Some 30 years ago Jack Engler published an influential study based on his experience as both a Buddhist meditation teacher and a clinical psychologist. He had discovered over the years that many people who come to Buddhism are looking for the kind of help they ought properly to seek in psychotherapy. “With the ‘triumph of the therapeutic’ in Western culture,” he wrote, there is a tendency in mindfulness meditation to “analyze mental content instead of simply observing it.”

In more recent years this conflation between Buddhist practice and psychotherapy has only deepened. Books tracing associations between the two traditions have proliferated, and the use of mindfulness meditation in a therapeutic setting has become commonplace. Indeed, pristine, unassailable mental health is often assumed to be the ultimate goal of all study and practice of the dharma.

The problem, however, is that it isn’t. And when, as it happens, an accomplished Buddhist meditator struggles with severe depression or anxiety—symptoms of a clinically diagnosed psychological disorder—it can be especially difficult for students to understand. Writing after the death of the Canadian Buddhist teacher Michael Stone, who had struggled with bipolar disorder, the Scottish Zen monk Dogo Barry Graham reflected on would-be students who were disappointed to hear that what treats his own mental health issues is not meditation, but Prozac. “Some were upset when I told them to see a doctor before they attempted meditation practice,” he wrote on his blog.

We run the risk of conflating the ultimate goal of Buddhist practice with an altogether conventional, secular understanding of mental health.

At this point there can be little doubt that a great deal of personal suffering has been alleviated through the judicious application of mindfulness meditation to the various maladies of the psychosocial self. Such success in employing mindfulness as a therapeutic instrument has granted scientific credibility to an ancient form of Buddhist ritual activity—a credibility that cannot help but influence our understanding of the benefits and goals of traditional Buddhist spiritual practice. For precisely this reason, it’s essential that we appreciate the critical difference between how mindfulness is used in the context of modern psychotherapy and how this same meditative technique has traditionally functioned as an indispensable element of the Buddhist path to enlightenment (nibbana). If we fail to grasp this distinction, we run the risk of conflating the ultimate goal of Buddhist practice with an altogether conventional, secular understanding of mental health.

Both Buddhism and psychotherapy are directed toward the problem of human suffering, but nibbana—the goal of Theravada Buddhist practice—and the therapeutic goal of “mental health” are grounded in two distinct understandings of the nature and scope of human suffering. While psychotherapy aims at the alleviation of symptoms experienced as extrinsic or peripheral to the patient’s underlying core sense of self, Buddhism addresses a form of suffering (dukkha) considered intrinsic to the experience of the personal self as an independent agent defined by its capacity to analyze and think, to judge, choose, act and be acted upon. Buddhist teachings associate these two forms of suffering with two distinct but interrelated truths about the self and its world: the first is “conventional” truth (sammuti-sacca), which governs day-to-day, practical affairs, where appearances are all that matters; and the second is “ultimate” or “absolute” truth (paramattha-sacca), which reveals the illusory nature of these same appearances.

The practice of psychotherapy is, accordingly, dedicated to a method of healing that leaves the conventional structure of self-as-agent intact as the focal point of attention, whereas Buddhist spiritual practice engages in a sustained, methodical dismantling of our customary preoccupation with self-centered experience.

One way to illustrate the subtle but profound difference between these two forms, or levels, of suffering is through reference to the clinical condition known as obsessive-compulsive disorder (OCD). OCD is defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as the presence of obsessions, compulsions, or both. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, and in most patients cause marked anxiety or distress. Compulsions are repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession, as an attempt to reduce or mitigate the accompanying anxiety. Unfortunately, as DSM-5 explains, compulsive acts “are not connected in a realistic way with what they are designed to neutralize or prevent”; consequently, they serve only to increase the individual’s distress.

