Incorporating Meditation Training Into an Outpatient Psychiatry Practice

Basic Awareness Meditation

COMMENTARY

You can’t open a newspaper or browse a health website these days without seeing the latest glowing testimonial to the benefits of meditation training. Yet only a small subset of psychiatrists actually practice meditation, and fewer still incorporate awareness training into their tool kit in treating their patients. It’s not as if there has been an absence of attention to meditation in the mental health community. The works of Drs Jon Kabat-Zinn,¹ Mark Epstein,² Marsha Linehan,³ and others^4-7 as well as more recent research⁸ have reinforced meditation’s ameliorative effect on most chronic medical and psychological conditions.

Nevertheless, many psychiatrists have not caught on. Some mistrust the validity of a practice that entrains observation of a subjective, hard-to-assess interior experience. Others may misunderstand it as uncomfortably associated with religiosity. There is also the practical obstacle of squeezing even basic meditation skills training into the psychiatrist’s already over-subscribed treatment visits. Regardless of our possible reasons for stiff-arming it, meditation training remains a valuable, thoroughly secular tool for psychiatrists to incorporate into our patient practices-and our own personal self-care routines.

Meditation: what is it?

Meditation is a purposeful practice in the observation of experience. It entrains the skill of attention with the goal of optimizing our observing and “holding” experiences of daily life in mind. It can be thought of as the “lesson plan” in developing mindfulness, defined by Kabat-Zinn⁹ as “non-judgmental, moment-to-moment awareness.” That task may sound easy enough to perform until one recognizes that the human mind is an endless fountain of narrative content and editorial judgments on one’s ongoing experience. Modern minds, deeply invested in our intellectual analytic skills, tend to overvalue our trails of cortical production.

A simpler witnessing of the phenomena present in any moment, without running off in additional mental production, cannot and should not replace our prodigious cortical capabilities. But it does add an important tool in basic adaptation to experience, a developing ability to “sit with” painful but usually temporary states of interior suffering such as physical pain, anxiety, anger, sadness, and uncertainty. There is also benefit in discovering one’s own conditioning, the linking of specific patterns of thought, feeling, and sensation and even the loss or reduction in attention itself as a defensive maneuver of the mind.

While a survey of the totality of writings on meditation over millennia reveals thousands of variations on practice and technique, most texts break them into 3 main types.

1. Concentration practice involves entraining attention via intense observation of a single object in the mind’s eye. Breath meditation, a very common starting point for any beginner, is a concentration practice. Meditating on the heartbeat, a mantra, or a visual object such as a candle flame also represents types of concentration practice.

2. Insight practice entrains the bare awareness of all phenomena in the field of mind as they come and go. For many, this is a more advanced practice that can have a more spiritual connotation, as it is associated in Buddhism with experiencing an ultimate sense of oneness and cosmic connection. This practice can also have a great diagnostic utility in psychotherapy, entraining observation of patterns of thought and feeling that co-occur in response to the triggers in day-to-day life.

3. Compassion practice uses globally familiar phenomena of positive human feelings-equanimity toward others, compassion, kindness, and joy-as an “object of mind” to hold and observe one’s reactions to.

A model of mind

I’ve found in my teaching of these techniques to my own patients-and in teaching medical residents about how to convey them to theirs-that a “landscape” model is effective. The metaphor involves observing one’s experience in any one moment like a walk outdoors, witnessing the field of mind as an observer/photographer. When working with a patient, I describe basic components of that field:

• Physical: including “interior” experiences of the breath, heartbeat, and bodily sensations, such as pain and muscle tension; and “exterior” sensory inputs such as sight, hearing, smell, taste, and touch

• Emotional: usefully compared with the “weather in the field,” these include anger, anxiety, joy, and sadness

• Thought: most ardently pulling our attention in mind, these include concepts, memory, new creative synthesis, speculation, and analysis

Two other elements can be added: the field itself (the “space” around the phenomena, allowing for examination of the clarity of awareness or lack thereof) and the felt sense of observing (ie, the experience of the observer).

