Making a Mindful Nation: Mental Health and Governance in the Twenty-First Century

MAKING A MINDFUL NATION

Making a Mindful Nation

MENTAL HEALTH AND GOVERNANCE IN THE TWENTY-FIRST CENTURY

JOANNA COOK

PRINCETON UNIVERSITY PRESS

PRINCETON & OXFORD

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CONTENTS

Acknowledgementsvii

Introduction 1

If Mindfulness is the Answer, What is the Question?

1 A Genealogy of the ‘Present Moment’20

2 Depression, Optimism and Metacognition44

3 Mindfulness in the Extraordinary Ordinary65

4 Mindful Parliamentarians: Common Sense and Living Well85

5 Mindful Politics, Participation and Evidence106

6 The Skilful Means of the Mindful Advocate125

Conclusion 144

Keep Calm and Carry On?

Notes159

Bibliography169

Index195

ACKNOWLEDGEMENTS

I COULD NOT HAVE WRITTEN this book without the support and kindnesses of numerous friends, colleagues, students, and institutions.

First and foremost, I am beyond grateful to the mindfulness practitioners who welcomed me into their worlds, personal and professional, and who included me in the ups and downs of their relationships with mindfulness over the years. Their generosity is at the heart of this book.

A British Academy Senior Research Fellowship and a Visiting Fellowship at Stanford University supported the writing of the book, both of which enabled me to develop a first draft. Two of the chapters have appeared elsewhere. Chapter 1 was first published in the Journal of Global Buddhism 22 (1) (2021) and material from chapter 5 appears in Beyond Description (Heywood and Candea 2023); I am grateful to the editors for their permission to publish the work here.

UCL has provided me with a wonderful home, and I am grateful to my colleagues for their wholeheartedness and passion for anthropology, particularly Allen Abramson, Timothy Carroll, Haidy Geismer, Martin Holbraad, Susanne Keuchler and Charles Stewart. The Medical Anthropology section have been a supportive and exciting group of people with whom to work: Gareth Breen, Joe Calabrese, Sahra Gibbon, Dalia Iskander, David Napier, Aaron Parkhurst, Sara Randall and Carrie Ryan. My brilliant students at UCL have challenged and inspired me throughout the writing of this book, particularly those on the course ‘Anthropology of Ethics and Morality’, and I am grateful to them for genuinely exciting and exploratory conversations.

A partial list of all those who kindly gave advice and support must include Matei Candea, Nick Evans, Caroline Humphrey, Nick Long, Mathew Thomson and Soumhya Venkatesan. At Stanford, my thanks go to Tanya Luhrmann for unfailing support, encouragement and friendship. And I am very grateful to Leslie Pritchett for providing me with a home, wine and ridiculous amounts of fun during my time in the States. I am humbly obliged to those who read substantial portions of my manuscript and did their best to make them better: Peter Allen, Madeleine Bunting, James Laidlaw and Jon Mair—thanks also to Jon for setting up (and enforcing) pretend chapter deadlines to keep me on track. I thank Fred Appel, James Collier and my two anonymous readers for Press, for believing in this project, and Ali Parrington and Francis Eaves for their careful work on its production.

I am very grateful to my family: to Beatrice, whose birth gave me a hard deadline to work with, my brother, David Cook, for always being there, and to my parents Marcus Cook and Sally Burnley, and their respective partners, Tasha Mundy and Paul Burnley. And to my in-laws, Peter and Jennifer Heywood, and to Bertie the dog. I also give thanks for the extraordinary friendships that have carried me through all of it: with Joanna Beasley, Yasmin Khan, Stefan Moss, Natasha Moscovici, Ella Saltmarshe, Annabelle Stanley, Kary Stewart and Lorna Watson.

Finally, I am indebted most of all to my husband, Paolo Heywood, who has read every draft of every chapter with patience and love, and who is a brilliant thinker, my closest friend, an incredible father and generally the best person with whom to share a life.

MAKING A MINDFUL NATION

INTRODUCTION

If Mindfulness is the Answer, What is the Question?

