Doctors have the highest rate of suicide

Today is National Doctor’s Day.  ⠀⠀  Here is something you may, or may not know—But you may want to.  ⠀⠀  Doctors' Suicide Rate is the Highest of Any Profession  ⠀⠀  In fact, One doctor commits suicide in the U.S. every day.  ⠀⠀  Doctors who die by suicide often have untreated depression or other mental illnesses, including high rates of alcoholism and substance abuse.  ⠀⠀  Just like in the general population, A major barrier to solving this phenomenon is STIMGA —One study found that 50% of doctors would not seek help because of stigma; Much higher than the general population.  ⠀⠀  We can do better — We can do better within the profession, and as a society. We can all do a better job of taking care of each other, and ourselves.  ⠀⠀  We are only as sick as our secrets.  ⠀⠀  One love ❤️ ☮️  ⠀⠀  #NationalDoctorsDay #suicide #MentalHealth #ipreview via

Today is National Doctor’s Day.


Here is something you may, or may not know—But you may want to.


Doctors' Suicide Rate is the Highest of Any Profession


In fact, One doctor commits suicide in the U.S. every day.


Doctors who die by suicide often have untreated depression or other mental illnesses, including high rates of alcoholism and substance abuse.


Just like in the general population, A major barrier to solving this phenomenon is STIMGA —One study found that 50% of doctors would not seek help because of stigma; Much higher than the general population.


We can do better — We can do better within the profession, and as a society. We can all do a better job of taking care of each other, and ourselves.


We are only as sick as our secrets.


One love ❤️ ☮️


#NationalDoctorsDay #suicide #MentalHealth #ipreview via

Placing mindfulness within the Buddhist Culture


Mindfulness and Buddhist Culture

It is valuable to consider the benefits of mindfulness (and its relevance to potentially decreasing dark side of flow) in the greater context of Buddhist philosophy. Groves and Farmer (1994) indicate “Buddhist doctrines deal in detail with craving and attachment, how they arise, the forms they take, their results, and also how they can be managed” (p.183). The Four Noble Truths—one of the oldest articulations of Buddhist doctrine that is said to be the first discourse given by the Buddha after his Enlightenment—depicts how craving and attachment lead to suffering (Groves, & Farmer, 1994).

The Four Noble Truths are (1), suffering exists; (2), there is a cause of suffering, and the cause of suffering is craving; (3), there is the cessation of suffering which is Enlightenment; and (4), there is a path that leads to the cessation of suffering which is the Noble Eightfold Path (right view/understanding, right intention/thoughts, right speech, right action, right livelihood, right effort, right mindfulness, right concentration) (Van Gordon, Shonin, Griffiths, Singh, 2015). Marlatt (2002) described the Four Noble Truths as being at the heart of all Buddhist practice. 

The First Noble Truth is that life is suffering (dukkha). Dukkha is usually translated as suffering, but includes misery, change, pain, imperfection or a lack of satisfactoriness (Marlatt, 2002). Marlatt (2002) stated, “the first truth is that the experience of suffering is universal; it is part of the human experience to have periods of physical, emotional, or psychological distress” (Marlatt, 2002, p. 45-6). This type of all encompassing suffering can be considered an existential dissatisfaction.  Buddha detailed “birth is suffering, aging is suffering, illness is suffering, death is suffering; union with what is displeasing is suffering; separation from what is pleasing is suffering” (Van Gordon, Chonin, Griffiths, Singh, 2015, p. 10).

Beyond the present moment experience of suffering, Buddha described how there is also potential suffering, that is, fear that something may happen to cause future unhappiness (Groves, Farmer, 1994).  This category of enduring and covert suffering is known in Buddhism as “all-pervasive suffering” (Van Gordon, Chonin, Griffiths, Singh, 2015, p. 11).

The Second Noble Truth is that the root cause of suffering is caused by attachment to either pleasurable experiences (craving) or attachment to avoiding unpleasant experiences (aversion) (Groves, & Farmer, 1994; Marlatt, 2002). Groves and Farmer (1994) state, “craving is said to arise in dependence on vedana, usually translated as feeling [emotions], which may be pleasant, unpleasant or neutral” (Groves, Farmer, 1994, p. 185).

Marlatt (2002), elucidating Buddhist doctrine, described how “engaging in drug use or other addictive behaviors is a "false refuge" [from suffering] because it is motivated by a strong desire or "craving" for relief from suffering, despite the fact that continued involvement in the addictive behavior increases pain and suffering in the long run” (p. 46). In this regard, addictive behaviors such as flow provide a temporary refuge by enhancing positive emotional states and/or eliminating individuals’ experience of negative emotional states, but they do not provide an ultimate solution (refuge) (Marlatt, 2002).  In this perspective, it can be hypothesized that the rewarding and transcendental experience of flow may provide a false refuge.

Buddha illumined an additional challenge with attachment that is relevant to our exploration of action and adventure sport athletes. As outlined by Marlatt (2002) “addiction is enhanced to the extent that the individual becomes increasingly dependent on or "attached" to the behavior that appears to offer refuge and relief from suffering”  (p.46).  And, as individual’s attachment to their addictive behavior grows, “the individual is likely to experience increased "craving" for the anticipated relief associated with engaging in the addictive behavior” (Marlatt, 2002, p. 46). Action and adventure sport athletes therefore may become trapped in suffering when they cling to their flow-inducing sport as the only source of relief from suffering. This may be an important consideration given the praise and drive that action and adventure sport athletes receive from others which may further assert their (false, in the Buddhist sense) self.

