Notes on The Last Psychiatrist

I love few things more than a great blog. My latest find: The Last Psychiatrist, an archived blog, mostly about narcissism.

I was so excited to learn his insights… I made notes.

What follows are his finest insights about narcissism and my comments.

Imagine a crowded subway, and a beautiful woman gets on. Hyper-beautiful, the kind of woman who can wear no makeup, a parka, earmuffs and a bulky scarf and that somehow makes her look even prettier. A handsome man about her age in an expensive suit gets up and says, “please, take my seat.” She smiles, and hastily sits down.

TLP (The Last Psychiatrist), as the author refers to himself, gives us two options as to how the woman should think about this:

  1. This was a sexually motivated act as far as the man was concerned
  2. He was just being nice

If you think of narcissism as grandiosity you miss the nuances, e.g. in her case the problem is narcissism without any grandiosity:

she is so consumed with her identity (as not pretty) that she is not able to read, to empathise with, other people’s feelings. Source

In another post, TLP explains why narcissism isn’t necessarily about grandiosity. This is a blatantly obvious point that escapes most people, unfortunately.

Being the main character of your own film isn’t necessarily grandiose. It is narcissistic though because all the other characters are only important because they help the viewer to understand the main story line.

Here are some less obvious traits of narcissism TLP outlined:

Shame over guilt (I think this is because shame is an emotion directed at the self, whereas guilt is an emotion directed at your victim)

envy over greed (greed would be a primary reason to look for something, whereas envy is only a desire to catch up because otherwise otherwise it’s a bad reflection on you. I liked how this was called “existential agency” here.)

He [the narcissist] thinks the problem is people don’t like him, or not enough, so he exerts massive energy into the creation and maintenance of an identity: if they think of me as X… (and that’s one of the reasons why we love brands)

The narcissist feels unhappy because he thinks his life isn’t as it should be, or things are going wrong;  but all of those feelings find origin in frustration, a specific frustration: the inability to love the other person.

And this really brings it back to the original myth that TLP broke down beautifully here:

Narcissus mother took him to a clairvoyant who said, “He’ll have a long life as long as he never knows himself.

Narcissus kept rejecting people who fell in love with him because they weren’t good enough.

One rejected lover was furious and begged Nemesis, the goddess of vengeance, for retribution.  “If Narcissus ever falls in love, don’t let the love be returned!”

Nemesis  heard the prayer and caused Narcissus to fall in love with himself: he was lead to a  pool of water, and when he looked into it, he fell in love with what he saw.  And what he saw wasn’t real, so of course it couldn’t love him back.  But Narcissus sat patiently, forever, hoping that one day that beautiful person in the bottom of the pool was going to come out and love him.

Because he never loved anyone, he fell in love with himself. That was Narcissus’s punishment.

This brings up an interesting point: how are you meant to feel about yourself?

Let’s first look at what we want. What we pay for. A huge portion of marketing directly helps us to be in love with ourselves, because we’re worth it. They’re not even trying to hide that the feeling of being in love with yourself is what they’re selling. And it’s not punishment as we see it – otherwise we wouldn’t buy it. I suppose it’s a psychic equivalent of putting a person on heroin. You mightn’t feel it’s a punishment, but it is.

Then there are the more subtle “intellectual” publications that help you love yourself (see the distinction from being in love with yourself? Cause that would be shallow.) I wonder how many pages were dedicated to helping people see Narcissus’ infatuation as Buddhist acceptance or some other high and mighty concept.

There isn’t really anywhere that would tell you that you’re meant to not love yourself.

What happened to Narcissus doesn’t really sound so horrible in today’s culture. Maybe he wouldn’t have even retaken a selfie if he lived today and been happy with the first shot? That level of self-acceptance is just enviable! He’s winning at life by millennial standards!… Indeed, TPL calls narcissism “a generational pathology”.

TLP goes on to discuss Narcissus’ parents’ role, which I thought was priceless:

He will have a long life, if he never knows himself.

Forget about whether the prophecy is true.  Ask instead, “what would the parents have done once they heard it?”…

Next time I feel insignificant and weak, maybe I need to hold on to that feeling, because my culture will obviously infuse me with my own grandiosity without me ever trying.

TLP has another explanation for why Narcissus stayed looking at the primordial selfie lake though.

He didn’t stay there for years because the reflection had pretty hair.  He stayed because daydreaming takes a lot of time.

In other words, Narcissus didn’t recognise himself and spent all that time conjuring up images of how wonderful life would be with that person in the reflection…

And the DSM says exactly that, only it adds a grandiose twist: “preoccupation with fantasies of unlimited success, power, brilliance, beauty, or ideal love”.

I am confused now.

Narcissus fell in love with himself, only he didn’t know if was himself.

So, as far as Narcissus was concerned, he was genuinely in love with another human being – only they were unreachable. Their personality was entirely a figment of his imagination…

Wait, that’s not Narcissus, that’s Gatsby! (Who also dies in a body of water, fair dues to FitzGerald).

Narcissus’ crime wasn’t being in love with himself at all. Phew, it’s ok to let L’Oreal and #positivethinking to get money and likes.

Narcissus’ crime was not knowing himself.

Actually, no, again.

TLP puts it better:

The moral of the story of Narcissus, told as a warning for the very people who refuse to hear it as such, is that how Narcissus came to be is irrelevant.  What was important was what he did, and what he did – was nothing.

And that’s his main crime: he never cared about anyone real. To me that’s all one ever needs to know to understand narcissism.

TLPs advice on how to not be a narcissist is to fake it. I think what TLP’s getting at is that your behaviour is much more important than your identity.

Side effects of meditation: be warned!

In the professional medical world, Medscape is probably the most trusted up to date online resource. I am delighted to see that yesterday they published an article that highlights some of the more challenging and distressing aspects of meditation based on a recent scientific paper in PLOS One.

