Mindfulness Meditation and 'Normal Stress'
By Howell Sasser, PhD. Dr. Sasser is Director, Research Epidemiology, R. Stuart Dickson Institute for Health Studies, Carolinas HealthCare System, Charlotte, NC; he reports no consultant, stockholder, speaker's bureau, research, or other financial relationships with companies having ties to this field of study.
Survey research confirms the intuitive sense that stress is a common problem even among comparatively healthy people. In the interviews that formed the basis for the American Psychological Association's 2007 report, "Stress in America," 79% of respondents agreed that stress was a "fact of life," and nearly half reported having at least some highly stressful days every month.1 Similar proportions reported that stress had an impact on their emotional or physical well-being.
An article published in the April 2008 issue of Alternative Medicine Alert looked at some of the recent research on the use of mindfulness meditation as a tool for coping with the stress and other consequences of serious illness.2 Most of this literature reports work with cancer patients and survivors, although other conditions have sometimes been included. While primary care clinicians certainly see patients with life-threatening and life-altering acute and chronic illnesses, they also see many others who are generally well but feel the effects of stress in their day-to-day lives. If this technique, used successfully by many patients with major stressors, were also shown to be effective in those with "sub-acute" stress, this would provide a resource to aid in the important task of day-to-day coping.
Mindfulness meditation (or Mindfulness-Based Stress Reduction [MBSR]) is most accurately described as a group of practices that serve to focus the attention on the present, making the practitioner aware of his or her physical and mental state. In this way, unproductive rumination on unchangeable past events and worry about still uncertain future challenges can more easily be put into proper perspective. Although many meditative practices were originally developed to clear the mind for contemplation of the transcendent, a religious element need not be present in any specific form, indeed need not be present at all.
A Basic Pattern
Nearly all studies of mindfulness meditation refer directly or indirectly to the work of Jon Kabat-Zinn, now an emeritus professor at the University of Massachusetts School of Medicine. Beginning in the early 1980s, in a series of journal articles and books, he described the elements that have come to be standard in many clinical mindfulness meditation programs.3 Because the studies reviewed in this article patterned their interventions on this model, it is worth reviewing briefly the essential components of mindfulness meditation:
"Sweeping" or Body Scan. The meditator directs his or her attention to each area of the body in turn, focusing non-judgmentally on sensations and feelings. Attention is brought back periodically to breathing and relaxation.
Seated Meditation. The meditator focuses on the moment, awareness of breathing, and other perceptions. When the consciousness drifts to other thoughts, it is brought back gently to the present moment. Strong feelings or emotions are observed in a detached manner and then consciousness is again brought to the present moment. All thoughts and feelings are treated as equal, and are neither pursued nor rejected.
Hatha Yoga. Yoga postures are used to help develop mindfulness during movement, but also to reduce and reverse disuse atrophy and enhance joint range of motion. Although, as Kabat-Zinn notes, yoga is not a traditional part of mindfulness practice, the inclusion of a physical component in a program aimed at a state that often manifests in physical ways seems intuitively appealing.
Other factors considered to be important include the group format for weekly sessions, an explicitly stated expectation that the program will bring relief of symptoms, a philosophy of "non-striving" (ie, the deliberate avoidance of long-term goals to maximize present benefit), a variety of techniques offered to suit varying individual needs and styles, and individual responsibility for gains through sustained work. Since the practice is one of experiencing the moment, patients need not worry about failing to do meditation "correctly."
Kabat-Zinn developed a 10-week course of weekly 2-hour sessions. Later programs have reduced the length of the course to six to 8 weeks, and the duration of the individual sessions to 60 to 90 minutes.
Evidence Base
Far less research has been published with healthy participants as compared with those who are clinically ill. Most studies have been small, most likely because of the time and attention required for proper implementation of the intervention. No study has attempted to incorporate blinding or masking. Clearly, it would be impractical to keep participants naïve as to their treatment assignment, but a level of sophistication that is still lacking in the available literature would be some attempt to introduce blinded evaluation of outcomes.
Chang and colleagues recruited a group of 43 participants in a mid-career continuing education course.4 The intervention was intensive 150-minute sessions weekly for eight weeks, as well as a full-day retreat. In place of a control group, participants served as their own controls in a pre-post analytical design. The effect of the intervention was measured using the Pain Rating Scale (PRS) (a 10-point "Likert-like" instrument), the Positive States of Mind questionnaire (PSOM) (a 6-item instrument about healthy attitudinal habits), the Perceived Stress Scale (PSS) (a 10-item "Likert-like" questionnaire), and the Mindfulness Self Efficacy questionnaire (MSE), which assessed participants' confidence in implementing the intervention. When scores from before and after the intervention were compared, participants showed significant improvement in all the psychological dimensions (PSOM, PSS, MSE), but not in the physical (PRS). This lack of a physical effect is in contrast to the findings of studies focusing on those with chronic illnesses. The authors speculated that there might be a "floor effect," below which pain was not prominent enough to be affected.
