Meditation Is Not What You Think

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You may have seen “Meditation Is Not What You Think” on a bumper sticker. It would be a great name for a college course on philosophy because it evokes such a wide range of important discussions and debates. The word meditation conjures up different images and practices depending on an individual’s exposure to the context in which this word is used. Meditation is often discussed and taught as a self-directed practice to enhance attention and relaxation, but my very first published article reviewed the unveiling of traumatic memories and emotions during the practice of mindfulness and concentration meditation.¹

Generally speaking, there are 2 basic subtypes of meditation: concentration and mindfulness. The practice of concentration meditation is essential before embarking on the practice of mindfulness. Concentration practices—such as focusing one’s attention on the inbreath and the outbreath, which occurs in the present moment and is devoid of thought—allow our conscious self to have a neutral object to serve as an anchor to reinforce the mind pattern of being grounded and aware.

Once the meditator is able to keep their attention on the breath for an extended period of time without distraction, shifting to mindfulness meditation becomes possible. With mindfulness, while grounded with a concentrated mind, the task is to be aware of whatever intrudes into our experience that is trying to pull us away from the quiet stillness of the present moment. The challenge is to maintain concentration and simply observe the distraction with the intention of learning about our mind through this process. Often what distracts us is an uncomfortable sensation in our body, a conflicted memory from the past, or an unresolved emotion letting us know it is still waiting to be processed and then integrated into our biographical memory with resolution, rather than lurking in our primitive amygdala, waiting for us to revisit.

A Complex Topic

Often the word meditation is used to describe a technique to aid in relaxation, stress reduction, and achieving peace and quiet of the mind. Commonly, the instructions for meditation are to sit in a quiet and comfortable place and pay attention to the inbreath and the outbreath to help counteract the fight-or-flight response that is a common result of our busy and stressful lives. When the mind’s attention is distracted, which it most certainly will be, as soon as we are aware of this distraction we return our attention to breathing.

It sounds pretty straightforward and simple to do, but in reality, for the vast majority of meditators, their minds spend most of the meditative session distracted and involved in internal dialogues of all types. The common result is frustration, discouragement, and the feeling of being unable to meditate, although these experiences are foundational to the meditative journey. This is why the vast majority of individuals who begin to meditate stop after a short excursion into the process.

In other settings, meditation is the word used to describe a religion’s spiritual practice that may involve praying, chanting a mantra, singing, staring at an altar or statue with focused attention, or being silent with oneself while hoping to engage with a higher power. In clinical settings in the United States, meditation has been used as a part of various treatments to ideally facilitate healing. Examples include meditation-assisted psychotherapy,² stress reduction programs,³ meditation while receiving light therapy for psoriasis,⁴ treatment for insomnia or anxiety,^5,6 mindfulness-based cognitive therapy,7 mindfulness as a core part of dialectic and behavior therapy (DBT),⁸ and more.

Meditation Can Include What You Think

Paradoxically, in mindfulness meditation, what is being thought can be the object of the meditation, with 1 important caveat. The conscious awareness that has been developed through both concentration and mindfulness practices is like a large peaceful open space that is equanimous and curious, ready for whatever intrusion tries to pull us from that peaceful space. It could be an itch on our leg, discomfort from sitting, a sound that is offensive, an object passing by if our eyes are open, an unpleasant or pleasant odor, the taste of our last meal lingering in our palate, or a memory or emotion that seduces us away from that mindful open space. With steady concentration and mindfulness, the instructions are to simply observe the intrusion, including the thought itself, for what it truly is: a fleeting experience that only has as much power and control over us as we give it.

