples include: using medication regularly (especially pain relief medication), resting as an act of generosity, establishing and respecting physical boundaries when effortful work is necessary, cultivating encouraging and compassionate internal and external speech, and eating in a way that is consistent with good nourishment or not indulging in activities such as reading materials or watching TV programs that may be discouraging and negative in tone. Examples of such behaviours for each of the four aspects of experience can be found in Table l.

To practice. skilfulness in each segment of experience independently of other segments of experience seems artificial at first because the total experience of physicality and emotionality arises out of a sensational whole of body and mind. However, most participants present their experience asa fused whole unable to differentiate a healthy body from a distressed reaction to what is evolving in the body. Thus, a gentle deconstruction of the experience into its component parts is useful and eventually beneficial to a fuller understanding of the nature of individual experience.

Interestingly, in the context of program evaluation we sent a questionnaire to program alumni asking, among other questions, to indicate if they practiced the Five Skilful Habits and if they did to provide exampless, Of those who responded to the questionnaire, approximately half engaged in the Five Skilful Habits. Table 2 offers the behavioural examples described by respondents.

A meditation practiced while lying down on your back and moving your awareness from one body part to another

6 The research was conducted by Ms. Catherine Shaw as part of a practicum course at Carleton University Department of Psychology. There was a 10% response to the request for participation (14 out of 140 participants responded) and so these results may not be representative of the larger sample.

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Table 1: Five Skilful Habits to Cultivate
Habit to train Behavioural examples
Body: Exercise
Emotions; Note 11o~ nega-ti~e -e-mo-tlons -Ieacf to physical --
L Respect problems such as hypertension
formortali ty Se-nsatio~s: -No-d~e -th-e- sensation orio~t hea~t beat~ a-ch"--
ing, joint pain, heaviness, lightness, etc.
_____________ ~ ____ w~ __________________________________
Thoughts: Note negative thoughts
Body: Rest, sleep in
E~~ti~~;: AIlo~ -yo~ts-elf i:~ -{eel g~iit,- ange~,- h~ppi~e;;,- --
etc ...
2. Generosity Se;;s-atio~;; -P;a-;;ti~~ -J;e-p ~fi~phr;g~~[i~- b~eathi~g ~he~--
you notice uncomfortable sensations
__________________ ~p_m_ft_ft _______ ~~w __________________
Thoughts: Allow thoughts to come and go (allow yourself
to hop off trains)
Body: Note when fatigued, appropriate pain monitoring,
say No appropriately
-------------------------------------.----------------
Emotions: Note negative emotions and sit with them as
3. Respect of long as is comfortable for you
limits ----------------------------------~-~------------------
Sensations: Stay with sensations as long as is comfortable
for you - play with that edge
-ij;~~ght;~ N;ti;; ~h~~ -y~~; th~~ghts- ;~~ ~fi~t~ti~-g y~~~ --
limits rather than your body (e.g, I can't do this)
Body: Notice something positive and say it
______________________________________ ft __ ~~ ___________
Emotions: Try to approach all emotions with an attitude
4.Compassionate of curiosity
speech ________________________________________ ~ft ___ .~~~ _____
Sensations: Refrain from judging sensations noticed,
rather, praise yourself for noticing
__________________ ~~ftRR_ftR _______ w_~_~ ________________
Thoughts: Accept the thoughts as they are, just thoughts
Body: Limit snacks, take time for lunch
E~~-ti~~~; N ;t~ - th; ~~;ti-;~~f ~ffe~-t; ";{ ';"h;t- y;~ - ate--- - - -
5. Mindful watching on television, emotional eating
______ ft~ftft ____ .y~ ______________________________________
consumption Sensations: Note sensations of satiation
-----------------------------------------.-~~---------
Thoughts: Note thoughts while eating (e.g. I shouldn't,
I'm fat, what will my next bite taste like) FIVE SKILFUL HAelTS

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Table 2: Behavioural Examples of Five Skilful Habits Practiced
by Program Alumni
Habit to train Body Emotions Sensations Thoughts
• Health-related • Attend to • Observe
Skilful (e.g. while emotional ("tune in") • Attend to
sustaining of suffering underlying pain
life (Respect for eating. paying • Esta blished a • Try not to when thinking
mortality) attention to formal gratitude avoid pain "violent" thoughts
body) practice
• Non-violent
commu nication • Compassion, self-
(speech or • Listening
• Exercise thoughts) • Eating empathy, focusing
Generosity • Rest to identify slowly • Tapas acupressure
responsibility technique
• Charitable
donations
• Saying "no" • Reduce and • Expressi ng
Skilful Attention • Taking time for • Expressing deal with gratitude
to Boundaries self and others emotions in ways
(Respect of • Taking breaks, not be harmful to negative • Noticinggood
Limits) not over-exerti ng self or others events! in life
self emotions
• Express and allow • Let go of negative
emotions to exist thoughts
• Being non- • Express self i n • Welcome thoughts
Skilful Speech non·harmful but let them pass
(Compassionate judgmental ways (choose • Listening • Watch "tra in"
about health-
Speech) related choices words carefu Ily (thoughts) pass
and be aware of a nd refocus on now
intentions behi nd • More sensitive to
words) others, less critical
Skilful • Not eating foods • More relaxed
Consumption that are hard to (no partidpants • Eating • More positive
(Mindful digest (heaithy provided examples slowly • Accepting "this
Consumption) choices) here) is me" COU NSElLING AND SPIRITUALITY

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Conclusion

As Eastern concepts such as mindfulness gain in currency, commonly held beliefs about the psychology of human behaviour and the applications that derive from those beliefs are being challenged. The insertion of a base of ethics in a treatment process presents a particular challenge to the view that psychological interventions are required to be valuefree and it is tempting to avoid the potential of censure. However, teaching mindfulness as a disembodied practice not only misrepresents its intent but also reduces it to a tool whose misuse could lead to more harm than good as exemplified by Roshi Joan Halifax (1993). Placed and practiced in its context of transforming the suffering self, the way of mindfulness becomes a process through which the individual can embody a generative and sustaining approach to creating internal and external coherence.

The Five Mindfulness Trainings are creative in their simplicity and secularity. There are few who would argue against practicing how to respect one's mortality, become more generous, use one's resources in a sustainable way, speak with compassion, and be physically and emotionally ecologically-minded in all activities. The appeal of the Mindfulness Trainings is in their encouragement to engage in the process of becoming aware of intended and unintended consequences before engaging in an action or thought. That is, they are not about right or wrong actions but about cultivating oneself so that there is a seamless continuity of awareness and a progression in skilfulness.

The adaptation of the Five Mindfulness Trainings to reflect more strongly the behavioural aspects of practice has been a useful and beneficial component of the overall Mindfulness-Based interventions offered at the Ottawa Mindfulness Clinic. As the Five Skilful Habits, they have provided a formal guide to the development of mindfulness and taken some of the mystery out of the details of how to practice. By providing a clear focus in each week of an ethically-derived way to establish mindfulness, the skills accrue in strength and are more easily re-directed towards healthy choices.

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