Loving-Kindness in the Treatmentof Traumatized Refugees and Minorities

8/13/2019 Loving-Kindness in the Treatmentof Traumatized Refugees and Minorities

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Loving-Kindness in the Treatment of Traumatized RefMinority Groups: A Typology of Mindfulness and the Model of Affect and Affect Regulation

Devon E. Hinton,1,2 Rebecca A. Ojserkis, 1 Baland Jalal, 3 Sonith Peou, 4

and Stefan G. Hofmann 5

1Massachusetts General Hospital and Harvard Medical School 2Arbour Counseling Services3U.C. San Diego4Metta Health Center of Lowell Community Health Center5Boston University

This article discusses how loving-kindness can be used to treat traumatized refugees and minority

groups, focusing on examples from our treatment, culturally adapted cognitive-behavioral therapy (CA-CBT). To show how we integrate loving-kindness with other mindfulness interventions and why loving-kindness should be an effective therapeutic technique, we present a typology of mindfulness statesand the Nodal Network Model (NNM) of Affect and Affect Regulation. We argue that mindfulnesstechniques such as loving-kindness are therapeutic for refugees and minority populations because oftheir potential for increasing emotional exibility, decreasing rumination, serving as emotional regulationtechniques, and forming part of a new adaptive processing mode centered on psychological exibility.We present a case to illustrate the clinical use of loving-kindness within the context of CA-CBT. C 2013Wiley Periodicals, Inc. J. Clin. Psychol: In Session 69:817828, 2013.

Keywords: acceptance; mindfulness; meditation; posttraumatic stress disorder; cross-cultural

Introduction

In Buddhism, loving-kindness is highly emphasized. It is one of four emotions or virtues that arecalled bramavihara , meaning sublime attitudes, literally, the abodes of brahma. The virtuesinclude compassion, or karuna ; joy in the joy of others, or mudita ; detached, curious observation(also called equanimity), or ubekhaa ; and loving-kindness, or metta . (Often, Cambodians andother groups conate compassion and loving-kindness into one concept, metta garunaa .)In Cambodia, monks frequently entreat laypersons to develop a dharma heart, which entailscultivating these four virtues, for example, the virtue of having a loving-kindness heart. Thesefour emotions are thought to be important to cultivate to promote happiness, and parentsare exhorted to cultivate these four attitudes to be successful in raising children. A four-facedBrahma image is said to represent these four virtues, each face representing one of the virtues.In Cambodia, this four-faced Brahma image is depicted in many forms, from the tops of entiretemples, to small representations placed next to the Buddha images in the temple, to small wooddepictions that are kept in the home.

In our treatment for traumatized refugees, we emphasize loving-kindness. We refer to ourmanualized 14-session treatment for traumatized refugees and ethnic minority populations asculturally adapted cognitive-behavior therapy (CBT), or CA-CBT, which might also be calledculturally adapted exibility-focused therapy, or CA-FT, for reasons that will be describedbelow. The treatment emphasizes emotion regulation techniques such as mindfulness. In CA-CBT, mindfulness techniques are important parts of the anxiety, trauma, and anger protocols,

Please address correspondence to: Devon E. Hinton, Massachusetts General Hospital, Department of Psychiatry, 15 Parkman Street, WACC 812, Boston, MA 02114. E-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 69(8), 817828 (2013) C 2013 Wiley Periodicals, Inc.Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22017


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which are practiced at the beginning of almost all sessions. Our treatment has been shown tobe effective for traumatized ethnic minority (Latino) and refugee (Cambodian and Vietnamese)groups as compared with a waitlist condition and applied muscle relaxation (Hinton, Hofmann,Rivera, Otto, & Pollack, 2011).

Below, we rst describe two models that guide our treatment, namely, our typology of mind-

fulness states and the Nodal Network Model (NNM) of Affect and Affect Regulation. We usethese models to explain why loving-kindness and mindfulness states more generally may be effec-tive for reducing distress in traumatized groups. We next describe how we use loving-kindness inour treatment protocol and how we adapt loving-kindness for different groups. This is followedby a case example.

