The Role of Mindfulness in Healthcare Reform: A Policy Paper
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GUEST EDITORIAL
The Role of Mindfulness in Healthcare
Reform: A Policy Paper
Kelley McCabe Ruff, MBA and Elizabeth R. Mackenzie, PhD
by 2012.2 Clearly, our healthcare system is
Contributing Authors: “Awareness and meditation are, for me,
Michael Baime, MD — University of unsustainable both in terms of its financial
fundamental to the deep change that is
Pennsylvania and human costs. However, despite a nearly
necessary for healing. Chronic illness is a
Gina Biegel, MA, LMFT — Kaiser Permanente unanimous call for reform, there remains a
Jeff Brantley, MD — Duke Intergrative way of life as well as, perhaps even more
lack of consensus about what form the
Medicine than, a disease entity. Before we can be
Jeanne Chadwick, PhD — University of free of the symptoms of illness and the changes should take, and different stake-
Connecticut role of the sick person, we need to know holders have put forth a variety of ap-
Connen OⱊConnell, MA — Won Institute proaches.
Jeffery Dusek, PhD — Penny George what has precipitated those symptoms,
and how we are responding to our sick- At this stage, one of the most important
Institute for Health and Healing, Abbott
Northwestern Hospital ness. We need to recognize in our own questions we can ask is, “What is driving
Jakie Gardner-Nix, PhD, MRCP (UK) — lives the psychological, biological, and so- healthcare costs?” It is reasonable to as-
St. Michael’s Hospital Pain Clinic, sume that if we can identify the underly-
ciological factors that may affect our
Sunnybrook Health Sciences Centre
health. ing problem, we will increase our chances
Pain Management Programme
Arnold Kozak, PhD — University of Awareness allows us to see where we of arriving at an effective solution.
Vermont are; to stand for a moment outside our- Like most commodities, healthcare is
Ellen Langer, PhD — Harvard University selves; to appreciate in a powerful, per- subject to the rule of supply and demand.
Sasha Loring, MA — Duke Intergrative
Medicine sonal way, how the world around us af- Right now, we have a high demand for
Elizabeth R. Mackenzie, PhD — School of fects us; to observe the thoughts, feelings, healthcare procedures characterized by so-
Arts and Sciences, University of and sensations that arise in us. Meditation phisticated and expensive medical tech-
Pennsylvania is a state of moment-to-moment aware- nology. The evidence suggests that ad-
Elise Mahovlich — Living Yoga Studios
ness that over time may help to dissolve vances in medical technology are the
Timoty McCall, MD — Medical Editor of
Yoga Journal physical symptoms and habitual ways of single biggest factor driving up healthcare
Jane McCool, PhD — Northeastern thinking and acting. Both awareness and costs over the last 50 years or so, eclipsing
University meditation enable us to experience the all the other factors such as aging popula-
Lisa Dalle Miller, MFT — private practice way our mind may limit or free us. To-
David Nixa — eMindful Inc. tion, costs of health insurance, rising in-
Beatriz Olson, MD — Yale University gether they prepare us to use our mind to comes, defensive medicine, administrative
Helen Rosen, PhD — Won Institute make the deep changes in thought, feel- costs, lower productivity, end-of-life care,
Kelley McCabe Ruff, MBA — CEO ing, and action that are necessary for our and the like.2 However, since advances in
eMindful Inc. healing.”
Kevin Thompson — eMindful Inc. medical technology have also tended to
—James S. Gordon, MD1 produce better health outcomes for cer-
Glenn Wallis, PhD — Won Institute
Ruth Wolever, PhD — Duke Intergrative tain conditions,3 we do not want to thwart
Medicine technological progress. The problem is
Elaine Yuen, PhD — Thomas Jefferson numbers of Americans are uninsured (med-
University ical bills are a leading cause of bankruptcy), that the nation, regardless of who pays for
Lidia Zylowska, MD — UCLA and the aging of the so-called baby boomer healthcare, can no longer afford to keep
generation threatens to burden Medicare be- supplying the ever-increasing demand.
yond its capacity. The United States spends One solution is to put limits on the sup-
THE URGENCY OF HEALTHCARE over $2 trillion annually on healthcare, yet ply—to engage in healthcare rationing.
REFORM some key national health indicators lag sig- There are many serious objections to this
By now it is clear to everyone— econo- nificantly behind other developed nations approach, chief among them the moral is-
mists, lawmakers, health professionals, (eg, infant mortality rates in the United sue of denying potentially life-saving pro-
and the public—that healthcare reform is an States rank 23rd globally, on par with Po- cedures to human beings. Fortunately,
urgent need, a national emergency that re- land and Slovakia). As a percentage of gross there is another more humane and sensi-
quires immediate and focused attention. domestic product, healthcare spending ex- ble solution: reducing the demand by leverag-
Costs continue to spiral out of control, large ceeds 16% and is projected to reach 17.7% ing preventive medicine.
