≥ 90% of participants will understand the concept of mindfulness and how they can use it in their practice as well as in their own lives to support a healthy lifestyle.
After completing this continuing education course, the participant will be able to:
Mindfulness is the awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally, according to Jon Kabat-Zinn. The origins of mindfulness are rooted in Buddhist philosophy and date back around two and a half thousand years. The earliest example of a formalized program called Mindfulness-Based Stress Reduction (MBSR) was developed by Kabat-Zinn to assist individuals in managing an illness, pain, and stress.1
MBSR encompasses practices related to meditation, such as focused breathing, but mindfulness is different from meditation. Mindfulness describes a qualitative state of consciousness involving the ability to be fully engaged in the present moment. Meditation is the process commonly used to facilitate this state of conscious engagement. Studies have found that MBSR improves mood and wellbeing in individuals with cancer as well as healthy adults.2
In 2010 it was reported that MBSR was used in over 250 hospitals across the country and in many more around the world to assist individuals with managing stress, anxiety, depression, and chronic pain. Since 1979, there has been a tremendous amount of research from high ranking institutions such as Harvard, UCLA, Stanford, and UW-Madison providing insight into how MBSR approaches work and how they can change our brains for the better.3
Since the introduction of MBSR, a variety of other mindfulness-based treatment programs have been developed, including mindfulness-based cognitive therapy and dialectical behavioral therapy. Mindfulness-based cognitive therapy focuses on the skill of cognitive attention in individuals with depression, and dialectical behavioral therapy addresses emotional regulation skills in individuals with a borderline personality disorder.2
The mind is a known factor in stress and stress-reduction disorders; therefore, it appears that mindfulness has potential benefits for patients with a wide range of disorders and diseases. Most people think an average of 60,000 thoughts a day, and most of them are the same thoughts that they had the day before and the day before that. Science is now confirming that the thoughts we think affect our body through neuropeptides, which are the chemical messengers that travel throughout our bodies. They have also discovered that negative thoughts are toxic.4 In her groundbreaking book Molecules of Emotion, Candace Pert explains more about how thoughts and emotions chemically affect our body, altering the health of the body. She also talks about the power of breathwork for affecting homeostasis and pain regulation in the human body.
Psychiatrist and Holocaust survivor Viktor Frankl was quoted saying, “Between stimulus and response there's a space, in that space lies our power to choose our response, in our response lies our growth and our freedom." Meaning that before we react to triggers in life such as stress or pain, there is a moment of choice; most of us are unaware of this moment because we simply react out of habitual patterns. The MBSR program focuses on increasing an individual’s awareness of their habitual responses and helps them relate to themselves in a new way in order to interrupt this cycle and create more choice in life.3
The focus of a study on gray matter was to identify brain regions that changed in association with participation in an eight-week Mindfulness-Based Stress Reduction course. The results of the study revealed that regions within the brainstem had increased in gray matter concentration after the participants completed the eight-week course. The researchers reported that whole-brain analyses identified increases in the posterior cingulate cortex, the temporoparietal junction, and the cerebellum in the MBSR group compared to the controls. They stated that the results suggest that participation in MBSR is associated with changes in gray matter concentration in brain areas related to learning and memory processes, emotional regulation, self-referential processing, and perspective-taking. The positive impact of mindfulness-based programs on symptoms of anxiety, depression, sleep patterns, and attention has been well documented. The morphological changes reported in this study appear to provide anatomical evidence that supports the positive effects of MBSR.5
A more recent focus on the benefits of mindfulness-based interventions has moved towards children and adolescents. One of the rationales for introducing mindfulness to this population includes enhancing the core cognitive skills that support academic and social functioning.1 Using an array of cognitive-behavioral, neurophysiological, and psychological indicators, one study examined the effectiveness of a social-emotional learning program for children. The findings indicated that mindfulness attention training in combination with opportunities to practice optimism, gratitude, perspective-taking, and kindness, improved cognitive skills, and increased social and emotional competence and well-being.6 Another study involving high-quality school-based MBSR instruction for youth in urban public schools lead to improvements in psychological symptoms, including coping and posttraumatic stress symptoms. The authors theorized that improvements in these domains could reduce the negative impact of stress and trauma experienced in childhood and adolescence and ultimately lead to significant positive effects when realized over the course of a lifetime.7
A meta-analysis comprised of thirty-three independent studies, including 3,666 children and adolescents, were included in random-effects meta-analyses. The outcome measures were categorized into mindfulness, cognition (executive functioning and attention), behavior (social and negative behavior), and emotion (depression and stress/anxiety) outcomes. All included studies involved mindfulness-based interventions (MBIs) delivered face-to-face over a series of sessions by trained mindfulness instructors with participants 18 years or younger and used control groups. The researchers found significant positive effects of MBIs, relative to controls, for the outcome categories of mindfulness, executive functioning, attention, depression, anxiety/stress, and negative behaviors.1
MBIs have been integrated into the workplace in a variety of different ways, including web-based programs, yoga or meditation classes, and full mindfulness-based stress reduction programs. These MBIs each have challenges including, cost, time commitment, level of expertise, and participant retention. Despite the challenges, MBIs offer substantial advantages, because they provide workers with coping skills for stress reduction (work-related or not) and for improving mood management and emotional regulation. Mindfulness practice can improve workers’ resilience, enabling them to better deal with stress while preventing burnout, especially in high-stress occupations. MBIs have been found to be effective in health behavior modification, such as smoking cessation and substance abuse prevention. Therefore reducing chronic health conditions, such as heart disease and cancer, resulting in an overall healthier workforce. Other potential benefits of workplace MBIs include increased productivity, memory, creativity, focus, impulse control, and emotional intelligence.8
