Thursday, October 18, 2012

Digesting the Moose Jaw adventure: Part V, Mindfulness

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby..
Digesting the Moose Jaw adventure: Part III, Sensory testing for neuropathic pain
Digesting the Moose Jaw adventure: Part IV, the nature of pain

I've looked at this topic quite a lot in the past: "Mindfulness Based Stress Reduction" - Jon Kabat-Zinn", Still meditating on meditation, and a 1 hr 12 min. video supplied in the comment section, Mindfulness with Jon Kabat-Zinn; other posts include Growing a steering wheel for one's brain, and "Everything you wanted to know about phobias and were afraid to ask" - Gordon Asmundson on fear avoidance

A lot of what pain seems to be about, at least according to me, is some sort of unfortunate standoff between the critter brain, or internal regulation system,  and human brain, whereby the human brain doesn't understand how to let the critter brain do its own thing. I'm going to deliberately call it Critter brain (I want it to have its own identity, personify it a bit, deliberately exaggerate its differentness from Human brain, aka, mind). It includes the insular cortex, involved in the spinal cord system Bud Craig says is 500 million years old (see Notes re: Interoception, point 5), in contrast to the human part, thought to be only a couple hundred thousand years old at most.

It seems to me that mindfulness is all about teaching Human brain to back off, watch, but not interfere with Critter brain: learn how to appreciate, and interact with rather than try to override, interrupt, control, dominate or punish Critter brain. It's only our lifeboat on the vast ocean of life, after all - once it gets a hole in it and deflates, we're done.

At the Moose Jaw conference, mindfulness came up more than once. Dr. Anita Chakravarti, a Saskatoon anesthesiologist, presented Mindfulness for Pain Management, in the second segment of Day I. 
She began by reading a reflection by a patient who has chronic pain, and another by a physician who looks after others who have chronic pain. Both reflections contained helpless exhaustion and frustration.
Then she said, "Both of these are me. I wrote them both."
And I was hooked. 

She reminded the audience of the WHO definition of health:
"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Her entire talk was about how mindfulness serves not only those who have chronic pain, but also caregivers who look after patients who have chronic pain. She led the group through a few experiential exercises, talked about others (like spending 45 minutes eating a single raisin). 

I live tweeted her talk, #SNPC. Live tweet streams degrade rapidly, and this stream already has, so I went into PSD's official (permanent) tweet list, and have reproduced the tweets here: 
* Mindfulness! Is a didactic concept but also experiential 
Mindfulness is efficacious for pain AND for caregiver stress 
Mindfulness is EB tool, has helped improve quality of life, find strengths, resilience. 
 Process of being completely in the moment = mindfulness 
* 21st century medicine. Different roles have evolved. Chronic disease has replaced acute as the most common. 9 million Canadians with chronic disease.  
"We don't see things as they are - we see them as WE are." 
 Self awareness is important for how we take in information from our patients. 
* High level of health care worker burnout. Quality of life and health and wellbeing most importnat for most people. What does this mean?  
 turning inward... any sort of sensation can be pleasant or unpleasant or neutral. Turning toward rather than away. 
Takes adaptation, graded exposure. Self reflection and self awareness, not just a cognitive idea. Takes work, practice.. 
Listen. Choices we make in the middle of life. Not just on holiday. Each moment has choices. 
Our sensations are not who we are, our worries are not who we are, our emotions are not who we are. 
In mindfulness you begin to realize what you are... NOT. Kabat-Zinn: Pay attention in a particular way, on purpose, no judgment. 
You don't try to stop the waves of "crap" - you learn to surf ON them. 
Principles: Pay attention to both internal and external processes, processing. 
Principles of mindfulness: be aware of mental, emotional, physical thoughts and feelings in the moment. Pause. Make mindful response 
 Mindfulness: CHOOSE response. Promotes awareness, balance, choice, acceptance of what is. Not about letting go, is about being with. 
Choose where attention goes. Acceptance and curiosity. Dip a toe in. Be with the pain. Turning inward means facing possible change. 
Attention awareness non-judging beginner's mind, critical curiosity, presence, letting go, acceptance, trust, non-attachment 
patience, attentive observation, vigilance, engagement, clear comprehension. 
Don't assign meaning too swiftly. Mindfulness teases things apart. Deconflates. 
Science is moving the goalposts. Mindfulness is constantly being redefined as is pain. 
Mindfulness training for troops pre and post deployment. Better resiliency. Also is being offered in prison systems. 
Has been shown to help with stress, Q of Life, pain, psoriasis, HIV, hot flashes - very very long list. 
Various kinds of pain, including fibromyalgia, measured with various pain tools; mindfulness has shown good results 
Good when combined with CBT. 
Mindfulness when taught in med school leads to medical error reduction and better patient outcomes. 
Decreased burnout! 
 Not just quality of care - quality of carING. 
 Decreased suicide in physicians etc., many other benefits for carers.. 
Taking 45 minutes to eat a raisin. Learning all about eating. Mindful eating. 
mindful walking. Transition times are great, important times to be mindful. Others: breathing, mindbody scan 
Transitioning between patients - mindfulness during the day: touching the next doorknob can be a reminder to refocus. Two mins, AM, PM
"Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom."- Victor E. Frankl

Absolutely good sensible advice. The word "spiritual" showed up on a few slides. Apart from always having a bit of allergic reaction to that word, such a human-centric adjective, a memeplex suggestive of potentially misleading woo, I thought her content was simply very good and practical advice on how to slow down one's mind and be a decent human being when dealing with one's own and others' critter brains, especially for busy doctors. 


1. Holman H, JAMA 2004; 292; 1057-1059
2. A Braemeling et al Healthcare quarterly  2008
3. Bohmer Harvard Business Review April 2010 p 66
4. K Wilkins Health Reports Vol 18 No 4 Stats Canada Nov 2007
5. Mindfulness Based Stress reduction Kabat-Zinn 1994
6. Gen Hospital Psychiatry 1982; 4(1): 33-37 J. Kabat-Zinn
7. Mindfulness in Medicine JAMA 2008; 300(11): 1350-52 D. Ludwig; J Kabat-Zinn
8. Mindful Practice Epstein RM JAMA 1999; 228: 833-839
9. Association of an educational program in mindful communication with brunout, empathy, and attitudes among primary care physicians. Krasner MS, Epstein RM et al JAMA (2009) 302, 1284-1293 
10. Mindful Practice Programs University of Rochester 2010 


Steve said...

Mindfulness has a vital role in helping get the distance from bodily and mental experiences that allows the patient to become more flexible in their pain management approaches. With mindfulness in place the self becomes just that little bit protected from the buffets of experience. With it I can get so much more cognitive traction on the neuromatrix. Without it they are Teflon coated.
Is it promoting routeing consciousness through the left insular, maybe. Putting a little gap between the interoceptive overload of conditions like FMS and CP and the fragile 'self'? Or just good old fashioned 7/11 breathing in new guise?
Whatever it is doing it is increasingly a vital first step in helping patients to self-manage their chronic pain problems.
Kind thoughts,

Diane Jacobs said...

I concur.
Love your analogy, Teflon-coated. :)

Diane Jacobs said...

Frank Forencich has this to say about mindfulness, on his blog, exuberant animal: