Because they’ve seen the evidence that mindfulness is profoundly healing, they’re taking it right into the middle of the American health care system, from prevention, diagnosis, and treatment, through cure, palliative care, and even health administration and medical training. With the help of Susan G. Komen for the Cure, the world’s largest grassroots network of breast cancer survivors and activists and sponsor of the Lynn Lectures on integrative medicine, we brought together three of the world’s leading specialists on the healing power of mindfulness and the benefits of integrative medicine for a discussion of the present and future of mind–body medicine.
How Awareness Heals
Barry Boyce: What are some of the benefits of mindfulness—both the practice and the state of mind—for our health and healing? Jon Kabat-Zinn: To be in relationship to what you are going through, to hold it, and, in some sense, to befriend it—that is where the healing or transformative power of the practice of mindfulness lies. When we can actually be where we are, not trying to find another state of mind, we discover deep internal resources we can make use of. Coming to terms with things as they are is my definition of healing. Appreciating this kind of awareness can have virtually immediate effects on health and well-being. As crazy as it sounds, it’s possible to befriend your pain or your fear—rather than feeling that you can’t get anywhere until this thing that bothers you is cut out or walled off or shut down. That’s a really profound realization for someone to come to. It’s very healing to realize, if only for a moment here and a moment there, that you can be in a wiser relationship with your interior experience than just being driven by liking it or hating it. We say to our patients who come to Mindfulness-Based Stress Reduction that there’s more right with them than wrong with them, no matter what their diagnosis is. We’re going to pour energy into what’s right with them, and see what happens. It’s a great adventure and it’s very satisfying to be able to see people light up as they experience the knowledge that it’s okay to be where they are as they are. Daniel Siegel: To help people be with their pain, or with knowledge of their metastasis, or of their mortality, it’s so valuable for them to discover a spaciousness of mind where they realize they’re part of a universal flow of things—people get ill, people do die, and they’re part of that big picture. Within that spaciousness, there is a great clarity that isn’t the same as relaxation. It’s not just hanging loose. You get beyond your internal dialogue of “I want to be better now.” You can be in the midst of great difficulties and yet find immense composure and clarity. Susan Bauer-Wu: It’s so very important for people who have cancer or any other serious illness to be in tune with what they’re experiencing, rather than shut off from it, which can so often be the case. One of the most important benefits of mindfulness is attentiveness to what is happening in your body, your mind, and your environment—being present for what’s happening to you, with you, and around you at a particular moment in time. Mindfulness becomes a foundation to help patients make good decisions and navigate all they have to go through. Another benefit of mindfulness is having less emotional reactivity and more stability of mind. Not overreacting emotionally brings greater mental clarity, which is healthy in and of itself. Having stability of mind makes you better able to cope with the experience of illness and all it involves. That is a very significant and positive outcome.
Mindfulness as a Way of Being, Not a State of Perfection
Jon Kabat-Zinn: Actually, we don’t yet have a language for describing what mindfulness is. That’s one of the exciting parts of all the mindfulness research that’s happening. With so many different perspectives coming to bear on it, including neuroscience and clinical medicine, we will be able to describe it more richly. I’m fine with calling it a practice, but we have to distinguish it from many other kinds of practice. It’s not exactly like practicing the piano, for example. It does involve discipline in that way, but you’re not trying to become a virtuoso. I prefer to call mindfulness a way of being. That gives people much more latitude in what they’re actually experiencing, because it’s not about trying to be in a special state, and if you’re not in that state, then you’re doing something wrong. It’s rather that you can bring awareness to any state you happen to be in. There’s nothing wrong with being caught up in difficult, stressful, agitated, or confusing moments. That’s why characterizing mindfulness as a mind state can be problematic. If we’re talking about transforming health care or transforming any individual’s relationship to their own body—especially if they’re in pain or suffering with cancer or another life-threatening illness—the idea that mindfulness is a particular mind state can be misleading. When we’re experiencing these conditions, the mind might be very agitated and disturbed. There will be emotional reactions, as