Meditation and Psychiatry

Abstract

How might meditation promote wellness and healing from psychiatric illness? How might it contribute to the practice of psychiatry? This review of the literature attempts to answer these questions. Meditation is the consciously willed practice of two actions, attending and abstaining, that all people spontaneously perform to a greater or lesser degree. Psychological health may correlate in part with the degree to which we naturally perform these actions. This review analyzes the nature of meditation and its therapeutic benefits. It then concludes with a summary of the issues pertinent to the adjunctive use of meditation in psychiatric care.

What is Meditation?

“To meditate is to live simply and honestly in the world as it is.”¹

—Jonathan C. Smith

Insight, or mindfulness meditation, is “a psychological state of active passivity and creative quiescence,”² in which the meditator purposefully and nonjudgmentally pays attention to the present moment,³ attending to the multitude of sights, sounds, sensations, feelings, and thoughts that simultaneously present themselves to his or her awareness in each moment. His or her focus is on the process, or flow of psychic content, rather than on the content itself.

Mindfulness meditation is to be distinguished from concentrative meditation, where awareness is concentrated upon a single stimulus, such as a mantra or the breath. Used to induce a state of calm, peacefulness, or bliss, this technique can quell internal turmoil and strengthen the sense of internal focus of control.⁴

With mindfulness practice, however, the meditator becomes more aware of the nature of the process of experience, a phenomenon that has been termed reperceiving, because the act of intentionally attending with a nonjudgmental attitude triggers a shift in perspective; what was previously “subject” (thoughts and feelings that make up a sense of self) now becomes the “object” of awareness.⁵ Practitioners describe a subjective experience of “waking up”⁶ to a different experience than their ordinary state of consciousness, in which the experience of self is directly seen as merely a coherent system of thoughts and feelings. In this state of subjectively enhanced awareness, there is a disidentification of self from ego, as the meditator enters a hypo-egoic state⁷ and experiences reality to be a unified, undifferentiated field of pure awareness apart from thoughts about or perceptions of reality.⁸ In this state, unity with the present moment brings an acceptance, even as one acts to make changes, accompanied by subjective experiences of understanding, joy, serenity, freedom and self fulfillment.⁹

Although remarkably simple, meditation is nearly impossible for the untrained mind to do well for more than a few seconds. This can be verified by sitting comfortably and counting one’s breaths up to 10 before starting over again. Attention is quickly diffused back into the flow of thought. Only after many years can most people maintain an observing awareness of thinking or attend so completely to their external perceptions that all thinking stops and an experience of still awareness emerges. This is a state of pure, empty awareness and is a source of the experience of wisdom and enlightenment.¹⁰ Ultimately, it is the meditator’s goal to experience this sense of stillness in everyday life. As the Chinese poet, Do Hyun Choe, said, “Stillness is what creates love. Movement is what creates life. To be still and still moving—this is everything.”

Meditation, Psychotherapy, and Mental Health

Many have suggested that meditation may enhance mental health.^4,6,10–17 Literally millions of people over the past 2,000 years have come to this conclusion on the basis of their personal experiences. In recent decades, many authors have explored the use of meditation in psychotherapy.^2,8,18–43 The consensus is that meditation may promote the diminishment of psychiatric illness, character change, and the resolution of neurosis when used adjunctively with psychodynamically oriented and cognitive behavioral psychotherapy.

The seminal work of Marsha Linehan, who developed dilectical behavioral therapy (DBT), is one example of the successful integration of mindfulness meditation with psychotherapy for the treatment of character pathology, depression, addictions, and eating disorders. DBT has helped legitimize meditation as a credible component of psychiatric treatment.^34,44

Several studies have indicated a positive impact of meditation in reducing stress and enhancing general wellbeing.^45–56 Several studies have also suggested that meditation can be helpful for the treatment of anxiety,^57–63 addiction,^64–77 aggression,⁷⁸ suicidality,⁷⁹ and depression.^80–83

Other studies addressing meditation’s impact on medical illnesses have indicated a possible role for meditation in the treatment of chronic medical illnesses,^84–90 including chronic pain,⁹¹ insomnia,⁹² and hypertension.^93,94

