Loving-Kindness in the Treatment of Traumatized Refugees and Minority Groups: A Typology of Mindfulness and the Nodal Network Model

of Affect and Affect Regulation

Devon E. Hinton,1,2 Rebecca A. Ojserkis,1 Baland Jalal,3 Sonith Peou,4 and Stefan G. Hofmann5
1 2

Massachusetts General Hospital and Harvard Medical School Arbour Counseling Services 3 U.C. San Diego 4 Metta Health Center of Lowell Community Health Center 5 Boston University
This article discusses how loving-kindness can be used to treat traumatized refugees and minority groups, focusing on examples from our treatment, culturally adapted cognitive-behavioral therapy (CACBT). To show how we integrate loving-kindness with other mindfulness interventions and why lovingkindness should be an effective therapeutic technique, we present a typology of mindfulness states and the Nodal Network Model (NNM) of Affect and Affect Regulation. We argue that mindfulness techniques such as loving-kindness are therapeutic for refugees and minority populations because of their potential for increasing emotional exibility, decreasing rumination, serving as emotional regulation techniques, and forming part of a new adaptive processing mode centered on psychological exibility. We present a case to illustrate the clinical use of loving-kindness within the context of CA-CBT. C 2013 Wiley Periodicals, Inc. J. Clin. Psychol: In Session 69:817828, 2013. Keywords: acceptance; mindfulness; meditation; posttraumatic stress disorder; cross-cultural

Introduction
In Buddhism, loving-kindness is highly emphasized. It is one of four emotions or virtues that are called bramavihara, meaning sublime attitudes, literally, the abodes of brahma. The virtues include compassion, or karuna; joy in the joy of others, or mudita; detached, curious observation (also called equanimity), or ubekhaa; and loving-kindness, or metta. (Often, Cambodians and other groups conate compassion and loving-kindness into one concept, metta garunaa.) In Cambodia, monks frequently entreat laypersons to develop a dharma heart, which entails cultivating these four virtues, for example, the virtue of having a loving-kindness heart. These four emotions are thought to be important to cultivate to promote happiness, and parents are exhorted to cultivate these four attitudes to be successful in raising children. A four-faced Brahma image is said to represent these four virtues, each face representing one of the virtues. In Cambodia, this four-faced Brahma image is depicted in many forms, from the tops of entire temples, to small representations placed next to the Buddha images in the temple, to small wood depictions that are kept in the home. In our treatment for traumatized refugees, we emphasize loving-kindness. We refer to our manualized 14-session treatment for traumatized refugees and ethnic minority populations as culturally adapted cognitive-behavior therapy (CBT), or CA-CBT, which might also be called culturally adapted exibility-focused therapy, or CA-FT, for reasons that will be described below. The treatment emphasizes emotion regulation techniques such as mindfulness. In CACBT, mindfulness techniques are important parts of the anxiety, trauma, and anger protocols,

Please address correspondence to: Devon E. Hinton, Massachusetts General Hospital, Department of Psychiatry, 15 Parkman Street, WACC 812, Boston, MA 02114. E-mail: devon_hinton@hms.harvard.edu
C 2013 Wiley Periodicals, Inc. JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 69(8), 817828 (2013) Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22017

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which are practiced at the beginning of almost all sessions. Our treatment has been shown to be effective for traumatized ethnic minority (Latino) and refugee (Cambodian and Vietnamese) groups as compared with a waitlist condition and applied muscle relaxation (Hinton, Hofmann, Rivera, Otto, & Pollack, 2011). Below, we rst describe two models that guide our treatment, namely, our typology of mindfulness states and the Nodal Network Model (NNM) of Affect and Affect Regulation. We use these models to explain why loving-kindness and mindfulness states more generally may be effective for reducing distress in traumatized groups. We next describe how we use loving-kindness in our treatment protocol and how we adapt loving-kindness for different groups. This is followed by a case example.