MINDFULNESS IS EVERYWHERE. Advertisements encourage consumers to ‘Breathe in for as long as it takes to read this line. Breathe out for as long as it takes to read this line.’ Magazines at supermarket checkouts list meditation in features offering advice on ‘10 tips for a happier life’. Radio DJs and talk-show hosts interview monks and mindfulness teachers, and books on meditation, psychology and the brain sciences sell in their millions, while tens of thousands of news stories wax lyrical about mindfulness’s benefits for stress management in workaday lives (Van Dam et al. 2018, 68). It is now so normal for people to practise mindfulness (or think that they ought to) that if you have an iPhone, you have an inbuilt mindfulness section in your health data app that tells you that ‘taking some time to quiet your mind, be in the moment, can make you less stressed and improve your health overall’. In short, learning to ‘be present in the moment’ is having its moment.

The timing of this meteoric public ascent is noteworthy. Mindfulness is being championed as a prophylactic psychological support at a time of intense public concern about mental health and psychological vulnerability. Depression is the number one cause of disability worldwide (Kousoulis 2019, 2), and the burden of mental health is on the rise (WHO 2020). In the United States, one in four Americans is reported to have a mental or substance use disorder (McCane-Katz 2020) and the National Center for Health Statistics reported a suicide-rate increase of 35 per cent between 1999 and 2018 (Hedegaard, Curtin and Warner 2020). In the UK, it is estimated that up to 10 per cent of the adult population will experience symptoms of depression in any given week and depressive relapse rates are high: following one episode of depression 50 per cent will go on to have a second episode, and 80 per cent of these will go on to have three or more episodes (Singleton et al. 2003). Since 2009 the number of sick days lost to stress, depression and anxiety has increased by 24 per cent and the number lost to serious mental illness has doubled (Mehta, Murphy and Lillford-Wildman 2014). And this rise in mental health challenges is not limited to adult populations. The number of fifteen- to sixteen-year-olds with depression nearly doubled between the 1980s and the 2000s (Nuffield Foundation 2013), and over half of those who experience mental illness in childhood suffer it again as adults (Kim-Cohen et al. 2003; Kessler, Berglund et al. 2005).

Interest in mental health is not limited to clinical conditions. Researchers focusing on positive mental health conceptualise mental health as a spectrum encompassing mental disorder, ‘languishing’ and ‘flourishing’ (see Huppert 2009; Keyes 2002a; 2002b; also Huppert 2005);¹ and primary prevention is a central focus of public mental health campaigns that seek to stop mental health problems before they arise. As the Mental Health Foundation states on its website (MHF 2022), ‘[w]e all have mental health, just as we all have physical health’. Researchers characterise positive mental health, or ‘flourishing’, as the presence of psychological and social well-being, a categorisation that extends far beyond the absence of mental illness. And they suggest that many of us may be occupying the suboptimal space of ‘languishing’ most of the time.

By the time I began the fieldwork for this book, a body of research was growing that linked mindfulness to the prevention of mental disorder and the cultivation of positive mental health. Thousands of articles in scientific journals explored the therapeutic potential of mindfulness, examining everything from brain waves to irritability.² Evidence was being compiled that suggested that Mindfulness-Based Cognitive Therapy (MBCT) might help large numbers of people experiencing depressive affect and patterns of recurring depression (Baer 2003; Coelho, Canter and Ernst 2007) and three randomised-controlled trials had found that MBCT significantly reduced the risk of depressive relapse (Kuyken et al. 2008; Ma and Teasdale 2004; Teasdale, Segal et al 2000).³ Clinical studies were investigating the benefits of meditation, motivated by the possibility of reducing stress, increasing productivity, addressing psychological disorders and supporting ‘flourishing’. Bolstered by an increasingly healthy evidence base, advocates and practitioners had introduced mindfulness into schools and universities, prisons, the probation service, healthcare institutions and workplaces (public, private and third sector). It is an extraordinary phenomenon that a Buddhist awareness training practice is now being framed as a solution to societal challenges as wide-ranging as criminal recidivism, academic attainment, depressive relapse and workplace absenteeism.

In this book I ask, if mindfulness is the answer, what is the question? What is it that unites the workplace and the prison cell? How are the classroom and the hospital understood, such that they are connected by an awareness practice? And how have mindfulness practitioners come to think of cultivating a kindly relationship with their own minds as a constituent aspect of the ‘good life’? How has it happened that mindfulness has become an appropriate support for such a range and variety of different societal challenges? What has changed to lead to this framing? And how have these changes affected how people relate to themselves and to others? To put it another way: if mindfulness is an appropriate practice in every area, from the clinic to the classroom, and for diverse people, from people who are leading healthy, happy lives to those struggling with their mental health in circumstances that are stacked against them, what does this tell us about the questions people are asking about the mind and how they understand themselves in relation to their minds?

