Mindfulness for Healthcare Professionals

According to Jon Kabat-Zinn, mindfulness is the awareness that arises through paying attention on purpose in the present moment, non-judgmentally. 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 (Dunning et al., 2018).

MBSR encompasses practices related to meditation, such as focused breathing, but mindfulness differs from meditation. Mindfulness describes a qualitative state of consciousness involving the ability to fully engage 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 and healthy adults (Hebert, 2016).

In 2010, it was reported that MBSR was used in over 250 hospitals across the country and many more around the world to assist individuals in 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 (Goldstein, 2020).

Since the introduction of MBSR, various 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 borderline personality disorder (Hebert, 2016).

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 our thoughts affect our body through neuropeptides, which are the chemical messengers that travel throughout our bodies. They have also discovered that negative thoughts are toxic (Hay, 2019). 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 said, "Between stimulus and response there is 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 because we simply react out of habitual patterns. The MBSR program focuses on increasing individuals' awareness of their habitual responses and helps them relate to themselves in a new way to interrupt this cycle and create more choices in life (Goldstein, 2020).

Susan was an 18-year-old female admitted to the obstetrics floor at 22 weeks to manage high blood pressure and severe preeclampsia. The attending physician told Susan and her family that the baby would need to be delivered immediately, given the diagnosis at less than 24 weeks gestation. Despite the risks to herself and her baby Susan wanted to prolong her pregnancy. Her physician ordered occupational therapy services after the seventh day of hospitalization, 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 was 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 that 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 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 daily 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 an intentional shift of attention to valued activities, resulting in increased calm and clarity of feelings. 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 fifth session. They discussed how to use the mindfulness materials post-discharge for continued management of anxiety and stress (McCammon, 2015).

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 your teaching individuals. Mindfulness is pure experience, and putting an academic label on it before you understand its subtleties may cause you to appear 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 will make for the party next weekend. When the mind is constantly chattering in the past or future, 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 in the mind from one moment to another.

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 exercise (Practicing Mindfulness, 2019):

• With the eyes closed
• Inhale slowly for a count of seven
• Hold for a couple of seconds
• Exhale slowly for a count of eleven
• This should be continued for a few minutes until the participant feels calmer
• Turn your attention to your thoughts if they are going wild
• Yell "STOP" in your mind as loud as you can (to disrupt the pattern)
• Picture pure black
• If/when the thoughts resume, yell "stop" again
• If the thoughts are seen against the black, feel free to push them away
• Continue this for five-minute increments

Most experts recommend that mindfulness be integrated with meditation practices because it 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  (Mindful Millennials, 2016).

The following is a small compilation of mindfulness exercises you can try yourself and 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 in experiencing certain states that will ultimately lead to mindfulness.

Mindful Hand Awareness Exercise

Grasp your hands 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 remain focused on just that object for as long as possible. Keep a mental watch on when your mind starts to wander, then 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.

Tactile Exercise

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 pinched site. This exercise can 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.

Olfactory Exercise

Smell something strong like coffee beans or perfume, and pay close attention to what happens in your nose and what feels different scents evoke. You can also elicit gustatory awareness by using this exercise with taste instead of smell.

Melting Exercise

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

Stop and look around if it's safe to do so wherever you are. Take a few deep breaths and become aware of everything your senses pick up. How do you feel: over-stimulated or anxious? What do you smell, hear, see, or take in all the details of this moment?

Silence Exercise

Spend an hour or two in complete silence and absorb your surroundings. Earplugs might help this exercise (Practicing Mindfulness, 2019).

Mindful breathing

This exercise can be done standing up or sitting down and pretty much anywhere if you can, sit down in the meditation (lotus) position. All you have to do is be still and focus on your breath for just one minute.

• Start by breathing in and out slowly. One breath cycle should last for approximately 6 seconds.
• Breathe in through your nose and out through your mouth, letting your breath flow effortlessly in and out of your body.
• Let go of your thoughts. Let go of things you have to do later today or pending projects that need your attention. Let thoughts rise and fall of their own accord, and be at one with your breath.
• Purposefully watch your breath, focusing your sense of awareness and its pathway as it enters your body and fills you with life.
• Then, watch with your awareness as it works its way up and out of your mouth, and its energy dissipates into the world.
• If you are someone who thought they would never be able to meditate, guess what? You are halfway there already! If you enjoyed one minute of this mind-calming exercise, why not try two or three?

