Meditation
Cynthia R. Gross
Michael S. Christopher
Maryanne Reilly-Spong
Meditation has numerous attributes that make it particularly appealing for nurses. Meditation training can be provided to patients across the life span with a wide spectrum of conditions, without any equipment or expensive technology, and presented one on one or in a group setting. Moreover, meditation is a pathway for attaining emotional regulation and insight, and a building block for forming self-sustaining skills to cope with life and health challenges. Many nurses and nursing students use meditation skills for stress reduction, enhancing relationships, and building resilience. Nursing is a stressful profession in which symptoms of burnout are not uncommon. In this chapter meditation practices for health are described, the state of the art of meditation research is summarized, and new directions are outlined. Readers are also encouraged to read Leaves Falling Gently: Living Fully with Serious and Life-Limiting Illness through Mindfulness, Compassion, and Connectedness (Bauer-Wu, 2011). This slim, exquisitely written text by Susan Bauer-Wu, a nurse and researcher from Emory University, has detailed examples of how to integrate mindfulness into one’s life and health care practice, and it is based on her experiences teaching meditation practices to hundreds of patients, including bonemarrow transplant recipients.
Meditation is the quintessential mind-body practice and the foundation for a number of widely used training programs, each with a rapidly growing evidence base to support health benefits. In the past decade, the number of U.S. adults turning to meditation for health reasons has significantly increased—from 7.2% in 2002, to 9.4% in 2007—with the primary
reasons for use being control of symptoms such as pain and anxiety, and self-management of chronic conditions (Barnes, Bloom, & Nahin, 2008). Among the most widely used and well-researched meditation programs are mindfulness-based stress reduction (MBSR) and transcendental meditation (TM®). In this section, the focus is on these and closely related programs. This chapter also discusses new experimental findings of structural, physiological, cognitive, and emotional effects from meditation training with a standardized brief meditation instruction protocol, integrative body-mind training (IBMT). Although inclusive definitions of mindfulness consider practices such as yoga, Tai Chi, and Qigong as meditative practices, in this book these movement-focused practices are described separately and in-depth, and therefore they are not included in this segment on meditation. Many religious traditions incorporate meditation within the context of religious observance and prayer (e.g., chanting, use of prayer [Rosary] beads, walking the labyrinth); however, these practices are also not included in this chapter.
reasons for use being control of symptoms such as pain and anxiety, and self-management of chronic conditions (Barnes, Bloom, & Nahin, 2008). Among the most widely used and well-researched meditation programs are mindfulness-based stress reduction (MBSR) and transcendental meditation (TM®). In this section, the focus is on these and closely related programs. This chapter also discusses new experimental findings of structural, physiological, cognitive, and emotional effects from meditation training with a standardized brief meditation instruction protocol, integrative body-mind training (IBMT). Although inclusive definitions of mindfulness consider practices such as yoga, Tai Chi, and Qigong as meditative practices, in this book these movement-focused practices are described separately and in-depth, and therefore they are not included in this segment on meditation. Many religious traditions incorporate meditation within the context of religious observance and prayer (e.g., chanting, use of prayer [Rosary] beads, walking the labyrinth); however, these practices are also not included in this chapter.
Research published since 2005 is emphasized in this section. In 2007, a major evidence report concluded that no firm conclusions could be drawn regarding the therapeutic impacts of any meditative practice or program based on available evidence (Ospina et al., 2007). However, the 2007 review evaluated only work published through 2005, and in the ensuing years there has been a veritable explosion of research on meditation— particularly mindfulness meditation (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010; Chiesa & Serretti, 2009; Fjorback, Arendt, Ornbol, Fink, & Walach, 2011; Hofmann, Sawyer, Witt, & Oh, 2010; Shennan, Payne, & Fenlon, 2011).
DEFINITION
Meditation practices have played an important role in many civilizations for thousands of years for religious purposes and as a means of cultivating well-being. In this chapter meditation is defined as a set of attentional practices leading to an altered state or trait of consciousness characterized by expanded awareness, greater presence, and a more integrated sense of self (Davis, Lau, & Cairns, 2009). These procedures are used to self-regulate the mind and body, thereby affecting mental events by engaging a specific attentional set. There are many distinct meditative techniques, but given that self-regulation of attention is a major component that is common among all of them, it is possible to classify meditative style on a continuum, depending on how attentional processes are directed (Cahn & Polich, 2006). Lutz, Slagter, Dunne, and Davidson (2008) proposed a theoretical framework in which meditation practices are categorized in two main groups—mindfulness and concentration. Mindfulness meditation strategies involve bringing one’s attention in a nonjudgmental or accepting way to whatever experience arises in the present moment.
