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| Dr Samantha Batt-Rawden |
INTRODUCTION
It has been suggested that “the body is the medium by which concepts of the self are
formed” (Corbin and Strauss, 1987). Therefore, it is intuitive that chronic illness,
deemed to be a failure of the body, presents a monumental challenge to one’s
mental health. The psychological sequelae following diagnosis of disease are well
documented (Stanton, Revenson and Tennen, 2007). Although the exact
mechanisms behind this association remain unclear it has been suggested that
negative schema may be responsible for the high levels of affective disorders found
in those suffering from chronic illness (Ingram, Miranda and Segal, 1998; Teasdale,
Segal and Williams, 1994). These are thought to ensue from rumination of anxiety
provoking thoughts such as the impact of a disease on one’s mortality, or in
catastrophizing unfamiliar somatic stimuli.
Whilst it remains clear that those suffering from chronic illness carry a harrowing
psychological burden, patients have limited access to programmes specifically
designed to address psychological and spiritual adjustment to disease. This is
despite the knowledge that those patients with concurrent psychological morbidity
tend to have poorer clinical outcomes than those who do not (Ciechanowski, 2000;
Hermann, Seidenberg and Bell, 2000; Norwood, 2006). The few interventions that do
exist specifically target individual disorders and focus on distraction techniques to
limit symptom burden (Grossman, Niemann, Schmidt and Walach, 2004). Clearly
there is a need for a heterogeneous cost-effective intervention that specifically aims
to facilitate the maintenance of psychological and spiritual well-being in patients with
chronic disease.
Mindfulness
Mindfulness based mediation (MBM), also known insight-orientated meditation or
Vipassana, resides at the core of Theravada Buddhist teaching and has been
defined as “the awareness that emerges through paying attention on purpose, in the
present moment, and non-judgmentally to the unfolding of experience moment by
moment” (Kabat-Zinn, 2003, pp.145-146). By maintaining a dispassionate state of
constant vigilance one is able to observe mental phenomena in complete
acceptance before allowing the thought or emotion to pass and becoming once
again fully immersed in the task at hand. In employing this technique of attention
regulation, practitioners are able to live in the present, capable of acknowledging
both external and internal stimuli as they arise whilst not dwelling on those that may
be harmful to one’s psychological health.
Mindfulness Based Stress Reduction
Developed in such a way that would be deemed as acceptable to non-Buddhists in the West, Kabat-
Zinn introduced Mindfulness to the Massachusetts Medical Centre in 1979
(Praissman, 2008). The structured therapy package of Mindfulness Based Stress
Reduction (MBSR) harnesses the core concept of MBM combined with Hatha yoga,
a gentle form of exercise that can be readily performed by patients with a range of physical impairments. MBSR has received much attention in recent years due to its
growing popularity in conventional Western medicine and the reported empirical
evidence of a clear benefit in both clinical and healthy populations.
The highly structured 8-10 week program aims to cultivate the cognitive skills of
attention and awareness. It requires considerable commitment. In addition to a full
day ‘retreat’ and weekly group sessions of approximately 2.5 hours, participants are
expected hone their newly acquired skills with 45 minutes of daily practice of MBM
(Praissman, 2008).
HOW MINDFULNESS BASED STRESS REDUCTION WORKS
Attentional Control and Rumination
Recent neuroimaging studies have demonstrated that patients with depression
appear to have different patterns of brain activation on functional MRI to controls
(Siegal, et al., 2002). These studies suggest that the frontal lobe has an integral role
in the onset and maintenance of depression, more specifically the failure of the
anterior lobe to inhibit the amygdala. This is thought to be the mechanism
responsible for the excessive rumination that accompanies the onset of depression.
MBSR aims replace the caustic cycle of rumination with cogitation by enhancing the
attentional control of participants; the skill of thought regulation allows one to simply
observe emotions in a reflective as oppose to a reactive manner, before once again
assuming attentional control.
Interestingly Davidson et al. (2003) demonstrated increased left anterior brain
function on electroencephalography (EEG) post-intervention in 25 participants
compared to 25 controls who did not receive MBSR. Further support for this theory is
provided by Ramel, Goldin, Carmona, and McQuaid (2004). In this unique study
rumination was measured amongst other outcomes using the Response Style
Questionnaire (the RSQ, a well accepted and reliable tool) following MBSR. Authors
note significantly decreased rumination post-intervention, which had a negative
correlation with symptoms of depression and anxiety. Interestingly, on conducting a
regression analysis, authors found a significant association between the amount of
individual MBM practice and decreased levels of rumination (Praissman, 2008).
