Wiki

Mindfulness

The Process of Turning Toward Rather than Away; Non-Judgmentally

Contents

• Summary
• Introduction to Concepts
• Mindfulness in Relation to General Health
• Therapies
• Thought-Provoking Questions
• Further References
• Links to Multimedia 
• References

Summary

To get a good idea about what Mindfulness really is, watch this video by Jon Kabat-Zinn, founder of the Center for Mindfulness in Medicine, Health Care and Society, as well as, founder of the Stress Reduction Clinic at the University of Massachusetts Medical School. Kabat-Zinn brought mindfulness into mainstream medicine and society.

Mindfulness is thought to enhance physical self-monitoring, and body awareness, leading to a reduction in negative thoughts and improved coping strategies which results in overall better health in patients.

Interventions in mindfulness are becoming increasingly popular. The main therapies reviewed in the literature are:

• MBSR
  • Therapy in mindfulness meditation which helps reduce stress & manage anxieties in everyday life and chronic illnesses.
• MBCT
  • Therapy combining mindfulness techniques and cognitive therapy to specifically help treat depression.
• ACT
  • Third-wave behaviour therapy combining mindfulness and other skills to lead a values directed life & develop psychological flexibility.
    

Introduction to Concepts

• Meditation and Mindfulness

Meditation is a broad term for sort of religious or cultural exercises. In Eastern cultures meditation is considered a fundamental and central mind expanding exercise while mindfulness and concentration exercises calm and collect themind.These desired states of consciousness are often described with different terms such as silence, emptiness, Oneness, to be in the here and now, or even to be free of thought.

Even though the variety of meditation techniques is not straightforward, all meditation techniques can be understood as a tool to exert a distinct awareness of the everyday state of consciousness. Mindfulness meditation techniques can be divided roughly into two groups:

• Passive (contemplative) meditation: practiced in a quiet sitting.

• Active meditation: when physical movement such as mindful action or loud chanting for meditation is used.

Mindfulness plays a central role in Buddhism: to be mindfully means entirely in the present, being in the here and now and be fully aware of ones feelings, thoughts and actions at every moment. Buddhists practice mindfulness primarily in meditation. However, Buddhist masters emphasize the importance of making mindfulness into a dominant and pervading state of mind throughout the whole life. The Buddhist mindfulness sets out the doctrine of the four foundations of mindfulness: mindfulness of the body, mindfulness of the emotions / feelings, mindfulness of the mind, and mindfulness of the mind-objects.

The Buddhist mindfulness meditation was brought to western culture by teachers as such as Jon Kabat-Zinn. According to Kabat-Zinn (2003) mindfulness 'is the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience, moment by moment. In a sense then, mindfulness has to do with particular qualities of attention and awareness that can be cultivated and developed through meditation.' It is important to remember, non-judgmental awareness is universal and is not a Buddhist concept, even though it originates from there.

*For this site we concentrate on mindfulness meditation. For further information on different meditation types and techniques see http://www.bbc.co.uk/religion/religions/buddhism/customs/meditation_2.shtml and http://www.project-meditation.org/a_mt4/meditation_types.html .*

• Meditation and Mindfulness in Psychology
  

Mindfulness meditation techniques are increasingly being used in western psychology. In spiritually oriented mindfulness exercises or mindfulness meditation enhanced self-and world-experience is sought, whereby health and quality of life are desired side-effects. The therapeutic mindfulness exercises serve primarily for the reduction of disease symptoms and the preservation of health.

Bishop et al (2004) defines mindfulness in the context of psychology as a two component conceptualization:

• The first component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment.
  

• The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance. (2004:232)

In order to achieve a desired outcome, one should concentrate on the process and intrinsic qualities of an activity rather than the extrensic outcome. This in turn will reduce the likelihood of anxiety and increase pleasures of joy in the process. This paradox, having to let go of the desired outcome in order to acquire it (Borkovec, 2002), has to be learnt through regular and daily practice, which is a challange faced by those entering therapies.

More and more emphasis is being placed on the development of mindfulness skills within Western societies, with regards to both general health and the so-called 'third-wave' of behavioural therapies. These include: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT) , Acceptance and Commitment Thearpy (ACT) and Dialectical Behaviour Therapy (DBT) (Baer, 2003; Harris, 2006). 'Third-wave' therapies emphasise mindfulness as a core principle in undermining destructive emotional, cognitive and behavioural patterns (Harris, 2006; For a review, see Öst (2008)).

