What’s in the web for family physicians – mindfulness-based interventions

Sophie YY Cheung 張茵茵，Silvia SW Lee 李思慧，Martina SL Cheung 張嬋玲，William WH Chui 崔永豪， Alfred KY Tang 鄧權恩

What is mindfulness?

http://franticworld.com/what-is-mindfulness/

Mindfulness is originated from Eastern meditation practice and operationally defined as “the awareness that arises by paying attention on purpose, in the present moment, and nonjudgmentally” (https://www.youtube.com/watch?v=CyiwVwwjFtQ).¹ During mindfulness practice, participants are encouraged to attend to their own internal experiences including bodily sensations, thoughts, and emotions or external stimuli such as visions or sounds at the present moment; an attitude of non-judgmental acceptance is advocated, by which participants are invited to observe own cognitions, emotions, sensation or perceptions without evaluation (https://www.youtube.com/watch?v=3nwwKbM_vJc).² Despite this seemingly simple definition, mindfulness is in fact a complex process which involves one’s ability in attentional control, emotion regulation and self-awareness. ³

How does mindfulness change the brain?

http://www.awakeatwork.net/sites/default/files/ Tang_1426855548_1%20-final.pdf

Practice of mindfulness leads to brain changes (https://www.youtube.com/watch?v=8GVwnxkWmSM). Imaging studies reveal the structural changes in various brain regions which are related to attention control, emotion regulation and self-awareness. These three components interact closely to constitute the important process of self-regulation, i.e. managing oneself well.

For example, emotion regulation refers to strategies that can influence which emotions arise and when and how long they occur, and how these emotions are experienced and expressed. Studies support the hypothesis that mindful emotion regulation works by strengthening the prefrontal cognitive control mechanisms and thus downregulates activity in regions relevant to affect processing, such as the amygdala.³ The connection between the emotion part (amygdala) and the rational part (prefrontal cortex) is strengthened; as a result, when the amygdala is “ringing” like a fire alarm, the prefrontal cortex can “reach” this alarm and switch it off after the real danger is over.

Mindfulness-based Stress Reduction (MBSR)

https://health.ucsd.edu/specialties/mindfulness/ programs/mbsr/Pages/default.aspx

https://www.umassmed.edu/cfm/ummhc-mindfulnessin- medicine/UMMHC-Videos/

MBSR was originally developed in a behavioural medicine setting for patients with chronic pain and stress-related condition.¹ MBSR is based on intensive training in mindfulness meditation. In its standard form, it is conducted as an 8-week class with weekly sessions lasting 2.5 to 3 hours. Extensive homework practice of 45-minute formal mindfulness exercises and other informal practices are also required. These 8 group sessions are highly experiential, with considerable time devoted to practice of mindfulness exercises and discussion of group members’ experiences with them. Major exercises included body scan, sitting meditation, yoga, walking meditation, and mindfulness in daily life (https://www.youtube.com/watch?v=u4gZgnCy5ew).⁴ A systematic review examined randomised control trials of MBSR. Regarding the application of MBSR to clinical populations with physical illnesses like rheumatoid arthritis, human immunodeficiency virus (HIV) and various types of cancers, there were reported improvements compared to the control groups.⁵

Mindfulness-based cognitive therapy (MBCT)

http://oxfordmindfulness.org/for-you/resources/

https://www.nice.org.uk/guidance/cg90/chapter/1- Guidance#continuation-and-relapse-prevention

MBCT was originally developed for the prevention of relapse of major depressive episodes. MBCT programme treatment protocol combines elements of cognitive behavioural therapy for depression and mindfulness meditation from MBSR programme.¹ It is an 8-session weekly group programme, which composes of 9-15 participants with about 2 hours of training per sessions. Content of the protocol includes mindfulness practices (i.e. body scan, sitting meditation, mindful stretching, mindful walking), discussions on patients’ mindfulness experiences and daily home practices (i.e. 45 minutes of mindfulness practice or application of mindfulness skills in daily routines). After the 8-session programme, booster sessions would also extend on discussing relapse prevention strategies such as soliciting social support or specific activities which interrupt the relapse processes.⁶

