Meditation on drugs

Recently a couple of friends admitted something to me.  They both asked me not to judge them, and then sheepishly told me they were taking antidepressants.  On both occasions I looked back at them and said, 'Me too'.

In fact, I've been taking them, off and on, for about a decade, ever since I began having chronic pain.  After trying a number of different drugs, I was prescribed amitriptyline.  It was easily the most helpful medication I'd been offered, and I've stuck with it.

Amitriptyline is an one of a family of older-generation drugs called tricyclic antidepressants.  It affects the levels of both serotonin and norepinephrine in the brain, unlike the newer SSRIs, which more precisely target the reuptake of serotonin.

Nowadays it's very commonly prescribed for chronic pain, usually at a lower dosage than is indicated for depression.  I started off taking 20mg a day in England, which helped me finish my first degree but left me in considerable pain. 

In my first three years in California (with the help of more liberal doctors) I was on 100mg a day.  I had periods when I was pain free, and though I did feel the side-effects (drowsiness and dry mouth) more strongly, I felt that the drug would never do me any harm.

That all changed one winter when I started taking 150mg a day because of some extra pain deriving from some dental surgery.  I began feeling very depressed, and noticed that I was twitching, itching, and sweating profusely all the time. 

I didn't know it, but those were the symptoms of 'serotonitis', an overdose of serotonin.  When I realized, I went cold-turkey, which immeditately made me feel better but which brought the same symptoms on in a more intense form.  I remember sitting in the Castro Theater one night in that period, sweating and itching and twitching, watching some noir classic in a strange euphoria of relief.

After that I was more cautious.  In the last few years I've gone off the drug completely a few times, only to go back on it again.  In some ways being off it isn't that different; I feel the pain much of the time in both states, but it feels more distant and manageable when I'm on the drug (and sometimes it's completely absent). 

Both of my friends who talked to me about antidepressants had spiritual or religious doubts about taking them, so I thought I might raise the issue here.  Are antidepressants antagonistic to a spiritual practice, or complementary? 

I can't answer the question definitively, partly because there are a lot of different drugs and practices out there.  But I have looked into this a bit online, and it might seem at first as if meditation and antidepressants are doing more or less the same thing, since they both raise levels of serotonin in the brain.

This is actually more complicated than it seems, though.  One recent Norwegian study (with only 27 subjects) suggested that regular meditators had higher levels of serotonin than non-meditators, but that meditation itself seemed to reduce the level of serotonin in their blood. 

An older Harvard study appeared to show that people who meditated produced the same amount of norepinephrine (a 'fight or flight' drug), but that it had ceased to trigger an emergency response in meditators. 

So the scientific evidence on this appears complex, and I'm not particularly well-qualified to assess it.  Looking at this from a traditional Buddhist angle also raises some hard questions, such as whether antidepressants should be discouraged as intoxicants, or encouraged as pain-reducing medicines.

I'm not sure that I have much to add from than angle, either.  But I can say a bit more about my own experiences of meditation and one kind of antidepressant, in the hope that it may be useful to other people who are in a similar situation.

I've practised meditation through the whole period I've been on amitriptyline, usually for twenty minutes a day, though occasionally less (and very occasionally more) than that.  Of course all I can do is tell you what it felt like to me (which may not be unimportant).

I think that meditation without the drug is more challenging.  My mind is more anxious and I'm distracted by pain more.  On the other hand, it's also more rewarding, since the difference between my state of mind before and after sitting is more dramatic.

When I'm on a lot of the drug, meditation is often very pleasant.  I breathe in, I breathe in, and it all flows along very pleasantly.  But in some way it feels more superficial.  I feel like things have gone more smoothly but that I have gained less insight about myself and my condition.

Ultimately, the plan is to go off the drugs.  The plan (often revised) usually involves doing more and more meditation as I slowly come off it.  Unfortunately, I've been too busy lately to commit to longer retreats of the kind I had in mind, so full implementation of the plan will have to wait a bit longer.

In the meantime, I try not to beat myself up about it.  Some people take insulin for diabetes.  Other take statins for high cholesterol.  I take amitriptyline for chronic pain.  I also meditate, which is cheaper and doesn't make my mouth dry.  In other ways they're just two different things that help. 

