Editors’ Note: This review article is the first of two companion papers on the topic of mindfulness to be published in this Journal. The second paper is a research article titled “Mindfulness, Self-Care, and Participatory Medicine: A Community’s Clinical Evidence.”  

Abstract

Summary: Therapeutic modalities involving the practice of mindfulness are gaining wide acceptance as effective interventions in medicine and psychotherapy. A growing body of well-designed research studies demonstrate significant and enduring improvements in a host of physical and mental health domains as a consequence of the practice. This effectiveness may be due in large part to the nature of mindfulness, which is an elemental dimension of proactive self-care. In this review and position paper we outline and explore 3 decades of evidence for the relevance of mindfulness in the model of Participatory Medicine. Also included is a summary of one community’s experience with a mindfulness-based intervention, Mindfulness-Based Stress Reduction (MBSR). The authors of this paper are community physicians, psychologists, therapists, patients, and teachers who have direct personal experience of mindfulness practice and/or observations of their patients who completed the MBSR program. The authors conclude that with such rich evidence for its enhancement of health status and the parallel improvements in proactive self-care, mindfulness should be considered a fundamental principle in the evolving model of Participatory Medicine.
Keywords: Participatory medicine, self-care, mindfulness, Mindfulness-Based Stress Reduction, MBSR, therapy, meditation.
Citation: Rogers B, Christopher M, Sunbay-Bilgen Z, Pielage M, Fung H, Dahl L, Scott J, Sarma AR, Connor D, Gryde C, Alvarez K, Hills M, Holt J, Drury N, Beale N. Mindfulness in participatory medicine: context and relevance. J Participat Med. 2013 Feb 14; 5:e7.
Published: February 14, 2013.
Competing Interests: The authors have declared that no competing interests exist.

Mindfulness, Healing, and Medicine

One of the first mentions of the term “participatory medicine” in the medical literature was made by Jon Kabat-Zinn in 2000.[1] He described the effects of mindfulness practice on patients undergoing standard medical treatment for psoriasis. Those who practiced mindfulness briefly during standard treatment showed a significant and unexpected medical improvement in their condition relative to a control group undergoing standard treatment. Patients acknowledged that they felt a sense of personal empowerment by engaging in the short, guided mindfulness practice. Pondering these results Kabat-Zinn noted, “As care-givers, we have to remind ourselves of what we of course already know, namely that all human beings, including ourselves and our patients have, to varying degrees but almost always, far more than we suspect, deep and life-long inner resources for learning, growing, healing and personal transformation.”

Tom Ferguson[2] recognized that when patients work collaboratively with one another and their caregivers there is this same sort of transformation in their level of personal engagement. He notes that this goes far beyond the tools of information and technology that are currently so abundant in medicine, including the model of Participatory Medicine. Shen[3] similarly noted that beyond the lure of technology, the social-cultural and biological dimensions of Participatory Medicine can enrich the model in fundamental ways. Johnson-Quijada[4] described the transformation that empowered her and her patients as she embraced self-care in participatory medical practice. This collaborative dimension of health and healing is interpersonal and is an important element of healing that is missing in current predominant, disease management-focused models of health care. Medical historian Ann Harrington reviewed historical narratives describing this often overlooked element of medicine, concluding that it is an effective, collaborative, and transformative aspect of human health.[5]

Neurobiologist and medical doctor Daniel Siegel also acknowledged that these interpersonal relationships are a fundamental source of health and well-being.[6] He added that our relationship with ourself, an intrapersonal relationship, is neurobiologically similar and occurs in tandem with this interpersonal dimension of health and well-being. Recent neurobiological research broadly supports this.[7]

The fruits of mindfulness in the therapeutic setting are reviewed by Grossman, Niemann, Schmidt, & Walach,[8] who noted that the practice of mindfulness is a particularly suitable healing modality for helping people live with the complex biopsychosocial dimensions of chronic illnesses with their significant components of comorbidity. These inter- and intrapersonal dimensions of mindfulness explain its natural compatibility with the model of Participatory Medicine.

Participatory Medicine, Participatory Authorship

True to the model of Participatory Medicine, we write this paper as a mutual expression of the integrative nature of mindfulness practice and as an embodiment of its value to health care. We are 15 authors and some of us work as clinicians in a diversity of organizations in one community, a medium-sized city in Oregon. As clinicians, we work in family medicine, internal medicine, integrative medicine, psychiatry, clinical psychology, clinical social work, teaching, physical therapy, and occupational therapy. We all have either learned mindfulness practice though the MBSR program, referred patients to the program, or both.

