10 Meditation as Psychotherapy

 

10 Meditation as Psychotherapy

 

Dr. Aaron Beck, the founder of cognitive therapy, had a question: “What is mindfulness?”

 

It was the mid-1980s, and Dr. Beck was asking Tara Bennett-Goleman, Dan’s wife. She had come to his home in Ardmore, Pennsylvania, at Dr. Beck’s request, because Judge Judith Beck, his wife, was about to undergo some elective surgery. Dr. Beck had a hunch meditation might help better prepare her mentally and, perhaps, even physically.

 

Tara instructed the couple on the spot. Following her guidance the Becks sat quietly and observed the sensations of their breathing in and out, then tried a walking meditation in their living room.

 

That was a hint of what has since become a strong movement in “mindfulness-based cognitive therapy,” or MBCT. Tara’s book Emotional Alchemy: How the Mind Can Heal the Heart was the first to integrate mindfulness with cognitive therapy.1

 

Tara had for years been a student of vipassana meditation and had recently completed a months-long intensive retreat with the Burmese meditation master U Pandita. That deep dive into the mind had yielded many insights, including one about the lightness of thoughts when viewed through the lens of mindfulness. That insight mirrors a principle in cognitive therapy of “decentering,” observing thoughts and feelings without being overly identified with them. We can reappraise our suffering.

 

Dr. Beck had heard about Tara from one of his close students, Dr. Jeffrey Young, who at the time was establishing the first cognitive therapy center in New York City. Tara, with a freshly minted master’s degree in counseling, was training with Dr. Young at his center. The two were jointly treating a young woman who suffered from panic attacks.

 

Dr. Young used a cognitive therapy approach, helping her distance herself from her catastrophizing thoughts—I can’t breathe, I’m going to die —and challenge them. Tara brought mindfulness into the sessions, complementing Dr. Young’s therapy approach with this unique lens on the mind. Learning to observe her breath mindfully—calmly and clearly, without panic—helped that patient overcome her panic attacks.

 

Working independently, psychologist John Teasdale at the University of Oxford, with Zindel Segal and Mark Williams, was writing MindfulnessBased Cognitive Therapy for Depression, another such integration.2 His research had revealed that for people with depression so severe that drugs or even electroshock treatments were no help, this mindfulness-based cognitive therapy (MBCT) cut the rate of relapse by half—more than any medication.

 

Such remarkable findings unleashed what has become a wave of research on MBCT. As has been true of most studies of meditation and psychotherapy, though, many of those studies (including Teasdale’s original one) failed to meet the gold standard for clinical outcome research: randomized control groups and an equivalent comparison treatment by practitioners who believe theirs will bring results.

 

Some years later a group from Johns Hopkins University looked at what numbered by then forty-seven studies of meditation alone (that is, without including cognitive therapy) with patients suffering from distress ranging from depression and pain to sleep problems and overall quality of life—as well as maladies ranging from diabetes and arterial disease to tinnitus and irritable bowel syndrome.

 

This review, by the way, was exemplary in calculating the hours of meditation practice being studied: MBSR entailed twenty to twenty-seven hours of training over eight weeks, other mindfulness programs about half that. Transcendental meditation trials gave sixteen to thirty-nine hours over three to twelve months, and other mantra meditations about half that amount.

 

In a prominent article in one of the JAMA journals (the official publications of the American Medical Association), the researchers concluded that mindfulness (but not mantra-based meditation like TM, for which there were too few well-designed studies to make any conclusions) could lessen anxiety and depression, as well as pain. The degree of improvement was about as much as for medications, but without troubling side effects—making mindfulness-based therapies a viable alternative treatment for these conditions.

 

But no such benefits were found for other health indicators like eating habits, sleep, substance use, or weight problems. When it came to other psychological troubles, like ugly moods, addictions, and poor attention, the meta-analysis found little or no evidence that any kind of meditation might help—at least in the short-term interventions used in the research. Longterm meditation practice, they note, might well offer more benefits, though there were too little data on this for them to draw any conclusion.

 

The main problem: what had seemed promising for relieving problems from earlier studies of meditation disappeared into a mist when compared to the benefits from an active control like exercise. Bottom line for a wide range of stress-based problems: “insufficient evidence of any effect,” at least as yet.3

 

From a medical perspective, these studies were the equivalent of a “lowdose, short-term” trial of a medication. The recommendation here: that more research be done, using far larger numbers of people and for a far longer period. That’s quite apt for studies of treatments like a drug—the research model dominant in medicine. But such studies are enormously expensive, costing in the millions of dollars—and are paid for by drug companies or the National Institutes of Health. No such luck when it comes to meditation.

