Taking Charge of Your Health

JOHN NEMEC: Clinical care and research. What we’re going
to do is we’re going to have two papers and then there will be a break for lunch for about
90 minutes. So there’ll be a nice break there and then we’ll continue again in the afternoon. Without further ado, the first speaker is
our own John Schorling who is a professor in the school of medicine and is the head
of the Mindfulness Center at the medical school. He has been heavily involved in that practice
and that tradition for many many years. He’s going to give us slides and a presentation
entitled The Origin and Impact of Mindfulness in Western Medicine. Welcome. JOHN SCHORLING: Thank you, it’s good to be here. This is a
great event, I think, bringing together, as was said, four schools from the university,
as well as outside speakers. I think of this talk, really, as follow up
on some of Fred’s comments about where we are going in bringing some of these Eastern
traditions into Western medicine. We are not really going to have time to talk
about the basic question that he posed about what is the role of taking these traditions
– the practices from these traditions – into Western medicine. We’re not really going to have time to talk
about that. Although, I will say that it’s definitely a conversation that is ongoing
at the Contemplative Sciences Center. I use the term Western medicine in the title
of this talk, but what I’m really referring to is, that, the other term we use, is allopathic
medicine. The type of medicine that’s practiced in the
health center here at UVa. There are other Western medical traditions
besides that, but that’s really what I’m going to be talking about. So, just as an overview, I am going to talk
about mindfulness, in particular, Mindfulness Based Stress Reduction. When I talk about mindfulness today, it really
is from the vantage point of the specific type of mindfulness training called Mindfulness
Based Stress Reduction. Kim Pemberthy, who is following me, is going to be talking about
Mindfulness Based Relapse Prevention, which is another application of mindfulness. It comes from the same basic background, but
it’s a little bit different than Mindfulness Based Stress Reduction. I’m going to talk briefly about the health
effects of Mindfulness Based Stress Reduction. Then a little bit about burnout and the impact
of mindfulness training among healthcare providers. Then finally a quick overview of some of the
potential mechanisms for the effects of MBSR. MBSR is the acronym we use for Mindfulness
Based Stress reduction. I just want to give a brief overview of the
history of the use of meditation in healthcare in the United States. It really began – it
began a little bit before this – but the big movement to bring meditative practices into
medicine really began with Transcendental Meditation, in the 1960’s. The first publication by RL Wallace in 1970
– and it wasn’t a bad start – the first publication about Transcendental Meditation and it’s effects
was in Science (Zotero ID: 8ABE9PBP ), which is the premier journal in the sciences, – one
of the premier journals in the sciences in the the world. So this is a pretty auspicious start, actually,
for the study of meditation. And then
Herbert Benson actually worked with RL Wallace on Transcendental Meditation but then he adapted
what he called The Relaxation Response (Zotero ID: 9JMVQ2CX), secularizing it even more and
getting rid of the word meditation completely. Herbert Benson was a cardiologist at Harvard
so this was a movement from RL Wallace, as a physiologist, but he actually worked within
the Transcendental Meditation community. Herbert Benson was a cardiologist at Harvard
and really brought a different level of respectability to the practices. Then in 1979, Jon Kabat-Zinn developed Mindfulness
Based Stress Reduction and that really led to the explosion of interest in mindfulness
over the past 30 some years. There’s the definition – there are a number
of definitions of mindfulness. The one that’s used primarily in the practice that is associated
with Mindfulness Based Stress Reduction is: “paying attention in a particular way, on
purpose, in the present moment, and non-judgmentally.” J.Kabat-Zinn. [sic] Wherever You Go, There
You Are, 1994 (Zotero ID: 4J84FEQ3) So there are really three aspects to this. It’s paying attention to present moment experience. Doing it intentionally. And bringing a spirit of non judging to doing
it. So what is Mindfulness Based Stress Reduction? I just wanted to give – because I’m going
to be talking about it a lot – I wanted to give a brief overview. It’s an eight week course. There are weekly
two-and-a-half hour sessions. One all day silent retreat. The components that are taught include: sitting
and walking meditation, yoga and the body scan, as well as discussions of various forms
of stress and coping strategies. One of the things we talk about a lot in this
training is both formal practice, that is sitting down and doing breath meditation for
a period of time, and informal practice – that is where we actually take what we learned
from doing the formal practice and bring it into the rest of our lives. We ask students who take these classes to
do 45 minutes of practice six days a week. So where did this come from? It’s actually quite interesting. And I do
– another aside, before I talk about the genesis – the reference that’s listed at the bottom
of this slide (Kabat-Zinn J, Contemporary Buddhism V12, 01, 2011 (Zotero ID: CVFEBXEQ).
