When it’s the wrong time for meditation, Part I

About a year ago, Elisha Goldstein over at Mindfulness & Psychotherapy published one of his typically excellent interviews on his blog; this one was with John Briere, the psychologist and trauma expert.  I found the interview interesting at the time–and indeed linked to it from this site–because Briere is also an expert on mindfulness. In my professional practice right now, I am working quite a lot with traumatized children and adolescents; I therefore I return to the interview frequently in my mind.

Lately I’ve been thinking about it for another reason. As anyone who has read my blog even casually knows, I have been watching the rising tide of mindfulness-based therapy with a mixture of excitement and fear because I don’t consider all forms of mindfulness as being totally benign with all clients….or in the hands of all therapists, for that matter. But it seems so refreshing and exciting to many (and rightfully so) that it’s being widely practiced by therapists and clients who may not have the experience and hence tools to deal with the negative side-effects such as dissassociation or anxiety that can arise when mindfulness such as meditation is practiced.

Meditation is awesome, don’t get me wrong, and I think nearly everyone can benefit from it in when they are exposed to it in the appropriate fashion. But many of the clients who come into our clinical practices are vulnerable and already experiencing anxiety, emotional lability, stress and/or trauma that is completely overwhelming. They quite frequently have overwhelming and pervasive thoughts that intrude on them even when distractions are attempted. They may not be ready to attempt mindfulness, even outside of meditation.

In the M&P interview, Briere notes:

“An unfortunate aspect of psychological trauma is that, in order to move out of pain, we have to sit with pain, even if we may prefer the seeming protection of  deadened emotions and reduced awareness. The journey of the trauma survivor can sometimes require great bravery — to approach rather than avoid, to reach out when isolation seems like a better idea. ….Initially, the individual may be too overwhelmed to engage in formal psychotherapy, let alone learn mindfulness.”

I’ve been to countless presentations on mindfulness and/or meditation aimed at orienting and educating therapists on how to use it in their practices. I’ve very rarely heard any presenter say anything along the lines of the above, even though I would venture to guess that any serious meditation practitioner is aware that it can be overwhelming when practiced before a person is properly prepared.  Though scholarship on this subject (and frankly, all mindfulness-based clinical interventions) is relatively thin, there have been several studies devoted to the phenomenon of “relaxation-induced anxiety,” a phenomenon which appears to be especially frequent in clients practicing meditation over, say, progressive muscle relaxation. There is even some evidence to demonstrate that some forms of meditation, specifically objectless meditation like some Zazen, is particularly likely to cause this.

A study on the use of meditation in therapy (“Meditation as an Adjunct to Pyschotherapy,” Kutz, Ilan et al.) found “[The intervention] resulted for some patients in feelings of defenselessness, which in turn produced unpleasant affective experiences, such as fear, anger, apprehension, and despair. At times such emotions were accompanied by sobbing during the meditation session. At other times the meditation resulted in the arousal of latent content. For example, 4 patients had a dramatic unveiling of screen memories and meaningful material from their past that had been blocked during a protracted course of therapy. Hidden themes from the past, such as incest, rejection, and abandonment appeared in intense, vivid forms and challenged the patients’ defensive image of their past and themselves.

They continued on to say, “Those unpleasant affective experiences were on other occasions counteracted and balanced by an enhanced sense of self and centeredness which allowed the patients to contain their fears and to therefore continue their self-exploration in meditation…It was then the role of the therapist to reflect back to the patient the meaning of his or her sense of self, both in its positive expression of healthy self-esteem and in its potential function as a narcissistic defense against conflict and psychic pain.”

All well and good and everyone benefits–if the therapist is appropriately prepared for this phenomenon to occur. Consider the potential risk to be found in unknowingly provoking feelings of defenselessness and fear in a client who has a trauma history; consider the alarming unveiling of screen memories in a client who is already overwhelmed by emotion and pervasive anxiety.

More on this topic to come later this week.


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Mindfulness therapy is no fad, experts say [LA Times]

A new article in the LA Times puts forth the case for mindfulness as a psychological intervention with staying power.

An excerpt:

“Mindfulness has become a buzzword, especially with younger therapists,” said Stefan Hofmann, a professor of psychology at Boston University’s Center for Anxiety and Related Disorders.

Mindfulness therapy encourages patients to focus on their breathing and their body, to notice but not judge their thoughts and to generally live in the moment. It may sound a bit squishy and New Agey to some, but Hofmann and other experts say mindfulness has something that discredited theories of the past never had: solid evidence that it can help.

“I was skeptical at first.” Hofmann said. “I wondered, ‘Why on Earth should this work?’ But it seems to work quite well.”

Hofmann and colleagues burnished the scientific credentials of mindfulness therapy with a review article in the April issue of the Journal of Consulting and Clinical Psychology. After combining results of 39 previous studies involving 1,140 patients, the researchers concluded that mindfulness therapy was effective for relieving anxiety and improving mood.

The treatment seemed to help ease the mental stress of people recovering from cancer and other serious illnesses, but it had the strongest benefits for people diagnosed with mood disorders, including generalized anxiety disorder and recurring depression.

