Clinical Handbook of Mindfulness (50 page)

tress temporarily. This behavioral approach can certainly be reinforcing, and

thus can become quite habitual, automatic, and rigid. However, attempts to

avoid the inner experience of fear, anxiety, and panic not only fail to ame-

liorate the root cause of emotional upset, but also paradoxically exacerbate

the inner experience of suffering by reinforcing maladaptive (i.e., avoidant)

coping behaviors that permit an emotionally upsetting experience to recur

indefinitely outside of an appropriate context.

Knowing Without Identifying or Reacting

From the perspective of mindfulness, thoughts, emotions, physical sensa-

tions, and impulses that arise in association with one’s internal experience

of fear, anxiety or panic are merely events in the broad field of one’s present-

moment awareness
(Brantley
,
2003).
Mindfulness practice is believed to
Chapter 10 Mindfulness and Anxiety Disorders

177

improve effective self-regulation of anxiety-related cognition, emotion, sen-

sation and behavior, although the precise mechanisms are not yet clear

(Baer, 2003;
Bishop, 2002;
Garland, 2007; Kabat-Zinn, 1990;
Shapiro, Carlson, Astin, & Freedman,
2006; Shapiro, & Schwartz, 2000).

Central to the self-regulatory capacity of mindfulness is a fundamental shift

in one’s relationship with one’s inner life and the outer world. In essence,

mindfulness enables conscious awareness of inner life and physical sensa-

tions. This shift in awareness brought about by mindfulness has variably been

termed “reperceiving,” “decentering,” “detachment,” “metacognitive aware-

ness,” “bare attention,” and “clear seeing”
(Salzberg & Goldstein, 2001;
Segal et al.,
2002; Shapiro et al., 2006; Teasdale et al., 2002). Shapiro et al. (2006),

for instance, have described reperceiving as “rather than being immersed in

the drama of our personal narrative or life story, we are able to stand back

and simply witness it.”

The capacity for mindfulness – and its resultant perspective shift on the

inner life – is traditionally cultivated by regular meditation practice
(Hahn,

1976; Kabat-Zinn, 1990;
Salzberg & Goldstein, 2001;
Brantley, 2003).
Meditation can be understood as an intentional training of attention, embedded

with acceptance, and the resulting awareness and understanding that emerge

(Brantley, 2003).
As observed by
Goleman (1980),
“The first realization in

‘meditation’ is that the phenomena contemplated are distinct from the mind

contemplating them.”

Walsh and Shapiro
(2006)
have emphasized that meditation training typ-

ically differs from other self-regulatory strategies such as self-hypnosis,

visualization, and psychotherapy in that meditation primarily aims to train

attention and awareness, whereas other approaches primarily intend to

change mental contents (i.e., thoughts, images, beliefs, emotions) and mod-

ify behavior. Although mindfulness has been described as the “heart of Bud-

dhist meditation,” being mindful is considered an innate human capacity that

is universal, secular, and compatible with nearly every major world religion

(Kabat-Zinn, 2005).
Indeed, mindfulness and the ability to reperceive are conceptualized as part of a developmental process
(Shapiro et al., 2006).

From a meditation teacher’s perspective, practicing mindfulness may help

in the following way. As one pays attention on purpose to one’s actual direct

experience of anxiety, as opposed to being identified with what one
thinks

about anxiety, one gains significantly greater understanding and insight about

the experience of anxiety and about oneself in relation to one’s world

(Goldstein, 1976).
Such understanding and insight can provide a foundation for more skillful responses in the face of fear, anxiety and panic, including

equanimity rather than reactivity and wise self-regulation rather than aver-

sion. By virtue of the psychological and behavioral flexibility mindfulness

can afford in the present moment, one might be better able to consciously

choose actions that are effective in meeting one’s needs for safety, a sense of

security, and calm.

“How Are You Treating Anxiety?” Establishing Wise Relationship

Put simply, distress seems to increase as we stray further from the present

moment. As Mark Twain, a famous worrywart, once said, “There has

been much tragedy in my life; at least half of it actually happened.” The

178

Jeffrey Greeson, Jeffrey Brantley

consequences for psychological suffering are clear when we live in the

future. Moreover, reflexively and rigidly attempting to avoid one’s inner expe-

rience of fear, anxiety, and panic not only fails to address the problem, but

actually functions to exacerbate it and prolong suffering. But, what happens

when one deliberately takes a different relationship to one’s inner life experi-

ence? A more conscious and allowing relationship? Can such an act of inten-

tion, attention, and acceptance increase one’s awareness of the mind/body

connection, including implications for self-regulation, wise action, and opti-

mal health?

