Do We Underestimate the Potential Harms of Mindfulness Interventions?

Researchers argue that flawed methodologies underestimate the potential harms of mindfulness-based stress reduction interventions.

Emaline Friedman, PhD
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New research scrutinizes a recent study on the harms associated with mindfulness-based stress reduction (MBSR) programs. The researchers argue that studies on mindfulness present insufficient evidence to support the conclusion that ‘MBSR is no more harmful than no treatment.’

“Overall, the claims made by the [original study] authors provide a much sought-after reassurance that is as yet unfounded in our view. A series of recent studies have suggested that adverse events can and do happen in meditation-based interventions, including those with a focus on mindfulness,” the authors write. 
Public Domain

Mindfulness-based practices have only grown in popularity since their introduction into therapeutic and wellness programs around the turn of the 21st century. A body of research attesting to their effectiveness has grown since then, too, with psychologists exploring their mechanisms of positive change and their promise in preventing relapses of depression symptoms.

Despite the enthusiasm, meta-analyses have found that mindfulness-based interventions are seldom studied with randomized control or comparison conditions (in research with adolescents, for example).

To address this gap, researchers at the University of Melbourne and the University of Cambridge critique a recent study of harm following the completion of mindfulness-based stress reduction (MSBR) programs, pointing out methodological limitations that undermine confidence in the authors’ conclusions.

The first methodological limitation found is data attrition, at levels as high as ~23% in their largest sample. This large percentage of missing data is concerning because it could mask harm. Although gender and participation year were predictive of missingness and the original research team adjusted accordingly, they still considered the data to be “missing at random,” which affects the statistical analysis. Such variables are not sufficient to address the potential causes for missingness when investigating harm. In their model, harm outcomes are expected to be low-prevalence events, making data imputation all the more problematic.

The authors also take issue with the focus of analysis in the study: deterioration of illness and the emergence of new symptoms as endorsed on a medical symptom checklist. Generally, simple checklists are poor tools for detecting adverse events. Moreover, MBSR guidelines tend to encourage continued practice outside of formal, studied course activities. This makes the post-intervention period difficult to monitor.

People cannot report harm if they are not asked about them, and it is possible that more serious harms only emerge when the practice is implemented without the support of MBSR instructors.

Sample bias was also detected. The overall level of impairment, as measured by the Global Severity Index (GSI) is significantly higher in the community sample than either of the two groups in the randomized controlled trials (RCTs; v. MBSR, Cohen’s d = −0.99, t(2309) = −10.03, p < 0.001; v. WLC, Cohen’s d = −1.17, t(2271) = −9.86, p < 0.001), and is above the T value (i.e. 60) commonly used to detect psychological distress (M = 61.78, s.d. = 42.67).

The community sample represents a large selection of individuals who sought out and paid to receive MBSR to help address their psychological distress, causing self-selection bias that makes favorable ratings at discharge more likely. As this represents a non-blinded intervention, it likely suffers from inflated effect size estimates and attrition rates. Those who were dissatisfied with the program are more likely to have discontinued the treatment early on.

There was a general lack of information about the collation of data across three trials whose procedures may have differed, all of which were analyzed together in the study. Only one of these was registered as a controlled trial under P01AT004952. It measured but did not report on GSI. They also did not publish a prospective protocol used for the analysis, increasing the chances of bias.

MBSR programs offer an effective and much-needed alternative to more invasive and stigmatizing mental health interventions. However, this review suggests that methodological and reporting quality needs to improve before strong claims about their potential adverse effects are made.

 

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Van Dam, N., & Galante, J. (2020). Underestimating harm in mindfulness-based stress reduction. Psychological Medicine, 1-3. doi:10.1017/S003329172000447X (Link)

37 COMMENTS

  1. Good point Oldhead, it wouldn’t surprise me if it was!

    I had a friend who tried mindfulness breathing meditation and he told me he had a panic attack half way through the session.

    I find mindfulness meditation very good – but it’s my kind of thing.

  2. I am concerned that this new “study” might basically be just a hit piece.

    However, I don’t think meditation techniques should be mixed up with the field of “mental health” as it currently exists.

    This is possibly, though, a case of meditation teachers seeking a share of the “mental health market” and traditional therapists complaining about it. I don’t think meditation can be practiced non-voluntarily, as mentioned above. So that gives us a different “intervention model” (or whatever they want to call it).

