Access to psychotherapy is still limited by various barriers, and little is known about the facilitating circumstances. This study aims to assess self-reported barriers and facilitators to psychotherapy utilisation in private practice and how these access factors relate to psychotherapy goals as formulated by patients. The dataset consists of 21 face-to-face semi-structured interviews with patients treated by psychotherapists in private practice in Austria. Data were analysed using qualitative content analysis, including a frequency count of the number of codings to analyse relations between categories. A critical external barrier theme was unaffordable psychotherapy and confusion about how the Austrian funding system works. A negative experience with psychotherapy prior to the current one, such as not being understood and answered well enough by one’s therapist, was a frequently reported internal barrier. Individuals who faced more internal barriers and more external facilitators in seeking therapy, such as moral support from significant others and professionals, formulated less elaborate treatment goals. Although the study was carried out amid the COVID-19 pandemic, the pandemic played a minor role in patients’ self-reported barrier and facilitator themes. While a broad infrastructure for psychotherapeutic treatment exists in industrialised countries, access to psychotherapy is still limited by various barriers that preclude providing adequate services . With thKnowing not only about perceived barriers but also about factors promoting positive attitudes and willingness to participate in psychotherapy can be influential in understanding mental health service use . In geneSince psychotherapy goals are an essential factor related to clinical outcomes , and sinBarriers comprise internal  and external  obstacles to psychotherapy utilisation. Facilitators may be internal  and external factors  that aid in psychotherapy use. Perceived barriers and facilitators are usually assessed qualitatively by face-to-face interviews with open-ended questions ,15,16. IQuantitative research suggests that the most critical external barriers to mental health service utilisation are structural and, as such, rooted in socio-demographic characteristics. They include the male gender, low levels of education and living in rural areas. Other critical but internal inhibiting factors are a higher level of psychopathology or a specific type of traumatic event . QualitaIndividuals such as family members, friends, psychologists or doctors often support patients with mental health problems in their quest for therapy  because The primary aim of the current study is to advance insight into the process of access to psychotherapy by providing up-to-date qualitative knowledge regarding the perceived barriers and their facilitating counterparts in a group of adult patients since the autumn of 2020 amid the COVID-19 pandemic. The secondary aim is to find out how the reported “external barriers”, “internal barriers”, “external facilitators”, “internal facilitators” and “psychotherapeutic goals” are related. This leads to two research questions. Firstly, what barriers and facilitators hinder or facilitate psychotherapy utilisation in private practice? Secondly, are patients who formulate a high number of psychotherapeutic goals equally affected by barriers and facilitators as patients who formulate a low number of psychotherapeutic goals? Our findings should help researchers, gatekeepers and mental health professionals create strategies to enhance mental health care in times of increased demand. They should also shed light on how psychotherapists can harness what they know about their patients’ pathways to psychotherapy for setting therapy goals with their patients.To achieve the goals of this paper, a qualitative descriptive design ,29,30 waIn a further step, we split the group of participants (N = 21). We undertook a comparison between a group that reported, relatively speaking, more psychotherapeutic goals compared to a group that reported, relatively speaking, fewer goals. We investigated which group mentioned a higher number of external barriers, internal barriers, external facilitators and internal facilitators to psychotherapy utilisation.This study is part of a larger ongoing project on the Process and Outcome of Psychotherapy in Private Practice (POPP), which relies on an integration of quantitative and qualitative research methods. Individual psychotherapies are being researched under practical conditions in outpatient psychotherapeutic practices. In addition to the effectiveness (outcome), the process of psychotherapy is also examined, focusing on the therapeutic relationship as a process variable .The Austrian field of psychotherapy care offers patients many psychotherapeutic schools based on different theories about the development and course of disorders and corresponding emphasis in the treatment. Austria has 23 accredited psychotherapeutic schools  broadly Psychotherapeutic services in Austria are mainly concentrated in cities and their surrounding areas. The proportion of psychotherapists working exclusively in private practice tends to increase and is currently around 63%. It can be assumed that there is an undersupply in some rural regions, as barriers, such as information deficits, social control and missing or distant offers, are more pronounced in remote rural areas . While sThis study is based on data from patients treated by psychotherapists in private practice. The participating patients were invited by their psychotherapists to participate within a larger framework of the aforementioned study on the Process and Outcome of Psychotherapy in Private Practice (POPP) . All psyThroughout 2021, a qualitative sub-study was conducted. All participating patients from the POPP study were asked to register actively for a qualitative interview via a homepage, and 24 patients took up the opportunity by June 2021. Ultimately, 3 patients withdrew their commitment or were unavailable, so we collected 21 interviews. Patients contacted us for participation in the qualitative sub-study from October 2020 up to June 2021. This study was conducted in accordance with the Declaration of Helsinki. Research ethical approval for the study was obtained from the Ethics Committee of Danube University Krems, Austria (EK GZ 28/2018-2021).We chose semi-structured face-to-face interviews to yield the richness of data required in qualitative descriptive designs. The problem-centred interview enabled the interviewers to explore issues together with the participants by encouraging depth and rigour ,32, thusThe detailed and accurate interview guide used by the interviewers was designed for the POPP study to assess why patients decided to undergo psychotherapy; what goals and expectations they had in the beginning, how the psychotherapy developed; how they experienced their therapist as a person of the same or different gender; what aspects they found helpful and challenging in the psychotherapy process; if and how they perceived psychotherapy via phone or video conference during the lockdown, and what changed for them.The participants chose the locations of the interviews, typically in their own homes, at a quiet café or at a psychotherapeutic practice. On average, the interviews lasted 67 min (ranging from 39 to 110 min). The interviews were recorded and then transcribed verbatim by the interviewers. The transcripts were given a study number and had all personally identifiable data removed, and transcripts were provided with a chiffre instead of the names of the participants.The participants (N = 21) were patients who had sought help from a therapist in private practice between autumn 2020 and spring/summer 2021. Sixteen of their therapists were female. The number of sessions participants had attended with their current therapist when they were interviewed varied from n = 5 to n = 37, with an average of n = 20 sessions see .A qualitative content analysis was used to analyse the obtained data  focusingAfter carefully reading the first interviews, the first author (Y.S.) coded all 21 interviews manually using ATLAS.ti Mac (Version 22.1.0) . In lineTo answer our second research question, we also included an a priori set first-order category on goals .Each of the five first-order categories was then defined as a code group containing all the codings referring to second- and third-order categories. Common barriers and facilitators, such as “geographical distance” or “support from professionals”, were coded deductively based on a list of frequently found barriers and facilitators . This liBecause this is a secondary analysis  of data To answer the second research question, we assumed that not all participants (N = 21) would equally elaborate on “external barriers”, “internal barriers”, “external facilitators”, “internal facilitators” and “therapeutic goals”. We therefore considered the frequency count of the number of codings, that is, the total of lower order categories belonging to each first-order category per case, as an indicator of significance. We proceeded in two steps. First, we determined the distribution of codings for the first-order categories per case. We used relative frequencies for comparing code distributions across the code groups (each first-order category is defined as a code group containing codings referring to second- and third-order categories), as percentages are easier to comprehend see . Second,The categories are described as follows: Each first-order category forms a sub-section marked by a heading . Within each of these sub-sections, the second-order categories are given, starting with the largest one. Second-order category numbers  are marked in bold. If a second-order category includes further sub-categories, these are reported, again, starting with the largest third-order category (n = X). Note that not all second-order categories are split into third-order categories, which is why not all bold second-order categories (n = X) are followed by third-order categories (n = X). Instead, a bold second-order category (n = X) might also be followed by another bold second-order category (n = X).Selected statements from our participants are offered to illustrate how participants conceive of barriers, facilitators and goals.Participants named a variety of external barriers that prevented them from utilising psychotherapy. Bureaucratic obstacles to covering psychotherapy costs were cited most frequently (n = 11). Participants’ concerns about funding referred most often (n = 8) to financial pressure, which sometimes led to a limited frequency of sessions. One woman who was financially severely affected by the economic consequences of the COVID-19 pandemic reported her predicament between her need for psychotherapy and her need to economise as follows:(…) I thought, “I cannot afford this right now”. We [my husband and I] are self-employed, work in the arts and culture sector, and are massively affected by Covid. Moreover//um//I thought//um//the insurance pays a little extra, but it is marginal. So, therapy is something you must be able to afford (-)//be able//. So that was an issue. And I thought to myself, no, I cannot afford it now. And now I think, “yes, but I have to afford it” .Further concerns regarding therapy funding ranged from confusion about how the Austrian funding system worked (n = 3) to failed attempts to receive total funding (n = 2) due to long waiting lists, which discouraged participants from seeking total funding via governmental insurance (n = 1). The participants described the funding system as socially unjust, exhausting or pressuring.Another frequently mentioned external barrier was that participants (n = 9) had intermittently found alternative ways to deal with their mental health problems rather than utilising psychotherapy. For example, three participants (n = 3) had undergone free counselling as a previous or interim solution before they took up psychotherapy (again), with one participant