By Dr. Phang Cheng Kar (M.D.),
First published in Eastern Horizon (September 2011).
I am not crazy!
Should a person with mental illness meditate? This is one of the often asked questions that I face in my effort to promote mental health education in the Buddhist community. At a glance, you may think that this article has nothing to do with you, “I’m interested in Buddhist meditation, but I’m not crazy!” In the last Malaysian National Health & Morbidity Survey (2011), it was found that the prevalence of generalized anxiety disorder, major depressive disorder and suicidal ideation among adults was around 2%. As for children and adolescents, 1 in 5 had significant mental health problems. Not surprisingly, whenever I give sharing in Buddhist temples or centers, I often meet people with psychological distress. No, I definitely do not mean that you are crazy: this is such a derogatory and stigmatizing term. What I mean is many of us in the Buddhist community do have mental health or emotional problems, and a significant number would have been diagnosed with mental illness if we had sought help from mental health professionals. Of course, many people never do so due to lack of awareness on mental illness and social stigma. Hence, this article may be of relevance to you.
What is mental illness?
Other names for mental illness include mental disorder, psychological illness, emotional sickness, etc. It is basically a group of psychological conditions, e.g. major depressive disorder, generalized anxiety disorder, schizophrenia, bipolar disorder, etc., that negatively affects the way we think, feel and behave, to the extent that it seriously interferes with our daily functions in life. This includes our spiritual pursuit and meditation practice. As the mind is closely connected to the body, mental illnesses are also medical conditions that affect our brain functions and physical health.
For easy understanding, mental illnesses are divided into two big groups: psychotic disorders and neurotic disorders. Psychotic disorders, e.g. schizophrenia are characterized by bizarre signs and symptoms, e.g. auditory and visual hallucinations, paranoid ideas, feeling of being possessed, odd religious beliefs, talking non-sense, abnormal body movements or gestures, violence, etc. Neurotic disorders are less severe and include features such as excessive sadness, fears and worries, loss of interest in life, sleep difficulties, significant appetite and weight change, irritability, unexplained tiredness, poor concentration, feeling useless and hopeless, suicidal thoughts, etc. How do we know whether we may have a mental illness? If one has some of the symptoms, having them almost every day for two weeks or more, and they are disturbing your daily functions (e.g. difficulty at work, unable to study or cannot manage household), it is a good idea to consult a mental health professional for clarification and assessment. You may email me at email@example.com for information on where and how to do that.
As mental health awareness in Malaysia is still in its infancy stage, I have repeatedly seen people with mental illness who had sought help through a psycho-spiritual pathway, e.g. meditation practice, instead of consulting mental health professionals such as psychiatrist, clinical psychologist and counselor.
This is understandable, and it is probably a useful community-based mental health strategy in Malaysia whereby mental health services are relatively scarce.
However, when people meditate with wrong attitudes, they are bound to worsen their situation. It gets worse when there are unrealistic expectation, and ignorance as to how meditation can interfere or worsen the existing mental illness. One also may not know how to adjust their meditation practice in a way that is helpful for the mental illness.
What is meditation?
The word ‘meditation’ is now very popular and used with diverse meanings. From a Buddhist perspective, meditation is described as mental cultivation or bhavana. It is a mental training to develop spiritual wisdom and positive mental states such as composure, confidence, loving-kindness, compassion, and appreciative joy. Common Buddhist meditation methods that you may have come across include Vipassanā /Insight /Mindfulness Meditation, Loving-kindness (Mettā) Meditation, Breath Meditation (Anapanasati), Medicine Buddha Visualization, Tonglen Compassion Meditation, etc.
Recent scientific research by Dr. Herbert Benson (Relaxation Response), Dr. Jon Kabat-Zinn (Mindfulness-based Stress Reduction - MBSR), Dr. Mark Williams (Mindfulness-based Cognitive Therapy - MBCT), etc. has supported the effectiveness of the meditation-based program to overcome stress, anxiety, and depression. The local MINDFULGym program that I have developed has also been found to be beneficial for medical students in coping with stress in their studies.
So, Buddhist meditation can be a helpful option for overcoming stress, anxiety, depression and to complement the treatment of physical and mental illnesses. However, it should be done correctly for optimal benefit.
The following points are guidelines for those who have or may have mental illness and wish to try meditation for mental health and wellness.
