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• • • • • • • • • • • • • •
A Metacognitive Therapy for Anxiety Disorders:
Buddhist Psychology Applied
Tony Toneatto,
Buddhist psychology and philosophy have the potential of contributing to the cognitive behavioral conceptualization and treatment
of psychopathology. In this article, the relevance of Buddhism to the treatment of clinical anxiety is presented. Metacognition is
viewed as a concept that can bridge Buddhist and cognitive behavioral psychology. In addition to delineating Buddhist conceptions
of cognition and cognitive functioning, practical applications, in the form of mindful attention, are outlined.
Give u p all n e g a t i v e a c t i o n s ;
Always act p e r f e c t l y in virtue;
Develop complete mastery of your own mind;
T h i s is t h e t e a c h i n g o f t h e B u d d h a .
--Buddha Shakyamuni
NE OF THE ENDURING s t r e n g t h s o f c o g n i t i v e - b e h a v -
O ioral t h e r a p y is its i n h e r e n t a d a p t i v e n e s s . N o t e c h -
n i q u e o r s t r a t e g y is e x c l u d e d as a c o g n i t i v e - b e h a v i o r a l
t e c h n i q u e if e m p i r i c a l e v i d e n c e is s u p p o r t i v e . As a result,
Cognitive and Behavioral Practice 9, 72-78, 2002
107%7229/02/72-7851.00/0
Copyright © 2002 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
Toneatto
meditation-based stress reduction program on mood and symp-
toms of stress in cancer outpatients. PsychosomaticMedicine, 62,
61,'4-622.
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tive therapy prevent depressive relapse and why should atten-
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(1993). The effects of stress and relaxation on the in vitro
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CRCP Press.
Address correspondence to Susan Logsdon-Conradsen, Berry College,
Department of Psychology, 2277 Martha Berry Hwy., NW, Mount Berry,
GA 30149; e-mail: sconradsen@berry.edu.
Received: January 10, 2000
Acc@ted: February20, 2001
• • • • • • • • • • • • • • •
University o f Toronto
c o g n i t i v e - b e h a v i o r a l t h e r a p y c o n t i n u e s to d e v e l o p a w i d e
r a n g e o f i n t e r v e n t i o n tools s u i t a b l e to a n e v e r - i n c r e a s i n g
r a n g e o f clinical p h e n o m e n a a n d p o p u l a t i o n s . Its a d h e r -
e n c e to a scientific m o d e l o f d e v e l o p m e n t e n s u r e s t h a t
s u c h p r o l i f e r a t i o n d o e s n o t l e a d to a h a p h a z a r d r e l i a n c e
o n u n s u b s t a n t i a t e d clinical tools. D e s p i t e its y o u t h as a
s c i e n c e , it h a s m a d e r e m a r k a b l e a d v a n c e s i n effectively
r e l i e v i n g h u m a n s u f f e r i n g . It is n o t s u r p r i s i n g t h a t t h e r e
is a n o p e n n e s s by r e s e a r c h e r s a n d c l i n i c i a n s w o r k i n g
w i t h i n a c o g n i t i v e - b e h a v i o r a l f r a m e w o r k to t h e i n s i g h t s o f
t h e B u d d h a , w h i c h d a t e b a c k o v e r 2 m i l l e n n i a . T h e Bud-
d h a also e m p l o y e d a strict e m p i r i c a l a p p r o a c h to devel-
o p i n g his i n s i g h t s o n t h e n a t u r e o f h u m a n s u f f e r i n g a n d
its alleviation. H e d i s c o u r a g e d his f o l l o w e r s f r o m a c c e p t -
 Buddhism and Anxiety Disorders
ing his instruction without also validating them within
their own experience.
As the article by Sameet Kumar (2002) has made very
clear, Buddhism encompasses a wide variety of traditions
and definitions that defy simple summary. Kumar pro-
vides a concise summary of the key concepts c o m m o n to
Buddhism and an excellent context for the articles in this
series. Any application of Buddhist psychology to cogni-
tive and behavioral practice should clarify the tradition
that informs the application. In this case, the author is a
practitioner of the Tibetan (Tantric) Buddhist tradition.
O f course, this is not an appropriate forum for an exposi-
tion of Tibetan Buddhism, and what is discussed in this
article only represents one of many applications that
could be made. But in keeping with the emphasis on
practical aspects of Buddhist philosophy for cognitive
and behavioral practice, theoretical, metaphysical, or re-
ligious aspects of Tibetan Buddhism will be eschewed. In-
stead, practical change strategies based on Buddhist in-
sights about the mind and behavior will be discussed as
they relate to the understanding and treatment of clinical
anxiety disorders.