stating that men’s counselling had helped him overcome a tough time:How did I get to my new therapy now? Well, it was pretty tricky. In the end, I did not go for treatment for half a year because, at that time, I was feeling terrible, really//shit//[not good]. At this time, I went to men’s counselling for a while .Meditation and yoga were presented as other alternative practices that helped, as one participant had put it, “at a non-cognitive level” (n = 3). Other alternative healing contexts presented were visiting a self-help group (n = 1), getting advice from a spiritual healer (n = 1), having had a trustful relationship with one’s teacher (n = 1), having learned martial arts to defend oneself and getting to know one’s body (n = 1). Additionally, dance sessions were described as a supportive alternative context (n = 1):I said: hey, I need something that gives me pleasure. Something that invigorates. And I sort of started dancing hip-hop. (--) And after one and a half years of hip-hop, it became breaking. Well, that is usually called breakdancing. (--) And that is when I found myself again .Another reported external barrier was that close family members disapproved the participants seeing a psychotherapist (n = 4). For example, one female patient revealed that since she keeps visiting her psychotherapist, her husband…… feels that now a therapist is allying//herself with his wife against him .A further reported external barrier to participating in psychotherapeutic treatment was the variety of psychotherapeutic schools to choose from and the confusion that comes with trying to find the right one (n = 3). One patient reported that he initially felt so overwhelmed by the many options available in Austria that he was unable to decide on one therapist or school over an extended period:… I had an awful lot of first interviews, far too many, and I just did not manage to (-). I was completely overwhelmed with what was offered in Vienna because there were far too many therapists. I was utterly overwhelmed by the range of schools on offer because I did not know which type of therapy I should choose .Another patient further illustrated this point:(…) I find that//I find it somehow tricky. The search, and also finding someone. What criteria should be followed ?The other reported obstacles were that patients initially desired to work with a particular psychotherapist but found that they were not eligible due to a close personal or professional relationship with the patient (n = 2). A similar barrier reported was that patients desired to work with an expert from a specific school but found that this expert had no free capacity at the time they would have wanted to start their treatment (n = 2).A different type of barrier to treatment utilisation was that patients lived too far away geographically from their psychotherapist to attend psychotherapy regularly (n = 2), that they had experienced time constraints, which prevented them from regularly attending because they were single parents (n = 1), and that they found the therapy room to be unappealing. Hence, they no longer wanted to go there (n = 1).The most frequently reported internal barrier was a negative experience with psychotherapy prior to the current one (n = 10). A negative former therapy experience was not having been understood and answered well enough (n = 7). The participants attempted to explain their former therapist’s unresponsive behaviour. For example, one patient tried to explain that a former therapist acted the way he did due to being overworked because of the pandemic:I also saw this therapist who just nodded the whole time, like “mhm,//mhm//mhm” I mean, he is not bad or anything. Still, the others also said that they did not like it, that he nods all the time, and so on.//Mhm//But I can understand it; it was just, he had a lot of work probably, a lot with Corona, too .In another case, a former therapist’s male gender was presumed to be why a female patient felt she could not talk openly. Another assumed cause of a failed therapeutic alliance was a misfit related to the therapist’s theoretical orientation (n = 3). According to one patient, this orientation was to blame for his emotional needs remaining unmet:The problem was that he (-) gave me the feeling that I was treating him instead of him treating me. So, he rambled a lot and had many theories; I could not do anything with that. I think that was because of his orientation; it did not fit .Further reported unsatisfactory former encounters with psychotherapists, some of whom were visited only once, included the experience of discomfort or relational distance (n = 3), feeling pre-judged (n = 2), experiencing that the session had ended before or after the regular end time (n = 1) and having unresolved controversy about a topic that felt important to the patient (n = 1). A different reported internal barrier was a negative experience with psychologists and doctors in general (n = 6). Participants felt that they were ineffectively helped (n = 3), given a diagnosis or judgement based on only superficial examination (n = 2), felt misunderstood (n = 1), felt not appreciated (n = 1) or were repeatedly forgotten to be called back (n = 1). Shame or fear of stigmatisation (n = 5) was a further reported internal barrier that caused participants to overthink before seeking psychotherapy:For us here, it [psychotherapy] is a somewhat notorious story. And I think almost no one in my circle has ever done one. Or just not told it, you know. It’s more of a secret discovery if someone finds out (laughs) .Some patients also stated that they hesitated because of a symptom-related failure to perceive a need to seek help, which they could not reflect upon at the given time (n = 4). Two patients reported failing to seek help in the past because of negative beliefs. They were convinced that psychotherapy could not help them (n = 2). Further internal barriers mentioned were that patients found it challenging to speak about emotional topics (n = 1), or that they felt concerned about the psychotherapist’s confidentiality (n = 1). Internal barriers that emerged during the participant’s current psychotherapy were unfulfilled expectations, e.g., that they missed concrete instructions or feedback from their therapists (n = 3). Another patient was afraid to communicate their genuine concerns or even prepared to quit therapy because of personal traits (n = 1):I am one of those people for whom everything has to fit. Otherwise, if there is disharmony, if something does not run smoothly, I end things or just tell them what they want to hear, and that is not the purpose of therapy.//mhm//.Mental health seeking also involves a social aspect. In this vein, all participants reported that they received moral support from significant others (N = 21) who recommended seeking psychotherapy and shared knowledge on finding a psychotherapist. Some recommended their own psychotherapist and passed on their contact details. Some took on an otherwise supportive role. This support mainly came from friends (n = 11). Consider the following statement about a friend who shared his own psychotherapy experiences with a participant in this study:And//mhm//I have a pretty good friend, yes, he is part of the family now, um, who regularly sees a therapist because he has epilepsy, and it is severe. And then we talked about it a bit. And that was then maybe all together, where I said, OK, now you tackle it and look for help.//mhm, mhm, yes//Yes .Additionally, worried parents (n = 10) and other family members, such as siblings and cousins (n = 10), helped the participants find treatment. Moral support through one’s partner (n = 7) and work environment (n = 3) was likewise reported:My boss is accommodating, his ears are open to such things, and then we said together that it would not be a mistake//ah//if I make sure that I get help .A further participant (n = 1) found herself in a situation where her adult daughters supported her health-seeking because they had noticed their mother’s struggle. External support for psychotherapy utilisation was not only provided by significant others but also by professionals (n = 11). These supporting professionals most often came from the clearing centres, social services or welfare organisations specialising in particular disorders. They provided help seekers with relevant information and a list of qualified therapists (n = 5). Additionally, psychiatrists encouraged psychotherapy utilisation for some participants (n = 5), followed by family doctors (n = 4) and professional helplines (n = 3). One participant revealed that he was counselled on where to seek help in rather specific terms through a helpline:Um, the hospital was not open or did not pick up the phone, and then I called the//ahm//the telephone, the telephone helpline (-). And a trauma therapist picked up the phone. And I told her in a few minutes what was going on with me. And she said that I had emotional childhood trauma. She recognised it quickly and told me to seek body-oriented individual therapy .Other healthcare providers supporting this study’s participants in seeking psychotherapy in private practice worked in hospitals (n = 2), psychiatric rehabilitation clinics (n = 2), or worked as clinical counsellors (n = 2), school physicians or school psychologists (n = 2). Additionally, an outpatient clinic (n = 1) was mentioned. One participant said that she was referred to individual psychotherapy by her and her partner’s couple therapist (n = 1). Another participant was recommended to undergo psychotherapy by her child’s therapist, who suggested that parents of troubled children should also seek treatment (n = 1). Information about psychotherapy utilisation was sometimes also found on the internet, which participants (n = 6) described as a source of valuable information regarding therapeutic schools, practice locations and photographs of psychotherapists. Psychotherapists’ professional homepages were described as providing relevant information to making a good match with a therapist:Well, how I chose her was simple, I saw a picture of her, and I liked that. And her homepage was appealing. And with the others, I felt more like//ahm//I did not know if they would suit me because they were for older people, not younger people. And with her, I immediately felt that (-) we would fit .Other external factors that facilitated the use of psychotherapy were the physical proximity to a psychotherapist’s practice, so as not to travel long distances (n = 3). Living close to a psychotherapeutic practice was not only seen as beneficial for quick access but also for better mutual understanding:I think it is essential that a therapist comes from the same region. Because she [the psychotherapist] has the same//um//background, she has grown up in the same circumstances//living the same village life .As we already know from the external barrier section, the way to finance psychotherapy is crucial to accessing it (n = 6). In this vein, three participants reported receiving full or partial financial support from their parents or other family members (n = 3). Another group of three felt relieved because they received full or partial funding from their insurance (n = 3). One participant expressed alleviation at having found Skype as a medium of communication with the therapist, as it is more flexible and saves long journeys (n = 1):We do it like this, um, I can do it via Skype,//aha//which helps me terribly because it’s a twenty-kilometre drive into the city. And with the children and my husband working shifts and then a shared car,//mhm, mhm//And she [the psychotherapist] only has certain days she is available, which narrows it down a lot. (…) It is very convenient for me that I can do it via Skype. And, um, I think that also helped with Corona greatly .More than half of the participants (n = 16) stated that they experienced a peak or crisis point in their suffering, which led to a desire for change, and thus, to seeking treatment. Fourteen (n = 14) of them used