Guest Editorial EXPLORE November/December 2009, Vol. 5, No. 6 313The fundamental problem in our for greatest impact. Strategies for health with chronic disease; the randomized
healthcare system—the factor most respon- promotion and disease prevention—those controlled trial (RCT) of 952 patients
sible for driving up healthcare costs—is the that focus on self-responsibility and that sup- indicated a cost savings of approxi-
neglect of low-tech strategies to prevent port positive behavioral change—will yield mately $750 per participant, more than
disease and promote health in favor of the greatest long-term cost savings and are 10 times the cost of the program
high-tech interventions to treat disease af- the foundation for a sustainable health- ● in an RCT of 335 patients scheduled for
ter it has arisen. We must change the way care system for the 21st century. surgery, those who listened to guided
we think about health and healthcare if we As Risa Lavizzo-Mourey, MD, MBA, imagery audiotapes beforehand experi-
are to produce meaningful and lasting the CEO of the Robert Wood Johnson enced a 43% reduction in blood loss and
healthcare reform. As a society, we have Foundation, recently pointed out, al- were able to leave the hospital a day earlier
become habituated to looking outside though we spend over $2 trillion annually ● two RCTs of premature infants found
ourselves for answers to our problems, of- in the United States on healthcare, only that those who were massaged three
ten turning to technological solutions 5% of that money goes toward public times a day for 10 days gained weight
that, although typically effective in the health and disease prevention.4 Perhaps more rapidly and were discharged from the
short-term, may not be the best long-term these figures can explain why we have be- hospital five to six days earlier, yielding a
approach. Thus, we have a high incidence come so good at treating disease, but so savings of more than $10,000 per infant
of cardiovascular disease and a plethora of deficient in preventing disease from oc-
sophisticated approaches to treating it, curring in the first place. Lavizzo-Mourey As Sobel has pointed out, the beauty of
ranging from pharmaceutical interven- calls on lawmakers to “. . . reconfigure these low-tech mind-body interventions is
tions to heart transplants. The success of what we spend to build a ‘culture of well- that they result in both better health out-
these interventions is wonderful to be- ness’ in this country.”4 comes and significant cost-savings.6 As the
hold, and they are responsible for saving In summary, the problem facing us is a evidence mounts that mind-body medi-
many lives. But what if we were able to disease-oriented healthcare system. It is a cine is both clinically effectual and cost ef-
reduce the demand for such interventions problem because the costs— both human fective, it is increasingly clear that the time
by lowering the incidence of heart disease and financial—are unsustainable. The hu- has come to integrate these approaches into
in the United States? What if we had a mane and sensible solution is to employ a conventional healthcare. In fact, with sup-
healthcare system that successfully im- low-tech approach to health promotion that port from the Bravewell Collaborative, an
proved the health of our population so is successful, accessible, feasible, equitable, award-winning documentary titled The New
much that the demand for costly proce- and cost effective. Luckily, this approach has Medicine, produced in 2006, presented
already been discovered and is now being many of the ways in which new scientific
dures declined, resulting in both cost sav-
implemented and tested across the nation. knowledge about the mind-body connec-
ings and a healthier citizenry? In this sce-
tion can be integrated within existing health-
nario, healthcare rationing (limiting the
care systems to both improve health out-
supply) would be irrelevant due to the sig-
comes and lower costs.7
nificantly reduced demand for costly pro- COST-SAVINGS ASSOCIATED WITH
cedures. Sophisticated medical technol- MIND-BODY MEDICINE
ogy would be there to serve patients whose Mind-body medicine focuses on the rela-
lives depended on it. However, there tionships among the mind, body, brain, MIND-BODY APPROACHES TO
would be fewer such cases, lowering costs and behavior, and produces interventions DISEASE PREVENTION AND
overall and increasing the general well-be- that use these connections to achieve and HEALTH PROMOTION
ing of the population. Such a scenario is maintain health.5 A small cadre of re- Mind-body medicine is not just a promis-
feasible if we can tap into the potential of searchers has been quietly compiling data ing avenue for treating disease; there are
preventive medicine. for many years on mind-body interven- many indications that it can actually pre-
By leveraging preventive medicine, we tions and their potential cost savings. vent disease from occurring at all.
can reduce the incidence of catastrophic Among them is David S. Sobel, MD, “Heart disease, diabetes, prostate can-
illness and serious disease, thereby dimin- MPH, of Kaiser Permanente, who summa- cer, breast cancer, and obesity account for
ishing the need for expensive interven- rized years of research in a short review 75% of health-care costs, and yet these are
tions. As the old adage has it, “an ounce of article published in the Journal of the Amer- largely preventable and even reversible by
prevention is worth a pound of cure,” yet ican Medical Association in 20006: changing diet and lifestyle. . . . The latest
our current system focuses mostly on cure scientific studies show that our bodies
and largely overlooks the advantages of ● one study of 107 patients with heart dis- have a remarkable capacity to begin heal-
investing in prevention. Paying more at- ease found that psychosocial interven- ing, and much more quickly than we had
tention to disease prevention and health tions (ie, stress management practices) once realized, if we address lifestyle factors
promotion will result in a healthier popu- reduced the risk of subsequent cardiac that often cause these chronic diseases.”8
lation with less call for expensive medical events by 75% (compared to usual care The authors of this Wall Street Journal
interventions. Low-tech, cost-effective ap- only) op-ed cite the INTERHEART study,9
proaches to disease prevention and health ● Kaiser Permanente and Stanford Uni- which “followed 30,000 men and women
promotion already exist; it is merely a mat- versity implemented a seven-week pa- on six continents and found that changing
ter of exploring how best to employ them tient education program for patients lifestyle could prevent at least 90% of all
314 EXPLORE November/December 2009, Vol. 5, No. 6 Guest Editorialheart disease.”8 Clearly, it is more cost ef- der et al,13 and Dusek et al14). Stressors acti- effect on immunity and the overall ho-
fective to spend money to help people eat vate the sympathetic nervous system (the meostatic regulation of the body.
healthfully, exercise, and manage their fight-or-flight response), causing higher Recent studies point to the role of
stress than to treat heart disease after it has blood pressure and having a deleterious meditation in bolstering immunity by
developed. This is the proverbial “no- effect on the heart. Meditation, on the modulating the stress response. In a land-
brainer,” and yet we have been slow to other hand, actually reduces sympathetic mark study, Davidson et al19 were the first
invest in relatively inexpensive health pro- activation (measured by blood biomarkers to demonstrate that meditation changes
motion programs known to prevent all and cardiac indices). For example, a study both brain and immune function. They
manner of diseases, like cardiovascular dis- of 19 patients with congestive heart failure found that an eight-week mindfulness
ease, that are very expensive to treat after found that a 12-week meditation program meditation program produced beneficial
they have arisen. reduced blood levels of the stress hor- changes in both brain and immune func-
mone norepinephrine, improved cardio- tion in a group of 25 healthy participants.