This volume of Contemporary Buddhism in 201, actually is entirely devoted to the intersection
between mindfulness and Buddhism. And really, a number of the authors address
the question that Fred had raised, about: what is this all about, taking the practices
from these traditions and applying them to Western medicine? So, if you’re interested in that topic, I
would refer you to this – the entire issue of this journal was devoted to that question. So, Jon Kabat- Zinn developed MBSR in 1979.
The story of where it came from is actually, as you can see it in the second point there,
is actually quite interesting. He had a vision at a vipassana retreat at the Insight Meditation
Society. On the tenth day of a 14 day retreat he was
sitting in his room and it came to him, in it’s entirety. And it’s existed, essentially,
the same way ever since. He wrote it down after that retreat. He began
teaching it at the University of Massachusetts the following year and the rest is history. His motivation, as he says in this article,
was “to relieve suffering and catalyze greater compassion and wisdom in our lives and our
culture.” MBSR has, primarily, Buddhist roots. And again
this is a quote from the same article from Jon: “MBSR was developed as one of a possibly infinite
number of skillful means for bringing the dharma into mainstream settings.” So even though MBSR is the secularized version
of these practices – Buddhism is never mentioned, explicitly, when we teach MBSR- it’s very
clear that it has strong Buddhist roots. Jon says – again – one more comment about
bringing these traditions into Western medicine – he talks about, not a decontextualizing
of these practices, but a recontextualizing of these practices. The principle influence is from Theravada
Buddhism, vipassana in particular, but there are also influences from Mahayana and Zen
traditions. In particular, the koan based dharma combat
of one of Jon’s principal teachers Seung Sahn where we have inquiry into the classes. Where
we, as teachers, spend a lot of time with students inquiring into the nature of their
practice and what’s arising for them. There are influences from yogic traditions
as well, very explicit in that we teach Hatha yoga poses as part of the mindfulness practice. The first publication on MBSR was in 1982:
An outpatient program in behavioral medicine for chronic pain patients based in the practice
of mindfulness meditation: theoretical considerations and preliminary results (Zotero ID: QIGENUXH). So there was one publication in 1982. One
or two a year till 1995. Almost 100 between 2000 and 2004. Over 400 between 2004 and 2009. And 800 in the last three years. There are now over 3,000 publications in the
last 30 years about – related to – mindfulness in health care. These are – this was mindfulness searched
in a healthcare database, not in the database of religious literature – this is solely in
healthcare. So now over 3,000 publications. So, in the remaining time, I’m going to give
you what I think are some of the highlights out of those 3,000 publications. So, first of all, just briefly, the health
benefits of Mindfulness Based Stress Reduction. A review and an analysis of multiple studies
was done, was published in the Journal of Psychosomatic Research in 2004 (Zotero ID:
XRZXTTM4). At that time there were 20 studies, including
seven randomized trials, which we consider to be the best type of study to do. They looked at both mental health and physical
health variables among patients with chronic pain and cancers – and CAD stands for coronary
artery disease. They found the effect size – 50 percent means
individuals who went through the course classes compared to people who didn’t – on average had a 50 percent greater improvement
in whatever they were measuring, whether it was stress or pain. People who went through the course did 50
percent better than the people who didn’t. In a more recent review, just a couple years
ago, of another 18 controlled studies, looking at psychological health in particular, showed
that individuals that went through this eight week course had decreased anxiety, decreased depression, decreased perceived
stress, increased positive affect – that means over all mood- increased self compassion,
and increased quality of life. So, significant evidence, now, of the potential
health benefits from these classes and these practices. I wanted to talk a little bit more about occupational
stress, which is one of my particular interests. Occupational stress is very common in a number
of professions including teachers, nurses, and doctors where the rates of burnout in
recent studies have exceeded 40 percent in all of those professions. What do we mean by burnout? When you hear the term burnout, most of the
time, especially if it’s related to a research study, it’s burnout measured by something
called the Maslach Burnout Inventory, which has three components. The first is emotional exhaustion, which is
just what it sounds like. Being emotionally overextended and exhausted by work. Coming
home at the end of the day and saying, oh man, I’m just drained, is emotional exhaustion. The depersonalization tends to follow emotional
exhaustion. That’s developing a negative, or cynical attitude, and treating others as
objects. One of the ways that’s manifested in health
care is when we start talking about patients as their diseases. That’s not always the case,
sometimes it’s just shorthand. So, if you happen to hear a healthcare provider
talking about someone this way, it doesn’t automatically mean they have burnout. But,
it often is an indicator. So, instead of saying Mrs. Jones, who had
the heart attack in room seven, we’d just say the heart attack in room seven, it’s just
the disease we’re paying attention to, not the patient. So, that’s the second stage of burnout. The third is a sense of low personal accomplishment,
feeling of incompetence, inefficiency, and inadequacy. Feeling like what we are doing
doesn’t have a purpose, it’s not meaningful any more. So, those are the three components of burnout.
