Mindfulness Practices and Transformative Mindfulness: Medical Applications

Piero Dolara Professor of Toxicology, Department of Pharmacology, University of Florence, Florence, Italy. E-mail: piero.dolara@unifi.it Abstract Mindfulness Practices are techniques originating from Oriental religions, introduced to the West for nearly a century, but only recently accepted by enlightened personalities in the medical profession. Experimental research on the effects of Mindfulness Practices has produced particularly interesting results in the field of neuroscience, where neuroimaging has documented profound variations in the cerebral functions during meditation. This is likely the basis of many of its medical effects. Mindfulness practices are very effective in the control of pain, since they interfere with the neuronal transmission of painful stimuli and reduce unpleasant emotional components associated with pain in the central nervous system. Mindfulness practices, led by an experienced teacher, begin with breathing exercises (Anapanasati), followed by a “Body Scan”, in which the subjects are guided to observe and later may draw on paper the images of the principal vital energy centres. Problematic areas are usually identified by strong colours and strange shapes. During sessions of “Transformative Mindfulness”, a full acceptance of the problematic areas is induced associated with a strong desire of self healing, leading to a reduction of symptoms and, at times, to a partial or total cure of the disease. The application of Mindfulness Practices is manifold: cardiovascular diseases, metabolic syndromes, hypertension, psoriasis, psychiatric diseases, migraine headaches, epilepsy, depression, bipolar disorders and drug addiction. In many clinical situations the effects of Mindfulness Practices are interesting, but anecdotal, and require further confirmation. As a whole they offer new therapeutic approach which deserves to be studied with modern methods in controlled, double blind, randomized clinical trials. Introduction Mindfulness Practices are techniques which focus on mind control that originate from old Oriental philosophies and religions. Although they have been introduced to the West for nearly a century, their therapeutic applications have become of scientific interest only in the last few years. Without even considering the numerous popular press reports on this topic, by now there are about 1,500 articles published in international scientific journals regarding the therapeutic effects of meditation. In this field a branch of the U.S. National Institute of Health (the National Centre for Complementary and Alternative Medicine, http://nccam.nih.gov/) supports specific research and programs for the education of medical and paramedical personnel. In Canada, Australia and the United States several health institutes use meditation in their alternative therapy programs. Jon Kabat-Zinn is the director of one of the most famous active centres in this field: the Stress Reduction Unit of the Clinical Center, University of Massachusetts, Boston, U.S.A (http://umassmed.edu/behavmed/faculty/kabat-zinn.cfm). Kabat-Zinn was the first to form a group of healthcare personnel that uses “Mindfulness practices” for therapy of mental disorders, neurological and cardiovascular diseases and chronic pain control in a large University hospital. The promising results are published in many scientific journals.1 Shinzen Young works in California and is also well known for using meditation techniques against chronic pain. Shinzen Young (http://www.shinzen.org/) has written fewer scientific articles in medical journals, but many books and articles in the popular press on this subject, and has made a collection of wonderful CDs on long distant teaching of meditation techniques. Meditation techniques are not only used in famous clinical centres but also in numerous medical contexts, as shown by the results published in scientific journals (750 articles in Medline in just the last seven years http://www.ncbi.nlm.nih.gov/pubmed/) Brief Historical Background One of the main origins of the teachings and beliefs described by the words “Mindfulness Practices” is linked with one of the most tragic events of the last sixty years: the Chinese invasion of Tibet that led to the diaspora of hundreds of thousands of people and to an attempted cultural genocide by the Chinese government. The origin of Tibetan Buddhism traces back centuries after the death of its founder (Siddhartha, 5th century B.C.),when religious men and philosophers migrated from India to Tibet and other east-Asian countries. In Tibet, a number of practices and doctrines were developed in complete isolation and in harsh environmental conditions. Before the recent Chinese invasion the Buddhist Tibetan beliefs were handed down both in orally and in written religious treatises that were kept in monastic libraries. Every year, for more than ten centuries, all the most influential monks were invited to write essays, the best of which were transcribed and conserved, while the worst were “tied to the tail of a dog”, a habit that should be applied to scientific publications