Regarding the Buddhist etiology of suffering, Shonin et al. (2013) formulated the concept of ontological addiction to describe this nuanced and complex concept. Ontological addiction is defined as “the unwillingness to relinquish an erroneous and deep-rooted belief in an inherently existing ‘self’ or ‘I’ as well as the ‘impaired functionality’ that arises from such a belief” (Van Gordon, Shonin, Griffiths, & Singh, 2015, p. 13).  As described prior, Buddha taught that afflictive mental states arise as a result of the false belief in an inherent sense of “self” which unremittingly craves after items it considers to be attractive or projects dislike towards objects it considers to be unattractive (Van Gordon, Shonin, Griffiths, & Singh, 2015).

In Buddhist philosophy, suffering ultimately arises “due to an individual’s ignorance as to the ultimate nature of self and reality” (Van Gordon, Shonin, Griffiths, & Singh, 2015, p. 12). This is an important consideration to keep in mind when reviewing how flow theory describes the notion of the ‘self’ (Csikszentmihalyi, 1990).

The Third Noble Truth is that it is possible to be free from suffering and that there is a path to alleviate suffering. The truth of the cessation of suffering is described as “the complete fading-away and extinction of this craving, its forsaking and abandonment, liberation from it, detachment from it” (Groves & Farmer, 1994, p. 186). The complete cessation of suffering is synonymous with Enlightenment or Nirvana, and is considered taking true refuge (Groves & Farmer, 1994).

The Fourth Noble Truth is that the end of suffering is contained in the Noble Eightfold path. The Noble Eightfold path includes: (1) right view/understanding, (2) right intention/thoughts, (3) right speech, (4) right action, (5) right livelihood, (6) right effort, (7) right mindfulness, (8) right concentration (Van Gordon, Shonin, Griffiths, & Singh, 2015). While it is beyond the scope of this project to delineate the complexity of the Noble Eightfold path, the concept of the Noble Eightfold path that is particularly relevant to our current discussion is how a fundamental wrong view that happiness can be achieved through worldly existence (such as in the accomplishments that result from flow) can lead to happiness (refuge). Moreover, an important view central to Buddhism is ‘impermanence’, that all things change, including, therefore, flow state (Groves, Farmer, 1994).


Can Mindfulness decrease flow-state?

Mindfulness decreases some aspects of flow: the incompatibility of mindfulness and flow absorption. Sheldon et al. (2015) presented a strong case for the differences between flow and mindfulness via the metaphor of a stream of consciousness. Mindful people are self-reflective, sitting on the bank of the stream, watching with acceptance as the water/emotions/thoughts move through their consciousness. In contrast, an individual in flow jumps into the stream and loses their capacity for self-reflection, meeting challenges that confront them in the stream (Sheldon et al., 2015). Sheldon et al. (2015) hypothesized that “the two states may in fact be antagonistic, with mindfulness tending to bring one back to the bank of the stream, precluding flow” (p. 276).

Sheldon et al. (2015) argued that the ability to remain mindful during an activity may hinder an individual’s tendency to become absorbed in a flow experience and lose awareness of self. They found a negative correlation between mindfulness and flow for the absorption aspect of flow; individuals who remained mindful had less of a “feeling of being carried away by activity, with an altered sense of time and a loss of self-awareness (Sheldon et al., 2015, p. 281). Past researchers found that being mindful increases general flow (Aherne et al., 2011; Kaufman, Glass, & Arnkoff, 2009). Sheldon et al. (2015) found this was not the case for absorption and loss of self-reflective awareness, which suggests mindfulness increases flow and self-regulation.

Mindfulness and flow in elite athletes

Mindfulness and flow in elite athletes.

Cathcart, McGregor, and Groundwater (2014) recently explored the relationship between mindfulness and flow in elite athletes. Cathcart, McGregor, and Groundwater’s (2014) research extends previous research (Bernier, Thienot, Codron, & Fournier, 2009; Salmon, Hanneman, & Harwood, 2010; Schwanhausser, 2009) which has shown mindfulness may be one potential method for enhancing flow and to improve athletic performance.  McGregor and Groundwater (2014) suggested that the symbiotic relationship between mindfulness and flow may be the core element of present-moment focus and immersion in the task at hand, as noted by others (e.g., Gardner & Moore, 2004, 2006; Kaufman et al., 2009; Kee & Wang, 2008; Salmon et al., 2010).

An interesting cultural variable that Cathcart, McGregor, and Groundwater (2014) included was exploring weather gender and choice of sport impacted the relationship between mindfulness and flow. There results indicate that gender and sport did not display a difference in the propensity for mindfulness and flow. However, Cathcart, McGregor, and Groundwater (2014) described that gender and sport was related to a different relationship between the subscale constructs of mindfulness and flow. In particularly, Cathcart, McGregor, and Groundwater (2014) state “the relationship between mindfulness and flow may possibly be stronger in individual-pacing sports compared with team-based non-pacing sports, and mindfulness may possibly be related to different facets of flow in males compared with females” (p. 139).

