Abstract
COVID-19 has created a great deal of stress and therefore has also heightened our awareness of the breath. There is so much that many people feel they cannot control, “When will this pandemic end? Will the vaccine work?” Coping with changes in work circumstances, including using Zoom rather than having in-person meetings has added layers of complexity to peoples' lives. So, it is not surprising that the demand for meditation and mindfulness programs as well as apps have increased dramatically. According to multiple sources, there has been a surge of downloads for mediation apps with Calm, Headspace and Meditopia recently leading the way. It has been reported that there were 3.9 million downloads for Calm; 1.5 million downloads for Headspace, and Meditopia, with 1.4 million for Meditopia in April 2020. 2 This data during the surge and continuation of COVID-19 reveals how desperate people were/are for a sense of calm and stress relief and how meditation is viewed as a possible pathway to peace of mind.
Clinically, I have noticed that more providers and patients are interested in meditation since the pandemic. During the initial surge in Boston, I organized an effort called “PAVING the Path to Wellness” for clinical providers during which Massachusetts General Hospital (MGH), Boston, MA, providers met via Zoom for weekly sessions of exercise, nutrition information, social connection and meditation. In my role as Director of Lifestyle Medicine and Wellness for the Department of Surgery at MGH, I worked alongside Antonia Stephen, MD. Dr. Stephen is a surgeon who is also leading the way in wellness for the department, to provide a six-week introduction to meditation for the surgery residents during the pandemic. As for patients, increasing numbers of my own clients were feeling overwhelmed and out of control. In my own practice, I worked with patients more on meditation during COVID than I ever had prior to the pandemic. This trend continues. Many worksites are looking for wellness workshops and specifically asking for stress reduction techniques including meditation. COVID has been the instigator for many providers and patients to begin or restart a practice of meditation.
From my perspective and in general, meditation training across contemplative traditions most generally refers to any practice that involves self-regulation of attention and can be used for spiritual purposes as suggested by Dr. Frates, or philosophical understanding of the mind. Meditation may also involve the rather common, uncultivated, spontaneous experience of absorption in an activity like what is experienced during flow states in life activities such as sports or art. For a bit more context, meditation became the translation for the Sanskrit and Tibetan words, dhyāna and bhavana originating in the sixth century BCE, respectively referring to “cultivation of mental development” and “developing familiarity with one's mind.” There are many types and styles of meditation used across contemplative traditions, and for the most part, scientific investigations into meditation have not adequately disentangled the unique benefits of each.
Modern-day teachings most commonly emphasize focused attention, open monitoring, body scan, and open awareness as the most relevant styles of meditation practice for contemporary mindfulness meditation training. Currently, one of the most common meditation training programs is based on the Mindfulness-based Stress Reduction (MBSR) protocol developed in 1979. It should be noted that most contemporary practitioners exposed to eight-week trainings in mindfulness are reported to practice for their own well-being—most commonly for self-regulation and stress reduction. The prescriptive standardized protocol for first-generation mindfulness-based interventions (MBIs) and mindfulness-based programs has involved 18 to 26 hours of in-person training (1.5–2.5 hours per class) and one 6-hour all-day retreat over the course of eight weeks. The MBIs also include movement-based somatic practices (e.g., light Hatha style yoga, walking meditation), and informal practice bringing mindful awareness into everyday life (e.g., brushing teeth, social interactions).
It is believed that between 200 and 500 million people meditate globally, and this represents a hybrid between traditional long-term and contemporary modernist practitioners. Before the pandemic began, however, there has been a clear increase in the number of people who meditate. Why is that? Why are so many people meditating, and why is the trend continuing to grow aside from the pandemic? One potential reason is the increasing scientific evidence regarding meditation, and the evidence itself appears to be motivating individuals to practice. Science may provide conviction and trust in the teachings—allowing an individual to create more clear expectations about the training.
