Bruce I. Goderez, MD

Most of us in the mental health professions would agree with the following statements:

 are important, even central concerns for a large portion of the population

• Many people insist that their religious and/or spiritual practices help them cope with the inescapable vicissitudes of life

• It has long been recognized that some psychiatric conditions can involve religious preoccupations and alleged spiritual experiences

• Over the last 50 years meditation practices-generally inherited from various religious traditions-have become widely accepted as beneficial for management of stress and have been increasingly adopted by the mental health community as a treatment modality

In view of these observations you would think that psychiatrists would be well-versed in these topics, but the reality is that they are barely touched upon during our training and we are given very little guidance as to how to respond when our patients raise religious or spiritual concerns. Since meditation can be practiced without reference to the religious traditions that transmitted various techniques to us we can feel comfortable recommending it to our patients. But when it comes to relating to the larger questions about life, the nature of suffering, the inevitability of death, etc, we generally have no idea how to proceed.

 give us several examples of attempts to address these topics. The May 2019 issue presented an interview of Dr Paul Summergard by Dr Lloyd Sederer, “

,” in which Dr Summergard shares his experience and suggests a general attitude to adopt when patients bring up religious concerns. In more recent issues, Dr John Miller shared two editorials exploring the clinical applications of mindfulness practice, “

Since our profession has no agreed-upon body of knowledge about the relationship of religion and spirituality to mental illness and mental health, it makes sense that those of us who present ourselves as having something useful to say should establish some sort of credentials. Dr Summergard mentioned that he did a number of years of intensive 

, and Dr Miller recounts extensive experience with a meditation tradition derived from the 

, including a 3-month silent meditation retreat. Both doctors commented on the impact these experiences had on their personal as well as professional lives. So, their credentials for holding forth on these topics consist of substantial experience with meditation practice as taught by two different Buddhist traditions, exposure to the intellectual content of these traditions, and on their perception that these experiences had a significant impact on their personal lives as well as their practice of psychiatry.

In this column I propose to present a framework for understanding the basic psychological mechanisms involved in the practice of mindfulness meditation, which may clarify why it is helpful in many different situations. But if I am going to pontificate on these weighty matters, I too must establish my credentials.

I was raised in a completely secular Jewish family, with virtually no exposure to even a secular Jewish social environment. I entered medical school with the intention of going into psychiatry. In my fourth year I stumbled on the book 

 by Alan Watts, one of the first well-known Western proponents of Zen Buddhism, which piqued my interest in Buddhism as a psychological system. To make a long story short, I followed a path similar to that of Drs Summergard and Miller-I took a year off between my rotating internship and psychiatric residency to engage in intensive meditation and study of Buddhism, then another block of time after my residency, after which I settled down into my career and raising a family.

The particular tradition I connected with was Tibetan Buddhism as taught by Chogyam Trungpa, a Tibetan Lama who founded numerous meditation centers as well as Naropa University in Boulder, CO, which to this day offers a Masters degree in Eastern and Western Psychology. Along the way I did a 1-month meditation retreat, a 10-day solo meditation retreat in an isolated cabin, and a 3-month program with Chogyam Trungpa that  involved extensive meditation practice as well as a systematic presentation of the history and formal teachings of Tibetan Buddhism. After my residency I spent 3 months at a meditation center in which I experienced a novel meditation system created by Trungpa in collaboration with Suzuki Roshi, a well-known Zen teacher. The system was based on methods used in Tibetan and Japanese Buddhist monasteries to help stabilize monks who developed serious psychological issues or psychosis in the course of intensive meditation practice.

Trungpa presented the Buddhist tradition to us, a modern American audience, as a psychological system. He made it clear that we did not need to accept anything on faith and stated explicitly that we need not accept any teachings that we could not confirm by our own personal experience. In that environment there were many individuals who enthusiastically accepted the religious aspect of the teachings, which is to say the traditional teachings about the nature of the universe, what happens after death, and so on. As a scientifically trained person from a totally secular background I had some discomfort about these issues. A small incident put my mind at ease: a young man asked Trungpa a question, “Everything you have taught us is great, I love all the stuff about meditation . . . but I have to be honest . . . I have a lot of trouble with this whole reincarnation thing.” Trungpa replied, “For you, sir, reincarnation is waking up in the morning. Don’t worry about the rest.”

