Being mindful about mindfulness


I’m generally a supporter of mindfulness practice. It’s been a great discipline for me as I deal with everyday life and everything. I don’t admit to being incredibly disciplined about “making time for meditation” every day – that is, I don’t sit down and do the whole thing at a set time each day – but I do dip in and out of mindfulness throughout my day. While I’m brushing my teeth, slurping on a coffee, driving, sitting in the sun, looking at the leaves on the trees, cuddling my Sheba-dog I’ll bring myself to the present moment and take a couple of minutes to be fully present. Oddly enough I don’t do this nearly as often when I’m cold (like this morning when it’s about 8 degrees in my office!), or when I’m eating parsnip (ewwwww!), or waiting to see a dentist. Or perhaps that’s not odd at all, because I wonder if we have a skewed view on mindfulness and what it’s about.

My reason for writing this post comes from reading Anhever, Haller, Barth, Lauche, Dobos & Cramer (2017) recent review of mindfulness-based stress reduction for treating low back pain. In it, they found “MBSR was associated with short-term improvements in pain intensity (4 RCTs; mean difference [MD], −0.96 point on a numerical rating scale [95% CI, −1.64 to −0.34 point]; standardized mean difference [SMD], −0.48 point [CI, −0.82 to −0.14 point]) and physical functioning (2 RCTs; MD, 2.50 [CI, 0.90 to 4.10 point]; SMD, 0.25 [CI, 0.09 to 0.41 point]) that were not sustained in the long term.” There were only seven RCTs included in the study, with a total of only 864 participants, and many of the studies had no active control groups, so my interpretation is that there are flaws in many of the studies examining MBSR, and that it’s difficult to draw any conclusions, let alone strong conclusions.

Where do we go wrong with mindfulness? The first point about the studies included in Anhever and colleagues paper is that there is a difference between mindfulness in general and mindfulness based stress reduction – and although the difference may be minimal, it’s nevertheless worth understanding. MBSR is a full programme that includes mindfulness as one element (Kabat-Zinn, 1982). Mindfulness is a key component, yes, but the programmes include other elements.  The second point is that perhaps we’re assuming mindfulness to be something that it isn’t –  I suspect, from reading numerous articles in both the popular media and research papers, that mindfulness is being applied as another form of relaxation.

Relaxation training was introduced as part of a behavioural approach to managing stress. In pain management it’s been part of programmes since the 1970’s, particularly using forms of progressive muscle relaxation (See Dawn & Seers, 1998). The intention is to provide an experience that is incompatible with tension, and to develop the capability to down-regulate the body and mind to mitigate the stress response that is so often part of persistent pain.

Relaxation training can take many forms, and breath control is a common component. I use it often for myself, and when working with clients – I’m aiming to show people that although they may not be able to control heart rate or blood pressure, they can control breath and muscle tension. It’s useful especially as part of sleep management.

The thing with relaxation training is it’s entire purpose is to help downregulate an upregulated nervous system. Mindfulness, on the other hand, is not.

What is mindfulness about if it’s not about relaxation? Well, mindfulness has been defined in many different ways, but the one I especially like is by Kabat-Zinn (1990) “a process of bringing a certain quality of attention to moment-by-moment experience”.  This definition can be further unpacked by examining its components: “Mindfulness begins by bringing awareness to current experience—observing and attending to the changing field of thoughts, feelings, and sensations from moment to moment—by regulating the focus of attention.” (italics are mine) –  this quote is from Bishop, Lau, Shapiro and colleagues (2004) and is from a paper looking at defining mindfulness in an operational way (so we can be aware of what it means in practice, or as we teach others). These authors go on to say that this process leads to a feeling of being very alert to what is occurring in the here and now. I like to remind people that it’s about being here rather than remembering or anticipating what might.

So at least one part of mindfulness is learning how to attend to what YOU want to attend to, rather than being dragged back to memories, or forward to predictions, or to experiences or moments that you don’t want to notice at that moment.  The definition also points to noticing and experiencing what is happening, rather than thoughts or ruminations about what you’re experiencing. For people living with persistent pain, I think this is an invaluable tool for dealing with the interruptive effects of pain on attention.