The reason I am so glad is that it means we’re moving to a different approach to meditation, one with more well-warranted rigour in how people talk about this intervention and away from the perception that this is something without side-effects.

Crux of the study:

  • the challenging aspects of Buddhist-derived meditation practices are well described in Buddhist tradition but are less so in Western scientific literature
  • the researchers interviewed nearly 100 meditators and meditation teachers from each of three main traditions: Theravāda, Zen, and Tibetan.dangers of meditation, side effects of mindfulness
  • the researchers developed a taxonomy of 59 experiences organised into seven domains: cognitive, perceptual, affective (emotions and moods), somatic (relating to the body), conative (motivation or will), sense of self, and social.
  • all meditators reported multiple unexpected experiences across the seven domains of experience. 
  • the duration of the effects people described in their interviews varied widely, ranging from a few days to months to more than a decade, the investigators report.
  • some meditators reported their feelings, even the desirable ones, went too far or lasted too long, or they felt violated, exposed, or disoriented. 
  • meditation experiences that felt positive during retreats sometimes persisted and interfered with their ability to function or work when they left the retreat and returned to normal life.
  • the meditator’s practice intensity, psychiatric history, trauma history and the quality of supervision are important factors that influence the meditators experience, but not for everyone.factors that influence quality of meditation
  • the study highlights that the one size fits all approach isn’t ideal: “The good news is that there are many different programs out there and different practices available, and with a little bit of homework and informed shopping, someone could find a really good match for what they are after,” she said. “But I think often people just sign up for whatever is the most convenient or the best marketed, and it’s not always a good match for their constitution or their goals.”

Dissecting the side effects 

Here are the reported side effects with the percentage of people who reported them in brackets:

side effects of meditation cognitive, perceptual, affective, somatic, sense of self, social

It’s fascinating to note that nearly 50% noted a change in worldview. Open mind, new philosophy – fair enough. I would be on the fence about saying that I have a different world view because of meditation. It’s clearer, it’s calmer, it’s more adaptable, but it’s not really changed. Thus, it is possible that people who try to meditate are often looking for a new worldview or are quite suggestible.

Nearly the same number of people reported delusional, irrational and paranormal beliefs! I guess this is all based on Buddhism and there is a strong religious element to it. However, people were clearly made uncomfortable by it. I certainly experienced this: this is why I tread carefully when I go exploring meditation resources. A huge number of them are zealous, either for reasons of unquestioning devotion, or commercial ones. Snake oil requires faith.

Again, over 40% reported hallucinations. Just as a reminder – delusions and hallucinations are the key ingredients of psychosis and good reason to admit someone to a psychiatric ward. Obviously, these must not be quite as persistent as those associated with psychiatric disease, but if I had seen this table before starting mindfulness, I would have thought much more carefully. In this sample, 32% of people had a prior psychiatric history. This doesn’t explain how common all these DSM-sounding symptoms are among them.

Fear, anxiety, panic or paranoia came up for over 80% of people. I think is more a reflection on the sample than on meditation. Why to people meditate? Often they come upon it as a cure for anxiety. Indeed, in my experience, besides actually getting rid of the anxiogenic stimulus, meditation is a great method to deal with it. Depression was very common too at over 50%. Anhedonia and avolition – being unable to experience pleasure and not having any desire to do anything – are hallmarks of depression and were experienced by 18%. Personally, anxiety has always accompanied meditation in some way or another, but not in a bad way. It’s a little bit like saying that exercise cause shortness of breath. However, panic and paranoia are step to far.

Where there are mood changes, there are autonomic function changes and indeed they seem to have been affected too: level of energy, quality of sleep, appetite, etc. It’s unfortunate to note that many of those changes were negative with common reports of fatigue and pain.

As expected, 75% of meditators had their mind bent by Buddhist approaches to the self. We also know from MRI studies, that the anatomical self, seated in default mode network is modified by meditation, so this is expected.

Clarity, meta-cognition and increased cognitive processing – that’s our thinking clearly box ticked.

What does all of this mean?

To meditate or not? Meditate, but proceed with caution, a healthy balance of open-mindedness and scepticism – and preferably with supervision. In the words of Dr Walsh, it’s important to be challenged, but not overwhelmed.

As for me, I often take breaks from meditation. If it’s not happening, I don’t force myself too much. Thirty seconds of mindfulness is better than ten minutes of desperate striving effort and then feeling exposed, lonely and inadequate. To give it a Buddhist twist, we can think of the experience as if it is the weather. You may have decided that you are jogging today, but if it is stormy outside, it’s better to be a bit more adaptable, stay at home and practice your planks. Same here.

Reference:

Lindahl JR, Fisher NE, Cooper DJ, Rosen RK, Britton WB (2017) The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS ONE 12(5): e0176239. https://doi.org/10.1371/journal.pone.0176239

P.S. Have a look at this Christian blogger explaining the emotional conflict she experienced when exploring yoga. It’s not important to be religious to understand that imposing one system of beliefs over another, whatever it may be, can be highly distressing.

negative effects of meditation
Just a picture of Dublin in the sun

 

The darker side of mindfulness: being overwhelmed, side effects and the difficulty of finding a good teacher

It was my pleasure to speak to Dr Chris Walsh, an Australian mindfulness pioneer since the 1980’s and a respected psychiatrist. Dr Walsh has trained with leading Western mindfulness figures such as Jon Kabatt Zinn, Mark Williams, Kristin Neff and Daniel Siegal. Dr Walsh and I spoke about the darker side of mindfulness.

As with any area experiencing such strong growth, mindfulness is surrounded by myths and misconceptions. What is one that you feel particularly strongly about?

