Bullet Ants, Vision Quests and Mental Health Recovery as an Endurance Event

The Sateré-Mawé tribe of the northern region of the Amazonas in South America have a sacred ritual for young warriors that is quite unique. They have to prove their worth to the tribe by remaining in a calm state whilst suffering agonising pain. The tribe sow sedated bullet ants (named as their sting is said to be as painful as being shot) into gloves made of leaves. Boys as young as twelve have their hands placed into the gloves. As the ants awaken, they are stung for five minutes or longer. The ant’s toxins interfere with their nervous system and the venom continues acting for hours after being removed. The young warriors endure pain & paralysis, disorientation and hallucinations in these hours that follow. They need to go through this herculean ordeal twenty times to earn the respect of the tribe and be recognised as full warriors. Their only distraction during the ceremony is the tribe’s ceremonial song and dance!

Tests of endurance are perhaps as old as humankind. Vision quests, Sundance’s and land diving have given rise to the modern triathlon, iron man and ultra-marathons. I think that some days during mental health recovery are like endurance tests. When you wake to your intense symptoms and they persist till you attempt to sleep, it is somewhat like an endurance test. But one you have not chosen to take part in and often won’t gain the respect of your tribe. However, we can use the same tools that endurance athletes use to go through this process. Tools like breathing and relaxing, motivational and instructional self-talk (especially with a kind and compassionate tone) and mindful attentional training. We can use attentional control skills and develop our ability to accept pain in the service of moving towards our valued goals in life. Runners will often focus out into their environment rather than be drawn into the intoxicating feelings of exhaustion. The Sateré-Mawé focus intently onto the rhythmic music and dancing. We can find our own ceremonial drums.

A focus on values and goals can help us in this difficult place. Athletes will remind themselves of their goals, the time or position they are hoping for, why they are running and their team that are supporting them. This can help them to dig deeper and persist. Humans are a deeply social animal. We can draw on strength and support from our team, the crowds and supporters. Even in a vision quest the lone adventurer has the intention to pass through the trial so they can come back stronger and wiser for the tribe. There is fascinating research demonstrating that people anticipate mountains to be less steep when they are with a friend or group. Find your support network and tribe.

I’ve had days in the past when waves of panic or depersonalization were my constant companion. When the heavy weight of depression held me like the burning lactic acid climbing that first mountain or when repetitive rumination and obsessive thoughts felt like an enemy hunting me through the forest. And at those times it was helpful to frame it like a hero’s journey, rite of passage or endurance test. To constantly accept the anxiety and return my attention to the conversation I was having, or the activity I was doing, and to ensure I had a kind compassionate inner coach with me all day in my self-talk. To come back to my values and goals each hour to check I was moving towards what I cared about rather than running from what I feared. And I think at these times when we are facing our shadow, we train our new brains to regulate our old brains at a much deeper level. A simplified model is our pre-frontal cortex is getting stronger and more able to calm our limbic system, even when we are in our fight, flight or freeze response.

If we have days during recovery when we feel good then that’s great, we can savour and enjoy that. But if during the recovery marathon we have days that are dominated by anxiety & depersonalization, depression, obsessions & compulsions, then this is a chance to practice acceptance and following our valued direction in life – like weight training for our brain. On these days we are competing in the endurance race of recovery, if we can gently and patiently keep going, we are laying the synaptic pathways for freedom and a deeper happiness. It’s tough but we can build these skills over time. You may need the help of a professional skilled in the journey of recovery, just as a coach is an essential part of a physical fitness team. You will almost certainly need a training buddy or group – humans can’t do many things without the tribe. But with practice you can get there. So maybe think of the Sateré-Mawé when you are next having a tough day of suffering and maybe this concept might help you through it. There is a light at the end of the tunnel, the only way is through, whilst using whatever tools support you best.

Take a Walk on the Grateful Side – The Gratitude Walk

As the great stoic philosopher Epictetus said:

 ‘He is a wise man who does not grieve for the things which he has not, but rejoices for those which he has

Epictetus spent his youth as a slave in Rome. He was crippled on the journey to Rome and lay below deck on the ship for days, controlling his reaction to the pain. He lived alone for much of his life with few possessions. It’s not exactly the life you might think would give rise to an appreciation of the power of gratitude. However, Epictetus practiced a philosophy that held that all you could really control in life was your rational mind and what it focused on.

Gratitude has been demonstrated to improve the frequency of positive emotions (even amongst people with chronic illness), reduce physical health symptoms like headaches, improve sleep and even enhance interpersonal relationships (Lyubomirsky 2007). It is a practice closely related to mindfulness, in the brilliant Mindfulness Finding Peace in a Frantic world they talk about having the quality of ‘appreciative attention’. Mindfulness helps us to have the attentional skills to apply and focus on gratitude, especially when we are in difficult circumstances.

