Meditation and Mindfulness in Clinical P r a c tic e Deborah R. Simkin, MD, DFAACAPa,b,c,*, Nancy B. Black, MD, DFAACAPb,d KEYWORDS Meditation Mindfulness Transcendental meditation Anxiety Depression Children Adolescents KEY POINTS Meditation and mindfulness techniques derive from traditional contemplative practices, but are applied in modern clinical settings without the original religious and spiritual overtones. Five types of meditation have been systematically examined in children and adolescents: focused attention, open monitoring, automatic self-transcending (transcendental meditation), mind-body techniques, and body-mind techniques. Only a few randomized controlled trials have been conducted in children and adolescents, and more rigorous research is needed. Meditative and movement techniques have been shown to produce benefits for anxiety, depressive, and other negative affects, behavioral and emotional symptoms, and somatic functioning. Meditation and mindfulness techniques produce neurobiological changes in the brain and physiologic improvements in body function that have been shown to be enduring for patients who continue to practice these techniques. No significant adverse effects have been identified. Providers who offer these techniques should be well trained to ensure the best results. Research outcome measures demonstrate that there is a direct correlation between the amounts of time spent practicing, or participating in formal guided practice, with increased effectiveness of the techniques.
a
Attention, Memory and Cognition Center, 4641 Gulfstarr Drive, Suite 106, Destin, FL, USA; Committee on Integrative Medicine, American Academy of Child and Adolescent Psychiatry; c Emory University School of Medicine, Atlanta, GA, USA; d National Capital Consortium, Child and Adolescent Psychiatry Fellowship, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA * Corresponding author. Attention, Memory and Cognition Center, 4641 Gulfstarr Drive, Suite 106, Destin, FL. E-mail address: [email protected] b
Child Adolesc Psychiatric Clin N Am 23 (2014) 487–534 http://dx.doi.org/10.1016/j.chc.2014.03.002 childpsych.theclinics.com 1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Abbreviations AAP ABC ACT ACTeRS ADHD ADIS-C AN ANT AR ASD AST BASC-2 BDI BMI BN BRIEF CAM CAS CBCL CBT CD CDRS-R CFIT CHIP-AE CM CPRS CPT II CTI D-KEFS DBM DBT DMN DMT EDE EDNOS eLORETA or LORETA EMG ES FA fMRI GABA GEFT IT KIDNET M-B MANOVA MAP MASC MBCT MBI MBRP MBSR MBST MED-RELAX MET MFQ MM
Attention Academy Program Aberrant Behavioral Checklist Acceptance and commitment therapy ADD-H Comprehensive Teacher Rating Scale Attention-deficit/hyperactivity disorder Anxiety Disorder Interview Schedule for Children Anorexia nervosa Attention Network Test Biofeedback Autistic spectrum disorder Automatic self-transcending Behavioral Assessment System for Children, second edition Beck Depression Inventory Body mass index Bulimia nervosa Behavior Rating Inventory of Executive Function Complementary and alternative medicine Cognitive Assessment System Child Behavior Checklist Cognitive-behavioral therapy Conduct disordered Child Depression Rating Scale—Revised Culture Fair Intelligence Test Child Health and Illness Profile Adolescent Edition Contemplation meditation Child-Parent Relationship Scale Connor’s Continuous Performance Test II Constructive Thinking Inventory Delis-Kaplan Executive Function System Deep-breathing meditation Dialectical behavior therapy Default mode network Dance/movement therapy Eating Disorder Examination Eating disorder not otherwise specified Low-resolution brain electromagnetic tomography Electromyographic Effect size Focused attention Functional magnetic resonance imaging g-Aminobutyric acid Group Embedded Figures Test Inspection time Narrative Exposure Therapy for children Mind-body Multivariate analysis of variance Mindfulness awareness practices Multidimensional Anxiety Scale for Children Mindfulness-based cognitive therapy Primary basis of mindfulness-based interventions Mindfulness-based relapse prevention Mindfulness-based stress reduction Mindfulness-based stress reduction Meditation-relaxation Motivational enhancement therapy Mood and Feelings Questionnaire Mindfulness meditation
Meditation and Mindfulness in Clinical Practice
MNS MT NCCAM ODD OM PE POMS-SF PMR PS PSI PSS PTSD PR R-VT RCMAS RFT RR RT SM SNAP-IV SSM STAI STAIC SYM TAS TAU TCT-DP TEA-Ch TM TOL USPSTF YEQ YRS