Buddhist Psychology and Metacognition
A potentially useful way of discussing Buddhist philos-
ophy within a cognitive-behavioral framework is through
the construct of metacognition. Metacognition has been
defined as beliefs and attitudes held about cognition (e.g.,
cognition about cognition; Flavell & Ross, 1981) or an ac-
tive and reflective process that is directed at one's own
cognitive activity (Allen & Armour-Thomas, 1991; Kluwe,
1982). Yussen (1985) defines metacognition as cognitive
activity for which other cognitive activities are the object
o f reflection (i.e., thinking about thinking). According
to Slife (1987), without metacognition, awareness of any
other cognition, such as thoughts, feelings, and memo-
ries, would be impossible. Metacognitive variables have
been widely used to understand how children acquire
problem-solving skills, monitor and regulate their mental
processes, and acquire knowledge of their abilities (e.g.,
reading, academic performance; Berardi-Coletta, Buyer,
Rellinger, & Dominowski, 1995). More recently, there has
been increasing interest in applying metacognition to the
understanding and treatment of psychopathology (Nel-
son, Stuart, Howard, & Crowley, 1999; Rachman & Shaf-
ran, 1999; Teasdale, 1999; Toneatto, 1995, 1999a, 1999b;
Wells, 1997).
Metacognition may serve as a means of introducing
Buddhism into cognitive and behavioral practice as both
are concerned with an individual's cognitive response to
his or her own cognition. In a metacognitive treatment
model for anxiety disorders, the client's distorted beliefs
about his or her own anxiety-related cognitions are con-
73
sidered to be highly important in the maintenance of the
disorder. Both Buddhist psychology and metacognitive
theory make a distinction between adaptive or correct
metacognitions and maladaptive or erroneous metacog-
nitions. These two sets of metacognitions are distin-
guished by the degree to which a statement about cogni-
tive experience is valid (discussed below). Anxiety-related
metacognitions tend to be highly exaggerated, cata-
strophic, and inaccurate appraisals of what are, in actual-
ity, quite ordinary (in the sense of being well within the
range of h u m a n experience and typically quite c o m m o n )
perceptions and sensations. Both cognitive-behavioral
therapy and Buddhist psychology stress the importance
of correcting erroneous cognizing of the external and in-
ternal environment. As a result, Buddhism may have
m u c h to offer to the cognitive-behavioral understanding
and treatment of psychopathology.
Prior to elucidating the contribution of Buddhist psy-
chology to a metacognitive model of clinical anxiety, it is
important to first describe how the terms cognition and
anxiety will be employed t h r o u g h o u t this article.
Cognition
Cognition will be understood as those subjective expe-
riences that one can know or become aware of. Thus,
cognition includes all mental or psychological states of
which one can be conscious. Cognition should not be re-
duced to discursive thinking (better termed cogitative or
cogitation) as is c o m m o n l y d o n e in many m o d e r n versions
of cognitive-behavioral therapy. Thus, cognition can in-
clude all emotion, mood, feeling, discursive thinking, im-
agery, memory, dreaming, sensory perception, and so-
matic sensation. In short, whatever can be experienced
by h u m a n consciousness is cognition. Cognition should be
distinguished from awareness, the latter of which refers to
the ability of the h u m a n mind to distinguish cognition
(e.g., feeling or thinking) from cognizing (e.g., to know
that one is feeling or thinking).
Although several types of cognition are differentiated
within Buddhist psychology (which cannot be described
in detail here), it will be important to at least distinguish
between perceptual cognitions and conceptual cogni-
tions (Komito, 1987). Perceptual cognition refers to the
way that events in the external environment and within
our own body actually present to our awareness. Concep-
tual cognition refers to the thoughts, feelings, memories,
sensations, and so on that almost immediately and insep-
arably arise or co-emerge with the perceptual cognition.
Conceptual cognitions may be merely descriptive (e.g.,
"That is a sound"), analytic (e.g., "That is a loud sound"),
or evaluative (e.g., "That is an unpleasant sound").
Within a Buddhist perspective, metacognitions are con-
ceptual cognitions that have, as their object, other per-
ceptual and conceptual cognitions. W h e n the metacogni-
74 Toneatto
tion is perfectly accurate, a n d without distortion or bias,
m e t a c o g n i t i o n is equivalent to awareness.
T h r o u g h o u t this article, terms such as cognition, cogni-
tive experiences, cognitive states, mental even& mental phenom-
ena, cognitive phenomena, a n d cognitive event.s"will be used
interchangeably.
Anxiety Disorders
T h e c o n c e p t o f anxiety within c o n t e m p o r a r y psychol-
ogy h a d gradually becoxne a retried concept. Within a
metacognitive framework, a n d consistent with Buddhist
psychology, anxiety is u n d e r s t o o d as a subjective experi-
ence consisting o f several types of cognitive events (such
as thoughts, sensations, images, feelings, a n d m e m o r i e s ) .
