CHAPTER 4
This chapter provides a summary and focuses on some of the science and evidence on mindfulness and its clinical effectiveness. We’ll try to make sure that it’s not too dry, but if science is really not your thing then please avert your eyes now and go on to the next chapter. Later chapters will look at how mindfulness is applied to various physical and mental health issues, but we hope this one will help you feel motivated that mindfulness is a useful thing to do—and realise that it’s much more than just sitting down doing a lot of nothing.
Preventing and managing chronic illnesses and the symptoms associated with them isn’t something that our conventional healthcare system does really well, with examples including asthma and chronic pain. It’s one of the main reasons why people in the West are increasingly turning to complementary and alternative medicine. Take depression as an example. Depression is predicted to be far and away the greatest single burden of disease—that is, it will create greater disability than any other condition—in developed countries by the year 2030.[1] This trend has been gathering momentum over the past 60 years. The causes of mental health problems involve many factors including our coping style, upbringing, lifestyle (for example, poor diet and lack of exercise) and environment, but inattention may be a much more important factor than previously thought. Unfortunately the biomedical approach to managing depression has placed far too much emphasis on medications and far too little emphasis on all the other factors. The pharmaceutical treatments for depression aren’t as effective as many doctors and patients assume they are. Some recent reviews of the evidence suggest that antidepressant drugs are only as good as placebos (sugar pills) for mild to moderate depression.[2][3] For severe depression, patients start to get an effect that can be attributed to the chemical action of the drug; up to that point, the effect is based on a person’s belief in what the drug will do, not the chemical itself.
That doesn’t mean that there’s nothing a person can do to manage their depression—far from it. It’s just that the best approaches in the long term need to include training people to use their mind better. This is where mindfulness comes in. It’s probably the research on the use of mindfulness for depression that has created more interest in mindfulness than any other single area, and this has stimulated a lot of other research.
Although we may think that we’re happiest when we’re thinking about all the wonderful things we did last summer or what we have planned this coming weekend, according to a study from Harvard University we’re happiest while our minds aren’t wandering from what we are currently doing.[4] This was tested by giving people an iPhone and phoning them at random times during the day and asking them three questions. One: At this moment rate your happiness from 1 to 100. Two: What are you physically doing? Three: What is your attention on (unpleasant, neutral or pleasant daydreams, or were you paying attention to what you were doing?)? It seems we’re happiest when we’re paying attention to what we’re doing. The authors concluded that the ‘human mind is a wandering mind, and a wandering mind is an unhappy mind. The ability to think about what’s not happening is a cognitive “achievement” that comes at an emotional cost.’ Why? When we’re inattentive our mind is most vulnerable to slipping into its habitual low gear—rumination and worry—which are central to depression and anxiety.
The list of applications of mindfulness in healthcare and education keeps growing year upon year (Table 1).[5] The research into preventing relapse in depression has probably caused more interest than any other single application.
Mental health
• Depression-relapse prevention
• Reduced anxiety, panic disorder and stress
• Better emotional regulation
• Greater emotional intelligence
• Management of addiction
• Better sleep
• Helping manage psychosis
• Borderline personality disorder
• Better control and less avoidance
Neuroscience
• Structural and functional changes in the brain
• Preservation of brain cells and generation of new brain cells (neurogenesis) particularly in the memory and executive functioning centres, which is important for preventing dementia
• Reduced activity in the amygdala, which is associated with aggression
• Enhanced attention and self-regulation
Clinical
• Pain management
• Symptom control
• Coping with major illnesses such as cancer
• Reduced allostatic load (long-term stress response)
• Metabolic benefits
• Hormonal changes
• Improved genetic function and repair and possibly slower ageing
• Reduced incidence of illnesses associated with ageing and poor mental health
• Facilitation of healthy lifestyle change
Improved performance
• Sport
• Academic
• Leadership
Spiritual
• Deep peace
• Insight
• Oneness
• Transcendence
When we aren’t paying attention to the present moment we often perceive stressors in our imagination that don’t actually exist. Our body doesn’t distinguish between imaginary stressors and real ones: if it gets the message from our mind that we’re under threat it turns on our stress-response alarm system. This amplified level of stress takes a toll on our mental and physical health, especially over the long term. The fight-or-flight response is a natural, necessary and appropriate response to a threatening situation—if it’s based on a clearly perceived actual, real-time, threat: say, confronting a hungry tiger or an angry employer. The resulting turbo-charge of energy happens in order to preserve life (Table 2).