The biggest shift in how people access meditation training since the COVID-19 pandemic began has been towards virtual modalities using video conferencing or mobile apps. Dr. Frates pointed out the dramatic increase in downloads from the currently most popular meditation apps. Both clinical and research protocols for meditation training has now shifted to adapt to the new rules of social distancing. For example, the most common standardized MBIs coming from the most respected in-person training programs are now being offered online and on a limited basis, in-person. Many research labs, including my own, had to change our standards for data collection, as well as move the intervention from in-person to on-line classes. Many clinical trials of MBIs had to be cut short or start over with the new format. This resulted in many federal dollars being lost in investment and a new standard for delivering content that has been otherwise untested. With this shift, it remains unclear whether the teachings are more or less impactful through the lens of the desktop camera, Zoom rooms, and a distanced social support circle. Although virtual teachings have reduced our ability to feel an in-person connection through presence and physical touch, the format has allowed for more access, in general. For example, Jon Kabat-Zinn was leading free meditations for many months in 2020 that was streamed live to thousands of people worldwide. That kind of reach is rarely achieved in-person.
At the individual level, we began to see how people began to feel stripped of their humanity during the pandemic. This had to do with the very nature of the infectious vector, and how transmissible it was. Families were unable to be with their loved ones in their greatest time of need—most notably, at the time of death. Health care providers themselves were overwhelmed by various factors including long hours worked, lack of personal protective equipment, and uncertainty about transmission itself, including many other factors.
At the societal level, the COVID-19 pandemic highlighted the underlying socioeconomic and racial inequities, especially around the distribution of health care resources. These inequities were no longer hidden—locally, nationally, and worldwide. So we began to see how truly stretched we were as individuals, nations, and as a humanity.
In that manner, meditation has provided an opportunity to truly build compassion—both for our own selves, and those around and in front of us. At my respective institutions, we created tailored experiential curricula to help individuals build resiliency through mind-body and cognitive practices—modeled after the stress management and resiliency training developed at the Benson-Henry Institute for Mind Body Medicine, Boston, MA. In addition, in my role as director of a newly created Office for Well-Being within the Center for Faculty Development at MGH, we have had drop-in weekly guided meditations, which have touched nearly 1000 unique employees at our institutions. Who could have imagined that this level of engagement would have even been possible at one of the most conservative academic medical centers in the United States?
Recommending group meditation sessions conducted by the clinician, colleagues in their practice, or introducing patients to other meditation classes, either local or virtual, are other options for introducing patients to this practice. Some patients may want to explore information on their own prior to participating in meditation sessions. A book such as Jon Kabat-Zinn's Meditation is Not What you Think: Mindfulness and Why It Is So or the classic book by Herbert Benson, The Relaxation Response, might be just what the patient needs. Other patients might be hungry for the research about how meditation helps the body and brain. In these cases sharing the original journal articles with patients or recommending online videos such as Sara Lazar's original Ted Talk titled, “How Meditation Can Reshape our Brains” could be helpful. Work at the Center for Mind-Body Medicine, Washington, DC, is powerful and can help patients to better understand meditation as well as provide instruction on how to meditate with a variety of videos on YouTube and Facebook.
According to the National Institutes of Health (NIH), 1 there is evidence that patients with high blood pressure (BP) and those with irritable bowel syndrome and flare-ups with ulcerative colitis may benefit from meditation. In addition, research indicates that meditation may help reduce symptoms of anxiety and depression and help people with insomnia.
Many people without evidence of illness or a diagnosis of a disease are benefitting from meditation as well. Meditation has been used with athletes and leaders to help improve performance, focus and mindset. Deep breathing can activate the parasympathetic nervous system and quiet the sympathetic nervous system, which has many immediate benefits for people including thinking more clearly, being able to gain perspective, enhancing the ability to listen, increase connection and collaboration, and improve brainstorming. Many of us aspire to be calm in the chaos, and meditation may well be one pathway to help us achieve this goal.
