THE CENTER FOR MINDFULNESS IN MEDICINE, HEALTH CARE, AND SOCIETY UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL. MINDFULNESS-BASED STRESS REDUCTION (MBSR)  STANDARDS OF PRACTICE. Edited and Revised by: Saki F. Santorelli, EdD, MA  Professor of Medicine Executive Director, Center for Mindfulness Director, Stress Reduction ProgramFrom:

February 2014

Center for Mindfulness in Medicine, Health Care & Society Department of Medicine. Division of Preventive and Behavioral Medicine

Background and Overview

Mindfulness-Based Stress Reduction Jon Kabat-Zinn, PhD

Kabat-Zinn, J. Mindfulness Meditation: What It Is, What It Isn’t, And It’s Role In Health Care and Medicine In: Haruki, Y., Ishii, Y., and Suzuki, M. Comparative and Psychological Study on Meditation. Eburon, Netherlands, 1996. Pg. 161-169.

Mindfulness-Based Stress Reduction (MBSR) is a well-defined and systematic patient-centered educational approach which uses relatively intensive training in mindfulness meditation as the core of a program to teach people how to take better care of themselves and live healthier and more adaptive lives. The prototype program was developed at the Stress Reduction Clinic at the University of Massachusetts Medical Center. This model has been successfully utilized with appropriate modifications in a number of other medical centers, as well as in non-medical settings such as schools, prisons, athletic training programs, professional programs, and the workplace. We emphasize that there are many different ways to structure and deliver mindfulness-based stress reduction programs. The optimal form and its delivery will depend critically on local factors and on the level of experience and understanding of the people undertaking the teaching. Rather than “clone” or “franchise” one cookie-cutter approach, mindfulness ultimately requires the effective use of the present moment as the core indicator of the appropriateness of particular choices. However, there are key principles and aspects of MBSR which are universally important to consider and to embody within any context of teaching. These include:

It is in part from this orientation [§f], which differs considerably from traditional medical or psychiatric models, which orient interventions as specifically as specifically as possible to particular diagnostic categories, that the generic and universal qualities of MBSR stem. Of course, stress, pain, and illness are common experiences within the medical context, but beyond that, and even more fundamentally, the participants share being alive, having a body, breathing, thinking, feeling, perceiving, and incessant flow of mental states, including anxiety, worry, frustration, irritation and anger, depression, sorrow, helplessness, despair, joy, and satisfaction, and the capacity to cultivate moment-to-moment awareness by directing attention in particular systematic ways. They also share, in our view, the capacity to access their own inner resources for learning, growing, and healing (as distinguished from curing) within the context of mindfulness practice.

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In addition to these factors, which encourage flexibility and appropriate modification for non-hospital-based and non-medically-based MBSR programs, there are minimal standards of form and content for medically-oriented, HMO and hospital-based programs to appropriately call themselves MBSR. These are outlined in detail in the following section.

While individual pre and post program interviews have not been used in all HMO-delivered programs, (see Appendix C) they are highly recommended as an integral and important part of the MBSR intervention. If omitted, an appropriate and thoughtful substitute must be included to ensure an effective “launch” of the MBSR experience for individual participants and the class as a whole.

MINDFULNESS-BASED STRESS REDUCTION (MBSR)
STRUCTURE, METHODS, AND KEY PROGRAM CHARACTERISTICS

Structure and Methods

Key Characteristics

·         A fundamental component of good medical care

·         Participants are referred by their physicians or other health care professionals or via self-referral

·         Intensive training in mindfulness meditation

·         Educational orientation

·         Group format - 15-40 participants per class

·         Individually tailored instruction

·         Experiential, highly participatory format

·         Highly challenging and strongly supportive

·         Self-responsibility emphasized within the context of a collaborative relationship between participant, MBSR provider, and referring physician or other health care professional

·         Array of mindfulness methods to meet individual participant needs and learning styles

·         Interactive instructor and patient-initiated dialogue and inquiry intended to explore perceptions, mental and behavioral habits and patterns that maybe inhibiting learning, growth, and healing.

·         short-term intervention: MBSR is relatively brief in duration (8 weeks). The structure is intended to foster participant self-regulation and self-reliance

·         Life-long learning: MBSR is both an immediate and deliberate shift in health orientation and a method for enhancing health and well being across the life span

Program Standards

1.    MBSR Teacher Readiness and Competency

All prospective instructors should meet the Qualifications and Recommended

Guidelines for MBSR Teachers as the developed and implemented by Oasis Institute for Mindfulness-Based Professional Education and Training at the UMMS Center for Mindfulness in Medicine, Health Care, and Society (CFM). Additional information about teacher readiness can be found on the CFM website (www.umassmed.edu/cfm/oasis) and printed materials describing Mindfulness-Based Professional Education and Training Programs, and Teacher Certification in Mindfulness-Based Stress Reduction.

2.    Pre-Program Group Orientation Sessions

In March 2001, the UMMS Stress Reduction Clinic replaced individual pre-program interviews with a group Orientation Sessions. Likewise, we no longer conduct individual post-program interviews. All pre-program assessment data is collected at the required Orientation Session. All post-program assessment data is collected during an extended Class 8 (last session) of the Stress Reduction Program. Orientation Sessions are conducted on an ongoing basis for three weeks prior to the start of each teaching cycle of the Stress Reduction Program (SRP). Attendance is required of all candidates seeking enrollment in the course. Orientation Sessions are approximately 150 minutes in length.

Prior to attendance at an Orientation Session all program candidates receive an individual telephone call intended to help us understand their interest in the program, explain the nature, focus and structure of the program and the commitment required, and answer any questions prospective participants might have about the program. If the candidate remains interested, they are then enrolled in an Orientation Session. In addition to telephone contact, each program candidate receives via mail a packet of background information about the SRP.

During the Orientation Session, all program candidates fill out pre-program assessment data, learn more about the Stress Reduction Program, experience, first hand, mindfulness meditation practice, have an opportunity to ask questions about the SRP, and make a decision about enrollment in the Stress Reduction Program. If a candidate makes the decision to enroll in the SRP they are then asked to determine and write down three goals they intend to address during the SRP.