In mindfulness, practitioners are instructed to allow any thought, feeling, or sensation to arise in consciousness while maintaining a nonreactive awareness to what is being experienced. Mindfulness practice was primarily developed in Buddhism, where it has been an integral component of a 2,500-year-old system of training that leads to insight and the overcoming of suffering (Bodhi, 2011). In the West, mindfulness has been integrated into medicine, nursing, psychology, and related fields, with the goal of teaching patients a more mindful approach to reducing distress, preventing relapse, and enhancing quality of life (e.g., MBSR; Kabat-Zinn, 1990). Concentrative meditation processes involve focusing attention on a selected mental or sensory object. The object of focus may be breath or body sensations, a subvocal repeated sound or word (mantra), or an imagined mental image. In concentration meditation, awareness is narrowed so that the mind only attends to the object of focus. The mind is gently returned to the object of meditation when the meditator notices that it has wandered. Similar to mindfulness, concentration meditation was primarily developed in Buddhism, but it is also a core element in Sufism, Hinduism, and many other religious traditions. It has also become a widely practiced meditation in the West, beginning in the 1960s with the development of TM (Yogi, 1963). In comparing the two types of meditation, Germer (2005) noted that mindfulness meditation is akin to a searchlight that illuminates a wider range of objects as they arise in awareness, one at a time, whereas concentration meditation is like a laser light beam that highlights whatever object on which it is directed. It has been hypothesized that meditators pass through stages, from effortful to effortless maintenance of a meditative state (Tang & Posner, 2013). Consistent with this conceptualization, the concentrative and guided-meditation techniques, which are taught to novices, have been termed “scaffolding” by Jon Kabat-Zinn, and others have commented on mantras with the phrase “you use it to lose it.”
In mindfulness, practitioners are instructed to allow any thought, feeling, or sensation to arise in consciousness while maintaining a nonreactive awareness to what is being experienced. Mindfulness practice was primarily developed in Buddhism, where it has been an integral component of a 2,500-year-old system of training that leads to insight and the overcoming of suffering (Bodhi, 2011). In the West, mindfulness has been integrated into medicine, nursing, psychology, and related fields, with the goal of teaching patients a more mindful approach to reducing distress, preventing relapse, and enhancing quality of life (e.g., MBSR; Kabat-Zinn, 1990). Concentrative meditation processes involve focusing attention on a selected mental or sensory object. The object of focus may be breath or body sensations, a subvocal repeated sound or word (mantra), or an imagined mental image. In concentration meditation, awareness is narrowed so that the mind only attends to the object of focus. The mind is gently returned to the object of meditation when the meditator notices that it has wandered. Similar to mindfulness, concentration meditation was primarily developed in Buddhism, but it is also a core element in Sufism, Hinduism, and many other religious traditions. It has also become a widely practiced meditation in the West, beginning in the 1960s with the development of TM (Yogi, 1963). In comparing the two types of meditation, Germer (2005) noted that mindfulness meditation is akin to a searchlight that illuminates a wider range of objects as they arise in awareness, one at a time, whereas concentration meditation is like a laser light beam that highlights whatever object on which it is directed. It has been hypothesized that meditators pass through stages, from effortful to effortless maintenance of a meditative state (Tang & Posner, 2013). Consistent with this conceptualization, the concentrative and guided-meditation techniques, which are taught to novices, have been termed “scaffolding” by Jon Kabat-Zinn, and others have commented on mantras with the phrase “you use it to lose it.”