Mindfulness provides a window onto a particular moment in which the mind has become a preeminent focus (see McMahan 2008, 201–2). The category of mental health has progressively altered in recent years, shifting from an either/or categorisation of those who do or do not suffer from mental ill-health, to one of an affliction affecting one in four people, to one of a fluctuating condition of all human life. Sometimes described as a shifting landscape, sometimes as a scale, location on which changes, mental ill-health is often now thought of as something that affects all people to a greater or lesser extent at different points in their lives. The expansion of the category of mental health swells the populations for whom it is a concern and transforms responses to address it. ‘Mental health’ is no longer only relevant for those who would qualify for a mental health diagnosis; in this new categorisation, all people are more or less well at different points in their lives. And emphasis shifts from illness to health: the prevention of illness is met and supported by the active cultivation of positive mental health in order to ‘live well’. In this book, I interrogate the consequences of these transformations, examining how people think of themselves, what they think they should do, the values with which mental health is invested, the policies that are created around it and the ways in which the goals of those policies are achieved. Mental health has become a transversal feature of life and one that can be actively supported through dedicated practices. Through my focus on mindfulness, I show how mental health is incorporated into people’s relationships with themselves, therapeutic interventions, structures of governance and political campaigns.

An Anthropology of Metacognition

Mindfulness is often thought of as a solitary activity (people sitting still with their eyes shut, perhaps), and is commonly described as an acultural, universal, timeless or ancient practice. But recent anthropological and social scientific work has challenged these assumptions, revealing the historical and cultural processes that inform mindfulness and meditation in diverse contexts. Kirmayer (2015a) has rightly highlighted that adapting techniques like mindfulness from the social contexts in which they originate changes the meaning, nature and effect of their practice; and, as Gajaweera emphasizes (2016) in her work with ethnic and racial minority meditators in Los Angeles, origin traditions do not themselves stay still, and are perpetually subject to proximate and foreign influences. Historians and religious scholars have provided excellent considerations of the development of mindfulness and its relationship to wider religious and secular contexts (see Braun 2022; Husgafvel 2018; McMahan 2008; Nathoo 2019; Wilson 2014; 2017). And anthropologists have demonstrated that mindfulness is informed by normative registers that influence the self-knowledge generated through practice (see Cassaniti 2018; Hedegaard 2020; Mautner 2020; McKay 2019; Myers, Lewis and Dutton 2015; Pagis 2009; 2010; 2019; Vogel 2017; Wheater 2017), providing descriptive accounts of the ways in which interior experiences are socially enabled. Anthropologists have shown, that is, that far from being timeless and universal, mindfulness is fundamentally informed by the cultures and the contexts in which it is ensconced.

Mindfulness, as it is now found in institutions around the world, originated in Buddhist meditation, and the term itself is often taken to be a translation of the Pali word sati (see Cassaniti 2018; Gethin 2011 for sustained discussions of this). Beginning in the 1950s in south-east Asia, reformist monks developed, reinvigorated and propagated a form of meditation, vipassanā, based on a Buddhist text, The Mahāsatipatthāna Sutta (see Braun 2013; Cook 2010a; Jordt 2007). Reformers understood sati as an ethically positive perspectival awareness, which could be cultivated through meditative discipline, requiring morality, concentration and wisdom. Therapeutic mindfulness-based interventions are described by their originators as ‘marriages’ between a conceptual framework from cognitive psychology and quite intensive training in mediation, a ‘confluence of two powerful and potentially synergistic epistemologies’ (Williams and Kabat-Zinn 2011, 1). But while the Buddhist roots of mindfulness may be fleetingly referenced in mindfulness courses, mindfulness is most commonly interpreted as a universal human capacity that can be cultivated by practitioners in order to alleviate mental, physical and emotional suffering. Thus, while mindfulness is understood to have originated in Buddhism, it is commonly conceptualised as modern, scientific and secular. And it is framed as a universal and acultural psychological skill that can support the reduction of suffering and the cultivation of mental health.