It’s used by business to make people work harder. It’s not so much a myth, it’s just the way it is being used.

People think it’s a relaxation technique. This is tricky to address. Mindfulness does help people to relax, but that’s not the main game. It’s about training your awareness.

You cannot count on mindfulness to make you relax.

If occasionally mindfulness doesn’t help you relax, you will feel that it’s not working and are missing out on an opportunity to learn to hold an unpleasant feeling. This can be destructive.

Chris Walsh mindfulness expert tips

Mindfulness can bring out negative emotions, especially during the initial stages. How would you recommend that a person deals with that?

The first thing is to have a good teacher. It’s a delicate balance and it can be hard to know when to lean into the negative emotion and when to stand back from it.

The basic principle is that it is ok to feel challenged, but it’s not okay to feel overwhelmed.

With any kind of learning, including learning to be mindful, it is normal to oscillate between feeling comfortable and feeling challenged. If you’re never challenged, especially with something experiential like mindfulness or a sport, the learning isn’t in its optimal state. Getting overwhelmed in mindfulness is the equivalent of getting injured when training, and this sets back the progress.

I have a few tricks on how to deal with being overwhelmed during mindfulness.

  • The feeling of being overwhelmed is most likely to occur when doing a body scan, especially when focusing on the chest and abdomen as this is where we tend to feel anxiety. I encourage people to find “safe places” where they are less likely to feel this anxiety: such as the resting one’s attention on the sensation of breath in their nose. Even this can be too much for some people.
  • Awareness of sounds can also help, as the attention is then focused on something outside the body.
  • Allowing oneself to move can also help to deal with the sense of being overwhelmed. In the Tibetan mindfulness tradition you can move; in the Zen tradition you are meant to be still no matter how much one’s knees hurt. This stillness doesn’t work for people with a lot of agitation. Doing walking mindfulness or exercising before doing mindfulness can help greatly. Some people think that this is an avoidance behaviour. I believe, it is taking a distance, while still still remaining present to the difficult experience.
  • Sometimes it is okay to let one’s mind wander off. When I run classes with inpatients, I tell them that it’s okay to daydream if it gets too much. The important thing is: come back because this way you can learn what has changed. This is very empowering: we don’t always have to do something to change things. They change by themselves.

These tips work for patients with mental health issues, e.g. PTSD, as well as people with no mental health issues.

the darker side of mindfulness chris walsh

Have you ever had any experiences when mindfulness had side effects? The “decentering” in mindfulness may impact an individual’s concept of the “self”. There are anecdotal reports of some vulnerable individuals developing dissociation and psychosis after reading self-help books or attending seminars – and more recently after practicing mindfulness. Do you see any risks in “trying it at home” when it comes to mindfulness?

It is damaging when people use mindfulness to dissociate or disconnect in some way. Two patients I encountered were attached to ecstatic states.

The first was a man with a background of heroin and alcohol addiction. He was able to stay away from drugs and alcohol for 10 years and then relapsed – which is when he came to me. He told me he was using mindfulness to stay away from his addictions and meditated for 8 hours a day! Just before the relapse he got a job: this stopped him from meditating for 8 hours a day, and so he relapsed.

When I questioned him about his mindfulness practice, he told me that he would just got into a blissful state for 8 hours, never experiencing any negative emotions.

I asked him to deliberately call to mind some unpleasant experiences while practicing mindfulness and pay attention to how it felt in his body rather than holding on to these blissful states. The lesson here is to get comfortable with feeling uncomfortable. In Tibetan Buddhism, they talk about samadhi. It is a blissful state – and sometimes people get addicted to this state. Some people this is enlightenment, but the Buddhist teachers say that that’s a delusion, an unhealthy attachement to something.

The second case that comes to mind was of a man with schizophrenia. Many of my patients with schizophrenia derived a great benefit from mindfulness. This man was having a Kundalini experience, where energy was going up and down his spine. They talk about it in the Hindu tradition. He would go through this experience for many hours a day and it made him more delusional and psychotic. It was very hard to persuade him to do less meditation!

I wouldn’t’ call either of these experiences mindfulness, as they weren’t this open, non-judgemental states. This is why having a teacher is important: so that you can reflect on your experience and receive some guidance.

how to choose mindfulness teacher

How should one go about choosing their mindfulness teacher?

There are no absolute guarantees. I am aware of some highly trained psychiatrists who teach mindfulness, but don’t practice it. They say they do, but by talking to them, you quickly realise they don’t: they have a kind of striving attitude.

For people with psychiatric conditions, it is better to have someone who understands both the Western and the Eastern traditions. If you have a teacher, a psychologist or psychiatrist, who comes from the Western tradition only, it is important that they practice mindfulness themselves. It’s important for a teacher to be able to tune into the problems that arise for people as they go through their mindfulness journey rather than sticking to a rigid program.

does mindfulness have side effects

There is a one size fits all approach to mindfulness among the public at the moment. Do you feel that that it’s appropriate for someone to use an app or should they find a teacher?

In my classes, I have a handout that reviews the apps and advises my patients to beware of any apps that tell them what to feel or that they should relax. People can play with apps – it gives them experiential information that allows them to commit to go to a class. Some people learn a lot from the apps. I haven’t seen the good apps causing any harm. Headspace is quite good. Buddhify is great for getting past the idea that mindfulness only happens on a cushion and has lots of shorter meditations that people like. Insight timer has nice mindfulness bells and nice soundtracks. Some are a bit New Age-y, so people need guidance in choosing the right ones. iTunes U UCLA meditations are quite good too. I send people to my website as I have some soundtracks there.

how to deal with feeling overwhelmed during mindfulness

What are your thoughts on transcendental meditation? It became commercialised quite quickly once it reached the West. Do you worry that mindfulness is headed in that same direction?