Any o r all of these cognitive p h e n o m e n a may be p r e s e n t
d u r i n g an episode o f anxiety. W h a t unifies this diversity
of cognitive events into an e x p e r i e n c e o f anxiety is the
cognition o f a p p r e h e n s i v e feat. Thus, d u r i n g an episode
of anxiety, thoughts have a high fear content, imagery
may display scenes o f fear, a n d the somatic sensations co>
r e s p o n d to those observed d u r i n g fear. It is i m p o r t a n t to
distinguish a m o n g these elements of anxiety within recta-
cognitive theory a n d Buddhist psychology since the anx-
ious individual does n o t e x p e r i e n c e anxiety but r a t h e r in-
dividual cognitions. For example, an individual who is
panicking is aware primarily of highly aversive somatic
symptoms; a social phobic may be particularly sensitive to
self-judgmental thoughts that they attribute to others.
Consequently, it is not possible to adequately treat anxi-
ety if the constituent c o m p o n e n t s are n o t individually
analyzed.
Clinical anxiety disorders can be classified into two
b r o a d categories: fear of cognitions that have their
source ostensibly in the external e n v i r o n m e n t (which in-
clude the p h o b i c disorders snch as a g o r a p h o b i a , social
phobia, specific p h o b i a ) a n d the fear o f cognitions that
have their source ostensihly in the internal e n v i r o n m e n t
(which include the anxiety states such as obsessive-
compulsive disorder, posttramnatic stress disorder, gener-
alized anxiety disorder, panic disorder, acute stress disor-
der). In both categories, the individual responds in an
exaggerated, maladaptive, o r overreactive m a n n e r to a
cognition that is u n d e r s t o o d to be, at least on an intellec-
tual level, harmless. Exposure to the feared cognition
elicits a strong aversive reaction and c o n c e r t e d efforts to
avoid or escape. This may involve modifying one's social
relationships (e.g., social phobia) in o r d e r to prevent the
o c c u r r e n c e o f self-critical thoughts, restricting behavioral
choices (e.g., a g o r a p h o b i a , specific phobia) in o r d e r to
prevent the o c c u r r e n c e o f aversive somatic sensations or
beliefs o f i m m i n e n t danger, a d o p t i o n of rituals o r com-
pulsions (e.g., obsessive-compulsive disorder) in o r d e r to
eliminate highly aversive discursive thoughts, seeking as-
surance from others (e.g., posttraumatic stress disorder,
generalized anxiety disorder) to attenuate frightful imag-
ery and thoughts o f dangeI: T h e high risk o f substance
abuse as a c o p i n g response is an indication o f the mea-
sures an individual suffering from severe anxiety may
a d o p t in o r d e r to escape fearful cognitions (Toneatto,
1995, 1999b). It must be stressed, however, that the anx-
ious individual is taking e x t r a o r d i n a r y measures to es-
cape or avoid stimuli that are, by definition, n e i t h e r
harmful n o r dangerous. It is this knowledge that informs
and justifies efforts to help cognitive-behavioral therapies
and is the key insight that Buddhist psychology hopes to
inculcate. Cognitive-behavioral treatments for anxiety
disorders seek to explicitly modity anxiety-specific meta-
cognitions t h r o u g h actual e x p o s u r e to the feared cogni-
tions (e.g., phobic stimulus), c o m b i n e d with a critical ex-
a m i n a t i o n o f the a t t e n d a n t cognitive processes (e.g.,
catastrophization). Successful t r e a t m e n t usually results in
a reappraisal of feared cognitions (e.g., "My fast h e a r t
rate means I am having a h e a r t attack") that is closer to
what the average person might believe (e.g., "My fast
h e a r t rate is unusual, but I d o u b t I am having a h e a r t
attack").
Potential Contribution of Buddhist Psychology
Consistent with the metacognitive m o d e l o f anxiety
briefly described above, Buddhist psychology stresses
how h u m a n s continually e x p e r i e n c e intense suffering be-
cause o f their m i s u n d e r s t a n d i n g o f the nature o f phe-
n o m e n a as they p r e s e n t to their own awareness. Not only
is their own cognition misunderstood, there is little in-
sight into this confllsion. Consequently a n d invariably,
they seek to grasp at their confused cognition behavior-
ally, emotionally, a n d cognitively by striving to acquire
that which is b e l i e v e d to be d e s i r a b l e o r p l e a s u r a b l e
a n d to e l i m i n a t e what is believed to be u n d e s i r a b l e o r
unpleasurable.
T h e teachings o f the B u d d h a not only accurately de-
scribe these h u m a n tendencies but also prescribe specific
means for o v e r c o m i n g this i n h e r e n t confusion a n d o f re-
alizing o u r highest h u m a n potential, c o m m o n l y referred
to as Buddha-nature. Buddhist insights into the n a t u r e o f
mental functioning a n d the m i n d training that defines
Buddhist practice are highly relevant to the t r e a t m e n t of
clinical anxiety disorders.
