Integrating mindfulness practices into psychological care

Medical and mental health professionals need to be familiar with the benefits and risks of mindfulness practices.

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Mindfulness is the practice of complete present-moment awareness (Lasater, 2000). Mindfulness practices include seated meditation; mindful exercise, such as yoga, tai chi and the martial arts; and mindfulness practices that have been adapted and/or developed for clinical use, such as Mindfulness Based Stress Reduction. Research demonstrates the wide-reaching benefits of mindfulness practices, including improved psychological health (through reduced stress, anxiety and depression, and increased satisfaction with life), improved physical health (reduced blood pressure and cholesterol, improved hormonal profiles), and improved functioning within the context of other health conditions such as chronic pain and during cancer treatment (for instance, see Bhushan & Sinha, 2001; Bonura & Pargman, 2009; Bonura & Tenenbaum, 2014; Eppley, Abrams, & Shear, 1989; Krishnamurthy & Telles, 2007; Nezt & Lidor, 2003; Woolery, Myers, Sternlieb, & Zeltzer, 2004).

The use of complementary and alternative (CAM) therapies, such as mindfulness training, offer an approach to health promotion and disease prevention and treatment, which can supplement modern medical interventions, especially with regard to chronic conditions, which are often inadequately treated with conventional medicine approaches (such as pharmacological agents). CAM therapies can “be used as primary therapy to treat specific diseases, as injunctive therapy in comprehensive treatment plans, and as a means of improving the quality of life of individuals with chronic or debilitating illnesses” (Yuen & Baime, 2006, p. 233).

Use of CAM practices, including mindfulness strategies, continues to grow, with many individuals choosing to use these techniques for self-care and as an adjunct to medical care. A cross-sectional survey of 1,200 community-dwelling older adults (older than age 65) found that 62.9 percent used at least one CAM modality, with an average of three modalities per respondent (Cheung, Wyman, & Halcon, 2007). Many CAM users implement these approaches, at least in part, for the management of disorders that are either psychological or stress-related (Wolsko, Eisenberg, Davis, & Phillips, 2004). For instance, 34 percent of respondents with anxiety spectrum disorders reported using mind-body therapies in the management of their condition. Similarly, mind-body therapies were used in the management of symptoms for 26.5 percent of respondents with depression; 18.5 percent with chronic pain, including headaches and neck and back pain; 18 percent with heart problems or chest pain; 13.3 percent with insomnia; and 12.1 percent with fatigue. Similarly, among veterans with posttraumatic stress disorder, 40 percent report using CAM to address emotional and mental concerns (Strauss & Lang, 2012). Yoga is one of the most commonly used mind-body approaches for psychological and stress-related conditions. Among yoga practitioners, 63.7 percent reported implementing yoga techniques for wellness and preventative benefits, and 47.9 percent reported implementing yoga techniques for the management of specific health conditions (Saper, Eisenberg, Davis, Culpepper, & Phillips, 2004). Individuals who report either physical or psychological medical problems are twice as likely to use CAM techniques as are individuals without reported medical problems (Rossler et al., 2007). Individuals with chronic and acute health conditions are more likely to use CAM modalities than the general public. For instance, while the National Center for Complementary and Integrative Care reports that about 30 percent of U.S. adults use CAM modalities, research shows that up to 59 percent of individuals with autoimmune disorders (Hui, Johnston, Brodsky, Tafur, & Ho, 2007) and up to 73 percent of individuals with cancer (Chandwani et al., 2012) use CAM therapies.

While CAM and mind-body approaches like yoga are becoming more popular, only 53 percent of users report their use to their primary care practitioner (Cheung, Wyman, & Halcon, 2007). There can be contraindications and risks for CAM practices, including certain forms of yoga and martial arts. Therefore, it is important for medical and mental health professionals to be familiar with the benefits and risks of both mindfulness practices in general and specific approaches. They should feel comfortable discussing these practices with their patients and making appropriate recommendations for their use as self-care and as an adjunct to psychological therapy and/or medication.

When medical and mental health professionals engage in open and informed dialogue with their patients, they support patients' disclosure of approaches that may carry risks along with benefits. If medical and mental health professionals understand how mindfulness practice may influence physical and psychological health, they can provide supportive guidance to their patients. Medical and mental health professionals may be able to recommend mindfulness strategies to support self-care as part of a wider treatment plan, particularly in populations who might be resistant to other psychological interventions. Mindfulness-based interventions offer a minimally invasive treatment protocol, which is easy to deliver in group format. Mindfulness practice offers a low-cost intervention strategy at both the individual and the community level. For individuals, some community recreation centers offer discounted or free yoga, tai chi and meditation classes. For communities seeking to promote self-care strategies, mindfulness practices can be provided in a low-cost format requiring minimal resources at community centers, schools and health facilities.

