We have mentioned a number of ways in which mindful awareness might be cultivated and maintained, concentrating on those that have been used in particular clinical contexts (Also read Science of Mindfulness , Mindfulness and Mental Health). As these have diversified, so has the range of techniques for becoming more mindful. Having a short attention span, being subjected to unusually insistent, intrusive phenomena, or having access to past experiences or body sensations restricted through internal defenses can each make it particularly difficult to maintain a traditional practice for lengthy intervals of time. These limitations have been accommodated through some of the techniques. As a result, there is a considerable menu of methods that have now been widely used in the development of mindfulness:
Techniques for experiencing mindfulness
· Sitting meditations (mindfulness of breathing, body sensations, sounds, thoughts, etc.)
· Movement meditations (walking meditation, mindful yoga stretches)
· Group exchange (led exercises, guided discussion of experience)
· Mindful activity (mindful eating, cleaning, driving, etc.)
· Structured exercises (thought dispersal, breathing space, etc.)
· Contemplations (poetry, aesthetic experiences)
The traditional methods for developing mindfulness discussed in Mindfulness – Origins and Concepts have been augmented by others, both formal and informal. The current list is likely to be far from exhaustive. The preliminary study described in Science of Mindfulness has already indicated that research into how people actually acquire mindfulness could be particularly instructive in suggesting new methods, techniques and tips.
Changing gear – the role of mindfulness retreats
If there are so many potential ways of cultivating mindfulness, do any have a special place because they carry a promise of greater intensity, depth, or purity of experience? Is there any reliable way in which mindfulness might be maximized? One traditional answer is through the intensification of practice that a dedicated retreat provides. Whether such retreats last a day or a month, the following elements seem to be characteristic:
- physical seclusion without regular contact with family, friends, or broadcast media
- an environment that minimizes distraction with simple decor, an unfussy (usually vegetarian) diet, segregated sleeping arrangements, etc.
- long periods of continuing silence, usually with an early reveille to access full silence in the later hours of the night
- rules restricting communication between participants – whether verbally, by signals, eye contact, etc.
- rules restricting distracting activities such as reading, games, writing
- a programme of formal practices based on alternating group sittings in mindful meditation and opportunities for mindful walking (other practices also possible)
- some teaching and instruction, which may be provided completely separately from the practice sessions themselves
- clear induction and leaving processes at the start and end of the retreat.
While it is easy to assume that the other aspects function to amplify the experience obtained during the formal practices listed at item 6 in this list, it is likely they are very potent modifiers of awareness in themselves. In representing a modulated form of sensory deprivation, they seem likely to encourage a greater awareness of events in the mind, before any specific meditative exercises are added. Once such exercises are underway, the structure is intended to prevent the immediate diffusion of changes in consciousness, engendering a (not necessarily welcome) continuity between exercise sessions, with a gradual intensification of any changes that result.
Apart from the synergy between milieu and the formal practices, attempts to identify just what lends retreats their intensity can also be confounded by the didactic, cognitive input (during induction, instruction sessions, and dhamma talks) that places the practices in a framework of beliefs and expectations. As we saw in Mindfulness – Origins and Concepts, motivation to undertake a practice is likely to be reinforced by beliefs that provide a rationale for it. These, in turn, will also influence details of the procedure so that the practice is credible as a means of realizing the desired goals. As we saw in the discussion of ‘permeation’ of mindfulness in Science of Mindfulness, the new way of being aware gains momentum so that it becomes increasingly prevalent. This is enhanced by the lack of interruption a retreat setting offers. As we saw in Mindfulness and Mental Health, one aspect of the potency of retreat experiences lies in the relative ease with which unexpected and sometimes unwelcome sensory aberrations can occur. These are often seen as a further tool for the steadying of awareness – provided they can themselves become an object of awareness no different from any other.
A key question concerning the value of mindfulness retreats concerns how far they enable states of mind to be experienced that would be unattainable otherwise. There are conflicting views on this. A supremely articulate spokesperson for the retreat camp is B. Alan Wallace, a physicist, who has spent many years in meditation, often under austere conditions. Wallace (2006) sees meditation as a linear path toward higher states of consciousness, for which a training no less arduous than that of an Olympic athlete is likely to be required. He follows a classification of stages toward attentional balance in which ten levels are identified, divided into three phases.
In the first phase, outward attention is refined in its continuity and its quality. In the second, a taming and pacification of the attention accompany it being turned inward. In the third, object-less awareness of awareness is cultivated until the goal, the completely balanced state of shamatha, is attained. Wallace suggests that a different meditative practice is optimal, but not essential, during each of these stages. Through the first four stages that make up phase one, he proposes that this is practice of mindfulness, as mindfulness of breathing. There should be a progression through these first four steps as a specific aspect is mastered in each. In the first step, proficiency is developed in directing attention for very short periods. In the second, the capacity to maintain attention in the face of distraction improves. During the third, attention becomes more vivid, as skills are acquired in maintaining an equilibrium between lethargy and excitation within focused attention. And in the fourth step, awareness of the breathing becomes much more subtle, as attention to it becomes increasingly close.
Wallace feels it is extremely unlikely that even the third step here can be mastered without experience of meditating in a retreat setting. When he comes to the fourth step, it is assumed this is the context in which students are applying themselves. Wallace therefore provides an especially clear rationale for the intensification of practice during retreats. However, he also feels obliged to point out where and how his concept of ‘mindfulness’ differs from the one that is most prevalent in the West (and in this book):
The modern Vipassana (contemplative insight) tradition of Theravada Buddhism differs significantly from the Indo-Tibetan Buddhist version [of mindfulness]. The modern Vipassana approach views mindfulness as non-discriminating, moment-to-moment ‘bare awareness’; the Indo-Tibetan tradition, however, characterizes mindfulness as bearing in mind the object of attention, the state of not forgetting, not being distracted, and not floating.(Wallace 2006: 60)
In the terms favored by most classifiers of meditation (Goleman 1988; Sole-Leris 1992), it seems that Wallace is identifying mindfulness practice with ‘concentration’ rather than ‘insight’. As traditional teaching on insight meditations has suggested that they can be taken up once a relatively rudimentary level of concentration has been attained, the same link between the intensity of practice and experience of retreat settings may not apply. Speculation on such lines can find some support in the relative inexperience of the Asian mindfulness adepts discussed in Science of Mindfulness (Brown and Engler 1986). Whatever their potential, retreats are felt to be challenging. In practice, they generate a good deal of fear and resistance – before the event and during it. They certainly generate mixed attitudes among mindfulness teachers. Many feel they are especially helpful in accelerating development. Others can voice some suspicion of how far they truly offer something that cannot be obtained through the regular practice of the right kind, perhaps seeing them as an unnecessary separation from family, and even a ‘retreat’ from the most important challenges to becoming a remaining mindful.