Mindfulness States: Typology and Key Aspects

In the psychological and Buddhist literature, compassion and loving-kindness are usually con-sidered to be forms of mindfulness meditation (Kabat-Zinn, 2005; Orsillo & Roemer, 2009).Whereas several mindfulness meditation practices involve a nonjudgmental awareness that fo-

cuses on breathing or other sensory modalities, these two other mindfulness modes involvehaving a certain feeling towards others: in compassion meditation (CM), a feeling of compas-sion for the suffering of others, and in loving-kindness meditation (LKM), a feeling of love forall beings.

Our denition of mindfulness is based on the Buddhist and psychological literature (for areview, see Hinton, Pich, Hofmann, & Otto, 2013). We dene mindfulness as the maintainingof one of several mindsets that involve a present-oriented experiencing and that are benecialto psychological well-being. To be mindful is to try to maintain one of the auspicious mindsetsin which a certain attentional object is viewed with a certain emotional attitude such as loving-kindness (see Table 1; cf. Shapiro, Carlson, Astin, & Freedman, 2006). According to thisdenition, mindfulness is a set of related practices, what might be called adaptive, present-

oriented mindsets, which are of several typese.g., cognitive sets, emotion sets, expressive sets,body setsthat differ enough that one cannot assume they will have the same effect through theirpractice.

The NNM of Affect and Affect Regulation

We consider negative mood states to be maintained by multiple interacting systems as depictedin the Nodal Network Model of Affect (Figures 1 and 2), a model resembling Teasdales(1996) Interactive Cognitive Subsystem (ICS) model. According to our model (Figure 1),trauma-related disorder is maintained by multiple interacting systems: a certain psychologi-cal appraisal mode (a sense of being threatened and being inadequate to deal with current

challenges); attentional bias (attention to threat and insult); mental-content processing mode(tendency to ruminate/worry); a certain set-shift predisposition (poor set-shift ability); a certaindecentering ability (overidentication with mental content, poor metacognitive awareness); ac-tion predisposition (withdrawal/perceived slight); self-image (a sense of being unable to adjust);muscle-based body state (rigidity, tenseness, negative posture); autonomic arousal state (chesttightness, shortness of breath, sweating); mood state (fear, anger, depression); and memory recallbias (negative memory). Successful emotion regulation can be conceived as the ability to changethe network nodes to more adaptive ones, with shifts in one node tending to change all theother nodes in the network, for example, a shift from the negative affective mode, depicted inFigure 1, to a positive mode, depicted in Figure 2. (For further description of the NNM, seeHinton et al., 2013; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012.)

Reasons for the Effectiveness of Mindfulness Techniques as Applied to Minorityand Refugee Populations

Mindfulness techniques derived from the Buddhist tradition have been shown to be effectivefor many disorders and have been included in several treatment protocols (Hofmann, Sawyer,


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T a b l e 1

A T y p o

l o g y o f M

i n d f u l n e s s T e c

h n i q u e s U s e d i n t h e B u d d h i s t a n d E a s t e r n T r a d i t i o n s

( A u s p i c i o u s M i n d s e t s : C o g n i t i v e S e t s , M o o

d S e t s , E m b o d i e d E x p r e s s i v e S e t s ,

B o d y S e t s )

T y p e

A t t e n t i o n a l o b j e c t

E m o t i o n

A c t i o n t e n d e n c y

A s s o c i a t e d p h y s i o l o g i c a l

s t a t e

A s s o c i a t e d B u d d h i s t

i m a g e r y a n d m e t a p h o r s

S e n s o r i a l a s p e c t s o f t h e

b o d y ( i . e . , c o n t e m p l a t i n g

t h e s e n s o r i a l a s p e c t s o f

t h e b o d y )

S e n s o r i a l e x p e r i e n c i n g i n i t s

v a r i o u s m o d a l i t i e s :

a t t e n d i n g t o t h e b r e a t h ,

k i n e s t h e t i c s ( b o d y

m o v e m e n t i n s p a c e ) ,

s m e l l s , s o u n d s

, o r v i s u a l

i m a g e s ( c o l o r , m

o v e m

e n t ,

s h a p e )