Moreover, Cathcart, McGregor, and Groundwater (2014) also suggested that the following are features of mindfulness that are not features of flow: “(a) an orientation to, and openness and acceptance of, experience, cultivated through mindful meditation; (b) an explicit intention to observe the transient nature and subjectivity (as opposed to validity) of experience (including feelings, cognitions, sensations); and (c) a focus on the internal experience. Further, Bishop et al. suggested that flow is better considered as a potential outcome of mindfulness, rather than a comparable process” (Cathcart, McGregor, and Groundwater, 2014, p.138). Cathcart, McGregor, and Groundwater (2014) assert, “given previous research indicating that mindfulness is useful for enhancing athletic performance and well-being in elite athletes, further research should be conducted to replicate and extend the present exploratory results” (p.139). The current study utilizes the same measurements of Cathcart, McGregor, and Groundwater (2014), therefore our results may be considered as one study that has replicated and extended their previous work.

Research on the intersection of mindfulness and flow-state

Mindfulness and Flow

Living in the present. Flow depends on the ability of performers to remain focused on the present moment. Jackson and Csikszentmihalyi (1990) suggested, “concentration on the task at hand is the most obvious feature of being in the flow” (p. 110). Being in the present enhances performance and improves the quality of experiences (Jackson & Csikszentmihalyi, 1990). Present-centeredness is a state in which things appear to happen effortlessly because the strategies and assessments that typically occupy the mind are silent (Jackson & Csikszentmihalyi, 1990). Flow requires the capacity to live in the moment and focus (Jackson & Csikszentmihalyi, 1999; Jackson & Delehanty, 1995; Orlick, 1990; Ravissa, 2002). Aherne et al. (2011) asserted that “concentration, or the ability to focus on the task at hand while ignoring distractions, is a crucial prerequisite of successful performance in sport” (p. 177). Jackson (1995) found that flow requires a present, non-self-conscious concentration on a task. Jackson (1995) reported that the main barriers to athletes achieving flow were cognitive factors (e.g., thinking too much, focusing on the self).

There is some empirical research supporting that people with a high disposition for flow are more mindful and vice versa (Bernier, Thienot, Codron, & Fournier, 2009; Kee & John Wang, 2008; Moore, 2013). Indeed, to many researchers, mindfulness and flow appear to be similar psychological states. Previous researchers have highlighted a clear theoretical relationship between the concepts, mainly there emphasis on present-moment focus (see Gardner & Moore, 2004; Kaufman et al., 2009; Kee & Wang, 2008; Salmon et al., 2010; McGregor, & Groundwater, 2014). Wright et al. (2006) suggested that flow and mindfulness may be on an experiential continuum. Sheldon, Prentice, and Halusic (2015) proposed that increasing the ability to be mindful might also increase the ability to experience flow. Flow and mindfulness both emphasize the importance of the present moment, but few researchers assessed athletes’ mindfulness and experiences of flow (Aherne et al., 2011). Kee and Wang (2008) asserted, “there was a lack of research addressing the relationship between flow and mindfulness” (p. 396).

Relationship between mindfulness, flow dispositions, and mental skills adoption. Kee and Wang (2008) used a cluster analysis approach to examine the relationship between mindfulness, flow disposition, and mental skill adoption. Individuals who were more mindful tended to be more likely to experience flow. High mindfulness cluster individuals had higher scores on five of the nine flow dimensions, including challenge-skill balance, clear goals, concentration, sense of control, and loss of self-consciousness (Kee & Wang, 2008). Kee and Wang (2008) proposed that flexible attitudes could “lead to more favorable perception of balance between challenge and ability, making it conducive for flow to occur” (p. 406). Flow is dependent upon how one perceives their ability to overcome challenges; the mindfulness cluster’s increased flexibility allowed them to be less deterred by perceptions of skill and challenges. Kee and Wang (2008) explained the reason for an increased loss of self-consciousness in the high mindfulness group may be a result of increased self-esteem and lower susceptibility to introjections. Cultivation of a sense of unselfconsciousness in mindfulness (i.e., letting go of ego) could result in greater flow.

Mindfulness increases some aspects of flow. Aherne et al. (2011) investigated mindfulness for its ability to strengthen attention and increase flow. Before 2011, there was qualitative research by Jackson (1995) and a quantitative cluster analysis by Kee and Wang (2008) that linked mindfulness with the flow experience. However, the design of previous studies did not suggest that mindfulness caused athletes to experience greater flow. Aherne et al. (2011) tested the effects of a mindfulness training program on athletes’ flow experience during competitive training and found that mindfulness increased global flow scores and specific flow dimensions. Like Kee and Wang (2008) and Sheldon, Prentice, and Halusic (2015), Aherne et al. (2011) found that mindfulness specifically increased the flow subscales of clear goals and sense of control. Aherne et al. (2011) suggested this may relate to attention; those who are more mindful tend to be more aware of their goals and may also have a greater sense of control. Kee and Wang (2008) did not find that mindfulness increased scores on flow subscales for loss of self-consciousness, challenge-skill balance, or concentration.