    From a science point of view then, you might be comparing apples to oranges rather than different kinds of apples.

  3. This article (Van Dam & Galante, 2020) is about mere ‘speculation’ (on how it “might be harmful”) – it is NOT about real results that have been obtained/observed. I would say that living without mindfulness results in much more harm (from rumination, feeling overwhelmed, focusing on regrets, being anxious about the future, etc.).

    For example, studies have found that rumination is a transdiagnostic risk factor of mental illness, and that mindfulness practices are very effective to combat rumination.

    If someone has trouble with engaging in physical activities, then it is gradually introduced. Similarly for some individuals, it might be best to practice mindful yoga, tai chi, or even engage in regular physical activities before starting formal sitting mindfulness meditation practices.

  4. Eckhart Tolle recommends focusing on the feelings when a person is ‘in a state’.

    I did this a few days ago when I woke up full of ‘doom and gloom’. With difficulty – it worked for me.

    If I tried to think my way out, I’d have gotten ‘locked in’.

  5. Please forgive me when did living without mindfulness lead to harm; except maybe not being mindful to turn off the oven when you leave the house or not locking the door when you leave. I also did not know that ruminating caused harm as my grandparents and great-grandparents always ruminated especially in church. Actually, could you not consider that mindfulness might very well lead to obsessive tendencies. The drugs made me especially mindful of making sure doors were locked; such that I even concocted rituals to make sure I did that. In my opinion, we rely too much on buzzwords like mindfulness. We really need to focus on the individual ways each person thinks and relates and responds to the world. It’s a whole lot better to say that’s just the way whomever is and stop trying to force them either implicitly or explicitly into mindfulness; including physical activity, etc. Thank you.

    • Good observations, very mindful. I think some”obsessive” rituals can also serve a non-verbal centering function, and contain a unique meaning specific to the individual (though anything can be taken to extremes). And, depending on the part of town you live in, there can be much worse things than constantly checking your locks. Or your pepper spray. I’m always unconsciously patting my pocket to make sure I feel my keys there.

      At its core “mindfulness” seems to be little more than a more expensive way of “paying attention.”

    • Mindfulness is so much more than remembering to lock doors!!! Also, since you ask why “living without mindfulness can lead to harm” – please see the references below. [By the way, for some reason I do not receive notifications from this site (i.e., replies to my comments) – so, if you reply, I may not see your reply (unless I happen to occasionally check the article for any new comments)].
      References:
      Kaplan, D. M., et al. (2018). Maladaptive repetitive thought as a transdiagnostic phenomenon and treatment target: An integrative review. Journal of clinical psychology.

      Querstret, D., & Cropley, M. (2013). Assessing treatments used to reduce rumination and/or worry: A systematic review. Clinical Psychology Review, 33, 996-1009.

      Whitfield-Gabrieli, S., Ford, J.M., 2012. Default mode network activity and connectivity in psychopathology. Annu. Rev. Clin. Psychol. 8, 49–76.

      Tomlinson, E. R., et al. (2017). Dispositional mindfulness and psychological health: a systematic review. Mindfulness, 1-21.

      • The “mental health” version of “mindfulness” was also appropriated from Buddhism and Hinduism, and as such, misses a lot of the substance of what “mindfulness meditation” is really about and what it is intended to accomplish. It’s not about breathing deeply to make us feel less anxious, even if it happens to have that effect. But anything spiritual seems to be anathema to the mental health industry, and in particular to most of the psychiatrists I’ve encountered.

      • With all due respect, I notice that you have felt the need to list a lot of references in various psychological/psychiatric journals to back up your opinion. I can say that many to most on this site who read the articles presented here and thus comment on them are highly skeptical of any referencing from academic journals. Many on this site are actually hurting from the damage done to them by psychiatry and psychology. Some of their hurt has originated from academic journals such as these. Perhaps mindfulness is more than locking doors and perhaps, it isn’t. There have been many excellent comments on mindfulness. The main point that some and I included are presenting is that mindfulness is just being presented as another therapy, another drug and thus if not, a tool for damage, it might very well even cause damage. And, I am really not sure if we know if mindfulness may or may not cause any sort of brain damage as already known to be caused by drugs. Thank you.

