Is Your Mindfulness Program Trauma-Sensitive? 3 reasons you need to know and 3 questions to ask.

It was a busy day in the week about 16 or 17  years ago. Emails were still clunky communication channels, which was good because the voicemail I was listening to carried all the emotions we miss in typescript. She was scared, she said. Having a hard time breathing. After a treatment program. Meditation. Mindfulness. Please call.

Back then, I wasn’t a fan of mindfulness-based programs – a seemingly new-fangled, somewhat New-Age-ish approach to treating mental health difficulties. There was little research to support it as a psychological treatment and, what seemed to me, a whole lot of blind enthusiasm for it. As a long-time meditator, I was also resistant to the idea of bringing something that was clearly a spiritual practice into a healthcare field with its clear rules against imposing religious or personal spiritual practices on our patients/clients.

When I met with the caller, I was ready for a story of incompetence and cult-like indoctrination by the people offering the program. It wasn’t that simple. The mindfulness program had been offered by someone with current training (training is very different now) and the meditations were within the range of what any professional trained in psychological approaches would use as relaxation response or calming breath strategies. And yet, the program had triggered something very distressing for her. From the first day of the program and until she left abruptly, she experienced panic attacks, a sense of being separate from the immediate environment, disembodied, and had nightmares. She didn’t inform the facilitator nor had there been any follow-up when she stopped attending the classes. When I asked, she described having been told in the second class, during a homework review when she disclosed her reaction to the Body Scan, that she simply had to “stay with it”. There were reassurances that “it will pass” and “just sitting with it” would resolve the feelings of anxiety.

This initial case became one of many over the years. Buddhist practitioners who had gone to silent retreats, mindfulness-seekers attending 8-week programs or short intense versions of the same, long-term meditators who suddenly found themselves in whirlpools of distressing emotional and physical experiences. They spoke of feeling like failures in their spiritual practices; angry and betrayed that something intended to relieve psychological distress had caused more suffering. They all had one question: Why were they not warned?

Why is knowing about adverse psychological experiences (APEs) important? Here are five reasons.

Reason 1: It’s not new.

That spiritual practices can lead to distress has been known for as long as spiritual practices have been around. My colleague, Jane Compson¹, discussed the different ways spiritual practitioners view these periods of intense distress.

(A) psychiatrist trained in Western allopathic medicine may judge that the distress is symptomatic of mental illness exacerbated by meditation, and suggest that the person stop meditating.  A Buddhist teacher, on the other hand, may understand the distress as a sign that the meditator is progressing through stages of insight towards liberation of suffering, and suggest more meditation or auxiliary practices as a way of moving through this stage.

She calls for a greater awareness of these APEs because their potential for harming the individual practitioner raises ethical issues of whether and how to offer meditation practices in any setting, spiritual or secular.

Reason 2: It can happen independently of experience or context.

Buddhist scholar/researcher Jared Lindahl, neuropsychologist Willoughby Britton and their colleagues² published what is likely the first in-depth examination of APEs among meditators. They reported that among Western Buddhist meditators

More than a quarter (29%) of practitioners first encountered challenges within their first year of practice, almost one half (45%) between 1±10 years of practice, and one quarter (25%) after more than 10 years of practice.

Challenges occurred during or immediately following a retreat for 43 practitioners (72%). The other 17 practitioners (28%) reported challenging experiences in the context of daily practice. About three-quarters (72%) of participants were regularly practicing within a meditation community or were working with a teacher (75%) when challenging experiences arose.

While we may think that spiritual practitioners experience a different context and intensity of meditation, Lindahl and colleagues point out that

…a number of participants also reported challenging or difficult experiences under similar conditions as MBIs, that is: in the context of daily practice; while meditating less than 1 hour per day, or within the first 50 hours of practice; and with an aim of health, well-being or stress-reduction. Some types of practice associated with challenging meditation experiences were in many cases not dissimilar from the primary components of MBIs.

Reason 3: Awareness of psychological and trauma history is important

More relevant to our discussion here, in Lindahl’s study 32% had a psychiatric history and 43% had a trauma history. They are careful to indicate that prior histories are not necessarily predictive or considered risk factors. At the same time, we know enough about the way psychological challenges, in particular, trauma, are processed that some caution is advisable.

