Most of us in the mental health professions would agree with the following statements:

Religion and spirituality are important, even central concerns for a large portion of the population

Many people insist that their religious and/or spiritual practices help them cope with the inescapable vicissitudes of life

It has long been recognized that some psychiatric conditions can involve religious preoccupations and alleged spiritual experiences

Over the last 50 years meditation practicesgenerally inherited from various religious traditionshave become widely accepted as beneficial for management of stress and have been increasingly adopted by the mental health community as a treatment modality

In view of these observations you would think that psychiatrists would be well-versed in these topics, but the reality is that they are barely touched upon during our training and we are given very little guidance as to how to respond when our patients raise religious or spiritual concerns. Since meditation can be practiced without reference to the religious traditions that transmitted various techniques to us we can feel comfortable recommending it to our patients. But when it comes to relating to the larger questions about life, the nature of suffering, the inevitability of death, etc, we generally have no idea how to proceed.

Recent articles in Psychiatric Times give us several examples of attempts to address these topics. The May 2019 issue presented an interview of Dr Paul Summergard by Dr Lloyd Sederer, Spirituality in the Psychiatric Office, in which Dr Summergard shares his experience and suggests a general attitude to adopt when patients bring up religious concerns. In more recent issues, Dr John Miller shared two editorials exploring the clinical applications of mindfulness practice, Be Here Now, and Mindfulness.

Since our profession has no agreed-upon body of knowledge about the relationship of religion and spirituality to mental illness and mental health, it makes sense that those of us who present ourselves as having something useful to say should establish some sort of credentials. Dr Summergard mentioned that he did a number of years of intensive Zen meditation, and Dr Miller recounts extensive experience with a meditation tradition derived from the Theravadan Buddhist tradition, including a 3-month silent meditation retreat. Both doctors commented on the impact these experiences had on their personal as well as professional lives. So, their credentials for holding forth on these topics consist of substantial experience with meditation practice as taught by two different Buddhist traditions, exposure to the intellectual content of these traditions, and on their perception that these experiences had a significant impact on their personal lives as well as their practice of psychiatry.

In this column I propose to present a framework for understanding the basic psychological mechanisms involved in the practice of mindfulness meditation, which may clarify why it is helpful in many different situations. But if I am going to pontificate on these weighty matters, I too must establish my credentials.

I was raised in a completely secular Jewish family, with virtually no exposure to even a secular Jewish social environment. I entered medical school with the intention of going into psychiatry. In my fourth year I stumbled on the book Psychotherapy East and West by Alan Watts, one of the first well-known Western proponents of Zen Buddhism, which piqued my interest in Buddhism as a psychological system. To make a long story short, I followed a path similar to that of Drs Summergard and MillerI took a year off between my rotating internship and psychiatric residency to engage in intensive meditation and study of Buddhism, then another block of time after my residency, after which I settled down into my career and raising a family.

The particular tradition I connected with was Tibetan Buddhism as taught by Chogyam Trungpa, a Tibetan Lama who founded numerous meditation centers as well as Naropa University in Boulder, CO, which to this day offers a Masters degree in Eastern and Western Psychology. Along the way I did a 1-month meditation retreat, a 10-day solo meditation retreat in an isolated cabin, and a 3-month program with Chogyam Trungpa that involved extensive meditation practice as well as a systematic presentation of the history and formal teachings of Tibetan Buddhism. After my residency I spent 3 months at a meditation center in which I experienced a novel meditation system created by Trungpa in collaboration with Suzuki Roshi, a well-known Zen teacher. The system was based on methods used in Tibetan and Japanese Buddhist monasteries to help stabilize monks who developed serious psychological issues or psychosis in the course of intensive meditation practice.

Trungpa presented the Buddhist tradition to us, a modern American audience, as a psychological system. He made it clear that we did not need to accept anything on faith and stated explicitly that we need not accept any teachings that we could not confirm by our own personal experience. In that environment there were many individuals who enthusiastically accepted the religious aspect of the teachings, which is to say the traditional teachings about the nature of the universe, what happens after death, and so on. As a scientifically trained person from a totally secular background I had some discomfort about these issues. A small incident put my mind at ease: a young man asked Trungpa a question, Everything you have taught us is great, I love all the stuff about meditation . . . but I have to be honest . . . I have a lot of trouble with this whole reincarnation thing. Trungpa replied, For you, sir, reincarnation is waking up in the morning. Dont worry about the rest.

