by Michael McGee, MD
Dr. McGee is Clinical Instructor in Psychiatry, McLean Hospital, Harvard Medical School, Nashua, New Hampshire
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.
Key Words
meditation, mindfulness, psychiatry, psychiatric illness, psychiatric treatment, wellness
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 state[7] 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 cognition[101] 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 efficiency[114] and enhanced perceptual clarity[115] 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 split[4] 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.
References
1. Smith JC. Meditation: A Sensible Guide to a Timeless Discipline Champaign, IL: Research Press, 1986.
2. Shafii M. Silence in service of the ego. Int J Psychoanal 1973;54:431–43.
3. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York, NY: Hyperion, 1994.
4. Engler J. Therapeutic aims in psychotherapy and meditation: Developmental stages in the representation of self. J Transpersonal Psychol 1984;16:25–61.
5. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. J Clin Psychol 2006;62:373–86.
6. Tart CT. Waking Up. Boston, MA: Shambala, 1986.
7. Leary MR, Adams CE, Tate EB. Hypo-egoic self-regulation: Exercising self-control by diminishing the influence of the self. J Pers 2006;74:1803–31.
8. Fromm E (ed.) Psychoanalysis and Zen Buddhism. New York, NY: Harper and Row, 1960.
9. Deshmukh VD. Neuroscience of meditation. Sci World J 2006;6:2239–53.
10. Deikman AJ. The Observing Self. Boston, MA:Beacon Press, 1982.
11. Epstein M. Thoughts Without a Thinker. New York, NY: Basic Books, 1995.
12. Cloninger CR. Spirituality and the science of feeling good. South Med J 2007;100:740–3.
13. Cloninger CR. Feeling Good: The Science of Well-Being. New York, NY: Oxford University Press, 2004.
14. Brown DP. Mastery of the mind east and west: Excellence in being and doing and everyday happiness. Ann N Y Acad Sci 2007 Sep 28 [Epub ahead of print].
15. Goldstein T. The Experience of Insight: A Natural Unfolding. Santa Cruz, PA: Unity Press, 1976.
16. Goleman D, Epstein M. Meditation and well being: An Eastern model of pscyhological health. Revision 1980;3:73–85.
17. Levine S. A Gradual Awakening. Garden City, NY: Anchor Press/Doubleday, 1979.
18. Allen NB, Chambers R, Knight, W. Mindfulness-based psychotherapies: A review of conceptual foundations, empirical evidence, and practical considerations. Aust N Z J Psychiatry 2006;40:285–94.
19. Bloomfield HH. In: Orme-Johnson DW, Farrow JT (eds). Scientific Research on Transcendental Meditation. Weggis, Switzerland: MERU Press, 1977:70–107.
20. Boorstein S. The use of bibliotherapy and mindfulness meditation in a psychiatric setting. J Transpersonal Psychol 1983;15:173–9.
21. Candelent T, Candelent G. Teaching transcendental meditation in a psychiatric setting. Hosp Comm Psychiatry 1975;26:156–9.
22. Carpenter JT. Meditation, esoteric traditions: Contributions to psychotherapy. Am J Psychother 1977;31:394–404.
23. Carrington P, Effron HS. Meditation and psychoanalysis. J Am Acad Psychoanal 1975;3:43–57.
24. Carrington P, Ehpron HS. New Domensions in Psychiatry: A World View. Arieti S, Ghazanowski G. New York, NY: John Wiley & Sons, Inc.
25. Dean SR. Metapsychiatry: The interface between psychiatry and mysticism. Am J Psychiatry 1973;30:1036–8.
26. Deatheridge G. The clinical use of “mindfulness” meditation techniques in short-term psychotherapy. J Trspl Psych 1975;2:133–44.
27. Ellis A.The place of meditation in cognitive-behavior therapy and rational-emotive therapy. In: Shapirio D, Walsh R (eds). Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984:671–3.
28. Glueck BC, Stroebel CF. Biofeedback and meditation in the treatment of psychiatric illness. Comp Psychiatry 1975;16:303–21.
29. Goleman D. Meditation as metatherapy: Hypothesis toward a proposed fifth state of consciousness. J Transpersonal Psychol 1971;3:1–25.
