Part II: Mind–Body–Spirit Therapies
Chapter 11: Meditation
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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 med-itation (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 medita-tion training with a standardized brief meditamedita-tion instrucmedita-tion 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 medi-tation within the context of religious observance and prayer (e.g., chant-ing, 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 ensu-ing 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 cultivat-ing well-becultivat-ing. 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 medi-tation strategies involve bringing one’s attention in a nonjudgmental or accepting way to whatever experience arises in the present moment.
11. MedItatIon 169 In mindfulness, practitioners are instructed to allow any thought, feel-ing, or sensation to arise in consciousness while maintaining a nonreac-tive awareness to what is being experienced. Mindfulness practice was primarily developed in Buddhism, where it has been an integral com-ponent 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 (man-tra), or an imagined mental image. In concentration meditation, aware-ness 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 medita-tor 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 arith-metic 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 respi-ratory 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 follow-ing meditation trainfollow-ing.
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 pro-posed 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 mindful-ness 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, con-siderable 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 ben-efits 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 (low-density lipoprotein [LDL-C]) for TM, but findings were qualified due to het-erogeneity 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.
11. MedItatIon 171 Outcomes evaluated included measures of emotion, personality, cogni-tion, 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 com-pared 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 out-comes. Findings varied by type of meditation. Authors of both of these meta-analyses identified flawed methodology in the conduct of the clini-cal 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 med-itation 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, conclud-ing that mindfulness interventions have promisconclud-ing results for subjectively (e.g., anxiety, sexual dysfunction) and objectively (e.g., physiologic arousal, immune function) measured outcomes. Their findings suggest that mind-fulness 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 psychologi-cal distress in adults with chronic medipsychologi-cal diseases. They identified eight randomized, controlled clinical trials of MBSR or related adaptations pub-lished 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 pro-posed 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 dis-tress), 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 pub-lished between 1997 and 2008, most with wait-list controls. They concluded
that evidence supported nonspecific beneficial effects for MBSR on mea-sures 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 well-validated 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 com-prised 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 out-comes 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 associ-ated with greater benefit. Novel and notable results were MBSR-relassoci-ated 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 col-leagues 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 dia-betes 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 dia-betes 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 curricu-lum was integrated with discussion about diabetes-specific thoughts and feelings. Findings at year 1 showed no differences in progression of albu-minuria, based on intent-to-treat analyses adjusted for baseline values, age, and gender. However, the MBSR group reported less depression, bet-ter mental health, and lower diastolic blood pressures. Because HEDIS is a 5-year study, the authors remain optimistic The year-1 treatment impact