also today. The dialectical process, which was widely cultivated in the Tibetan monasteries and the philosophical texts, were articulated and as complex as holy texts of the Christian or Jewish religion. These were studied and discussed with an undogmatic approach which reminds us of the Socratic method and the debates of the early Christian Church Fathers. The Chinese invasion interrupted this original cultural process by killing, imprisoning and banning the monks, by burning their libraries and by persecuting their culture and ancient teachings. A few monks were able to escape to India with the, at the time, young Dalai Lama. The most important philosophical treatises of the Tibetan Buddhist tradition have been translated into English during the diaspora of the last 50 years, and this ancient culture has been diffused around the world by the surviving master teachers, called Lamas, in seminars and retreats. The Dalai Lama is the most famous representative of this older generation of religious thinkers, a generation that unfortunately is now aging and dying. As happens to all diaspora refugees, the Tibetans had to adapt to new environments and interact with different cultures and values, both in their community in exile in India and in the rest of the world. What happened in Tibet may remind us of the dispersal of the Hebrews and Christians from Palestine after the destruction of Jerusalem and the Reign of Judah, in the 1st century A.D. When Christ's followers, whether Hebrew or not, had to take refuge in Roman cities, they adapted the teachings of early Christianity to the Roman Empire's culture and tradition, and started using the languages that were most common at the time in the Mediterranean lands. This explains why the Gospels were not written in Aramaic but first in Greek and then in Latin. The originality of Tibetan Buddhist philosophy and mental awareness techniques is partly due to the fact that the Tibetan intellectuals were geographically and culturally isolated for more than ten centuries. On the other hand, this particular Buddhist culture has successfully spread throughout the world after the recent Chinese invasion because the most important classic works and teachings by the Lamas have been translated, or written, in English. The Tibetan Buddhist philosophical view shares some beliefs with other important religions (the immortality of the soul, the transmigration of all living beings etc.) but it also embraces principles that can have universal applications in different cultures. The core of these applications, rooted in ancient Indian philosophies, is the practice of mind control (commonly known as “meditation technique”) and the control of mental interactions using codified exercises. These applications have now been used in medicine and psychology. They are similar in a way to the ascetic practices of Christian Saints, which have been slowly abandoned throughout the centuries in western cultures. During early Christianity ascetic practices were seen as the way of obtaining holiness and eternal salvation. In Tibetan Buddhist culture, individual salvation is achieved by following a “path” which purifies and frees the mind from pain and negative passions (envy, malice, greed). In the “path to liberation” great attention is dedicated to mind control techniques. These techniques are achieved by codified practices, taught by Lamas and then by laymen wherever there are cultural and religious activities belonging to this tradition. The Dalai Lama in recent time has also encouraged research on the neurological effects of meditation and their potential applications in medical contexts. This is why he was invited to The Neuroscience Meeting in 2005 as the “Keynote Lecturer”. (http://www.npr.org/templates/story/story.php?storyId=5008565) In an interview that took place after this meeting, he said “If science demonstrates that a Buddhist teaching is wrong, then we will change that teaching”. This is certainly an exceptional (and encouraging) stand considering it was taken by the leader of one of the world’s most important and ancient religions. Some therapeutic results of Mindfulness Medical research on Mindfulness techniques has achieved especially interesting results in the field of neuroscience, where neuroimaging methods have documented variations in the cerebral functions in people that practice meditation.2,3 In practical medicine, meditation is mostly applied to pain control and support therapies for patients with cardiovascular diseases. Concerning the analgesic effect of meditation, a study has recently proved through imaging techniques on healthy volunteers that there is a 40-50% reduction in the thalamus and the prefrontal cortex of the response evoked by peripheral activation of pain pathways using meditation techniques.4 Still the application of techniques of “Mindfulness” to pain treatment is based not only on neurophysiologic effects that have not been documented until recent years but also on mental modulation of the pain syndrome. In this case, the peripheral component (the activation of that part of the nervous system which processes pain information, known