The discomfort experienced by an OCD patient is triggered by thoughts that are unambiguously experienced as alien to the patient’s core sense of self. Even in the most serious cases, when the unwanted thought arises—say, a compulsion to wash one’s hands for the tenth time in an hour—the patient is aware that her hands are not actually dirty. That is to say, in people suffering from OCD some part of the conscious mind remains aloof as an impartial spectator, aware of the compulsive thought but not identified with it. This feeling of being compelled, against one’s will, into an intimate alliance with thoughts and desires not my own is referred to technically as “ego-dystonic thinking”—a defining symptom of obsessive-compulsive disorder.

Ego-dystonic thinking is not peculiar to OCD patients; to some extent, it’s a familiar dimension of everyone’s mental life. Although most of us are deeply identified with our thoughts most of the time—“I think, therefore I am”—nevertheless under certain circumstances we know what it is to experience a thought as intrusive, or to reflect in such way as to distance ourselves from thoughts that cry out for attention. Unlike the OCD patient, even when an intrusive thought persists, most of the time we can resist the siren’s call to action.

For example, let’s say I’m going out of town for several days. Before leaving my home, I carefully go over a checklist of things that need to be done, making sure that the thermostat is adjusted correctly, that lights and stove are turned off, and so forth. I go over the list several times, until I’m sure everything is in order. But then, sitting in the car with the engine running, I’m seized by an urge to go back inside and check one more time. A critical difference between the normal experience of ego-dystonic thoughts and the pathological experience of the OCD sufferer is that I do not experience such thoughts as a source of unbearable anxiety, much less as an irresistible summons to act; rather, I can sit back and simply watch the urge come and go.

Jeffrey Schwartz, a research neuroscientist in the Department of Psychiatry of UCLA’s medical school who specializes in the treatment of OCD, discovered a way to turn his patients’ severely ego-dystonic thinking into the means of their cure. He noted early on that OCD’s “intrinsic pathology is, in effect, replicating an aspect of meditation, affording the patient an impartial, detached perspective on his own thoughts.” Drawing on his personal experience with the practice of mindfulness, Schwartz painstakingly taught his patients how to drive a wedge between the intrusive thought and the simple awareness of that thought, effectively widening the gap between, on the one hand, the patient’s subjective sense of self and, on the other, the unwanted urge, which is viewed as not mine. He calls this first step “relabeling” the thought. The second step is to “reattribute” the obsessive thought, consciously recognizing it as a function of pathological brain circuitry. The patient then “refocuses,” shifting his attention away from the obsessive thought toward a thought felt to be consonant with his core sense of self. Finally, he “revalues” the original obsessive thought, assigning it no power or authority over his (now) clearly separate identity as a healthy person.

Schwartz’s technique works. A significant percentage of patients undergoing his therapeutic regimen have found partial or even total relief from their symptoms. The anxiety generated by obsessive thoughts is lessened, and with the lowering of this anxiety, the need for associated compulsive behaviors is no longer present.

Notice that mindfulness meditation is only employed here temporarily, in the initial stage of Schwartz’s regimen. Having achieved adequate distance from the disturbing thoughts and urges, the patient moves seamlessly from simply observing them as they arise, unbidden, to actively judging such thoughts as pathological, and finally to consciously choosing a way of thinking and acting consonant with the “healthy” or “normal” desires of the core self experienced as a volitional agent engaged in purposeful action.

But what if literally every thought were experienced as “painfully amplified”? What if the entirety of one’s mental and emotional life were to be experienced as insistent, discomfiting, and intrusive?

Such is the human condition seen from the point of view of an advanced Buddhist meditator. Here, for example, in this passage from the postcanonical Abhidhammattha Sangaha, we find a description of how mindfulness is used as a tool for cultivating insight (vipassana) into the painful nature of ever more refined states of concentration (jhanas):

Consider the monk who, aloof from sense desires, enters and abides in the first jhana: whatever occurs there of form, feeling, perception, mind or consciousness, he sees wholly as impermanent phenomena, as ill, as a disease, a sting, a hurt, an affliction, as something alien, gimcrack, empty, not the self.