 

Another sticking point, and this a bit nerdy: the meta-analysis began by collecting 18,753 citations of articles of all kinds about meditation (a huge number, given that we could find but a paltry handful back in the 1970s, and just above 6,000 now—they used a broader number of search terms than we did). About half of those the authors spotted, though, were not reports of actual data; of the empirical reports, about 4,800 had no control group or were not randomized. After careful sifting, only 3 percent (that’s the 47 in the analysis)—of the studies proved sufficiently well designed that they could be included in the review. As the Hopkins group points out, this simply underscores the need to upgrade meditation research.

 

This type of review carries great weight with physicians, in an era when medicine strives to become more evidence based. The Hopkins group did this meta-analysis for the Agency for Healthcare Research and Quality, whose guidelines physicians try to follow.

 

The review’s conclusion: meditation (in particular, mindfulness) can have a role in treating depression, anxiety, and pain—about as much as medications but with no side effects. Meditation also can, to a lesser degree, reduce the toll of psychological stress. Overall, meditation has not been proven better for psychological distress than medical treatments, though the evidence for stronger conclusions remains insufficient.

 

But this was true as of 2013 (the study was published in January, 2014). With the quickened pace of meditation research, more and better-designed studies may overturn such judgments, at least to a degree.

 

Depression marks a singular case in point.

 

CHASING THE BLUES AWAY—WITH MINDFULNESS

 

The remarkable finding from John Teasdale’s group at Oxford, that MBCT cut relapse in severe depression by around 50 percent, energized some impressive follow-up research. After all, a 50 percent drop in relapse outreaches by far what any medication used for severe depression can claim. If this beneficial impact were true of a drug, some pharmaceutical company would be minting money from it.

 

 The need for more rigorous studies was clear; the original Teasdale pilot study had no control group, let alone a comparison activity. Mark Williams, one of Teasdale’s original research partners at Oxford, spearheaded the research needed. His team recruited almost three hundred people with depression so severe that medications could not prevent them relapsing into doom and gloom—the same sort of difficult-to-treat patients as in the original study.

 

But this time the patients were randomly assigned to either MBCT or one of two active control groups where they either learned the basics of cognitive therapy or just had the usual psychiatric treatments.4 The patients were tracked for six months to see if they had a relapse. MBCT proved more effective when it came to patients with a history of childhood trauma (which can make depression all the worse), and about the same as standard treatments with run-of-the-mill depression.

 

Soon after, a European group found that for a similar group with depression so severe that no medication helped them, MBCT did.5 This, too, was a randomized study with an active control group. And by 2016 a meta-analysis of nine such studies with a total 1,258 patients concluded that, over a year afterward, MBCT was an effective way to lower the relapse rate in severe depression. The more severe the symptoms of depression, the larger the benefits from MBCT.6

 

Zindel Segal, one of John Teasdale’s collaborators, delved more deeply into why MBCT seemed so effective.7 He used fMRI to compare patients who had recovered from a bout of major depression, some of whom did MBCT, while the others received standard cognitive therapy (that is, without mindfulness). Those patients who, after treatments, showed a greater increase in the activity of their insula had 35 percent fewer relapses.

 

The reason? In a later analysis, Segal found the best outcomes were in those patients most able to “decenter,” that is, step outside their thoughts and feelings enough to see them as just coming and going, rather than getting carried away by “my thoughts and feelings.” In other words, these patients were more mindful. And the more time they put into mindfulness practice, the lower their odds of a relapse into depression.

 

At last a critical mass of research demonstrated to the satisfaction of the skeptical medical world that a mindfulness-based method could be effective for treating depression. There are several variations of promising applications of MBCT for depression.

 

For instance, women who are pregnant and have a previous history of depressive episodes naturally want to be sure they do not get depressed while carrying their baby or after the birth, and they are understandably leery of taking antidepressants while pregnant. Good news: a team led by Sona Dimidjian, another grad of the Summer Research Institute, found that MBCT could lower the depression risk in these women, and so offered a user-friendly alternative to drugs.8

 

When researchers from the Maharishi International University taught TM to prisoners with standard prison programs as the comparison, they found that four months later the prisoners doing TM showed fewer symptoms of trauma, anxiety, and depression; they also slept better and perceived their days as less stressful.9

 

Another instance: the angst-filled teen years can see the first onset of depressive symptoms. In 2015, 12.5 percent of the US population aged twelve to seventeen had at least one major depressive episode the previous year. This translates to about 3 million teens. While some of the more obvious signs of depression include negative thinking, severe self-criticism, and the like, sometimes the signs take subtle forms, like trouble sleeping or thinking or shortness of breath. A mindfulness program designed for teens reduced overt depression and such subtle signs, even six months after it ended.10

 

All of these studies, tantalizing as they are, need replication as well as upgrades to their design if they are to be acceptable to strict medical review standards. Still, for the person suffering from depressive bouts—or anxiety or pain—MBCT (and maybe TM) offers the possibility of relief. Then there’s the question of whether MBCT or meditation in alternate forms might relieve symptoms of other psychiatric maladies. And if so, what are the mechanisms that explain this?