In the spirit of transparency, everything I will say is derived from what I learned through both study and meditation practice in those particular settings. I am not a scholar in these matters, nor can I pretend to be a highly accomplished meditator or teacher. Nevertheless, these experiences were transformative on a personal level, giving me the capacity to cope with extreme stress at various points in my life with a degree of equanimity that would not have been possible previously. They also had a profound effect on my work as a psychiatrist, in particular giving me a wider context in which to understand my patients’ struggles. I have found that when patients bring up religious or spiritual concerns I am completely at ease conversing with them in a way that is appropriate for that individual, which would have been impossible in my natural state as a person with no exposure whatsoever to religious practices.

When I deal with psychotic people reporting apparent spiritual experiences, I find that I can often understand what it is they are trying to describe and respond in a reassuring way that acknowledges their experience. Don’t get me wrong-I also give them an antipsychotic. But there is great value in meeting people where they are at, so to speak. I ascribe whatever ability I have developed to deal with these issues effectively to a combination of my personal experiences in the course of meditation practice, but equally to having been given a systematic intellectual framework for understanding the nature of spiritual experiences altogether, and their relationship to our normal mental state as well as to mental illness.

So much for credentials. Now let us turn to the narrow topic of mindfulness meditation. First, what do we mean by the word “meditation”? Lots of my patients tell me that they meditate, but on further questioning most of them are talking about guided meditation recordings-which in reality is akin to hypnosis-or perhaps they do a few minutes of chanting a mantra in a yoga class. To be sure, these activities can be very beneficial for stress management, sleep, and so on, but they are not meditation. Mindfulness meditation has robust stress-management benefits, but that is somewhat of a side effect. Its primary purpose, interestingly, is to mitigate our habitual mental patterns, which in Western psychology we have conceptualized-at least in previous generations-as “neurosis.”

Broadly speaking there are two types of meditation practice-concentration techniques and 

-awareness techniques. Concentration techniques involve focusing one’s mind on a single object-a candle, a picture, a thought, a sound or “mantra,” part of the body, pretty much anything. If practiced sufficiently this type of meditation produces trance states-states of altered consciousness that can be intense and at times ecstatic. The intensity of these experiences is often interpreted as evidence that this is “real” spirituality and can motivate people to pursue them even more vigorously. There are numerous elaborate traditions utilizing these types of practices. However, there are distinct dangers to taking these techniques to extremes, and they should only be practiced under the close supervision of a knowledgeable guide.

Mindfulness meditation, on the other hand, can be described as a simple technique for observing our own mental processes in granular detail. The usual instruction is to sit upright without a backrest-mostly so we will start to fall over if we doze off, which keeps us awake (meditation can be boring). The tradition is to sit cross-legged on a cushion. There is no particular reason to adopt a lotus posture or anything else uncomfortable-this is not about overcoming 

. If you are of a certain age, by all means sit on a chair. Most traditions instruct us to close our eyes, but I was taught to meditate with eyes open. The explanation we were given was that if we close our eyes it is too easy to space out and get lost in our thoughts.

The meditative technique itself is usually to turn our attention on the breath. Easy! The trouble is, after about a microsecond . . . blah, blah, blah-we are talking to ourselves. There are numerous variations and nuances in the instructions given by different traditions and different teachers on how to handle this “grasshopper” quality of our minds. The technique I learned was that as soon as we realize we are not on our breaths we literally say to ourselves “thinking,” and gently return attention to our breath. At some point we inevitably get frustrated, thinking, “I can’t do this, this is ridiculous, I’m leaving.” At that point . . . back to your breath.

