Huge trial finds mindfulness makes some teenagers' mental health worse
Dr Willoughby Britton is right: we need to be much more aware of the potential adverse impacts of meditation.
Anyone hoping to ‘solve’ the mental health crisis should think very carefully: am I going to make it worse? Unfortunately, every decade a new intervention becomes the hot new thing, the magic bullet that is going to save the world, and the people promoting it become wide-eyed evangelists. ‘We are saving the world! We are doing such important work!’ Such is their enthusiasm, they never stop to ask, ‘is it possible this intervention will harm some people?’
When you look at the history of mental health, it is littered with failed interventions that turned out to do more harm than good.
Just a few months ago, one of the largest-ever mindfulness studies published its results. The MYRIAD study, led by Dr Mark Williams of the Oxford Mindfulness Centre, took eight years, involved teams at six universities, with 100 researchers working with 28,000 students in 650 schools. It was a massive effort, to see if a mindfulness course could reduce anxiety and depression and improve outcomes in teenagers. What could be more important than that!
When it finally published its results in June, it found no evidence that the mindfulness course was any more effective than what the schools were already offering for social and emotional learning. Meditation only helped the minority of students who got into it sufficiently to practice it in their own time. Most students found mindfulness classes boring.
What the media didn’t report, on the whole, was that the mindfulness intervention actually made some young people’s mental health worse. This is from the paper:
Only for five of 28 secondary outcomes was there some evidence of a difference between the trial arms. Intervention arm students had higher self-reported hyperactivity/inattention on the SDQ subscale at both postintervention and 1 year follow-up, and higher panic disorder and obsessive-compulsive scores on the RCADS measure at postintervention, lower levels of mindfulness skills on the CAMM postintervention only plus higher teacher-reported emotional symptoms on the SDQ at 1 year follow-up only, suggesting that they are doing worse, although marginally, on these outcomes than the control arm.
Can you imagine if you’re one of the researchers working on the trial and, after eight years, that’s what you discover. Your intervention actually harmed teenagers. One year after the intervention and their mental health is worse. Imagine reading that if you’re one of the countless mindfulness evangelists of the last 30 years, utterly convinced that the answer to all the world’s problems is: mindfulness, mindfulness, more mindfulness. And then, in the biggest study yet of mindfulness in schools, it turns out it harms some kids’ mental health.
This is the risk when people get evangelical and dogmatic about their particular mental health intervention, whether it’s Christianity or eugenics or psychoanalysis or lobotomies or insulin-induced comas or ‘the rest cure’ or Prozac or CBT or mindfulness or Stoicism or psychedelic therapy or ‘trauma-informed therapy’. When they become convinced it will ‘save the world’. They never ask themselves: ‘could this actually do harm?’
Mindfulness is an example of how mental health interventions are extremely vulnerable to fashion. If you plotted the fashionability of mindfulness or meditation more generally, it became somewhat more fashionable in the 60s, 70s and 80s, before becoming hugely popular in the 1990s, when baby-boomers were in positions of power and influence in medical colleges and the science of mindfulness really took off.
It's hey-day was in the Noughties, around 2000-2020, when it seemed like every school, university and corporation had some sort of mindfulness wellness programme, when mindfulness apps were big business, when half the British parliament reportedly practiced mindfulness, and it became something like the unofficial religion of post-Christian Britain.
I remember going to the Mind and Life conference in 2014 in the US. It was absolutely enormous – so many panels, papers, so many eager researchers. ‘We’re saving the world! We’re doing such important work!’ The veterans of the field were treated like rock stars. When the Dalai Lama arrived, the entire hall stood up in reverent silence. ‘His Holiness has instructed us’, the president of the Mind and Life Institute told the audience. Oh the ecstasy! We are saving the world!
Eight years later, cut to the new MYRIAD study finally reporting its results. ‘We seem to…er…have made them worse.’
But at least they looked for evidence! At least they admitted their intervention made people worse. Compare that to the religion of psychoanalysis, which spread around the world, and persuaded people to spend a fortune lying on a couch talking about their awful parents every day for years, until they finally admitted their Oedipus Complex or Penis Envy or whatever. What was the evidence? Freud’s own case studies. Talk about ‘doctored evidence’.
Dr Britton’s work on meditation-related adverse effects
The presentation I found most interesting at the Mind and Life Conference was by someone called Dr Willoughby Britton, who has been studying adverse meditation experiences for ten years at Brown University. She has published multiple papers on the topic, and launched a charity to support people who have them, called Cheetah House.
How often do people experience adverse meditation experiences? She defines an adverse experience not as transient distress but as an effect that wasn’t expected, is disturbing, has lasting duration, and / or a negative impact on a person’s life-functioning. In her studies, about 10% of people who practice meditation have a meditation-related adverse effect that lasts more than a month. And that includes people meditating for just a few minutes a day. Not loads, but that’s one in ten people getting harmed. Roughly the same percentage report lasting problems requiring psychological assistance after psychedelics by the by, according to the Global Ayahuasca Survey.
What adverse events or forms of impairment are most common? She has mapped over 60 different types of adverse event, but the most common are: hyperarousal, where your attention has become so intensified that ordinary life becomes disturbing (note that the students in the MYRIAD trial had higher levels of hyperactivity and panic than the control group); dissociation; emotional flattening; social impairment; and executive impairment – problems making decisions or remembering things. She’s teased out how serious these impairments can be – for example, if someone reports executive dysfunction, it’s much more likely to have lasting bad effects than other forms of adverse effects.