In an attempt to understand how and why meditation might be therapeutic, investigators have examined its effect on a variety of complex psychophysiological functions and behaviors. Decreased stress and hypertension have been related to decreased autonomic arousal or reactivity,^95–97 a possible means, along with positive emotions, reduced oxidative damage,^98,99 and enhanced immune functioning,¹⁰⁰ by which meditation may preserve cognition¹⁰¹ and reduce age-related allostatic stress and neuronal loss, thereby promoting brain longevity, plasticity, and learning.^102,103 Imaging studies have shown increased gray matter, particularly in the prefrontal cortex, the right anterior insula, and the putamen, areas associated with attention, interoception, and sensory processing, with differences correlating with meditation experience, suggesting neural plasticity with meditation.^104,105

A number of EEG and imaging studies have shown changes in EEG patterns and regional cerebral blood flow with meditation. Overall, these studies show theta, alpha, and gamma activation along with increased EEG coherence involving predominantly the anterior cingulate and frontal lobes in experienced meditators.¹⁰⁶ Imaging studies show increased regional blood flow to the anterior cingulate cortex and dorsolateral prefrontal cortex during meditation.¹⁰⁶

Other studies have shown effects of meditation on cognitive functioning. Meditation may enhance perceptual receptivity and discrimination,^107,108 decrease reaction times,¹⁰⁹ and improve problem-solving ability.^110,111 Meditation affects the allocation of brain resources in part to systems mediating attention.^112,113 This may explain observations of improved executive processing efficiency¹¹⁴ and enhanced perceptual clarity¹¹⁵ in meditators. One study of Zen masters showed a failure to habituate, on EEG, to a repetitive stimulus, further supporting the idea that meditation enhances perceptual receptivity and openness.¹¹⁶ Studies have shown meditators to be superior to control subjects in their ability to empathize,^117,118 and meditation may even enhance therapeutic outcomes in patients of psychotherapists who meditate.¹¹⁹

Despite the substantial literature suggesting meditation’s benefits for a variety of psychiatric and medical conditions and for enhancing wellbeing and functioning, questions remain regarding the nature of meditation’s efficacy due in part to methodological problems,¹²⁰ limitations in study designs, and the need for further research.^{39,40,121–125} Investigators have yet to fully identify, with controlled studies, the benefits that are attributable specifically to the act of meditating apart from the possible benefits of just sitting and doing nothing, of relaxing,^126–128 of doing something with the expectation of benefit,^129,130 of practicing an activity with discipline, and of introducing a routine time for self care. In addition, some studies have inadequately controlled for sample population variables, such as self selection bias, socioeconomic status, and psychosocial history, as well as for individual characteristics, such as motivation, commitment, psychological mindedness, discipline, desire to change, or adherence to particular values.^131–133 More sophisticated studies are needed to define sample populations more thoroughly, adequately isolate the independent variable (the act of meditating) for scrutiny, and then use appropriate control groups.^39,120

Notwithstanding these research problems, the wealth of experience and data gleaned to date is substantial and raises the question of why most psychiatrists have not adopted meditation as a standard adjunctive tool. There are probably several reasons. First, Western psychotherapists are culturally unfamiliar with the various meditative traditions, which have been uprooted from their ancient Asian culture. Not only are few Western psychiatrists also experienced meditators, but we have yet to develop a coherent psychiatric framework, as distinct from an Eastern religious one, in which meditation makes sense as a technique for enhancing healing from psychiatric illnesses.

Second, ambivalence exists in the field of psychiatry about techniques developed to enhance wellness and those used to alleviate mental illness. The practice of psychiatry has traditionally been applied to individuals with mental illness who have impairments in their abilities to work, love, or play.⁸ In contrast, meditation evolved out of a Buddhist spiritual tradition as a vehicle for attaining enlightenment, or “ultimate mental health.”^4,16 As such, it was a technique not for the neurotic, psychotic, or character-disordered person, but for the well-adjusted, spiritually sensitive few who were not content with immersion in the unconscious drama of human affairs and took up a meditative practice to address what Freud called “normal human happiness.”¹³⁴

As the culture now asks psychiatry to respond to its concerns with personal meaning and self fulfillment, psychiatry responds hesitantly. The term mental wellness is entwined with religion and spirituality, which science, and thus psychiatry, divorced itself from long ago during the Renaissance.^135,136 The rapprochement between psychiatry and spirituality has been anxious and tentative, as psychiatry focuses on the biological realm to fortify itself as a respectable medical specialty.