psychological vocabulary to describe the experienced phenomena. They talked about anxiety, panic attacks, depressive moods, self-mutilation or suicidal thoughts. The experience of physical symptoms (n = 4), a failure to cope with everyday life (n = 4), a loss in professional activity (n = 4), exhaustion (n = 2), a breakdown experience (n = 2), feeling humiliated (n = 1) or limited by one’s symptoms (n = 1) were other acute problems formulated in more everyday language, which contributed to making participants feel uncomfortable enough to seek treatment.After finding their current psychotherapist, most participants (n = 16) reported having had a positive impression from their early sessions. Nine (n = 9) of them said they immediately felt trust or sympathy for their therapist. One participant illustrated this point through a revealing example in which she was encouraged to tell if something felt wrong immediately:It impressed me that she said: You do not have to stay here [in psychotherapy] only to visit. You may say: this does not fit me. Alternatively, you can always say it does not work for me anymore. So, I felt I could tell her that at any time. (-) And that//I think//already inspired much trust in me when I first saw her .Participants also reported that it felt good to get an unbiased perspective on one’s problems (n = 5), that they found the therapy room atmospherically and aesthetically appealing (n = 5), that they found it easy to talk about emotional issues (n = 2), that they received helpful instructions right away (n = 1) and that they liked that their psychotherapist seemed to be an authentic person (n = 1). Another large category was “decision making,” endorsed by fifteen participants (n = 15). Eight participants (n = 8) stated that they had taken a conscious decision to seek treatment even though they were not necessarily alone in the decision-making process. Others (n = 5) had decided to look for a new psychotherapist because they wanted a new perspective on their problems. Working in a same-sex dyad was an operational decision for some female participants (n = 5) who wanted to discuss gender-specific aspects with a female psychotherapist:There are things I only want to discuss with a woman.//mhm, mhm//where I certainly do not need a man’s point of view .Five participants reported a general desire for support (n = 5). Three participants (n = 3) stated that their recent decision to seek treatment had to do with feeling that now was “the right time” to reflect. One participant used the metaphor of “tidying up from the inside” to illustrate her point:I remember that last autumn, there was this lockdown, and I had the feeling that now we have, I do not know, two or three weeks where you can reflect on yourself (-). So you use this dark time of year, my birthday, it is always like that, and//ahm//to reflect, look at things that you do not usually get to, and tidy up from the inside. And that started this process .Prior psychotherapy utilisation, as long as it was mentioned in a neutral or positive light, was likewise interpreted as a facilitator to current psychotherapy utilisation. Twelve participants reported having utilised psychotherapy before their current therapy (n = 12), which they had found helpful…Yeah, so, having done therapy before in 2019, I have known that it helps me .Knowledge about psychotherapy approaches and personal needs was another large category of internal facilitators to participation in psychotherapy. About half of the patients (n = 10) reported knowledge or at least some ideas about the therapeutic school they were about to choose and why a particular approach with a particular set of methods would suit their needs:Once I came to her, my priorities at that time were already bodywork and feeling understood; those were priorities number one .A third of the participants (n = 7) stated they had general positive expectations and hoped psychotherapy could help them:I have never//wished//[to be in psychotherapy] as much as I did back then because I just knew it would help me .All participants (N = 21) could describe at least one goal-related aspect they wanted to achieve with the help of psychotherapy. Almost half of them recognised and reported harmful patterns of emotion, thoughts or behaviours they wanted to alter (n = 10), such as:I wanted to learn ways to work on specific memories, associations or experiences. They were always there anyway, but I never actively worked on them. It always felt very stagnant, and with psychotherapy, I learned to bring things into a flow .Or, as another participant put it:I want to be able to go back to work and learn from my mistakes so that I do not slip into the old patterns again .The more unidimensional goals mentioned were to change one’s behaviour (n = 8), to improve one’s social interactions (n = 8), to understand oneself and others better (n = 6), to find joy in life again (n = 6), to clarify one’s professional goal (n = 5), to strengthen one’s self-worth (n = 5), to take control of one’s own life, instead of just pleasing others (n = 5), to accept oneself and one’s circumstances (n = 4), to function again in everyday life and at work (n = 3), to decide on a relationship status (n = 2), not to transfer one’s old patterns to one’s children (n = 2) and to become better without pills (n = 1).Across cases, the codings referring to the five items were distributed as follows: external barriers , internal barriers , external facilitators , internal facilitators  and psychotherapy goals . See Using a cut-off score of 20% to divide the participants into a group with a high number of codings per item and a group with a low number of codings per item, we defined a high-goal group  and a low-goal group .Across cases in the high-goal type group, the codings referring to the five first-order categories were distributed as follows: external barriers , internal barriers , external facilitators , internal facilitators  and psychotherapy goals . For more details, see the Across cases in the low-goal type group, the codings referring to the five first-order categories were distributed as follows: external barriers , internal barriers , external facilitators , internal facilitators  and psychotherapy goals . For more details, see the The distribution of codings referring to the five first-order categories in the high-goal and the low-goal group indicates that patients with a high number of goals mentioned fewer external barriers to treatment, fewer internal barriers to treatment, fewer external facilitators and more internal facilitators to treatment see . For morThe present study sought to investigate the perceived barriers and facilitators to psychotherapy utilisation (research question 1), their relation to psychotherapy goals as patients formulated them at the beginning of their treatment and whether patients who formulated a high number of psychotherapeutic goals were equally affected by barriers and facilitators as patients who formulated a low number of psychotherapeutic goals (research question 2).To better understand the results presented, it helps to reiterate the central features of the psychotherapeutic system in Austria. A variety of 23 psychotherapeutic schools are practised in Austria, for example, systemic therapy, integrative psychotherapy, concentrative movement therapy, logotherapy or gestalt-theoretical psychotherapy, each of which belongs to one of four general theoretical orientations. Then, only limited places for fully funded psychotherapy are available, and there is no national uniform strategy to inform patients about their options for funding. Indeed, the characteristics of our sample suggest that only four (n = 4) out of all (N = 21) participants received total funding, with the majority (n = 15) being only partially reimbursed.Yet another particularity should be kept in mind when discussing this paper’s results: the pandemic situation at the time of data collection.The results show that one central external barrier theme in facilitating psychotherapy is that of affordable and accessible psychotherapy. Half of this study’s participants (n = 11) mentioned obstacles to covering psychotherapy costs, which caused distress through financial pressure in 8 (n = 8) participants. The rest (n = 3) reported confusion about how the system worked, failed attempts to receive total funding and long waiting times. Other qualitative studies, too, have identified such barriers for patients in Austria ,14. AustSince this study was conducted during the COVID-19 pandemic, during which the rates of depression, anxiety, insomnia and stress have increased 2–8 times among the general population ,43,44, aAlmost half of our sample (n = 9) sought alternative ways of dealing with their mental health problems, such as counselling, yoga, meditation, seeking a spiritual medium, etc., before they started seeing their current psychotherapist. While this is not unusual, it may well be related to the fact that these alternatives were cheaper and more accessible. We would like to clarify that we understand these alternatives only in the sense of a barrier in that they may have delayed the start of therapy or that they were seen as a temporary replacement for it. Therefore, the question remains as to whether the participants would have profited more if they had had better access to psychotherapy and sought treatment earlier.A widespread internal barrier theme is that of a previous negative psychotherapy experience. Almost half (n = 10) of the interviewed patients stated that they felt misunderstood or ignored regarding their core concerns in earlier psychotherapy, that is, before seeing their current psychotherapist. This underlines the importance of therapists providing their patients with contextualised and individualised conceptualisations of their problems right at the beginning of treatment. Not paying attention to some core aspects of the patient’s difficulties, as experienced by the patient themselves, can be a significant obstacle to future therapeutic work . ExperieA quarter of our sample patients (n = 5) reported shame or fear of stigmatisation, which underlines the need for improvement in the de-stigmatisation of psychotherapeutic treatment, as pointed to also by the respondents of another Austrian study .The importance of social support in seeking professional help  was reflOn the other hand, the professionals only supported half of this study’s participants (n = 11). Additionally, their recommendations were often very concrete. For example, they provided the participants with lists of qualified therapists or recommended certain types of therapy for specific disorders. These results suggest that missing centralised information through nationwide campaigns is compensated through support from the patients’ friends and families and, to a lesser extent, also through help from professionals.The more self-directed way in which patients acquire relevant information is through the internet. This study’s participants (n = 6) reported having found homepages in which psychotherapists present themselves via photographs, personal information and the specifics of their therapeutic school.Regarding the coverage of psychotherapy costs, six (n = 6) participants mentioned that they received funding through their relatives or insurance, which they found was essential support for accessing psychotherapy. This again highlights that the financial means or insurance coverage for mental health service use is paramount to enabling psychotherapy .More than two-thirds of our participants reported a high level of psychological distress and symptom severity as a crucial need factor  for engaThe other categories refer to enabling characteristics , that isAnother large internal facilitator category (n = 15) regarded different aspects of active decision making. The decisions remembered and reported by the participants referred to different areas, such as having taken a conscious decision to seek treatment (n = 8), having decided to get a fresh perspective on