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. 

Half lotus land

There's a story about an old monk with a withered leg who couldn't sit in what's traditionally seen as the ideal position for meditation, with legs crossed and both feet on the top of the opposite thigh (a posture called 'full lotus').  On his one hundredth birthday he came into the meditation hall, sat down on his cushion, looked at his leg and declared, 'All my life I have been at your service.  Now, for once, you will be at mine!'  With that, with a quick and determined heave, he pulled his crippled limb up, breaking it off, reaching enlightenment, and dying all at the same time.  Robert Aitken has a characteristically laconic comment on this, advising the newcomer to Zen not to attempt such an energetic practice, at least not until they are ready to die.

A lot of books on Zen still state that full lotus is the ideal position for meditation, but you'd be hard-pressed to find anyone who could demonstrate it for you.  I saw one of my friends at school doing it once outside of the hall we were about to go in to do some important exams (and afterwards he went to Cambridge to study medicine, so it must have done the trick).  I saw somebody do it next to me at San Francisco Zen Center the other week.  And that's about all the people I've ever seen actually sit full lotus in any of the half-dozen or so meditation groups I've been a part of over the years.  There was one other guy doing it in the group I sat with in Oxford, and the teacher looked at him and said, 'Wow, I've only ever seen one other person who could sit full lotus before'.

But there are many people who say that you can get to full lotus eventually with a little application; okay, a lot of application.  The Dutchman Janwillem van de Wetering, who lived at a Zen monastery in Japan for a year in the early 1970s, tells of being forced to sit in full lotus for as many as fifteen hours a day.  They say that after a few months of that kind of practice, anyone can sit in full lotus pretty comfortably.  There are people who even see the excruciating pain caused by sitting - or trying to sit - in full lotus as a key part of the Zen practice of achieving detachment from your mental states and observing them with something approaching objectivity.  I've seen quotations from medical scientists appealing to the 'training' the posture offers to explain the success experienced meditators have in controlling pain or their reactions to it.

If you come to meditation as a Westerner, especially if you start out practising in either the secular or vipassana styles, it's likely your teacher will encourage you above all to be comfortable, giving you the choice of sitting on a cushion, on a chair, or even lying down.  This is actually in line with Buddhist tradition, in which there are four classical poses for meditation - sitting, standing, lying, and walking.  (I've tried all of these except for standing, though it sounds like a good approach.)  If you don't believe me, just consider any of the millions of depictions of Siddartha Gautama meditating lying on his side, for example the colossal statue at the Wat Pho temple in Bangkok.  All the Zen places I've been to, and the Tibetan temple in London I once frequented, alternate longer periods of sitting with shorter bouts of walking, usually in a line, slowly (though the Rinzai sect people like to race around).

One of the things I like most about my main Wind in Grass group is that we're always told, and always tell newcomers, to meditate in whatever position makes us feel most comfortable.  Most people seem to go for seiza, kneeling, either with their bum on a cushion and their legs to each side of it, or with their calves on the floor and their bum on a small bench.  This freedom is also extended on Pacific Zen Institute retreats, where you do see a lot of people sitting in half lotus (an easier version of full lotus, where only one of your feet is up on the opposite leg), but where an equal number of people sit on chairs.  One of them is the teacher David Weinstein, whom I've never seen meditating in any other position than seated on a chair.  Once when I was complaining of back pain David sympathetically told me about another student he'd had who had such serious spinal trouble that he used to meditate stretched out flat on his back or on his stomach.

But though the trend seems to be towards a more generous conception of how your limbs might be arranged when you meditate, there are signs of a holdout in some quarters, or maybe even a backlash.  Brad Warner, the onetime punk rocker who is now a Zen priest, is hardly the type of guy who stands on formalities.  And yet he's repeatedly insisted that 'sitting in chairs is not zazen' (that is, Zen meditation).  His reasoning is that zazen is at least partly a physical practice, like a yoga posture; doing zazen in a chair is like trying to do downward-facing dog standing up.  People who really need to sit in chairs because of spinal issues should be allowed to do so, but most of us don't really need to sit in chairs for that kind of reason.  We should keep pushing ourselves just a little bit, because getting used to discomfort is one of the main things we are doing when we engage in Zen training.

I don't want to add to the comments below Brad's post by people who've been encouraged to sit zazen and who've hurt themselves as a result.  But I do wonder whether physical posture defines zazen in the same way as it defines downward-facing dog; after all the yoga asanas are called postures, while zazen is a word for meditation.  Siddartha Gautama and hundreds of other masters after him seem to have done just fine meditating without their crossed legs reminding them of the first noble truth.  If pain and suffering are a part of life, it seems rather obnoxious to seek them out ourselves, as if we didn't have what's in our heads to keep pushing us towards endurance every second.  And what happens when we greet moments of awakening in everyday life?  Do we have to take up half-lotus in the restaurant?