When we say someone has burnout we mean they score high on any one of those three things. It doesn’t mean all three. It could be just
one of them. So, a study done last year – published last
year- done by the American Medical Association – so, a random sample of physicians from across
the country, found among practicing physicians now in the United States, the burnout rate
is 46 percent. Almost half of all physicians in this country
now have one of those, have at least one of those characteristics that was on the last
slide. There are some specialties where it is over
half: emergency medicine, general internal medicine
– which is actually my field, I practice general internal medicine and palliative care – neurology,
and family medicine. So, of note on this slide are the two of the
three, primary care – principle primary care specialties in this country – general internal
medicine, and family medicine are on the list. As we expand health care, have this great
need for primary care physicians, it creates a potential dilemma for us. Medical students aren’t immune. Studies of
medical students over the past few years have also shown that their rates of burnout are
about 50 percent. That’s across all four years of medical school.
The rates go up about six months into the first year and remain high throughout medical
school. Although, even without any interventions,
a quarter of students who have burnout in one year it’s gone the next year. So, as a
result, there have been several adaptations of MBSR that have been developed for healthcare
providers. One was done at the University of Rochester:
Mindful Communication Program for Primary Care Physicians, which included aspects of
the Mindfulness Based Stress Reduction program that I meant. In this study they showed improved mindfulness,
decreased burnout, improved mental health status, increased empathy, and they followed
up with the people in their study for 15 months and they had decreased burnout 15 months after
the program. We’ve developed an eight week course here
that’s much more closely related to Mindfulness Based Stress Reduction. Which, essentially
is identical to MBSR, except for the last bullet point there – where we place significantly more emphasis
on kindness and compassion than in Mindfulness Based Stress Reduction. That’s, in part, because individuals that
go into healthcare and helping fields often have high standards for themselves and are
self critical. When things don’t go well and the outcomes
aren’t the way they hoped for, they can wind up blaming themselves a lot. And often don’t have a lot of self compassion,
don’t have an understanding of their own suffering, and a willingness, or an openness to addressing
their own suffering. I believe that before we can truly be compassionate
with others, we have to be compassionate with ourselves first. So, we really focus on self
compassion in this course. To date, 112 participants, 59 physicians,
53 other health providers including, nurses, psychologists, social workers and others. The first study I showed you from the University
of Rochester was all doctors. Our classes include doctors and other healthcare providers. These are the results. Improvement in overall
mental health of 25 percent, reduction in emotional exhaustion by 25 percent, reduction
in depersonalization by 25 percent, improvement in personal accomplishment by almost 10 percent. Our results, and those from the university
of Rochester, are essentially the same, they’re identical, or almost identical. So, these courses in mindfulness have shown
to have a benefit for physicians and other healthcare providers who are especially at
risk for burnout and work related stress.’ So why do we do this? When I say, this – why in the context of these
classes, in particular – why are we so self critical? Why do – and when you think about it, and
this is really one of the foundational principles underlying mindfulness practice – is that
it’s our thoughts that create so much stress. We spend so much time thinking about the future,
worrying about the past, and we are not paying attention to the present moment. Which again, the mindfulness definition is
intentional, present moment awareness, non judgmentally. So, the reason we now understand more of why
we do this really comes from – associated with this explosion of mindfulness research
in general – has been – much greater sophistication in neuroscience,
and really being able to understand, to a degree never possible before, the underlying
mechanisms of what’s going on in our brain. So, we’ve described, through neuroscience,
that we have this default state of narrative self reference, which is based on linking
subjective experiences across time. That means thinking about the past, worrying
about the future. We’re telling stories to ourselves all the time. There are certain parts of the brain that
light up when we do functional MRI studies. I’m going to talk about that more in a minute. The other thing we know about our brains is
the more we use certain pathways, the more robust they become. Our brains are plastic,