In a randomized controlled trial consisting of a twelve-week integrative exercise program for war veterans with PTSD, researchers reported significant improvements in mindfulness, interoceptive body awareness, and positive states of mind compared to a waitlist. The intervention investigated combined physical fitness training with breath training and yoga as well as attitudinal principles of mindfulness drawn from the MBSR program.9
This small case series design study was conducted on youth with reported concussion symptoms; the participants were exposed to mindfulness-based Yoga (MBY), mindfulness meditation with attention anchored on the sensations of breathing and the body, and training of the mind to notice when distractions and thinking occurred. The training regarded thoughts, feelings, emotions, and physical sensations as passing states and unimportant. Participants were encouraged to use mental noting (i.e., labeling thoughts as “planning,” “remembering,” or “thinking” without attaching value or judgment) in order to disengage from rumination and encourage returned focus on the breath. Yoga postures were described as novice level and included standing, supine, prone, and seated stances, postures were modified to match participants’ comfort level. Participants attended a total of eleven sessions, three assessment sessions (pre, post, and follow-up), and eight MBY intervention sessions. MBY does not explicitly address post-concussion symptoms; however, these results found that symptoms decreased across all domains.
The authors reported that their findings have the following implications for occupational therapy practice:
This study found that differences in sensory processing patterns are related to mindfulness in daily life. The researchers reported that individuals with sensory styles, including low registration and sensory sensitivity, demonstrated a higher incidence of mind wandering in daily life. In low registration, the high sensory threshold increases the time needed for sensory information to be registered by the nervous system. These individuals require constant sensory cues from the environment, or mind-wandering becomes more severe and more likely to interfere with daily activities.
The sensory sensitivity processing style was associated with increased rates of mind wandering in this study. In contrast to low registration, the low sensory threshold experienced by individuals with sensory sensitivity suggests that awareness of sensory information is a protective response. The researchers reported that this information might be so intensely experienced, that it absorbs extra cognitive resources, leading to mind wandering from the current task to the sensory aspects of the environment. This hypersensitivity to sensory information with an associated reduction in cognitive resources could explain findings of increased rates of internalizing conditions (such as anxiety, depression, or pain) in individuals with sensory sensitivity.
Occupational therapists routinely treat individuals with sensory processing dysfunction, sensory modulation disorders, and psychological conditions associated with sensory dysfunction. Self-awareness, focused attention, emotional awareness, and self-regulation are mindfulness skills that easily fit into occupational therapy’s scope of practice, especially when taught in the context of daily life skills. Therapists involved in providing interventions to these populations may want to consider including mindfulness techniques to increase awareness of the sensory information in the environment when engaging in activities of daily living.2
A systematic review of sixteen studies reported that mind-body therapies are feasible for children and adults with Autism Spectrum Disorder (ASD) and are generally considered safe, but additional studies are needed. Most of the studies that included children with ASD focused on various aspects of behavior, including aggressive, maladaptive, imitation, and aberrant behaviors. There was little homogeneity between studies on outcome measures or specific interventions used, making it difficult to compare studies. Multiple studies showed improved mental health with different mind-body therapies in people with ASD. Mind-body therapies were defined as practices that focus on a connection between the mind, body, and health. An RCT of an autism-adapted mindfulness program showed moderate to large effect sizes for improving anxiety, depression, and rumination in adults with ASD. Many mind-body therapies use figurative language, which can be challenging for people with ASD, who tend to take language literally. Of the mindfulness-based interventions, two used a nine-week (verses eight weeks) protocol adapted for ASD. The protocols used less metaphorical and ambiguous language, omitted cognitive elements (e.g., ‘‘examination of one’s thoughts’’), and increased the amount of time on breathing exercises and weeks of training to account for the individuals with slower cognitive processing abilities. Another mindfulness-based study used less abstract language and added an additional week of mindfulness training. They also provided detailed, outlined overviews of each session to participants so they would feel more at ease and able to anticipate the goals and tasks in each mindfulness session. Participants in this study provided feedback that they preferred silence during meditation sessions rather than guided meditations.11
Susan was an 18-year-old female admitted to the obstetrics floor at 22 weeks for management of high blood pressure and severe preeclampsia. The attending physician told Susan and her family that given the diagnosis at less than 24 weeks gestation, the baby would need to be delivered immediately. Despite the risks to herself and her baby Susan wanted to prolong her pregnancy. After the seventh day of hospitalization, her physician ordered occupational therapy services, asking specifically for “diversional” activities to provide a more enriched environment. The occupational therapist consulted with the physician regarding the value of therapeutic activities and using tools such as mindfulness. An initial OT evaluation was completed, and an occupational profile generated. Susan reported that sleeping was her primary coping skill but was open to learning new strategies to help her manage her anxiety and fear around her current condition. Susan could not tolerate talking about the possibility of losing her baby or post-discharge plans, including taking care of her child. The therapist designed a treatment plan which addressed Susan’s ability to shift attention to the present moment and included value-based activities and mindfulness practice.