Importantly, prior to the conclusion of the Orientation Session, SRP instructors meet briefly with  each candidate to review the assessment forms, answer individual questions, and make  screening decisions and determinations about candidate appropriateness for the SRP. If deemed necessary, additional follow up appointments are arranged between the instructor and program candidate to further screen, determine appropriateness, and, if required, negotiate specific requirements for participation (for a detailed schedule of Orientation Sessions see Appendix B).

In the final class (Class 8 - which is 3.5 hours), three distinct yet interdependent elements are included: Practice, Assessment, and Closure. Various aspects of Practice and Closure are discussed at length in the Curriculum Outlines included in this manual. In the context of this section on Practice Standards, Assessment refers to the distribution and collection of final assessment measures and the use of both pre and post-program assessment forms as a self-awareness/self-education methodology for each individual SRP participant.

Pre-Program Group Orientation Sessions (continued):

Toward the beginning of the second hour of Class 8, post-program assessment measures are distributed to each participant. All participants are given adequate time to fill out the forms and all forms are reviewed by the instructor for completion. Following this review, a collated set of each participant’s pre and post-program assessment forms are given to participants as another form of self-education, comparison and as a review of their targeted pre-program goals. Following this review, all forms (pre and post) are returned to the instructor and deposited in a data collection station.

3) Screening Criteria for Exclusion from the SRP

MBSR is a practical educational approach rather than a conventional group therapy intervention. As such, it utilizes large “classes” (15-40 participants), is time-limited (8-weeks), and relies on the creation of a highly participatory community of learners intent on cultivating and integrating into their everyday lives the various practices, approaches, and attitudes characteristic of MBSR (see Kabat-Zinn excerpt “Mindfulness-Based Stress Reduction”). Its primary focus of attention is directed toward the development of a person’s first hand understanding of the body, mind, and body-mind interactions leading to the incremental development of greater somato-psychic awareness that can be fluidly integrated into the life of program participants as a means of 1) mitigating the negative consequences of patterned, habitual conditioning, 2) becoming more capable of self-regulation, 3) coping more effectively with the challenges and demands of everyday life and 4) discovering and becoming increasingly familiar with one’s hidden yet innate resources for learning, growing, healing, and thriving.

Keeping in mind the structure, methods, and key characteristics of MBSR as previously described, the following screening criteria for exclusion were informally established with the founding of the Stress Reduction Program in 1979. These criteria were formalized in 1993 and continually updated and refined (most recently in February 2014).

Lifestyle Issues:

·         Active substance dependence - legal or illicit

·         People with substance dependence new to recovery (less than one year)

·         Inadequate comprehension of language in which the course is taught

Exceptions: In terms of dependence and/or addiction:

1.    If someone is in recovery less than one year and seems highly motivated or is in a highly supportive treatment environment that is congruent with the approach used in the Stress Reduction Program, they may be considered for program participation.

2.    If a program candidate is dependent to pain medication for a chronic pain condition and is capable of mounting the requisite mental concentration and energy required to learn and practice the meditation and mindfulness practices utilized in the SRP, they may be considered for program participation.

If there is a problem with language comprehension, provisions can be made for interpretation services. The same holds true for hearing impairment. While we attempt to arrange for these services, we cannot guarantee that these services will be available to Stress Reduction Program (SRP) candidates.

Screening Criteria for Exclusion from the SRP (continued): Psychological issues:

·         Suicidality

·         Psychosis (not treatable with medication)

·         PTSD

·         Depression (clinical) or other major psychiatric diagnosis (if it interferes with participation in the SRP).

·         Social anxiety (difficulty with being in a classroom situation)

Exceptions: Anyone who is highly motivated and receiving therapy and/or medication for the above mentioned diagnoses may be considered for enrollment in the Stress Reduction Program.

However, in these cases, it is essential that prior to the start of classes we establish the following agreements:

1.    Receive permission from the SRP candidate to speak with their primary mental health provider as deemed appropriate,

2.    Negotiate an agreement with the SRP instructor, program candidate and the primary mental health provider that the mental health provider is first responder in the case of mental health emergency rather than the SRP instructor.

3.    Establish that the SRP teacher will maintain on-going collaboration with the program candidate’s current mental healthcare provider and primary care physician as necessary for the duration of the program.

Attitudinal Issues:

·         Inability to comprehend the nature and limitations of program (wanting a “quick fix” without the necessary and required investment of time and energy)

·         Inability to commit to attending classes (if someone is going to miss three or more classes they are referred to a future program cycle)

Physical Issues:

·         Inability to physically attend weekly program classes. This does not refer to physical impairment, which is not an exclusion criterion. Rather, this refers to the inability of program candidates to actually get to class because of being bedridden or homebound or without transportation.

Note: In rare instances, home visits for individual instruction may be arranged. The use of this service is based on SRP instructor availability. Fees for this service differ significantly from usual program costs.

In all cases, final decisions regarding these exclusion criteria are subject to the judgment of the SRP instructor conducting pre-program Orientation Sessions or individual class sessions.

4) Participant/Provider Informal Learning Contract

Each MBSR candidate who enrolls in the program is encouraged to intentionally and actively commit themselves to an oral learning contract that includes:

·         attending all weekly classes

·         engaging in daily home assignments

·         participating in the all-day silent retreat

·         making-up weekly classes they have missed when possible and

·         participating in the post-program interview (when this model is followed).

5)    Hours of Instruction

Approximately 30-31 hours of in-class instruction will be provided. The first class is 3.0 hours; the last class is 3.5 hours. Classes two through seven are 2.5 hours. The day of silent retreat is 7.5 hours. In addition, when deemed important by the participant and instructor, personalized individual instruction is sometimes required and recommended. (typically, the SRP does not charge for this time)

6)    Classroom Instruction: Curriculum Guidelines

a)    Introduction, Sequencing, and Systematic Development of Mindfulness Meditation Practice

There is an array of instructional material detailing the teaching of MBSR. Great care should be exercised to introduce and discuss both the formal and informal aspects of mindfulness meditation practice free of the language, belief systems, dogma, and cultural contexts in which they originated. Primary attention should be given to the cultivation of non-judgmental, non-striving, moment-to-moment attention framed within the context of a gentle yet persistent commitment to on-going, daily practice. Across weekly classes, careful attention should taken to the introduction, sequencing, and systematic development of the “formal” mindfulness practices. The MBSR Curriculum Guide created by Dr. Jon Kabat-Zinn) and the weekly Session Guide developed by Dr. Saki Santorelli (see Two Curriculum Outlines) detail the systematic presentation of mindfulness practice within the context of MBSR as an approach to health, self-care, and self-regulation.

b)    Formal and Informal Mindfulness Practice

Each MBSR class includes the introduction and cultivation of both formal and informal dimensions mindfulness meditation practice.