This is where things get really complicated. Many of us may not know that or don’t see ourselves as having experienced trauma. While I do get irritated when some authors equate the “trauma” of burnt toast to the level of aversive childhood experiences (ACEs) that lead to significant debilitation in adulthood, trauma is an historic reality for many of us. The challenge is when we are so functional that we, ourselves, no longer view our history as “traumatic”. We may well have rebounded from it in healthy ways and feel it is something in our past.

But the body knows the trauma differently.

This is where being trauma-informed as a mindfulness therapist and as a mindfulness consumer is very important. The following three questions may help to be trauma-informed and know if the program you are considering is trauma-sensitive.

Question 1: Is the program trauma-sensitive?

This is actually a pre-program question. Ask the facilitators if they are informed of the potential challenges someone with trauma may encounter. Practices such as the Body Scan can evoke reactions if the participant has a history of physical or sexual abuse. Meditations that drop into deep relaxation and open the field of awareness can be anxiety-provoking. What are the facilitators’ approaches should this happen – in the classroom or between classes?

Question 2: What do certain terms mean?

“Just sit with it” or “turn towards the distress” are typical suggestions when participants are feeling distressing sensations or emotions. For the most part, they are acceptable suggestions or invitations to develop distress tolerance. However, if the distress escalates quickly or becomes too intense, these are not the best first line of practice. Ask for clarity and expect responses that are in everyday language.

Question 3: What practices are being taught to help when APEs occur?

Every program is different however there should be a component of grounding practices, resetting the physiology (using the breath), and/or adaptations to typical approaches in meditation. Can you open your eyes if things get activating internally? Can you stand, step out of the room and return, or care for yourself in some way that respects your needs and those of other participants? Can you meet with the facilitator after the class or, if you need to, during the week?

Mindfulness programs can be very helpful and life-changing. Our role as facilitators is to ensure that these practices can change your life in the right direction. Our role as participant is to feel safe and supported as we go along this path of practice.

Recommended Book: Trauma-Sensitive Mindfulness: Practices for safe and transformative healing by David Treleaven, W.W. Norton & Company


  1. Compson, J.C. (2018). Adverse Meditation Experiences: Navigating Buddhist and Secular Frameworks for Addressing Them. Mindfulness, http://link.springer.com/article/10.1007/s12671-017-0878-8
  2. Lindahl et al., (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

Book Review: Siddhartha’s Brain by James Kingsland

sid-brainSiddhartha’s Brain, written by science journalist James Kingsland, opens with what would be a somewhat shocking quote from Ajahn Amaro, a Buddhist monastic in the UK.

We are all mentally ill.

While this should not quite raise the eyebrows of mental health professionals, it is a rather bald (apologies to Ajahn Amaro!) statement to make in public. However, it does set the tone of Kingsland’s book which takes, by turns, an unflinching look at the state of the mindfulness industry today and the roots of its conception in Buddhist teachings. Kingsland presents his work imaginatively. Using the development of the Buddha, Siddhartha, from pampered and protected prince to a teacher of the Eightfold Path to liberation from suffering, he weaves what we know of Siddhartha’s quest and practice into what we know of the results of our current pursuit of liberation through mindfulness. And, it begins with acknowledging that we are all mentally ill.

In this insightful book interlacing the current findings of brain function, mental states, and mental health with the teachings of Buddhist psychology, Kingsland is a craftsman in making neuroscience accessible and presenting it through the lens of contemplative practices. Using the story of Siddhartha Gautama’s own journey to enlightenment, he draws a rich landscape of the merging of Eastern contemplative practice, Western psychology, and contemporary mindfulness.

As a device to introduce us to the roots of contemporary mindfulness and place the history and progress of the Western approach to knowing the mind in that historical context, Kingsland has done a much better job than most writers. Siddhartha’s Brain doesn’t fall into a polemic of modern science or a contemplative holier-than-thou pit; that is refreshing. The writing is crisp and clear, quiet and confident. It invites examination of concepts not by attempting to convince but by introducing perspectives that are easily testable by the reader. Of course, that is in essence the basic teaching of the Buddha: ehi passiko – come and see (for yourself).