Mood Clarity
In addition, MBSR aims to alter metacognitive processes by encouraging patients to
reflect on and gain insight into their emotions. Not only is metacognitive adaptation
seen as a vehicle in enhancing emotional intelligence but it is also a prerequisite of
self-regulation of emotion as discussed above. Indeed, in a study of patients with
rheumatoid arthritis those that achieved the greatest understanding and recognition
of one’s mood and emotions through MBSR had superior clinical outcomes (Zautra,
Smith, Affleck and Tennen, 2001).
Cognitive change
MBSR encourages the view that thoughts are fleeting and not necessarily reflective
of reality. Participants are taught that just because one has the thought that they are
useless, or ‘tired all the time’ for example, this does not make it true. Kristeller and
Hallett (1999) attribute the reported success of MBSR in patients with binge eating
disorders to cognitive change. Authors argue that participants developed non-
judgemental acceptance of negative thoughts surrounding their weight and the need
for food and were able to recognise that these thoughts were not necessarily
congruent with reality.
Exposure
It was insinuated by Kabat-Zinn (2003) that actively encouraging participants to pay
particular attention to somatic pain and discomfort may lead to desensitization. The
‘body-scan’ technique, for example, promotes the acknowledgement of bodily pain in
a safe environment. Participants are taught to focus their attention on each part of
the body in turn, accepting any arising somatic stimuli, before intentionally relaxing
that particular body part. This is designed to equip participants with a reflective style
of coping as oppose to a reactive, hyper-emotional response. Accepting pain
dispassionately, the authors suggest, is key in preventing the elicitation of
catastrophization when the same symptom arises in the future. Thus MBSR acts as
a form of exposure therapy, teaching participants to approach negative stimuli
without excessive emotional reactivity thus improving tolerability of their symptoms.
Control
Participants are taught and encouraged to practice ‘sitting meditation’, which
involves remaining in one position for some length of time and resisting the urge to
alter their posture in response to physical discomfort. It is argued that this affords
participants a sense of physical control over their symptoms. Kristeller and Hallett
(1999) suggest that MBSR is able to teach patients with eating disorders the ability
to simply acknowledge the urge to binge without feeling the overwhelming need to
yield to such an urge.
The incorporation of Hatha yoga into MBSR has also been cited as responsible for
giving participants greater authority over their bodies. As Hatha yoga teaches the
use of the whole body it may serve to challenge maladaptive schemas in those with
significant functional impairment due to somatic disorders (Hamilton, Kitzman and
Guyotte, 2006). Practitioners report an increase in flexibility in a single class. Such
change in physical ability may provide those that are chronically impaired with
increased self-efficacy which is increasingly recognised as critical in improving
rehabilitation outcomes (Arnstein et al., 1999).
Acceptance
Whilst it is well recognised that having an achievable goal may augment self-efficacy
in rehabilitation, it is also understood this is not constructive for those who strive to
regain or maintain an unattainable level of functioning (Orbell et al., 2001).
Participants in MBSR are encouraged to adopt a ‘non-striving’ attitude and to accept
physical illness and consequent limitations in a reflective rather than a reactive
manner. In this way, patients are able to focus on their abilities, so called positive
psychology, as opposed to their disabilities. MBSR teaching encourages positive
reflection on the transiency of health and life so that participants may become aware
of the anxieties they have attached to their own morbidity and mortality. Central to
Buddhist teaching is the concept that suffering results from unconscious attachment
to transient states such as youth, health and life; mindfulness of this lessens the
influence of morbidity and mortality associated anxiety on the participant (Hamilton,
Kitzman and Guyotte, 2006).
Relaxation
The benefits of MBSR are reportedly less profound in patients suffering from chronic
pain states than those with an affective diagnosis. However, studies of MBSR in
chronic pain groups have shown a benefit; this may be due to the relaxation effect of
Hatha yoga which is reported to reduce muscle tension. Studies have also reported
the clear benefit of yoga for rheumatic and musculoskeletal conditions (Garfinkel et
al., 1994; Greendale et al., 2002).