Synaptic juice

The San Francisco Bay Area is its own little world.  I don't mean that in the sense people sometimes mean it: the most reflexively left-leaning corner of America, one of the most pot-friendly, a haven and promised land for gays with the dubious luck to be have been born and raised in the Bible Belt.  All those things are true, of course, and are worth enjoying, and maybe even being proud of: I have to say that I savoured the rare juxtaposition of a rock musical powered by drag queens on a recent Friday night with a meditation and service with black-robbed monks in the Zen Center the following Saturday morning.  But what I appreciate most isn't the area's well-defined and well-known profile, but its less celebrated diversity: not the fact of weirdness but its multifacetedness, and even its coexistence with the humdrum.  Alongside the gays of the Catro and the Mission's hipsters, there are also the yuppies in the Marina or the retirees of Marin.  And maybe no region attracts as much interest from outside the area, and as much ambivalence from inside it, as the South Bay, not so recently rebranded as Silicon Valley.

The Bay Area's an interesting place to practise meditation for a range of reasons.  There's a certain liberal tolerance of what others get up to, an open-mindedness about spiritual practices inherited from the hippy movement, and longstanding connections with Asia, as close to SF as to any American city.  But one reason it's an interesting place to become acquainted with an ancient tradition is its hyperbolic modernity, its position at the cutting edge of scientific research and technological innovation.  The cultures of Eastern mysticism and high-tech entrepreneurship come into contact more than you think, and have settled into a comfortable enough relationship: I only recently met a young man at SFZN who leads mediation sessions at Google, a company that regularly hosts talks by such mindfulness luninaries as Jon Kabat-Zinn.  I have my doubts about the spiritual-technological complex, partly because the union of an ascetic tradition enjoining detachment and a computer industry focused on making a profit looks to me like an awkward hook-up.  Still, like many an awkward hook-up, it's hard to deny after the fact that the experience has been interesting. 

In the Bay Area, the junction of science and spirituality is something you can decide not to pursue, but which will probably thrust itself into your attention every few months regardless, so I thought I'd give you an update on a couple of recent experiences (that is, experiments) that I've had.  The first was a result of an email that was sent around to the Buddhist Community at Stanford mailing list.  Now, I've seen negative reactions to people using that list to send round requests to support the monks' protests in Burma, on the grounds that the issue was a political and not a spiritual one.  But, this being Stanford, we quite regularly get emails from researchers - research, you see, is never political, especially when it might lead to the development of an iPhone app.  And on this occasion the researcher involved offered us a coupon for Jamba Juice, and fruit smoothies can be counted on to constitute just too much temptation for any California Buddhist to resist.  I signed up immediately, and booked a slot at Stanford's Calming Technology Lab.  I never knew it existed, but as I can now assure you, it does.

I was met at the lab by a friendly young doctoral researcher called Neema Moraveji.  He fixed me up with an apparatus designed to track my breathing, which consisted of a band that I put around my torso and some wires  He then asked me to sit at a desk and perform some simple tasks on the computer: one of them was to count down from a given number in sevens.  After a certain point I was told to watch a video informing me that your brain performs better when you're calm, and that calm states correlated with states of deep, slow breathing.  After that, I was told to try to deepen and slow my breathing, something I found surprisingly easy - maybe it's all the meditation, although none of the styles I practice encourage you actively to control your breath, just to notice it.  Finally, I was asked to return to the exercises on the computer, and repeated them for a second time.  The aim, as I understood it, was to develop technology that would encourage office-workers to slow their breathing, thus increasing both industrial productivity and inner contentment.  Win-win.

The second recent experience of this type started after a pretty dry dharma-talk at SFZC.  A young woman stood up after the Ino had finished his announcements and introduced herself as Kim Fisher, a doctoral student at the California Institute of Integral Studies.  She needed meditators to volunteer for an experiment she was conducting as part of her dissertation.  CIIS is an institution that was founded in the early 70s by SF types connected with the human potential movement and interested in bringing together East and West, spirituality and science.  They offer Master's courses in subjects like 'East-West Psychology' and 'Dance Therapy', as well as doctoral programs in Psychology and related disciplines.  It's a small school with not a lot of money, so they were not able to offer me a boosted smoothie in return for breathing deeply.  But I went along anyway to one of their buildings in the Upper Market area of town, just before the street turns really nasty.