they’re changing all the time. When I went to medical school I learned that
our brains are pretty much fully formed and fixed by the time we went to kindergarten
and it was downhill from there. We know that’s not true anymore. Our brains
are constantly creating new connections and we have influence over those. So, I’m going to show a couple fMRI slides,
so I – just to describe what this is. Magnetic Resonance Imaging, even though they’re done
in radiology departments isn’t a x-ray. It’s actually a – a MRI machine is a giant
magnet. If you ever have laid in a MRI and heard the thunking it’s the magnet going. Hemoglobin, which is what carries oxygen in
the blood is affected by a magnetic field differently, whether it has oxygen or it doesn’t. So hemoglobin carries oxygen and it delivers
it to cells, and it’s used in the cells. So, using a MRI, we can measure when the oxygen
goes out of the blood, this is called the blood oxygen level dependent signal. Less
oxygen in the blood is an indirect measure of the areas of the brain that are more active. So, here is a fMRI, of people sitting in a
MRI, in the default condition of narrative self reference. So, just thinking about the
past, worrying about the future. These are the parts of the brain that light
up. In particular, the prefrontal cortex. This is at the front of the brain. This is
the skull. This is the front of the brain and this whole
big area lights up. Again, when I went to medical school, I learned a very reductionist
view of the brain, that there was a spot in the brain that took care of everything. At that point we would have thought there
was a narrative self reference point in the brain. That’s not true at all. Obviously, you can see it’s a whole network
that involves the thinking part of the brain and a few other areas. But this is the thinking
part of the brain, so basically this is just showing we’re thinking, we’re thinking about
things in this state. Experiential self focus is really mindfulness.
It’s paying attention to present moment experiences, of thoughts, emotions, and bodily sensations. So, in this study, they took people who had
been through an MBSR class, or those who hadn’t, and did the functional MRIs on them again,
and they showed differences in the brain. These blue areas are areas that were decreased
and the red, or the yellow areas, were increased. Then they looked at the correlation between
the areas. What’s important about this slide, really,
what the authors pointed out, was this little thing in here, which shows a certain part
of the PFC, or the prefrontal cortex, the central medial prefrontal cortex – that’s the area that was really lighting
up on the first slide I showed you – and the insula – which is the area, or the part of
the brain, where we really interpret emotion – is disconnected in people, or the connection
is reduced, in people who go through mindfulness training. That makes sense. When we get in this narrative
self reference, we have a thought, it causes worry, it stimulates the part of the brain
– the insula – which creates physical sensations and then we worry more and we get into this
cycle. What the authors thought, from this study,
was that mindfulness practice – and beginning to pay attention to present moment experience
– uncoupled the insula part of the brain from
the ventromedial prefrontal cortex, so we’re not so caught up in that cycle. So this, I
think, is a really significant study in that regard. So that was functional MRI, that was looking
at the function of the brain. There’s also structural MRI, which is what you’re used
to. If you have a normal MRI, it’s a structural
MRI. It’s looking at the structure in the body, not the function. So this is another study, before and after
a MBSR course, where they measured stress using a specific scale, then they looked at
the brain using regular MRI. They showed that the amygdala – which is the
part of the brain that is primarily involved in both fear based responses, strong emotional
responses, and memory – that not only was the function changed, but the size of the
amygdala was actually smaller. The amygdala is this tiny little part of the
brain right here. As stress went down, the size of the amygdala went down. So this gets back to what I was saying before,
not only does the function of our brain change, the structure actually changes. This was a really important study in showing
that a part of the brain, intimately involved with emotion, actually changes size after
only eight weeks of practice. Another thing I wanted to talk about was a
study we did here, looking at patients with palpitations. Palpitations are irregular heartbeats
that are disconcerting. This was done with a number of other people
here, Justine Owens and Peggy Plews-Ogan – from general medicine with me – and John Dent and
Randall Moorman, who are cardiologists. These were people who had disabling palpitations
without serious underlying heart disease. We randomly assigned them to Mindfulness Based
