Speaker 1 · 0:04Welcome everyone. I'm really looking forward to today and today's guest. We have Willoughby Britton to talk about identifying and managing the adverse effects of mindfulness meditation. For those of you not familiar with her, she's a clinical psychologist, an associate professor of psychiatry and human behavior at Brown University Medical School, and the director of Brown's Clinical and Effective Neuroscience Laboratory. Her clinical neuroscience research investigates the effects of contemplative practices on the brain and the body in the treatment of mood disorders, trauma, and other emotional disturbances. She is especially interested in practice-specific effects, individual differences, and moderators of treatment outcome, or in other words, which practices are best or worst suited for which types of people or conditions and why. Dr. Britton is the founder of Cheetah House, a nonprofit organization that provides support for meditators who are experiencing meditation-related difficulties and meditation safety trainings to providers and organizations. Willoughby, it's an honor to have you. Thank you so much for joining us.
Speaker 2 · 1:35So, what is the frequency of meditation-related adverse effects? It sounds like a really simple question, but it's incredibly difficult to answer. One reason why it's difficult to answer is that most studies don't measure adverse effects. So, this is a meta-analysis that was conducted in 2020 of over 12,000 studies of meditation. And they found that only 1% actually measured adverse effects. So that's not helping. The other reason is that the definition of adverse effect is going to determine the frequency. And everybody defines it differently. So basically, before our study in 2017, there were really no studies on meditation-related adverse effects, or very, very few well-done studies. And since then, I found 10 more. And the percentage, the frequency, is all over the place, depending on how you define adverse effect. And so you can see that there's up to 90% of people have adverse effects. If you define an adverse effect as seeking medical treatment, it's 6%. So it's all over the place. And it depends on whether it's a regular meditator or a mindfulness-based program. There's all sorts of different reasons that affect frequency. So I'm going to focus on two that I was involved with because I think that the way we defined it was very precise. So this is all covered in a paper that I wrote basically during the pandemic called Defining and Measuring Meditation Related Adverse Effects in Mindfulness-based programs. And just to give you my definition, a side effect is any effect outside the intended goal of whatever you're advertising. So if you're advertising stress reduction, you know, it's anything outside of that, any category of this varieties of contemplative experience study and any valence. This could be positive, negative, or neutral. So side effects don't have to be negative, they can be positive too. An adverse effect could mean a lot of different things, but we're defining three different kinds. One is a negative valence, which is something that is negative when it's occurring. So basically transient negative distress during meditation. And then negative impact is when now we're talking about things that impact you off the cushion. They start impacting your life and functioning. They start impacting how you behave. And then we have something called lasting bad effects, which is negative impact on your life and functioning for more than just a brief period. So more than a day, more than a week, or more than a month were the ones that we looked at. So in the research study that I did, and this was actually a dismantling study of mindfulness-based cognitive therapy, and just call it a mindfulness-based program, we found that 83% of the sample, so like almost everyone, had some kind of side effect, meaning an unusual meditation experience. And I don't think it's surprising that I think we all know that meditation can cause altered states of consciousness. So that shouldn't be news. But what might be interesting is that we're seeing this very commonly even in mindfulness-based programs, the secular mindfulness-based programs. Secondly, and these are the unpleasant experiences or transient distress during meditation. This is also extremely common. Meditation is not always relaxing. People should know that. This can be managed with expectations, what people expect when they come, and just to know that it's not always relaxing. So I don't personally consider these adverse effects. I think adverse effects are when it starts to impact your life off the cushion. And so in our sample, we found 37% had some impact on their life. And that could be something where they didn't want to meditate or they might feel kind of spaced out afterwards and had this to walk around the block a couple of times before they wanted to drive. So impairment of functioning didn't have to be a serious impairment. It just had to involve some kind of change in behavior. And then for lasting bad effects, we found six to 14% of people had something that lasted more than a day, more than a week, or more than a month. And just for reference, lasting bad effects in psychotherapy are about 5% to 13%. So we're basically seeing very similar kinds of adverse effects as you would see in psychotherapy. So that was my study in MVPs. And then this other study I did with Richie Davidson and Simon Goldberg. I created the questionnaire based on that study that I just showed you. And this was done in an epidemiological sample, which basically just means that it's very representative. It's a sample that is pretty valid in terms of making generalizations. And that sample was people in the US who had tried meditation at least once. And so here's what they found. The first piece of data, which was really kind of mind-blowing, was that almost half of all people in the US have tried meditation at least once. That's the highest number so far of any study done so far. So almost half. And then in terms of adverse effects, almost half of all meditators reported at least one meditative-related adverse effect. 