Mindfulness Exercise: Yoga, Tai Chi and the Martial Arts

Mindfulness exercise practices offer a form of physical activity that is uniquely suited to support both psychological and physical health. Mindfulness exercise practices, which include yoga, qi gong, tai chi and martial art forms such as kung fu, karate, and tae kwon do, combine physical activity with deliberate breathing exercises and focused attentional strategies. This combination of activity, breathing and focus helps the individual practitioner to develop an increased capacity for self-control. Research with mindfulness exercise practices indicates that the combination of exercise and mindfulness strategies may offer unique psychological and physical benefits above and beyond either meditation training or exercise training alone (Bonura & Pargman, 2009; Bonura & Tenenbaum, 2014).

While physical exercise is an integral part of mindful fitness practices, within the mindfulness context, physical exercise is a means to better understand the participant's mental process. Mindfulness approaches work by “using intervention strategies with mechanisms familiar to cognitive behavioral therapists …[and] promote positive adjustment by strengthening metacognitive skills and by changing schemas related to emotion, health, and illness” (Hamilton, Kitzman, & Guyotte, 2006, p. 123). Mindfulness makes yoga and the martial arts fundamentally different from non-mindful exercise, even when similar physical movements are practiced. A mindful fitness class teaches a physical process (i.e., feeling the sensation of the breath in the nostrils or standing completely still), which is intended to teach a cognitive process (i.e., controlling the thoughts and actions and maintaining awareness in the present moment). This helps the individual to learn self-control, which improves the individual's capacity to manage emotions and stress. Self-control is correlated with improved psychological health in mindfulness practitioners (Bonura & Tenenbaum, 2014).

Integrating Mindfulness Strategies into Psychological Practice

Psychologists who want to refer patients to mindfulness training practices should seek out relationships with certified instructors who have appropriate training and relevant experience. For instance, mindful fitness instructors may have specialized training that allows them to support specific populations, such as older adults, prenatal/postnatal women, older adults and military populations. Psychologists should seek to form relationships with mindfulness instructors who have training and professional experience relevant to the psychologist's clients. Further, psychologists who intend to recommend mindfulness practices as a supportive self-care tool for their patients should have at least minimal experience with mindfulness practices themselves and should try various instructors in their local area to better make recommendations as to appropriate venues for their patients.

Provided below is a list of resources, including websites, audio self-study programs and books that provide insight and training about the use of mindfulness practices to support health and wellness. As well, a search of the APA website offers a variety of a published articles, textbooks and videos, some of which are available for continuing education credits through APA, outlining best practices for implementing mindfulness strategies within psychological practice.

Recommended Resources

APA Continuing Education

Earn APA continuing education credits by taking an exam based on this book:

Shapiro, S., & Carlson, L. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psychological Association.

Websites

National Center for Complementary and Integrative Health, a division of the United States National Institutes of Health
Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, where Jon Kabat-Zinn, PhD, developed MBSR. Offers options for MBSR training on site and online.
Vipassana Meditation, as taught by S.N. Goenka
Yoga Alliance maintains a registry of yoga teachers who have met standards for yoga teacher training

Self-Study/Self-Practice Materials

Kornfield, J. (1993). The inner art of meditation (Audiobook). Louisville, CO: Sounds True.
Weil, A. (2001). Breathing: The master key to self-health (Audiobook). Louisville, CO: Sounds True.

Readings

Ameli, R. (2014). 25 lessons in mindfulness: Now time for healthy living . Washington, DC: American Psychological Association.
Anh-Huong, N., & Hanh, T.N. (2006). Walking meditation: Peace is every step. It turns the endless path to joy . Louisville, CO: Sounds True.
Barnett, J., Shale, A., Elkins, G., & Fisher, W. (2014). Complementary and alternative medicine for psychologists: An essential resource . Washington, DC: American Psychological Association.
Brown, R.P., & Gerbarg, P. (2012). The healing power of the breath: Simple techniques to reduce stress and anxiety, enhance concentration and balance your emotions . Boulder, CO: Shambhala Publications.
Kabat-Zinn, J. (2011). Mindfulness for beginners: Reclaiming the present moment – and your life . Louisville, CO: Sounds True.
Lasater, J. H. (2011). Relax and renew: Restful yoga for stressful times (2nd ed.). Berkeley, CA: Rodmell Press.
Nghiem, D. (2015). Mindfulness as medicine: A story of healing body and spirit . Berkeley, CA: Parallax Press.
Stahl, B., & Goldstein, E. (2010). A mindfulness-based stress reduction workbook . Oakland, CA: New Harbinger Publications.
Yee, R. (2002). Yoga: The poetry of the body . New York: St. Martin's Griffin.