Furthermore, the attitude of members of the medical profession of psychiatry toward mysticism, which is the package in which meditation arrived in the Western world, has been one of skepticism ever since Freud. Some have felt that the practice of meditation itself might be a regressive and maladaptive manifestation of character pathology or other psychiatric disturbances.^{4,134,137,138} There may be an important germ of truth in all of this that needs to be understood in order to use meditation in the treatment of psychopathology. Engler notes that people with narcissistic or borderline character structures may attempt to use meditation to make themselves “pure” or to recast feelings of emptiness and fragmentation as the “voidness” or “selflessness” of enlightenment. These people want enlightenment, but on their terms, as a substitute for legitimate suffering and to avoid the painful struggle to grow up and achieve a stable sense of identity and meaningful relationships with others. Such an attempt to shortcut healing can be dangerous and is doomed to failure.⁴

A final reason why attempts to integrate meditation into psychiatry have met with some resistance may be a reluctance to employ a technique that “pollutes” the psychotherapeutic environment. This concern resides beneath a more general concern with the complications and complexities that arise when behavioral techniques or medications are prescribed in a psychodynamic setting.^139,140 This is yet another aspect of the complex art of psychiatry that now calls for attention under the evolution of integrative psychiatry.¹⁴¹ Meditation may yet flourish as a psychotherapeutic technique as integrative expertise develops in the search for ways to better help patients.

Meditation and Psychopathology

Having said that meditation is a practice for enhancing mental health, meditation can also be a helpful tool for promoting the healing of individuals who are mentally ill. This is somewhat paradoxical. This issue is laced with complexity and confusion. It does seem true, as Engler summarizes, that “you have to become somebody before you can become nobody,”⁴ meaning that one needs to have developed a coherent sense of oneself and relatively healthy object relations before one can attain a deeper understanding of reality or of one’s true nature through meditation. In fact, meditation can actually be harmful; it can precipitate psychosis or release a debilitating flood of painful affect in some seriously disturbed individuals.^{4,24,142–144} In others, it can exacerbate obsessive and schizoid traits.¹⁰ Like a drug, meditation must be prescribed with careful attention to the psychological status of the patient.

The problem lies in making a rigid distinction between the otherwise useful concepts of “mental health” and “mental illness.” Once established that the practice of meditation requires a degree of psychological integrity, the fact remains that no one is either devoid of mental health or entirely free from mental illness. Patients have both strengths and weaknesses. Even the most enlightened of Zen masters can possess characterological blind spots and may benefit from psychotherapy. It is more accurate to say that ego repair and awakening are two separate and simultaneous processes, which can intermingle and influence one another synergistically.^24,33 This symbiotic interaction is poorly understood and calls for careful scrutiny in order to understand exactly how meditation fosters healing. By discerning the therapeutic psychological sequelae of a meditation practice, psychiatrists may be able to develop the conceptual framework that is necessary to apply this technique intelligently and effectively in their work with patients.

Psychological Consequence of Meditation

Two distinctions help in the analysis of the meditative process. The first is among the various component actions of daily meditation, for this is a complex act. Apart from the act of attending to the present moment, there are also the acts of sitting still (or abstaining from movement), structuring one’s life around a disciplined practice, and allying oneself with a social system that provides the meaning and values that the practitioner uses to conceptualize his or her experience.

A second distinction can be made for each of these component actions between the primary and secondary consequences of each act. Primary consequences are inherent in the nature of the act itself (e.g., eating fills the stomach), and secondary consequences follow from these primary consequences (e.g., eating too much causes weight gain). By understanding the relationships between primary and secondary consequences, we can begin to understand how meditating could lead to complex consequences, such as wellbeing, compassion, or personal integrity.