While there are some disagreements about how mindfulness should be defined (see Mikulas 2011), it is most commonly understood as an awareness-training practice that enables people to ‘[pay] attention in a particular way, on purpose, in the present moment and non-judgementally’ (Segal, Williams and Teasdale 2002, 121). Through daily practice, mindfulness practitioners learn to ‘pay attention’; that is, to develop awareness of the patterns of their thoughts, emotions and bodily experiences. This is done ‘on purpose’ as practitioners intentionally change the focus and style of their attention, by ‘non-judgementally’ focusing on what they experience in the ‘present moment’, making emotional experience and the fluctuations of cognition the object of self-conscious reflection without trying to alter that experience. Through this ongoing cultivation of awareness, people intend to relate differently to their experiences and, as a result, to live healthier lives.

Mindfulness gained legitimacy as a secular and therapeutic practice following the development of Mindfulness-Based Stress Reduction (MBSR), an intervention designed by Jon Kabat-Zinn in America in the 1970s to treat chronic disease and pain, though it was only with the development of Mindfulness-Based Cognitive Therapy (MBCT) by Mark Williams, Zindel Segal and John Teasdale in 1991 that mindfulness-based interventions began to influence mental healthcare significantly in the UK (see chapter 1). MBCT is a psychosocial group-based intervention for people who have had three or more depressive episodes but who are currently well. The course is a practice-based training to support participants to identify early signs of depression in order to prevent relapse and to actively maintain their mental health. It encourages participants to develop awareness of small fluctuations in mood, thoughts or bodily experiences, and they learn that developing awareness in this way while they are well has the potential to prevent them relapsing into depression. Practitioners and promotors of mindfulness describe this metacognitive ability as a universal human capacity that can be cultivated,⁴ and they learn to relate to the mind as a mind, to think about thinking in a peculiarly committed way, by recognising thoughts as ‘objects in the mind’ and relating to them with kindliness.

Anthropologists have highlighted that attentional and metacognitive skills vary across cultures (see Proust and Fortier 2018) and that how people think about thinking has effects on the strategies that they employ in relation to thought, and on the habits and skills that they seek to cultivate in order to influence the direction or quality of their attention (see Cassaniti and Luhrmann 2014; Hirschkind 2001; 2006; Luhrmann 2012, xxi; Mair 2018). They have shown that people have clear ideas about the nature of thought and how they ought to relate to it, and that these ideas are embedded in particular relationships and practices. Anthropological accounts reveal the effortful practice that people make to attend to attention in particular ways; that people wilfully and actively cultivate attentional skills in order to effect change in their lives. The pan-human capacity for metacognition is invested with specific cultural and attitudinal values through the practice of mindfulness. And it is the particular way in which people relate to their minds (and not just the fact that they do so) that is central to mindfulness. The mindfulness practitioners who are the focus of this book intentionally cultivate forms of awareness and attentional focus through mindfulness training. They learn that they can have a relationship with their own minds, and they learn techniques for developing a particular form of effortful attention to the mind that involve repetitive practice, requiring ongoing training in metacognitive awareness. They think that cultivating metacognitive ability, or learning to ‘make friends’ with one’s own mind through self-reflective practice, is of benefit to all people in the maintenance of mental health, whether or not they have ever received a mental health diagnosis. For them, living well is characterised by metacognitive skill, attentional training and the cultivation of a kindly relationship with one’s own objectified mind. In chapters 2 and 3 I delineate the particular attitudinal dispositions that characterise the metacognitive skill that mindfulness practitioners cultivate. In mindfulness as a therapeutic intervention and as a daily practice, the attitudinal quality of kindliness imbues metacognitive ability and is central to the objectification of the mind.