as the “nociceptive system”) is always associated with activation of numerous cerebral areas that “enrich” the pain sensation with important emotive components. Pain is essential to maintain the integrity of the organism and the stimulation of the nociceptive fibers (the fibers that carry pain signals from the periphery to the brain) activates a series of emotions and behavioural reactions with the aim of averting the harmful stimulus. So pain is an authoritative, if unpleasant, adviser and not a displeasing and useless nuisance. Some of the typical unpleasant emotions that follow physical suffering (anxiety, anguish, denial, depression) have multiple effects on the nociceptive system. Transformative mindfulness can control the psychological components of pain, whereas only the nociceptive system is the target of analgesic drugs. It is useful to remember that morphine and its synthetic derivates are powerful analgesics because they not only affect the transmission of the nervous impulse but they also interact with the emotional component of pain (they do not erase the pain sensations but they make them bearable, as the old pharmacology textbooks say). Transformative mindfulness techniques interfere with the transmission of the nociceptive impulse4 like morphine and control the emotional component associated with the pain sensation.5 A possible explanation for this double effect can be found in some observations of the 90s (which require further confirmation) where meditation techniques have proven to increase the level of circulating endorphins and corticotrophin releasing factor.6,7 Whichever way these mechanisms work, the clinical experience of the medical centres that use mindfulness methods show that these techniques help many patients to control pain. The application of meditation techniques in the cardiovascular sector is widespread in the USA and Canada and clinically controlled research is beginning to appear in the international literature. One of these articles, recently published, demonstrates that patients with coronary diseases8 and metabolic syndrome 9, thanks to the use of meditation techniques, obtain a considerable reduction in arterial pressure 10, resistance to insulin11 and variations of cardiac rhythm.12 Interesting results were obtained in dermatological diseases with psychosomatic causes such as psoriasis.13 In the sector of cardiovascular pathologies, documented data of the beneficial effects of meditation is relatively copious, but not of high scientific quality (130 articles published in Medline up to now), and recently this was the subject of an authoritative article in an American Medical Journal.14 This publication underlined the need for further clinically controlled studies. As stated before, in addition to pain control and cardiovascular diseases, meditation techniques have been applied to many other different fields (psychiatric diseases, migraine headaches, epilepsy, depression, metabolic syndrome, hypertension, bipolar disorders and drug addiction). In many cases reported data on meditation effects are interesting but anecdotal and require further confirmation by clinically controlled trials. The demonstration of the multiple alleged medical effects of meditation understandably perplexes some western physicians, who are used to not trusting therapies that “resolve” too many problems. However, the human nervous system, with 100 billions of cells and 10,000 billions of synapses, is a complex machine of which we still have imperfect knowledge. Meditation techniques control the functioning of this machine on many levels and this necessarily involves various biological effects and influences many pathological processes, especially if associated with a stress component. The best scientific attitude to maintain about meditation techniques, or other “unconventional” medical practices, is, on the opinion of the writer of this article, to accept the data when scientifically documented with solid methodological approaches and when obtained in clinically controlled studies that include placebo treatments (double-blind, placebo-controlled trials). A practical course in “Trans-formative Practice” in Florence, Italy “Transformative Mindfulness” methods are still imperfectly known in Europe in general and in Italy in particular. This explains why in 2007 we have organized in the Department of Pharmacology of the University of Florence, a series of seminars on pain and emotion control. Some other Italian Universities had similar seminars with the participation of John Kabat Zinn. The seminars in Florence were held by an experienced teacher now practicing in Canada and in other countries around the world (Dekyi-Lee Oldershaw (http://dlo-consulting.wordpress.com; http://word.press.com/contact). She has trained professionals in “Transformative Mindfulness” in different countries and has organized, a rehabilitation program for patients with cardiovascular diseases in Australia. At the Toronto McMaster University Medical Center (one of the most important Canadian research hospitals), she has consulted their Palliative Care Consultation Team and these methods have also