Propensity for experiencing flow: The roles of cognitive flexibility and mindfulness. Moore (2013) examined cognitive skills related to flow disposition and stated that “mindfulness can predict flow disposition” (p. 328). Moore (2013) asserted that this link may be because both mindfulness and flow require self-regulation of attention in the present moment. Cognitive flexibility and mindfulness are codependent (Moore, 2013). Cognitive flexibility is creativity and freedom from cognitive rigidity; it includes at least one of three factors: (a) the ability to adapt to change; (b) the ability to think of a variety of categories and concepts; and (c) the ability to perceive multiple perspectives or thoughts (Moore, 2013). Cognitive flexibility may be necessary to maintain flow as challenges and demands of an activity change.

Mindfulness as a therapeutic intervention

Mindfulness as a Therapeutic Intervention. In the health professions, including psychology and medicine, mindfulness is gaining popularity for its ability to help people respond more skillfully to internal experiences that contribute to emotional distress and maladaptive behavior (Bishop, 2002; Bishop et al., 2004). Siegal (2007) suggested, “the general clinical benefits of mindfulness is that the acceptance of one’s situation may alleviate the internal conflict[s] that may emerge when expectations of how life should be fail to match how life actually is” (Kaufman, Glass, Arnkoff, 2009 p. 336). As in the TOTE model, the comparator more easily accepts discrepancies and decreases emotional responses, thus improving self-regulation of goal-directed behaviors. Anderson, Lau, Segal, and Bishop (2007) suggested that mindfulness-based interventions are clinically effective for a wide range of conditions (See Bishop, 2002; Bishop et al., 2004).

Kabat-Zinn (1982) introduced mindfulness-based stress reduction (MBSR), a manualized treatment program. MBSR was originally for the management of chronic pain (Kabat-Zinn, Lipworth, & Burney, 1985; Kabat-Zinn, Lipworth, Burney, & Sellers, 1986). MBSR facilitates the reduction of many affective symptoms associated with various medical illnesses, stress and anxiety in healthy individuals, and depressive relapse (Anderson et al., 2007; Kabat-Zinn, 1998). MBSR also eases stress and improves emotional well-being in nonclinical samples (Anderson et al., 2007).

Mindfulness is also popular as a therapeutic intervention in multiple theoretical orientations (e.g., dialectical behavior therapy).  Mindfulness reduces self-harm and suicidal behavior in individuals with borderline personality disorder (Bishop et al., 2004; Linehan, Armstrong, Saurez, Allmon, & Heard, 1991). Mindfulness-based cognitive therapy reduces the rate of relapse in patients with recurrent major depression (Bishop et al., 2004; Teasdale, Segal, Williams, Ridgeway, Soulsby, Lau, 2000). Mindfulness may help treat generalized anxiety disorder, post-traumatic stress, substance abuse, and eating disorders (Roemer & Orsillo, 2002; Wells, 1999).

What is Mindfulness?


What is Mindfulness?

 The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will. No one is compos sui if he have it not. An education which should improve this faculty would be the education par excellence. But it is easier to define this ideal, than to give practical directions to bring it about. (James, 1980)

 Mindfulness has its roots in contemplative Eastern spiritual traditions, especially Buddhism, in which individuals actively cultivate consciousness. Mindfulness is a “moment-to-moment, non-judgmental awareness, cultivated by paying attention in a specific way, that is, in the present moment, and as non-reactively, as non-judgmentally, and as open heartedly as possible” (Kabat-Zinn, 2015, p. 1481). Nyanaponika (1972) described mindfulness as “the clear and single-minded awareness of what actually happens to us and around us in the successive moments of perception” (p. 5). Mindfulness is an innate quality of mind and a mental skill that people can refine through contemplative practice, such as in meditation (Kabat-Zinn, 2015). Kabat-Zinn (1994) suggested that mindfulness meditation is synonymous with the practice of non-doing, an effortless effort that is similar to flow.

Mindfulness begins with consciousness, which often entails both awareness and attention (Brown & Ryan, 2003). Brown and Ryan (2003) described awareness as “the background ‘radar’ of consciousness, continually monitoring the inner and outer environment” (p. 822). An individual may be aware of stimuli, but the mechanism of attention focuses “conscious awareness, providing heightened sensitivity to a limited range of experience” (Brown & Ryan, 2003, p. 822). Buddhist Dharma asserts that mindfulness is a path that can lead to the cessation of personal suffering (Bishop, Lau, Shapiro, Carlson, Anderson, Carmody, Devins, 2004). Mindfulness has been considered “the heart of Buddhist meditation” (Kabat-Zinn, 2015, p. 1482). Mindfulness is central to all Buddhist teachings and traditions around the world but is not inherently religious and spreads in a non-secular form.

The initial inspiration to investigate mindfulness as a tool to harness the power of flow was Murphy and White’s book, In the Zone: Transcendent Experiences in Sport (1995), which explained that athletes “have trouble recapturing peak moments in sport because they have difficulty incorporating them into the rest of their lives” (p. 118). Murphy and White (1995) stated,

Many athletes have trouble recapturing peak moments in sport because they have difficulty incorporating them into the rest of their lives. Former quarterback John Brodie described this problem: “Football players and athletes generally get into this kind of being or beingness – call it what you will – more often than is generally recognized. They often don’t have a workable philosophy or understanding to support the kind of thing they get into while they are playing [italics my own]. They don’t have the words for it. So, after a game you see some of them coming down, making fools of themselves sometimes, coming way down in their tone level. But during the game they come way up. A missing ingredient for many people, I guess, is that they don’t have a supporting philosophy or discipline for a better life. (p. 118)

 For athletes to incorporate flow in their lives, athletes “must live in tune with their truth by practicing some kind of spiritual discipline” (Murphy & White, 1995, p. 118). The current study suggests mindfulness may help athletes live in harmony with self-transcendent experiences of flow.