When I went in Kim immediately asked me to meditate for half an hour in whatever style I chose.  I knew that she was interested in testing intellectual performance, so I went for my concentration practice, after describing it to her.  She had cushions and mats set out just like in the Zen Center and sat next to me when I sat.  (Considering that she was doing that all day, her experiment must be affording her a pretty good chance to get some sitting in, dissertation research meeting Buddhist retreat.)  After we'd finished I was called over to a desk, told a short story, and asked to repeat it word for word.  Then I was shown a complex geometric object and asked to reproduce it on a piece of paper using only a pencil and memory.  It looked like a 7-year-old boy's design for a space-ship.  At a certain point the fire-alarm went off, which she said would probably force her to throw away some of my results.  A week later I was called back in and I did similar tests but this time without meditating first.

I asked both of these researchers more about their projects, but it's understandable that they were cagey about the details, seeing that the studies were ongoing.  On the other hand, it's not hard to guess that the basic methodology involved in both is to compare performance on mental tasks before and after meditative practices of various sorts (in the first experiment, it was the physiological correlates of relaxation that were tracked, whereas in the second meditation was left to each individual's own definition).  Both studies were extremely interesting to take part in, and it's hard to be against learning more about meditation in this way (though I've had a go in previous posts on this blog).  It will be key for both scientists, I would suppose, to restrict their conclusions to claims about the effects of meditation on subtracting by seven and redrawing space-ships, and not on global intelligence (whatever that is).  And though (to be fair) neither researcher is explicitly excluding the spiritual aspect of meditation, it's hard not to feel that, in giving people an app that reminds them to take deep breaths rather than integrating them into a challenging ancient practice, they're missing out on something.  What that something is can't be quantified; but so much the worse for quantification.

Zen people are assholes

Once there was a temple that was destroyed by fire; its great library was completely destroyed.  Priests from a nearby shrine came to the great temple concerned about the loss of ancient Tang and Sung dynasty texts.  The master told them, 'None of them have been harmed'.  'Where are they then?' one of the priests asked doubtfully; 'Would you show us the Tang edition of the Mahavairochana sutra?'  The master held up one hand.  The priests didn't know what to make of this, but another one asked to see the later translations of the Lotus Sutra.  Again, the master held up one hand.  He said, 'The covers were burned, but you can still hold the texts in your hand'.

That was one of the first koans I heard at Wind in Grass.  When it came to the discussion, everyone put their interpretive pennies into the hat.  When the Zen bug (which preceded the disembodied Buddha head) came to one hipster girl though, she just put up her hand.  She looked kind of pissed off.  Later on I got to know her better when she ended up being up at retreat the first time I went to one.  Before you eat a meal on retreat there's a weird ritual where a plate is passed around every table and everyone puts a morsel of food on it.  Then one person from each table takes the plate up to the altar and offers the food up.  The whole while everyone in the room is muttering a dark twisted form of grace in which we invoke all the demons and hungry ghosts, asking them to take our food and be at peace.  One of the first times I was involved in this I took a particularly plump raspberry and put on the offering plate.  A few seconds after the rite had been concluded the girl whispered harshly over at me, 'I can't believe you gave a whole fucking raspberry to the hungry ghosts!  They don't even exist!' 

Zen people can be assholes.  I don't mean that in a complaining way; it's just something I've noticed and appreciated.  It's part of what makes me feel at home at Wind in Grass, since there's a certain normality there.  The hipster girl told me how she'd been on a vipassana retreat for a whole month once.  It had changed her permanently and made her happy and all that, but one of the things that stuck in her mind was that it was impossible to go through doorways, because whenever you tried there'd be a smiling Buddhist on the other side inviting you to go through first (at which point you'd obviously have to smile back and insist that the smiling Buddhist go through before you).  That doesn't seem to be a problem at Zen retreats.  I was definitely intimidated by some of the people I saw at my first retreat, but then I got to know them better, and now they just scare me.

Ultimately, the practise is about compassion (like all true religious paths, perhaps).  But there's a lot of emphasis at the outset on authenticity, too: you never get the impression that people have plastered smiles on their faces, which has sometimes been my suspicion at meditation events of different persuasions (not that having a smile plastered on your face isn't better than having most other things plastered on your face).  If you're pissed or randy or distraught, the Zen prescription seems to be to just be pissed off or randy or distraught (and maybe: notice that you're pissed or randy or distraught).  Don't criticize yourself for it.  After a while you'll realize that being pissed, randy, and distraught are all fine states of mind to be in, and you won't be so desperate to change your state of mind or the state of the union.  And from below the surface of that equanimity compassion will bubble up naturally.