old problems (n = 5), having decided to work in a same-sex dyad (n = 5) or having felt that the “right time” has come for treatment (n = 3). We think these reported moments of decision-making point towards an intrinsic pretreatment motivation, which is significantly associated with a patient’s active engagement in therapy to change and communicate . The repConsiderable mental health and psychotherapy literacy among this study’s participants is demonstrated by the fact that half of them had already thought about which school of therapy to choose (n = 10). This relates to the high rate of treatment experience in this sample and the fact that the Austrian therapy system, with its variety of schools, suggests and inspires such considerations.A third (n = 7) of the participants uttered that they had hope or positive expectations towards psychotherapy, which, according to the literature, significantly predicts the rates of improvement ,58.Again, also in this section, the theme of psychotherapeutic schools was recurrent, as it appeared in the patients’ considerations for planning psychotherapy.The goals described by this study’s participants are manifold, and all participants could at least describe one aim they wanted to achieve. In general, the formulation of goals results from a collaboration between the patient and the psychotherapist, and there is research evidence that this collaboration is related to client outcomes . Except Comparing the distribution of the previously discussed categories on a case-by-case basis , a heterComparing two sub-groups, one group is defined as a high-goal type group . The other group, as a low-goal type group  , suggestThis study has several limitations. First, we cannot rule out a possible selection bias, as participants willing to participate in the POPP study’s qualitative sub-study may have been more likely to open up and seek professional help. Second, there is also a potential for recall bias. Since this study’s participants saw their current psychotherapists already for n = 20 sessions, on average, at the time they were being interviewed, it cannot be excluded that their recent experiences with psychotherapy did alter the memories of reported psychotherapy processes from the past. Third, regarding data analysis, data were evaluated and interpreted outside their immediate survey context and set into the theoretical context of health-seeking behaviour. Therefore, our analysis is a secondary analysis, meaning that data were taken out of their initial narrative form and re-contextualised  into theNevertheless, the emerging hypothesis seems plausible enough to be tested with a larger sample and an interview guide that includes specific questions about barriers. For future research, we recommend a larger sample and the inclusion of predisposing characteristics, such as demographic characteristics, particularly age and gender, and social structure, as proposed by Andersen’s behavioural model . MoreoveA strength of this study is that extensive interviews were conducted face-to-face in an open and safe atmosphere, examining the participants’ individual experiences in their own context. As the participants were allowed to tell their own stories with psychotherapy, the facilitators, a concept on which there has been little research so far , could bAlthough COVID-19 increased the demand for mental health services, the pandemic played a minor role in patients’ self-reported barrier and facilitator themes. Since a critical external barrier theme was unaffordable psychotherapy and confusion about how the Austrian funding system works, reducing this barrier would mean providing better access to mental health services, including a nationwide information campaign, an increase in insurance subsidies and more fully refunded psychotherapy. Our findings also have implications for clinical assessment. This study’s participants were less likely to formulate elaborate treatment goals when they had greater internal barriers and more external support in seeking treatment. Thus, psychotherapists should particularly emphasise working with their patients to develop psychotherapy goals when they know that their patients have been sent to therapy or when they report several internal barriers.


When it came to formal philanthropy, Grundy County was not on the map. That changed with the 2012 establishment of South Cumberland Community Fund, which serves the plateau portions of Grundy, Franklin, and Marion counties. It’s lunchtime at Sam’s Corner restaurant in Coalmont, Tennessee. A group of six women is gathered at one of the larger tables, conversing while they await their orders. When the steaming food arrives, the talk slows a bit, but it does not stop. The subject: how to improve community health. And in Grundy County, Tennessee, that means there is a lot to talk about.“It all goes back to what my mom and dad said,” says Emily Partin, one of women at the large table, referring to efforts to address the county’s difficult health issues. “You have to bloom where you’re planted.”That’s not always easy. Last year rural Grundy County ranked last in Tennessee in its “health outcomes” in the annual County Health Rankings and Roadmaps report. There are signs of change. In this year’s rankings,But at the lunch table, 2 months before the release of the new report, the women aren’t focused on their position on the list.  But they are focused on improving their residents’ health.They have a lot to show for it. The community has implemented several new programs in recent years because of local leadership, with outside technical assistance and funding at key points along the way. So how does a county that lies near the bottom in Tennessee’s health rankings create a top-tier effort to change?One indicator of health is residents’ access to recreational facilities. The Mountain Goat Trail AllianceOnly a third of Grundy County residents say they have access to exercise opportunities, such as walking trails. With easily accessible and family-friendly trails, walking is much more practical. Local people have started competing in a national walking challenge. For example, Tracy City First United Methodist had about 60 people sign up for the challenge last year. Together they logged about 11,000 miles and engaged in friendly competition with other groups.And the Mountain Goat Trail keeps growing. Grundy County government acquired 17 more miles of railroad right of way in 2018. That will extend the trail all the way to Palmer, a former coal camp that lies just a mile or two from Savage Gulf State Natural Area.Another set of community efforts has addressed parenting and children. Grundy County was the first rural site (and just the second in the entire state) to create a safe-babies court team.“In baby court, even though our focus is on that baby and that family, there’s an even bigger chance that the next baby being born into that family is going to get the benefits of the energy, time, and resources we’ve put into that family,” said Katie Goforth, who manages the AmeriCorps VISTA project at the University of the South and whose background is in behavioral health.For other parents, Partin has started Discover Together. She calls the program a place-based family co-op for families with children from birth to 5 years old. Twenty families are participating; they meet twice a week for 2–3 hours for multiage activities that mix toddlers, preschoolers, and parents. The multi-age mixing can surprise people. The long-term goal is for parents in the program to share what they learn. “We are hoping that they are going to become the ambassadors that take the information out to others,” Partin said.When it came to formal philanthropy, Grundy County was not on the map. That changed with the 2012 establishment of South Cumberland Community Fund, which serves the plateau portions of Grundy, Franklin, and Marion counties.“Previously, there were no local philanthropic resources,” said Jack Murrah, an early proponent of the foundation. A resident of Monteagle, Murrah moved to Grundy County after a career at the Lyndhurst Foundation in Chattanooga.With professional expertise and community contacts, volunteers found ways to tap community wealth. The University of the South at Sewanee, a liberal arts college located on the plateau a few miles from Grundy County, played a big role. Early support also came from second-home owners and residents who moved to the area for its natural amenities. Since 2012 the South Cumberland Community Fund has awarded more than $500,000 for community-minded projects to 45 different organizations.The organization provides more than money, Murrah said. “[The fund] supports the nonprofit sector with technical assistance and training,” he said. “They have helped with capacity building and building a network within the nonprofit sector.” The foundation also sponsors training, such as courses through Nashville’s Center for Nonprofit Management.The University of the South has a long history of involvement with communities on the Cumberland Plateau. Besides helping start and sustain the community foundation, the school also established the Office of Civic Engagement, which connects the university directly to local agencies. The program takes its cues from local institutions, many of which are working on health-related issues, said Jim Peterman, a philosophy professor who also heads the Civic Engagement Office.“Our orientation for working in the community, right from the outset, was not the traditional service model,” Peterman said. “It has been to work in communities in ways that build capacity for them to achieve their own aspirations.”The office facilitates student internships, community-focused research, and an AmeriCorps VISTA program with local agencies, among other activities.Despite Grundy County’s improvement in the 2019 rankings, the county remains near the bottom of Tennessee’s 95 counties. So are the programs making a difference?“What stands out in Grundy County is that they have decided to take action,” said Aliana Havrilla, a community coach with County Health Rankings and Roadmaps. “There’s a core group of people in the community working to improve health outcomes and strengthen the community. And they are reaching out to others to include them in the journey.”