A practice for cultivating gratitude which I enjoy regularly when I walk my dog is ‘The Gratitude Walk’ (of course the walking can be replaced with any appropriate movement or it can be done sitting if movement is an issue):

  1. Begin with 2-5minutes of mindful walking. You can bring your awareness to the sensations of walking, or your breath or you can open your awareness to your sensory experience of sight, sound, feeling, smell, taste etc
  2. Start to reflect on different things in your life which you feel grateful for and (using any language that works for you) say silently in your mind ‘I’m grateful for x’
  3. Categories for gratitude could be relationships, resources, opportunities, abilities, hobbies, work, a (relatively) healthy body and mind etc. You can also express gratitude for the things you see around you like nature or the people you are with
  4. Expand this out so that you reflect on something you are grateful for and then deepen this by expressing why you are grateful for it. For example, ‘I am grateful for my dog, because he is always pleased to see me and keeps me regularly walking in nature
  5. Let your awareness ‘dance’ between the thoughts of gratitude and any pleasant feelings in your body like the feeling of gratitude, warmth, openness, relaxation, joy etc in the heart, face and whole body
  6. If your mind drifts away notice and return. If your mind resists the practice with judgement, doubt, self-attack, inner critic etc then see if you can notice this in a kind and accepting way and gently keep bringing your attention back to expressing gratitude. Let the doubt be in the background. We have the capacity to experience different emotions at the same time, we can have gratitude whilst feeling anxious, depressed, obsessing etc. Let the other thoughts and feelings be in the background of your awareness and gratitude takes centre stage
  7. Continue for 10-20 minutes or as long as feels right
  8. Try to find different things to be grateful for each time you practice, including different things that have happened through your day. This trains our attention to be searching for positive occurrences throughout the day

Our brains have evolved a negativity bias that prepares us to search for threats in our environment. It made more sense for our ancestors to spot the dangers of their environment (like Lions, Tigers and Hyena’s) than it did to continuously savour the beauty of their world. So, our baseline state can often be one when the brain defaults to searching for danger. Gratitude is a wonderful practice to offset this and to prime our minds to take in the good. People often struggle with gratitude, especially if they are experiencing low mood. When this happens, a person suffering from depression can end up denigrating themselves for ‘failing’ at another thing. This is where we gently use our mindful acceptance skills to allow these thoughts to be there whilst we place our attention on the gratitude practice. We can experience gratitude even in the midst of emotional or physical pain. So, start gently, maybe just writing down three things for which you feel grateful for or spending two minutes through the day to reflect on gratitude.

The other thing people struggle with is what gratitude means in a world full of social injustice. But it’s important to reflect that gratitude can be a complementary practice to support us in working to create a better world. We can resource ourselves to help others with gratitude and reduce the chance of burn out. Even people in very difficult situations have found benefits with gratitude. For example, Shawn Achor did research with cancer patients, African farmers that had lost their land and homeless people and found they all benefited from the practice of gratitude for their well-being.

So why not try Epictetus’s approach and experience the ‘freedom of being the master of yourself’ by cultivating an attitude of gratitude. Take a walk on the grateful side.

Lost in Oblivion – An Exploration of Adverse Meditation Experiences

(Please note this is a long blog post in order for me to do this subject justice. It’s likely to be of most interest if you have experienced adverse meditative affects)

Meditation is not all spa music, oxytocin, sandalwood and light! There can be stages that are like arduous rights of passage. A shamanic vision quest. There might be underlying mental health pathologies that mean that practice, or at least intense practice might be unwise. Yet in the west mindfulness has been marketed as a panacea (although it is already facing a backlash in the press like and also). But traditional practices are well aware of these potential challenges. For a start, many schools of meditation aim at ‘deconstructing the sense of self’ and ‘realizing emptiness’ which clearly are not the same as relaxation and improving corporate performance. Take for example a classic manual from the meditative world: 

At the peak of insight knowledge of dissolution, one clearly realizes that mental and physical phenomena vanished in the past, are vanishing in the present, and will also vanish in the future. As a result, conditioned phenomena begin to appear fearful. At this point insight knowledge of fear arises’ (Mahasi Sayadaw, Manual of Insight). This is followed by the insight knowledge of danger when ‘conditioned phenomena’ will be experienced as ‘unpleasant, detestable, and harsh’. This is from one of the traditional Burmese teachers that the modern mindfulness movement has in part grown out of (Zen and Vipassana being Jon Kabat-Zinn’s main practices before developing MBSR).

The brilliant Neuroscientist and Zen practitioner James Austin describes in Zen and the brain, Makyo, which is the Zen traditions version of side effects of meditation. He states Makyo is ‘what can happen when the brain opens up the barriers which would otherwise separate its states of waking, sleeping and dreaming’. And ‘intensive meditative concentration for weeks or months invariably yields visual or auditory aberrations, hallucinations, or unusual somatic experiences’. In Zen training, students are taught to disregard Makyo and to continue with the practice no matter what happens.

In Tibetan Buddhist traditions, this category of experiences is known as Nyams and can mean everything from visions, psychological distress, physical pain, paranoia and terror. There are a number of famous western Tibetan teachers who have talked about intense adverse experiences after doing the traditional 3-year retreats that are part of the Tibetan path. From shamanic practices to the pragmatic dharma of modern ‘hardcore practitioners’ you find the equivalent stages in almost every spiritual practice involving contemplative practices. In their highly engaging book ‘The Science of Meditation’ Daniel Goleman and Richard Davidson state ‘dark nights are not unique to vipassana; most every meditative tradition warns about them. In Judaism, for example, Kabbalistic texts caution that contemplative methods are best reserved for middle age, lest an unformed ego fall apart’. There are even studies that show long term practioners can experience many of the same ‘symptoms’ as depersonalization disorder (DPD) but without the negative affective (emotional) tone.