A growing body of literature indicates that mindfulness can enhance flow and performance in sport setting (Cathcart, McGregor, & Groundwater, 2014). Indeed, a number of studies (Kabat-Zinn, Beall, & Rippe, 1985; Wolanin, 2005; Gardner, & Moore 2004, 2006; Bernier et al. 2009; Schwanhausser, 2009; Aherne et al. 2011) found mindfulness training increased flow and sport performance following mindfulness training.  

 Mindful Self-Regulation. Mindfulness is a method to achieve emotional balance and enhance goal attainment through improved perception and judgment (Hayes & Feldman, 2004). Bishop et al. (2004) suggested a two-component definition of mindfulness that provides a clear framework for the mechanism of mindfulness and how it optimizes emotion regulation. The first component of mindfulness is the self-regulation of attention on the present moment (Bishop et al., 2004). The second component is openness and acceptance of all experiences, regardless of desirability (Bishop et al., 2004). These two components enable individuals to develop a “decentered” relationship with their internal and external experiences, which decreases emotional reactivity and promotes greater emotional stability (Hayes & Feldman, 2004; Segal, William, & Teasdale, 2013). Mindfulness results in emotional engagement that is the opposite of under-, and over-, and mis-regulation (i.e., maladaptive emotion regulation) (Bishop et al., 2004; Hayes & Feldman, 2004).

Mindfulness is a tool for self-regulation that enables individuals to disengage from automatic thoughts, habits, and behavior patterns (Deci & Ryan, 1980). Deci and Ryan (1980) suggested that the open awareness of mindfulness may be necessary to choose behaviors that are consistent with personal goals, needs, values, and interests. Individuals must regain the capacity for an open attention to see things “as they are” and reestablish the appropriate regulatory communication for self-control (Brown & Ryan, 2003, p. 824). Mindfulness may play a key role in fostering self-endorsed behavioral regulation (Ryan & Deci, 2000).

Carver and Scheier (1981) argued that the TOTE model shows attention is vital to self-regulation and a lack of attention via substance abuse (and perhaps transient hypo-frontality) may impair self-regulation. Brown and Ryan (2003) suggested “mindfulness is also compromised when individuals behave compulsively or automatically, without awareness of or attention to one’s behavior” (p. 823). Self-regulation failure can also occur if a person pays too much attention to information that enters awareness and it becomes cognitively exaggerated (Brown & Ryan, 2003; Clark, 1986).

Flow-State and Culture

Flow and Culture

Cultures are defensive constructions against chaos, designed to reduce the impact of randomness on experience…cultures prescribe norms, evolve goals, build beliefs that help us tackle the challenges of existence. In so doing they must rule out many alternative goals and beliefs, and thereby limit possibilities; but this channeling of attention to a limited set of goals and means is what allows effortless action within self-centered boundaries. (Csikszentmihalyi, 1990, p. 81)

 Moneta (2004a) asserted, “we still know little about the features, situational/personal determinants, and behavioral/psychological implications as well as consequences of flow in non-Western cultures” (p. 146). Therefore, there may be validity concerns when applying flow theory with its Western model of self, that is fundamentally independent or autonomous, to Eastern models of self that are interdependent or collectivist (Asakawa, 2010). Due to different conceptualization of self, flow may be culturally biased and may not accurately assess optimal psychology in Eastern collectivist cultures.

Flow and culture: Western flow versus Eastern flow. Nakamura and Csikszentmihalyi (2002) emphasized “the [flow] experience is the same across lines of culture, class, gender, and age, as well as across kinds of activity” (p. 90). Asakawa (2010) argued, “cultures affect how people experience flow” (p. 220). Moneta (2004a; 2004b) claimed that internalization of cultural values and self-perception moderate the flow model. Diversity of cultural values, including differing ways of conceptualizing and engaging with a sense of self, make flow dynamic; how one experiences it changes depending on their culture. Most researchers of culture and flow highlighted difference in how people experience flow in the Eastern cultures of China and Japan compared to the Western cultures of North American.

Westerners conceptualize the self as fundamentally independent; Easterners’ model of self is fundamentally interdependent (Moneta, 2004a; 2004b). A Western conception of self reflects a tendency to construe personal existence as separate from the social context and others (Moneta, 2004a; 2004b). On the other hand, Eastern sense of self is interdependent and reflects the tendency to construe individual existence as a holistic part of the social context united with others (Moneta, 2004a; 2004b). A Western sense of self favors the pursuit of unique goals that occurs through the skill-stretching process of flow (Moneta, 2004a; 2004b). An Eastern sense of self may result in a weaker desire to be unique and less inclination toward the challenge-skill balance. Moneta (2004a; 2004b) asserted that Easterners have a greater need to maintain social harmony.