—trans. E. M. Hare

According to the first noble truth, one of the four foundational principles of Buddhist thought, a level of anxiety or suffering is woven into the very fabric of our thinking, feeling, sensing, and perceiving, a primal discontent inherent to even the most exalted states of concentration and bliss—not to mention the ceaseless mental turmoil present in normal, “healthy” ego-centered experience. To imagine that this deep-seated malaise could somehow be eradicated while still preserving one’s habitual preoccupation with these same basic structures of thought, feeling, and sensation is to fail to grapple with the ultimate truth about human suffering.

Buddhist teachings remind us that we will never achieve real or lasting satisfaction by adopting a different, better way of thinking or acting.

From the Buddhist point of view, therapeutic programs designed to make the ego happier or more comfortable are geared toward the relatively superficial or “conventional” notion of suffering. Buddhist teachings remind us that we will never achieve real or lasting satisfaction by adopting a different, better way of thinking or acting. The effort to find happiness in this way may bring relief from the more extreme forms of anxiety to which the personality is subject, but it is nonetheless based on an endlessly replicating fantasy charged by an unquenchable, obsessive thirst that serves only to perpetuate the ego’s compulsive activity and its attendant suffering. This is the very definition of bondage to karma, the engine of a chronic existential disease. The insatiable yearning to analyze and discriminate, judge and choose—and thereby to control or shape the self in the image of its constantly shifting desires—is the elemental force of dukkha in its most basic form. It is the inescapable plight of the self.

This brings us to the central concern of Theravada Buddhism, and to mindfulness meditation as the primary means for stepping away from the whole project of searching for happiness by judging and choosing, rejecting some things while accepting others.

As a tool for cultivating insight into the inherent suffering of the ego, mindfulness meditation opens up a field of awareness disassociated with any form of volitional activity. To maintain a deep, sustained practice of mindfulness is to consistently disidentify with the experience of self as willing agent, to let go of the obsessive need to discriminate, judge, and choose. Such practice leads to the ultimate annihilation of our incessant thirst (tanhakkhaya), the utter peace and freedom of nibbana: “Here, monks, I say there is no coming, no going, no standing still; no passing away and no being reborn. It is not established, not moving, without support. Just this is the end of dukkha” (Udana 8.1, trans. Peter Masefield).

In principle, what the unconditional peace and freedom of nibbana asks of us stands in stark contrast to our conventional desires: either let go of the self and its world without reservation, or embrace them both wholeheartedly, just as they are. The first is the expression of insight or wisdom, the second, that of boundless empathy and universal compassion. Either way, the point is that with the realization of nibbana, attention is no longer dominated by the obsessive, anxious need to discriminate between what is acceptable and what is not, and the associated compulsion to act on the basis of such distinctions. This need defines both the self and its suffering; by contrast, an uncompromising disidentification with the volitional self and its tortured particularity is the hallmark of Buddhist practice. This is where psychotherapy and Buddhism part ways in their interests and methods.

At the time of Engler’s study 30 years ago, those undertaking Buddhist practice to solve psychotherapeutic issues—and, according to him, there were many such people—often suffered from various clinical disorders characteristic of an ego that had been traumatized and arrested in the course of its development. They were frequently searching for a way to avoid the developmental tasks essential to the formation of a functioning ego; Buddhism was particularly attractive to them because of its core teaching of no-self, mistakenly perceived as a “shortcut solution to the developmental tasks appropriate and necessary to their stage of the life cycle.” However, what they found in Buddhist practice was, ironically, nothing but an endless hall of mirrors reflecting their own fears and desires.

“My impression,” Engler wrote in his groundbreaking study, “is that narcissistic personalities represent a sizable subgroup of those individuals with borderline levels of ego organization who are drawn to meditation.” For this type of personality, the ideal of enlightenment or nibbana offers a unique attraction:

This [ideal] is cathected as the acme of personal perfection with eradication of all mental defilements (kilesas) and fetters (samyojanas). In other words, it represents a purified state of complete and invulnerable self-sufficiency from which all badness has been expelled, the aim of all narcissistic strivings. For this kind of personality, “perfection” often unconsciously means freedom from symptoms so they can be superior to everyone else. The second attraction is the possibility of establishing a mirroring or idealizing type of narcissistic transference with spiritual teachers who are perceived as powerful, admirable beings of special worth in whose halo they can participate.