A couple of comments about breath. There is nothing mystical about it-it’s just a convenient way to help us stay in the present moment. Then there is the question of how intensely to focus on the breath. A traditional teaching story tells of a student of the Buddha, a famous musician, who asked the Buddha how intensely to focus his attention. The Buddha asked him how tightly he adjusted the strings on his instrument. The student replied, “Not too tight, and not too loose, or the sound will be no good.” The Buddha said, “Just so. Your focus on your breath should be not too tight, and not too loose.” That is, if we make no effort, we don’t focus at all on the breath and no progress will be made. But if we get too intense about it, it can turn into a concentration technique focused on the breath, which is definitely not what is intended. If that starts to happen, a competent meditation instructor will tell us to lighten up, maybe look around a little, shift our position-then come back to the breath.

There is no such thing as not being able to meditate. This statement requires some explanation, which brings us to the discussion of what this meditation technique actually accomplishes.

As we move around in the world and encounter things, or as we sit on the cushion and encounter things in our mind, there are three reflexive impulses that can occur. If the object or thought makes us feel good, confirmed, safe, we want to pull it in, build it up, make it last longer. If it is threatening or uncomfortable, we want to push it away, destroy it. And if it is neither confirming nor threatening, we ignore it. Consequently, we tend to ignore 99% of everything that crosses our awareness. In traditional meditation texts these three impulses are known as the Three Poisons-Passion, Aggression, and Ignorance-the obstacles to successful meditation practice. The meaning of these three words in daily life is obvious: Passion: love, greed, obsession, addiction; Aggression: anger, cruelty, destructiveness; Ignorance: maybe . . . cluelessness? From the point of view of evolutionary psychology, these three impulses are completely natural and highly adaptive: we are attracted to what makes us feel good, we are repelled by what makes us feel bad, and we don’t waste energy on the rest.

But in this case, we are not talking about our behavior in the world, rather we are talking about these three impulses as our reflexive reactions to each moment-to-moment thought. What we are being instructed to do when we sit down to meditate is very simple, very difficult, and quite unnatural-we are being asked to do “none of the above.” That is, whatever thought comes along, we are instructed to neither cultivate it, nor drive it away . . . nor ignore it. We are asked to simply notice it and come back to the breath.

Initially we are terrible at this. We get lost in a sexual fantasy, or business plans, or political tooth-gnashing. Oh yeah, back to the breath! We obsess about that time we were humiliated, and what we should have said. Back to the breath! But if we persist, little by little, we begin to relax into our own thoughts. They never go away-we are explicitly not trying to make that happen-but we begin to spend more and more time just watching them come and go, without building them up or pushing them away, and without ignoring them.

This process can be characterized as developing an attitude of equanimity toward our own thoughts. Over time, somewhat magically, we notice that as we move about in the world and stuff comes up, we are less reactive. Something that would have left us upset all day becomes less of a big deal. Some compulsion that we would ordinarily find irresistible becomes less compelling. We begin to feel calmer overall, clearer, and with more freedom to deal with what comes up in whatever way seems best-as opposed to endlessly repeating dysfunctional habitual patterns. These emotional and behavioral changes are gradual and spontaneous.

That is why I say there is no such thing as not being able to meditate. I view it like doing pushups. If we resolve to start exercising with pushups, and we can’t do even one, we start with half a pushup. If we work out regularly, eventually we can knock off a whole bunch of pushups. It just takes patience and practice. That’s why we call this activity meditation “practice.” At this level it is a very simple training program, whose goal could also be described as the art of not taking our own thoughts too seriously.

With this model in mind it becomes clearer why meditation practice can be helpful in so many clinical situations, and why the average person with no identified “conditions” may find it beneficial. It is also noteworthy that the benefit is not dependent on adopting any particular philosophy or spiritual teaching. The benefits of meditation are a spontaneous result of gradually changing the nature of our relationship to our own thought process.

