Reported by Dr. Maya Spencer
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Through the 1980's and 90's, Dr. Jon Kabat-Zinn and his team at
the University of Massachusetts Medical Centre have quietly been
setting the stage for a revolution in medicine. Hundreds of
outpatients have learnt to meditate as part of their medical
treatment by going through the Mindfulness - Based Stress Reduction
Programme, held in a specialist clinic within the department of
medicine. In August 2001 Dr. Kabat-Zinn and the present director of
the clinic, Saki Santorelli, came over to the UK to present their
work in an experiential 5-day workshop at Bangor University, aimed
primarily at health professionals.
The mindfulness-based stress reduction (MBSR) programme is an
8-week course in which patients attend a weekly class where they
are instructed in mindfulness meditation (sitting and walking),
yoga, and the body-scan technique. They commit to meditating in one
or other of these modes at home, for 40 minutes a day, 6 times a
week. They also have other homework. The beauty of mindfulness
meditation is that it can be generalised to whatever one is doing
in the moment, so it is possible to take a shower mindfully, to do
the washing up mindfully etc. - or so I am told, I haven't achieved
it yet! Mindfulness simply means non-judgmental, moment-by-moment
awareness - of thoughts, feelings, and sensations. It develops
concentration, and the faculty of witnessing - as opposed to being
caught up in - mental activity.
In the Bangor workshop, we received similar instruction as in
the stress reduction classes, and our commitment was to start each
day with sitting meditation at 6 am. Afterwards, we divided the
time between meditation and yoga practice periods, with time also
given to question and answer sessions with Jon and Saki. I can't
make much comment on the body scan technique other than to say it
was extremely relaxing as I went to sleep each time! In fact, it is
not a relaxation technique, but requires one to focus the attention
on physical sensations during an inner tour of the body.
It was an intensive programme with evening sessions as well. One
evening Jon gave an inspiring account of how the mindfulness-based
programme developed, and has spread not only around North America,
but also to other parts of the world. Another time, he gave a
sumMary of the considerable amount of research that has been
carried out, which shows the effectiveness of the programme. One of
the appeals of his work is that it has a strong evidence-base. Most
riveting, of course, were the moving accounts of patients'
experiences and responses to the programme.
There were around one hundred participants in the workshop, with
about two-thirds coming from Holland and Germany. It was held in a
large hall, and it is a tribute to Jon and Saki that they overcame
the impersonal space and a poor PA system to create a wonderfully
intimate atmosphere. They did this by being ordinary, fallible
human beings to a degree that is extraordinary in my experience of
academic events. Their sincerity and utter dedication to their work
was deeply impressive. They both participated with us at all times
(yes, even at 6 a.m.) and it was plain that being present with us,
including mealtimes and the walks back to the accommodation site
for meals, was their priority. Their depth of experience with both
meditation and patients carried an unassailable conviction: they do
indeed 'walk their talk'.
Is there a place for similar programmes here, in the UK, in
psychiatry? Bearing in mind that the University of Massachusetts
clinic takes patients who are referred by physicians, it is
important to realise that the Stress Reduction Programme caters for
patients who are in the domain of liaison, not general, psychiatry.
The centre is staffed by clinical psychologists. Research showing
benefits of the programme to patients with anxiety and depression
was carried out with medical, not psychiatric, patients with these
conditions. Dr. Santorelli told me of some exciting pioneering work
by a psychiatrist in another state, who is adapting the programme
for people with schizophrenia, but this seemed to be an isolated
example of its application within the field of severe mental
illness.
It was hard to imagine the transposition of the programme into
the NHS in Britain, and others I spoke to felt the same. It
requires a high level of commitment to making a major life style
change, and often that commitment seemed to come from feeling that
all avenues of medical treatment have been tried without success,
that MBSR is the last hope. Research has shown that benefit from
the programme correlates with time spent meditating at home, not
with clinic attendance (1). One of the most
encouraging aspects of the work with the programme has been its
success with an inner city, Spanish-speaking population (2). For them, yoga was called 'gentle stretching' and
meditation was 'relaxation', to make the programme more
acceptable.
The one place with significant experience of trying out the
programme over here is Bangor, where the community mental health
team have linked in with research being carried out in the
University into a possible marriage of mindfulness meditation with
cognitive therapy. The experience is predominantly positive, as has
been demonstrated in a multi-centre clinical trial involving John
Teasdale's group in Cambridge and another centre in Toronto
(3). For those interested in this
development within cognitive therapy, a book will be coming out in
November 2001, entitled Mindfulness-Based Cognitive Therapy for
Depression, and endorsed by Aaron Beck. An interesting finding
has been that the programme seems to work best for those with
several episodes of recurrent depression, perhaps pointing again to
the prime importance of failure of conventional treatment in
motivation for compliance with mindfulness practice.
Jon made it plain that an MBSR programme can only be run by
people who consistently practise mindfulness themselves. Training
requires people to have meditated consistently for at least three
years before starting. It would be interesting to know how big a
pool of regular meditators there are in the health service in the
UK, but on the face of it this stringent, though obviously
necessary, requirement appears to preclude the spread of similar
programmes over here, before we even start on funding issues. Once
again we are faced with the great divide between those with
traditional skills who have professional access to patients, and
those who have developed other personal resources that could help
people help to themselves more effectively, but who find little
invitation to join with a health service that still often regards
them with suspicion and condescension. The MBSR programme has
successfully bridged the gap, and appears to me to fit best over
here in a priMary care context, in the development of self-help
programmes for those patients with significant illness or distress
whose psychological needs generally fall outside the remit of the
community mental health team and are currently very poorly attended
to by the NHS.
Jon Kabat-Zinn has achieved what few do: he has set up an
innovative programme in the field of mind-body medicine that has
been accepted by general hospital physicians, and that has been of
enormous value to large numbers of patients. He has confirmed this
value with sound research. He has inspired others to emulate him,
and his work has spread internationally. He has brought
spirituality to the forefront of medicine in a way that is
independent of religious affiliation and acceptable to all. It was
a privilege to attend his workshop, as well as a beneficial
experience both personally and professionally. I couldn't resist a
little mischievous smile while doing my yoga stretches to think
this was actually paid study - leave! That's definitely progress
towards bringing spirituality into psychiatry.
References
(1) Kabat-Zinn, J. et al (1992)
Effectiveness of a meditation-based stress reduction program in the
treatment of anxiety disorders. American Journal of
Psychiatry, 149, 936-943.
(2) Roth, B. & Creaser, T.
(1997) Mindfulness meditation-based stress reduction: Experience
with an inner city program. The Nurse Practitioner,
22, 150-176.
(3) Williams, J.M.G.,
Teasdale, J.D., Segal, Z.V. & Soulsby, J. Mindfulness-based
cognitive therapy reduces over-general autobiographical memory in
formerly depressed patients. Journal of Abnormal
Psychology (in press).
Recommended reading
Jon Kabat-Zinn (1990) Full Catastrophe Living: Using the
Wisdom of your Body and Mind to Face Stress, Pain and Illness.
Piatkus, London
Jon Kabat-Zinn (1994) Wherever you go, there you are:
Mindfulness Meditation in Everyday Life. Hyperion, New
York
Saki Santorelli (1999) Heal Thyself, Lessons on Mindfulness
in Medicine. Random House/Bell Tower, New York
Audiotapes of guided meditations
Available from http://www.mindfulnesstapes.com/