This response is associated with the following reactions in our body and mind.
Increased blood flow
• Dynamic circulation: elevation of blood pressure and heart rate, and the strength of the heartbeat
• Blood flow is diverted away from gut and skin (meaning that the gut shuts down and we go pale) and is diverted to the muscles ready for action
• Sweating in order to regulate temperature while we exert ourselves
Increased metabolism
• Increased metabolic rate
• Increased respiration and opening up of airways to get lots of oxygen onboard and to breathe off carbon dioxide
• Mobilisation of energy (glucose and fat) stores
Arming defences
• Blood gets thicker (platelet adhesiveness) ready to stop bleeding faster
• Mobilisation of immune cells ready to fight infections
Preparing for tissue repair
• Mobilising inflammatory hormones (for example, cortisol, cytokines, interleukins) to help repair tissues damaged while dealing with the threat
Alertness (mindfulness)
• Attention centres in the brain activate
• We pick up a lot more information about what is going on in the environment
When we appropriately switch on our fight-or-flight response we don’t experience it as anxiety but rather as a surge of energy that is associated with an increase of mindfulness. On the other hand, when we inappropriately switch it on we experience it as anxiety and we do it because we’re unmindful. All the switched-on chemicals and processes are all dressed up with nowhere to go and nothing to do, except create trouble in the form of symptoms and disease. The name given to the long-term over-activation of the stress response is ‘allostatic load’.[6] This is like physiological wear-and-tear on our body and is seen in chronic depression and anxiety (Table 3). If we want to accelerate our ageing process then this is the best way to do it. The positive message is that these effects can all be reversed over time with the regular practice of mindfulness. What goes up comes back down again and what goes down comes back up. Focusing our attention on the here and now helps us to see which stressors are actually real and which ones are in our imagination.
• Immune dysregulation (lowered defences against infections and increased inflammation)
• Hardening of the arteries (atherosclerosis), which leads to cardiovascular disease
• Metabolic syndrome (high blood pressure, high blood lipids, high blood glucose and increased weight around the trunk)
• Thinning of the bones (osteoporosis)
• Loss of brain cells (accelerated ageing or atrophy), particularly in the hippocampus and prefrontal cortex (learning, memory and executive functioning areas of the brain), which predisposes to Alzheimer’s Disease in later life[7][8]
• Growth and increased reactivity of the amygdala (the fear and stress centre of the brain)
Stress is often valued as a way of improving performance. To an extent, stress is good or at least better than apathy as far as being productive is concerned. The relaxation associated with apathy and lack of focus should, however, not be mistaken for the relaxation associated with the inner calm and focus of mindfulness. Furthermore, too much stress is associated with a lack of focus, poor performance and an increased number of mistakes. Depressed hospital doctors, for example, make more than six times as many medication errors compared to non-depressed doctors doing the same job.[9] The chapters on performance (Chapters 18, 19 and 20) will explore this in more detail.
Mindfulness also enhances executive functioning associated with an area of the brain called the prefrontal cortex. Executive functions include short-term (working) memory, processing information, attention regulation, making decisions, emotional regulation and prioritising. Mindfulness training stabilises this area of the brain and helps it to function well whereas an overactive stress centre (amygdala) hijacks this area of the brain, making effective functioning difficult, if not impossible.[10]
Sports people notice that they function best when they are focused. As an article about sports psychology put it:
Another challenge in truly focusing is the prevalence in our modern world of ‘multitasking’. Although we can do many things at once, contrary to popular belief we just can’t do them all well, nor do we have in-depth or rewarding experiences while our attention skims across the surface of life. To illustrate, the chance of having a motor vehicle accident within 5 minutes of using a mobile phone is over 400 per cent higher than what it is normally.[12] Many work environments are so fast these days (some people call it ‘hyperkinetic’) that we become conditioned into very short attention spans. This is called ‘Attention Deficit Trait’—the tendency to be inattentive—and it’s a big reason why smart, capable people underperform.[13]
The modern myth of efficiency and fullness of living being the result of multitasking is one that we should question. Let’s not confuse busyness with productiveness. You may have noticed that you are increasingly likely to be asked, ‘How are you, keeping busy?’ as if busyness is now all that matters. Furthermore, the lack of enjoyment (anhedonia) that is a central part of poor mental health is a direct result of a lack of engagement with life as it unfolds. One of the greatest benefits of mindfulness is an increase in the richness of life as well as in our capacity to tell the difference between real and imagined stressors.[14]
Learning to pay attention is therefore central in improving our performance and efficiency, deepening our enjoyment of life and protecting our mind from the destructive cognitive processes behind poor mental health. Mindfulness training isn’t about avoidance; it’s about engagement. Avoidance and distraction are the problem—mindfulness is the remedy.
