Keywords

Introduction

For more than a century, many aspects of Buddhist teaching and practices have been recognized for its psychotherapeutic effects by Western scholars (Davids 1914). Psychotherapy and Buddhist practice share similar objectives in reducing human suffering associated with the mind and promoting humanity (Young-Eisendrath and Muramoto 2002). There is also increasing recognition of the potential mental health benefits of the practice of mindfulness in Buddhism, both in the mental health field and in the general public.

In recent years, a group of evidence-based psychotherapies have been noted to share in common the incorporation of the principles of acceptance and mindfulness, and they have been collectively termed “third-wave” behavioral interventions (Hayes et al. 2004). Acceptance and Commitment Therapy (ACT) is an exemplar of this family of psychotherapy. It has been used in many clinical and nonclinical populations, from the treatment of depression, anxiety, addictions, and psychosis, to improving patient outcomes with diabetes and epilepsy, to reducing stigma and burnout (Ruiz 2010). A recent meta-analysis of 39 randomized controlled trials on mental disorders and somatic health problems found that ACT outperformed control conditions and treatment as usual (A-Tjak et al. 2015).

Although ACT reflects many common tenets underlying Zen Buddhism, little has been written about the relationship between Zen Buddhism and ACT. A few researchers have highlighted the parallels between Zen Buddhism and ACT (Fung 2015; Hayes 2002), but writing about the plausible influences of Buddhism on the development of ACT is almost nonexistent. In this chapter, we provide a short account of the historical development of Western Buddhism in America and explore its influence on ACT; describe how ACT is similar to and different from Zen Buddhism; and propose a more explicit integration of Zen Buddhism into ACT to strengthen its practice.

Influence of Buddhism on Western Thought

While a comprehensive account of Buddhist influence on Western thought is beyond the scope of this chapter, reflecting on the historical development of Western Buddhism in America allows us to examine the cultural appropriation, diffusion, and hybridization of Buddhist philosophy in present day’s field of psychology and the self-help industry in the West. While some researchers and practitioners like Tara Brach openly declare themselves as Buddhist psychologists, many others use or promote therapeutic approaches that resemble Buddhism without making any explicit reference to it. Non-Christian and non-Western approaches for mental well-being are often Westernized, and this norm to Westernize or appropriate foreign thoughts can be seen in Jon Kabat-Zinn’s reflection on his ambivalence to accept an endorsement from a Buddhist Monk on his book, Full Catastrophe Living:

… it would be disrespectful, having asked for it, not to use it. However, I did think twice about it. It precipitated something of a crisis in me for a time, because not only was Thich Nhat Hanh definitely a Buddhist authority, his brief endorsement used the very foreign word dharma not once, but four times… I wondered: ‘Is this the right time for this? Would it be skillful to stretch the envelope at this point? Or would it in the end cause more harm than good?’ In retrospect, these concerns now sound a bit silly to me. But at the time, they felt significant. (Kabat-Zinn 2011, pp. 282–283)

Kabat-Zinn’s reticence to openly acknowledge the Buddhist foundation of his work in mindfulness-based stress reduction (MBSR) a decade after he had established his MBSR Clinic’s work speaks to the power of the embedded Orientalist “Othering” and Anglo-Eurocentrism in American culture. Identifying this dynamic is important in understanding the development of Western Buddhism and the invisibility of Buddhist influence on modern and postmodern Western thoughts and therapeutic approaches.

European contact with Buddhist cultures started as early as the mid-thirteenth century when Franciscan pilgrims journeyed through Mongolia, China, and Japan. However, Western interest on the systematic study of Buddhism began only in the nineteenth century when transcendentalists rejected Christian puritanism and looked to Eastern religions for philosophical truths (Franklin 2008; Tamney 1992). Prior to the 1800s, Hinduism was an object of systematic study due to European political, commercial, and colonial interests on India. Thus, in the early days of intellectual encounters with Buddhism in the West, many transcendentalists, including Ralph Waldo Emerson, confused Buddhism with Hinduism; others understood Buddhism through an Orientalist lens and held the view of Buddhism as an atheistic religion grounded in pessimistic nihilism (Tamney 1992).

American transcendentalists were drawn to Buddhism for its emphasis on personal awakening instead of glorifying a deity. In his essay on transcendentalism, Emerson wrote:

…if there is anything grand and daring in human thought or virtue, any reliance on the vast, the unknown. . . adopts it as most in nature. The oriental mind has always tended to this largeness. Buddhism is an expression of it. The Buddhist who thanks no man, who says, “do not flatter your benefactors,” but who in his conviction that every good deed can by no possibility escape its reward, will not deceive the benefactor by pretending that he has done more than he should, is a Transcendentalist (Emerson and Myerson 2015, p. 168)

While Emerson resonated with the karmic suppositions in Buddhism, he was not a Buddhist. Like many others, his interest in Buddhism was more literary, whereas Henry David Thoreau’s interest was more contemplative (Fields 1992).

In 1844, Thoreau published passages of the Lotus Sutra in the Ethnical Scripture section of the Dial, a journal on new spirituality established by Emerson, and it opened up discussions on Buddhism within the transcendentalist literacy circles. However, wider interest on Buddhism in America emerged around 1875 when the Theosophical Society was established in New York City and when Sir Arnold Edwin published his book Light in Asia in 1879. Its popularity, with eighty editions and sales between half a million to one million copies, was attributed to Edwin’s ability to tell the story of Buddha “in a way that matched Victorian taste… His Buddha is part romantic hero, part self-reliant man, and part Christ without being Christ” (Fields 1992, p. 68). The deep-rooted psyche of Western superiority and Christian cultural habitus deterred the full embracement of Buddhism among Europeans and Americans (Sutin 2006).

The convening of the 1893 World’s Parliament of Religions in Chicago was a catalyst for cultural diffusion and growth of Zen Buddhism in America. Influential Buddhists from Asia attended and spoke at the Parliament and it promoted interest among intellectuals other than Orientalists and faddists. Zen was the first Buddhist tradition to take roots in America, largely due to: the enthusiasm of Paul Carus, a theologian and managing editor of Open Court Publishing Company; influential lectures of a Japanese Rinzai master, Soyen Shaku, and the writings of Shaku’s student D.T. Suzuki, who “introduced paradoxical Zen thought to many fascinated Western intellectuals” (Coleman 2002, p. 8). Suzuki studied with Carus and his prolific writing was published through the Open Court Publishing Company. Until the 1960s, most materials about Zen in the English-speaking world were written by Suzuki (Layman 1976).

