Panel Speaker Bios:
Laurence J. Kirmayer, MD, FRCPC, FCAHS, FRSC is James McGill Professor and Director, Division of Social and Transcultural Psychiatry, Department of Psychiatry, McGill University. He is Editor-in-Chief of the journal Transcultural Psychiatry and directs the Culture & Mental Health Research Unit at the Institute of Community and Family Psychiatry, Jewish General Hospital, in Montreal, where he conducts research on culturally responsive mental health services, the mental health of Indigenous peoples, psychiatric anthropology, and the philosophy of psychiatry. His publications include the co-edited volumes, Cultural Consultation: Encountering the Other in Mental Health Care (Springer, 2013); Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health (Cambridge, 2015) and Culture, Mind and Brain: Emerging Concepts, Methods, and Applications (Cambridge, 2020). He is a Fellow of the Canadian Academy of Health Sciences and the Royal Society of Canada.
Alexander B. Levitov MD, FCCM, FCCP, RDCS is a professor in the division of Pulmonary & Critical Care Medicine and Director of the Ultrasound Training Program at Eastern Virginia Medical School. He is board certified in Internal Medicine and Critical Care Medicine and a Registered Diagnostic Cardiac Sonographer. Dr. Levitov is a nationally and internationally recognized expert in bedside ultrasound. He received the Presidential Citation for Outstanding Contributions from the Society of Critical Care Medicine. Dr. Levitov is a visiting professor at Harvard Medical School, Goethe University in Frankfurt, Germany and Yangzhou University in China. He directs several Certified Medical Education ultrasound courses in the United States and internationally. His invitational lectures are too numerous to count. He is a known and respected teacher and is a member of the University of Virginia Academy of distinguished educators since 2006. Dr. Levitov serves on the SCCM’s Critical Care Ultrasound Guidelines Task Force, the ACCP’s Taskforce on Critical Care Ultrasonography, and he is a member of the ACC/AHA’s Non-invasive Evaluation Appropriateness Task Force. Dr. Levitov holds several patents related to medical innovation including ultrasonography.
Jennifer “Kim” Penberthy, Ph.D., ABPP is the Chester F. Carlson Professor of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine. Kim is a board certified clinical psychologist and conducts research, teaches, and provides clinical care at UVA in psychiatry and the cancer center. Her research interests include studying the mind-body relationship and exploring human consciousness as well as extraordinary human experiences and abilities. She is a founding member of the UVA Contemplative Sciences Center and a member of the UVA Academy of Distinguished Educators, the UVA Leadership in Academic Matters Program, and is a Fellow of Humanism in Medicine at the University of Virginia. Dr. Penberthy is dedicated to promoting diversity and inclusion and exploring contemplative practices across cultures. She has published extensively on psychotherapy and mindfulness, and her most recent book is “Living Mindfully Across the Lifespan: An Intergenerational Guide” co-authored with her daughter, Morgan.
- Maria KozhenikovOkay so we will continue with our, with our, third panel on the risks and benefits associated with advanced Vajrayana practices, and I will introduce our panelists.
- So we have here Laurence Kirmayer, who is professor at McGill University and director of the Division of Social and Transcultural Psychiatry at the Department of Psychiatry. And we also have Jennifer Penberthy professor of research in Psychiatric Medicine Department of Psychiatry and Neurobehavioral Sciences, it’s the School of Medicine in University of Virginia.
- And we will also, we also have Alex Levitov who also joins in this panel. Okay so, uh, we talked a lot about, um, positive effect of these practices, and Alex Levitov was telling about positive effects of blood flow to the brain. But, uh, there is probably a lot of risk associated with them.
- And we know that there are risk even of mindfulness, so some people have adverse effect of practice in mindfulness. And here we have way more kind of aggressive types visualization which requires really stress control. So, it’s probably not that safe to practice them.
- And actually Tibetan do not advise to practice them unless a person had already quite a significant, quite a serious ground in preliminaries. So, it would be really interesting your views as medical doctors as psychiatrists and psychologists just understand how dangerous, how dangerous, this practice is on one hand but how beneficial they can be on the other hand. So, um yeah, anyone want to start from our panelists just to give your view on what you think about the safety and risks of these practices.