The learning of mindfulness has been helpful for us and our patients. The benefits of this practice are many and varied: changes in medical symptoms, relief from challenging emotional states, a greater sense of ability to engage challenges, and more. While not a replacement for medical care or therapy, the practice of mindfulness has been a very effective complement. We believe it has potential to enhance models of health care that rely on patients caring for themselves in a proactive way while participating with those around them. We agree with McCabe-Ruff & Mackenzie[9] that this practice has the potential for broad benefits in medicine and society.

Mindfulness and Mindfulness-Based Stress Reduction

Mindfulness is a basic human capacity for attentiveness to the direct experience of living moment-to-moment. A very accessible and therapeutically relevant expression of mindfulness is “awareness, of present experience, with acceptance.[10]” During times of acute stress, trauma, or difficulty the body will appropriately adapt by shifting to a mode of high-alert. This mode may echo through a person’s life in some form as an ongoing state physiologically, neurologically and emotionally. External stressors may be gone, but the state may endure for a long time and decrease the capacity for ease and recuperation. Such lingering stress may take many forms such as pain, difficult physiological states, moods, and more. This can affect health over the long term, often in profound, destructive ways.[11][12]

The practice of mindfulness meditation, a foundational element of self-care, can mitigate this lingering stress. It enhances the capacity for mindfulness, the ability to rest sustained awareness on the direct experiences of life: physical sensations, thoughts, sounds, affective states, churning of thought, and more. Being more capable of sustained attention on current experience enhances the capacity to discern the experience of unconscious reactivity and distraction from the capacity for intuitive choice and conscious attentiveness. As a consequence, there is a tendency to be more responsive and less reactive: physiologically, neurologically, emotionally and socially. As these burdens lift, people are potentially more healthy and capable of healing. Practitioners are more capable of compassionate and healthy inter- and intrapersonal relationships. The therapeutic consequences of this practice are substantial and are being well recognized in the fields of medicine and psychotherapy in a variety of ways.[13][14][15]

Mindfulness-Based Stress Reduction (MBSR) is a well-studied and well-known mindfulness-based group-oriented learning intervention. It emerged as a complement to medical care in a hospital setting more than 30 years ago.[11] It is an 8-week experiential education program for learning the practice of mindfulness involving more than 20 hours of classroom participation and as many hours of homework. It introduces participants to a variety of modes of experiential practice: mindful movement (gentle, adaptive yoga), body awareness meditation (body scan), sitting mindfulness practice, mindful eating, mindful walking and more. The aim of the program is to help participants make the practice relevant to daily living and thereby helpful in the face of life’s inevitable stressors. This elemental dimension of self-care is thus enhanced.

The Role of Mindfulness in Medicine

Mindfulness practice is being recognized as an effective complement to medical care and therapy. Research shows that it alters the stress response and a number of biological markers including blood pressure, inflammation, and immune response.[16][17][18] Many recent studies show that significant alterations of brain structure and function associated with self-regulation, learning, memory, emotional regulation, perspective and self-referential processing are a consequence of mindfulness practice.[7][19] A rapidly growing number of studies show that the practice of mindfulness is helpful for those who suffer from a variety of medical and psychiatric disorders: arthritis,[20][21] anxiety,[22] cancer,[23][24][25] diabetes,[26] fibromyalgia,[27] HIV,[28][29] insomnia,[30] irritable bowel syndrome, [31] obesity,[32] multiple sclerosis,[33] pain, [34][35][36][37] PTSD,[38] and tinnitus.[39] Likewise, mindfulness has been shown to be helpful for life situations impacting health: aging,[40] caregiver stress,[41][42] grieving,[43] health care profession stress,[44][45][46] incarceration,[47] and military deployment. [48]

A host of interventions that include the practice of mindfulness are now offered to patients in treatment and as preventive care including: Acceptance and Commitment Therapy (ACT),[49] Dialectical Behavior Therapy (DBT),[50] MBSR,[51] Mindfulness-Based Childbirth and Parenting (MBCP),[52] Mindfulness-Based Cognitive Therapy (MBCT),[53] Mindfulness-Based Mind Fitness Training (MMFT), [48][54] Mindfulness-Based Relapse Prevention (MBRP),[55] Mindfulness-Based Cancer Recovery (MBCR),[56] Mindfulness-Based Elder Care (MBEC),[57] and Mindfulness-Based Chronic Pain Management.[58]