Susan mentioned. Therefore, the idea that there is a sought-after mind state, and that if you were really good enough you would find it and everything would be great for the rest of your life, would be a misapprehension of what mindfulness really is. Daniel Siegel: In neuroscience, we do talk about a momentary set of brain firing patterns that we would call a brain state. If you want to jump from brain to mind, some people would call it a state of mind. You could make the argument that there is something we could call “awareness,” and within that general term there are many different ways of being aware. For example, if I’m really angry, and I have a gun in my hand, I’m aware that the gun is in my hand. If I shoot someone, you could say I’m perfectly aware that I committed this act. But when we discuss what we might call “mindful awareness,” something more is going on. If I am mindfully aware, I will be imbued with all sorts of discernment about whether the action I’m about to take is a good action for the person in front of me and for me. I would have a broader sense than just being aware of the gun in my hand. I would have a larger picture of the moment-to-moment unfolding, not just the sensation. So I might put the gun down. As the teacher Joan Halifax pointed out in a recent retreat I took part in, there is a difference between being aware and being aware with wisdom. When you look at the neuroscience, being aware with wisdom likely involves a whole set of what we would call the middle structures of the prefrontal area. One possible view is this: When we talk about the focus of attention, we often are referring to the dorsolateral, or side, areas. Wisdom, compassion, empathy, self-understanding, being aware of your own body, being able to be flexible, pausing before you act—all those elements of our mental experience seem to correlate with middle prefrontal activity, not just the side prefrontal activity. The person using his dorsolateral area is aware of the gun and aims well, because he’s got good attention. But the person who is mindfully aware, we can propose, harnesses all the correlates of wisdom and compassion, and in that moment he either doesn’t pick up the gun, or thinks of other options, or pauses before the impulse turns into action.
Mindfulness Isn’t All Calm and Peace
Barry Boyce: Mindfulness practice can uncover dark and difficult thoughts, which people can find quite shocking. Is that beneficial in the middle of a health crisis? Daniel Siegel: Much of what happens in the mind is not within consciousness, yet these non-conscious processes have an impact on our health. Bringing these negative thoughts, such as fear, hostility, betrayal, or sadness, to awareness is part of basic health, because those thoughts—what in my field are called unintegrated neural processes—are basically like black holes. They have so much gravity to them that they suck the energy out of life. They influence the health of the mind, its flexibility and fluidity, its sense of joy and gratitude. They impact relationships, leading to rigid ways of behaving or explosive ways of interacting. They also influence the body itself, including the nervous system and the immune system. So an exploratory process like mindfulness that brings those fearful negative thoughts to awareness can be very beneficial. Sometimes you have to name it to tame it. A number of studies suggest that when you bring something into awareness, and describe it, you can move that previously negative energy—a draining thought or cognition—into a new form. With mindfulness, what was not available to awareness becomes available. We need to support people in that journey, because bringing more of what’s going on in the mind to awareness can be a very helpful development in a person’s life. Jon Kabat-Zinn: We often relate to our thoughts, whether they’re intensely negative or not, as a reliable statement of the truth. When you’re angry, everything can seem threatening or annoying or inadequate. You believe what your thoughts are telling you. Mindfulness of thoughts allows you to be aware of a thought or strong emotion as a kind of a storm in the mind or an event in awareness. Once you see it as an event or a storm, it no longer has the same power over you. Depression, which is a major concern for patients, is to a very large degree a disease of disregulated thinking. There’s a lot of evidence that mindfulness can actually help you develop a whole different relationship with the stream of negative thoughts called depressive rumination. Mindfulness has profound health implications for depression and also for anxiety disorders. Susan Bauer-Wu: It’s important to emphasize that noticing negative thoughts through mindfulness is not merely a passive process. Noticing the thoughts allows you to take action. You gain the insight and then you can do something about it. Jon Kabat-Zinn: Yes. The real meditation practice is your life and how you conduct it from moment to moment. Mindfulness helps you to take wise and discerning action, which is vitally important if you want to participate in your own healing process.