A second aspect of mindfulness is an attitude – one of curiosity. When being mindful, you’re not trying to produce any particular state, instead you’re being curious about what you are experiencing, whether it’s something you’d ordinarily want to experience – or not. This approach to experience is really similar to what we’re aiming for in persistent pain management – acknowledging and being willing to experience what is, rather than attempting to avoid that experience, or quickly change it to something more palatable.

Now this aspect of mindfulness is often brought to bear on new and pleasant experiences – sometimes people are asked to mindfully eat a raisin, or mindfully examine a ballpoint pen (one of my favourites). But it’s also just as valid to bring this attitude to bear on less than pleasant experiences like my cold fingers and legs (it’s cold in my office this morning). Or to pain and where it is – and where it isn’t.

So I wonder if part of our approach to using mindfulness in pain management is incorrect. If we’re intending people to come away from mindfulness feeling relaxed and calm, perhaps we’re doing it wrong. If we think people should feel better after mindfulness, again, perhaps we’re doing it wrong. Sometimes, yes, these are the effects we’ll have. Other times, not so much. What we will always develop, over time, however, is better ability to focus attention where we want it to go, and more openness to being present to what is rather than struggling against it. And I think those are incredibly valuable tools in life, not just persistent pain management. And perhaps, just perhaps, if we began viewing our use of mindfulness in these ways, the outcomes from RCTs of mindfulness might show more of what it can do.

 

Anheyer, D., Haller, H., Barth, J., Lauche, R., Dobos, G., & Cramer, H. (2017). Mindfulness-based stress reduction for treating low back pain: A systematic review and meta-analysis. Annals of Internal Medicine, 1-9. doi:10.7326/M16-1997

Dawn, Carroll, and Kate Seers. “Relaxation for the relief of chronic pain: a systematic review.” Journal of advanced nursing 27.3 (1998): 476-487.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind to face stress, pain and illness. New York:Dell.

Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General hospital psychiatry, 4(1), 33-47. doi:http://dx.doi.org/10.1016/0163-8343(82)90026-3

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14 comments

  1. The Cochrane review of mind&body therapies for the archetypal pain syndrome of fibro, by Auckland’s Theadom & co, determined that mindfulness (MF) was ineffectual. Interestingly, they’d classified Schubiner’s “Unlearn your pain” as psychotherapy – despite it cloning J.K-Z’s MBSR.
    It seems that deregulated courses are vulnerable to misinterpretation or politicising of results.
    Regardless of spin, I agree that improvements are insufficient, but am sure that evolving adjuncts from neuroscience will improve the clinical usefulness of MF.

  2. Hi Bronnie, thank you for this post. I am currently doing the University of Massachusetts MBSR (the J K-Z)program online and the definition they give for mindfulness is: Paying attention in a particular way: on purpose, in the present moment, non-judgementally. I thought that definition might be helpful here. I appreciate the attention you have brought to this, I hope you have more to share on this topic!

  3. As a mindfulness purist(?) I feel that to get the full benefit of mindfulness it has to be understood and used in its proper context; as should any theory. Taking out bits and pieces because it does or doesn’t sit well within other frameworks we might use is a dis-service to the approach.

    First of all, mindfulness involves training the mind both to pay and to sustain attention.
    And secondly attention is being trained for a purpose. That is to see things clearly as they are and to bring an end to suffering. Fundamental to the approach is the investigation of the 3 basic characteristics of all human experience;
    * its impersonal nature and the absence of an enduring self,
    *the impermanence of all phenomena (including the sense of self) and
    *the suffering that ensues when these two are not understood.

    The texts describe this process using three Pali words
    Sati, Sampajannya and Pannya i.e., Mindfulness, Clear seeing/comprehension, Wisdom

    Training is a life long process and not confined to 8 weeks. Hence expecting any dramatic and sustainable results after 8 or whatever number of weeks is not realistic.