Moneta (2010b) explained that Chinese individuals often seek a state of optimal functioning that differs from the Anglo-Saxon Western concept of flow. Chinese people experience flow informed by “Taoist and Confucianism principles of prudence, attention to detail, balance between proactivity and receptiveness, and inter-connectedness with others” (Iyengar & Lepper, 1999, p. 125). Chinese cultures promote social harmony and values or behaviors that achieve it (Moneta, 2010b). These cultures encourage conforming behavior over adventure or exploration, which are the epitome of North American concepts of flow. The Chinese approach to challenges may change their optimal challenge/skill balance to be heavily biased toward skills. Unlike more autonomous American individuals, Chinese athletes may feel motivated by safer mastery-practice approaches to challenges.

Japan and self-criticism. Asakawa (2010) noted that Japanese people experience flow in a uniquely cultural way. Japanese college students experienced Csikszentmihalyi’s concept of flow significantly less than their Western counterparts. Asakawa (2010) explained that North American and Western European cultures have a self-enhancement tendency and people in Asian cultures have a self-criticism tendency (Kitayama, Markus, Matsumoto, & Norasakkunkit, 1997; Markus & Kitayama 1991). Kitayama et al. (1997) stated, “in Japanese culture self-criticism represents a constructive process, allowing Japanese individuals to obtain information vital to maintaining and supporting the social group norms that are valued over Western concept of individuality, autonomy, or uniqueness” (p. 115). Japanese people often focus on their shortcomings and try to fix weaknesses for group cohesion. Therefore, Japanese people may experience less of a Western version of flow because they concentrate less on individualized activity and more on social impact. Therefore, Japanese people may not lose their sense of self-consciousness in activities in the same way Anglo-Saxon individualistic Westerners do. Flow theory may not apply for people from more collectivist cultures (Asakawa, 2010).

The Neuroscience of Flow-State

The Neuroscience of Flow—The Transient Hypo-Frontality Theory

 Prior to recent neuroscience advances, Csikszentmihalyi’s flow theory was merely a phenomenological theory based on qualitative interviews or self-report scales. Recent advancements in brain imaging and physiological measurement techniques provide details of the neurobiological underpinnings of flow.

The neuroanatomy of the brain as well as cognitive function evolved in a hierarchical fashion (Dietrich, 2003, 2004, 2006). It began with the development of the outermost area of the brain known as the cerebral cortex, particularly the pre-frontal cortex (Dietrich, 2003, 2004, 2006). The pre-frontal cortex increases cognitive and behavioral flexibility, which increased adaptability of the human species. The frontal cortex enables evolutionary adaptive capacities due to its ability for higher-cognitive function, including, but not limited to self-construct, self-reflective consciousness and cognitive flexibility, complex social function, and theory of mind (Dietrich, 2003, 2004, 2006). Despite the importance of these functions for long-term survival, they appear in direct contrast to the experience of a loss of self-awareness while in flow. Therefore, Dietrich (2003, 2004, 2006) suggested that flow occurs because of ‘transient hypo-frontality,’ a temporary suppression of prefrontal circuits.

Transient hypo-frontality theory (THT). Dietrich (2003, 2004a, 2006) described a down-regulation of activity in the prefrontal and conscious explicit brain during execution of well-learned skills (such as athletic skills). Sport activity creates a reliance on the cerebellar implicit motor and sensory regions of the brain (Sadlo, 2016). THT suggests that the brain down-regulates neural structures that are not necessary for the activity (Dietrich, 2003, 2004a, 2006). Dietrich (2009) suggested that the down-regulation of neural circuits progresses from brain areas supporting “the highest cognitive functions [of the pre-frontal cortex], down the functional hierarchy, one phenomenological subtraction at a time, to brain areas supporting the most basic ones” (p. 74). Dietrich (2009) posited that THT is based on well-researched principles of brain functioning: “(1) the brain has a finite energy supply; (2) that bodily motion is an extremely demanding task in computational terms - that is for the brain, not the body; and (3) that neural processing occurs on a competitive basis” (p. 73).

Due to the limited energy supply, the brain has limited resources (Dietrich, 2002). Dietrich (2003) proposed athletes may be particularly susceptible to transient hypo-frontality because “activation of motor and sensory systems during exercise comes at the expense of, first and foremost, the higher cognitive centers of the prefrontal cortex” (p. 240). The foundation of THT is that bodily motion forces the brain to make profound changes to the way it assigns metabolic resources (Dietrich, 2006). Information processing in the brain is competitive (Dietrich, 2006). Dietrich (2006) explained “because the brain cannot maintain activation in all neural structures at once, the activation of a given structure must come at the expense of others” (p. 80). When an individual experiences flow, Dietrich (2006) argued the brain experiences “a severe strain on the brain's limited information-processing capacity,” which “should result in a concomitant transient decrease in neural activity in structures that are not directly essential to the maintenance of the exercise” (p. 81).

Researchers refer to the explicit-implicit system as “conscious-unconscious, declarative-non-declarative, voluntary-automatic, or deliberate-spontaneous” (Dietrich, 2004a, p. 749). THT suggests that through skill repetition, individuals’ brains rely less on the explicit pre-frontal system and more on the implicit cerebellum and basal-ganglia (Sadlo, 2016). The process of building a skill in the implicit system is the act of “internalizing” or an action becoming “second nature” (Dietrich, 2004a, p. 750). The deactivation of the frontal cortex may benefit athletes as it suppresses a hyper-vigilante mind-state that overanalyzes internal experiences with respect to personal relevance (Dietrich, 2004a). THT results in a trade-off between the flexible pre-frontal system, in favor of the efficient implicit performance system (Dietrich, 2003, 2004a, 2006).