          • oldhead, Thank you. I never think of myself as “consciousness-raising.” I just think of myself who gets a lots of stuff in my brain, some of it I confess is clutter, that must come out some way. And, this is one good way, I guess to do it. Thank you.

  6. Hi Everyone,

    I’m a fairly new reader on Mad in America and this is my first time commenting here. This is a hard subject for me to pull all of my thoughts together on since it directly ties in with some deep seated trauma, so bear with me. The practices that fall under the umbrella of “mindfulness” (and “meditation”) are extremely nuanced and can have vastly different effects on the nervous system. Both the mainstream mental health system and alternative mental health entities are almost always naive and occasionaly negligent in how they promote mindfulness and meditation as a support for almost all forms of psychic distress and physical pain. With that in mind, some of the practices under this umbrella can be extremely helpful and empowering for people. My own story is that I came to mindfulness and meditation practice seeking an alternative to medication for anxiety. When I first started in 2010, it was very helpful. At that point I wasn’t using any specific practice, just a mix of guided meditations (some sitting, some walking/moving, breath tracking, open awareness noting, etc) 3 times a week led by one of my professors in grad school for social work who was also a mental health clinician and mindfulness teacher. I drifted away from doing it regularly after I finished the school year, but wanted to get back into it. Fast forward to 2014, I was seeing a trusted integrative medicine MD for some ideas on how to manage anxiety without SSRIs and he recommended a more intense form of meditation via a 10 day residential Vipassana meditation course (Vipassana is usually understood to be very specific and intense category of mindfulness meditation practices). He told me that it was friendly beginners, that there would be plenty of support on site for folks like me who struggled with mild to moderate anxiety, it was secular, and that after finishing it, I’d have a really helpful tool that I could use for the rest of my life. Unfortunately, this was quite far from the truth of what I experienced. During the meditation course, I experienced a swell of fear and insomnia, which was described by the staff on site as a normal upwelling of trauma and a sign of progress. When I returned home, I continued to decompensate to the point where I was in a near constant state of non-referential terror, and was not able to sleep after multiple medication trials over the course of a month. As a result of the stress to my body, I lost 20% of my bodyweight and got a heart arrhythmia among other things. I ended up needing to go inpatient (technically voluntary), which was only helpful in finding the right nasty antipsychotic to get me sleeping again, but other than that mostly harmful, I’m sure does not come as a surprise to most people here on the MIA website. Fast forward to now, I have a diagnosis of PTSD. I am in a much better place than I was in before, but my nervous system has been profoundly altered. Ironically, I still use self-regulation strategies which are technically also mindfulness practices to get through each day, albeit they are radically different from what I was told to use in 2014.

    I’m quite surprised that there aren’t more articles on the adverse effects of mindfulness and meditation here on MIA. I both volunteer for and receive services from a non-profit organization called Cheetah House, which is peer led and provides resources for people like me. I encourage anyone who is interested in this subject to visit the Cheetah House website.

    https://www.cheetahhouse.org

    If you are a nerd like me, or a clinician/researcher, Cheetah House has a comprehensive bibliography of academic literature on the subject of adverse experiences with meditation:
    https://www.cheetahhouse.org/bibliography

    • Thank you so much for your story!

      Much like any “fad,” everyone who has benefited from mindfulness techniques thinks everyone should do it. They aren’t really aware of the fact that people are different and some might not be ready for it, or it might just not be the thing for them. Such practices will always be voluntary, so they will never get tested on a wide variety of different people, like drugs are supposed to be.

      Those techniques are not the only non-drug route to emotional healing. All such routes should be discussed and evaluated, not just the ones the mainstream thinks are “cool.”

  7. I agree with you Steve McCrea! Using “mindfulness” as a mere therapy misses a LOT of the substance of what “mindfulness meditation” is really about, and what it is intended to accomplish.

    We shouldn’t forget that the so-called “harm from mindfulness” comes about because one uses mindfulness as if it is some “thing” (a pill!), without any deep understanding of the broader context of how and why it is practiced. We shouldn’t forget that we only have one thought moment at a time that is experienced in the *present moment* – the past and the future happen as thoughts in the present moment. Understanding such things (i.e., how our minds work) and our thought processes lead to wisdom, and people who use mindfulness as a mere technique misses all these rich understandings.