SCIENTIFIC BASIS
Understanding how meditation works is the basis for groundbreaking research by leading neuroscientists, including collaborators Yi-Yuan Tang and Michael Posner. In a recent review, Tang summarized the findings from a series of clinical trials they conducted to examine the effects of IBMT, a brief meditation training program that he developed (Tang, 2011). In the first trial, 80 undergraduate students in China were randomly assigned to 5 days of 20 minutes training per day with IBMT, or to relaxation training. Findings showed that meditation, compared to relaxation, improves mood and abilities to self-regulate emotions and efficiently deploy cognitive resources. The IBMT group had significantly better attentional control (important for executive functioning); more
energy/vigor; plus less anxiety, depression, anger, and fatigue on the profile of mood states (POMS). Less stress reactivity to a mental arithmetic stressor based on cortisol levels; and greater immunoreactivity. Additional clinical trials have been conducted using the same treatment and a range of outcomes, including brain imaging (measures of regional cerebral blood flow), electroencephalography (EEG), heart rate, and respiratory rate. Findings supported hypotheses that meditation improved regulation of the autonomic nervous system via systems in the ventral midfrontal brain system. In more recent studies, these investigators have begun to explore neuroplasticity: changes in brain morphology following meditation training.
energy/vigor; plus less anxiety, depression, anger, and fatigue on the profile of mood states (POMS). Less stress reactivity to a mental arithmetic stressor based on cortisol levels; and greater immunoreactivity. Additional clinical trials have been conducted using the same treatment and a range of outcomes, including brain imaging (measures of regional cerebral blood flow), electroencephalography (EEG), heart rate, and respiratory rate. Findings supported hypotheses that meditation improved regulation of the autonomic nervous system via systems in the ventral midfrontal brain system. In more recent studies, these investigators have begun to explore neuroplasticity: changes in brain morphology following meditation training.
Hölzel and colleagues recently summarized and integrated self-report, brain imaging and experimental evidence from Tang’s group and others (Hölzel et al., 2011). Based on the evidence found, these authors proposed four distinct but interrelated mechanisms of action for mindfulness meditation: attention regulation, body awareness, emotional regulation, and change in perspective on the self. These authors note that mindfulness techniques may differ in the extent they activate each mechanism, which suggests an opportunity to tailor practices to specific health needs. Both Tang (2011) and Hölzel et al. (2011) state that research to establish the mechanisms responsible for the health benefits of meditation is in its early stages.
Although the mechanisms of action have not been established, considerable empirical research has been conducted to identify the health impacts of meditation. A comprehensive review of the literature on the health effects of meditation practices funded by the Agency for Healthcare Research and Quality examined studies of MBSR, TM, yoga, and other meditation-related procedures with caregivers, students, and people in the general community published between 1956 and 2005 (Ospina et al., 2007). Whereas multiple conditions and outcomes were studied, meta-analytic results were available only for hypertension and cardiovascular diseases. Meta-analyses of studies of TM compared to progressive muscle relaxation for hypertensive patients showed potentially clinically significant benefits to blood pressure (systolic blood pressure [SBP] and diastolic blood pressure [DBP]) with TM, and for Zen Buddhist meditation versus blood pressure checks (DBP only); other meta-analyses of studies with healthy people showed significant benefits to blood pressure and cholesterol (lowdensity lipoprotein [LDL-C]) for TM, but findings were qualified due to heterogeneity across studies. Considering all the collective evidence through 2005, these authors concluded that, “the therapeutic effects of meditation practices cannot be established based on the current literature.”
A more recent comprehensive meta-analysis examined the effects of meditation on psychological outcomes in healthy adults (Sedlmeier et al., 2012). This review included 163 studies of concentrative, mindfulness, or guided-meditation interventions conducted between 1970 and 2011.
Outcomes evaluated included measures of emotion, personality, cognition, affect, behavior, and well-being. To provide an overall summary of impact, effects were pooled across all outcomes where meditation could be regarded as having either a positive or negative impact. This global analysis revealed medium-sized beneficial effects for meditation compared to active controls (such as relaxation) and no-treatment comparison groups. Examination of individual outcomes showed the largest effect sizes were for emotional (e.g., anxiety reduction) and relationship outcomes. Findings varied by type of meditation. Authors of both of these meta-analyses identified flawed methodology in the conduct of the clinical trials and a significant lack of quality (Ospina et al., 2007; Sedlemeier et al., 2012), including issues such as wait-list control groups, lack of double-blind procedures, and small sample sizes.