The brilliant Neuroscientist Willoughby Britton of Brown University has been leading pioneering work in this field in the Varieties of Contemplative Experience Study (VCE). Britton began researching solely on the positive side of mindfulness for wellbeing, but after directly experiencing patients suffering from severe adverse effects she started to look at this area. Supportive of mindfulness, Britton is keen that it is not framed as a panacea and the nuance of these powerful practices are understood (as they are rolled out en masse as mental health interventions). She interviewed long term meditators including expert teachers from a wide range of practices (Zen, Theravada, Tibetan). Her team found that there was a huge range of experiences both cognitive and somatic and the emotional valence ‘ranged from very positive to very negative, and the associated level of distress and functional impairment ranged from minimal and transient to severe and enduring’. She receives multiple phone calls a week from meditators experiencing issues and has set up a support group and in the beginning of her work she even had long term severely impaired meditators staying in her house to recover.

On top of this there are endless accounts of seemingly ‘high level’ teachers who end up doing unforgiveable things, that speak of mental health difficulties. Some of this element is explored in the Buddha Pill, in which Dr Miguel Farias and Catherine Wikholm examine this aspect in detail and other shadow sides of meditation. I think this is a book that is worth all meditation teachers having a look at in order to gain a mature view of their art. It attempts to give a balanced assessment on what meditation can and cannot do for mental health and life at large. They have a chapter examining the ‘dark night of the soul’ and interestingly they note that the Diagnostic and Statistical Manual of Mental Disorders has had a clause noting mental health problems, such as depersonalization, may arise as a temporary result of spiritual practices. Working with Dr Farias there is a meditation group in the UK headed by Damcho Pamo who experienced her own psychosis and mania after attending a Zen retreat, and now seeks to support others. There website speaks of some of the potential adverse effects in a balanced and supportive way.

Now clearly as a mindfulness teacher, I am a fan of mindfulness, but I am keen that we take a sensible approach to how we use it for improving mental health. It is not a panacea. Much like physical exercise not everyone can start training for a marathon right away or compete in crossfit. Some people may carry injuries that need physiotherapy first and for some people they might have to adapt their physical training to match their genetic body type and vulnerabilities. I think this is a useful analogue for intensive meditation practice. Briefly my own story with adverse effects includes experiencing anxiety, panic, OCD, depression and depersonalization from a young age (many of my earliest memories were panic attacks). Some of these challenges definitely brought me to practice Zen and Qigong twenty years ago in an attempt to heal myself. And as I practiced through the years I learned tools that helped me manage my anxiety (although it wasn’t till I had CBT that the pieces came together to help me).

Many of the earlier years in practice I would experience intense emotions, pain from long sits and other adverse experiences and I got pretty good at sitting with these. I did a number of silent retreats which I practiced intensely through each day from waking to sleeping for 9 days. I would do extra sits, sit through part of the night and engage in ‘strong determination sitting’ which for someone with early onset arthritis meant a lot of knee and back pain. For many years’ depersonalization had not been a major feature of my mental health challenges, then after a retreat for the following months I was trying to sit as much as I could and practice through the day, then I had an intense adverse experience. I had levels of primal terror I had never experienced before, sensory alteration, existential anxiety, strange somatic experiences, depression, depersonalization more intense than I had ever experienced and many other symptoms. This period coincided with other intense life trials like the intensity of psychotherapy training, a number of bereavements and life choices so I believe it was a combination of causes following a lot of intense practice.

Ultimately this experience was positive in that it made me look deeply at my life, how I was practicing and what was meaningful to me. From an acceptance and commitment frame I was far away from many of my values, isolated and practicing meditation excessively. It also increased my empathy for those suffering from intense mental health disorders. It helped me refine my understanding of using mindfulness to help recovery from mental health issues, and how to adapt the practice for anxiety disorders and other mental health problems. Interestingly I’ve had no students have these types of experiences in 8 years of teaching. Occasionally I have had someone experience a heightening of stress in the beginning of mindfulness practice, normally when they are living a stressed and busy life in London. However, I think the intensity of my experience followed about 15 years of disciplined practice (practicing many hours a day), a number of retreats and a number of months of attempting continuous practice through much of my daily life. As I write this its obvious how out of balance and obsessive my approach had gotten.

Here are some suggestions based off my own experience. The first being to consult a trained mental health professional (ideally one that knows this territory) if you are experiencing difficulties:

