Abstract
Mindfulness is a form of meditative practice in which participants are taught to bring a heightened awareness to the present moment, without judgement or reaction. Although there are a number of different intervention types, in mental health services it is often used with cognitive therapy, or stress reduction principles to help people experiencing a wide range of physical and mental health concerns. Although variations in treatment format exist, it is typically delivered in a structured group intervention comprised of eight, 2-hour sessions.
The GP curriculum and mindfulness practice
Understand the range of psychological therapies available including cognitive behavioural therapies, mindfulness, counselling, psychodynamic, psychosexual and family therapy Understand specific interventions and guidelines for individual conditions using, where appropriate, best practice as described in the Scottish Intercollegiate Guidelines Network or National Institute for Health and Clinical Excellence guidelines Manage people experiencing mental health problems in primary care, using alternative interventions where appropriate, including forms of talking therapy, medication and self-help
What is mindfulness?
Mindfulness is a form of meditative practice that has been developed over the last 2500 years. Although it originates from Buddhist teachings and practice, in its contemporary format mindfulness has become a secular intervention as a result of the work of Jon Kabat-Zinn (1982), a physician at the University of Massachusetts’ Medical School. Using mindfulness techniques, blended with contemporary psychological theory, he attempted to help out-patients experiencing distress and low mood as a result of chronic pain. His work was guided by the view that mindfulness could reduce stress from the primary physical health condition through better body awareness, relaxation and improved coping skills, resilience and stress management (Creswell, 2017).
Kabat-Zinn’s work attracted the attention of Segal et al. (2012) who had noticed that people with mental health problems often experienced thoughts and emotions, and displayed behaviours, that were maladaptive or which exacerbated their distress. They developed a mindfulness programme that blended meditation and cognitive therapy principles (which explore thoughts, emotions and behaviours) in relation to a participant’s presentation. They aimed to develop a psychosocial intervention that taught people with recurrent depressive episodes skills they could use to maintain wellbeing (Williams and Kuyken, 2012).
The practice of mindfulness itself involves bringing a conscious awareness to one’s body, speech, feelings and thoughts, observing their emergent nature without placing any attachment or judgment to them (Lynn, 2010). Rather than expending effort to forcibly control, expand or evaluate negative thoughts and emotions, individuals are encouraged to acknowledge their presence, observing them objectively while directing their attention towards their breathing in the present moment (Chiesa and Malinowski, 2011). This process aims to help the participant raise awareness of their negative thoughts, emotions or physical sensations and enable them to respond in a more flexible, rather than reactive way (Keng et al., 2011).
Unlike traditional Western models of health, mindfulness does not assume pathology, nor is the goal to change the patient’s experience. Change, however, does often occur, but tends to be because people learn to live with and accept their psychological and physical limitations, rather than because they have managed to push away undesirable conditions or emotions (Hamilton et al., 2006).
The aim of the practice is therefore to enhance an individual’s adaptive coping to stressful events by the self-regulation of attention towards their immediate experience, and by taking an open and accepting orientation towards that experience in the present (Bishop et al., 2006). It is about paying attention, on purpose, in a particular, non-judgmental way, in the preset moment as outlined in Fig. 1.
The philosophy of mindfulness.
The seven foundations of mindfulness.
What are the current approaches in contemporary mindful practice?
Although mindfulness is used as a generic name, it is in fact an umbrella term for a number of different meditative approaches. In the UK, the NHS provision of mindfulness-based therapies is generally through local Improving Access to Psychological Therapies (IAPT) services and tends to be in one of two forms: mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1990) and its offspring mindfulness-based cognitive therapy (MBCT) (Segal et al., 2013). Those interested in mindfulness interventions may also self-refer to the local IAPT teams in many areas, or may be able to access more traditional mindfulness interventions offered by local practitioners outside of the NHS. It is often helpful to offer patients a choice in how and where they would like to access the intervention and it is helpful for GPs to be aware of local provision.