How Mindfulness Can Keep Us Healthy
Barry Boyce: What role can mindfulness play in prevention? Susan Bauer-Wu: I see three overarching areas where mindfulness aids in prevention: stress reduction, early diagnosis, and making healthy lifestyle choices. We know there’s a clear association between stress and illness. Acute illness, such as an upper respiratory infection or gastrointestinal irritability, is often exacerbated or triggered by stress. We know that mindfulness and related interventions reduce stress reactivity and make one less prone to developing these acute illnesses and infections. There are many studies supporting this effect, including one that Jon was involved in that showed increased antibody levels after mindfulness practice. In terms of chronic illnesses—ranging from cancer to cardiovascular disease, diabetes, and autoimmune disease—all of them have an inflammatory component, and inflammation and stress are absolutely associated. We’re showing through studies that mindfulness practices have an impact on inflammatory processes in the body. Conceivably, if you begin these practices earlier, you may be able to prevent some serious chronic illnesses associated with inflammation. In terms of early diagnosis, many people are not really in tune with their bodies, so they don’t notice when something’s wrong. Their body might be alerting them to something that needs to be checked out, but they’re not really paying attention to their way of being and what’s happening in their body. With mindfulness, they might notice it sooner, when it could be diagnosed at an earlier stage. In terms of healthy lifestyle choices, we can think of Dan’s analogy of dropping the gun. The gun could be a cigarette, another piece of cake, or working to the point of fatigue. Mindfulness can help you notice what the body needs and help you make good lifestyle choices. So in all of these ways, mindfulness can help to prevent illnesses down the road. Daniel Siegel: In addition to what it can do for the body, the mindful way of being supports a healthy mind and more empathic relationships. Those three—body, mind, and relationship—are the three major dimensions of the human experience that an integrated health care ought to be concerned with. Self-compassion and compassion for others are enhanced with a mindful way of being. These are very helpful for someone undergoing treatment, which is a process involving relationships with family members, friends, and colleagues, as well as caregivers and health administrators. Barry Boyce: How can mindfulness help in the diagnosis and treatment phases of illness? Susan Bauer-Wu: In the early phase, after someone is diagnosed with serious disease, there is an intense period of uncertainty. Of course, there is uncertainty throughout the whole trajectory from diagnosis through treatment and cure or palliative care, but at the beginning there are so many questions in people’s minds. It’s very common for the mind to jump to the worst-case scenario and spin a whole story of what’s going to happen. Mindfulness practice helps to ground people in what is true for them right now. It helps them break out of the story, to be more centered and less overwhelmed. It also increases their ability to communicate effectively with their caregivers, and helps the caregivers communicate better with them. During the treatment phase of cancer of radiation, chemotherapy, or surgery, there is a whole host of physical symptoms ranging from pain to nausea to itching to diarrhea. Body–mind awareness practices help people ride the waves of these symptoms, which are constantly in flux. Jon Kabat-Zinn: One of the reasons our health care system is breaking down is that we need more participation from the people who are suffering. Mindfulness can help you take a more active role in your health and healing. You are not a machine being taken to the shop for a repair or a tune up. It’s best if you can begin participating in your own health care as early as possible. Starting in childhood by learning mindfulness practices in school would put people on the road to a much more healthy relationship to their body and their emotions. That’s much healthier than the default mode where you just hope for the best and treat the body more or less as an automobile that you drive into the hospital for repairs when it breaks down. Your participation in the process is important for many reasons. In addition to awareness of your lifestyle and the state of your body and mind, as Susan and Dan were talking about, once you have been diagnosed it’s important to be able to negotiate with your doctor about treatment options. There are so many potential pathways you can go down, and you need to have as much agency as possible in that situation. For one thing, it brings a certain peace of mind when you’re an engaged participant as opposed to a passive recipient of treatment. This speaks to an entirely different way of practicing medicine that recruits the internal resources of the patient in the treatment process. That’s what MBSR is designed to do. There is now more than thirty-one years of evidence that the program can make a remarkable difference in people’s relationship to their illness and