Kingsland makes the important point – as have many Buddhist teachers – that one does not have to be Buddhist to meditate or benefit from the practice. In fact, one of the enjoyable aspects of Siddhartha’s Brain is a broader bandwidth than just a Buddhist social and political transmission of wisdom. Kingsland draws from evolution science, psychology, anthropology, and philosophy, weaving them together  with ease. Most poignant for me was his examination of the early beginnings of meditation through the stories of Herbert Benson and the Transcendental Meditation practitioners of Indian guru Maharishi Mahesh Yogi. Benson’s downfall in the community of psychology is a sad part of our collective history and Kingsland’s insight into Benson’s work – that the foundation of all meditation is the evocation of the relaxation response – is a validation of Benson’s valuable work.

I particularly recommend Chapters Three and Four for their lucid descriptions of the roots (The Cloud of Unknowing) and rationale (The Second Dart) for meditation and practice (and a more universal presentation than just a Buddhist one). It’s a bit more of a slog in Chapter Five (The Man Who Disappeared) only because the idea of a “self” that is not fixed in any one definition or role is still alien to our Western senses. Even in psychology today the discussion of identity is a confounding mess with terms like self-esteem, self-image, existential self, categorical self – all of which rests on a concept of a separate(d), individuated entity. Chapter Five will challenge your notions of these variegated and rarefied selves but also introduce you to the social neuroscience that actually supports the observation that there is no fixed unity called a “Self”. As Kingsland puts it:

Thus, from moment to moment, each of us is no more than a unique blend of spices, a homemade garam masala. (p. 101)

My favourite part of the book is the running theme of the Default Mode Network (DMN), a concept gaining much traction in the neuroscience of mindfulness to explain the fluid state of connection/disconnection that can lead to rumination as well as creativity. Kingsland’s description of how the DMN plays a role as our “Self app” that “(posts) repetitive messages of a personal nature on the screen” is a brilliant image of what happens when we wander down those “dark neighbourhoods” noted by the writer Anne Lamott as places she “never goes alone”.

Kingsland continues in Chapter Ten (Wonderful and Marvelous):

The marvel is that we can learn to control at will the signals that determine which track we take at any particular moment. By honing our powers of attention and emotion regulation through mindfulness practice, we can, if we wish, restrict the time we spend in self-focused, narrative mode of thinking that can lead to anxiety and depression. We can choose to take the scenic route, favouring a more experiential mode of being in which we are not held captive by our thoughts but rather treat them as transient mental events. (p. 235)

Now, I do have two quibbles – not with the book itself but the information offered from two sources. First, (p. 249) when inquiring into the frequently made claim that meditation can trigger unstable mind states, researcher Britta Hölzel is quoted as saying (somewhat flat-footedly) that “I (Hölzel) have never seen any major problems like that in our classes.” This is a common statement I hear from researchers and teachers of various mindfulness-based programs, which while true evades the question itself. In fact, we have, at the Ottawa Mindfulness Clinic, had many applicants to our program who want to learn mindfulness and are fearful because previous experiences have resulted in intense mental distress, including dissociation, depersonalization, and profound anxiety. Whereas it is quite likely that in Hölzel’s experience there have not been such occurrences, it does not therefore mean this is not an area to be sensitive about as clinicians and to investigate further as researchers. Ottawa psychologist Nicola Wright and colleagues have written about adapting mindfulness for vulnerable populations and it does behoove us to acknowledge this as a necessary direction for future research and definitely for caution.

Second, Ajhan Amaro, who seems to have been a delightful guide and teacher for Kingsland, wrote an important response to our target article in Mindfulness (journal). He calls for a need to include ethics explicitly as a core component of mindfulness programs. I do respect the stance taken by MBSR developers that the cultivation of ethical action is inherent in its programming (see discussion on p. 269 of Siddhartha’s Brain). However, a statement of presumed fact is not a substantiated fact nor does it address whether the outcome is in the desired direction. Given that no therapeutic intervention is values-neutral, the examination of how mindfulness can become weaponized (see my earlier blog post) is important. After all, we are collectively responsible to examine if mindfulness training does give rise to skillful action and ultimately compassion for ourselves and all others.

Kingsland has done well in this book to translate complex concepts into accessible knowledge and convey ancient wisdom with a gentle, inviting voice. If you are at all fascinated by how and why our brains and being are the way they are, read this book. If you are curious about how meditation and mindfulness practices can help with the everyday struggles of just being human, read this book.