MBSR was originally developed to help people manage general stress-related conditions, or depression and anxiety as a result of physical health issues. It uses both meditation and gentle physical exercise, such as hatha yoga, and can be taught in an individual, as well as a group format. Presently, GPs may refer those who experience distress as a result of chronic pain or who have had less than three episodes of depression, or those who are currently well and who wish to learn techniques for coping with stress.
However, the focus of MBCT is to help patients manage their thoughts and feelings about depression and anxiety. It uses cognitive and behavioural therapy techniques alongside mindfulness techniques within the sessions to help people change the relationship they have with their thoughts, feelings and physical sensations (Williams and Kuyken, 2012), and GPs are encouraged to refer those who have had three or more episodes of depression.
Both these approaches are very similar and have meditation/mindfulness as the fundamental building block of the intervention. They are facilitated by trained practitioners and are usually delivered in a small group format over eight weeks in 2-hour sessions. The purpose of this is to develop a supportive experience and help to strengthen relationships between participants. They are also encouraged to undertake home practice and specific guided and self-guided meditations of various types and length are prescribed for ’homework’ and then discussed as a group at the next session. Such practices range from mindful eating and walking, to 3-minute breathing spaces and longer (about 40 minute) body-scans. The purpose of these is to help bolster, not only the practice of meditation, but also the skill of sitting with difficulty, and help support and encourage the participant to take an active and responsive (as well as preventative) stance in the management of their situation.
In addition to these options, dialectical behaviour therapy is used to help support those with a personality disorder, and acceptance and commitment therapy also uses mindfulness-based approaches within treatment.
What evidence is there supporting its effectiveness?
Although the majority of GPs believe that mindfulness would be beneficial for their patients, 69% rarely or never refer people with depression for mindfulness-based interventions, with 75% of GPs prescribing anti-depressants instead (Rycroft-Malone et al., 2014). Although in part this could be due to the limited availability of access to mindfulness in the NHS (Rycroft-Malone et al., 2014), it is worth noting that research has shown that mindfulness can help reduce repeated attendance and non-mental health-related use of primary care services (Kurdyak et al., 2014).
There is strong evidence to support mindfulness in recurrent depression. A meta-analysis of six randomised control trials found that it reduced the risk of relapse by 43%, in comparison with control groups, in people with a history of three or more depressive episodes (Piet and Hougaard, 2011). Other studies have shown that, delivered in a primary care setting, it is as effective as medication in the same population type (Kuyken et al., 2015; Williams et al., 2013), and has beneficial effects even in those who would prefer to take medication (Huijbers et al., 2016). It has also been found to reduce symptom severity in those experiencing an ongoing or current episode of depression (Strauss et al., 2014).
There is evidence that MBSR can help those who experience stress, depression or anxiety as a result of a physical health condition. In a review of 114 studies Carlson (2012) found improved mental health and wellbeing in people experiencing cancer, human immunodeficiency virus, arthritis, lower back pain, and irritable bowel syndrome, among others. It has also been found to improve sleep quality and reduce sleep disturbance in cancer patients (Carlson and Garland, 2005), and reduce systolic and diastolic blood pressure in those at risk of cardiovascular disease (Anderson et al., 2008).
NICE guidelines on depression.
Although not recommended by NICE currently, there is also promising recent and ongoing research into the use of mindfulness-based interventions with other mental health problems seen in primary care such as psychosis (Khoury et al., 2013), anxiety (Strauss et al., 2014), health anxiety (McManus et al., 2012), social anxiety, generalised anxiety disorder, panic disorder and anxiety disorders not otherwise specified (Boettcher et al., 2013).
In general practice, medication adherence, especially to anti-depressants, can be problematic (Chong et al., 2011) and mindfulness may therefore be a suitable evidence-based alternative if medication adherence is an issue, or for those who wish to explore alternative psychological options. MBCT has been shown to be as effective as maintenance anti-depressants in those with recurring episodes of depression, and as the cost of delivering mindfulness interventions is equivalent to that of medication (Kuyken et al., 2015), no extra financial burden on health service budgets is expected.