Mindfulness has been seen for millennia as a means for reliving suffering. In our modern day we give ‘suffering’ different names, such as depression, stress and anxiety. As we mentioned in previous chapters, mindfulness is more than meditation, it’s also a foundation for various forms of psychotherapy.
Jon Kabat-Zinn developed Mindfulness-Based Stress Reduction (MBSR) for the management of stress and chronic pain at the UMass Medical Center in Worcester, Massachusetts. Mindfulness-Based Cognitive Therapy (MBCT) was developed by some prominent psychologists by the names of Teasdale, Williams and Segal from the work of Jon Kabat-Zinn for application in managing depression. MBCT was initially found to better than halve the relapse rate for people who have had recurrent depression in the past, compared to treatment as usual.[15] It also improves mood, anxiety and coping in people dealing with major and life-threatening illnesses such as cancer.[16]
Conventional cognitive therapy aims to change people’s thoughts, whereas MBCT aims to change people’s relationship to negative thoughts and emotions (non-attachment).[17] It has been found through various forms of brain imaging (brain scans) that changes in brain function during mindfulness include increased signals in brain regions related to mood regulation and attention control, with an increased release of dopamine—a brain chemical associated with feeling good.[18][19] It has also been found that mindfulness reduces levels of some of the inflammatory chemicals we release when we are stressed, such as cytokines, which cause a range of symptoms associated with depression.[20]
Mindfulness not only reduces depressive symptoms but also reduces the reactivity of the amygdala, which is overactive in people with depression.[21] In adolescents, mindfulness reduces symptoms of anxiety, depression and somatic distress, and increases self-esteem and sleep quality.[22] Improving sleep is likely to be one of the most important reasons why mindfulness is therapeutic for depression. (We discuss this further in Chapter 16.)
Depression and anxiety often co-exist so it is important to find approaches that are therapeutic for both. Mindfulness seems to do that. It helps with generalised anxiety and related symptoms such as social anxiety disorder.[23]
Mindfulness programs have also been found to reduce stress, anxiety and depression among high-performing students, such as medical students. At Monash University a six-week mindfulness program has been part of the core curriculum since 2002, and our research indicates that the students who have participated are more resilient and have better mental health as a result.[24] A program developed by a former Monash tutor for the University of Tasmania medical course has shown similar findings.[25] Research undertaken by the authors indicates that medical students who have been taught about mindfulness and its clinical applications are far more likely to be disposed to recommend it to their patients.[26]
Mindfulness is just as important for health professionals as it is for the people they look after. For example, it has been found to enhance doctor wellbeing, reduce burnout (burnout is measured by its effects on emotional exhaustion, depersonalisation, lack of personal accomplishment) and mood disturbance, and increase empathy, responsiveness to patients and conscientiousness.[27]
A range of mental health benefits have also been found for teachers who learn mindfulness,[28] and mindfulness programs are increasingly being adapted to schools. One of the authors has been involved with running mindfulness programs for staff and senior students. For example, a program for year 12 students found that those who learned mindfulness performed significantly better on the General Health Questionnaire (GHQ) than did year 12 students who didn’t.[29] The wider interest in mindfulness has led to it being a topic at a range of education-related conferences.
One study on primary school children had them complete the Strengths and Difficulties Questionnaire (SDQ) and a modified version of the Children’s Depression Inventory (CDI)—pre and post mindfulness program. There was a significant decrease in both scales on overall average scores and the number of children diagnosed with mental health problems. For example, we found that 25.6 per cent of children scored in the borderline or diagnostic category for the SDQ pre mindfulness program, but only 16.3 per cent post. This suggests that mindfulness training warrants consideration as an element of a whole school mental-health promotion program.[30] A range of mental health benefits are also found for teachers who learn mindfulness—which is comforting because they probably need it more than their students do!