COMPARISONS WITH COGNITIVE BEHAVIOURAL THERAPY
MBSR has been likened to Cognitive Behavioural Therapy (CBT) in that both
techniques discourage emotional reactance and encourage adoption of a reflective
as oppose to a suppressive or reactive coping style. As previously discussed MBSR
employs the technique of desensitization that can be likened to the deconditioning
effect of exposure therapy used in CBT.
The fundamental difference is that CBT assumes psychopathology, whereas MBSR
does not. CBT teaches the identification of negative schema as pathological and
destructive; patients are then encouraged to reject these harmful thoughts arising
from pathology, in order to reduce rumination. In contrast, MBSR teaches
participants to embrace such thoughts as they occur in a state of naturalistic
observation. Kabat-Zinn (1990, p.3) summarises this distinction eloquently through
metaphor; “if you only know how to sail with the wind at your back, you will only go
where the wind blows you”. By using MBSR, or “turning into the wind”, we may
“orient ourselves in such a way that we can use the pressure of the problem itself to
propel ourselves through it”. Thus MBSR actively encourages reflection on negative
schema, but in a distanced manner. Hence, whilst both techniques teach the uncoupling of thought and emotion, the process of achieving such affective
detachment is incongruous.
LITERATURE REVIEW OF CURRENT EVIDENCE FOR MBSR
Methods
A systematic literature review was conducted to evaluate the empirical evidence of a
clinical benefit of MBSR. Medline, PsycINFO and the Cochrane Library were
searched using the key terms: mindfulness, meditation, stress reduction, MBSR,
vipassana, yoga. Reference lists of relevant articles were also hand searched. All
study designs evaluating the independent use of MBSR in both clinical and non-
clinical populations with an abstract published in the English language were
included. Excluded studies evaluated the effect of non-mindfulness meditation
techniques or the combined effect of MBSR and cognitive or didactic behavioural
therapy. Unpublished dissertations or conference abstracts were also excluded.
Overview
Twenty-nine studies were identified as fulfilling the inclusion criteria. The use of
MBSR has been investigated in groups with an array of psychiatric diagnoses
including: affective, anxiety, somatic and eating disorders; medical diagnoses
including: fibromyalgia, cancer, coronary artery disease, rheumatic disease and
chronic pain states; as well as nonclinical populations, students and healthcare
professionals.
Somatic disorders and chronic pain
Three studies were identified as evaluating the effect of MBSR in groups of patients
with chronic pain. All three were conducted by the same lead author (Kabat-Zinn, et
al., 1982, 1985, 1987) using the same pool of patients. Therefore, there is
considerable overlap between samples (Bishop, 2002). In addition, the studies are
all relatively small, the largest consisting of 90 patients, and none employed the use
of a control group. Initial results suggested some mitigation of pain; although self -
reported pain did increase following completion of MBSR, it did not return to pre-
interventional levels. The authors also report a significant decrease in psychological
distress, and that this benefit was maintained over an extensive follow up period of 4
years.
One further study was identified reporting on the use of MBSR specifically in
fibromyalgia patients (Kaplan, Goldenberg and Galvin-Nadeau, 1993). Authors note
a significant reduction (39%) in psychological distress although one must take into
account the serious methodological limitations of this particular study which include
the lack of control group and arbitrary determinant of clinical response (Bishop,
2002).
Affective disorders
Kabat-Zinn, et al. (1992) conducted a further study in 22 patients with generalized
anxiety and panic disorders. The authors report a significant reduction in symptom
burden, with mean reduction to non-clinical or sub-clinical levels. The strength of the
study lies in the rigorous assessment used to identify eligible patients and in the
evaluation of post intervention psychological morbidity. Miller, Fletcher and Kabat-
Zinn (1995) reported on a 3 year follow up of the same study sample and found that
these benefits had been maintained. However, the lack of a control group in both
studies and the fact that 55% of participants were also receiving pharmacological
treatment during the intervention calls into question the validity and clinical
applicability of these findings (Bishop, 2002).
Ramel, Goldin, Carmona, and McQuaid (2004) can also be credited on the use of
well accepted and validated tools to measure anxiety and depression. Scales
included: the Beck Depression Inventory (BDI), the Spielberger State-Trait Anxiety
Inventory, the Dysfunctional Attitudes Scale (DAS) and Response Style
Questionnaire (RSQ). The study compared 11 controls recruited from the MBSR
waiting list to the 11 of the 23 participants in the intervention group who most closely
matched them by baseline symptomology and epidemiological characteristics
(Praissman, 2008). As discussed elsewhere in this essay authors noticed a
significant difference between groups in rumination, which was found to positively
correlate with depression and anxiety. However, the small sample size and lack of
appropriate control group limits the generalisability of these results.
