Lorena Hillman's Articles on Lions Roar

In this 2009 Buddhadharma feature, physicians and long-term meditators Roger Walsh, Robin Bitner, Bruce Victor, and Lorena Hillman explain why both antidepressants and meditation have an important role to play in treating depression. When we first set foot on the spiritual path, many of us believed that spiritual practice was all we needed. Ancient texts spellbound us with stories along the lines of, “They heard the teaching, retired into the forest to meditate, and awoke.” End of story! How simple and easy. But somewhere along the path we ran into a problem—reality. It became glaringly apparent that many classic accounts of spiritual life were extremely idealistic, similar to the Hollywood sagas of boy meets girl, where boy and girl fall in love, ride off into the sunset, and live happily ever after. Anyone in an intimate relationship knows that something has been left out of the story. In short, spiritual practice turned out to be far more complex and demanding than advertised. True, there were many gifts and graces, and some awe-inspiring glimpses of our spiritual potentials along the way. But covering up these potentials were often layer upon layer of difficult emotions, compulsive conditioning, and countless old wounds, fears, and phobias. And ironically, spiritual practice frequently makes these challenges more painfully obvious. Clearly we had taken on a big project, and our initial fantasies of doing a few retreats, and thereafter basking in unalloyed bliss, quickly faded as a more realistic appreciation of the path dawned. The enormous challenge of healing and awakening one mind—let alone all minds as per the bodhisattva vow—became dauntingly apparent. Some of us even began to wonder if spiritual practice by itself was always adequate to the task. Spiritual practice turns out to be far more complex and demanding than advertised. True, there are gifts and graces, but also difficult emotions, compulsive conditioning, and countless old wounds, fears, and phobias. As a result, many of us who have practiced meditation and undertaken a spiritual path for an extended period have questioned whether there are other methods we can draw upon in trying to optimize our individual and collective healing and awakening—methods that don’t come from the spiritual traditions themselves. And as the number of spiritual, psychological, medical, and other healing practices continues to multiply, this becomes an increasingly perplexing—and ever-more relevant—question. We need a significant and disciplined evaluation of how best to combine dharma and diverse therapeutic disciplines, including the most controversial of all therapies: medication. In fact, such an evaluation has already begun. It’s in its early stages, but it is indeed underway. Psychotherapy and Meditation When Buddhism first came to the West, many teachers and practitioners initially dismissed psychotherapy as superficial, unnecessary, and possibly counterproductive. As time went on, more and more students faced crises or simply felt their spiritual practice was not dealing with deeper problems that were hindering their development. Psychotherapy’s relationship to spiritual practice started to undergo a reevaluation, and the two disciplines began to intermingle a bit more. Among the first to bridge the divide between therapy and spiritual practice was Jack Kornfield, who is both a meditation teacher and psychologist. In 1993, he wrote an article called “Even the Best Meditators Have Old Wounds to Heal: Combining Meditation and Psychotherapy,” which was published in the book Paths Beyond Ego: The Transpersonal Vision. In it he argued: For most people, meditation practice doesn’t “do it all.” At best, it’s one important piece of a complex path of opening and awakening… There are many areas of growth (grief and other unfinished business, communication and maturing of relationships, sexuality and intimacy, career and work issues, certain fears and phobias, early wounds, and more) where good Western therapy is on the whole much quicker and more successful than meditation… Does this mean we should trade meditation for psychotherapy? Not at all… What is required is the courage to face the totality of what arises. Only then can we find the deep healing we seek—for ourselves and for our planet. Controversial in their time, Kornfield’s ideas have now gained wide acceptance. In fact, meditation and psychotherapy are being integrated in many different contexts, as therapy clients and patients are offered meditation and meditators are offered therapy. Research has convinced therapists of the value of meditation for a host of psychological and psychosomatic difficulties. In fact, many therapists and meditation teachers now agree that meditation and psychotherapy can be mutually facilitating. Meditators seem to progress more quickly in therapy, while psychotherapy can improve the effectiveness of their meditation. In addition, combination therapies that integrate meditation