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Making Space for Mindfulness
Increasingly, clinicians here are turning to an ancient practice to help their patients — and themselves.
Illustration by Ben Giles
“Mindfulness helps us disengage the more primitive parts of the brain while engaging the more evolved parts.”
— Neda Gould, clinical psychologist
We’ve put a lot of time and effort into this article, and obviously, we want you to read it. But not just yet. First, pause for half a minute and turn your attention to your breathing. Close your eyes and focus on the sensations in your body as you take a deep breath in ... and then a long exhalation out ... three times.
There. You just completed one of the most basic mindfulness exercises. Hopefully, it will help you be a little more attentive as you continue reading about how Johns Hopkins clinicians and researchers are incorporating mindfulness-based interventions into traditional Western medicine — and how the practice has gained a following among faculty members themselves in their quest to reduce their own stress, anxiety and burnout.
A Learned Skill
Definitions of mindfulness abound, but they all contain the core ideas of paying attention to your present reality, without judgment. Your “reality” encompasses all thoughts, feelings and bodily sensations, and the lack of judgment refers to accepting your experience as it is, not labeling it as good or bad, not fighting it or clinging to it.
While some people might naturally tend toward mindfulness more than others, the mind’s strong inclination to wander means that mindfulness for most is a learned skill that requires training and practice, especially in this age of smartphones and multitasking. Developing a strong habit of mindfulness requires a combination of time devoted to structured exercises and the moment-to-moment practice of intentionally bringing your mind to focus on your present reality, whether it’s writing a paper, taking a shower or feeling anxious.
“Humans are uniquely able to turn on the body’s stress response by thinking,” says clinical psychologist Neda Gould, who has become something of a mindfulness guru at Johns Hopkins. “Often those thoughts are ruminations about the past or worries about the future. Mindfulness helps bring us back to the present.”
The Western practice of mindfulness originates from Hindu and Buddhist meditation practices, which got their start thousands of years ago. Its adoption in the United States didn’t begin until 1965. That’s when it was introduced by a visiting Zen missionary to Jon Kabat-Zinn, a molecular biology doctoral student at MIT.
By 1979, Kabat-Zinn, on faculty at the University of Massachusetts Medical School, had founded the Stress Reduction Clinic, based on the tenets of mindfulness. He had also created a secularized eight-week mindfulness course — now called Mindfulness-Based Stress Reduction (MBSR) — to help patients with chronic pain. More than 24,000 people have completed the MBSR program in the 35 years since it was launched, according to the program’s website. One of them was Gould.
“The course was transformative for me. It allowed me to see the world in a whole different way,” says Gould, who enrolled 10 years ago when she was a postdoctoral fellow working on the burn unit at Johns Hopkins, hoping to gain tools to help patients who were suffering from post-traumatic stress disorder. “I’m a pretty driven, high-strung individual, but mindfulness opened my eyes to an entirely new experience of living in the present moment,” she says. “I now have the capability to be with my stress and work with it, as opposed to running from it — which didn’t work anyway.”
Seeing its potential, Gould embarked on an intensive MBSR certification process and has since brought mindfulness training to hundreds of patients with all sorts of illnesses through classes at Johns Hopkins Bayview Medical Center. She also works with patients at Johns Hopkins’ Amos Food, Body and Mind Center, and she offers ongoing courses for faculty and staff members. Participation has far exceeded expectation, she says, which underscores the reality that employees at Johns Hopkins are hungry for ways to decrease stress, reduce burnout and live happier lives.
Michelle Horner, a child and adolescence psychiatrist who is a faculty associate at the Bloomberg School of Public Health, took Gould’s class about two years ago. Partly, she wanted to learn the MBSR skills, since mindfulness is part of the therapy provided to her patients, but she also wanted to live more in the moment herself. “As faculty, we’re often submitting grants and seeing patients while thinking about the next one coming up. We allow our future planning to interrupt our experience of life,” she says. “I’m so thankful for the skills Dr. Gould taught me and for the university’s support of her classes.”
Paying Attention to Pain
It might seem obvious that it’s good to be mindful when driving or performing surgery, but what about when you’re in pain? How can “being present” to the pain be helpful?
“Mindfulness reframes how we think about pain,” says rheumatologist Dana DiRenzo. “Our awareness of pain often arrives with thoughts about how bad it was last time or how long it might last. That catastrophizing ramps up the sympathetic nervous system, which makes things worse.”
DiRenzo just finished her fellowship in rheumatology at Johns Hopkins and joined the faculty this summer. She has always been interested in mind-body interventions and was looking for additional ways to help her patients cope with their often debilitating pain. That’s when a colleague introduced her to Gould. DiRenzo took Gould’s MBSR class twice and then completed meditation and mindfulness teacher training.
One patient who’s grateful for DiRenzo’s knowledge of mindfulness is Wynette Sims, a 54-year-old Baltimore mother of twins who used to work as an academic adviser for The Johns Hopkins University’s Center for Talented Youth — until her illness forced her to go out on disability. Sims has ankylosing spondylitis, a rare inflammatory disease with no cure that causes joint pain and stiffness, especially in the lower back. Its hallmark is the ectopic formation of new bone in the spine, which can fuse the lower vertebrae together, causing a hunched posture.
