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Basic introduction to meditation concepts and tactics in conveying to patientsTRANSCRIPT
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Basic Awareness Meditation
Incorporating Meditation Training Into anOutpatient Psychiatry PracticeFebruary 22, 2016 | Integrative PsychiatryBy Greg Sazima, MD
COMMENTARY
You can’t open a newspaper or browse a healthwebsite these days without seeing the latestglowing testimonial to the benefits of meditationtraining. Yet only a small subset of psychiatristsactually practice meditation, and fewer stillincorporate awareness training into their tool kit intreating their patients. It’s not as if there has beenan absence of attention to meditation in the mentalhealth community. The works of Drs Jon Kabat-Zinn, Mark Epstein, Marsha Linehan, andothers as well as more recent research havereinforced meditation’s ameliorative effect on mostchronic medical and psychological conditions.
Nevertheless, many psychiatrists have not caught on. Some mistrust the validity ofa practice that entrains observation of a subjective, hard-to-assess interiorexperience. Others may misunderstand it as uncomfortably associated withreligiosity. There is also the practical obstacle of squeezing even basic meditationskills training into the psychiatrist’s already over-subscribed treatment visits.Regardless of our possible reasons for stiff-arming it, meditation training remains avaluable, thoroughly secular tool for psychiatrists to incorporate into our patientpractices—and our own personal self-care routines.
Meditation: what is it?
Meditation is a purposeful practice in the observation of experience. It entrains theskill of attention with the goal of optimizing our observing and “holding” experiences of daily life in mind. It can be thought of asthe “lesson plan” in developing mindfulness, defined byKabat-Zinn as “non-judgmental, moment-to-momentawareness.” That task may sound easy enough toperform until one recognizes that the human mind is anendless fountain of narrative content and editorialjudgments on one’s ongoing experience. Modernminds, deeply invested in our intellectual analytic skills,tend to overvalue our trails of cortical production.
A simpler witnessing of the phenomena present in any moment, without running off in additional mental production,cannot and should not replace our prodigious cortical capabilities. But it does add an important tool in basicadaptation to experience, a developing ability to “sit with” painful but usually temporary states of interior sufferingsuch as physical pain, anxiety, anger, sadness, and uncertainty. There is also benefit in discovering one’s ownconditioning, the linking of specific patterns of thought, feeling, and sensation and even the loss or reduction in
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attention itself as a defensive maneuver of the mind.
While a survey of the totality of writings on meditation over millennia reveals thousands of variations on practice andtechnique, most texts break them into 3 main types.
1. Concentration practice involves entraining attention via intense observation of a single object in the mind’s eye.Breath meditation, a very common starting point for any beginner, is a concentration practice. Meditating on theheartbeat, a mantra, or a visual object such as a candle flame also represents types of concentration practice.
2. Insight practice entrains the bare awareness of all phenomena in the field of mind as they come and go. Formany, this is a more advanced practice that can have a more spiritual connotation, as it is associated in Buddhismwith experiencing an ultimate sense of oneness and cosmic connection. This practice can also have a greatdiagnostic utility in psychotherapy, entraining observation of patterns of thought and feeling that co-occur inresponse to the triggers in day-to-day life.
3. Compassion practice uses globally familiar phenomena of positive human feelings—equanimity toward others,compassion, kindness, and joy—as an “object of mind” to hold and observe one’s reactions to.
A model of mind
I’ve found in my teaching of these techniques to my own patients—and in teaching medical residents about how toconvey them to theirs—that a “landscape” model is effective. The metaphor involves observing one’s experience inany one moment like a walk outdoors, witnessing the field of mind as an observer/photographer. When working witha patient, I describe basic components of that field:
• Physical: including “interior” experiences of the breath, heartbeat, and bodily sensations, such as pain and muscletension; and “exterior” sensory inputs such as sight, hearing, smell, taste, and touch
• Emotional: usefully compared with the “weather in the field,” these include anger, anxiety, joy, and sadness
• Thought: most ardently pulling our attention in mind, these include concepts, memory, new creative synthesis,speculation, and analysis
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Basic Awareness Meditation
Incorporating Meditation Training Into anOutpatient Psychiatry Practice: Page 2 of 3February 22, 2016 | Integrative PsychiatryBy Greg Sazima, MD
Two other elements can be added: the field itself (the “space” around thephenomena, allowing for examination of the clarity of awareness or lack thereof) andthe felt sense of observing (ie, the experience of the observer).
