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Cancer Research Center Hotline Carl-Wilhelm Vogel MD, PhD, Contributing EditorHawaii Medical Journal, Volume 66, December 2007
MINDFULNESS MEDITATION AND ITS MEDICAL AND NON-MEDICAL APPLICATIONS
Thanh V. Huynh MD, John A. Burns School of Medicine (Departments of Surgery and Complementary & Alternative Medicine), and Cancer Research Center of Hawai‘i, University of Hawai‘i;
Carolyn Gotay PhD, Cancer Research Center of Hawai‘i, University of Hawai‘i;
Gabriela Layi MA, Cancer Research Center of Hawai‘i, University of Hawai‘i;
Susan Garrard BA, Cancer Research Center of Hawai‘i, University of Hawai‘i
This paper focuses on a promising health care intervention—mindfulness meditation—that is the subject of considerable and increasing interest. The authors describe what mindfulness means, how it has been applied in patient and non-patient populations, and current activities in Hawai‘i.
There is an increasing volume of peer reviewed literature reporting the use of mindfulness meditation in medical settings. In fact, the Agency for Healthcare Research and Quality has just released an encyclopedic review of research on health-related meditation practices, including mindfulness meditation (MM). This report identified 127 published studies of MM, including 50 randomized controlled trials. While such data indicate a wide and growing interest in MM and related techniques, the report also indicates that considerable additional rigorous research is needed to understand more fully the potential contributions of meditation practices to health. This paper discusses what MM is, reviews findings in specified populations, and discusses preliminary research in Hawai‘i. What is Mindfulness?
Mindfulness meditation is derived from ancient Buddhist practices and tenets. A number of forms of MM are in use . The most common MM approach used in health care settings is based on the secular Mindfulness Based Stress Reduction (MBSR) approach developed by Kabat-Zinn at the University of Massachusetts in the late 1970s. He was the first to apply MM in a behavioral medicine setting for populations with a wide range of chronic pain and stress-related disorders . MM is based on the premise that many people go through life on auto pilot”, without paying attention to what is going on in and around them. If they do happen to attend to themselves and their environment, they often do so in the context of a priori expectations, judgments, and habits. MM training enables individuals to attend to their current environment by teaching them how to become aware of what is happening to them at the present time, in a non-judgmental way. An individual’s environment includes the full range of physical experiences (e.g, body posture and bodily sensations), and pleasant, neutral, and unpleasant feelings, thoughts, mental states and emotions. MM allows a practitioner to perceive his/her world clearly and objectively, without subjective biases due to current mood, past experiences, or expectations of how things should be. MM differs from other meditation practices that require full concentration on a specified meditation object. In MM, one keeps an open, “free flowing” perspective, allowing an openness to all life experiences and avoidance of clinging to a pleasant experience or resisting or ignoring an unpleasant one. This dispassionate state of self-observation is thought to introduce a ‘space’ between one’s perception and response that allows one to respond to situations more reflectively (as opposed to reflexively) . Mindfulness is therefore associated with patience and acceptance and enhanced relaxation and tolerance, and at the same time fewer negative reactions without being passive or withdrawn. It can be self-cultivated and practiced by anyone, including school-age children, following simple instructions.
Although mindfulness-based interventions rely on meditation techniques to teach the necessary skills for evoking mindfulness, this mode of awareness is not limited to meditation (i.e., sitting in one spot for a prolonged period). One of the most attractive aspects of MM is that once the skills are learned, individuals can regulate their attention to evoke mindfulness in many situations—for example, while stuck in traffic. This practice can thus allow the practitioner to respond skillfully to situations that might otherwise provoke emotional reactions (e.g., “road rage”). A typical 4 to 10 week course in mindfulness training includes progressive instruction in formal sitting and walking meditation (20-60 minutes a day) as well as how to be mindful during all daily life activities to the extent possible. The most frequently cited method of mindfulness training in clinical populations is the structured MBSR program developed by Kabat-Zinn and colleagues . See Appendix 1 for an example of MM training. Medical Applications of Mindfulness Meditation
MM has been applied in a number of medical conditions, and several reviews of the literature have been reported [1,4] including one meta-analysis that conducted pooled analyses of effect size across 20 reports.5 Studies have been conducted in patients with medical conditions including chronic pain, fibromyalgia, anxiety and panic disorders, psoriasis, depression, substance abuse, binge eating disorders, burnout, personality disorders, cancer and heterogeneous patient populations [1,4,5]. Despite methodological limitations noted in all of these reports, this literature, as a whole, suggests that MM is helpful for patients with a wide variety of medical conditions. Grossman, et al’s meta-analysis  showed that compared to a control group, MM interventions significantly improved both mental and physical health indicators for patients across a variety of diagnoses, regardless of whether a randomized or non-randomized study design was used. They also reported that changes in scores before and after the intervention reflected improvement in both mental and physical well-being. The “medium” effect sizes (slightly exceeding d=.5 for all reported analyses) imply that these improvements are likely to be clinically meaningful.