Mindfulness-based strategies have also been applied to patients with schizophrenia who are in remission, with some promising results,[31][32] although the current evidence suggests that mindfulness may not be appropriate for people with psychosis. Mindfulness improves function and reduces anxiety in many patients, including those with schizophrenia, therefore helping avoid a relapse of schizophrenia. It may also be helpful in reducing the intrusiveness of hallucinations by helping patients to be less distracted by and reactive to them. Mindfulness for schizophrenia shouldn’t be seen as an alternative to medications, and it should be used by experienced mental health practitioners. Intensive practice or retreats should probably be avoided in managing psychosis.
Contrary to what has been taught in medical schools for decades, we now understand that the brain is constantly rewiring itself, throughout our life. Neuroplasticity simply means that the brain (neuro-) can change or adapt (-plasticity) depending on what we experience and how we train it. From a therapeutic point of view it means that we can ‘unwire’ unhelpful patterns of thought and behaviour and wire in helpful ones.[33] Mindfulness research is changing the way we understand the brain, and the Mind and Life Institute is a collection of leading scientists exploring this field.[34] If you would like to read further on this topic, Norman Doidge’s book The Brain that Changes Itself gives a great overview of this subject.
To summarise some of the key findings about mindfulness and neuroplasticity: brain scans measuring the thickness of the ‘grey matter’ in long-term mindfulness meditators indicate that this is thicker, particularly in the areas associated with the senses, memory, emotional regulation, paying attention and executive functioning.[35] Blood flow to such areas of the brain is also increased.[36] This confirms what people report about functioning better, and also indicates a slowing of ageing of the brain by reversing the negative effects of the high allostatic load discussed earlier.[37][38][39]
Leisure activities during which we don’t pay attention (such as watching TV) are associated with higher rates of attention deficit problems in children and roughly a fourfold increased life-long risk of developing Alzheimer’s Disease[40][41]—compared to those whose leisure activity requires attention, such as reading, playing board games, playing musical instruments and dancing.[42] The amount of screen time that a lot of young people now engage in—the average is about four hours a day—may have as important implications for the health of their brains as it does for levels of obesity and physical inactivity. It seems clear that the brain thrives on attention and engagement and it wastes away with inattention and disengagement. Essentially, if we’re engaged with life then we’re more likely to be enjoying it—so enjoyment and a healthy brain go hand in hand.
There are particular areas of the brain associated with the experience of empathy and compassion, and it seems that over the long term these areas of the brain become more responsive—wake up, if you like—when people learn to meditate on compassion.[43] There should be nothing surprising in the finding that if we pay more attention, including to the person in front of us, we will relate to them a whole lot better. Compassion may be a natural side effect of attention and a lack of compassion a side effect of inattention.
It is because of mindfulness’s capacity to foster compassion that it also helps to prevent ‘carer fatigue’ or ‘carer burnout’ because it can teach us to be compassionate to ourselves as well as others. This is illustrated by a study of an eight-week mindfulness program for doctors that was associated with improvements on all measures of wellbeing. The more mindful the doctors became the less burnout (emotional exhaustion, depersonalisation, personal accomplishment) they experienced, the greater their empathy and responsiveness to the psychosocial aspects of their patients’ situations, the less mood disturbance they experienced, and the more conscientious and emotionally stable they became.[44]
There are two main types of brain activity that depend on how focused or connected we are: active engagement (tasks associated with paying attention) and default states (when our mind is inattentive, idle, recalling the past, daydreaming, ruminating).
Brain regions active in default states in adolescents and young adults are not only associated with depression, but also show the early changes found in the elderly with Alzheimer’s Disease.[45] This may have to do with wear and tear on the brain through all the aimless mental activity associated with constantly going over the past and the stress this causes.[46] Default mental activity is largely to do with thinking about our ideas about ourselves—our imaginary selves. This is why it is so much a part of depression and anxiety. Mindfulness is the direct remedy for default mental activity because when we are paying attention it doesn’t find a way in.
Work led by Australia’s Nobel Prize-winning researcher Elizabeth Blackburn has found that mindfulness may slow genetic ageing and enhance genetic repair.[47] We will explore this topic more deeply in Chapter 6.