Within the retreat environment, the psychological impact of the sustained attention it fosters can be troubling. We saw examples of unusual sensory phenomena arising in this way in Science of Mindfulness, but the manifestations seem most likely to be cognitive, emotional, or physical (VanderKooi 1997). At the same time, as some focus group participants mentioned, ordinary actions and responses become more difficult to carry out or feel inaccessible, compounding a feeling of disorientation. Such changes are disturbing when there is a reaction to them, although a concomitant capacity to tolerate and even welcome novel experiences are usually reported. Faith in the power of retreats to intensify meditative experience is confined neither to mindfulness practitioners nor to students of Wallace’s method. One of the qualifications shared by all the members of the super-meditators group in Lutz’s study of brain gamma activity was that they had all been on at least one 3-year-long retreat.
There is much scope for the experiment when assessing the extent to which retreats represent a unique opportunity, and if they do, how they might be optimally organized. In terms of mindfulness practice, no comparative data are available concerning, say, the impact of a course of training within a 10-day retreat and the equivalent amount of practice undertaken in classes during an 8-week, part-time course interspersed with daily personal practice. However, the elements of sleep cycle, diet, type of practice, continuity, abstinence from other activities, and teaching are all intermingled and would need to be better distinguished. The development of mindfulness training retreats, designed to meet the needs of professionals wishing to offer mindfulness as an intervention for others, has led to retreats with a wider menu of activities (a dilution of traditional abstinence) and distinctive teaching that does not centre on traditional Buddhist teaching. A comparative evaluation of the impact of modern and traditional retreats on participants’ mindfulness would be very revealing, not least in offering a means of assessing the contributions of teaching, through differences in what (Shauna) Shapiro and colleagues (2006) term ‘intention’ and ‘attitude’, to the quality of awareness that follows.
Widening the spectrum of mindful practices: the example of poetry
In setting out some of the most common ways in which mindfulness is cultivated, it was implied these were not exhaustive. How might the repertoire of methods be extended? Answers seem most likely to be forthcoming by considering the innate qualities of awareness rather than theoretical deduction. One of these particular qualities seems to be a sensitivity to resonance – how concerted activity in one mind can sympathetically elicit a similar sort of activity in a neighboring one simply by proximity. This kind of action, as well as underlying the claims for embodiment in the transmission of MBSR to enhance its transmission by example, underpins the capacity of some poetry to modify awareness, something that has also been incorporated into teaching MBSR and MBCT with clinical populations.
Mindful reading often takes the form of reading poetry. The regular use of poetry is one of the striking features of the practice of MBSR that can be inadequately conveyed in written accounts. Selected poems are read (preferably recited) to students in the course of classes, once an initial receptivity has been established. Two poems are especially popular in this context. One is ‘The Guest House’:
The Guest House
This being human is a guest house.(Rumi, trans. Coleman Barks; 1994)
Every morning a new arrival
A joy, a depression, a meanness,
as an unexpected visitor.
Even if they’re a crowd of sorrows,
empty of its furniture,
for some new delight.
meet them at the door laughing,
because each has been sent
The poem is taken from the fifth book of Rumi’s six-volume mystical epic, the Mathnawi. It is clearly prescriptive and conveys a morality by which we should not only tolerate but also honor whatever life brings. The unexpected and the sorrowful have a purpose, a role in our development as a ‘guide from beyond’, even if this is not apparent. At the same time, there is an affirmation that a constant stream of new experience assails us, each a ‘momentary awareness’. The poem’s advice dwells exclusively on experiences that are ‘a crowd of sorrows’, but with an injunction to respond to them by acceptance (‘welcome and entertain them all’; ‘invite them in’), without getting dragged down by them (‘meet them at the door laughing’). One assumes the same would apply to the expected or the positively joyous visitor, with the poem encapsulating the virtues of staying equally receptive and tolerant of all experiences in a memorable and inspiring way.
Although Rumi has many translators, the verse seems always to be used in Coleman Barks’ version in the context of mindfulness training. This is an extremely free and much condensed reading that has been very carefully shaped as a poem in its own right. A fuller and more literal translation (Helminski 2000: 187-8) shows a number of divergences. It is the body that is a guest house and the heart where thoughts ‘from the invisible world’ are registered. They are not only registered, but, in being honoured, are also retained; for example, ‘My soul, regard each thought as a person, for every person’s value is in the thought they hold.’ Whereas Barks implies that the arrivals include ‘a joy’ as well as ‘a depression, a meanness, Helminski’s guests are pure sorrow. Indeed, the poem becomes one about the cleansing power of sorrow as it ‘furiously sweeps your house clean’. There are many active metaphors to drive this home – leaves being cleared from the bough of the heart to allow fresher ones to grow; pulling up rotten roots that were hidden from sight so something better can take their place. It is sorrow alone that is ‘the servant of the intuitive’. Its grey presence is also protective, in the way that ‘frowning clouds’ prevent burning by the ‘smiling sun’. (This appeal to reason, to strike a calculating balance, is perhaps wisely omitted altogether in Barks’ version.) Without venturing into the cosmological implications of references to the source and astrological correspondences that are also absent from Coleman Barks’ version, this alternative translation opens up intriguing ambiguities in the basic drift of this widely used poem.
Another favourite is ‘Wild Geese’:
You do not have to be good.Mary Oliver (Oliver 1986: 14)
You do not have to walk on your knees
for a hundred miles through the desert, repenting.
You only have to let the soft animal of your body love what it loves.
Tell me about despair, yours, and I will tell you mine.
Meanwhile the world goes on.
Meanwhile the sun and the clear pebbles of the rain are moving across the landscapes,
over the prairies and the deep trees, the mountains and the rivers.
Meanwhile the wild geese, high in the clean blue air, are heading home again.
Whoever you are, no matter how lonely, the world offers itself to your imagination,
calls to you like the wild geese, harsh and exciting – over and over announcing your place in the family of things.