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Mindfulness potpourri

Zen Habits has posted 9 Mindfulness Rituals to Make Your Day Better. Unfortunately for me the night owl, they include “sit in the morning.” Damn!

Ironically I struggle quite a bit with mindfulness in my workplace. Thankfully, I’m usually pretty mindful when I’m actually in session with a client. But between sessions when I’m supposed to be working on my documentation, responding to emails, making phone calls or faxing things to other agencies, I tend to get so overwhelmed with the many things on my to do list that I will start one before finishing another–a mortal sin in mindful living directly opposed to the last item on Zen Habits’ list, “Work with focus.”  I can tell you two things that have helped me work with more focus than I otherwise would:

  1. A literal to-do list that I keep on my desk. This isn’t so much a mindfulness trick as an ADHD trick. Hey, no one said I can’t have moments of both.
  2. Mindful breathing. My favorite short mindful breathing exercise that can be done anywhere, at any time is “The Relaxing Breath” that I first heard of through Dr. Andrew Weil. Maybe he invented it, I don’t know.  Here’s the rundown direct from his site:
  • Exhale completely through your mouth, making a whoosh sound.
  • Close your mouth and inhale quietly through your nose to a mental count of four.
  • Hold your breath for a count of seven.
  • Exhale completely through your mouth, making a whoosh sound to a count of eight.
  • This is one breath. Now inhale again and repeat the cycle three more times for a total of four breaths.

I do this exercise regularly–in traffic, when I’m flustered in my workday, when my puppy won’t stop ringing the bell to go to the yard at midnight, whatever. I also can tell you that it’s been the single most effective breathing exercise that I’ve used with my teenage and older clients (the single most effective breathing exercise that I’ve used with younger clients is the awesome “flower and candle” exercise, wherein a child is instructed to form two fists and envision a candle in one fist and a flower in the other. She’s then asked to smell the flower and blow out the candle in turns; a great intro to mindfulness for children).

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Remembering Alan Marlatt

Alan MarlattI got the news today that Dr. G. Alan Marlatt of the University of Washington in Seattle passed away this morning from complications of cancer. I was quite shocked because I hadn’t known he was ill, and saddened because of what his loss meant–not only because by all accounts including my own limited experience he was a great person, but because his death constitutes a great loss to the field of mindfulness-based clinical interventions.

To say that Alan Marlatt was a pioneer in mindfulness-based relapse prevention is akin to saying that Abraham Lincoln was a pioneer in stovepipe hats. Sure, it may be true but it hardly tells the whole of the story.

I started this blog last year in the interests of exploring mindfulness-based relapse prevention for an independent study in my last year of graduate school. When I began, the obvious person to go to for information was Dr. Marlatt.  Aside from the fact that he absolutely created the field when he began his research into mindfulness-based relapse prevention, and aside from the fact that his courage in taking this approach seriously when all his colleagues were staring at him befuddled is nothing short of remarkable, he’s just a cool guy. I got an academic crush on him from reading his great personal account of how he got started, Mindfulness Meditation: Reflections from a personal journey.

The article begins: “Having high blood pressure opened the door to meditation in my life.” It goes on to describe his experiments with meditation (not just Zen, which Dr. Marlatt did eventually practice) to reduce the blood pressure that had been high for him for so long, long enough to disqualify him for service in Vietnam. Because Dr. Marlatt was a psychologist who worshipped at the shrine of hard figures and scientific evidence,  his initial skepticism was morphed by the success of these experiences into an interest in taking it to the next level and attempting to use mindfulness as an effective, evidence-based clinical intervention for recidivism for those with chemical dependency.

Mindfulness is trendy in psychology right now, but this was not always the case.  Dr. Marlatt’s decision to follow this line of research initially resulted in funny looks and a general disparaging reception from many of the hard-core scientists.  The following is from my interview with Suzanne Cooper, PMHNP, posted earlier on this blog:

“I went to a conference two years ago—the ASAM conference in Seattle. Alan [Marlatt] was there, and he got up and started talking about walking meditation with Thích Nhất Hạnh and had talked to someone who went to Plum Village and took the Five Mindfulness Trainings. He was talking about his Mindfulness-Based Relapse Prevention [protocol] and kept bringing in Thích Nhất Hạnh. That was like….wow! It was a medical conference. It was about drugs for craving, Suboxone [a drug that treats opiate dependence], the effects of cocaine on the brain and amphetamines and PET scans and Nora Volkow (the head of NIDA) was there. It was very medically research-oriented. I was blown away. He talked about his grant and research, and just that it was being used. It just completely floored me.”
A few days before I interviewed Suzanne, I had the privilege of sitting down with Alan Marlatt who mentioned this same scene to me. He stated that many in attendance were very taken aback by his discussion of mindfulness at such a traditional, medical-model conference, and that there had been more than a few suggestions that he was misguided in talking and writing about mindfulness.

