Mindfulness for our Patients

Original Editor - Merinda Rodseth based on the course by Shrey Vazir

Top Contributors - Jess Bell, Tarina van der Stockt and Merinda Rodseth  

Introduction[edit | edit source]

Over the last 40 years there has been a great shift in mindset from the traditional “biomedical” tissue-based model of health care to a biopsychosocial model.[1][2][3] The biopsychosocial model assesses the “whole person”, taking into account the dynamic interactions between the bio, psycho and social factors of the pain-experience process.[1][4]Understanding that every thought, every feeling and every interaction with the environment is linked to a chemical reaction in the neuroimmune system, with possible structural and functional consequences, increases the clinician’s insight and truly embeds biopsychosocial thinking into practice”.[4]

Pain is the most common reason for people seeking healthcare. When pain is unresolved, it results in chronic pain (i.e. pain lasting longer than 3 months), which has become a major public health problem globally.[4][5][6] Chronic pain also poses a significant therapeutic challenge and has subsequently lead to a change in focus from studying tissue damage to studying pain itself.[4][5] Focusing our attention on the person rather than on the tissues has caused a shift in treatment from a single-minded focus on eliminating pain to a much bigger goal of improving quality of life and enabling patients to re-engage in life roles that are meaningful to them.[4] This is reiterated in the concept of mindfulness where the goal is not to eliminate pain or stress, but rather to teach patients to be self-aware and to respond to stress and pain in a more constructive and healthy way.[5][7] Empowering patients to be in control of their own pain experience is fundamental to this patient-centred care and enables patients to self-manage and recover their life roles.[4]

Recognising Potential Patients[edit | edit source]

Despite its proposed benefits, mindfulness practice is not considered a panacea for all conditions, people and circumstances.[8] Even though mindfulness practice would probably be beneficial to most individuals, its impact on a smaller subset of patients could be much more enhanced. Consideration of the established effects and benefits of mindfulness could help physiotherapists identify which patients would potentially most benefit from mindfulness training, and are proposed to include the following subgroups:[9]

  • Patients with persistent and chronic pain [5][10][11]
  • Chronically stressed, anxious, worried and tense patients [12]
  • Patients who ruminate on the past or the future (this becomes evident in key phrases and words used by patients) [8][12]
  • Motivated patients [8]
  • Good therapeutic relationship [8]

Integrating Mindfulness into Clinical Practice[edit | edit source]

Germer et al[13] conceptualised three pathways in which to integrate mindfulness into therapeutic work:

  1. Personal practise of mindfulness in order to cultivate a mindful presence in therapeutic work - mindful therapist
  2. Integrating the wisdom and insights from the psychological mindfulness literature into one’s own therapeutic practice - mindfulness-informed therapy
  3. Explicitly teaching mindfulness skills and practices to patients to enhance their own mindfulness - mindfulness-based therapy

When considering the concept of being a “mindful therapist”, it is important to be aware that “relationship” has proven to be the strongest predictor of the outcomes of therapy. “Relationships characterised by empathy, unconditional positive regard, and congruence between therapist and client have proven most beneficial”.[8] Thich Nhat Hanh stated: “A therapist has to practice being fully present and has to cultivate the energy of compassion in order to be helpful”.[8] Therefore, introducing patients to mindfulness practice should really start with a mindful attitude of the therapist.[8]

Mindfulness practice can also be utilised using the framework that supports the concepts cultivated by it, i.e. mindfulness-informed practice. Shapiro & Carlson[8] highlighted a few potential points for exploration based on insights informed by mindfulness that may be useful to explore with patients during therapy:

  • Impermanence - the fact that everything changes and life is not static, permanent and unchanging
  • No “self” - the concept that “self” is also ever-changing and in continuous flux
  • Accepting what is - much of our suffering follows our resistance to what is actually happening, wanting things to be different from what they are. “What we resist, persists”. When we resist our experience, we increase our suffering.
  • Conscious responding versus automatic reactivity - stop and attend to stimuli/problems/emotions instead of automatically reacting
  • Curiosity and investigation of one’s own experience - paying attention specifically to the body, feelings, the mind and the underlying principles of experience. Be curious about internal experiences and explore them.
  • Paradox can be a means of liberation, an instrument to move beyond the usual way of seeing things to a position of greater flexibility and perspective (e.g. “to care and not to care”)
  • Interdependence - all things are connected and mutually interdependent, we are not separate or isolated
  • Essential nature/inherent goodness