  • Significantly reduce your practice time. I would advise anyone experiencing adverse effects to slow down their practice, and significantly reduce the time spent sitting. Even cut the practice down to 5 minutes or 3 minutes or take a break from practice. If you do decide to keep going, then make sure you are working with an advanced meditation teacher who understands this process. For example, for the teacher training at Spirit Rock – head teacher Jack Kornfield makes all teachers do training in the trauma therapy approach Somatic Experiencing. But honestly, I would say don’t continue on retreats or intense practice if you are having adverse effects. Get back into your life and make your practice a smaller supporting part of it.
  • See a professional, ideally a therapist skilled in this area and often they will be a trauma therapist trained in modalities like Somatic Trauma Therapy, Sensorimotor Therapy or Somatic Experiencing. David Treleaven book Trauma Sensitive Mindfulness is a brilliant resource here (and a must for anyone teaching Mindfulness or Meditation). Also, Babette Rothchild’s The Body Remembers part 2 has excellent guidance on how to adapt mindfulness for individuals who have experienced trauma. She suggests the areas of high risk with MBSR training being: ‘the rigidity of program structure and task instructions; the inward focus of mindfulness targets; the length of practice sessions; postural positions for practice and the possibility of relaxation-induced anxiety for people with PTSD, anxiety or panic disorders’. She recommends more agency and control for the student to adapt the practice, placing focus on the ‘exteroceptors’ of sight, hearing, taste, touch and smell. PTSD sufferers are often overwhelmed by their ‘interoceptor’ sensations when focusing inside their bodies, she even suggests potentially switching back and forth between the focus from inside to outside the practitioner (which I found useful myself). The portions, pacing and positions are important with recommendations to engage in mini practices, adjusting to postures which don’t trigger sufferers (lying down or sitting still can trigger freezing in PTSD) and promoting practitioner agency.
  • Focus on life goals and values. The teachings from Acceptance and Commitment Therapy particularly focusing on value-based actions is really useful here. We can use our meditative skills to accept difficulties and then focus out into the world and engage with life. Don’t spend long periods of time focusing deeply on your symptoms in an attempt to ‘see their impermanence’. There are certain experiences that may just be too much, and you are better to use acceptance and then read a good book or speak to a friend. Can you build acceptance towards your symptoms of depression, anxiety, DPD etc and engage in a meaningful life? Here we use the skills of meditation to direct our attention out in the world.
  • Reduce self-focus. Linked to this is the negative impact of excessive self-focus found in many mental health issues. Intense meditation practice can potentially exacerbate this and the more we can train our focus out into the world the better. Many Cognitive Behavioural Therapy experts emphasise training this external focus. Particularly I got a lot from David Veale and Rob Wilson’s work on reducing self-focus, their books such as Manage Your Mood and Overcoming Health Anxiety have a lot of useful techniques for dealing with adverse effects linked to excessive self-focus. Techniques such as attentional training and situational attentional refocusing
  • Try some different meditative approaches – if the breath feels uncomfortable and panicky then you could switch to different anchors for example physical sensation of sitting, sounds, gently staring at a rock or candle. If closing your eyes seems destabilising then you can open your eyes. You could try visualisation practice and imagery like Compassion Focused Therapy imagery. You could even use thinking to describe the image in compassion focused or safe place imagery thus engaging the language centres of your brain whilst meditating which I think can be helpful. You could use an app on your phone to lead you in breathing exercises as engaging with an external source can be useful. Loving Kindness practice might be a better choice right now (although people do have adverse effects from this practice), I found switching to this practice is shorter doses was particularly helpful.
  • Rotate between meditation and thinking. It’s important to have both approaches online, in fact there can be an overlap between intense meditation practice which quietens the default mode network (often described as a beneficial quietening but more nuanced in reality) and symptoms of dissociation. Sit for a while, say 10 minutes and then either let your mind wander or actively think about things. Maybe switch back and forth between meditating and thinking. This can help your brain move more easily from a quiet default mode to a more active one. Another approach I found useful was to sit for a while and then read a fiction book or watch a tv show. This is similar to Babette Rothschild suggestion of switching between an internal focus and an outside focus (mentioned above) but also engages the language centres of the brain. Linked to this is using affect labelling which I mentioned in previous blogs. I particularly think compassionate thinking is brilliant here. The brilliant Scott Barry Kaufman has written a lot about the (highly relative to this point) concept of positive constructive daydreaming.
  • Working with a blank mind. To build on the above step, a lot of people who experience adverse effects and depersonalization, experience having a blank mind – but not in a positive way. It’s like the anxiety response has shut down thinking (similar to a trauma response), or thoughts are so vague and nebulous that you can’t really find them (these experiences can be reported as positive things in meditation, but for many people they can be terrifying). In this case it can be helpful to re-cultivate the ability to think. Sub-vocalising or even saying thoughts gently can help, reading books as slow as you need to in order to engage and possibly reading out loud. I particularly like the concept from compassion focused therapy technique of compassionate thinking, or Barbara Fredrickson’s concept of narrating your day in a kind way. Just building acceptance of your mind and how you are feeling whilst engaging in thinking about your current task can be so powerful here.
  • Working with relaxation induced anxiety. When I began practicing qigong and meditation many years ago I experienced a lot of relaxation induced anxiety. Through many years of practice and exposure this reduced, although I would still occasionally experience it when I did long sits or got into deeper states of relaxation and concentration. When I experienced some adverse effects I found Prof Paul Gilbert’s advice from his brilliant book Overcoming Depression really useful. He describes for people who find either breathing or relaxing to invoke anxiety, that it can be a useful practice to do slow soothing breathing and progressive relaxing whilst doing another activity. This can be something more physical like walking or gardening, or a relaxing soothing activity like having a bath. You can even squeeze a ball and have your focus on touch and the breath and relaxation in the background. Additionally, alternating between tension and relaxation as per progressive relaxation can be useful, and practicing yoga that might actually strengthen, solidify and tense your muscles.
