Perspectives on Mindfulness Amidst the Reckoning on Race and Disparities

Abstract

Editor's Note: In response to the murder of George Floyd at the hands of Minneapolis police in May 2020, I tracked the public responses of a score of professions and organizations related to integrative health. Many issued statements of solidarity with the Black Lives Matter movement. A subset began deeper processes of grappling with the integrative health community's challenges in substantively contributing to ending systemic racism and, specifically, in addressing health equity. In this regular JACM column from the Osher Center for Integrative Medicine at Harvard Medical School-Brigham and Women's Hospital, the author trio focuses on potential contributions of mind-body interventions regarding racial injustice and the interrelated determinants of health. An additional note: congratulations to my cherished colleague and regular contributor here, Peter Wayne, PhD, a JACM executive editor, for his recent appointment as director of the Harvard Osher Center.

—John Weeks, Editor-in-Chief, JACM

Stress, Economic Disparities, and Chronic Obstructive Pulmonary Disease: A Possible Role for Mind–Body Practices

Peter M. Wayne, PhD, Director, Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital

The dramatic and disproportionate impact that the current COVID-19 pandemic has had on people who belong to low-income communities has brought to the fore the tragic impact that economic inequities have on individual health. They highlight our need to better understand how social determinants of health (SDH) translate into biologic and clinical outcomes across different medical conditions. They also underscore the dearth of practical upstream and preventive and rehabilitative programs that address health disparities from an integrative biopsychosocial perspective.

One vulnerable population in the current COVID-19 crisis includes individuals with chronic obstructive pulmonary disease (COPD), who have a fivefold risk of severe COVID-19-related infections.¹ The focus of this commentary explores how SDH factors interact with perceived stress to influence rates of COPD-related hospitalizations and readmissions.

Parekh et al. at the University of Alabama at Birmingham conducted a survey-based study in individuals with COPD (n = 126) that assessed SDH.² Participants were categorized into two groups based on stress level: (1) high stress and (2) low stress. Stress level was assessed with the Cohen's Perceived Stress Scale, a 10-item Likert scale instrument that assesses stress level over the prior month. Income was defined by the median split of income; low-income individuals reported <$2,000 monthly total family income and high-income individuals reported ≥$2,000 family income. Participants were categorized into four groups based on income and stress level: (1) high income+low stress, (2) low income+low stress, (3) high income+high stress, and (4) low income+high stress. The primary outcome was acute care use, which was defined as a COPD-related emergency department visit or hospitalization in the 2 years before study enrollment.

The study's main finding, based on multivariate logistic regression, was that the high-stress group had a 2.5-fold increased adjusted odds of acute care use compared with the low-stress group, whereas the low-income+high-stress group had a 4.0-fold increased adjusted odds of acute care use compared with high-income+low-stress group.

In the next decade, COPD is projected to surpass ischemic heart disease as the leading cause of hospitalizations in the United States. The magnitude of this public health issue, its link with psychologic factors such as stress, and its disproportionate impact on the socioeconomically disadvantaged, represents a call to action for the mind–body and integrative medicine communities. COPD is a complex condition that is best addressed by multimodal approaches, including biologic, psychologic, and behavioral strategies. The results of this study highlight a clear relationship between stress and acute care use in individuals with COPD, which is magnified by those who are vulnerable and may lack financial and emotional resources needed to cope with stressful events.

Not surprisingly, in this study individuals in the low-income+high-stress group had higher rates of smoking—an unfortunate established stress coping mechanism in lower socioeconomic populations that negatively feeds back on COPD-related morbidity. Might healthier strategies be deployed to manage stress and improve symptom management? Multimodal mind–body exercises, such as t'ai chi and yoga, show some promise in COPD for improving clinically meaningful outcomes such as 6-min walk distance and health-related quality of life, reducing stress-related comorbidities such as anxiety and depression, and effecting longer-term behavior change. However, paralleling the broader field of integrative medicine, early research has not yet taken into consideration cultural and socioeconomic factors that greatly impact access, uptake, longer-term compliance, and ultimately the effectiveness of such programs in disadvantaged populations. The development and implementation of culturally and socioeconomically sensitive multimodal mind–body programs for individuals with COPD, importantly, in conjunction with parallel efforts to address structural causes of economic and related social disparities, would address a very important public health and social equity need.

Citations: 1. Lippi G, Henry BM. Chronic obstructive pulmonary disease is associated with severe coronavirus disease 2019 (COVID-19). Respir Med 2020;167:105941.

2. Parekh T, Cherrington AL, Bhatia S, et al. The association of low income and high stress with acute care use in COPD patients. Chronic Obstr Pulm Dis 2020;7:107–117.