Meditative training in specifically observing one of these components of the field of mind-versus sitting in observation of more or all of the phenomena in the field-can be compared metaphorically with the “telephoto” versus “landscape” settings of a camera. The observer can aim the “camera” of attention on any aspect of the field-or on the whole. In beginning practice, we usually start with the breath.

Beginning tactics

The setting should be quiet with a minimum of stimuli in terms of unpredictable or novel sensory inputs. Picking a time is a matter of preference. Some prefer early mornings as an attitudinal preparation for the day; for others, evening meditation provides a contemplative winding down of daily events and effects. Still others do both. However, the time and place are organized; creating a routine in order to reduce the chance of interruption is important. These introductory tactics are summarized in the Sidebar.

The details of sitting (chair or cushion, cross-legged or kneeling, palms up or down) receive a great deal of attention, perhaps too much. A full lotus position is not essential; neither is a fancy sitting cushion or an elaborate setting. A position that allows for a body at rest without undue discomfort but remaining alert is the essential aspect. Eyes can be open slightly or closed; keeping the eyes open and trained on a trivial spot in the visual field (such as a spot on the wall or floor) is usually preferred in early training to avoid somnolence.

One can meditate on any phenomenon of experience or all of them, but millennia of trials have pointed to using the breath as an excellent starting “anchor” point of reference to attend to and return to. One can pick an anatomic spot (nostrils, throat, or diaphragm) to observe. Although it is common to start by engaging in relaxation or “belly” breathing, forcing a certain type of breathing is not the point. Instead, allowing the breathing to occur without any “scripting” is the prime instruction, while one settles back to observe the sensation. One watches the in-breath, then the out-breath; this is repeated until attention to that simple act is lost. Once that lost attention is discovered, without fanfare or judgment, one returns the attention to the breathing.

These instructions are simple to convey but often very difficult to perform at first. Those who are just starting meditation can be shocked at how much of a “blizzard” of discursive thoughts, shifting emotional states, and somatic signals clutter the field of mind with the initial foray. My instructions to patients starting meditation involve 3 prompts (a long, slow breath taken with each):

Here: With the first breath, a re-connecting with one’s mind as a vast field with all its components: physical, emotional, thought, the encompassing field, and the observing self.

We: With the second breath, a recognition that one is not alone, with all of us in our own ways striving to reduce our suffering and find fulfillment and meaning. This prompt can help reduce what can sometimes feel like a lonely task.

Go: With the third breath, set a specific intention for the session’s practice-usually, at first, this is watching the in and out of the breath. As meditation develops, this intention often moves beyond watching the breath to other phenomena of experience; you may want to start with breath meditation, then plan to shift to a different object of mind. Setting an intention in this way helps with “returning home” after the inevitable losing of one’s way in any session.

A regular beginning routine often starts with a short (2- to 10-minute) session of sitting in the first week, expanding the time to 20 to 30 minutes or more as a sense of improvement takes hold in the clarity of attention, the length of holding that attention, and the flexibility in pivoting back to the task after the inevitable losses of attention. In this way, it truly is a trainable skill, comparable to learning piano scales. Although any one session can be blissful or a struggle for both rookies and veterans, meditation generally improves with practice.

Regardless of where the “camera is aimed” and how tight the focus is, some essential factors need to be understood and conveyed to the new practitioner. The first is that thoughts inevitably come and go in the field, and that we tend to inevitably “grab on” and add to that narrative at some point, whether a few seconds into sitting or many minutes. Mindful attention inevitably degrades into a loss of focus; it’s not whether but when.

Having gotten “lost,” the next factor involves the moment when one realizes that attention has been lost. The instruction here is to resettle oneself and return to the practice of watching one’s breath, without judgment. Yet this is easier said than done, especially early in training. We start into judgmental thinking about having lost attention, which is just more thinking added to the field to get distracted by. Instead, the direction is to re-steady the “camera” without additional judgment and try again. This lowers the bar on persistence in the training and often provides a useful lesson in observing the nature of our own reflexive self-critical tendencies.