§§  Formal mindfulness practices include: the Body Scan Meditation, Sitting

Meditation, Hatha Yoga, and Walking Meditation

·         Informal mindfulness practices include: awareness of pleasant and unpleasant events, routine events, interpersonal communications, repetitive cognitions and emotions and their relationship to bodily sensations and habitual actions and behaviors in everyday life.

c) Didactic Presentations

A first-hand, on-going, experiential engagement in mindfulness practice on the part of both the instructor and the patients (participants) is the primary feature of MBSR. However, whether MBSR is used in a medical or non-medical setting, it is critically important for the instructor to provide a contextual framework whereby participants can begin to understand the relationship between mindfulness practice and their ability to learn to cope more effectively with stress. Therefore, instructors should provide information on such topics as: stress physiology, stress reactivity and the learned ability to respond, the effects of perception, appraisal, and attitude on health habits and behavior, patterns of intra- and interpersonal communication. Importantly, rather than

Didactic Presentations (continued):

“lecturing” to program participants, the attention and skill of the instructor should be directed towards listening to the rich, information-laden insights and examples provided by program participants and then, in turn, to use as much as possible these participant-generated experiences as a starting point for “weaving” the more didactic material into the structure and fabric of each class. Rather than simply offering a “lecture” on stress physiology, the goal is to make the didactic elements of the curriculum come alive via elicitation of and dialogue oriented around the direct experience of program participants. In essence, such an approach provides an opportunity for the science to emerge spontaneously out of the direct experience of participants. Done skillfully, the understanding of the physiology of stress is called forth out of direct experience. The result: personal identification leading to excitement, interest, and a commitment on the part of participants to pay close attention to the felt and perceived somato-psychic signs of stress reactivity and response in everyday life.

c) Class Dialogue and Inquiry

It is essential that a significant amount of time in each class be dedicated to an exploration of the participants’ first hand experience of the formal and informal mindfulness practices and other weekly home assignments. This requires the instructor to sharpen her/his ability to listen closely, allow space, refrain from the impulse to give advice, and instead, to inquire directly into the actually of the participant’s experience. To do so requires the instructor to create a safe space and to encourage program participants to assist in the co-creation of a sensitive, safe environment. Creating such safety requires willingness on the part of the instructor to suspend judgment, to attempt to understand as much as possible the experience of the participants, to refrain from using formulaic responses when confronted with difficult or uncomfortable classroom experiences, and to listen keenly as well as redirect participants as required within the class discourse. If classroom dialogue is to be authentic and alive, it is essential that it arise out of the freshness of the present moment. The instructor must be constantly attentive to the needs and variety of verbal and non-verbal expressiveness of individual participants as they exist within the context the larger classroom population. Beginning in Class 1 “ground rules” for classroom participation should be made explicit, emphasizing a combination of individual responsibility, confidentiality among class members, and an atmosphere of respect and mutual discovery.

d)    Attitudinal Qualities Associated with Mindfulness Practice

There are a host of attitudinal qualities that lend themselves to the cultivation of mindfulness. These foundational attitudes are central to the pedagogical approach of MBSR. The gradual process of embodying such qualities relies on the intention of the instructor and on his/her commitment to life-long learning. In turn, such a personal commitment on the part of the instructor becomes the basis for the awakening of these attitudes in the minds and hearts of the class participants. Rather than being conceived of as a set of ideas or concepts that one “must” or “should” have in order to be an MBSR teacher or class participant, they are attitudes to be consciously cultivated via mindfulness practice. These foundational attitudes are inextricably linked to one another and include: non-judging, patience, a beginner’s mind, trust, non-striving, acceptance or acknowledgement, and letting go or letting be. A detailed explanation of these attitudes can be found in Appendix A.

e)    Home Assignments

The cultivation of knowledge and the development of any skill require

deliberate, consistent attention on the part of the learner. Therefore, the transformational backbone of MBSR is daily home assignments. Although there are 30+ hours of direct classroom contact during a typical 8-week program, this is not enough time for participants to begin to learn, deepen, and apply mindfulness in their everyday lives. What is required is ongoing homework. Home assignments consistent of formal and informal mindfulness practices, a variety of awareness exercises systematically sequenced and assigned throughout the course of the program. (see Appendix A and References for more detail).

f)     Program Enrollment

While highly therapeutic, MBSR is an educational orientation primarily offered in a classroom format. In the SRC, classes range from 20-40 participants. Median class size is thirty. The group format is a salient feature of MBSR that must be clearly explained to the MBSR program candidate by the instructor prior to enrollment. Care should be taken to ascertain the participants’ level of comfort with this approach and consideration must be given to the candidates’ capacity to comfortably and effectively function within a large class format.

g)    Suggested Resources for Continuity of Practice after Program Completion

·         Instructors should be familiar with and able to recommend a host of community resources available to participants following the completion of MBSR. It is helpful for the instructor to develop and provide program graduates with a list of reading materials, retreat centers, and other suggestions for fostering the continuity of mindfulness practice.

·         To enhance adherence to the methods learned during the program, past participants of the program are offered the opportunity to enroll in advanced or “graduate” stress reduction programs several times per year in which they can enrich their practice of the methods acquired during the basic MBSR program, sustain their commitment to the new lifestyle and attitudinal changes adopted during the program, and continue to move towards greater levels of health and well being.

At the Center for Mindfulness, these programs are taught by senior MBSR instructors. A variety of formats are utilized in different graduate programs. These include weekly, bi-weekly, weekend, and monthly formats usually totaling 15-25 hours of direct instruction.