Stress Reduction immediately, or doing the course later. We measured heart rate variability, which
is a beat to beat variation in the heart measured in very tiny intervals. It’s not heart rate,
it’s the variability in rate between beats. It reflects the balance between the sympathetic
– which is the stress response part of the brain, fight or flight – and the parasympathetic
nervous system, which is associated more with relaxation. Low heart rate variability is associated with
stress and increased sympathetic hormones like adrenaline. It’s been associated with infections in premature
infants and with mortality in heart attacks. People who have this high adrenaline in their
body are more likely to suffer – more likely to die – after they’ve had a heart attack. So, first of all, in our study we showed – the
people who are in the MBSR group are in red and the other group, who didn’t take it, are
in blue. The blue folks had the same number of palpitations,
both the baseline after the class and four weeks later and you can see there was a significant
reduction in palpitations in the patients who had taken the class. Then we looked at their heart rate variability
and what this shows is that, one month after people finished the course, how much their
– this shows a greater reduction in palpitations. So if we’re going out here, people at this
end had more reduction in their palpitations than at this end. There was a strong correlation
with increased heart rate variability, which is decreased sympathetic tone. So, the mindfulness class is not only affected
their perceptions of the palpitations, it actually had an affect on their hearts. Then finally, there have been a lot of studies
that have looked at the immune response in patients, in individuals, with mindfulness
training. One of the things about all these studies
that I’ve talked with you about so far, is that the people who go through the mindfulness
training have been compared to people who haven’t. One of the big criticisms of a lot of this
literature is, well. if you take any group of people you get together two-and-a-half
hours every week, you talk about your problems, after eight weeks you’re likely to feel better
and have less stress. So it’s not that it’s anything unique about
mindfulness, it’s that people are just de-stressed because they’ve gotten together with folks
they’ve come to like, and they get to spend two-and-a-half hours with them every week. So, the people at the University of Washington,
and Richard Davidson’s group – which is probably now the preeminent group, for the United States,
looking at the neuroscience of meditation – they designed this Health Enhancement Program,
or HEP, which is the same amount of time as Mindfulness Based Stress Reduction, but doesn’t
involve any mindfulness practice. At the end of eight weeks the people who go
through this program have the same perceived reduction in stress as the people who go through
Mindfulness Based Stress Reduction. So, it causes the same reduction in stress,
so what this group wanted to look at was, okay it causes the same reduction in stress,
does it cause the same effect on the immune system, which other studies have shown for
mindfulness. So, they had the same reduction in stress,
but MBSR was associated with significantly smaller post stress responses, measured by
inflammatory markers in the blood. TNF is tumor necrosis factor and this is an
interleukin, these are compounds we measure in the blood that are released with inflammation. So, in this, the red line is the MBSR group,
the green line is the Enhancement group – I can’t remember the full name of their – This showed, as people meditated more, their
inflammation went down and as people did the enhancement techniques more, their inflammation
went up and that was true for two markers. So this was really – again, this was just
published earlier this year – this is really a landmark study in that it addressed the
issue. It’s not just getting together with a bunch
of people for two-and-a-half hours every eight weeks. There’s something specific about – there seems to be something in addition
– about mindfulness practice, that, in this
case, affects the immune response, that’s different. So, this is another really important
study. So, in summary, I mentioned and started with
MBSR is rooted in both Buddhist and yogic traditions. There certainly has been an explosion
of interest and research in mindfulness, especially over the last ten years. And what I think a lot of this shows is that
where we choose to place our attention matters. That paying attention, practicing paying attention
to our present moment experience, makes a difference, and has a number of health benefits. The things that we’ve talked about today,
paying attention to the present moment – I showed evidence that it can affect the mind,
both functionally and structurally. It can affect the heart in terms of heart
rate variability, and it can affect the immune system, and that it does, in fact, have the
potential to improve overall well-being. Thank You.

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