Local and global political events contributed to a revival of Western enthusiasm in Buddhism in the 1960s and 1970s. Similar to the Western intellectualists who turned to Eastern religions as resistance against Christian puritanism and the dissident Orientalists who deployed Buddhism against the empire in the nineteenth century (Cox 2013; Turner 2013), many Americans and Europeans turned to Zen Buddhism to deal with loneliness, powerlessness, and meaninglessness in the modern industrialized society (Fromm 1959; Riesman et al. 1967).

By the 1990s, Buddhism is no longer exotic. Bits and pieces lie around in American culture. Health professionals have secularized meditation, often using it simply as a kind of tranquilizer. Christian clergy borrow the same techniques, using them to attract modern Americans searching for an experiential ground for their ultimate beliefs… Writers like Thomas Merton tamed Zen, convincing some that it was not a distinct religion but pure mysticism (Tamney 1992, p. 102).

Accounts of the historical engagement with Buddhism in America and the West provide a useful backdrop for the understanding of the seldom-acknowledged Buddhist influence on the third-wave behavioral interventions such as ACT. It also invites us to be open-minded in order to fully appreciate Buddhism and not necessarily attempt to comprehend it from a Western lens, which tends to be analytic rather than holistic and intolerant of paradoxes (Cheng 1973; Varnum et al. 2010).

Philosophy Underlying ACT: Functional Contextualism

ACT is underpinned by a philosophy of science called functional contextualism, which has its roots in pragmatism and contextualism (Hayes et al. 1999). Pragmatism is concerned with the effective realization of beneficial goals based on human necessities and desirabilities within the context that we live in (Rescher 2012). Contextualism is a worldview that can be understood through examining its root metaphor of “an-act-in-context,” that is, in any life event, actions cannot be understood separately from its context, including its current and past history and environment (Fox 2006). It is noteworthy that key figures of American pragmatism, including William James and John Dewey, were in fact heavily influenced by Buddhism as they developed their philosophy, including the functionalist orientation of Buddhism (Scott 1995, 2011).

Functional contextualism is not interested in any ontological claims about “truth.” Instead, the truth criterion is “workability”—that is, the truth of any idea or concept depends pragmatically on its success in achieving a stated purposive goal (Hayes et al. 1999). The specific stated goal of functional contextualism is to be able to predict and influence the psychological events of interest (i.e., thoughts, feelings, behaviors) by deriving empirically based concepts and rules and manipulating contexts.

Theory of the Mind and Understanding of Suffering in RFT/ACT

Based on functional contextualism, relational frame theory (RFT) is a scientific theory to explain complex human behaviors, including language and cognition (Hayes et al. 2001). According to RFT, human language, the use of symbols externally in communication or internally in thought, developed from our unique capacity to relate events arbitrarily in a specific way. Properties of relational responding include: mutual entailment, combinatorial entailment, and transformation of stimulus functions. Mutual entailment describes the bidirectionality of stimulus relations [e.g., if A is greater than B, then B is less than A—in the class of “relational frame” of comparisons (of quantities)]. Combinatorial entailment describes the relationships among more than two stimuli, which themselves are in mutual entailment (e.g., if A is great than B and B is great than C, then A is great than C and C is less than A). Transformation of stimulus function is when function of one stimulus in the relational network is altered based on the functions of another stimulus in the network and the derived relation between the two (e.g., if A is greater than B and B becomes anxiety-provoking, then A also becomes anxiety-provoking and even more so than B.) There are many different types of arbitrary relationships that can be formed. A particular kind of relational frame, deictic relations, specify relations with respect to the perspective of a speaker—such as I versus you, here versus there, now versus then. This gives rise to a sense of self, which may be critical for perspective taking.

Based on RFT, the clinical implication for ACT practitioners is that language and cognition can be seen as the root of psychological suffering, and as such, it is intrinsic and inevitable to the “normal” human condition (Hayes et al. 1999). This suffering comes from our inherent capacity to form arbitrary connections between events; the inability to let go of and function outside of this constructed illusory world; and the engagement in avoidant behaviors or actions dictated by unworkable rules rather than pursuing a meaningful life. The ability to make arbitrary comparisons and relationships can give rise clinically to thoughts like “I am less worthy than her” or “death is less painful than living.” In fact, the concept of suffering is a psychological verbal construct, hence the useful therapeutic distinction between pain and suffering. The ACT consistent adage “pain is inevitable, suffering is optional” by Japanese writer Murakami Haruki expresses this point. Our capacity to think is often the root of psychological suffering due to verbal processes (i.e., when we get entangled in our thoughts and feel stuck, disappointed, angered, jealous, etc.), and it is also this capacity that makes us become aware of and judge that we are “suffering.”

Understanding of Suffering and Theory of the Mind in Zen Buddhism

Suffering is one of the core concepts in Buddhist psychology and is part of The Four Noble Truths, one of the most widely known Buddhist teachings. They are: (1) there is suffering (dukkha); (2) the roots and nature of suffering (samudaya) can be known, and they arise from ignorance, attachment/desire, and aversion; (3) cessation (nirodha) of creating suffering or emancipation from suffering is possible (by letting go of the desire and attachment); and (4) the path (marga) to enlightenment or the path to liberate us from doing things that lead to suffering is the Noble Eightfold Path (Bodhi 1994; Nhất Hạnh 1991, 1999; Santina 1984). The Noble Eightfold Path, which will be described in detail in a latter section, can be grouped into three clusters: (i) Wisdom (prajñā)—Right View (samyag-dṛṣṭi) and Right Intention (samyak-saṃkalpa); (ii) Ethical Conduct (śīla)—Right Speech (samyag-vāc), Right Action (samyak-karmānta), and Right Livelihood (samyag-ājīva); and (iii) Concentration of the Mind (samādhi)—Right Effort (samyag-vyāyāma), Right Mindfulness (samyak-smṛti), and Right Concentration (samyak-samādhi)).