Mindfulness States: Typology and Key Aspects

In the psychological and Buddhist literature, compassion and loving-kindness are usually considered to be forms of mindfulness meditation (Kabat-Zinn, 2005; Orsillo & Roemer, 2009). Whereas several mindfulness meditation practices involve a nonjudgmental awareness that focuses on breathing or other sensory modalities, these two other mindfulness modes involve having a certain feeling towards others: in compassion meditation (CM), a feeling of compassion for the suffering of others, and in loving-kindness meditation (LKM), a feeling of love for all beings. Our denition of mindfulness is based on the Buddhist and psychological literature (for a review, see Hinton, Pich, Hofmann, & Otto, 2013). We dene mindfulness as the maintaining of one of several mindsets that involve a present-oriented experiencing and that are benecial to psychological well-being. To be mindful is to try to maintain one of the auspicious mindsets in which a certain attentional object is viewed with a certain emotional attitude such as lovingkindness (see Table 1; cf. Shapiro, Carlson, Astin, & Freedman, 2006). According to this denition, mindfulness is a set of related practices, what might be called adaptive, presentoriented mindsets, which are of several typese.g., cognitive sets, emotion sets, expressive sets, body setsthat differ enough that one cannot assume they will have the same effect through their practice.

The NNM of Affect and Affect Regulation

We consider negative mood states to be maintained by multiple interacting systems as depicted in the Nodal Network Model of Affect (Figures 1 and 2), a model resembling Teasdales (1996) Interactive Cognitive Subsystem (ICS) model. According to our model (Figure 1), trauma-related disorder is maintained by multiple interacting systems: a certain psychological appraisal mode (a sense of being threatened and being inadequate to deal with current challenges); attentional bias (attention to threat and insult); mental-content processing mode (tendency to ruminate/worry); a certain set-shift predisposition (poor set-shift ability); a certain decentering ability (overidentication with mental content, poor metacognitive awareness); action predisposition (withdrawal/perceived slight); self-image (a sense of being unable to adjust); muscle-based body state (rigidity, tenseness, negative posture); autonomic arousal state (chest tightness, shortness of breath, sweating); mood state (fear, anger, depression); and memory recall bias (negative memory). Successful emotion regulation can be conceived as the ability to change the network nodes to more adaptive ones, with shifts in one node tending to change all the other nodes in the network, for example, a shift from the negative affective mode, depicted in Figure 1, to a positive mode, depicted in Figure 2. (For further description of the NNM, see Hinton et al., 2013; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012.)

Reasons for the Effectiveness of Mindfulness Techniques as Applied to Minority and Refugee Populations
Mindfulness techniques derived from the Buddhist tradition have been shown to be effective for many disorders and have been included in several treatment protocols (Hofmann, Sawyer,

Table 1

A Typology of Mindfulness Techniques Used in the Buddhist and Eastern Traditions (Auspicious Mindsets: Cognitive Sets, Mood Sets, Embodied Expressive Sets, Body Sets)
Emotion Solitary and withdrawal Action tendency Associated physiological state Associated Buddhist imagery and metaphors

Type

Attentional object

Sensorial aspects of the body(i.e., contemplating the sensorial aspects of the body)

Sensorial experiencing in its Detached observation various modalities: attending to the breath, kinesthetics (body movement in space), smells, sounds, or visual images (color, movement, shape) Solitary and withdrawal

Loving-Kindness

Vagal dominance; increased The soul as being with the body, the soul not oating heart rate variability; away from the body, a activation of the anterior feeling of bodily weight cingulate cortex and the rather than lightness. executive control network Attention that is not broken, is not like a monkey swinging from branch to branch. Vagal dominance, increased The mind as a spotlight. Attention that is not heart rate variability; broken, is not activation of the anterior dispersed, is not like a cingulate cortex and the monkey swinging from executive control network branch to branch.

Sensorial aspects of external The sensorial properties of Detached observation external objects, often objects (i.e., with a focus on the visual contemplating the aspect (e.g., the sensorial qualities of an movement, color, or external objects) shape of a candle ame, clouds, or leaves) Detached observation Mood Mood state, which is verbally labeled and distanced from Solitary and withdrawal

Compassion (karunaa)

All beings, including oneself Compassion for the suffering of all beings, including oneself

Interactional and interpersonal engagment

Vagal dominance, increased Mood is often analogized to a cloud that enters and heart rate variability; then leaves the sky, with activation of the anterior the mind being compared cingulate cortex and the to the sky. executive control network Insula and the anterior Something projected in all cingulate cortex; oxytocin directions: water or warmth that spreads out from the heart. One of the fours faces of the Brahma.

