Mindfulness-Based Stress Reduction

Lena Fernandez, NMD

Tolle Totum

A Non-pharmacologic Approach to Long-term Health & Well-being

Mindfulness-Based Stress Reduction (MBSR) therapy is well known for its effectiveness in alleviating a wide range of medical conditions, including stress, anxiety, panic, depression, and chronic pain. Developed by Professor Jon Kabat-Zinn, PhD, in the 1970s, MBSR combines mind, body consciousness, and yoga movements to help individuals be more in the present moment, permanently change the way they handle stress, and eliminate chronic illness. A large prospective study of more than 10,000 public servants in London over 14 years concluded that 5-10% of cardiovascular disease appeared to be caused by job-related stress.1 There is also increasing evidence that traumatic life events increase the risk of both physical and psychological problems that can impact health and quality of life.2

It has been determined that routine mindfulness practice can revolutionize the healthcare system, improving both individuals and organizations. This therapy has been successfully utilized with appropriate modification in a number of medical centers, as well as in non-medical settings such as schools, prisons, athletic training programs, professional programs, and the workplace.2,3

MBSR is taught in classes and in clinics globally. Individuals who work their way through an MBSR program become able to replace stress-promoting habits with mindful skills that last a lifetime and foster a healthier, happier, and more fulfilled life. Mindfulness is no longer a new therapy; it has made its way into the mainstream, with people from all walks of life – whether young adults, new mothers, physicians, or CEOs – recognizing its value and taking steps to make it a habit.4,5

Why MBSR is Needed in Primary Healthcare

In today’s society, patients, doctors, and staff experience nearly unavoidable stress and pain. In the long run, this can lead to feelings of overwhelm, poor-quality sleep, and burnout. Stress also takes its toll on kids. A survey by the American Psychological Association showed that almost one-third of children within the previous month had experienced physical symptoms associated with stress, such as stomach ache, headache, or difficulty falling or staying asleep.6 Families that experience time constraints, financial pressure, exhaustion, and/or emotional stress often don’t realize how much their children’s health and well-being are being affected.6

Within the healthcare industry, chronically high stress has been shown to associate with adverse outcomes in the workplace, including burnout, lower productivity, absenteeism, less job satisfaction, and turnover in the workplace.7 In return, relationships and optimal care of patients, families, and staff become compromised. A qualitative study, using focus groups to evaluate the efficacy of MBSR for mental healthcare workers, concluded that mindfulness training helps staff to have better focus and improved interactions with patients.8

For both staff and patients, the effective use of the present moment, as trained using the MBSR approach, may be the core indicator of the appropriateness of particular choices.9 The University of Massachusetts Medical Center has demonstrated MBSR to be a well-defined and systematic patient-centered educational approach that teaches people how to take better care of themselves and live healthier and more adaptive lives.10,11

So, is it possible to manage stress with through a trained positive mindset? Yes, it’s actually easier than it might seem.

What Conditions Can Be Treated with MBSR?

Most outcomes assessed are psychological in nature and show substantial benefit; however, some physical and disease-related parameters have also been evaluated and found to respond positively to MBSR.4,12  

  • Pain (chronic pain, low back pain, fibromyalgia, and rheumatoid arthritis)
  • Burnout
  • Eating disorders
  • Hypertension
  • Diabetes
  • Irritable bowel syndrome
  • Ulcerative colitis
  • Anxiety, depression, PTSD
  • Attention deficit disorder
  • Insomnia
  • Smoking cessation
  • HIV/AIDS
  • Diagnosis of cancer

Chronic pain is one of the most common presenting problems in primary care settings. The use of MBSR therapy in medical centers may be one of the most powerful ways to reduce or eliminate physical pain in patients. A pilot study in Canada evaluated the impact of MBSR on 17 patients with chronic pain over an 8-week treatment period, in terms of its effects on subjective ratings of pain, pain disability and psychological distress associated with the pain, and level of activity. Results demonstrated significant improvements on all levels.5 A Kaiser Permanente study, which evaluated patients 1 year following participation in an 8-week MBSR program, also noted significant improvements in pain and function, along with improvements in self-efficacy and psychological symptoms.13

MBSR Protocols & Principles

MBSR is now being offered as a group-based intervention program at several-hundred healthcare institutions in the United States and Europe. Generally, MBSR involves an 8-week program training in mindfulness. The standard program consists of weekly sessions lasting 30 minutes to 2½ hours, as well as 1 all-day session after 6 to 7 weeks. Some programs use shorter weekly sessions (30-90 minutes), and some omit the all-day session. The weekly sessions contain standardized core elements consisting of different mental and physical mindfulness exercises. 8,9,14,15

De Vibe and colleagues listed the following 4 components of an MBSR program4:

  1. Body-scan exercises
  2. Mental exercises focusing one’s attention on the breath
  3. Physical exercises with focus on being aware of bodily sensations and one’s own limits during the exercises
  4. Practicing being fully aware during everyday activities by using the breath as an anchor for the attention.