been used to compliment treatment of multiple sclerosis. It might seem strange that a Pharmacology Department in a public University would host activities like “Transformative Mindfulness”, because the main task of pharmacologists is to discover new drugs and explain how they work. But pharmacology is an open-minded science that accepts input from many disciplines, and many pharmacologists are not afraid of trying alternative approaches to drug therapy, although they are confident of the status of therapists with chemical substances, which, after all, have been the mainstay of medical treatment in the last 2,500 years. Besides, pain is one of the main research objects of neuropharmacology. Consequently, Transformative Mindfulness techniques can become an additional contribution, that can complement drug-oriented pain treatments by enhancing the effect of chemical analgesics and giving physicians further therapeutic possibilities when drugs do not work or do not work anymore (and this is often the case in chronic pain). Principal forms of transformative mindfulness There are a number of Transformative Mindfulness techniques. They are not completely standardized, and while they are relatively simple, they are not banal. These techniques can be taught by experts to specialized healthcare personnel. The Boston Centre of Kabat-Zinn accepts patients in mindfulness meditation programs only if they are willing to undergo at least one hour a day of practice for a minimum of six months. In fact some of these practices do not have any effect if not done on a regular, daily basis. They may encounter difficulties, barriers and cultural prejudices, since the common values of our society encourage behaviour that is the opposite of what meditation techniques offer: extroversion vs. introversion, agitation vs. mental tranquillitty, distraction vs. concentration, aggression vs. love, ego-centricity vs. empathy. On the other hand, the presence of a disease often rings a bell that changes our way of dealing with life’s difficulties. The American and Canadian experiences have proven that Mindfulness also works when practiced by people in stressful occupations such as corporate chiefs, lawyers, etc. Presumably these techniques could also be efficacious in European countries, provided that individuals are highly enough motivated to want to learn them. The first aims common to most Mindfulness methods are the attainment of a state of inner peace, the control over any distractions of the mind and the capacity to focus and refine one’s attention. This is obtained through variations of the “Anapanasati” techniques, a Sanskrit term where “anapa” means breathing in and out and “sati” means awareness. The position assumed during these practices has to be comfortable, with the vertebrae of the back vertical and aligned in order to achieve a relaxed posture (this position in western individuals is more successfully obtained when sitting in a chair with a straight back). After having assumed this posture an instructor teaches the pupils how to control the flow of their minds, while focusing their attention on breathing and forcing away the constant whirl of thoughts that pursue us in every moment of life. The Anapanasati instructions are apparently simple, but learning them thoroughly requires many years of practice, since their level of difficulty progresses in terms of complexity and mental control. For medical applications it is sufficient to know about the first levels that can be learned in a few sessions (such as techniques which control breathing) and focusing one’s attention on simple body images. Breathing is a simple rhythmic activity. Intense attention focused on this rhythmic process induces a synchronization of cerebral activity that controls the intellect and emotions. Anapanasati is therefore an activity very similar to music, rhythmic exercise, ritual prayers, but more powerful since it is conscious and directed. With experience it becomes a mental attitude which the user can call upon when needed to induce sleep in any environment, to calm one’s emotions during situations of conflict and stress, to control one’s cardiovascular system (cardiac rate and blood pressure) and to reduce and control pain. Specific to Transformative Mindfulness methods, the initial focusing meditation phase of breathing is followed by the awareness practice known as “Body Scan”. The instructor leads the class through the observation of the principal vital organs and energy centres: the feet, the base (legs, hip-joints and rectal area), the sacral or pelvic area (genitals, bladder, lower intestine), the solar plexus (stomach, intestine, kidneys), the heart (heart, lungs and circulatory organs), the throat (throat, thyroid, trachea, mouth, teeth), the head (eyes, ears, pineal gland, brain), and, finally, the “crown” or area directly above our head (central nervous system, our connection to more inspired energy, our “soul”, our body energy, a bit like the halo of the Saints in medieval paintings). Each participant is then invited to draw or document information or images related to each of these areas on a piece of paper using