Meditation and psychosis

There’s something weird going on in the field of meditation and mindfulness research. On the one hand there are voices warning that meditation can cause psychosis – leading people to lose touch with reality and experience symptoms such as hallucinations, delusions and disturbing thoughts – on the other there are equally persuasive voices claiming that it should be used to treat psychosis.

They can’t both be right, can they?

An ongoing project led by Willoughby Britton at Brown University on Rhode Island in the US, called the Variety of Contemplative Experience Study, aims to classify the full range of positive and negative experiences that meditators from different traditions have, then identify which practices and conditions are most likely to create difficulties, and who may be most at risk. The work grew from anecdotal reports of people on meditation retreats developing disturbing symptoms, including depersonalisation, psychosis and the resurfacing of traumatic memories. These symptoms sometimes persisted long after the retreat had finished.

So it comes as a surprise that Paul Chadwick at the Institute of Psychiatry in London has been calling for more research into whether mindfulness meditation can be used as a treatment for psychosis. His own preliminary studies investigating the potential benefits of fostering greater mindfulness in people with psychosis have yielded promising results. In the British Journal of Psychiatry last year he wrote that fears about meditation triggering psychosis were holding back progress in this area, despite growing evidence that a specially adapted form of mindfulness training could prove safe and very beneficial for these patients.

An excellent paper by Polish psychologists, published this month in Archives of Psychiatry and Psychotherapy this month, goes a long way towards clearing up the confusion. Krzysztof Dyga and Radosław Stupak from Jagiellonian University in Krakøw conducted a thorough review of the available evidence and conclude that tailor-made, mindfulness-based therapy for psychosis is well worth consideration provided the following criteria are met:

• The usual 30-45 minutes of continuous meditations in an MBSR (mindfulness-based stress reduction) class is reduced to 10 minutes.
• The body scan is reduced from 3 minutes to 1 minute.
• More frequent verbal instructions are given during each meditation practice to avoid problematic patterns of thought from developing.
• A 15-minute coffee break is provided in the middle of each weekly session.
• There are six weekly sessions in total instead of eight.
• Each class has only six participants rather than the usual dozen or so.
• Instructors are sufficiently experienced and well trained in this specialist field.

Chadwick has been developing just such a programme. He believes the ethos of mindfulness is ideally suited to this group of patients, because it teaches that unusual or distressing mental states can be accepted without being ruminated upon or followed through. This leads to the realisation that they are temporary phenomena and need not define the person. Cultivating this attitude can yield significant improvements in patients’ behaviour and wellbeing, he says, even if some of the underlying symptoms remain.

Diego and Stupak point to evidence suggesting patients who are prone to psychosis might be more willing to persist with mindfulness therapy than other approaches. While talking therapies such as CBT are aimed at re-educating people to think differently, mindfulness interventions don’t attempt to challenge thoughts, emotions and beliefs or try to convince patients they are pathological – the instructors don’t present themselves as knowing better which are healthy and which are not. “Perhaps this makes patients feel more respected, and surely it prevents a difficult-to-handle cognitive dissonance, and this in turn leads to smaller attrition rates than in the case of traditional CBT,” they write.

Importantly, however, they also call for large, well-designed studies to investigate the potential downsides of meditation.

I recently raised concerns about potential adverse effects with scientists closely involved in developing other types of mindfulness therapy. Willem Kuyken, director of the Oxford Mindfulness Centre in the UK, assured me that he and his colleagues hadn’t encountered any such problems with MBCT (mindfulness-based cognitive therapy), which is designed to prevent relapse in people prone to depression. Nevertheless, he said a well-trained instructor would be able to adapt their teaching approach to work one-to-one with anyone who experiences difficulties in the course of the programme. He was also at pains to stress that everyone who comes on an MBCT course has been psychologically assessed to make sure they’re ready and will benefit.

When I spoke to Britta Hölzel, a neuroscientist formerly at Massachusetts General Hospital in the US now working at the Technical University in Munich, Germany, who was closely involved in developing a mindfulness therapy for people with bipolar disorder (which shares some symptoms with psychosis), she was also able to report that there had been no serious adverse events among patients during sessions. Any minor difficulties that arose were turned into learning opportunities. If for example anxieties came up in the course of a guided session, she said, these were made the focus of instruction and used to teach participants how to address such experiences more skilfully.

This is obviously good to know, but what of the reports of debilitating psychiatric problems triggered by meditation, such as the ones that Britton has been documenting? The vast majority seem to arise during meditation retreats. The most comprehensive survey to date, according to Diego and Stupak, was conducted by a psychologist called Lois VanderKooi in 1997 and involved interviewing Buddhist meditation teachers. According to this survey, “far less than 1%” of meditators on retreat experienced any symptoms of psychosis and the instructors believed these were brought on by overexertion during deep concentration states. Those affected tended to be inexperienced in the practice.

So part of the problem seems to be people new to meditation “overdosing” on the altered states of consciousness associated with prolonged, single-pointed concentration. There are intensive retreats that entail more than 10 hours of meditation a day, so it may come as a surprise that more people aren’t making themselves ill. Equally importantly, Diego and Stupak point to other factors that are inherent to retreats, in particular sleep deprivation, that can make people more susceptible to psychotic experiences. This is borne out by my own admittedly very limited experience of retreats: an evening meditation session can leave one feeling “wired” and quite incapable of sleep. This can make the next day (which may start at 5am or earlier) challenging to say the least. The researchers also single out hunger, the absence of normal social interaction on silent retreats, and a possible failure to take medication. It shouldn’t come as a surprise therefore that people on retreats are not always on tip-top form mentally, as anyone who has ever felt tired, hungry and socially isolated will know.

It also occurs to me that people going through psychologically challenging times may be more likely to turn to meditation to ease their distress. In defence of retreat centres, my quick and unscientific survey suggests that most of them actively discourage anybody with a psychiatric diagnosis from enrolling. It should also be mentioned that the kind of people who lead retreats tend to be compassionate, caring individuals. On a recent retreat I attended at Amaravati Buddhist Monastery near Hemel Hempstead, there was a manager on duty at all times to offer help and to watch out for any problems that might be developing.

Not all retreat centres are so well run. The ultimate aim of the Variety of Contemplative Experience project is to produce a manual for clinicians and retreat centres about the potential problems, with guidelines about how best to avoid them and how to handle them should they arise.

Photograph: Mitchell Joyce/Flickr