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Table 1

Continued
Emotion Action tendency Associated physiological state Associated Buddhist imagery and metaphors

Type

Attentional object

Loving-kindness (Metta)

All beings, including oneself Love for all beings, including oneself

Sympathetic joy (muditaa)

Equanimity (upekkha) (of note, this is very similar to mood mindfulness)

The joy of others and the Joy in the joy of others reason for their joy All emotions, mental Detached observation objects, with all emotions and thoughts being verbally labeled and distanced from

Gratitude (deung kun)

Interactional and Insula and the anterior Something projected in all interpersonal engagement cingulate cortex; oxytocin directions: water that spreads out from the heart. One of the fours faces of the Brahma. Staying in the middle. Interactional and Oxytocin One of the four faces of the interpersonal engagement Brahma. Solitary and withdrawal Vagal dominance, increased Staying in the middle. Mood heart rate variability; is often analogized to a activation of the anterior cloud that enters and then cingulate cortex and the leaves the sky, with the executive control network mind being compared to the sky. One of the fours faces of the Brahma. Interactional and Oxytocin Blooming lotus interpersonal engagement

Smile Jocular joy Relaxed, joyful, and alert

Grateful joy Person to whom one is grateful, things for which one is grateful Facial expression Joyful

Journal of Clinical Psychology: In Session, August 2013

Humor

Muscle relaxation and exibility

What is humourous, laughter itself Bodily exibility

Interactional and Oxytocin Loving-kindness imagery, a interpersonal engagement blooming lotus Interactional and Oxytocin N/A interpersonal engagement Decrease sympathetics, Bamboo, other nature Interactional and increase parasympethetics images of exibility interpersonal engagement (I can adjust to any situation)

Note. On the physiology of these mindfulness states, see Hofmann, Gross, & Hinton, 2011; Immordino-Yang et al., 2009; Lutz et al., 2008; Posner, Rothbart, & Sheese, 2007.

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Figure 1. The NNM of negative affect: focus on inexibility aspects. Note. This is a nodal network model of negative affect, showing how multiple nodes interact to create a negative affective state. At one point in time, one or another node may be the object of attention or may be more active in determining the current mode of processing. As one node becomes active, all the other nodes tend to be so as well; if one node shifts, all the others tend to as well. It shows aspects of mood state that need to be targeted in emotion regulation, shows therapeutic entrance points. See Figure 2 for the state to which emotion regulation attempts to shift, including the specic node shifts.

Witt, & Oh, 2010); a recent review suggests the potential value of integrating loving-kindness into psychological treatments (Hofmann, Grossman, & Hinton, 2011). As illustrated by the typology of mindfulness and the NNM of Affect and Affect Regulation, mindfulness states such as loving-kindness should bring about improvement in several ways. Mindfulness states such as loving-kindness help to create a new adaptive default-processing network centered on psychological exibility (Figure 2). (Other treatment developers also present evidence that mindfulness promotes psychological exibility; see, e.g., Hayes, Strosahl, & Wilson, 1999.) Recent studies postulate that such mindfulness techniques create long-lasting neuronal networks that become part of the general top-down processing, that is, they become new default modes of processing (Kok & Fredrickson, 2010). In our treatment, we try to create a nodal network centered on exibility. The exibility nodal network may be activated by mindfulness techniques such as multisensorial meditation, loving-kindness, mindful stretching, or a smile. We consider a key part of exibility to be emotional exibility. This includes trying to learn to

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Figure 2. The NNM of positive affect: focus on exibility aspects. Note. Certain therapeutic techniques may change many nodes, shifting from the negative state shown in Figure 1 to a new processing mode, centered on exibility. For this reasons, we refer to this as the NNM of Affect and Affect Regulation, because it shows how mood states shift and how one may bring about mood change. The model shows various therapeutic entrance points. For example, doing loving-kindness will change many nodes: It will change mood, decrease rumination, bring to mind positive imagery that is highly valued (the person identied with the Buddha and other gures who make merit), change self-image, and create a prosocial, active engagement. In turn, when these nodes shift, all the other nodes will tend to shift towards the processing mode shown here in Figure 2.

