Perez-De-Albeniz and Jeremy Holmes
Journal of Psychotherapy, Mar2000, Vol. 5 Issue 1, p49, 10p
article reviews 75 scientific selected articles in the field of
meditation, including Transcendental Meditation among others. It
summarizes definitions of meditation, psychological and physiological
changes, and negative side-effects encountered by 62.9% of meditators
studied. While the authors did not restrict their study to TM, the
side-effects reported were similar to those found in the "German Study" of
Transcendental Meditators: relaxation-induced anxiety and panic;
paradoxical increases in tension; less motivation in life; boredom; pain;
impaired reality testing; confusion and disorientation; feeling 'spaced
out'; depression; increased negativity; being more judgmental; feeling
addicted to meditation; uncomfortable kinaesthetic sensations; mild
dissociation; feelings of guilt; psychosis-like symptoms; grandiosity;
elation; destructive behavior; suicidal feelings; defenselessness; fear;
anger; apprehension; and despair.
Meditation can be defined in a
number of different ways, philosophical or operational. Webster's
dictionary defines meditation as an 'act of spiritual contemplation'. It
seems that in its wider modern usages, it denotes (Kokoszka, 1990):
self-experience, self-realisation and, in some religious traditions, a
specific practice to achieve the discovery of the ultimate truth.
From a psychophysiological perspective, meditation is the intentional
self-regulation of attention, in the service of self-inquiry, in the here
and now (Masion et al., 1995). Most descriptions of meditation expressed
in behavioural terms (Craven, 1989), include the following components: (1)
relaxation, (2) concentration, (3) altered state of awareness, (4)
suspension of logical thought processes, and (5) maintenance of
There are many different techniques of meditation, which can be classified
according to Shapiro (1982) as: those which focus on the field or
background perception and experience, called 'mindfulness meditation;
those which focus on a preselected specific object, or 'concentrative'
meditation', and those which shift between the field and the object.
In mindfulness meditation, the subject sits comfortably, in silence,
centring attention by focusing mental awareness an object or process
(either the breathing process, a sound, a mantra koan or riddle evoking
questions, a visualisation, or an exercise) and then consciously is
encouraged to scan their thoughts in an open focus, shifting freely from
one perception to the next (Kutz et al., 1985a, b). No thought, image or
sensation is considered an intrusion. The meditator, with a 'no effort'
attitude, is asked to remain in the here and now. Using the focus as an
'anchor' (Teasdale et al., 1995) brings the subject constantly back to the
present, avoiding cognitive analysis or fantasy regarding the contents of
awareness, and increasing tolerance and relaxation of secondary thought
Meditation can also be practised walking or doing some simple exercises,
where it aims to break down habitual automatic mental categories, thus
regaining the primary nature of perceptions and events, focusing attention
on the process while disregarding its purpose or final outcome. If based
in a visualisation such as the Chinese Qi Gong meditation (Liu et al.,
1990), the subject concentrates on a certain 'energy' (Qi) in his body,
starting in his lower abdomen and then, through visualisation, circulating
through various parts of the body, until the energy is eventually
'dispersed'. This is combined with repetitive, positive, reinforcing
suggestions from the instructor and the subject himself, resulting in a
strong belief in the subject that s/he can manipulate this 'energy' at
Meditation is claimed to enhance the sense of mastery through the
mediator's self-observing cognitive attitude. The mediator realises his or
her role as 'writer-director' in charge of inner dramas and discovers the
element of choice in the 'cutting and editing' of perceptions of reality.
It suspends habitual logical-verbal construing, and so frees the
individual of his/her usual defensive constructions, allowing
consciousness to move in new directions (Bogart, 1991). It is said to free
the mediator from bodily and cognitive tensions.
