Mindfulness: 102

Mindfulness and the Emergency Healthcare Professional

Chapter 16: summarising, yet again

At its most basic level, mindfulness is a retraining of our default emotional responses to stress and ‘triggers’.  By constant and deliberate application of another set of responses, that is, the calm and mindful responses, we grow to realise that the situations outside us are separate from our emotional and physical reactions to them.  By progressively detaching ourselves from ‘doing anger’ and ‘doing irritable’, external stressor situations lose their sting.  The situations themselves become less painful. 

And, because we are coming from a calmer response, we also cause less collateral emotional damage to others around us, and thereby help them in their journeys.  We teach in every moment, by the way we behave and react.

That’s all very theoretical”, you could say.  So, let’s break it down into three broad areas.

The three-pronged approach to mindfulness

Mindfulness practice can be viewed as comprising three main domains.  This could be described as a “three-pronged” approach.

1. A cognitive framework of ongoing psychological or spiritual growth
2. A moment-to-moment retraining of our default responses to stresses, both ‘outer’ and ‘inner’
3. A daily dedication to longer practice sessions by which we accelerate our understanding

Mindfulness requires work.  It also requires a readiness in us to acknowledge that our previous patterns of reaction are causing us hurt, and perhaps also to others around us.  Without a willingness to start what is for some quite profound inner change, the metaphorical “train” does not really “leave the station”.

Choosing our cognitive framework

This will be an individual choice.  The range of cognitive frameworks for mindfulness and related explorations can be likened to taking an ECG on a patient.  Each ECG lead records the same electrical phenomenon, but from a slightly different perspective, and the resulting recordings are slightly different.  In mindfulness, we each choose our starting perspective – based on our preferences and past experiences.

The “hard science” model

Our minds may be more comfortable with a “hard science” approach to mindfulness, for example, an approach which looks at objective and measurable indicators of stress reduction, with evidence-based scientific studies as a backdrop. Such studies provide discussion of EEG evidence of increased brain wave coherence as we incorporate mindfulness into our day.  Other papers show objective anatomical changes in the brain structure of meditators when examined in an fMRI scanner, compared to a control group of non-meditators. 

The methodology of mindfulness practice in the “scientific” paradigm would be completely  “unfluffy ” and free of any “weird stuff”, focussing instead on the methods of breathing techniques for relaxation and body scanning exercises, and watching for observable improvements in stress and mood, or reduced conflict in our relationships.

This approach is probably the “best fit” initially for most of us in emergency medicine, who come from a clinical and scientific starting point. Jon Kabat-Zinn had this in mind when creating his books and training courses in Mindfulness Based Stress Reduction (MBSR).  Without a clear compatibility with the way many people conceive of our mind and consciousness, the uptake of mindfulness in the West would have been more limited.   Instead, his model of mindfulness has expanded rapidly across Western medical schools, and in many other community groups, including schools.  Kabat-Zinn continues to have a prominent influence, and is one of many well known “change leaders” in the development of mindfulness practice in our context.

The “spiritual growth” model

It’s fair to say that many people working in the emergency department would not call themselves spiritual, and the label would sit uncomfortably for those.  Hence the value of a “hard science” model for mindfulness for emergency clinicians, which makes these concepts more approachable.  I know that such stereotyping is not an accurate portrayal of all emergency clinicians, but the general idea may remain useful as a starting point.

But there is also no denying that the science of mindfulness and meditation developed in parallel around the globe, beginning some 2000 years ago, as an element of the world’s great religious and philosophical traditions.  Individual experiences of the “something greater than me”, or a sense of the “profound”, have probably always intrigued humans, to varying degrees.

This sense of curiosity about the ‘profound’ motivates some to study philosophies like Buddhism, for one example.  Buddhism perhaps provides the neatest “fit” with modern Western mindfulness, and most of its concepts are paraphrased from established Buddhist meditation techniques. Dr Jon Kabat-Zinn himself was a Buddhist teacher, and from this he developed a “Western” mindfulness model².

To learn about Buddhism, the three-pronged approach I described above would consist of, firstly, the cognitive elements in the ancient texts and sutras, and then the other two “prongs” would comprise “right daily living” practice, and then several daily longer meditation periods¹.  A large element of the Buddhist “curriculum” is based on structured meditation training and experience.  The meditation, or mindfulness, components help to integrate the theoretical framework with subjective experience that, interestingly, builds a common sequence of learning and experience that is fairly similar between different practitioners².  The Buddhist sutras recognise this commonality in mindfulness practice, and describe maps of the shared learning stages³.