Buddhism and Cognition
In o r d e r to apply Buddhist psychology to the cogni-
tive-behavioral t r e a t m e n t o f anxiety disorders, it is impor-
tant to briefly describe the Buddhist perspective o f cogni-
tion. With an u n d e r s t a n d i n g of the nature o f cognition,
several practical a p p r o a c h e s to the t r e a t m e n t o f anxiety
disorders can be elaborated.
Cognitive phenomena are nonveridieal. T h e cognitive
 Buddhism and Anxiety Disorders
p h e n o m e n a of which we are aware are rarely based on an
accurate or "true" description of the e n v i r o n m e n t as it
presents to o u r six senses (the B u d d h a c o n s i d e r e d m i n d
or consciousness to be a sense organ, with concepts,
thoughts, etc., as its object). Rather, valid p e r c e p t i o n s are
inextricably b o u n d u p with o u r beliefs, feelings, assump-
tions, a n d attitudes a b o u t that p e r c e p t i o n . Thus, h e a r i n g
a s o u n d will n o t only lead to o u r auditory nerve being
stimulated b u t also an array of c o n c e p t i o n s a b o u t that
s o u n d (e.g., pleasant, loud, etc.). Similarly, the occur-
r e n c e o f a t h o u g h t will usually elicit additional thoughts
that e l a b o r a t e , j u d g e , or transform it a n d may be accom-
p a n i e d by images, memories, a n d somatic sensations, for
example. Virtually all o f o u r mental activity consists of
e i t h e r p e r c e p t u a l or conceptual cognitions. T h e latter
t e n d to be c o n d i t i o n e d , biased, a n d distorted (whether in
an adaptive or maladaptive direction).
Cognitive phenomena are unavoidable. Humans, while
alive a n d conscious, are continuously cognitively active.
T h e ubiquity of cognitive activity is a reflection of the
mind's vast creative capacity and responsiveness. Through-
out a typical day, an i n n u m e r a b l e series of sensations,
thoughts, perceptions, a n d images pass t h r o u g h o u r
awareness. Efforts to prevent cognition are ineffectual.
While pleasant cognitive p h e n o m e n a are generally pre-
ferred, u n p l e a s a n t cognitive p h e n o m e n a will regularly
occur t h r o u g h o u t the lifespan o f every h u m a n , despite
efforts to avoid such experiences. Within a Buddhist per-
spective, pleasant a n d u n p l e a s a n t cognitions are often in-
timately connected. For example, when pleasant experi-
ences cease o r d o n o t e n d u r e for as l o n g as we would like,
t h e n u n p l e a s a n t feelings may arise. Similarly, when un-
pleasant experiences cease, often this is e x p e r i e n c e d as
pleasure. Thus, regardless of the initial valence o f an ex-
perience, there is a great l i k e l i h o o d that the opposite va-
lence will also occur.
The onset of cognitive activity is outside of our control.
Cognitive states a p p e a r to arise, abide, a n d cease within
awareness without any a p p a r e n t conscious involvement
o f the individual. This is most obvious with r e g a r d to the
activity o f o u r senses, which are completely outside o f o u r
conscious control. Even mental events such as thoughts
are rarely initiated in a deliberate fashion b u t typically
simply arise within awareness. Discursive thought, for ex-
ample, is n o t a c c o m p a n i e d by any awareness o f the pro-
cess that leads to the selection o f specific words, gram-
mar, o r syntax. Careful e x a m i n a t i o n o f o u r cognition
suggests that these p h e n o m e n a seem to be automatic,
c o n d i t i o n e d , a n d a u t o n o m o u s . T h e role o f the experi-
encing individual appears limited to labeling o f such phe-
n o m e n a (e.g., "I feel anxious") a n d r e s p o n d i n g metacog-
nitively (e.g., "I hate feeling anxious") a n d behaviorally
(e.g., "I am going to take some m e d i c a t i o n to h e l p calm
m e down"). Attempts to prevent cognition are virtually
75
impossible as the suppression of cognition is usually diffi-
cult a n d ineffective. Often, the only o p t i o n is to a t t e m p t
to interfere with such cognitive activity t h r o u g h behav-
ioral distraction.
Cognitive events are impermanent. While unavoidable
a n d o m n i p r e s e n t , all cognition is e p h e m e r a l a n d con-
stantly changing. T h o u g h t s continuously (and often re-
peatedly) e n t e r o u r awareness, evolve into o t h e r thoughts
o r cease j u s t as quickly; the senses are continually stimu-
lated by the physical e n v i r o n m e n t , m e m o r i e s rapidly
form a n d dissolve, m o o d s oscillate in intensity, images
continuously shift. Careful e x a m i n a t i o n o f this m e n t a l ac-
tivity d e m o n s t r a t e s the i n h e r e n t i m p e r m a n e n c e o f all
cognitive p h e n o m e n a . Even cognitive states that a p p e a r
to be p r o l o n g e d o r long-lasting, such as pain o r depres-
sion, are seen to consist of discrete m o m e n t s of cognitive
activity that may differ slightly from m o m e n t to m o m e n t .