The act of attending

The act of attending to this moment in meditation separates the observer from the contents of awareness. The meditator takes in all that is this moment, yet realizes that “this,” or the awareness of this moment, is not the verbal-cognitive understanding of this moment. In fact, any such understanding is just another aspect of experience, which is subject to scrutiny by the meditator.

The act of attending to this moment results in two fundamental primary consequences: an increased perceptual receptivity and the segregation of awareness from the contents of awareness. Increased perceptual receptivity occurs when the meditator attends to this moment, because it is an act of inquisitiveness. It is an act of embracing reality—of accepting whatever arises in awareness regardless of whatever value might be ascribed to it. The act entails an attitude of benevolent unconditionality, a respectful honoring of the flow of reality as the meditator continuously redirects attention to the instant of the present.

In maintaining awareness on the flow of experience rather than the contents, the meditator segregates awareness from the contents of awareness. This induces a therapeutic split in the ego,⁴ in which the observing self¹⁰ comes to experience its true nature devoid of the contents of awareness, including ideas and feelings of a sense of self, which are seen to be illusory. This action is called disidentification,⁴ because the empty self is disidentified with the contents of awareness.^4,10,145

Concentration is the third primary consequence of the act of attending, because effort is expended to repeatedly refocus attention on the present moment. Let us now turn our attention to the secondary consequences that arise from these three primary consequences of attending.

Heightened perceptual receptivity

Done well, the practice of attending induces a pleasurable sharpness of perception and a sense of freshness, presence, fullness, and openness. Attending to each moment as if it has never before been experienced (which it hasn’t) stimulates interest and enthusiasm. One Zen master once said there was nothing more satisfying for him than this “fullness of awareness.”

The act of attending prevents habituation and increases cognitive flexibility.^33,38,39,116 There can be an experience of seeing things differently than before. Other writers have conceived of this experience as a type of regression to a pre-verbal state of consciousness in which primary-process cognition predominates,^2,33 and have compared it to the controlled “regression in the service of ego,” which can be stimulated by the psychoanalytic process.² This experience is nonlinear and can be creative. From the literature reviewed on EEG coherence, attending to the present may cause a more balanced, integrated functioning of the left and right cerebral hemispheres, inducing more holistic, simultaneous, synthetic thinking.¹⁴⁶

Because people see more when they look, attending to the present enhances awareness of both oneself and of others. In attending inwardly, the meditator asks, “What am I?” This act gives to oneself the sort of full, acceptant attention patients yearned to receive from their parents and appreciate when a therapist actively listens to them. The quality of attention given to one’s experience is crucial; it should be acceptant and caring, regardless of how distasteful the contents of awareness. In this way, patients provide a therapeutic service to themselves. Attending to their experience is then an act of self care and self love and thus strengthens these ego functions. It can even be thought of as a form of re-parenting.

By attending to themselves without judgment, repression diminishes, allowing exploration of the feelings hidden beneath the foliage of defenses. Defenselessness and self honesty are nurtured, and self awareness is enhanced as affect becomes much more available to consciousness.^24,33

Although the concern is ultimately more with the process of experience than with the content, meditators do notice that attending to experience stimulates observing ego functions of thinking about our experience. This is called “meta-cognition.” This is the level of thinking at which psychological insight takes place. Some Buddhists might see this as a side effect or a distraction. The meditator need not let his or her attention become lost in this level of cognition, but merely note how a cognitive understanding of self is deepened by an awareness of the present. Insights can then be brought to psychotherapy for elaboration and clarification.

Enhanced awareness of feelings includes awareness of pain. Here the act of focusing attention on suffering is counter-reflexive and requires conscious effort. But to do so is to replace neurotic suffering with legitimate suffering as the practitioner encounters feelings of fear, rage, emptiness, or yearning, which were previously hidden from awareness. Although painful, this process promotes healing by enabling mourning, abreaction, and coping. The question, “What is this?” helps prevent premature closure as the meditator endures the vicissitudes of an often protracted (even lifelong) healing process. The continual return to painful experience is similar to the phobic’s exposure to his or her phobic stimulus. With time it invokes the process of desensitization, which allows the patient to face reality more fully and work through his or her pain with greater equanimity.