  • Movement can be incredibly powerful. For example Hans Burgschmidt, as told in Jeff Warren’s brilliant article (worth checking out Jeff’s other work as well) various types of physical practice were key to Hans recovery. The most ideal thing is if we can engage in a group-based activity, in nature which we find engaging and physical challenging. Too much time on our own spent exercising might not be the ideal practice here. I think it’s great to do a combination of slower more meditative practices and also more intense exercise (cardio and strength training). Exercise is such a great support to our mental health.
  • Practice Gratitude and other more ‘cognitive’ practices. This means engaging meditative practices which actively keep our thinking and conceptual faculties on line. Sometimes the non-conceptual awareness of meditation is not what you need for robust mental health. This is where gratitude and savouring practices from positive psychology come in handy. We do a meditative practice when we actively reflect on the details of the different things in our life we feel grateful for, and we also tune into the feeling of gratitude in our body and hearts. In savouring we can cognitively reflect on what we are enjoying in the moment and subvocalize phrases that reflect this like ‘this feels good, I love doing x/y/z’ whilst savouring the pleasant aspects of our present moment experience. Also, the visualisation and imagery practices as found in Compassion Focused Therapy might be useful here.
  • Reading novels and enjoyable literature, and engagement in enjoyable hobbies. I found that in my difficult periods I was compulsively reading a lot of books on meditation, philosophy, psychology and consciousness science etc. For now, it would be worth putting down these books, stop listening to podcasts on these topics and step away from the YouTube dharma talk! If we focus on this it can continue to send the brain signals that we are trying to solve this uncertainty (around existence, the self, life, our symptoms etc) and it will keep the anxiety going that feeds the depersonalization. By all means you will be able to get back to reading and studying this material, but ideally in a more balanced and less compulsive way. For now reading enjoyable novels, engaging in artistic pursuits, learning a musical instrument, listening to enjoyable audio books might all be a better choice for your tired brain.
  • Join your community, and find connection. As is the case with many aspects of mental health, human connection is a key part of recovery. We are wired to connect and often people experience adverse effects in meditation when they may be isolated and lacking meaningful connections. I think that retreat practice can be a brilliant way to build mindfulness skills but often adverse effects occur in the retreat setting. Most retreat centres screen for mental health issues, but the silence and hours of intense practice are not the right approach for everyone. Be honest with yourself as to whether this is the right choice for you. Even the famous podcaster Tim Ferris experienced adverse effects on retreat, which he reports to be ultimately healing and leading in a positive direction, but were intense none the less. So, make sure you are connected and in community to support your practice. Join a group, especially one with teachers who are familiar and experienced in working with adverse effects. Maybe you would be better to practice being in the moment with awareness whilst listening and talking to a friend rather than sitting in silence. This was undoubtedly a part of what led to my experiences. In Jeffrey Young’s schema therapy, there is the concept of the detached protector mode that patients can experience. People who have experienced attachment trauma in childhood, learn to withdraw and depend on themselves. Experiences like DPD are often a part of this mode, in order to break this pattern, we might need to push against this isolated protector and connect with others. This could be part of a mindfulness practice, to engage in mindful and compassionate connection with others.
  • Be kind to yourself, don’t just sit through emotional adversity. As with a lot of my approach to mental health, self-compassion sits at the heart of it. There are many teachers who will just advise students to sit through any intense experience and develop mindfulness with it. You have brilliant teachers like Mingyur Rinpoche and Joseph Goldstein who both talk about using anxiety their own anxiety and panic to develop mindfulness, sitting and observing it closely. This is not always appropriate advice for everyone as demonstrated in some of the accounts I have linked to and in the trauma work of Treleaven and Rothschild. In my own experience I had levels of anxiety that I sat with, it was not uncommon for me to sit for an hour or longer with anxiety watching my body and mind and building acceptance. But then I hit levels which were far too overwhelming for me to sit with, the more I sat the more they would be the dominant emotion throughout the day and would intensify and disrupt my functioning – making me experience more intense levels of depersonalization and depression. What was better was to accept these emotions and then actively pursue meaningful activities in the world with people I care about, using meditation to focus out into the world rather than into myself. Teachers who advise this approach may not have experienced trauma, may not be prone to depersonalization and may have a very different brain to you. More sitting is not always better. Sometimes it can be better to use your meditation skills to accept challenging emotions and bring your focus to reading a good book, art or music or talking to a friend. Don’t spend a lot of time observing difficult thoughts and feelings (it’s easy to get tangled with old memories, or to amplify the fear through somatosensory amplification) instead label and passively disengage and then place your attention on something positive and meaningful to you.
  • Exposure and response prevention can be useful. It’s worth getting professional help with is aspect. If you have existential rumination/ocd alongside your issues it might be helpful. From talking with others and reading accounts of adverse effects there can be a connection to existential rumination typical of obsessive-compulsive disorder. This was the case for my own experiences. This is often pertinent in depersonalization disorder as described in the brilliant Overcoming Depersonalization Disorder by Katharine Donnelly  and Fugen Neziroglu (a book that I think is a must for anyone suffering from adverse effects along with Elaine Hunter’s DPD Book). Exposure was even a path of great meditation masters like Ajahn Chah meditating in charnel grounds and exposing themselves to existential fear.