That's my understanding of the teaching at this point, and I don't like it all that much.  (So my understanding may still be imperfect, or the teaching may just be crap.)  But it does raise an interesting and obvious point about Buddhism: that's it's a capacious and varied set of practices, and it shouldn't be surprising that different emphases in terms of the ethics will lead to practitioners who react differently when they meet each other at doorways.  This also links up with the recent posts on meditation and neuroscience, since it's often amusing to me to read of studies that show how 'meditation' has this or that effect in the brain.  What kind of meditation?  Often they'll stipulate it's 'Buddhist meditation'.  Thanks.  (My former teacher Mike Hagerty's work is an exception in this regard, often describing in detail the particular type of meditation that's being studied).

It's pretty obvious, though, that different types of mental exercise will lead to the development of different features of personality, just as different physical exercises lead to the development of different muscles in the body.  That actually seems to be one of the starting assumptions of lots of meditative practices: people who do metta for example, are aiming partly to cultivate a generous attitude that will issue in right deeds and good action.  So it's no surprise that meditators who concentrate on an object of meditation will develop a certain one-pointedness, and that Zen types who just fucking sit for hours at a time will become increasingly badass.  I don't want to emphasize this too much, since in the end there seems to be something common to all types of meditation which just grants you peace in an unpredictable way (maybe in the way that all types of exercise make you feel slightly better somehow).  But it's worth noticing, and worth bearing in mind: be careful what you sit for.

This is your brain on meditation

Let's return to the question of the scientific evidence for the benefits of meditation, making the scope of our enquiry slightly broader than pain this time around.  There seems to be a lot of research out there suggesting than regular meditation can improve your overall health, reduce anxiety and depression, and even make you smarter.  As far as I can tell, the claims seem to be true, though I wouldn't be surprised or dismayed if some of them turned out not to be.  But I want to make two points here: the first is that it has always seemed to me that the hardest way to get the benefits of meditation is to try to get the benefits of meditation; and the second is that health, cheerfulness and smarts are all very well, but there's a way in which meditators who focus on getting them are missing out on something much better and readier to hand. 

There are plenty of meta-scientific studies out there showing that research on most novel medical treatments follows a consistent pattern: at first, the new technique is acclaimed, as study after study demonstrates that it has incredible benefits, low costs, and few side-effects.  After a while, there's a reaction, as studies appear that imply that the vaunted effects represent little more than the action of placebo.  In a final stage, researchers settle into a consensus that the novel treatment, though not the panacea it had at first seemed, is also not the fraudulent practice some had accused it of being.  And something similar may well be in store for research on meditation, scientific research into which is still relatively young.

On the other hand, meditation itself is not a new practice but an ancient one, dating back at least 2500 years.  There's a sense in which anyone who has met an experienced and authentic meditator - a monk, say - knows that their practice has developed certain character traits, whether or not they want to develop those traits themselves.  And there's a sense in which what neuroscientists look at (brain waves, neurogenesis, activation of various areas of the brain) are phenomena of secondary importance when it comes to meditation.  We don't experience the ion channels in our neurons, can't tune into our brain waves, don't feel our amygdala lighting up the way it does on a scan.  But we do feel better about the world after sitting still for a little while, and that may be all the evidence some of us need.

Still, it's encouraging to see how the initially sceptical scientific community in the West has fallen slowly but surely head over heels for meditation.  There have been a number of crucial contributions.  One was the medical researcher Herbert Benson's work on the 'relaxation response' and its health benefits in Boston in the 1970s.   Another has been the cooperation encouraged by the spiritual leader Tenzin Gyatso between neuroscientists and advanced meditators at the annual Mind and Life conference, inaugurated in 1987.  And another was the neurologist James Austin's 1998 book Zen and the Brain.  There are now centres dedicated to meditation research across the US, including one at Stanford.