Unlike the MBSR, the didactic information in the MBCT focuses primarily on the nature of depression rather than on stress. Some other special practices are designed specifically for the MBCT, such as three-minute breathing space (https://www. youtube.com/watch?v=rOne1P0TKL8&t=40s) and sitting with the difficult (https://www.youtube.com/ watch?v=nlEFKxGNPHk). In the middle of MBCT, the instructions for sitting meditation are extended to include a period of deliberately calling to mind a difficult issue or problem and noticing where in the body associated sensations arise. A randomised controlled trial showed that depression patients who received MBCT with tapering or discontinuation of antidepressant were similar to those who received maintenance antidepressant in terms of the time to relapse or recurrence of depression over 24 months.⁷ A recent meta-analysis on the efficacy of MBCT showed that it was effective in reducing depression relapse within a 60-week follow-up period with a hazard ratio of 0.69 when compared with no intervention control; and a hazard ration of 0.79 when compared with active treatment.⁸

The clinical guideline of the National Institute for Health and Care Excellence (NICE) recommends “mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression” as a psychological intervention for relapse prevention.⁹

Mindful parenting

https://www.uvamindsyou.nl/site/professional/mymindtraining- amsterdam

Mindful Parenting includes: 1) greater awareness of a child’s unique nature, feelings and needs; 2) a greater ability to be present and listen with full attention; 3) recognising and accepting things as they are in each moment, whether pleasant or unpleasant; and 4) recognising one’s own reactive impulses and learning to respond more appropriately and imaginatively, with greater clarity and kindness. It aims to improve parenting by improving the quality of parental attention, increasing awareness of parental stress, reducing parental reactivity and decreasing the intergenerational transmission of dysfunctional parenting. It is an adaption version from the MBCT and MBSR programs. The target audience are parents of children or adolescents with externalising problems (like attention deficit hyperactivity disorder, oppositional defiant or conduct disorders), internalising problems (like anxiety or depression), or developmental disorders like autism spectrum disorder. Other parents with their own emotional problems (like depression or anxiety disorders) or other problems like attention, impulsivity or other serious family conflicts are also targeted audience.¹⁰ Preliminary studies found significant improvements in both the parents and the children.¹¹

Mindfulness for young people

https://mindfulnessinschools.org/

Why bother to let young people practice mindfulness? Mindfulness involves learning how to cultivate greater awareness of self and others. The applications of this learning are seemingly boundless. We do not know what specific knowledge our children are going to most need ten or twenty years from now, because their world will be so different from ours. Nevertheless, what we do know is that they will need to know how to pay attention, how to focus and concentrate, how to listen and how to learn, and how to be in wise relationship with themselves – including their thoughts and emotions – and with others. That skill set lies at the heart of mindfulness.¹²

In the United Kingdom, the Mindfulness in Schools Program, as known as the “.b”, was developed as a universal intervention for adolescents (https://www. youtube.com/watch?v=mNojLd_Jbh8). “.b”, pronounced as [dot-be], stands for “Stop, Breathe and Be!”. A nonrandomised controlled trial evaluated the effectiveness of “.b” in secondary schools. There was strong evidence of lower depression scores, increased well-being and lower stress in the intervention group.¹³

Is mindfulness safe and how to find service locally?

http://oxfordmindfulness.org/news/is-mindfulness-safe/

Mindfulness practice is sometimes compared to physical exercise, but the science of mindfulness is at a much earlier stage. Harmful effects of mindfulness practice appear to be rare but have not yet been thoroughly studied. Like doing physical exercise, practicing mindfulness safely requires consideration of the intensity of the practice, the vulnerability of the person and the quality of the mindfulness instruction. It is wise for anyone interested in mindfulness is to begin with low to moderate-intensity practices. Mindfulness: A Practical Guide to Finding Peace in a Frantic World by Williams & Penman was a programme developed to introduce mindfulness believed to be safe and showing evidence of effectiveness.¹⁴

People who have physical or psychological difficulties and are interested in more intensive practice should work with an experienced teacher offering evidence-based classes (such as MBSR and MBCT). People with mental health problem should only undertake a programme taught by a person who has the training and experience in mindfulness and mental health.

Information about the mindfulness courses available in Hong Kong by trained mindfulness teachers can be found in the following websites:

https://mindfulness.hk/cn/ (Chinese)

https://mindfulness.hk/en/ (English)

Pamphlets about the mindfulness-based interventions can be found in the following websites:

http://www3.ha.org.hk/cph/imh/mhi/article_04_03_03. asp

http://www3.ha.org.hk/cph/imh/doc/information/ publications/6_5_tc_2017.pdf