The theory of transient hypo-frontality explains what happens in the brains of athletes in flow—including the costs and benefits of efficient information processing in the implicit system. The flexibility/efficiency trade-off of transient hypo-frontality has advantages for athletic performance in flow activities; however, the suppression of the frontal cortex and flexible explicit system may impair other areas of life. For example, pre-frontal damage to the ventral medial (VM) region impairs social function (Dietrich, 2004a). As in the case of Phineas Gage, damage to the VM cortex results in “frontal syndrome” leading to “inappropriate social behaviors, lack of moral judgment, few social inhibitions, few abstract thought processes, an inability to plan for the future, and/or difficulty to maintain a plan of action” (Dietrich, 2004a, p. 1013). Without an active prefrontal cortex, athletes may lose the ability to inhibit inappropriate or maladaptive behaviors that place them at risk of the negative consequences associated with the dark side of flow (Dietrich, 2004a). Moreover, the brain structures not required for exercise (e.g., the amygdala, which is responsible for fear/threat detection), might fail during flow, which could explain increased risky behavior while in flow (Dietrich, 2004a).

The neurochemistry of flow. The positive consequences of flow may be due to alterations in neurotransmitter mechanisms such as dopamine (De Manzano, Cervenka, Jucaite, Hellenäs, Farde, & Ullén, 2013), endorphins (Hoffman, 1997), norepinephrine (Dishman, 1997), endocannabinoids (Dietrich & McDaniel, 2004; Sparling, Giuffrida, Piomelli, Rosskopf, & Dietrich, 2003; Tantimonaco, Ceci, Sabatini, Catani, Rossi, Gasperi, & Maccarrone, 2014), and serotonin (Chaouloff, 1997). Kotler (2014a) expanded on the impact of these neurochemicals, stating these are among the most addictive neurochemicals in the world. Further exploration of the neurochemistry of flow is beyond the scope of this project; however it will be further explored in future research.

The (lesser known) Dark Side of Flow-State

The Potential Negative Consequences of Flow—The Dark Side of Flow

            Csikszentmihalyi (1990) indicated, “while flow is a powerful motivator, it does not guarantee virtue in those who experience it” (p. 82). Although the literature is sparse with research on potential negative consequences of flow, Csikszentmihalyi (1990) hinted at a possible destructive side of flow stating that “like other forms of energy, from fire to nuclear fission, [flow] can be used for both positive and destructive ends” (p. 70). The danger of flow is evident in Csikszentmihalyi, Rathunde, and Whalen’s (1993) characterization of flow as “a subjective state that people report when they are completely involved in something to the point of forgetting time, fatigue, and everything else but the activity itself” (p. 59). The potential for flow’s negative consequences is also apparent in Csikszentmihalyi’s (1990) extended definition of flow as a state “in which people are so involved in an activity that nothing else seems to matter; the experience itself is so enjoyable that people will do it even at great cost, for the sheer sake of doing it” (p. 4). Therefore, a culture that enhances flow is not necessarily “good” in any moral sense (Csikszentmihalyi, 1990, p. 81).

Schüler (2012) hypothesized that while “the deep involvement in a task is usually described as a positive feeling…it is also associated with a loss of self-awareness, which means not thinking about the compatibility between one’s current activity and one’s future goals and personal values” (p. 124-125). Schüler (2012) asserted, “flow might produce short-term and long-term goal and psychological conflicts” that may impair self-regulation (p. 125). Schüler (2012) hypothesized that narrowed attention during flow could impact athletes’ ability to note additional information that may be relevant for long-term self-regulation. The perceived sense of control in flow may result in athletes underestimating their vulnerability and losing time awareness. This researcher reviewed all research that specifically explored negative consequences of flow.

Dependence in big wave surfing. Partington, Partington, and Olivier (2009) conducted a study of the negative consequences of flow dependence in big wave surfers. They found that flowing big wave surfers experienced many signs of dependence as outlined by Bamber, Cockrill, Rodgers, and Carroll (2003) and Hausenblas and Downs (2002a, 2002b). Big wave surfers experienced tolerance (i.e., a need for continuous increase in the size and speed of the surf to get the same rewarding flow experience) (Partington et al., 2009). They also experienced social impairment and conflicts; surfing dominated their behaviors and took precedence over gaining employment, attending social events, and starting families (Partington et al., 2009). Big wave surfers continued to surf despite injury and harm to their health, which may be as a loss of control (Bamber et al., 2003; Sachs, 1982). Table 1.1 includes examples from Partington et al. (2009) of ways surfers described their dependence on surfing.

 Table 1.1

 Dependence in Big Wave Surfers (Partington et al., 2009)

Addiction -“Once you get familiar with that feeling, it’s an addiction” (p. 176)

Tolerance - “Nothing is ever enough,” “After each turn, you want to accelerate faster in to the next turn” (p. 176)

Withdrawal - “There is psychologically after all that is done, there is a depression almost” (p. 179)

Social conflicts - “My husband wants to have babies. I kinda don’t cause I want to keep surfing you know?” (p. 179)

Continuation - “I have heard that a separated rib is more annoying than a broken rib…I went on for over 6 months. I tried to pad it, put on wetsuits” (p. 179)

Note. Adapted from Schüler (2012) and Partington et al., (2009)


The concept of exercise dependence is controversial. It can be either positive or negative. Partington et al. (2009) indicated that the dependence of big wave surfers is negative because the surfers were not able to inhibit their desire to surf.  Partington et al., (2009) noted, “several of the surfers themselves confessed to being unable to function ‘normally’ in society because of their involvement in surfing” (p. 183).