While the poems of Rumi have been widely read among people with overtly spiritual inclinations, the work of Mary Oliver enjoys an even wider constituency. She is a hugely successful poet who has earned popular and literary acclaim. It was fitting that a poem by Oliver formed the preface to the most successful new poetry anthology of recent years, Staying Alive (Astley 2002). The poem that was chosen was ‘Wild Geese’. In some ways, Oliver’s verse is the antithesis of the religiose Rumi. Within this poem, ‘being good’ and going through the most bizarre contortions in the name of ‘repentance’ crisply sum up the psychological legacy of religion for many people. The poem also conjures up a sense of innate warmth and the simplicity of emotional truthfulness in the two lines that follow. Afterward, the reiterations of ‘meanwhile’ are a reminder of the independence of nature, amplified by the vastness of the references to prairies, deep trees, mountains and rivers. Connection is re-established through the geese of the title, whose call is not soft – or intelligible – but ‘harsh and exciting’. There is some restoration, not to the family at the kitchen table, nor to religion’s family of man, but to the broad yet homely ‘family of things’. In so far as the poem still attracts a slightly sentimental and cloying quality, it is through anthropomorphism as in the geese ‘heading home again’. If ‘Wild Geese’ lacks the absolute impersonality and mirror finish of a successful haiku, its descriptive language has remained sparse, with details left to the reader’s imagination. There is a baring of attention as, like the ‘sun and the clear pebbles of the rain’, it moves across landscapes taking us with it. As well as conveying a sense of hugeness and hope, the poem is a direct demonstration of a clear, present awareness.
It, too, can therefore help to depict qualities that are sought in the practice of mindfulness. And its simple directness early on, implying that striving too hard can be a long step in the wrong direction, cleverly identifies a trap earnest Westerners face in taking up mindfulness as a practice or discipline invested with a whole new set of ‘shoulds’.
Poetry has assumed a place in mindfulness training that no other arts, whether visual, musical or performance, have enjoyed. There is a concentration of meaning in poetry, but also an engagement with words on a physical and bodily level, that is unique to it. Some works, such as David Whyte’s Enough (Whyte 1990), even make a direct parallel between engagement in poetic and meditative practices.
In a helpful commentary, Shauna Shapiro (2001) reflects on how, as an object for attention, poetry ‘appeared to provide students with an alternative route to learning, allowing them to feel, listen and discover in different ways’. In offering a description of her flexible use of poetry to underline the dominant themes of sessions during a mindfulness course, she addresses her readers in similar terms to her students: ‘Since each poem affects individuals differently, in reading on, I invite you to notice the effect of the excerpted phrases on your own body, emotions, heart, and mind. Notice what arises and see if you can simply observe each response with non-judgmental compassion’ (Shapiro 2001: 505). This broad conception of the use of poetry as a distillation of experience comes close to Jon Kabat-Zinn’s (2005) comments on the primacy of poetry in the context of mindfulness training. In this, he draws a parallel between great poets, yogis, and teachers of meditation based on ‘deep interior explorations of the mind and of words and of the intimate relationship between inner and outer landscapes’. Poetry, therefore, possesses ‘the potential to enhance our seeing . . .
and our ability to feel the poignancy and relevance of our own situations, our own psyches, and our own lives, in ways that help us to understand where the meditation practice may be asking us to look and to see . . . what it is making possible for us to feel and to know’. Kabat-Zinn describes poems as providing fresh lenses for seeing ourselves ‘across the span of cultures and of time, offering something more fundamental, something more human than the expected or the already known’(Kabat-Zinn 2005: 27).
Poetry’s potential role as an aid in mindfulness training seems multifarious. Poems can be didactic in illustrating an attitude of even-handedness or acceptance that is difficult to communicate by strict definition. They can also serve as particularly fruitful objects for mindful contemplation, by virtue of the combinations of sensation, feeling and thought that they inspire. Yet, in practice, only a tiny minority of published poems are adopted for mindful reading. As in the examples above, these have tended to lack very pronounced metre or rhyme and to be vernacular in their tone, and translations as well as late twentieth-century writers have been favoured. Beyond this, poems seem to be selected only if their substance is overtly compatible with a kindly, meditative outlook. This has tended to be overlooked when comments about the use of poems in mindfulness training are generalised to the whole of poetry. But perhaps the range might be wider, and an apparent fear of non-free verse overcome, if Kabat-Zinn’s hope that the spans of time as well as culture be bridged is realised. Is any poem more steeped in mindfulness than this one by Shakespeare?
Where the bee sucks, there suck I:Shakespeare, The Tempest, Act V, scene i.
There I couch when owls do cry.
After summer merrily,
Merrily, merrily shall I live now
Under the blossom that hangs on the bough.
Under the blossom that hangs on the bough.
There are many ways in which poetry can seem privileged in its relationship to mindfulness. Kabat-Zinn might have added that poetry is felt by many to have a special integrity among art forms because it is the least likely to lead to either wealth or celebrity. It is hard to be engaged with it without being driven by passion and inner need, rather than possible gains. However, poetry is not necessarily unique, either in the way it introduces a deep resonance that helps hearers become aware in a different way of the reality in and around them or in the way it provides a direct and extra-ordinarily compact taste of somebody else’s world.
For some people, the latter effect is heightened if a poem is set to music in a way that reflects its underlying sensibility. The former effect is something that people can experience if they absorb themselves in the space of particular buildings or other artistic manifestations of frozen form such as sculpture – the impermanent kind as well as the enduring. Here, music has a distinct and vast potential, one that is exploited in the use of bells and chanting in Eastern monastic practices. The ability of bells to impact on other aspects of awareness, long after their sound can no longer be heard, is also called on whenever they are used to signal the start or conclusion of meditation sessions. Related phenomena are described by musically sensitive people, at the conclusion of a piece of music, in terms of an aftertaste as the music literally continues to penetrate and inhabit parts of the mind that few other experiences seem to touch. (In the music systems of India, in which there is a particularly sophisticated understanding of the interconnections between musical form and subtle psychological states, the way in which each raga or scale system is associated with its characteristic feeling is spoken of in terms of taste or rasa.) This is far from exhausting music’s capacity to support mindfulness. Among the members of the focus group reported in Science of Mindfulness, one experienced practitioner had described the importance of musical improvisation in mindful action. Someone with less experience of mindfulness talked with great appreciation of how the discipline of musical practice had brought a focusing of attention along with a sense of internal connectedness. Listening with awareness can initiate a change in consciousness – simply observe the stillness and respiration of someone at a concert who is attentively engaged with what they are hearing.
The relative neglect of music among currently favoured ways of developing mindfulness appears to be a historical accident rather than a necessity. The potential of other art forms, too, to foster mindful awareness seems to be underdeveloped. The practical importance of this is that not every mindfulness teacher seems to be equally comfortable in the use of poetry in classes, nor every student equally responsive to it. Perhaps the same flexibility that is often brought to the choice of meditative or directed exercises to foster mindfulness could be brought to the introduction of different art forms.