Mindfulness practice, with its origins in Buddhist philosophy, is often not widely accepted in the Western world. Some patients might be resistant to its use even though it could be separated from its religious roots, which may necessitate a measure of convincing them to engage in it. Hence, approaching it according to the following steps might result in better acceptance:

  1. Mindfulness practice should be introduced in a gentle, non-judgemental and open way
  2. Exploring mindfulness can start with bare awareness to simple breathing.[8] Incorporate easy breathing techniques into the patient’s daily routine/exercise programme while asking them to pay attention to their breath - feeling the breathing in and breathing out, the rise and fall of the abdomen, the “touch of air at the nostrils”[8]
  3. The simple breathing exercises can be progressed to more specific breathing techniques such as the “3-minute breathing space”[8], “4-7-8 breathing” and “box breathing”[9]
  4. Provide patients with handouts and additional resources to increase their knowledge
  5. Engage patients in guided meditations performed either by a therapist or through the use of mindfulness applications available online or on smartphones (Apps)
  6. Help patients find structured or community mindfulness programmes (i.e. 6-14 week programmes)
  7. Encourage patients to engage in mindfulness practice long-term for maximal benefit[11]

Phrases that may be useful to engage patients in mindfulness practice during therapy include:[9]

Phrases for Mindfulness therapy.jpg[9]

Mindfulness-Based Applications[edit | edit source]

The popularity of mindfulness combined with the ubiquity of smartphones has led to an exponential increase in Mindfulness-Based mobile Applications (MBAs) available. MBAs have been shown to effectively reduce stress and improve wellbeing and can target wider audiences than typical mindfulness meditation training, making mindfulness more accessible to the general public.[14][15][16] Apps increase flexibility in terms of time and place and offer reminder functions and supporting material (pictures, videos), facilitating the integration of mindfulness techniques into daily life.[17] MBAs mostly focus on guided meditations and often start with breathing exercises, asking the users to focus their attention on their body.[15] There is a wide variety of MBAs available with Calm, Headspace, InsightTimer, Smiling Mind and Stop Breathe Think only being a few examples.[14][15][16] Despite the benefits seen with MBAs, it is important to note that MBAs are not necessarily beneficial for everyone and could in fact be harmful to some patients, specifically those with severe depression, PTSD, suicidal ideation and a history of trauma.[9] This leads to the concept of trauma-sensitive mindfulness, a modified trauma-informed approach to mindfulness that is much better positioned to safely facilitate mindfulness in trauma survivors where traditional mindfulness practice (including meditation apps) could potentially be harmful.[9][18]

Trauma-Sensitive Mindfulness[edit | edit source]

The concept that mindfulness can be a cure-all for every condition and problem, including trauma, has had some unintended consequences.[18] Even though many people who regularly practise mindfulness experience great benefits, not everyone has that experience - especially not those who have experienced trauma (“an extreme form of stress that can overwhelm our ability to cope”).[18] Trauma and mindfulness, although seemingly allies, have a complex relationship.[18] For many people who have experienced trauma, mindfulness can elicit symptoms of traumatic stress. This can take the form of flashbacks, volatile emotional reactions, agonising physical sensations and dissociation - a disconnect between one’s thoughts, emotions and physical sensations.[18] Although mindfulness might seem innocuous and beneficial for trauma survivors, it often opens emotional wounds that need more than mindful awareness for healing. “When we ask someone with trauma to pay close, sustained attention to their internal experience, we invite them into contact with traumatic stimuli - thoughts, images, memories, and physical sensations that may be related to a traumatic experience….this can aggravate and intensify symptoms of traumatic stress, in some cases even lead to retraumatization - a relapse into an intensely traumatized state.” [18] Focusing attention on injuries that are often internal and unseen, can cause distress, anxiety and humiliation in trauma survivors, placing them in an “unsafe” environment.[18] Despite this, mindfulness could also be an invaluable resource for trauma survivors - strengthening body awareness, boosting attention and improving emotion regulation, skills essential for trauma recovery.[18]

This dilemma raised the question as to how the potential dangers of mindfulness to trauma survivors can be minimised while simultaneously harnessing its potential benefits, which gave birth to the concept of Trauma-Sensitive Mindfulness.[18] Basic mindfulness practice is safer and more effective when paired with an understanding of trauma.[18] Trauma is not limited to assault survivors or combat veterans, and is surprising less about the content of an event than it is about its impact. Pat Ogden, veteran trauma specialist, stated, “any experience that is stressful enough to leave us feeling helpless, frightened, overwhelmed, or profoundly unsafe is considered a trauma”.[18] This can vary from witnessing or experiencing violence, losing a loved one to being targeted by oppression - people experience trauma in various ways.