References

Bhushan S., & Sinha P. (2001). Yoganidra and management of anxiety and hostility. Journal of Indian Psychology, 19, 44-49.

Bonura, K.B., & Pargman, D. (2009). The effects of yoga versus exercise on stress, anxiety, and depression in older adults. International Journal of Yoga Therapy, 19, 79-89.

Bonura, K., & Tenenbaum, G. (2014). The impact of yoga on psychological health in older adults. Journal of Physical Activity and Health, 11, 1334-1341.

Chandwani, K.D., Ryan, J.L., Peppone, M.M., Sprod, L.K., Devine, K., Trevino, L., et al. (2012). Cancer-related stress and complementary and alternative medicine: A review. Evidence-Based Complementary and Alternative Medicine . doi:10.1155/2012/979213.

Cheung, C., Wyman, J., & Halcon, L. (2007). Use of complementary and alternative therapies in community-dwelling older adults. Journal of Alternative and Complementary Medicine, 13 , 997-1006.

Eppley K. R., Abrams, A.I., & Shear J. (1989). Differential effects of relaxation techniques on trait anxiety: A Meta-analysis. Journal of Clinical Psychology, 45, 957-979.

Hamilton, N., Kitzman, H., & Guyotte, S. (2006). Enhancing health and emotion: Mindfulness as a missing link between cognitive therapy and positive psychology. Journal of Cognitive Psychotherapy, 20, 123 – 134.

Hui, K., Johnston, M.F., Brodsky, M., Tafur, J., & Ho, M.K. (2009). Scleroderma, stress, and CAM utilization. eCAM, 6, 503-506.

Krishnamurthy, M., & Telles, S. (2007). Assessing depression following two ancient Indian interventions: Effects of yoga and Ayurveda on older adults in a residential home. Journal of Gerontological Nursing, 33, 17-23.

Lasater, J. (2000). Living your yoga: Finding the spiritual in everyday life. Berkeley, CA: Rodmell Press.

Netz, Y. & Lidor, R. (2003). Mood alterations in mindful versus aerobic exercise modes. Journal of Psychology: Interdisciplinary & Applied, 137, 405-419.

Rossler, W., Lauber, C., Angst, J., Haker, H., Gamma, A., Eich, D., Kessler, R., & Ajdacic-Gross, V. (2007). The use of complementary and alternative medicine in the general population: Results from a longitudinal community study. Psychological Medicine, 37, 73-84.

Saper, R.B., Eisenberg, D.M., Davis, R.B., Culpepper, L., & Phillips, R.S. (2004). Prevalence and patterns of adult yoga use in the United States: Results of a national survey. Alternative Therapies in Health and Medicine, 10, 44-49.

Strauss, J.L., & Lang, A.J. (2012). Complementary and alternative treatments for PTSD. PTSD Research Quarterly, 23, 1-3.

Wolsko, P.M., Eisenberg, D.M., Davis, R.D., & Phillips, R.S. (2004). Use of mind–body medical therapies: Results of a national survey. Journal of General Internal Medicine, 9, 43-50.

Woolery, A., Myers, H., Sternlieb, B., & Zeltzer, L. (2004). A Yoga Intervention for Young Adults with Elevated Symptoms of Depression. Alternative Therapies, 10, 60-63.

Yuen, E., & Baime, M. (2006). Meditation and healthy aging. In E. Mackenzie & B. Rakel (Eds.), Complementary and alternative medicine for older adults: A guide to holistic approaches to healthy aging (pp. 233-270). New York: Springer.

Kimberlee Bethany Bonura, PhD, E-RYT, is a fitness and wellness educator and a contributing faculty member with the Walden University School of Psychology. Bonura is an experienced registered yoga teacher who has been teaching yoga and mindfulness practice for two decades. She earned her PhD in educational psychology with a research emphasis in sport and exercise psychology from Florida State University. Her doctoral dissertation, “The Impact of Yoga on Psychological Health in Older Adults,” earned awards from APA Div. 47 (Society for Sport, Exercise and Performance Psychology) and the Association for Applied Sport Psychology. Contact Bonura and view her website.