APPENDIX A

The Foundation of Mindfulness Practice: Attitudes & Commitment

Jon Kabat-Zinn, Ph.D.
From:

FULL CATASTROPHE LIVING: USING THE WISDOM OF YOUR BODY AND MIND
TO FACE STRESS, PAIN, AND ILLNESS

The Foundations of Mindfulness Practice: Attitudes and Commitment

To cultivate the healing power of mindfulness requires much more than mechanically following a recipe or a set of instructions. No real process of learning is like that. It is only when the mind is open and receptive that learning and seeing and change can occur. In practicing mindfulness you will have to bring your whole being to the process. You can’t just assume a meditative posture and think something will happen or play a tape and think that the tape is going to “do something” for you.

The attitude with which you undertake the practice of paying attention and being in the present is crucial. It is the soil in which you will be cultivating your ability to calm your mind and to relax your body, to concentrate and to see more clearly. If the attitudinal soil is depleted, that is, if your energy and commitment to practice are low, it will be hard to develop calmness and relaxation with any consistency. If the soil is really polluted, that is, if you are trying to force yourself to feel relaxed and demand of yourself that “something happen,” nothing will grow at all and you will quickly conclude that “meditation doesn’t work.”

To cultivate meditative awareness requires an entirely new way of looking at the process of learning. Since thinking that we know what we need and where we want to get are so ingrained in our minds, we can easily get caught up in trying to control things to make them turn out “our way,” the way we want them to. But this attitude is antithetical to the work of awareness and healing. Awareness requires only that we pay attention and see things as they are. It doesn’t require only that we pay attention and see things as they are. It doesn’t require that we change anything. And healing requires receptivity and acceptance, a tuning to connectedness and wholeness. None of this can be forced, just as you cannot force yourself to go to sleep. You have to create the right conditions for falling asleep and then you have to let go. The same is true for relaxation. It cannot be achieved through force of will. That kind of effort will only produce tension and frustration.

If you come to the meditation practice thinking to yourself, “This won’t work but I’ll do it anyway,” the chances are it will not be very helpful. The first time you feel any pain or discomfort, you will be able to say to yourself, “See, I knew my pain wouldn’t go away,” or “I knew I wouldn’t be able to concentrate,” and that will confirm your suspicion that it wasn’t going to work and you will drop it.

If you come as a “true believer,” certain that this is the right path for you, that meditation is “the answer,” the chances are you will soon become disappointed too. As soon as you find that you are the same person you always were and that this work requires effort and consistency and not just a romantic belief in the value of meditation or relaxation, you may find yourself with considerably less enthusiasm than before.

In the stress clinic, we find that those people who come with a skeptical but open attitude do the best. Their attitude is “I don’t know whether this will work or not, I have my doubts, but I am going to give it my best shot and see what happens.”

So the attitude that we bring to the practice of mindfulness will to a large extent determine its long-term value to us. This is why consciously cultivating certain attitudes can be very helpful in getting the most out of the process of meditation. Your intentions set the stage for what is possible. They remind you from moment to moment of why you are practicing in the first place. Keeping particular attitudes in mind is actually part of the training itself, a way of directing and channeling your energies so that they can be most effectively brought to bear in the work of growing and healing.

Seven attitudinal factors constitute the major pillars of mindfulness practice as we teach it in the stress clinic. They are non-judging, patience, a beginner’s mind, trust, non-striving, acceptance, and letting go. These attitudes are to be cultivated consciously when you practice. They are not independent of each other. Each one relies on and influences the degree to which you are able to cultivate the others. Working on any one will rapidly lead you to the others. Since together they constitute the foundation upon which you will be able to build a strong meditation

practice of your own, we are introducing them before you encounter the techniques themselves so that you can become familiar with these attitudes from the very beginning. Once you are engaged in the ways you might continue to fertilize this attitudinal soil so that your mindfulness practice will flourish.

THE ATTITUDINAL FOUNDATION OF MINDFULNESS PRACTICE

1.    Non-judging

Mindfulness is cultivated by assuming the stance of an impartial witness to your own experience. To do this requires that you become aware of the constant stream of judging and reacting to inner and outer experiences that we are all normally caught up in, and learn to step back from it. When we begin practicing paying attention to the activity of our own mind, it is common to discover and to be surprised by the fact that we are constantly generating judgments about out experience. Almost everything we see is labeled and categorized by the mind. We react to everything we experience in terms of what we think its value is to us. Some things, people, and events are judged as “good” because they make us feel good for some reason. Others are equally quickly condemned as “bad” because they make us feel bad. The rest is categorized as “neutral” because we don’t think it has much relevance. Neutral things, people, and events are almost completely turned out of our consciousness. We usually find them the most boring to give attention to.

This habit of categorizing and judging our experience locks us into mechanical reactions that we are not even aware of and that often have no objective basis at all. These judgments tend to dominate our minds, making it difficult for us ever to find any peace within ourselves. It’s as if the mind were a yo-yo, going up and down on the string of our own judging thoughts all day long. If you doubt this description of your mind, just observe how much you are preoccupied with liking and disliking, say during a ten-minute period as you go about your business.

If we are to find a more effective way of handling the stress in our lives, the first thing we will need to do is to be aware of the automatic judgments so that we can see through out own prejudices and fears and liberate ourselves from their tyranny.

When practicing mindfulness, it is important to recognize this judging quality of mind when it appears and to intentionally assume the stance of an impartial witness by reminding yourself to just observe it. When you find the mind judging, you don’t have to stop it from doing that. All that is required is to be aware of it happening. No need to judge the judging and make matters even more complicated for yourself.

As an example, let’s say you are practicing watching your breathing, as you did in the last chapter and as we will do a lot more in the next. At a certain point you may find your mind saying something like, “This is boring,” or “This isn’t working,” or “I can’t do this.” These are judgments. When they come up in your mind, it is very important to recognize them as judgmental thinking and remind yourself that the practice involves suspending judgment and just watching whatever comes up, including your own judging thoughts, without pursuing them or acting on them in any way. Then proceed with watching your breathing.

2.    Patience

Patience is a form of wisdom. It demonstrates that we understand and accept the fact that sometimes things must unfold in their own time. A child may try to help a butterfly to emerge by breaking open its chrysalis. Usually the butterfly doesn’t benefit from this. Any adult knows that the butterfly can only emerge in its own time, that the process cannot be hurried.