Mirror neuron system Massage therapy National Center for Complementary and Alternative Medicine Oppositional defiant disorder Open monitoring Physical education Profile of Mood States—Short Form Progressive muscle relaxation Parent Scale Parent Stress Index Perceived stress Posttraumatic Stress Disorder Progressive relaxation Relaxation videotape Revised Child Manifest Anxiety Scale Relation frame theory Relaxation response Relaxation therapy Sahaja meditation Swanson, Nolan and Pelham Scale Sahaja Samadhi meditation State and Trait Anxiety Scale State-Trait Anxiety Inventory for Children Sahaja Yoga meditation Test Anxiety Scale Treatment as usual Test for Creative Thinking-Drawing Production Test of Everyday Attention for Children Transcendental meditation Tower of London United States Preventive Services Task Force Yoga Evaluation Questionnaire Youth Self Report
INTRODUCTION
Meditation has been practiced in diverse forms for centuries in various non-Western cultures, and this long and complex history has given rise to a variety of definitions, forms, and techniques.1 As a result, there is no single definition for meditation, although its general goal is to train the mind to achieve a particular goal. Meditation and mindfulness interventions may enhance the individual skills of children and adolescents, specifically by helping them feel more relaxed, focused, and creative. Parents who practice these techniques may also benefit from these effects, and find that meditation can enhance their parenting skills. Meditation in particular and mind-body medicine in general are described by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health as “focusing on the interactions among the brain, mind, body, and behavior, and on the powerful ways in which emotional, mental, social, spiritual and behavioral factors can directly affect health” (www.NCCAM.NIH.gov). Meditation may be divided into 5 categories for the purposes of explication in this article (Table 1). Each of these techniques is described in terms of their therapeutic goals, how to use the techniques, their physiologic and neurobiological effects, and the available clinical
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Table 1 Meditation-based therapy Types of Meditation
Therapeutic Meditation Approaches
Focused attention (FA) Primary basis of mindfulness-based interventions (MBI)
Mindfulness-based stress reduction (MBST) Mindfulness-based cognitive therapy (MBCT) Dialectical behavior therapy (DBT) Acceptance and commitment therapy (ACT) Mindfulness-based relapse prevention (MBRP)
Open monitoring (OM)
Sahaja meditation (SM) Sahaja Samadhi meditation (SSM) Sahaja yoga meditation (SYM)
Automatic self-transcending (AST)/Transcendental meditation (TM) Mind-body (M-B)
Meditation-relaxation (MED-RELAX) Progressive muscle relaxation (PMR) Deep breathing meditation (DBM)
Body-mind (B-M)
Exercise Movement therapy or dance therapy Tai Chi Qi Gong Yoga
research on their use in treating psychopathology in youth (and, in some cases, families). Readers seeking greater detail are referred to the references for these techniques.2–6 The studies for the therapeutic approaches are presented in the final section of this article, and evidence-based outcomes are presented in the relevant section in Table 3 according to the disorders treated. Meditation and Mindfulness: Evolution from Buddhist Traditions to Modern Western Techniques
Focused attention (FA) and open monitoring (OM) have roots in Zen, Vipassana, and Tibetan Buddhist meditation traditions. FA (concentration training) uses explicit objects to attend to so that the mind will not wander. OM (mindfulness) involves being aware moment to moment of any thought or feeling that occurs in personal experience without focusing on an explicit object. Buddhist meditations were and are intended for healthy individuals.7 Western clinical adaptations of these techniques are designed to target pathologic states of mind, such as anxiety. In the tradition of Vipassana meditation, concentration training followed by mindfulness training together are used to gain insight. First, using concentration training, the person learns to attend to one object so as to not allow the mind to be distracted or to wander. Then, mindfulness is used to observe negative thoughts and feelings in a nonjudgmental way so that the person can detach from them. Doing this allows the person to observe these thoughts and feelings in an objective way without reacting to them. One gains insight or awareness.8 As one becomes more aware, one makes further observations about these negative states (ie, what triggers them) as they arise, without reacting to them. When the mind achieves stillness, there is an enduring absence of reactivity.