and psychotherapy are proliferating, and often prove more effective than either application alone. The original inspiration was Jon Kabat-Zinn’s widely used “mindfulness-based stress reduction” (MBSR). Originally designed to treat chronic pain, MBSR has since proved helpful with a diverse array of psychological and psychosomatic difficulties. Examples of disorders that have responded well to MBSR range from anxiety, aggression, stress, and eating disorders on the psychological side to asthma, angina, and high blood pressure on the somatic side. Several recent combinations merge Buddhist mindfulness with specific psychotherapies. These include, for example, “mindfulness-based cognitive therapy” for depression, “mindfulness-based sleep management” for insomnia, and “mindfulness-based relationship therapy” for enhancing relationships. Research affirms the effectiveness of each of these approaches. More broad-based combination treatments—such as transpersonal and integral therapies—incorporate multiple psychological, spiritual, and somatic strategies. In short, the integration of contemplative and conventional therapies is proceeding rapidly, and the results are promising. Combining meditation and psychotherapy makes sense if we appreciate how they work in complementary ways. For the most part, meditation focuses primarily on developing capacities such as concentration and awareness, whereas psychotherapy focuses primarily on changing the objects of awareness, such as emotions and beliefs. Of course, there are also significant overlaps, but this complementarity suggests why combining both approaches can be very helpful. Meditative qualities can facilitate psychotherapeutic healing of painful patterns, while the psychotherapeutic healing of these painful patterns can reduce their disruption of spiritual practice. Trying to tough it out and heal oneself with spiritual practice alone may not only prolong unnecessary suffering, but also lead to greater risk of relapse, chronicity, and complications. What are the practical implications of this conjunction of psychotherapy and spiritual practice? It seems clear that the question of whether meditation and psychotherapy can enhance one another has been decided: many people benefit from combining them, and this has been observed by clinicians and demonstrated by research. When old traumas, pains, and patterns recycle endlessly, or make spiritual practice seem overwhelming and hopeless, the best answer may not be simply the classic one of more practice. Instead, psychotherapy may be called for. Medication and Meditation Sometimes neither meditation nor psychotherapy—nor even the combination of the two—is enough. Depression can be so debilitating, anxiety so agitating, and old pains so traumatic that spiritual practice withers and psychotherapy has little effect. Mental approaches alone prove insufficient. And this brings us to one of the most hotly debated topics among spiritual practitioners: the appropriateness of using medication to help with psychological and spiritual difficulties. Two groups have staked out polar positions. We could call them the purists and the pragmatists. Spiritual purists argue that if mental suffering is fundamentally spiritual and karmic, spiritual practice alone is appropriate to treat it. A standard response to difficulties is therefore “more practice.” Moreover, they are concerned that medication may dull or derail spiritual practice. They worry that if suffering is merely dissolved with a pill, the motivation to practice may dissolve with it. They also worry that medications may reduce or distort awareness, and thereby make practice more difficult. In this view, medications such as antidepressant or antianxiety agents can be novel forms of the “mind-clouding intoxicants” prohibited by the lay precepts to which many Buddhist practitioners adhere. Therefore, taking these modern pharmacological agents is tantamount to violating this precept. Another worry is that potentially valuable spiritual challenges such as the classic “dark night of the soul” may be misdiagnosed as psychopathology, and then be suppressed with drugs rather than explored and mined. By contrast, pragmatists hold that spiritual practice alone is simply insufficient, or at least not optimal, for healing all mental suffering. While not denying the validity of some purist concerns, pragmatists argue that certain problems and pathologies respond best to other therapies, and one of these therapies can be medication. Stan and Christina Grof—who have written extensively about spiritual emergencies and founded the Spiritual Emergence Network to offer support to people who find themselves in such emergencies—encourage this pragmatic perspective. They certainly agree that some spiritual emergencies are best treated not with medical suppression, but with time-honored spiritual and psychological principles. These principles include providing a supportive relationship with a...

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