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					Mindfulness Meditation
Excerpt from:
Rediger, J, Summers, L. Mindfulness Meditation. In Lake, J and Spiegel, D (ed.),
Clinical Manual of Complementary and Alternative Treatments in Mental Health.
Washington, DC: American Psychiatric Press, Inc. 2006.

Introduction
In recent years, as a general shift in consciousness occurs that includes advances in physics,
neurophysiology, and a burgeoning interest in spirituality, western scientists are slowly moving into realms
that were previously considered outside the purview of traditional science. One of the most compelling areas
of new inquiry is the growing interest in studies on the nature and capacities of human consciousness. The
exploration of consciousness has enormous implications for all of the humanities and sciences, and
especially psychiatry, because a deeper understanding of consciousness is the key to both self-understanding
– and cultural understanding. Because Westerners are conditioned by a pervasive materialist worldview, it is
difficult for the western mind to accept the claim that objective knowledge about ourselves and the world can
arise independently of the five senses.

Meditation provides a particularly interesting window into the nature and capacities of human consciousness.
Believed to enhance the success and improve the quality of life for so many ordinary and extra-ordinary
people—-housewives, attorneys, adolescents studying martial arts, and even championship players on
basketball teams like the Chicago Bulls and Los Angeles Lakers – meditation is a practice whose time has
come. According to Salmon, Santorelli, and Kabat-Zinn (1998; cited by Baer 2003), by 1997 over 240
hospitals and clinics in the United States and abroad were offering their medical patients stress reduction
programs based on mindfulness meditation, a particular type of meditation examined below.

As interest in meditation grows, it is increasingly becoming the object of scientific investigation. The
meeting of eastern contemplative traditions with western science is a meeting of great import and meaning.
In a sense, it is a union of western post-Enlightenment rationalism with eastern concepts of enlightenment.
Psychiatry stands to reap important insights from the scientific study of meditation. This chapter summarizes
progress that has been made to date. The published research literature on meditation as an intervention for
psychiatric disorders is critically reviewed, clinical guidelines are presented, and future research goals are
suggested.

A Brief History and Definition
Historical studies of meditation
The Western medical literature contains over thirty years of published studies on meditation. One important
general observation is that different types of meditation cannot be easily compared, not only in terms of the
therapeutic benefits of particular meditation practices, but also in terms of empirical measures of cognitive,
emotional and bodily effects. Some forms of meditation are ecstatic or cathartic whereas others promote
calmness and relaxation. Some approaches attend to the fluctuation of internal experience, e.g., of thoughts,
emotions or bodily sensations; others train the mind to pay attention to particular external auditory or visual
cues. Physiological changes assoicated with meditation, including electrical brain activity , vary widely,
depending on the style of meditation, the duration of practice, and many factors that are difficult to quantify.
Claims of remarkable emotional and physiological benefits achieved by advanced meditators have attracted
considerable attention from western scientists. However, current research methods used to investigate these
claims are limited by our incomplete understanding of consciousness in general and the absence of
standardized protocols for measuring changes in functional brain activity during meditation.
Past Meditation Research
Transcendental meditation (T.M.) an approach in which the meditator achieves a meditative state by
repeating a word or phrase called a mantra, is a form of meditation that received considerable research
attention during the 1970s and 1980s. Most research into the effects of TM has been carried out at the
Maharishi International School of Management in Iowa, but other centers and individuals are engaged in TM
research as well. (Taylor, 1999–2004). During this same period, Dr. Herbert Benson‘s Relaxation Response
(1975) was rigorously tested as an intervention for both physical and psychological problems. To date most
formal research studies on meditation have focused on physical problems, and general anxiety or stress
associated with them. Fewer studies have examined claims of beneficial psychological changes including an
increased sense of general well-being and life satisfaction, and only very few studies have been done on
particular psychiatric disorders.