vascular function, and enhanced quality In addition to showing that the medita-
MEDITATION of life.15 Walton et al16 evaluated studies tion group, compared to the controls, had
There are a number of mind-body prac- of meditation and cardiovascular disease increased brain activity in an area associ-
tices and interventions that researchers and found that meditation “may be re- ated with positive emotions, they also
have found to be effective for a variety of sponsible for reductions of 80% or greater demonstrated increased production of an-
conditions, including yoga, tai chi, Qi in medical insurance claims and payments tibodies in response to a flu vaccine. Sim-
gong (or Chi Kung), biofeedback, and to physicians.” Another study of medita- ilarly, when Pace et al20 randomized 61
therapeutic bodywork techniques that ad- tion among 23 African Americans recently healthy adults to a short meditation train-
dress both mind and body. All of these hospitalized with congestive heart failure ing (six weeks) or a control group, they
modalities are worthy of discussion and found that the meditation group had found that the new meditators responded
have enormous potential to promote fewer rehospitalizations and better cardiac to stressors differently than the controls.
health and treat disease; however, they are function than the control group.17 Not Specifically, following a standardized
beyond the scope of this paper, which fo- surprisingly, they also exhibited improved stressor, those who meditated had lower
cuses on meditation. There are many dif- mood and enhanced quality of life. The levels of both distress and inflammation,
ferent styles of meditation—too many to seminal study by Dean Ornish et al18 pub- suggesting that meditation reduces stress-
enumerate here—and some are rooted in lished in the Journal of the American Medical induced immune responses. Another
spiritual traditions (eg, Christianity, Bud- Association found that lifestyle changes study looked at a form of mindfulness
dhism, Taoism, and Hinduism), whereas meditation on immune function, quality
that included meditation-based stress
others are not tied to any specific religious of life, and psychological coping in a
management actually reversed coronary
practice. group of women recently diagnosed with
atherosclerosis over a five-year period in a
The fundamental concept at the core of breast cancer.21 They found that the
group of 20 persons with moderate to se-
meditation is similar across all traditions—to women in the eight-week meditation
vere coronary heart disease. Patients in the
group (when compared to controls over
promote increased awareness through fo- control group (n ⫽ 15) had more than
cused attention in the present moment. time) had better immune system biomar-
twice as many cardiac events than those in
Meditation is primarily a reflective disci- kers, reduced stress hormones, improved
the experimental group. As many mind-
pline that requires a quiet introspection, quality of life, and better coping skills.
body medicine advocates have pointed
typically leading to a fundamental shift in Carlson et al22 explored an eight-week
out, if there were a pill that could do this,
one’s perspective on daily life. Interest- mindfulness meditation program as an in-
the government would mandate its imme-
ingly, the practice of meditation is associ- tervention for early-stage breast and pros-
diate and widespread use.
ated with increased resilience to stress tate cancer patients and found that the
Psychoneuroimmunology is a growing persons in the mindfulness group had en-
and significant health improvements. Re- field of research that seeks to map the bio-
searchers have demonstrated that psycho- hanced quality of life, decreased stress
mechanical pathways associated with the symptoms, and may have experienced
social stress plays a pivotal role in the de- mind-body connection. It is no secret that
velopment of disease.10,11 This may beneficial changes in the endocrine sys-
our thoughts and emotions can influence tem, a component of the immune system.
explain why meditation can both prevent our immune systems, but the science of In sum, meditation appears to protect the
and treat a large range of conditions, ev- exactly how this happens is still not com- body from the potentially damaging ef-
erything from cardiovascular disease to fi- pletely understood. What the psychoneu- fects of psychological stress by physiolog-
bromyalgia. roimmunology studies have documented ically interrupting stress pathways and
is that our perceptions, thoughts, and strengthening the body’s immune re-
feelings can influence our immune and sponses, thus improving health directly.
MEDITATION: THE PHYSICAL hormonal systems in both adaptive
EFFECTS and nonadaptive ways. How we perceive
The practice of meditation is known to daily life experiences (eg, being over-
have effects on human physiology, includ- whelmed or feeling threatened) can lead to MEDITATION AND THE BRAIN
ing improved blood pressure and cardiac chronic psychological stress. Such chronic Neuroscience studies of meditation have
functioning (eg, Anderson et al,12 Schnei- stress has been shown to have a deleterious demonstrated enduring and beneficial
Guest Editorial EXPLORE November/December 2009, Vol. 5, No. 6 315changes in both the function and structure found to have a beneficial effect for this designed to prevent future relapse, and re-
of the brain that persist beyond the period of and many other mental health prob- search shows that it is more effective than
meditation.19,23-26 Neuroscientist Daniel lems.28 In fact, a meditation-based inter- treatment as usual.37,38
Siegel27 concludes that mindfulness pro- vention for depression was shown to be There is also some evidence suggesting
duces a form of neural integration and better at preventing relapse into depres- that mindfulness meditation discourages
coherence that leads to more adaptive sion than the standard treatment (antide- self-destructive behavior in response to
functioning. The areas of the prefrontal pressant medication),29 and a meditation- stress through acceptance rather than avoid-
cortex that show increases in gray matter based stress reduction intervention was ance of negative emotions such as sorrow,
are responsible for emotional regulation found to successfully treat anxiety disorders, guilt, or loneliness.39,40 Anecdotal evidence
(including modulating fear) and an in- not only in the short term but even at suggests that mind-body practices such as
creased ability to be resilient in the face of the three-year follow-up.30 Meditation also meditation help individuals make the jour-
stress. Other capacities affected include holds promise as an intervention for the ney from self-destructive to self-supportive
the regulation of body systems, attuning treatment of posttraumatic stress disorder behavior. Furthermore, mind-body inter-
to others, responding flexibly, and exhib- (PTSD), a particularly debilitating condi- ventions serve as catalysts for virtuous cy-
iting insight and empathy. For example, tion that plagues many US veterans.31 Al- cles, initiating a cascade of positive side ef-
Lazar et al24 found that mindfulness med- though not yet systematically studied in a fects. As with all truly holistic interventions,
itation led to a thickening in areas of the population of US veterans, an RCT of a the effects of meditation are not confined to
prefrontal cortex linked to these func- mind-body intervention that included a single symptom or condition. For exam-
tions, and that these changes were corre- meditation was found to successfully treat ple, someone may begin a meditation pro-
lated with the length of time practicing. adolescents suffering from PTSD in post- gram to stop smoking and find that not only
Lutz et al25 conclude that: war Kosovo.32 Researchers at the Veterans does their craving for cigarettes decrease,
Affairs Health Care System in San Diego their mood improves, their relationships are
tested a mantra meditation practice in a more harmonious, and their hypertension
Many of our core mental processes group of veterans and found it to be an diminishes.