10% had a meditation-related adverse effect that lasted more than a month. And 10% had one that was associated with functional impairment. So I know I'm going to be throwing lots of numbers at you, but the one number to remember was that if you're thinking about frequency, you should say at least 10%. At the very minimum, you're going to see 10% of people who are having an adverse effect that you need to worry about, that needs some kind of attention from the teacher, one out of 10. So the second question is what types of meditation-related adverse effects are most likely in mindfulness-based programs? So back to the contemplative varieties of contemplative experience study. If you go to that study and download some of the supplemental material, there's a phenomenology codebook, which is basically a list of 59 categories of potentially challenging meditation experiences. And, you know, this was a different sample and a sample of people who were doing lots of intensive retreats. So there's some more intense symptoms like psychosis and things like that in this handbook, but we're not going to talk about that today because that's pretty unlikely that you're going to see that. We're going to talk about what you're most likely to see in mindfulness-based programs without retreats. And in particular, I'm not even going to talk about the most common things. I'm going to be talking about the things that are the most likely to be associated with negative impact. So in my study, these were the things that the participants rated as having a negative impact on their functioning outside of meditating. So as a result, but on their life and functioning. We have symptoms of hyper-arousal. And that's going to be things like anxiety and panic, agitation, emotional reactivity, re-experiencing of traumatic memories or just stressful memories, insomnia or nightmares, headaches or body pain, perceptual hypersensitivity, and involuntary movements, somewhat associated with hypoarousal. So this is the dissociation symptoms. So disturbance is in sense of self, emotional numbing, concept loss is the inability to use concepts. And one example from a meditator who was coming back from a retreat, was driving and she saw the color red, the stoplight was red. And she could see that it was red, but she couldn't remember what it meant. She couldn't remember that it meant stop, which you could see how that could be a pretty serious problem. And so that's what concept loss is like. People train in non-conceptuality and then they lose their ability to use concepts. Derealization is the world appearing dreamlike or unreal. Temporal disintegration is a loss of time, particularly hyper nowness and losing past and future. And then kind of a hybrid of these could be either hyper-arousal or dissociation. So executive impairment, so problems concentrating, remembering things, and making decisions. And then also social impairment or social withdrawal or disengagement. So these are kind of the ones to watch. And then we re-ran the analyses to look at, statistically speaking, which symptoms predict lasting bad effects, lasting impairment. Things like anxiety and insomnia and things people are going to experience as negative and they're likely to tell you. People don't necessarily even know that they are having dissociation or it's not necessarily negative. And so they won't necessarily report it to you. And what's interesting about that is that, you know, I was trained to tell people to basically whatever comes up, just accept it and, you know, reappraise it as not a problem. And this is basically saying that that's not going to be enough. In the case of dissociation, many people don't mind dissociation. So they're not judging it as negative, but it will still lead to impairment and functioning. Another thing to notice is traumatic re-experiencing didn't actually increase risk for impairment or problems. So that means that even though we're like very focused on trauma-informed or re-experiencing trauma as this thing that we need to watch out for, our data suggests that it's not actually as sort of problematic as other symptoms to watch for. And we know that some people can have re-experiencing and it can be healing, and some people it becomes destabilizing. But I would look more for dissociation. Okay, so the next section is on neurobiological mechanisms. And this I'm drawing from two videos that I have online that are each an hour long. There's a lot of different models of mechanisms of hyper-arousal. If you are interested in trauma particularly, I would recommend going to see those and particularly focusing on dual representation theory, which I'm not going to be talking about today, but is particularly relevant for trauma. So some of this is covered in a paper that I wrote called Can Mindfulness Be Too Much of a Good Thing? The value of a middle way? And the main point of this paper is something that is called the inverted U-shape curve. And this is a principle that, if you understand this principle, it'll make sense to you why and how meditation can cause problems. So the basic idea behind this inverted U is that everything has an optimal level. Every physiological and psychological process has an optimal level. And if you go further than optimal into an excess, it can start to have negative effects. This is also called the Yerkes-Dodson law. I don't know if that rings a bell from like fourth grade biology class, or it comes from Hans Sely's stress research where there's an optimal level of arousal. So for example, right now, I'm