Psychosis or spiritual emergency? A Foucauldian discourse analysis of case reports of extreme mental states in the context of meditation

Abstract

Meditation is becoming increasingly popular in the West and research on its effects is growing. While studies point to various benefits of meditation on mental and physical health, reports of extreme mental states in the context of meditation have also been published. This study employed Foucauldian discourse analysis to examine how the experience of extreme mental states has been constructed in case reports and what kind of practices were employed to address them. The study analyses how extreme mental states associated with meditation are framed within the scientific literature and how such differential framings may affect the meaning making and help-seeking of persons experiencing these states. A systematic scientific literature search identified 22 case studies of extreme mental states experienced by practitioners of various types of meditation. The analysis suggests a discursive divide between two dominant framings: a biomedical discourse which constructs such experiences as psychiatric symptoms and an alternative discursive, which understands them as spiritual emergencies. Both approaches offered distinct therapeutic avenues. This divide maps onto the disciplinary divides within the mental health field more generally, which may obscure a better understanding of these experiences. However, the two discourses are not necessarily mutually exclusive and authors of three articles chose to blend them for their case reports. A supportive environment could help those experiencing extreme state integrate them into their lives. Our findings encourage collaboration between clinicians, therapists and spiritual teachers in order to make a range of approaches available.

Keywords

meditation spiritual emergency psychosis discourse transpersonal psychology

Introduction

Meditation is a practice that has been used within many spiritual and philosophical traditions (Shapiro & Walsh, 1984). While some common elements can be identified, meditation encompasses a wide range of techniques (Shapiro, 1984). Different mental faculties may be used (e.g. attention, visualisation, bodily awareness) actively or passively and focus might be directed at different objects such as thoughts, images or internal energy (Sedlmeier et al., 2012). The degree of intensity of meditation techniques varies and a number of taxonomies of meditation exist (Komjathy, 2015). Ospina et al (2008), for example, suggest five broad categories of meditation practice which include mindfulness meditation, yoga, mantra meditation, t’ai chi, and qigong, which originated from Hinduism, Buddhism and Chinese martial arts and medicine (Ospina et al., 2008; Posadzki, 2010; Suchday et al., 2014). Mediation practices can also be classified according to the primary cognitive mechanism involved – attentional, constructive or deconstructive (Dahl et al., 2015).

Meditation is also increasingly an object of scientific enquiry (Suchday et al., 2014). Attempts have been made to evaluate its effects on the brain using neuroimaging (Chiesa, 2010; Fox et al., 2014; Hazari & Sarkar, 2014) and to examine psychological variables to better understand how meditation works (Sedlmeier et al., 2012). This literature has focussed particularly on the positive effects of meditation on mental health such as enhanced psychological well-being (Josefsson et al., 2011), reduced anxiety (Chen et al., 2012; Goyal et al., 2014), stress and negative mood (Lane et al., 2007), and as a support to those who experience more severe mental health difficulties (Chadwick, 2005; Cramer et al., 2013; Shonin et al., 2014a; Shonin et al., 2014b; Shannahoff-Khalsa, 2004). Mindfulness-based cognitive therapy is currently recommended for recurring depression by the National Institute for Health and Clinical Excellence (NICE, CG90, 2009).

However, it has also been argued that an overly positive picture is being painted of meditation and its benefits. For example, a number of scholars have pointed out that “the dark side of meditation” encompasses various unexpected and adverse side effects which have been largely ignored in the scientific literature (Farias & Wikholm, 2015, p. 216; Farias & Wikholm, 2016). VanderKooi (1997) pointed out that experiences of confusion, hallucinations, frightening images, irritability and extreme fear were documented as early as the 5^th Century in Buddhist Teachings. A recent mixed-method study by Lindahl and colleagues (2017) identified a range of distressing effects of Buddhist meditation across cognitive, emotional and somatic domains of experience. Detailed personal accounts of these are also available (Krishna, 1985; Kornfield, 1994; Gyatso, 1995).

In scientific articles, these phenomena have been variously described as psychiatric symptoms, “non-ordinary states of consciousness” or “extreme mental states” (VanderKooi, 1997; Walsh & Roche, 1979), with a focus on individual risk factors (Kuijpers et al., 2007). More recently, attempts have been made to explore such extreme mental states in different traditions such as Buddhist meditation practitioners (Lindahl et al., 2017; Kaselionyte & Gumley, 2018) and Kundalini yoga (Kaselionyte & Gumley, 2018). In order to gain a fuller understanding of these phenomena, in this paper we analyse how such experiences are discursively constructed in the scientific literature.

Method

In this study, discourse analysis was employed to explore the ways “extreme mental states” in meditation are framed in published case reports. Discourse analysis can be situated within a social constructionist framework that seeks to examine how knowledge is historically and culturally relative (Burr, 2003). Therefore, there is not one knowledge but different “knowledges”, and the same phenomenon can be understood and described differently (Willig, 2001). Language is seen as more than a medium enabling communication or a reflection of reality but a powerful tool that can be used to construct different versions of it (Jorgensen & Phillips, 2002; Parker, 2015; Willig, 2001).