Mindfulness meditation
[Mindfulness training is a form of meditation that has been investigated as a treatment for particular
psychiatric disorders. Research into the relative advantages and disadvantages of mindfulness training with
respect to other styles of meditation has been coordinated by the mindfulness based stress reduction (MBSR)
program, led by Jon Kabat-Zinn at the University of Massachusetts School of Medicine. Kabat-Zinn‘s initial
focus was on the treatment of cancer, chronic pain, and other medical illnesses in which stress and anxiety
are frequent comorbid complaints. The MBSR program began examining the efficacy of mindfulness
training as an intervention for psychiatric disorders during the early 1990s, and many studies have
subsequently been undertaken by independent researchers.
Kabat-Zinn‘s work came from a long-standing practice of Buddhist meditation, from which he developed an
interest in exploring the beneficial health implications of vipassanâ meditation. Vipassanâ is a Buddhist
meditation practice in which the objective is to seek insight into the nature of one‘s own thoughts. Vipassana
can be translated as ―insight meditation‖ or ―seeing clearly.‖ Kabat-Zinn was a pioneer in translating subtle
eastern concepts about the nature of consciousness and meditation into descriptions of mindfulness practices
that are comprehensible to western patients and health care providers. The neutral term mindfulness is a term
used to describe a meditative approach that entails non-judgmental, detached awareness of thoughts and
feelings. He describes some of the reasons for his approach as follows: ―The choice of mindfulness as the
primary meditative approach was due to its immediate applicability to a great variety of present-moment
experiences. This orientation lends a quality of ‗ordinariness‘ to the intervention that makes it more
acceptable and accessible to a wide range of people with different life stressors and different medical
disorders‖ (Kabat-Zinn et al. 1992). Mindfulness meditation differs from transcendental meditation in that
the meditator may attend to a wide range of mental objects while maintaining moment-to-moment
awareness, rather than restricting his or her focus to a single mental task or object such as a mantra (Kabat-
Zinn et al. 1992).

Kabat-Zinn and colleagues have explained this approach in light of the fight-or-flight response: ―The
approach to present-moment experience characterized by mindfulness can abate or short-circuit the fight or
flight reaction characteristic of the sympathetic nervous system, particularly in stressful or anxiety-producing
social situations where it is non-adaptive‖ (Miller et al. 1995). They believe that mindfulness increases the
capacity of humans to bear physical pain and emotional stress by encouraging meditators to experience
strong associated feelings through a detached self-observing stance that facilitates acceptance and release. ,.
This occurs as the meditator gains increasing experience and begins to realize the transient nature of feelings
and thoughts. Subjective mental and emotional experiences come and go ―like waves in the sea‖ and the
meditator eventually realizes that he or she is not defined or limited by them. In contrast to other meditation
practices which are more didactic or abstract, in mindfulness training the meditator actually experiences
having a body or mind rather than simplybeing a body and mind. In other words, the meditator realizes that
he or she is more than the pain or stress. The pain and stress do not define the person, or his or her choices,
as much as has been assumed. Kabat-Zinn et al. have commented that mindfulness training permits the
practitioner to meditate both in a group setting or in solitude.
Generalized anxiety disorder and panic disorder

The first major study on mindfulness meditation as treatment of psychiatric disorders was completed in 1992
when Kabat-Zinn investigated generalized anxiety disorder, panic disorder, and panic disorder with
agoraphobia. The project was a prospective outcome study of group stress reduction with a repeated
measures design. 24 participants between the ages of 24 and 64 were enrolled in the study. 22 completed the
trial. The participants were screened by psychologists and psychiatrists trained in administering the
Structured Clinical Interview for DSM-III-R (SCID) and met criteria for generalized anxiety disorder or
panic disorder with or without agoraphobia. A score in the 70th%ile on the anxiety subscale of the Symptom
Checklist-90-Revised and 10 or more anxiety-related symptoms on the Medical Symptom Checklist were
required for inclusion in the study. Patients with other primary psychiatric diagnoses, any psychotic disorder,
endocrine disorder or significant alcohol or substance abuse were excluded. Individuals taking anxiolytic or
other psychiatric medications were allowed to participate; however, medications were closely monitored
throughout the study. All subjects were assessed in person at recruitment, weekly throughout the study
period, and at 3-month follow-up,. Study participants were also evaluated by telephone monthly up to 3
months after the study ended using the Beck Anxiety Inventory, Beck Depression Inventory, as well as
ratings of the frequency and severity of panic attacks. Subjects functioned as their own pre-treatment and
post-treatment controls.