Meditation is related but distinguishable from daydreaming, hypnosis (Fromm,
1975), praying, cardiovascular and neurovascular feedback, autogenic
training and relaxation techniques (Kokoszka, 1994). Meditation differs
from these other techniques or practices in its emphasis on maintaining
alertness, and its philosophical/cognitive background aims at expanding
self-awareness and an increased sense of integration and cohesiveness (Snaith,
Traditionally meditation has been
practised within a religious context. Only in modern times have the
techniques of meditation been extracted from their spiritual and
philosophical context and applied to the promotion of individual
well-being. Most literature in scientific journals and research about
meditation has been based on this personal health-enhancing aspect
(Epstein, 1990; Globus, 1980; Leuschitz & Harlman, 1996; Russell, 1986;
Shapiro, 1994; Tyler, 1977; West, 1987). Atwood & Maltin (1991) described
how meditation helps the patient to understand that there are no quick
solutions. It develops patience: to be aware of the problem before
attempting to solve it. It promotes a non-judgmental attitude, it helps
the patient to come to terms with 'what is', rather than to fight
hopelessly for 'what might be', or 'might have been'. It helps people to
be comfortable with ambiguity, ignorance and uncertainty. Meditators learn
to recognise and trust their inner nature and wisdom. Meditation fosters
the recognition of personal responsibility. The meditator's feelings
during and about meditation itself cannot be displaced or disowned.
Different components of the technique of meditation, such as physical
posture, attentional focus, style and breathing, have been proposed as
explanations for the positive effects of meditation (Colby, 1991;
Levenstein, 1996). Kutz et al. (1985a, b) explained meditation as a
repetitive dose of corrective emotional experience similar to an
interpersonal therapeutic encounter which may have its counterpart in
gradual interneuronal modulation. 'It's tempting to speculate that such
neural plasticity can be enhanced by causing a functional shift in the
state of the CNS. Such a psychobiological shift may be elicited by mental
practices such as meditation'. Craven described the following effects:
integration of subjective experiences, increased acceptance and tolerance
of affect and increased self-awareness. Atwood & Maltin (1991) claim that
meditation optimises the process of memory. Kutz et al. (1985a,b) reported
an increase in vigor. Shapiro (1992) found that 88% of the subjects of her
research subjects (n = 27) reported greater happiness and joy, positive
thinking, increased self-confidence, effectiveness (getting things done),
and better problem-solving skills. Other reported beneficial effects
include enhanced acceptance, compassion and tolerance to self and others (Dua
& Swinden, 1992), more relaxation, resilience, and better ability to
control feelings (Scheler, 1992).
However, none of these findings were based on properly randomised and
controlled trials, and a placebo comparison for meditation is even more
problematic than it is for psychotherapy.
Meditation is claimed to produce
an integrated response with peripheral circulatory and metabolic changes
subserving central nervous activity. Jevning et al. (1992) called it an 'awakeful
hypometabolic integrated response'.
The physiological effects include: increased cardiac output, slow heart
rate (Dillbeck & Orme-Johnson, 1987), muscle relaxation (Narayu et al.,
1990), apparent cessation of CO[sub 2] generation by muscle, decreased
renal and hepatic blood flow, increased cerebral flow, decreased
respiratory frequency (Kesterson & Clinch, 1989), significantly decreased
sensitivity to ambient CO[sub 2], less O[sub 2] consumption (Wilson et
al., 1987), increased skin galvanic resistance, decreased spontaneous
electrodermal response, EEG synchrony with increased intensity of slow
alpha in central and frontal regions, and increased theta waves in frontal
areas of the brain (Telles & Desraju, 1993), enhancement of brain stem
auditory evoked response (Liu et al., 1990), increased alpha and beta
coherence (Sim & Tsol, 1992), and shift in hemispheral dominance with
greater activation of the centres in the right hemisphere (to which
non-verbal, intuitive, spatial, holistic, non-sequential qualities are
attributed; Telles et al., 1994).
Metabolical effects include: increased blood pH during meditation but
decreased arterial pH afterwards, resulting in a mild metabolic acidosis;
decreased plasma lactate (probably due to changes in erythrocyte
metabolism); changes of glucose metabolism pattern (Herzog et al., 1990);
decreased adrenocortical activity just after 30 minutes of meditation and
long-term decreased cortisol secretion (Sudsang et al, 1991); decreased
TSH; increased concentration of arginine vasopresine (which is said to
play an important part in learning and memory); increased levels of
phenylalanine concentration (in 3-5 year meditators); increased 5
hydroxyindole-3 acetic acid urinary metabolite of serotonin after 30
minutes of meditation (Travis & Orme-John, 1989); and increased levels of
melatonin (urinary 6 sulphatoxymelatonin) which is produced in the pineal
gland (Masion et al., 1995). Through melatonin, there is an increased
inhibitory effect of GABA, which has a benzodiazepine-like effect
(analgesia, antistress, anti-insomnia; Elias & Wilson 1995; Harte et al.,
Benson et al. (1990), in a descriptive study of three very experienced
Tibetan monks, claimed that metabolic rate could be raised up to 61% or
lowered to 64% at the meditator's will, and that EEG showed a marked
asymmetry in alpha and beta activity between the hemispheres with
increased beta activity. Lou et al. (1999), using 150 h20 PET measures of
CBF (cerebral blood flow), found a differential activity noticeable mainly
in the posterior sensory and associative cortices known to participate in
imagery, in meditation, compared with the resting state of normal
consciousness, although the mean global flow remained unchanged.