Basic mindfulness principles were introduced to Susan and her boyfriend, who was present for most sessions. Interventions focused on education and the use of mindfulness exercises to reduce stress and anxiety. Susan practiced several specific mindfulness exercises, including attention to breath, music, and guided imagery. She was appreciative of the activities and looking forward to trying more. She reported feeling comfortable doing these exercises and voiced an understanding of how to use them on a daily basis with the support of her boyfriend.
Toward the end of our fourth session, Susan was told she needed to deliver the baby and began experiencing increased anxiety. She talked about the possibility that the baby might not make it and demonstrated more flexible thinking about her situation, and kept her attention focused on the present moment. Susan used visual imaging to create a more relaxed state of mind and reported giving her “mind a break” from feelings of worry and fear. The therapist reframed the experience as intentional shifting of attention to valued activities, which often results in increased feelings of calm and clarity. Susan admitted she had been thinking about the possibility of her baby dying, indicating some move towards a better ability to accept this reality. After the baby’s birth, Susan was seen by the OT for the 5th session they discussed how to use the mindfulness materials post-discharge for continued management of anxiety and stress.12
If you want to teach mindfulness, it is best to become a practitioner yourself first. You will learn what mindfulness feels like and how it affects you and develop empathy for the individuals you teach. Mindfulness is pure experience and putting an academic label on it before you understand its subtleties may cause you to come off as inauthentic.
As previously stated, mindfulness involves observing and being in the present moment, the now! It is impossible to practice while your mind is racing between the thing you regretted saying yesterday and worrying about what you are going to make for the party next weekend. When the mind is in the past or future constantly chattering, it is impossible to be in the present moment. Practicing mindfulness and meditation will invariably quiet the mind, but it is important to understand that our mind will not necessarily be completely quiet, it is always going to be doing something. Mindfulness will greatly lessen the confusion and chaos that exists in the mind from one moment to the next.
In order to quiet the mind, it is imperative to learn to let things go or face getting stuck thinking about things in endless loops with the mind in the past or future instead of the present. In order to snap out of the endless loops and get the mind to quiet down, one author recommended this exercise13:
Most experts recommend that mindfulness be integrated with meditation practices because then the practice is holistic and rooted in its historical origins. For those not quite ready to delve into the practice of meditation, mindfulness can still be a helpful tool.14
The following is a small compilation of mindfulness exercises you can try yourself, then with clients; there are thousands of ideas in the literature and on the internet. Keep in mind that these are tools and nothing more, exercises are not what mindfulness is about, but they may assist individuals to experience certain states that will ultimately lead to mindfulness.
Mindful Hand Awareness Exercise
Grasp your hands really tight and hold for 5 to 10 seconds, then release and pay attention to how your hands feel. Keep your attention focused on the feeling for as long as you can.
Mental Focus Exercise
Stare at any object and try to remain focused on just that object for as long as possible. Keep a mental watch on when your mind starts to wander, then just bring it back to the object. The longer you can remain focused, the better, do this whenever you think about it, and try to increase your focus time each day.
Pinch your arm and pay close attention to how it feels and what emotions you experience. Pay attention to the pain and how it radiates out from the site you pinched. This exercise can really tune you into how your body deals with discomfort and the feelings around that. Do you get angry when you feel pain?