30. Goleman D. Meditation and consciousness: An Asian approach to mental health. Am J Psychotherapy 1975;30:41–54.
31. Hirai T. Zen Meditation Therapy. Tokyo: Japan Publications, 1975.
32. Kretschemer W. Meditative techniques in psychotherapy. Psychologia 1962;5:76–83.
33. Kutz I., Borysenko JZ, Benson H. Meditation and psychotherapy: A rationale for the integration of dynamic psychotherapy, the relaxation response, and mindfulness meditation. Am J Psychiatry 1985;142:1–8.
34. Lau MA, McMain, S. F. Integrating mindfulness meditation with cognitive and behavioural therapies: The challenge of combining acceptance- and change-based strategies. Can J Psychiatry 2005;50:863–9.
35. Lesh TV. Zen and psychotherapy: A partially annotated bibliography. J Hum Psych 1970;10:75–83.
36. Marcus J. Transcendental meditation: Consciousness expansion as a rehabilitation technique. J Psychedelic Drugs 1975;7:2.
37. Nichol D. Buddhism and psychoanalysis: A personal reflection. Am J Psychoanalysis 2006;66:157–72.
38. Shafii M. Adaptive and therapeutic aspects of meditation. Int J Psychoanal Psychother 1973;2:364–82.
39. Shapiro DH, Giber D. Meditation and psychotherapeutic effects: Self regulation strategy and altered state of consciousness. Arch Gen Psychiatry 1978;35:294–302.
40. Smith JC. Meditation as psychotherapy: A review of the literature. Psychol Bull 1975;82:558–64.
41. Smith JC. The psychotherapeutic effects of transcendental meditation with controls for expectation of relief and daily sitting. J Consult Clin Psychol 1976;44:456–67.
42. Watts, A. Psychotherapy East and West. New York, Pantheon, 1961.
43. Weis M, Nordlie JW, Siegel EP. Mindfulness-based stress reduction as an adjunct to outpatient psychotherapy. Psychother Psychosom 2005;74:108–12.
44. Linehan M. Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. New York, Guilford Press, 2007.
45. Carmody J, Baer RA. Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. J Behav Med 2007 Sep 25 [Epub ahead of print].
46. Chesney MA, Darbes LA, Hoerster K, et al. Positive emotions: Exploring the other hemisphere in behavioral medicine. Int J Behav Med 2005;12(2):50–8.
47. Carrington P, Collings GH Jr, Benson H, et al. The use of meditation-relaxation techniques for the management of stress in a working population. J Occup Med 1980;22(4):221–31.
48. Goleman D, Schwartz G. Meditation as an intervention in stress reactivity. J Consult Clin Psychol 1976;44:456–66.
49. Michaels R, Huter M, McConn D. Evaluation of transcendental meditation as a method of reducing stress. Science 1976;192:1242–4.
50. Woolfolk RL, Lehrer PM, McConn BS, Rooney AJ. Effects of progressive relaxation and meditation on cognitive and somatic manifestations of daily stress. Behav Res Ther 1982;20:461–7.
51. Jain S, Shapiro SL, Swanick S, et al. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Ann Behav Med 2007;33(1):11–21.
52. Lane JD, Seskevich JE, Pieper CF. Brief meditation training can improve perceived stress and negative mood. Altern Ther Health Med 2007;13:38–44.
53. Levenson MR, Jennings PA, Aldwin CM, Shiraishi RW. Self-transcendence: Conceptualization and measurement. Int J Aging Hum Dev 2005;60:127–43.
54. Moritz S, Quan H, Rickhi B, et al. A home study-based spirituality education program decreases emotional distress and increases quality of life: A randomized, controlled trial. Altern Ther Health Med 2006;12(6):26–35.
55. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Med 2000;62:613–22 .
56. Waelde LC, Thompson L, Gallagher-Thompson D. A pilot study of a yoga and meditation intervention for dementia caregiver stress. J Clin Psychol 2004;60:677–87.
57. Evans S, Ferrando S, Findler M, et al. Mindfulness-based cognitive therapy for generalized anxiety disorder. J Anxiety Disord 2007 Jul 22 [Epub ahead of print]
58. Shapiro DH, Giber D. Meditation and behavioral self-control strategies applied to a case of generalized anxiety. Psychologia 1976;19:134–8.
59. Boswell PC, Murray GJ. Effects of meditation on psychological and physiological measures of anxiety. J Consult Clin Psychol 1979;47:606–7.
60. Benson H, Frankel FH, Apfel R, et al. Treatment of anxiety: A comparison of the usefulness of self-hypnosis and a meditational relaxation technique: An overview. Psychother Psychosom 1978;30:229–42.
