Mary Anne La Torre Perspectives in Psychiatric Care Jul-Sep 2001

It may come as a surprise to some practitioners, but as early as 1977, the American Psychiatric Association was suggesting that "meditation could facilitate the therapeutic process" and it encouraged research to "evaluate its possible usefulness" (Task Force on Meditation, 1977). That statement was made because a growing number of clinicians, particularly psychoanalysts, were working with meditation and psychotherapy together and finding it a powerful combination (Carrington & Ephron, 1975; Shafii, 1973). So, one might wonder, what's happened? How could an approach that seemed so promising and is so effective still be considered somewhat on the fringe?

The answer, in part, may go back to some of the originators of psychoanalytic theory. Freud, while unfamiliar and inexperienced in meditation, believed it evoked a regressive state and considered it pathological rather than a productive integrative approach (Epstein, 1984). His attitude was adopted by many of his followers and tended to perpetuate a tradition that equated meditation with religious, irrational, and infantile thinking. A small minority of neo-Freudian psychoanalysts did approach the concepts of meditation and psychotherapy with an open mind (Homey, 1945; Kelman, 1960), but they did little to change the deeply entrenched view that these two approaches stood very much apart.

Current research into the effectiveness of meditation on a whole range of medical and psychological problems has begun to call into question this old separatist view, as more and more data support the use of meditation for any number of psychological problems ranging from anxiety to schizophrenia (Kutz, Leserman, et al., 1985). Over time, considering the growing number of practitioners who are using and researching this combination, the use of meditation in the therapeutic process may become an important tool to support change and increase insight. This column discusses some of the advantages of combining meditation with psychotherapy and provides a description of what a sitting meditation practice looks like and how it can be generated in the therapeutic session. A brief clinical example is given to show how the principles can be integrated into a whole.

The term meditation may mean any number of things and approaches, from focusing on the breath to repeating a mantra (word). Whether one is practicing transcendental meditation, mindful meditation, or another kind of meditation, a number of principles are basic. First, there is a focusing of attention (Kabat-Zinn, 1982). This focusing is achieved by "restricting the attention to a single repetitive stimuli, such as a word, sound, prayer, phrase, the sensation of breath or a visual object" (Kutz, Borysenko, et al., 1985, p. 2). At the same time, the participant maintains a passive attitude and becomes a silent witness to his/her thoughts, accepting whatever they may be with a nonjudgmental attitude (Castleman, 1996). When the attention wanders, the meditation continually refocuses on the meditative stimulus. When strong feelings arise, the meditator notices the feeling and allows himself or herself to be with the feeling as it occurs, observing it until it subsides, then returning to the object of attention (Astin, 1997). As the ability to meditate and focus increases, a number of physiological changes have been shown to occur in the participant. Benson (1974) termed these changes "the relaxation response" and noted they include a decreased heart rate and breathing rate and a lowering of blood pressure. Further studies also have shown changes in EEG brain-wave activity as well as increased hormonal levels of cortisol and serotonin (MacLean et al., 1997).

Beyond these significant physiological changes, there is a change in the perception of the meditator. With observation comes increased awareness of the content of thoughts and images. Patterns and habits begin to emerge, and feelings that were once overwhelming begin to be just a part of the whole that is being observed (Kutz, Borysenko, & Benson, 1985). In addition, Kutz et al. point out, there is a loosening of defenses, an emotional receptivity, which allows for the emergence of repressed material. This heightening of emotional awareness occurs in a quiet soothing state, which allows for feelings to be owned and felt from a greater place of safety (Kutz et al.).

One can easily see how combining meditation and psychotherapy, each reinforcing the other, would enhance the process. As the meditator becomes aware of feelings and discomforts, the therapeutic session provides the opportunity to discuss and explore. As new insights emerge, the meditative arena provides the opportunity to observe and reflect them. The meditative technique can be practiced away from the therapeutic session as well as in the session itself, thereby giving the client a greater sense of freedom and self-mastery. Smith (1998) found this self-management increased confidence and motivation, which, when brought back into the therapeutic session, enhanced the ability to tolerate change and fostered greater personal responsibility.

Clinical Practice

To introduce the concepts and techniques of meditation into the therapy session, it is helpful for clinicians to have had some experience with the approach. It makes it easier to teach as well as to support clients, as they practice the approach and wonder initially whether it will have any positive effects or if they are "doing it right." In this day and age, where the expectation is instant relief, meditation takes time and patience, but as the client becomes more and more involved in the process, it becomes easier and very natural. The clinician who has had experience with some form of focusing can be helpful in those times of doubt and resistance.

The initial approach usually involves focusing on the breath as a way of increasing awareness as well as going inward and generally relaxing the body. The idea of "taking a deep breath" is something we all can relate to as a way of transitioning into another place. Kabat-Zinn et al. (1992) suggest doing a body scan at this time further relaxes the body and enhances focusing. This can be accomplished by having participants turn their awareness inward and noticing any sensations in their body while they remain aware of their breathing (Castleman, 1996). The noticing begins at the toes and works slowly upward as the participant becomes aware of any tension in particular areas of the body and uses the breath to focus on releasing and relaxing the area (Astin, 1997). This approach gives the participant a method of relaxing and beginning the process of meditating that can be used and practiced both in the session and at home.