Advanced meditators focused on mindfulness often learn a great deal about the structure and content of their mind through this process, with the possibility of spending more time in the equanimous open space of pure attention and less time ruminating over distractions. In my opinion, the best definition of mindfulness was provided by my first meditation mentor when I was a medical student and psychiatry resident at the University of Massachusetts Medical Center and the person who introduced mindfulness meditation practices into Western medicine, Jon Kabat-Zinn, PhD. His definition of mindfulness is “paying attention, on purpose, in the present moment, in the service of self-understanding.” Dr Kabat-Zinn has authored many books that are considered classics in this area.^3,9

Informed Consent

Unlike meditative practices outside of a clinical setting, such as at a monastery, religious gathering, spiritual ceremony, or through self-directed meditation, when any meditative practice is used in the context of a clinical setting—be it meditation-assisted psychotherapy, a stress-reduction program, treatment for insomnia, or DBT—it is important that the clinician have and document a comprehensive risk-benefit discussion with their patient before utilizing meditation as part of the clinical treatment. In my experience, this remains a huge blind spot with the use of meditation in clinical settings.

Although there are no absolutes, some individuals should not meditate or should utilize a modified approach to decrease risks. One example is individuals with a psychotic disorder, which can worsen with many meditative practices. Another example is individuals with a significant history of trauma, either remembered or repressed, because meditation is known to lower a person’s psychological defenses and increase the risk of emotional distress. At the extreme, the meditation may unveil previously repressed memories/experiences that can result in significant emotional distress, regression, and in some cases psychosis.¹

Concluding Thoughts

Meditation is a simple word that is often loosely used but ultimately represents a wide range of meditative techniques that are practiced in diverse settings for very different reasons. Meditation has preceded medical treatments by thousands of years, and it has a rich history in religious, spiritual, and self-guided inquiry residing in a category and context separate from the application of meditation in a clinical setting. A fair analogy is the historical use of psilocybin in spiritual ceremonies for thousands of years, where it has a well-established cultural acceptance, and it should be respected for its role in these cultures.

However, administering psilocybin in any clinical or medical setting requires the standard evidence-based research with clinical trials approved by ethics boards and ultimately crossing the threshold of general clinical usage based on its demonstrated benefits and safety. Both meditation and psilocybin share a rich history of use over the millennia primarily for spiritual practices that do not require the guide rails that are essential and that we expect in the medical/clinical setting. Once a licensed clinician adds either meditation or naturally occurring drugs such as psilocybin to their treatment toolbox, incorporating comprehensive informed consent, evidence-based treatment protocols, and clinical monitoring for risks and benefits is essential to maintain the integrity of our profession.

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Staff Psychiatrist, Seacoast Mental Health Center, Exeter; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.

References

1. Miller JJ. The unveiling of traumatic memories and emotions through mindfulness and concentration meditation: clinical implications and three case reports. Journal of Transpersonal Psychology. 1993;25(2):169-180.

2. Bogart G. The use of meditation in psychotherapy: a review of the literature. Am J Psychother. 1991;45(3):383-412.

3. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Delacorte Press; 1990.

4. Bernhard JD, Kristeller J, Kabat-Zinn J. Effectiveness of relaxation and visualization techniques as an adjunct to phototherapy and photochemotherapy of psoriasis. J Am Acad Dermatol. 1988;19(3):572-574.

5. Gong H, Ni CX, Liu YZ, et al. Mindfulness meditation for insomnia: a meta-analysis of randomized controlled trials. J Psychosom Res. 2016;89:1-6.

6. Hoge EA, Bui E, Marques L, et al. Randomized controlled trial of mindfulness meditation for generalized anxiety disorder: effects on anxiety and stress reactivity. J Clin Psychiatry. 2013;74(8):786-792.

7. Sipe WEB, Eisendrath SJ. Mindfulness-based cognitive therapy: theory and practice. Can J Psychiatry. 2012;57(2):63-69.

8. Welch SS, Rizvi S, Dimidjian S. Mindfulness in dialectical behavior therapy (DBT) for borderline personality disorder. In: Baer RA, ed. Mindfulness-Based Treatment Approaches. Elsevier; 2006:117-138.

9. Kabat-Zinn J. Wherever You Go There You Are: Mindfulness Meditation in Everyday Life. Hyperion; 1994.