In the published article, there was an error in affiliation 13. Instead of “Cardiology Department, Santa Maria Nuova Hospital, Reggio Emilia, Italy,” it should be “Divisione di Cardiologia, Arcispedale S. Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio-Emilia, Reggio Emilia, Italy.”The authors apologize for this error and state that this does not change the scientific conclusions of the article in any way. The original article has been updated.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This paper revisits the proposal for the classification of meditation methods which we introduced in our initial 2013 publication, “Toward a Universal Taxonomy and Definition of Meditation”. At that time, we advanced the thesis that meditation methods could be effectively segregated into three orthogonal categories by integrating the taxonomic principle of functional essentialism and the paradigm of Affect and Cognition; and we presented relevant research findings which supported that assertion. This iteration expands upon those theoretical and methodological elements by articulating a more comprehensive Three Tier Classification System which accounts for the full range of meditation methods; and demonstrates how recent neuroscience research continues to validate and support our thesis. This paper also introduces a novel criterion-based protocol for formulating classification systems of meditation methods, and demonstrates how this model can be used to compare and evaluate various other taxonomy proposals that have been published over the past 15 years. This iteration reaffirms our original assertion that the Aristotelian taxonomic school of functional essentialism appears to be the most suitable theoretical basis for the classification of immaterial processes such as meditation; and we discuss in detail why it is problematic and ineffective to rely solely on empirically-driven, statistical, and inductive/intuitive-type methods.The primary objectives of this paper are:to present a more compelling case for CoNS researchers to give due diligence to the established taxonomic theories, principles, and standards that have been promulgated by the disciplines of Philosophy of Taxonomy and the Science of Systematics;to update and refine the classification system that we introduced in the original NNA 2013 paper; expand the typology to account for the full range of meditation methods by including both simple and more complex methods; and provide a more in-depth discussion of the foundational principles which informed the original thesis and have carried over to this iteration;to introduce a new criterion-based model for the formulation of classification systems; to demonstrate how these criteria were used to inform this proposal; and to use this model to evaluate various other “competing” taxonomy proposals;to offer an efficacious and straightforward three-tier classification system that could serve as a useful model for meditation research; andto demonstrate how recent neuroscience research continues to support and validate the original taxonomic theses advanced by the paper of NNA (2013).2.Our 2013 paper proposed a two-tier classification system for relatively simple meditation methods that were singular in intent—a higher order system of three overarching orthogonal domains based on the notions of Affect, Cognition, and the absence of such (Null); and a sub-classification system based on nine defining characteristics called Taxonomic Keys. That model was predicated on three inter-dependent principles:functional essence of whatever entity/process that one is attempting to classify.The philosophy of functional essentialism, which espouses the necessity of determining the functional essence of a meditation method is its intention to engender a meditative state, aka an enhanced mental state (EMS) which is differentiated from the mundane waking state to a more “profound” state of consciousness that can include an enhanced sense of well-being, increased focus, intense affect, profound calmness or bliss, detachment, insight, or emptiness to name a few.The assertion that the intentionality with the aforementioned typology of Affect, Cognition, and Null, to devise a classification scheme of three orthogonal overarching domains of meditation methods.The integration of this notion of This paper conforms with, and builds upon, these foundational principles.3.3.1.Since there are many kinds of meditation methods, with different goals and with varying techniques, researchers and authors need to be able to communicate their findings to each other and the general public in a way that is not confusing or wide-open to mis-interpretation. A cogent taxonomy provides the structure for accomplishing this. The following review is presented here in the hope that it may influence future efforts to give due consideration to these precepts.3.1.1.A well-conceived and useful taxonomy has the power to frame all theoretical considerations of a particular field of study. It is natural, and in fact historical, for scientists and philosophers to desire to segregate and classify the things and processes of this world  have been defined as “emotional and attentional regulatory training regimes developed for various ends, including the cultivation of well-being and emotional balance” . In thisFor the purposes of this paper, the MM is defined as the prescribed set of instructions and techniques that the practitioner can choose to employ in an attempt to facilitate the attainment of a particular intended EMS . Since this is a proposal directed to the field of CoNS, our taxonomy focuses on those MM that have been, or will be, the subject of CoNS research.bona fide MM. With that caveat in mind, this taxonomic proposal adheres to the confines of the mental training definition above, and we have excluded consideration of those methods (that some may consider to be meditation) which have a primary focus on physical/somatic skills, e.g., various forms of Hatha Yoga, external/martial forms of Tai Chi, etc. For a more detailed discussion of the conceptual issues regarding somatic elements in the taxonomy of meditation—see section 8.1.1.Admittedly, it would be presumptuous for anyone to claim that there is only one “right” definition of what is (and what is not) a It is important to note that the 2013 paper only considered MMs that were simple, singular of purpose methods—that is, methods which were designed to engender one particular type of meditative state. This proposal has been expanded to account for complex MMs, which were designed to engender more than one type of EMS within a given meditation session. The former group has been designated as Simple Methods, and the latter as Complex Methods—see section 6.0.3.2.2.bona fide MM—an enhanced mental state (EMS) with defining neurophysiological and phenomenological properties/characteristics. Within the context of this typology, the term “enhanced” is used as a distinction to the mundane state of waking consciousness, and is intended to connote notions, such as “deeper,” “higher,” “intensified,” “expanded,” and “more profound.” This iteration adheres to our original thesis of three distinctive EMSs—affective, cognitive, and null (see section 5.2.2). The neurophysiological correlates of these states and their implications for taxonomy are discussed in section 7.0.The 2013 paper defined the meditative state as the intended result of the successful application of a In general terms, the meditative state has been described in subjective first-person reports as a shift in consciousness from the mundane waking state to a more “profound” mental state, e.g., an enhanced sense of well-being, focus, calm, detachment, insight, affect, bliss, emptiness, etc.; and many research studies have demonstrated distinctive neurophysiological correlates of the meditative state e.g., . The med3.2.3.In our Definition Section of the 2013 paper, we introduced the notion of meditation as a dynamic process, inclusive of both method and state; depicted as five sequential and inter-connected steps: Intention to Begin, Preliminaries, engaging with the MM itself, the EMS itself, and Intention to Finish . The idea that meditation can be considered an immaterial process  has taxonomic implications when contrasted with classifications of physical entities such as biological organisms—an important distinction discussed in the following section.3.3.The first major attempt to classify the full range of MMs was initiated outside the field of CoNS, but had important implications for the entire scope of meditation research. Dr. Maria Ospina and her group of researchers prepared a comprehensive report on meditation and health for the U.S. Department of Health and Human Services . They reIn an attempt to find answers to this quandary, we conducted a literature review within the disciplines of the Philosophy of Taxonomy and the Science of Systematics. It became apparent that, although the Ospina team had not made any reference to fundamental taxonomic principles (and none were cited), they had inadvertently employed an approach which was quite similar to “material essentialism,” “taxonomic pluralism,” “pheneticism,” and “cluster analysis.” Although these taxonomic philosophies/methods have proved quite successful in creating useful classifications for living organisms , it called to question whether they were suitable for the classification of an immaterial phenomenon such as meditation.In the 2013 paper, we argued that attempting to classify MMs by using the aforementioned phenetic-like (an inadvertent application of pheneticism), empirical/intuitive approach  would likely prove problematic. It seems that this assertion has mostly fallen on deaf ears. Virtually all of the meditation taxonomies published since the 2013 paper replicated the approach of Here are some notable examples from other taxonomy proposals that attempted to formulate orthogonal categories for MMs, but did not succeed for varying reasons (the bold type has been added by us for emphasis):could not classify meditation as being exclusively of any one class because meditation practice demonstrates varying emphases on concentration, mindfulness, or guidance”; and “virtually all practices involve a combination of these strategies”; and “despite the potential value of various classification schemes, comparative analyses based on meditation type were not undertaken here.” (p.53).potentially meaningful clusters, which are open to interpretation by the researcher.” (p.7)this could lead to a false association of effects” .many practices contain elements of all three families,” and “given the complexity of each practice listed here, we present this system as an initial step in the long process of studying the diversity of meditation practices” (p. 517).A comprehensive review of these and several other representative taxonomy publications  revealed several in-common themes or elements that could account for these difficultiesOnly one of the papers made any mention of taxonomic principles and theory, and all relied on the aforementioned empirical/intuitive approach.All used a phenetic-like method to construct overarching classification categories based on observable characteristics/elements of the various MMs.All but one devised their own unique first-person terminology for the construction of some or all of their classification categories.All but one devised their own unique first-person terminology for various other descriptive and or explanatory purposes within their classification scheme.We concluded that the recurring nature of the problems and obstacles described above called for some kind of standardized approach that could serve as a useful tool for meditation researchers interested in avoiding these confounding taxonomic issues.4.Our initial review of the Philosophy of Taxonomy literature  providedThe four criteria contained within this model are: Theoretical Taxonomic Foundation, Orthogonality, Semantic Lucidity, and Utility.4.1.The first criterion is quite simple, but is perhaps the most important—the fundamental taxonomic principle that all classification proposals require a cogent theoretical foundation , 2007. G4.2.We argue that it stands to reason that all classifications of MMs intended for scientific investigation should present an effective methodology for differentiating, segregating, and grouping MMs. For the purposes of this paper, we consider orthogonality to include:A system of mutually exclusive overarching categories/domains whereby all MMs that are essentially and demonstrably similar are segregated together in the same domain , and all members within any one particular domain cannot overlap and appear in any of the other domains.A collectively exhaustive scheme whereby the totality of the members within all of the overarching domains should encompass, at least in principle, the entire range of MMs within the sphere of interest. Creating “escape-hatch” categories such as “Other” or “Miscellaneous,” as some authors have suggested, could be considered to be a hedge and an implicit admission that there is a fundamental conceptual problem with the universality of their proposal.4.3.All classification proposals should be relatively easy to understand, and demonstrate a clarity of terms and categories that we would like to refer to here as “semantic lucidity.” For example:Use of clear and unambiguous terms for the labeling of categories and for the presentation of arguments; as opposed to the use of verbiage that makes it difficult to comprehend what is being proposed and how to implement it.Avoidance of ineffable (difficult to measure) designations and first-person neologisms/fabrications which are prone to conflation and debate; such issues arise with terms like “awareness