The first noble truth of dukkha or suffering is often misunderstood to mean that living is nothing but pain and suffering. Actually, suffering in Buddhism refers to being caught in a cyclic existence of dissatisfaction (samsara) arising from wrong perceptions or an ignorance of the Three Dharma Seals (Dharma mudra), leading to attachment, craving and grasping that fuel the samara cycle. The Three Dharma Seals are as follows: impermanence (anitya)—all phenomena change, arising and disintegrating; nonself (anatman)—there is no separate independent self/entities; and true freedom (nirvana)—extinction of ignorance can lead to liberation from the cycle of samsara (Nhất Hạnh 1999). Our attachment and desire for things to be permanent when they are not can become a source of our suffering (e.g., in grief and loss). Our perception of things being discrete entities also causes us to suffer as we develop dualistic thinking. For example, the distinction of me versus not me and mine versus not mine gives rise to emotions such as desire, jealousy, greed, and hatred.

According to Zen, the correct perception includes seeing everything as interconnected, invoked in concepts such as interbeing (i.e., any one thing or self is actually made of nonself elements and thus is dependent on and inseparable from other things) and interpenetration (i.e., one thing contains all existing things, and all things contain that one thing), and hence the transcendence of dualistic thinking is central to Buddhist teachings. The Three Dharma Seals constitute a way of understanding suffering as well as the key to truly perceive reality. “To get to that reality, we have to let go of the images we create in our consciousness and our notions of self and other, inside and outside. Our practice is to correct this tendency to discriminate and think dualistically, so that reality will have a chance to reveal itself” (Nhất Hạnh 2006, p. 57). In fact, this is applicable to all dualistic concepts so that we can “go beyond ideas of being and nonbeing, coming and going, same and different, birth and death” (Nhất Hạnh 2006, p. 184).

It may be difficult to accept or understand this let alone truly achieve this unless we have reached the proposed state of enlightenment. However, Thích Nhất Hạnh encourages us to begin on this journey by perceiving the cloud and rain as being in the flower rather than as distinct entities. We can understand this rationally—the cloud gives rise to rain that becomes part of the flower when it is absorbed. The challenge is to be able to reach this through perception and contemplation rather than intellectualized understanding, and to be able to experience other things in this similar interconnected way, transcending notions of time, space, or boundaries. Experiencing this kind of interdependence will make the distinction and boundaries between dependence, independence, and interdependence fuzzy—the boundaries themselves may or may not exist.

In this vein, in Buddhist psychology, the mind and body are recognized as one. Based on the Manifestation-Only school, there are eight different consciousnesses: store consciousness, manas, mind consciousness, and the five sense consciousness (Nhất Hạnh 2006). Each of these consciousnesses can be understood as representing a different layer or function of consciousness, yet they are also considered one consciousness. For instance, our store consciousness, the deepest “root” layer of consciousness “inter-be with other consciousnesses. The one contains and is made of the all, and the all contains and is made of the one” (Nhất Hạnh 2006, p. 77).

The store consciousness is the ground and storage of all mental phenomena (in fact, including all phenomena, if the dualistic distinction between psychological and real world is completely let go of). Psychologically, information that we have received and phenomena that we have experienced or perceived are stored and preserved metaphorically as “seeds” in our consciousness. For example, names, words, and related images that are learned through our current life experience become seeds in the store consciousness. Our store consciousness is also thought to include seeds that may not have been learned by an individual in this lifetime (Nhất Hạnh 2006). Transcending the constraints of time, space, or any kind of duality/boundaries (e.g., objective vs. subjective worlds, individual vs. collective consciousness), seeds may reflect influences that occur even before an individual’s lifetime, by the society at large, as well as by the physical environment. Just as the cloud and rain are in the flower, there may be latent seeds in an individual laid down by his/her ancestors or former lives (i.e., transcending time through karma), by society (e.g., shared seeds in the collective consciousness; the impact of systemic factors like racism), and even by the physical environment (i.e., transcending space or boundaries and connecting what apparently are unrelated things or events like the “butterfly effect” in chaos theory).

Under certain conditions and context, latent seeds will become manifestations and conceptually develop into and experienced as “mental formations.” The exact number of mental formations varies according to the specific Buddhist schools. A system taught by Zen Master Thich Nhất Hạnh includes 51 mental formations (Nhất Hạnh 2006).Footnote 1 There are five “universal” mental formations (contact, attention, feeling, perception, and volition), which manifest in all layers of consciousness. Five particular mental formations (zeal, determination, mindfulness, concentration, and insight) are associated with manas, mind consciousness, and the five sense consciousness. There are 11 wholesome mental formations (e.g., faith; inner shame or remorse; outer shame or humility; absence of craving; equanimity; nondiscrimination; nonviolence, etc.), 26 unwholesome mental formations (e.g., greed; craving or attachment; hatred, etc.), and 4 indeterminate mental formations.

The wholesome or unwholesome “mental formations” arise from wholesome seeds (e.g., love, compassion, peace, understanding, joy, etc.) and unwholesome seeds (e.g., greed, hatred, ignorance, pride, jealousy, etc.), respectively. This teaching has the function of preventing complete moral relativism and serves as a guide toward increasing our compassion and well-being while lessening our suffering. These seeds and formations are not dualistic in the sense of being categorically different or diametrically opposites, like good and evil, god and devil. Rather, the metaphors help us understand the karmic consequences of cultivating and expressing different kinds of seeds. Indeed, the path toward ending suffering involves cultivating the wholesome seeds while transforming unwholesome seeds through mindfulness and other practices.

Manas is the second deepest layer of consciousness, evolving from the store consciousness (Nhất Hạnh 2006). Manas is thought to grasp on to the “perceiver” aspect within store consciousness, cling on to a mental representation of it, and defend it, thereby creating an illusory autonomous and independent psychological self. This corresponds to learning deictic frames in RFT, i.e., learning the distinction between “I” and “not-I.” Manas is driven by craving and delusions arising from unwholesome seeds, and thus its perception is distorted.

The five sense consciousness arises when our five sense organs acting as “sense base” (i.e., eyes, ears, tongue, nose, or body) are in contact with their corresponding “objects of the senses” (i.e., form, sound, taste, smell, and tactile sensation) (Nhất Hạnh 2006). Similarly, our mind consciousness arises when manas as the “sense base” is in contact with the “objects of the mind.” The information that manas passes on to the mind consciousness from the store consciousness is usually distorted because of the nature of manas, and therefore, our mind consciousness is also vulnerable to perceiving things with distortion.