Some adaptations that have been made to adapt mindfulness techniques for adults whose psychological disabilities could compromise their ability to use them were described in Mindfulness and Mental Health. Other accommodations are likely to be needed to take account of groups of people who differ in other ways. The very young and the very old are clear examples of this.
Semple et al. (2006) describe how the format of MBCT can be adapted to hold the interest of young children. Parents are actively involved throughout, attending a preliminary session in which they learn the basic techniques that their child will be taught. They receive information too about the entire programme session by session so that they can offer support as co-facilitators. They are also invited to a post-course review session, in which ways in which they can continue to support their child are discussed (Semple et al. 2006). Parents do not usually attend the group sessions, which are held for 6±8 children over 12 weeks for no more than 90 minutes at a time. Care is taken to demonstrate that this is not an extension of what they do at home or at school. Children and instructors always sit on the ¯oor, using cushions as well as mats as necessary. As with adult MBCT, exercises are interspersed with discussion sessions, but mindfulness exercises are more varied as well as sometimes being very active. Time for drawing, writing games and stories can also be included. Meditations themselves may not be attempted for more than 5 minutes at a time with frequent changes between activities. These are calculated to involve as many sensory modalities as possible, including sound (with the aid of music), taste and smell. Discussion periods are prefaced by written rules about treating others with care and kindness and asking to speak before doing so. Talking is discouraged during exercises by a written rule of this kind, while one child at any one time can opt-out of an activity by sitting in a designated chair. Throughout, the home practice exercises and achievements in the session are rewarded and reinforced with cartoon stickers. The children keep a portfolio of summaries, worksheets, poems and stories as well as the drawings and writings they produce in their own course notebook.
Working with elderly people can present quite different challenges. While their maturity and relative stillness of mind can make them particularly receptive to mindfulness-based approaches, age-related infirmities can interfere with attempts to provide them by a traditional format (Smith 2006). The experience of Smith and others with this population suggests that sessions are best kept short, and particular attention should be paid to cognitive capacities when screening people for the course. Physical infirmities are likely to require sensitive modification of stretching exercises, while walking meditation poses a unique challenge. Although it is normally an opportunity to practise mindfulness of the body in the course of very slow and deliberate movements, paying attention to the parts of the body in the process of walking increases the risk of falls, as it becomes destabilising in the elderly. It is therefore important to restrict instructions to being mindful of being present in their surroundings, in order to avoid such consequences.
Mindfulness might be harnessed in the deliberate resolution of a psychological problem, but without any of the discussion that would make the intervention a talking therapy. An interesting set of techniques for this, which he has derived from his reading of Krishnamurti, are described by Robert Cloninger (2004: 84-94). These call forward a state of mindful awareness in the consulting room, in which patients loosen their resistances and silently reacquaint themselves with fended-off experience, without being placed under any pressure to express or verbally reflect upon these. There is an initial phase in which a sense of being calm and awake is encouraged by guidance through a sequence of deep breathing, focusing on the top of the head, and on a positive experience. Cloninger’s instructions emphasise acceptance of what is already here, and how the client is, without the wish to become something else.
After 5 minutes, Cloninger moves to the stage he terms ‘mindfulness’. Here observation of the emergence of thoughts, as well as letting them go, is paramount. There is an impartial observation of the causes and effects of a thought as it comes into awareness, with a ‘metacognitive’ awareness of motivation that is a kind of understanding without being a rationalization or commentary. If thought is problematic, it is given precedence. All it attaches to is encouraged to surface, without pressure to comment. There is a bringing into presence of the subconscious mind, which Cloninger refers to as ‘centering’. This state is held for around 15 minutes. The stage of mindfulness then moves into a final, ‘contemplative’ one in which a kind of non-dual awareness is sought. Here, after the mind has grown very quiet, the psyche is addressed by the client with a request for help in deepening self-understanding. There is an enlargement of awareness while the client is encouraged not to demand or expect any results. Silence is maintained as an experience of resolution and unity develops.
Cloninger reports that this can lead to the removal of the distinction between subject and object. There is a complete and instantaneous understanding of the interdependence of thinking and feeling such that they stop, and the mind (and the brain) becomes very quiet. It is a state of being that is also frictionless because there is no longer internal opposition between parts of the mind that attempt to give direction to others. Like Krishnamurti, he sees this stilling as a natural process, even if it goes against the grain of all habitual mental activity. The entire guided exercise takes no more than 30 minutes.
There is quite a paradox in this procedure as an active application of Krishnamurti’s principles. Although Krishnamurti sometimes called the process of understanding the mind ‘meditation’, he seemed to mean the antithesis of what everybody else refers to as meditation. According to Krishnamurti, meditative practices are ways of dulling the mind rather than liberating it: ‘A well-disciplined mind is not a free mind, and it is only in freedom that any discoveries can be made’; ‘Through self-discipline, the mind can strengthen itself in its purpose; but this purpose is self-projected and so it is not the real’ (Krishnamurti 1988: 68). For him, meditation was not a discipline of any kind, but what remained when all striving ceased: ‘Silence of the mind cannot be brought about through the action of will. There is silence when will ceases. This is meditation’ (Krishnamurti 1986: 167). Perhaps the active role of the therapist in Cloninger’s procedure, orchestrating the client’s process of internal recollection, takes the process closer to Krishnamurti’s idea in so far as it attenuates the impact of the client’s own intentionality. It seems an intriguing development. This quiet therapy is neither quite a meditation nor therapy. Yet, it harnesses something that resembles mindfulness in its effects.
This return to therapy may be the right moment to make an important general but practical point. Working with mindfulness is different from any other health technology, because of what it is as an attentional discipline and the kind of involvement it requires from practitioner and patient. A corollary of this is that both parties are likely to be opening in other ways at the same time as dealing with the kind of mental formations that are recognised by traditional psychopathology. These further developments may not be the point of the intervention, and they might have been achieved in other ways, but they need to be recognised.