And what have all these researchers found?  I can't hope even to survey the findings of the thousand or more studies on meditation that have been published since the 1970s.  But here a few especially suggestive findings.  Researchers at the Medical College of Wisconsin in Milwaukee studied 201 African Americans in their fifties and sixties who had been diagnosed with heart disease, following these subjects' health over nine years.  Half the group was assigned to a course on diet and exercise, while the other half enrolled in a meditation class.  At the end of the study, the researchers found that the incidence of heart attack and stroke in the group of meditators was only about half the rate in the control group.

Similarly spectacular results were reported for the treatment of depression in a study carried out at UCLA.  The group of subjects is this case was a worryingly small one, of only 36 people, all of whom had been diagnosed with clinical depression, and all of whom were taught to meditate.  Reported symptoms of depression in the group as a whole had nearly halved after three months, and the benefits were retained for the rest of the year.  (The three-month duration of the activation period, reported in a few studies I've seen, chimes with my experience.  It was about three months after I'd started meditating for the first time than I began to feel I had a real handle on my facial pain).

Another smallish study from UCLA looked at the brains of 44 people, half of whom had practised meditation for several years.  MRI scans showed that the hippocampus - an area of the brain associated with memory - was significantly larger in the brains of the meditators than in the control group.  Admittedly, this may have been because people with large hippocampi are pre-disposed to meditate rather than because meditation increases the size of your hippocampus.  But researchers at Harvard and Yale have interpreted similar results as suggesting that meditation actually stimulates the production of more grey and white matter in regions such as the anterior cingulate cortex. 

This is just a glance at a few studies on three aspects of health that meditation has been claimed to improve.  But it looks like we have a simple technique that is free, has no side-effects, is available to everyone, and that reliably makes people healthier, happier, and cleverer.  I'm not in a position to be able to offer any sort of reliable meta-analysis of this research, but the balance of evidence seems clear.  But though I suppose that meditation might make you healthier and happier and smarter, I don't think people should meditate in order to achieve these goals.  I don't really think people should meditate in order to achieve other goals either.  The thing is, I don't think people should meditate to achieve any goals at all.  In fact, meditation for me is partly about realizing that there aren't any goals you need to achieve apart from appreciating the amazing show the daylight is putting on for free.

My first problem with meditating for health and happiness (or even wealth, as I'm sure some do) is that it makes the practice into another kind of striving.  Even sophisticated (or just plain honest) Christians like C.S. Lewis have always stressed that prayer isn't about getting what you want, but about putting your heart in the right place so that you want (or at least accept) what you get.  And as a matter of observation it seems that you only stop being nervous about a presentation when you stop making its success such a big deal; you only stop worrying about a date when you realize that your happiness isn't going to depend on its outcome (though your ego might); and that in general, and paradoxically, things only start falling into your lap once you've sat down and given up reaching for them.

My second problem with focusing excessively on the medical gains of meditation is that it misses the real windfall.  When they asked Gautama what he'd gained from enlightenment, he reportedly (I get this from Henry Miller) replied, 'Nothing - and that's exactly why it's enlightenment'.  Stopping worrying about your job, your health, even your family, must all ultimately be part of an understanding that there's nothing you can possibly lose (or fail to gain) that will take away this moment, with the lamplight and the stillness and sounds of the night.  And it may be that that realization will heal your heart and grow your brain.  I don't care.  I sit in the half-light, listen to the silence, look around at the restful objects teaching me how not to move, knowing there's no improvement I can make that will make this moment more true.

Meditation and pain

'You're going to be in pain' is the general idea of the first noble truth, usually translated grimly as 'Life is suffering'.  The other noble truths conspire to tell you what's causing the pain (being thirsty) and that there's a way out of it.  I suppose that the orthodox prescription is to adopt the ethical practices of the eightfold path, thus reducing your thirst for things and so your annoyance when you don't get them (or your disappointment when you do).  But is there any evidence that meditation itself can reduce pain?  Isn't the idea that the mind can influence the body a load of hippy shit?  And even if I think that meditation is helping my headaches, couldn't I just be wrong?

In the early days of my headaches, I tried a number of different therapies, some conventional and some less so.  I tried to get an idea through the popular press about what therapies had scientific support and what did not.  I went to various chiropractors, who would give my neck sharp twists, as if they were trying to finish me off around the wrong corner of a Steven Seagal film.  I found out that though there's a cultural bias in the research, there's a relatively good amount of evidence suggesting that acupuncture can help with one or two conditions (mainly idiopathic headaches and nausea), but it didn't work for me.  I went to an osteopath who - I could swear - could make my right arm weaker or stronger by adjusting my neck (and no, I've never been able to figure out how that worked). 