Several other studies using more rigorous randomized designs also have been published. Oman and colleagues used advertisements and class presentations to recruit 47 college undergraduates.5 This group was assigned randomly to a form of MBSR (N=16), another meditation-based approach called Easwaran's Eight-Point Program (EPP) (N=16), or a wait-list control group (N=15). Both the MBSR and EPP groups met weekly, 90 minutes per session, for eight weeks. Outcomes were measured in each group at baseline, at the end of the intervention, and eight weeks later. Psychological dimensions were assessed using the PSS, the Rumination and Reflection Questionnaire (RRQ) (a measure of several negative psychological and emotional states), the Heartland Forgiveness Scale (HFS) (a measure of the respondent's ability to forgive those who have hurt or disappointed him/her), and the Adult Dispositional Hope Scale (ADHS). Participants were also asked about the strength and variety of their spirituality. No questions about physical functioning or symptoms were asked. In the analysis of the study results, the authors found no significant difference in any measure between the MBSR and EPP groups, so these were combined as a global meditation group and compared with the wait-list controls. Those in the mediation group showed positive changes in perceived stress, although interestingly, this difference was only marginally significant by the end of the intervention and continued to grow in the following eight weeks. The meditation group also showed greater improvement in forgiveness, but no significant difference in hope could be demonstrated. These outcomes did not appear to vary with participants' spirituality.
Jain et al reported another student-based study.6 Medical, nursing, and undergraduate premedical/prehealth students were recruited. A total of 81 were randomly assigned to MBSR (N=27), another awareness-based technique called Somatic Relaxation (SR) (N=24), or to a wait-list control condition (N=30). The intervention was comparatively brief four weeks but the class sessions were 90 minutes in length as in other studies. Outcomes were measured with the Brief Symptom Inventory (BSI) (a 53-item measure of psychological symptoms), the PSOM, the Daily Emotion Report (DER) (a measure of distractive and ruminative thoughts associated with depression), and the Index of Core Spiritual Experiences (INSPIRIT-R). The results of the study showed significantly better scores from pre- to post-test on rumination and distraction, but the SR group showed better progress on relaxation. Both groups showed significant improvement on most measures as compared with the control group.
Two other published articles relevant to this subject have design aspects that limit their applicability to the present subject, but are worth mentioning. Moritz and colleagues recruited a group of 165 outpatients who reported moderate mood disturbance (using a Profile of Mood States (POMS) score of >40).7 These were assigned randomly to an at-home recorded spirituality program, MBSR, or a wait-list control group. Both active interventions lasted eight weeks. The major outcomes of interest were changes in the POMS score and participants' overall assessment of their quality of life, using the SF-36 questionnaire. All groups showed improvement in both measures, but the spirituality group's changes were about twice as great as those of the MBSR group, which in turn were about twice as great as those for the control group. Grossman and colleagues conducted a meta analysis of MBSR studies.8 The majority of the studies included involved participants with significant clinical illness, but the authors did a small sub-analysis of studies with generally healthy participants. Regrettably for the present purpose, studies of community-dwelling people were grouped for this analysis with studies of prison inmates. That aside, they found significant positive effects of MBSR on both physical and emotional well-being.
Conclusions
There appears to be moderate support for an effect of MBSR on emotional functioning and well-being in generally healthy people. Very few studies have measured the effect of MBSR on physical manifestations of stress in this population, and those that have paint an equivocal picture. This is in contrast to the literature on MBSR in those with chronic and/or life-threatening illness. As was suggested by the Chang article, this may reflect a kind of hierarchy of symptoms, but presents a challenge for the primary care clinician. If, as is often the case, a patient presents with somatic complaints as the mainor only symptoms of stress, a recommendation of MBSR or another meditative practice may not lead to adequate relief.
Recommendations
An important guide to the clinician in recommending MBSR or related practices to a patient is a clear understanding of the patient "constructs" (the issues that led to the consultation). MBSR may be most useful for those who already have some insight into the sources and manifestations of their stress, but it may also help those who feel confused or powerless in the face of stress to (re)discover parts of themselves over which they can exercise some calming influence. MBSR's combination of optimism regarding success with an awareness that what defines success will be very individual makes it appealing as an option even for those who may be timid or skeptical. At the same time, the presence of symptoms which MBSR appears not to influence may lead to frustration and perhaps make the acceptance of subsequent therapies more difficult. For this reason, clear communication of goals and commitment between clinician and patient will be most important.
References
1. American Psychological Association. 2007. "Stress in America." Accessed July 3, 2008, at http://apahelpcenter.mediaroom.com/file.php/138/Stress+in+America+REPORT+FINAL.doc.
2. Sasser H. Mindfulness Meditation & Coping with Cancer. Alt Med Alert. 2008;11:37-40.
3. Kabat-Zinn J. Gen Hosp Psy. 1982;4:33-47.
4. Chang VY, et al. Stress & Health. 2004;20:141-147.
5. Oman D, et al. J Am Col Health. 2008;56:569-578.
6. Jain S, et al. Ann Behav Med. 2007;33:11-21.
7. Moritz S, et al. Alt Ther. 2006;12:26-35.
8. Grossman P, et al. J Psychosom Res. 2004;57:35-43.
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