Identifying clinical needs
We have referred several times to the importance of choice and of matching the practice to the individual. While this could be seen as a fetish from an over-instrumental approach to mindfulness – one that sees practices as technologies rather than ways of being – the art of matching a meditative method to a student’s needs and temperament is explored in classic manuals such as the Visuddhimagga (Buddhaghosa 1999). Harnessing mindfulness at an individual level is likely to be assisted by an updated system of formulation of the factors that are likely to assist such choices. In the field of psychotherapy, there is widespread agreement on the desirability of having some basis on which to formulate someone’s capacities and requirements, but rather less consensus on how this is to be done (Johnstone and Dallos 2006). However, if we take the findings from the previous articles into account, it is perhaps possible to list the factors that a mindfulness formulation might take into account. These need to include psychological capabilities that indicate the kind of methods someone is most likely to respond to, as well as factors that assist in the diagnosis and delineation of key areas of blockage and difficulty that are likely to be amenable to a mindfulness-based approach. By deliberately restricting the list to 12 candidates, six cognitive abilities and six psychological attributes, the following factors have recommended themselves as being distinct from one another, as having wide-spread currency, and as being relevant in the context of diagnosable mental health problems:
Factors to consider in case formulation
Concentration (capacity to sustain attention) Receptiveness (openness and freshness of attention) Somatic awareness (sensitivity to somatic sensations) Visualisation (capacity to generate internal images) Cognitive identification (capacity to relate to thoughts as thoughts)
Recollection (vividness and availability of past memories)
Internal coherence (sense of personal continuity and agency) Emotional modulation (awareness, tolerance and self-regulation of feelings)
Empathy (ability to enter into others’ feelings and viewpoint) Warmth (capacity to demonstrate love and affection) Self-attack (tendency to judge, criticise or punish oneself ) Purposefulness (sense of ultimate goals and capacity to generate new meanings)
While there are other cognitive and psychological factors that could be added to a list of this kind, they are unlikely to be independent of these 12 in practice. For instance, emotional range (the breadth of people’s emotional experience) will be closely related to their capacity to be aware of feelings. Other factors may be important within other formulation systems, such as verbal intelligence or the capacity to symbolise. They are simply less relevant to choosing between methods where mindfulness-based interventions are concerned.
The aim is not to be exhaustive, and this is all too easily achieved by endless splitting and multiplication of elements, but to have a system whose structure is simple and self-explanatory, and that directly meets the needs of therapists and prospective clients. In a similar spirit, the components of the formulation would be qualities that can be recognised from a face-to-face meeting without recourse to distracting tests and inventories, with sensitivity to them deepening with practice. Use of them should develop and organise observations that a therapist naturally values and makes instinctively. The results can be discussed openly with clients in order to arrive at an agreement of where they currently stand. This provisional schema needs to be fully tested out in practice before it is used in a prescriptive way. Each component’s inclusion will be justified by its usefulness when shaping plans for interventions that are likely to be beneficial for a given client or patient.
Josie, a teacher in her early forties, has been seeking help since she was suddenly left by her husband four months before. She has no history of frank psychiatric illness or use of meditative techniques. She used cannabis intermittently in adolescence and at college and describes lifelong self-doubt and a pattern of living through her husband and his friends’ wives. She had been unable to conceive with him, and, while he had tried to reassure her that this did not matter, he has now set up home with a younger woman. She has felt she is falling apart and is kept awake by nightmares in which she experiences herself as having a miscarriage of a fully formed foetus without anybody there to help her, after which she cannot stop bleeding. She finds it difficult to notice the weather or to taste the coffee she is drinking. She hates being alone and is constantly phoning up their friends. She feels she is alienating them with her crying, remonstrations and questions. She switches between believing that her husband is a demon that she should be revenged upon, and feeling that she is a useless, unattractive bore whom anybody would be better off without.
What is very distinctive about the phenomenology here is the profusion of affects (anger, self-hate, guilt and sadness), far from fully felt, alongside evidence that these are poorly modulated. Affective changes are associated with discontinuities in Josie’s sense of herself, while she attacks herself psychologically even if there is no frank physical self-harm. (The specificity of her recollections may be a relevant and positive prognostic sign here.) Experiences from which she is emotionally cut off seem more accessible to her through visualization than from awareness of what is happening in her body.
A number of different treatment approaches for Josie are possible. The analysis here is likely to be helpful when considering mindfulness-based ones. Josie would be likely to find the full force of her feelings overwhelming if they were to be suddenly released. A recommendation for her to face them in a more modulated way would emphasise a gradual introduction to somatic focusing, first as a way of being able to ground herself away from the maelstrom of what is rushing through her head, and then to build up some attentional stability. Once there is a capacity to give attention to ordinary sensations and to experience these relatively fully, consideration could be given to moving attention to her thoughts and feelings so that these are experienced in themselves, instead of a chaotic confusion. Ultimately, being able to decentre from the very rigid either/or thinking that accompanies her sudden mood changes is likely to be of considerable help in finding ways to disengage from them. None of this would be a substitute for a working relationship with someone who is simultaneously and empathically able to help her explore and articulate what is happening at each step. However, judicious introduction of attentional practices in this way seems likely to facilitate and hasten a healing process.
In this instance, formulation is being used to design an individualised treatment. It suggests components it might include (and avoid) as well as highlighting likely areas of difficulty. Some other instances of how mindfulness techniques can be chosen and incorporated within individualized treatments are provided by Germer (2005a). When choices are being made between complete packages such as DBT or ACT, much can depend upon the components that accompany the mindfulness training they offer. They cannot be considered solely in terms of their approach to mindfulness. DBT may be indicated not only by the brevity of patients’ attention span, but also by the prominence of their self-destructive behaviour. Patients likely to benefit from DBT’s explanations and contained guidance may find, say, ACT’s radical questioning of underlying goals too challenging until they have achieved greater internal stability.
Integrating mindfulness within the clinical setting
Harnessing mindfulness is not only a matter of being able to introduce it and having an appropriate set of tools to offer. In clinical practice, it has to be introduced into a setting whose impact is likely to be critical in either supporting or undermining what is taught.
The development of MCBT as a specific treatment for depression that can be learned and used by mental health professionals is a hugely significant development in bringing mindfulness into routine mental health practice. Earlier articles have illustrated how MBCT and the MBSR programme can be adapted to meet the needs of people diagnosed with individual disorders. In generic community mental health practice, these diagnoses may be less clear-cut, and the client population quite mixed in the spread of the difficulties they represent. Prospective participants are also relatively vulnerable, and examples have been given already of how and when untimely attempts to engage in mindfulness practice can worsen their difficulties or bring additional problems. In order to present an 8-week training package to a mixed group of mental health service attenders, two issues that have to be confronted straight away are assessment of potential group members and the working format of the groups.
