Clinical and Health Affairs
By Karen Lawson, M.D.
Mindfulness-based stress reduction (MBSR) is an approach to health and wellness that an increasing number of health care providers are practicing and recommending to their patients. This article describes MBSR, its use in health care, and its benefits for patients with conditions such as anxiety, depression, chronic pain syndromes, and insomnia. It also offers advice about how physicians can incorporate elements of MBSR into their daily practices in order to reduce stress in their lives and prevent burnout.
If we keep our eyes open, we begin to discover that the healing relationship is itself a pathway, a Way of working with ourselves and others leading to the blurring of contrived boundaries, an awakening into our mutual shocking brilliance, the recovery of a deep and abiding joy … To walk such a path requires a method: a disciplined way of learning to pay attention to all that is arising within. This is called “mindfulness.” —Saki Santorelli1
The year was 1992. More than 280 health care professionals from all over the country had gathered at the Omega Institute in Rhinebeck, New York, for one of the first professional training programs in mindfulness-based stress reduction (MBSR) offered by Jon Kabat-Zinn, M.D., and Saki Santorelli, Ed.D., of the University of Massachusetts Center for Mindfulness in Medicine, Healthcare, and Society. I was one of them. During the first three days, we were to learn about and begin practicing mindful meditation. The next five days were devoted to learning about the science and research behind the practice, discussion of professional applications, and dialogue about future clinical and research collaborations. To some extent, that was accomplished; but that wasn’t really what happened. As we began to practice mindfulness in the supportive environment at Omega, we found ourselves revealing to each other our hidden wounds, denied joys, and forgotten passions. Through laughter and tears, we talked late into the evening about our flaws and challenged humanness. It was painfully clear we were suffering as much as any of our patients, perhaps, in some ways, even more so. That event changed the life of every person there, myself included.
What we had discovered was that mindfulness was a direct means to access and monitor our thoughts, emotions, sensations, motivations, and behaviors. Kabat-Zinn describes it as “paying attention, in a particular way, on purpose, and in the present moment.”2 Different from a relaxation technique, mindfulness enhances awareness and helps us disengage from maladaptive patterns of thinking such as generalizing, worrying, and perseverating, which create deleterious reactions to stress. It promotes the use of coping responses that are healthier and more effective.
Mindfulness-Based Stress Reduction
Mindfulness is a form of meditation originally derived from the Theravada tradition of Buddhism that is often translated as “to see with discernment.”3 Over the last several decades, meditation has extended beyond the boundaries of religion or spirituality. For example, Daniel Goleman, author of Emotional Intelligence, speaks of it as an intentional self-regulation of attention.4
What You Can Do Today
Simple ways to invite mindfulness into your day:
- Focus on doing one thing at a time and minimize multitasking;
- Take a walk outside without your pager or cell phone;
- Take a meal break without your computer, phone, or reading material; focus on all aspects of the food;
- Before each patient encounter, stop and take three deep belly breaths—one to release any thoughts about what has already happened in your day, one to release any expectations for the day, and one to invite yourself fully into the moment to be with the person you are about to see;
- Schedule time for relaxation, celebration, and fun—or just time that can’t be scheduled;
- Spend time outside every day—even a few minutes;
- Begin meetings with 30 to 60 seconds of silence and breathing or share a brief, meaningful poem;
- Laugh often;
- Pay attention to your body, moving and stretching whenever you can even if you are at your desk, in the office, or in the hallway;
- Practice gratitude; end each day by acknowledging one thing you are grateful for (challenge yourself to never repeat things);
- Practice listening without interrupting or ruminating about what to say next;
- Ask for help;
- Create time everyday to leave behind your professional role and move into your personal roles with friends, family, or just yourself;
- Try a yoga, Tai Chi, or qigong class and take along a friend or colleague.
Mindfulness was introduced to the health care community as a technique for stress reduction by Kabat-Zinn in 1979. Since its inception, more than 18,000 people have completed his Stress Reduction Program; but thousands more have participated in spin-off programs around the world. Through these programs, individuals learn how to use their resources and abilities to respond more effectively to stress, pain, and illness. Participants not only include patients but also leaders within the business, education, and health care communities, along with health care providers. The central focus of the programs is intensive training in mindfulness meditation and how to integrate it into everyday life.
In its original format, MBSR training consists of 30 hours of class time (eight two-and-a-half-hour sessions once a week and one full-day retreat). The core program components are:
- Sitting meditation, which involves awareness of body sensations, thoughts, and emotions, and continuously returning the focus of attention to the breath;
- Body scan, a progressive movement of attention through the body from the toes to the head, observing any sensations in the different regions of the body;
- Hatha yoga, which consists of stretches and postures designed to enhance awareness and strengthen the musculoskeletal system; and
- A commitment to practice 45 minutes a day, six days a week.
The format has been modified in some settings. For example, some have added a three-minute mini-meditation that involves focusing on one’s breath, body, and surroundings; others include Metta meditation, which is adapted from Buddhist practice.