With practice, the benefits of feeling calmer and more adaptive to the difficulties of daily life are observable not just during meditation but also “off the cushion.” More careful observation of one’s full experience, not just immersion in it, becomes gradually internalized as a way of being and behaving in daily life.

Integrating meditation training into patient treatment

Initial training in concentration practice-using the breath, body sensations, or an external visualized object-has its rewards in entraining calming and adaptation; a patient need not go any further to reap the benefit of basic meditation’s calming effect. It is common, for instance, to experience a relaxation of muscle tension once we acknowledge it rather than trying to ignore it. This basic practice in meditation is truly suited for any but the most thought-disordered patients as a self-care tactic in calming the mind and adapting to interior states.

Insight practice can represent a next step, opening to the entire display of changing moment-to-moment experience in one’s field of mind. In tuning more deeply into interior states of experience, patients can become more aware of linked sensations, affects, and thoughts as they occur on the cushion and off; and how emotional tone and somatic sensation interplay with ritual loops of thought. They can also begin to identify what external inputs may trigger those patterns. With careful use in psychotherapy practice, this ongoing, interior observation of how the patient’s mind works with its patterning can generate rich material for the clinician and patient to cull for meaning.

Compassion practice-involving the individual in consciously generating positive states of experience such as compassion, empathy, kindness, or joy-can be of enormous benefit to patients but perhaps even more so for clinicians in our own practices. Meditating on positive feeling states such as these can involve empathizing with one’s own suffering, with that of another person, or with a more general opening to all others.

Deeper explanations of practices beyond basic stress reduction, involving incremental gaining of skills in insight orientation and compassion, are beyond the scope of this article but nevertheless fruitful. These deeper practices in self-awareness can also bear some risk, generating provocative and even destabilizing states of mind for more temperamentally fragile patients.¹⁰ Working collaboratively with a local meditation teacher can be useful.

In conclusion: start with yourself

The instructions in beginning meditation are not complicated; they can be taught to patients briefly and easily as we do with information on sleep hygiene, mood diaries, and other helpful clinical routines. Nevertheless, in guiding patients through a practice about an interior, subjective state, nothing can replace the psychiatrist’s direct engagement in basic meditation before teaching it to patients, as well as in modeling its benefits. The hackneyed but valid bromide we may remember from medical training, “see one, do one, teach one,” is applicable here. Another, “physician, heal thyself,” can also apply as we work to sustain our well-being in a rewarding but often stressful career.

Acknowledgement-The research assistance of Ryan Sazima in preparation of this article is gratefully acknowledged.

Disclosures:

Dr Sazima is a psychiatrist in private practice in Roseville, CA, and is Senior Behavioral Faculty at the San Jose/O’Connor Family Medicine Residency Program, San Jose, CA (affiliate, Stanford University School of Medicine). He has also developed and taught mindfulness training programs for adults and children for 12 years.

References:

1. Kabat-Zinn J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. NY: Delta Trade Paperbacks; 1991.

2. Epstein M. Thoughts Without a Thinker: Psychotherapy From a Buddhist Perspective. NY: Basic Books; 1995.

3. Linehan M. Cognitive-Behavioral Treatment for Borderline Personality Disorder. NY: Guilford Press; 1993.

4. Thich NH. The Miracle of Mindfulness. Boston: Beacon Press; 1975.

5. Benson H. The Relaxation Response. NY: Harper Collins; 1971.

6. Boorstein S. Don’t Just Do Something, Sit There. San Francisco: Harper; 1996.

7. Dalai Lama, Cutler H. The Art of Happiness. New South Wales, Australia: Riverbed Books; 1998.

8. Goyal M, Singh S, Sibinga EMS, et al. Meditation programs for psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med. 2014;174:357-368.

9. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. NY: Hyperion Books; 1994.

10. McGee M. Meditation and psychiatry. Psychiatry (Edgmont). 2008;5:28-4