    Sitting on the cushion helps to process our understanding bit by bit which is harder to do when we are in the midst of all our doings. Having said that testing and application continues when we are off the cushion too. I would liken it to how for a concert pianist skill and understanding grow both during practise and while playing at a concert.

    And finally mindfulness sits within 7 other mutually supporting factors

    1. Hi Radhika, thanks so much for taking the time to comment. I hope you’ll see Neil’s comments too and add your points to his – both wonderfully skilled and embedded practitioners with lovely viewpoints to the mindfulness practice and experience.

  4. Nicely written Bronnie. This is an important and complex issue, that we need to sort out.
    Maybe we can forget about the terminology that is associated with these traditions. Mindfulness can be placed in a category of awareness practices/techniques. In these, the person ‘being aware’ is, as you mention, being curious. Awareness practices can include awareness of anything, yet in most contemplative traditions the focus is internal, to the aspects of our existence we often ignore experiencing consciously and/or automatically.
    Much of mindfulness teaching suggests we become aware of the ever changing sensations, thoughts, images, emotions, …, that arise, while being curious and being detached from emotionally and analytically reacting to what comes up. Often people are told not to think, and told not to judge – both of which are troublesome instructions, since these are the things that the brain does automatically. So a better instruction can be to notice when you are thinking or emoting, then let it go and see what else comes up.
    Language in this area is a mess – Wolf Mehling’s work has tried to come to a common language for scientists and practitioners. And those who have not much personal experience with awareness practices or in teaching it to people one-one (in situations in which people feedback how it is for them and what they are understanding) can really make a muddle of discussing this topic.
    Awareness can also be specific to the body, or to thoughts, or even to specific sensations – such as taking awareness to subtle non-pain sensations, or even taking awareness to the pain itself. Both of these are typically very difficult processes, and require practice, yet many in pain describe these are powerful and positive experiences.
    Awareness practices ‘by definition’ are not intending to regulate. This means that they are not intending to regulate pain, or breath or muscle tension, or emotions. It gets sticky when discussing thoughts though. Awareness practices typically ask us to regulate how we think about what we are thinking and emoting. They might also ask us to change what we are ‘naturally’ being aware of, for example, shifting awareness from sensations of pain in out leg to he subtle non-pain sensations in the leg. So some awareness practices are also inclusive of meta cognition.
    So if awareness is not about changing things, but rather awareness, there are a few things to consider …
    – those teaching it need to be very clear in their language about awareness versus regulation. (I know from a lot of experience that they often are not clear at all in their instructions)
    – we have no clinical measurement tool of success with awareness practices – of course this relates to a recent blog of yours about ‘an individual’s reports’ compared to ‘things we can measure with an instrument’.
    – we can measure changes in blood flow to the brain in the insula and OFC and DLPFC hat occur with interoceptive practices, but these do not tell us what else is going on or the level of awareness
    – how do we complete quantitative research on a technique that in and of itself is intended to not change things?
    – why on earth do we use pain intensity as an outcome of importance for his practice? And many think this is the wrong focus of treating people in pain anyway!
    – why would we expect changes to be sustained? This is not A FIX-IT practice! if one’s systems have learned to become hypervigilant, why would anyone expect that the systems would ‘forget’ how to do this with a relatively brief intervention. This makes no sense from what we understand from the lived experience of pain, or from psychoneuroimmunology.

    Rather than go on, I will end with a thank you for starting more of this conversation.
    And one final point – in research of awareness practices we are using inconsistent paradigms, and often the wrong ones. Just like opioids, which should assessed as helpful in clinic and in research when they help people in percents pain to move with more ease, awareness practices, as you state, are being researched with inappropriate outcome measures.