The traditional assessment model for the MBSR outpatient programme in physical health settings has been an opt-in model. Potential participants for a course are identified and are invited to attend an introductory seminar in which the principles of mindfulness practice, the nature of the course, and the likely gains and pains are set out. Any screening and exclusion of individuals on the basis of suspected inability to benefit or potential disruption to the class has ordinarily taken place by this stage through the information provided by referrers, possibly with the addition of prospective clients’ responses to preliminary questionnaires. They are invited to make a choice, based on this experience, whether they wish to continue, the course being likely to follow in subsequent weeks. These sessions are potentially helpful for instructors to get a sense of the overall balance of a new group before it begins, its strengths and potential sticking points.
In running a group with users of mental health services, it is very unlikely that the large groups of over 30 individuals (plus trainees and other visitors) often found in MBSR practice in general hospitals would be appropriate. Many people with mental health problems are very wary of others, and of others’ reactions to them, in ways that make coming to a group with strangers, and under-taking and talking about challenging new experiences in front of them, much more threatening than they would be otherwise. In addition, there will be some tension between the principles of an adult learning or coaching model, in which professionals make themselves available to develop skills in the service of a client’s life choices, and the formal duties of care under which mental health professionals ordinarily work. These bring a need to be highly attentive to changes in patients’ mental health, and a readiness to take additional action where there is justifiable concern about an individual. In effect, this is likely to mean that mindfulness teachers have to be able to pay attention to each individual within the group and to think systematically about each individual, whether or not in attendance, for each week of the programme.
Careful thought needs to be given to both the overall size of the group and to how the format is modified within sessions to reduce feelings of pressure. Although didactic phases, in which techniques are introduced, poems read, or homework set, may be delivered to the entire group, phases in which exploration and disclosure are required, as when experiences of exercises and the findings from homework are discussed, maybe better met by dividing the group. Initial discussions of reactions to new material might be in private pairs rather than before the whole group. When the instructors’ input is essential, the group may divide, with one instructor per subgroup. With time, as confidence in discussion grows, the group can take on more of the character of a therapeutic group, with members learning directly from the experience of anyone else present.
The development of courses in either community or inpatient settings is greatly facilitated if the staff responsible can establish a group of their own. This allows coming together for a shared experience of mindfulness (through a shared meditation or exercise) as well as an opportunity to share and learn from experiences in the patient groups. In this, as in the concerted work to maintain a working group format in the sessions for service attenders, there is the exploitation of the principle of resonance, by which mindfulness is enhanced by others’ participation and proximity.
Meeting the needs of future professionals
Mindfulness-based interventions have been used successfully with medical students for around 15 years. This reflects the high-stress levels these students often exhibit, as well, perhaps, as the considerable consequences that failure on their courses would carry. Despite this, the evaluative literature on these interventions is relatively scant, although a good deal has been learned and reported about effective methods of engaging and teaching this population. Three current models can be briefly contrasted, as practiced in Philadelphia, Arizona, and Monash, Australia.
The Philadelphia model
The leaders at Jefferson Medical College are Diane Reibel and Steven Rosenzweig. They have used two different models for providing mindfulness training since the late 1990s. At first, the training was an option that students selected from alternatives during regular teaching hours, only a minority taking it up. Subsequently, it has become an out-of-hours option for as many students as wish to come. In either format, it has been closely integrated with formal teaching on the physiology of stress. Three hours of this teaching are provided in the first year of medical training, with an emphasis on the importance of individuals’ contributions to experienced stress and on students checking out their own experiences (Rosenzweig 2004). For instance, students might be invited to notice what is going on in their bodies and minds before a slide is introduced with the words, ‘any word on the next slide could be on your exam’. They are then invited to relate the sensations going on in their bodies to the picture of the autonomic nervous system that the slide in fact carries. Later, they will be invited to check how they can modify the action of their own autonomic nervous system through breathing exercises. More colourful examples of the extremes of self-regulation are presented prior to an introduction to readily available systems such as bio-feedback and autogenic training. Subsequent teaching builds on this to emphasise the serious health consequences of stress and failure to self-regulate, constantly referring to students’ existing scientific knowledge.
After stress physiology teaching, those who are interested in learning more self-regulatory techniques are invited to an introductory session, to learn about MBSR. Following a specimen-led meditation, a 6-week ‘elective’ training is offered to volunteers. It appears that this is best timed early in the students’ studies, but after they have had some opportunity to experience the stresses of this new role. These come from several sources, social as well as academic (financial stress from debt, the loss of free time, and disconnection from family, as well as the existential challenge of facing death in the course of medical work). Reibel and Rosenzweig have also referred to the spiritual challenge of life being demystified through a relentless induction into reductionist thinking. On top of all this comes the personal psychological challenge of enduring sleeplessness alongside a relative absence of social support, something that may be exacerbated as traditional mechanisms for peer support within the medical community has been eroded.
MBSR was therefore conceived as a way of improving personal wellness in the face of these challenges, as well as a means of developing or preserving compassion in the face of demands either to close down emotionally or be overwhelmed by patients’ difficulties. Learning to follow an explicit path of compassion through such training was seen as a middle way that could be bearable, without compromising personal sensitivity. It also brought wider benefits because it relied on students learning how to teach useful techniques to their patients.
In practice, the student courses are very similar to MBSR as taught in other settings. The foundational practices from MBSR programmes are included, such as sitting meditations, body scan, walking meditation and guided yoga. The personal wellness theme is introduced with a ‘well meditation’, in which participants are invited to be as authentic as possible and to acknowledge their reasons for coming. Information on relevant scientific papers is provided, while students are reminded that the class will not be about these, depending instead on direct experience. Overall, the curriculum is skeletal and flexible, providing a counterweight to the over-organization and indigestibility of other classes the students encounter. The leader reassures them that the rate and order of presentation will depend upon what is happening in the class and requests a commitment to regular practice between sessions. This is usually 20 minutes per day, assisted by pre-recorded practice tapes.
Given students’ tendency to live and suffer in their heads, Rosenzweig and Reibel have found it very important to use physical movement in classes with this group – starting every class with this in different forms. Medical students tend to be very competitive and self-sufficient; sharing experiences in group discussions can be much harder for them than for other groups. Little sharing is required to begin with, with the introduction of ‘mindful listening, practiced in pairs at first. A distinctive part of the content of the student mindfulness curriculum is a practice in silently cultivating wholesome states through specific meditations. In this way,
compassion, loving-kindness, and joy are experienced with encouragement that these can be made available for others. This is emphasised in the discussion of what to do when apparently nothing more can be done for a patient. This seems to be an especially valued aspect of the instruction.