such as awareness and attention and effective method of reducing symptoms of
emotion regulation, including our very stress and anxiety.33
capacity for happiness and compas-
Meditation not only improves health
sion, should best be conceptualized as AGING AND THE MIND
trainable skills. The meditative tradi- directly (eg, normalizing blood pressure,
Finding cost-effective ways to support the
tions provide a compelling example of enhancing immunity, lowering levels of
healthy aging of the US population is one
strategies and techniques that have stress hormones, and improving brain of the cornerstones of healthcare reform,
evolved over time to enhance and op- function), it improves health indirectly by and researchers continue to uncover in-
timize human potential and well-be- helping individuals to avoid maladaptive triguing indications that the mind has a
ing. The neuroscientific study of these responses to stress (eg, excessive drinking,
traditions is still in its infancy but the profound influence on how the body ages.
substance abuse, smoking, binge eating), For example, following her studies on self-
early findings promise to reveal the thus improving health indirectly. It has
mechanisms by which such training may efficacy and longevity,41,42 Ellen Langer’s
exert its effects as well as underscore the long been known that five behavioral fac- groundbreaking 1979 study on the psy-
plasticity of the brain circuits that under- tors significantly contribute to the rising chology of aging raises a number of ques-
lie complex mental functions.25 costs associated with the chronic disease tions about the conventional perspective
burden in the United States: excessive on the biological causes of aging.43 In this
As this fledging field progresses, it is drinking, smoking, eating, inactivity, and study, a group of male nursing home resi-
very likely that neuroscientists will be able stress. Meditation has been shown to help dents in their late 70s and early 80s were
to demonstrate—in scientific terms— ex- in all these areas. Meditation addresses taken on a weeklong retreat, where they
actly how and why meditative practices stress directly by enhancing our ability to were encouraged to live as if it were 1959.
produce the kinds of health benefits prac- cope with psychological stressors that The researchers took steps to create a psy-
titioners report anecdotally and research- would otherwise adversely affect our phys- chological environment that took the par-
ers have found in their clinical studies. iology, as discussed above. It can also as- ticipants’ imaginations back in time, al-
sist persons in making the lifestyle changes lowing them to live in a fictional 1959.
(eg, smoking cessation, reducing or elimi- They then measured a range of indicators of
MEDITATION AND THE MIND nating alcohol consumption) necessary chronological age, and they found signifi-
Meditation can protect the body from the for good health.34 For example, studies cant changes in the experimental group, in-
negative effects of psychological stress, as have shown that mindfulness meditation cluding improvements in joint flexibility,
discussed above; it can also help to pre- can help people quit smoking,35 decrease manual dexterity, and even finger length.
vent and treat mental health problems binge eating,36 and reduce alcohol and Other studies have demonstrated that a
such as depression and anxiety. Depres- substance abuse.37 Mindfulness-based simple change in mental attitude can re-
sion is one of the most common chronic interventions specifically targeted for sult in weight loss and lower blood pres-
mental health problems, and it inflicts a substance abuse relapse prevention have sure,44 as well as improved vision.43 Find-
heavy societal toll in terms of both human proved successful. Mindfulness-based re- ings of this nature fly in the face of the
and financial costs. Meditation has been lapse prevention is an eight-week program conventional view of human physiology
316 EXPLORE November/December 2009, Vol. 5, No. 6 Guest Editorialyet are the fruits of legitimate research. Interest in the clinical application of and cost effective, particularly in the treat-
What might explain these research find- mindfulness is gaining momentum, and ment of chronic disease.
ings? One clue is found in studies suggest- there is convincing evidence that mindful- Roth and Stanley62 report that an eight-
ing that mind-body practices such as med- ness can improve health and quality of life week MBSR program at a community
itation can actually alter gene expression. through the following: health center (N ⫽ 73) resulted in a signifi-
Jeffery Dusek et al45 conducted a study on cant decrease in chronic care office visits af-
long-term practitioners of a variety of ● decreased perception of pain ter the MBSR program was completed,
mind-body practices and found that, com- ● increased ability to tolerate pain based on a review of utilization records. The
pared with control subjects, the mind- ● reduced stress, anxiety, and depression authors conclude that MBSR programs may
body practitioners had more than 2,000 ● diminished use of medication (lessen- help to contain healthcare costs in similar
differently expressed genes. When they ex- ing adverse effects of drugs) inner-city community health centers.
posed the nonpractitioners to eight weeks ● enhanced medical decision making A small study of adult offenders with mild
of meditation training, the expression of ● better adherence to medical treatments intellectual disabilities (N ⫽ 6) found that a
more than 1,500 genes was altered. Repli- ● increased motivation to make lifestyle simple mindfulness exercise reduced physi-
cating and confirming these studies would changes cal aggression so much that “no Stat medi-
open up a new world of possibility for ● more social connection and enriched cation or physical restraint was required, and
healthy aging, among other things, with interpersonal there were no staff or peer injuries.”63 The
important implications for both improved ● enhanced neuroendocrine and immune authors estimate a 95.7% reduction in costs
quality of life and reduced medical costs system function46 associated with lost workdays and rehabilita-
among the elderly. tion.
