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.