It is too early in the science of meditation to know which clinical populations are best served by which styles of meditation or trainings. We don't have that kind of resolution or predictive power yet. Aside from using clinical judgment and experimentation with mindfulness state inductions with clients, group-based mindfulness-based cognitive therapy (MBCT) is proving to be most effective for clinical levels of anxiety and depression. In the United Kingdom, MBCT was recommended by the National Institute for Health and Clinical Excellence in 2004. In 2009 the recommendation was updated and given “key priority” status. This treatment is specifically designed to reduce relapse in individuals who have had three or more major depressive episodes. So, finding a local course by a certified teacher is likely best for moderate levels of clinical anxiety and depression. From my read of the literature, the most consistent research findings appear to suggest the MBI works best for preventing normal age-related cognitive decline and associated brain atrophy in adults older than 60 years of age. A recent systematic review and meta-analysis by Whitfield and colleagues demonstrates such findings across the extant literature. 3
The good news from research is that larger scale clinical trials with multiple control arms and leveraging big data analytics for predictive modeling are beginning. This type of science will better be able to predict which format and teaching model can best serve the needs of people who are suffering. At this point, the best recommendations for clinicians interested in prescribing or teaching meditation with their clients is to first seek out hands-on experience and participate in an MBI like MBSR or MBCT. This is in fact a pre-requisite for the MBCT teacher training program at Centre for Mindfulness Studies in Toronto, Ontario, the Mindfulness Center at Brown, Providence, Rhode Island, or the University of California San Diego, San Diego, California. These are among the most respected training programs, and there are a handful of other credible teacher training courses that provide certifications to teach mindfulness.
There are also important considerations of adverse events that may come up during meditation practice, which may trigger traumatic memories and/or lead to profound shifts in mood. These experiences are not common, but they do happen especially in some clinical populations with trauma histories. I do suggest clinicians also check out some of the trauma-sensitive and safety mindfulness trainings such as “First Do No Harm: Foundational Competencies for Working Skillfully with Meditation-related Challenge” 4 both as a clinician and for individuals who are experiencing profound shifts in consciousness or emotional challenges in general.
Lastly, I do think it's important when referring to the science of meditation that we properly contextualize the findings. This means, rather than simply citing the headlines, we make more effort to describe how the study applies to the sample in the study, not typically the general population, and to consider the limitations. There are currently over 12,000 studies that use mindfulness or meditation as a key word in the title or abstract between the year 2000 and the present day. Yet, the majority of clinical studies are initial, single-arm feasibility and safety studies that explored efficacy in small samples of individuals. There remains a lot of hype around these preliminary findings and a paper by Van Dam et al. 5 provides a more tempered view of the literature and makes more modest recommendations about interpretation of the findings for the general population.
Even though the NIH website suggests eight-week mindfulness courses can reduce anxiety and depression, many of the past systematic reviews have used mixed criteria for which studies to include, often reporting on heterogenous samples with varied methodological rigor, different styles of practice like Integrative Body-Mind Training, Transcendental meditation, other mantra-based practices mixed with MBI studies that stay true to the standard protocol. Furthermore, there is often no distinction made between long-term practitioners and naïve practitioners exposed to only the eight-week training. Beyond the encouragement for a person to try meditation and see how it feels, it may be deceiving to set up the expectation that other people have improved his/her anxiety or depression through meditation, leaving many people wondering, why is it not working for me?
It does not take a lot of time to have an effect. Research suggests that 10 minutes a day of meditation can have a positive impact and improve mood state, and additional research suggests that increasing the time of the meditation to at least 20 minutes per session is a great goal for people.
It is important to emphasize appreciating the results of the meditation practice no matter how long it lasts. Asking patients to focus on how they feel after meditation and to specifically check in with their body as well as their mind and asking questions like, “What feels different? How does the day go if they meditate first? How is their sleep if they meditate prior to bed?” will help focus the patient on the benefits they are experiencing. These internal motivators help inspire patients to continue.
Using an app like Headspace, 10% Happier, Calm, the Peloton app or many others can help guide people through meditations of various lengths that they can select depending on their situation and needs. Videos of meditation practices can also encourage beginners to adopt routine meditation time. It is important for beginners to try a variety of meditation options—guided meditation, MBSR, relaxation response, mantra meditation and others.
The most important point to share is, “Don't stress about your meditation practice. Don't worry about if you are doing it right or not.” People need to experiment and practice various meditation techniques. They need to have fun in the process.
Dan Harris and his app, 10% Happier has also focused on this question—how to sustain a practice, and I encourage people to check out his book, Meditation for Fidgety Skeptics. In this book Dan, tackles the myths and misconceptions that stop people from meditating.