Outcomes evaluated included measures of emotion, personality, cognition, affect, behavior, and well-being. To provide an overall summary of impact, effects were pooled across all outcomes where meditation could be regarded as having either a positive or negative impact. This global analysis revealed medium-sized beneficial effects for meditation compared to active controls (such as relaxation) and no-treatment comparison groups. Examination of individual outcomes showed the largest effect sizes were for emotional (e.g., anxiety reduction) and relationship outcomes. Findings varied by type of meditation. Authors of both of these meta-analyses identified flawed methodology in the conduct of the clinical trials and a significant lack of quality (Ospina et al., 2007; Sedlemeier et al., 2012), including issues such as wait-list control groups, lack of double-blind procedures, and small sample sizes.
Recent reviews and meta-analyses of the impacts of mindfulness meditation training with MBSR, MBCT (mindfulness-based cognitive therapy), and related programs have generally found small to medium treatment effects, but also noted gaps and methodological flaws in the meditation literature. Shennan and colleagues (2011) reviewed the evidence for use of mindfulness-based interventions in cancer. They identified 13 studies, published from 2007 to 2009, in patients with varying types of cancer. They included quantitative, qualitative, and mixed-methods reports, concluding that mindfulness interventions have promising results for subjectively (e.g., anxiety, sexual dysfunction) and objectively (e.g., physiologic arousal, immune function) measured outcomes. Their findings suggest that mindfulness interventions may be useful across the cancer trajectory.
Bohlmeijer et al. (2010) conducted a meta-analysis to estimate the impact of mindfulness training on anxiety, depression, and psychological distress in adults with chronic medical diseases. They identified eight randomized, controlled clinical trials of MBSR or related adaptations published between 2000 and 2008. Study populations included patients with chronic back pain, heart disease, chronic fatigue syndrome, fibromyalgia, rheumatoid arthritis, and cancer. Outcomes were assessed with widely used, psychometrically strong self-report measures such as the State-Trait Anxiety Inventory Scale (STAI-S), Hospital Anxiety and Depression Scale (HADS), POMS, and SF-36 Mental Component Score (MCS). Criteria proposed by the Cochrane Collaborative were used to evaluate study quality. Initial meta-analytic effect sizes were small to medium-sized (d = 0.26 for depression, d = 0.47 for anxiety, and d = 0.32 for overall psychological distress), but varied with study quality. When only studies of high or medium quality were included, all effect sizes were significant but smaller. These authors suggested that integrating mindfulness with other behavioral therapies specific for each condition may enhance efficacy.
A meta-analysis of MBSR programs for stress reduction in healthy people by Chiesa and Serretti (2009) identified 10 comparative trials published between 1997 and 2008, most with wait-list controls. They concluded
that evidence supported nonspecific beneficial effects for MBSR on measures of stress and increased spirituality compared to inactive controls, but there was limited evidence for specific effects when compared to an active control, relaxation training.
that evidence supported nonspecific beneficial effects for MBSR on measures of stress and increased spirituality compared to inactive controls, but there was limited evidence for specific effects when compared to an active control, relaxation training.
Hoffman and colleagues (2012) led a randomized, wait-list controlled trial of the impact of MBSR on mood and quality of life, assessed by wellvalidated instruments, including the POMS (primary outcome), Functional Assessment of Cancer Therapy-Breast (FACT-B), Functional Assessment of Cancer Therapy-Endocrine Symptoms (FACT-ES) scales, and the World Health Organization Well-Being Questionnaire (WHO-5). The sample comprised 229 women with breast cancer (stages 0 to III, 2 months to 2 years after cancer treatment, ages between 18 and 80). Women were randomized to the MBSR group or to the wait-list control group. The intervention followed the standard MBSR curriculum. Twelve MBSR groups (10 to 20 participants) were conducted by Hoffman. Findings showed MBSR provided significant benefits compared to wait-list for essentially all POMS, FACT, and WHO outcomes at posttreatment, 12-week follow-up, or both. MBSR treatment effects reached the accepted level for clinical importance for the FACT-B. Practice and participation time during the 8-week intervention period was associated with greater benefit. Novel and notable results were MBSR-related improvements in endocrine-related symptoms. It was noted that those with stage III cancer and those who had received more extensive chemotherapy and hormone therapies were less willing to join this study. Hoffman and colleagues conclude that MBSR can benefit mood and quality of life for women with breast cancer, including those who receive hormone therapy.