Meditation & Mental Health Guidelines:
1. Seek help from mental health professionals besides meditating, as treatment of mental illness should be holistic. Do not use meditation as a treatment for psychotic disorders, such as schizophrenia. Psychosis is a very serious psychiatric condition that requires medication treatment and professional help. Trying to meditate without supervision when you are mentally unstable, e.g. suicidal, very restless and irritable is also not helpful; it may even make things worse. Unsupervised meditation is usually only helpful when the mind is relatively stable.
2. Do not stop your psychiatric medications without prior discussion with your doctor. It is fine to continue medications while meditating. Please tell the meditation program organizers that you are on treatment for mental illness. If you have medication side effects that can interfere with meditation, e.g. drowsiness, discuss with your doctor on options to overcome the problem, e.g. dosage adjustment or change of medications.
3. Inform your mental health provider if you are planning to meditate. If you think that they do not understand enough about meditation and your need to meditate, you may want to seek a second opinion from Buddhism-influenced mental health professionals.
4. Join a meditation group and practice under the close supervision of a well-trained meditation teacher. Practicing in a group is less fearful and more reassuring. Please start slow; do not straight away go for intensive meditation practice, e.g. continuous one-week meditation retreat or retreat in the forest, especially without close supervision. A meditation teaching that teaches you to be aware/mindful in daily living is more suitable.
5. It is important to have adequate sleep, food, water and rest if you are going for a meditation retreat. Relapse of mental illness during meditation retreat due to sleep deprivation and intense fasting has been reported. If you find that your meditation is making you more stressful, it means that you need to check the way you are meditating. Do discuss with your meditation teacher.
6. If you have any new or unusual experience, remember to discuss with your meditation teacher and mental healthcare provider. Sometimes it may be difficult to differentiate a spiritual experience from a psychotic phenomenon, e.g. auditory hallucinations in the form of voices from spirits giving advice.
7. If you are restless or agitated (a common symptom in neurotic disorders) and have difficulty to sit still for sitting meditation, it may be better to do walking meditation and mindful awareness of daily activities. Chanting, hymns singing, and simple relaxation exercises such as progressive muscle relaxation and deep breathing may also be helpful.
8. It is not a must to close your eyes in meditation. Closing the eyes may generate more fear and promote wandering mind in individuals with neurosis. As for individuals with psychosis, the dark ‘mental screen’ of closed eyes may be fertile ground for the development of visual hallucinations and psychiatric delusions. It is safer and may be even more effective to meditate with the eyes naturally open.
9. Loving-kindness (Mettā) meditation, i.e. cultivating kind thoughts and actions to self and other sentient beings is relatively easy to do, safe and helpful for many symptoms associated with neurosis, e.g. sleep difficulty, irritability, and guilt. It can be practiced with eyes opened, in any posture, at any time, and anywhere. It is easier and more helpful to begin practicing mettā to ourselves, and those whom we had pleasant experience, before extending it to more challenging ones, e.g. neutral and hateful individuals. Meditation on appreciative joy (Mudita), e.g. rejoicing on one’s strength, good deeds, meaningful achievements, and cultivating gratitude (Katannuta) are useful antidotes for depression. Equanimity (Upekkha) meditation, e.g. mountain or lake imagery, and recollection on the spiritual qualities of the Triple Gem are useful for building confidence and overcoming fears in neurosis.
10. It is extremely important to have the Right View (Samma Ditthi) in meditation. Meditation should not be used as an avoidance strategy, e.g. repeatedly going for meditation retreats to avoid necessary negotiation with the wife on marital issues.
The role of meditation in mental illness is to compose the mind, develop understanding of the psycho-spiritual factors that contributes to one’s mental illness, and cultivate positive mental states that are conducive for mental health.
Last but not least, if you wish to find out more information on mental health and mental illness from a Buddhist perspective, you are welcome to visit the Kuala Lumpur Buddhist Mental Health Association (BMHA).
About the author: Phang Cheng Kar, M.D., received his medical degree from Universiti Putra Malaysia (UPM) and postgraduate training in psychiatry from Universiti Kebangsaan Malaysia (UKM). He is currently a consultant psychiatrist and mindfulness-based therapist at Sunway Medical Centre. Prior to that, he was lecturing in the UPM Medical School and practicing at the Kuala Lumpur and Kajang General Hospitals. His research interest is on mindfulness-based psychotherapies and he has developed MINDFULGym, which is a Malaysian mindfulness-based stress reduction and wellness program. He is also the founder president of Kuala Lumpur Buddhist Mental Health Association (BMHA). His hobbies include meditating, doing voluntary service, reading, writing, and watching trees.