Introduction

Effective techniques for stress management are varied. They typically include behaviors that improve physical health, such as nutrition and exercise, but may also incorporate strategies that improve cognitive and emotional functioning. The stress-reduction approach based on mindfulness practices has recently enjoyed an explosion of interest from a variety of healthcare and epidemiological researchers.[1][2][3] The concept of mindfulness, which originates from practices of Buddhism, is defined as a focused awareness of one’s experience, and purposeful and nonjudgmental focus on the present moment.[4] Structured interventions, such as the Mindfulness-Based Stress Reduction (MBSR) program, provide participants with the opportunity to learn breathing meditation, body scanning techniques, and gentle, yoga-inspired physical exercises.[5] With practice, individuals learn to process emotions, thoughts, and sensations as they arise. Individuals learn to modify their reflexive conditioning from automatically reacting or worrying about the future to a more adaptive, measured response with greater awareness of the present moment.[6] The literature is replete with evidence suggesting that, with practice, individuals can become more mindful, increasing their capacity to fully process emotions, thoughts, and sensations as they arise.[7][8][9][10][11][12] MBSR interventions have been adapted to a wide variety of individuals, from those suffering from chronic or debilitating health conditions to healthy undergraduate or medical students. Randomized controlled trials of MBSR interventions have demonstrated improvements to psychological and physiological processes with relevance to health outcomes and improved stress management.

Some individuals have a greater innate, or trait, capacity for mindfulness. These individuals, who have not participated in mindfulness-training interventions, tend to experience better physical health, report fewer physiological symptoms such as pain, and utilize fewer healthcare resources.[13] Trait mindfulness has been associated with lower ratings of anxiety and depression in a variety of medical and non-medical populations.[14] Trait mindfulness may emerge from a genetic predisposition. A recent epidemiological study of adolescent twins revealed that trait mindfulness was 32% heritable.[15] The same study also revealed that 66% of the variance in trait mindfulness was due to environmental factors, suggesting that is also a skill that can be learned. In fact, an MBSR study in university undergraduates revealed that, while increases in mindfulness and psychological outcomes can be observed in participants as a whole, effects may be more pronounced among individuals higher in trait mindfulness at study entry.[16] These data substantiate the utility of mindfulness training, even for high-trait individuals.

Issues of Concern

Standard MBSR Programs

Standard MBSR programs have demonstrated potential to ameliorate physiological dysregulation, including attenuated hypothalamic-pituitary-adrenal (HPA) axis activation, autonomic activation, and inflammation.[17][18] A study of healthy adult males who endorsed a higher capacity for present-moment focus found they also exhibited reduced emotional distress and autonomic (heart rate) reactivity when exposed to hypoxic conditions.[19] Neural correlates may underlie relationships between mindfulness practices and central nervous system (CNS) function reported in the literature. Higher trait mindfulness positively correlates with activity in the anterior cingulate and prefrontal cortices in healthy adults, both of which demonstrate reduced activity in studies of individuals suffering from anxiety and depressive disorders.[20] Levels of trait mindfulness also correlate with grey matter volume reductions in the amygdala and caudate in healthy adults and greater volume in bilateral gyri of adults with generalized anxiety disorder.[20] Likewise, studies also demonstrate that mindfulness training results in increased blood flow in the amygdala and hippocampal regions among breast cancer patients and increased grey matter concentrations in the norepinephrine and serotonin systems in the brain of in healthy adults.[21][22] This evidence for shared neural circuitry suggests at least partial mechanisms by which mindful approaches may be beneficial for individuals who are experiencing prolonged psychological distress or difficulty managing stress.