Meditation and Mindfulness in Clinical Practice
Then, an appreciation for the mind’s natural state, which involves positive emotions, occurs. Thus, the technique allows the participant to be aware of positive mental states, such as patience, harmlessness, loving kindness, and empathy.9 Through these steps, Vipassana meditation builds a more positive state of mind. In Western cultures, FA and OM have been blended into what is called, for the purpose of this review, mindfulness meditation (MM). MM is derived from either Vipassana or Zen meditation, but Vipassana techniques are often chosen over Zen in Western cultures.10 Eastern traditions entail extensive training and involve both FA and OM. FA is the primary basis of mindfulness-based interventions (MBIs). Mindfulness-based stress reduction (MBSR) is the only FA technique overtly rooted in Buddhist philosophy,11–14 more heavily based in Vipassana with some Zen influence. FOCUSED ATTENTION MINDFULNESS-BASED INTERVENTIONS
Chiesa and Malinowski11 described 4 therapeutic techniques that are based on FA or concentration training as MBIs. A recent addition to MBI is Mindfulness-based relapse prevention (MBRP). The 5 techniques based in MBI are: 1. 2. 3. 4. 5.
Mindfulness-based stress reduction (MBSR) Mindfulness cognitive-behavioral therapy (MBCT) Dialectical behavior therapy (DBT) Acceptance and commitment therapy (ACT) Mindfulness-based relapse prevention (MBRP)
Kabat-Zinn12,15 developed MBSR in 1990 as an easily learned type of meditation for the general Western public. Segal13 developed MBCT specifically as a treatment for clinical depression and its accompanying cognitive distortions. Three different approaches of FA were subsequently adapted for clinical use with patients with 3 specific disorders; the 3 approaches use mindfulness skills, but not formal meditation techniques: Linehan16 developed DBT for treating patients with borderline personality disorder, although it is often used to help a variety of patients manage their extreme affects and problems with behavioral control. Hayes17 developed ACT which uses acceptance and mindfulness strategies, as well as, commitment and behavior change to increase psychological flexibility. MBRP was designed to target substance abusers.18 Goals of Focused Attention Mindfulness-Based Intervention
For MBI techniques the goal is clinically oriented. Their main aim is to relieve unwanted physical and psychological symptoms such as pain, anxiety, and depression. MBSR, MBCT, and MBRP are specifically concerned with relief from negative symptoms by targeting negative thoughts or emotions, achieved by means of developing an enhanced way to cope with and/or relate differently to them.9 The goal of DBT and ACT is to help patients manage symptoms. DBT can reduce dangerous behaviors such as suicidal behaviors. ACT also helps foster acceptance of unwanted feelings and thoughts, and discourages avoidance of them.17 Mindfulness-Based Stress-Reduction Techniques and Approaches
Techniques used to learn to focus on a specific object can vary. For instance, participants can use a body scan (sweeping attention from head to foot focusing
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noncritically on any sensation of feeling) or attention breathing (for instance, emphasis on focusing on one’s breathing while in a state of nonjudgmental awareness of cognition and distraction).12,15 Programs may include 8 sessions for 2 hours per day. Details of the techniques and outcomes are discussed in the section on studies. Mindfulness-Based Cognitive Therapy Techniques and Approaches
MBCT, a variation on CBT, is based on the observation that the way we perceive and understand events is a large determinant of how we feel about them and how we behave in response to them. As in Buddhist philosophy, it emphasizes selfresponsibility in the form of self-management, self-control, and self-improvement.9,13 For example, children are encouraged to focus on remembering negative experiences and then to allow themselves to focus on feeling those emotions and becoming aware of the bodily sensations that accompany the memory of the experience. After several minutes they are asked to take a 3-minute “breathing space,” when they are asked to focus on their breathing and what is going on in their body and mind. Then, in a relaxed state, they tell themselves that they can handle anything and then focus back on their body as a whole. MBCT encourages the use of this 3-minute breathing space to allow individuals to integrate formal practice into daily life whenever unpleasant feelings are noted. MBSR and MBCT both emphasize the attitude one brings to the meditation experience. Both techniques emphasize a nonjudgmental, nonstriving, and noneffort approach; this develops as practice deepens, resulting in more effortless, enhanced meditation whereby one moves more easily from concentration to mental stability.3 Details of the techniques and outcomes are discussed in the section on studies. Dialectical Behavioral Therapy Approaches and Techniques
DBT is derived from behavioral science, dialectical philosophy, and Zen practice. This approach is hypothesized to work by encouraging nonreinforced engagement with emotionally evocative stimuli while blocking dysfunctional escape, avoidance behavior, or ineffective responses to intense emotions. DBT teaches mindfulnessbased skills, such as being nonjudgmental, to allow the participant to reach a level of acceptance and change. This approach is used with borderline personality disorders and suicidal behaviors.16 Details of the techniques and outcomes are discussed in the section on studies. Acceptance and Commitment Therapy Techniques and Approaches
ACT is based on relation frame theory (RFT), which is derived from a philosophic view called functional contextualism. Functional contextualism uses the idea that cognitions gain importance mostly from the context in which they occur. Changing the context in which relationships occur is one example of how ACT works. Doing so can alter and limit behavior.17 For instance, ACT uses mindful techniques, which include the ability to recognize an observing self that is capable of watching its own bodily sensations, thoughts, and emotions by seeing these aspects as separate from the person having them. For instance, a participant would recognize “I am having a thought that I am a bad person” rather than “I am a bad person.”17 Mindfulness-Based Relapse Prevention Techniques and Approaches
MBRP is used to prevent relapse in individuals with substance abuse problems.9 MBRP was developed to target substance abusers by using cognitive behavioral therapy, mindfulness and relapse prevention techniques.