61. Hankey A. CAM and post-traumatic stress disorder. Evid Based Complement Alternat Med 2007;4:131–2.
62. Koszycki D, Benger M., Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behav Res Ther 2007;45:251–56.
63. Lee SH, Ahn SC, Lee YJ, et al. Effectiveness of a meditation-based stress management program as an adjunct to pharmacotherapy in patients with anxiety disorder. J Psychosom Res 2007;62(2):189–95.
64. Benson H, Wallace RK. In: Zarafonetis CTD (ed). Proceedings of the International Symposium on Drug Abuse. Philadelphia, PA: Lea & Febiger Publishers, 1972:369–76.
65. Marlatt GA, Chawla M. Meditation and alcohol use. South Med J 2007;100:451–3.
66. Bowen S, Witkiewitz K, Sillworth TM, Marlett GA. The role of thought suppression in the relationship between mindfulness meditation and alcohol use. Addict Behav 2007;32:2324–8.
67. Davis JM, Fleming MF, Bonus KA, Baker TB. A pilot study on mindfulness based stress reduction for smokers. BMC Complement Altern Med 2007;7:2.
68. Galanter M. Spirituality and addiction: A research and clinical perspective. Am J Addict 2006;15:286–92.
69. Geppert C, Bogenschutz MP, Miller WR. Development of a bibliography on religion, spirituality and addictions. Drug Alcohol Rev 2007;26:389–95.
70. Hoppes K. The application of mindfulness-based cognitive interventions in the treatment of co-occurring addictive and mood disorders. CNS Spectr 2006;11:829–51.
71. Lazar A. The effects of the transcendental meditation program on anxiety, drug abuse, cigarette smoking, and alcohol consumption. In: Orne-Johnson D, Dowash L, Farrow T (eds). Scientific research on the Transcendental Meditation program, Collected Papers. Geneva: MIU Press, 1975.
72. Leigh J, Bowen S, Marlatt GA. Spirituality, mindfulness and substance abuse. Addict Behav 2005;30:1335–41.
73. Marlatt GA, Pagano RR, Ross RM, Marques JK. Effects of meditation and relaxation training upon alcohol use in male social drinkers. In: Shapirio DH, Walsh R (eds). Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984;105–20.
74. Shafii M, Lavely R, Jaffe R. Meditation and marijuana. Am J Psychiatry 1974;131:60–3.
75. Shafii M, Lavely R, Jaffe R. Meditation and the prevention of alcohol abuse. Am J Psychiatry 1975;132:942–5.
76. Shapiro DH, Zifferblatt SM. An applied clinical combination of Zen meditation and behavioral self-management techniques: Reducing methadone dosage in drug addiction. Behavior Therapy 1976;7:694–5.
77. Simpson TL, Kaysen D, Bowen S, et al. PTSD symptoms, substance use, and vipassana meditation among incarcerated individuals. J Trauma Stress 2007;20(3):239–49.
78. Singh NN, Lancioni GE, Winton AS, et al. Individuals with mental illness can control their aggressive behavior through mindfulness training. Behav Modif 2007;31(3):313–28.
79. Williams JM, Duggan DS, Crane C, Fennell MJ. Mindfulness-based cognitive therapy for prevention of tecurrence of suicidal behavior. J Clin Psychol 2006;62:201–10.
80. Finucane A, Mercer SW. An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry 2006;6:14.
81. Sephton SE, Salmon P, Weissbecker I, et al. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial. Arthritis Rheum 2007;57(1):77–85.
82. Teasdale JD, Segal ZV, Williams JM, et al. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000;68(4):615–23.
83. Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry 2007;52:260–6.
84. Astin JA, Shapiro SL, Eisenberg DM, Forys KL. Mind-body medicine: State of the science, implications for practice. J Am Board Fam Pract 2003;16:131–47.
85. Grossman P, Niemann L, Schmidt S, Walach, H. Mindfulness-based stress reduction and health benefits: A meta-analysis. J Psychosom Res 2004;57:35–43.
86. Bonadonna R. Meditation’s impact on chronic illness. Holist Nurs Pract 2003;17(6):309–19.
87. Fitzpatrick AL, Standish LJ, Berger J, et al. Survival in HIV-1-positve adults practicing psychological or spiritual activities for one year. Altern Ther Health Med 2007;13(5):18–24.
88. Lindberg DA. Integrative review of research related to meditation, spirituality, and the elderly. Geriatr Nurs 2005;26:372–7.