From this point, any number of approaches can be considered: selecting a single word or phrase, or mantra, and repeating it over and over; looking at a candle flame; or just continuing to breathe. Kabat-Zinn explains, "It's not so much what you focus on but how you do it, the quality of awareness you bring to each moment" (1990, p. 71). The key to this awareness is a sense of acceptance of whatever is, an observing attitude that notices without judging. When strong feelings or emotions arise, they are just noticed, observed for what they are, and allowed to be in the awareness for as long as they need to be (Castleman, 1996). As feelings subside, the participant returns to the focusing object (the breath or phrase) and the process continues in this way, with thoughts and feelings ebbing and flowing as the participant becomes aware that thoughts and feelings are transitory events that one watches, not that one is (Astin, 1997).

Generally, it takes at least 10 to 15 minutes of quiet focusing to begin to establish the pattern of observing and accepting, although some experts feel more time is necessary (Kabat-Zinn, 1990). In the beginning, practitioners may have difficulty with even that amount of time, but gradually, as they begin to enjoy the calming and relaxing benefits of meditation, it becomes easier. Sometimes atonal music can be supportive in this time as a way of helping the client settle into the meditative practice.

Deciding when to take this meditative time in the session depends on the client and the focus of treatment. I've found incorporating 15 minutes of meditation at the beginning of a therapy session usually creates more relaxation and focusing in the session itself. I've used the approach in the middle of a session, when the client appears blocked or is having difficulty accessing or articulating his or her feelings. I've also used the approach at the end of a session to promote some reflective time before the client leaves, thereby encouraging and supporting further work outside the session. Each case is different, but in most cases incorporating meditation into the session has enriched the therapeutic milieu and given the client a greater sense of control and awareness.

Clinical Example

Kathy, 35 years old, had been married for 4 years and felt she was at a critical time in her life. There seemed to be so many questions without answers. Should she have children? What about her career? Why couldn't she decide anything and just go ahead with it? There seemed to be no end to the "life stuff." It overwhelmed and immobilized her, creating a sense she was wrong no matter what she decided, and she was wrong because she couldn't decide. Depression was a constant companion, and even when it seemed to let up, she would continue to worry and feel guilty.

In the sessions, she moved from option to option, confused and unclear, feeling her thoughts were as cluttered as her surroundings. As we talked, she tried to work out what was really causing the distress, but she seemed unable to move beyond the constant chatter and pressure from her thoughts. Since initially she had asked to learn some relaxation techniques as a way of helping, I began to incorporate some exercises, starting with deep breathing and a visual body scan. We would start each session by taking some deep breaths and then focusing on the tension in her body. Since Kathy seemed to spend so much time in her head, myriad thoughts endlessly rolling around, focusing on the body both shifted attention and reduced tightness in areas that physically held much of her psychological tension. Then, too, increasing her awareness of her body and relaxing it gave her a sense of success-she could do this-and perhaps it suggested she could do other things as well.

As Kathy became more proficient in the breathing and relaxation exercises, our sessions began to focus increasingly on her sense of underlying sadness. She felt disconnected, as if she was searching and couldn't find what she needed, yet she didn't know what she was looking for. Her thoughts were less scattered and agitated, even though she still felt immobilized and indecisive. At this point, I introduced the concept of meditation, explaining it as an extension of our relaxation exercises and as a further way for her to access her thoughts and feelings, as well as relax her body. Kathy was agreeable to expand our relaxation time, and I began taking the first 15 minutes of each of our sessions for a meditation exercise. I would begin the process by focusing her on her breathing, asking her to continue to watch her breathing as she observed what thoughts and feelings arose. We would breathe together, and after 15 minutes I would ring a bell to let her know our meditation time was over.

Kathy was quite responsive to this approach. She liked the quiet breathing; it seemed to settle her and center her thoughts. Issues related to her mother and feelings of abandonment began to emerge, as the meditations brought up emotions and thoughts that became subjects to focus on in the sessions. Since we focused on them often as something that came up in the meditation rather than something she was distressed about, it seemed easier to explore and discuss, less tainted with emotional baggage.

Gradually, Kathy was able to see a pattern emerge related to the pressure she put on herself to perform and her family's expectations. She also became aware that she never really asked herself what she wanted, only what she was "supposed" to be doing. This shift in her internal dialogue allowed Kathy to begin to feel comfortable. Meditation practice at home increased her ability to be more present to what she needed, rather than what she should be doing.

When Kathy found out she was pregnant, she felt a greater sense of hope that she could be a good mother and nurture herself as well. The meditation practice seemed to provide the cornerstone, easing her transition into this role and allowing her to decrease our sessions as she became more confident in her own ability and self-mastery.

Kathy's situation is an example of how effective meditation and psychotherapy can be practical together. As more clinicians feel comfortable with this combination both for themselves and their clients, there will be even more creative applications to support the healing process.