- Laurence KirmayerWell, I’ll say just a couple of quick things Maria. I don’t know if it will fit with the time and the framing, but I have a couple of slides that I could show that might also help in terms of resources for thinking about this. So if that’s okay, if you make me a cohost, I’ll share my screen whenever that’s appropriate. If not, I can just speak.
- Here we go. First of all, I want to say just how deeply appreciative I am of the chance to take part in this meeting. It’s completely fascinating and lots of new vistas and, like some of the other people, here lots of moments when I’m way out of my depth in terms of my knowledge of the phenomena we’re talking about and what I might have to contribute. But I just wanted to say a couple things, specifically to Maria’s question and then some background things. I didn’t prepare a talk beforehand because of just total overload of other things in my life, but I did want to introduce just a couple ideas that maybe are helpful in this discussion.
- My contribution to the whole issue of adverse effects is really based mainly on two articles that I did with Jared Lindahl and Willoughby Britton which were based on a large corpus of data from people who had adverse experiences that they collected through various meditation circles and communities, and they were able to do in-depth interviews with people to try to get both the quality of the experience, some sort of phenomenological account of what they were going through, and some pieces of contextual information and then we thought together about that.
- And I’m not going to belabor any of that—and there’s another article I’ll show later in terms of a way to approach assessment—but this is one article and they have many others in this Varieties of Contemplative Experience project that looks at adverse experiencesÉ and this [paper by Lambert et al.] is a recent synthetic review of 39 studies of people having adverse effects. So I guess the first thing to say is that in the largely Western context of meditation retreats and so on, lots of people have adverse effects.
- And it makes sense that, if you’re arguing on the one hand these are powerful techniques, they can cause some surprising physiological effects and can cause some profound shifts in sense of self and non-self, and so on, you would expect that if it has that potency, then there are going to be things that can go wrong along the way. And I think understanding what those are and what those might teach us is important.
- Maria made the point yesterday that studying experts and studying exceptional states can be revealing even if it’s extremely complex because lots of things are going on at the same time and you’re not always sure exactly what the important element is or the operative element.
- It’s analogous, of course, to the long history in medicine and psychiatry of studying pathology and using it that way and we have the same problem there: that pathology is rarely one thing, and there’s a cascade effect, and so we don’t always know what we’re attributing [to pathology]. So there is something there.
- The kinds of effects that people have — this is just sort of a rough summary of the common kinds of effects. Emotional distress obviously is a very common one; again, I’m speaking now not in the monastic context of Vajrayana. I asked the Rinpoches on the first evening about that kind of experience; interestingly, he immediately talked about psychotic experiences, saying that they don’t see that or don’t see much of that.
- But I think the more common things that we see in terms of people who are distressed and who come out of a retreat or have to leave or something else like that, is often associated with strong affective states, sometimes associated with people having a history of some kind of traumatic experience that comes up more or less spontaneously in the context of the practice that they’re doing, and then they experience it so vividly and so distressing that they have to stop.
- There are people who experience hallucinations, delusions, other psychotic symptoms, and I’ll come back to what that might mean in a moment. And then I think in some ways most interestingly in terms of our attempts to understand the underlying processes in these practices, there are people who have changes in their sense of self and their perception of self, and those are not - the ones that are distressing - are usually not transient experiences, because I guess you can have a profound experience but if it subsides, you’re probably going to be able to, you know, put yourself back together in some kind of functioning way.
- But people have persistent changes in self. So one person in the Britton and Lindahl study said words to the effect that “Well, I lost my self during that practice and I haven’t had it back now for five years.” There are some people who talk about prolonged states of depersonalization, derealization that are completely disruptive to their sense of wellbeing and their functioning in their life. So that to me is an extraordinarily interesting - and again this is not about Vajrayana specifically -
- But it’s extraordinarily interesting that a practice that does not involve pharmacology and that does not involve obvious physical manipulations, let’s say, of the nervous system, but it’s coming through bodily practices and through instructions and through a process of self-monitoring and so on, could have such profound and persistent effects, I think, definitely seems to teach us something very important.