of awareness,” “deity merging,” or “experiential fusion” which are difficult if not impossible for CoNS researchers to operationalize for scientific experimentation (see section 8.1.2 below).4.4.We argue that it is reasonable to expect plausible, and readily testable categories that could be validated or refuted by CoNS researchers. In other words: can scientific investigation validate that those MMs which have been classified within a given domain demonstrate similar neurophysiological and phenomenological parameters to each other, that are significantly different than the parameters of those MMs that have been classified in other domains?It should be noted that by “utility,” we mean a broad conception that encompasses verifiability, testability, and plausibility for CoNS researchers, as well as the notions of usefulness, applicability, relevance, and practicality.The proposal should contribute toward a greater understanding of the phenomenological and/or neurophysiological elements of the meditation process in ways that are measurable and replicable.CoNS researchers should be able to use the proposed classification scheme to inform and test their own hypotheses.The proposal should not be not overly complex, convoluted, and unwieldy.In the following two sections, we re-visit the foundational concepts presented in the NNA 2013 paper that remain central to this iteration, and we demonstrate how we applied the aforementioned Four Criteria to the construction of our new Three Tier Classification proposal.5.5.1.To review, the employment of an Aristotelian teleological approach requires the discernment of the functional essence of the entity/process of interest, i.e., what is its purpose?, what was it designed to do?, and We used the following set of observations, conditions, and assumptions to make this determination for MMs :Meditation methods were derived for specific aims/purposes/goals.Such aims typically include various “lofty” ultimate goals and claims, such as: controlling the mind, purifying the mind, purifying the heart, gaining a greater sense of well-being, attaining spiritual insight, realizing self-actualization and enlightenment, etc. Practically speaking, these ineffable qualities ; they are difficult to accurately describe in words or define in scientific terms, and therefore are not amenable to measurement and verification in a CoNS laboratory setting. In addition, the heterogeneity of MMs employed by long-term meditators presents a confounding factor for researchers . For theMeditation methods were derived to facilitate a shift from the mundane waking state to a meditative state, aka an enhanced mental state (EMS) with the understanding/hope that consistent, long-term practice will lead to the attainment of a particular ultimate goal(s).Meditation methods exhibit a great degree of variance, e.g., how and when instructions are given, the specific techniques employed, the suggested posture, the sequence of steps, the length of time suggested, etc.The successful attainment of the desired EMS ultimately depends on a host of factors, both extrinsic (unpredictable outside conditions and circumstances), and intrinsic . These factors undoubtedly affect the quality of the experience regardless of what any given MM purports or intends to accomplish. It is reasonable to conclude therefore, that the MM is just a facilitative tool, which only offers the potential (not a guarantee) for the attainment of the immediate and ultimate goals.From a phenomenological perspective, the meditative state is somewhat ineffable, in that the content and qualitative nature of the experience itself often escapes description in words.For these reasons, we determined that the functional essence of a MM was its intention  in an immediate sense—that is, to engender the attainment of one or more particular EMSs during a given meditation session. Long-term goals, the phenomenology of resultant states, and the peculiarities of the techniques employed were excluded from consideration for reasons outlined above. Since it may be considered rather awkward and inappropriate to think of methods as having intention, the analogous notion of directionality was used instead .This assertion that MMs possess a specific intended outcome, purpose, or goal is not a new idea, and has been discussed at length in the CoNS literature since 1987 e.g., .5.2.In order to operationalize this notion of directionality, our 2013 paper presented a scheme and nomenclature of orthogonal domains by integrating the following foundational concepts:5.2.1.Since the rigors of scientific investigation require confidence in the validity and reliability of orthogonal distinctions, we felt that it was essential to create a nomenclature based on a stable and well-established third-person paradigm, rather than attempting to invent an entirely new and original semantic based on first person experiences or other ineffable concepts that cannot be operationalized with any clarity. Given our decision to abide by the definition of meditation as a form of mental training (see 3.2.1), it seemed most prudent to look to the Cognitive Sciences for an appropriate conceptual framework. The Cognitive Sciences tell us that all mundane waking state conscious mental activity can be reduced to affective content and processes, cognitive content and processes, and an interplay between the two . The notWestern 18th century philosophers divided psychology’s subject matter into three distinct mental faculties: cognition, affect, and conation . AlthougWe relied on the standard, commonly-used definitions of affect and cognition that could be found in psychology textbooks and popular dictionaries:Affect: a mental state in which the phenomenological content is primarily an emotion or “feeling.”This thesis limits the broad spectrum of the affect paradigm to those positive emotions that are characteristic of traditional MMs, e.g., loving-kindness, compassion, and sympathetic joy (as featured in Buddhist tradition).Cognition: includes a host of mental processes associated with thinking; including, but not limited to: learning, reasoning, observing, perceiving, remembering, concentrating, imagining, processing information, and acquiring knowledge. With regard to traditional MMs, cognition can be exemplified by notions such as one-pointedness, mindfulness, insight, etc.We think it is important to emphasize that when the terms “affect” and “cognition” were used in our original typology, we did not assume or imply that these mental states were “pure” and mutually exclusive (since cognitive states involve some affective components and affective states involve some cognition). Regardless, this issue was not of primary concern to us at that time because our taxonomic model was based on the intention/purpose of Simple MMs , not on the phenomenology, “purity,” or qualities of the resultant state.5.2.2.In 2013, our review of the various types of MMs led us to conclude that there was a group of methods that were neither affective or cognitive in content or intention, and thus a third category was required. As such, our original proposal advanced the thesis that the meditative state consisted of three types of EMSs—an enhanced cognitive state, an enhanced affective state, and an enhanced mental state devoid of cognitive or affective content—which we dubbed “the null state.” This section focuses on the mental/phenomenological characteristics of these three states, and section 7.0 discusses their distinctive neurophysiological parameters.metta and karuna meditations, whereas “an unconditional feeling of loving-kindness and compassion pervades the whole mind as a way of being, with no other consideration, or discursive thoughts” (Enhanced Affective State (EAS): a meditative state in which the phenomenological content is primarily an intensified/heightened emotion or feeling. It is typically described by words, such as intense bliss, peace, love, compassion, joy, and happiness. This state is perhaps best exemplified by the Buddhist houghts”  p.1. Althoughts” .samatha .Enhanced Cognitive State (ECS): a meditative state in which the phenomenological content is primarily an intensified/heightened cognition; exemplified by the traditional Buddhist methods of samadhi, shunyata, and turiya; and the Pali word nirodha-samāpatti. There have been numerous attempts to translate and explicate these arguably ineffable concepts into English, such as : “absolute unitary being” (Upanishads transl. by Enhanced Null State (ENS)y being” ; “cessaty being” ; “conteny being” ; “emptiny being” ; “neutray being” ; “non-duy being” , 2019; “y being” , 1996; aIt is admittedly difficult to distill the essence connoted by all of these various esoteric terms into a singular lucid delineation. However, for the purposes of this typology, this notion of a null state is inclusive of all of the aforementioned, and is best captured by the following quotes from meditation masters, practitioners, and scholars:From a highly experienced meditator  who was a subject in a recent study: “clear, aware openness without any thoughts, physical, or sensory perception, and even without any sense of self, time, and space” .samadhi and turiya: “no object in the mind, no content…, not meditating upon something, but dropping everything (so that) not even a ripple arises in the lake of your consciousness”  in order to further differentiate MMs that have been grouped together in the same second Tier domain.6.1.Given our premise that the functional intention of any given MM is to engender one or more particular EMSs within a given meditation session (see section 5.1), it seemed self-evident to divide the “universe” of MMs in Simple MMs are those methods which were designed with a singularity of purpose—to engender one of the three EMSs (described above) during a given meditation session. Simple MMs are exemplified by the traditional forms of meditation that have been the primary focus of CoNS research to date.Complex MMs are fundamentally different than Simple MMs in that they are intended to foster more than one type of EMS within a given meditation session, i.e., they were designed to engender a combination of separate and distinct affective, cognitive, and null states. Complex MMs present researchers with the difficult challenge of discerning which type of EMS is present at any given phase of the meditation session, and are therefore more difficult to study and explain when compared to Simple MMs. Since these methods have been mostly ignored by CoNS research , Cognitive Directed Methods (CDM), and Null Directed Methods (NDM)ADMs are those MMs which are primarily purposed/intended to engender an enhanced affective state (EAS as described above) during the meditation session eg. ADM → EAS, whereas the arrow represents intention.CDMs are those MMs which are primarily purposed/intended to engender an enhanced cognitive state (ECS as described above) during the meditation session eg. CDM → ECS, whereas the arrow represents intention.NDMs are those MMs which are primarily purposed/intended to engender an enhanced null state, which is neither affective or cognitive, (ENS as described above) during the meditation session eg. NDM → ENS, whereas the arrow represents intention.6.2.2.Complex MMs can be logically segregated into four categories/types based on the four possible combinations of separate EMSs intended by the method:Type 1 are those MMs that were purposed to engender a separate affective EMS and a separate cognitive EMS during the meditation session (not necessarily in that order).Type 2 are those MMs that were purposed to engender a separate affective EMS and a separate null EMS during the meditation session (not necessarily in that order).Type 3 are those MMs that were purposed to engender a separate cognitive EMS and a separate null EMS during the meditation session (not necessarily in that order).Type 4 are those MMs that were purposed to engender all three EMSs during the meditation session—separate affective, cognitive, and null EMSs (not necessarily in that order).6.2.3.An obviously crucial step in the classification process is deciding which MM goes where. Since this taxonomy is based on the intention/directionality of the method, a determination needs to be made as to the intention/goal/purpose of each MM. For the purposes of this paper, we made the following assignments based on a review of the relevant literature, public-facing claims made on official websites, personal communications with experienced practitioners, and the authors’ long-term personal practice and research experience with several of these methods.6.2.3.1.The classification of several simple meditation methods into the three main domains is displayed in 6.2.3.2.Although there is scant information about this category of MM, it is an important designation from a conceptual point of view. Here are two likely examples and a tentative classification assignment:www.3ho.org; www.kundaliniresearchinstitute.org)—it appears that the method is intended to engender three different EMSs during a given meditation session: “cognitive benefits” , “total stillness” , and “bliss consciousness” .The Kirtan Kriya Method is perhaps the most well-known MM which could reasonably be considered to be a Complex Type 4 Method. Kirtan Kriya (KK) was introduced to the West by Yogi Bhajan in the late 1960s—early 70s. Proponents claim it to be a traditional form of Kundalini Yoga of Northern Indian origin, taught by a lineage of Sikh Masters for over 500 years. There are many forms of KK meditation, typified by the online “12-min technique,” which has been the subject of several neuroscientific investigations . Based oThe Light and Sound Method was purportedly derived from Sufi and Sikh traditions, and was popularized in the West by two Vietnamese meditation Masters ; however, this MM can be considered to be somewhat of an outlier since no neuroscience studies could be found. This MM aims to foster two meditative states in one session, and as such is a likely candidate for a Type 3 Complex Method. The “Light” portion of the technique involves the silent repetition of a sequence of five mantras with the intention of engendering an ENS ; it is followed by the “Sound” portion which involves concentration on one’s internal “heavenly sound” in order to facilitate an ECS of profound one-pointedness .Examples of other possible Complex MMs are: Yoga Nidra , Sahaja 6.3.Principles of Systematic Zoology, 1969)—a phenetic delineation of nine salient elements of MMs, commencing with a general description of the particular MM being considered. Our keys also highlight various neurophysiological correlates associated with these elements that might otherwise be conflated with the correlates of the meditative state itself—see the notations below each key .In order to complete the classification process, a standardized method of lower-order differentiation is required to distinguish between similar MMs that have been grouped together into the same second Tier domain. To that end, our 2013 paper introduced a system of Taxonomic KeysVipassana have many forms.General description mentions the specific name of the technique  and a general reference to the history, origin, culture, and contemplative tradition if there is one. It is also important to specify any particular style or subset, because several MMs may share the same generic name but may be significantly different, e.g., Yoga, Zen, Tai Chi, Qigong, and The specific keys are based on common characteristics readily observable during the meditation process and/or within the instructions associated with the MM.#1. The specific cognitive strategies which are prescribed within the MM directions (what one has to do in order to achieve the intended result) e.g., concentration/focused attention, passive observation without attachment, visualization and imagination, memorization and repetition, selective or effortless awareness, contemplation, introspection, inquiry, sensory perception(s).This element is important from a research perspective since there could be distinct changes observed in the brain and body depending on the strategy used. For example, a visualization task is likely to activate the visual cortex, whereas reciting a prayer or phrase is likely to activate the verbal centers of the brain  that are the focus of attention, e.g., the breath, a mantra, a symbol, an image, a phrase, an idea, a narrative, a sound, etc.Researchers need account for the possibility that focus on certain objects might produce distinctive neurophysiological effects in the brain, e.g., activation of visual centers by simple, complex, color, or black and white images, or the activation of the auditory pathways by listening to music or a voice guiding the meditation process.#3. Whether the MM requires certain beliefs or special knowledge, i.e., a particular religious, spiritual, metaphysical, or philosophical teaching or system.While this is more difficult to identify from a neurophysiological perspective, several studies have explored the various neural manifestations of different beliefs, especially between those who are believers and non-believers  during meditation practices such as Qigong between having eyes open and eyes closed .These elements are likely to effect neurophysiological changes in those parts of the brain associated with motor activity/body movement, e.g., the motor cortex, basal ganglia, and cerebellum. In addition, movement can be associated with differences in energy utilization, adrenal function, cardiovascular function, and respiratory function.#6. Whether the process is non-verbal , verbal , or both.Vocalization is associated with specific cortical activity, e.g., the auditory cortex and the thalamus may be differentially activated in the presence of sound. Regarding silent mantra vs. vocal chanting, #7. Whether a specific type of postural position is suggested or required, e.g., seated in a normal comfortable position, straight spine, lotus position, fully reclined, supine, or standing (this key could be considered as a sub-set of #5 above).The brain may respond differently to being in, and maintaining, different postures. Proprioceptive functions are likely to be activated as the brain works to ensure that a posture is maintained. Research on the effects of positional changes has demonstrated decreases in EEG power in various brain centers as subjects move from upright to supine, as well as changes in the activity of the autonomic nervous system as measured by changes in skin conductance levels (e levels .#8. Whether the process is intrinsic (self-reliant/independent), extrinsic (dependent on the intervention or guidance of an outside person or medium), or a combination of the two.Performing meditation under one’s own volition vs. being guided can result in substantial differences in brain function. Evidence suggests decreased frontal activity during externally guided word generation compared to internal or volitional word generation ; and five are different (in bold standard print).The following two MMs are both classified as CDMs,Anapanasati (concentration on the breath) is one of the most popular and most researched of the traditional Buddhist techniques; in its most basic form is considered to be a samatha MM, intended to calm and focus the mind.utilizes concentration as the main cognitive strategy;the focus is on the breath and the parts of the body associated with breathing;knowledge and belief in the teachings of Buddhism is recommended but not essential;the eyes are closed;the body is static;the practice is mostly non-verbal, although out-loud/verbal versions are also employed;the recommended posture is seated with straight spine; a cross-legged/lotus position is optional;the solo practice is intrinsic, but an extrinsic guided form is common in group practice; andnormal breathing pattern with no intention to control the breath.Walking meditation is a simple, well-known technique, commonly taught and practiced at Buddhist monasteries and at meditation retreats all over the world; exemplified here by the technique taught by the famous Vietnamese meditation Master Thich Nhat Hanh, as a means to cultivate mindfulness .utilizes awareness as the main cognitive strategy;the focus of attention is on the feet and the sensations of walking;knowledge and belief in the teachings of Buddhism is recommended but not essential;the eyes are open;the body is in motion (kinetic), walking in a slow but normal gait, preferably bare-footed;non-verbal;standing position with a normal, comfortable posture;intrinsic; andnormal breathing pattern with no intention to control the breath.7.As previously discussed, our 2013 publication advanced the thesis that all MMs are causally related to one of three resultant meditative states, which we described as enhanced mental states (EMS). That paper cited research from the broader fields of cognitive and affective neuroscience, as well as from the field of CoNS, which supported the notion that these enhanced cognitive, affective, and null states demonstrated distinctly different and measurable neurophysiological correlates e.g., .8Since then, our original thesis has been supported by more recent research as well e.g., , 2021. LOn the basis of these and other similar findings, we can confidently state that during meditation, neural activity in the brain  varies dependent upon which type of MM is employed. For example, CoNS research has demonstrated that the EAS engendered by various ADMs  demonstrates distinctly different neural activity than the ECS engendered by various CDMs . In addition, cognitive and affective neuroscience research has demonstrated specific hormones and neural transmitters that are distinctive for affective vs. cognitive states . RegardiIt is not the intention of this paper to undertake and present an exhaustive review of CoNS research or the disciplines of cognitive/affective neuroscience. Rather, the following section presents a sampling of research findings, in greater detail, which support the conclusions cited above.7.1.It is reasonable to expect that an ECS engendered by a CDM would demonstrate heightened neural activity in one or more of the cortical areas of the brain  that subserve higher cognitive processing, e.g., attention, concentration, observation, verbal reasoning, and abstract thought. Since the early 1990s, a number of neuroimaging studies have corroborated this hypothesis by showing activation of the PFC during CDMs ; and act7.2.Affective neuroscience research has long established a connection between affect and specific areas of brain function, e.g., the thalamus, hypothalamus, cingulate gyrus, hippocampi, and amygdala . CoNS re7.3.So’ham japa as described by Since the ENS associated with NDMs presents a greater challenge to describe and measure (see section 5.2.2), this null state warrants a bit more discussion here than the more straightforward categories of Affect and Cognition. CoNS research of MMs which seem to fall into this non-affect/non-cognitive category include: TM , we have classified it as a NDM. TM research has reported, among other things, that frontal alpha1 EEG coherence is distinctive of TM practice vs. other MMs . Hankey rigpa and mahamudra meditations from the Tibetan Buddhist tradition, various Kashimiri Shaivist meditations, Zen shikan-taza, and various other meditations in the Vedanta tradition .NDA is included here because it is described as an enhanced state which is profoundly different than the mundane waking state—characterized by a dissolution of the subject-object sense of duality, with an absence of both affective and cognitive mental content . ExampleJosipovic has proposed that a dynamic functional network with its main node in the central area of precuneus, and its main axis node in the dorso-lateral prefrontal cortex, is the likely neural correlate of NDA ; and he So’ham MM (of ancient Hindu Vedanta origin) is included here because proponents claim that the method can engender a null state of samadhi —Taxonomic Foundation, Orthogonality, Semantic Lucidity, and Utility.Here is the list of the nine publications, in chronological order. Three of these did not emanate from, nor were specifically directed to, the CoNS community—Dahl et al., Ospina et al., and Pilla et al., but were included here because they were notable contributions to the broader field of meditation research and provided instructive examples of the taxonomic issues that are of concern in this paper.