89. Majumdar M, Grossman P, Dietz-Waschkowski B, et al. Does mindfulness meditation contribute to health? Outcome evaluation of a German sample. J Altern Complement Med 2002;8:719–30.
90. Seeman TE, Dubin LF, Seeman M. Religiosity/spirituality and health. A critical review of the evidence for biological pathways. Am Psychol 2003;58:53–63.
91. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation. General Hosp Psychiatry 1982;4:33–47.
92. Woolfolk RL, Carr-Kaffston L, McNully TF, Lehrer PM. Meditation training as a treatment for insomnia. Behav Therapy 1976;7:359–65.
93. Benson H. The Relaxation Response. New York, NY: William Marrow & Co, 1975.
94. Stone RA, Deleo J. Psychotherapeutic control of hypertension. N Eng J Med 1976;294:80–4.
95. Wallace RK, Benson H. The physiology of meditation. Sci Am 1972;226:84–90.
96. Walrath LC, Hamilton DW. Autonomic correlates of meditation and hypnosis. Am J Clin Hypnosis 1975;17:190–7.
97. Woolfolk RL. Psychophysiological correlates of meditation: A review. Arch Gen Psychiatry 1975;32:1326–33.
98. Kim DH, Moon YS, Kim HS, et al. Effect of Zen meditation on serum nitric oxide activity and lipid peroxidation. Prog Neuropsychopharmacol Biol Psychiatry 2005;29(2):327–31.
99. Van Wijk EP, Koch H, Bosman S, Van Wijk R. Anatomic characterization of human ultra-weak photon emission in practitioners of transcendental meditation (TM) and control subjects. J Altern Complement Med 2006;12:31–8.
100. Davidson RJ, Kabat-Zinn J, Schumacher J, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003;65(4):564–70.
101. Wilson RS, Schneider JA, Boyle PA, et al. Chronic distress and incidence of mild cognitive impairment. Neurology 2007;68:2085–92.
102. Doraiswamy PM, Xiong GL. Does meditation enhance cognition and brain longevity? Ann N Y Acad Sci 2007 Sep 28 .
103. Loizzo JJ. Optimizing learning and quuaity of life throughout the lifespan: A global framework for research and application. Ann N Y Acad Sci 2007 Sep 28 [Epub ahead of print].
104. Lazar SW, Kerr CE, Wasserman RH, et al. Meditation experience is associated with increased cortical thickness. Neuroreport 2005;16(17):1893–7
105. Pagnoni G, Cekic M. Age effects on gray matter volume and attentional performance in Zen meditation. Neurobiol Aging 2007;28:1623–7.
106. Cahn BR, Polich J. Meditation states and traits: EEG, ERP, and neuroimaging studies. Psychol Bull 2006;132:180–211.
107. Shapiro DH. Meditation: Self-Regulation Strategy and Altered State of Consciousness. New York, NY: Aldine, 1980.
108. Shapiro DH, Walsh RN (eds.) Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984.
109. Shaw R, Kolb D. Improved reaction time following the transcendental meditation technique. In: Orme-Johnson DW, Domash L, Farrow JT (eds). Scientific Research on the Transcendental Meditation Program, Collected Papers. Geneva, MIU Press, 1975.
110. Dillbeck MC. Meditation and flexibility of visual perception and verbal problem solving. Memory and Cognition 1982;10:207–15.
111. Kindler HS. The influence of meditation relaxation technique on group problem-solving effectiveness. J Appl Behav Sci 1979;15:527–33.
112. Jha AP, Krompinger J, Baime MJ. Mindfulness training modifies subsystems of attention. Cogn Affect Behav Neurosci 2007;7:109–19.
113. Slagter HA, Lutz A, Greischar LL, et al. Mental training affects distribution of limited brain resources. PLoS Biol 2007;5(6):e138.
114. Chan D, Woollacott M. Effects of level of meditation experience on attentional focus: Is the efficiency of executive or orientation networks improved? J Altern Complement Med 2007;13:651–7.
115. Nielsen L, Kaszniak AW. Awareness of subtle emotional feelings: A comparison of long-term meditators and nonmeditators. Emotion 2006;6:392–405.
116. Naranjo CG, Ornstein RE. On the Psychology of Meditation. New York, Viking Press, 1971.
117. Leah TV. Zen meditation and the development of empathy in counselors. Hum Psychol 1970;10:39–83.
118. Leung P. Comparative effects of training in external and internal concentration on two counseling behaviors. J Counsel Psych 1973;20:227–34.