 

Let’s revisit that research on MBSR for people with social anxiety done by Philippe Goldin and James Gross at Stanford University (we reviewed it in chapter five). Social anxiety, which can look like anything from stage fright to shyness at gatherings, turns out to be a surprisingly common emotional problem, affecting more than 6 percent of the US population, around 15 million people.11

 

After the eight-week MBSR course the patients reported feeling less anxiety, a good sign. But you may recall the next step, which makes the study more intriguing: the patients also went into a brain scanner while doing a breath awareness meditation to manage their emotions as they listened to upsetting phrases like “people always judge me,” one of the common fears in the mental self-talk among those with social anxiety. The patients reported feeling less anxious than usual on hearing such emotional triggers—and at the same time, brain activity lessened in their amygdala and increased in circuitry for attention.

 

This peek at the underlying brain activity may hint at the future of research on how meditation might relieve mental problems. For several years now—at least as of this writing—the National Institute of Mental Health (NIMH), the main source of funding for studies in this area, has disdained research that relies on the old categories of psychiatry listed in the field’s Diagnostic and Statistical Manual (DSM).

 

While mental disorders like “depression” in its several varieties are in the DSM, the NIMH favors research that focuses on specific symptom clusters and their underlying brain circuitry—not just DSM categories. Along these lines, we wonder, for example, if the finding from Oxford, that MBCT works well with depressed patients who have a history of trauma, suggests that an overly reactive amygdala may be more involved in this treatmentresistant subgroup than among others who get depressed from time to time.

 

While we are pondering future research, here are a few more questions: What precisely is the added value of mindfulness compared with cognitive therapy? What disorders does meditation (including its use in MBSR and MBCT) relieve better than current standard psychiatric treatments? Should these methods be used along with those standard interventions? And what specific kinds of meditation work best to relieve which mental problems— and while we’re at it, what’s the underlying neural circuitry?

 

For now, these are unanswered questions. We’re waiting to find out.

 

LOVING-KINDNESS MEDITATION FOR TRAUMA

 

Recall that on September 11, 2001, a jet smashed into the Pentagon near Steve Z, and what had been an open office was instantly blasted into a hazefilled sea of wreckage, reeking of burned fuel. When the office was rebuilt he moved back to the very desk he had been sitting at on 9/11, but in a much lonelier setting—most of his office buddies had been killed in the fireball.

 

Steve recalls his feelings then: “We were fueled by rage: Those bastards —we’ll get them! It was a dark place, a miserable time.”

 

His severe PTSD was cumulative; Steve had previously served in combat theaters in Desert Storm and Iraq. The catastrophe of 9/11 intensified the trauma that had already been building.

 

For years after, anger, frustration, and hypervigilant distrust roiled within. But if anyone asked how he was doing, Steve’s story line was, “No problem.” He tried self-soothing with alcohol, hard jogging, visiting family, reading—anything to try to get a grip.

 

Steve was close to suicide when he entered Walter Reed Hospital for help, went through detox from alcohol, and slowly began the road to healing. He learned about his condition and agreed to meet with the psychotherapist he still sees, who introduced him to mindfulness meditation.

 

After two or three months of sobriety he tried to join a local mindfulness group, which met once a week. The first few times Steve went he walked in hesitantly, checked around the place, saw “these are not my people”—and walked out. Besides, he felt claustrophobic in closed spaces.

 

When he was finally able to try a short mindfulness retreat, he found it helped. And in particular what really clicked was the loving-kindness practice, a workable way to have compassion for himself as well as other people. With loving-kindness, he felt “at home again,” a deep reminder of how he felt as a young boy playing with friends—a strong sense things were going to be okay.

 

“Practice helped me stay with those feelings and know, ‘This will pass.’ If I was getting angry, I could throw a little compassion and loving-kindness for myself and the other person.”

 

Last we heard, Steve had gone back to school in mental health counseling, gotten credentialed as a psychotherapist, and was completing a clinical doctorate. His dissertation topic: “moral injury and spiritual wellness.”