I did TM for a few years and found it helpful. I studied Buddhist meditation before that and it gave me the impression that the mind has to be completely quiet – which caused a lot of agitation. TM helped me to get past that as it involved returning to the mantra without trying to eliminate thoughts. TM also taught me about preliminary practices such as exercise.

In the East, mindfulness is used to investigate the mind as well as everything else. A lot of the insights of Buddhist psychology are now being confirmed using Western methods, such as fMRI. I believe this aspect of the Eastern tradition doesn’t get enough attention. However, we need to separate the psychology, philosophy and the religion. Those who say that Buddhism isn’t a religion are lying: it is a religion, but as well as that there are psychological and a philosophical components. These can be separated out, just like has happened in the West.

The tradition in the East is 2,500 years old, so we run into a lot of interpretation and translation problems. The Eastern languages have changed in meaning and nuance in that time just as much as Western languages have. Jus think how much trouble we have interpreting Shakespeare and his writing was only 500 years ago. Furthermore, Buddhist psychology is based on  human investigation that has evolved over time, so it’s not like the Bible that has been “handed down” and and passed on as some kind of unchanging truth. The Eastern mindfulness tradition, in fact, has a lot in common with the Western scientific tradition. This tradition has evolved from the Socratic tradition which is based on debate and questioning. rather than prescriptive rote learning. I believe that if we start paying more attention to what is already known in the East our progress in understanding the mind will be accelerated and our meditation practices will become even more effective.

Dr Walsh’s own website contains a lot of case studies and blog articles on mindfulness that I would highly recommend: mindfulness.org.au

A downward facing doc explains the brain wiring behind mindfulness

Do you ever just wish you could get someone who knows virtually everything that’s known about the brain and quiz them about mindfulness? Well, I do – a lot – and I just got my wish!

It is my pleasure to present this interview with John McBurney MD. A practicing physician with of over 35 years’ experience, he is board certified in Neurology, Clinical Neurophysiology and Sleep Medicine. He holds an Integrative Medicine Fellowship… The list of his professional accomplishments is obscenely impressive, so I will jump to the bit we all really want to know about: Dr. McBurney maintains a daily mindfulness meditation practice as well as home yoga practice, hence the downward facing bit. Needless to say, I was beyond curious to find out his understanding of how mindfulness affects the brain.

For those of us who are put off by the mystical connotations that surround mindfulness, could you take us back to a schematic, reflex-arc type view of the process and describe the neurological response to mindfulness practice?

I think that the issue of mindfulness intersect with the leading-edge of neuroscience. It is supported by extraordinarily robust data. This area of study has been termed contemplative neuroscience. The Mind and Life Institute which is an outgrowth of the dialogues between the neuroscience community and the Dalai Llama  is an important sponsor of research and education on contemplative neuroscience. It ultimately comes down to the concept of neuroplasticity.

Donald O. Hebb coined the doctrine: “neurons that fire together, wire together”. It was an extension of the work done by an American philosopher and psychologist William James in the early XX century. You can practice “bad” things or “good” things – and neuronal ensembles form accordingly. In mindfulness, we are essentially practicing good things.

There is a resting ensemble of neural networks called the default mode network that was discovered using fMRI studies where individuals were asked to lay in the scanner and think of nothing in particular. This kind of mindless mental activity is accompanied by a lot of  self-referential ruminative recursive thoughts that are subserved by brain regions that lie along the midline, especially the prominent in medial parietal lobe. Those types of internal mental states that are remarkably robust and persist under deep general anaesthesia and even in a coma and are probably the neural basis for the self.

The more outward facing parts of the brain – like the dorsolateral prefrontal cortex – are more responsible for an outward orientation to the world have top down executive influence on the activation of those networks.

In mindfulness, in cultivating awareness of the breath and voluntary moment by moment awareness of the brain, we are training the brain – just like when you are learning to play the violin or any other complex skill – we are training to break out of those self-referential ruminative recursive mental states and to achieve an orientation toward the outer world and in the present moment rather than anticipating the future or reliving the past.

contemplative neuroscience mechanisms behind mindfulness

There is evidence that mindfulness leads to weaker connections in default mode network. Could we be losing something by focusing more on the external realities rather than the self?

Not everyone has a well formed default mode network. People who have been subjected to severe developmental trauma, neglect and lack secure attachment do not have robust default mode networks. Mindfulness can lower defence mechanisms that are there with good reason. However, most people with a well formed default mode network and secure attachment. We are “taming an elephant”: there is very little chance that we will significantly weaken the elephant.

Occasionally, we do hear of adverse experiences arising from mindfulness. With any robust intervention there are always potential risks.

How long does it take for mindfulness to have a manifest effect?

The results can happen almost immediately, however, they are also cumulative. We are still figuring out what the minimum effective dose it. This reminds me of the discussion of the minimum effective dose of aspirin in stroke and heart attack prevention. When I was a resident, we were advising patients to take two 325 mg tablets twice a day. Over time this dropped to 81 mg of aspirin a day. There is speculation that the required dose may even be lower.

There is a study that defines a new marker. The original fMRI/EEG studies were done by Richard Davidson in Tibetan Buddhist meditators with over 10,000 hours of meditation. This number is somewhat arbitrary and refers to this idea that is the number of hours to become an expert at anything. However, the question arises: what is the relevance of the changes in functional connectivity in the brain in someone who has devoted such a monumental amount of time to meditation to the likes of you and me?

A very neat study was published by David Cresswell in Biological Psychiatry in 2016. They invited individuals with high level of stress, unemployed adults, to a weekend retreat experience. They were randomised to in 2 groups:

  • a 3 day mindfulness retreat (the treatment group) and
  • a 3 day relaxation retreat where they read stories, told jokes and had a good time (the control group).