PTSD, Growth & Recovery: Bouncing Forward by Michaela Haas

Trauma and its sequelae are likely the greatest challenge we face as individuals who have experienced them and as healthcare professionals who try to help. For decades and generations, post-traumatic experiences have been misunderstood, mislabeled, and misrepresented. It wasn’t that long ago when I found myself in a shouting match with a military medical healthcare individual who kept screaming at me, “There is no SUCH thing as PTSD!” It wasn’t that long ago when I listened to some of my education program cohort telling me my reactions to what I felt was professorial bullying were probably “cultural” and “well, you know, not Canadian-like.”

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Self-Compassion Practices for Emotional Distress: It’s not just about being kind

leavesSelf-Compassion practices and programs are gaining momentum in psychological treatments and look like they might well become the next wave of transforming our painful feelings. Mindful Self-Compassion (1), developed by Drs. Christopher Germer and Kristen Neff, is an approach that can be both an adjunct to conventional therapies as well as a stand-alone treatment model. The interesting and very useful aspects of this approach are its applicability to our multilayered experiences of suffering. First, let’s look at what they define as Self-Compassion.

Neff (2) describes it as a three-fold system that are antidotes to the experiences that cause us suffering. (A sidebar note: Suffering is typically described as Pain multiplied by our Resistance to the reality of that pain (3)). Here’s a table that summarizes Neff’s definition of self-compassion. Continue reading

Solitude, Solstice & the Longest Night

tree

 

We enter solitude, in which also we lose loneliness…

True solitude is found in the wild places, where one is without human obligation.

One’s inner voices become audible. One feels the attraction of one’s most intimate sources.

In consequence, one responds more clearly to other lives. The more coherent one becomes within oneself as a creature, the more fully one enters into the communion of all creatures.

Wendell Berry on solitude from Brain Pickings

 

December 21 (today) will be the shortest day and longest night. As a bonus, tonight will also be the longest night in earth’s history (apparently not according to the linked article). Fascinating astronomical facts! This date, in a mind-opening way, is also the turning point at which the days begin to get longer. As poet and artist Richard Wehrman wrote, introducing his Solstice poem: At the darkest, the turn toward the light.

This time of year is also a time of contemplation, of entering into a period of reflection on the path our life has taken and the cultivation of a wish for the direction it can take. It’s ironically embedded in the most emotionally activating time of year as well. However, we also fear this opportunity for solitude and perhaps fall into the rush and chaos as a welcomed escape from our thoughts because the idea of solitude, being with ourselves, lies too close to our fear of loneliness, being alone, without support or care.

In one recent study, later refuted by Keiran Fox and Kalina Christoff, it seemed like people would prefer to avoid their thoughts to such an extent that they would rather shock themselves. Fox & Christoff re-visited the data from the original researchers and showed that the conclusions didn’t support the conclusion of the participants’ aversion to being alone with their thoughts. Fox & Christoff interpreted the data as suggesting the participants were curious about the shock itself and that several didn’t use the shock at all. Others were thinking pleasant things about weekends, etc. In other words, we don’t tend to be horribly avoidant of our thoughts however we may not be very skillful in relating to them either.

lighthouseSolitude, especially where there is no structured task or schedule, provides the opportunity for spontaneous thoughts that can play a role in creativity. We can also get so caught up in these live-streaming thoughts that we lose track of what our intention was; this is the downside of ‘mind wandering’ (MW). Typically, we believe that the alternative to mind wandering is to get control over that mental process, suppress the thoughts and re-direct ourselves back to the task at hand. In their chapter on this topic, Fox and Christoff explore how the interaction between the mind wandering part of our brain and the metacognitive (reflective, monitoring our own thoughts) is actually cooperative and symbiotic. The positive aspects of this relationship are creativity, mindfulness or insight, and lucid dreaming. Interestingly, in meditation spontaneous thoughts are present as is the awareness or monitoring of these thoughts; and, areas of the brain connected to mind wandering and metacognitive functions both are active.

This contemplative time of year offers us the opportunity to connect with these aspects of our mind. As with anything, it can be directed in a healthy way or in a way that leads us to feel bad (or worse).  This is why consistent and dedicated practice is important. More specifically, a commitment to meditative practice is crucial. Spontaneous thoughts arise and suppression never works; we need to be aware that some thoughts have a positive trajectory, some neutral and some take us down paths that are harmful to our mental health. The metacognitive practice – monitoring the quality and directionality of our thoughts – plays an important role in discerning which thoughts patterns are just re-hashing old unhelpful stories and which are healthy and creative ways of engaging in our life at this moment.