The two major forms of discourse analysis are discursive psychology and Foucauldian discourse analysis, also known as deconstructionism (Willig, 2001; Burr, 2003). The former is concerned with how meanings are negotiated in everyday social interactions and analyses naturally occurring conversations and texts (Willig, 2001). The latter, inspired by the work of the French philosopher Michel Foucault, analyses how discourses create a particular version of reality and may use any kind of written texts or even non-textual material (Burr, 2003). Foucauldian discourse analysis was chosen as most appropriate for this study because we wished to focus on how experiences of extreme mental states in the context of meditation are discursively framed in published case reports.

Foucauldian discourse analysis views discourse not only as language but also as “practices which form the objects of which they speak” (Burr, 2003, p. 64; Foucault, 1972, p. 49). In other words, certain ways of seeing and being in the world become available as a result of discursive constructions, which in effect create a range of different subject positions (Willig, 2001). Subject positions are positions of agency and identity formed in relation to particular forms of knowledge and practice (Hall, 1997). Furthermore, at any given time certain discursive constructions become regarded as the truth or “common sense” and Foucauldian discourse analysis posits that their production is closely tied in with power (Burr, 2003). Recognising marginalised accounts and alternative ways of how knowledge can be conceptualised becomes important to the diffusion of such power (Ceci et al., 2002). Finally, Foucauldian discourse analysis is concerned with the interaction between discourses and social and institutional practices, which validate and reinforce each other (Willig, 2001).

Literature search

A systematic literature search was performed to identify research articles containing case reports about extreme mental states in the context of meditation. Research articles on the positive effects of meditation and studies monitoring neurological processes during meditation were excluded. All other genres of publications such as grey literature, books, dissertations, newspaper articles, and conference papers were excluded. The systematic literature review was conducted following the PRISMA guidelines (Moher et al, 2009).

The following bibliographic databases were searched: PsychINFO, Psychology and Behavioural Sciences Collection, Embase (1947-31^st December 2014), Anthropology Plus, CINAHL, MEDLINE, SocINDEX and PsycArticles. These were accessed via EBSCOhost platform, apart from Embase (1947-31^st December 2014), which was searched using the Ovid interface. The initial search terms were: [(meditat* OR yoga) AND (mental OR psych*)]. Additional search terms were informed by the initial literature search, which were: [Kundalini AND psych*] and [(Spiritual crisis OR spiritual emergenc*) and (mental OR psych*)]. The search was restricted to articles written in the languages spoken by the researchers: English, Russian, Spanish, French, and Lithuanian. The database search was conducted in December 2014 and repeated in December 2016.

The identified articles were screened using the following steps. First, the title and abstract were read to determine eligibility. Second, duplicates were removed and full-text papers were read in order to ascertain whether inclusion criteria were met. Third, a manual reference search was performed drawing on the bibliographies of the selected articles. The newly identified articles were reviewed for eligibility accordingly. Finally, only papers containing case reports (i.e. descriptions of the cases where a person experienced extreme mental states in the context of meditation) were included in the discourse analysis.

Analysis

The selected articles were analysed starting with repeated reading and initial inductive coding (Georgaca & Avdi, 2012). The six-step guide for Foucauldian discourse analysis developed by Willig (2001) was followed. First, we asked how discursive objects were constructed in order to better understand the differences between existing constructs. Then we focused on what these specific discursive constructions achieved. Finally, we explored the different subject positions and practices engendered by these discourses.

The following questions formed the analytical framework: “How is the experience of extreme mental states described in the text?”; “To what extent is the person’s agency acknowledged?”; “What is the frame of reference used in the descriptions of these experiences?”; “To what extent are alternative explanations incorporated?,” and “What was the response to these experiences?” Lastly, linguistic analytical tools described by Fairclough (2004) were also utilised to closely examine the language, and the lexical and grammatical features of the discourse, such as nominalisation (transforming verbs into a type of noun which entails excluding social agents in the representation of events), modality (writer’s stance or a degree of affinity with their own statements) and transitivity (choosing passive or active processes, verbs, to describe events).

Reflexivity and transparency

Social constructionist approaches question the notion of objectivity because “no human being can step outside of their humanity and view the world from no position at all, which is what the idea of objectivity suggests” (Burr, 2003, p. 152). Researchers using Foucauldian discourse analysis are therefore encouraged to reflect on their own modes of knowledge production, their claims and assumptions, and acknowledge that their own publications become discursive products (Willig, 2001). Author JK is an MSc in Global Mental Health and a researcher working in the field of social psychiatry. She is interested in spirituality, non-ordinary states of consciousness and alternative approaches to supporting people experiencing distress. Author AG is a clinical psychologist and professor of psychological therapy. He has a particular interest in understanding psychosis, psychological approaches to alleviate distressing psychosis and the promotion of recovery.

In our analysis, we refrain from using the psychiatric term “psychosis” to describe the phenomena that meditation practitioners encountered and employ instead VanderKooi’s term “extreme mental states” (1997), which captures the intensity of such experiences and their potential to prompt a change in how the individual relates to the world as well as trigger a response from meditation teachers or mental health services. Individuals who experienced these states are referred to as “persons with extreme mental states.” Finally, supporting excerpts from the articles are presented to ensure a degree of transparency and allow the reader, “as far as possible, to “test” the claims made” (Jorgensen & Phillips, 2002, p. 173).

