I’ve known Andy (not his real name) since we were at college together in the 1980s. In those days he was a drummer in his own Heavy Metal band, a bundle of untamed energy. His friends joked that he reminded them of Animal from the Muppets. Above all else he loved partying and being the centre of attention. But the sudden death of his father halfway through his course hit Andy hard. He started to spend more and more time alone in his room with his books, obsessively reading and thinking. Pastimes that had once given him pleasure no longer held any appeal.
The old, extroverted Andy never returned, and shortly after graduating – ejected from the relative calm, stability and familiarity of college life – he began to suspect he was the target of a conspiracy involving the government, the military and several people we knew. Fearing for his life, he lashed out at a stranger in a public park and wound up in a police cell. A few weeks later he was diagnosed with paranoid schizophrenia and sent to a secure psychiatric hospital.
In schizophrenia, people like my friend lose touch with reality. They develop bizarre paranoid delusions, sometimes as a result of auditory hallucinations – “hearing voices”. Andy is fortunate not to experience any hallucinations and has responded well to antipsychotic medication, but during his occasional relapses over the years he will often misinterpret overheard conversations between strangers in such a way that they feed into his delusions of persecution. In addition to these “positive symptoms”, people who develop schizophrenia often lose their enjoyment of life, their get-up-and-go, and their ability to maintain social contacts and generally look after themselves. These are known as “negative symptoms”.
Drugs can lessen the positive symptoms, but as ever in mental illness, they can only ever be part of any successful therapy. The compassionate support of friends, family and professionals is essential if people with this illness are to lead relatively normal lives, in particular to help them overcome their negative symptoms. Psychotherapies such as CBT (cognitive behavioural therapy) have proved their worth in clinical trials, but unlike in major depression and anxiety disorders, there has been a reluctance to try mindfulness approaches in schizophrenia. Despite sparse evidence of harm in the clinical context and some data suggesting it could be helpful, the concern among psychiatrists has been that meditation will only makes things worse.
So I was heartened to read about a recent study at two outpatient clinics in Hong Kong which provides evidence that a specially tailored, mindfulness-based education programme can not only improve patients’ psychotic symptoms and insight into their condition but also reduce the length of any hospitalisations when they relapse. Crucially, there were no “adverse events” reported during the study that could be attributed to the mindfulness practices.
This was a reassuringly well designed and executed clinical trial. A total of 138 patients were randomly assigned to one of three groups: a standard psychoeducation programme for people with schizophrenia, psychoeducation plus mindfulness, or treatment as usual. Their progress was monitored over a six-month period by independent assessors who didn’t know which treatment each was receiving.
The mindfulness programme was designed to enhance patients’ awareness of and acceptance of their symptoms, improve their understanding of the illness and teach them strategies for managing downturns. It was based on the well established Mindfulness-Based Stress Reduction (MBSR) programme with its emphasis on non-judgmental, present-moment awareness of bodily sensations, thoughts and feelings. In addition to attending 12, two-hour group sessions every two weeks, patients were encouraged to perform formal mindfulness exercises at home for at least 20 minutes, twice a day.
On several measures, patients in the mindfulness programme did significantly better over the six-month follow-up period than those in the other two groups. There were larger improvements in their positive and negative symptoms, they developed more insight into their illness, were better able to look after themselves and enjoyed bigger improvements in the quality of their social interactions. While the number of hospitalisations was not significantly fewer overall than in the other two groups, the length of stay and frequency of admissions declined in the mindfulness group over the course of the follow-up period, whereas in the other two groups these measures stayed the same or got worse.
The patients who took part in this study were young, educated, financially secure and were fortunate to have good family and community support, so the findings may not be generalisable to the wider population. It’s also worth noting that Buddhism – the original inspiration for secular mindfulness courses – has deep cultural roots in Hong Kong. But these findings do look very promising and should give confidence to other researchers who want to investigate using mindfulness to treat schizophrenia. Worldwide, about one in a hundred people has this debilitating and profoundly distressing condition, so any new therapeutic approach that might reduce their suffering and that of their close friends and family is to be welcomed.
Andy has made terrific progress over the three decades since his diagnosis. He lives independently, has an excellent social network and has regained much of his former enthusiasm for life. Most of the time, he recognises his occasional delusions for what they really are. His life isn’t easy – he feels keenly the lack of a long-term relationship, children of his own, a career – but it is bearable. On the rare occasions over the years when he has relapsed, this has been the result of changes in his medication or a failure to take it.
His story is particularly relevant in this context because around 25 years ago, Andy learned how to meditate from a yogi in the Hindu Brahma Kumaris tradition and has been practising diligently ever since. Meditation and mindfulness foster a sense of calm and cultivate insight into the workings of one’s mind. It’s impossible to know for sure, but I have a strong suspicion that mindfulness has played a critical role in the way Andy has come to terms with his condition – maybe even allowing him to transcend it in some respects. Perhaps one day many more people with schizophrenia like Andy will get the opportunity to benefit from it.