For the best literature review, please scroll down to the Further Resources section!

• A Gentle Warning Regarding Concepts

Seligman describes Positive Psychology as the quest for life satisfaction, which is done through conenctrating on the virtues of the individual, and learning to make the most of them so that they can lead a happier life. It is said that there is more to happiness than the mere experience of positive emotions. Nevertheless, they argue that one should aim to increase the amount of positive emotions as much as possible, and do it through mindfulness techniques and Buddhist meditation on positive feelings.

Jon Kabat-Zinn on the other hand defines mindfulness as the non-judgemental awareness of the present moment, observing private experiences without attaching negative or positive labels to them. In this sense, mindfulness is not used for the cultivation of positive emotions, because it is (1) for observing and noticing and (2) is non-judgemental. Furthermore, Kabat-Zinn stresses that the art of mindfulness is universal, and not unique to Buddhism (even though it has origins in the religion).

If you're interested to read more on this 'conceptual debate' and my views on it, go here: DebAte.

Mindfulness in Relation to General Health

Mindfulness Mediation can alleviate suffering associated with physical, psychosomative and psychiatric disorders as it allows for greater awareness, reduces negative thoughts and improves coping strategies. It has therefore become a widely used technique. Grossman et al (2004) found that although these results were derived from a relatively small number of studies, their results still suggested that Mindfulness-Based Stress Reduction (MBSR) therapy can help a broad range of individuals to cope with clinical and non-clinical problems. Improvements were consistently seen across a spectrun of standardized mental health issues including (but not exclusively) the following: improving quality of life, depression, anxiety, coping style, medical symptoms, sensory pain, and physical impairment. Overall the benefits of Mindfulness in relation to general health are wind ranging and involve enhanced emotional processing, coping with chronic ilness and stress along with still allowing patients to enjoy and full and rich life.

Dobkin (2008) also found that as participants became more mindful they began to take better care of themselves, and tended to view life as more meaningful and manageable, furthermore reduction in levels of stress and medical symptoms were also reported.

Mindfulness enhances physical self-monitoring and body awareness, which possibly leads to improved body mechanics and improved self care, thus resulting in better general health.

Roth and Robins (2004) go on further to suggest that in addition to improving health and well-being, MBSR may also decrease mortality and use of health care facilities.

Davidson et al (2003) found that a short program of mindfulness meditation produces demonstrable effects on brain and immune functions. Whether these results are truly informative can be questioned and future research using more neuroanatomical techniques such as FMRi should be investigated.

While all the ideas above show the advantages of Mindfulness and Meditation there are some limiting factors. These include but are not exclusive to the following: socieconomic status, cultural differences and conception and self-assessment of health which is often one of the main techniques these theories apply. Furthermore, whether the effects of mindfulness are shown in the long term are unclear. The studies looked at here do not show the biological consequences of the intervention which would shed more light onto its application to general health.

*Recent News (from http://news.bbc.co.uk/1/hi/health/8363302.stm)

Researchers in America have compared a Meditation group to an lifestyle change group who received educational classes in risk factors related to health conditions. Results showed that as well as reductions in heart attacks, strokes and death in the meditation group, their average blood pressure was lower and similar to previous findings discussed there was a significant reduction in psychological stress seen in some patients.

Criticisms - the study was only based on a small number of patients and with only one ethnic group so these would both need to be improved.

Mindfulness-Based Stress Reduction (MBSR)

Over the past 20 years mindfulness based stress reduction therapy has grown widely and is the most cited method of mindfulness training. It provides patients training in mindfulness meditation to help reduce stress and manage emotions and anxieties that come with both everyday life and chronic illnesses. This therapy is thought to be an effective treatment, with no negative side effects.

As a therapy, MBSR combines mindfulness-based meditation with Hatha yoga. The treatment is carried out over an 8-10 week period where participants, in up to groups of 30, meet for a 2-2 ½ hour session each week, with one 8 hour day, usually on the 6^th week. Along with this, patients are given homework, to practise meditation and yoga, which increases their observation power. This can be practiced in any quiet setting for about 45 minutes each day. Patients are also taught how to perform a body scan – focusing their attention on breath and also observing sensations in each part of their body, and then relaxing them.

Clinical Populations

MBSR has been studied in various clinical settings. Although the majority of results show MBSR to be beneficial, there are criticisms in that most of the studies had small samples and many did not contain control groups.