With enhanced self awareness comes an increase in psychological differentiation;²⁴ patients gain a stronger sense of themselves as distinct from others, helping to consolidate a sense of identity. Through constant attention to their experience, patients can develop greater self trust and confidence. This leads to more decisiveness and assertiveness in interactions with others. As one Zen teacher said, “believe in yourself (your experience) 100 percent.” There can be an increased experience of calm and strength in anxiety-provoking interactions with others, as awareness is maintained of direct experience, of what is “true” for the experiencer.²⁴

Heightened perceptual receptivity also extends to the world outside the body. Awareness of others can also be enhanced by attending to others. The “micro-expressions” of others may become more readily perceivable, such as when someone shakes their head while speaking affirmatively about some feeling. Meditation may enhance the ability to perceive when others are deceitful or to empathize more fully with how someone is feeling.^117,118

The act of attending may benefit interpersonal relationships not only because of an improved ability to empathize but also because people greatly appreciate being attended to. To attend to another is an act of care and concern. Attention is a gift that invites intimacy and genuine sharing with those who wish for this. Outwardly attending increases our relatedness to the world. An impartial attention to all aspects of experience, both inner and outer, diminishes our sense of separateness or isolation. This experience is the seed of the mystical experience of oneness.¹⁰ In fact, meditation does catalyze a gradual decathexis of the self,¹⁴⁷ or decentralization of the ego.¹⁴⁸ Balanced attending imparts the realization that we are not but one aspect of a vast life process in which we are inextricably embedded.

Empty awareness

There are times after a prolonged practice of meditation when one can sit and observe the world without any thinking for an extended period of time. This state of consciousness can be called “pure awareness” or “empty mind,” because it has no cognitive content. It is into this empty field of consciousness that thoughts and feelings arise and are then observed. Thoughts and feelings come and go, leaving only empty awareness as a constant. One realizes one is not only one’s thoughts and feelings. One disidentifies from a sense of concept of self once it is seen that this is merely a complex matrix of thoughts and feelings that is relatively invariant over time.

The observing self, which is contentless, is to be distinguished from the observing ego of traditional psychoanalytic thought, which is that complex of functions constituting meta-cognition or reflexive awareness, and is filled with content, namely the secondary reactions to, and elaborations of, our immediate sensory/affective/ cognitive experience. The observing ego is stimulated by the process of attending, and greater psychological self awareness ensues. From the vantage point of empty awareness, this self awareness is observed as another set of thoughts and feelings that wax and wane and constantly transform.

This large awareness is imperturbable, because there is nothing to perturb. Active investment of conscious attention into the vastness of the present stimulates a sense of the inconceivable nature of reality: One perceives that reality is reality and thoughts are only thoughts.

This is a difficult experience about which to speak, in part because it seems unspeakable. Practitioners say that it brings one “out of one’s head” into the immediacy of the inconceivable present moment. It is a pre-verbal, primary process experience that casts a different perspective on the rest of experience. There is an immediate sense of the mystery of this universe and of ourselves as a process of the universe being aware of itself.

How does this experience, the result of a therapeutic split⁴ of awareness from ego, contribute to psychological healing? One possibility is that it may promote a restructuring of the superego, because the thoughts and feelings that arise from superego functioning are seen as not the ultimate truth and are met with an attitude of nonjudgmental, compassionate acceptance. Robbed of its potency, the superego loses its dominance over behavior, with a resultant reduction in inhibition, guilt and self-legislation. Meditation may then promote spontaneity. The ego, charged with a more realistic perspective on the self and the world, is relieved of the unnecessary suffering borne of an unrealistic equation of the superego with ultimate truth (whatever that might be). A sense of freedom and lightness ensues.