Such an impressive array of studies and therapeutic interventions makes it tempting to place mindfulness on the cookbook list of treatment guidelines followed by health care providers in this fast-paced, supply-side culture of contemporary medicine focused on managing disease quickly and efficiently. This would not support the intentions and value of mindfulness practice. The goal-oriented seeking of an outcome that is routinely packaged by a health care provider who has little personal experience with the practice is contrary to the nature of mindfulness and, as a consequence, may diminish its beneficial outcomes.[59]

At the heart of mindfulness is proactive personal engagement, a willingness to make space in daily living for cultivating the intrapersonal relationship described by Siegel[6] that parallels the interpersonal nature of healing relationships. A number of studies acknowledge that mindfulness does indeed measurably impact self-care in substantial ways.[15][42][45][48][60][61]

An Example of Mindfulness in Participatory Care

We conducted a naturalistic study of the clinical relevance of mindfulness for the model of Participatory Medicine for both patients and health care providers in one community over a 4-year period.[15] Nearly 200 participants who completed an MBSR program were tracked for health status, self-care, and continuity of mindfulness practice at pre-, post-, and long-term followup. Clinicians who were known by participants of the program were asked if they had noticed a difference in their patients’ attitudes and behaviors regarding self-care.

Participants endorsed substantial improvements in many areas of health status such as coping, energy levels, activity levels, pain, medication use, and blood pressure. Many of these improvements endured over years. Participants indicated that their attitudes and behaviors toward self-care substantially improved as a consequence of the program and this is parallel to observations of the clinicians who referred them to the program. The study also documented a strong relationship between the continuity of mindfulness practice and levels self-care and stress. The vast majority of program participants reported a continued formal or informal mindfulness practice, which correlated significantly with decreased levels of stress and improved self-care in the long term. We have included some comments from participants and clinicians to provide a qualitative and personal description of the experiences of the community of people who participated with one another while learning mindfulness practice during this study (Table 1 & Table 2).

Table 1. Comments from referring clinicians about the value of mindfulness practice and MBSR to their patients.

Table 2. Comments from MBSR program participants about the value of mindfulness practice in their experience of health care.

Mindfulness, Participatory Medicine, and Standards of Care

A growing body of quasi-experimental and controlled studies, meta-analyses, and established mindfulness-based interventions provide abundant evidence for the generalized therapeutic value of the practice of mindfulness in medicine and psychotherapy. It has proven to be broadly relevant for both patients and clinicians as it enhances the ability to meet the suffering that accompanies illness with proactive participation.

As our society moves from unsustainable fee-for-service care to an outcome-oriented way of managing health and illness, the model of Participatory Medicine becomes more practical and relevant. We believe that it is time to begin considering mindfulness as an elemental principle in standards of care in this model. We acknowledge that meeting a modern standard of care through specialist associations, government, or health care organizations is a daunting prospect, and especially so as the most common source of standard of care criteria is the courtroom.[62] We postulate that evidence for the value of mindfulness practice will soon meet the evidence-based criteria for best practices in participatory care and self-care. The next phase in the development of the role of mindfulness in medicine is to continue to weave together communities of clinicians and patients in order to expand its clinical relevance. As the outcomes become more tangible for patients and clinicians, the standards of care will emerge more clearly and will help define the paradigm of participatory care. This will be particularly relevant with the emergence of accountable care organizations and the importance this model places on proactive patient self-care.

Conclusions

Mindfulness is an inherent human quality and an elemental dimension of self-care that is often diminished in the face of stress and illness. This, in turn, amplifies the medical, psychological, social, and self-care difficulties of illness. Mindfulness-based interventions have proven to be effective complements to medical care and therapies that mitigate each of these difficulties in substantial and enduring ways. As such, we believe that mindfulness should be considered a fundamental principle in the evolving model of Participatory Medicine and that mindfulness-based interventions should be included in development of standards of participatory medical care.

Addendum

The authors would like to add this acknowledgement: Saki Santorelli planted the seeds for our work with his inspiring 2010 talk about mindfulness in model of Participatory Medicine.[63] His teaching and writings, including his seminal book Heal They Self: Lessons on Mindfulness in Medicine, continue to nourish us.[64]

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Copyright: © 2013 Brant Rogers, Michael Christopher, Zeynep Sunbay-Bilgen, Marie Pielage, Hui-Ning Fung, Lauren Dahl, Jennifer Scott, Akkaraju R. Sarma, Danni Connor, Carol Gryde, Kathy Alvarez, Melissa Hills, Jan Holt, Nancy Drury, and Nicole Beale. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.