Mindfulness Meditation in Clinical Practice - Salmon, Sephton et. al. (2004) - Article

The practical aspects of mindfulness have been integrated into contemporary clinical psychology. It is based on Buddhism but now integrated into Western healthcare, especially in psychotherapy and stress management. Nowadays mindfulness has become a systematic clinical intervention. In this article the stress-reducing function of mindfulness meditation in medical settings will be described.

Kabat-Zinn was the first who applied mindfulness meditation in a clinical setting. He set up a program to reduce stress in patients called Mindfulness-Based Stress Reduction (MBSR). The key of mindfulness is to focus your attention on what is happening now without judging this. Paying attention to what is happening now prevents you from extensive thinking about past experiences, which almost never increase quality of life. Ideas of Buddhism are to some extent similar to Western pragmatism, in which independency of behaviour, emotions, cognition and memory is important. In mindfulness you have to become aware of these interactions. Mindfulness is described as ‘’ learning to observe internal and external events without ending them if they are unpleasant and making them last longer if they are pleasant. This can be used to extinct anxiety and avoiding of the events or thoughts. People learn that thoughts are just thoughts, you do not have to act on them. Acceptance and Commitment Therapy (ACT) is a mindfulness based intervention that emphasizes acceptation of what is happening, clarity of perception and freedom from the judgemental aspects of language. Psychodynamic therapies can also be based on mindfulness. Meditation is nowadays more seen as a certain way of perceiving and reaction on the world. The experienced is deepened because of a focus on the present.

Two cautionary notes are important in the application of mindfulness in clinical practice. First, in clinical psychology the principles of mindfulness are applied in order to increase health and mental well-being and to reduce suffering of illness, whereas in Buddhism mindfulness is a way of ‘’being with’’ the suffering that is unavoidable a part of life. Second, in Western psychotherapy the ‘’self’’ is emphasized whereas in Buddhism the ‘self’ is seen as something artificial, a concept based on language that limits the perception. Preoccupation with the ‘self’ can prevent you from change and acceptation and it can elicit rigidity. Attachment lies at the root of suffering. This includes attachment in any context such as possessions, personal relationships or any endeavour that becomes object of deliberate attainment.

Kabat-Zinn and others emphasize the importance of acceptation which is to adopt an open and non-judgemental observational style in relation to yourself. He also describes how paying attention can lead to stress reduction. To be aware of the effects that stress have on you is required to engage in an effective coping strategy.

By engaging in mindfulness you will be able to detect minimal psychological reactions that can lead to over activation of the autonomic nervous system and elicit a fight/flight reaction. This activates a chain of dysfunctional reactions and the negative effects will accumulate. This is called allostatic load. If the allostatic load further increases, the regulatory systems will desensitize. As a result of chronic activation stress response mechanisms may contribute to stress-related diseases. Mindfulness can break through this cycle of because people have to pay attention to stress symptoms on a low level after which they can respond more consciously. The MBSR program, often in a group setting and of limited time, helps people to recognize stress symptoms and to respond to them more effectively. Aspects that are relevant in clinical practice: (1) conscious allocation of attention (2) non-judgemental awareness (3) a state of physiological hypo-arousal with the intention to (4) enhance present moment awareness and (e) diminishing habitual patterns of cognitive, behavioural, and physiological reactivity.

Regulation of attention

Regulation and allocation of attention are important principles in meditation practice. Meditation focuses on observable phenomena such as breathing, this in contrast to cognitive therapy that focuses on the content of thoughts and cognitions. Although paying attention to your breathing may sound simple, practice is needed and from here one can proceed to other objects of attention. Mindfulness focuses on a broad range of cognitions and mental states. People learn to detach from their thoughts and to observe them as objects of attention without analysing them. The idea is that the more you try to suppress a certain thought the more salient it will become.

Non-judgemental-awareness

Non-judgemental awareness is the capability to observe events, thoughts, evaluations, memories and other mental activities as they occur without judging. Evaluative self-statements can become thing-like and static rather than a moment-to-moment flow, this is called reification. As soon as judgement of other cognitive commentaries come up we are in a diminished state of awareness. Acceptation is related to non-judgemental awareness because it is a way of relating to one’s experience irrespective of its nature, pleasant or unpleasant. In psychodynamic theories this is also important. Some researchers found similarities between meditation and psychodynamic uncovering in which neutral observation is important as well as the development of a therapeutic split, becoming a witness to one’s experience.

Physiological hypoarousal

Low physiological arousal stimulates mindfulness and related techniques in a positive way. In contrast to the increased autonomic arousal that is present in our daily behaviours. Hypoarousal elicits a slower metabolism, reduced energy expenditure and broadening of awareness that promotes relaxed awareness. In people who experience chronic stress, the process of allostasis causes a continued state of vigilance, also when one is relaxing. In homeostase the bodily processes are more in balance. Meditation exercises are aimed to open up awareness without physiological inferences which can stimulate the gradual slowing of physiological and cognitive activity.

Present-moment focus

The key of mindfulness is to focus on the present moment. This can be challenging since there is a lot of competition going on usually between different stimuli that want to grab your attention. Since many actions can be done automatically without much thinking, it is possible to engage in other cognitive activities simultaneously but it take’s the focus away from the present situation. This could be illustrated by a musical analogy, careful attention to the notes of musical composition as it unfolds from moment to moment is an form of mindfulness practice.