Her conclusion, after ten years of studying meditation-related adverse events, is that ‘more is not necessarily better’. Meditation practices change the brain in certain ways, but at a certain point this can become too much for people to handle, and they become hyper-aroused and over-sensitive. In her dissertation, she studied whether mindfulness would improve people’s sleep. It actually made them sleep worse.
What does she suggest, today? Should people be screened before they take part in meditation programmes? She says she’s not a fan of screening and deciding who should or shouldn’t meditate. Sometimes people with risk factors for adverse events get a lot of benefit from meditation, while other times people with no risk factors get into problems.
Nonetheless, she says it’s helpful to recognize that some groups do seem more prone to adverse events – younger people (especially 18-25-year-old men), racial minorities, people on lower incomes and with less education, people who experienced childhood adversity, people with anxiety or depression.
In the MYRIAD trial, according to Dr Julieta Galante (a supervisor on our own project), the students whose mental health suffered where young people with pre-existing mental health problems. She told The Educator website:
it’s important to note that the students who got worse tended to have existing, underlying mental health difficulties. From here, if we think about how mindfulness actually works, there is a fairly simple and plausible explanation. Consider that many mindfulness activities involve the person bringing their attention to bodily sensations, the breath, or to thoughts. For those with existing mental health issues, or a history of trauma, sustained attention like this can actually bring about unwelcome thoughts, feelings and sensations more clearly into awareness. This, understandably, can be unpleasant. In short, mindfulness is unlikely to cause trauma, but it certainly can cause the re-experiencing of traumatic memories for some meditators.
Dr Britton suggests one way to minimize harm is to improve informed consent – let people know about the risks, and give them options for how to practice, rather than forcing everyone down the same narrow path. She promotes ‘diversity-informed mindfulness’, appreciating that people are different, and trying to help them engage with contemplative practices in a way that maximizes the likelihood of benefits and minimizes the likelihood of harm. ‘Different people have different responses’, she says, ‘and you can reduce the likelihood of causing harm by giving people more options in how and if they practice contemplation.’
Dr Mark Williams of the MYRIAD study came to the same conclusion, telling the Guardian:
If today’s young people are to be enthused enough to practise mindfulness, then updating training to suit different needs and giving them a say in the approach they prefer are the vital next steps.
The mindfulness culture (and wellness cultures more broadly) can also improve how it relates to adverse experiences. At the moment, Dr Britton says, few meditation training programmes include modules on adverse experiences and how best to handle them, or modules on trauma-informed care. Classic mindfulness studies, like psychedelic studies, typically exclude people with mental health problems - which means they’re not representative of the general population and don’t predict how their interventions will play out in the real world.
She adds: ‘The solution to adverse experiences isn’t always ‘more meditation’. And yet, when she interviewed meditation teachers about adverse effects, that was usually their response – the solution is more meditation. They would tell Dr Britton things like ‘the only way forward is through the difficulties’ or ‘suffering is caused by resistance’.
This reminds me of the attitude of psychedelic healers, who often say things like ‘the medicine always knows what you need’ or ‘the medicine is always right’. Can you imagine thinking your preferred drug-treatment is an all-knowing, totally-benevolent spirit-ally? With such a frame, the response to a bad trip is always: trip again. Go deeper. Work through your resistance.
Sometimes, Dr Britton suggests, a better response to meditation-related adverse effects might be: slow down, or stop meditating for a while. Not ‘more gas’ but ‘more brake’. What forms of meditation practice increase the intensity, and what forms lessen the intensity? For example, no social interaction increases the intensity, while allowing social interaction decreases it. Getting people to sit still increases the intensity, while letting people walk around decreases it. It’s all about giving people options – some people find it disturbing to focus on the breath coming in and out of their nose (which is the standard method of teaching mindfulness). When given the option, most people prefer focusing their attention on something other than the breath.
One can also develop a culture where it’s OK to report an adverse experience. Dr Britton says: ‘When people report an adverse effect, the general response is often not skillful. There is denial, minimization, and victim-blaming’.
You certainly see that in psychedelic culture as well. Rachael Peterson wrote an excellent piece on having an adverse quasi-psychotic reaction to psilocybin after taking part in a clinical trial at Johns Hopkins. The article in general had extremely positive responses (you’d think no one had ever written about having a bad trip before…perhaps it was the fact Peterson is at Harvard, or that she had her bad trip during a clinical trial at Johns Hopkins, as well as the fact the article is very well written and brought in analysis at multiple levels, including the theological. I just wish she’d mentioned our survey!) Anyway, Dr Britton posted the article on the Facebook page of Cheetah House. This was one of the responses:
This is on the Facebook page of a charity that supports people who have adverse meditation experiences – and yet the author of the comment could still be so insensitive! Dr Britton says: ‘When you disclose negative effects it’s not uncommon to be attacked. And often, the social response makes an adverse event much worse. We can’t prevent adverse events from happening. But the shame and the isolation afterwards – that part we can address.’
Dr Britton also mentioned, by the by, that some meditation apps were causing a lot of adverse events. She appeared on the Sam Harris Waking Up podcast last year and read Sam an email they received from a person who got into psychological difficulties after following Harris’ meditation course.
Fancy that – a New Atheist causing harm through over-evangelical promotion of meditation! Still, good on Harris for reaching out to her and hosting her on his podcast. You can listen to their conversation here - Dr Britton reads out the email at one hour 53 mins in:
After the paywall, subscribers get links to this week’s articles on psychedelic and ecstatic harm reduction.
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