The study was conducted in one centre over one weekend, so it is well controlled. Initially, both groups rated the interventions as being equally helpful to them, subjectively.

The researchers looked at the functional connectivity between the dorsolateral prefrontal cortex and the cingulate gyrus. They also looked at Interleukin-6, a known marker of inflammation, that has been previously shown to be elevated in stressed out unemployed people.

Even with this brief weekend mindfulness intervention, the treatment group developed increased connectivity between the dorsolateral prefrontal cortex and the cyngulate gyrus. There was a neuroplastic response even after a 3 day mindfulness retreat. This was also associated with a decrease in the marker IL-6. Even after 4 months, IL-6 was decreased in the treatment group, but in the control group, IL-6 levels continued to rise, independent of whether they managed to get a job or not.

This is also relevant to doctors, who are at high risk for burnout. Because of their work commitments, the mindfulness retreat for doctors was condensed from the standard 8 week model developed by John Kabat-Zinn to a weekend intervention. The question was: does the weekend model work? The research at the University of Wisconsin where this was developed was reassuring: the residents are less stressed out, more effective and have a greater level of satisfaction.

We still don’t know the absolute minimum dose, but it seems that a weekend of mindfulness can be life-changing for the brain.

Another paper published in PLOS ONE from the Benson-Henry Institute for Mind Body Medicine in Harvard looked at the practices such as meditation, prayer, mindful yoga, Tai-Chi, Qi Gong, etc, i.e. ones that elicit a relaxation response (as opposed the stress response).

This study showed that in both novice and experienced practitioners of relaxation response modalities, there were changes in the epigenetic transcription of the genome. There was upregulation of pathways associated with mitochondrial integrity, downregulation of inflammatory pathways, improved insulin-related metabolism and improved nitric oxide signalling.

Long term potentiation, the standard mechanism for memory formation, strengthens existing neural connections. This happens immediately, as you read this. Over time, long term potentiation leads to formation of new connections,through synaptogenesis, dendritic arborisation and neurogenesis i.e. brain structure changes. In turn, this affects the most neuroplastic neurons located in the hippocampus.

mindfulness minimum effective dose response neurology

In reference to this fascinating recent study of the fight or flight response, it seems plausible that breathing regulates our stress levels much more than conscious thought. Could you explain the significance of this in terms of mindfulness?

The ancients believed that emotions reside in the body. This comes up a lot in serious yoga classes.

This highly innovative study shows that the control of the adrenal medulla – the main effector of the stress response – is not from the conscious ruminating thinking centres, but by the motor and sensory cortex.

This explains why breathing, as well as yoga and Tai-Chi, are an important part of meditative practice. In my experience, these kind of interventions do affect the stress response in a beneficial way.

Mindful exercise exists in many form. For example, weightlifters need to be very mindful to maintain perfect form. Cycling is another example: it is vital to concentrate on every pedal stroke and maintain an even cadence. Once you start to day dream, you notice straight away that your output is way worse. This overlaps with the concept of flow. It is about getting in the zone. There is a very inspiring TED talk by Judson Brewer MD, Ph.D. that explains the physiology behind flow and how it is augmented by mindfulness. Mindfulness is work, and it does require discipline. There is a paradox here of non-striving and non-doing while also being disciplined.

You are a sleep medicine expert. Could you comment on the relationship between mindfulness and sleep?

Insomnia is a complex problem with many causes. However, for most people with idiopathic insomnia, the cause it these self-referential recursive ruminations. They aren’t able to “turn their brain off”. Through mindfulness practice, they are generally able to tame the default mode network that’s responsible for ruminating and daydreaming. A simple strategy would be to lie in bed and concentrate on the breath. This would ease the transition between wakefulness and sleep.

mindfulness default mode network neurological basis for the self

Mindfulness is a mainstay treatment for many mental health disorders. What about use of mindfulness in the treatment for organic pathology of the brain usually treated by neurologists?

There is some preliminary data that mindfulness training has a beneficial effect of seizure frequency in patients with epilepsy. It is a medical condition associated with tremendous anxiety and stress, so mindfulness could have a significant benefit in more than one way. It may even have a benefit it terms of remembering to take medication on time, etc.

Some robust studies show that the frequency of relapse in multiple sclerosis decreases with mindfulness intervention. The effect from mindfulness is similar in magnitude to the effect from beta-interferon. There is also some research showing that the frequency of inflamed Gadolinuim-enhancing lesions decreases with mindfulness.

John Kabat-Zinn used to take the patients who suffered from chronic pain or had diseases for which we had no answer, and those patients got better. Even beyond neurology, there is some evidence that mindfulness can have benefits in psoriasis. We are probably only at the bottom of this mountain.

Dr McBurney is a board member of Mindful Medicine. It is a non-profit organisation that focuses on teaching mindfulness to health professionals using retreats. He is founder of McBurney Integrative Neurology and is a clinical assistant professor at the University of New Mexico School of Medicine. Dr. McBurney is a native of Alabama and a graduate of Auburn University and the Emory University School of Medicine. He completed his neurology residency and EEG/Epilepsy fellowship at Walter Reed Army Medical Center.  In 2014 he completed the Integrative Medicine Fellowship at the University of Arizona Center for Integrative Medicine.

Dr McBurney has given me so much to think about. I will follow up with part 2 of our discussion that focuses more on the philosophical and life experience aspects of mindfulness once I wrap my head around it.

neurological path mindfulness default mode network adrenal medulla

What psychiatrists think of Donald Trump

It is considered unethical and unprofessional for psychiatrists to hand out opinions about public personalities from afar. This rule was broken recently, with regards to, of course, Donald Trump.