This model of meditation practice is very simple, yet very fundamental. Along the way I have alluded to a number of far more complex issues. What is the distinction between “religion” and “spirituality”? What do we mean by the term “spiritual experience”? What is the nature of the transformative experiences hallucinogenic drugs can sometimes produce, and what about the religious preoccupations and spiritual experiences of some of our patients? And, what does meditation practice have to do with all of this?

Buddhist psychology provides a comprehensive framework that can illuminate the relationship of these disparate phenomena. Interestingly, it is all about ego-a concept that is also at the core of Western psychological thinking. In a future article, I will try to summarize the basic model of the Buddhist psychological tradition in terms that are understandable to students of the Western psychological tradition.

 is a psychopharmacologist and integrative medicine practitioner in private practice. He offers hyperbaric oxygen therapy for traumatic brain injury and other neuropsychiatric conditions including dementia and radiation necrosis.

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You would think that psychiatrists are well-versed in religion and spirituality, but the reality is that they are barely touched upon during our training.

Making Sense of Meditation: Religion and Spirituality

Hyperbaric oxygen therapy (HBOT) is defined as the use of oxygen at higher than atmospheric pressure for the treatment of underlying disease processes and the diseases they produce. Modern HBOT in which 100% O2 is breathed in a pressurized chamber dates back to the 1930s, when it was first used for treatment of decompression illness in divers. There are currently 13 FDA-approved uses for HBOT, including decompression illness, gas gangrene, air embolism, osteomyelitis, radiation necrosis, and the most recent addition-diabetic ulcers.

Just as practicing physicians routinely identify off-label uses for medications, over the years HBOT physicians have identified many other conditions that respond to HBOT. A number of chronic neurological conditions including traumatic brain injury (TBI) have been shown to respond particularly well. There is published literature supporting HBOT’s efficacy for TBI, including human trials and animal research, but due to the impossibility of arranging sham pressure there are no rigorous double-blind placebo-controlled trials.

 As a result, HBOT is not FDA-approved for TBI, and insurance will generally not pay for it.

HBOT can dramatically and permanently improve symptoms of chronic TBI months or even many years after the original head injury. This assertion is generally met with skepticism within the medical establishment because we have been taught for generations that any post-concussion symptoms persisting more than 6 months or so after a head injury are due to permanent brain damage that cannot be repaired. Therefore, treatment has been limited to symptom management and rehabilitative services, and any claim suggesting that fundamental healing is possible is suspect. The combination of entrenched skepticism and lack of insurance coverage has made it very difficult for patients to access treatment.

Another source of skepticism has been the large number of disparate conditions that are claimed to be helped by HBOT. A brief review of the mechanisms through which HBOT triggers healing responses, with particular reference to the modern understanding of the pathophysiology of TBI, provides a theoretical framework to explain these claims.

About 97% of the total oxygen in blood is tightly bound to hemoglobin when breathing room air (21% O2) at sea level (1 atmosphere, or 1 ATM; 3% of the oxygen is dissolved in blood serum. This amounts to about 0.3 mL of oxygen dissolved in 100 mL of serum. By the time oxygen diffuses out of the circulatory system and ultimately reaches the mitochondria, there is just a trace amount present. HBOT’s primary mechanism is to temporarily hyper-oxygenate body tissues. HBOT delivered at 1.3 ATM increases dissolved oxygen in serum by a factor of 7. HBOT delivered in hard chambers at 2.5 to 3.0 ATM increases dissolved oxygen by a factor of 15 or more. Oxygen levels in body tissues outside the circulatory system will be increased commensurately.

If a hyper-oxygenated state is maintained for long periods it will cause significant oxidative damage, but when it is “pulsed” for an hour it triggers a variety of healing processes without overwhelming the body’s anti-oxidant system. The currently known mechanisms include a powerful anti-inflammatory effect, reduction of edema, increased blood perfusion, angiogenesis, stimulation of the immune system, stimulation of endogenous antioxidant systems, mobilization of stem cells from bone marrow, axonal regrowth, and modulation of the expression of thousands of genes involved in the inflammatory response and various healing responses.