A German study of 21 persons with
chronic illnesses (physical and psychologi-
MINDFULNESS MEDITATION AND MINDFULNESS-BASED
cal) found that an eight-week mindfulness
MEDICINE INTERVENTIONS FOR CHRONIC
meditation program resulted in lasting re-
The most common form of meditation CONDITIONS
ductions in symptoms as well as improved
found in clinical settings is mindfulness- Mindfulness-based stress reduction has
quality of life and general well-being as mea-
based stress reduction (MBSR), a clinically been tested as a clinical intervention for a
sured in a three-month poststudy follow-
tested, secular form of meditation popu- wide range of conditions. A brief overview
up.64 The authors conclude that mindful-
larized by Jon Kabat-Zinn, PhD, professor of mindfulness-based interventions for
chronic disease shows that it may be an ef- ness training has important cost-control
emeritus at the University of Massachu- benefits.
setts Medical School, and founding direc- fective treatment or adjunct intervention for
a range of disorders, including depres- A 2008 qualitative study of 27 older
tor of both the Stress Reduction Clinic adults with chronic lower back pain (a con-
and the Center for Mindfulness in Medi- sion,47,29 anxiety,48 substance abuse,37 eat-
dition associated with significant healthcare
cine, Healthcare and Society. Kabat- ing disorders,49 binge eating,50 insomnia,51
costs) found that an eight-week mindfulness
Zinn’s work has provided a foundation for chronic pain,52 psoriasis,53 type 2 diabe-
meditation program produced numerous
the use of mindfulness meditation as a tes,54 fibromyalgia,55 rheumatoid arthri-
health improvements including diminished
medical intervention, and his books, tis,56,57 attention-deficit/hyperactivity disor-
pain, improved attention, better sleep, en-
scholarly articles, and scientific studies der,58 HIV,59 cancer,21 and heart disease.60
hanced well-being, and improved quality of
have greatly advanced our understanding A comprehensive literature review of four
life.52
of the mind-body connection. of the largest health sciences databases
(EBSCO, CINAHL, PSYCHLINE, and Kreitzer et al51 studied the effects of an
The concept of mindfulness is simple. eight-week mindfulness meditation pro-
“The goal of all mindfulness is to maintain MEDLINE) found that “MBSR is an effec-
tive treatment for reducing the stress and gram on 20 organ transplant recipients.
awareness moment by moment, disengag- Transplant recipients typically experience a
ing oneself from strong attachment to be- anxiety that accompanies daily life and
chronic illness. . . . No negative side host of symptoms after their surgery, such as
liefs, thoughts, or emotions, thereby de- anxiety, depression, and insomnia, all of
veloping a greater sense of emotional effects from MBSR have been docu-
mented.”61 Researchers hypothesize that which add to the expense of their recupera-
balance and well-being.”46 Detachment tion. The recipients who completed the rel-
its effectiveness for so many different types
from thoughts and emotions allows indi- atively low-cost mindfulness meditation
of conditions is due to its ability to modu-
viduals to observe their habitual patterns program experienced better sleep quality
late the stress response. In other words,
of behavior without judgment, creating even six months after completing the
MBSR allows us to use the wisdom of our
space for wiser choices. Using his own ex- course, resulting in decreased anxiety/de-
minds and the innate healing capacity of our
periences with mindfulness meditation, pression and better quality of life.
bodies to improve our physical health.
Kabat-Zinn developed and standardized
an eight-week mindfulness meditation
program for use in clinical settings that he MINDFULNESS FOR HEALTH
called mindfulness-based stress reduction. STUDIES OF MINDFULNESS THAT PROFESSIONALS: THE
His MBSR program has become a guide INCLUDED COST IMPLICATIONS IMPORTANCE OF SELF-CARE
and a standard for virtually all other clini- Accumulating data indicates that mindful- The routine training of health profession-
cally oriented mindfulness programs. ness meditation is clinically efficacious als (eg, physicians, nurses, clinical social
Guest Editorial EXPLORE November/December 2009, Vol. 5, No. 6 317workers, psychologists) in mindfulness be integrated into existing curricula in to continue using mindfulness in the class-
programs such as MBSR may be one of the schools of medicine, nursing, and social room. A recent RCT demonstrated that
most effective ways to disseminate its ben- work. In fact, a number of programs seek- adolescents with a whole host of medical
efits widely throughout the healthcare sys- ing to address clinician burnout and stress and mental health problems experienced
tem, improving both the professional lives already offer mindfulness training. Kabat- significant improvements after an eight-
of clinicians and the health of patients. Zinn and his colleagues have taught mind- week program of MBSR, including re-
A stressed healthcare workforce leads to fulness techniques to medical students at duced anxiety, depression, and improved
increased costs associated with practitio- the University of Massachusetts for over self-esteem and sleep quality. These clini-
ner burnout, high staff turnover, clinical 20 years,79 and similar programs are being cally significant changes were sustained
errors, and lower quality care for patients. offered elsewhere, such as the Penn Pro- over the three-month follow-up.83
Costs associated with medical errors are ap- gram for Mindfulness at the University of Such research suggests that mindfulness
proximately $17 billion annually, whereas Pennsylvania and the Mindfulness Insti- training could be an important comple-
those stemming from high rates of staff tute at Thomas Jefferson University.76 ment to existing public health initiatives
turnover are about $21 billion per year.65 These programs could be expanded, en- to address childhood obesity, reduce
Poor physician-patient communication is couraged, and replicated through Na- school violence, and improve educational
one of the factors responsible for the prac- tional Institutes of Health training grants. achievement. Teaching children the basics
tice of defensive medicine,66 which is as- Health professionals already in the work- of mindfulness has the immeasurable
sociated with annual costs of about $210 place can be encouraged to seek mindful- added benefit of giving young people cop-
billion.65 Mindfulness training can ad- ness training through programs and work- ing skills that may prevent the develop-