Kristeller & Hallet (1999) examined the effects of MBSR in female patients with binge eating disorders. Results showed significant improvements in both eating and mood.

In a study of psoriasis patients, Kabat-Zinn et al. (1998) found those who listened to mindfulness audiotapes during sessions of light therpay, showed quicker clearing of their skin.

Kabat-Zinn et al. (1992) examined patients with generalized anxiety and panic disorders. When treated with MBSR there were reductions in the severity of symptoms and improvements in several measures of anxiety and depression, both at post-treatment and at a 3-month follow-up.

Speca et al. (2000) carried out a study on cancer patients who underwent MBSR. Findings showed patients to have lower scores on total mood disturbance and also reduced symptoms of stress. Smith et al. (2005) also found improved mood and sleep quality in people with cancer.

Ramel et al. (2004) found that after receiving MBSR, there was a decrease in depressive and anxiety symptoms in patients who had a mood disorder.

As MBSR has been found to reduce anxieties, benefits have also been found in patients with cardiovascular disease, as their anxiety had decreased and an increase in managing to express negative emotions was shown, (Tacon et al., 2003).

Mindfulness-Based Cognitive Therapy (MBCT)

MBCT is similar to the interevention therapy and is based on: MBSR. Differences are that MBCT also includes elements of cognitive therapy, which thus encourage a detachment from one's negative thoughts, along with emotions and bodily sensations. MBCT is a treatments programme specifically designed to address suppressed vulnerability to depression. It combines training in mindfulness meditations and interventions from cognitive therapy and is delivered in a group setting.

Clinical Populations

In 2000, Teasdale et al., carried out a trial of MBCT in patients with recovered recurrently depression. Results found show that those who had previously had 3 or more depression episodes had a significantly reduced risk of having a recurrence or relapse of depresssion.

Griffiths, Camic & Hutton. (2009) found MBCT to be a potentially useful clinical intervention for the cardiac rehabilitation population. Participants felt increased awareness in thoughts, feelings and the world around them and also a better understanding of their cardiac problems and the effects of stress on their bodies.

Evans et al. (2008) found MBCT to be a potentially effective treatment for reducing anxiety and mood symptoms and increasing awareness of everyday experiences in patients with GAD.

Criticisms to MBSR & MBCT

Although many studies of mindfulness-based techniques have been shown to be effective, there are few studies of actual rigorous scientific validity that have been carried out. Many of the studies have significant methodological flaws that make it hard to make clear conclusions from the findings, thus further research is needed to support these matters.

MBCT in Youths Reduces Risk of Later Depressive Disorders

Rumination

Rumination is a mental process conceptualized as a particular way of relating to the contents of the mind (Ramel et al., 2004).

Definitions of rumination have included: passively focusing one’s attention on a negative emotional state, intrusive thinking about a distressing event and distress associated with thoughts about recent negative event (Nolen-Hoeksema, 1991).

Rumination: A Risk Factor for Depression

The tendency to ‘ruminate’ may be a risk factor for later onset of major depressive disorder, this has been demonstrated in healthy individuals with no prior history of depression (eg, Nolen-Hoeksema, 2000, Just and Alloy, 1997).

Mindfulness: Protective

Given that higher rates of rumination are associated with greater vulnerability to depression, it is logical to conclude that reductions in rumination would be protective against the later manifestation of a major depressive episode (Deo et al, 2009).

Also, according to Segal, Williams & Teasdale (2002), rumination could be reduced by focusing on the present, (an element of mindfulness). Further, mindfulness training can teach individuals to respond to depressed moods in ways other than rumination (Rood et al., 2009).

How Mindfulness Decreases Rumination

· MBCT

MBCT aims at reducing typically depressive thinking processes such as rumination by encouraging the depressive client to ‘observe ’ depressive thoughts instead of dwelling on them, this way disengaging from the thought (Teasdale et al., 2000).

· Daily Mindfulness

Learning to respond more mindfully to one’s emotions may decrease the likelihood that a negative mood will spiral into a major depressive episode (Deo et al., 2009).

Related Research

Adults

Watkins et al. (2007) recently provided preliminary evidence that an adaptation of MCBT specifically focused on reducing ruminations, was an efficacious treatment for depression in adults.

Children

Broderick and Korteland (2004) suggested examining the effectiveness of mindfulness-based approaches in the treatment of ruminative coping in children and adolescents.