D e t a c h e d o b s e r v a t i o n

S o l i t a r y a n d w i t h d r a w a l

V a g a l d o m i n a n c e ; i n c r e a s e d

h e a r t r a t e v a r i a b i l i t y ;

a c t i v a t i o n o f t h e a n t e r i o r

c i n g u l a t e c o r t e x a n d t h e

e x e c u t i v e c o n t r o l n e t w o r k

T h e s o u l a s b e i n g w i t h t h e

b o d y

, t h e s o u l n o t o a t i n g

a w a y f r o m

t h e b o d y , a

f e e l i n g o f b o d i l y w e i g h t

r a t h e r t h a n l i g h t n e s s .

A t t e n t i o n

t h a t i s n o t

b r o k e n , i s n o t l i k e a

m o n k e y s w i n g i n g f r o m

b r a n c h t o

b r a n c h .

S e n s o r i a l a s p e c t s o f e x t e r n a l

o b j e c t s ( i . e

. ,

c o n t e m p l a t i n g t h e

s e n s o r i a l q u a l i t i e s o f a n

e x t e r n a l o b j e c t s )

T h e s e n s o r i a l p r o p e r t i e s o f

e x t e r n a l o b j e c t s , o f t e n

w i t h a f o c u s o n t h e v i s u a l

a s p e c t ( e

. g . ,

t h e

m o v e m e n t , c o l o r , o r

s h a p e o f a c a n d l e a m e ,

c l o u d s

, o r l e a v e s )



V a g a l d o m i n a n c e , i

n c r e a s e d





T h e m i n d a s a s p o t l i g h t

.

A t t e n t i o n

t h a t i s n o t

b r o k e n , i s n o t

d i s p e r s e d , i

s n o t l i k e a

m o n k e y s w i n g i n g f r o m

b r a n c h t o

b r a n c h .

M o o d

M o o d s t a t e , w h i c h i s

v e r b a l l y l a b e l e d a n d

d i s t a n c e d f r o m




n c r e a s e d





M o o d i s o f t e n a n a l o g i z e d t o

a c l o u d t h a t e n t e r s a n d

t h e n l e a v e s t h e s k y , w i t h

t h e m i n d b e i n g c o m p a r e d

t o t h e s k y .

C o m p a s s i o n ( k a r u n a a

)

A l l b e i n g s , i

n c l u d i n g o n e s e l f C o m p a s s i o n f o r t h e

s u f f e r i n g o f a l l b e i n g s ,

i n c l u d i n g o n e s e l f

I n t e r a c t i o n a l a n d

i n t e r p e r s o n a l e n g a g m e n t

I n s u l a a n d t h e a n t e r i o r

c i n g u l a t e c o r t e x ; o x y t o c i n

S o m e t h i n g p r o j e c t e d i n a l l

d i r e c t i o n s : w a t e r o r

w a r m t h t h a t s p r e a d s o u t

f r o m t h e h e a r t . O n e o f t h e

f o u r s f a c e s o f t h e

B r a h m a .


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T a b l e 1

C o n t i n u e d

T y p e

A t t e n t i o n a l o b j e c t

E m o t i o n

A c t i o n t e n d e n c y

A s s o c i a t e d p h y s i o l o g i c a l

s t a t e

A s s o c i a t e d B u d d h i s t

i m a g e r y a n d m e t a p h o r s

L o v i n g - k

i n d n e s s ( M e t t a )

A l l b e i n g s , i

n c l u d i n g o n e s e l f L o v e f o r a l l b e i n g s ,

i n c l u d i n g o n e s e l f


i n t e r p e r s o n a l e n g a g e m e n t

I n s u l a a n d t h e a n t e r i o r

c i n g u l a t e c o r t e x ; o x y t o c i n

S o m e t h i n g p r o j e c t e d i n a l l

d i r e c t i o n s : w a t e r t h a t

s p r e a d s o u t f r o m t h e

h e a r t . O n e o f t h e f o u r s

f a c e s o f t h e B r a h m a .