Behavioural responsiveness (versus reactivity)

In mindfulness there is a difference between habitual patterns of reactivity and deliberate responses. Stress is seen as an automated network that causes activation without awareness. In mindfulness you have to become aware of these reactions as they are occurring to engage a more deliberate response, this has been linked to increased self-efficacy, personal agency and coherence.

Clinical and research applications of mindfulness meditation

There are three trends visible in the use of mindfulness in Western therapy. (1) in stress reduction interventions, to prevent stress related disorders. (2) In psychotherapy where it provides a framework for both the client and the therapist. An observational stance toward inner experience is being encouraged. Maybe it can be extended to cognitive factors that play a role in stress related symptoms. (3) Mindfulness contributes to research on attention, suppression and other psychological constructs that are related to consciousness.

The MBSR program

The most well-known and cited intervention that is based on mindfulness is the MBSR program developed by Kabat-Zinn. The program focuses on stress-related symptoms in medical patients. It is based on the assumption that diseases can cause a lot of stress that can be amplified beyond the direct medical consequences. The meditation techniques are aimed to reduce the suffering from stress symptoms and not to cure the disease. This approach has shown to be effective in patients with chronical pain, anxiety/panic disorder and in preventing relapse in depression. There is a difference between the structural and program oriented elements of the therapy. Structural includes a group program of a certain number of sessions in which meditation techniques are being taught and homework is given. Concerning program oriented, the emphasize lays on the fact that mediation practice can really provide relief, however, without focusing on goal orientation. A third key element is the idea of personal responsibility for self-healing through application of the taught techniques. This in contrast to the more passive attitude of patients in traditional medical settings. The participant need to practice mediation on a daily basis, motivated or not. Finally, the program is also presented in a long-term perspective, one can improve one’s health in general, not only their response to stressors.

The MBSR program has become a group intervention of 8 sessions lasting 2,5 to 3 hours and a weekend retreat at the and. Contrary to group therapy, there is little focus on group interactions but more on developing a shared sense of participating in what is essentially an inward-focusing practice. The program focuses on mediation in combination with other cognitive interventions. Formal meditation exists of three practices: (1) body scan (2) hatha yoga and (3) sitting meditation. In the body scan, the attention is being allocated to different parts of the body for 30-45 minutes. Hatha yoga concerns subtle movements through which the attention is being allocated in order to increase the awareness of the body. Sitting meditation is about the development of self-observation in which the attention is directed to different sensory stimuli, physical sensations, thoughts etc. The idea is that also in daily life you could direct your attention to activities such as driving a car, having lunch, interactions with people etc.

MBSR, as said earlier, exists of 8 sessions. The first session is to get to know each other and a first exercise will be done, namely, the participants have to eat a raisin while direction attention it. Furthermore the body scan will be introduced and a sitting meditation as well. Through the body scan participants will learn to become aware of discomfort and to accept this. They are taught how to react and to recognize how the pain sensation is related to other mental activities that also contribute to the suffering. It is practiced how physical pain can be disassociated from cognitive, affective and other experiences that collectively comprise the experience. The fundamental lesson is that forms of suffering (pain, anxiety, worry or stress) are due to difficulty accepting present moment experience. This is also reinforced by the body scan. Commitment to the program which means to practice every day is very important. It is difficult not to see this as an assignment in a goal-oriented way, something you have to become better in, but this is exactly what is taught, namely that you have to be comfortable with the situation at the present time.

In the second session the experiences of doing a body scan will be discussed. By encouraging participants to accept feelings of distress the distress will be reduced. In this session sitting meditation is included of which the duration increases every weak. During the third session yoga is introduced and practiced. This and following sessions will also include sitting mediation in which participants have to focus on their breath. Also a topic related to stress will be presented every session, such as recognizing stress reactivity or mindful eating. Between the 6^th and 7^th session there is a silent retreat held. After eight sessions the program has finished and experiences will be shared.

There are usually three phases of development experienced. (1) people participate to decrease their pain or to learn to relax. In this phase acceptation of what one is experiencing is important. (2) In this phase, the participants realize that it is the response on stress related symptoms that elicits the suffering.. (3) in this phase the participants may begin to appreciate the impermanence of experience, both distress and pleasure. This stage is associated with a progressive deepening and compassion for oneself and others. Also the importance of observing in a patient and non-judgemental way is emphasized, as mentioned earlier.

There are some directions for future research described. First, mindfulness seems a promising intervention despite of the fact that the conducted studies could be improved. For example, the use of control groups, randomisation and the predictive function could be improved. In the future a multimodal assessment strategy might be effective to study the physiological processes such as the allostatic load. In addition, in medical settings mindfulness is used reduce distress and pain but the original idea of mindfulness was different. Meditation practice emphasizes cultivating a calm, contemplative frame of mind accompanied by a corresponding state of psychophysiological tranquillity. Third, future research should focus more on culture and gender aspects that may have an influence on the working of mindfulness therapy. Finally, the program could be divided in different elements, to investigate which parts of the intervention are effective.