Enhanced concentration

Meditation is a practice of concentration. As the ability to concentrate improves, patients may become more productive at tasks that require concentration, especially when fatigued or in pain. Greater concentration strengthens the quality of meditation, and thus of perceptual receptivity and empty awareness. Concentration allows the person in pain to continue to attend to that pain and thus nurture a developing ability to bear what is painful.

The act of abstinence

Sitting still, or abstaining from movement, can actually be thought of as a behavioral technique. The meditator inhibits him- or herself from responding to any impulse for the period of meditation unless there is a risk of physical damage. If there is pain, or an itch, or restlessness, there are all calmly observed without movement.

Response prevention, or the delinking of action from impulse, has profound implications for healing. First, delinking fosters relaxation. For many, merely inhibiting movement encourages relaxation. When sitting motionless is associated with anxiety, tension, or restlessness, delinking maintains an in-vivo exposure and enables desensitization so that relaxation can occur. The association of quiescence with discomfort causes autonomic desensitization and blunting of the sympathetic response to stress.⁹⁵ This leads to a general reduction in sympathetic tone, resulting in greater calm, productivity, and physical wellbeing. Blunted sympathetic responsiveness also encourages equanimity.

With practice, delinking allows patients to become acquainted with the automatic, reflexive, and unconscious nature of most actions. In a dynamic setting, the compulsion to repeat is attended to and action inhibited, with a resultant decrease in self-destructive behavior, such as drug abuse. Meditation can thus introduce a therapeutic delay, which creates a sense of control and freedom as patients generalize appropriate delinking throughout their daily lives. This is the grounding for true personality change; to find oneself able to act with greater personal responsibility and integrity as freedom is gained from the sway of habitual urges. Patients can be taught to accept and let their experience be, with greater equanimity, when they let go of their automatic grasping for pleasure and avoidance of pain. With meditative abstinence, energy is diverted from doing something to attending to. With this change comes a new happiness borne not of immersion in pleasure but of acceptantly facing the richness of experience.¹⁵

The ability to face experience fully without having to do something other than attend to it enables the capacity to bear suffering. This may nurture compassion for both self and others because of an enhanced ability to attend to both one’s own as well as others’ suffering. As psychiatrists, this capacity to attend allows us to just sit, with presence and compassion, with suffering patients when little else can be done.

Another secondary consequence of abstinence may be an enhancement of self esteem and self efficacy. As patients gain more control over their behavior, they are more able to delay gratification, to respond correctly to a given situation, and to appropriately refrain from acting on self-destructive urges. Sitting still can thus be a catalyst for the development of greater self-confidence and respect.

The act of routine practice

Practicing meditation routinely has three immediate consequences: increased discipline, regularization of one’s lifestyle, and increased commitment to one’s own self care. Meditation is a practice of psychological weightlifting. By conditioning the habit of psychological self care, meditation promotes the many positive consequences already discussed.

The act of allying with a therapeutic context

When placed in a psychotherapeutic context, the act of meditating is an act of allying with that context and with the meanings and values with which meditating is associated. Values might include a commitment to self care, to enhancing functioning, to being truthful, or to behaving ethically with others. These values are then used as a reference point to influence actions as patients modify old behavior patterns. Often the values implicit in psychotherapy conflict with a patient’s preexisting, self-destructive values, and difficulties arise as meditation is attempted. Meditation then acts as a catalyst for exposing these values for scrutiny. One example is a patient who stopped her morning meditation because she felt guilty providing herself this time. She felt she did not deserve it. This conflicted with her desire to get better and the notion of self care, and led to a working through of the early parent-child interactions, which created her attitude towards self care. In this instance, daily meditation, as an extension of her psychotherapy, became a way of practicing self care without guilt.

The psychotherapeutic context provides a cognitive framework for directing and lending meaning to one’s daily actions. To accept a prescription to meditate and thus adopt its context into one’s daily life can be a profound, life-altering experience. It may be a good prognostic sign and a reflection of the patient’s commitment to change when she or he adopts such a practice as a part of the work of healing (although refusal to meditate is not necessarily a sign of resistance).