W i t h o u t the transience o f such cognition, it would n o t be
possible to have any e x p e r i e n c e at all as the cessation o f
each cognition creates the necessary c o n d i t i o n for the
arising o f another.
Cognitive stales are insubstantial or illusory. While the ac-
tivities o f o u r consciousness seem very real a n d salient,
they are, nonetheless, difficult to define, locate, describe,
or physically isolate. Cognitive p h e n o m e n a n e i t h e r ap-
p e a r to have any substantiality p r i o r to their a p p e a r a n c e
within o u r awareness n o r any existence following their
cessation. This is analogous to a m o t i o n picture, which is
capable of entertaining, horrifying, o r e d u c a t i n g us
t h r o u g h the successive display of images that otherwise
have no existence p r i o r to a n d following their appear-
ance o n the movie screen. F u r t h e r m o r e , the images that
are displayed c a n n o t in any way be isolated or r e m o v e d
from contact with the movie screen without utterly de-
stroying the image. Thus, while o u r cognition is u n d e n i -
ably p r e s e n t a n d obvious, its nature is i n h e r e n t l y illusory
a n d without self-sufficiency. In Buddhist philosophy, this
is an indication o f the e m p t y n a t u r e o f cognition insofar
as such experiences are functions o f o t h e r processes, con-
texts, a n d conditions a n d readily dissolve when these pro-
cesses, contexts, a n d conditions cease. In fact, if it were
n o t for this ability for cognitive p h e n o m e n a to dissolve
(i.e., to be empty), it would n o t be possible to have cogni-
tion at all.
T h e r e is no e n d to the a m o u n t of questions to
which you can subject a t h o u g h t such as "I saw my
f r i e n d yesterday." W h e r e is this thought? W h e r e d i d
it c o m e from? W h a t is it m a d e of?. Is this t h o u g h t
the same shape as your friend a n d is the image o f
your f i i e n d the same as your friend himself?. W h e n
this t h o u g h t passes, does it leave no trace like a
c l o u d d i s a p p e a r i n g from the sky, or does it leave a
f o o t p r i n t like a child walking on the beach? If you
76 Toneatto

say this t h o u g h t has no qualities a n d c a n n o t be Buddhist Formulation of Anxiety Disorders

found, then what a b o u t the t h o u g h t that thinks
In light of the Buddhist view o f the nature o f cognitive
that? I f a m u t e person c a n n o t p u t his thoughts into
p h e n o m e n a , individuals suffering from clinically signifi-
words, does this m e a n he has no thoughts? By inter-
cant levels o f anxiety have m i s i n t e r p r e t e d their anxiety-
rogating t h o u g h t like this you can "question it to
related cognitions. T h e onset o f these feelings, sensa-
death." Persistent questioning takes the life out o f
tions, perceptions, a n d thoughts, t h o u g h u n p l e a s a n t a n d
t h e m a n d they will not b o t h e r to c o m e so often.
undesirable, are n o t c o n s t r u e d as natural, harmless, im-
A n d when they do they will be weaker in force a n d
p e r m a n e n t , and illusory expressions o f the creative a n d
n o t so bold. (Rinpoche, 1981, pp. 74-75)
responsive capacity o f the mind. Instead, anxiety-related
cognitions are attributed a significance a n d potency that
Cognitive states have no inherent potency. Sensory percep-
they do n o t inherently possess, thus transforming these
tions, memories, thoughts, and dreams do not have the ca-
cognitive states into dangerous, uncontrollable, a n d aver-
pability of direct influence on behavior or on the environ-
sire sources of psychological o r physical harm. As a result,
ment. While most p e o p l e can readily distinguish between
metacognitions o f danger, discomfort, a n d powerlessness
cognitive states that are pleasant or unpleasant, this dis-
p r e d o m i n a t e . T h e fact that symptoms o f anxiety often ap-
tinction should not lead to the assumption that unpleas-
p e a r spontaneously a n d never intentionally (e.g., panic
ant cognitive states are therefore dangerous or harmful
symptoms, obsessions, traumatic memories, worries seem
a n d pleasant ones harmless and helpful. While cognitive
to arise automatically) a n d seem to be impervious to the
states such as horrifying m e m o r i e s a n d images, panic anx-
individual's efforts to eliminate t h e m f u r t h e r reinforces
iety, and intense physical pain are undeniably unpleasant
these beliefs. It is n o t remarkable, given such a view, that
to most o f those who experience them, in a n d o f them-
the anxious individual develops phobias, readily ingests
selves they are incapable o f inflicting harm. Again, using
p h a r m a c o l o g i c a l agents, a n d suffers panic attacks. Meta-
the motion picture analogy, horrific movie images do not
cognitively, anxious individuals believe that their anxiety-
d a m a g e the screen on which they are projected. My
related cognitive processes are threats to their well-being,
thought, "That wall is blue," will in no way modify a wall
intolerable, dangerous, a n d undesirable.