In the same way we cultivate patience toward our own minds and bodies when practicing mindfulness. We intentionally remind ourselves that there is no need to be impatient with ourselves because we find the mind judging all the time, or because we are tense or agitated or frightened, or because we have been practicing for some time and nothing positive seems to have

happened. We give ourselves room to have these experiences. Why? Because we are having them anyway! When they come up, they are our reality, they are part of our life unfolding in this moment. So we treat ourselves as well as we would treat the butterfly. Why rush through some moments to get to other, “better” ones? After all, each one is your life in that moment.

When you practice being with yourself in this way, you are bound to find that your mind has “a mind of its own.” We have already seen in Chapter 1 that one of its favorite activities is to wander into the past and into the future and lose itself in thinking. Some of its thoughts are pleasant. Others are painful and anxiety producing. In either case thinking itself exerts a strong pull on our awareness. Much of the time our thoughts overwhelm our perception of the present moment. They cause us to lose our connection to the present.

Patience can be a particularly helpful quality to invoke when the mind is agitated. It can help us to accept this wandering tendency of the mind while reminding us that we don’t have to get caught up in its travels. Practicing patience reminds us that we don’t have to fill up our moments with activity and with more thinking in order for them to be rich. In fact it helps us to remember that quite the opposite is true. To be patient is simply to be completely open to each moment, accepting it in its fullness, knowing that, like the butterfly, things can only unfold in their own time.

3.   Beginner’s Mind

The richness of present-moment experience is the richness of life itself. To often we let our thinking and out beliefs about what we “know” prevent us from seeing things as they really are. We tend to take the ordinary for granted and fail to grasp the extraordinariness of the ordinary. To see the richness of the present moment, we need to cultivate what had bee called “beginner’s mind,” a mind that is willing to see everything as if for the first time.

This attitude will be particularly important when we practice the formal meditation techniques described in the following chapters. Whatever particular technique we might be using, whether it is the body scan or the sitting meditation or the yoga, we should bring our beginner’s mind with us each time we practice so that we can be free of our expectations based on our past experiences. An open, “beginner’s” mind allows us to be receptive to new possibilities and prevents us from getting stuck in the rut of our own expertise, which often thinks it knows more than it does. No moment is the same as any other. Each is unique and contains unique possibilities. Beginner’s mind reminds us of the simple truth.

You might try to cultivate your own beginner’s mind in you daily life as an experiment. The next time you see somebody who is familiar to you, ask yourself if you are seeing this person with fresh eyes, as he or she really is, or if you are only seeing the reflection of your own thoughts about this person. Try it with your children, your spouse, your friends and co-workers, with your dog or cat if you have one. Try it with problems when they arise. Try it when you are outdoors in nature. Are you able to see the sky, the stars, the trees and the water and the stones, and really see them as they are right now with a clear and uncluttered mind? Or are you actually only seeing them through the veil of your own thoughts and opinions?

4.   Trust

Developing a basic trust in yourself and your feelings is an integral part of meditation training. It is far better to trust in your intuition and you own authority, even if you make some “mistakes” along the way, than always to look outside of yourself for guidance. If at any time something doesn’t feel right to you, why not honor your feelings? Why should you discount them or write them off as invalid because some authority or some group of people thing or say differently? This attitude of trusting yourself and your own basic wisdom and goodness is very important in all aspects of the meditation practice. It will be particularly useful in the yoga. When practicing yoga, you will have to honor your own feelings when your body tells you to stop or to back off in a particular stretch. If you don’t listen, you might injure yourself.

Some people who get involved in meditation get so caught up in the reputation and authority of their teachers that they don’t honor their own feelings and intuition. They believe that

their teacher must be a much wiser and more advanced person, so they think they should imitate him and do what he says without question and venerate him as a model of perfect wisdom. This attitude is completely contrary to the spirit of meditation, which emphasizes being your own person and understating what it means to be yourself. Anybody who is imitating somebody else, no matter who it is, is heading in the wrong direction.

It is impossible to become like somebody else. Your only hope is to become more fully yourself. That is the reason for practicing meditation in the first place. Teachers and books and tapes can only be guides, signposts. It is important to be open and receptive what you can learn from other sources, but ultimately you still have to live your own life, every moment of it. In practicing mindfulness, you are practicing taking responsibility for being yourself and learning to listen and trust your own being. The more you cultivate this trust in your own being, the easier you will find it will be to trust other people more and to see their basic goodness as well.

5.   Non-striving

Almost everything we do we do for a purpose, to get something or somewhere. But in meditation this attitude can be a real obstacle. That is because meditation is different from all other human activities. Although it takes a lot of work and energy of a certain kind, ultimately meditation is non-doing. It has no goal other than for you to be yourself. The irony is that you already are. This sounds paradoxical and a little crazy. Yet this paradox and craziness may be pointing you toward a new way of seeing yourself, one in which you are trying less and being more. This comes from intentionally cultivating the attitude of non-striving.

For example, if you sit down and meditate and you think, “I am going to get relaxed, or get enlightened, or control my pain, or become a better person,” then you have introduced an idea into your mind of where you should be, and along with it comes the notion that you are not okay right now. “If I were only more calm, or more intelligent, or a harder worker, or more this or more that, if only my heart were healthier or my knee were better, then I would be okay. But right now, I am not okay.”

This attitude undermines the cultivation of mindfulness, which involves simply paying attention to whatever is happening. If you are tense, then just pay attention to the tension. If you are in pain, then be with the pain as best you can. If you are criticizing yourself, then observe the activity of the judging mind. Just watch. Remember, we are simply allowing anything and everything that we experience from moment to moment to be here, because it already is.

People are sent to the stress clinic by their doctors because something is the matter. The first time they come, we ask them to identify three goals that they want to work toward in the program. But then, often to their surprise, we encourage them not to try to make any progress toward their goals over the eight weeks. In particular, if one of their goals is to lower their blood pressure or to reduce their pain or their anxiety, they are instructed not to try to lower their blood pressure nor to try to make their pain or their anxiety go away, but simply to stay in the present and carefully follow the meditation instructions.

As you will see shortly, in the meditative domain, the best way to achieve your own goals is to back off from striving for results and instead to start focusing carefully on seeing and accepting things as they are, moment by moment. With patience and regular practice, movement toward your goals will take place by itself. This movement becomes an unfolding that you are inviting to happen within you.