An important goal of an MBSR program is the development of a non-reactive and accepting attitude to one’s experience each moment. Although MBSR derives from Buddhist Vipassana meditation practices and yoga exercises, its current adaptation in western society is devoid of any particular religious affiliation.4

Along with these exercises is discussion about stress management and the application of mindfulness to interpersonal communication. In each session, time is allowed for group members to reflect together on their experiences during mindfulness practice. Between sessions, students are encouraged to practice the exercises every day for 30-45 minutes while listening to audiotapes that guide them through body-scan exercises, sitting meditation while focusing on the breath, and yoga. Each group typically consists of 10-30 members and is led by 1 or 2 instructors.4

Most importantly, in a short few weeks, people will master being in the present moment. The group experience facilitates emotional support and helps participants to not feel isolated or alone, which are, in all likelihood, important factors in healing. This optimal learning environment also promotes ongoing growth and development that assists in future coping and problem-solving.3

In this medically heterogeneous environment, people with a broad range of medical conditions participate together in class. It has been suggested that this approach helps participants to focus on what they have in common rather than what is special about their particular illness (ie, what is “right” with them rather than what is “wrong” with them).3 Because feelings of stress, pain, anxiety, and helplessness, etc, are shared by most individuals suffering from illness regardless of their specific medical condition, the group experience fosters a sense of sharing as they master mindfulness methods.8,15

Structure & Methods of MBSR

Here is a typical MBSR program structure, as described by the University of Massachusetts Medical School’s Center for Mindfulness16:

Pre & Post Interviews

  • Pre-program interviews (45-60 mins)

Pre-program interviews with a MBSR candidate are conducted in order to: 1) better understand the uniqueness and life circumstances of the program candidate; 2) explain MBSR to the candidate including its relevance in their life; and 3) evaluate the appropriateness and readiness of the candidate

  • Post-program interviews (45-60 mins)

Post-program interviews are conducted in order to: 1) provide the participant an opportunity to review his or her experience in the program; 2) further refine MBSR methods and develop health goals for the near and long term; and 3) make appropriate medical referrals when necessary

Program Overview

And here is an overview of their MBSR program16:

  • Group Pre-program Orientation Sessions (30 min-2.5 hr) followed by a brief individual interview (5-10 min)
  • Eight weekly classes (30 min-2.5 hr)
  • An all-day silent retreat during the sixth week of the program (7.5 hrs)
  • “Formal” Mindfulness Meditation Methods:
    • Body Scan Meditation – a supine meditation
    • Gentle Hatha Yoga – practiced with mindful awareness of the body
    • Sitting Meditation – mindfulness of breath, body, feelings, thoughts, and emotions
    • Walking Meditation
  • “Informal” Mindfulness Meditation Practices (mindfulness in everyday life):
    • Awareness of pleasant and unpleasant events
    • Awareness of breathing
    • Deliberate awareness of routine activities and events, such as eating, weather, driving, walking, interpersonal communications
  • Daily home assignments, including a minimum of 45 min/d of formal mindfulness practice and 5-15 min of informal practice, 6 days per week for the entire duration of the course
  • Individual and group dialogue and inquiry oriented around weekly home assignments, including an exploration of hindrances to mindfulness and development and integration of mindfulness- based self-regulatory skills and capacities
  • Incorporation of exit assessment instruments and participant self-evaluation at Week 8
    • Total in-class contact: 30+ hours
    • Total home assignments: minimum of 42-48 hr
    • Total group Orientation Session time: 2.5 hr

Prior to the start of classes, the following steps should be taken16:

  1. Permission is obtained from the MBSR candidate to speak with his or her primary mental health provider, as deemed appropriate.
  2. An agreement is made with the program instructor, program candidate, and the candidate’s primary mental health provider that the mental health provider will be the first responder in the case of mental health emergency, rather than the MBSR instructor.
  3. The MBSR instructor agrees to maintain ongoing communication with the program candidate’s current mental healthcare provider and primary care physician, as necessary, during the program.3

Summary

In a short few weeks, individuals in an MBSR program have learned non-judgment, patience, greater trust, acceptance, letting go, non-striving, commitment, and self-discipline. They have also mastered skilled that allow them to experience less stress, become more mindful in everyday life, be less critical of themselves, be more interested in exploring possibilities, develop a positive mindset without negative side effects, and to experience a greater quality of life; they also have an improved immune system. Compared to ongoing antidepressant treatment, an MBSR program is also inexpensive and has no negative side effects.