Several studies of oncology patients, led by Carlson and colleagues, illustrate the kind of research that has been reported. Speca, et al’s randomized controlled trial  demonstrated less mood disturbance and fewer symptoms of stress in cancer outpatients who completed a MM course (N=90), and these benefits were maintained 6 months later . In a study with patients with breast and prostate cancers (N=42)  significant improvements were seen in overall quality of life and stress following MM training. A one-year follow up  demonstrated continued enhanced quality of life and decreased stress symptoms and cortisol and immune patterns consistent with less stress and mood disturbance, and decreased blood pressure. Several reviews of these studies and others in this area have been published [10-12] and all conclude that this is a promising line of research that needs to be replicated and extended to other cancer patient populations. Non-Medical Applications of Mindfulness Meditation
Several reviews  also included studies of healthy volunteers and found that, in general, similar increases in well-being to those shown in patient populations were demonstrated. There are several kinds of applications of MM in healthy populations that are of particular interest.
Mindfulness meditation in education:
MM has been taught in medical schools and law schools. Shapiro and colleagues of the University of Arizona conducted a well-controlled, statistical design study using an 8-week mindfulness meditation-based stress reduction intervention on premedical and medical students . Findings indicate that participation in the intervention effectively reduced self-reported state and trait anxiety and reports of overall psychological distress including depression, and increased scores on overall empathy levels, and on a measure of spiritual experiences assessed at the end of the intervention. A study from Jefferson University shows similar results in 140 volunteer medical students .
Mindfulness meditation in sports:
MM has also been used with great success in professional sports. Former Chicago Bulls coach Phil Jackson, now of the Los Angeles Lakers , has used mindfulness practice in basketball training for many years. Olympic athletes like US Gold Medalist speed skater Apolo Ohno and golf star Tiger Woods have also employed mindfulness practice as part of their training. The Boston College basketball team has been trained in mindfulness by its sport psychologist, George Mumford, with good results.
Mindfulness Meditation Research In Hawai‘i
1- Online MM for cancer patients:
All published studies of MM for cancer patients to date use the popular 8- to 10-week classroom setting to teach this self-administered technique. This approach, while it may be effective, limits the availability of this training to patients who may need it, since not everyone has access (e.g., transportation, mobility) to attend such sessions, and the timing of MM sessions may not be consistent with patient needs or preferences. To address these barriers, researchers at the Cancer Research Center of Hawai‘i (CG, TH) developed and conducted a pilot feasibility study of an online, internet-based MM course for cancer patients led by a project director (GL). As far as we know, this is the first group to try such an approach. The course used a 6-week MM program and was open to cancer patients within six months of diagnosis. This study has been completed with target sample size(N=15) achieved. The course was able to attract participants from the Neighbor Islands and from Saipan, and the computer-based system was easy for the participants to use, even those who had no previous computer experience. The course also provided instructions that could be downloaded for use in portable listening systems, and many patients found this to be very helpful. The majority (80%) of participants completed the course and reported many significant benefits: e.g., stress reduction, relaxation, easing pain, and counteracting negative feelings. Most said they would recommend such a program for other cancer patients and planned to continue practicing MM even when the study was completed.
This project demonstrated that cancer patients can be trained in MM in a very cost-effective way, and they can practice MM by themselves as an adjunctive measure, without interfering with cancer-directed therapy provided by their physicians. The researchers have discussed this study at the national level, and there is considerable enthusiasm for developing a MM protocol based on this pilot study that can be tested for efficacy in the national clinical cooperative cancer groups. MM for Medical Students and the Public :
The researchers are in the process of establishing an improved version of this online MM course based partially on the study participants’ feedback, and intend to make this available within University of Hawai‘i John A. Burn’s School of Medicine Complementary and Alternative Medicine department for students, staff, and patients.