Flow, online game addiction, and Internet addiction. Thatcher, Wrestschko, and Fridjhon (2008) investigated flow and addictive tendencies among more than one thousand Internet users. Problematic Internet use is “use of the Internet that creates psychological, social, school, and/or work difficulties in a person’s life” (Beard & Wolf, 2001, p. 378). Thatcher et al. (2008) found evidence of a “flow-addiction link” in individuals who had stronger experiences of flow and higher problematic Internet use. Kim and Davis (2009) also discovered an association between flow and problematic Internet use.

Schüler (2012) described the reward mechanism by which flow leads to addiction. It is the principle of operant conditioning, “the positive quality of the flow experience functions as a reward which enhances the probability that the activity will be performed again” (Schüler, 2012, p. 126). Strong motivation to engage in a challenging activity may lead to skill mastery, but individuals may also fall victim to “a powerful motivating force at the expense of conscious control” (Schüler, 2012, p. 126). Csikszentmihalyi (1990) stated,

…when a person becomes so dependent on the ability to control an enjoyable activity that he cannot pay attention to anything else, then he loses the ultimate control: the freedom to determine the contents of consciousness. Thus, enjoyable activities that produce flow have a potentially negative aspect. (p. 62)

 Does flow experience lead to risk? How and for whom. Schüler and Nakamura (2013) examined the relationship of flow and risk awareness/risky behavior. They analyzed the flow-self-efficacy-risk-taking relationship to determine whether levels of self-efficacy predicted the flow-to-risk-taking phenomenon. Schüler and Nakamura (2013) based their hypothesis on Bandura’s (1997) assertion that self-efficacy leads to risk-taking. Those with low self-efficacy avoid risk-taking and those with high self-efficacy engage in risk-taking (Schüler & Nakamura, 2013).

Schüler and Nakamura (2013) found that flow caused low risk awareness and high risk-taking behavior, but this relationship only occurred in inexperienced individuals “because experienced athletes have more information at their disposal when evaluating sports situations, they are less easily seduced into responding to flow with an underestimation of risk” (p. 376). Schüler and Nakamura (2013) concluded, “experienced athletes can get the most out of flow. They feel effective, but their experience in the sport situation does not lead them to underestimate risk or engage in risky behavior. In short, their expertise protects them from risks” (p. 325).

Schüler and Nakamura (2013) suggested their findings may have heightened importance in contemporary culture that encourages risky behavior across multiple domains. High-risk sports with potential for severe injury or death are becoming increasingly popular (Llewellyn & Sanchez, 2008; Llewellyn, Sanchez, Asghar, & Jones, 2008; Salanova, Lorente, & Martínez, 2012). Despite negative possibilities, individuals should seek flow due to its positive effects (Schüler & Nakamura, 2013). However, for beginners, flow may be a “double-edged sword” (Schüler & Nakamura, 2013, p. 327).

Flow requires a balance between skills and challenges. This principle requires individuals to increase challenges to experience flow and therefore increase their risks. The loss of self-awareness (transient hypo-frontality) in flow “prevents worrying about danger, and the restriction of perception to a limited field of activity, which prevents the perception of signs of danger, combined with a high sense of control can be highly problematic when performing high-risk sports” (Schüler, 2013, p. 130). The rewarding consequences of flow can be so great that individuals willingly place themselves as risk and even endanger their lives.

Flow in anti-social behavior. When people lack the flow experience in life, they may seek flow in destructive or anti-social activities (Schüler, 2012). Harari (2008) studied antipersonnel flow and found that soldiers lost a sense of self-awareness when completely absorbed in the act of killing. Reviewing subjective statements by solders in previous literature, Harari (2008) discovered that the soldiers experienced a “heightened sense of being alive”, a loss of self-awareness, concentration, and a distortion in time (p. 132). Schüler (2012) suggested that this loss of self-reflective awareness may enable soldiers to perform killing without worries about “morality and human lives” (p. 131). Harari (2008) proposed that, like flow, a positive characteristic of combat is that “one’s entire awareness is absorbed in the present moment” (p. 254). Harari (2008) illustrated the experience of flow in combat with the following quote from an American soldier.

It was hard to describe how he felt…it was like an epiphany. Close to death, he had never felt so completely alive…The only thing he could compare it to was the feeling he found sometimes when he surfed, when he was inside the tube of a big wave and everything around him was energy and motion and he was being carried along by some terrific force and all he could do was focus intently on holding his balance, riding it out. Surfers called it The Green Room. Combat was another door to that room. A state of complete mental and physical awareness. In those hours on the street he had not been Shawn Nelson, he had no connection to the larger world, no bills to pay, no emotional ties, nothing. He had just been a human being staying alive from one nano-second to the next, drawing one breath after another, fully aware that each one might be his last. He felt he would never be the same. (Bowden, 2001, p. 301-302)