Sometimes these existential ruminations are what keep the adverse effects going. There is excessive self-focus and checking of how we feel, intense reading of meditation literature or videos that discuss whether the self is real, whether we have agency, is life ultimately suffering etc all tangle together to feed the DPD. When the meditator is not practicing they might be ruminating on deep existential questions that have not been answered by anyone, that might cause terror and anxiety which further feed the issues. Sitting under this may be fears about losing ones mind, living an unhappy life or brain disease leading to death. As with other forms of OCD exposure and response prevention can be key here. For example, you can write out and read through an exposure script that runs through the worst-case scenario ultimately leading to mental breakdown, misery or death (Donnelly and Neziroglu’s book is an excellent guide on how to do this step). It can also be good to write exposure cards or to agree with these thoughts and expose yourself to them in the moment as per this excellent article by CBT expert Fred Penzel.

Then the response prevention means you use your meditative skills to accept the initial obsessional thought and then do not engage in the rumination of trying to solve these unsolvable mysteries of life. For this step, what has seemingly caused the issue is the tool to get out of it, i.e. the attentional skills developed through meditation. This is not to say that there is not a place to ponder life’s mysteries but generally people doing this are able to shut off their thoughts after some time of pondering, or these thoughts don’t cause intense anxiety or depression typical of DPD. You will be able to come back to pondering these questions and reading from time to time but for now it would be wise to reduce or stop any compulsive ruminating or reading on this topic.

I think adverse effects can be caused for a variety of reasons. They might be as simple as you are living a stressful life and its only when you sit still you notice how stressed and anxious you are. It might indicate that you have a trauma history, that might not be known to you, and that this might be resurfacing (this can be healing when it is done at the right pacing with a professional). They might be natural effects of deep and intense practice as have been described through the ages, and depending on how you frame them and how ‘robust’ your sense of self is, you might move safely between these ‘no-self’ states and daily life. They might also relate to individual genetic makeup and brains. For example, in the DPD world a lot of people are triggered through taking drugs. And this demonstrates how different brains can react to different stimulus, as many people take drugs without experiencing DPD, it could be the same with intense meditation practice. It could reflect other underlying mental health issues, or your vulnerabilities from your childhood attachment histories. Clearly it is a complex topic and I’m sure the work of scientists like Britton will begin to shed light on the nuances so that everyone can benefit from the positives of meditation at the right ‘dose’ and pacing. Some people never experience this territory, others do for brief periods without major impact to their lives, but some people do get stuck in these modes for long periods of time. Hopefully especially the latter group will benefit from ideas in this post. Feel free to contact me if you have any queries about adverse effects as a result of meditation practice.

Behavioural Activation Part 6 – A Tool for the Future and a Promethean Act of Will

William James (1842 – 1910), the philosopher and pioneer of American psychology (teaching the first psychology course in the USA at Harvard) suffered bouts of depression throughout his life. At times they took what he described as a ‘Promethean Act of Will’ to overcome this ‘crisis of meaning’. BA is a tool that you can use for the rest of your life. At times it will be easy, for some people at times, it will require James’ Promethean Act of Will.

You may have times when you use BA more formally and write down an hour by hour daily plan. Other times you might use the principles to ensure you are giving yourself a balance of pleasant and mastery focused activities. You may completely forget about BA at times and then decide to come back to it if you notice changes in your mood.

These last two points are considerations for the future:

9. Prepare for lapses – Unfortunately for most people with anxiety or mood disorders there are likely to be lapses. When life throws new pain and losses at you, stress levels rise, or we stop looking after ourselves so well, then old brain pathways can resurface. Be ready for this and restart what worked as soon as you notice any signs of a lapse. Start planning BA and use your other tools as soon as you can. This was one of the key ideas of MBCT, the ability to detect the early warning signs of depression using mindfulness and to start to take care of ourselves early with BA.

10. Connect and get help – I have mentioned already that a number of these steps work better with friends or in groups. However, we have to watch for the tendency to ruminate out loud with another person. Can we instead put our attention on what they are saying, on their life? Can we do shared activities together rather than talk about our depression? It can be useful to talk to a professional therapist or a close friend or family member. But if it seems like we are going over the same unsolvable loops out loud, then try to switch into a problem-solving mode of what actions you are going to take, or observe and accept the thoughts whilst taking action with the other people.

Again, it’s worth noting that indigenous communities with lower levels of depression tend to spend almost every hour of the day with their friends and family. As they say in Dialectical Behavioural Therapy we need to do opposite action to what the emotion is telling us. So, try to connect with others and face to face connection is always best! Our blood pressure lowers and our heart rate variability improves when we are with friends, its how our nervous systems have evolved!

It can be really disheartening if we experience a lapse or a relapse in our symptoms. It can be important to contact our therapist right away or to connect with our support networks. Depression can resurface but if we continue to practice what worked and to open up with acceptance to these feelings and pursue meaningful activities, then we can recover again. As we develop these skills in a lapse, we actually become more confident that we know what to do next time. Each time we experience these difficult emotions and develop the ability to focus on meaningful goal-directed actions with the people we love (willingly carrying these emotions on our backs), our confidence grows. We get stronger through these promethean trials, much like a right of passage. I hope you have found this series useful and feel free to share any thoughts or questions in the comments below.

Behavioural Activation Part 5 – Lets Get Physical – Activate Through Activity

If you look at many high functioning people who have experienced depression, you often find exercise is part of their recovery. The likes of Tim Ferris, Stephen Fry and world class endurance athlete Christopher Bergland all have credited exercise to helping them maintain and improve their mental health (if you do a little more research online you’ll find the list is extensive). Exercise has been found to have comparable effects to anti-depressant medication in a number of studies. Not to mention the fact that there are all of the additional health benefits of exercise.

But what if you can’t get off the couch, out of bed or think clearly enough to exercise? We all find it difficult to exercise at times, imagine how difficult it is when you are suffering from major depression and you can barely move. I have experienced this dark place myself and it feels like an Olympian feat to simply get moving! But we do have some agency in the painful abyss of depression. We can strengthen the ability to make healthy choices whilst carrying these Atlas-like emotions on our backs. This is where scheduling physical activity in your BA schedule can be so helpful and having the support of friends and family to get you moving. Here are a few other ideas that might help:

7. Start small and build up – Walking is a really useful tool here. The key is to start with a really small and gentle amount. This might even be walking round your house for 2 minutes. Then moving onto a 5-minute brisk walk, then 10 minutes round the block and upwards. Also try integrating exercise with things, you have to do in your day – like commuting, shopping or visiting friends.