At each site of impact a contusion can develop-essentially a bruise that may involve local bleeding and neuronal death. Over hours to days an area of inflammation will develop around the contusion, just as inflammation will occur around an injury anywhere in the body. Since the brain is encased in the skull swelling is strictly limited, resulting in increased pressure in the affected area. The increased pressure results in reduced blood flow, damaging a much larger area of cortex than was initially injured. Within this penumbra, neurons may be injured and unable to carry out their prime function of transmitting neuronal impulses, yet they can survive in this stunned or “idling” state indefinitely.

This understanding of the pathophysiology of TBI explains the typical evolution of symptoms after a concussion. The patient may lose consciousness or may just feel stunned for some time. There may be an initial headache and some degree of confusion, which often improve over the next few hours. However, as the inflammatory process evolves more severe symptoms develop, usually peaking within 1 to 2 weeks. These include headache, “brain fog,” nausea, photophobia, hyperacusis, difficulty with focus and multitasking, impaired memory, difficulty with visual processing with prominent difficulty looking at screens, and profound fatigue. The symptoms eventually stabilize, then begin a slow recovery over several months.

This type of injury is referred to as “mild” TBI, since there is no gross destruction of brain matter. The absence of gross damage is reflected in the typical finding of unremarkable CT and MRI scans even in the presence of disabling symptoms. However, in many cases a brain perfusion (SPECT) scan can image macroscopic areas of reduced perfusion of the cortex.

HBOT is regulated by the FDA as a drug, and like a drug, the appropriate dose can vary with the condition being treated. Dose is determined by the pressure in the chamber and the total hours of treatment. HBOT for FDA-approved indications is most commonly delivered in hospital settings, usually in large multiplace chambers at a pressure of 2.0 ATM or higher. High pressure treatment is superior for infections and for other acute severe problems.

It took several decades to determine that, due to excessive oxidative stress, high pressure HBOT carries a significant risk of further damage in chronic diffuse neurological conditions. Treatment at lower pressures in conjunction with limits on the number of sessions has been shown to be safer and more effective for these conditions, including TBI.

The recommended protocol for TBI is currently one or more blocks of 40, 1-hour HBOT sessions delivered at 1.3 to 1.5 ATM. Treatment can be conveniently delivered in “mild” hyperbaric chambers, soft vinyl chambers limited to 1.3 ATM that are inflated by a small compressor using room air (eliminating the risk of fire). Oxygen is extracted from ambient air by a portable oxygen concentrator, removing the need for oxygen tanks. Oxygen is fed into the chamber through a tube and delivered to the patient via an ordinary hospital oxygen mask.

These chambers are affordable, simple to assemble, simple to operate, and can be used in the outpatient setting. They are considered class II medical devices similar to a continuous positive airway pressure machine, requiring a doctor’s prescription but usable at home without direct medical supervision.

RP is a 55-year-old man who originally entered treatment with a 20-year history of bipolar disorder. His life had been chaotic because of lack of treatment adherence. He was stabilized on a modest dose of lithium and has been in a stable relationship and successfully self-employed for the past 10 years.

When it occurred to me to ask him about concussions, it emerged that there were several significant sports-related concussions during adolescence and at least a half-dozen serious concussions in early adulthood, possibly related to recklessness during manic episodes. His last concussion occurred 30 years before this history was obtained. He was unable to describe any specific post-concussion symptoms, possibly because he had so many concussions starting in adolescence, and could not remember what his functioning was like prior to his concussions. A brain-perfusion SPECT scan showed extensive perfusion defects consistent with TBI, which is a strong predictor of clinical benefit with HBOT. Accordingly, he was offered treatment even in the absence of a clear history of acquired symptoms.

The patient rented a mild-HBOT chamber and did the treatment at home. He completed two blocks of 40 one-hour sessions of mild HBOT (1.3 ATM, 100% O2) over the course of 4 months. A post-treatment SPECT scan was obtained about 56 months after he completed the treatment protocol.