Compared to the uncertain evidence supporting many alternative therapies, studies suggesting that meditation helps reduce pain are rather numerous (though some are vitiated by a lack of proper controls).  In the 1980s Jon Kabat-Zinn conducted a series of experiments at the University of Massachusetts Medical School involving subjects in chronic pain who were invited to take part in a ten-week course in mindfulness meditation.  There was a statistically significant decrease in reported lower levels of present pain, negative body image, and pain-related depression among the patients who completed the course, and no significant improvement on any of these dimensions by members of a control group, who were given more conventional treatments such as nerve blocks, physical therapy, and antidepressants. 

More recently, a research group at the Université de Montréal compared pain tolerance in 13 Zen practitioners (with over one thousand hours of meditation each) to that of 13 non-meditators (with no or little experience of meditation).  The researchers placed heating plates on the subjects' calves, and warmed them up to between 43 and 53 degrees Celsius.  The meditators tolerated greater levels of pain in both meditative and on-meditative states.  More recently still, scientists at Wake Forest University subjected 15 people to the same level of heat before and after a course consisting of only 80 minutes of meditation, and found that the individuals reported significantly less discomfort after the training (and that the reported reduction in sensation was accompanied by differences in brain activity).

But meditation happens in the mind, while pain affects the body, so how does that work?  There are two common misconceptions here: one is about how pain works and one is about the relationship betweend mind and body.  As its happens, both misconceptions could be attributed to Descartes, although both ideas have an insidious plausibility that makes it likely that people have often come to them independently.

The first unhelpful notion is that pain is a signal that travels along a nerve from a stimulus (the tack you stepped on) to the brain (which registers the sensation); pain represents an accurate signal of damage to tissues.  Fortunately and unfortunately, things are actually more complicated than that.  In fact, there's no reliable link between how much you're hurt and how much pain you're in, as suggested on the one hand by soldiers who get their arms blown off and don't feel any pain until they're out of the combat area (lots of damage, no pain), and on the other hand by sufferers of chronic pain (lots of pain, not always much continuing damage).  The neurologists Ronald Melzack and Patrick Wall drew attention to cases like these and explained them with their gate-control theory of pain, in which downward inhibitory signals from the brain (saying 'I can't take in that pain signal now because I have to protect my comrades in battle') and constantly-reinforced signals (saying 'your head must still hurt because the experience of that car-accident was so traumatic') have as much to do with what you feel as what is happening to your body.

The second unhelpful Cartesian idea is dualism, that mind and body are two separate substances.  The theory has of course been extensively debunked over the last four hundred years for a number of reasons, chief among them the philosopher's inability to give any satisfactory account of how the two separate stuffs could possibly interact with one another.  And yet the assumption that the mind can be conceived of as existing separately from its physical substrate underlies many of the thought-experiments that seem still to be in vogue (as in Hofstadter and Dennett's collection, The Mind's I).  Against this backdrop, the more of an uncompromising monist you are (believing either that everything is completely mental, like Berkeley, or that everything is entirely physical, like Hobbes), the more likely you are to comprehend how meditation has an effect on physical pain.  Meditation can reduce pain because it impacts the brain, and the idea that the neurological control-centre might have an effect on the peripheral nervous system should not be considered an outrageous one.

Sometimes I wonder whether the benefits I'm deriving from meditation are just all in my mind.  That is partly why I like to look up scientific studies, to reassure myself that all the time I'm investing in meditation isn't being wasted.  But in my better moments I realize that this is a peculiarly ridiculous kind of doubt.  The benefits of meditation are, of course, all in my mind - it's just that my mind includes my body (or, if you want, they're all in my body, which is also where the mind is).  And in any case, can I really be wrong about my own state of pain?  Pain is a subjective state, and if the relief I'm perceiving is merely subjective, that's fine with me.  In the end, whatever regions of my brain are lighting up when I meditate, and whatever neurons are firing or being generated, all that really matters for me is that sitting down on my own, without any desire to get well or change things, makes being or not being in pain not really matter so much at all.