Our mind consciousness operates in five different states of mind (Nhất Hạnh 2006). It can operate with sense consciousness (e.g., when we are aware of seeing or hearing something) or independently of sense consciousness (e.g., dreaming). It can operate in a dispersed way (e.g., our usual way of thinking, getting caught up in the past or future) or in an unstable way (e.g., in a state of psychosis). Finally, it can also function in a focused way through the training of mindfulness. Through the energy of mindfulness, mind consciousness has the increased capacity to be in direct perception of “thing-as-it-is” in the store consciousness as opposed to distorted mental representations offered by manas and thus, the capacity to transform unwholesome seeds. Mind consciousness is the source of all our actions in thought, speech, and behavior. With the state of mindfulness and the correct perception of impermanence, nonself, and interbeing, mind consciousness as the “gardener” will help cultivate the wholesome seeds in our store consciousness, ultimately bearing the fruit of enlightenment and cessation of suffering.

At this point, it is useful to note that the overall formulation of suffering caused by attachment to language and cognition in RFT and ACT bears some correspondence to Buddhism. The constructed relational frames in RFT, and hence our thoughts and psychological way of making sense of the world, may be seen as a natural cause of our belief in the illusions of permanence and selfhood in our psychological representation of the world. From a Buddhist perspective, true perception of reality arises when all constructed relational frames are let go of. This is consistent with the emphasis on the benefits of mindfulness meditation where the practice is not to attain more logical understanding but to loosen our attachment to all our words, thoughts, concepts, and language. It is also of note that Buddhist psychology has a lot of elaborations such as seeds and mental formations that are completely absent in RFT/ACT, as is further discussed in the next section.

Acceptance and Commitment Therapy and Relationship to Zen

ACT is the clinical application of functional contextualism and RFT. In clinical practice, ACT seeks to promote six psychological processes: defusion, acceptance, contact with the present moment, self-as-context, values, and committed action (Hayes et al. 1999, 2012). These six processes are all interrelated and enhance an individual’s psychological flexibility, which is “the ability to contact the present moment more fully as a conscious human being and to change or persist in behavior when doing so serves valued ends” (Hayes and Strosahl 2004).

Cognitive defusion is the ACT process of relating to thoughts as thoughts, no more and no less. We often do not notice our process of thinking and relate to our thoughts as if they are fused with reality and that the two are equivalent, especially if we believe our thoughts to be logical and true. While our thoughts are indispensably helpful most of the time, they are but a tool and a mere representation of the real world. Even the truest thought is in effect just a thought. An ACT metaphor illustrates this—no matter how detailed and precise you think of a chair, you cannot sit on the chair in your thought (Hayes et al. 1999). In therapy, cognitive defusion exercises aim to facilitate clients to experience and gradually gain the capacity to defuse from their thoughts, regardless of whether they believe their thought to be true or not. This can be applied equally to all types of thoughts, including thoughts that often engender a sense of rigidity and “stuckness,” including judgments or evaluations (“I am an utter failure”); assumptions (“I will never succeed or get better”); or rules (“I can never do something that makes me feel anxious”). This allows us to relate to our thoughts differently when they are not helpful to us. For example, a client may be asked to repeat a word out loud for a minute and notice that the word begins to lose its meaning, or guiding a client to label or thank their thoughts (e.g., “here it goes… a judgment…thank you, mind, for giving me this thought”) rather than engaging with the thoughts’ content. Thus, unlike other types of therapies, the emphasis is not on evaluating the thoughts; gaining understanding and insight; nor changing them into more positive, desirable, or rational thoughts. The therapeutic aim is on increasing the capacity to flexibly relate to these thoughts in a defused way when these thoughts are not helpful; rather than adhering to concepts and rules when they are not beneficial in a particular context, it increases our behavioral repertoire and responsiveness to real-world contingencies, thereby promoting “workability” in life.

Similarly, in Buddhist psychology, suffering occurs when perceptions generated from seeds in our store consciousness are reified and treated as aspects of the ultimate truth. In this process of reification, reality is objectified and the object is apprehended as “an alien thing that is independent of its producer” (Moore 1995, p. 701). The reified mental image and representations (e.g., dreams, imagination, or perceived reality) are fueled by our “habit energies” derived from all sources of past and present experiences and thoughts, including those from our ancestors, friends and family, and society; they prevent us from seeing things as they truly are (Nhất Hạnh 2006). Through mindfulness practice, Zen Buddhists seek to de-reify habitual patterns of thoughts and socialized perceptions of reality and to extinguish the notions of permanence and duality.

Acceptance in ACT describes the state of openness and willingness to experience what is present internally, including thoughts, feelings, emotions, and sensations. It is not, as it is often misunderstood to be, the passive acceptance of the conditions that lead to suffering. Acceptance is distinguished from experiential avoidance (Hayes et al. 1996), where one may attempt to control, suppress, or withdraw from these aversive internal experiences. Experiential avoidance is thought to be at the heart of many forms of apparent psychopathology as well as other common difficulties presenting in therapy. The act of avoidance itself can sometimes directly lead to worsening symptoms, such as pain or anxiety, contributing to “dirty” psychological pain which compounds the “clean” original pain (Hayes et al. 1996). Persistent avoidance may also reinforce rigid unworkable avoidant behaviors, which become a barrier to doing meaningful activities.

Metaphors are often helpful to enable clients to reflect on the nature of avoidance versus acceptance. An example is the reflection of what happens if one engages in a tug-of-war with a stronger opponent, such as an imagined overpowering “anxiety” monster (Hayes et al. 1999). One might be using all of one’s strength if the stakes are high and the tug-of-war takes place over a bottomless abyss between one and the monster. In this case, a viable option is to “let go” of the rope, even if this means having to continue to face the monster on the other side of the abyss. In this metaphor, acceptance is the “letting go” of the struggle, even if it does not eliminate what is feared. This is distinct from “giving up” as it takes courage to let go of the struggle to face what is feared. Other similar physicalized metaphors, such as the Chair Sculpture of Suffering (Fung and Zurowski 2016), may also be used to engage clients in a group format to explore the stance of acceptance. In this exercise, the group facilitator invites participants to use their own chairs representing coping strategies to cover up the “chair of pain” in the center of the group circle, thereby creating a “chair sculpture of suffering.” The participants can be invited to observe that their coping strategies do not eliminate pain and discomfort (the center chair) but can add to suffering (overall sculpture), regardless of what the coping strategy is. They can collectively reflect on how much effort they have exerted in this process, as they sacrifice their own chair to build the sculpture. Clients often find this to be a nonblaming approach. Through this exercise, their efforts to cope are acknowledged, while they also become aware that their diligence in finding a cure rather than accepting what they feel may have compounded their suffering, especially if they have devoted a lot of resources to fighting pain, anxiety, or other internal discomfort.