 

He connected with the Veterans Administration and support groups for military people like him with PTSD, and has been getting referrals from them for his small private practice. Steve feels uniquely equipped to help.

 

First findings say Steve’s instincts had it right. At the Seattle Veterans Administration hospital, forty-two vets with PTSD took a twelve-week course in loving-kindness meditation, the kind Steve found helped him.12 Three months later their PTSD symptoms had improved, and depression—a common side symptom—had lessened a bit.

 

These early findings are promising, but we don’t know, say, if an active control condition like HEP would be just as effective. The caveats for the research on PTSD to date pretty much sum up the state of the art for scientific validation of meditation as a treatment for most psychiatric disorders.

 

Still, there are many arguments for compassion practice as an antidote to PTSD, beginning with anecdotal reports like Steve’s.13 Many are practical. A large proportion of veterans have PTSD; in any given year, between 11 and 20 percent of veterans suffer from PTSD, and over a veteran’s lifetime that number goes up to 30 percent. If loving-kindness practice works, it offers a cost-effective group treatment.

 

Another reason: among the symptoms of PTSD are emotional numbness, alienation, and a sense of “deadness” in relationships—all of which lovingkindness might help reverse by the cultivation of positive feelings toward others. Still another: many vets dislike the side effects of the drugs they are given for PTSD, so they do not take them at all—and on their own are searching for nontraditional treatments. Loving-kindness appeals on both counts.

 

DARK NIGHTS

 

“I experienced a wave of self-hatred so shocking, so intense, that it changed the way I relate … to my own dharma path and the meaning of life itself.” So recalls Jay Michaelson of the moment on a long, silent vipassana retreat when he fell into what he calls a “dark night” of intensely difficult mental states.14

 

The Visuddhimagga pegs this crisis as most likely at the point a meditator experiences the transitory lightness of thoughts. Right on schedule, Michaelson hit his dark night after having cruised through a quietly ecstatic landmark on that path, the stage of “arising and passing,” where thoughts seem to disappear as soon as they begin, in rapid succession.

 

Shortly afterward he plunged into his dark night, a thick mixture of morbid doubt, self-loathing, anger, guilt, and anxiety. At one point the toxic mix was so strong, his practice collapsed; he broke down in tears.

 

But then he slowly began observing his mind rather than being sucked into the thoughts and feelings that swirled through it. He began to see these feelings as passing mental states, like any others. The episode was over.

 

Other such tales of meditative dark nights do not always have such a clean resolution; the meditator’s suffering can be ongoing long after leaving the meditation center. Because the many positive impacts of meditation are far more widely known, some who go through dark nights discover people can’t comprehend or even believe that they are hurting. All too frequently psychotherapists are little or no help.

 

Realizing the need, Willoughby Britton, a psychologist at Brown University (and a grad of the SRI), heads the “dark night project,” which aids people who suffer from meditation-related psychological difficulties. Her Varieties of the Contemplative Experience project, as it is more formally called, adds to the more widely known beneficial impacts of meditation a caveat: When might it do harm?

 

 At the moment, there are no firm answers. Britton has been collecting case studies and helping those who suffer from a dark night to understand what they are going through, that they are not alone, and, hopefully, to recover. Her study subjects have been largely referrals from guiding teachers at vipassana meditation centers where, over the years, there have been occasional dark night casualties during intensive retreats—despite those centers trying to weed out the vulnerable by asking on enrollment forms about psychiatric histories. To be sure, dark nights may not be related to such histories.

 

Dark nights are not unique to vipassana; most every meditative tradition warns about them. In Judaism, for example, Kabbalistic texts caution that contemplative methods are best reserved for middle age, lest an unformed ego fall apart.

 

At this point no one knows whether intensive meditation practice is in itself a danger to certain people, or if those who suffer dark nights might have had a breakdown of some sort no matter their circumstances. While Britton’s case studies are anecdotal, their very existence is compelling.

 

The proportion of dark nights among all those who do prolonged retreats are, by all accounts, very small—though no one can say precisely what that proportion might be. From a research perspective, one of the findings needed would be to establish base rates for such difficulties both among meditators and in the population at large.

 

Nearly one in five adults in the United States, nearly 44 million, were found by the National Institute of Mental Health to suffer from a mental illness in any given year. Both freshman year at college and military boot camp—and even psychotherapy—are known to precipitate psychological crises in a certain small percentage of people. The research question becomes, Is there something about deep meditation that puts some people at risk over and above this base rate?

