Buddhist-Derived Loving-Kindness and Compassion Meditation ...self- Loving-Kindness and Compassion Meditation for the Treatment of Psychopathology: a Systematic Review ... and compassion

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  • ORIGINAL PAPER

    Buddhist-Derived Loving-Kindness and Compassion Meditationfor the Treatment of Psychopathology: a Systematic Review

    Edo Shonin & William Van Gordon & Angelo Compare &Masood Zangeneh & Mark D. Griffiths

    # Springer Science+Business Media New York 2014

    Abstract Although clinical interest has predominantly fo-cused on mindfulness meditation, interest into the clinicalutility of Buddhist-derived loving-kindness meditation(LKM) and compassion meditation (CM) is also growing.This paper follows the preferred reporting items for systematicreviews andmeta-analysis (PRISMA) guidelines and providesan evaluative systematic review of LKM and CM interventionstudies. Five electronic academic databases were systemati-cally searched to identify all intervention studies assessingchanges in the symptom severity of Diagnostic andStatistical Manual of Mental Disorders (text revision fourthedition) Axis I disorders in clinical samples and/or knownconcomitants thereof in subclinical/healthy samples. Thecomprehensive database search yielded 342 papers and 20studies (comprising a total of 1,312 participants) were eligiblefor inclusion. The Quality Assessment Tool for QuantitativeStudies was then used to assess study quality. Participantsdemonstrated significant improvements across fivepsychopathology-relevant outcome domains: (i) positive andnegative affect, (ii) psychological distress, (iii) positive think-ing, (iv) interpersonal relations, and (v) empathic accuracy. Itis concluded that LKM and CM interventions may have utilityfor treating a variety of psychopathologies. However, to over-come obstacles to clinical integration, a lessons-learned

    approach is recommended whereby issues encountered duringthe (ongoing) operationalization of mindfulness interventionsare duly considered. In particular, there is a need to establishaccurate working definitions for LKM and CM.

    Keywords Loving-kindness meditation . Compassionmeditation .Mindfulness . Psychopathology .

    Buddhist-derived interventions

    Introduction

    Buddhist-derived meditation practices are increasingly beingemployed in the treatment of psychopathology. Throughoutthe last two decades, clinical interest has predominantly fo-cused on mindfulness meditation, and specific mindfulnessinterventional approaches are increasingly being advocatedand/or employed in the treatment of psychiatric disorders(see, for example, American Psychiatric Association (2010)and National Institute for Health and Clinical Excellence(NICE) (2009) practice guidelines for the treatment of depres-sion). However, in the last 10 years, there has also been agrowth of interest into the clinical utility of other Buddhistmeditative techniques (Shonin et al. 2014a). Of particularsignificance are novel interventions that integrate meditativetechniques known as loving-kindness meditation (LKM)and compassion meditation (CM). Studies of LKM and CMinterventions have demonstrated a broad range ofpsychopathology-related salutary outcomes that include im-provements in the following (for example): (i) schizophreniasymptomatology (Johnson et al. 2011); (ii) positive and neg-ative affect (May et al. 2012); (iii) depression, anxiety, andstress (Van Gordon et al. 2013); (iv) anger regulation (Carsonet al. 2005); (v) personal resources (Fredrickson et al. 2008);(vi) the accuracy and encoding of social-relevant stimuli

    E. Shonin (*) :W. Van Gordon :M. D. GriffithsPsychology Division, Nottingham Trent University,Nottinghamshire, UK NG1 4BUe-mail: meditation@ntu.ac.uk

    A. CompareFaculty of Human and Social Sciences, University of Bergamo,Bergamo, Italy

    M. ZangenehFactor-Inwentash, Faculty of Social Work, University of Toronto,Toronto, ON, Canada

    MindfulnessDOI 10.1007/s12671-014-0368-1

  • (Mascaro et al. 2013a, b); and (vii) affective processing(Desbordes et al. 2012).

    CM is described in the psychological literature as themeditative development of affective empathy as part of thevisceral sharing of others suffering (Shamay-Tsoory 2011).LKM is more concerned with the meditative cultivation of afeeling of love for all beings (Lee et al. 2012). Depending onwhether they are practising LKM or CM, the meditationpractitioner first establishes themselves in meditative absorp-tion and then intentionally directs either compassionate (CM)or altruistic/loving (LKM) feelings towards a specific individ-ual, group of individuals (which can also include sentientbeings in general), and/or situation, and has conviction thatthey are tangibly enhancing the well-being of the person orpersons concerned (Shonin et al. 2014c). Although CM andLKM interventions in clinical contexts are typically deliveredusing a secular format (i.e., without the explicit use ofBuddhist terminology), the manner in which CM and LKMtechniques are operationalized in clinical settings is still rea-sonably closely aligned with the traditional Buddhist model.