In Buddhism, acceptance is also promoted, but quite differently from ACT. Mindfulness can be used to foster an acceptance stance in order to transform unwholesome seeds and mental formations, including negative thoughts and feelings. “It is important to learn to embrace our anger, to recognize it and allow it to be. Then we can touch it with our mindfulness in order to transform it… every time a negative formation is recognized, it loses some of its strength” (Nhất Hạnh 2006, p. 80). The notion of emptiness in Zen Buddhism, essentially the concept of nonself, that describes the lack of independent durable essential nature of any entity also offers the wisdom that promotes acceptance. In the Heart Sutra, Bodhisattva Avalokita says, “Listen, Shariputra, form is emptiness, and emptiness is form. Form is not other than emptiness, emptiness is not other than form. The same is true with feelings, perceptions, mental formations, and consciousness…” (Nhất Hạnh 2012, p. 411). Thus, emptiness includes the emptiness of form (a permanent body), feelings, perceptions, mental formations, and consciousness. Finally, the concept of karma and past lives (collective histories and conditions) can foster radical acceptance of both internal and external conditions. The law of karma describes the nature of cause and effect, sowing seeds (individually and collectively) will eventually bear their corresponding fruits, wholesome or unwholesome (Nhất Hạnh 2006; Santina 1984). Therefore, it is not a pessimistic fatalistic retreat, but a fundamental way of promoting acceptance of our current contextual circumstances and responsibility for our actions that influence the future. The notion of transformation of unwholesome seeds and mental formations; the realization of emptiness; and the understanding of karma all draw on unique beliefs of Buddhism that is not within ACT and, therefore, promote acceptance in a way that ACT does not.

Contact with the Present Moment in ACT refers to the deliberate practice of attending to what is present in the here-and-now. While there is only one reality which is embedded in the on-going “now,” our capacity for thought allows us to get stuck thinking about the past, which might have been filled with anger, hurt, trauma, or regrets or paralyzed in fearing for an imagined future. Increased contact with the present moment may support us to decrease our suffering associated with getting stuck in the past or worrying about the future. This also involves taking ourselves off “autopilot” and allowing ourselves to be in fuller contact with whatever actions that are being engaged in including eating, walking, and other complex behaviors. This may lead to renewed appreciation of positive and other rewarding experiences. It increases our capacity to react more flexibly and appropriately to the situational context rather than by reacting based on learned habits, unworkable rules, or reactive impulses. In an ACT session, the therapist may simply draw the client’s attention to and observation of the “here-and-now,” including immediate feelings and thoughts, to increase contact with the present moment. The therapist may also encourage the patient to work on this skill during and/or outside the therapy session by doing formal mindfulness practice of being in the present moment and being aware of the here-and-now; these practice activities are often taken or adapted from traditional Zen Buddhist meditative practices.

From a Buddhist perspective, mindfulness unites the body and mind and enables us to be aware of our physical body (feelings and sensations), our perceptions (thoughts, ideas, and views), and our disposition (habit energies that work with our store consciousness). Mindfulness practice enables us to look deeply (vipashyana) to gain the understanding that is needed to transform our own suffering and the suffering of the world (Nhất Hạnh 1999). Mindfulness meditative practice is an important step in practicing the Noble Eightfold Path—with Right Mindfulness, we are able to develop Right View and Right Thinking, which is integral to Right Speech, Right Action, Right Livelihood, and Right Diligence, and the cycle of practice goes on (see below). Thus, mindfulness in Buddhism is grounded in the ultimate purpose of achieving enlightenment, which is not the purpose of ACT. In mindfulness-based psychological interventions, mindfulness is often taken to be a skill to decrease psychological suffering, detached from its spiritual roots.

Self-as-context is also referred to as the transcendent self or observer self. This concept helps clients loosen up their attachment to the conceptualized self formed by identification of the self with any kind of psychological content, such as thoughts (e.g., “I am my thoughts”), feelings (e.g., “I am happy”), roles (e.g., “I am a father,” “I am a psychologist,” etc.), personality traits (“I am shy”), sociocultural identities (“I am Caucasian”), memories, self-narratives, and body image. While these concepts and phenomena help a person maintain a coherent view of the self and guide function in our daily lives, this fusion may also lead to rigidity when the person is unable to make changes in his action patterns. For example, a person who identifies himself or herself as “damaged” may refuse to engage in intimate relationships. Strong attachment to self-concepts may also lead to suffering from perceived losses of the self. For example, a person who strongly identifies with being a parent may be unable to recover when their child dies and they feel a part of the self has died.

In contrast, self-as-context refers to the experience of the self as the context in which psychological content occurs as opposed to the contents themselves. This is most directly experienced as being the “I” (and “not you”) in the “here-and-now” across time and space, hence the transcendent sense of self. Metaphors can be used to facilitate contact with this observer self, such as the commonly used chess metaphor (Hayes et al. 1999). While clients may be entangled with which chess pieces best represent their true selves or their correct thoughts, the clients are guided to notice the difference between seeing themselves as the individual chess pieces versus being the board that holds all the pieces. The chessboard continues to be there regardless of the chess pieces’ positions, which side is winning, or which side is “correct.” Rather than struggling with having positive beliefs or true beliefs about the self, realizing that the self-as-context can continue on regardless of content can be an empowering experience in increasing one’s resilience.

As discussed, the loosening of our attachment to self-concepts can be found in the Dharma Seal of nonself (anatman), a key Buddhist doctrine. The notions of nonself and impermanence are intricately connected. Since all things are constantly changing, they are devoid of absolute identity, and therefore, “A is not A, B is not B, and A can be B” (Nhất Hạnh 1995, p. 39). Furthermore, the practice of looking deeply into our self (through mindfulness practice) enables us to step outside of our subjective self to better appreciate the reality of nonself and the principle of dependent arising, that is, the conditions necessary to make up our objective world in relation to others (Kalupahana 1988). It allows us to see the reality of interbeing, that is, we do not exist independent of others; the self is made only of nonself elements, and humans are made up of nonhuman elements (Nhất Hạnh 1999). Things come into manifestation when the right conditions exist, as Thich Nhất Hạnh writes: “All that is created and destroyed, all that can be obtained and lost, is conditioned. A thing is lost when the conditions are no longer favorable” (Nhất Hạnh 1995, p. 83). The wisdom behind The Three Dharma Seals is for us to recognize concepts as concepts (e.g., Buddha is God) and not to confuse concepts with reality (e.g., Buddha nature in human).

