Readers of Healthskills will know I have a fascination for mindfulness as an intervention for people who have ongoing pain. Mindfulness is relatively easy to learn, is portable – is free, and has no calories! Seriously, as a seemingly simple intervention, it has appeal not only because it is readily used, but also because so many studies have found that it is effective for reducing distress and disability.
What is it?
Mindfulness is “moment-by-moment attention and observation of external and internal stimuli (eg, thoughts, feelings, bodily sensations) in a nonjudgemental and nonreactive way” (Cassidy, Atherton, Robertson, Walsh & Gillett, 2012). It’s thought to be the opposite of catastrophising, which is the tendency to interpret those same experiences as an indication of harm or damage.
Learning mindfulness is relatively simple – but hard to maintain, practice is everything. This is my process, developed from multiple readings over the years so I am completely unable to identify where I got it from! Readers keen to learn more about how to teach mindfulness should head to the Center for Mindfulness in Medicine, Healthcare and Society based in the University of Massachusetts, alternatively, read anything by Jon Kabat-Zinn.
I begin with asking the person to become aware of their breathing. Not changing it, not trying to breath more slowly or deeply or anything – just become aware of it. I might guide the person to
become aware of cool air as it enters the nostrils and flows down the back of the throat;
to notice the warmth of the air that passes back out;
to be aware of the rise and fall of the abdomen or chest;
to become aware of what it feels like when the chest expands
…and so on. I often extend this awareness to notice the body sensations of contact with the support, or the warmth of the hands as they rest on the lap – for as long as I think the person is remaining aware and not drifting into other thoughts. I know I can’t really be aware of the person’s thoughts, but I watch very carefully to see whether the person’s eyes are moving (usually they’re closed during this session) and whether they’re fidgeting or shifting in the chair. This initial introduction is usually quite brief – only a few minutes – to give the person a taste of what it might feel like to experience without naming or judging or labelling.
Debriefing at the conclusion of this brief session is essential, IMHO. This is where therapist’s personal use of mindfulness is important – whatever the person experiences is OK. I ask about what they noticed during this experience, mainly to identify whether they’re labelling the experience as “good”, or “bad”, or shades in between. Essentially I’m hoping for the person to simply list the sensations rather than indicating whether they are judged as something. An example might help: if the person said “I was surprised at how warm my hands were” is a judgement – the word “surprised” suggests a judgement about what is usually experienced. My response might be “So you noticed your warm hands” rather than probing as to what the “normal” state is, or reflecting that the person was surprised.
For home-based learning, I suggest doing this same breathing exercise at least three times a day. Or I might suggest being mindful while cleaning the teeth, noticing the sensations of brushing and the taste of toothpaste. It’s a simple activity that is done regularly and is usually not interrupted!
Why focus on mindfulness?
There are a couple of reasons I like mindfulness. I indicated earlier that it’s a portable, relatively simple strategy that can be used anywhere – and that it’s the opposite of catastrophising. Delving into the mechanics of how mindfulness works is beyond the scope of a post like this, but it does seem that observing without judgement reduces the automatic evaluation of a body sensation as “something really bad”, ie catastrophising. We know that catastrophising is associated with increased disability, anxiety, low mood and can serve to maintain behavioural avoidance.
The study by Cassidy and colleagues found that “greater mindfulness was predictive of lower levels of disability, anxiety, depression and catastrophizing, even when pain severity was controlled” in the context of delivering a multidisciplinary pain management programme. We can’t determine from the design of this study whether the practice of mindfulness influenced catastrophising, but some statistical analysis of the relationships between mindfulness, catastrophising and disability found that the degree to which mindfulness influenced disability was itself influenced by catastrophising, and that mindfulness had a direct relationship with catastrophising, and in turn had a relationship with disability.
What this means is that increased mindfulness appeared to reduce catastrophising, which in turn reduced disability.
The explanation given is that mindfulness involves greater use of nonjudgemental awareness of events, experiences, sensations around an individual, and that by doing this, the tendency to jump to a negative conclusion about the meaning of that experience is reduced.
It’s worth considering how mindfulness can be integrated into daily clinical practice – for both the practitioner and the client. It’s certainly easier to teach something that has been personally experienced, and it is likely to help maintain that broad awareness that is needed when observing what is going on with a patient. It does mean giving oneself space to later recall and interpret what is being observed, but I find it’s a whole lot easier to do so than if I’ve been trying to interpret at the same time. This, of course, will depend on the content of a treatment session.
Cassidy, E., Atherton, R., Robertson, N., Walsh, D., & Gillett, R. (2012). Mindfulness, functioning and catastrophizing after multidisciplinary pain management for chronic low back pain PAIN, 153 (3), 644-650 DOI: 10.1016/j.pain.2011.11.027