Findings

Literature search

The results of the systematic literature search are shown in Figure S1 (supplementary material can be found online with this article). We initially identified a total of 14,044 records. These were screened on basis of title and abstract and 13,949 were excluded either because they were not research papers (books, conference papers, etc.), or did not discuss extreme mental states in the context of meditation. Duplicates were removed and 66 full-text articles were screened for eligibility. As a result, we excluded 49 articles because they focused on the benefits of meditation on physical or psychological health or reported on neurological experiments performed on meditation practitioners. Studies which did not contain case reports were also excluded. At this stage a manual reference search produced an additional five articles, which met inclusion criteria. A total of 22 research papers were selected for discourse analysis (Table S1, supplementary material can be found online with this article); 21 of these were written in English and one article was in Spanish. Table S1 provides the number of cases, the types of meditation (where specified) and the discursive framing used in each article.

Discourse Analysis

We identified two main discourses in the articles, which we distinguish as the biomedical and the alternative discourse. The majority of articles (n = 15) drew on the biomedical discourse to describe the phenomenology of extreme mental states and ways of these states were responded to. The alternative discourse (n = 4) emerged as a counter-discourse to the biomedical one, offering different constructions of these experiences and alternative approaches to supporting people. In the following, the main characteristics of each discourse are provided discussed drawing on quotations from the case reports.

The biomedical discourse

In the biomedical discourse, the experiences of extreme mental states associated with meditation were described using psychiatric language and clinical terminology. The experiences of meditation practitioners were commonly framed as delusions or hallucinations and the authors described the cases by listing what they perceived of as “psychiatric symptoms”:

“… the patient displayed flat affect, endorsed ideas of reference and delusional thinking, and was uncharacteristically preoccupied with religious ideation …” (Lu & Pierre, 2007, p. 1761).

“She was thought disordered with pressure of speech” (Yorston, 2001, p. 210).

“… visual hallucinations, psychomotor agitation, paranoid delusions, auditory hallucinations and intense anxiety” (Trujillo et al., 1992, p. 40).

“… labile affect, mild loosening of association and very poor insight and judgement” (Chan-Ob & Boonyanaruthee, 1999, p. 926).

“… he was suddenly agitated with hyperthymia” (Xu, 1994, p. 232).

“… psychomotor retardation, and poverty of speech” (Sadzio et al., 2014, p. 145).

“… paranoid negativistic delusional thoughts, intense anxieties, mood swings and suicidal ideation” (Kuijpers et al., 2007, p. 462).

These descriptions were marked with a high degree of certainty (e.g. “… was clearly psychotic.” (Walsh & Roche, 1979, p. 1085)), which was further reinforced by the implied scientific objectivity of the psychiatric examinations and psychological or neurological tests, which “revealed” or “showed” pathology in the persons described:

“Neuropsychological testing revealed marked deficits in multiple cognitive domains” (Sadzio et al., 2014, p. 146).

“Examinations revealed delusions of persecution and of reference, and auditory hallucinations” (Sethi & Bhargava, 2003, p. 1085).

“Neurocognitive assessment revealed moderate impairment in attention, mental speed, verbal fluency, verbal learning and memory, visual learning and memory and difficulty in planning and representation of 3D in 2D” (Paradkar & Chaturvedi, 2010, p. 28).

“The Rivermead Postconcussion Symptoms Questionnaire showed extroversion while the Minnesota Multiphasic Personality Inventory showed schizophrenic character” (Shan, 2000, p. 14).

In contrast to the implied scientific objectivity, the accounts of persons with extreme mental states were presented as subjective using such verbs as “claimed” and “believed”, often to emphasise the irrationality of their beliefs:

“He believed that he was able to contact God, read people’s minds and know everything” (Chan-Ob & Boonyanaruthee, 1999, p. 926).

“He claimed that he knew something special about the world including “the sea is associated with water” (Shan, 2000, p. 13).

“… believed that she was invincible” (Hwang, 2007, p. 547).

Another feature of these case presentations was that authors tended to omit the individual or personal qualities of the participant as a broader context for the experiences under discussion. Persons with extreme mental states were positioned as “patients” or “subjects” in the descriptions of their cases. They were often referred to by their title and the first letter of their name or their sex briefly stating their age and occupation and mentioning psychiatric history without going into the detail about their life context:

“During the intervals of attacks, the patient was normal” (Xu, 1994, p. 232).

“The subject had an unremarkable psychiatric family history” (Paradkar & Chaturvedi, 2010, p. 27).

“A 24-year-old Caucasian male artist was referred because of an acute sensation of being mentally split during a Hindustan type meditation” (Kuijpers et al., 2007, p. 462).

Extreme mental states were framed as psychiatric disorders or illnesses in the biomedical discourse and its authors engaged in extensive discussions on their diagnostic formulations using the established psychiatric nosology:

“According to the clinical descriptions of ICD-10, most patients were suffering from an Acute and Transient Psychotic Disorder. In the DSM-IV they would have met the criteria for a Brief Psychotic Disorder” (Kuijpers et al., 2007, p. 462).