S t a y i n g i n

t h e m i d d l e .

S y m p a t h e t i c j o y ( m u d i t a a )

T h e j o y o f o t h e r s a n d t h e

r e a s o n f o r t h e i r j o y

J o y i n t h e j o y o f o t h e r s



O x y t o c i n

O n e o f t h e f o u r f a c e s o f t h e

B r a h m a .

E q u a n i m i t y ( u p e k k h a ) ( o f

n o t e , t

h i s i s v e r y s i m i l a r

t o m o o d m i n d f u l n e s s )

A l l e m o t i o n s , m

e n t a l

o b j e c t s , w i t h a l l e m o t i o n s

a n d t h o u g h t s b e i n g

v e r b a l l y l a b e l e d a n d

d i s t a n c e d f r o m




n c r e a s e d





S t a y i n g i n t h e m i d d l e . M o o d

i s o f t e n a n a l o g i z e d t o a

c l o u d t h a t e n t e r s a n d t h e n

l e a v e s t h e s k y , w i t h t h e

m i n d b e i n g c o m p a r e d t o

t h e s k y . O n e o f t h e f o u r s

f a c e s o f t h e B r a h m a .

G r a t i t u d e ( d e u n g

k u n )

P e r s o n t o w h o m o n e i s

g r a t e f u l , t

h i n g s f o r w h i c h

o n e i s g r a t e f u l

G r a t e f u l j o y



O x y t o c i n

B l o o m i n g l o t u s

S m i l e

F a c i a l e x p r e s s i o n

J o y f u l



O x y t o c i n

L o v i n g - k i n

d n e s s i m a g e r y , a

b l o o m i n g l o t u s

H u m o r

W h a t i s h u m o u r o u s ,

l a u g h t e r i t s e l f

J o c u l a r j o y



O x y t o c i n

N / A

M u s c l e r e l a x a t i o n a n d

e x i b i l i t y

B o d i l y e x i b i l i t y

R e l a x e d , j

o y f u l , a n d a l e r t



( I c a n a d j u s t t o a n y

s i t u a t i o n )

D e c r e a s e s y m p a t h e t i c s ,

i n c r e a s e p a r a s y m p e t h e t i c s

B a m b o o , o t h e r n a t u r e

i m a g e s o f e x i b i l i t y

N o t e . O n t h e p h y s i o l o g y o f t h e s e m i n d f u l n e s s s t a t e s , s e e H o f m a n n , G r o s s , &

H i n t o n , 2 0 1 1 ; I m m o r d i n o - Y a n g e t a l . ,

2 0 0 9 ; L u t z e t a l . , 2 0 0 8 ; P o s n e r , R o t h b a r t , &

S h e e s e , 2 0 0 7

.


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Loving-Kindness 821

Figure 1. The NNM of negative affect: focus on inexibility aspects.Note . This is a nodal network model of negative affect, showing how multiple nodes interact to create anegative affective state. At one point in time, one or another node may be the object of attention or may bemore active in determining the current mode of processing. As one node becomes active, all the other nodestend to be so as well; if one node shifts, all the others tend to as well. It shows aspects of mood state that

need to be targeted in emotion regulation, shows therapeutic entrance points. See Figure 2 for the state towhich emotion regulation attempts to shift, including the specic node shifts.

Witt, & Oh, 2010); a recent review suggests the potential value of integrating loving-kindnessinto psychological treatments (Hofmann, Grossman, & Hinton, 2011). As illustrated by thetypology of mindfulness and the NNM of Affect and Affect Regulation, mindfulness states suchas loving-kindness should bring about improvement in several ways.