119. Grepmair L, Mitterlehner F, Rother W, Nickel M. Promotion of mindfulness in psychotherapists in training and treatment results of their patients. J Psychosom Res 2006;60:649–50.
120. Caspi O, Burleson KO. Methodological challenges in meditation research. Adv Mind Body Med 2005;21:4–11.
121. Bishop SR. What do we really know about mindfulness-based stress reduction? Psychosom Med 2002;64:71–84.
122. Canter PH. The therapeutic effects of meditation. BMJ 2003;326:1049–50.
123. Emerson V. Research on meditation. In: White J (ed). What is meditation? New York, NY: Anchor Books, 1974:225–44.
124. Krisanaprakornkit T, Krisanaprakornkit W, Piyavhatkul N, Laopaiboon M. Meditation therapy for anxiety disorders. Cochrane Database Syst Rev 2006;(1):CD004998.
125. Ospina MB, Bond K, Karkhaneh M, et al. Meditation practices for health: state of the research. Evid Rep Technol Assess (Full Rep). 2007;(155):1–263.
126. Cauthen N, Prymak C. Meditation versus relaxation. J Consult Clin Psych 1977;45:446–87.
127. Holmes DS. To meditate or to simply rest, that is the question: A response to the comments of Shapiro. Am Psychologist 1985;40:722-725.
128. Holmes DS. To meditate or rest? The answer is rest. Am Psychologist 1985;40:728–31.
129. Kent RN, O’Leary KD, Diament C, Dietz A. Expectation biases in observational evaluation of therapeutic change. J Consult Clin Psychol 1974;42(6):774–80.
130. Weiner AJ. Attention and expectation: Their contribution to the meditation effect. Dissertation Abs 1973;33:2228–9B.
131. Beiman IH, Johnson SA, Puente AE, et al. The relationship of client characteristics to outcome for transcendental meditation, behavior therapy and self relaxation. In: Shapiro DH, Walsh RN (eds). Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984:565–71.
132. Maupin E. Individual differences in response to a Zen meditation exercise. J Consult Psych 1965;29:139–45.
133. Stek RJ, Bass BA. Personal adjustment and perceived focus of control among students interested in meditation. Psychol Rep 1973;32:1019–22.
134. Freud S. Civilization and its Discontents. New York, NY: WW Norton and Company, Inc., 1961.
135. Bergin AE. Psychotherapy and religious values. J Consult Clin Psychol 1980;48:95–105.
136. Peck MS. The Road Less Traveled New York, NY: Simon & Schuster, 1978.
137. Deikman AJ. Mysticism: Spiritual Quest of Psychic Disorder. New York, NY: Group for the Advancement of Psychiatry, 1976:GAP Publication 97.
138. Kuijpers HJ, van der Heijden FM, Tuinier S, Verhoeven WM. Meditation-induced psychosis. Psychopathology 2007;40:461–4.
139. Goisman RM. The psychodynamics of prescribing behavior therapy. Am J Psychiatry 1985;142:675–9.
140. Gutheil TG. The psychology of psychopharmacology. Bull Menninger Clin 1982;46:321–30.
141. Babcock HH. Integrative psychotherapy: Collaborative aspects of behavioral and psychodynamic therapies. Psychiatr Ann 1988;18(5):271–2.
142. Kennedy RB. Self-induced depersonalization syndrome. Am J Psychiatry 1976;133:1326–8.
143. Lazarus AA. Psychiatric problems precipitated by transcendental meditation. Psychologic Rep 1976;39:601–2.
144. Otis LS. Adverse effects of transcendental meditation. In: Shapirio DH, Walsh RN (eds). Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984:201–8.
145. Goleman D. The Meditative Mind: The Varieties of Meditative Experience. Los Angeles, CA: Jeremy P. Tarcher, Inc., 1988.
146. Earle JBB. Cerebral laterality and meditation: A review of the literature. In: Shapirio DH, Walsh RN (eds). Meditation: Classic and Contemporary Perspectives. New York, NY: Aldine, 1984:396–414.
147. Kohut H. Forms and transformations of narcissism. J Am Psychoanalyt Assoc 1966;5:389–407.
148. Keen S. To a Dancing God. New York, NY: Harper & Row, 1970.
149. Johnson SK. Humanizing the Narcissistic Style. New York, NY: WW Norton and Company, 1987.
