Mindfulness

Mindfulness & General Practice

‘Just when I seemed to be walled up in a life sentence of chronic pain, someone proposed a bizarre way out: sit still, they said, and breathe.’  

Tim Parks, Teach us to Sit Still

 Is mindfulness the new CBT?

 Ten to fifteen years ago CBT evolved from being a form of psychotherapy little known in mainstream medicine to panacea for all chronic ills. Panacea, of course, was the goddess of universal remedy and, interestingly, was a sister of Hygieia the goddess of cleanliness and sanitation. They knew how to run a health service up on Mount Olympus.

Five years ago, mindfulness started to appear in the UK literature with respect to relapse prevention in depression. Prior to that, it had been pioneered by Jon Kabat-Zinn in Boston, with his Mindfulness Based Stress Reduction Programme (MBSR) at Massachusetts General. But it all seemed, to many doctors at least, slightly ‘kooky’ generating images of kaftans, beards and incense. Now mindfulness seems to be the therapy ‘du jour’, and the new psycho-panacea as its evidence base grows not just for depression and anxiety but also for coping with chronic pain and disease.

 This is perhaps not surprising. I see CBT and mindfulness as complimentary ‘life-skills’, fused together as mindfulness based cognitive therapy (MBCT), from which we can all benefit. We all have repetitive patterns of dysfunctional thinking and behaviours which trap us; learning to recognise and challenge them through CBT can be revelatory and helpful. Likewise, with mindfulness. Our minds are perpetually buzzing with random thoughts; they blind us to the joy of the present, and trigger emotional reactions which make us feel ill. Learning to empty the mind, to meditate and to recognise our random passing thoughts and moods as just ‘clouds that skim across the sky’ dispassionately, and without reacting to them emotionally, is a life skill which will simply make you feel better. It is not our thoughts that make us feel ill or hurt us, but our emotional reaction to them. One fascinating discovery of doing mindfulness is that we are not our thoughts. Descartes was wrong about lots of things, including cogito ergo sum!

As GPs we see so much chronic pain, disease, unexplainable distressing symptoms and unhappiness. Most of the time, of course, people cannot be cured and our raison d’etre is to ease the burden. For patients, the bitter paradox is that the natural human desire to be cured of something from which we can’t (and indeed the cultural expectation to ‘fight it’), only increases our suffering and makes it worse. As we know better than anyone, when patients are understood, cared for and supported into a ‘coping rather than curing’ mind-set, things improve. CBT awareness and mindfulness are the two core, evidence-based skills we can give to patients to help them learn to cope better with the ‘full catastrophe’ of living.  

 What is the evidence that mindfulness-based therapies are effective?

In 2010 the Mental Health Foundation commissioned a report which examined the evidence for the effectiveness of mindfulness based therapies, as well as laying the groundwork for greater access to them throughout the NHS as an evidence-based intervention. You can read it here:

( http://www.livingmindfully.co.uk/downloads/Mindfulness_Report.pdf)

 MBCT has the strongest evidence to support it for mental health problems (recommended by NICE for relapse-prevention in depression since 2009) and MBSR for chronic pain and distress associated with chronic disease. MBSR has been shown to help patients cope with their problems (http://www.ncbi.nlm.nih.gov/pubmed/15256293).

 As we discussed on our recent Hot Topics course, for chronic pain Acceptance and Commitment Therapy, which incorporates elements of mindfulness, is actually more effective than CBT (http://www.painjournalonline.com/article/S0304-3959(11)00339-3/abstract).

 How can I refer patients for mindfulness?

For patients, and for us, it has never been easier to access mindfulness groups. We can do this  through IAPT programmes, through MIND or private groups (which are often relatively low-cost). Many areas of the country are now providing MBSR and MBCT on the NHS, for example:

http://www.exeter.ac.uk/media/universityofexeter/schoolofpsychology/mooddisordercentre/Mindfulness_GP_QA_web_version_indd.pdf

 

What resources can I recommend to patients?

The evidence of efficacy of mindfulness results from group based interventions, however groups are not for everyone. Anecdotally, I have never been one for groups and I’ve never done a mindfulness course. Ironically, I have a bit of a hang-up about speaking in public…But, reading and learning more about mindfulness using the resources below has helped me enormously to deal with my low moods, migraines and the stress of 2 jobs, 3 children and a ludicrous mortgage! These are useful resources to tap into:

► Web-sites    http://www.bemindful.co.uk/  

An excellent resource of courses and on-line materials from the Mental Health Foundation. Includes a ‘surgery toolkit’ to promote mindfulness in your patient population. Great idea for practice development.

 

►Books:  There are many, but my favourites are:

·         Mindfulness: a practical guide to finding peace in a frantic world by Mark Williams and Danny Penman. Very readable, practical yet erudite, and with a CD of guided meditations. Highly recommended to all GPs and most of our patients! I think the best mindfulness self-help book for most patients.

·         Quiet the Mind by Matthew Johnstone. Matthew is the author of the quite brilliant picture book about depression, I Had a Black Dog. This is a similar book that teaches us, and patients, that learning to relax takes some work! Excellent for all, but particularly for those not into reading books….He deserves every medal going.

·         Mindfulness for Beginners, by Jon Kabat Zinn. What is says on the tin. Has an e-book version on i-books with integrated guided meditations which is excellent on the i-pad.

·         Full catastrophe living, by Jon Kabat Zinn. This book was based on JKZ’s work on the MBSR programme. It was first given to me by a patient 10 years ago. She said it changed her life; I was sceptical. It is a good read but I think it is too long to be useful as a self-help book for most people. It is worth reading though if only for the opening chapter which describes the patients in your waiting room perfectly!

·         Teach us to Sit Still, Tim Parks. Not a book on mindfulness as such, but a superb account of living with chronic pelvic pain syndrome, the failure of a medical profession driven by interventions and drugs to help and eventual resolution through meditation. It makes us realise how much ‘unexplained’ chronic pain is tied up with stress and muscle tension. It is also a very funny and erudite read, and full of great quotes such as: ‘Every illness is a narrative. What matters is the version you tell yourself.’

 ►Podcasts

http://www.mentalhealth.org.uk/help-information/podcasts/what-is-mindfulness/?view=Standard

http://www.mentalhealth.org.uk/help-information/podcasts/mindfulness-10-minute/?view=Standard

 So, in conclusion….

Learning more about mindfulness, and practising it, over the next year would be an incredibly worthwhile thing to have on your PDP and use of your CPD time and ‘learning credits’. But, much more importantly, it will also help you to help your patients and to look after yourself. Remember the in-flight advice: first put the oxygen mask on yourself before you place it on those you are caring for.

 Simon

If you have come across any more good resources, or have any experience you would like to add, please post them in the comments sections!