that is red. O f course, behavioral responses to disagree-
able mental states may i n d e e d be harmful in a very direct
way (e.g., suicide, violence, intoxication, social isolation) Implications of Buddhist Psychology for
to the individual or others. T h e tt-ue potency of cognition Cognitive and Behavioral Treatment
is in its indirect effect on behavior a n d the e n v i r o n m e n t
In o r d e r to train your m i n d a n d overcome suffer-
when an individual decides to r e s p o n d to cognition.
ing, you must rely on the power o f hearing, think-
All cognitive activity has value. Cognitive states, but es-
ing, a n d meditating. You must first h e a r a correct
pecially u n p l e a s a n t ones, m o r e often than not are indi-
e x p l a n a t i o n o f the teachings, on the n a t u r e o f
cators of the n e e d tbr significant changes in o u r lives.
mind, for instance, a n d then think a b o u t t h e m in
U n p l e a s a n t cognitive states serve the same function, psy-
o r d e r to ascertain their meaning. The latter is like
chologically, as does pain for o u r physical well-being.
looking at the m i n d a n d subjecting it to endless
Physical pain, while u n d e n i a b l y unpleasant, is a harmless
questions and logical analysis. Finally, when you
b u t p o t e n t motivator to seek a n d resolve the source of the
have r e a c h e d a decision a b o u t the nature o f the
pain. Similarly, u n p l e a s a n t cognitive states serve to moti-
mind, you must meditate a n d actually e x p e r i e n c e it
vate changes in o u r behavior, lifestyle, social relationships,
to be so. T h r o u g h the h e l p of your Teacher you
interpersonal behaviors, and so on. M1 experiences, desir-
c o m e to recognize it from your meditation. Thus
able or not, have value for increasing self-knowledge a n d
all three are n e e d e d . (Rinpoche, 1981, p. 119)
self-understanding.
Cognitive activity is not separate from the functioning of the Cognitive-behavioral t r e a t m e n t i n f o r m e d by a Bud-
mind. Whatever the valence or the specific c o n t e n t attrib- dhist theory of cognition has as its initial goal the correc-
u t e d to cognition, the activities that occur within one's tion o f metacognitive beliefs a b o u t anxiety-related cogni-
awareness are an expression of the n o r m a l functioning of tive p h e n o m e n a . T h e client is instructed in a m o d e l o f
the h m n a n mind. They are n o t foreign or alien events cognitive functioning in which the symptoms o f anxiety
that require elimination, suppression, or destruction. must be construed as perfectly natural, harmless, a n d en-
Rather, all cognition is actually a display of the power of tirely transient events taking place within their own
the m i n d a n d completely identified with it. Thus, it is in- awareness (albeit u n d e n i a b l y unpleasant). This is best ac-
correct to separate mental activities from consciousness c o m p l i s h e d by d e v e l o p i n g a certainty a b o u t the veridical-
itself in the same way fire a n d heat or water a n d waves ity of the nature o f cognition as taught within Buddhist
c a n n o t be separated e x c e p t conceptually. philosophy. O f course, this is n o t possible solely t h r o u g h
 Buddhism and Anxiety Disorders
t h e r a p e u t i c discourse. Nevertheless, it is in this setting
that the client should receive instruction a b o u t the na-
ture o f cognitive functioning. W i t h o u t a t h o r o u g h under-
standing o f how consciousness functions, a client c a n n o t
be e x p e c t e d to learn to cope effectively with anxiety (in
the same way, without a knowledge o f mathematics, engi-
n e e r i n g is impossible). T h r o u g h application o f this
knowledge to b o t h clinically relevant a n d o r d i n a r y expe-
riences (see below), the client can actually e x p e r i e n c e
the insights r e g a r d i n g m e n t a l functioning a n d verify
their value as taught by Buddhism.
O n c e a firm insight into the n a t u r e of their cognition
is achieved, the client can t h e n be instructed into practi-
cal m e t h o d s to apply to anxiety-related cognitive phe-
n o m e n a . In the active phase o f t r e a t m e n t the client
learns to correct the metacognitions that have trans-
f o r m e d o r d i n a r y experiences into panic feelings, en-
counters with p h o b i c stimuli, o r discursive rumination,
by a d o p t i n g the most veridical metacognitive appraisal o f
such experiences that they can generate. In practice, this
requires the p a t i e n t to realize that the activities of the
m i n d are inherently natural, illusory, i m p e r m a n e n t , a n d
harmless. Within Buddhist psychology, certain concep-
tual metacognitions are c o n s i d e r e d to be therapeutic,
adaptive, or liberating (e.g., "These thoughts are all tran-
sient a n d insubstantial electrical brain activity") while
others are highly maladaptive a n d incorrect (e.g., "These
thoughts will never stop").