This perspective goes beyond the aphorism that “thoughts are not facts.” The existence of thoughts IS a fact. However the belief that they direct our actions is not a fact. Thoughts play an important role as indicators of wise choices, markers of health and activate our creative encounter with life.

Take this time to discover this new relationship with yourself.

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The staff and teachers of the Ottawa Mindfulness Clinic send you warmest wishes for a vivid and luscious celebration of solitude as we turn toward the lightening days ahead.

Thank you for your support of the OMC and our best wishes for the New Year!

OMC at the UCSD conference February 2013 – Bridging the Hearts and Minds of Youth

We are so thrilled that our workshop, Fired Up by Generosity or Burned Out by Giving: How to Survive the Demands of Caring – Lynette Monteiro and Frank Musten, will be presented at the University of California – San Diego Center for Mindfulness Conference February 2013.  Please help to spread the word about this terrific conference!  As you can read below in a letter from Dr. Steve Hickman, Director of CFM, the central gift in the conference features Jon and Myla Kabat-Zinn who will offer a public talk, keynote speech, and a parenting workshop.  Please share this valuable information freely with your colleagues, friends, and family!
 

This past February, the UC San Diego Center for Mindfulness hosted the first national conference dedicated to the fast-growing field of teaching mindfulness to youth, entitled Bridging the Hearts and Minds of Youth: Mindfulness in Clinical Practice, Education and Research, and it was a resounding success! I like to say that what happened in San Diego those 2 days was “a community discovering that it IS a community” and celebrating their existence and work thus far.

Thanks in large part to a commitment by Jon Kabat-Zinn and his wife Myla, to speak and offer a workshop on Mindful Parenting, the Second Annual conference is now booked and open for registration on February 1-3, 2013 at the Catamaran Hotel in San Diego and I hope that you will consider attending. In addition to Jon’s public talk on Friday evening and the parenting workshop, we will be adding two research symposia and a poster session, and will be featuring keynote talks by notable leaders in the field Linda Lantieri, Margaret Cullen and Tish Jennings. There will also be a number of pre- and post-conference workshops dedicated to practical skill-building and training in a variety of approaches to mindfulness with youth.

I strongly urge you to consider attending and/or sharing this information with any of your colleagues or friends who may have an interest. Our intended “market” is clinicians, educators, researchers and interested parents who wish to explore and expand their understanding of bringing mindfulness to our kids and teens. Continuing Education credits for physicians, psychologists, therapists and educators will be available.

Here is the link to the conference site: http://cme.ucsd.edu/bridging/

Thanks for taking the time to read, forward and consider this invitation!

The Up Side of Down

Why being up can get you down

I fell in love with jogging when I was in my mid-20’s.  Over-weight, miserable, and in a soul-devouring job, I took to the gym every day.  This love affair with jogging has lasted all my life though, like anything that is not a full-hearted commitment, it has suffered from severe neglect for great lengths of time.  Yet every winter I decide I will train for another 5 km run and dive happily into the daily workouts and practices.  And every summer, I hit the same motivation wall at the start line of the run. My running friends give me great advice on how to overcome this runner’s block.  Be positive!  Put yourself at the end of the race!  Do it for someone you love!  Offer it up as a gift to someone!  Pay yourself with bling!  Have a donut at the end!

I really appreciate all this post hoc cheerleading and that suggestion for bling truly speaks to my inner magpie.  However, it rarely works for me.  In fact, on one race, my marriage almost ended as my dear partner, sensing my plummeting morale, cried out, “What a beautiful day!  Isn’t it such a joy to be running along the canal on a day like this!?”  I credit my Buddhist practice of non-violence (and the fear of horrible re-birth) for not pushing him into the canal.

What’s wrong with being a Cherrie Cheerful?

Other than running the risk of being naïve or insensitive to what’s actually going on, there’s probably nothing bad I can say about being cheerful.  However, it is really important to understand that having a positive stance to our experience is not the same as engaging in positive chatter no matter how well-meaning.  Perhaps a better way to put it is that, when faced with challenges, it helps to cultivate an even-handed stance to our experience.  “Positive” in this sense means we look at what is happening in a way that keeps us steady in the face of the difficulty.  We see what is happening and do our best not to avoid the uncomfortable feelings by distracting ourselves from it.  Although positive commentary (or affirmations) may be somewhat useful here, it is more likely to defer the inevitable or prevent us from making clear-minded decisions by tangling up our thinking.

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