So in sum, I knew I wanted to meet the guy. Emailing Alan was pretty comical as I didn’t have a whole lot of juice behind my name, and he’s a busy, important personage in the field. Let’s be honest–when you have your own page on wikipedia, you’ve arrived. I was going to have to rely on his appreciation for the lowly, humble graduate students and his kindness toward fellow Buddhist practitioners.

I had very little experience working with chemical dependency and addiction, but rather a lot of experience in mindfulness as I’ve been practicing Zen for about ten years. I began my practice in my home state of Colorado at the Denver Zen Center under Danan Henry Roshi, a teacher in the Diamond Sangha. From there I moved to Eugene, Oregon and am now in Portland. My clinical supervisor, Scott Ruplin, has practiced in this tradition for about twenty years or so now. And in my professional work, I do use mindfulness-based interventions with clients (for example, I run a DBT group for teens). Thus have my professional practice and my spiritual practice intertwined. As Dr. Marlatt’s experiences have been similarly both personal and professional I hoped he’d at least consent to an email interview.

His response was warm and immediate. Yes, he’d like to meet with me, how about over lunch at a restaurant that he liked near the university? Could I arrange to come to Seattle?

We met at the restaurant and were seated at a little table overlooking the water, where he was warmly greeted personally by each busser and waiter that passed by (have you ever heard to judge people by how kind they are to their waiter? By that assessment Alan can be judged very well indeed). We spoke about his field, why he got started, and his beliefs about the future over a lunch that stretched to over two hours. All this for a graduate student from Portland he didn’t know at all.

The cherry on top is that he gave me so much to think about at this interview that when I went home I didn’t even post it! It was so ominous, such a huge amount of information to organize, that I didn’t even know where to begin. I had brought a tape recorder to the interview, but the ambient noise in the restaurant made getting anything out of the recording an exercise in futility. I was left with scrambled notes that say ambiguous things such as “prisons Vipassana gender segregated” and “Kohlenberg mindfulness possible tx alternatives.”

The closest thing to a recognizable sentence is under the heading “academic reception,” where I have written: “beginning pretty negative. Positive additions–TM with frat boys, alternative to abstinence. discouraged to write the 2004 paper. Dalai Lama said they would change the philosophy the last five years mindfulness is acceptable–now with neuroscience.”  Although this seems ambiguous, it highlights to me what one of the defining points of the interview was: that mindfulness-based relapse prevention was viewed by Alan as one of many possible paths to healthy living and victory over addictions, not THE path.  He said: “For some, 12-step programs will be the right approach, but others may need something else. What I want to do is help people find a path that works for them.”

When I returned home with this tangled mass of information, my graduate school days coming to an end, and began the work of wrapping up one phase of my life and starting another as I had recently gotten a job, I filed the interview under the heading of “enriching meetings that may not have resulted in what I wanted them to” (the actual blog post) “but which will benefit me personally.” Nevertheless, I lived with the guilt that comes with knowing that you haven’t quite done all you can do with a certain experience.  I wanted to write about him, damn it. Oh well, life goes on.

Until it doesn’t. Death makes you think, doesn’t it? The majority of us live each day under the guise of invincibility.  Operating under a facade of permanency and immortality, we are able to face things such as crossing the street or saying goodbye to a sibling at the end of a conversation on the telephone.  But as we all know, as Zen knows perhaps best of all, permanency is the ultimate illusion, the ultimate in self-deception.  The only constant is change, and so on and so forth. The best we can hope for is that we make some kind of lasting impact on others in our sangha, our community, that contributes to positive change–am I successful in that? Are you?

Thanks for everything, Alan, and deep bows.

** UCSD Center for Mindfulness has posted a nice tribute to Dr. Marlatt on their blog, here.


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The Pathological Arrow

Emily Mills writes that boiled down, the fear of dissolving the self leads to a lot of psychopathology, and the way we deal with that fear as clinicians might speak to how we address it in our own lives. Do we seek to alleviate it, or do we call it into the light of day? Continue reading


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Zen and the Art of “What If?”

Could your life have been totally different had you never made a certain mistake?

We’ve all wondered this from time to time and sometimes this wonder becomes pervasive. Below is a Zen student’s Dharma talk focused on the explication of a kōan. Kōans are the folk literature of Zen and, in the Harada-Yasutani and Rinzai schools, are used as the focus of Zazen (Zen seated meditation). They elucidate, in poetic form, the workings of the phenomenal world.

Click here to read the dharma talk

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Is too much lost?

Earlier this year I sat in on a MBRP addictions treatment group led by Chris Finucane, a LCSW with Kaiser Permanente, where I was an intern for a year (in the Mental and Behavioral Health department), and Suzanne Cooper, a Nurse Practitioner in the Addiction Medicine department at Kaiser. Suzanne is one of the kindest people anyone could meet. She’s a devotee of Thích Nhất Hạnh, the Vietnamese monk who is widely considered one of the greatest living Zen masters, and has practiced with him in Vietnam, France, and the United States.  I asked her how she arrived at incorporating her personal mindfulness background into her clinical practice with addictions, ways in which she felt that mindfulness could address shortcomings in traditional addiction treatment, and of course, what Thầy is like! Continue reading

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