pencils and colours and to identify his own “problematic” areas. While healthy patients/participants have no or few problematic areas, those with disease usually mark these areas with strong patches of darker colour and shapes signifying challenges. The Body Scan technique helps identify and characterize these problematic areas (dimension, colour, weight, pulsation) next to the perfectly healthy ones. If the Body Scan is repeated every few days, it can help the patient to visualize the changes that happen in the different vital organs and areas of their body and act on them on a second level, the level of Transformative Mindfulness or mental transformation. In this second phase the visualization of the different areas, and especially the problematic ones, is followed by a series of mental procedures: the full acceptance, without judgment or critical observations, of the problematic area and the request for help (the demand to augment the spontaneous processes of recovery through the help of the other functional healthy centres, or for religious believers, by supplicating the intervention of a superior entity). Finally, the patient must release preconceived expectations of particular results, observe and allow resultant mental and physical changes. Reinforcement of his/her belief in the success of the process of recovery grows as positive results are observed either mentally, physically or both. This procedure can have better therapeutic results if the patient is directed by an accepting, compassionate leader, mentor or practitioner for whom they have respect, who possibly has a deep understanding of meditation techniques. Anecdotal results suggest that the application of these techniques, first introduced in a group and then continued privately, can solve many pathological syndromes. Through the use of various mindfulness methods, good results have been achieved on fibromyalgia15, irritable colon16, migraine17, depression18 and bipolar syndromes19. Unfortunately, as stated before, controlled clinical studies on adequate numbers of patients are still few. In patients with chronic pain, the “Body Scan” practices help to convince him/her that, as long as there is life, every pathological problem acts only on some vital organs and not all of them. Regardless of the disease, the localized problem can become compatible with an acceptable quality of life. In fact, except in rare cases, Body Scan practices can produce a total body image where the healthy vital organs prevail over the problematic ones. Specific practices exist for pain, based on the experiences of the Lamas, who usually have a great tolerance to physical suffering and discomfort. The first of these practices is the acceptance and interpretation of pain as a signal separated from its emotional contents. The second one is a critical analysis of peripheral pain sensation (location, density, colour, temperature, time fluctuation). The third one is the mental dissociation of pain from its associated emotive components (impatience, fear, anger, sadness). These practices, begun with the help of a teacher and then repeated privately, in the majority of patients start a process of mental control of primary pain sensations and permit the reduction or elimination of most adverse emotional reactions. These procedures must be supervised by an expert, but they can also be followed through recorded vocal instructions and can be associated (but not necessarily) with the use of classical pain-killers with activity on the peripheral or central nociceptive functions. Future prospects “Transformative Mindfulness” techniques are offering new therapeutic approaches to medicine that deserve to be studied with modern methods of clinical and instrumental diagnosis in controlled clinical trials; after this verification they will be probably accepted in most areas of medicine as an useful supplement to classic pharmacological therapy. On this ground it would be very useful if official western medicine would immediately draw physicians’ and patients' attention to these techniques with special courses and, if possible, with clinically controlled research. For this purpose many clinical centres and Universities are organising Mindfulness courses in Europe, Asia and America and some scientists are directing controlled clinical studies. As scientists, doctors, health practitioners and patients, we should use any occasion to express our gratitude to the Lamas who have invented, improved and diffused their techniques of meditation and mind control all over the world. Florence, Italy October 21rst, 2008 (English translation by Mary Forrest, Teodora Dolara and Tommaso Poggi) References 1)Ludwig DS, Kabat-Zinn J. Mindfulness in medicine.JAMA. 2008 Sep 17;300(11):1350-2. 2) Lutz A, Brefczynski-Lewis J, Johnstone T, Davidson RJ. Regulation of the neural circuitry of emotion by compassion meditation: effects of meditative expertise.PLoS ONE. 2008 Mar 26;3(3):e1897. 3) Brefczynski-Lewis JA, Lutz A, Schaefer HS, Levinson DB, Davidson RJ. Neural correlates of attentional expertise in long-term meditation practitioners. 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