The Buddhist doctrines of suffering, emptiness, and nonself are often misunderstood as a religion of pessimism, nihilism, or self-denial. However, Kalupahana (1988) suggests that Buddhist psychology of the mind, which recognizes the five mutually dependent aspects of the conscious human personality (the material body, feelings or sensation, perception, disposition, and consciousness), provides a solution to the Cartesian dualistic conceptualization of the separate body and mind. Zen Buddhism, based on the Mahayana tradition, emphasizes that enlightenment is achieved through one’s awareness and insights, which cannot be transmitted by the Zen teacher (Suzuki 1994). Zen practices of mindfulness and koanFootnote 2 function as paths to enlightenment that enable us to let go of the wrong view of an independent enduring self and to recognize that our subjective self (“I”) exists only in the context of the objective conditions surrounding us.

Nonself in Buddhism may seem contradictory to the apparent enduring nature of self-as-context. It may be helpful to understand that self-as-context in ACT is not an ontological claim of an enduring spiritual self but a useful concept for psychological functioning; in RFT, the sense of self arises from forming deictic frames discussed above, as we learn to distinguish “I” versus “you.” In fact, it can also be pointed out that a dualistic understanding of self versus nonself is not accurate in Buddhism, as both are ideas that need to be transcended in the ultimate dimension. “The notion of self relies on the notion of nonself. Both ideas are products of our conceptual mind… nonself is a crucial teaching… But the teaching is not something to worship… When we are able to touch reality, both notions will be removed” (Nhất Hạnh 2006, p. 164).

In summary, both Buddhism and ACT acknowledge the pragmatic use of self for daily functioning. ACT loosens attachment to conceptualized self when it is not helpful, but reinforces self-as-context as it is still rooted in typical Western psychology. Buddhism goes one step further than ACT as it advocates for giving up the need to hang on to a sense of an autonomous independent self in spiritual development, and does not view it necessary for psychological health, especially as it embraces interdependence and nondualism, notions that will avoid nihilism but are missing in ACT.

Values refer to what an individual person holds as being most important to them in their lives. This is distinguished from goals that are achievable. The commonly used metaphor is that values serve as a guiding direction while goals are individual destinations along the way. If one’s path is obstructed along a guided direction, one can find alternative paths to express the underlying values, enhancing one’s flexibility. As values are not something that is ever attainable or able to be completed like a goal, this broad sense of life direction engenders less fusion with ideas like failure. In ACT, clients are encouraged to reflect on and clarify what their freely chosen values in various life domains are, including how they want to behave in their workplace; how they want to interact with their friends and family; how they want to parent; how they would like to be in touch with their spirituality; how they want to contribute to the community, etc.

There is an inherent clinical assumption in ACT that clients’ chosen core values contain social and altruistic aspects that can lead to a meaningful and fulfilling life (Hayes et al. 2012). An ACT therapist’s task is not to judge the clients’ values or impose their own social values on the clients but to help them clarify their values. Sometimes, apparent selfish interests that are being pursued are really a “means” to an “ends,” a “pseudo-value,” rather than true values that need to be teased out (e.g., if a person said his value is to make a lot of money, behind this could be his value in providing for his family and loved ones) (Hayes et al. 2012).

Unlike ACT which emphasizes freely chosen values, Zen Buddhist values are grounded in the Noble Eightfold Paths (see below) and the five mindfulness training or precepts. These values do not constitute absolute laws to govern one’s action. In Zen Buddhism, “good is what produces good consequences (attha) and such consequences are dependently arisen, that is, they depend upon various factors pertaining within each context” (Kalupahana 1988, pp. 301–302

In Zen Buddhism ethics, a person is considered inherently ethical. However, people often act in unethical ways because their Buddha nature has been distorted by conditioning that arises from ignorance and attachment (Brazier 1996). One can reconnect to one’s Buddha nature—the capacity to wake up, to understand, and to love—through mindfulness practice. Zen Buddhist principles of ethics and notions of wholesome and unwholesome seeds in the context of the Noble Eightfold Paths may be useful in supporting clients to identify and clarify their values. Perhaps one of the most important Zen Buddhist values that may enhance the effectiveness of ACT is the unconditional compassion for the interdependent self and sentient beings. In Buddhism, compassionate acceptance is thought to transform habit energies that fuel unwholesome seeds in our store consciousness.

Committed Action

Ultimately, one of the emphases in ACT is to enable clients to act in alignment with their values and thereby to fully live their life with vitality and meaning, with an assumption that this potential is within each client. Clients are encouraged to use the other ACT processes to overcome barriers, freeing themselves from reasoning as barriers and various forms of experiential avoidance, in the service of their values. The commitment can be seen as the deliberate and persistent engagement in an ever-larger pattern of action to express one’s values. In therapy, many kinds of common behavioral interventions, from exposure to behavioral activation to various kinds of homework, may be framed as committed action when linked with specific chosen values.

In Buddhism, actions (karma) are of three types: mind action (thoughts), speech action, and bodily action (Nhất Hạnh 2006). Thus, similar to functional contextualism, thoughts are treated as an action/behavior. Our mind consciousness can initiate actions that result in cultivating wholesome or unwholesome seeds. By practicing the Noble Eightfold Path, we learn to nurture and sustain wholesome seeds and mental formations, while returning unwholesome seeds and mental formations to the store consciousness. Speech and bodily actions are also thought to result in seeds that can transcend life-and-death in the store consciousness, and be transmitted continuously through our interbeing.

Ultimately, liberation from suffering is possible through acting in accordance with the Noble Eightfold Path. In Zen Buddhism, something is “right” when it is connected to the path of liberation from suffering, including the understanding of the Three Dharma Seals. The interrelated Noble Eightfold Paths are summarized here (Bodhi 1994; Nhất Hạnh 1999; Santina 1984):

  1. 1.

    Right View is our ability to distinguish wholesome roots or seeds (kushala mula) from unwholesome roots in the depth of our stored consciousness, and to let go of our perceptions.

  2. 2.

    Right Thinking occurs when our thinking is aligned with Right View and when our body and mind are in unity through the practice of mindfulness.

  3. 3.

    Right Mindfulness is at the heart of Buddhist teaching. Mindfulness (smriti) is returning to the present moment; Right Mindfulness embraces everything without judging or reacting; it is a practice of finding ways to sustain appropriate attention throughout the day.

  4. 4.