Stopping smoking or any other addiction isn’t easy and to do it we have to learn to deal with cravings. The common way to deal with cravings is to suppress them, but this comes at a mental health cost. A study on the effectiveness of suppression versus mindfulness for coping with cigarette cravings reported that the mindfulness group reduced smoking and also achieved a far more stable affect (mood) and reduced depressive symptoms, whereas the suppression group found that their mood significantly declined.[48]
Acceptance therapy, a core element of mindfulness training, has been found to be effective for alcohol and other forms of substance abuse because it helps to reduce the negative mood, distress and craving that are such common triggers for relapse.[49][50][51] Vipassana meditation has also been studied as a therapy for addiction among prison inmates: it led to a decrease in alcohol-related problems and psychiatric symptoms and to increases in positive psychosocial outcomes.[52] We will explore the topic of addiction in more depth in Chapter 9.
Mindfulness-based skills have been central elements in most successful lifestyle programs for chronic illnesses such as heart disease and cancer. The Ornish program is probably the best-known example. We will explore these programs more deeply in future chapters on heart disease and cancer (Chapters 13 and 14).
Research has found that people who rate highly on mindfulness scales also rate highly on emotional intelligence (EI)[53] and empathy.[54] EI has a number of elements, including self-awareness, self-regulation, empathy, motivation and social skills. This is one of the main reasons that educators and leadership trainers are becoming more interested in mindfulness—because it is associated with the qualities that make up good social beings and responsive leaders. We will explore this more deeply in Chapter 21.
Mindfulness is a promising approach to the management of eating disorders. It possibly works for this by increasing our awareness of our eating behaviour and physical cues, helps us deal with self-criticism and negative self-image, and assists us in managing impulsivity and negative emotions.[55] Mindfulness programs for eating disorders such as binge-eating are designed to help people control their responses to their varying emotional states, make conscious food choices, develop an awareness of hunger and satiety cues and cultivate self-acceptance.[56]
Interviews with women going through such programs report that they experience a transformation from their emotional and behavioral extremes, disembodiment and self-loathing to an inner connection with themselves resulting in greater self-awareness, acceptance and compassion.[57] We will explore this more deeply in Chapter 12.
A study on cancer patients who learned mindfulness in their cancer management had significantly lower scores for negative mood, depression, anxiety, anger and confusion, and they also had more vigour. They also had fewer overall physical and stress symptoms.[58] Mindfulness has also been shown to reduce cortisol levels and inflammation in cancer patients—signs of a poor prognosis—and improve immunity and quality of life.[59][60] We will explore this more deeply in Chapter 14.
Mindfulness meditation is associated with a significant reduction in pain, fatigue and sleeplessness, and with improved function, mood and general health for people with chronic pain syndromes.[61][62][63] One of the main reasons for this is likely to be the reduced emotional reactivity to pain that reduces the suffering associated with it.[64] We will explore this topic more deeply in Chapter 11.
Mindfulness training improves immune function because it has the opposite effect to the stress response and allostatic load that disrupt immunity. For example, people within the workplace show better immune response to vaccinations and increases in antibodies after an eight-week mindfulness program.[65] Mindfulness and compassion meditation practices are also associated with reduced inflammation,[66] and may therefore be important in the management of a wide range of inflammatory and autoimmune illnesses such as asthma, arthritis, dermatitis, Multiple Sclerosis and Inflammatory Bowel Disease.
Mindfulness helps to significantly improve sleep quality by helping people go to sleep more easily, have a longer sleep duration and require less use of sleep medications.[67] Enhanced sleep may be part of the explanation for mindfulness reducing depression in those with chronic insomnia.[68] We will explore this topic more deeply in Chapter 16.
We can’t always control the things that happen to us, which might be what makes life the adventure that it is, but we can have more control over our responses to life events and our attitudes to them. Mindfulness helps us to develop more adaptive and less avoidant coping styles, which helps us to learn faster and to get on with dealing with situations—rather than putting them off.[69][70] This is important for mental health, which will be explored in depth particularly in Chapters 6–8.
In summary, what mindfulness can teach us may be tremendously useful for our physical and psychological wellbeing because it: improves how effectively we function; positively changes our bodies physiologically and metabolically; has indirect benefits by improving our lifestyle; enhances our relationships and compassion to others and to ourselves; improves the way we cope with life challenges; and enriches our enjoyment of life.