Attending and Abstaining

The above analysis paves the way for dissolving the mystique of meditation. We see that everyone performs some of the acts of meditating automatically to some degree. Meditation is merely a consciously willed, formal practice of these actions.

Everyone periodically directs attention to the present moment, albeit briefly. For example, attention to the present is enhanced when presented with some novel stimulus, such as a loud sound. Meditation merely makes this directed attention a willed act. Regarding the act of abstinence, many people inhibit their behavior when appropriate rather than act on every whim.

Even the altered states of consciousness induced by meditation are known to most people: the sense of the fullness and wonder of the world or the mystery of nature. Fully 60 percent of people in one survey reported a nonordinary state of consciousness, or peak experience of unity or boundlessness, at some point in their lives.¹³ Many people, for example, have felt an uncanny sense of wholeness and wellbeing during a walk through the woods or along the seashore.

Some people seem more able to attend to their feelings. Some seem more inclined to observe their environment and other people in greater detail. Some are more able to note their own thoughts and behaviors, and others to sit still while experiencing strong urges or frustrations.

An illustrative example of the healing nature of the actions of attending and abstaining is the case of a patient who was undergoing a painful divorce. When she and her husband separated, she went into an initial state of “frenzied activity” in which she “felt dead inside” and “out of touch” with her body. She described living as having a forced, controlled quality. She understood this as her attempt to cope with overwhelming sadness and anxiety. Approximately one month after her separation, she contracted a severe case of the flu and was confined to her bed for several days, unable to continue her hypomanic pace. Forced into inactivity, she became very sad, and experienced feelings of loneliness and fear. She cried almost continuously for three days.

Although a miserable experience, it was also cathartic. Her flu had forced her to abstain and attend to the emotional reality within her. The act precipitated a grieving process from which she emerged feeling relieved, “less tight,” and “more balanced.”

This vignette portrays how abstaining and attending are psychological processes that can enhance healing. Meditation is merely a formal, consciously willed exercising of these functions.

There are at least three issues here that need clarifying. First, psychotherapy is another practice that exercises these functions. Many authors have noted the similarities and differences between meditation and psychoanalysis.^2,23,24,33 Many higher functioning individuals actively defend against “the archaic demands and affects of the real self,”¹⁴⁹ and psychotherapy is for them a gentle art of uncovering (attending to) an inner cauldron of painful affect, and encouraging abstinence from numbing the pain in habitual but unhelpful ways.

Another practice that brings us closer to the reality of our existence is our engagement in healthy, meaningful, intimate relationships, for these can entail the sort of sharing and confrontation that evoke a deepening of awareness and working through of emotional conflicts. In this case, abstaining means not withdrawing from the relationship before these conflicts can be resolved.

Second, although attending and abstaining are important actions for mental health, they are not enough. Healing occurs in the process of being in the world by working, loving, and playing. The insights and abilities acquired through meditation can only strengthen our patients’ abilities to engage the healing process in their daily lives. Healthy living entails healthy relating; when the meditation session is over, patients have to get up and go forth into the world.

A third issue concerns the nature of attention given in meditation versus other activities. Meditation is unique because the act of attending is part of the process of mentation and not solely the contents or the conceptual insights stimulated by this act. This is a reminder that meditation was developed to do other things than to merely foster psychological abilities which happen to promote healing.

A final comment seems appropriate on the relationships between abstinence and spontaneity. Briefly put, spontaneity is a quality that arises as patients learn to both watch themselves mindfully and let themselves be who they are.

Attending allows for trust and faith in oneself to develop. Abstinence in this context is a spontaneous action that occurs whenever one senses that acting on an impulse would be hurtful to oneself or others. It seems that the ability to act freely and spontaneously on the basic desire to not cause suffering depends on the ability to abstain when appropriate. Thus, practicing abstinence enhances appropriate spontaneity. There is a story of a Zen master who once was sitting on top of a 10-story building and suddenly heard scuffling and the cry for help on the street below. He looked over the ledge to see two thieves beating and robbing their victim. He let out an ear-splitting bark, which so startled the two thieves that they immediately fled. He saw clearly the correct response and responded spontaneously. Here, spontaneity is distinguishable from impulsivity by the quality of attentive awareness with which it is endowed.