Letter to the editor

A letter to the editor in The New York times, signed by Lance Dodes, an addiction psychiatrist, former Harvard assistant professor (and 34 other professionals) on the 13th Feb 2017 stated:

“Silence from the country’s mental health organizations has been due to a self-imposed dictum about evaluating public figures (the American Psychiatric Association’s 1973 Goldwater Rule). But this silence has resulted in a failure to lend our expertise to worried journalists and members of Congress at this critical time. We fear that too much is at stake to be silent any longer.”

“Mr. Trump’s speech and actions demonstrate an inability to tolerate views different from his own, leading to rage reactions. His words and behavior suggest a profound inability to empathize. Individuals with these traits distort reality to suit their psychological state, attacking facts and those who convey them (journalists, scientists).”

“In a powerful leader, these attacks are likely to increase, as his personal myth of greatness appears to be confirmed. We believe that the grave emotional instability indicated by Mr. Trump’s speech and actions makes him incapable of serving safely as president.”

A strongly-worded response to the letter

A pretty badass response came in the next day, 14th Feb 2017: a follow-up letter to the editor from Allen Francis, who wrote much of the DSM IV, including the diagnostic criteria for Narcissistic Personality Disorder. Much as the DSM IV has its flaws, this guy is really on point, in my more than humble opinion:

Most amateur diagnosticians have mislabeled President Trump with the diagnosis of narcissistic personality disorder. I wrote the criteria that define this disorder, and Mr. Trump doesn’t meet them. He may be a world-class narcissist, but this doesn’t make him mentally ill, because he does not suffer from the distress and impairment required to diagnose mental disorder.”

“It is a stigmatizing insult to the mentally ill (who are mostly well behaved and well meaning) to be lumped with Mr. Trump (who is neither).”

“Bad behavior is rarely a sign of mental illness, and the mentally ill behave badly only rarely. Psychiatric name-calling is a misguided way of countering Mr. Trump’s attack on democracy. He can, and should, be appropriately denounced for his ignorance, incompetence, impulsivity and pursuit of dictatorial powers.”

His psychological motivations are too obvious to be interesting, and analyzing them will not halt his headlong power grab. The antidote to a dystopic Trumpean dark age is political, not psychological.”

Should psychiatrists stay silent?

Looking down from her moral high ground on the 2 lads in a newspaper fight is the president of the American Psychiatric Association, Maria A Oquendo, who pointed out that while she could understand the desire to “get inside the mind” of a presidential candidate, having psychiatrists comment publicly about people they have not examined threatens to erode the public’s confidence in the profession.

“Simply put, breaking the Goldwater rule is irresponsible, potentially stigmatizing, and definitely unethical,” she wrote.

As for me, I believe that, psychiatrists shouldn’t be analysing living political figures – as psychiatrists. As people with opinions, however, I feel they should be heard – just like anyone else. They also happen to be very good at analysing people’s behaviour. It is up to the reader to understand that this is not an excerpt from Trump’s personal medical files, instead it is just another opinion made legitimate by our commitment to free speech.

What is this psychiatric condition they are debating about?

Narcissistic personality disorder is a mental disorder in which people have an inflated sense of their own importance, a deep need for admiration and a lack of empathy for others. But behind this mask of ultraconfidence lies a fragile self-esteem that’s vulnerable to the slightest criticism. For those of you not familiar with the DSM, it is a (the?) diagnostic guide for psychiatrists. We are currently of the 5th edition. Here are the criteria for NPD:

The essential features of a personality disorder are impairments in personality (self and interpersonal) functioning and the presence of pathological personality traits. To diagnose narcissistic personality disorder, the following criteria must be met:

A. Significant impairments in personality functioning manifest by:

1. Impairments in self functioning (a or b):

a. Identity: Excessive reference to others for self-definition and self-esteem regulation; exaggerated self-appraisal may be inflated or deflated, or vacillate between extremes; emotional regulation mirrors fluctuations in self-esteem.

b. Self-direction: Goal-setting is based on gaining approval from others; personal standards are unreasonably high in order to see oneself as exceptional, or too low based on a sense of entitlement; often unaware of own motivations.

AND

2. Impairments in interpersonal functioning (a or b):

a. Empathy: Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effect on others.

b. Intimacy: Relationships largely superficial and exist to serve self-esteem regulation; mutuality constrained by little genuine interest in others‟ experiences and predominance of a need for personal gain

B. Pathological personality traits in the following domain:

1. Antagonism, characterized by:

a. Grandiosity: Feelings of entitlement, either overt or covert; self-centeredness; firmly holding to the belief that one is better than others; condescending toward others.

b. Attention seeking: Excessive attempts to attract and be the focus of the attention of others; admiration seeking.

C. The impairments in personality functioning and the individual‟s personality trait expression are relatively stable across time and consistent across situations.

D. The impairments in personality functioning and the individual‟s personality trait expression are not better understood as normative for the individual‟s developmental stage or socio-cultural environment.

E. The impairments in personality functioning and the individual‟s personality trait expression are not solely due to the direct physiological effects of a substance (e.g., a drug of abuse, medication) or a general medical condition (e.g., severe head trauma).

Five philosophical myths about mindfulness that are sabotaging your practice

From a useful superstition with medical benefits to a deeply spiritual practice, mindfulness has seen a variety of labels. Together with Nguyên Giác, we put together a list of common misplaced attitudes towards mindfulness, so that you don’t sabotage your practice. [Watch video instead]

Mindfulness has become quite popular and seems to be gaining further momentum. It is set to soon be mainstream.

As is often the case with explosive popularity, there are some misconception and misinterpretations about mindfulness making the rounds among bloggers and on social media. 

1. Mindfulness is a Buddhist concept

It’s not uniquely Buddhist. Mindfulness has roots going back to Christianity. More that that: wherever humans have existed, they have discovered mindfulness. Many traditions poke around the mindfulness bush, some more directly than others. Why? Because mindfulness is healthy. It makes sense, evolutionarily. A mindful population will thrive. A population lacking mindfulness will have a hard time propagating the memes (Richard Dawkin’s meme, not the funny picture, meme.. although they are related) and genes that define its character.