Following is the summary section of the radiologist report for each scan. Note that a normal SPECT scan should show homogeneous perfusion, whereas areas of reduced perfusion or heterogeneous (spotty) perfusion indicate cortical areas of reduced blood flow.

“Findings: Decreased tracer perfusion is seen in the right temporal lobe and also there is heterogeneous perfusion in the bilateral parietal and posterior frontal lobes. The cerebellar hemispheres are symmetrically perfused in the correct clinical settings, this may reflect sequelae of traumatic brain injury.”

Post-treatment SPECT scan,
	Dec. 27, 2017

“Findings: Brain SPECT images demonstrate homogeneous perfusion of the cerebral hemispheres. There are no asymmetric perfusion defects, with interval resolution of previously seen asymmetrically decreased radiotracer uptake in the right temporal lobe. Similarly, previously seen decreased perfusion in bilateral parietal and posterior frontal lobes has resolved. Impression: Normal brain perfusion SPECT with interval resolution of previously seen areas of decreased perfusion.”

After completing treatment he reported improvement in focus, improved ability to multitask, and generally more stable emotional functioning. He noted that he was using vocabulary that he had not used since he was a teenager, which was readily observable on interview. He found that he was communicating with people in a much more direct way, in contrast to his usual tendency to be tangential with difficulty getting to the point. He stopped using an appointment book for his business, finding that he could keep track of appointments with his clients for several weeks ahead by memory.

This case is not ideal as a teaching vehicle because of the lack of clear documentation of changes in post-concussion symptoms or neuropsychological testing results. However, the normalization of a grossly abnormal SPECT scan is clear indication that HBOT can repair neurological damage even decades after an injury, bringing macroscopic areas of cortex back “on-line.” The changes in the patient’s functioning and demeanor were striking, and clinically there was no doubt about the magnitude of the response. A controlled trial in a series of similar patients including pre- and post-neuropsychological testing, rating scales, and serial SPECT scans was published in 2012.

Cerebral palsy (CP) can be considered to be perinatal TBI and patients with CP have been shown to respond significantly to HBOT.

 Benefits brought about by HBOT in TBI and CP are generally permanent, although patients may be more vulnerable to reinjury. Clinical experience and compelling case reports suggests that Alzheimer disease and multiple sclerosis can be improved to some extent by HBOT. Benefits in patients with progressive illnesses such as multiple sclerosis will tend to deteriorate over time. A maintenance schedule of perhaps a few sessions per week can slow down and, in some cases, appears to prevent progression.

HBOT can bring about dramatic improvement in many neurological conditions for which we have had very little to offer other than palliative care. Considering the high incidence of many of these neurological conditions, the safety of treatment, and the simplicity and relatively low cost of mild-HBOT, it is unfortunate that it is not more widely available.

Dr Goderez is a psychopharmacologist and integrative medicine practitioner in private practice. He offers hyperbaric oxygen therapy for traumatic brain injury and other neuropsychiatric conditions including dementia and radiation necrosis.

 Harch PG, Andrews SR, Fogarty EF, et.al. A phase I study of low-pressure hyperbaric oxygen therapy for blast-induced post-concussion syndrome and post-traumatic stress disorder. 

 Efrati S, Ben-Jacob E. How and why hyperbaric oxygen therapy can bring new hope for children suffering from cerebral palsy: an editorial perspective. 

 Harch, P. Hyperbaric oxygen in chronic traumatic brain injury: oxygen, pressure, and gene therapy. 

 Mukherjee A, Raison M, Sahni T, et.al. Intensive rehabilitation combined with HBO2 therapy in children with cerebral palsy: a controlled longitudinal study. 

 Harch PG, Fogarty EF. Hyperbaric oxygen therapy for Alzheimer’s dementia with positron emission tomography imaging: a case report. 

. New York, NY: Springer International Publishing AG; 2017: 345-348. 

HBOT can bring about dramatic improvement in many neurological conditions for which we have had very little to offer other than palliative care.

Author | Bruce I. Goderez, MD

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