use different affective states such as loving-kindness. We frame all these interventions in terms of exibility during the treatment. Mindfulness states such as loving-kindness promote emotional exibility and psychological exibility more generally, for example, through the emotional exibility protocol, in which there is a shift from one to another affective state (see below for a description of this protocol). Mindfulness techniques increase psychological exibility, helping to shift to a more adaptive processing mode such as illustrated in the shift from Figure 1 to Figure 2 (Hinton et al., 2013; Hinton et al., 2012). In keeping with a large emerging literature (for a review, see Hinton et al., 2013), we consider psychological exibility as the ability to do the following: (a) disengage/distance/decenter from a current mindset to enter a state of contemplating that mindset rather than enacting it (this might be called a switch to a distancing mindset); (b) consider other

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possible mindsets, in which the term mindset is meant in a broad sense that includes affect set (i.e., a certain emotion, like loving-kindness), action set (i.e., performing a certain action, such as maintaining a smile or stretching), explanatory set, and attentional-object set; and (c) enact different mindsets in the attempt to adapt to the situation. Mindfulness techniques help to achieve a state of disengaging/decentering/distancing, and meditation techniques involve practice in mindset shifting such as from verbal processing to sensorial experiencing, for example, from engaging in verbal-centered worries about a future event to attending to the ow of the breath or to practicing loving-kindness. We consider psychological exibility to be an adaptive processing mode in opposition to other negative modes, such as a threat mode. Psychological exibility decreases rumination, depression, and anxiety (Koster, De Lissnyder, Derakshan, & De Raedt, 2011), and so too does mindfulness (Roemer et al., 2009). Mindfulness techniques decrease rumination by serving as emotion regulation techniquesfor example, through directing attention to another focus, that is, through attention regulation and shiftthat help the individual to stop the vicious cycle of rumination. Worry and rumination are important treatment targets in ethnic and minority traumatized populations because they have hyperreactivity to worry and because they have frequent induction of worry, often owing to living in poor urban contexts and confronting many stressors that range from nances to health problems to truancy/gang violence to personal safety concerns (Hinton, Nickerson, & Bryant, 2011). Worry may greatly worsen posttraumatic stress disorder (PTSD; Hinton, Nickerson et al., 2011); worry episodes result in a threat-mode, in irritability, and in panic-like autonomic arousal (worry attacks) that may cause mental and somatic symptoms that give rise to catastrophic cognitions and trauma recall. Some theories of worry consider it to result in decreased arousal in response to stressors (Borkovec & Hu, 1990); however, studies indicate that patients with worry have high rates of arousal symptoms, are particularly hypervigilant to phasic changes in arousal symptoms, and are at increased risk for panic, including having panic triggered by worry episodes (Andor, Gerlach, & Rist, 2008). For refugee and ethnic minority groups, psychological exibility is a key skill that better equips them to adjust to a new social, cultural, and linguistic context. For example, a Cambodian patient needs to switch between the English and Cambodian language and between the American and Cambodian cultures, and this switching between registers is particularly important in respect to dealing with children who are often highly acculturated and speak minimal Cambodian (Hinton, Rasmussen et al., 2009). Moreover, mindfulness techniques such as loving-kindness decrease somatic complaints, a key distress presentation and treatment target among ethnic minority and refugee populations (Hinton & Lewis-Fern andez, 2011). Mindfulness provides mindsets that shift the attentional focus from a hypervigilant surveying of the body for somatic distress to another focus. Mindfulness techniques serve as emotion regulation techniques that decrease arousal (Goldin & Gross, 2010; Hofmann, Sawyer, Fang, & Asnaani, 2012) and hence somatic symptoms. In addition, mindfulness techniques serve as emotion regulation techniques more generally, and they can be used following exposure to change fear networks. The resulting shift in self-image and other effects help bring improvement as is discussed in the next section.

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

In certain sessions of CA-CBT, we teach the patient to radiate loving-kindness to himself or herself and in all directions to all beings, and in several sessions we have the patient practice projecting loving-kindness while returning home (see Table 2 for the version used with Asian patients). This practice helps to decrease anger, among other effects (Lutz, Slagter, Dunne, & Davidson, 2008). Loving-kindness is also part of several key protocols in our treatment. In one protocol, which might be called the emotional exibility protocol, we tell the patient that always using only one or two emotions all the time is like being a painter who uses only one or two colors to paint, a musician who uses only one or two notes, or a cook who uses only one or two ingredients. We then have the patient experience four different emotional states. See Table 3 for a full description of this protocol.