Christianity has elements of mindfulness practice present in ritual and scriptural form (both within and outside of the canon).

There are a number of passages that obviously point to the practice of mindfulness, and there are many others that, when understood in context, point to mindfulness practice.

Whenever you have people that are practicing awareness of what they are doing in that moment, you have mindful people. When people know they are washing dishes, they are mindful dishwashers. Christians who are mindfully carrying candles, passing out bread and wine, and consciously delighting in each other’s company are Buddhist Christians – they are increasing awakeness in the world.

As Thich Nhat Hanh says,

“‘Buddhism is a practice. Like Yoga’. It is not a ‘religion’ in the way that Christianity is a religion. There are no gods. No required beliefs.. Nothing to take ‘on faith’.”

It is an open-handed teaching, hiding nothing, encouraging actual practice, letting you realise things without forcing it. The labels of “Buddhist” and “Christian” can be hindrances. It is nice to respect our spiritual ancestors, but it is foolish to isolate ourselves within the confines of some set of teachings. Old “maps” may not accurately represent the present territory.

Some people make the claim that there is an actual historical link between Jesus and Buddha. Indeed, there were Mahayana Monks in Egypt during Jesus’ lifetime. But, with or without the causal connection, Buddha/Gnosis is one – the message is the same. People can happen across the same spiritual truths in totally separate cultural contexts. The historical connection would be interesting and exciting, but it is not necessary.

So, in conclusion, there are some big chasms to cross as one journeys between world views, but if we look within we will find one human experience– we are unique, but we share common ground. It is beautiful. If we can learn to gently share our ideas with respect and give credit where credit is due, this era of history can be an amazing one.

Naturally, mindfulness occurs in religions other than Christianity and Buddhism, we shall try to address that another time.

myths and misconceptions about mindfulness
Sure, who wants an article on mindfulness without a picture of a woman meditating?

2. Mindfulness is about detachment and emptiness

Buddhist terminology also presents some problems for the Western Mind.

The translators of yore did not have the proper conceptual tools to work with the subtle ideas generated by Buddhist genius. And, still, people are hung up on ideas of “nonself”, “emptiness”, “detachment”, etc.

The Christian West has to do some serious psychic judo to make sense of these things without experiencing intense fear and trembling.

There are many potential points of conflict, but, let’s focus on non-self. Anatman. Anatta. No atman. This seems to have been one of the Buddha’s big ideas. There is no independently existing ego, or self-sustaining identity, anywhere in existence. All is dependent on all. Every square inch, square centimetre, every atom is as significant as the largest star. Look at “Indra’s Net”. It’s a nice way to visualise emptiness, or non-self: emptiness and non-self are the same idea. Interdependence is a better word. So when you read, “non-self”, “emptiness”, “voidness”, etc… just remember interdependence.

In the West, largely populated with traditional Christians, many have trouble with all this. There is this idea of “something out of nothing” that the Christian must accept in order to fall in line with dogma. It is totally illogical. Therefore, the Christian declares that faith is necessary. The question, “what was before the beginning?” will never be answered. Those who try to convince you that they have answered that question are liars or fools. Asserting that “God did it” is dangerous, the priests who make such assertions are “like dogs in the cattle manger, they can’t eat and they won’t let the cattle eat”. And, this is what Jesus is implying in the Gospel of Thomas when he encourages us to ignore those who claim to know “the way to heaven”.

On a more comforting note, the Jesus of the Gospel of Thomas also recognises this truth of non-self, which is very closely related to the truth of impermanence, another central Buddhist idea.

He also declares that all things that come together will fall apart. Everything will change.

Gospel of Thomas, 11:

Yeshua said / This heaven will pass away / and the one above it will pass away. / The dead are not alive / and the living will not die. / During the days when you ate what is dead / you made it alive. / When you are in the light, what will you do? / On the day when you were one / you became two. / But when you become two, what will you do?

Some people want to hide in their meditation halls, with their tibetan loving-kindness mantras – that’s fine… However, the Bodhisattva (the being tending toward awakening) engages the world and meets people where they are at. By helping others in real life, the Bodhisattva also develops her own Buddha Nature.

what we get wrong about mindfulness meditation

3. Mindfulness is part of the positive thinking / law of attraction world view

Many have come to view mindfulness as a close cousin of positive thinking. This is a misconception.

Mindfulness cultivates non-judgement – which the exact polar opposite of insisting on only ever dignifying positive thoughts with our attention.

A concept seemingly resonant with positive thinking/ law of attraction appears in the Dhammapada, one of the primary collections of teachings attributed to Siddhartha Gautama:

Mind precedes all mental states. Mind is their chief; they are all mind-wrought. If with an impure mind a person speaks or acts suffering follows him like the wheel that follows the foot of the ox.”

However, mindfulness emphasises the value of accepting things as they come.

Yes, we “create our own reality”, but we certainly don’t do it alone.

Reality is seen from a fundamentally different viewpoint in the philosophy underpinning mindfulness. The Bodhisattva does not proclaim that things are either positive, negative or neutral– Buddha abides “beyond good an evil” – beyond positive and negative and neutral.

In many Buddhist schools, there is this idea of the Five Skandhas. The Five Heaps. The Five Collections or Aggregates. Instead of a self-sustaining ego, Buddha spoke of these components – the Five Skandhas – that make up a personality.

The sensory experience, contact with sense objects through one of the sense doors (light / eye, sound / ear, chemical / taste and smell, pressure and heat / touch, thought / mind), is either positive, negative or neutral.

