Mindfulness for psychosis: healing or harmful?
Mindfulness has transformed the treatment of many mental illnesses, but people with schizophrenia have been left out. It’s time clinicians forget the frightening images of meditation-induced psychotic relapse and embrace mindfulness for treating psychosis.
Schizophrenia spectrum disorders are among the most debilitating of psychological conditions. People on the schizophrenia spectrum experience positive symptoms (hallucinations and delusions), and negative symptoms (disorganized thinking and speech, loss of motivation and interest, cognitive impairments, etc.). These positive symptoms are also referred to as psychosis. The words schizophrenia and psychosis are sometimes used interchangeably, but strictly speaking, psychosis is a group of symptoms associated with schizophrenia. It is important to note that while other disorders — such as borderline personality disorder and bipolar disorder — can also cause psychosis, this article focuses on psychosis within the context of schizophrenia as it is the most common and tends to be the most severe.
Mixing mindfulness and psychosis
The current gold standard treatment for psychosis consists of either cognitive behavioral therapy or family therapy, combined with antipsychotic drugs; however, these interventions are hardly ideal. One major issue with treatment is the prevalence of patients choosing to discontinue their medication, often because of the intolerable and sometimes life-threatening side effects of antipsychotic drugs.
In recent years, clinicians have found success in treating various psychological disorders with mindfulness-based interventions (MBIs). Most MBIs work best in a group setting and incorporate body scans, mindfully focusing on the senses, and accepting one’s thoughts in a non-judgemental manner.
The slow growth of MBIs as a treatment for psychosis is largely due to an idea that still prevails among some clinicians today — namely, that psychosis can be exacerbated or even caused by MBIs. Multiple studies (most published decades ago) have claimed that MBIs can cause distressing symptoms such as depersonalization, an altered sense of reality, and even full psychotic episodes for psychosis-prone individuals. These historical concerns about the safety of MBIs for people with psychosis seem to have caused the shortage of randomized controlled trials investigating the topic.
New evidence for MBI efficacy
Since 2016, multiple meta-analyses have been published that detail the efficacy and safety of MBIs for people with psychosis and schizophrenia. Systematic review papers by Cramer et al., Hodann-Caudevilla et al., and Jansen et al. have produced evidence that MBIs have moderate effects on reducing symptoms of psychosis. None of the studies used in the meta-analyses reported any adverse effects on the mental or physical health of the participants involved.
In these reviews, MBIs had an effect similar to that of cognitive behavioral therapy in decreasing positive symptoms of schizophrenia. This alone is very encouraging for the treatment of psychosis. Perhaps even more promising is that the MBIs had a large effect on the psychosocial functioning of the participants. All three papers recommended MBIs as part of a treatment approach to psychosis.
The reasoning behind why MBIs might help treat psychosis centers around awareness and acceptance; recognizing one’s own psychotic symptoms allow the individual to distance themselves and accept their symptoms as temporary phenomena. Importantly, MBIs do not target the psychotic symptoms themselves, but rather decrease the stress associated with battling them. It is theorized that this learned ability to “observe” rather than experience one’s own psychotic symptoms is the reason that participants in MBI studies report that they experience fewer symptoms.
A fresh look at the past
Two seminal studies published decades apart — one in 1979 and another in 1999 — were perhaps most influential in scaring psychosis researchers away from studying MBIs. Each study reported three cases of psychotic relapse in individuals taking part in an MBI. It is useful to consider the commonalities between the studies that advise against MBIs for psychosis to get a better understanding of where they went wrong. First, the MBIs for both studies featured extremely long hours of meditation per day for many days in a row, and communication with others was discouraged. Sleep deprivation was also a factor in both studies. Considering these circumstances, the case reports of psychotic relapse are unsurprising.
MBI applications for psychosis
Researchers are now discovering that with some notable modifications to MBIs, individuals with psychosis will finally be able to safely participate. 10 minutes of mindfulness meditation — rather than the usual 40 —should be the limit for people with psychosis. Further, vocal guidance in these sessions should occur every 30-60 seconds, and practitioners should avoid long silences. Easily accessible language should be used. Finally, psychotic symptoms should be given no special status during the MBI — they should be seen as thoughts equivalent to any other.
The ultimate goal of MBIs for those with psychosis is to increase their psychological well-being. Despite their unfortunate place in a bygone era of research, it seems that MBIs will soon become a powerful weapon in the battle against the debilitating nature of psychosis. Now that there is ample evidence for the efficacy of MBIs for psychosis, it is paramount that afflicted individuals are no longer denied access to these treatments simply because of their diagnosis.