Mindfulness states such as loving-kindness help to create a new adaptive default-processingnetwork centered on psychologicalexibility (Figure 2). (Other treatmentdevelopersalsopresentevidence that mindfulness promotes psychologicalexibility; see, e.g., Hayes, Strosahl,& Wilson,

1999.) Recent studies postulate that such mindfulness techniques create long-lasting neuronalnetworks that become part of the general top-down processing, that is, they become new defaultmodes of processing (Kok & Fredrickson, 2010). In our treatment, we try to create a nodalnetwork centered on exibility. The exibility nodal network may be activated by mindfulnesstechniques such as multisensorial meditation, loving-kindness, mindful stretching, or a smile.We consider a key part of exibility to be emotional exibility. This includes trying to learn to


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Figure 2. The NNM of positive affect: focus on exibility aspects.Note. Certain therapeutic techniques may change many nodes, shifting from the negative state shown inFigure 1 to a new processing mode, centered on exibility. For this reasons, we refer to this as the NNMof Affect and Affect Regulation, because it shows how mood states shift and how one may bring about

mood change. The model shows various therapeutic entrance points. For example, doing loving-kindnesswill change many nodes: It will change mood, decrease rumination, bring to mind positive imagery that ishighly valued (the person identied with the Buddha and other gures who make merit), change self-image,and create a prosocial, active engagement. In turn, when these nodes shift, all the other nodes will tend toshift towards the processing mode shown here in Figure 2.

use different affective states such as loving-kindness. We frame all these interventions in termsof exibility during the treatment.

Mindfulness states such as loving-kindness promote emotional exibility and psychologicalexibility more generally, for example, through the emotional exibility protocol, in which thereis a shift from one to another affective state (see below for a description of this protocol).

Mindfulness techniques increase psychological exibility, helping to shift to a more adaptiveprocessing mode such as illustrated in the shift from Figure 1 to Figure 2 (Hinton et al., 2013;Hinton et al., 2012). In keeping with a large emerging literature (for a review, see Hintonet al., 2013), we consider psychological exibility as the ability to do the following: (a) disen-gage/distance/decenter from a current mindset to enter a state of contemplating that mindsetrather than enacting it (this might be called a switch to a distancing mindset); (b) consider other


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Loving-Kindness 823

possible mindsets, in which the term mindset is meant in a broad sense that includes affectset (i.e., a certain emotion, like loving-kindness), action set (i.e., performing a certain action,such as maintaining a smile or stretching), explanatory set, and attentional-object set; and (c)enact different mindsets in the attempt to adapt to the situation. Mindfulness techniques help toachieve a state of disengaging/decentering/distancing, and meditation techniques involve prac-

tice in mindset shifting such as from verbal processing to sensorial experiencing, for example,from engaging in verbal-centered worries about a future event to attending to the ow of thebreath or to practicing loving-kindness.

We consider psychological exibility to be an adaptive processing mode in opposition toother negative modes, such as a threat mode. Psychological exibility decreases rumination,depression, and anxiety (Koster, De Lissnyder, Derakshan, & De Raedt, 2011), and so too doesmindfulness (Roemer et al., 2009). Mindfulness techniques decrease rumination by serving asemotion regulation techniquesfor example, through directing attention to another focus, thatis, through attention regulation and shiftthat help the individual to stop the vicious cycleof rumination. Worry and rumination are important treatment targets in ethnic and minoritytraumatized populations because they have hyperreactivity to worry and because they have

frequent induction of worry, often owing to living in poor urban contexts and confronting manystressors that range from nances to health problems to truancy/gang violence to personalsafety concerns (Hinton, Nickerson, & Bryant, 2011).

Worry may greatly worsen posttraumatic stress disorder (PTSD; Hinton, Nickerson et al.,2011); worry episodes result in a threat-mode, in irritability, and in panic-like autonomic arousal(worry attacks) that may cause mental and somatic symptoms that give rise to catastrophiccognitions and trauma recall. Some theories of worry consider it to result in decreased arousalin response to stressors (Borkovec & Hu, 1990); however, studies indicate that patients withworry have high rates of arousal symptoms, are particularly hypervigilant to phasic changes inarousal symptoms, and are at increased risk for panic, including having panic triggered by worryepisodes (Andor, Gerlach, & Rist, 2008).