I myself can't meditate in a chair for more than five minutes without falling asleep, even if there are people stomping about offering to whack me with sticks.  For some reason I can't even discipline myself not to let my back touch the back-rest, which is when the slumber comes.  I like half lotus, and find it most comfortable when my foot isn't all the way at the top of the opposite thigh, but just resting over the opposite foot.  But for some reason I do try to sit full half lotus, and have a vague ambition to one day sit full full lotus.  I could fuck up my back, like my friend Dan, who now sits in a chair with straps to help him stay upright.  I do have pain in my lower right back and near the right groin, but that may have as much to do with working on an archaeological site this summer than with Zen Buddhism.  But I go on sitting that way, and also practising meditation in the running, working, eating, meditating, playing squash, and watching a play positions.  I heartily recommend them all.

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.

Some light on me

Since I'm writing under a pseudonym, maybe it's a good idea if I tell you a little about myself and how I reached this wonderful end point of being a bewildered beginner at Zen.  Well, I was born in Calgary but never really lived there.  I lived in England but I'm not really from there.  I study ancient Greece from hypermodern California.  And I know a thing or two about Augustine and Aquinas but couldn't really tell a Dogen from a Hakuin at this stage.  Despite that, there are two main things that have apparently made me well-suited for a Buddhist practice: being a Christian and being in pain.

What kind of Christian was I?  Several.  My first great teacher was my mother, who seems to know nothing about Christian doctrine and cares even less.  My earliest memories of organised religion are of stuffy churches in army barracks that we went to as a family every Sunday as an obligation.  But once I remember we were swimming in the lake outside our family cottage, the sun was laying down a line of light on the water like a blurry path, and my mother was telling me that this was what was wonderful about Christianity, that it wasn't about any particular God but just enjoying being in that light.  Even then the comment struck me as pretty obviously false, but I sensed that behind or beside it was something interesting.

When I moved to England I went to a traditional Anglican boarding school where we were made to go to Chapel three times a week, sometimes four.  There was also an optional candlelit mass on Friday nights that I would go to.  I remember sitting in a pew at one of these and looking up at the light falling on the stone arches opposite me.  At some point the Reverend asked us in Theology what being a Christian was all about.  We suggested love, kindness, going to church, but all those answers were wrong; apparently the core of the faith was to believe that Jesus redeemed our sins by dying on the cross.  I decided that I either didn't understand that or did and didn't believe it, so I must not be a Christian.  It didn't make me sad, because I was sixteen, but later I'd miss that moment in chapel.

Near the end of my first year of university I started feeling pain in my face.  The doctor told me I needed to relax, so I went to Italy for the summer, drank lots of red wine, and started meditating after reading an article about it on the internet.  I did it in secret and pretended I was doing something different if someone caught me in the act, like wanking.  After a while my facial pain got better and I felt like something interesting was just behind or underneath the light falling on the wall in my room.  Then I got hit on the head playing rugby, and have had a headache ever since.  I stopped meditating because it scared me to think of what might be happening to my concussed brain.  I tried exercising three times a day, not drinking tea, drinking a bottle of wine every night, switching girlfriends.

And somehow I was still meditating, not every day or every other day, but occasionally.  I joined a group the term I did my final exams at Oxford and didn't like it much, but felt lighter walking home hugging my cushion.  I went to a temple in London and didn't like that much either, but remember once noticing the way the light was falling on a tree outside and kind of enjoying it.  When I moved to California, I found myself studying what I loved with a group of close friends in a land of eternal sunshine, but for some reason I was still suffering.  I tried taking more pain medication, using anaesthetic patches on my neck, getting a tooth removed.  And somehow I kept meditating, off on and on, and then suddenly on and on, every day, with a new technique another grad student taught me.

I still use that concentration practice, but there was something about it that pushed me more towards discipline than freedom.  I spent a year being unhappy but calm and wondering if I was simply calm but unhappy.  When I walked into Wind in Grass I found a bunch of nutcases in party hats who seemed neither calm nor happy but keen on wondering.  I didn't take to some of the traditional koans - I couldn't care less about whether the dog had buddhanature, whatever that was.  I didn't like the liturgy, especially when we chanted about people like Guanyin - who was he?  But every so often I'd find myself sitting there, wondering at the pain and the play of light, and I'd be in the lake with my mother, the chapel in England, and also no other place but here, after all this time the only real place to be.