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Table 2
Loving-Kindness for Asian Patients (Buddhist)
Practicing having a good attentional object and a good emotion We want you to practice having another feeling and to put your mind and focus on a good thing. We want you to practice having other types of emotion. Performing loving-kindness (water and cooling imagery) Upon leaving the ofce today, as you walk along, practice spreading loving-kindness to all beings Loving-kindness is a way to practice having a positive emotion Direct love and kindness to yourself Direct love and kindness to all beings Imagine love owing from your heart, like a cooling water Imagine the water going out from your heart in all directions Imagine that the water extinguishes all anger Wish that all beings be happy Wish that all beings be free from anger Wish that all beings have wisdom Imagine loving-kindness owing from your heart to all beings, like a water owing from your heart Practice projecting a feeling of love and kindness to all beings as you go home, and during the next week Note. For a Spanish patient, we use the image of a heat and light owing from the heart rather than cooling water.

Table 3
Emotional Flexibility Protocol
Dont get stuck on certain emotions Sometimes we forget to practice having different emotions. We get stuck with one emotion, like anger, envy, regret, or worry. Lack of emotional range: comparison to cooking, painting, and music You want to practice having different emotions. Otherwise, you are like: A painter with only one or two colors A cook that uses just one or two ingredients A musician who always plays the same two notes. Practicing emotion shifting: Try practicing these following emotions Here are some four emotions that research has shown will help you to be happy, that you should practice. Try one. [After giving each example, the therapist should pause; the therapist should speak slowly; this gives the patient time to imagine having the emotion]: Compassion. A feeling of compassion for the sufferings of all beings Joy in the joy of others. A feeling of joy when others are successful or happy. Loving-kindness. A feeling of loving-kindness, a feeling of love for yourself and all beings. Detached, curious observation. Observation and non-action. A feeling of observing and letting go of all emotions, of just watching your emotions, of not acting on them, a feeling of nonjudging, of waiting and watching your emotions. Stay distant from emotion in a state of curious observation. Label and observe effects. Just label the emotion, look at the effects of the emotion on you thoughts and body, and let it go, stay distant from it. Say to yourself, Oh, I have anger, and watch it, stay distant from it, let it go, not acting on it. Comparison of a mood to a cloud. Like clouds in the sky, so too new thoughts and emotions will come to you. Just watch them, stay at distance, and soon they will pass, like clouds from a sky.

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

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frame. There is a shift from a cognitive appraisal of hopelessness, self-blame, self-hatred, and other-directed hatred to the emotion of compassion and a positive self-image among other effects. We change loving-kindness imagery depending on the group. During loving-kindness meditation with Latino populations, we have patients conjure the image of a light and heat emanating from the heart. This image is an extremely prominent aspect of the iconography in the Latin American religious tradition, in which it is referred to as the Sagrado Coraz on de J esus, or the Sacred Heart of Jesus. For Buddhist Asian populations, we have the patient visualize water and coolness owing from the heart and body. In the Buddhist context, cooling and water evoke ideas of merit, centered mind, and freedom from anger or other negative states, and water has a wide range of resonances. Two of the most common and celebrated scenes of Buddhist iconography are the Buddha pointing to the ground to summon the Earth Goddess and the Earth Goddess wringing a torrent of water from her hair. (In a Cambodian temple, the central Buddha image is usually in this posture and often there is an image of the Earth Goddess wringing her hair.) These images celebrate the moment Siddhartha reached Nirvana, that is, enlightenment. When attacked by Mara and his demons, Buddha pointed to the ground to request that the Earth Goddess give witness to all the good deeds he had done in his previous lives; in accordance with the Indic tradition, he had poured a little water on the ground each time he made merit in this way. Responding to the request, the Earth Goddess then appeared and wrung her hair and water owed down in a ood to drown Mara and all his legions.