Mindfulness-Based Stress Reduction

Mindfulness-Based Stress Reduction (MBSR) was initially designed to relieve suffering among chronic pain patients by teaching skills that cultivate present moment-focused, non-judgmental awareness.[5] Three formal mindfulness techniques are taught over eight weeks: The “body scan,” an attention-focusing technique; gentle yoga; and sitting meditation. The body scan is performed supine with attention directed systematically and non-judgmentally through regions of the body, encouraging relaxed awareness and acceptance of proprioceptive and interoceptive sensation. Hatha yoga consists of gentle movement and stretching sequences that promote awareness of movement and position. Sitting meditation helps develop a stable cognitive perspective from which to observe mental events with openness and acceptance without becoming caught up in distressing thoughts or feelings. Informal mindfulness practice is also encouraged: Participants cultivate an awareness of the present moment, whether perceived as pleasant or unpleasant. The intent is to help participants become engaged with the experiences of each moment as they arise and learn to face stressful events in a way that is skillfully responsive rather than habitually reactive. With practice, individuals learn to modify their reflexive conditioning from automatically reacting or worrying about the future to a more adaptive, measured response with greater awareness of the present moment.

Traditional MBSR Interventions

Traditional MBSR interventions can easily be performed without the use of specialized equipment. Many group administrators and practitioners prefer to have materials handy to help modify movement-based exercises and yoga poses for those with physical limitations. Typically a yoga mat, blocks, and strap are sufficient. Studies of MBSR group interventions have suggested that limiting group size to less than 20 individuals is preferable to build a cohesive dynamic between practitioners (see Lehrer, Woolfolk, and Sime, Principles and practice of stress management. New York: Guilford).[23] Guided practices, including the body scan and sitting meditations, are available on electronic media or for download from several sources. There is also an abundance of freely available apps and podcasts that offer mindfulness teachings, guided and unguided timed sitting and supine meditations, and guided mindfulness practices to listen to during activities such as exercising or cleaning. Most are available for free or for a range of modest costs. Some offer free trials, while some apps and many quality podcasts are totally free. Encourage interested individuals to try out a few different options and find what works best for them. Practitioners also may find that different approaches are more preferable, depending on the day, stress level, and practice time available. We caution individuals to avoid listening to guided sessions or podcasts while driving, as increased drowsiness may occur. 

Mindfulness-based interventions may be optimized to enhance pre-existing practitioner strengths and address specific stress-management needs. Among cancer patients, a benefit was observed after an MBSR program incorporated a shortened length of meditation assignments, reduced frequency of group meetings, and adjustments of the physical movements taught (e.g., yoga poses). Similar modifications have been considered for other cancer patient samples, including changing the usual mindful (raisin) eating exercise to utilize a liquid for those who have trouble eating or swallowing, omitting the day-long silent retreat if thought to be too taxing or inappropriate for the population, adjusting physical movements to account for any injury or pain that may be present, and employing an individual (versus group) format to better incorporate session scheduling with medical appointments.[24] Given the similar improvements to psychological measures when compared to standard MBSR program outcomes, modified interventions may not be an inferior approach to increasing mindfulness practices among participants. These strategies may be advantageous with regard to implementation and utilization by practitioners who are experiencing busy daily activities and have limited flexibility to facilitate adding a new routine to their daily lives. 

Clinical Significance

Several authors have offered thoughtful conceptualizations of mechanisms by which mindfulness may reduce stress and ameliorate illness symptoms.[25] Theoretical models focus on metacognitive factors, explore mindfulness in the context of a widely accepted model of stress and coping, and contrast this practice, which stems from Eastern tradition and includes Western psychology.[26][27] Other recent work has highlighted the need to examine process variables related to the techniques used, individual meditation practice, social factors, and other aspects of MBSR.[28]

Novice mindfulness practitioners also engage in "informal" practice as they learn to observe their own thoughts and sensations and explore a new stance as a nonjudgmental observer of their own life. Attending to one’s own experience may set up a dynamic cognitive interaction that can facilitate a capacity to respond to ongoing experiences as if they are occurring for the first time, typically referred to as "beginner’s mind." This interrupts the automatic processes of relying on previously conditioned stress reactions. Paradoxically, positive changes seem especially likely to occur when one can let go of the struggle of trying to change or control the process. This perspective lies at the core of empirically validated acceptance-based intervention model. A focus on the present moment can potentially help decondition habitual reaction patterns and increase response flexibility. From a cognitive perspective, this suggests that viewing present circumstances as new and unique experiences increases one’s capacity for generating multiple alternative response options. Mindfulness also may address cognitive-behavioral factors, such as self-focused attention, experiential avoidance, and perceived control.[29][30]