Exercising with other people is even more powerful and if you get out in nature as well then you have the coup de gras. It can be beneficial to do a mixture of relaxing and slow exercise like yoga & tai chi and also more intense aerobic exercise & weight lifting. This combination can have a really positive impact on our mental health.

8.What if it’s boring – A lot of people find exercise boring, even when they are feeling well, so (as always) be kind and self-compassionate. If exercise is boring then you might not have found the right fit. What did you use to enjoy before depression? Think back to when you were a kid (a useful tool for filling your BA schedule more generally) and what games, sports, outdoor activities did you use to enjoy and can you add them back in? Connect with other people in groups. Get an exercise buddy to help motivate you. Sometimes (as long as we have the all clear from our doctor) boredom can be a sign that we are not pushing ourselves hard enough. We might need a bit more sweat to access the pleasant rewards of exercise. Its also important to congratulate yourself in your head for achieving your goal when you finish your exercise. Many people don’t do this last step and often berate themselves and go straight into negative rumination after exercise.

Can we use exercise to train our focus and concentration, either through mindfulness of movement and breath or even by listening to music or a favourite podcast? Every time our mind drifts away we notice and come back. Sometimes people use exercise as a time to ruminate, engage in self-criticism or to worry. Can we notice and accept these thoughts and bring our minds back to the present moment? You can use encouraging self-talk to help you as we have talked about in the previous articles. Just like an endurance athlete encourages themselves internally and thinks of their goals.

Some theorists suggest that the stress of living a modern life, far from what we evolved for in the Pleistocene epoch, is one cause of the rise in depression. Indigenous cultures that report much lower levels of depression tend to get 4 hours + of exercise a day (just by going about their day and living their lives) and middle aged and older individuals are built like Olympic athletes! Can we reclaim a bit of this indigenous antidepressant lifestyle by building more exercise into our lives? Alongside exercise, a healthy diet and sleep are incredibly important ways to take care of ourselves and build into our behavioural activation. We will look at these topics in future articles.

Let me know your favourite ways to activate yourself through exercise below?

Behavioural Activation Part 4 – Actions Speak Louder Than Thoughts and Emotions

Our feelings have evolved to hijack our attention, behaviour and motivational systems. At times this can be incredibly useful, even lifesaving. But there are times when the better-safe-than-sorry ‘smoke detectors’ in our brain produce feelings that drive behaviours that don’t help us! There is a level of sadness which can be useful in helping us to pause and reflect, to feel love and compassion or to appreciate the bitter-sweet flavours of our life’s banquet. But there is a level of sadness that pushes us into a numbness or painful states of depression that induce shutdown and social isolation. The pain can be unbearable, there are even common neural correlates in the brain between depression and pain. These agonising feelings can place real barriers to behavioural activation. Often, we need to do the opposite to what our feelings are telling us. We need to get up and exercise when our beds call soporifically to our exhaustion. We need to contact and connect with our friends when every impulse in us is saying to avoid them and retreat back to the cave. We have covered a number of useful tools for working with painful emotions in part 3 of this series, but here are two more ideas to put in the mix:

5. Fake it till you make it – as Mark Freeman says ‘focus on changing actions, not thoughts and feelings’. It’s much better to do your chosen BA actions focusing on what you are doing and trying as best as you can not to monitor how you feel. Excessive self-focus is a large part of the problem. Can you aim to have far more of your focus out on the world and the people you are with? You may very well feel awful when you first start BA, but can you improve your ability to function and concentrate whilst these difficult thoughts and feelings are in the background? Can that be your aim, rather than aiming to feel better?

It is likely it has taken months and years to build to this point of your depression. It might well take some time to break the patterns that led to it, so it’s far better to focus on achieving your goals and concentrating out into the world rather than whether or not you are feeling better. Do the activities you used to enjoy, or new activities that reflect your values even if you don’t feel like it. Having experienced depression, anxiety, depersonalisation and OCD myself, I know how difficult this is, but if we progress gradually then we can get better at changing actions with the heavy thoughts and feelings in the background.

6. Parallel emotions – Another useful concept that I found in the work of a number of expert’s (Mark Freeman ,Reid Wilson, Leslie Greenberg) is the concept that you can have emotions in parallel. There is space for depression and gratitude, anxiety and savouring. In fact, Greenberg (leading researcher and expert on Emotion Focused Therapy) has found that to transform painful emotions they need to be activated alongside positive emotions. Can you learn to accept or tolerate the emotion whilst your concentration is on something enjoyable or satisfying? We really can train this skill of concentrating on gratitude, savouring and flow even when our concentration feels weakened by depression. I found flow to be particularly useful here as we just need to (i) focus (ii) have goals with clear feedback, and (iii) have a balance between our skill and the challenge (not too easy or too hard).

The key is not to battle with our painful emotions. We can use different tools to help us tolerate and then accept our pain but we need to try and develop them alongside our pain, not to battle with it. You might also find my article the acceptance spectrum useful for ideas on managing challenging emotions.