Meditation and Mindfulness in Clinical Practice
Physiologic and Neurobiological Effects of Focused Attention Mindfulness-Based Interventions
The literature reflects a variety of findings according to the design and tools used. The neurobiology of traditional Vipassana (which is meant to target healthy individuals) is discussed first, followed by the neurobiological effects seen in MBI (which are used to target pathologic states). Vipassana meditation
Meditators showed stronger activations in the rostral anterior cingulate cortex and the dorsal medial prefrontal cortex bilaterally in comparison with controls. The involvement of the rostral anterior cingulate suggests greater attention control during meditation, and the involvement of the dorsal medial prefrontal cortex suggests detecting interference between competing responses, thus signaling the need for control so that the mind will not wander.19 Meditators in another study (who had meditated an average of 20 years and had been meditating daily for at least 2 years), had magnetic resonance imaging (MRI) results indicating greater gray matter concentration in the right anterior insula, which is involved in interoceptive awareness or the ability of the mind to integrate different sensory signals from the body to produce the experience of the body as the person’s own. These same mediators had greater gray matter concentration in the left inferior temporal gyrus and right hippocampus. The hippocampus is involved in modulating cortical arousal and responsiveness. The hippocampus also modulates amygdalar activity and its involvement in attention and emotional processes. The mean value of gray matter concentration in the left inferior temporal gyrus was correlated with the amount of meditation training. Thus, the greater the meditation training, the greater was the gray matter concentration seen in this region. The temporal lobe has been implicated in religious activity, which is characterized by the feeling of deep pleasure and the experience of insight.20 Results suggest that meditation practice is associated with structural differences in regions that are typically activated during meditation, and in regions that are relevant for the task of meditation. In another study of Vipassana meditators, the P3a amplitude from a distracter (white noise) was reduced during meditation. P3a is hypothesized to index frontal neural activity produced by stimulus-driven attention mechanisms. Consistent with the aim of Vipassana meditation, to reduce cognitive and emotional reactivity the state effect of reduced P3a amplitude to distracting stimuli reflects decreased automatic reactivity and the ability to evaluate and ignore irrelevant attention-demanding stimuli.21 In this same study, increased oscillation over the parietal-occipital region was seen in the gamma frequency range (35–45 Hz), signifying exclusion of external stimuli, and increased frontal theta (4–8 Hz), signifying the processing of positive internal emotions.22 Taken together, the neurobiological evidence correlates with the sequence of events that occur in persons who perform Vipassana meditation. 1. First, during the meditation, the person focuses attention on an object (rostral anterior cingulate), and competing stimuli are avoided so as to not allow the brain to be distracted (dorsal medial prefrontal cortex). 2. Then the person is aware of negative bodily sensations, thoughts, or feelings moment to moment (right anterior insula) but without reactivity, as if they are
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irrelevant (hippocampus and corresponding influence over the amygdala, reduced amplitude of P3a), thus allowing a more objective way of observing them. 3. Finally, the increase in gamma waves in the parietal-occipital areas and the increased theta in the frontal area occurs when all external stimuli are excluded and only positive internal emotions occur, such as empathy. Mindfulness-based intervention: changing pathologic states MRI results After 8 weeks of MBSR training, MRI data confirmed increases in gray
matter concentration within the left hippocampus. Whole brain analyses also identified increased gray matter in the posterior cingulate cortex, the temporoparietal junction, and the cerebellum in the MBSR group when compared with the controls. The results suggest that participation in MBSR is associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking.23 In another study all participants completed the 8-week MBSR program, consisting of weekly group meetings and daily home mindfulness practices. Individuals were eligible to enter the study if their score on the Perceived Stress Scale (PSS) was 1 standard deviation (SD) or more above the population mean. The PSS is a validated selfreport questionnaire widely used for assessing an individual’s self-perception of stress. However, in this study, individuals were excluded if they had a current psychiatric illness or medical illness, ineligibility for MRI scanning (claustrophobia, metallic implants, pregnancy, and so forth), or significant previous meditation or yoga experience. After 8 weeks of MBSR, perceived stress was rated again on the PSS. PSS scores decreased from preintervention (mean 20.7; SD 5.6) to postintervention (mean 15.2; SD 4.7; T 5 3.7; df 5 25; P