For refugee and ethnic minority groups, psychological exibility is a key skill that better equipsthem to adjust to a newsocial, cultural,and linguistic context. For example, a Cambodianpatientneeds to switch between the English and Cambodian language and between the American andCambodian cultures, and this switching between registers is particularly important in respectto dealing with children who are often highly acculturated and speak minimal Cambodian(Hinton, Rasmussen et al., 2009). Moreover, mindfulness techniques such as loving-kindnessdecrease somatic complaints, a key distress presentation and treatment target among ethnicminority and refugee populations (Hinton & Lewis-Fern andez, 2011). Mindfulness providesmindsets that shift the attentional focus from a hypervigilant surveying of the body for somaticdistress to another focus. Mindfulness techniques serve as emotion regulation techniques thatdecrease arousal (Goldin & Gross, 2010; Hofmann, Sawyer, Fang, & Asnaani, 2012) and hence

somatic symptoms.In addition, mindfulness techniques serve as emotion regulation techniques more generally,and they can be used following exposure to change fear networks. The resultingshift in self-imageand other effects help bring improvement as is discussed in the next section.

Loving-kindness in CA-CBT and its Adaptation to Cultural Groups

In certain sessions of CA-CBT, we teach the patient to radiate loving-kindness to himself orherself and in all directions to all beings, and in several sessions we have the patient practiceprojecting loving-kindness while returning home (see Table 2 for the version used with Asianpatients). This practice helps to decrease anger, among other effects (Lutz, Slagter, Dunne, &

Davidson, 2008). Loving-kindness is also part of several key protocols in our treatment. In oneprotocol, which might be called the emotional exibility protocol, we tell the patient that alwaysusing only one or two emotions all the time is like being a painter who uses only one or twocolors to paint, a musician who uses only one or two notes, or a cook who uses only one or twoingredients. We then have the patient experience four different emotional states. See Table 3 fora full description of this protocol.


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Table 2Loving-Kindness for Asian Patients (Buddhist)

Practicing having a good attentional object and a good emotionWe want you to practice having another feeling and to put your mind and focus on a good thing. We

want you to practice having other types of emotion. Performing loving-kindness (water and cooling imagery)

Upon leaving the ofce today, as you walk along, practice spreading loving-kindness to all beings Loving-kindness is a way to practice having a positive emotion Direct love and kindness to yourself Direct love and kindness to all beings Imagine love owing from your heart, like a cooling water Imagine the water going out from your heart in all directions Imagine that the water extinguishes all anger Wish that all beings be happy Wish that all beings be free from anger Wish that all beings have wisdom Imagine loving-kindness owing from your heart to all beings, like a water owing from your heart Practice projecting a feeling of love and kindness to all beings as you go home, and during the next week

Note. For a Spanish patient, we use the image of a heat and light owing from the heart rather than coolingwater.

Table 3Emotional Flexibility Protocol

Dont get stuck on certain emotionsSometimes we forget to practice having different emotions. We get stuck with one emotion, like anger,

envy, regret, or worry. Lack of emotional range: comparison to cooking, painting, and music

You want to practice having different emotions. Otherwise, you are like: A painter with only one or two colors A cook that uses just one or two ingredients A musician who always plays the same two notes.

Practicing emotion shifting: Try practicing these following emotionsHere are some four emotions that research has shown will help you to be happy, that you should

practice. Try one. [After giving each example, the therapist should pause; the therapist should speakslowly; this gives the patient time to imagine having the emotion]:

Compassion . A feeling of compassion for the sufferings of all beings Joy in the joy of others . A feeling of joy when others are successful or happy. Loving-kindness . A feeling of loving-kindness, a feeling of love for yourself and all beings. Detached, curious observation .

Observation and non-action . A feeling of observing and letting go of all emotions, of just watchingyour emotions, of not acting on them, a feeling of nonjudging, of waiting and watching your emotions.Stay distant from emotion in a state of curious observation.

Label and observe effects . Just label the emotion, look at the effects of the emotion on you thoughtsand body, and let it go, stay distant from it. Say to yourself, Oh, I have anger, and watch it, stay distantfrom it, let it go, not acting on it. Comparison of a mood to a cloud . Like clouds in the sky, so too new thoughts and emotions will come toyou. Just watch them, stay at distance, and soon they will pass, like clouds from a sky.