Yes, “Black Girls Do Yoga”: Racism, Black Women, and Respect of Diversity and Commonality

Gloria Y. Yeh, MD, MPH, Director of Clinical Research, Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Director, Research Fellowship in Integrative Medicine, Division of General Medicine, Beth Israel Deaconess Medical Center

Decades of research provide empirical evidence that socioeconomic factors alone do not account for all racial/ethnic health disparities. Racism is now considered a fundamental cause of poor health outcomes for minorities. Multiple levels—institutional racism, cultural racism, individual-level discrimination, and microaggressions—have been linked to poor mental and physical health outcomes. The impact is wide-ranging, from depression, obesity, and cardiovascular disease, to preterm birth and later-stage diagnoses in breast cancer.

Black women, in particular, have been identified as an especially vulnerable population. Since 1995, the Black Women's Health Study, a prospective cohort study led by the Boston University, following 59,000 black women, ages 21–60 years, has been a major contributor to understanding health inequities. The most recent study published online by Coogan et al.¹ from a subset of this cohort has reported that self-reported racism is a significant psychosocial stressor among black women and that these experiences are associated with lower cognitive function several years later. These findings received much lay press in the midst of the current highly charged national conversation regarding diversity, equity, inclusion, and social justice.

So, how can the field of integrative medicine step forward and take social and moral responsibility within this crisis? What is it that integrative medicine can and should do to affect positive change in addressing this deeply ingrained problem? On perhaps a first level, we might consider how we can improve access to integrative therapies to those in need in culturally sensitive and responsible ways that respect and accommodate our differences. In the case of cognitive decline, we know that mind–body medicine can certainly be relevant. Mind–body exercises and mindfulness interventions have been shown to beneficially impact brain health. Yet yoga, for example, has consistently been characterized in national surveys as an activity for upper-middle class white women, mirroring the common demographic for integrative therapy use broadly in this country.

Sadly, not much research within integrative medicine has sought to address this head on. One small qualitative study by Tenfelde et al.² at Loyola University Chicago, offers some interesting insights. Investigators set out to better understand the stressors and needs of black women and explore perceptions of yoga and mindfulness to inform whether and how these interventions may be better offered to their community. Black women (N = 22) from inner-city Chicago communities were recruited to focus group discussions, stratified by age group (from 18–34 to 66 years and older). Women who participated were predominantly lower income (77% with average household income <$50,000) and reported higher than average stress levels (mean 15.6) on the Perceived Stress Scale.

As expected, participants mentioned many social stressors, including known social determinants of health, violence in their communities, perceived disadvantages due to race, and a sense of helplessness to be able to change society. Notably, however, most common experiences emphasized were completely race agnostic and more fundamentally about being a mother or matriarch. The women spoke about putting their family first, worry about their children's well-being and success, as well as family finance-related problems. When asked about mind–body therapies, overall there was openness to yoga as a path to peace and stress management, and as a possible strategy for self-care. Among the older group, there was an expressed need to demystify the mind–body–spirit connection, and to separate spiritual aspects from their deep traditions of faith. The women suggested reframing the practices as “soul movement” and as a positive connection with one's self. There was also a call to use culturally relevant language and to change the social norm/public image of yoga to include women of color and of varied body shapes.

Although the Tenfelde study has its limitations due to small sample size and convenience sample, taken in the context of the recent Coogan report, the studies illustrate several important points. First, health inequities due to systemic racism are pervasive. Possible downstream health effects of racism include the expected and more studied (e.g., cardiovascular disease, mental health, and cancer), but perhaps also unexpected areas (e.g., cognitive impairment). Second, there are ways to broaden our reach to diverse communities if we simply ask and engage one another. The Tenfelde study shows us one example of a successful dialogue on an individual-community level. This is a key aspect of our social and moral imperative—to thoughtfully and respectfully engage one another to work toward positive change, and this can and should start in our individual communities.

Finally, regardless of race/ethnicity, we all share similar basic needs and stresses. As part of one humanity, we are mothers who care for and want the best for our children. We thrive on community, inclusion, faith, and we all seek health and wellness. As integrative medicine strives to make a positive impact in this ongoing conversation, we should remember these unifying fundamentals. Although we recognize, respect, and make changes because of our differences, we should not forget to celebrate and take advantage of our basic commonalities.

Citations: 1. Coogan P, Schon K, Li S, et al. Experiences of racism and subjective cognitive function in African American women. Alzheimer's Dement 2020;12:e12067.

2. Tenfelde SM, Hatchett L, Saban KL. “Maybe black girls do yoga”: A focus group study with predominantly low-income African-American women. Complement Ther Med 2018;40:230–235.