Musical Stimuli Exercise
Listen to your favorite songs and pay attention to how they make you feel. What emotions do they stir? What memories come up, and how do those memories make you feel? Engage the emotions and see where they lead.
Smell something strong like coffee beans or perfume and pay close attention to what happens in your nose, and then what feelings different scents evoke. You can also elicit gustatory awareness by using this exercise with taste instead of smell.
Sit and relax, and imagine yourself melting into everything around you. You might begin to feel at one with everything after some practice.
Full Sensory Awareness Exercise
Wherever you are, stop and look around if it’s safe to do so. Take a few deep breaths and become aware of everything that your senses pick up. How do you feel; over-stimulated or anxious? What do you smell, hear, see, take in all the details of this moment?
Spend an hour or two in complete silence, and just absorb your surroundings. Earplugs might help this exercise.13
This exercise can be done standing up or sitting down and pretty much anywhere at any time. If you can sit down in the meditation (lotus) position, that's great. All you have to do is be still and focus on your breath for just one minute.
This exercise is simple but powerful; it helps you notice and appreciate seemingly simple elements of your environment in a more profound way. It is designed to connect us with the beauty of the natural environment, something that is easily missed when we are rushing from one place to another in our daily lives.
This is designed to cultivate a heightened awareness and appreciation of simple daily tasks. Think of something that happens every day more than once, something you take for granted, like opening a door, for example.
This is designed to open your ears to sound in a non-judgmental way and to train your mind to be less swayed by the influence of past experiences and preconceptions. Past experiences influence much of what we feel emotionally. For example, we may dislike a song because it reminds us of a breakup or another period of life when things were not going so well. The purpose of this exercise is to listen to music from a neutral standpoint, with a present awareness unhindered by preconception.
The intention of this exercise is to cultivate the intention to live in the moment and escape the persistent striving we find ourselves caught up in daily. Rather than anxiously rushing through in order to finish an everyday task, embrace the routine, and experience it fully. If you are cleaning your house, pay attention to as many details of the activity as you can; the smell of the cleaning products, how shiny the floors look, the tracks the vacuum makes in the carpet, or your beautiful face in the clean mirror. The key here is to attend to the task, not what you are doing later or what you did yesterday.
For this exercise, notice five things during your day that usually go by unappreciated. These things can be objects or people. Use a notepad or the notes app on your phone to jot down the five things as you go about your day. The intent of this exercise is to give thanks and appreciate the seemingly insignificant things in life, the things we take for granted that support our existence but typically slide by unnoticed. Examples might be; the electricity that powers your kettle, the postman that delivers your mail, the clothes that provide you warmth, your nose that lets you smell, or the people you pass at the grocery store.
Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). This 12-item questionnaire is designed to examine both attentional and attitudinal components of mindfulness in individuals with no previous meditation experience. It assesses four theoretical domains of mindfulness: attention, present-focus; awareness; and acceptance. Responses are rated on a four-point scale ranging from 1 (rarely/not at all) to 4 (almost always). Sample questions include ‘‘I can accept things I cannot change’’ and ‘‘I am able to focus on the present moment.’’ Responses are summed across domains into a single score ranging from 12 to 48, with higher scores reflecting more mindfulness. The overall scale has good internal consistency.
Mindful Attention Awareness Scale (MAAS). This 15-item questionnaire assesses the frequency of present-moment experiences in everyday life. Unlike most other measures of mindfulness, the MAAS requires individuals to report the frequency of mind-wandering or distracted episodes that occur on a daily basis. These experiences of absence are theorized to be more related to introspection in individuals without exposure to formal meditation training. The frequency of each experience is rated on a six-point scale ranging from 1 (almost always) to 6 (almost never).2
The Five Facet Mindfulness Questionnaire (FFMQ) is a 39-item scale that measures five factors of mindfulness:
Responses to the items are given on a 5-point Likert-type scale (1 = never or very rarely true, 5 = very often or always true).5
If you are reading this article, you are likely open to mindfulness and meditation. However, it is important to remember that many of our clients may be skeptical, and it makes sense; we are conditioned not to believe everything we are told. Acknowledge their skepticism but invite them to be open to trying some of the mindful techniques listed in this article or find some you think would work better for them. There are apps and YouTube videos that may provide more credibility to support your mindfulness-based intervention plan. You may decide to share your experience using the exercises with your clients. Be authentic, we are all people trying to manage life, and in my experience, mindfulness takes practice. There are hundreds of research articles out there that mention mindfulness in the description. In this article, studies were chosen with participants experiencing a variety of physical and mental health challenges to give the reader a sampling of the possibilities for using mindfulness. Mindfulness-based activities can be a valuable intervention tool to use not only by occupational therapists but by other healthcare practitioners to assist clients and to improve their own health and wellbeing.