    To ‘RosyLeaDNVT,’ I would say that rather than using mindfulness as a way of trying to archive something, get somewhere, or cure something, mindfulness needs to be used for letting go: i.e., letting go worries of the past and anxieties of the future and living in the present. Also, labels like PTSD are social constructions (diagnosed using a checklist). Using mindfulness, one can even let go of thoughts like “I have been harmed” or “I have I have a diagnosis of PTSD,” (which are thoughts that come up in the present moment if the conditions are there for them to come up). The potential of mindfulness is tremendous and if one probes deeper, Buddhist teachings even describe how to overcome ‘hindrances’ to meditation.

    To ‘rebel’: I would say that MIA is not sceptical at all of all academic articles – if that was the case, this site would not have survived all these years. What I like about MIA is that it engages in healthy debates on the underlying *assumptions* mainly regarding discipline of psychiatry which has been built on very shaky foundations.

    • With all due respect, “Nancy99” you have discounted both “RosyLeaDNVT” heartfelt experience with the damaging effects of mindfulness and what I said about your use of articles in academic journals to make your point and back up your opinion. I am thankful to “RosyLeaDNVT” because it does answer my question that for some, damage even some brain damage might result from “mindfulness.” However, I will let “RosyLeaDNVT” post her reply to what you stated about her post; if she so chooses to reply. As for what I said about the articles in academic journals, I was not referencing MIA, the Website, I was referencing those who read and comment on the articles posted on the website. My point is that due to the harm many who go to this website have experienced from psychiatry, psychology, etc. the referencing of these articles may not only bring skepticism, but a concern that again they may been discounted in the pain and damage they have endured from psychiatry, etc. which also includes the writers of many articles in academic journals. In essence, yes, I do have a deep concern over the use of mindfulness in therapies and in daily life. There are way too many questions than answers and until we can safely answer those questions, we must consider the vulnerable and perhaps slow down and maybe even reconsider it as a tool for any type of behavior or thought control. Thank you.

  8. Hi Rebel: What you are reporting are your beliefs and personal opinions. I prefer to look at carefully conducted studies and academic articles published in peer-reviewed journals to resolve these types of issues.

    Numerous studies have carefully investigated the effects of mindfulness on the brain, and the results of these studies overwhelmingly show favourable changes (healthy changes) in the brain that happen as a result of mindfulness. There are many studies. I have listed a few below. Overall, the studies clearly indicate favourable changes, and also that reductions in patient’s psychological symptoms correlate with observed biological changes in the brain (indicating the causal direction).

    I know that you do not like academic articles but I prefer those to views and opinions of people. Again, the articles are not my opinions – this is what the research clearly indicates. As I see it, those who read and comment on the articles posted on this website need to look at the evidence without basing their conclusions on the opinions of commentators and their likes and dislikes. I think that is the intention of MIA as well.

    References:

    Hölzel, et al., (2010). Stress reduction correlates with structural changes in the amygdala. Social cognitive and affective neuroscience, 5(1), 11-17.

    Joss, D., et al. (2020). Effects of a mindfulness based behavioral intervention for young adults with childhood maltreatment history on hippocampal morphometry: a pilot MRI study with voxel-based morphometry. Psychiatry Research: Neuroimaging, 111087.

    Santarnecchi, E., et al. (2014). Interaction between neuroanatomical and psychological changes after mindfulness-based training. PloS one, 9(10), e108359.

    Hoge, E. et al. (2017). The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Research.

    • I have seen brain studies on Buddhist monks who have meditated for decades. It indicates that the areas of the brain associated with calmness and focus are larger. Now that doesn’t mean that people being forced to “meditate” are going to see any benefits, and I’m guessing they probably are likely to be harmful in some cases. I do have serious doubts about actual brain damage occurring, but psychological damage seems likely whenever force or coercion is involved.

      • Thanks. I don’t think the article we are discussing (Van Dam & Galante, 2020) is about forced meditation. I also don’t think it is possible to force anyone to meditate, although people can be encouraged to do so by explaining what exactly is done in meditation.

        By the way, the references I posted clearly show reductions in stress and anxiety that happen along with changes in the brain. There also seem to be a link between meditation and reduced brain aging. See:

        Kurth, F., et al. (2017). Promising links between meditation and reduced (brain) aging: an attempt to bridge some gaps. Frontiers in psychology, 8, 860.