Meditative training in specifically observing one ofthese components of the field of mind—versussitting in observation of more or all of thephenomena in the field—can be comparedmetaphorically with the “telephoto” versus“landscape” settings of a camera. The observer canaim the “camera” of attention on any aspect of thefield—or on the whole. In beginning practice, weusually start with the breath.
Beginning tactics
The setting should be quiet with a minimum of stimuli in terms of unpredictable ornovel sensory inputs. Picking a time is a matter of preference. Some prefer earlymornings as an attitudinal preparation for the day; for others, evening meditationprovides a contemplative winding down of daily events and effects. Still others doboth. However, the time and place are organized; creating a routine in order toreduce the chance of interruption is important. These introductory tactics aresummarized in the Sidebar.
The details of sitting (chair or cushion, cross-legged or kneeling, palms up or down)receive a great deal of attention, perhaps too much. A full lotus position is notessential; neither is a fancy sitting cushion or an elaborate setting. A position thatallows for a body at rest without undue discomfort but remaining alert is theessential aspect. Eyes can be open slightly or closed; keeping the eyes open andtrained on a trivial spot in the visual field (such as a spot on the wall or floor) isusually preferred in early training to avoid somnolence.
One can meditate on any phenomenon of experience or all of them, but millennia oftrials have pointed to using the breath as an excellent starting “anchor” point ofreference to attend to and return to. One can pick an anatomic spot (nostrils, throat,or diaphragm) to observe. Although it is common to start by engaging in relaxationor “belly” breathing, forcing a certain type of breathing is not the point. Instead,allowing the breathing to occur without any “scripting” is the prime instruction, whileone settles back to observe the sensation. One watches the in-breath, then the out-breath; this is repeated until attention to that simple act is lost. Once that lost
attention is discovered, without fanfare or judgment, one returns the attention to the breathing.
These instructions are simple to convey but often very difficult to perform at first. Those who are just startingmeditation can be shocked at how much of a “blizzard” of discursive thoughts, shifting emotional states, and somaticsignals clutter the field of mind with the initial foray. My instructions to patients starting meditation involve 3 prompts
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(a long, slow breath taken with each):
Here: With the first breath, a re-connecting with one’s mind as a vast field with all its components: physical,emotional, thought, the encompassing field, and the observing self.
We: With the second breath, a recognition that one is not alone, with all of us in our own ways striving to reduceour suffering and find fulfillment and meaning. This prompt can help reduce what can sometimes feel like alonely task.
Go: With the third breath, set a specific intention for the session’s practice—usually, at first, this is watching thein and out of the breath. As meditation develops, this intention often moves beyond watching the breath to otherphenomena of experience; you may want to start with breath meditation, then plan to shift to a different object ofmind. Setting an intention in this way helps with “returning home” after the inevitable losing of one’s way in anysession.
A regular beginning routine often starts with a short (2- to 10-minute) session of sitting in the first week, expandingthe time to 20 to 30 minutes or more as a sense of improvement takes hold in the clarity of attention, the length ofholding that attention, and the flexibility in pivoting back to the task after the inevitable losses of attention. In this way,it truly is a trainable skill, comparable to learning piano scales. Although any one session can be blissful or a strugglefor both rookies and veterans, meditation generally improves with practice.
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Basic Awareness Meditation
Incorporating Meditation Training Into anOutpatient Psychiatry Practice: Page 3 of 3February 22, 2016 | Integrative PsychiatryBy Greg Sazima, MD
Regardless of where the “camera is aimed” and how tight the focus is, someessential factors need to be understood and conveyed to the new practitioner.The first is that thoughts inevitably come and go in the field, and that we tendto inevitably “grab on” and add to that narrative at some point, whether a fewseconds into sitting or many minutes. Mindful attention inevitably degradesinto a loss of focus; it’s not whether but when.