As success in accurately e x p e r i e n c i n g anxiety-related
cognitive events accumulates, a natural evolution occurs
in the kinds o f behavioral solutions that are selected in
response to such cognitions. Rather than simply avoiding
or escaping (and consequently severely c o m p r o m i s i n g
quality o f life), the individual is able to m o r e accurately
perceive his o r h e r (internal o r external) environment.
A m o n g the techniques that may be o f benefit, the
most i m p o r t a n t is the ability to apply n a k e d o r bare mind-
f u l attention to the anxiety-related p h e n o m e n a . Mindful
attention a p p l i e d to cognitive activity is the primary a n d
most effective tool taught by the B u d d h a for r e d u c i n g or
correcting the t e n d e n c y to e n g a g e in e r r o n e o u s metacog-
nitive activity. In m i n d f u l attention the client is encour-
aged to observe the display o f cognitive events o c c u r r i n g
within ordinary awareness (the everyday, u n t r a i n e d mind)
b u t refrain from e n g a g i n g in any metacognitive (i.e.,
j u d g m e n t a l ) activity. As Epstein (1995) has d e f i n e d this
attentional technique, "Pay precise attention, moment by mo~
ment, to exactly what you are experiencing, right now, separating
out your reactions from the raw sensory events" (p. 110). Due
to the m i n d ' s c o n d i t i o n e d t e n d e n c y to identify with any
o f the myriad forms o f c o g n i t i o n that may arise, this
t e c h n i q u e requires r e p e a t e d a n d persistent r e t u r n to
this a t t e n t i o n a l stance in o r d e r to extinguish this habit.
T h e r e are m a n y excellent p u b l i c a t i o n s detailing the ba-
77
sic techniques o f mindfulness m e d i t a t i o n (e.g., Kabat-
Zinn, 1990).
Within a stance o f m i n d f u l attention, cognitions, re-
gardless of content, are p e r m i t t e d to arise a n d dissolve ac-
c o r d i n g to their nature. If clients find that they have
b e g u n to engage in an i n n e r dialogue a b o u t what they
are e x p e r i e n c i n g or have i m m e r s e d themselves in a par-
ticular mental activity, they are e n c o u r a g e d to r e t u r n to
the initial attentional posture in which they are to simply
observe, nonjudgmentally, all cognitive activity. In so
doing, the natural history o f cognitive p h e n o m e n a can
be readily observed a n d gradually a distinction m a d e be-
tween mental experiences a n d the observing o f these
m e n t a l experiences. Growing awareness o f this space be-
tween the e x p e r i e n c e a n d the observation o f the experi-
ence is a j u n c t u r e at which the i n h e r e n t insubstantial na-
ture o f anxiety-related p h e n o m e n a can be observed to
arise a n d dissolve without any effort o r i n p u t necessary by
the client.
If you can focus without any c o n c e p t u a l thoughts
o r ideas, this is good. But should they arise, d o n o t
follow t h e m out. Just let t h e m pass a n d they will
disappear. If you allow a t h o u g h t to grow into a
train of thought, it will be an obstacle to your medi-
tation. You must realize that thoughts are the play
o f the mind, like ripples on water a n d light on
leaves. They naturally dissolve. (Rinpoche, 1981,
pp. 43-44)
To aid this effort, the client is e n c o u r a g e d to n e i t h e r
pursue cognitive p h e n o m e n a that they find pleasing n o r
avoid u n p l e a s a n t cognitive p h e n o m e n a . In the case o f
anxious individuals, the paradoxical t e n d e n c y to elabo-
rate a n d f u r t h e r articulate fearful images o r discursive
thinking is resisted. Such responses o n the p a r t o f the
anxious individual interfere with the natural course o f a
cognitive event, which is to arise a n d subside, a n d trans-
form it into a fearful a n x i o g e n i c c o g n i t i o n (which will,
o f course, also arise a n d dissolve). Thus, a m e a s u r e o f de-
t a c h m e n t o r psychological distance is necessary to
c o u n t e r the t e n d e n c y to select a n d identify with certain
aspects o f o u r cognition.
