Differential Diagnosis and Intervention Criteria for Meditation-Related Challenges: Perspectives from Buddhist Meditation Teachers and Practitioners
by Jared R. Lindahl1*, David J. Cooper2, Nathan E. Fisher3, Laurence J. Kirmayer4, Willoughby B. Britton2
Frontiers in Psychology: doi: 10.3389/fpsyg.2020.01905
ABSTRACT:
Studies in the psychology and phenomenology of religious experience have long acknowledged similarities with various forms of psychopathology. Consequently, it has been important for religious practitioners and mental health professionals to establish criteria by which religious, spiritual, or mystical experiences can be differentiated from psychopathological experiences. Many previous attempts at differential diagnosis have been based on textual accounts of mystical experience or on outdated theoretical studies of mysticism. In contrast, this study presents qualitative data from contemporary Buddhist meditation practitioners and teachers to identify salient features that can be used to guide differential diagnosis. The use of certain existing criteria is complicated by Buddhist worldviews that some difficult or distressing experiences may be expected as a part of progress on the contemplative path. This paper argues that it is important to expand the framework for assessment in both scholarly and clinical contexts to include not only criteria for determining normative fit with religious experience or with psychopathology, but also for determining need for intervention, whether religious or clinical. Qualitative data from Buddhist communities shows that there is a wider range of experiences that are evaluated as potentially warranting intervention than has previously been discussed. Decision making around these experiences often takes into account contextual factors when determining appraisals or need for intervention. This is in line with person-centered approaches in mental health care that emphasize the importance of considering the interpersonal and cultural dynamics that inevitably constitute the context in which experiences are evaluated and rendered meaningful.
Keywords: Religious experiences, Adverse experiences, Meditation, Buddhism, Mental Health, Psychiatric Diagnosis
Key Findings:
Past research indicates that appraisal of a meditation-related experience as “spiritual” or “psychopathological” rarely depends on the nature of qualities of the experience itself, but rather by many other factors, including the duration or impact of the experience and the goals and training of the person making the appraisal. In our research, we assessed how meditation teachers decide on the need for intervention, not theoretically or in the abstract, but in real world scenarios. We also asked meditators what criteria they used to appraise their experiences. The most and least useful criteria are described below. Since meditators and teachers often disagreed on how to appraise their experience, we recommend a person-centered approach where the meditator’s perspective and best interests be given priority.
What were the most useful criteria?
Distress, duration, and control, functional impairment, loss of critical attitude, and certain phenomenological qualities—especially loss of ability to sleep, mania, delusions, suicidality and disruptive behaviors— were regularly used, especially by teachers, in determining need for intervention.
Problematic criteria: (Projected positive) impact and Meditator’s Health History
Two criteria—positive impacts and a meditator’s health history or conditions—seemed particularly problematic with respect to practical decision making about meditation-related challenges. First, relying on downstream positive impacts in order to retrospectively appraise an experience as spiritual or religious does not facilitate immediate decision making about whether an intervention is warranted. One of the consequences for those who valued this criterion and framework was that further meditation practice might be recommended instead of alternate interventions, which in some instances may have further exacerbated the problem. Furthermore, the use of vague and unfalsifiable constructs such as expectations of “purification” or “spiritual growth,” also hinder the utility of this criterion. Although negative impacts or deteriorations also require a diachronic assessment, these judgments tend to be made upon observable behaviors such as ongoing or increasing symptoms, or worsening levels of distress or functional impairment.
A meditator’s medical, psychiatric, or trauma history or conditions could also function as a retrospective explanation for why some practitioners had challenging or destabilizing experiences while others did not. Teachers sometimes assumed that psychiatric or trauma histories were the primary and sometimes even the sole explanation for meditation-related challenges, although the demographic data from the VCE study does not support this strong association (Lindahl et al., 2017). Indeed, this criterion could lead to circular reasoning as well as discrimination: if challenging or unusual meditation effects that occur in individuals with psychiatric histories are always evaluated as psychopathology, then this criterion would preclude those with psychiatric or trauma history from having their challenging experiences legitimately appraised as spiritual or religious. In fact, psychiatric or trauma history and religious experiences are not mutually exclusive. Practitioners with psychiatric or trauma histories can have what they or others consider to be valid, if challenging, religious experiences; conversely, as many teachers and practitioners stated above, individuals without any prior history of mental health problems can develop meditation-related challenges appraised as psychopathology (Yorsten, 2001; Lindahl et al., 2017; Lindahl and Britton, 2019). Evaluating experiences with retrospective criteria such as positive impacts or health history also enables authorities (i.e., meditation teachers) to claim the benefits from the cases that happen to turn out well by appraising such experiences as religious and attributing those effects to the practice, while deflecting responsibility for and distancing themselves from the negative implications of the cases that do not turn out well.
Spiritual vs Pathological is not the right question. Instead ask “What kind of support does this person need?
Another key finding in this study is that in many instances, the focus of meditation practitioners and meditation teachers was not strictly determining the nature of a given experience as either “religious” or “psychopathological,” but a more pragmatic concern with determining whether a particular experience, regardless of appraisal, warranted additional support or intervention. Shifting the question from the either/or of differentiating religious experience from psychopathology to determining the need for some form of intervention can allow a more nuanced and flexible approach to emerge, especially in ambiguous situations.
Consider the social position of the meditator with a person-centered approach
Distinguishing personally and spiritually valuable experiences from illness and affliction that require medical and psychological intervention is challenging but becomes especially difficult in settings where there are conflicts of interest. The social and professional positioning of the appraiser often determines which frameworks are applied and how (Helderman, 2019), and this may not always be in the best interests of the practitioner. When an appraisal of a practitioner’s experience is used to protect the interests of the teacher and organization, there is the potential for great harm to the individual. In contrast, when differential diagnosis is person-centered and the practitioner’s values and goals are explored as part of the assessment process, some of these problems can be avoided (Kirmayer et al., 2016). Making sense of the individual’s experience also requires systematic attention to the social and political contexts in which it occurs. A truly person-centered differential diagnosis would take seriously the criteria that the meditator would use or want used, even if this conflicts with the personal views of the meditation teacher or the religious tradition (Lindahl et al., 2019).
Clinical interventions for anomalous experiences are more effective when they accord with “the understanding and meaning relevant to the culture of the individual having the experience,” and in cases where there are conflicting explanatory frameworks, acknowledging the individual’s preferred cultural framework(s), whether religious or biomedical, is beneficial