In summary, it seems that meditation has a bimodal biological impact along
time. Initially there is a physiological relaxation response in the short
term. This effect also corresponds with findings in the study of imagery
on brain activity as described by Laine et al. (1997). More enduring
hormonal and metabolic changes can later be detected in experienced
meditations, some 12 to 18 months after starting meditation practice.
Not all effects of the practice
of meditation are beneficial. Shapiro (1992) found that 62.9% of the
subjects reported adverse effects during and after meditation and 7.4%
experienced profoundly adverse effects. The length of practice (from 16 to
105 months) did not make any difference to the quality and frequency of
adverse effects. These adverse effects were relaxation-induced anxiety and
panic; paradoxical increases in tension; less motivation in life; boredom;
pain; impaired reality testing; confusion and disorientation; feeling
'spaced out'; depression; increased negativity; being more judgmental;
and, ironically, feeling addicted to meditation.
Other adverse effects described (Craven, 1989) are uncomfortable
kinaesthetic sensations, mild dissociation, feelings of guilt and, via
anxiety-provoking phenomena, psychosis-like symptoms, grandiosity,
elation, destructive behaviour and suicidal feelings. Kutz et al.
(1985a,b) described feelings of defencelessness, which in turn produce
unpleasant affective experiences, such as fear, anger, apprehension and
despair. Sobbing and hidden memories and themes from the past, such as
incest, rejection, and abandonment appeared in intense, vivid forms and
challenged the subject's previously constructed image of their past and
themselves. On the other hand, it is not uncommon to encounter a meditator
who claims that has found 'the answers' when in fact he has been actively
engaged in a subtle manoeuvre of avoiding his basic questions.
Therefore, Shapiro (1992) recommended caution when the answer encountered
to every dilemma was 'adverse effects are only part of the path. It takes
years of practice'. This statement is reminiscent of the classical
psychoanalytic dictum: 'insight causes cure; if you are not cured, by
definition you need more insight'--and its misuse.
The side-effect profile summarised also resembles many of the
neurotic/anxiety constellation of symptoms. None of the studies reviewed
tried to disentangle the effects of meditation per se from the influence
of the presenting problem or/and premorbid personality of the subjects. It
is unclear whether certain personality types are more likely to try
meditation or whether the effect of meditation increases the awareness of
those feelings, symptoms and personality traits (Morse, 1984).
Meditation and Psychotherapy
Increased self-awareness is a
common theme in most psychotherapies. It is often proposed as an initial
step in freeing oneself from distressing symptoms, and forms the basis of
behavioural monitoring and feedback, cognitive diaries and
psychoanalytical analysis of transference, dreams and free association.
>From a personal construct perspective (Kelly, 1955), meditative
concentration techniques can be viewed as deliberately experimenting with
'constriction' in the Kellyan sense. In constriction the perceptual field
is shrunk to a few elements in an attempt to reorganise and make
manageable the construct system. Mindfulness techniques can be seen as
'dilation' in a Kellyan terms, whereby the person broadens his/her
perceptual field to include more elements, with the aim of a more
comprehensive organisation of his/her construct system (Del Monte, 1987).
Thus meditation allows its practitioner to step out of conceptual
limitations, a process which is considered to be the hallmark of insight
and creativity, and the converse of neuroticism (Craven, 1989; Greguire,
1990). The detachment from self experienced in meditation can be related
to the split described by Freud (1930) between the experiencing ego and
the observing ego. This capacity to rise above the self increases
motivation, tolerance of guilt, and enhancing a sense of unity and
On the other hand, in order to reach this deeper stability, one has to
become fundamentally destabilised, which may require preliminary strength
and faith (Shapiro, 1992).