dress these concerns (eg, Kabat-Zinn,67 shops that offer continuing education ment of mental and physical disease later
Baime,68 and Brown and Ryan69). There credits (CEUs). in life.84 Researchers have found a correla-
are many immediate benefits to exposing tion between childhood abuse (physical
clinicians to mindfulness training: and/or sexual) and certain kinds of ill-
nesses later in life (eg, irritable bowel syn-
MINDFULNESS IN THE SCHOOLS: drome, fibromyalgia).85,86 One recently
● evidence suggests that mindfulness training
PROMOTING HEALTH AND published study of over 15,000 individu-
of physicians can reduce medical errors70
ACADEMIC ACHIEVEMENT als found that “childhood traumatic stress
● a study of 53 medical residents suggests
Children often experience just as much increased the likelihood of hospitalization
that training in self-awareness enhances
psychological stress as their parents, yet with a diagnosed autoimmune disease de-
the ability to conduct patient-centered have few resources with which to cope. cades into adulthood.”87 The authors dis-
interviews,71 thereby improving physi- Children and adolescents living in low- cussed these findings in connection with
cian-patient communication and ulti- income, high-crime areas, or whose par- recent biological studies on the impact of
mately resulting in higher quality of ents are coping with high levels of psycho- childhood stress on subsequent inflamma-
care68 social stress (for example, due to divorce, tory responses.87 The findings strongly sug-
● a number of studies and reviews have job loss, chronic disease, or substance gest that giving children an effective method
suggested that increased self-awareness abuse) are especially vulnerable. This can to cope with psychological stressors can help
can help prevent and manage stress and lead to a host of dysfunctions such as to prevent the development of serious, de-
burnout, and increase empathy72-77 behavioral problems, eating disorders, bilitating, and costly diseases later in life.
● studies suggest that teaching mindful- substance abuse, depression/anxiety, inter-
ness to health professionals improves personal conflict, aggression, and poor aca-
the quality of care they deliver through demic performance.81 A number of re-
enhancing caregiver self-efficacy,78 im- searchers across the nation are pioneering TELEMEDICINE AND THE
proving clinician well-being and coping the study of MBSR in schools, and the DELIVERY OF MINDFULNESS
skills,79 and that training psychothera- results of their research are promising. For TRAINING
pists in mindfulness significantly im- example, Park Day School in Oakland, Currently, the most common method of
proves the mental health of the patients California, has initiated a program in delivery of mindfulness instruction is face-
under their care80 mindfulness for elementary students in to-face group trainings in classroomlike
the Oakland area.82 Over 5,000 children settings. It is a cost-effective way to pro-
What the research underscores is the in 20 schools have received mindfulness mote physical and psychological well-be-
crucial importance of self-care for health training. Analysis of the research findings ing, yet there are limitations to how many
professionals if they are to have the capac- is ongoing, but preliminary data show that persons can access mindfulness instruc-
ity to deliver truly high-quality care to pa- 93% of students report that mindfulness tion due to a finite number of qualified
tients, minimizing clinical errors, improving has helped them in some way, 85% say mindfulness meditation teachers. New in-
physician-patient communication, lessen- they will use mindfulness techniques in formation technologies can improve ac-
ing the incidence of burnout, enhancing pa- the future, 61% say it helps them calm cess to mindfulness instruction. The age of
tient-centered care, and reducing the fear of down; and 59% say it helps them focus telemedicine has arrived. Based on a grow-
litigation. Health professionals can receive better in the classroom. Among teachers, ing awareness of the benefits of telemedi-
training in mindfulness through a number 96% say that the mindfulness training has cine, state governments are beginning to
of avenues. First, mindfulness training can benefited them personally, and 94% plan support its use. For example, in June 2009
318 EXPLORE November/December 2009, Vol. 5, No. 6 Guest Editorialthe state of Maine passed a law requiring cally and cost-effective adjunct to conven- PAYING FOR MINDFULNESS
health insurance plans to cover telemedi- tional face-to-face care. TRAINING
cine services.88 Telemedicine (or telehealth The use of Web-based, online mindful- The costs associated with delivering mind-
or eHealth) refers to the use of communica- ness programs is a convenient, practical, and fulness-based services and training health-
tions and information technologies in the cost-effective way to allow large numbers of care professionals to deliver such services
delivery of clinical care, and its proponents people (health professionals, patients, and will pay for themselves if the prevailing
are enthusiastic about telemedicine’s po- the public) to access mindfulness medita- paradigm within healthcare can be shifted
tential to address rising costs, inequities in tion. At present, one of the main barriers to from treating to preventing disease. Cur-
healthcare delivery, and barriers to care.89 the widespread dissemination of mindful- rently, many individuals receiving mind-
Examples of telemedicine include distant ness is the paucity of highly qualified and fulness meditation instruction pay for it
health education initiatives, telephone- experienced meditation teachers. Although out of pocket. Insurance companies, who
based case management and home moni- there is no formal licensure or credentialing would incur significant cost savings in the
toring programs, use of communication for meditation instructors, it is generally long run, may choose to cover the costs,
perhaps with a modest copay, discounts in
technologies to coordinate care, and the agreed that only persons trained at a handful
premiums, or with flexible spending ac-
use of Internet-based clinical interven- of professional training programs (such as
counts. Employers, wishing to support the
tions. the stress reduction program at the Univer-
health and productivity of their employ-
Although this is a newly emergent field, sity of Massachusetts) should be considered
ees, could support mindfulness programs.