Loving-kindness is also part of our trauma protocol. In the protocol, the patient describes

any trauma event recalled in the last week, which usually causes the individual to become upset.Then the patient is brought through several mindfulness states, including loving-kindness, so thatexposure becomes a chance to practice emotion regulation. Doing the trauma protocol promotesacceptance in that the individual stays with the sense of pain and the reality of the trauma eventbut does so with a sense of compassion. This serves as exposure to and reprocessing of thetrauma network because the patient relives the event but with a different affect and cognitive


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Loving-Kindness 825

frame. There is a shift from a cognitive appraisal of hopelessness, self-blame, self-hatred, andother-directed hatred to the emotion of compassion and a positive self-image among othereffects.

We change loving-kindness imagery depending on the group. During loving-kindness medita-tion with Latino populations, we have patients conjure the image of a light and heat emanating

from the heart. This image is an extremely prominent aspect of the iconography in the LatinAmerican religious tradition, in which it is referred to as the Sagrado Coraz on de J esus, or theSacred Heart of Jesus. For Buddhist Asian populations, we have the patient visualize water andcoolness owing from the heart and body. In the Buddhist context, cooling and water evoke ideasof merit, centered mind, and freedom from anger or other negative states, and water has a widerange of resonances. Two of the most common and celebrated scenes of Buddhist iconographyare the Buddha pointing to the ground to summon the Earth Goddess and the Earth Goddesswringing a torrent of water from her hair. (In a Cambodian temple, the central Buddha imageis usually in this posture and often there is an image of the Earth Goddess wringing her hair.)These images celebrate the moment Siddhartha reached Nirvana , that is, enlightenment. Whenattacked by Mara and his demons, Buddha pointed to the ground to request that the Earth

Goddess give witness to all the good deeds he had done in his previous lives; in accordance withthe Indic tradition, he had poured a little water on the ground each time he made merit in thisway. Responding to the request, the Earth Goddess then appeared and wrung her hair and waterowed down in a ood to drown Mara and all his legions.

Case Example

Above we described how we used loving-kindness in the setting of our 14-session treatment.Below we will illustrate an example of how we use loving-kindness for patients not in our14-session CBT treatment. This case will also help to illustrate how we consider loving-kindnessto be one of several positive mental states we try to cultivate in keeping with our typology of

mindfulness and the NNM of Affect and Affect Regulation.

Case: A Cambodian Patient: Leng

Before arriving in the United States, Cambodian refugees passed through periods of extremeadversity. Several years of bloody civil war preceded the Khmer Rouge rule from 1975 to 1979.During the Khmer Rouge period, a quarter of Cambodias population of 8 million people diedfrom starvation, illness, and execution, most commonly by a blow to the back of the neckbefore being dumped into a large burial pit. In 1979, during the Vietnamese invasion, manyCambodians were caught in crossre, and others died of starvation when driven into the jungleby the Khmer Rouge; many ed to the Thai border. Getting to border camps was risky along

paths that were mined and patrolled by marauders; once in these camps, Cambodians oftenlived for months or even years under local warlords, frequently besieged by Khmer Rouge,Vietnamese, and Thai soldiers; next came a stay in inner Thailand in chaotic and sometimesdangerous refugee camps, awaiting permission to come to the United States. Upon arrival to theUnited States, Cambodians had to adjust to a completely new culture and language and oftenlived in urban settings where they faced poverty and contexts of endemic violence.

All these events had been endured by Leng, who presented to our outpatient psychiatric clinicin Lowell, Massachusetts, a city that is home to over 25,000 Cambodians, the second largestpopulation in the United States. The rst author (DH), who is uent in Cambodian, was herclinician. Leng had suffered the loss of both her parents and eight siblings due to starvationduring the Pol Pot period. She also lost her husband and three of ve children to starvation. She

currently lived with her daughter and three grandchildren. Recently, her PTSD had worsenedand she had a great increase of anger, trauma recall, and poor sleep. She ruminated excessivelyabout possible problems (e.g., the health condition of several relatives), and she was often angry,had started swearing frequently, and was somewhat paranoid and hypervigilant to threat.