pretty amped because I have a lot to remember and I drank a lot of coffee. But if I started to get any more amped, I would start to get anxious and I would start to stutter and lose my thinking. And if I was any less amped, then I'd be like too sleepy and I wouldn't be able to remember everything. So like there's an optimal level of arousal and there's an optimal level of mindfulness. So that's the basic idea. And I'm going to take this principle, the inverted you principle, and I'm going to apply it to a whole bunch of different things, and you'll start to see why and how mindfulness can lead to certain problems. The first thing I want to talk about is the attention and arousal systems. And I think that this is very intuitive and obvious if you think about it. So the systems of the brain that are involved in attention are also involved in arousal. And if you think about any of the drugs that people take in order to improve attention, so coffee, cocaine, amphetamine, Ritalin, any of those types of drugs, if you take enough of them, they're going to start to cause anxiety and insomnia. So yes, they'll improve your attention sort of at low levels, but then if you keep going, it's going to start causing insomnia and anxiety, too much arousal. And that's basically the same idea that if you think of meditation as a attention-enhancing drug that changes your brain, which it does, you can overdo it and start to have too much cortical arousal. Ironically, this was actually the first study that I ever did. So this was my dissertation study where I actually watched 200 people sleep in a lab, and then I taught them meditation, and then I watched them sleep in a lab again. Many nights of my life was the study. I thought I was going to prove that meditation improves sleep and be one of the first people to prove that. And it was like completely the opposite of what I thought. So this was another part of my origin story is that meditation actually caused cortical arousal in a dose-dependent way. So we recorded brain waves and we found that the more people meditated, the more awakenings they had at night according to their brain. Less than 30 minutes a day was sleep enhancing. More than 30 minutes a day started to increase arousal. And the same thing for slow wave sleep, which is your deep sleep or delta sleep. The more people meditated, the more frequently they meditated, the less deep sleep they had. And the cutoffs seem to be more than five days a week. They had less deep sleep, less than five days a week, and they had more deep sleep. So there's a dose response, you can over-meditate. Unless you want to not sleep, then you can, so it really depends on what your goals are. The second way that meditation can lead to hyper-arousal, over-arousal, is something called somatosensory amplification or sensitization through interoception or body awareness. And it's focused on an area called the insulacortex, which you may have heard of. And, you know, within the neuroscience of meditation, there are not a lot of consistent results. They're kind of all over the place. But one of the few results across different kinds of meditation is the insulacortex, that it increases in size and activation. It tends to be higher in activation and size in advanced meditators compared to novices. It's increased in activation during meditation versus at rest. It increases following mindfulness-based interventions, and the increase is correlated with practice amounts. So that is like a lot of really consistent data. So you're going to see increases in the size and activation of this one area of the brain called the insular cortex. Now, often you hear, especially in the mindfulness world, that increases in insula activation are associated with enhanced interoception or body awareness. And that's true, but what they don't tell you is that it's also associated with arousal, emotional intensity. If you stimulate the insular cortex, you can induce terror or fear. It's also a marker of anxiety and PTSD and flashbacks. So going back to our ubiquitous U-shaped curve, you can have an optimal level of insula activation or body awareness. If your body awareness is low, then doing body scans and breath awareness and really getting to know your body can increase that sort of deficit that you had, and you can really get to know what your emotions are, which are going to help you detect your emotions earlier and regulate your emotions better. However, you can overdo that and you can develop something called central sensitization, which is basically too much arousal, like I said, insomnia, high levels of emotional intensity, anxiety, pain syndromes, tinnitus, and headaches. Here's a little bit of data to just kind of make this point again. This was a study by Tanya Singer from Max Planck Institute in Germany. And she basically did this amazing study called the Resource Project, where she compared a lot of different kinds of mindfulness practices. And they did them for like nine months. And then she put them through the ringer and did all sorts of tests on them, physiological tests. And this particular test was the trier social stress test, where people gave a public speech, which is incredibly stressful. And then they looked at their cortisol responses or their stress hormone responses. And the group that got interoceptive awareness, which was basically breath awareness and body scans, which is pretty standard for mindfulness training. That's what I teach in MBSR and MBCT. They had the highest level of stress reactivity, of cortisol reactivity. So body awareness can actually increase signs of arousal. Interestingly, she actually found that the lowest level of stress reactivity was in a really novel kind of practice where she had people meditating in dyads. This is just kind of a fun fact, but I think it's something that we often forget that we're