Broderick, (2005) provide evidence of the effectiveness of mindfulness techniques as an intervention to reduce depression in undergraduate students: mindfulness meditation compared with distractive behaviours more successfully alleviated dysphoric mood.

Review

In a recently published meta-analytic review regarding the influence of emotion-focused rumination and distraction on depressive symptoms in non-clinical youth (Rood et al, 2009), ‘Mindfulness Meditation’ was discussed as a potentially efficient method of ‘attention training’ to be utilised in interventions aimed at reducing rates of depression amongst youths.

Clinical Importance:

• The effectiveness of interventions that aim to reduce rumination and thereby depression in youngsters might be an important avenue for future prevention and treatment research.

• Screening on rumination in early adolescence and consequently offering a mild mindfulness-based intervention could help reduce the risk for the development of major depressive disorder in early adulthood.

Recommended reading for overview see the 'Further Resources' section.

Acceptance and Commitment Therapy (ACT): Learn to Embrace your Demons!

Overview

The 'formula' of ACT is: mindfulness + values + action = psychological flexibility

ACT proposes that psychological distress arises because people tend to (1) fuse with their thoughts, (2) evaluate their experiences, (3) avoid experiences and try to find (4) reason for their behaviours; these processes are often referred to by the acronym FEAR. To reduce distress and create a meaningful life, one has to ACT: (1) accept one’s own reactions and present situation, (2) choose and define their valued directions, and (3) take action in those defined directions. With the help of ACT one can develop a life-changing mindset, known as ‘psychological flexibility’. In contrast with most Western psyhotherapies ACT does not aim to reduce symptoms, since attempting to get rid of them creates a clinical disorder in the first place. Symptom reduction happens as a by-product of the therapy.

Background & Theoretical Bases

Click on BackGround to read more about the idea behind ACT.

The 6 core principles that make up ACT that work together to create psychological flexibility are (1-4. are often regarded as subsets of mindfulness skills; Harris, 2006):

1. defusion: relate to unhelpful thoughts in a way that they have less effect on the individual (e.g. techniques include (a) rehearsing these thoughts in a funny tone, which make them look less serious as well as make the person realise that they are just words in their head or (b) taking the mind for sending these messages yet again).
2. expansion: making room for unpleasant feelings & emotions instead of suppressing them
3. connection: connect fully with what’s here and now
4. the 'observing self': a changing continuity of consciousness; getting in touch with a transcendent sense of self, known as the “self-as-context”, that is capable of watching own bodily sensations/thoughts/emotions rather than with the one experiencing them
5. values: must be clarified and connect with them
6. committed action: effective and guided by values

So for instance, rather than trying to fight, resist or avoid these negative experiences, the individual should just accept them as they are and see them for what they are, thoughts. This can be done for instance through a funny voice or fusing with one’s observing self. Easy-to-learn techniques can be found in the 'Happiness Trap', written by Russ Harris (2008).

Applications

ACT was the first of the 'the third wave' therapies and is the best researched one; having had the most participants and randomised controlled studies. It is empirically supported to be an effective intervention for a range of psychological problems:

1. Obsessive Compulsive Disorder: Marcks & Woods (2007) tested ACT as an alternative therapy for OCD patients based on the assumptions that thought-action fusion beliefs coupled with ineffective coping strategies (such as suppression) lead to the development of OCD. Although an initial controlled study by Twohig et al (2006) had promising findings, further investigation is required.
2. Psychosis: 4 hours of ACT significantly cut down the re-hospitalitation of patient with positive psychosic symptoms by 50% (Bach & Hayes, 2002); findings that were later replicated by others (Gaudiano & Herbert, 2006; Gaudiano &Colleagues, 2007; Pankey & Hayes, 2003) and could be further enhanced if complemented by functional analytic psychotherapy (Baruch et al., 2009).
3. Eating Disorders: Considering the disfunctional behavioural strategies in the context of eating disorders it seems sensible to apply ACT to treat them, suggested by Hayes & Pankey (2002). Baer & colleagues (2005) findings have promising results for future studies in this direction.
4. Substance Abuse: Wilson et al. (2000) explored ACT as a complementary treatment to the standard 12-step treatment for substance abuse, while in a case study Batten & Hayes (2005) examined its application for comorbind substance abuse and PTSD.
5. Post-Traumatic Stress Disorder: Orsillo & Batten (2005) proposed a framework for ACT applied to PTSD. It has proven useful in a case study but further controlled studies are needed.
6. Anxiety or Depression: Forman et al. (2007) studied a large number of outpatients and found that ACT was just as effective as cognitive therapy; acceptance proven more effective in reducing distress than suppression in a study by Campbell-Sills et al. (2005) as well.
7. Sexual Abuse: based on past evidence that more common psychological disorders being developed after a sexual assault; Gutiérrez-Martínez & García-Montes (2001) debates whether ACT could possibly contribute as a treatment.
8. Chronic Pain: Dahl & Lundgren (2006) developed a book based on ACT to help endure chronic pain; after Dahl et al. (2004) positive findings. Based on a big sample (117) patients Esteve et al. (2007) also found that acceptance of pain is successful in the maintenance of functioning and been suggested as a complementary approach to active coping and control beliefs.
   