Psychological Governance and the Ethical Turn

In the 1950s, depression was so rare that pharmaceutical companies saw no benefit in investing money in its treatment (Healy 1997). And yet, by the 1990s, the second most prescribed drug in the United States was the antidepressant Prozac (Elliott 2018). While statistics about the projected costs, prevalence and severity of depression all point to an emerging public health crisis and provide grounds for immediate action, such as funding, research and intervention to support individuals and communities, anthropologists have argued that cause and effect work the other way: that depression is ‘socially constructed’ through changes to diagnostic criteria, increased awareness, and the medicalisation and commercialisation of mental states (see Hirschbein 2014; Kitanaka 2011). Social scientists have characterised shifting dynamics of mental health classification and presentation as a diagnostic (rather than a psychological or biological) epidemic, finding in escalating mental health statistics a ‘contagion of representation’ (Mattingly 2017; see also Grinker 2007). Such social constructionist accounts provide illuminating insights into the cultural and historical conditions that inform the way that categories of representation such as ‘mental health’, ‘depression’ or ‘anxiety’, are constructed, charting the new forms of biosociality established around changes in diagnostic criteria as scientific research is targeted, rights and services are expanded and people come together in activist movements and self-help groups organised around a particular illness or disability (Rabinow 1996; Rose and Rabinow 2006).

Important studies of the cultural history of psychology have highlighted how truth discourses about human character are taken up by different authorities, informing strategies for intervention and the ways in which individuals work on themselves in support of individual or collective health (see Cushman 1995; Danziger 1990; Rose 1985; 1996b). Psychological terms, diagnoses, explanations, values and judgements thus get entangled with a more general contemporary ‘regime of the self’ as the prudent yet enterprising individual actively shapes his or her life course through acts of choice (see Novas and Rose 2000). As psychological thinking expands, it informs the habits, values and obligations of the self-sufficient, ‘responsibilised’ citizen who is able to withstand the uncertainties of modern life (Brown 2003; Cruikshank 1996; Rose 1996a, 1996b). In such a reading, it is people’s freedom that enables them to become objects of governance, because it binds them ‘to a subjection that is more profound because it appears to emanate from our autonomous quest for ourselves, it appears as a matter of freedom’ (Rose 1990, 256, emphasis added). The intensified attention to the inner life of psychological subjectivity is, as Rose revealed in his seminal work, intimately connected to the marriage between political agendas and ‘the personal projects of individuals to live a good life’ (ibid., 10; see also Kleinman et al. 2011). Such approaches afford us the opportunity to examine one form of relationship between self-governance and social forces: the influence of psychological knowledge and technologies for the identification and management of populations, and the influence of expert knowledge in the creation of psychological subjectivity. Psychological knowledge doesn’t just describe experience; it also creates and shapes subjects, informing what people think they know about themselves and what it is to be human; and this influences the ways in which they relate to themselves and others.

Where I differ from such approaches is in placing the emphasis of my analysis on first-person experiences of mental health in order to reflect on the categories and structures of governance to which they are constitutively related. In what follows I show that the micro-level efforts that people make to support their mental health, to engage in intentional projects of cognitive and emotional discipline in order to prevent mental ill-health and to promote psychological well-being and flourishing are intimately related to macro-level projects of governance and social structure. Transformations in social services, institutional structures and governmental agendas reflect and contribute to the everyday efforts that people make to attend to their psychological selves. In what follows, I examine how transformations in the category of mental health are central to the reimagining of psychological subjects, the reshaping of techniques of governance and the refashioning of the relationship between parliamentarians and citizen-subjects. And yet, I am in no way arguing that people are determined by the social or material forces in which they are ensconced. In fact, this book may be read as a critique of the ‘neoliberalism made ‘em do it’ arguments that circulate around psychological subjectivity and self-governance. Rather, I examine the social processes by which mental health is lived, the normative values that inform it and the practices of self-cultivation by which it is addressed. That is, I extend my analysis beyond the Althusserian ‘interpellation’ of changing social categories and expert practices to examine the values and efforts with which people navigate the world, and the ethical complexity and cultural particularity of so doing (see also Cook 2023). For example, in the transformations in the category of depression from an acute to a relapsing or recurring condition, or the shift in the category of mental health from relevant for certain at-risk populations to a constituent aspect of life for everyone, how do people’s relationships with themselves and others change, what values inform their efforts to live well, and what is the lived experience of these?

In this approach, this book takes inspiration from the recent ethical turn in anthropology (Faubion 2001a; Laidlaw 2002; Lambek 2000a). The development of the anthropology of ethics is seen by some as a move away from earlier culturalist claims that people think or behave in certain ways because of the society, culture or ideology in which they find themselves (Heywood 2017; Laidlaw 2002).⁵