Can Mindfulness Training be a Part of the Antiracism Solution: A Pilot Study of Law Enforcement Officers

Darshan H. Mehta, MD, MPH, Director of Education, Osher Center for Integrative Medicine, Harvard Medical School and Brigham and Women's Hospital, Medical Director, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital

As exemplified by the George Floyd murder, black people and communities of color face three times increased likelihood of being killed by police as white people (https://mappingpoliceviolence.org). Black communities have faced centuries of injustice, innumerable acts of violence at the hands of law enforcement, and toxic stress exposures. At the same time, it is important to recognize that law enforcement officers often deal with stressful situations, which often require quick decision-making. When such decisions are being made, especially around the use of deadly force, individuals are more likely to react with automaticity—which often become subject to underlying explicit and implicit biases. For example, a white police officer may incorrectly identify a harmless object held by a black civilian male—due to the underlying association of a black man with a sense of threat. Research on implicit bias has found that these associations also impact whether police officers are slower/quicker to shoot individuals based on their race and color of skin. This is a public health issue. This is an antiracism issue. And such deep-rooted problems will require novel and innovative solutions that can facilitate structural and societal change. One proposed and humble piece to the solution is mindfulness training. Mindfulness is commonly defined as nonjudgmental moment-to-moment awareness. And so, can mindfulness training affect the actions of law enforcement officers?

In this prospected single-blinded randomized trial by Hunsinger et al.,¹ 61 law enforcement officers were randomized to an 8-session mindfulness-based resilience training (MBRT) or a no-intervention control group. Each 2-h MBRT class met weekly, delivered as a standardized protocol by a mindfulness-based stress reduction (MBSR)-certified teacher. MBRT was an adaptation of MBSR, and the language was adapted for law enforcement officers based on feedback and previous study experience by the authors.

The study investigators used the shooter bias task (SBT) to assess the impact of implicit race stereotypes on force response decision-making, such as weapon identification. Similar in style to the implicit association tests (IAT), participants have to decide within a very short period of time whether an individual is armed or unarmed, whether their response is correct/incorrect, and how they respond to black and white targets and the corresponding error rates. The investigators also collected data on expectation on how the training might improve stress levels, job performance, and resilience. Finally, they assessed the intervention using the Five Facet Mindfulness Questionnaire-short form—a measure of trait mindfulness—as well as home meditation practice data by issuing iPods with guided formal and informal meditation practices. These iPods also recorded when and for how long study participants engaged in meditation practice. The participants were largely male, white, and not Hispanic; both groups were very evenly matched in baseline characteristics include years of experience (just over 18 years); not surprisingly, the intervention group expected the intervention to improve stress, performance, and resilience.

There were no differences between groups in trait mindfulness from baseline to follow-up. Interestingly, there was no demonstration of racial bias at baseline, based on the SBT. In the MBRT group, participants engaged in just <2 days of meditation practice per week over the course of the 8 weeks, averaging a total of just over 30 min each week. And after the intervention ended, only two participants engaged in any meditation practice. The MBRT group also did not impact racial bias at follow-up points.

This study is provocative for several reasons. The SBT has been shown to be associated with implicit bias against black individuals. However, in this study, because there was no evidence of bias at the outset, there may not have been room for improvement. Moreover, the study authors suggest that law enforcement officers in the study may be using more cognitive control—especially with black individuals. This would effectively and appropriately “override” the underlying stereotypes. Furthermore, the SBT may not be sensitive enough to assess for change through an intervention such as the MBRT. Perhaps using the race IAT may have been a better option. This measure has certainly been studied among clinicians, and its findings have been associated with differences in clinical behaviors in acute settings (e.g., myocardial infarction).

What does this mean? Obviously, future studies are needed to understand the effects of mindfulness training in this population. Moreover, it is important to note that the law enforcement officers did not engage in the recommended amount of practice. This finding is similar to other mindfulness-based interventions in which individuals rarely participate in the degree of practice that is asked of them. Newer “reminder” tools need to be employed—such as those seen in present-day smart watches. These were experienced law enforcement officers. Maybe we need to intervene much earlier in training—for example, new recruits—then see what effect that might have. This idea is similar to what has been seen in health care professions training. Finally, for some, a mind body intervention may not necessarily be the right first step. We have to be willing and able to explore our internalized racism. Perhaps a better first step is the creation of safe and vulnerable spaces for personal exploration and dialogue.

Citation: 1. Hunsinger M, Christopher M, Schmidt AM. Mindfulness training, implicit bias, and force response decision-making. Mindfulness 2019;10:2555–2566.