References:

  1. Chandola T, Britton A, Brunner E, et al. Work stress and coronary heart disease: what are the mechanisms? Eur Heart J. 2008;29(5):640-648.
  2. De Vibe M, Bjørndal A, Tipton E, et al. Mindfulness based stress reduction (MBSR) for improving health, quality of life and social functioning in adults. Campbell Systematic Reviews; 2012;3. Available at: https://www.campbellcollaboration.org/library/mindfulness-stress-reduction-for-adults.html?tmpl=component&print=1. Accessed March 10, 2017.
  3. Kabat-Zinn J. Mindfulness Meditation: What It Is, What It Isn’t, and Its Role In Health Care and Medicine. In: Ishii Y, Suzuki M (eds), Haruki Y (auth). Comparative and Psychological Study on Meditation. Eburon, Netherlands; 1996.
  4. Carlson LE. Mindfulness-based interventions for physical conditions: a narrative review evaluating levels of evidence. ISRN Psychiatry. 2012;2012:651583.
  5. Beaulac J, Bailly M. Mindfulness-Based Stress Reduction: pilot study of a treatment group for patients with chronic pain in a primary care setting. Prim Health Care Res Dev. 2015;16(4):424-428.
  6. Clay RA. Stressed In America. American Psychological Association. 2011;42(1):60. Available at: http://www.apa.org/monitor/2011/01/stressed-america.aspx. Accessed March 12, 2017.
  7. Bazarko D, Cate RA, Azocar F, Kreitzer MJ. The Impact of an Innovative Mindfulness-Based Stress Reduction Program on the Health and Well-Being of Nurses Employed in a Corporate Setting. J Workplace Behav Health. 2013;28(2):107-133.
  8. Byron G, Ziedonis DM, McGrath C, et al. Implementation of Mindfulness Training for Mental Health Staff: Organizational Context and Stakeholder Perspectives. Mindfulness (N Y). 2015;6(4):861-872.
  9. Leebov W. The One Skill That Can Transform Health Care. January 21, 2014. Hospitals & Health Networks web site. http://www.hhnmag.com/articles//5276-the-one-skill-that-can-transform-health-care. Accessed March 12, 2017.
  10. Beach MC, Roter D, Korthuis PT, et al. A multicenter study of physician mindfulness and health care quality. Ann Fam Med. 2013;11(5):421-428.
  11. Kaplan KH, Goldenberg DL, Galvin-Nadeau M. The impact of a meditation-based stress reduction program on fibromyalgia. Gen Hosp Psychiatry. 1993;15(5):284-289.
  12. Niazi AK, Niazi SK. Mindfulness-based stress reduction: a non-pharmacological approach for chronic illnesses. N Am J Med Sci. 2011;3(1):20-23.
  13. Mccubbin T, Dimidjian S, Kempe K, et al. Mindfulness-based stress reduction in an integrated care delivery system: one-year impacts on patient-centered outcomes and health care utilization. Perm J. 2014;18(4):4-9.
  14. Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-Based Stress Reduction for Health Care Professionals: Results From a Randomized Trial. Int J Stress Manag. 2005;12(2):164-176. Available at: https://pdfs.semanticscholar.org/00a3/f4a4906373dff0a0290f1354d7bd0f2bd016.pdf. Accessed March 12, 2017.
  15. Demarzo MM, Montero-Marin J, Cuijpers P, et al. The Efficacy of Mindfulness-Based Interventions in Primary Care: A Meta-Analytic Review. Ann Fam Med. 2015;13(6):573-582.
  16. Mindfulness-Based Stress Reduction. February 2014. Center for Mindfulness in Medicine, Health Care & Society, University of Massachusetts Medical School. Available at: http://tinyurl.com/macv5al. Accessed March 10, 2017.

Lena Fernandez, NMD, graduated from Southwest College of Naturopathic Medicine in Tempe, AZ, and practices in AZ as a board-certified, licensed naturopathic physician. In addition to completing post-graduate studies in general family medicine, Dr Fernandez has had advanced training in prolotherapy, prolozone, platelet-rich plasma, stem cell therapy, chelation therapy, and ozone therapy. Dr Fernandez trains and educates people both locally and globally about how to get well and stay healthy from within. She is currently in private practice at Sunshine Health Care Center in Peoria, AZ. Learn more about Dr Fernandez at www.drlenafernandez.com and follow her trainings at facebook.com/drlenabfernandez/.

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