All subjects participated in an 8-week long treatment course at the SRandRP and were assigned to meditation
classes with other students who had a range of medical and psychological disorders, some of whom were not
enrolled in the study. The course involved weekly 2-hour classes and a 7.5-hour intensive silent ―meditation
retreat‖ held two weeks prior to the end of the program. Formal meditation techniques such as body scan,
sitting meditation, and mindful hatha yoga were taught as well as informal mindfulness techniques that could
be practiced independently. Participants kept daily journals, used audiotapes, and practiced both formal and
informal meditation techniques. The program was designed to increase the duration of time spent in
meditation over the course of treatment until patients were meditating up to 45 minutes at a time. Instructors
encouraged participants to silently observe anxious thoughts as they arise rather than responding to them.
The same instructor remained with each class for the duration of the program. Instructors did not know
which students were in the study, nor were they told about their students‘ DSM III-R diagnoses.

The Beck Anxiety Inventory, the Beck Depression Inventory, the Hamilton Rating Scale for Anxiety, the
Hamilton Rating Scale for Depression, the Fear Survey Schedule and the Mobility Inventory for
Agoraphobia were administered on a weekly basis, and a compliance questionnaire was used at the end of
treatment and at follow-up.

22 of the 24 subjects completed the intervention (92%). There were clinically and statistically significant
reductions in both self-ratings and clinician-administered measures of anxiety during the intervention and
these were maintained at 3-month follow-up (see Table 1). Repeated measures ANOVA indicated that the
Hamilton and Beck anxiety and depression scale scores showed significant decreases over the course of the
study and these improvements were maintained at 3-month follow-up. Clinical improvements were unrelated
to the type or dosing of conventional medications. Of 13 participants who reported at least one panic attack
during the week before the study began, only five reported a panic attack in the week before post-treatment
assessment (mean Hamilton panic score = 18; SD = 8.40, range = 13–34). This trend continued at follow-up.
Co-morbid depression reported by 8 participants was not associated with significant differences in outcome.
An independent effect of mindfulness training on depressive symptoms was not investigated.

This study is significant because it is the first formal demonstration of the clinical benefits of regular
mindfulness meditation for anxiety disorders. However, the small study size, and the absence of a randomly
selected comparison group preclude general conclusions. Furthermore, , the groups were too small to
determine whether a mindfulness training program is equally effective for individuals who take psychiatric
medications compared to those who do not.

In a second study, a 3-year follow-up of the same cohort showed maintenance of the gains and good
compliance with regular meditation practice (Miller et al. 1995). Of the original 22 subjects, one declined to
participate, one was unreachable, and two were noncompliant with several attempts to schedule interviews.
10 subjects were interviewed in person and 8 by telephone. As in the original study, repeated measures
analysis demonstrated maintenance of gains obtained using the Hamilton and Beck anxiety scales as well as
other standardized scales. Most respondents believed that mindfulness training had ―lasting value.‖ No
differences in outcomes were noted between subjects who entered the study taking benzodiazepines or
antidepressants and subjects who were medication-free.

To determine whether these results could be generalized, Miller et al. examined 58 ―nonstudy‖ subjects
reported on in the original study. All subjects had met the screening criteria, had received identical treatment
in the SRandRP, and showed reductions in anxiety comparable to the study subjects using a standardized
symptom rating scale. All subjects were retested on this measure and on compliance measures. Data were
available for 39 of these 58 non-study subjects at pre-treatment, post-treatment and 3-year follow-up.
Significant reduction in anxiety was sustained for the majority of these responders, and Miller et al.
concluded that the finding of significant clinical improvement in anxiety found in the intensively studied
cohort could be generalized to the larger group of participants who also had high anxiety.

These findings suggest that individuals with chronic anxiety, whether undergoing other forms of treatment
for anxiety or not, can make substantial and enduring positive change in their lives to reduce anxiety and
panic by participating in a weekly outpatient mindfulness-based group stress reduction program (Miller et al
1995). The researchers proposed that mindfulness training should be used as a short-term therapy with
conventional medications, and potentially as a long-term therapy replacing medications. The appeal of
mindfulness training lies in its orientation toward what is ―right‖ with people rather than what is ―wrong.‖
This orientation derives from the goal of mindfulness training to nurture and strengthen a person‘s innate
capacity for relaxation, self-awareness, insight and positive changes in behavior.


The above findings are promising, however their significance is limited by small study size and
methodological flaws (Kabat-Zinn 1992; Miller et al. 1995). Both studies lack a randomized non-treatment
control group for comparison. Small sample size is a problem for most studies reviewed in this chapter and is
further discussed below. Both GAD and panic disorder patients responded equally well to the SRandRP
intervention; however, a larger sample size is needed to determine whether the SRandRP is equally effective
in each case.

				
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