6.   Acceptance

Acceptance means seeing things as they actually are in the present. If you have a headache, accept that you have a headache. If you are overweight, why not accept it as a description of your body at this time? Sooner or later we have to come to terms with things as they are and accept them, whether it is a diagnosis of cancer or learning of someone’s death. Often acceptance is only reached after we have gone through very emotion-filled periods of denial and then anger. These stages are a natural progression in the process of coming to terms with what is.

They are all part of the healing process.

However, putting aside for the moment the major calamities that usually take a great deal of time to heal from, in the course of our daily lives we often waste a lot of energy denying and resisting what is already fact. When we do that, we are basically trying to force situations to be the way we would like them to be, which only makes for more tension. This actually prevents positive change from occurring. We may be so busy denying and forcing and struggling that we have little energy left for healing and growing, and what little we have may be dissipated by our lack of awareness and intentionality.

If you are overweight and feel bad about your body, it’s no good to wait until you are the weight you think you should be before you start liking you body and yourself. At a certain point, if you don’t want to remain stuck in a frustrating vicious cycle, you might realize that it is all right to love yourself at the weight that you are now because this is the only time you can love yourself. Remember, now is the only time you have for anything. You have to accept yourself as you are before you can really change.

When you start thinking this way, losing weight becomes less important. It also becomes a lot easier. By intentionally cultivating acceptance, you are creating the preconditions for healing.

Acceptance does not mean that you have to like everything or that you have to take a passive attitude toward everything and abandon your principles and values. It does not mean that you are satisfied with things as they are or that you are resigned to tolerating things as they “have to be.” It does not mean that you should stop trying to break free of your own self-destructive habits or to give up on your desire to change and grow, or that you should tolerate injustice, for instance, or avoid getting involved in changing the world around you because it is the way it is and therefore hopeless. Acceptance as we are speaking of it simply means that you have come around to a willingness to see things as they are. This attitude sets the stage for acting appropriately in you life, no matter what is happening. You are much more likely to know what to do and have the inner conviction to act when you have a clear picture of what is actually happening than when your vision is clouded by your mind’s self-serving judgments and desires or its fears and prejudices.

In the meditation practice, we cultivate acceptance by taking each moment as it comes and being with it fully, as it is. We try not to impose our ideas about what we should be feeling or thinking or seeing on our experience but just remind ourselves to be receptive and open to whatever we are feeling, thinking, or seeing, and to accept it because it is here right now. If we keep our attention focused on the present, we can be sure of one thing, namely that whatever we are attending to in this moment will change, giving us the opportunity to practice accepting whatever it is that will emerge in the next moment. Clearly there is wisdom in cultivating acceptance.

7. Letting Go

They say that in India there is a particularly clever way of catching monkeys. As the story goes, hunters will cut a hole in a coconut that is just big enough for a monkey to put its hand through. Then they will drill two smaller holes in the other end, pass a wire through, and secure the coconut to the base of a tree. Then they put a banana inside the coconut and hide. The monkey comes down, puts his hand in and takes hold of the banana. The hole is crafted so that the open hand can go in but the fist cannot get out. All the monkey has to do to be free is to let go of the banana. But it seems most monkeys don’t let go.

Often our minds get us caught in very much the same way in spite of all our intelligence. For this reason, cultivating the attitude of letting go, or non-attachment, is fundamental to the practice of mindfulness. When we start paying attention to our inner experiences, we rapidly discover that there are certain thoughts and feeling and situations that the mind seems to want to hold on to. If they are pleasant, we try to prolong these thoughts or feelings or situations, stretch them out, and conjure them up again and again.

Similarly there are many thoughts and feelings and experiences that we try to get rid or to prevent and protect ourselves from having because they are unpleasant and painful and frightening in one way or another.

In the meditation practice we intentionally put aside the tendency to elevate some aspects of our experience and to reject others. Instead we just let our experience be what it is and practice observing it from moment to moment. Letting go is a way of letting things be, of accepting things as they are. When we observe our own mind grasping and pushing away, we remind ourselves to let go of those impulses on purpose, just to see what will happen if we do. When we find ourselves judging our own experience, we let go of those judging thoughts. We recognize them and we just don’t pursue them any further. We let them be, and in doing so we let them go. Similarly when thoughts of the past or of the future come up, we let go of them. We just watch.

If we find it particularly difficult to let go of something because it has such a strong hold over our mind, we can direct our attention to what “holding on” feels like. Holding on is the opposite of letting go. We can become an expert on our own attachments, whatever they may be and their consequences in our lives, as well as how it feels in those moments when we finally do let go and what the consequences of that are. Being willing to look at the ways we hold on ultimately shows us a lot about the experience of its opposite. So whether we are “successful” at letting go or not, mindfulness continues to teach us if we are willing look.

Letting go is not such a foreign experience. We do it every night when we go to sleep. We lie down on a padded surface, with the lights out, in a quiet place, and we let go of our mind and body. If you can’t let go, you can’t go to sleep.

Most of us have experienced times when the mind would just not shut down when we got into bed. This is one of the first signs of elevated stress. At these times we may be unable to free ourselves from certain thoughts because our involvement in them is just too powerful. If we try to force ourselves to sleep, it just makes things worse. So if you can go to sleep, you are already an expert in letting go. Now you just need to practice applying this skill in waking situations as well.

COMMITMENT, SELF-DISCIPLINE, AND INTENTIONALITY

Purposefully cultivating the attitudes of non-judging, patience, trust, beginner’s mind, non-striving, acceptance, and letting go will greatly support and deepen your practice of the meditation techniques you will be encountering in the following chapters.

In addition to these attitudes, you will also need to bring a particular energy or motivation to your practice. Mindfulness doesn’t just come about by itself because you have decided that it is a good idea to be more aware of things. A strong commitment to working on yourself and enough self-discipline to persevere in the process are essential to developing a strong meditation practice and a high degree of mindfulness. We have already seen in Chapter 1 how important self-discipline and regular practice are to the work undertaken by the patients in the stress clinic. Self-discipline and regular practice are vital to developing the power of mindfulness.