    Right Speech is being aware of the suffering caused by unmindful speech and the commitment to cultivating deep listening and loving speech to bring joy and happiness to others.

  5. 5.

    Right Action is closely linked to four of the five Buddhist precepts or mindfulness trainings: reverence for life; generosity and commitment to social justice; ethical sexual responsibilities; and mindful consumption.

  6. 6.

    Right Diligence or Right Effort consists of practices that are based on Right View: preventing unwholesome seeds in our store consciousness from arising; helping unwholesome seeds that have arisen to return to our store consciousness; watering wholesome seeds in our store consciousness to promote blossoms; and nourishing wholesome seeds that have arisen so they stay strong in our mind consciousness.

  7. 7.

    Right Concentration is the practice of cultivating a one-pointed mind of evenness; there are two kinds of concentration—active and selective. In active concentration, the mind dwells on the present moment; in selective concentration, we select one object to focus on this object to gain insight and liberation from suffering.

  8. 8.

    Right Livelihood refers to earning one’s living without transgressing the five Buddhist precepts or mindfulness trainings. Based on the Zen Buddhist doctrine of interbeing and interdependent co-rising, Right Livelihood is viewed not as a personal matter but our collective karma.

Clinical Application of ACT

ACT is based on a transdiagnostic model of human suffering that is not specific to a particular type of psychopathology. As discussed, it has been widely applied to many different clinical populations, including depression, anxiety, and psychotic disorders (A-Tjak et al. 2015; Ruiz 2010). It has also been applied to many nonclinical populations, such as for preventing burnout and addressing issues related to stigma. There is great variability in how it is applied, from traditional individual therapy to group therapy; from single-session to short-term to long-term therapy; from clinical setting to educational/work setting to public setting. To remain consistent to the ACT model, it is more important that the techniques are flexibly applied and consistent with its principles rather than rigidly striving to conform to rigid standards or structure (Hayes et al. 2012). The therapist’s capacity to adopt an acceptance stance toward the patient and guide experiential rather than intellectual learning is a key.

Clinical Case Example

The following is a disguised composite case example illustrating how ACT was applied to foster acceptance, enhance resilience, and increase committed action. In this case, the client had been followed by a psychiatrist over several years from a chance inpatient encounter to continued outpatient follow-up. The use of ACT was embedded in psychiatric follow-up appointments longitudinally over the years.

Ms. Chen is a 42-year-old married woman, who immigrated from China to Canada around 5 years ago. Her first experience with psychiatry was being involuntarily detained at a hospital two years ago when she was three months postpartum. She presented with severe depression with anxiety and psychotic symptoms. She was initially reluctant to disclose much about her experience to the treating team. Her husband and 10-year-old son visited her regularly at the hospital, and the whole family minimized her symptoms because of the stigma around mental illness and the fears about being detained in a hospital. When she was connected to a Chinese psychiatrist who facilitated her dialogue with the treatment team and subsequent discharge, she became hesitantly more trusting with treatment. The therapeutic relationship with the psychiatrist gradually increased over time after her condition became more stable and the psychiatrist helped her negotiated through another child protection services issue as an outpatient.

Ms. Chen and her husband are well off. Her husband works in China most of the time operating a very successful business. They moved to Canada because of the one child policy and for their son’s education. While she became less depressed with medication treatment, she continued to have significant anxiety symptoms. An ACT approach was used by the psychiatrist to engage the patient and facilitate her recovery. Through therapy, she became aware that both she and the psychiatrist could observe rather than to judge her thoughts, emotions, and imageries in her mind, and she gradually opened up much more about her experiences.

She disclosed that she actually had vivid hallucinations of herself throwing her child out of the window when she was hospitalized. For some time, she had also been experiencing visual hallucinations of her husband’s face on the wall yelling at her. When she got agitated, she screamed back or threw things at the wall. At times, she experienced symptoms of dissociation because of her distress, including sleepwalking at night. She further disclosed about an emotional abusive cycle from her husband where he becomes verbally abusive and apologizes afterward. She talked about how this reminded her of being yelled at by her mother, who favored her other siblings in the family. Her parents gave her a boy’s name and were disappointed that she turned out to be the third girl in the family. Her younger brother, however, had been showered with affection. Her mother also was particularly harsh on her since her appearance resembled her mother’s critical mother-in-law.

Defusion exercises helped her slowly face some of her internalized deprecating thoughts about herself. In one exercise, she wrote down some of these thoughts on paper, read them backward, and began to experience these thoughts in a different way. Mindfulness exercises were introduced to further help her become an observer of her own thoughts rather than getting attached to the meaning of her thoughts. Self-as-context work helped her become less attached to her negative labels about herself.

At one of the turning points in treatment, the patient was facing an acute crisis, as she had to return to China to attend her aunt’s funeral. She had not seen her mother for years. She remained terrified of seeing her critical mother. She was bitter that her mother continued to favor all her other siblings, even though she was the only child in the family who had been financially supporting her mother over the years. From time to time, her mother would express care and concern about her siblings’ finances and compelled her to help them financially as well.

Through an intense guided imagery exercise, she was able to deeply get in touch with her past traumatic memories of being verbally abused by her mother. Physicalizing her emotions in her mind, including both her anger and fear, she was able to make room for these emotions in her heart. She was able to regain her strength by remaining in contact with the present moment of her as an adult and be in touch with her observer self. The idea of the double-sided coin of suffering and values was introduced. She was able to connect with her painful yearning for her mother’s approval, and through this, get in touch with her values as a daughter and love for her mother.

The use of ACT helped the patient to face and relate to her mother in a more mindful compassionate way. She became aware of how frail and old her mother was. She had become more accepting of her mother, while allowing herself to be aware of, and yet not controlled by, various kinds of negative thoughts and emotions about her mother. Forgiveness and acceptance from an ACT perspective and compassion and loving-kindness from the Zen perspective were discussed. At this point, her hallucinations of her mother and husband scolding at her dramatically decreased. She felt more empowered to relate to her husband. She took active steps to confront her husband about his behaviors. She chose to remain in the relationship and has been asserting her boundaries more decisively. Her sense of helplessness and suicidal ideation has resolved and has been dedicating her time to care for her children and resume some long-distance work in China.

Discussion

Despite a lack of explicit reference to the application of Zen Buddhist philosophy in ACT, we have shown that ACT is aligned with some of the principles and practices of Zen Buddhism. Namely, as in Zen Buddhist practice, ACT uses experiential exercises that support clients to gain insights about their attachment to concepts and stuckness in their habit energies. It emphasizes the importance of context in understanding one’s suffering.