Dr Daniel M Ingram is an American emergency physician and Buddhist, and author of “Mastering the Core Teachings of the Buddha: An Unusually Hardcore Dharma Book”³

This mindfulness stuff is everywhere, it seems!

Buddhism is but one example of various spiritual or philosophical self-development paths,  that use structures incorporating mindfulness elements into the “training course”.

Yoga and mindfulness

Another well-known example is yoga, which certainly involves the asanas (bodypositions), and progressive musculoskeletal training.  This sounds a bit like physiotherapy, if we just  describe yoga using the “hard science” model, but yoga also incorporates a deliberate slowness in the movements and asana transitions, that naturally brings the practitioner’s mind into a relaxed or meditative state.  It is hardly surprising that we often incorporate yoga sessions into our ACEM Annual Scientific Meetings, as a counter-balance to the fast-paced life of emergency medicine!

A further component of yoga, or similar movement-based martial arts like tai-chi, is that we stop talking during the practice, which allows for the experience of mindfulness to develop naturally.  In itself, silence alone helps to provide a space to help us recalibrate our levels of nervous tension.

Meditation and spirituality overlap in many ways.  Further examples include people who use nature as a rebalancing environment.  When a person goes into a natural or wilderness environment, and spends some time sitting in mindfulness or meditation practice, the experience seems to be heightened or reinforced by just being in that place.  The pursuits of fishing, or kayaking, or bushwalking quietly, create an automatic form of mindfulness, or increased mental coherence.

So, what is the common thread in all the above approaches to mindfulness?  Firstly, the introduction of silence, or relatively few words.  Additionally, slowly going through a repetitive activity.  One foot in front of the other, in a slow walking rhythm, or one cast of the fishing rod after the other, and a lot of standing still perhaps waiting for the fish to bite. Mindful biting, of course.

The physical environment itself also has a measurable effect on our mental state, which is intuitive but not completely understood, and which is increasingly being utilised in the design of public spaces, to enhance community wellbeing.  ED architectural design could utilise such principles to a much greater extent than we currently do.

For those already interested in exploration of their own spirituality, whatever they conceive this to be, there are many approaches which incorporate mindfulness.  The language might be different.  Those coming through a religious or faith-based entry point into mindfulness might call the process prayer. 

So, there are many options.   Wherever we start from, the likelihood is that we will change our understanding significantly along the way, as we experience the definite benefits.

One common element that develops at some point is trust.  By practising the three-pronged elements described above (remember that they are: cognitive framework, moment-to-moment mindfulness, and daily mindfulness practice sessions), our own experience of benefits will start.  There will likely be different experiences and rates of change for different individuals, but it will start.

And then, to our surprise, we will discover that we can change our patterns.  This, in turn, builds a nascent sense of trust that we can effect such changes, and increase our enjoyment of this thing called life.

If we are coming through a spiritual paradigm to mindfulness, the word we might use instead of trust might be faith.  Regardless of terminology, the overall process is similar, no matter how we try and select words to describe what is happening.

And in closing …

So, are the two models described above really so separate after all?  The distinctions actually become blurry, just as they do in modern cosmology or quantum physics.

In the next instalment, we will look at some “in the moment” breathing techniques that can help us mentally and emotionally “change tracks” right in the midst of stress, both in the ED, and also in life outside the hospital walls.

Thank you for reading this, and take care of yourself.

Further reading

1. Hạnh TN. The Miracle of Mindfulness: An Introduction to the Practice of Meditation. Boston, MA: Beacon Press; 1975. 2e 1996
2. Kabat-Zinn, J. Wherever you go, there you are: Mindfulness Meditation in Everyday Life. Hachette Books, 2005
3. Ingram DM. Mastering the Core Teachings of the Buddha: An Unusually Hardcore Dharma Book – Revised and Expanded Edition. Aeon Books 2018 [Publisher PDF]

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Andrew Dean

A/Prof Andrew Dean, MBBS FACEM Grad Cert Clinical Simulation. Emergency Physician and DEMT at St John of God Hospital, Ballarat, Victoria, Australia. Head of Ballarat Rural Clinical School, School of Medicine Sydney, University of Notre Dame Australia.

Still searching for new and innovative teaching methods for emergency medicine education.  Also a committed advocate for mindfulness meditation, and the nurturing of emotionally intelligent clinical teams in health care.