Treleaven & Britton[18] defined Trauma-Senstive practice as:

“A program, organisation, or system that is trauma-informed realises the widespread impact of trauma and understands potential paths for recovery; recognizes the signs and symptoms of trauma in clients, families, staff, and others involved with the system; responds by fully integrating knowledge about trauma into policies, procedures, and practices; and seeks to actively resist re-traumatisation.”

They proposed that the primary task of therapists lie in the four R’s evident in the definition: realising the pervasive impact of trauma, recognising symptoms, and responding to them skillfully - all with the aim of preventing re-traumatisation.[18]

The 5 core principles of trauma-sensitive mindfulness practice include:[18]

  1. Stay within the window of tolerance - the zone between hyperarousal and hypoarousal which can also be described as the internal zone/range of their experience where they can safely observe and tolerate, without exceeding what they can handle.[18][19] It is important to motivate trauma survivors to begin tracking their window of tolerance, so that they can self-regulate, knowing what they can stay present for and what they can’t tolerate.
  2. Shift attention to support stability - survivors must learn that they can shift their attention away from traumatic stimuli in order to support their window of tolerance (e.g. opening eyes and focussing on the environment).  Establish stable anchors of attention by focusing on something other than breath, like the sensation of their feet on the floor/buttocks on the chair or the sounds around them.
  3. Keep the body in mind - working with dissociation. Survivors need to eventually come back into connection with their bodies, befriending their inner world through an awareness of inner body sensations. Providing choices/options such as keeping their eyes open/closed, adopting a posture that works for them and opting out of / or stopping any practice, helps to create a safe environment for survivors, giving them autonomy of the situation. Be cautious of using body scan as a mindfulness technique with trauma survivors.
  4. Practise in relationship - use the benefits of interpersonal relationships to buoy the safety, stability and window of tolerance of trauma survivors. Trauma cannot be healed in solitude - recovery requires relationship. Screening patients for a history of trauma provides the opportunity to identify trauma survivors who might not do well with mindfulness practice and might benefit more from consulting a trauma professional first.
  5. Understand social context - working effectively across differences. It is important to be aware that we all have a unique history and are being shaped by the systems around us. Social context includes social identity (age, gender, race, ethnicity, class background, sexual identity, dis/ability, religion), locale (city, town, suburb), peers, community and country of residence. Trauma can affect anyone but people in marginalised social groups are more vulnerable to experience traumatic events.

Following the principles defined by Treleaven & Britton[18] there are some trauma-sensitive modification strategies that could be useful in clinical practice when engaging patients in mindfulness practice. These include:[9]

  • Screening patients for PTSD, severe depression, trauma and suicidal ideations
  • Providing options to patients during mindfulness practice (keep eyes closed/open; different postures)
  • Establishing a safe environment
  • Giving patients permission to step out of / stop at any time
  • Providing patients with an alternate anchor to breath, such as sounds or physical sensations

Advanced training is required to treat survivors of severe trauma and trauma practitioners are better positioned to provide the necessary intervention.[9][18] Recommending the use of mindfulness apps are therefore not encouraged for patients with a history of trauma and especially not for those with PTSD, severe depression and suicidal ideation as it may result in re-traumatisation.[9]

Key Considerations Concerning Mindfulness[edit | edit source]

  • Mindfulness is not intended to be blissful, rather, like exercise, it can be uncomfortable at times
  • Mindfulness is not the panacea/universal solution to reduce stress and improve well-being. There are many other tools and options available
  • Mindfulness is intended to be open-minded and inviting, not forcing anyone but allowing participants to explore, experiment and build an approach that best works for them

“What we resist, persists”[8]

Mindfulness quote.jpg

[18]

Resources[edit | edit source]

Books:

Videos:​


References[edit | edit source]