“We initially diagnosed a major depression. … we reappraised the above described phenomena as psychotic symptoms … the diagnosis was changed to schizoaffective disorder … despite the lack of hallucinations and delusions, DSM-IV and ICD-10 diagnostic criteria are fulfilled, as our patient also exhibited formal thought disorder and negative symptoms (alogia, poverty of speech, social withdrawal)” (Sadzio et al., 2014, pp. 146–147).

“Considering these symptoms the diagnosis of schizophrenia was entertained according to ICD-10” (Sharma et al., 2016, p. 247).

The accounts of persons with extreme mental states and their understanding of these experiences were not generally incorporated in the articles that utilised the biomedical discourse. However, where their views were mentioned, they were framed in an invalidating manner, awarding more weight to the authors’ interpretation:

“… she chose to deny the findings of the MRI and neurocognitive deficits, refusing neurocognitive retraining on the pretext that it was merely a result of the rupture in the crown chakra …” (Paradkar & Chaturvedi, 2010, p. 32).

“Medication has addressed his delusions and improved his self-care, functional activities. However, he continued to see the Kundalini awakening as the life for his future” (Valanciute & Thampy, p. 840).

The authors drawing on the biomedical discourse also discussed vulnerability and pre-disposing factors (such as stress, sleep deprivation, personality structure, history of mental health difficulties, discontinuation of psychiatric medication or organic vulnerability), which, in their view, contributed to the development of “psychiatric symptoms” in the context of meditation:

“… an increased risk for meditation-related occurrence of psychotic symptoms in individuals with a history of psychiatric symptoms or certain personality structure and in cases of sleep deprivation or physical exhaustion … meditation can act as a stressor in vulnerable subjects” (Kuijpers et al., 2007, p. 462).

“Other more established risk factors for mania in this case are the positive family history of affective disorder and the discontinuation of carbamazepine” (Yorston, 2001, p. 212).

“In the case of Ms. A, the vulnerability appeared to stem from psychological stress and an organic vulnerability as indicated by the possible cerebral atrophy and empty sella state (as revealed on MRI) and compromised neurocognitive functions” (Paradkar, & Chaturvedi, 2010, p. 29).

“… a few schizoid traits could be elicited in his premorbid personality.” (Sharma et al., 2016, p. 247).

Therapeutic responses

In the biomedical discourse, responses to extreme mental states experienced by meditation practitioners included involuntary hospitalisation, restraint, psychiatric medication (antipsychotics) and electroconvulsive therapy. The descriptions of these therapies were characterised by the lack of individual therapeutic agency and by depicting the persons as passive recipients of the psychiatric interventions.

“She was detained and transferred to an intensive psychiatric care unit for three days where treatment with haloperidol 6mg and lorazepam 3mg was commenced” (Yorston, 2001, pp. 210–211).

“… he required physical restraint” (Walsh & Roche, 1979, p. 1085).

“After her initial evaluation she was managed pharmacologically” (Paradkar & Chaturvedi, 2010, p. 27).

“He was treated timely by ECT” (Xu, 1994, p. 232).

“He was initiated on low dose Amisulpride (200 mg) concomitantly. Along with this psychoeducation to the patients and family members was given about the nature of illness and need of medication” (Sharma et al., 2016, p. 247).

These interventions were presented as highly effective treatments, which lead to the prompt “recovery” of the persons and returned them back to “normal.” Normality and recovery in the biomedical discourse meant being calm, rational, critical of one’s delusions and free from “psychiatric symptoms” as well as returning to occupational functioning:

“… treated with aripiprazole 15mg/daily, with robust improvement in psychosis after 1 week and full resolution by 1 month … Aripiprazole was discontinued, and the patient continued to report feeling “normal” after the 4-month follow-up” (Lu & Pierre, 2007, p. 1761).

“This treatment regimen led to a rapid and complete recovery from psychotic symptoms and a gradual normalization of mood that persisted at follow-up after six months” (Kuijpers et al., 2007, p. 462).

“He was given 150mg of oral thioridazine within 4 hours was calm and rational.” (Walsh & Roche, 1979, pp. 1085–1086).

“A week later, he recovered from his illness and now works as before” (Xu, 1994, p. 233).

“… treatment with neuroleptics. Alterations of perception disappeared in a few days and he was able to be critical of his delusions” (Trujillo et al., 1992, p. 40).

“He was successfully treated with antipsychotic medication and is maintaining well.” (Sharma et al., 2016, p. 247).

However, not all people with extreme mental states took medication. They had to be “persuaded” by clinicians. Non-compliance was a common theme in the biomedical discourse. Stopping medication was described as the path to “relapse” and re-admission to the hospital.

“Mr D has been suggested antipsychotic medications, which he took after long persuasions” (Valanciute & Thampy, 2011, p. 840).

“Hospital staff noted that she initially refused to take her medication and then switched to cheeking her pills, which she subsequently confirmed.”(Hwang, 2007, p. 548).

“The patient did not follow maintenance treatment and continued to participate in the sessions of the sect, presenting two years later with another episode with similar characteristics” (Trujillo et al., 1992, p. 40).

“The patient discontinued treatment after 3 months and again became symptomatic. Treatment was reinstituted and he responded rapidly” (Sethi & Bhargava, 2003, p. 382).