For patients, books, videos, and apps are great resources, as I mentioned above. There are a plethora of books from which to choose. Here are a few recommendations:
How to Meditate: A Practical Guide to Making Friends with Your Mind—Pema Chödrön
Meditation for Beginners—Jack Kornfield
8 Minute Meditation Expanded: Quiet Your Mind. Change Your Life—Victor Davich
Practical Meditation for Beginners: 10 Days to a Happier, Calmer You—Benjamin W. Decker
The Mind Illuminated: A Complete Meditation Guide Integrating Buddhist Wisdom and Brain Science for Greater Mindfulness—John Yates, PhD, Matthew Immergut and Jeremey Graves
A hot topic pre-pandemic and during the pandemic is brain health and function. Sara Lazar, PhD, published a landmark study about 15 years ago that demonstrated an association with meditation and greater cortical thickness in the pre-frontal cortex, the area of the brain involved with complex behavior, executive functioning, emotion, and behavioral functioning. 7 The research also revealed an increase in cortical thickness of the insula, the area of the brain involved with self-awareness, perception and cognitive functioning. In addition, research has reported an association with meditation and a decrease in the size of the amygdala. 8 In the middle of a crisis or during any perceived threat, the amygdala responds with emotion and often irrationality. Thus, if we can do something to reduce its reactivity, we are allowing ourselves the time and space to respond with calm, quiet confidence in the midst of chaos. This pandemic has created many situations when chaos prevails for people.
In comparison to active control interventions (e.g., group-based psychoeducation, relaxation, nutrition, reading or social support) that attempt to control for non-specific factors, many of the reported benefits of MBIs are equivocal, with only a moderate percentage (∼20%) of reports where MBIs outperform the control. One should not be discouraged by these results, however, since we are talking about ∼30–70 studies in total and most have some methodological issues that can improve.
In addition, these clinical trials are also typically limited to a specific demographic: middle-aged, white, educated women. One paper describes the lack of diversity in the science of meditation. 11 It is critical for clinician scientists to consider that the 94 randomized controlled trials of mindfulness predominantly involved white (79%), middle-aged (46 years), highly educated (15 years), females (70%). The efficacy of MBIs are heavily biased towards this demographic with limited improvements in diversity composition and reporting of race over time. Future research and practice is encouraged to develop culturally responsive interventions that include underrepresented populations to counter observed systemic bias and address inclusion disparities in the field. In sum, there is clear benefit to doing mindfulness practice, exactly how and who benefits most over eight-week trainings vs. long-term traditional practitioners remains unclear from the extant scientific literature.
As for neuroimaging findings, I thought I could give a brief summary of the extant literature in support of the findings cited by Dr. Frates. Since 2000, there have been over 25 functional magnetic resonance imaging studies of state and trait effects of meditation, including studies of expert and naïve practitioners of Yoga Nidra (yogic deep relaxation), Kundalini Yoga, Tibetan, Pure Land (Mahayana Buddhist), Acem (secular Norwegian), Vipassana (mindfulness), Zen, Theravadan (traditional mindfulness), Soham (Vedanta), transcendental meditation (mantra), and visualization, and practitioners who went through MBIs, amongst others. In general, data suggest most meditation traditions can improve the strength and stability of activity in two higher order attentional brain networks called the fronto-parietal network and salience network. These two networks are found to flexibly couple with other brain networks to efficiently integrate information depending on the contextual demands to support sustained, unbiased attention, meta-awareness, flexible engagement of attention (between the external world and internal mental space), and controlled reactions of the autonomic nervous system. Limitations in experimental design, statistical methods, and methodological artifacts often drive reported effects, further undermining the evidence for deriving meaning from reports of training-dependent changes in the brain. Nevertheless, interesting findings have driven a narrative that meditation may be neuroprotective for age-related atrophy in areas associated with executive functioning, sensory processing, interoception, and meta-awareness.
Just a quick glimpse into the state of the world and its overall wellbeing: Millions of deaths worldwide along with psychosocial distress among the general population due to the wider social impact, including strict infection control, quarantine, physical distancing, and national lockdowns have led to massive increases in mental illness. As Dr. Frates pointed out, the pandemic has increased a general level of uncertainty about the fate of our loved ones, our way of life, and the planet. It is important to consider how meditation and associated practices of mindfulness and compassion are providing the necessary means to effectively manage the hardships attributed to the COVID-19 pandemic.
In a recent forward to a special issue examining the most recent scientific findings of mindfulness research, Jon Kabat-Zinn states that the science of meditation is providing the “seeds of a necessary global renaissance in the making: the refining of psychology's understanding of the nature of mind, self, and embodiment through the lens of mindfulness and its origins at a key inflection point for the species.” May it be so.