In the spirit of transparency, everything I will say is derived from what I learned through both study and meditation practice in those particular settings. I am not a scholar in these matters, nor can I pretend to be a highly accomplished meditator or teacher. Nevertheless, these experiences were transformative on a personal level, giving me the capacity to cope with extreme stress at various points in my life with a degree of equanimity that would not have been possible previously. They also had a profound effect on my work as a psychiatrist, in particular giving me a wider context in which to understand my patients struggles. I have found that when patients bring up religious or spiritual concerns I am completely at ease conversing with them in a way that is appropriate for that individual, which would have been impossible in my natural state as a person with no exposure whatsoever to religious practices.

When I deal with psychotic people reporting apparent spiritual experiences, I find that I can often understand what it is they are trying to describe and respond in a reassuring way that acknowledges their experience. Dont get me wrongI also give them an antipsychotic. But there is great value in meeting people where they are at, so to speak. I ascribe whatever ability I have developed to deal with these issues effectively to a combination of my personal experiences in the course of meditation practice, but equally to having been given a systematic intellectual framework for understanding the nature of spiritual experiences altogether, and their relationship to our normal mental state as well as to mental illness.

So much for credentials. Now let us turn to the narrow topic of mindfulness meditation. First, what do we mean by the word meditation? Lots of my patients tell me that they meditate, but on further questioning most of them are talking about guided meditation recordingswhich in reality is akin to hypnosisor perhaps they do a few minutes of chanting a mantra in a yoga class. To be sure, these activities can be very beneficial for stress management, sleep, and so on, but they are not meditation. Mindfulness meditation has robust stress-management benefits, but that is somewhat of a side effect. Its primary purpose, interestingly, is to mitigate our habitual mental patterns, which in Western psychology we have conceptualizedat least in previous generationsas neurosis.

Broadly speaking there are two types of meditation practiceconcentration techniques and mindfulnessawareness techniques. Concentration techniques involve focusing ones mind on a single objecta candle, a picture, a thought, a sound or mantra, part of the body, pretty much anything. If practiced sufficiently this type of meditation produces trance statesstates of altered consciousness that can be intense and at times ecstatic. The intensity of these experiences is often interpreted as evidence that this is real spirituality and can motivate people to pursue them even more vigorously. There are numerous elaborate traditions utilizing these types of practices. However, there are distinct dangers to taking these techniques to extremes, and they should only be practiced under the close supervision of a knowledgeable guide.

Mindfulness meditation, on the other hand, can be described as a simple technique for observing our own mental processes in granular detail. The usual instruction is to sit upright without a backrestmostly so we will start to fall over if we doze off, which keeps us awake (meditation can be boring). The tradition is to sit cross-legged on a cushion. There is no particular reason to adopt a lotus posture or anything else uncomfortablethis is not about overcoming pain. If you are of a certain age, by all means sit on a chair. Most traditions instruct us to close our eyes, but I was taught to meditate with eyes open. The explanation we were given was that if we close our eyes it is too easy to space out and get lost in our thoughts.

The meditative technique itself is usually to turn our attention on the breath. Easy! The trouble is, after about a microsecond . . . blah, blah, blahwe are talking to ourselves. There are numerous variations and nuances in the instructions given by different traditions and different teachers on how to handle this grasshopper quality of our minds. The technique I learned was that as soon as we realize we are not on our breaths we literally say to ourselves thinking, and gently return attention to our breath. At some point we inevitably get frustrated, thinking, I cant do this, this is ridiculous, Im leaving. At that point . . . back to your breath.

A couple of comments about breath. There is nothing mystical about itits just a convenient way to help us stay in the present moment. Then there is the question of how intensely to focus on the breath. A traditional teaching story tells of a student of the Buddha, a famous musician, who asked the Buddha how intensely to focus his attention. The Buddha asked him how tightly he adjusted the strings on his instrument. The student replied, Not too tight, and not too loose, or the sound will be no good. The Buddha said, Just so. Your focus on your breath should be not too tight, and not too loose. That is, if we make no effort, we dont focus at all on the breath and no progress will be made. But if we get too intense about it, it can turn into a concentration technique focused on the breath, which is definitely not what is intended. If that starts to happen, a competent meditation instructor will tell us to lighten up, maybe look around a little, shift our positionthen come back to the breath.