a
Attention, Memory and Cognition Center, 4641 Gulfstarr Drive, Suite 106, Destin, FL, USA; Committee on Integrative Medicine, American Academy of Child and Adolescent Psychiatry; c Emory University School of Medicine, Atlanta, GA, USA; d National Capital Consortium, Child and Adolescent Psychiatry Fellowship, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA * Corresponding author. Attention, Memory and Cognition Center, 4641 Gulfstarr Drive, Suite 106, Destin, FL. E-mail address: [email protected] b
Child Adolesc Psychiatric Clin N Am 23 (2014) 487–534 http://dx.doi.org/10.1016/j.chc.2014.03.002 childpsych.theclinics.com 1056-4993/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
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Simkin & Black
Abbreviations AAP ABC ACT ACTeRS ADHD ADIS-C AN ANT AR ASD AST BASC-2 BDI BMI BN BRIEF CAM CAS CBCL CBT CD CDRS-R CFIT CHIP-AE CM CPRS CPT II CTI D-KEFS DBM DBT DMN DMT EDE EDNOS eLORETA or LORETA EMG ES FA fMRI GABA GEFT IT KIDNET M-B MANOVA MAP MASC MBCT MBI MBRP MBSR MBST MED-RELAX MET MFQ MM
Attention Academy Program Aberrant Behavioral Checklist Acceptance and commitment therapy ADD-H Comprehensive Teacher Rating Scale Attention-deficit/hyperactivity disorder Anxiety Disorder Interview Schedule for Children Anorexia nervosa Attention Network Test Biofeedback Autistic spectrum disorder Automatic self-transcending Behavioral Assessment System for Children, second edition Beck Depression Inventory Body mass index Bulimia nervosa Behavior Rating Inventory of Executive Function Complementary and alternative medicine Cognitive Assessment System Child Behavior Checklist Cognitive-behavioral therapy Conduct disordered Child Depression Rating Scale—Revised Culture Fair Intelligence Test Child Health and Illness Profile Adolescent Edition Contemplation meditation Child-Parent Relationship Scale Connor’s Continuous Performance Test II Constructive Thinking Inventory Delis-Kaplan Executive Function System Deep-breathing meditation Dialectical behavior therapy Default mode network Dance/movement therapy Eating Disorder Examination Eating disorder not otherwise specified Low-resolution brain electromagnetic tomography Electromyographic Effect size Focused attention Functional magnetic resonance imaging g-Aminobutyric acid Group Embedded Figures Test Inspection time Narrative Exposure Therapy for children Mind-body Multivariate analysis of variance Mindfulness awareness practices Multidimensional Anxiety Scale for Children Mindfulness-based cognitive therapy Primary basis of mindfulness-based interventions Mindfulness-based relapse prevention Mindfulness-based stress reduction Mindfulness-based stress reduction Meditation-relaxation Motivational enhancement therapy Mood and Feelings Questionnaire Mindfulness meditation
Meditation and Mindfulness in Clinical Practice
MNS MT NCCAM ODD OM PE POMS-SF PMR PS PSI PSS PTSD PR R-VT RCMAS RFT RR RT SM SNAP-IV SSM STAI STAIC SYM TAS TAU TCT-DP TEA-Ch TM TOL USPSTF YEQ YRS
Mirror neuron system Massage therapy National Center for Complementary and Alternative Medicine Oppositional defiant disorder Open monitoring Physical education Profile of Mood States—Short Form Progressive muscle relaxation Parent Scale Parent Stress Index Perceived stress Posttraumatic Stress Disorder Progressive relaxation Relaxation videotape Revised Child Manifest Anxiety Scale Relation frame theory Relaxation response Relaxation therapy Sahaja meditation Swanson, Nolan and Pelham Scale Sahaja Samadhi meditation State and Trait Anxiety Scale State-Trait Anxiety Inventory for Children Sahaja Yoga meditation Test Anxiety Scale Treatment as usual Test for Creative Thinking-Drawing Production Test of Everyday Attention for Children Transcendental meditation Tower of London United States Preventive Services Task Force Yoga Evaluation Questionnaire Youth Self Report
INTRODUCTION