Eating disorders
Kristeller and Hallett (1999) studied the effect of MBSR in a group of 18 obese
women diagnosed with binge-eating disorders. The authors report that depressive
symptoms and the number of binge episodes occurring weekly were significantly
reduced post intervention. A later study of 25 participants of both genders
reproduced these findings, attributing the positive effects of MBSR to increased self-
acceptance and reduced need for emotional eating (Smith, Shelley, Leahigh and
Vanleit, 2006). Unfortunately neither of these studies demonstrated an effect on
weight loss. In addition due to the small sample sizes and lack of control groups the
clinical significance of these findings remains unclear.
Cardiovascular disease
A study of 18 women diagnosed with cardiovascular disease yielded positive results
following MBSR on comparison with a control group of the same number recruited
from the waiting list (Tacon, McComb, Caldera and Randolph, 2003). Anxiety, as
measured by the STAI was significantly reduced and the women who had received
MBSR were shown to have adopted a more reflective response to stress on the
Courtauld Emotional Control Scale (CECS). This was thought to be of clinical
importance as suppression has been implicated as a risk factor for developing
cardiovascular disease. However, this change was only observed in those women who had a habitual reactionary style of coping pre-intervention, and not those who
tended to use a reflective or suppressive style (Praissman, 2008). Hence whilst this
study strongly that suggests that MBSR may reduce anxiety in women with
cardiovascular disease this benefit may be limited to those currently using a reactive
coping styles.
Cancer
Perhaps the strongest evidence of a positive effect of MBSR is provided by Speca,
Garlson, Goodey and Angen (2000). The authors conducted a randomised controlled
trial consisting of 63 participants of mixed cancer diagnoses. Authors report a 65%
reduction in sleep disturbance (p .001) and 35% reduction in stress symptoms
(p<.001). There was a positive correlation between the effect size and time
dedicated to practicing MBM outside the weekly classes. In addition it was later
reported by Carlson et al. (2001) that these benefits were maintained at 6-month
follow up (Baer, 2006).
Carlson, Speca, Faris and Patel (2007) evaluated the effects of MBSR in 59 patients
with a diagnosis of prostate or breast cancer without psychological comorbidity. The
authors reported on a number of outcomes. Whilst it was reported that there was a
reduction in stress related symptoms post-intervention and that this was maintained
at 1 year follow up, the effect size was moderate (d=0.4) and the improvement was
independent of the amount of MBM practiced individually both during the MBSR
course and post-intervention. In addition, no significant effect on immune function,
dehydroepiandrosterone sulphate (DHEAS), melatonin or salivary cortisol was noted.
The authors did report a decrease in mean daily cortisol but concede that due to the
single day of collection and the known variation in cortisol levels that these results
need to be ratified with more rigorous data collection.
Psoriasis
A randomised controlled trial of 37 patients undergoing phototherapy (UVB) or
photochemotherapy (PUVA) appeared to show that the skin of those patients
randomised to receive MBSR whilst undergoing treatment cleared 4 times more
quickly than controls (who received PVB or PUVA alone). The study was well
designed and controlled for potential bias; dermatologists evaluating photographs of
skin status were blind to both patient identity and group assignment (Kabat-Zinn, et
al., 1998). Although this research is most promising and warrants further
investigation, the small sample size of this particular study limits the generalisability
of these findings.
Heterogeneous Clinical Populations
Several further studies have reported significant stress reduction following MBSR in
mixed clinical populations although none of these studies used a control group. Roth
and Creasor (1997) reported improved clinical outcomes and psychological well-
being following implementation of MBSR at an inner city health clinic in the United States. However, this study suffered from huge loss-to-follow bias as only 54% of
English speaking and 64% Latin American patients completed the course of MBSR
(Bishop, 2002). However, this study does provide us with an interesting insight as to
the acceptability of MBSR across cultures. Majumdar et al. (2002) reported on
significant reductions in stress, and increased quality of life, sleep and well-being in
21 German patients with a range of medical and mental illnesses. These benefits
were maintained at 3 month follow up and most participants reported that they were
extremely satisfied with the intervention.
Non-clinical populations
Interestingly, Massion et al (1995) found significantly higher levels of melatonin
metabolite in the urine of women who were trained in MBSR and who continued to
practice MBM regularly, when compared to those who had not. It has been
suggested that melatonin level may be related to immune function (Baer, 2006). In
addition Davidson et al. (2003) on giving 25 participants influenza vaccines post
intervention, demonstrated higher vaccine titres amongst those that had received
MBSR when compared with controls. Stress reduction using MBSR has also been
demonstrated in healthy volunteers (Williams, Kolar, Reger and Pearson, 2001).
Use in maintaining psychological well-being and empathy in students
Given the intensity of medical school is perhaps not surprising that higher levels of
stress, anxiety, sleep disturbance and other psychopathologies are found within the
undergraduate population of today. The concept of burnout is being increasingly
recognised as the result of long term exhaustion and mental fatigue and is a
psychological term almost exclusively applied to healthcare professionals. Several
studies have indicated that MBSR is an effective intervention to reduce the
prevalence of this phenomenon amongst both students and staff in medicine.
Participants have cited the development of novel strategies to cope with stress as
responsible for this reported benefit. Indeed, in a randomised control of trial of 300
students at Jefferson Medical College, Rosenzweig et al. (2009) found that
implementing MBSR reduced total mood disturbance, as well as fatigue and
depression on the Profile of Mood States. In addition, Shapiro, Schwartz and Bonner
(1998) conducted a prospective, cohort-controlled study of preclinical and clinical
medical students. The authors reported significant declines in depression and
anxiety which were maintained across the exam period.
Interestingly this study also reported increased mean empathy scores post-
intervention. The decline in empathy has been recently quantitively demonstrated in
undergraduate medical, dental and nursing students and as such has become
extremely topical. It has been suggested that this phenomenon may be a
manifestation of stress as there is an association between decline in empathy scores
and depression, anxiety and sleep disturbance. An expression of increasing cynicism
may be the result of an adoption of a ‘tick box’ approach; the aim of ‘getting through’ exams demands the full attention of the student and empathy is no longer a priority.
Kabat-Zinn (2003) argues that mindfulness is key in maximising the amount of
contact time one has with a patient. MBSR then may be of great benefit in both
stress reduction and in increasing the attentional control of students when with
patients, despite having a workload that seems all consuming. Confirming the
findings of Shapiro, Schwartz and Bonner, Beddoe and Murphy (2004) replicated the
successful use of MBSR to significantly decrease stress and foster empathy
amongst nursing students and similar findings have also been reported post
intervention amongst students enrolled on a counselling psychology course (Sharipo,
Warren and Biegel, 2007).
CONCLUSION
The majority of these studies show a significant stress reduction and increases in
psychological wellbeing following MBSR. However there is very little definitive
evidence for such a benefit. Although many studies do employ the use of a control
group often controls were recruited from the waiting list to receive MBSR. This may
bias the results of such studies as these subjects; clearly those interested in MBSR
are more likely to believe it has a clinical benefit. Aside from the clear methodological
problems associated with a lack of a control group, much of the available literature
suffers from further flaws which only serve to limit the generalisability and validity of
the reported results. These include: use of unvalidated tools to measure outcomes
and failure to control for confounding variables such as concurrent treatment and
arbitrary determination of the primary outcome measure as evidence for clinical
response.
This literature review highlights the need for large trials and methodologically sound
research. Yet there is evidence to suggest the potential promise of mindfulness as
an effective intervention for enhancing the psychological and spiritual wellbeing of
patients with wide range of medical disorders and psychiatric diagnoses, and for
healthcare professionals. Whilst the biological basis of both medical and psychiatric
disease is advancing exponentially, as we understand more about the human brain
questions are raised as to the basis of the mind, and the interface between
psychiatry, psychology, philosophy and spirituality becomes ever more interesting.
This, and its concurrent growing popularity, might suggest there is a role, alongside
more traditional treatments, for MBSR in modern medicine.
Note: The idea of making Buddhist teachings 'acceptable to the West' might misleadingly be seen to imply that Buddhism, as a world religion, is somehow unacceptable here in England. Of course Buddhism as a world religion has, for over 100 years, been more than acceptable to Buddhists throughout the West, and so the following minor edit was made to the above for greater clarity: 'Developed in such a way that would be deemed as acceptable to [non-Buddhists in] the West'.
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