In the stress clinic the basic ground rule is that everybody practices. Nobody goes along for the ride. We don’t let in any observers or spouses unless they are willing to practice the meditation just as the patients are doing, that is, forty-five minutes per day, six days per week. Doctors, medical students, therapists, nurses, and other health professionals who go though the stress clinic as part of an internship training program all have to agree to practice the meditation on the same schedule as the patients. Without this personal experience, it would not be possible for them really to understand what the patients are going though and how much of an effort it takes to work with the energies of one’s own mind and body.

The spirit of engaged commitment we ask of our patients during their eight weeks in the stress clinic is similar to that required in athletic training. The athlete who is training for a particular event doesn’t only practice when he or she feels like it, for instance, only when the weather is nice or there are other people to keep him or her company or there is enough time to fit it in. The

athlete trains regularly, every day, rain or shine, whether she feels good or not, whether the goal seems worth it or not on any particular day.

We encourage our patients to develop the same attitude. We tell them from the very start, “You don’t have to like it; you just have to do it. When the eight weeks are over, then you can tell us whether it was of any use or not. For now just keep practicing.”

Their own suffering and the possibility of being able to do something themselves to improve their health are usually motivation enough for the patients in the stress clinic to invest this degree of personal commitment, at least for the eight weeks we require it of them. For most it is a new experience to be in intensive training, to say nothing of working systematically in the domain of being. The discipline requires that they rearrange their lives to a certain extent around the training program. Taking the stress reduction program involves a major life-style change just to make the time every day to practice the formal meditation techniques for forty-five minutes at a stretch. This time does not appear magically in anyone’s life. You have to rearrange you schedule and your priorities and plan how you will free it up for practice. This is one of the ways in which taking the stress reduction program can increase the stress in a person’s life in the short run.

Those of us who teach in the clinic see meditation practice as an integral part of our own lives and of our own growth as people. So we are not asking our patients to do something that we don’t do on a regular basis ourselves. We know what we are asking of them because we do it too. We know the effort that it takes to make space in one’s life for meditation practice, and we know the value of living in this way. No one is ever considered for a staff position in the clinic unless he or she has had years of meditation training and has a strong daily meditation practice. The people referred to the stress clinic sense that what they are being asked to do is not something “remedial” but rather “advanced training” in mobilizing their deep inner resources for coping and for healing. Our own commitment to the practice conveys our belief that the journey we are inviting our patients to undertake is a true life adventure, one that we can pursue together. This feeling of being engaged in a common pursuit makes it a lot easier for everyone to keep up the discipline of the daily practice. Ultimately, however, we are asking even more than daily practice of our patients and of ourselves, for it is only by making the meditation a “way of being” that its power can be put to practical use.

To tap this power in your own life, we recommend that you set aside a particular block of time every day, or at least six days per week, for at least eight consecutive weeks to practice. Just making this amount of time every day for yourself will be a very positive life-style change. Our lives are so complex and our minds so busy and agitated most of the time that it is necessary, especially at the beginning, to protect and support your meditation practice by making a special time for it and, if possible, by making a special place in your home where you will feel particularly comfortable and “at home” while practicing.

This needs to be protected from interruptions and from other commitments so that you can just be yourself without having to do or respond to anything. This is not always possible, but it is helpful if you can manage to set things up in this way. One measure of your commitment is whether you can bring yourself to shut off your telephone for the time you will be practicing or to let someone else answer it and take messages. It is a great letting go in and of itself only to be home for yourself at those times, and great peace can follow from this alone.

Once you make the commitment to yourself to practice in this way, the self-discipline comes in carrying it out. Committing yourself to goals that are in your own self-interest is easy. But keeping to the path you have chosen when you run into obstacles and may not see “results” right away is the real measure of your commitment. This is where conscious intentionally comes in, the intention to practice whether you feel like it or not on a particular day, whether it is convenient or not, with the determination of an athlete.

Regular practice is not as hard as you might think once you make up your mind to do it and pick an appropriate time. Most people are inwardly disciplined already to an extent. Getting dinner on the table every night requires discipline. Getting up in the morning and going to work requires discipline. And taking time for yourself certainly does too. You are not going to be paid for it, and

chances are you will not be enrolled in a stress clinic in which you would know that everybody else is doing it and so feel some social pressure to keep up your end of things. You will have to do it for better reasons than those. Perhaps the ability to function more effectively under pressure or to be healthier and to feel better, or to be more relaxed and self-confident and happy will suffice. Ultimately you have to decide for yourself why you are making such a commitment.

Some people have resistance to the whole idea of taking time for themselves. The Puritan ethic has left a legacy of guilt when we do something for ourselves. Some people discover that they have a little voice inside that tells them that it is selfish or that they are undeserving of this kind of time and energy. Usually they recognize it as a message they were given very early on in their lives, “Live for others, not for yourself.” “Help others; don’t dwell on yourself.”

If you do feel undeserving of taking time for yourself, why no look at that as part of your mindfulness practice? Where do such feelings come from? What are the thoughts behind them? Can you observe them with acceptance? Are they accurate?

Even the degree to which you can really be of help to others, if that is what you believe is most important, depends directly on how balanced you are yourself. Taking time to “tune” your own instrument and restore your energy reserves can hardly be considered selfish. Intelligent would be a more apt description.

Happily once people start practicing mindfulness, most quickly get over the idea that it is “selfish” and “narcissistic” to take time for themselves as they see the difference that making some time to just be has on the quality of their lives and their self-esteem, as well as on their relationships.

We suggest that everyone find there own best time to practice. Mine is early in the morning. I like to get up an hour or so before I would otherwise and meditate and do yoga. I like the quiet of this time. It feels very good to be up and have nothing to do except to dwell in the present, being with things as they are, my mind open and aware. I know the phone won’t ring. I know the rest of my family is asleep, so the meditation is not taking time away from them. Most of the time my children stay asleep now, although for years the littlest one in the family always seemed to sense when there was awake energy in the house, no matter what time it was. There were periods when I had to push my meditation back as far as 4:00 A.M. to be sure to get some interrupted time. Sometimes now, the children meditate or do yoga with me. I don’t push it. It’s just something Daddy does, so it’s natural for them to know about it and to do it with me from time to time.