This course will be offered without tuition and could be used for future research in this line. See Appendix 2 for course outline.
2-There are regular mindfulness introductory workshops and retreats organized or sponsored by Vipassana Hawai‘i. These are held at various locations in Hawai‘i and elsewhere .
MM is a technique that has been applied and tested in a number of contexts. Given the high interest of Hawai‘i residents in complementary and alternative medicine  and the compatibility between meditation practices and the traditional culture of many Hawai‘i residents, MM holds considerable promise for improving the health and well-being of Hawai‘i residents. Research efforts in this area, such as those described here, are just beginning. Acknowledgements
We appreciate the assistance of Mark Tom in the preparation of the website, Brian
Issell MD in study design, Gregory Pai PhD in mindfulness course monitoring, and pilot study funding to Carolyn Gotay PhD (Ph: (808) 564-5820) from the Cancer Research Center of Hawai‘i for the conduct of the cancer patient study. Correspondence to:
Thanh V. Huynh MD, (Department of Radiation Therapy, 1301 Punchbowl Street, Honolulu, Hawai‘i 96813, Ph: (808) 547-4771, Fax: (808) 547-4507).
*** Currently: The Cancer Center of Hawaii. 808-547-6881.
1. Ospina MB, Bond TK, Karkhaneh M, et al. Meditation practices for health: state of the research. Evidence Report/Technology Assessment No. 155 (Prepared by the University of Alberta Evidence-Based Practice Center under Contract No. 290-02-0023.) AHRQ Publication No. 07-E010. Rockville, MD: Agency for Healthcare Research and Quality. June 2007.
2. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body to face stress, pain and illness. New York: Delacorte, 1990.
3. Bishop SR, Lau M, Shapiro S, Carlson LE, Anderson ND, Carmody J, Segal ZV, Abbey S, Speca M, Velting D, Devins G. Mindfulness: A proposed operational definition. Clin Psychol: Sci Pract. 2004 11: 230–241.
4. Shigaki CL, Glass B, Schopp LH. Mindfulness-based stress reduction in medical settings. J Clin Psychol in Med Settings Psychol in Med Settings 2006 13:209-216.
5. Grossmann P, Niemann L, Schmidt S, Walach H, Mindfulness-based stress reduction and health benefits A meta-analysis. J Psychosom Res J Psychosom Res 2004:35-43.
6. Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: the effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosom Med Psychosom Med 2000, 62:613-622.
7. Carlson LE, Ursuliak Z, Goodey E, Angen M, Speca M. The effects of a mindfulness meditation based stress reduction program on mood and symptoms of stress in cancer outpatients: Six month follow-up. Support Care Cancer Support Care Cancer 2001 9:112-123.
8. Carlson LE, Speca M, Patel KD, Goodey E. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosom Med Psychosom Med 2003 65:571-581.
9. Carlson LE, Speca M, Faris P, Patel KD. One year pre-post intervention follow-up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based stress reduction (MBSR) in breast and prostate cancer outpatients. Brain Behav Immun Brain Behav Immun 2007:1038-49. Epub 2007 May 22.
10. Matchim Y, Armer JM. Measuring the psychological impact of mindfulness meditation on health among patients with cancer: A literature review. Oncol Nurs ForumOncol Nurs Forum 2007 34:1059-1066.
11. Ott MJ, Norris RL, Bauer-Wu SM. Mindfulness meditation for oncology patients: A discussion and critical review. Integr Cancer TherIntegr Cancer Ther 2006, 5:98-108.
12. Smith JE, Richardson J, Hoffman C, Pilkington K. Mindfulness-based stress reduction as supportive therapy in cancer care: A systematic review. J Adv NursAdv Nurs 2005, 52:315-327.
13. Shapiro SL, Schwartz GE, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. J Behav MedJ Behav Med 1998, 21:581-99.
14. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Medeach Learn Med 2003, 15:88-92.