“The Top 10: Prevalence and Popularity of Basic Meditation Practices in Different Spiritual Traditions” (2018).“What Is Meditation? Proposing an Empirically Derived Classification System” (2019).“What Do Meditators Do When They Meditate? Proposing a Novel Basis for Future Meditation Research” (2021).5. 6. 7. 8.1.Several theoretical and methodological issues plagued these proposals.8.1.1.Eight of the papers made no mention whatsoever of taxonomic theory, principles, or methods. We have previously discussed and emphasized why this is a critical oversight (sections 3.3 and 4.1). Only Sparby and Sacchet cited both classical and contemporary theories of taxonomy. Unfortunately, they chose to base their thesis in the spirit of material essentialism and constructed their classification categories using the phenetic notion of observable characteristics. This led to an intuitive/empirical approach and the untoward outcomes associated with this strategy (see section 3.3).To further illustrate why a phenetic taxonomic strategy is problematic with regard to MMs, we examine two characteristics that were often employed as overarching domains in the classification proposals that we reviewed:Om mani padme hum” to facilitate an EAS of compassion vs. the TM mantra which aims to engender an ENS of “pure consciousness.” Even though both methods utilize a mantra technique, the goal is not the same, and the resultant EMS would demonstrate markedly different neurophysiological and phenomenological correlates—the former primarily affective and the later primarily null. In this case, we can see that the characteristic of mantra simply does not provide the level of distinction/differentiation required for an orthogonal overarching domain.Mantra: Although MMs grouped under this category undoubtedly share a common feature, it is important to ask—are all mantra methods “essentially” the same? e.g., . AlthougSomatic elements: This term refers to various bodily/physical characteristics, such as the prescribed postures and movements in Hatha Yoga, Tai Chi, Qigong, walking meditation, and mudras  are often used to facilitate the attainment of the desired meditative state, but they are not an end-point or a primary goal. As an example, we examine the walking meditation method discussed in 6.3.1, which some authors classify as a somatic technique. Walking meditation was derived in the Buddhist tradition as an effective way to cultivate mindfulness. It is not practiced in order to improve one’s walking skills. The act of walking is simply one of many modalities/techniques that are chosen in mindfulness training to develop the faculties of awareness. Although the aforementioned characteristics of “mantra” and “somatic elements” are problematic when employed as orthogonal categories, we have found them to be quite useful within our taxonomic keys scheme—see section 6.3.8.1.2.The Ospina team used standard, well-known terms for the construction of all of their overarching classification domains, and they were the only ones to do so. All the remaining papers devised first-person terms and neologisms for all or some of their domain designations, and for other descriptive purposes as well.Here are some specific examples to illustrate why such choices are problematic:formulating classification categories based on first-person semantics and/or newly coined terminologyWhen formulating terminology for their classification categories, many authors “borrow” previously published first-person semantics and/or devise their own designations, such as: “Constructive, and Deconstructive Families” ; “Amountusing unique first-person terminology for various purposes within one’s classification scheme.Various authors attempted to explicate and differentiate MMs by devising their own notions such as: “let go” vs. “stay open,” “release” vs. “focus,” and “justifiable belief of primary and secondary intentions” ; “visual8.1.3.Of the nine publications reviewed, many used classification categories/domains that were too broad to successfully segregate and differentiate MMs, and none offered a classification system capable of orthogonal distinctions:Seven papers made explicit statements conceding that their attempts to construct orthogonal categories had failed or were not without problem, e.g., Dahl et al., Fox et al., three papers by Matko et al., Ospina et al., and Sparby and Sacchet—see section 3.3 for more detail.Pilla et al. used domain categories that were too broad or vague, e.g., “Mantra,” “Yogic,” and “Others.”Engström et al. also used domain categories that were too broad or vague, e.g., “Somatic,” and “Self”; and assigned many MMs to two or more of their domain categories.8.1.4.Unfortunately, none of the papers satisfied the general or specific guidelines suggested under this criterion; especially the critical importance of providing CoNS researchers with plausible, unambiguous, and readily testable classification categories.9.The primary goal of this paper was to advance a cogent theoretical argument and an applicable structural model for CoNS; one which could successfully classify all applicable meditation methods into orthogonal domains. To those ends, a new Three Tier Classification System was presented based on established taxonomic principles and methods. This proposal also intended to influence due consideration of the merits of a third-person codification system based on the paradigm of Affect and Cognition vs. first-person nomenclatures and categories. We attempted to present a relatively straightforward classification scheme that could provide taxonomic order for the vast diversity of MMs that have been, and will be, the subject of study within this field. As such, the efficacy of our Three Tier Classification proposal must ultimately be determined by the CoNS community.We attempted to implement these goals by:expanding our original 2013 taxonomy proposal to encompass the full range of MMs within the purview of CoNS by accounting for both Simple and Complex MMs; this distinction became the first Tier of our new classification scheme;reviewing the salient definitional issues regarding meditation methods and states;providing discussion and a glossary of relevant terms/concepts from the fields of Taxonomic Philosophy and the Science of Systematics that could be applied toward the classification of MMs;demonstrating why the Aristotelian teleological theory of functional essentialism was the most efficacious taxonomic approach with regard to immaterial processes such as meditation;presenting the rationale for choosing “intention/directionality” as the functional essence of MMs;explaining the rationale behind merging this notion of “intention/directionality” with the paradigm of Affect and Cognition to form the conceptual basis of our second Tier—the three distinct meditative states of EAS, ECS, and ENS, and their corresponding classification categories of ADM, CDM, and NDM. The assignment of MMs within the second Tier was exemplified for both Simple and Complex methods;introducing a Four Criterion set of guidelines for constructing and evaluating classification systems for MMs: Theoretical Taxonomic Foundation, Orthogonality, Semantic Lucidity, and Utility; and explaining how these criteria informed the construction of our Three Tier Classification System;promoting the concept of Taxonomic Keys to serve several purposes: as the basis of the third Tier of the classification scheme so as to differentiate similar MMs within the same domain using nine salient characteristics/elements; as a guide for researchers regarding the neurophysiological implications of these elements, and as a standardized protocol for describing MMs;citing and reviewing more than two decades of neuroscience research to support and validate the taxonomic thesis and classification scheme of this paper;reviewing the theoretical and methodological issues that have plagued various other taxonomy of meditation proposals; and showing by specific examples why it is ineffective to bypass established taxonomic theories and principles in favor of an intuitive/empirical approach, observable characteristics, and first-person designations.10.Develop a much-needed standardized descriptive methodology for the full range of existing MMs of interest to CoNS researchers by expanding and refining the taxonomic keys suggested in this paper in a way that could gain consensus within the CoNS community.Initiate a comprehensive effort to determine, by consensus, the most appropriate classification assignments within the Affective/Cognitive/Null typology for the full range of Simple MMs; and identify, explicate, and classify a more exhaustive list of Complex MMs. This could be accomplished by soliciting the input of expert practitioners and proponents of each method; and by employing effective search, content analysis, and meta-analysis methods, e.g., the survey methodology advanced by via a broader utilization of recent technological advances in less obtrusive neuroelectric instrumentation and methods, e.g., shielded equipment that allows for simultaneous EEG and ANS recordings inside an active MRI tunnel (in order to better differentiate targeted brain activity from the confounding influences of the fMRI/MRI process itself); new MRI machines that allow the subject to sit during the recording (thereby eliminating the confound of requiring subjects to lie down during meditation); new MRI technology designed to reduce the acoustic noise output, e.g., GE Healthcare’s Silent Scan; invention of mobile, and light weight equipment to enable effective recording of those MMs which feature kinetic characteristics.Develop a laboratory environment for CoNS research, which is more “user-friendly” and less distracting for meditation subjects nirodha-samapatti.Undertake a multi-disciplinary investigation of the phenomenology of the Null State in an effort to determine if there are fundamental orthogonal distinctions between various MMs (sub-sets) that we have classified in this domain, i.e., pure consciousness compared to 11.This project was motivated by the conviction that, in order for our field of CoNS to progress, it is essential for meditation researchers to have a valid and reliable taxonomic system with which to classify MMs, test their hypotheses, and compare their findings. As such, this proposal was intended to offer a cogent theoretical and methodological approach which highlighted the critical importance of utilizing established taxonomic principles and methods—in this case, a teleological, essentialist, third-person approach; and to shed light on some of the confounding issues associated with various other taxonomy proposals that have been published in the last 15 years.Another emphasis of this paper, worth repeating here, is a plea to meditation researchers and authors to consider reporting more than just the name and a cursory general description of the various MMs that are being studied. The adoption of a standardized list of specific and agreed-upon taxonomic keys could provide a reasonable way to more effectively describe and compare various MMs, and to explicitly account for the neurophysiological correlates associated with these keys.Hopefully the CoNS community will be interested in the taxonomic model and ideas that we have presented in this paper, will test the efficacy of the designations that have been proposed, and offer constructive suggestions and refinements that will ultimately lead to a classification system that is worthy of consensus.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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