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

Case: A Cambodian Patient: Leng

Before arriving in the United States, Cambodian refugees passed through periods of extreme adversity. Several years of bloody civil war preceded the Khmer Rouge rule from 1975 to 1979. During the Khmer Rouge period, a quarter of Cambodias population of 8 million people died from starvation, illness, and execution, most commonly by a blow to the back of the neck before being dumped into a large burial pit. In 1979, during the Vietnamese invasion, many Cambodians were caught in crossre, and others died of starvation when driven into the jungle by the Khmer Rouge; many ed to the Thai border. Getting to border camps was risky along paths that were mined and patrolled by marauders; once in these camps, Cambodians often lived for months or even years under local warlords, frequently besieged by Khmer Rouge, Vietnamese, and Thai soldiers; next came a stay in inner Thailand in chaotic and sometimes dangerous refugee camps, awaiting permission to come to the United States. Upon arrival to the United States, Cambodians had to adjust to a completely new culture and language and often lived in urban settings where they faced poverty and contexts of endemic violence. All these events had been endured by Leng, who presented to our outpatient psychiatric clinic in Lowell, Massachusetts, a city that is home to over 25,000 Cambodians, the second largest population in the United States. The rst author (DH), who is uent in Cambodian, was her clinician. Leng had suffered the loss of both her parents and eight siblings due to starvation during the Pol Pot period. She also lost her husband and three of ve children to starvation. She currently lived with her daughter and three grandchildren. Recently, her PTSD had worsened and she had a great increase of anger, trauma recall, and poor sleep. She ruminated excessively about possible problems (e.g., the health condition of several relatives), and she was often angry, had started swearing frequently, and was somewhat paranoid and hypervigilant to threat. As an intervention, DH suggested to Leng that she should cultivate the virtue of gratitude for having arrived to the United States and having surviving family, and she should realize these

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to be blessings. DH explained to her that if she practiced loving-kindness, then she would be making merit for herself, her living relatives, and those who died in the Pol Pot period. (In Buddhism, there is the idea that if you do a good act, like meditation or alms giving, then this makes merit, a sort of supernatural holiness, which can be shared with the deceased; this helps the deceased to be reborn to a better rebirth. There is also the idea that if someone died a violent or horrible death, then they may not have been reborn owing to past demerit.) DH told Leng that if she wished to get better, she had to cultivate positive states, and that her medication and other treatments would be effective only if she did so. As an example of a positive state, DH gave the example of laughing, and to demonstrate this, DH laughed and got her to laugh along with him. There was quite a shift from her sullen state. DH said that belly laughs were curative. DH then modeled for her how to do loving-kindness (Table 2), moving the arms outward to demonstrate the envisioned ow of water from the heart. DH told her to practice having a sense of love like a cooling water ow from her heart, as she went home and in the coming days. DH said that rather than swearing and being angry, she should practice this mental state. DH explained that this would bring coolness and prosperity to the home. At the following visit, Leng was improved. She was less angry, as conrmed by her daughter. Leng smiled and laughed some, whereas before she never smiled and looked very tense. However, she continued to be hypervigilant to threat and accusative: she thought someone might steal her jewelry and accused someone falsely upon nding a piece missing. DH reminded Leng that the true jewels were her children and grandchildren, and not to worry so much about belongings. (According to Buddhism, when one gets older, it is particularly important to turn to a spiritual attitude.) DH also said she should think of her life in Cambodian during the Khmer Rouge, and its difculties, and be thankful for having survived. (The aim was to foster the positive emotion of gratitude.) DH said that she should not keep thinking about her belongings and their possible loss, but about her children and grandchildren: what they liked to eat, what they were doing, and so on. DH also advised Leng to laugh and smile more, that these were a form of loving-kindness, and that otherwise people would think she was mad at them. DH reiterated the importance of having a feeling of loving-kindness, as reected in laughter and smile. DH said these were good emotions, as opposed to anger, an inauspicious mood. We reviewed the loving-kindness practice (Table 2). At the next visit, Leng was further improved. She had decreased anger, ruminated less, and slept better. She was much less hypervigilant to threat. Lengs daughter conrmed that her mother was much improved and was no longer in a constantly angry and paranoid state. DH repeated the lessons about positive mental state and merit. DH emphasized that she should have gratitude to have a place to live, to have children and grandchildren, and to have survived the Pol Pot period. Leng improved progressively over the next several weeks. (Please note that in this case, the treatment emphasized the cultivation not only of loving-kindness but also of various positive emotional states, and that the treatment emphasized the cultivation not only of positive emotional states but also of body states that would promote positive emotional states: a smile and laughing.)