Two randomized trials of meditation training in patients with diabetes were published in the past year. These were the Heidelberger Diabetes and Stress Study (HEDIS; Hartmann et al., 2012) clinical trial in Heidelberg, Germany, and the DiaMind (van Son et al., 2012) trial of MBCT in the Netherlands. HEDIS is a 5-year trial of MBSR to reduce emotional distress and progression of nephropathy in patients with type 2 diabetes and albuminuria. Patients were randomized to the MBSR group or the treatment-as-usual control group. All participants received standard diabetes care. The primary outcome was change in albuminuria, a measure of nephropathy and a risk factor for cardiovascular disease. Secondary outcomes included the Patient Health Questionnaire (PHQ)-9 depression scale and the SF-12 (German version). Groups of six to eight participants attended 8 weekly MBSR sessions plus a booster session at 6 months, led by a psychologist and a resident in internal medicine. The MBSR curriculum was integrated with discussion about diabetes-specific thoughts and feelings. Findings at year 1 showed no differences in progression of albuminuria, based on intent-to-treat analyses adjusted for baseline values, age, and gender. However, the MBSR group reported less depression, better mental health, and lower diastolic blood pressures. Because HEDIS is a 5-year study, the authors remain optimistic The year-1 treatment impact
on albuminuria was in the correct direction and encouraging in magnitude (effect size of 0.40). Unlike some interventions, which wane with time, it has been posited that MBSR’s benefits increase with time.
on albuminuria was in the correct direction and encouraging in magnitude (effect size of 0.40). Unlike some interventions, which wane with time, it has been posited that MBSR’s benefits increase with time.
DiaMind (van Son et al., 2012) was designed to test the short-term effectiveness of MBCT on stress, mood, and health-related quality of life in patients with diabetes. The study sample comprised 139 outpatients with type 1 or type 2 diabetes, who reported low levels of emotional well-being. Participants were randomized to either MBCT or treatment as usual; all received standard diabetes care throughout the study. MBCT consisted of 8 weekly, 2-hour group sessions with four to eight participants led by certified mindfulness instructors who were also psychologists with a personal mindfulness practice. Program adaptations specific to diabetes were detailed in the design paper (van Son, Nyklíček, Pop, & Pouwer, 2011). Results indicated better outcomes for the MBCT group compared to controls for measures of stress, depression, anxiety, fatigue, and health-related quality of life with medium to large effects from baseline to postintervention based on mixed models and an intent-to-treat sample. Most outcomes showed some improvement by 4 weeks (mid intervention), and greater improvement by 8 weeks, the end of the intervention period. HbA1c results were not significant. Inability to detect improvements in HbA1c levels may be partly explained by relatively good glycemic control at baseline (mean HbA1c = 7.6%). There is also some question about the acceptability of the intervention because about 80% of those eligible declined to participate. These authors conclude the MBCT adapted for diabetes may be effective in reducing emotional distress and enhancing health-related quality of life for patients with diabetes.
Findings of medium to large effects for psychosocial outcomes from the Hoffman, HEDIS, and DiaMind trials are encouraging; however, enthusiasm must be tempered by the fact the each used an inactive control. Treatment effects tend to be biased upward when there are no controls for nonspecific effects such as the time and attention from an instructor, group support, or expectations of benefit (placebo effect; Chiesa & Serretti, 2009; Ospina et al., 2007). Establishing active control groups for meditation interventions is feasible, as evidenced by the work of Tang et al. (2012; Tang & Posner, 2013) and by another trial, which tested the impact of MBSR on symptoms of anxiety, depression, and insomnia in solid organ transplant recipients (Gross et al., 2010). In the latter trial, 150 recipients were randomized into one of three groups: MBSR; Health Education—a peer-led chronic disease self-management program conducted to match MBSR for time, attention, and group support; and a wait-list. Primary outcomes were the STAI, Center for Epidemiologic Studies Depression Scale (CESD), and the Pittsburgh Sleep Quality Inventory (PSQI). Results demonstrated that those receiving active interventions had better outcomes than those on the wait-list at 8 weeks (the end of the active intervention period). Over 1 year, MBSR (n = 63) was superior to Health Education
(n = 59) in reducing anxiety and sleep dysfunction based on mixed-model regression analyses. A notable finding in this trial was that outcomes continued to improve in the MBSR group over the entire follow-up period, whereas the active control group had an initial benefit but then returned to baseline levels.