- And I should say again from a mental health point of view - and I can stop here or I can go on, because I prepared too many things and this is supposed to be a discussion now - so let me just say one other thing related to this, which is that when we’re thinking about adverse effects we have to think about different scenarios:
- One in which people are coming into that situation already with certain problems. And you mentioned already, Maria, and the Rinpoche the other day mentioned too, that if someone comes and they’re already having certain kinds of mental instability, then they would work for a long time to get to a more stable state and then they could undertake these practices. So, I think that’s an important issue in reality, again, in North America in this sort of - the agora of people trying different things, people may come to take part in a retreat or some kind of intensive practice and may have preexisting or ongoing problems.
- They may also have vulnerabilities and that’s a little bit different kind of issue in terms of what kind of vulnerability might make a person prone to having certain problems. And you can imagine again who might be prone to - might have had traumatic experiences that get reactivated and lead to, you know, very extreme states of emotional distress.
- Keith Holyoak mentioned the notion of absorption. So, we know that there are people who are extremely high on Openness to Absorbing Experiences, who have what Steven J. Lynn many years ago called a “fantasy prone personality.” So, people who can get so readily absorbed, so readily lost in things, that they get disoriented. I had a patient who described her childhood as spending most of her time sitting in front of the window daydreaming while life kind of went by.
- So that’s a negative side of what could otherwise be a talent and a capacity and that might lead somebody in fact to have some positive and compelling experiences in meditation, but could also make them vulnerable to be led astray. So that’s the second category, people who have vulnerability. And the third is the possibility—and I don’t think we know this very well because this kind of study doesn’t get done—but people who have no particular history of mental health problems beforehand, who have no particular traits or vulnerabilities, and who, due something intrinsic in the practice, get into trouble of some kind.
- And so my remaining slides are trying to think about what that might be. But without belaboring the whole thing, I’ll just show one diagram here, this one here, to argue that what happens in experience— and we’ve been talking all around this, and this fits very much with the discussion we just had on metaphors — that what happens in experience is that there are things happening in the body that are part of the functioning of the body, and there are things that are happening in our way of narrating and understanding ourselves which come largely from outside, we learn them as ways of making sense of experience.
- And our moment-to-moment experience is some kind of interaction of those things. But it’s not an interaction like you just add one to the other, but is a looping effect, a process in which each is transforming the other in a dynamic way. And so it leads to the possibility that, first of all, that the ordinary experience of self is in fact a looping effect, and I think the studies like the rubber hand illusion or illusory sense of agency, or out-of-body experience are just very dramatic illustrations of the idea that our everyday sense of self which seems like a solid thing is involving a constant maintenance through a kind of sensorimotor loop.
- And if you fiddle with that loop you can radically change somebody’s sense of self and our identity and embodiment and so on. That’s a, I think, extremely important lesson, and the fact that it’s actually relatively easy to do for most of us, just by giving this different kind of feedback. So, what it raises is the possibility that that’s what happening in some sense in meditative practices: that people, without external devices, are learning to self-monitor in a different way, so that they set up a different kind of loop and then have a different experience of self. And that’s not just the end point but it’s instructive of the fact that the self is in fact something that’s being maintained through this kind of loop.
- Anyway, if there’s some validity to that rough way of thinking about things, it does have implications for the problem of pathology, because it says, “Well, those loops are self-maintaining and self-amplifying they can be very intense if they’re set up the wrong way.” If they’re set up, let’s say, so that a certain sensation you’re having makes you panic, and that intensifies the sensation further, you’re going to have a panic attack; or a certain sensation you have that makes you feel lost and disoriented is so confusing that you don’t know how to get any traction on it, and you have no slot to put it in, you might be left with a prolonged sense of confusion and sort of a reorganization of your own self-description in a way that maintains that [feeling of disorientation].
- So very crudely, that’s a kind of picture of problems. And probably we could have a typology in the end of what those problems look like—why some might give rise to very intense bodily sensations or visual sensations, or just a sense of disorganization of self, or difficulty in interacting with other people— as we understand better what those things are. So that’s essentially what I wanted to say. I’ve got lots of other slides that make exactly the same points, so I won’t belabor it further and thanks for your patience with that.