Freud, personally unfamiliar with meditation, interpreted the 'oceanic'
meditative experience as a reaction formation, a defence of omnipotence
against infantile helplessness. Even Jung (1936), who was better
acquainted with both mystical philosophy and Eastern ways of thinking, was
ambivalent about its use. He believed that Eastern methods and
philosophical doctrines put Western attempts along these lines into the
shade. On the other hand, he said; 'people will do anything, no matter how
absurd, in order to avoid facing their own souls. They will practice yoga
and all its exercises, observe a strict regime of diet, learn theosophy by
heart, or mechanically repeat mystic texts from the literature of the
whole world, all because they cannot get on with themselves and have not
the slightest faith that anything useful could ever come out of their
Looked at more positively, meditation can be seen as an undifferentiated
regressive state, which, like the mother-child bond, protects from fear of
separation and desolation. It is a 'regression in the service of the ego'
(Atwood & Maltin, 1991; Shaffii, 1973) where one's loneliness, even the
problematic nature of one's existence, is threateningly close and all that
matters is not being dead or disintegrating into non-existence. This very
early 'narcissistic' feeling of injury, experienced as a loss of the
safety provided by attachments to others, is temporarily counterbalanced
by the meditation-induced enhanced sense of the tangible self (Bogart,
1991). Shaffii (1973) emphasised the importance of silence and
conceptualises meditation as a temporary and controlled regression to the
preverbal level or 'somatosymbiotic phase' of the mother-child
relationship. This regression may rekindle unresolved themes from the
developmental phase in which the individual develops a sense of basic
In Buddhist terms, the ultimate aim, the realisation that the self-ego is
illusory, seems entirely irreconcilable with the goals of psychotherapy,
which is, rather, to facilitate the development of a coherent ego (Bradwejn
et al., 1985). But both Buddhist thought and psychoanalytic object
relations theory view human growth as a series of developmental stages (Engler,
1984). The ego is defined as an internalised image that is constructed out
of experience with the object world and which appears to have the
qualities of consistency, sameness and continuity. According to object
relations theory, the major cause of psychopathology is the inability to
establish a cohesive integrated self. In contrast Buddhist psychology
states that the deepest psychopathological problem is the protagonist of a
self, the 'clinging to personal existence'. But one has to be somebody
before one can be nobody. Meditation may be most helpful to people who
have achieved an adequate level of personality organisation. Meditation
can help both with getting in touch with oneself, and with letting go of
the self, where there is excessive investment in the self.
Perhaps meditation can offer the possibility of development beyond what
most therapies can offer, but proceeds more effectively when certain
fundamental ego-based issues, such as self-esteem, livelihood, intimacy
and sexuality have been, at least to some extent, tackled (Finn, 1992).
Relevance To Clinical Practice
Research into meditation is
mixed, and of poor quality. Most of the studies are methodologically
flawed, with insufficient number of cases, lack of standardised diagnostic
procedures and being limited to non-psychiatric populations (Atkinson et
Kutz et al., (1985a, b) studied the effect of a 10-week mindfulness
meditation programme on 20 patients who were also undergoing long-term
individual exploratory psychotherapy. The main outcome was improvement in
measures of psychological well-being. Smith et al. (1995) studied 36
undergraduate volunteers, and found that meditation had a positive effect
as part of a 'happiness enhancement program'. A three-year study with 22
subjects showed positive effects on people diagnosed with anxiety
disorders, using a meditation-based stress reduction intervention (Miller
et al., 1995).