Meditation has been practiced in diverse forms for centuries in various non-Western cultures, and this long and complex history has given rise to a variety of definitions, forms, and techniques.1 As a result, there is no single definition for meditation, although its general goal is to train the mind to achieve a particular goal. Meditation and mindfulness interventions may enhance the individual skills of children and adolescents, specifically by helping them feel more relaxed, focused, and creative. Parents who practice these techniques may also benefit from these effects, and find that meditation can enhance their parenting skills. Meditation in particular and mind-body medicine in general are described by the National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health as “focusing on the interactions among the brain, mind, body, and behavior, and on the powerful ways in which emotional, mental, social, spiritual and behavioral factors can directly affect health” (www.NCCAM.NIH.gov). Meditation may be divided into 5 categories for the purposes of explication in this article (Table 1). Each of these techniques is described in terms of their therapeutic goals, how to use the techniques, their physiologic and neurobiological effects, and the available clinical
489
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Simkin & Black
Table 1 Meditation-based therapy Types of Meditation
Therapeutic Meditation Approaches
Focused attention (FA) Primary basis of mindfulness-based interventions (MBI)
Mindfulness-based stress reduction (MBST) Mindfulness-based cognitive therapy (MBCT) Dialectical behavior therapy (DBT) Acceptance and commitment therapy (ACT) Mindfulness-based relapse prevention (MBRP)
Open monitoring (OM)
Sahaja meditation (SM) Sahaja Samadhi meditation (SSM) Sahaja yoga meditation (SYM)
Automatic self-transcending (AST)/Transcendental meditation (TM) Mind-body (M-B)
Meditation-relaxation (MED-RELAX) Progressive muscle relaxation (PMR) Deep breathing meditation (DBM)
Body-mind (B-M)
Exercise Movement therapy or dance therapy Tai Chi Qi Gong Yoga
research on their use in treating psychopathology in youth (and, in some cases, families). Readers seeking greater detail are referred to the references for these techniques.2–6 The studies for the therapeutic approaches are presented in the final section of this article, and evidence-based outcomes are presented in the relevant section in Table 3 according to the disorders treated. Meditation and Mindfulness: Evolution from Buddhist Traditions to Modern Western Techniques
Focused attention (FA) and open monitoring (OM) have roots in Zen, Vipassana, and Tibetan Buddhist meditation traditions. FA (concentration training) uses explicit objects to attend to so that the mind will not wander. OM (mindfulness) involves being aware moment to moment of any thought or feeling that occurs in personal experience without focusing on an explicit object. Buddhist meditations were and are intended for healthy individuals.7 Western clinical adaptations of these techniques are designed to target pathologic states of mind, such as anxiety. In the tradition of Vipassana meditation, concentration training followed by mindfulness training together are used to gain insight. First, using concentration training, the person learns to attend to one object so as to not allow the mind to be distracted or to wander. Then, mindfulness is used to observe negative thoughts and feelings in a nonjudgmental way so that the person can detach from them. Doing this allows the person to observe these thoughts and feelings in an objective way without reacting to them. One gains insight or awareness.8 As one becomes more aware, one makes further observations about these negative states (ie, what triggers them) as they arise, without reacting to them. When the mind achieves stillness, there is an enduring absence of reactivity.
Meditation and Mindfulness in Clinical Practice
Then, an appreciation for the mind’s natural state, which involves positive emotions, occurs. Thus, the technique allows the participant to be aware of positive mental states, such as patience, harmlessness, loving kindness, and empathy.9 Through these steps, Vipassana meditation builds a more positive state of mind. In Western cultures, FA and OM have been blended into what is called, for the purpose of this review, mindfulness meditation (MM). MM is derived from either Vipassana or Zen meditation, but Vipassana techniques are often chosen over Zen in Western cultures.10 Eastern traditions entail extensive training and involve both FA and OM. FA is the primary basis of mindfulness-based interventions (MBIs). Mindfulness-based stress reduction (MBSR) is the only FA technique overtly rooted in Buddhist philosophy,11–14 more heavily based in Vipassana with some Zen influence. FOCUSED ATTENTION MINDFULNESS-BASED INTERVENTIONS
Chiesa and Malinowski11 described 4 therapeutic techniques that are based on FA or concentration training as MBIs. A recent addition to MBI is Mindfulness-based relapse prevention (MBRP). The 5 techniques based in MBI are: 1. 2. 3. 4. 5.