There is no such thing as not being able to meditate. This statement requires some explanation, which brings us to the discussion of what this meditation technique actually accomplishes.

As we move around in the world and encounter things, or as we sit on the cushion and encounter things in our mind, there are three reflexive impulses that can occur. If the object or thought makes us feel good, confirmed, safe, we want to pull it in, build it up, make it last longer. If it is threatening or uncomfortable, we want to push it away, destroy it. And if it is neither confirming nor threatening, we ignore it. Consequently, we tend to ignore 99% of everything that crosses our awareness. In traditional meditation texts these three impulses are known as the Three PoisonsPassion, Aggression, and Ignorancethe obstacles to successful meditation practice. The meaning of these three words in daily life is obvious: Passion: love, greed, obsession, addiction; Aggression: anger, cruelty, destructiveness; Ignorance: maybe . . . cluelessness? From the point of view of evolutionary psychology, these three impulses are completely natural and highly adaptive: we are attracted to what makes us feel good, we are repelled by what makes us feel bad, and we dont waste energy on the rest.

But in this case, we are not talking about our behavior in the world, rather we are talking about these three impulses as our reflexive reactions to each moment-to-moment thought. What we are being instructed to do when we sit down to meditate is very simple, very difficult, and quite unnaturalwe are being asked to do none of the above. That is, whatever thought comes along, we are instructed to neither cultivate it, nor drive it away . . . nor ignore it. We are asked to simply notice it and come back to the breath.

Initially we are terrible at this. We get lost in a sexual fantasy, or business plans, or political tooth-gnashing. Oh yeah, back to the breath! We obsess about that time we were humiliated, and what we should have said. Back to the breath! But if we persist, little by little, we begin to relax into our own thoughts. They never go awaywe are explicitly not trying to make that happenbut we begin to spend more and more time just watching them come and go, without building them up or pushing them away, and without ignoring them.

This process can be characterized as developing an attitude of equanimity toward our own thoughts. Over time, somewhat magically, we notice that as we move about in the world and stuff comes up, we are less reactive. Something that would have left us upset all day becomes less of a big deal. Some compulsion that we would ordinarily find irresistible becomes less compelling. We begin to feel calmer overall, clearer, and with more freedom to deal with what comes up in whatever way seems bestas opposed to endlessly repeating dysfunctional habitual patterns. These emotional and behavioral changes are gradual and spontaneous.

That is why I say there is no such thing as not being able to meditate. I view it like doing pushups. If we resolve to start exercising with pushups, and we cant do even one, we start with half a pushup. If we work out regularly, eventually we can knock off a whole bunch of pushups. It just takes patience and practice. Thats why we call this activity meditation practice. At this level it is a very simple training program, whose goal could also be described as the art of not taking our own thoughts too seriously.

With this model in mind it becomes clearer why meditation practice can be helpful in so many clinical situations, and why the average person with no identified conditions may find it beneficial. It is also noteworthy that the benefit is not dependent on adopting any particular philosophy or spiritual teaching. The benefits of meditation are a spontaneous result of gradually changing the nature of our relationship to our own thought process.

This model of meditation practice is very simple, yet very fundamental. Along the way I have alluded to a number of far more complex issues. What is the distinction between religion and spirituality? What do we mean by the term spiritual experience? What is the nature of the transformative experiences hallucinogenic drugs can sometimes produce, and what about the religious preoccupations and spiritual experiences of some of our patients? And, what does meditation practice have to do with all of this?

Buddhist psychology provides a comprehensive framework that can illuminate the relationship of these disparate phenomena. Interestingly, it is all about egoa concept that is also at the core of Western psychological thinking. In a future article, I will try to summarize the basic model of the Buddhist psychological tradition in terms that are understandable to students of the Western psychological tradition.

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Making Sense of Meditation: Religion and Spirituality - Psychiatric Times