These ideas leave us with several intriguing questions. One hypothesis is that the people we admire because of their productivity, ability to relate, aliveness, and health are people who attend and abstain more than others. Another hypothesis is that people who are innately gifted with these abilities and who suffered physical and psychological trauma while growing up are more resilient. The natural ability to spontaneously perform these actions of meditation may be one predictor of the ability to heal. This is an exciting area for future research.

Issues and Applications

Given this understanding of the many benefits of a disciplined practice of meditation, the question remains of how best to use this practice in our work with patients. We need to address issues relevant to both prescription and monitoring of this behavioral technique, as we do when prescribing a drug or assigning homework. Effective application requires a sophisticated, yet sensible understanding of the relevant issues.

Prescription

To whom, for what symptom, in what form, in what dose, and for how long? Patients must first be able and willing to make the required investment of time and effort. They need to have sufficient motivation to resolve their difficulties and work through their ambivalence about changing. They must be able to adopt a positive mindset about the practice and maintain an expectation that they will benefit from it. The therapist’s experience and understanding are important here. Fantasies about what meditation is and what it will do need to be explored and realistic expectations developed. The therapist must be able to present meditation with clear instructions and with a sensible explanation of the effects and benefits to be expected.

A sophisticated prescription strategy would also include variations in the types of practice assigned. For people who have difficulty concentrating, or who are in severe distress, a concentrative technique might first be tried. For those with little awareness of their bodies, an action meditation, such as walking meditation, can be prescribed. For highly defended individuals, a mindfulness technique that helps to release available affect may be preferable.

The patient must not be psychotic or have too severe a character disorder, so as to avoid any psychiatric complications. Indications for meditation include the treatment of depression, anger, anxiety, stress, hypertension, addiction, insomnia, and chronic pain. Given its effects on awareness of self and others, availability and tolerance of affect, and ability to inhibit action, meditation is also a useful practice for patients with neuroses and mild to moderately severe character disorders who are plagued by defensiveness, lack of self awareness, vulnerability to intense and painful affects, and self-destructive behaviors. If applied intelligently, meditation can help those who are sufficiently motivated to practice.

Monitoring

Part of the intelligent use of meditation as a psychotherapeutic tool is the monitoring of its effects on the patient. Complications or difficulties have to be noted and corrected, such as dealing with negative feelings about the practice or restlessness during practice, impatience, and doubt or frustration at not being able to “do it right.”

The therapist should assess both the content and process of the practice. If the patient keeps a notebook for recording his or her experiences and impressions, there will be ample multidimensional, primary process material for exploration and the therapeutic process will be intensified.³³ This intensity needs to be carefully titrated with respect to the patient's capacities. The length and frequency of meditation sessions may require adjustment.²⁴

Transference reactions to the assignment of meditation as a task of psychotherapy will arise. If addressed effectively, insight will deepen and the dynamic work will be furthered. Patients may resist the benefits of meditation out of fear that the therapist will desert them if they get better or out of rage against a therapist whose simple instructions they may misconstrue as authoritarian commands. The possible roots of these distortions in past experiences can be teased out to the benefit of the patient.

Bringing material from meditation to psychotherapy for exploration can encourage an excessive fascination with content versus process and thus hinder the development of meditative insight. This needs to be guarded against. It should be reinforced that meditation is a method for enhancing particular qualities of being rather than solely for achieving greater cognitive understanding through metacognitive awareness, although the latter can be useful to the psychotherapeutic process.

Conclusion

Understanding meditation as a complex act that consists in part of attending and abstaining helps us to understand how the many positive consequences of meditation occur. It demystifies the process.

Not only do we all spontaneously attend and abstain to some degree, but much of our psychotherapeutic work is geared toward helping patients to perform these actions. Meditation can thus be recast as an individual, formal practice of actions that are also practiced in psychotherapy. From this perspective, it becomes obvious that the two are “technically compatible and physically reinforcing.”³³ There is a need for more psychiatrists to receive training in meditation so that they can augment their practices with this important technique.