        • I am aware that “mindfulness” is part of DBT, and a significant number of commenters on MIA have stated that they were coerced into doing “mindfulness” during DBT, or else suffering some kind of consequence from the group leader. While this is completely contradictory to actual meditation practice, it is being done, and frankly gives a very bad name to what I’ve found to be an extremely powerful and helpful practice.

        • https://www.madinamerica.com/2020/08/conclusions-brain-scan-studies-problematic-not-unsubstantiated/

          We are reducing the mind and mental experience to the brain when we conclude that brain changes are evidence of anything. We are also making the mistake of believing that meditation studied until controlled circumstances has any application to people at large.

          There’s been no demonstration from any of these studies that feeling more calm correlates with improved real-word outcomes in functioning in terms of health, housing, employment, socioeconomic status, educational attainment, disability status, stabler rewarding relationships, etc. We also can’t demonstrate that what is seen on an MRI from someone who has been taught to quiet their mind in a controlled environment has any real world effect when they are under duress in a less controlled environment.

          These studies have little practical applicable value besides the benefit to the careers of the researchers who have published. When I see studies that demonstrate mindfulness meditation having real-world applicable effects with confounding variables well controlled and demonstrating a causal relationship between meditating and positive outcomes, I’ll consider it of more value. Until then, I think it does a massive disservice to the people whose stories you’ve attempted to discount with a few links and claims of evidence.

          If a person can’t “do no harm”, they can at least keep their mouths shut and not respond to stories of harm with “but look at these brains scans and this real evidence”. The amount of “anecdotal” evidence in blogs and comments accumulated on this website could fill volumes. A few brain scan studies cannot refute the harms that have been shared over and over and over on these pages. I find the dismissal of personal stories callous but sadly typical of mental health professionals.

    • In my book, the problem with any study that looks at the effects of an “intervention” on the brain is that it is looking in the wrong place! If you want a good indicator of how a person is feeling, just LOOK at him and ask him a few questions! Who cares exactly what the brain is doing if the person is feeling better, getting more competent, or is obviously in better control of himself?

  9. No 1: All I am questioning is if “brain damage” could be caused by “mindfulness” forced or not? Could similar negative incidents that sometimes happen to the brain in therapy also happen in “mindfulness”? If anytime, any feels forced or compelled to engage in something like mindfulness or therapy, then it seems likely some damage might occur? The concept of brain damage may be a far reach, but, perhaps it should be investigated and not ruled out in various cases.
    No 2: Nancy99, I am sorry that you seem unable to accept my way of thinking as a viable alternative. This does not mean you need agree with me, but only to accept it as a possibility. I am even more sorry that seem to; as you say “prefer academic articles” to the “views and opinions of people.” Academic articles like all articles do also bear the views and opinions of the author or authors. It would be impossible to do any research without the bias of the researcher interceding. If I conducted any research, my first hypothesis would come from my subjective bias. I only first like to bring up questions, such what can of damage can be done by mindfulness, forced or not. Second, “views and opinions or people” are valid. The “views and opinions” of each commentator to this site is very valid. Many of us have been damaged and hurt by psychiatry and psychology in not only “medical” circles, but, also “academic circles” and even in “mainstream circles” such as the various forms of media and “pop psychology.” Each person here has an important view and opinion that needs to seriously be heard and appreciated. As for me personally, I am a very worthwhile human being with very valid views and opinions on a wide variety of subjects. And I am not the only one. Please do not discount me, for my brain may have been damaged from the drugs and therapy, etc. but it is remains wonderfully made and is still beautiful and fantastic. This also pertains to other contributors to this site, whether or not their brains have been damaged by drugs and therapy, etc. Thank you.

  10. I am definitely not talking about forced mindfulness! I have carefully studied Buddhist philosophical teachings. These teachings present comprehensive accounts of the mind (such as how the mind works etc., which are NOT beliefs but are verifiable first-person accounts). I have found these to be extremely useful to say the least. Mindfulness enables one to see for oneself how thoughts, emotions and moods, etc., come and go. Practicing mindfulness also enables one to not get carried away by thoughts (i.e., gives us control over how we can manage our own difficult emotions). Unfortunately this detailed information is not readily available to people who teach mindfulness. Further, these original teachings (that have been transmitted over several millennia) are difficult to understand – as a result, some people in the West gravely misrepresent them without much regard for the deep and profound original teachings.