how it unfolds. If you go into radiation, chemotherapy, or surgery with greater awareness and mindfulness, that will make a huge difference. Also, when you’re more accepting of what’s going on in the present moment, you bring less resistance and can be a full participant, not just a recipient of radiation and chemotherapy. Sometimes you even need less anesthetic if you’re being mindful. Daniel Siegel: It’s very easy to be in denial about a change in your body, whether it’s a change in intestinal functioning, a lump in the breast, or irregularity in breathing, all of which might indicate the onset of disease. Many people avoid going to the doctor even for a regular check-up for fear of what they might find out. When we operate on auto-pilot, we tend to avoid things that might be distressing. One of the elements of research on Mindfulness-Based Stress Reduction that I find most impressive is the work that Richie Davidson and Jon have done showing that even after one eight-week MBSR course, a “left-shift” has been noted, in which the left frontal activity of the brain is enhanced. This electrical change in brain function is thought to reflect the cultivation of an “approach state,” in which we move toward, rather than away from, a challenging external situation or internal mental function such as a thought, feeling, or memory. Such an approach state can be seen as the neural basis for resilience. With a mindful way of being, you’ve developed your skill to stay present for what you might otherwise try to escape. From that point of view, diagnosis would be enhanced, because denial would be overcome. If you think about it, this is the mind doing what is most helpful for mind and body. Ignoring is maladaptive. Also imbedded within the mindful way of being is the sensory mechanism we call “interoception”—being aware of your internal bodily state. An increased capacity for interoception correlates with activity in a part of the brain called the right insula, which is in the middle prefrontal area we discussed earlier. This area has been shown to be activated by mindful awareness practices. In addition, two studies out of Harvard and UCLA show structural changes in the right anterior insula suggesting that the regular practice of being mindful leads to changes in the structural connectivity within the nervous system that would indicate an increase in interoceptive ability. Jon Kabat-Zinn: We did a study on people with psoriasis, a skin disease that is an uncontrolled cell proliferation in the epidermis. We demonstrated that the skin of people who meditate while they’re receiving ultraviolet light therapy clears four times faster than in people who were getting the ultraviolet light by itself. That’s one example of a study suggesting how present-moment awareness can make a profound difference in the healing process. Since psoriasis and basal cell carcinoma have kissing-cousin genes in common, maybe it’s possible for the mind to regulate in some way or other the unfolding of even an oncogenic process. We just don’t know, but it certainly would be worth doing studies on that.
Mindfulness for Caregivers
Barry Boyce: We’ve been discussing mindfulness and health from the perspective of the patient. What role can mindfulness and awareness practices play for caregivers? Daniel Siegel: There are indications that mindfulness practices can be very beneficial for doctors, nurses, and other kinds of caregivers. A study by Krasner and Epstein showed that teaching primary care physicians mindfulness practices reduced burnout and maintained empathy. Work by Shauna Shapiro on medical students shows that teaching them mindfulness practices increases their capacity for empathy, and an empathic clinician can have a powerful effect on patient well-being. A study performed at the School of Medicine and Public Health at the University of Wisconsin–Madison showed that health care practitioners who are empathic seem to be able to reduce the duration of the common cold in patients and boost their immune systems. When I was being trained as a physician, we weren’t taught about things like listening or empathy. Even when you have empathic medical students at the start, by the time the socialization experience of medical school is done with, much of it has been wrung out of them. Mindfulness could serve as an antidote to the incredible pressures that young clinicians are exposed to. They would benefit from learning skills to help maintain inner resilience, so they can maintain an open, compassionate, receptive place for their patients while also taking care of themselves. It’s like the instruction on the airplane to put on your own oxygen mask first and then help others put theirs on. We’re not giving oxygen masks to these clinicians. They’re understandably overwhelmed and depressed, and often feel hopeless. They don’t know what to do with their own emotional world, so they just withdraw. Everyone suffers because of that. Susan Bauer-Wu: I heartily agree. And I would add that their own health suffers under the strain. When nurses get burned out, they often get sick and can’t show up for work. That becomes a burden to the health care system. Professional caregivers are also less attentive