Behavioural Activation Part 2 – Why You Need More than Common Sense

As I wrote in part 1 BA is a common-sense approach to mental health. The problem is when you are in the depths of depression and anxiety the logical common-sense part of your brain is inhibited. You also struggle to hold on to the positive experiences in this state. In fact, at times your brain actively seems to resist them. Professor Richard Davidson elucidated this in his brilliant bookThe Emotional Life of your Brain’. Davidson describes that in comparison studies, depressed patients report the same level of positive emotion in response to pleasant stimuli. The difference is in the half life of these positive emotions. In the control group these positive emotions increased as the subjects reflected and savoured the experience, whereas, in the depressed individuals the positive emotions dropped away sharply. This was reflected in the brain region related to reward and pleasure, the nucleus accumbens. The ‘notes’ of pleasure in the brains of depressed patients were trailing off far quicker than in healthy controls. I think anyone who has experienced depression will relate to this, there are moments of happiness and pleasure, but these are often followed by even deeper lows as you lament for what slipped through your fingers. Sometimes these highs are so subtle that they even go unregistered, so the depressed person is tricked into believing there is only the darkness.

There is also the lack of motivation or the paralysis of fear to deal with. You literally can’t get yourself to think, move or act in a positive way. You might even know what will help you but your body doesn’t seem to move or your overwhelming thoughts convince you that nothing will help or you don’t deserve recovery.

Many theorists posit that depression has an evolved function. In the days of our ancestors this mood state would induce you to go back to the cave to rest and avoid danger. Or it might mean that you kept a lower status in the group so that the dominant members of the tribe would not attack you. Is it perhaps a mechanism that in smaller dose’s can be beneficial, but is not designed for our modern world? Is depression triggered by an overactive physiological response to the everyday stresses of modern life? These theories make sense to me. Perhaps we can use them to help us be kind with our harsh inner critics and cut ourselves some slack. After all, it is not our fault that we have tricky brains.

So, what can you do when you are depressed and want to utilise BA? As MBCT states ‘In depression, we have to do something before we are able to want to do it’. Over the next series of blogs, I’m going to describe 10 tools that have helped me. Needless to say, it will always be most effective to do BA under the guidance of a trained professional.

 

  1. Divide and conquer – The science of procrastination has a lot of transferable tools here (see Prof Timothy Psychl brilliant book for more details). Divide every task up into smaller and smaller chunks, until it seems possible. At the extreme end of the scale, getting out of bed and going downstairs for breakfast could be divided into multiple steps, each one being focused on in turn. Start small in terms of changes, with one or two new items added to your schedule a day (or week). Start with the simpler tasks and build up to anything more challenging.

 

  1. Put it down on paper – As discussed in the first article, BA is typically recorded hour by hour on paper. It really helps to write the plan down and focus on each hour rather than the potentially overwhelming full day or week. Generate and write down your list of pleasure and mastery activities that reflect your values and goals.

 

These first two points work in partnership. Putting our plans down on paper helps us to divide and conquer. But what happens when your thoughts and feelings resist this process? We will take a look at tools to work with our tricky minds in the next article.

Behavioural Activation Part 1 – A Common Sense Approach to Mental Health Your Gran Would Agree With

I think the best psychotherapy and well being programmes have common sense overflowing from each practice, intervention or tool. Would your Gran have told you to do this when you were a child? Did the Greeks, Stoics and indigenous cultures do these things either consciously or as part of ‘the Good Life’? If the answer is an unequivocal yes then it’s definitely worth exploring. Behavioural Activation (BA) is certainly one of these common-sense tools. When we feel depressed or anxious we tend to isolate ourselves, stop doing things that make life meaningful and ruminate on our suffering. BA teaches us to challenge this by doing the opposite, making a list of varied activities to nourish our brains and recover our moods. Its not easy when you are depressed but it makes sense.

Mindfulness Based Cognitive Therapy (MBCT) was primarily developed for maintaining recovery from depression. Its creators had previously been experts in Cognitive Therapy and mixed elements of this with mindfulness in MBCT. One aspect was BA and they titled the session that focuses on it ‘How Can I Best Take Care of Myself’ to reflect the compassion embodied in Jon Kabat-Zinn’s original formulation of Mindfulness Based Stress Reduction.

BA came from the behavioural tradition of psychology, and holds that depression stems from a lack of positive environmental factors and/or too many punishing factors. There are different varying approaches to BA, often they start with an analysis of how you are spending your time hour by hour each day. How do these activities impact your emotions and moods? Then identifying positive experiences to add in and negative experiences to remove. This is followed with tracking the impact on your mood of increasing these positive steps and reducing negative factors. In MBCT we identify positive events by two categories: pleasure activities and mastery activities. Pleasure activities are inherently rewarding and involve enjoyment like talking with a close friend, eating nourishing food, listening to beautiful music etc. Mastery exercises give us a sense of satisfaction through mastery of our environment, like tidying our house, planning our monthly spending etc. Of course, there can be some overlap between pleasure and mastery, but it is good to schedule a balance of these activities.

It sounds very simple, but this can be a herculean task when you are depressed. When the weighted shirt of depression is on you, it can be a huge task just getting out of bed. You can’t think straight, your own mind is attacking you with the weapons of doubt, self-criticism and meaninglessness. So how can you use BA to move through the quicksand of depression or the paralysis of anxiety? In the next article I will explore some ideas that have helped me when using BA to work with my own anxiety and depression.