several studies point to the effectiveness of qualified to teach others how to meditate.93
Private foundations may be interested in
therapies delivered over the Internet. A Internet-based mindfulness programs, supporting such programs, particularly if
review of 14 studies comparing the effec- featuring live instruction in virtual class- they have a rigorous evaluation compo-
tiveness of Internet versus face-to-face psy- rooms by experienced teachers, can greatly nent. The National Institutes of Health
chological interventions showed no differ- expand the reach of the existing network of could fund training grants for health pro-
ences in outcomes.90 Perini et al91 found mindfulness teachers, helping them to reach fessionals, encouraging the widespread
that a clinician-assisted delivery over the many more students than otherwise possi- training of clinicians in schools of medi-
Internet of cognitive behavioral treatment ble. Online mindfulness training programs cine, nursing, and social work, with the
for depression produced clinically signifi- can also increase the number of health pro- ultimate goal of standardizing mindful-
cant results. Twenty persons diagnosed fessionals trained in mindfulness techniques ness training into the curriculum. Health-
with depression completed an eight-week by adding a distance education component care organizations currently bearing the
online program consisting of online ses- to existing professional training programs. burden of increased costs associated with
sions, weekly assignments, and email For example, health professionals could re- high rates of clinician turnover, clinician
contact with a clinical psychologist. Indi- ceive conventional, face-to-face mindful- stress, and burnout may opt to pay for
viduals in the treatment group reported ness training in a single workshop and then mindfulness training for their practitio-
significantly reduced symptoms of depres- continue their practice with support from ners.94 Health professionals could pay for
sion. Another study examined the use of the mindfulness teacher in online sessions such training as they do for other CEUs;
telemedicine to deliver mindfulness-based over the course of several months. Patients in fact, some organizations already offer
meditation to patients with chronic who have completed the standard eight- CEUs for mindfulness education pro-
pain.92 In this study, over 200 chronic week MBSR program could access ongoing grams such as those offered through the
pain patients were assigned to three instruction and support via Web-based in- National Institute for the Clinical Appli-
groups: a present site, distant site, or a struction. cation of Behavioral Medicine.95 Finally,
wait-list control group. Videoconferenc- School-based mindfulness programs state and local governments could fund
ing and CDs were used to deliver the in- could maximize their resources by aug- train-the-trainer programs through Area
tervention to the distant site participants menting in-person training with Internet- Agencies on Aging, YMCAs, Big Brother/
(n ⫽ 57). The researchers found that the based meditation instruction. As the Big Sister groups, and other community or-
distant site group’s improvements were emerging research findings suggest, some ganizations.
comparable to the present site group in patients who would otherwise not be able
two of the four key measures and conclude to access mindfulness programs can suc-
that telemedicine is a promising way to cessfully learn the practice of mindfulness A VISION FOR THE FUTURE
help chronic pain patients in rural areas from qualified teachers in the virtual class- Our vision is that mindfulness is widely
manage their condition. Not only can room. Students of mindfulness are already recognized as an indispensable tool in
such Web-based interventions improve using CDs produced by nationally recog- health promotion and disease prevention
access to care for persons living in remote nized teachers such as Jon Kabat-Zinn to initiatives, as well as a cost-effective inter-
areas or who find it difficult to leave their support them in their practice. Internet- vention for many chronic conditions and
homes due to disabilities, caregiving du- based meditation instruction takes this idea as an adjunct to conventional care. We
ties, frailty, or lack of transportation, de- a step further, using concepts from both tele- envision the creation of mindfulness pro-
livering clinically supervised care over the medicine and distance education to dissem- grams (using the MBSR program as a basic
Internet is extremely cost effective. All in- inate the benefits of mindfulness practice to model) for a number of constituencies
dications are that telemedicine is a clini- as many individuals as possible. across a variety of settings. A number of
Guest Editorial EXPLORE November/December 2009, Vol. 5, No. 6 319these programs already exist, such as mind- 1. Comparative effectiveness studies need healthcare centers (eg, Veterans Af-
fulness-based cognitive therapy, mindful- to evaluate mindfulness practice against fairs Medical Centers).
ness-based chronic pain management, and usual care for individuals with anxiety 9. Employers who offer mindfulness
mindful eating for bariatric patients, and and depression, pain, cardiovascular dis- programs and collect data on the cost
these can serve as templates. ease, and other chronic conditions.96 savings related to reduced absentee-
Mindfulness training for patients with 2. The feasibility, effectiveness, and ism, better employee retention, and
conditions shown to be responsive to this cost savings need to be studied of enhanced productivity could receive
intervention will become the standard of mindfulness practices and modali- tax incentives and/or discounts on
care, reducing costs and improving health ties in diverse populations (eg, eth- health insurance products.
outcomes across a spectrum of diseases nicity, age, gender, rural/urban) in 10. Institutions responsible for health
and conditions. We envision a widespread the United States. professions education can begin the
inclusion of mindfulness training in the 3. Cost-effectiveness studies need to process of integrating mindfulness
healthcare education system. Health pro- demonstrate the cost savings associ- training into their curricula for the
fessions training will integrate concepts ated with mindfulness interventions benefit of both practitioners and pa-
and techniques of mindfulness into the compared with usual care in popula- tients. This effort could be supported
existing professionalism and humanism tions for which there are already reli- through National Institutes of Health
curricula, diminishing burnout, reducing able records of cost (eg, Medicare). training grants.
clinical errors, and enhancing patient care. 4. Large-scale, longitudinal effective- 11. It is important to understand the ex-
Large-scale public health initiatives will le- ness studies are needed that docu-
verage our understanding of the mind- tent to which clinicians understand
ment the cascade of positive side ef- the health benefits of mindfulness
body connection and the role of stress in fects of mindfulness. Research into
determining health behavior by including practices so they will recommend
this area has been slow to emerge due
components of mindfulness training in these modalities to their patients. Al-
to the tendency of scientific study to
their health promotion efforts to combat though the research evidence on the
narrow its focus to one symptom or
obesity, substance abuse, cigarette smok- benefits of mindfulness practice are
condition in the interests of clarity
ing, domestic and school violence, and well established, these modalities
and precision). Although this reduc-
prevalent mental health disorders such as have not been disseminated widely
tionist approach has many benefits,
anxiety and depression. to the general public, and research on
it can miss the “big picture.” Devel-
Telemedicine will be employed to ex- healthcare professionals’ attitudes
oping a new kind of “person-cen-
pand access to high-quality mindfulness and knowledge of mindfulness is crit-
tered” rather than “disease-centered”
training and maintenance programs. Inter- ical in implementing these programs.
research model could assist us in bet-
net-based instruction will connect individ- Making mindfulness training a re-
ter comprehending the cascade of
uals with mindfulness teachers in the vir- quired component of annual CEUs
positive effects characteristic of
tual classrooms accessible through clinics, would be one way to further education
mindfulness interventions.
schools, workplaces, community centers, amongst healthcare professionals.