Mindful Observation

This exercise is simple but powerful; it helps you notice and appreciate seemingly simple elements of your environment more profoundly. It is designed to connect us with the beauty of the natural environment, which is easily missed when we rush from one place to another in our daily lives.

• Choose a natural object from within your immediate environment and focus on it for a minute or two. This object could be a flower or an insect, the clouds, or the moon.
• Do not do anything except notice the thing you are looking for. Simply relax into watching for as long as your concentration allows.
• Look at this object as if you are seeing it for the first time.
• Visually explore every aspect of its formation and allow yourself to be consumed by its presence.
• Allow yourself to connect with its energy and purpose within the natural world.

Mindful Awareness

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.

• The very moment you touch the doorknob, stop for a moment and be mindful of where you are, how you feel at that moment, and where the door will lead you.
• Alternatively, the moment you open your computer to start work, take a moment to appreciate the hands that enable this process, the brain that facilitates using it, and appreciate the technology that went into it to make our world easier.
• These 'touchpoint' cues do not have to be physical ones.
• For example, Each time you think of a negative thought, you might choose to take a moment to stop, label the thought, and replace it with a more positive one.
• Each time you smell food, you take a moment to stop and appreciate how blessed you are to have access to healthy food that nourishes your body.
• Choose a touchpoint that resonates with you today. Instead of going through your daily motions on autopilot, take occasional moments to stop and cultivate purposeful awareness of what you are doing and appreciate what is in your life.

Mindful Listening

This is designed to open your ears to sound in a non-judgmental way and train your mind to be less swayed by the influence of past experiences and preconceptions. Past experiences influence much of what we feel emotional. For example, we may dislike a song because it reminded us of a breakup or another period of life when things were not going so well. This exercise aims to listen to music from a neutral standpoint, with a present awareness unhindered by preconception.

• Select a music track, one you have never listened to before. Close your eyes and put on your headphones.
• Try not to judge the music by its genre, title, or artist name. Ignore labels and, neutrally, allow yourself to get lost in the sound journey for the duration of the song.
• Be mindful and explore every aspect of the track. Even if the music is not to your liking at first, let go and give your awareness full permission to climb inside the track and dance among the sound waves.
• Explore the song by listening to the dynamics of the instruments, separate each sound in your mind, and hear the differences in each one.
• Focus on the vocals: the sound of the voice, including the range and tones. If there is more than one voice, attend to the differences.
• Listen mindfully and become fully present with the composition; hear with your ears, not your mind.

Mindful Immersion

This exercise intends 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 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 on 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 yesterday.

• Feel and become the motion when sweeping the floor, sense the muscles you use when scrubbing the dishes, notice the pattern on the dishes, how warm the water feels, etc.
• Be creative and discover new experiences within that routine.
• Be aware of every step and fully immerse yourself in progress.
• Who knows, you might even enjoy cleaning!

Mindful Appreciation

For this exercise, notice five things that usually go by unappreciated during your day. 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. This exercise intends 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.

• Notice how some of these things work: touch, smell, feel, or what they do for you, or even just acknowledge that they are there.
• Appreciate these people or things either to yourself or let them know by telling them we all want to be appreciated.
• As you begin with five things, you will likely find and notice many others, integrating mindfulness into your daily life and quite possibly making you happier (Pocket Mindfulness, 2020).

Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). This 12-item questionnaire examines 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 can focus on the present moment." Responses are summed across domains into a 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 daily. 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 (seldom) (Hebert, 2016).

The Five Facet Mindfulness Questionnaire (FFMQ) is a 39-item scale that measures five factors of mindfulness:

• observing (attending to or noticing internal and external stimuli, such as sensations, emotions, cognitions, sights, sounds, and smells)
• describing (noting or mentally labeling these stimuli with words)
• acting with awareness (attending to one's current actions, as opposed to behaving automatically or absentmindedly)
• non-judging of inner experience (refraining from evaluation of one's sensations, cognitions, and emotions)
• non-reactivity to inner experience (allowing thoughts and feelings to come and go without attention becoming caught up in them)

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) (Holzel et al., 2011).

If you read this article, you will be 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. Apps and YouTube videos 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 that mention mindfulness in the description. In this article, studies were chosen with participants experiencing various 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 also by other healthcare practitioners to assist clients and improve their own health and wellbeing.

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