The majority of the biomedical articles (n = 10) did not incorporate other frames of reference when describing extreme mental states. Where alternative cultural explanations were mentioned, the authors did not depart from the medical model; they were used as means to aid psychiatric diagnosis and adherence to biomedical treatment:

“In Qi-gong cases, all Chinese authors describe a polysymptomatic psychiatric syndrome that corresponds to the Western categorical tradition so that the adoption of a separate class of culture-bound syndromes may not be appropriate” (Kuijpers et al., 2007, p. 462).

“It highlights the importance of understanding differing and varying philosophical and spiritual practices, applying it to clinical psychiatric care and placing it within a Western cultural context, especially when patients present with acute psychiatric conditions … This will aid in making informed decisions regarding the diagnosis and management of any psychiatric disorder” (Valanciute & Thampy, 2011, p. 841).

“This cultural formulation and affirmation of a local diagnostic label familiar to the patient also facilitated treatment acceptance” (Hwang, 2007, p. 559).

“Reformulating her experience led to a reduction in stigma and made help-seeking more acceptable, made treatment adherence better and reduced the patient’s internal dissonance” (Paradkar & Chaturvedi, 2010, p. 32).

Finally, the majority of authors (n = 14) drawing on biomedical constructs were academic or clinical psychiatrists with one author being a psychologist. Their articles were published in medical and psychiatric research journals such as Psychopathology, The American Journal of Psychiatry, Journal of the Medical Association of Thailand or Chinese Medical Journal. However, a number of papers were also found in journals that emphasize a cultural perspective on psychiatry such as Cultural Medical Psychiatry, Mental Health, Religion & Culture or the International Journal of Culture and Mental Health. As scientific journals with their own disciplinary and discursive conventions they prescribe and delimit the language that can be used to frame the experiences of extreme mental states during meditation.

The alternative discourse

Within what we call the alternative discourse, the experiences of extreme mental states associated with meditation were described with more “active” verbs and metaphors. The descriptions focused on what happened to the persons rather than what they “presented with.” First person accounts were often included:

“Bouncing, hopping, springing off her feet, she seemed motivated by some external force, driven. The breath rapid, drawn in and out in quick machine-gun bursts, her fingers clicking, snapping in stereotypic movements over and over again … She said people from other planets were after her” (Ossoff, 1993, p. 29).

“… going down a shaft, opening doors to different realities … she experienced an overwhelming sense of holiness and felt she had tapped into universal mind … crackling electricity traveled up and down her spine … She found her mind racing as she tried to figure everything out. She thought and thought and wandered around looking for her teacher, who she believed was God.” (VanderKooi, 1997, pp. 36–37).

“… this huge burst of energy shot through me. It was like electricity! And then there were all these voices exploding in my head. … There was so much energy, I thought I was dying … For weeks I had nightmares and visions and hallucinations.” (Waldman, 1992, pp. 117–118).

“He felt he did not want to live unless he could reduce this energy, that it would drive him crazy” (Hendlin, 1985, p. 83).

“… The process took me over …” (French et al., 1975, pp. 56–58).

“He felt at times that either he was not real or that his surroundings were not real” (Kennedy, 1976, p. 1326).

When describing persons with extreme mental states, the authors of the alternative discourse used the words “observed” and “seemed” to highlight their own observations and interpretations:

“… appeared so withdrawn, so “lost” as to be nearly catatonic. … I observed Rosita hopping, bounding upright, springing into walls … Rosita did not appear to be trying to harm herself, but was seemingly unable to control her own trajectory” (Ossoff, 1993, pp. 30–31).

“She seemed shy and perhaps a little frightened, and I noticed that I felt somewhat anxious and sad” (Waldman, 1992, p. 116).

In the alternative discourse, the individuals were referred to by name and thus given personhood (even if the real name was changed for confidentiality purposes). Their own interpretations of what was happening to them were preserved and reported in the narrative of the articles:

“She thought that she was going through an enlightening experience and did not understand people's concern. She felt hurt that they pushed her away … Ada could not talk about her pain and felt that people would lock her up if she did” (VanderKooi, 1997, pp. 36–38).

“I realized this week that all my visions are metaphors” (Waldman, 1992, p. 122).

“After gaining some trust in me, he confided that some of the episodes he experienced represented to him a sort of fusion with the cosmos” (Kennedy, 1976, p. 1327).

The alternative discourse conceptualised the experiences of extreme mental states outside of the medical model, framing them as cultural, spiritual or psychological phenomena:

“This woman was not psychotic, and what we had witnessed on Friday was not a psychotic episode, but was in fact, a Kundalini Awakening” (Ossoff, 1993, p. 29).

“… if properly understood and treated as difficult stages in natural developmental process, spiritual emergencies can result in emotional and psychosomatic healing, creative problem solving, personality transformation, and conscious evolution” (Hendlin, 1985, p. 79).

“A distinguishing characteristic of spiritual emergencies is that despite the distress, they can have very beneficial transformative effects on individuals who experience them” (Lukoff et al., 1998, p. 29).

“Rather than being a sign of spiritual awakening Julia's reaction can be seen more simply as a response to her experiencing radical alterations in consciousness” (Waldman, 1992, p. 132).