(n = 59) in reducing anxiety and sleep dysfunction based on mixed-model regression analyses. A notable finding in this trial was that outcomes continued to improve in the MBSR group over the entire follow-up period, whereas the active control group had an initial benefit but then returned to baseline levels.
The final study is a randomized, controlled prevention clinical trial to evaluate the impact of TM on cardiovascular mortality in African Americans with cardiovascular disease (Schneider et al., 2012). Participants were 201 African Americans with angiographic evidence of 50% or more stenosis of at least a coronary artery. Secondary outcomes included non-fatal cardiovascular events and lifestyle variables (smoking, alcohol use, diet, body mass index, and psychological distress). Participants were randomized to either TM or cardiovascular health education. The TM technique was taught by a certified instructor in a series of six 90-minute to 2-hour individual or group meetings, with home practice expectations of 20 minutes per day throughout follow-up. The health education program comprised information about diet, exercise, and stress, and was taught by professional health educators in a format designed to be similar in time and attention to the TM intervention. With an average of 5.4 years of follow-up, the TM group had a significant 42% risk reduction for cardiovascular mortality in a survival analysis stratified by age, gender, and lipid-lowering medications. Significant impacts for TM were also found for systolic blood pressure and the Anger Expression Scale. Both groups showed improvement in exercise and decreased alcohol consumption. No serious adverse events related to the interventions were reported. Study limitations include variations in follow-up procedures and substantial rates of nonparticipation (19% for the TM group and 10% for health education). The authors conclude that TM may be clinically useful in the secondary prevention of cardiovascular disease among African Americans.
INTERVENTION
Techniques and Guidelines
Although there are numerous meditation programs, four of the most widely used and researched meditation programs in Western health care were selected for description below: MBSR (and several related programs), IBMT, TM, and loving-kindness.
Mindfulness-Based Stress Reduction and Related Programs
MBSR was developed by Jon Kabat-Zinn at the Stress Reduction Clinic at the University of Massachusetts Medical Center (www.umassmed.edu/cfm/home/index.aspx) more than 30 years ago. It is a particular
way of learning mindfulness meditation that emerged in a hospital system and was fashioned as a complement to traditional medical care for patients with chronic pain conditions (Kabat-Zinn, 1990). The program is theoretically grounded in secularized Buddhist meditation practices, mind-body medicine, and the transactional model of stress that suggests people can be taught to manage their stress by adjusting their cognitive perspective and increasing their coping skills to build self-confidence in handling external, stressful situations. MBSR is an 8-week generic skillsbased program led by an instructor in a classroom format. The course comprises eight weekly 2.5-hour classes, one 7.5-hour meditation retreat, and 30 minutes to 45 minutes of daily homework practicing the techniques learned in the course. Sessions include information about stress, cognition, and health, but primarily concentrate on learning to focus attention through a variety of meditative techniques, such as focusing on the breath, body-scan, sitting and walking meditations, and gentle yoga. Participants are trained to perceive their immediate emotional and physical state, including pain or discomfort, and to let thoughts come and go into awareness with no attempt to change, suppress, or ruminate on these thoughts.
way of learning mindfulness meditation that emerged in a hospital system and was fashioned as a complement to traditional medical care for patients with chronic pain conditions (Kabat-Zinn, 1990). The program is theoretically grounded in secularized Buddhist meditation practices, mind-body medicine, and the transactional model of stress that suggests people can be taught to manage their stress by adjusting their cognitive perspective and increasing their coping skills to build self-confidence in handling external, stressful situations. MBSR is an 8-week generic skillsbased program led by an instructor in a classroom format. The course comprises eight weekly 2.5-hour classes, one 7.5-hour meditation retreat, and 30 minutes to 45 minutes of daily homework practicing the techniques learned in the course. Sessions include information about stress, cognition, and health, but primarily concentrate on learning to focus attention through a variety of meditative techniques, such as focusing on the breath, body-scan, sitting and walking meditations, and gentle yoga. Participants are trained to perceive their immediate emotional and physical state, including pain or discomfort, and to let thoughts come and go into awareness with no attempt to change, suppress, or ruminate on these thoughts.
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