Mindfulness-based stress reduction (MBSR) Mindfulness cognitive-behavioral therapy (MBCT) Dialectical behavior therapy (DBT) Acceptance and commitment therapy (ACT) Mindfulness-based relapse prevention (MBRP)
Kabat-Zinn12,15 developed MBSR in 1990 as an easily learned type of meditation for the general Western public. Segal13 developed MBCT specifically as a treatment for clinical depression and its accompanying cognitive distortions. Three different approaches of FA were subsequently adapted for clinical use with patients with 3 specific disorders; the 3 approaches use mindfulness skills, but not formal meditation techniques: Linehan16 developed DBT for treating patients with borderline personality disorder, although it is often used to help a variety of patients manage their extreme affects and problems with behavioral control. Hayes17 developed ACT which uses acceptance and mindfulness strategies, as well as, commitment and behavior change to increase psychological flexibility. MBRP was designed to target substance abusers.18 Goals of Focused Attention Mindfulness-Based Intervention
For MBI techniques the goal is clinically oriented. Their main aim is to relieve unwanted physical and psychological symptoms such as pain, anxiety, and depression. MBSR, MBCT, and MBRP are specifically concerned with relief from negative symptoms by targeting negative thoughts or emotions, achieved by means of developing an enhanced way to cope with and/or relate differently to them.9 The goal of DBT and ACT is to help patients manage symptoms. DBT can reduce dangerous behaviors such as suicidal behaviors. ACT also helps foster acceptance of unwanted feelings and thoughts, and discourages avoidance of them.17 Mindfulness-Based Stress-Reduction Techniques and Approaches
Techniques used to learn to focus on a specific object can vary. For instance, participants can use a body scan (sweeping attention from head to foot focusing
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noncritically on any sensation of feeling) or attention breathing (for instance, emphasis on focusing on one’s breathing while in a state of nonjudgmental awareness of cognition and distraction).12,15 Programs may include 8 sessions for 2 hours per day. Details of the techniques and outcomes are discussed in the section on studies. Mindfulness-Based Cognitive Therapy Techniques and Approaches
MBCT, a variation on CBT, is based on the observation that the way we perceive and understand events is a large determinant of how we feel about them and how we behave in response to them. As in Buddhist philosophy, it emphasizes selfresponsibility in the form of self-management, self-control, and self-improvement.9,13 For example, children are encouraged to focus on remembering negative experiences and then to allow themselves to focus on feeling those emotions and becoming aware of the bodily sensations that accompany the memory of the experience. After several minutes they are asked to take a 3-minute “breathing space,” when they are asked to focus on their breathing and what is going on in their body and mind. Then, in a relaxed state, they tell themselves that they can handle anything and then focus back on their body as a whole. MBCT encourages the use of this 3-minute breathing space to allow individuals to integrate formal practice into daily life whenever unpleasant feelings are noted. MBSR and MBCT both emphasize the attitude one brings to the meditation experience. Both techniques emphasize a nonjudgmental, nonstriving, and noneffort approach; this develops as practice deepens, resulting in more effortless, enhanced meditation whereby one moves more easily from concentration to mental stability.3 Details of the techniques and outcomes are discussed in the section on studies. Dialectical Behavioral Therapy Approaches and Techniques
DBT is derived from behavioral science, dialectical philosophy, and Zen practice. This approach is hypothesized to work by encouraging nonreinforced engagement with emotionally evocative stimuli while blocking dysfunctional escape, avoidance behavior, or ineffective responses to intense emotions. DBT teaches mindfulnessbased skills, such as being nonjudgmental, to allow the participant to reach a level of acceptance and change. This approach is used with borderline personality disorders and suicidal behaviors.16 Details of the techniques and outcomes are discussed in the section on studies. Acceptance and Commitment Therapy Techniques and Approaches
ACT is based on relation frame theory (RFT), which is derived from a philosophic view called functional contextualism. Functional contextualism uses the idea that cognitions gain importance mostly from the context in which they occur. Changing the context in which relationships occur is one example of how ACT works. Doing so can alter and limit behavior.17 For instance, ACT uses mindful techniques, which include the ability to recognize an observing self that is capable of watching its own bodily sensations, thoughts, and emotions by seeing these aspects as separate from the person having them. For instance, a participant would recognize “I am having a thought that I am a bad person” rather than “I am a bad person.”17 Mindfulness-Based Relapse Prevention Techniques and Approaches
MBRP is used to prevent relapse in individuals with substance abuse problems.9 MBRP was developed to target substance abusers by using cognitive behavioral therapy, mindfulness and relapse prevention techniques.