Another characteristic of the alternative discourse was the authors’ use of reflexivity. They included their thoughts and feelings when encountering the persons with extreme mental states in the description and acknowledged the limits of their knowledge, the uncertainty of their interpretations, or the constraints of their training. This created the impression that authors seemed to be keen on listening openly and non-judgementally to the person’s experiences.

“At the same time, I felt a frustration and personal disappointment, almost a kind of betrayal at my own blindness, my inability to go beyond, to “transcend” the psychiatric explanation of her experience until she uttered the magic word, “Shaktipat”, I also wondered to what degree we in the mental health field are so “hemmed in” by our training or cultural perspective, that we view events in an unvarying way. In other words, if this is a psychiatric center, then she must be psychotic!” (Ossoff, 1993, p. 36–37).

“… although I had worked with a variety of spiritually related issues, my knowledge of kundalini was limited. … I was somewhat skeptical [sic] about the phenomenon of kundalini, but I looked forward to meeting Julia and discussing her experience in more detail” (Waldman, 1992, p. 116).

“However, my lack of understanding of her changing religious identification hindered my ability to empathize with her … to be as open as possible to the internal struggles in both myself and my client; to listen without pretence” (Waldman, 1992, pp. 133–134).

However, examples of “diagnostic certainty” and apparent authority similar to those in the biomedical discourse could also be found.: “Friday became crystal clear - Rosita had undergone a Premature Kundalini Awakening (PKA)” (Ossof, 1993, p. 33).

Therapeutic responses

With regard to responding to extreme mental states, the approaches associated with the alternative discourse included support from a teacher or spiritual guide, supportive listening, “grounding” techniques, changing the diet, “normalising” the experiences and stopping meditation practice for a while:

“… advanced meditators need a qualified teacher to help with the practice … teachers generally assure students that such phenomena occur with deepening practice but will pass. … Teachers may also have more frequent interviews with the student, decrease the student’s sitting time, and involve the student in “grounding” physical activities.” (VanderKooi, 1997, pp. 40–42).

“First, I suggested she refrain from meditation for at least three months to allow the body and mind to assimilate the experiences, as well as the psycho-physiological changes she had gone through. … I therefore suggested a number of routines to help reduce vata, I gave her a list of foods, a diet. … She was also instructed to exercise moderately, since exercise would “ground” her in her body …” (Ossoff, 1993, pp. 38–39).

“I listen supportively to and am accepting of their significance to him without in any way labelling them “pathological”.” (Hendlin, 1985, pp. 85–86).

“… Another key component of treatment of spiritual emergencies is normalization of and education about the experience … because persons in the midst of spiritual emergencies are often afraid that the unusual nature of their experiences indicates that they are “going crazy”.” (Lukoff et al., 1998, pp. 41–2).

The outcomes of these alternative approaches were not extensively discussed in the alternative discourse. However, in some articles, the positive outcomes for the persons and some follow-up information were included.

“One week after Rosita was brought to us, she went home with her family - tired, curious, mystified, a little confused … She thanked us for “everything” and left … Rosita stated she was meditating again and was looking for a therapist as well. No occurrences of kundalini-induced physiological arousal or mental confusion had reappeared. Rosita was not taking any medication, but did ask what herbs might be suggested for her. The overall tone of the letter was hopeful, optimistic, and showed broad awareness, the awareness of one who is in the midst of emotional change, but who has a grasp of who she is and what steps she must take to continue her evolution and development.” (Ossoff, 1993, pp. 40–41).

“She told me that she was doing quite well, although she was still uncertain about what her crisis meant. Still, she found her involvement with the church quite calming and peaceful. “In fact,” she announced, “I'm considering becoming a nun.”.” (Waldman, 1992, p. 129).

The authors who conceptualised extreme mental states in the context of meditation as spiritual emergencies/transpersonal crisis also emphasised the “reliance on the client’s self-healing capacities” (Lukoff et al., 1998, p. 41–42). They adopted a critical stance towards the traditional psychiatric interventions (such as antipsychotic medication), which, according to them, are used to control and supress extreme mental states, which “can lead to chronicity and long-term dependence” (Hendling, 1985, p. 79–80).

In situations where medication was administered or physical restraint was used, the agent performing the action or making decisions was not omitted, suggesting that responsibility for these actions was acknowledged:

“There were four or five of us with her, and we attempted to hold her, protect her from hitting into walls. … The chief psychiatrist decided to give Rosita an anti-anxiety agent to calm her” (Ossoff, 1993, p. 31).

There was also willingness to incorporate other frames of reference such as Western psychological understandings of mental health difficulties and the acknowledgment of the complexity of differentiating between spiritual crises and mental health problems or organic brain disorders:

“Certainly, not all experiences of unusual states of consciousness and intense perceptual, emotional, cognitive, and psychosomatic changes are “spiritual emergencies” or can be treated by the new strategies. A good medical and psychiatric examination is necessary to rule out brain dysfunction or diseases of other organs or systems of the body” (Hendlin, 1985, p. 81).

“While supporting Robert’s framing of issues within a spiritual context, I made it clear to him that I believed basic psychological – developmental issues had been neglected which were now causing great conflict and which needed attention” (Hendlin, 1985, p. 85).