    Buddhist Construction of Loving-Kindness and Compassion

    Within Buddhism, loving-kindness (Sanskrit, maitr) is de-fined as the wish for all sentient beings to have happiness andits causes (Bodhi 1994). Compassion (Sanskrit, karun) isdefined as the wish for all sentient beings to be free fromsuffering and its causes. In conjunction with joy (Sanskrit,mudit) and equanimity (Sanskrit, upeks), loving-kindnessand compassion make up what are collectively known as thefour immeasurable att i tudes (Sanskrit , catvribrahmaviharas). Although in Buddhist meditation the fourimmeasurable attitudes are often generated and then emanatedto other sentient beings one at a time, each attitude is deeplyconnected to, and reliant upon, the others. For example, theimmeasurable attitude of joy highlights the Buddhist view thatgenuine loving-kindness and compassion can only develop ina mind that is well-soaked in meditative bliss, and that hastransmuted both gross and subtle forms of ego-attachment(Khyentse 2007). Likewise, given the objective is to distributeloving-kindness and/or compassion in equal and unlimitedmeasures to all sentient beings, the immeasurable attitude ofequanimity emphasizes the need for total impartiality in onesregard for others (for a detailed discussion of the four immea-surable attitudes, see Nanamoli 1979).

    While the practices of compassion and loving-kindness areintegral to all Buddhist traditions, this is particularly the casein Mahayana Buddhist schools (Shonin et al. 2014c). One ofthe fundamental principles of Mahayana Buddhism is theconcept of bodhichitta. Bodhichitta is a Sanskrit word thatmeans the mind of awakening and it refers to the disciplineand attitude by which spiritual practice is undertaken with thecessation of others material and spiritual suffering as the

    ultimate aim (for a discussion of the different types of suffer-ing in Buddhism, see Van Gordon et al. 2014b). Buddhistpractitioners who adopt and act upon such an attitude areknown as bodhisattvas (for more a detailed description ofbodhichitta and the bodhisattvas way of life, see Shantideva1997). According to Shonin et al. (2014c), dedicating oneslife (and future lives) to alleviating the suffering of othersrepresents a win-win scenario because it not only helpsother beings both materially and spiritually but it also causesthe meditation practitioner to assume a humble demeanourthat is essential for (i) dismantling attachment to the self,and (ii) acquiring spiritual wisdom (for a discussion of themeaning of wisdom in Buddhism, see Shonin et al. 2014a).According to Buddhist thought, the wisdom deficit or igno-rance that arises from being attached to an inherently existingself is the underlying cause of all forms of suffering, includingthe entire spectrum of psychological disorders (Shonin et al.2014a).

    One of the most common CM/LKM techniques employedin clinical settings derives from the Tibetan lojong (meaningmind training) Buddhist teachings (Shonin et al. 2014c). Thelojong teachings are practiced within each of the four primaryTibetan Buddhist traditions (i.e., the Nyingma, Gelug, Kagyu,and Sakya) and include instructions on a meditation techniqueknown as tonglen (meaning giving and taking or sending andreceiving). Tonglen involves synchronizing the visualizationpractice of taking others suffering (i.e., compassion) and giv-ing ones own happiness (i.e., loving-kindness) with the in-breath and out-breath, respectively (Sogyal Rinpoche 1998). Inthis manner and according to Buddhist theory, the regularprocess of breathing in and out becomes spiritually productiveand functions as a meditative referent that facilitates the main-tenance of meditative and altruistic/compassionate awarenessthroughout daily activities (Shonin et al. 2014c).

    As elucidated above, compassion and loving-kindness helpto foster spiritual wisdom, but their effective cultivation is alsodependent upon it. In other words, compassion and loving-kindness facilitate wisdom acquisition and wisdom in-turnfacilitates the development of compassion and loving-kindness (Dalai Lama 2001). This spiritual wisdom or insightthat develops in conjunction with compassion and loving-kindness is believed to play a vital role in bringing the med-itation practitioner to the understanding that while compassionand loving-kindness arise from the wish for others to havehappiness and be free of suffering, the prospect of an individ-ual permanently eliminating the suffering of another individ-ual is a fundamental impossibility (Van Gordon et al. 2014b).Indeed, Buddhism asserts that individuals must take respon-sibility for their own spiritual development and that an en-lightened or saintly being can only play a supporting/guidingrole (Shonin and Van Gordon 2014).

    Thus, as stated by the Buddha in his teaching on The FourNoble Truths, suffering exists (the first noble truth) and the

    Mindfulness

  • only means by which an individ