As with all interventions, it is important to be aware of potential adverse effects. Although the evidence to date is limited, there have been case reports of side-effects including depersonalisation/derealisation in those who have experienced trauma, and reports of anxiety, depressive, and psychotic symptoms in other cohorts (Lustyk et al., 2009). Particular attention needs to be paid to those who experience or have experienced epilepsy or psychosis. Participants regularly report feelings of agitation, discomfort, and mild anxiety, but these are normal temporary reactions and are part of the process of sitting with uncomfortable and difficult emotions, thoughts and sensations (Creswell, 2017). Properly supported practice will acknowledge and work with these situations in-session and support the person to engage with them as part of the practice, and if there are any doubts, the referrer should speak with the local course facilitator.
What mindfulness resources can I recommend to patients?
A walk around real or virtual stores will show the proliferation of ‘mindfulness resources’ available, from online mindfulness applications (apps) to colouring books and knitting. However, care needs to be taken when recommending these options, as many lack any evidence base. It is also important to note that mindfulness is not for everyone, and this is something to be discussed in consultation with the patient.
There is, however, increasing evidence supporting the use of self-help/self-guided mindfulness strategies that individuals may use to help their own mental health, particularly relevant when the provision of some mindfulness interventions can be resource-heavy or where access to supported mindfulness practice is limited. Unsupported self-help practice through the use of a MBCT manual has shown reductions on measures of depression, anxiety and stress in student populations (Taylor et al., 2014). This is further supported by a meta-analysis of 15 studies performed by Cavanagh et al (2014) who found that strategies such as specifically developed self-help and mindfulness instruction books, workbooks, computer programs, online applications (apps) and audio-visual self-help resources enabled users to develop mindfulness skills, requiring little, or no, therapist resources. Mindfulness interventions that are fully internet-based may be effective in anxiety disorders, with one small randomised control trial finding a positive impact on depression, anxiety and insomnia, with moderate improvement on quality-of-life scores (Boettcher et al., 2013).
There is also evidence to suggest that shortened or condensed mindfulness interventions can be helpful (for example, see Cavanagh et al. (2013)). This may be of use for those who are in full-time employment and struggle to take time away from work. Alongside these, some services also offer mindfulness programmes that incorporate online groups, which might also suit those with limited time or those with reduced mobility. In areas with limited, or no, access to mindfulness services, nurses working in primary care may train to become mindfulness teachers, or learn to incorporate mindfulness practice principles within their work to support patients (Williams et al., 2016).
However, for those with repeated relapses, the empirical evidence strongly indicates the benefits of the completion of an approved MBCT/MBSR programme run by local mental health services, as specifically recommended by NICE (2018). There are approved week-long programmes run by third sector and private organisations, however, when recommending these it is important to check that they are registered with the UK Network for Mindfulness-Based Teacher Training Organisations.
Apps and colouring books may be helpful tools that patients can use to aide in the practice of mindfulness, but they are not substitutes for a professional referral to the appropriate service, particularly in those with recurring mental health issues.
Is mindfulness just for patients?
Although the focus for mindfulness interventions is on those with diagnosed conditions, there is also research to indicate potential benefits for those working in the healthcare profession. In one study, from the United States, GPs who took part in a mindfulness-based intervention showed significant reductions in mood disturbance and burnout, alongside increased empathy (Krasner et al., 2009). In addition, a Dutch study found a change in GPs wellbeing and compassion towards self and others, including patients (Verweij et al., 2016). Again, like studies in general populations, shortened interventions for healthcare providers also show positive results with stress, anxiety, mindfulness, resilience and burnout (Gilmartin et al., 2017).
Similar results have also been found in studies with nurses whose perceived stress decreased, whereas their compassion towards others increased (Mahon et al., 2017), which is known to lead to improved patient outcomes (Brass, 2016).
What resources can GPs recommend?
Online resources.
KEY POINTS
Mindfulness does not assume pathology or set goals to change experience Mindfulness is about being in the present moment, on purpose, without judgement, bringing awareness to one’s experience Mindfulness teaches participants a set of skills that they can use to help manage their own experience The two key mindfulness techniques for those experiencing depression are MBCT and MBSR The research evidence strongly supports the use of mindfulness techniques in the treatment of recurrent depression and several other mental health problems, as well as in those experiencing distress as a result of physical illness