 

For those who do have such a dark night, Willoughby Britton’s program offers practical advice and comfort. And despite the (rather low) risk of dark nights, especially during prolonged retreats, meditation has come into vogue among psychotherapists.

 

MEDITATION AS METATHERAPY

 

In Dan’s first article on meditation he proposed it might be used in psychotherapy.15 That article, “Meditation as Meta-Therapy,” appeared during Dan’s 1971 sojourn in India, and nary a psychotherapist showed much interest. Yet on his return he somehow was invited to lecture on this notion at a meeting of the Massachusetts Psychological Association.

 

After his talk ended, a slim, bright-eyed young man wearing an ill-fitting sport jacket approached him, saying he was a graduate student in psychology with similar interests. He had spent several years as a monk in Thailand studying meditation, surviving there on the generosity of the Thai people, a country where every household finds it an honor to feed monks. No such luck in New England.

 

This grad student thought that as a psychologist he could adapt meditative tools, in the guise of psychotherapy, to alleviate people’s suffering. He was glad to hear someone else was making the connection between meditation and therapeutic applications.

 

That grad student was Jack Kornfield, on whose dissertation committee Richie served. Jack became one of the founders of, first, the Insight Meditation Society in Barre, Massachusetts, and then went on to found Spirit Rock, a meditation center in the San Francisco Bay Area. Jack has been a pioneer in translating Buddhist theories of the mind into language attuned to the modern sensibility.16

 

Jack, along with a group including Joseph Goldstein, designed and ran the teacher training program that graduated the very teachers who helped Steve Z recover from his PTSD all those years later. Jack’s own explanation of Buddhist psychological theories, The Wise Heart, shows how this perspective on the mind and working with meditation can be used in psychotherapy—or on your own. This synthesis was the first of his by now many books integrating traditional Eastern and modern approaches.

 

Another main voice in this movement has been Mark Epstein, a psychiatrist. Mark was a student in Dan’s psychology of consciousness course, and, as a Harvard senior, he asked Dan to be his faculty adviser for an honors project on Buddhist psychology. Dan, at the time the only member of the Harvard psychology department with interest and a bit of knowledge in the area, agreed; Mark and Dan later wrote an article together in a short-lived journal.17

 

In a series of books integrating psychoanalytic and Buddhist views of mind, Mark has continued to lead the way. His first book had the intriguing title Thoughts Without a Thinker, a phrase from the object relations theorist Donald Winnicott, which also voices a contemplative perspective.18 Tara’s, Mark’s, and Jack’s works are emblematic of a wider movement, with countless therapists now blending various contemplative practices or perspectives with their own approach to psychotherapy.

 

While the research establishment remains somewhat skeptical of the potency of meditation as a treatment for DSM-level disorders, the widening pool of psychotherapists enthusiastic about bringing together meditation and psychotherapy continues to grow. Although researchers await randomized studies with active controls, psychotherapists already offer meditation-enriched treatments for their clients.

 

For instance, as of this writing there have been 1,125 articles in the scientific literature on mindfulness-based cognitive therapy. Tellingly, more than 80 percent of these were published in the past five years.

 

Of course, meditation has its limits. Dan’s original interest in meditation during his college days was because he felt anxious. Meditation seemed to calm those feelings somewhat, but they still came and went.

 

Many people go to psychotherapists for just such problems. Dan did not. But years later he was diagnosed with that adrenal disorder, the cause of his long-standing high blood pressure. One of those adrenal symptoms: elevated levels of cortisol, the stress hormone that triggers feelings of anxiety. Along with his years of meditation, a drug that adjusts that adrenal problem seemed also to handle the cortisol—and the anxiety.

 

IN A NUTSHELL

 

Although meditation was not originally intended to treat psychological problems, in modern times it has shown promise in the treatment of some, particularly depression and anxiety disorders. In a meta-analysis of fortyseven studies on the application of meditation methods to treat patients with mental health problems, the findings show that meditation can lead to decreases in depression (particularly severe depression), anxiety, and pain— about as much as medications but with no side effects. Meditation also can, to a lesser degree, reduce the toll of psychological stress. Loving-kindness meditation may be particularly helpful to patients suffering from trauma, especially those with PTSD.

 

The melding of mindfulness with cognitive therapy, or MBCT, has become the most empirically well-validated psychological treatment with a meditation basis. This integration continues to have a wide impact in the clinical world, with empirical tests of applications to an ever larger range of psychological disorders under way. While there are occasional reports of negative effects of meditation, the findings to date underscore the potential promise of meditation-based strategies, and the enormous increase in scientific research in these areas bodes well for the future./.

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