It has also proven useful for:

1. Enhancing Athletic and Human Performance (ie. Life Coaching): Donaldson & Bond (2004) found that acceptance predicted physical- and general mental health but not job satisfaction, while emotional intelligence did not predict what acceptance did. Garcia et al. (2004) showed that ACT helped high-level canoeists accepting their bodily states and focus their behaviours in the direction of their values; even though a control group receiving hypnosis showed no significant differences.
2. Cessation of Smoking: Gifford et al. (2004) showed that a smoking-focused version of ACT helps long-term smoking outcomes via improvement of acceptance related skills. For a theoretical rationale and model description see Brown et al. (2008)
3. Enhancing the Quality of Life of the Elderly: Butler & Ciarrochi (2007) studied 187 elderly from various community groups and settings and found that higher levels of acceptance corresponded to higher quality of life regarding health, safety, community participation and emotional well-being.
   

Measures

1. Acceptance and Action Questionnaire (AAQ) - Kollman & colleagues (2009) found partial support for its construct validity (evidence for convergent and discriminant validity but not associated with concurrent validation measures).
2. Acceptance and Action Questionnaire for Weight-Related Difficulties (AAQW) - Hayes & Lillis (2008) a version of the AAQ scale applied to health problems shows good internal consistency and correlates with other measures well.
3. Chronic Pain Acceptance Questionnaire (CPAQ) - Vowels et al (2008) for measurement of chronic pain.
4. Voices Acceptance and Action Scale (VAAS) - Shwayer et al. (2007) developed to measure especially psychotic symptoms.
   

Conclusion and Criticism

ACT takes a radical approach to mental well-being by contradicting some fundamental myths all humans seem to hold: (1) Happiness is the natural state for all human beings, (2) If you are not happy you are defective, (3) To create a better life we must get rid of negative feelings or (4) We should be able to control what we think and feel (Harris, 2008). A growing body of literature and studies focused on ACT recently, which might be partially due to its 'common-sense' principles. However, most of the studies had promising outcomes. The majority of these focused on pain/chronic pain and depression and anxiety disorders. Other areas require further elaboration.

Öst's (2008) article for instance gives a comprehensive review of some of the third-wave therapies, including a comparison of ACT to CBT. He concludes that ACT does not qualify as an 'empirically supported treatment'; however, in response to this Guadiano (2009) argues that Öst's (2008) claims are problematic and his experiments lack some significant methodological considerations. A recent review by Pull (2008) calls for further studies to be able to decide whether ACT is generally as or more effective than other third-wave behavioural therapies.

More on ACT

Click on AccepTance for questions to think about regarding ACT.

If you would like to find out more, visit the Further Resources section.

Thought-Provoking Questions:

1. How do the theories differ from one another? What are the similarities?
2. Could a more Mindful approach help reduce symptoms of the common cold or other similar health issues?
3. How does Mindfulness fit in the context of Positive Psychology?
4. How does ACT differ from other Mindfulness therapies?
5. What are the third-wave behavioural therapies? Why are they called that?

Further Resources

• Key Papers:

• General

• Mindfulness-Based Stress Reduction

• Mindfulness-Based Cognitive Therapy & its Applications in Youth

• Acceptance and Commitment Therapy

Links to Multimedia

References

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Baer, R. A., Fischer, S., and Huss, D. B. (2005). Mindfulness and Acceptance in the Treatment of Disordered Eating. Journal of Rational-Emotive & Cognitive-Behavior Therapy, 23, 281-300.

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