T h o u g h t s are the result o f confusion a b o u t the true
n a t u r e o f reality a n d t h e r e are many different
kinds. Coarse o r r o u g h thoughts are easy to iden-
tify. For instance, if you are m e d i t a t i n g on a cup,
a n d the t h o u g h t arises that you want to d r i n k tea
a n d t h e n you call s o m e o n e to fetch it for you, this is
a coarse thought. A fine or subtle t h o u g h t would be
thinking, "This is a cup" or "It is m a d e o f white
porcelain." But whatever type o f t h o u g h t arises,
identify it for what it is. Recognize that it is merely a
thought, the play o f the m i n d like an image on a
78 Toneatto
mirror, a n d w i t h o u t g r a s p i n g at it let it pass. H a v e
y o u r t h o u g h t s c o n t i n u a l l y dissolve like a p a r a d e o f
c h a r a c t e r s m a r c h i n g across a stage w i t h o u t any e v e r
s t a n d i n g still. ( R i n p o c h e , 1981, p. 53)
Individuals s u f f e r i n g f r o m clinical anxiety s h o u l d be
e n c o u r a g e d to view a n x i e t y - r e l a t e d aspects o f t h e i r cogni-
tion with a m e a s u r e o f t o l e r a n c e , kindness, a n d accep-
t a n c e r a t h e r t h a n aversion, r e j e c t i o n , o r hatred. In fact,
anxiety is f r e q u e n t l y a m e a n s by w h i c h o n e ' s m i n d is pro-
v i d i n g f e e d b a c k a b o u t areas o f life f u n c t i o n i n g that may
r e q u i r e m o d i f i c a t i o n . In this role, a n x i e t y f u n c t i o n s as a
s o u r c e o f i n f o r m a t i o n , t r a n s m i t t i n g p a i n f u l b u t necessa W
i n f o r m a t i o n a b o u t o n e ' s life.
In a p p l y i n g m i n d f u l a t t e n t i o n to a n x i o u s cognitions,
an a t t i t u d e o f p a t i e n c e a n d t o l e r a n c e toward t h e some-
times u n p l e a s a n t a n d aversive cognitive activities is strongly
e n c o u r a g e d . T o l e r a n c e a n d p a t i e n c e r e q u i r e an a t t i t u d e
o f a c c e p t a n c e , n o n i n t e r f e r e n c e , a n d respect. Since indi-
viduals s u f f e r i n g f r o m clinical anxiety d i s o r d e r s o f t e n cre-
ate an a n t a g o n i s t i c o r c o m b a t i v e r e l a t i o n s h i p with t h e i r
own m e n t a l f u n c t i o n i n g , they naturally e n g a g e in efforts
to suppress, e l i m i n a t e , avoid, escape, o r reject t h e i r cog-
nition. Viewing the activities o f awareness with g r e a t e r
e q u a n i m i t y r e d u c e s this t e n d e n c y to e n g a g e in c o n t i n u -
ous c o n f l i c t with t h e i r own c o g n i t i o n .
F u r t h e r m o r e , s u p p o s e you are f e e l i n g self-satisfied
a n d h a p p y that t h o u g h t s a n d d e l u s i o n s are n o t
i n t e r r u p t i n g y o u r m e d i t a t i o n . T h e n all o f a s u d d e n
m a n y r o u g h t h o u g h t s u p s e t you violently a n d you
c a n n o t b r i n g t h e m u n d e r c o n t r o l in m e d i t a t i o n .
You m i g h t r e g a r d t h e s e t h o u g h t s as e n e m i e s that
h a v e arisen. Try to r e c o g n i z e t h e s e very t h o u g h t s
a n d t h e n a t u r e o f these very t h o u g h t s . D o n o t
r e g a r d t h e m as faults, b u t t h i n k o f t h e m with kind-
ness. (p. 126, the N i n t h K a r m a p a W a n g - c h ' u g d o , j e ,
1981)
Summary
A c o m p l e t e e l u c i d a t i o n o f the t e c h n i q u e s that derive
f r o m a B u d d h i s t p s y c h o l o g y is n o t possible within this ar-
ticle. M i n d f u l a t t e n t i o n r e m a i n s the c o r n e r s t o n e o f Bud-
d h i s m ' s c o n t r i b u t i o n to alleviating h u m a n suffering.
With i n s t r u c t i o n in t h e n a t u r e o f c o g n i t i o n a n d p r a c t i c e
o f m i n d f u l a t t e n t i o n , an i n d M d u a l with clinical anxiety
can d e v e l o p valid m e t a c o g n i t i o n s a b o u t anxiety-related
p h e n o m e n a . This insight will r e d u c e n o t only the symp-
t o m s specific to a n x i e t y b u t g e n e r a l i z e to o t h e r areas o f
life f u n c t i o n i n g as well.
C o g n i t i v e - b e h a v i o r a l therapists, with t h e i r wide array
o f practical t e c h n i q u e s , can d e v e l o p m a n y u n i q u e inter-
v e n t i o n s based u p o n the B u d d h i s t p s y c h o l o g y o f cogni-
tion t h a t can be o f i m m e n s e utility in t e a c h i n g the anx-
ious individual a m o r e a d a p t i v e b e l i e f system a b o u t the
nature of their cognition.
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Address correspondence to Tony Toneatto, Ph.D., Head, Addiction
Section, Clinical Research Department, Center for Addiction and
Mental Health, 33 Russell St., Toronto, Canada M5S 2S1; e-mail:
tony_toneatto@camh.net.
Received: Janua U 10, 2000
Accepted: February. 20, 2001