However, we have also discussed a number of important differences between Zen Buddhism and ACT. ACT does not have the goal of achieving nirvana or liberation from samsara. It does not teach any of the Three Dharma Seals specifically, including the concept of impermanence and nonself. Hence, interdependence and nondualism are not really discussed in ACT. ACT does not consist of sets of precepts or specific values, nor the idea of cultivating wholesome manifestations and seeds and transforming unwholesome ones.

These differences encourage ACT clients to develop psychological flexibility and achieve liberation based on their own set of values and religious beliefs. However, this may also potentially pose challenges and contradiction when one’s values are not aligned with the emphasis of context in both ACT and Zen Buddhism. For example, beliefs in certain dogma as the absolute nonnegotiable truth may lead to certain stuckness (e.g., eyes-closed meditation invites the devil; homosexual practice is evil; substance abuse is a moral flaw, etc.)

While mindfulness meditative practices have been adopted in Western psychology, it is often adopted as a standalone technique or skill to be practiced independent of one’s belief system or value. In Zen Buddhism, mindfulness practice is a focused practice, that is, being mindful of something (e.g., being mindful of the reality of nonself, or the seed of anger in store consciousness). In the absence of Buddhist understanding of interdependent arising, nonself, impermanence, and nonduality, it may be difficult for some ACT clients to sustain attainment of defusion or experiences of self-as-context.

Thus, if some of the core concepts of Zen Buddhism can be integrated into ACT and the clients are open to this, certain ACT processes may be more effectively grasped. Many of these concepts do not contradict RFT, but simply have not been articulated or elaborated in ACT. Illusions of permanence and independence can be introduced and become the explicit focus of defusion exercises and mindfulness practice. Contemplation of interdependence may also be embedded in a more extensive exploration of values. For example, a typical ACT values exercise may consist of contemplating one’s funeral and what one would want our loved ones to say about ourselves. This can be restructured to allow deeper contemplation about our interconnected relationships, as is done in other Asian psychotherapies like Naikan therapy, where the client is rigorously invited to contemplate three questions: “(a) “What did this person give to me?” (b) “What did I return to this person?” and (c) “What trouble did I cause this person?” (Ozawa-de Silva 2015). Similarly, rather than only focusing on self-as-context as ACT currently does, RFT researchers suggest that it may be in theory possible to discuss other-as-context (Stewart and McHugh 2013). As they are both transcendental, situated in the here-and-now, they can be linked as self-other-as-context—effectively an interdependent state of being. Whether a clinical technique can be derived based on this RFT hypothesis remains to be seen. It may be that this is only effectively achieved through the correct practice of mindfulness and deep contemplation on interdependence such that we are truly able to perceive the other in ourselves, the cloud in the flower, and ultimately the cloud and flower in all of us.

The Zen emphasis on interconnectedness, interbeing, and nonduality has other implications as well. In understanding the symptoms of any one individual (e.g., issues with substance abuse), Zen Buddhism is likely to take a broader perspective than most therapists and will cast the problem as not only within the individual, but also reflective of all history (personal and collective), of all societies (including all realms), and of all environments. The Zen Buddhist concept of interconnectedness can offer complex insights into the increasing acknowledgment of the social and structural determinants of mental health in the West (Allen et al. 2014).

Further, as everyone and everything is ultimately connected, Zen Buddhism is critical of quietistic, individualistic practice of attaining tranquility and spiritual perfection. Zen Buddhist practice, based on Mahayana Buddhism, emphasizes total immersion in the flux of everyday life (this part is similar to ACT); it also emphasizes compassionate engagement with the world (Feleppa 2009). In Zen Buddhism, also known as engaged Buddhism, Zen practitioners possess “the willingness and capacity of being there, listening, responding to suffering and helping beings” (Nhất Hạnh 1999, p. 239). Indeed, the volitional action of Zen Buddhists does not stop until all beings are free from suffering. Finally, the Sangha, a community of Zen Buddhist practitioners, is much more explicitly emphasized in Buddhism.

In parallel, but to a more limited scale, ACT also takes a larger contextual perspective than many other psychotherapies; ACT has been used successfully to combat stigma and motivate social justice actions (Fung and Wong 2014); and there is a value-based effort in building a mutually supportive community of practice, as exemplified by the Association of Contextual Behavioral Science. It may be fruitful for ACT practitioners to dialogue and discuss strategies in supporting clients to build communities of ACT practices that promote their well-being.

Conclusion

In summary, ACT is a mindfulness-based intervention with core therapeutic processes that are congruent to some of the Zen Buddhist teachings. Its underlying philosophy, functional contextualism, and scientific theory, relational frame theory, bear some semblance to Buddhist philosophy and theory of the mind, although they are also substantially different when we appreciate distinct Buddhist concepts such as emptiness and the elaborate postulates of the mind in the Manifestation-Only school of Buddhist psychology. The aim of ACT in alleviating suffering is similar to that of Buddhism, but the scope is more mundane, modest, and limited (to psychological problems in this life) and it is much less morally prescriptive. Key concepts, like impermanence and nonself, though not incompatible, are not explicitly included, likely due to cultural reasons or the legacy of the eighteenth century Enlightenment period in the West, whereby religions were separated from medicine and healing (Koenig 2000). Thus, a successful treatment with ACT may not necessarily lead to spiritual enlightenment or a sense of collective interconnectedness. However, a deeper understanding and potential integration of some of the Buddhist principles and teachings may help ACT practitioners to become even more compassionate and effective. It is hopeful that exploration, comparison, and integration of the wisdom from Buddhist and other spiritual traditions may gradually inform the future refinement of ACT and other psychotherapies for the benefit of all. As Maex noted, “It was a stroke of genius to take mindfulness training out of the Buddhist context, but the risk might be that, instead of opening a door to the Dharma, it might also close a door leading to the vast richness of that context full of valuable insights and practices” (Maex 2011, p. 166). Rather than being stuck in scientism or looking to abstracting and Westernizing traditional practices out of their context, it may be wiser, more pragmatic, and more effective for a therapist to respectfully and meaningfully incorporate the deeper wisdom embedded in the spiritual traditions, while conducting therapy in a culturally competent, safe, and respectful manner cognizant of the client’s own worldview and seeking opportunities to enhance cultural exchange and expansion of one’s worldview (Lo and Fung 2003; Seiden and Lam 2010).