There is a short list of recommendations a clinician can make to almost anyone, at almost any point, without a second thought. Sleep. Movement. And, for the last several years, mindfulness. Take a breath. Notice your thoughts. Try the app.
I want to argue that mindfulness does not belong on that list — not because it doesn't work, but because it does.
My co-host on Got Therapy?, Dan Rose, made the point with a medical analogy in our most recent episode. Some people are allergic to penicillin. That doesn't mean people shouldn't be taking penicillin. It means nobody prescribes it without asking first. Anything effective enough to help is effective enough to cause problems for somebody, and the more effective it is, the bigger that risk becomes for the small group it doesn't suit.
We apply that logic to medication without argument. We have mostly stopped applying it to mindfulness.
What the risk actually looks like
The episode was the second half of a conversation Dan and I have been having about meditation, and this half was about the drawbacks. Dan raised what an article we had discussed called meditation sickness — the observation that constant self-reflection can produce what looks like a psychotic state.
That sounds like an edge case. His clinical examples were not. For some people, panic is set off by inner emotional states themselves; a practice that trains close attention to those states can, at first, produce the very thing it was supposed to calm. Overthinking — Dan's phrase was "thinking about thinking about thinking" — can feed the states we are trying to quiet. Trauma histories call for real caution.
I have watched the unprepared version of this. People walk into a meditation group at the Y, sit down, and are told to calm down, with nobody having asked what calm down might cost them. And once someone slides from a meditative state into panic, there is no quick way back.
Symptom is not enough
The fix is not a new technique. It is an old one we have let slide.
Dan called assessment "kind of a lost art," and I think he is right. We assess for symptoms. We rarely assess for character structure — for defenses, for how much self a person has to work with. Yet that is exactly what tells you whether a practice designed to loosen the grip of the self is going to help. Someone struggling with psychosis, Dan said, needs to build a self, not lose one. Recommending that they practise letting go of it is aiming at the wrong target.
The other half is the assessment that never stops. "Our best supervisor is always the patient," Dan said, and it is the best line in the episode. Every second in the room, the client is telling us whether what we are doing is landing. A technique introduced abruptly — "let's meditate together right now" — can cut straight through that feedback loop.
Three things I would ask of the field
First, prepare people before practice. If a client is going to try mindfulness, a therapist can prepare them for what might come up — or rule it out. A drop-in class cannot do that.
Second, treat a bad reaction as information. A panic response to a breathing exercise is not a failed homework assignment. It may be telling you something about the severity of what the person brought in.
Third, train the reflex, not just the recommendation. Our trainees need time on what catches them off in a session — where their anxieties are, what makes them reach for the handout. Is this the patient's anxiety, or mine? is a question worth learning to ask in real time.
What I am not saying
I am not saying mindfulness is dangerous, or that clinicians should stop recommending it. Dan practises it. He described it as a way to start the day with a rhythm and pace, and some sense of choice — to have a day rather than have the day have you. That is a good thing, and plenty of clients will benefit from something like it.
I am also not saying critical thinking should give way to meditation, or the reverse. You need both. You need to be able to slow down and self-reflect, and you need to be able to turn the switch up and work harder. Most of us let the context — the job, the quota, the weekend — decide which one is running.
What I am saying is narrower. Mindfulness is an intervention. It should be assessed for, prepared for, and watched like one. There is no panacea. There is no free lunch. It depends on the individual, and we have to make good decisions about it.
That is not a controversial standard. We simply have not been holding this particular practice to it.
Michael Baltimore Ph.D. is Publisher and Editor-in-Chief of MIC LEDGER and co-host of Got Therapy? with Dan Rose Psy.D. This editorial draws on Episode 87, the second part of the show's conversation on meditation and mindfulness.