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.
think of now 
Erin –
Thanks for the fine post. This needs to be said much more often, but is not, I suspect because the self-styled “mindfulness gurus” don’t know it, having had little formal training (in Buddhist monastic settings or places like IMS), and because it inteferes with their marketing schemes. The “arousal of latent content” the study mentions is EXACTLY what’s supposed to happen when one beings meditating seriously. It’s similar to accessing what classical Buddhism called the Alaya-Vijnyana, the storehouse consciousness (let’s hear Dan Siegel talk about that, LOL), or repository of past experiences. Exposure therapy anyone? Since I am now an old Zen fart, I can say that “when we started practice, back in the day”, in my case the late 80s, we were taught to expect this difficulty. We were told that sustained practice was very, very hard, and a serious matter. Of course the rewards are also great, and the vast corpus of Buddhist literature provides inspiring tales to keep the practitioner going through all the anxiety and struggle. But this has been lost by the commodifiers of Dharma, who usually loathe even the word Dharma, and have tried to jettison all the wisdom in Buddhist teachings that is available as we walk the path.
I eagerly await your next essay!
Thanks Scott. I had a great comment emailed to me by a psychologist who echoes your thoughts on the importance of sitting through “the arousal of latent content” and what he believes to be some signs that that necessary confrontation hasn’t happened successfully. I’ll see if I can get permission to post it.
Thank you for this interesting post. I use mindfulness in conflict-zones and have often made similar reflections, so I’m glad to see that I’m not being overly-cautious when (and if) introducing mindfulness to clients who have experienced traumatic events. In some of her teachings Pema Chodron talks about ‘staying’ with the flashbacks during meditation, but she also says how important the support of an experienced teacher is, and how the client has to be ready to take that journey.
Thanks. I too agree that an experienced teacher is an indispensable part of meditation, just as a competent therapist is probably a requisite for ANY sort of safe exploration of trauma. Keep doing what you’re doing–I appreciate your important work.
Thank you for addressing a topic that may have fallen under the stampede. After thirty-five years of work as a counselor, I’ve come to understand that mindfulness may be an essential tool at some time during an individual process. However, it is no panacea. Both trauma survivors and others who have intensely high energy both in thinking and in body may not be able to do any meditation or mindfulness practice at all. If meditation is valorized as the “right method” or an ultimate goal, these people may feel that they are failing, that there is something”wrong” with them, or any number of negative self-judgements. If the therapist remains mindful and present to the needs of the client, then mindfulness can take its proper place in the client’s process and not be adopted as an ideology.
Awesome comments, Barbara. You are so right about the potential for people feeling like they “failed” at meditation (this happens even when a person has all the benefits of the greatest teachers!) and the importance of understanding the role of meditation in however one is using it. Thank you!
Extremely helpful – very clearly articulated. Thanks!
This is indeed important stuff to point out. I was trained as a psychiatrist in the military in D.C. and saw lots of PTSD and dissociative stuff. Fortunately we had fantastic faculty who educated us on the importance of not going lightly into the treatment of trauma. In these days of time- and session-limited treatment (including in military settings, I regretfully admit), there are definitely times when letting the sleeping dog lie is better than stirring it up when you don’t have the time and/or expertise to re-sedate it! (I know, imperfect metaphor but you get the idea…)
Thanks David, I appreciate your thoughts–I would love to hear more from people who have worked with mindfulness in the military and/or trauma in the military (of course, the latter is a robust area of work indeed).