July, 2012. I had the chance recently to see a film that I thoroughly enjoyed, The Best Exotic Marigold Hotel. I guess I would describe it as a parable about the triumph of hope in the context of reality. Fanciful and highly improbable it is, yes, but it is also magical and uplifting. Filmed beautifully in India, the story infuses the enthusiasm of youth into the despair of old age, against the metaphor of rehabilitating a decrepit relic of a resort hotel into a restored and welcoming “last adventure” for lost souls trying to figure out what to do with the last years of their lives. But it’s not just about the cycle of life—it’s also about racial, class, and sexual orientation bias, disapproval and fear of the unfamiliar, generational conflicts, and closed-mindedness versus open-mindedness. This is one of those films that has stayed with me, and I think the one word that best captures the film is attitude. The Miriam Webster definition of “attitude” is “a mental position with respect to (or a feeling or an emotion toward) a fact or state.” I guess I’d translate this definition a bit to characterize our attitudes as our beliefs and our feelings that accompany those beliefs. How fixed are they? Where do we get them? If they can be changed, do we want them to be changed? And how much do they govern what happens to us? These questions and more were the stuff of this film, asked gently, sensitively, and relatively unflinchingly, making it easy to forgive the improbability of the mostly happy ending, especially since that’s how we want it to come out!
Why do I go on at such length about this particular film? Well, partly because I saw it recently and I liked it, but more importantly because I think it relates to an area receiving a lot of attention in our field these days, though hardly a new set of ideas. In this issue of the Journal, Marchand presents an in-depth review of mindfulness-based stress reduction, mindfulness-based cognitive therapy, and Zen meditation for depression— approaches derived from eastern principles long recognized and valued in other nations but long disregarded in this country. I’m suggesting, of course, that the traditional lack of interest of western medicine in these approaches relates, at least in part, to our attitude of skepticism about “foreign” traditions or the unfamiliar. Marchand refers to the term mindfulness as “a practice of learning to focus attention and awareness on moment-to-moment experience with an attitude of curiosity, openness, and acceptance.” He adds that “during mindfulness, one becomes an observer of one’s own stream of consciousness” and that meditation is aimed at “bringing mental processes under voluntary control through focusing attention and awareness.” I might parenthetically add that these concepts bear some similarity to aspects of classical psychoanalysis such as “free association,” an exercise of exploring one’s mental and emotional states in the moment in an unstructured way. “Transference” itself could be described as a set of embedded attitudes toward others, many beyond conscious awareness.
Several forms of therapy have now been studied using carefully crafted randomized controlled study designs and have been shown to be effective for various patient populations. One such treatment, dialectical behavioral therapy, links explicitly with Zen principles and concepts of mindfulness. Another treatment, mentalization-based therapy, endorses the principle of “not knowing” on the part of the therapist—that is, attempting to shed preconceived bias and to be as open as possible to understanding the unique perspective of the patient. All in all, these are quite interesting developments within western psychiatric medicine. Certainly, all of us as therapists should be respectful, non-biased, and receptive to ideas and beliefs different from our own. But it is interesting to see our field of western psychiatric medicine changing its attitude to become more interested in and open to old ideas from the other side of the world.