when they’re sick and burned out. Errors occur and overall safety decreases. Patients are put at risk and costs rise. I believe that physicians and nurses who practice mindfulness are better diagnosticians. They are more sensitive to the subtleties of the whole person, not just the physical symptoms that the patient presents with at the time of the appointment. Some colleagues of mine and I have been doing work on the idea of “compassionate silence.” Mindfulness and compassion practices can help clinicians to be fully present and spacious in the very condensed time they have to meet with a patient. Physicians and nurses are not generally taught how to be okay with silence. When a clinician learns to hold whatever is arising, instead of trying to fix it, push it away, run out of the room, or ruminate about the next pressing thing they have to do, that’s profoundly healing for the patient. We also know that clinicians find those experiences some of the most rewarding as well. Jon Kabat-Zinn: Until very recently, physicians were not trained in how to be in relationship with another person who is suffering, who is frightened and doesn’t understand a lot of what’s going on. The potential benefits for both the patients and the physicians of cultivating that kind of empathic presence and silence—and perhaps embodying silence as a way of being—is unbelievably important. It’s also helpful for doctors to have the humbleness to know that they can’t immediately fix everything. There are lots of things that cannot be fixed in medicine. While it would be wonderful if there were more cures—and more research should definitely bring more cures in the future—healing is always possible, even without curing. If we recruited our patients as participants in fostering greater health and well-being, while coming to terms with whatever illness they may face with self-compassion and wisdom, it would cost the system a lot less money. You wouldn’t be throwing fixes that aren’t actually going to work at people who really don’t need them. But our system continues to do that out of a kind of desperation. It would make an enormous difference if mindfulness were made available at the wide mouth of the funnel, so to speak, before people wind up with a serious condition which requires surgery or a long hospital stay. Our hospitals and medical centers have the potential to become centers for integrative health care. If patients and their doctors have access to mindfulness training, it can revive the sacred dimension of the doctor–patient relationship based on the Hippocratic principles. It can move treatment more in the direction of healing the whole person rather than fixing body parts. The patient would be engaged as an important part of the process, doctors would be happier, nurses would be happier, and hospital administrators would be happier. It would cost a huge amount less. Daniel Siegel: Mindfulness is a part of a much larger frame that society has to move to: embracing the importance of our relationships with one another and seeing that the mind, though it’s not measurable like physical things are, is actually a real entity whose workings have monumental effects on the shape of our world—physical and otherwise. From a scientific research standpoint today, there’s much more support for putting understanding of relationships and mind on an equal footing with understanding the workings of the body. I see it becoming a fundamental part of how clinicians are trained, and I see a new unifying vocabulary emerging that will allow us to talk about subtleties that were left unexamined in our previous ways of talking about and practicing medicine. We now have worthwhile research results to present to a scientifically hungry medical student population. We can show them that these aren’t “soft things.” They aren’t elective, optional concerns. The dynamics of the mind and relationships with others are fundamental to what it means to be human and what it means to bring healing into the world. © Jon Kabat-Zinn, Ph.D., is the founding executive director of the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, and creator of the famed Mindfulness-Based Stress Reduction program. He is the author of several bestselling books, including Full Catastrophe Living; Wherever You Go, There You Are; and most recently, Mindfulness for Beginners: Reclaiming the Present Moment―and Your Life. Susan Bauer-Wu is a clinical researcher, educator, mindfulness practitioner and teacher. She is a professor of nursing and formerly the Tussi and John Kluge Professor in Contemplative End-of-Life Care at the University of Virginia School of Nursing and Adjunct Faculty in the Department of Religious Studies and member of the directorate of the Contemplative Sciences Center at the University of Virginia. Daniel Siegel, MD, is a clinical professor of psychiatry at the UCLA School of Medicine. He is director of the Mindsight Institute and co-director of the UCLA Mindful Awareness Research Center. He is the author of many bestsellers including The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being, and Mindsight: The New Science of Personal Transformation, and Brainstorm: The Power and Purpose of the Teenage Brain.