“The opposite see”nario [sic] is also likely. I’ve been in meditation courses where individuals with serious emotional disorders pass for “evolved” (Ossoff, 1993, p. 37).

“Making the differential diagnosis between a spiritual emergency and psychopathology can be difficult because the unusual experiences; behaviours; and visual, auditory, olfactory, or kinesthetic perceptions characteristic of spiritual emergencies can appear as symptoms the symptoms of mental disorders: delusions, loosening of associations, markedly illogical thinking, or grossly disorganised behaviour” (Lukoff et al., 1998, p. 39).

The authors utilising the alternative discourse were clinical psychologists and counselors. Their articles were published in psychology or psychotherapy oriented journals such as The Psychotherapy Patient, Journal of Humanistic Psychology or Journal of Transpersonal Psychology, which published three out of five alternative discourse articles included in this study. As with the biomedical discourse, the disciplinary conventions of these journals shaped the language and conceptual construction of extreme mental states individuals experienced.

Mixed discourses

It should be noted that three articles in our sample (French et al., 1975; Kennedy, 1976; VanderKooi, 1997) combined both the biomedical and the alternative discourse. For example, Kennedy (1976) included the interpretations of the person’s “out-of-body” experience after meditating and noted that psychotropic medication, such as phenothiazines, could be withheld and a referral to spiritual support groups may be helpful. However, he referred to these cases as “psychiatric casualties” and predicted that their number would rise as “more inherently disturbed individuals are attracted to groups with incompetent leaders” (p. 1327).

Similarly, the article by French et al. (1975) included fine-grained first person accounts of their experiences (“I was in a state of openness and readiness for new growth; I felt that there were unreached areas in my mind and that there must be more to life.” (p. 55)). However, their discourse was also characterised by clinical descriptions of the phenomena (“the affect became dysphoric …”, “She displayed substantial use of intellectual processes …” (p. 56)) and the reliance on psychological tests (“The Minesota Multiphasic Personality Inventory (MMPI) profile indicates …”, “Psychological test results at this point indicate a moderate thought disorder.” (p. 56)). Finally, while the majority of Vanderkooi’s (1997) article could be interpreted as utilising the alternative discourse, other parts aligned with the biomedical framing. For example, the author described one of the interviewee’s experiences as a “psychotic break” (p.35) and at times used clinical terms for her reflections: “experiences of Sara and Ada suggest that narcissistic issues around grandiosity and borderline issues around abandonment can be activated in more advanced stages of meditation” (p. 43).

Discussion

We identified two dominant discourses, and a number of mixed cases, in the literature on extreme mental states in the context of meditation. The biomedical discourse constructed such experiences as pathological and described them in clinical language with reference to psychiatric diagnostic nosology. It reflected the assumption that “a scientific way of looking at the world provides an unmediated, direct knowledge of reality, the way things actually are” (Donnelly, 1997, p. 1046). This language implied a sense of authority and expertise as the authors engaged in discussions about the proper psychiatric diagnosis. The person’s subject position was constructed as that of a “psychiatric subject,” which may influence how persons understand themselves and how they are perceived by others (Roberts, 2005). Psychiatric subjects were described as passive recipients of “highly effective” psychiatric interventions (e.g. medication and ECT) aimed at bringing them back to “normal”.

The alternative discourse suggested a different framing and non-medical support practices for people with extreme mental states. In contrast to the biomedical approach that described both patient symptomology and subsequent responses to treatment, efficacy of these alternative approaches was not central to the discussion. The authors of the alternative discourse conceptualised these extreme mental states as crisis, yet without pathologising them. In accordance with the literature on transpersonal psychology, this approach acknowledged that extreme mental states can be difficult and frightening but can also have the potential for spiritual growth and healing (Grof & Grof, 1989). From this perspective, psychiatric medication that suppresses these experiences is seen as potentially harmful for a person’s spiritual growth (Grof & Grof, 1989; Johnson & Friedman, 2008; Lukoff et al., 1995).

Both discourses, we suggest, can be viewed as equally biased and obscuring a better understanding of the experience of extreme mental states. The biomedical discourse while focusing on alleviating distress and functional impairment emphasised the superiority of scientific knowledge and was more reluctant to incorporate other frames of reference. The alternative discourse, while demonstrating reflexivity and willingness to give agency to persons who reported these experiences, focused on criticising the biomedical approach which in turn prevented meditation practitioners and their mentors from recognising that some persons might benefit from medical support, including psychiatry.

This discursive divide maps onto, and is reinforced by, the divide between the disciplines in mental health and their respective scientific journals. Alternative constructions of extreme mental states could not be found in ‘mainstream’ psychiatry journals but were published in ‘niche’ journals such as the Journal of Transpersonal Psychology. We suggest that efforts to overcoming this division should be made in order to develop a more balanced understanding and more comprehensive support for persons who encounter extreme mental states in their meditation practice. This could be achieved by collaboration between the different mental health professionals and spiritual teachers as well as offering a range of therapeutic approaches that include both biomedical and alternative healing techniques. There could also be greater involvement of people with lived experience of such extreme mental states as co-producers of case reports or more transparent consent procedures for publication (e.g. BMJ guidance on publication of case reports https://authors.bmj.com/policies/patient-consent-and-confidentiality/).