15. Jackson P. Sacred hoops: Spiritual lessons of a hardwood warrior. New York: Hyperion, 1995.
16. Harrigan R, Mbabuike N, Efird JT, Easa D, Shintani T, Hammatt Z, Perez J, Shomaker TS. Use of provider delivered complementary and alternative therapies in Hawai’i: results of the Hawai’i Health Survey. Hawaii Med J 2006, 65:130-2, 134-139, 151.
17. Huynh TV. Introduction to Mindfulness Meditation. http://vipassanahawaii.org/?q=node/19.
Typical mindfulness sitting instruction:
At the beginning of your sitting meditation, simply let go of thoughts about the past and future, relax and bring your awareness into the present moment by paying attention to your body posture and silently note “sitting”. Feel the uprightness of the body, straightening it a little if it slumps and relax it if it feels stiff. Try to maintain a balance between the two. Keep it this way from this point on without adjusting frequently during the sitting. Feel the pressure, vibration, firmness/softness or temperature where the body touches the sitting surface. Breathe normally without controlling the breath. Follow the changing sensations continuously from the beginning to the end of the in-breath, then from the beginning to the end of the out-breath (paying particular attention to the end of both the rising and falling movements).Feel the motion, tingling, pressure, vibration, lightness, heaviness, temperature, etc… Make a soft mental note “rising” during the in-breath, and “falling” during the out-breath as needed. You may prefer to use sounds as an object of meditation, at the beginning and at times, instead of the breath. Open the awareness widely to embrace all sounds as well as silent intervals, noting them as “hearing”, feeling the vibration at the ear doors without identifying what sounds they are (not thinking about them). If you find yourself lost in thoughts, rather than judging yourself (for example, “I should not be thinking about that”), simply acknowledge those thoughts as “thinking” or “wandering”. Then gently bring your attention back on your breath. Patiently begin again and again in the present moment by returning to the primary object regardless how many times the mind wanders. Try to stay with the primary object until you become concentrated rather than keep changing objects. When your mind becomes quiet, you are able to pay attention to the object that is most predominant, or obvious, at each moment. The object that you are attending to at this point does not reflect a choice or a judgment on your part (for example, “How long will this tightness last?”, “I like this soothing sound.” ,or “What should I focus on?”). Instead, it comes from a mindset that is choiceless (without preferences and preconceptions) and non-judgmental and open to all physical and mental objects that are happening at that particular moment in time. It is often described as “bare attention”.
Mindfulness during daily activities:
Try to be aware of one of the following activities and add one more each week: feel the transition of postures from lying to sitting to standing (and the reverse), feel the steps while walking, be mindful of the arm/hand bending, stretching or reaching for an object or the pressure or temperature while holding it. An experienced practitioner will also notice mental impulses before such movements. Extend eventually to all routine activities such as putting on clothes, washing in the shower etc...Feel the breath when ever you remember. A chime of the watch or clock, a doorbell or telephone ringing, a computer warning sound could be used as reminders of mindfulness. Pause and relax for a few seconds and/or take a couple of mindful breaths, or simply (come back to the present moment and) be mindful of what you are doing at each reminder. Remind yourself periodically to be mindful by asking if you are present (aware) or lost. Check your attitude to see if you are relaxed, having no expectation. It is also helpful to be aware of likes and dislikes in the mind while interacting with people or doing chores. With time, this awareness will extend to thoughts (such as judging) and emotions (or their corresponding physical sensations within the body).
Course Outline: Mindfulness Meditation -
An Online Experiential Course (JABSOM/CAM - July 2007) Catalog Description:
-Six weekly units of online instruction on the theory and practice of meditation.
-Daily meditation practice with audio/video-guided instruction.
-Internet forum for interaction with the instructor and other students. Course Objectives:
Upon completion of the course, the student should be able to:
1. differentiate various meditation techniques.
2. understand mindfulness and its components.
3. independently practice by applying mindfulness in formal meditation and in
4. describe the medical benefits of meditation. Course Content:
1. Introduction to meditation
2. Common meditation techniques.
3. Medical applications of mindfulness practice.
4. Definition and components of mindfulness.
5. Factors influencing the practice.
6. Techniques of mindfulness meditation:
Attitude for practice
Working with the body and the mind
Daily life mindfulness
Methods of Instruction: Online (flexible schedule) including:
Methods of Evaluating Student Progress:
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