Conclusion
In this article, we discussed why techniques such as loving-kindness should be effective using the typology of mindfulness states and the NNM of Affect and Affect Regulation. We discussed how loving-kindness is used in our treatment and the importance we place in treatment on emotional exibility and psychological exibility more generally. Finally, we presented a case to illustrate how we integrate loving-kindness into a treatment approach, an approach that emphasizes a certain typology of mindfulness states and the NNM of Affect. We presented the typology of mindfulness that guides our treatment. According to that typology, mindfulness is characterized by a certain object of attention. There are sensorial sets, such as attending to the color of leaves or their movement or attending to ones breath; object sets, such as observing the motion of a candle ame; verbal sets, such as the self-repetition of a phrase like I will adapt exibly like a leaf adjusts to each breeze; expressive sets (e.g., smile, laughter, upright posture, dynamic gestures); body sets, such as maintaining the body in a certain

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state, like exibility in the muscles and joints; image sets, such as maintaining in mind a certain visualized image (e.g., the lotus-ower image or the Sacred Heart of Jesus); and emotion sets (e.g., loving-kindness). In some cases, two attentional objects are simultaneously held in mind, such as when the stretching of the leg muscles is paired with self-statements of exibility, or as when the emotion of loving-kindness is paired with associated imagery, for example, a owing of water from the heart; these might be called bi-attentional sets. According to that typology, mindfulness is characterized by a certain emotional attitude toward the attentional object, for example, an attitude of curiosity, distanced contemplation, or loving-kindness. We have suggested that mindfulness states such as loving-kindness increase psychological exibility, decrease somatic distress, decrease rumination, serve as emotional regulation techniques, decrease the attentional bias to threat, and form part of a new adaptive processing mode characterized by psychological exibility. We have used mindfulness techniques in several controlled trials with Latino and Southeast Asian refugee populations (e.g., Hinton, Hofmann et al., 2011). In this article we provided examples of treatment adaptations of lovingkindness for Latino and Southeast Asian patients, but these techniques can be adapted for other groups as well. For the culture in question, one needs to determine the local terms to express the idea of loving-kindness and cultural imagery that might be used to express the idea of loving-kindness. We used the NNM of Affect and Affect Regulation to indicate the treatment targets of CA-CBT (what we also call culturally adapted exibility-focused therapy, or CA-FT) and to illustrate how the treatment brings about improvement. We presented this model and showed how the treatment creates a nodal network centered on psychological exibility. Therapeutic techniques to attain that goal are as follows: teaching how to achieve muscle relaxation along with joint exibility; pairing muscle relaxation/joint exibility with self-statements of exibility and exibility-encoding self-imagery; practicing set-shifting within mindfulness modes, such as attending to one and then another sensory modality; practicing set-shifting from a certain dysphoric state to the mindfulness mindset, such as from dysphoric affect to loving-kindness; practicing set-shifting during the anxiety, trauma, and anger protocols; cultivating the ability to distance from affect and mental content, which is a core aspect of psychological exibility (Hinton, Hofmann, Pollack, & Otto, 2009); and teaching to attend to various types of exibility primersthe image of the leaf and that of the candle ame. We have argued that the exibility nodal network forms an alternative processing mode to that of the threat mode, and that the nodal network inuences general top-down processing and thus becomes a new alternative default mode. We have argued that loving-kindness is an effective therapeutic intervention for several reasons, and that loving-kindness should be integrated with other mindfulness techniques as indicated in the typology of mindfulness states. Each of these mindfulness techniques has a different structure and would be expected to have different effects, as indicated in the typology. We presented the NNM to provide a clinically useful model of affect and affect regulation. The model shows clear treatment targets, what might be called therapeutic entrance points. In our conceptualization of treatment, exibility is emphasized because it is a quality that can be developed and promoted through therapeutic intervention, such as increasing emotional and bodily exibility. In this way, the embodying and enminding of exibility in all its aspects acts as both a means of mood regulation and a way to maintain a euphoric and adaptive processing mode. Future research needs to further determine the clinical utility of loving-kindness and the clinical utility and validity of the typology of mindfulness and the NNM of Affect and Affect Regulation.

Selected References and Recommended Reading

Andor, T., Gerlach, A. L., & Rist, F. (2008). Superior perception of phasic physiological arousal and the detrimental consequences of the conviction to be aroused on worrying and metacognitions in GAD. Journal of Abnormal Psychology, 117(1), 193205. Borkovec, T. D., & Hu, S. (1990). The effect of worry on cardiovascular response to phobic imagery. Behaviour Research and Therapy, 28(1), 6973.

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