Last fall, during a routine visit to her rheumatologist, Jemima Albayda, Sims asked for a referral to a therapist to help her deal with her stress, which was causing painful flare-ups. “I’m usually pretty positive and have a high tolerance for pain,” she says, “but it was starting to wear me down. On top of that, I was helping my daughters prepare for college tours and applications.”
DiRenzo, then a fellow, mentioned Gould’s MBSR class for patients with chronic illnesses. “The class was amazing,” says Sims. “Beyond anything I could have imagined. Now, instead of fighting the pain, I identify it, acknowledge that it’s part of my reality and breathe through it. It takes away the anxiety, which lowers the pain.” Sims says that some of her classmates were in so much pain they could barely get themselves to class, but by the end of their three-hour session, their pain levels were down from a 10 to a three.
“The class was … beyond anything I could have imagined. Now, instead of fighting the pain, I identify it, acknowledge that it’s part of my reality and breathe through it. It takes away the anxiety, which lowers the pain.”
— Patient Wynette Sims
Sims’ life was so transformed by learning mindfulness that she has been sharing it, informally, with everyone she knows. Her plan is to be trained so she can start teaching it officially. “Although my body doesn’t move too well, my mind has never stopped working,” she says. “I’m a person who yearns to learn and do good for the community, so I’m very excited to start this new effort.”
At Least as Powerful as Placebos
Anecdotes like Sims’ are not hard to find. Gould has gathered many such testimonies in the decade she’s been teaching mindfulness classes for Johns Hopkins patients with chronic pain and other medical and psychiatric diagnoses. But she has also been working with researchers testing mindfulness from within the framework of traditional Western (allopathic) medicine, whose gold standard is the randomized controlled trial.
“In general, the robustness of mindfulness trials has been gradually increasing over the last couple decades,” says internal medicine physician Madhav Goyal, who worked with Gould and 13 other Johns Hopkins researchers to write a 200-page systematic review of the scientific literature on meditation programs. Their report is summarized in a 2014 JAMA Internal Medicine article. It was funded by the Department of Health and Human Services’ Agency for Healthcare Research and Quality, precisely to help consumers and physicians understand the current state of evidence.
Screening nearly 20,000 citations, the team found only 47 randomized controlled trials with placebo-level controls. The studies examined a broad range of outcomes, including stress, anxiety and depression. In addition to assessing the magnitude and direction of the tallied outcomes, the review team also classified the strength of the evidence as high, moderate, low or insufficient. None of the meditation programs produced a high strength of evidence for any of the outcomes assessed, but mindfulness meditation had small effects on three outcomes with moderate strength of evidence: depression, pain and anxiety.
“Whether the studies focused on patients whose primary ailment was depression, pain or anxiety, or whether they studied other patients, like those with HIV or heart failure, each trial showed some level of improvement for those three indicators,” says Goyal.
Since the majority of evidence grades were low or insufficient, the group called for stronger study design, and Goyal says that’s already starting to improve, especially with increases in funding. Real placebo groups, or “active controls,” are expensive to include because they receive the same amount of in-person training as mindfulness class participants, just on a different health-related topic. For this reason, many studies use the less stringent “waitlist controls,” who receive no intervention.
That said, Goyal doesn’t believe all mindfulness studies have to reach the highest standard to be useful. “There are important academic questions that should be pursued with adequately controlled trials, like how does mindfulness work, and for which conditions? But mindfulness programs are trying to treat depression, anxiety and pain, not cancer or heart attacks. If a person finds that their symptoms are lower, that’s a beneficial outcome, whether or not there was a placebo control.”
Anchored in the Present
Formal mindfulness meditations involve “abiding calmly in the present moment” by concentrating one’s attention on an “anchor point,” like breathing, notes expert Mark Williams, founding director of the Oxford Mindfulness Centre. Another classic mindfulness meditation uses a point-by-point mental scan of the body as its anchor point, accounting for all sensations present from head to toe without fixating on any of them.
When the mind wanders away, as it’s apt to do, you gently bring it back to the anchor point without scolding it for having wandered. Johns Hopkins’ Neda Gould explains that this withholding of judgment provides a space that allows you to notice your experiences without getting caught up in narratives, like, “I’m no good at this meditation stuff. Actually, I’m no good at anything,” or “Oh no! My back is hurting again! Another day ruined.” Over time, you begin to see patterns. You gain insights about where your mind likes to take you and how it operates, which helps you gain the upper hand.
Beyond the Clinic
Like Goyal and Gould, Erica Sibinga, director of ambulatory pediatrics at Johns Hopkins Bayview Medical Center, trained in Western medicine. When in private practice, she was interested in how alternative approaches could be used in pediatrics, but, “the studies were often weak or written in a ‘different language’ from that of allopathic medicine,” she says. So she set out to evaluate them.