There is an event, and there is a knee-jerk reaction to it that is either good, bad, or not good or bad.

The Five Skandhas are empty”. They are interdependent. Sensation is just one of these heaps. Sensation depends on form, perception, mental formations, and consciousness. And – positive, negative and neutral are also empty!

There is no positive without negative or neutral, and the same is true for negative and neutral.

Our strength is not found in forcing reality to remain “positive”. We are considered accomplished because of the strength we have to endure the snaky shifting of Samsara. We endure the ups and downs, we remain in this mind system with these sentient beings, unperturbed by the positives and negatives and neutrals. We are beacons of peace and stability in this chaotic ocean.

4. Mindfulness is a natural remedy for anxiety

People want to talk about mindfulness like it’s some miracle pill. Despite what we so often hear, this practice of mindfulness is not always roses and cotton-candy. The practice of mindfulness may reveal things one has been been avoiding. This can be painful. This is the real work though! Learning to see clearly requires deep compassion for oneself and for all sentient beings. Gentleness can smooth over those scratchy rough spots.

Mindfulness meditation is work, but it is healthy, soothing work.

New things will be noticed. New things can cause fear. If new things aren’t being noticed, if fear isn’t arising, it is probably a good idea to refocus the practice. But how?

The goal is not to be rid of negative emotions.

Mindfulness meditation teaches us to put harsh feelings into context and not become totally overwhelmed by their presence. The goal is not to become a tranquil yuppy – it is to become present, aware and in touch with actual bold faced reality.

Yes, there are benefits. Mental and physical health benefits.

Breathing meditation can bring calm. “Negative” feelings can also arise – they are as real as “positive” feelings.

During practice, all of these arising positive and negative thoughts are gently touched – and like the fragile bubbles they are, they pop. It is not difficult. There is no strain. However, it is work. Perfectly paradoxical.

You may also like: Mindfulness is pointless – and that’s the point

what we misunderstand about mindfulness

5. Mindfulness is a medical treatment

Here in the West, the main drive for the explosion of mindfulness practice seems to be coming from the medical community. This is awesome. As always, medicalising normal processes is dangerous. It is especially common these days when people look to science for answers – rather than to religion. However, difficulty arises when science, which is much more about questions than it is about answers, becomes scientism, or high priests with Ph.D.’s handing out evidence-based dogma.

There is a lot of cultural appropriation going on around here. Doctors are not far off taking credit for practices that have already been employed for thousands of years. On the surface, this is all fine and dandy, but looking deeper we can see that it’s part of a larger pattern. We Westerners have not been so kind to our friends around the world. We take and take and take. The practice of mindfulness cannot be “owned”, but it seems to me that we should be giving more credit to it’s Eastern roots. Indeed, those roots extend beyond the Buddhist tradition. There are things to be learned from the cultures that have grown up with these practices.

Instead, it looks to me like as Westerners, we are trying to distill the “useful” practices from what we consider to be “superstition”.

Our sciences are constantly revealing a stranger and stranger reality. We would do well to hold our verdicts on what is and is not superstition.

philosophical misconceptions about meditation mindfulness

Four reasons why daydreams scare off mindfulness

Complex problems have simple easy to understand wrong answers.

Henry Louis Mencken

I have recently been very interested in what it is that makes mindfulness feel quite difficult at times.

Up to 96% of adults daydream every day.

I am using the term daydreaming in the broadest possible way. There are ways in which it is positive (visualisation, rehearsal, creativity), but we all know that it can get out of hand very easily.  These so called self-generated thoughts (SGTs) interfere with external task performance and can signal unhappiness and even mental health issues. They also occupy our thoughts for upwards of half of the time. In appropriate contexts, SGTs

  • allow us to connect our past and future selves together,
  • help us make successful long-term plans and
  • can provide a source of creative inspiration.

Given the time dedicated to the task, it seems natural to suggest that there must be an evolutionary advantage to being preoccupied with a daydream.

Contrary to the mindfulness rhetoric, daydreams can be seen as a mechanism for the consciousness gain freedom from the here and now – reflecting a key evolutionary adaptation for the mind.

There is evidence that  SGTs are normal and may even be beneficial, so our natural inclination  to dismiss mind-wandering – and recent odes to the benefits mindfulness – are perhaps oversimplifying the problem.

mindfulness slipping into daydream

For the moment, however, I will focus on the negative aspects of daydreaming.  In 2016, the Journal of Conscious Cognition did a study on self-identified “maladaptive daydreamers”. These guys had more daydreams that involved fictional characters and elaborate plots and spent 56% of their waking hours fantasising.

Maladaptive daydreaming caused significant distress to the affected and was associated with higher rates of ADHD and OCD.

Another study echoed the findings and showed that the daydreams were typified by complex fantasised mental scenarios that were often laced with emotionally compensatory themes involving competency, social recognition, and support.

Of note, solitude is required for elaborate daydreams – worsening any existing social dysfunction.

Mind-wandering is situations when attention is required is obviously negative: it can signify performance disruptions, cognitive problems, risk taking or low motivation to perform a task. At the same time, the question arises: how do we define a situation that requires attention?  The resolution here is obvious. The capacity to regulate the occurrence of SGTs so as to reduce the risk of derailing on-going task performance is a marker of properly functioning, well-adjusted cognition. It is context-dependent – and requires self-awareness. Indeed, a brain trained with the practice of mindfulness would seem better equipped to recognise appropriate situations and adapt more quickly.

On a more philosophical note, however, what’s to say one isn’t missing out on some important unknown unknown in an apparent “safe-to-daydream zone”?

Based on some research and a preliminary Twitter poll, I have come up with 4 main feelings that trigger daydreams.  If none of the four describe what it is like for you, please do comment, I am very keen to find out!

maladaptiveday dreaming mindfulness