The existing body of research on the effect of MBSR on health is large and broad. It has been found to have measurable positive effects on chronic pain, psoriasis, insomnia, and other conditions.5,6 The positive effects of MBSR on anxiety, depression, and other mood disorders led to the development of a new approach to cognitive therapy, termed mindfulness-based cognitive therapy.7 In a healthy population, MBSR has been found to decrease perceptions of daily hassles, psychological stresses, and nonspecific symptoms.8 Additional psychological benefits include having increased empathy for one’s self and others;9 an enhanced sense of well-being; and a greater sense of self-actualization, self-responsibility, and self-directedness.10
Mindfulness-based stress reduction programs are offered regularly in health care settings throughout Minnesota including the Woodwinds Health Campus in Woodbury and the Penny George Institute for Health and Healing at Abbott Northwestern Hospital in Minneapolis. In addition, a team of instructors teach MBSR at the Center for Spirituality in Healing at the University of Minnesota several times each year. The center also offers customized programs for hospitals and other organizations and has even piloted a telephonic version of the program for corporations and school districts.
Additionally, the center has conducted multiple NIH-funded studies on MBSR including an examination of its effect on anxiety, depression, sleep, and quality of life in solid- organ transplant patients. Other studies have compared the effectiveness of MBSR with Lunesta in improving sleep for those with chronic insomnia; compared its impact on vascular function and exercise capacity with that of aerobic exercise in women; and looked at its effect on the general health and stress levels of caregivers of Alzheimer’s patients.
Minnesota physicians describe how mindfulness has helped them in their personal life and practice.
I found the practice of mindfulness was far from simple. It was challenging to keep my attention on the present moment. The course offered helpful tools to counter my mind’s tendency to focus on the problems of the past or possible challenges in the future.
The encouragement to focus on gratitude, compassion, and forgivene ss was a helpful antidote to my tendency to think about the apparent shortcomings in my world. I continue to find mindfulness a helpful practice in my daily life. During my day, I will often notice how my mind is getting caught up in the frustration of the moment. When this happens, I can take a short pause, focus on my breath or other sensations for a moment, and let go of the negative thoughts.
—Michael Mesick, M.D.
Family Physician, Edina Sports Health and Wellness
If it weren’t for mindfulness-based stress reduction, I wouldn’t still be in medicine today. Metta meditation helped me start taking care of myself, listening to my body, cutting back. Since I learned to take care of myself, medicine has become fun again.
—David Von Weiss, M.D.
Family Physician, Park Nicollet Clinic, Eagan, and Methodist Hospital
Barely three years out of residency training, I was already frustrated in my role as a psychiatrist. I had assumed that psychiatry would offer a holistic way of working with patients, yet I spent my days managing crises and medications. It didn’t feel as if it worked well for my patients or me, and I couldn’t imagine doing this for an entire career. Then I saw Bill Moyers’ “Healing and the Mind” and was struck by the work of Jon Kabat-Zinn, who developed mindfulness-based stress reduction. I signed up to train with him in the fall of 1992.
I was profoundly affected by the training, and it helped shift my focus back to healing rather than just managing disease. I began offering classes immediately. We called them group psychotherapy and treated patients with anxiety and depression. I quickly realized that this had much of what I was looking for: It was cost-effective because it was done in large groups; it gave people tools they could use for themselves without relying on long-term therapy; and most importantly it worked. People recovered, and it prevented relapse.
—Henry Emmons, M.D.
Integrative Psychiatrist Developer of the Resilience Training Program, Penny George Institute for Health and Healing Abbott Northwestern Hospital
The Importance of MBSR to Physicians
There is abundant evidence that workplace stress can significantly and negatively affect physicians and other health care providers, leading to depression, compassion fatigue, diminished job satisfaction, and professional burnout.10-12 Logically, physicians should “pay attention” in clinical settings and during patient care; yet studies show individuals commonly demonstrate only brief and unpredictable attention. Thus, “mindlessness” has become a pervasive cognitive phenomenon in modern life, often occurring unintentionally for a substantial portion of the day and often leading to failures in task performance.13 Such failures can affect physicians’ relationships with their patients and even lead to life-threatening errors in judgment.14 In the future, mindfulness may be the link between relationship-centered care and evidence-based clinical practice.15
Mindfulness-based stress reduction has the potential to improve physicians’ health, well-being, and job satisfaction, as well as their effectiveness and safety on the job. Studies of medical, nursing, and dental students, medical residents, and practicing health care professionals, including doctors, have shown that MBSR can reduce depression and anxiety and increase empathy;16 decrease burnout by combating emotional exhaustion and depersonalization;17 and increase quality of life by reducing stress and increasing compassion for oneself.10
Although extensive efforts have been directed toward helping impaired or burned-out physicians, little emphasis has been placed on enhancing the well-being, health, and happiness of the professionals who should be modeling such a way of life for their patients.18 Mindfulness itself not only may be critical to personal and societal wellness, but it also may be an accessible route to developing and nurturing many other aspects of well-being. Mindfulness helps us be in touch with our physical and emotional states so that we can make conscious decisions that support our own health. It also can preserve our health and happiness, and keep us in medicine.
Most physicians go into medicine to be of service, to help individuals and families deal with the challenges of illness and trauma. Yet, after years of practice in a difficult and continually changing environment, many of us find ourselves struggling with fatigue, a sense of futility, frustration with forms and computers, inability to keep up with the rapid flow of new information, and the demands of our own lives. There may be little we can do to quickly change the external factors in our lives and practices. But we can change our internal responses to these challenges. Mindful presence invites us back into each moment as it happens, helping us compassionately set priorities, recognize our limits, and rediscover the meaning in our work. MM
Karen Lawson is an assistant professor in the department of family medicine and community health and director of health coaching at the Center for Spirituality and Healing at the University of Minnesota. She is a founding diplomat of the American Board of Integrative and Holistic Medicine.
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