The Philadelphia team have performed detailed evaluations of the impact of MBSR with a heterogeneous sample of 136 general hospital patients (Reibel et al. 2001) as well as a non-randomized but comparative evaluation of 140 second-year students opting to have classes in MBSR, compared with 162 students opting to have classes in complementary medicine (Rosenzweig et al. 2003). Their approach to the assessment of the impact of the intervention was quite different in the two populations. Observations of the students were confined to changes in total mood disturbance, using a little-used ‘profile of mood states’. Although mood disturbance was significantly greater among the self-selected cohort going through MBSR at the study’s outset, their scores showed a significant decrease, while the control subjects showed an even greater increase in mood disturbance over the same 10-week interval.
The Arizona programme
This is very closely linked to the MBSR model. The main amendment is a greater emphasis on cultivation of positive affect, through inclusion of specific exercises to engender feelings of loving kindness and forgiveness and the cultivation of empathy skills in the course of small group discussions. This reflects a rethinking of the qualities of mindfulness, which effectively provide the curriculum for the training. Jon Kabat-Zinn (1990: 33-40) had identified seven attitudinal foundations of mindfulness:
- non-judging (not evaluating or categorizing)
- patience (letting things unfold in their own time)
- beginner’s mind (being willing to see anything afresh)
- trust (of oneself, of one’s experience and of life)
- non-striving (not trying to get to a goal or outcome)
- acceptance (seeing things as they actually are in the present) 7 letting go (allowing thoughts, feelings, etc., to pass away).
To which Shapiro and colleagues have added these five (Shapiro and Schwarz 1999):
- gentleness (being soft, considerate and tender)
- generosity (giving without thought of return)
- empathy (feeling for and understanding others in the present)
- gratitude (reverence and appreciation for what is present)
- loving-kindness (unconditional benevolence and love).
This means that, even more explicitly than in the Philadelphia courses, fundamental attitudes of warmth, giving and self-negation are fostered, together with compassion and forgiveness (which Shapiro and Schwarz see as part of loving-kindness). Apart from benefits in terms of personal stress and coping, the course is intended to touch core professional values.
This programme is distinguished by being the subject of the only truly randomised comparative evaluation to date (Shapiro et al. 1998). An initial cohort of 200 students from more than one year (medical and premedical) were given the opportunity to participate, knowing they would be randomised between an intervention group and a ‘wait-list’ control. This produced 78 consenting participants, whose ‘random’ allocation was still stratified for gender, race and course year. The 37 students who received the intervention did so in two classes, each with a different instructor. The classes met over 8 weeks, the sequence of exercises closely following Kabat-Zinn (1990), with a strong emphasis on group discussion. Evaluation compared immediate post-course scores with precourse scores on measures of anxiety, global psychological distress, empathy and spiritual experiences. The post-course evaluation coincided with a time of high external stress (examinations), when comparisons were also drawn with the wait-list controls. (These were given a brief, one-off meditation class prior to testing to control for any post-session effects on the day of evaluation.) The wait-list controls went on to the intervention themselves, and showed similar positive changes at the end of 8 weeks. All evaluations were administered by an independent experimenter, blind to treatment exposure. The daily practice of participants was monitored to allow analysis of the impact of compliance with the programme.
The study allowed six sets of comparisons, all with significant differences between the pre- and post-intervention scores of the course attendees compared with controls. In three measures, the two groups moved in opposite directions – state anxiety, depression and empathy. In the other three, the controls’ scores were virtually static, with the course attendees’ scores moving in the expected direction (trait anxiety, general severity index and a measure of ‘spirituality’). The pre-post measures were then repeated for the control students who subsequently attended the course. In every case (except trait anxiety, which had to be omitted for operational reasons), the change in scores through the course replicated that of the original attendees. A particularly interesting aspect of the study is the demonstration of at least a short-term impact on the students’ empathy (measured using a local version of the Empathy Construct Rating Scale). While the measures of depression and anxiety support a stress-reducing effect, this is indeed evidence of how the training can further the development of core professional attitudes and values.
The Monash model
This Australian model differs significantly from the others here, as it was developed independently of the MBSR tradition. Mindful-ness skills are built up progressively from brief meditations to longer exercises, while there is a greater emphasis on simultaneous development of specific cognitive skills that are associated with ‘stress release’ (Hassed 2004). Introduced in sequence, these comprise perceptions, acceptance, presence of mind, limitations, listening, self-discipline, emotions, and understanding of ‘self-interest’. Classes involve illustration, discussion and exercises focusing on each skill, followed by review the next session. Despite its origins, Hassed’s model is not greatly different from ‘lite’ variations of MBSR that have been provided as introductory training for professional groups within tight time constraints elsewhere. What is unique is its complete integration within the medical school curriculum. It is compulsory for all students, being an integral part of teaching in a ‘health enhancement programme’ that bases all teaching around a positive conception of health, representing 5 percent of the total programme (Hassed 2005a). Stress management tutorials and skills training are provided over 6 weeks in the first semester of the first year, with top-ups in later years. Understanding of the principles of ‘mindfulness-based stress management is formally examined by OSCE (objective structured clinical examination) stations.
Hassed has conducted research into the impact of the programme but without standardised measures or investigation of its relative benefits in relation to specific sources of stress. He has produced data (from a partial sample of volunteers only) on students’ actual use of specific coping strategies subsequent to the programme (Hassed 2005b). This shows that, in addition to newly learned meditation and cognitive techniques, students subsequently rely more on healthy nutrition, exercise and social support to manage stress. However, this programme, too, appears to provide an education in professional values that goes well beyond stress reduction.
The fruits of mindfulness: a paradox
For many, the Buddha’s words to Bahiya, quoted at the outset of this article, are the quintessence of the Buddha’s teaching. Shorn of the elaboration and repetition that is so characteristic of the Buddhist scriptures encountered in the first article, we are left with a verse to meet the Dhammapada’s plea for a ‘single verse that brings peace’. When you see, do nothing but see. When you hear, do nothing but hear. For touching, tasting, sensing and cognising, likewise. Are things really so simple? As in so many of the commentaries and suttas, the Buddha’s reported words come within a context. Moreover, in the telling of this very famous story, it is a context that gets hugely changed in the telling. In all versions, Bahiya is a supplicant who comes to ask the Buddha how he may achieve liberation. When he hears the Buddha’s words, the effect is immediate and he achieves enlightenment straightaway. But why is the Buddha’s teaching so remarkably direct and so effective in Bahiya’s case?