As an intervention, DH suggested to Leng that she should cultivate the virtue of gratitudefor having arrived to the United States and having surviving family, and she should realize these


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to be blessings. DH explained to her that if she practiced loving-kindness, then she would bemaking merit for herself, her living relatives, and those who died in the Pol Pot period. (InBuddhism, there is the idea that if you do a good act, like meditation or alms giving, then thismakes merit, a sort of supernatural holiness, which can be shared with the deceased; this helpsthe deceased to be reborn to a better rebirth. There is also the idea that if someone died a violent

or horrible death, then they may not have been reborn owing to past demerit.)DH told Leng that if she wished to get better, she had to cultivate positive states, and that

her medication and other treatments would be effective only if she did so. As an example of apositive state, DH gave the example of laughing, and to demonstrate this, DH laughed and gother to laugh along with him. There was quite a shift from her sullen state. DH said that bellylaughs were curative. DH then modeled for her how to do loving-kindness (Table 2), movingthe arms outward to demonstrate the envisioned ow of water from the heart. DH told her topractice having a sense of love like a cooling water ow from her heart, as she went home andin the coming days. DH said that rather than swearing and being angry, she should practice thismental state. DH explained that this would bring coolness and prosperity to the home.

At the following visit, Leng was improved. She was less angry, as conrmed by her daughter.

Leng smiled and laughed some, whereas before she never smiled and looked very tense. However,she continued to be hypervigilant to threat and accusative: she thought someone might steal her jewelry and accused someone falsely upon nding a piece missing. DH reminded Leng that thetrue jewels were her children and grandchildren, and not to worry so much about belongings.(According to Buddhism, when one gets older, it is particularly important to turn to a spiritualattitude.) DH also said she should think of her life in Cambodian during the Khmer Rouge, andits difculties, and be thankful for having survived. (The aim was to foster the positive emotionof gratitude.) DH said that she should not keep thinking about her belongings and their possibleloss, but about her children and grandchildren: what they liked to eat, what they were doing, andso on. DH also advised Leng to laugh and smile more, that these were a form of loving-kindness,and that otherwise people would think she was mad at them. DH reiterated the importance of

having a feeling of loving-kindness, as reected in laughter and smile. DH said these were goodemotions, as opposed to anger, an inauspicious mood. We reviewed the loving-kindness practice(Table 2).

At the next visit, Leng was further improved. She had decreased anger, ruminated less, andslept better. She was much less hypervigilant to threat. Lengs daughter conrmed that hermother was much improved and was no longer in a constantly angry and paranoid state. DHrepeated the lessons about positive mental state and merit. DH emphasized that she should havegratitude to have a place to live, to have children and grandchildren, and to have survived thePol Pot period. Leng improved progressively over the next several weeks. (Please note that in thiscase, the treatment emphasized the cultivation not only of loving-kindness but also of variouspositive emotional states, and that the treatment emphasized the cultivation not only of positive

emotional states but also of body states that would promote positive emotional states: a smileand laughing.)

Conclusion

In this article, we discussed why techniques such as loving-kindness should be effective using thetypology of mindfulness states and the NNM of Affect and Affect Regulation. We discussed howloving-kindness is used in our treatment and the importance we place in treatment on emotionalexibility and psychological exibility more generally. Finally, we presented a case to illustratehow we integrate loving-kindness into a treatment approach, an approach that emphasizes acertain typology of mindfulness states and the NNM of Affect.

We presented the typology of mindfulness that guides our treatment. According to thattypology, mindfulness is characterized by a certain object of attention. There are sensorial sets,such as attending to the color of leaves or their movement or attending to ones breath; objectsets, such as observing the motion of a candle ame; verbal sets, such as the self-repetition of aphrase like I will adapt exibly like a leaf adjusts to each breeze; expressive sets (e.g., smile,laughter, upright posture, dynamic gestures); body sets, such as maintaining the body in a certain


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Documents

Loving-Kindness in the Treatmentof Traumatized Refugees and Minorities