Teasdale et al., (1995) found that mindfulness meditation used for stress
reduction based on the skills of attentional control achieved positive
effects for maintenance and relapse prevention of depression. This 'attentional
control training' has also proven to be significantly beneficial in the
treatment of chronic pain (Kabat-Zinn et al., 1992), psoriasis (Bernhard
et al., 1988; Kabat-Zinn et al., 1998), epilepsy (Deepack et al., 1994;
Persinger, 1993; Panjwani et al., 1995), substance misuse (Gelderloos et
al., 1991), fibromyalgia (Kaplan et al., 1993), hypertension (Schneider et
al., 1995), HIV patients (Taylor, 1995), anxiety-depression in old age (Deberry
et al., 1989) and anxiety and panic disorders (Kabat-Zinn et al., 1992)
Kutz et al., (1985a, b) studied the effect of meditation on 20 patients
diagnosed with narcissistic or borderline personality disorder (BPD),
anxiety and obsessional neurosis: 50% of them showed improved tension
reduction, and tolerance of stress; depression, anger, guilt, self-blame
and self-esteem were all helped, and 65% greatly improved on therapists'
estimate of insight and psychological mindedness.
Linehan (1993) based behaviour-dialectical therapy (DBT) on principles of
Zen philosophy. In this approach, with its built-in paradox, the patient
is encouraged to work towards self-acceptance of who s/he is, and promote
change while avoiding rejection of who s/he is. Meditative techniques are
adjunctive to individual and group therapy in a research package that
proved beneficial in the treatment of borderline personality disorders
with frequent parasuicidal behaviour.
Shapiro (1994) described contraindications for meditation in people
suffering mental illness such as psychosis, schizoid and schizotypal
personality, dissociative states, hypochondrial and somatization
disorders, as there is a risk that the patient will be distressed and
overwhelmed by the experience of the symptoms during meditation.
Bogart (1991) argued that Western therapy appears quicker and more
successful than meditation in many areas such as grief, communication
skills, maturation of relationships, sexuality and intimacy, career and
work issues, fears and phobias, and early trauma--not surprising, given
the lack of direct focus on symptoms or problems within meditation.
In a study with alcohol-dependent patients, using an 'attention placebo
group' which consisted in a group practising bibliotherapy, Benson (1975)
suggested that relaxation training, whether it was meditation, progressive
relaxation, or attention placebo, had a positive effect compared with
normal placebo, but there were no significant differences between the
three different relaxation processes (Holmes, 1985; Lazarus & Mayne,
Some authors like Chang-Yong-Chung (1990) recommended meditation as
advanced courses for training for psychotherapists as a way of improving
rapport and empathy. But Pearl & Carlozzi (1994), in a study with 24
student volunteers compared with a control group of 26, in on 8-week trial
found no significant effect on empathy, despite a positive effect on
Meditation is an ancient
technique that has recently been extracted from its spiritual framework,
and applied to therapy for the enhancement of personal well-being.
Although we have limited ourselves to reviewing studies that refer only to
meditation as a technique, there is abundant literature that relates
meditation to a religious-philosophical framework. It could be argued that
in extracting the technique from its theoretical and belief context, the
meaning and effect of meditation is deprived of its essence--just as an
interpretation, cognitive challenge, or a paradoxical injunction would not
have the same impact/outcome when removed from its therapeutic context.
There are different types of meditation, but all seem to be fundamentally
based on the concept of self-observation of the subject's psychic activity
in the here and now, with an acceptance of process rather than content.
The practice of meditation has positive short- and long-term rewards, the
main ones being a calm self-control, and what Benson called 'the
relaxation response'. These effects include a wakeful hypometabolic
physiological state and a balance of the parasympathetic or trophotropic
and sympathetic or ergotrophic functions.
The evidence of meditative physical effects is consistent with increasing
evidence of the biological impact of psychological interventions. It
refutes convincingly the stereotypical criticism that talking therapies
'do nothing' or are 'just' placebo.
Meditation is not free from side-effects, even for long-term meditators or
experienced teachers. Nor is it free of contraindications.
The common element with psychotherapy is the emphasis and goal of
self-awareness, and the freeing of the individual from habitual patterns
of thinking and feelings, paving the way for change. It differs from
psychotherapy in that meditation is a completely private and silent
There is mixed research on the efficacy of meditation as therapy or an
adjuvant to therapy. This study has not included anecdotal reports by
therapists of the use of meditation as a personal aid and maintenance to
their professional development. Most of the studies are based on small
numbers, and lack standardised diagnostic procedures. The current evidence
seems to indicate a value of meditation in the treatment of stress and
anxiety related disorders, but there is a need for a rigorous
meta-analysis in order to guarantee standards in evidence-based
We are grateful to Dr M. Segovia
and Dr J. Middleton for their useful comments on earlier drafts of this
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