Finally, the writing style, different research methodologies, and the restrictions imposed on authors by the publisher play an important role in separating the discursive constructions of extreme mental states. The alternative discourse drew on qualitative approaches and included numerous quotes of those who experienced extreme mental states.

Limitations

This study focussed on case reports, as “an arena in which claims to knowledge are made and epistemological assumptions are displayed” (Anspach, 1988, p. 357). Foucauldian discourse analysis allowed us to analyse how such phenomena are constructed differentially and what real-world effects such different constructions have (Willing, 2001). Adopting this approach and using linguistic analytical tools (Fairclough, 2004) allowed us to identify a divide in the literature. The heterogeneity of extreme mental states described in the articles could be seen as a limitation of this study. We used the term “extreme mental states” to avoid adopting a particular discursive stance (e.g. calling the experiences psychotic). However, the variability of these experiences made it difficult to distinguish between the biomedical and alternative discourses.

Conclusion

Meditation is becoming increasingly popular in the West. Despite the current “media and scientific hype” (Van Gordon et al, 2015, p. 4) surrounding its effects on mental health, it is important to be mindful of the extreme mental states that can occur in the context of meditation practice, and to pay attention to their discursive framing. Our study identified two dominant discourses in published case reports on extreme mental states in the context of meditation. They differed in their constructions and how processes of meaning-making and agency were taken into account.

The presence of both biomedical and alternative constructions in some of the articles raises the question whether these two discourses are as mutually exclusive as we have suggested. Those experiencing extreme mental states and those who support them may have multiple frames of reference when trying to make sense of these experiences. This can be illustrated by Kaselionyte and Gumley's (2018) study, in which Buddhist meditation teachers acknowledged both the possibility of spiritual difficulties in meditation and mental health problems that needed referral to a mental health professional. An important implication of this observation is the need for cross-disciplinary approaches to extreme mental states, which incorporate multiple perspectives, including those with lived experiences of extreme mental states.

Qualitative research points to the importance of the interpersonal context when integrating out-of-the-ordinary experiences into a person’s life, including the opinions of significant others and spiritual or medical professionals (Heriot-Maitland et al., 2012; Sedláková & Řiháček, 2016). It is therefore important not to apply fixed labels to such experiences. Adopting solely the biomedical or the alternative discourse and seeing them as mutually exclusive may harbor risks. While some people may find the spiritual emergency framework more acceptable, this may delay access to healthcare when needed. Others might find the biomedical approaches limiting and would benefit from resources outside of this framework.

We suggest that efforts should be made to create a supportive environment for people to integrate their extreme experiences and find meaning congruent with their values, beliefs and cultural background. Collaboration between spiritual teachers, therapists and clinicians should be encouraged to make a greater range of options available to persons with extreme mental states. For example, the International Spiritual Emergence Network supports people through spiritual crises worldwide and brings together mental health professionals and experts by experience (www.spiritualemergencenetwork.org). Furthermore, transpersonal psychotherapy focuses on both healing of personal issues and promoting spiritual growth (Bagdon, 1990). The evidence base on these alternative therapies should be expanded in order to provide more resources for clinicians to make recommendations to those experiencing extreme mental states.

Further research could explore the experience of extreme mental states through in-depth interviews with meditation practitioners, spiritual teachers and clinicians which could provide a more nuanced understanding of this phenomenon (e.g. Kaselionyte & Gumley, 2018; Lindahl et al., 2017). A wide range of systems of knowledge should be included within the empirical paradigm of evidence-based medicine to account for the range of co-existing understandings of such phenomena (Kirmayer, 2012). Perhaps the most important aspect when exploring such experiences is the suspension of judgement and prejudice, or in Tagore’s (1912) words, starting one’s journey “with empty hands and expectant heart” (p.28)

Supplemental Material

Supplemental material for Psychosis or spiritual emergency? A Foucauldian discourse analysis of case reports of extreme mental states in the context of meditation

Supplemental Material for Psychosis or spiritual emergency? A Foucauldian discourse analysis of case reports of extreme mental states in the context of meditation by Justina Kaselionyte and Andrew Gumley in Transcultural Psychiatry

Footnotes

Acknowledgements

None

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Justina Kaselionyte, MSc, BA, is a researcher at the Institute of Health and Wellbeing in the University of Glasgow. Her research interests are social determinants of mental health, global mental health and the relationship between spiritual practices and mental health. Her published work focuses on meditation and extreme mental states as well as interventions for carer involvement in mental healthcare.

Andrew Gumley, PhD, is a professor of psychological therapy in the Institute of Health and Wellbeing in the University of Glasgow. Prof. Gumley’s research interests include psychological therapies for emotional recovery and relapse prevention amongst people with experiences of psychosis. He is currently the Chief Investigator of the NIHR and MHMRC funded EMPOWER Trial, Principal Investigator for the NIHR funded FOCUS Trial and the MRC funded YouR study. His published works focus on psychological therapies research, and on cognitive, interpersonal and developmental mechanisms of relapse and emotional recovery amongst people with psychosis.

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