always trying to regulate ourselves and do everything on our own. And actually, other people and interacting with them actually is an incredibly calming effect physiologically. And so we should remember that. I think we can often forget that in meditation. So just to make the same point again, if you're talking about body awareness, if that's the sort of construct that you're measuring, there's an optimal level of body awareness. And if you have too much of it, you can start to develop signs of hyper-arousal anxiety and pain. Another way to say that is if you have signs of hyperarousal, anxiety, pain, insomnia, if that's showing up for you or for your patient, do less body awareness. And that will bring down the arousal. Okay, so that was hyperarousal. And then we're going to jump into dissociation. So mindfulness meditation and dissociation, in particular, depersonalization is a specific kind of dissociation. They have very overlapping neural correlates. They actually have very similar brain states. And so the parts that are similarly activated are the prefrontal cortex and the inferior parietal lobe. And the areas that are deactivated are the default mode network and the limbic system. Most of my research actually on the benefits of meditation for depression and anxiety are based on this model. So this is the way that meditation improves anxiety. And what's interesting about the ubiquitous U-shaped curve or the inverted U is that the same exact mechanisms that are behind the benefits are the same exact ones that are behind the adverse effects. So it's not a different thing, it's the same thing, just taken too far. So the prefrontal cortex controls the limbic system. So when you meditate, you increase your attention system, your control system, and it downregulates the limbic system, especially the amygdala. And so in mindfulness science, you often hear that the amygdala is sort of the threat detector. It's responsible for your fight or flight response. And when you downregulate it, your stress gets better. So that's totally true, but it's not complete. The amygdala is also responsible for positive emotions. And emotions in general are necessary for making decisions. And you know, having some threat detection is a good idea. And so if you continue past the optimal level of amygdala activation, you can actually become very blunted and have like no emotions at all. So here is some data to show you that. This is a study on meditators looking at their amygdala, their prefrontal control over the amygdala. And as their amygdala decreases, the intensity of their emotions in response to stimuli decreases and it decreases across the board. So it decreases to negative stimuli. So they have less negative emotions, but also less intense emotions to neutral stimuli and positive stimuli. So less positive emotions as well. So again, back to our U-shape curve, there's an optimal level of the amygdala. If you're feeling really stressed out and you're feeling like way too many emotions and way too much threat, way too much anxiety, sure, downregulate your amygdala, but you can overdo it. And if you start to find that your emotions are very flat or blunted, you feel apathetic, hypo aroused, lack of positive emotions, not making good decisions, not having enough like sort of threat detection, and not understanding other people. We really need our amygdalas to understand other people's emotions. So we don't want to take it completely offline. And just to say it again, if you're talking about prefrontal control over the limbic system, which is basically what concentration practices do, it's good for signs of hyperarousal. So if you're anxious, then you want to do concentration practices. However, if you start to see depression or blunted emotions or dissociation, then you want to back off on the concentration practices and do something else. So additional resources. David Trelevin's trauma-sensitive mindfulness, he has an awesome website, all sorts of cool stuff, courses, webinars, all sorts of things. If you want the 20-hour version of this talk, it does exist. You can get it on the Cheetah House website. It's also accompanied by a meditation safety toolbox, which is all kinds of best practices from all different mindfulness groups all over the world. And it's actually even translated into a couple different languages. And then there's also Cheetah House. So if you ever have a meditation client that is developing problems and you're not sure what to do, you can always send them to Cheetah House. So we have research-based information, we have a bibliography of different research studies, we have educational videos, we do teacher trainings, we have on-demand trainings, we have live webinars, and then for any meditator in distress, we have one-on-one peer support. We have four different support groups. We service 98 countries. In 2020, we had 20,000 visitors. So whatever it is, we can handle it. So if you didn't learn anything in the whole rest of this talk, here's a resource that you can send people if you feel like they're having meditation-related challenges that you're not sure how to handle.
Speaker 1 · 23:54Willoughby, thank you so much. It's an honor to have you. I see being able to identify and manage the adverse effects of mindfulness is one of our top, say, pillars of our training. It's something that's very important for mindfulness teachers to be aware of. And this research and practice, I think, continually evolves, and you're at the forefront of it. And so I just want to thank you for being here and teaching us all so that we can better help the people who we want to help. And so, Willoughby, thank you so much for giving us more tools, understanding to help us to help those people in ways that are more and more compassionate and with more and more wisdom. So thank you so much for everything, Willoughby.