Meditation and Mindfulness in Clinical Practice
Physiologic and Neurobiological Effects of Focused Attention Mindfulness-Based Interventions
The literature reflects a variety of findings according to the design and tools used. The neurobiology of traditional Vipassana (which is meant to target healthy individuals) is discussed first, followed by the neurobiological effects seen in MBI (which are used to target pathologic states). Vipassana meditation
Meditators showed stronger activations in the rostral anterior cingulate cortex and the dorsal medial prefrontal cortex bilaterally in comparison with controls. The involvement of the rostral anterior cingulate suggests greater attention control during meditation, and the involvement of the dorsal medial prefrontal cortex suggests detecting interference between competing responses, thus signaling the need for control so that the mind will not wander.19 Meditators in another study (who had meditated an average of 20 years and had been meditating daily for at least 2 years), had magnetic resonance imaging (MRI) results indicating greater gray matter concentration in the right anterior insula, which is involved in interoceptive awareness or the ability of the mind to integrate different sensory signals from the body to produce the experience of the body as the person’s own. These same mediators had greater gray matter concentration in the left inferior temporal gyrus and right hippocampus. The hippocampus is involved in modulating cortical arousal and responsiveness. The hippocampus also modulates amygdalar activity and its involvement in attention and emotional processes. The mean value of gray matter concentration in the left inferior temporal gyrus was correlated with the amount of meditation training. Thus, the greater the meditation training, the greater was the gray matter concentration seen in this region. The temporal lobe has been implicated in religious activity, which is characterized by the feeling of deep pleasure and the experience of insight.20 Results suggest that meditation practice is associated with structural differences in regions that are typically activated during meditation, and in regions that are relevant for the task of meditation. In another study of Vipassana meditators, the P3a amplitude from a distracter (white noise) was reduced during meditation. P3a is hypothesized to index frontal neural activity produced by stimulus-driven attention mechanisms. Consistent with the aim of Vipassana meditation, to reduce cognitive and emotional reactivity the state effect of reduced P3a amplitude to distracting stimuli reflects decreased automatic reactivity and the ability to evaluate and ignore irrelevant attention-demanding stimuli.21 In this same study, increased oscillation over the parietal-occipital region was seen in the gamma frequency range (35–45 Hz), signifying exclusion of external stimuli, and increased frontal theta (4–8 Hz), signifying the processing of positive internal emotions.22 Taken together, the neurobiological evidence correlates with the sequence of events that occur in persons who perform Vipassana meditation. 1. First, during the meditation, the person focuses attention on an object (rostral anterior cingulate), and competing stimuli are avoided so as to not allow the brain to be distracted (dorsal medial prefrontal cortex). 2. Then the person is aware of negative bodily sensations, thoughts, or feelings moment to moment (right anterior insula) but without reactivity, as if they are
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irrelevant (hippocampus and corresponding influence over the amygdala, reduced amplitude of P3a), thus allowing a more objective way of observing them. 3. Finally, the increase in gamma waves in the parietal-occipital areas and the increased theta in the frontal area occurs when all external stimuli are excluded and only positive internal emotions occur, such as empathy. Mindfulness-based intervention: changing pathologic states MRI results After 8 weeks of MBSR training, MRI data confirmed increases in gray
matter concentration within the left hippocampus. Whole brain analyses also identified increased gray matter in the posterior cingulate cortex, the temporoparietal junction, and the cerebellum in the MBSR group when compared with the controls. The results suggest that participation in MBSR is associated with changes in gray matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking.23 In another study all participants completed the 8-week MBSR program, consisting of weekly group meetings and daily home mindfulness practices. Individuals were eligible to enter the study if their score on the Perceived Stress Scale (PSS) was 1 standard deviation (SD) or more above the population mean. The PSS is a validated selfreport questionnaire widely used for assessing an individual’s self-perception of stress. However, in this study, individuals were excluded if they had a current psychiatric illness or medical illness, ineligibility for MRI scanning (claustrophobia, metallic implants, pregnancy, and so forth), or significant previous meditation or yoga experience. After 8 weeks of MBSR, perceived stress was rated again on the PSS. PSS scores decreased from preintervention (mean 20.7; SD 5.6) to postintervention (mean 15.2; SD 4.7; T 5 3.7; df 5 25; P