  1. 1.0 1.1 Bevers K, Watts L, Kishino ND, Gatchel RJ. The biopsychosocial model of the assessment, prevention, and treatment of chronic pain. US Neurol. 2016 Jan 1;12(2):98-104. DOI:10.17925/USN.2016.12.02.98 
  2. Bolton D, Gillett G. The biopsychosocial model of health and disease: New philosophical and scientific developments. Springer Nature; 2019. DOI:10.1007/978-3-030-11899-0
  3. Jull G. Biopsychosocial model of disease: 40 years on. Which way is the pendulum swinging? British Journal of Sports Medicine. 2017 Jan 6. DOI: 10.1136/bjsports-2016-097362
  4. 4.0 4.1 4.2 4.3 4.4 4.5 Parker R, Madden VJ. State of the art: What have the pain sciences brought to physiotherapy?. The South African journal of physiotherapy. 2020;76(1). DOI:10.4102/sajp.v76i1.1390
  5. 5.0 5.1 5.2 5.3 Smith SL, Langen WH. A systematic review of mindfulness practices for improving outcomes in chronic low back pain. International Journal of Yoga. 2020 Sep;13(3):177. DOI:10.4103/ijoy.IJOY_4_20
  6. Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, Colaiaco B, Maher AR, Shanman RM, Sorbero ME, Maglione MA. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Annals of Behavioral Medicine. 2017 Apr 1;51(2):199-213. DOI:10.1007/s12160-016-9844-2
  7. Shrey Vazir. Benefits and Evidence for Mindful Meditation. Physioplus Course. 2021
  8. 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 8.11 Shapiro SL, Carlson LE. The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. 2nd ed. Washington, DC: American Psychological Association; 2017.
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 Shrey Vazir. Mindfulness for Patients. Physioplus Course. 2021
  10. McClintock AS, McCarrick SM, Garland EL, Zeidan F, Zgierska AE. Brief mindfulness-based interventions for acute and chronic pain: A systematic review. The Journal of Alternative and Complementary Medicine. 2019 Mar 1;25(3):265-78. DOI: 10.1089/acm.2018.0351
  11. 11.0 11.1 Zeidan F, Baumgartner JN, Coghill RC. The neural mechanisms of mindfulness-based pain relief: a functional magnetic resonance imaging-based review and primer. Pain reports. 2019 Jul;4(4). DOI:10.1097/PR9.0000000000000759
  12. 12.0 12.1 Creswell JD. Mindfulness interventions. Annual review of psychology. 2017 Jan 3;68:491-516. DOI: 10.1146/annurev-psych-042716-051139
  13. Germer CK, Siegel RD, Fulton PR. Mindfulness and psychotherapy. New York: The Guilford press; 2005.
  14. 14.0 14.1 Nunes A, Castro SL, Limpo T. A review of mindfulness-based apps for children. Mindfulness. 2020 Sep;11(9):2089-101. DOI:10.1007/s12671-020-01410-w
  15. 15.0 15.1 15.2 Daudén Roquet C, Sas C. Evaluating mindfulness meditation apps. InExtended Abstracts of the 2018 CHI Conference on Human Factors in Computing Systems 2018 Apr 20 (pp. 1-6). DOI:10.1145/3170427.318861
  16. 16.0 16.1 Flett JA, Hayne H, Riordan BC, Thompson LM, Conner TS. Mobile mindfulness meditation: a randomised controlled trial of the effect of two popular apps on mental health. Mindfulness. 2019 May;10(5):863-76. DOI: 0.1007/s12671-018-1050-9
  17. Schultchen D, Terhorst Y, Holderied T, Stach M, Messner EM, Baumeister H, Sander LB. Stay Present with Your Phone: A Systematic Review and Standardized Rating of Mindfulness Apps in European App Stores. International Journal of Behavioral Medicine. 2020 Nov 20:1-9. DOI: 0.1007/s12529-020-09944-y
  18. 18.00 18.01 18.02 18.03 18.04 18.05 18.06 18.07 18.08 18.09 18.10 18.11 18.12 18.13 18.14 18.15 18.16 18.17 Treleaven D.A., Britton W. Trauma-sensitive mindfulness: Practices for safe and transformative healing. New York: WW Norton & Company; 2018 Feb 13.  
  19. Siegel DJ. The developing mind: Toward a neurobiology of interpersonal experience. 2nd ed. New York: Guilford Press; 2012
  20. DocMikeEvans. The Single Most Important Thing you can do for your Stress. Published 9 June 2012. Available from​: https://www.youtube.com/watch?v=I6402QJp52M [last accessed 9 April 2021].
  21. TED. All it takes is 10 mindful minutes. Andy Puddicombe. Published 11 Jan 2013. Available from: https://www.youtube.com/watch?v=qzR62JJCMBQ [last accessed 9 April 2021].
  22. Kelly McGonigal. What Science can Teach Us about Practice: The Neuroscience of Mindfulness. Published 2 Aug 2011. Available from: https://www.youtube.com/watch?v=jMsatDwx07o [last accessed 9 April 2021]