Two elements are usually present in the fuller story. One is that Bahiya is about to die. He knows he is going to die. The Buddha sees he is about to die. There is no time to be lost. Every word, every breath counts. So not a syllable is wasted. And just after his liberation, Bahiya’s death comes anyway. The other element is preparation. Bahiya may be presented as somebody who is primed for liberation through his precarnate relationship with the Buddha (as in Burlingame’s own account). Or the narrator may stress Bahiya’s saintliness achieved through good works and purity of mind (e.g. Hart 1988: 116-17). Sometimes Bahiya’s readiness is expressed in terms of having attained the eighth state of concentration as if the Buddha assisted with a final ineffable nudge that would otherwise have little effect.
Already, there are so many additional things that one should be doing – beyond just seeing – to generate no end of spiritual exertion. And that is assuming that the words actually had meaning to Bahiya as words; that happenings on the cusp of death are relevant to other phases of life; or that the sheer presence of the Buddha might not affect the relationship between mindful effort and awakening. Avid readers of Mindfulness – Origins and Concepts will recall how the great sutta on mindfulness closed with the Buddha radically dropping the threshold at which liberation might be achieved, provided the meditator’s inner condition was ripe. In this article’s discussion of retreats, it was evident that emphasis on patient, slow progress toward desired states of balanced attention was even greater in other schools than for the early Buddhism we have been drawing on here. The story of Bahiya provides enigmatically few answers as to the preparation that is truly required, if any, before untainted seeing, hearing, sensing or cognising becomes possible here and now.
While many methods of cultivating mindfulness are already available, much scope remains for others to be developed. Tracking the internal reverberations from different kinds of aesthetic experience affords just one example. The intensification of mindfulness during residential retreats offers an important opportunity to evaluate the relative contributions of practice, continuity, presence of others and teaching on changes in awareness. Methods of adapting individual techniques to the person can take non-psychological factors into account, including age. The formulation of a person’s attentional strengths and blind spots may be helpful in designing treatment plans to address individual clinical needs. Mindfulness can be adapted and taught to mixed groups in mental health settings if appropriate arrangements are made, while their potential use in inpatient settings seems underexplored. Current issues in the training of future professionals in mindfulness are considered in relation to the specific needs of medical students. These have included the refreshment and revitalization of basic motivations and values, as mindfulness practices are complemented by others designed to cultivate positive affects and compassion.
References and Further Reading
- Mascaro, J. (1973) The Dhammapada. Harmondsworth: Penguin.
- Khantipalo, B. E. (1996) A Treasury of Buddhist Stories from the References 171 Dhammapada Commentary (trans. E. R. Burlingame). Kandy: Buddhist Publication Society.
- Wallace, B. (2006) The Attention Revolution: Unlocking the Power of the Focused Mind. Boston, MA: Wisdom Publications.
- Goleman, D. (1988) The Meditative Mind. New York: Putnam.
- Sole-Leris, A. (1992) Tranquility and Insight. Kandy: Buddhist Publication Society.
- Brown, D. and Engler, J. (1986) The stages of mindfulness meditation: a validation study. In Transformations of Consciousness (Also in Journal of Transpersonal Psychology (1980), 12, 143-92) (eds K. Wilber, J. Engler and D. Brown). Boston, MA: Shambhala, pp. 161-91.
- VanderKooi, L. (1997) Buddhist teachers’ experience with extreme mental states in western meditators. Journal of Transpersonal Psychology, 29, 31-46.
- Lutz, A., Greischar, L., Rawlings, N. et al. (2004) Long-term meditators self-induce high-amplitude gamma synchrony during mental practice. Proceedings of the National Academy of Sciences of the United States of America, 101, 16369-73.
- Shapiro, S. L., Carlson, L. E., Astin, J. A. et al. (2006) Mechanisms of mindfulness. Journal of Clinical Psychology, 62, 373-86.
- Rumi (1994) Say I Am You: Poems of Rumi (trans. John Moyne and C. Barks). Athens, GA: Maypop Books.
- Helminski, K. (2000) The Rumi Collection. An Anthology of Translations of Mevlana Jalaluddin Rumi. Boston, MA: Shambhala.
- Oliver, M. (1986) Dream Work. New York: Atlantic Monthly Press.
- Astley, N. (ed.) (2002) Staying Alive. Tarset: Bloodaxe.
- Whyte, D. (1990) Where Many Rivers Meet. Langley, WA: Many Rivers Press.
- Shapiro, S. (2001) Poetry, mindfulness and medicine. Family Medicine, 33, 505-7.
- Kabat-Zinn, J. (2005) Coming to Our Senses. New York: Hyperion.
- Semple, R., Lee, J. and Miller, L. (2006) Mindfulness-based cognitive therapy for children. In Mindfulness-Based Treatment Approaches (ed. R. Baer), New York: Academic Press, pp. 143-66.
- Smith, A. (2006) `Like waking up from a dream’. Mindfulness training for older people with anxiety and depression. In Mindfulness-Based Treatment Approaches (ed. R. Baer), New York: Academic Press, pp. 191-215.
- Cloninger, C. (2004) Feeling Good: The Science of Well-Being. New York: Oxford University Press.
- Krishnamurti, J. (1986) Commentaries on Living: Second Series. London: Gollancz.
- Buddhaghosa, B. (1999) Vissudhimagga or the Path of Purification (trans. N. Thera). Seattle, WA: BPS Pariyatti Editions.
- Germer, G. (2005a) Teaching mindfulness in therapy. In Mindfulness and Psychotherapy (eds G. Germer, R. Siegal and P. Fulton), New York: Guilford, pp. 113-29.
- Reibel, D. K., Greeson, J. M., Brainard, G. C. et al. (2001) Mindfulnessbased stress reduction and health-related quality of life in a heterogeneous patient population. General Hospital Psychiatry, 23, 183-92.
- Rosenzweig, S. (2004) Integrating MBSR into a medical school curriculum. In Integrating Mindfulness-Based Interventions into Medicine, Health Care and Society. Worcester, MA.
- Shapiro, S. and Schwarz, G. (1999) Intentional systemic mindfulness: an integrative model for self-regulation and health. Advances in Mind-Body Medicine, 15, 128-34.
- Shapiro, S. L., Schwartz, G. E. and Bonner, G. (1998) Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine, 21, 581-99.
- Hassed, C. (2004) Bringing holism into mainstream biomedical education. Journal of Alternative and Complementary Medicine, 10, 405-7.
- Hart, W. (1988) The Art of Living: Vipassana Meditation as Taught by S.N. Goenka. Igatpuri: Vipassana Research Institute.