Practicing meditation and yoga in the early morning has a positive influence on the rest of the day for me. When I start off the day dwelling in stillness, being mindful, nourishing the domain of being, and cultivating calmness and concentration, I seem to be more mindful and relaxed the rest of the day and better able to recognize stress and handle it effectively. When I tune into my body and work it gently to stretch my joints and feel my muscles, my body feels more alive and vibrant that on the days I don’t do it. I also know what state my body is in that day and what I might want to watch out for, such as my low back or my neck if they are particularly stiff or painful that morning.

Some of our patients like to practice early in the morning, but a lot don’t or can’t. We leave it to each individual to experiment with times to practice and to choose the best one for his or her schedule. Practicing late at night is not recommended in the beginning, however, because it is very hard to keep up the alert attention required when you are tired.

In the first weeks of the stress reduction program, many people have trouble staying awake when they do the body scan (see Chapter 5), even when they do it in the daytime, because they get so relaxed. If I feel groggy when I wake up in the morning, I might splash cold water on my face until I know I am really away. I don’t want to meditate in a daze. I want to be alert. This may seem somewhat extreme, but really it is just knowing the value of being awake before trying to practice. It helps to remember that mindfulness is about being fully awake before trying to practice. It is not cultivated by relaxing to the point where unawareness and sleep take over. So we advocate doing anything necessary to wake up, even taking a cold showing that is what it takes.

Your meditation practice will only be as powerful as your motivation to dispel the fog of your own lack of awareness. When you are in this fog, it is hard to remember the importance of practicing mindfulness, and it is hard to locate your attitudinal bearings. Confusion, fatigue, depression, and anxiety are powerful mental states that can undermine your best intentions to practice regularly. You can easily get caught up and then stuck in them and not even know it.

That is when your commitment to practice is of greatest value. It keeps you engaged in the process. The momentum of regular practice helps to maintain a certain mental stability and resilience even as you go through states of turmoil, confusion, lack of clarity, and procrastination. These are some of the most fruitful times to practice, not to get right of your confusion or your feelings bust just to be conscious and accepting of them.

♦

Most people who come to the stress clinic, no matter what their medical problem is, tell us that they are really coming to attain peace of mind. This is an understandable goal, given their mental and physical pain. But to achieve peace of mind, people have to kindle a vision of what they really want for themselves and keep that vision alive in the face of inner and outer hardship, obstacles, and setbacks.

I used to think that meditation practice was so powerful in itself and so healing that as long as you did it at all, you would see growth and change. But time has taught me that some kind of personal vision is also necessary. Perhaps it could be a vision of what or who you might be if you were to let go of the fetters of your own mind and the limitations of your own body. This image or ideal will help carry you through the inevitable periods of low motivation and give continuity to your practice.

For some that vision might be one of vibrancy and health, for others it might be one of relaxations or kindness or peacefulness or harmony or wisdom. Your vision should be what is most important to you, what you believe is most fundamental to your ability to be your best self, to be at peace with yourself, to be whole.

The price of wholeness is nothing less than a total commitment to being whole and an unswerving belief in you capacity to embody it in any moment. C. G. Jung put it this way: “The attainment of wholeness requires one to stake one’s whole being. Nothing less will do; there can be no easier conditions, no substitutes, no compromises.”

With this background to help you to understand the spirit and the attitudes that are more helpful to cultivate in your meditation practice, we are now ready to explore the practice itself.

APPENDIX B

The Pre-Program Group Orientation Session Saki F. Santorelli, EdD, MA

The Pre-Program Group Orientation Session

Orientation sessions begin four weeks prior to the beginning of each teaching cycle (winter, spring, summer, and fall). Typically, we conduct two Orientation Sessions per week held at convenient times for prospective program participants (day and evening). Attendance at an Orientation Session is required for all incoming participants. These sessions are 2.5 hours in duration. During this time the Stress Reduction Program is described in detail and people are given the opportunity to speak about their lives and their reasons for considering participation in the program. Discussions are usually quite lively and informative. Instructors conducting these sessions have the opportunity to have individual exchanges with participants who either ask for or require more individual attention.

To better prepare participants for the Stress Reduction Program, prior to attendance at an Orientation Session all participants receive an informational packet describing the structure and key characteristics of the program of the program, financial costs and payment plans, and a brochure that describes the program and commitment required of participants.

Schedule of a Typical Orientation Session Time: 9:00-11:30 AM or 6:30 – 9:00 PM

6:30 p.m.           Participants begin arriving and staff members of the SRC greet people and direct them to

our meeting room. All participants are asked to complete a battery of pre-program assessment instruments.

7:00 p.m.           Instructor outlines the session format and creates a context by discussing the history and

central work of the Clinic, i.e. mindfulness, meditation, mind-body and integrative medicine, learning to take good care of yourself, developing your own internal resources, integrating mindfulness into everyday life, the critical role and value of clinical research.

This is usually followed by lots of questions and discussion and participants have an opportunity to speak about their intentions and reasons for considering taking the course.

After completing these phases of the Orientation Session, those attendees who decide to enroll in the Stress reduction program are asked to target and write down three self-set program goals.

8:00 p.m.           SRC instructors met with each enrollee individually; they review all pre-program

assessment forms and speak with each person about their interest and, if necessary, their appropriateness for the program. If follow-up calls are required, they are scheduled at this time.

8:15-9:00 p.m. Following these individual meetings, CFM administrative staff enroll people into the program, confirm class assignments, receive payment and arrange payment plans.

APPENDIX C

Individual Pre and Post-Program Interviews 1979-2000

From 1979-2000 orienting all program candidates to MBSR at the Stress Reduction Clinic occurred via individual pre-program intake/assessment interviews. Likewise, as a means of discussing, in-depth and individually, the participants’ experience of the program a post-program interview were utilized and recommended.

●         Pre-program interviews

Pre-program interviews are conducted in order to: 1) begin to understand the uniqueness and life-context of the program candidate, 2) explain the nature of MBSR to the candidate and the relevance in their life at present and, 3) ascertain the readiness and appropriateness of the candidate. (45-60 minutes)

●         Post-program interviews

Post-program interviews are conducted to: 1) give the participant the opportunity to review individually his/her experience of the program with their instructor, 2) fine tune the MBSR methods while developing short and long-range health goals, 3) make appropriate referrals to other health care professionals when necessary. (45­60 minutes)

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