    To ‘l_e_cox’ – I would say: I agree that how a person feels and acts is more important. However, we need to remember that our brains are constantly changing as a result of our experiences (this is called ‘neuroplasticity’) – for example, psychological stress results in several changes in the brain such as the shrinkage of the amygdala and studies consistently show that stress reduction (including mindfulness meditation) reverses these changes and also increases gray matter levels, etc. Therefore looking at the brain can give a general indication of how a person is, and what changes are happening, etc.

    To Rebel: You can have any opinion you like, but as I see it, if one is open minded, then one needs to be able to change one’s opinion based on new evidence. For example, would you prefer to believe that the earth is flat just because it is your opinion even when there is so much evidence that contradict that view? Please also understand that this article to which we are commenting here is based on a scientific article (which I assume you are agreeing with) – so, you cannot simply pick and choose what you like when it comes to science. Science is very aware of biases and it takes into account those variables. With psychiatry (giving labels and medications for “mental illnesses”) however there is a lot of faulty underlying assumptions (and vested interests at play) and that is a totally different story. In summary, the “views and opinions” of each commentator is valid until they are proven otherwise through several carefully conducted studies. I wish you the very best.

    • I’m sorry Nancy, but to me brain-based psychology is a farce!
      When you have a real spiritual being sitting right there staring you in the face, you don’t need neuroplasticity! The whole brain thing is a huge red herring that has derailed psychology for well over 100 years! I wonder why!

    • “Science is very aware of biases and it takes into account those variables.”

      Science is not an entity. You are preaching Scientism. Researcher bias and the corporate influence and profit motive has had a massive influence on current accepted scientific wisdom. Here are researchers at the Johns Hopkins Lyme Disease Research Center just *yesterday* pushing back strongly against the IDSA Guidelines on Lyme Disease treatment, saying they harm Lyme Disease patients. Lyme patients have been pushing back against these flawed guidelines for decades. Just as psychiatric survivors have been pushing back against the scientism used by psychiatry and other helping professions regarding “mental illness” and its treatments.

      https://www.hopkinslyme.org/news-impact/lyme-disease-research-center-newsletters/

      Using “science” as a cudgel to prove your point is crude and ineffective on those who actually appreciate legitimate science driven in the name of curiosity rather than the junk science produced at great cost under our current publish or perish system. You can sound as measured and learned as you want and still be wrong.

      It’s also pretty rich to suggest that Buddhist concepts are too complicated to understand so westerners misinterpret them. I wonder if Buddhists misinterpret the concept of a “loving” father drowning all of his children and starting Humanity 2.0 as the Christian SkyDaddy is supposed to have done. As has been pointed out here before, the western practice of picking and choosing bits and pieces of other cultures to try on and thoroughly bastardize is appropriation.

    • Nancy99: This is Rebel again! First, “open-minded” does not necessarily mean “one changes one’s opinion based on evidence.” It usually just means one is tolerant of other’s opinions and welcomes their opinions into the conversation whether in agreement or not. Second, using the “earth is flat” theory is well, useless, since only a few small group of people actually argue if the earth is flat anymore. It is so “Middle Ages!”
      Third, and I believe the most true; we do “pick and choose” what we think, believe, etc. regardless on the “science.” We do this based on life experiences, culture, education, etc. etc. etc. Fourth, science is not always well aware of their biases. How can it be? Science, like all fields, is made up of human beings. Human beings are naturally biased. It is both our curse and our blessing. All of this is meant to be a paradox. Our natural fallibility as humans shows up in science as in anywhere. By saying that “science is well aware of its biases and takes into account those variables” places science on a pedestal that makes it nothing less than God, All-Knowing, All-Seeing, All-Present. There is nothing we humans can say or do that can make us into Gods. And we do try it, we only become like Daedilus (forgive my spelling) who flew to the sun in his chariot and fell immediately and tragically back to the earth burnt and blinded by the Sun. This Greek Myth is a warning, but it is nor the only one in myth and in Spiritual/Religious Writings. I thank God for my unique biases because it has made me what I am today. Thank you.

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