During her fellowship in general academic pediatrics at Johns Hopkins’ Harriet Lane Clinic, which provides general pediatric care to children in the surrounding community and those visiting Johns Hopkins specialists, Sibinga found that some East Baltimore families were already using mind-body approaches to help them cope, especially those whose children were experiencing chronic pain from sickle cell disease. A literature search led her to Kabat-Zinn’s MBSR courses, but little research had been done in children. Undaunted, she worked with an experienced MBSR instructor to adapt the training to her pediatric population.
Her first National Institutes of Health-funded, randomized, active-controlled pilot trial was designed for Baltimore teens infected with HIV. Though only 40 completed the study, those in the MBSR group reported higher problem-solving skills and life satisfaction, and lower aggression. Intriguingly, their HIV viral load was also more likely to have declined over the course of the study (a reflection of better HIV disease control), even though there was no difference in that group’s self-reported adherence to medications.
“From our work with these youth, we also learned that they were applying their new coping skills to other aspects of their lives, unrelated to HIV,” Sibinga says, “so we expanded the program to the general pediatric population in Baltimore and then to other cities.”
A 2016 study she led assessed the efficacy of their 12-week, school-based MBSR curriculum versus a comparable health education program for 300 low-income middle school students in Baltimore’s public schools. The MBSR students reported significantly lower levels of several indicators, including depression, rumination, self-hostility, negative coping and post-traumatic stress symptoms.
Beyond the clinic and school, mindfulness practices are becoming prevalent in the workplace, as employers try to help their employees cope with stress and burnout. At Johns Hopkins, Gould’s mindfulness classes are an important part of Johns Hopkins Medicine’s new “Joy in Medicine” initiative, aimed at addressing burnout in faculty and staff members.
Mindfulness techniques are also becoming more accessible and flexible through apps like Calm and Headspace. Though most experienced practitioners agree these apps don’t fully substitute for a trained professional, Sibinga notes that not everyone has time to take an MBSR class. “We did a pilot study using an introductory video and audio-recorded meditations for moms with infants in the neonatal ICU and saw significant improvements, after just two weeks, in depressive, anxiety and trauma symptoms and in sleep,” she says.
All in Our Heads
As the positive experiences accumulate, many researchers are left wondering how mindfulness works its wonders. As Goyal says, it’s not an easy thing to study because it’s literally all in our heads. However, many studies — including two he recently completed on patients with recurrent migraines — have used neuroimaging to get a sense of things.
Gould summarizes the findings this way: “Mindfulness helps us disengage the more primitive parts of the brain while engaging the more evolved parts.”
For example, several studies suggest that the prefrontal cortex — much larger in humans than other primates and responsible for our executive functioning — increases inactivity and connectivity after MBSR training. Other areas of the brain that may be enhanced include the hippocampus, the insula and the cingulate cortex, generally held responsible for memory formation, self-awareness and emotional regulation, respectively. The main area downregulated is the amygdala, responsible for our fight-or-flight response.
“In modern-day life, the amygdala is often activated when there isn’t an actual threat to our physical integrity,” says Gould. “MBSR seems to increase the prefrontal cortex’s control over it, meaning faster deactivation after stressful stimuli and better emotional regulation. Essentially, mindfulness helps us distinguish real from perceived threats.”
The Promise of Mindfulness?
Although the evidence, both anecdotal and otherwise, continues to grow in favor of mindfulness, experts do issue a few warnings. First, Goyal mentions that part of meditation is the observation of one’s feelings, which are often suppressed during our day-to-day hustle, so “anxious or depressed feelings might come up. That’s part of the process, like muscle soreness after exercise.”
More importantly, the experts caution that mindfulness meditation might not be good for everyone, at least in the short term. Goyal says the current norm in the field is to advise patients with psychosis to avoid mindfulness meditation because it could worsen their symptoms. But he adds that there isn’t much data on it. Gould remarks that trained meditation instructors are able to help practitioners skillfully navigate any issues that come up; people in a place of significant distress can benefit from this guidance.
For now, there is no definitive ruling on the ability of mindfulness to relieve the myriad symptoms it is sometimes promised to help. But there is enough evidence for patients and physicians to be encouraged and to continue studying it.
“We need more studies and larger ones,” says Goyal. “There does appear to be a real signal that mindfulness is helpful, but we are still trying to identify which patients benefit and to what degree.”
Watch a Video: Find out more about how Neda Gould is pushing to improve the well-being of patients and clinicians at Johns Hopkins: bit.ly/GouldMindfulness
To that end, Johns Hopkins researchers are forging ahead with new trials. Some, like the one DiRenzo is leading for patients with rheumatic diseases, will look beyond mental health indicators to include measures of disease activity, like joint swelling and inflammatory markers. Sibinga, too, hopes to add biological tests to future studies, if funding allows. “It’s logistically challenging and time-consuming, but gathering data on cortisol levels, cytokines, immune function, autonomic function and brain imaging will help give us a fuller story on mindfulness,” she says.
In the meantime, you can consider mindfulness to be an unconventional tool that might one day become standard.