      1. sorry about those typos – one other thing about awareness practices that I have experienced clinically – if we consider that helping people move and live with more ease is a primary goal of our work, then awareness can be considered as important not only for its potential influence on pain and suffering at rest, but as the often missing piece required to move with ease. Without awareness of breath and of body tension and of mind, keeping all these calmer during movement is likely an impossibility … one cannot manage what one does not measure. In other words, holding breath or hyperventilating, gripping with the body, and being stuck on negative thoughts and emotions during movements that are intended to help us recover (increase evidence that it is safe to move) probably won’t be beneficial when there is chronic pain.

        Awareness practices are much like other ‘therapeutic’ practices. We need to decide what it is we are trying to change. And clinically it helps to instruct people in them as a daily practice – then once some proficiency is gained, ask the person to try them in each of these ways …

        We could use them as healthy distraction. To get a little respite from the pain.
        We can use them to help us sleep better – that’s an observation from many patients but I have seen no research on people using body awareness practices right before sleep.
        We can use them to calm physiological arousal (for all the benefits there).
        We can try them out to see if they have a positive ‘immediate’ influence on pain and suffering. Yet these are skills so it might take 4-6 weeks of daily practice to get results.
        We can use them to help us move and live a more active life with more ease.

        in regards to any effects related to practising awareness techniques – we should not expect them to be same in all persons (eg., some people with significant anxiety will experience more anxiety when trying awareness techniques without good guidance and modifications to the techniques) and we should know that all these techniques are skills, requiring practice, competing against systems that have become hyper vigilant in threat detection, and thus are subject to all the factors we understand about other skill acquisition in the face of high stress and competitive neuroplasticity

  5. great post and I think that this misconception of thinking about mindfulness as a relaxation tool is so important to teach people because you are right. I can think of many instances where I hear the two in the same sentence

  6. Thanks for the great article! Sometimes have difficulties practicing mindfulness. One thing that helps me is yoga.

  7. Hi Bronnie,

    I’m Maegan with Healthline, the fastest growing consumer health site on the web. Our mission is to make the world a stronger, healthier place by informing and uplifting.

    One of the ways we do that is by sharing articles and information with health communities. One way we do that is by answering common questions that can help people improve the quality of their lives.

    Our article about the causes of chronic pain details potential causes, treatments, and lifestyle remedies that can help people with chronic pain understand and treat their condition. We’ve gotten a lot of positive feedback that this article has helped those struggling with pain to find answers and effective solutions. You can read the article here:

    http://www.healthline.com/health/chronic-pain

    We would love it if you could share our article with your audience. We hope it will go a long way in helping those with chronic pain live happier, healthier lives.

    If you have any questions, please feel free to reach out!

    Warmly,

    Maegan Jones | Content Coordinator
    Healthline
    Your most trusted ally in pursuit of health and well-being

  8. I agree it is a good idea to examine exactly how mindfulness is useful for chronic pain (and how it isn’t).

    Personally I’d say these are advantages of selective mindfulness I’ve observed:

    learning to observe thoughts and not automatically get engrossed in them (including negative thoughts about living with pain);
    learning to do activities in ways that do not unnecessarily flare up pain, which can require concentration;
    observing what things are causing pain to flare up and what are easing it;
    investigating pain and discovering it is perhaps not as unpleasant as you’d assumed.

    These and others are mentioned in your post and people’s comments.

    Personally I think that selective mindfulness is often going to be the most beneficial approach, as there are times when distraction is helpful and when moving our attention from a painful body part to a non-painful body part can be very beneficial. I’m quite wary of mindfulness courses that heavily emphasise exploring pain, as surely this could further entrench pain pathways, as well as potentially being quite an unpleasant experience.

    1. I don’t agree that mindful awareness of pain will reinforce neural networks, enhancing the experience – instead it seems to be quite the opposite. By removing the fear/avoidance/negative appraisal, pain becomes just another experience to notice, without the need to try to control or avoid or change in any way. Initially it does feel weird to begin being curious about the experience – but that’s normal for any experience we generally avoid. Oddly enough, by uncoupling the negative judgement and emotions, the experience becomes less distressing and far easier to tolerate.

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