5. Rigorous research on telemedicine
and households across the United States. 12. Because the practice of defensive
and the delivery of mindfulness
Mindfulness meditation teachers, who medicine costs approximately $210
training, comparing mindfulness in-
formerly were limited by their geographic billion each year, we need studies that
struction in the virtual classroom
location in their ability to train students, explore how mindfulness training in-
with face-to-face instruction, needs
will be able to reach a far greater audience. fluences physician-patient communi-
to continue.
In this way, mindfulness meditation will cation. Previous research suggests that
6. Should additional research support
become a key component of self-care for physicians with better communication
the findings of the virtual classroom
health promotion, as well as an important skills are less likely to be the targets of
as an effective and inexpensive deliv-
adjunct to conventional clinical care. malpractice suits. Can mindfulness
ery medium, equitable insurance
and flexible-spending reimburse- training of health professionals de-
RESEARCH AND POLICY ments for Internet-based interven- crease the incidence and fear of litiga-
RECOMMENDATIONS tions should be considered. tion, thereby reducing the practice of
Practical next steps include the expansion 7. Veterans Affairs Medical Centers defensive medicine?
of research that explores the mechanisms would be an ideal setting for multi- 13. We need to conduct studies exploring
of mindfulness in different diseases, com- site trials of mindfulness for PTSD, the impact of mindfulness training
pares its effects with other approaches in cardiovascular disease, substance on clinician errors (currently costing
diverse populations, investigates different abuse, depression, and other condi- about $17 billion annually) and health
delivery models, demonstrates cost-sav- tions that are prevalent in this popu- staffing turnover ($21 billion).
ings, and establishes training require- lation, evaluating both its efficacy 14. Evaluating school-based mindfulness
ments. We also need to explore the imple- and cost-savings. training will help us to understand how
mentation of mindfulness training in 8. Mindfulness-based training pro- best to implement the mindful-schools
different settings, such as workplaces, clin- grams could be implemented and model currently being developed, and
ics, schools, and community centers. evaluated at federal workplaces and whether this approach can be a corner-
320 EXPLORE November/December 2009, Vol. 5, No. 6 Guest Editorialstone of pediatric public health pro- 5. National Center for Complementary and
motion in the future. At a hearing in June 2009, Tim Ryan, Alternative Medicine. Mind-body medi-
representative from the state of Ohio, cine: an overview. Backgrounder. October
asked Department of Health and Human 2004. Available at: http://nccam.nih.gov/
CONCLUSION Services Secretary Kathleen Sebelius to health/whatiscam/mind-body/D239_BKG.
Mindfulness practices can be an impor- keep in mind the positive effects of mind- pdf. Accessed June 30, 2009.
tant tool in addressing our public health fulness when reworking the nation’s 6. Sobel DS. Mind matter, money matters:
problems. Mindfulness training can en- healthcare system.97 “When we have these the cost effectiveness of mind-body medi-
hance other nationwide health promotion discussions about healthcare, there’s al- cine. JAMA. 2000;284:1705.
ways an issue we never really talk about, 7. The New Medicine [documentary]. 2006.
efforts by helping people become more
and it’s the issue of stress,” Ryan said. “A Minneapolis, MN: Bravewell Collabora-
self-aware, more resilient to stress, and
lot of us are seeing it in our Congressional tive.
more responsible about their lifestyle
districts because of the economic situation 8. Chopra D, Ornish D, Roy R, Weil A. Al-
choices. One of the great advantages of
we’re dealing with. And the issue of stress ternative medicine is mainstream. Wall
mindfulness training is that it assists peo- leads to, I think, we know, increased ill- Street Journal. Jan 9, 2009, A13.
ple in making those lifestyle changes we all ness.” Sebelius agreed that the technique 9. Yusef S, Hawken S, Ounpuu S, et al. Effect of
know we should make. It is one thing to was useful as a form of preventive medi- potentially modifiable risk factors associated
know that smoking or obesity very often cine that could reduce the need for more with myocardial infarction in 52 countries
lead to disease, but another thing to have costly treatments. “I think it’s a prevention (the INTERHEART study): case control
the capacity for behavioral change. Mind- strategy that I know has the potential of study. Lancet. 2004;364:937-952.
fulness-based practices can help us to cope paying huge dividends,” Sebelius said. 10. Hemingway H, Marmot M. Evidence
with psychological stress and support us based cardiology: psychosocial factors in
while we make the lifestyle changes we the aetiology and prognosis of coronary
know will help us to become healthier. heart disease. Systematic review of prospec-
Creating a “culture of wellness” entails Regardless of who pays for healthcare in tive cohort studies. BMJ. 1999;318:1460-
promoting a culture of self-responsibility, the United States, the costs must come 1467.
which requires a society composed of in- down. Without a reduction in healthcare 11. Innes KE, Vincent HK, Taylor AG.
dividuals cultivating self-awareness. expenditures, no system will be sustain- Chronic stress and insulin resistance–re-
As researchers have repeatedly noted, able for long. Applying what we know lated indices of cardiovascular disease risk,
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tracted and inattentive, or stuck on “autopi- costs in a meaningful way. Leveraging the
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