Having gotten “lost,” the next factor involves themoment when one realizes that attention has beenlost. The instruction here is to resettle oneself andreturn to the practice of watching one’s breath,without judgment. Yet this is easier said than done,especially early in training. We start into judgmentalthinking about having lost attention, which is justmore thinking added to the field to get distracted by.Instead, the direction is to re-steady the “camera” without additional judgment andtry again. This lowers the bar on persistence in the training and often provides auseful lesson in observing the nature of our own reflexive self-critical tendencies.
With practice, the benefits of feeling calmer and more adaptive to the difficulties ofdaily life are observable not just during meditation but also “off the cushion.” Morecareful observation of one’s full experience, not just immersion in it, becomesgradually internalized as a way of being and behaving in daily life.
Integrating meditation training into patient treatment
Initial training in concentration practice—using the breath, body sensations, or anexternal visualized object—has its rewards in entraining calming and adaptation; apatient need not go any further to reap the benefit of basic meditation’s calmingeffect. It is common, for instance, to experience a relaxation of muscle tension oncewe acknowledge it rather than trying to ignore it. This basic practice in meditation istruly suited for any but the most thought-disordered patients as a self-care tactic incalming the mind and adapting to interior states.
Insight practice can represent a next step, opening to the entire display of changingmoment-to-moment experience in one’s field of mind. In tuning more deeply intointerior states of experience, patients can become more aware of linked sensations,affects, and thoughts as they occur on the cushion and off; and how emotional toneand somatic sensation interplay with ritual loops of thought. They can also begin toidentify what external inputs may trigger those patterns. With careful use inpsychotherapy practice, this ongoing, interior observation of how the patient’s mindworks with its patterning can generate rich material for the clinician and patient tocull for meaning.
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Compassion practice—involving the individual in consciously generating positive states of experience such ascompassion, empathy, kindness, or joy—can be of enormous benefit to patients but perhaps even more so forclinicians in our own practices. Meditating on positive feeling states such as these can involve empathizing withone’s own suffering, with that of another person, or with a more general opening to all others.
Deeper explanations of practices beyond basic stress reduction, involving incremental gaining of skills in insightorientation and compassion, are beyond the scope of this article but nevertheless fruitful. These deeper practices inself-awareness can also bear some risk, generating provocative and even destabilizing states of mind for moretemperamentally fragile patients. Working collaboratively with a local meditation teacher can be useful.
In conclusion: start with yourself
The instructions in beginning meditation are not complicated; they can be taught to patients briefly and easily as wedo with information on sleep hygiene, mood diaries, and other helpful clinical routines. Nevertheless, in guidingpatients through a practice about an interior, subjective state, nothing can replace the psychiatrist’s directengagement in basic meditation before teaching it to patients, as well as in modeling its benefits. The hackneyed butvalid bromide we may remember from medical training, “see one, do one, teach one,” is applicable here. Another,“physician, heal thyself,” can also apply as we work to sustain our well-being in a rewarding but often stressfulcareer.
Acknowledgement—The research assistance of Ryan Sazima in preparation of this article is gratefullyacknowledged.
DISCLOSURES
Dr Sazima is a psychiatrist in private practice in Roseville, CA, and is Senior Behavioral Faculty at the SanJose/O’Connor Family Medicine Residency Program, San Jose, CA (affiliate, Stanford University School ofMedicine). He has also developed and taught mindfulness training programs for adults and children for 12 years.
REFERENCES
1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness.NY: Delta Trade Paperbacks; 1991.
2. Epstein M. Thoughts Without a Thinker: Psychotherapy From a Buddhist Perspective. NY: Basic Books; 1995.
3. Linehan M. Cognitive-Behavioral Treatment for Borderline Personality Disorder. NY: Guilford Press; 1993.
4. Thich NH. The Miracle of Mindfulness. Boston: Beacon Press; 1975.
5. Benson H. The Relaxation Response. NY: Harper Collins; 1971.
6. Boorstein S. Don’t Just Do Something, Sit There. San Francisco: Harper; 1996.
7. Dalai Lama, Cutler H. The Art of Happiness. New South Wales, Australia: Riverbed Books; 1998.
8. Goyal M, Singh S, Sibinga EMS, et al. Meditation programs for psychological stress and well-being: a systematicreview and meta-analysis. JAMA Intern Med. 2014;174:357-368.
9. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. NY: Hyperion Books;1994.
10. McGee M. Meditation and psychiatry. Psychiatry (Edgmont). 2008;5:28-4
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