Notice how the perspective of Engler’s narcissistic meditators parallels the perspective of Schwartz’s OCD patients: both groups experience particular thoughts as alien and painful to a core self that seeks to regain control of its psychological integrity through asserting its power to judge and then to choose and act on what is considered to be in its own best interest. In this case, however, the goal—idealized as “the acme of personal perfection . . . complete and invulnerable self-sufficiency”—is conceived in terms both unrecognizable to psychotherapy and antithetical to the basic principles of Buddhist doctrine and practice. The two traditions have become hopelessly conflated, to the detriment of both.

This conflation has its roots in a prevalent assumption, namely, that bare observation—the essence of mindfulness practice—has no power or value unless it can somehow be harnessed to the attainment of a goal that serves the purposes of the ego. Consider, for example, how Schwartz himself described the revelation that led him to apply mindfulness meditation to the treatment of OCD: “But perhaps, I thought, the impartial spectator needn’t remain a bystander. Perhaps it would be possible to use mindfulness training to empower the impartial spectator to become more than merely an effete observer.”

In the current environment, where the practice of mindfulness meditation is routinely detached from the broader context of Buddhist doctrine, even among Buddhist practitioners we’re much more likely to find the ultimate, liberating goal of nibbana confused with a conventional version of mental health. The problem Engler so skillfully documented 30 years ago is increasingly likely to occur and at the same time is increasingly less likely to be appreciated for what it is. Given this situation, his research is, arguably, even more germane now than when it was first published.

Let’s be clear: mindfulness meditation has proven to be an effective component in psychotherapeutic programs aimed at achieving the secular or (to use the Buddhist term) conventional goal of mental health. This in itself is an accomplishment of indisputable value. But mindfulness meditation in its “ultimate” application—as a Buddhist practice aimed toward realization of nibbana—is not concerned with shaping a functional ego. It is, rather, a way to disidentify with both health and illness, happiness and sorrow, pleasure and pain. To disidentify, that is, with the unavoidably painful nature of even the most refined varieties of self-centered experience.

As practiced in the traditional Buddhist context, mindfulness is not a powerful, spiritualized form of psychotherapy, a device for fine-tuning the ego—much less a strategy for achieving “complete and invulnerable self-sufficiency.” Although in an abridged form it can be legitimately harnessed to the business of healing the self of a range of mental and emotional disorders, as an essential component in the Buddhist path to nibbana, mindfulness is not about becoming a happier, better person. It’s not about “happiness” at all—at least not if “happiness” is understood as the fulfillment of desire. Mindfulness is, rather, about wisdom rooted in insight, renunciation, and unqualified self-surrender.

This is not a message easily appreciated by a society awash with self-help books promising the fulfillment of one’s desires through some sort of spiritual or psychological adjustment. It is worth remembering, though, that even in ancient India the search for nibbana was not for everyone. There was, from earliest times, a clear division in the sangha between lay and monastic practitioners. And even within the monastic community there was a recognition of what might be termed levels of interest and commitment.

If we are to avoid distorting Buddhist doctrine and practice in such a way that we risk sacrificing its ultimate promise of liberating insight, then it is vitally important that we draw a clear and careful distinction between the traditional goal of nibbana and modern psychotherapeutic definitions of mental health. In doing so, we need to pay close attention to the ways in which the ancient Buddhist mental discipline of mindfulness is being used and the purposes to which it is being turned as it is assimilated into what the American historian and social critic Christopher Lasch once called “the culture of narcissism.”

One of the most prominent and elegant of all Chinese Buddhist texts is the Hsin Hsin Ming, a poem attributed to the third patriarch of the Chan school. Its opening lines are traditionally considered to capture the essence of Buddhist meditation: