Introduction to Mindfulness Based Stress Reduction:

CALM of NEPA

Phillip Sallavanti

What is Meditation

• “Medicine” and “Meditation” arise from the same Indo-European root– Meaning “to measure”– Suggesting an action to establish wholeness-

health• MBSR has its core the practice of mindfulness

mediation and the intention to establish wholeness

What is Mindfulness

Jon Kabat-Zinn defines mindfulness as paying attention, on purpose, in the present moment and non-judgmentally

OR more simply BEING HERE NOW with an attitude of openness, curiosity and kindness

Defining Mindfulness in MBSR

Attention

Intention Attitude

A Model of Mindfulness

The three axioms of Intention, Attention, and Attitude (IAA) are not sequential, but rather are engaged simultaneously in the process of mindfulness (Shapiro, et al., 2006).

Defining Mindfulness in MBSR

• Three Axioms of Mindfulness (Shapiro et al., 2006)• Intention changes over time: “from self-regulation,

to self-exploration, and finally to self-liberation”• Attention has two facets: sustained focus and

flexibility of focus• Attitude of non-judgment: this is not an affect-free

“bare awareness,” but rather an accepting, open, and kind curiosity towards one’s own experience

Awareness is Continuous

• The “triangle” of awareness:• Body sensations• Thoughts• Emotions

• But we don’t always bring attention to our awareness• Much of the day, we’re on autopilot• Attending to the body/breath brings us into the

present moment — immediately

Mindfulness in MBSR

• A Meta-Mechanism of Mindfulness: Reperceiving (Shapiro et al., 2006)

• “…a rotation in consciousness in which what was previously ‘subject’ becomes ‘object.’”

• This is basic to human development; mindfulness practice simply accelerates development

• Does not create distance and disconnection from one’s experience, but rather enables one to look, feel, and know more deeply

Mindfulness in MBSR

• Self regulation and self management: We can identify and then choose to override habitual reactions and respond with more balance and greater skill

• Values clarification: We can reflect on values we may have adopted unquestioningly and choose to adapt or adopt values more resonant with the current context

The program

• Introduction to MBSR • 8 week program• 2 ½ hours a week Educational, not therapeutic orientation —

classes provide a community of learning and practice, for motivation, support, and belonging. Focus is on what‘s right with you not what‘s wrong with you.

Mindfulness Practice in MBSR is Formal or Informal

• Formal: a specific form of practice, at a specific time and place, for a set duration• Four common forms: Body scan, sitting

meditation, walking meditation, mindful movement

• Informal: bringing mindful attention to any activity, any situation, any time, anywhere

Mindfulness-Based Stress Reduction

• Offered at > 700 medical centers in U.S. and around the world

• 30 years of research in a wide range of chronic clinical ailments

• 700% increase in the amount of studies since 2003

Mindfulness Based Interventions

Mindfulness-Based Stress Reduction (MBSR)• Mindfulness-Based Cognitive Therapy (MBCT)• Mindfulness-Based Relapse Prevention (MBRP)• Mindfulness-Based Art Therapy (MBAT)• Mindfulness-Based Relationship Enhancement (MBRE)• Mindfulness-Based Eating Awareness Training (MB-EAT)• Mindfulness-Based Rational Emotive Behavior Therapy

(MBREBT)• Mindfulness-Based You Name It (MB-ETC)• Dialectical Behavior Therapy (DBT)• Acceptance and Commitment Therapy (ACT)

Definition of Stress

• Stress is the response to a perceived threat to our psychological or physical well being coupled with the believe that we don’t have the resources to cope

What happens in a traffic jam

• Body sensations• Thoughts• How we perceive something actually shapes

our experience.• Body cant distinguish between a thought and

an actual threat.• Hard wired for stress response.

Research on Mindfulness and Health

• National Institutes of Health funding wide range of clinical studies of mindfulness in medicine and mental health

• Asthma, bone marrow transplant, breast cancer, chronic pain, chronic obstructive pulmonary disease, fibromyalgia, HIV, hot flashes, hypertension, immune response to HPV, irritable bowel syndrome, lupus, myocardial ischemia, obesity, prostate cancer, rheumatoid arthritis, solid organ transplant, type-2 diabetes, and other medical conditions

• Anxiety disorders, delusional disorder, depression, drug abuse and dependence, eating disorders, personality disorders, PTSD, schizophrenia, suicidality, and other psychiatric disorders

Research on Mindfulness and Health

• National Institutes of Health funding wide range of clinical studies on mindfulness in medicine and mental health, including:

• Asthma, • bone marrow transplant, • breast cancer, chronic pain, • chronic obstructive pulmonary

disease, • fibromyalgia, • HIV, • hot flashes, • hypertension, • immune response to HPV, • irritable bowel syndrome,

• lupus,• myocardial ischemia, • obesity, • prostate cancer, • rheumatoid arthritis, • solid organ transplant, • type-2 diabetes, • other medical conditions

Research on Mindfulness and Mental Health

• Anxiety disorders, • delusional disorder, • depression, • drug abuse and

dependence, • eating disorders, • personality disorders, • PTSD,

• schizophrenia, • Suicidality,• other psychiatric

disorders

outcomes

• 45% reduction in anxiety• 35% reduction in depression

Stress reduction correlates with structural changes in the

amygdala.

Hölzel BK, Carmody J, Evans KC, Hoge EA, Dusek JA, Morgan L, Pitman RK, Lazar SW.

Soc Cogn Affect Neurosci. Mar 5, 2010

No similar changes in other

regions

MBSR and Cognitive Function

• Recently, researchers have reported improvement in sustained attention and working memory measures in novice meditators who underwent MBSR training relative to a comparison group who did not undergo the training. (Amishi Jha)

Brain Changes

• Participation in an MBSR program results in increases in regional brain gray matter density regions associated with learning, memory, emotion regulation, perspective taking. (Holzel et al., 2011)

Mindfulness Enhances Attention

• Slagter et al. (2007) found mindfulness practice affected distribution of attentional resources.

• Time required to identify and consolidate visual targets in short-term memory precludes recognition of second target within 500 ms.

• Mindfulness practitioners with 3 months’ experience identified second target within 500 ms window.

• Practitioners used fewer resources(measured by scalp recorded brain potentials) to identify first target.

Mindfulness and the Therapeutic Encounter

The Miracle of Attention

“The capacity to give one’s attention to a sufferer is a very rare and difficult thing; it is almost a miracle; it is a miracle.”

Simone Weil

From Waiting for God, New York: Putnam, 1951.

What Is Therapeutic Presence?

A definition (Bugenthal,1987):• Being open and available to all parts of the client or patient’s

experience…• Being open and available to all of one’s own experience as one

is with the client or patient…• Being able to respond from the immediacy of that

experience…

Therapeutic presence is not cognitive, contrived, or controlled. It is simply as “withness.”

Obstacles to Presence

• Processes that can interfere with present-moment awareness include:– Comparison and evaluation– Complexity, busy-ness, and confusion– “Yes, but” conversations– Taking sides– Strong past or future orientation (rumination/worry)– Focusing on what something “means about me”– Problem-solving orientation

Burnout and Empathic Stress

• Obstacles to presence may be sources of burnout and secondary traumatic stress – or “empathic stress fatigue” (Figley, 1995; Halifax, 2011).

• Symptoms can include:• Apathy• Demoralization• Intrusive thoughts• Reduced quality of life• Sleep disruption• Substance use

• Since 1978, approximately 30 empirical studies have been published involving the use of mindfulness-based interventions with health care professionals (ranging from physicians to nurses to psychologists).

• Outcomes have included improvements in:− Burnout symptoms and job engagement− Distress tolerance− Active listening and empathy− Nonjudgmental self-reflection and self-compassion

Mindfulness Interventions for Health Care Professionals

Therapist Practice Improves Patient Outcomes

• A controlled, double-blind study of therapy outcomes for inpatients whose psychotherapists meditated daily (Grepmair et al., 2007) found:

− Significant differences in symptom reduction for those whose therapists meditated -- as measured on 8 scales of SCL-90 (global severity index, somatization, insecurity in social contact, obsessiveness, anxiety, anger/hostility, phobic anxiety, & psychoticism)

− Patients of meditating therapists reported greater subjective improvement following their sessions and made better assessments of their development of new behaviors

Applying Mindfulness in Interpersonal Communication

• Mindfulness practice can facilitate compassionate communication even in high-stress environments:• Attend to self and other

• Slow down the interaction to enhance attention• Notice what you feel and where you feel it

• Adopt a non-judgmental stance• Acknowledge what you have heard • Validate the emotions

• Articulate needs (all parties)• Trust the interaction

Mindfulness for Teachers

A study with public school teachers by Diane Reibel, PhD, Jefferson

University

School District

• Urban-fringe district- directly adjacent to Philadelphia

• 8 elementary schools, 2 middle schools, 1 high school

• 5,500 students

Participants in First MBSR Program

• First 8 week MBSR program• 19 people –one dropped out mid-way• Age range 25- 60 years old, mean age 46 14 elementary school teachers 2 high school, 2 special education coaches 1 professional education coordinator

Brief Symptom Inventory Scores

All values means p<0.01 Reductions in GSI 53% ANX 48% DEP 58% SOM 58%

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Maslach Burnout Scale-Educators’ Survey Scores

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EE DP PA

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EE=Emotional Exhaustion, DP = Depersonalization PA= Personal Accomplishment25 % decease in EE and 13 % improvement in PA p<0.005

Teachers’ Feedback on Effectiveness of MBSR

How has this program helped you become more effective at work? (check all that apply)

• 0 It has not helped me to be more effective• 17 I am better able to manage stress• 5 I am more productive• 16 I can better manage my emotions• 8 I am better able to prioritize• 16 I am more present for my students

Research on mindfulness programs in K-12 schools shows student benefits in increased . . . - ability to discern detail- ability to refresh perception of the moment- metacognitive awareness- ability for self-regulation- emotional flexibility- awareness of body, thoughts, feelings- quick recovery to mental calm, emotional

balance- relaxation response capacity- satisfaction in everyday living

Photo from www.mindfulschools.org

MBSR Research at Jefferson

Medical Conditions of MBSR Participants (136)

• Chronic Pain (30%)• Hypertension (20%)• Anxiety/Panic Disorder (18%)• Depression (16%)• Cancer (12%)• GI Distress, Diabetes, Arthritis, Sleep disorders, AIDS/HIV, MS, Lupus • Significant comorbidity- 2/3 of participants had 2 or more illnesses

• (Mean Age 47, 70% Women, 30% men)

MBSR Research at Jefferson

MBSR Research at Jefferson

MBSR Research at Jefferson

One Year Follow-Up

• Benefits were maintained in Anx, Dep, Som, GSI, MSCL and five of eight of the SF-36 health related quality of life scores.

Health-Related Quality of Life Outcomesfor Patients with Chronic Pain (n=99)

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PF RP BP GHP VT SF RE MH

SF-36 Subscales

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*p<.05

MBSR Research at Jefferson

Change in NKCA following in Relationship to Improvement in MCS

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Post-MBSR

n=48 RCT

EEG: ↑left prefrontal cortex activation

Mindfulness supports Resilience

• Resilience the ability to respond constructively to life.

• Mindfulness feeds resiliency in 4 main ways1. Sensitivity increases to notice challenges2. Self calming by slowing down habitual reactions3. Experiencing comfortable and uncomfortable

emotions and sensations with conscious choices4. Recovering- shifting attention to the present

without self judgment or inner commentary

Mindfulness therapy helps prevent D & A relapse

• One year following treatment far fewer participants used drugs or alcohol.

• Teaching self awareness help people understand what drives cravings

• 8 percent in mindfulness participants reported drug use compared to 14 percent in 12 step program and 17 percent in traditional relapse prevention group.

• 8 percent reported drinking after 1 year compared to 20 percent in the other 2 therapy groups.

“Compared to what we ought to be, we are only half awake.” …William James

Mindfulness and Teens

• Teenage years are some of the most stressful of your life. 70% of teens say they are stressed out.

• Pressure about grades, parents who just don’t seem to “get it” and friends who drive you “crazy”.

The Good News

• If you learn a few strategies for getting stress under control now, you'll have the skills you need to deal with problems and difficult feelings that life sends your way in high school and beyond.

Mindfulness and Teens

• mindfulness approaches are producing benefits in teens in the form of more feelings of well-being, less anxiety and worry, and less emotional reactivity (Burke 2010).

• Research in mindfulness indicates that this program may help students improve focus, enhance self-confidence, and provide a basis for developing positive coping and time-management skills.

Mindfulness and Teens

• “These skills can help teenagers navigate effectively through a time in life that can be confusing, filled with uncertainties, and exceedingly stressful. These life-skills form the basis for building successful relationships, beginning with oneself.” Jon Kabat-Zinn, founder of MBSR, from forward of Learning to BREATHE.

What does Mindfulness have to do with SPORTS

• Seattle Seahawks are taught Yoga and Mindfulness Meditation as part of their training. Teaching them how to stay focused and placing their attention where they choose

The Zone

• Placing attention on the task by accepting internal and external distractions.

• Allowing them to be as they are• When an athlete can notice this and perceive

it for what it is simply a thought or a feeling they are better able to enter the zone.

Russell Okung

• “Meditation is as important as lifting weights and being out here on the field for practice, its about quieting the mind and getting into certain states where everything outside of you doesn't matter in that moment. There are so many things telling you that you can’t do something, but you take those thoughts captive, take power over them and change them.”

Mindfulness at Penn State

• For 15 minutes a day, Tim Frazier, Penn State's senior point guard, finds a quiet place, switches on a podcast, and meditates. Along with his teammates.

• "The game moves so fast, it's hard to focus on the here and now," said Frazier, who is pretty fleet of foot himself. "Meditation slows me down [mentally], keeps me more relaxed and more focused."

Mindfulness

• Sometimes during the game, you focus on whether past plays were good or bad," Frazier said, "but meditation brings you back to the play at hand.“

• Part of mindfulness is to learn to observe situations rather than automatically reacting to them," said Diane Reibel, director of the Mindfulness Institute at Jefferson University Hospital. "Mindfulness teaches you to pause for a split second and notice, for example, 'oh, yes, anger is rising.' It gives you a way to approach the anger without acting on it. You can choose to use that energy in a positive, rather than negative way. Outcomes can be different; you have a choice."

Mindfulness and Sports

• Mindfulness practice really isn't that different from athletic training,” mindfulness practice changes the structure of the brain through which awareness operates. Just as running increases the strength of the quadriceps muscle, mindfulness practice strengthens the executive control function of the brain."

Abridged Mindfulness Intervention to Support Wellness in First-Year Medical Students

• The beneficial effects of MBSR mirror those found in prior studies in student populations. Shapiro et al. studied a randomized population of premedical and medical students who underwent a similar 8-week mediation program and found reduced anxiety and depression, and increased empathy at the end of 8 weeks.22 Jain et al. demonstrated reductions in distress and improvements in positive mood states.31

• improved total mood disturbance scores in the MBSR group compared with controls in a sample of volunteer medical students.23 Warnecke et al. demonstrated that mindfulness reduced PSS and anxiety as measured by the DASS in a randomized group of senior medical students at 8 weeks.24

Our study extended the period of observation considerably to 6 months. The effect have been associated with positive findings relevant to medical student wellness in other published literature. Neff and McGehee32 reported mental health benefits including diminished anxiety and depression as well as greater feelings of social connectedness

The Time is NOW

Between the stimulus and the response there is a space.Within that space lies our freedom. Victor Frankel