When one changes their relationship to their internal experience from that

of automatic judgment, rigid thinking, and disconnection to one of accep-

tance, openness, and intentional connection, an immediate impact occurs

in the circuits and feedback loops of mind and body. Because mindfulness

represents a completely different perspective than the prevailing Western

cultural norm of narrowly focused attention, avoidance of unpleasantness,

and behavioral reactivity contingent on environmental circumstances, it has

been described as an “orthogonal rotation” in consciousness
(Kabat-Zinn,

2005).

Many mindfulness teachers emphasize that practicing mindfulness is an

invitation to relate to life differently. In more practical terms, mindfulness

may be described as an intentional willingness to fully and completely engage

with one’s direct experience of living, on a moment-to-moment basis, with

whatever pleasant, unpleasant, or neutral events that arise. The central goal

of living mindfully is to open to the fullness and richness of each moment,

and not to add, subtract, or modify any part of one’s psychological or phys-

ical experience. At its core, mindfulness is intended to help one live a life

of deep meaning, value, direction, and purpose even when emotional or

physical pain is present
(Kabat-Zinn, 2003).
By awakening to the possibilities available in the present moment, one often becomes empowered to choose

a wise response in the face of an upsetting internal experience or external

event, as opposed to having an upsetting experience or event dictate how

one responds.

Scientific Evidence to Support Mindfulness as a Model Self-

Regulatory Mechanism

Mindfulness enables one to establish a radically different relationship to one’s

experience of internal sensations and outer events by cultivating present-

moment awareness based on an attitude of allowance and a behavioral orien-

tation based on wise responsivity rather than automatic reactivity. As shown

in Figure 10.1, mindfulness offers an alternative response to the reactive ele-

ments of fear and anxiety in the mind and body. By purposefully engaging

higher order mental functions, including attention, awareness, and attitudes

of kindness, curiosity and compassion, mindfulness may effectively activate

control over emotional reactions via cortical inhibition of the limbic system.

Mindfulness practice, therefore, not only offers a new way of seeing, a new

way of being, in relationship to one’s interior life and external world, but

also provides a possible means for effective self-regulation of the mind/body

connection
(Kabat-Zinn, 2005, 1994, 1990).

Chapter 10 Mindfulness and Anxiety Disorders

179

F

Prefrontal Cortex (attention, intention)

M

e

i

a

n

Limbic System (emotional processing)

r

d

f

f

u

u

Brain Stem/Spinal Cord (vital functions)

l

l

r

r

Sympathetic Nervous System (SNS)

e

e

a

s

c

Organs (heart, gut, glands, immune)

p

t

o

i

n

Somatic symptoms ( HR, BP, tension)

o

s

n

e

Behavior (fight-or-flight; freeze; poise)

Figure. 10.1.
An automatic reaction versus a mindful response to the inner expe-

rience of fear. In the case of a fearful reaction, higher-order thinking centers in the

prefrontal cortex are taken “offline” (dashed line on left) so that one’s mind/body

experience is dictated by activation of the subcortical limbic system. Unencumbered

by conscious thought, activation of fear circuitry in the limbic system stimulates sym-

pathetic nerves that originate in the brain stem, descend through the spinal cord,

and innervate internal organs to prepare the body for vigorous defensive behavior

(e.g., “fight-or-flight”; solid lines on left). In the case of anxiety disorders, one’s per-

ception of threat may be greatly magnified or completely imagined. In this context,

mindfulness, including paying attention on purpose to one’s internal experience in

the present moment, may activate prefrontal cortex areas to come “online” (solid line

on right), which in turn, can inhibit reactive emotional circuitry, fear-related physio-

logical arousal, and automatic behavior (dashed lines on right).

Considerable data support the rationale for a model of conscious, accept-

ing attention to unfolding mind/body experiences as a skillful self-regulatory

process. A brief review of several psychological and biological pathways

through which mindful attention, awareness, and attitudes may influence

brain and body functioning follows.

First, mindfulness practice may increase one’s ability to maintain a stable

focus of attention that is intentional and chosen, as opposed to automati-

cally driven or hijacked by emotional reactivity
(Jha, Krompinger, & Baime,

2007).
Consequently, one may be more likely to avoid maladaptive, uncon-

scious patterns of anxiety-producing thinking, including perseveration on

upset, unpleasantness, or discomfort. Many forms of perseverative cogni-

tion, including worry, anticipatory anxiety, and rumination are associated

with increased sympathetic arousal and dysregulated (persistently activated)

cardiovascular, neuroendocrine, metabolic, neuromuscular, and immune pro-

cesses
(Brosschot et al., 2006; Brosschot, Pieper, & Thayer, 2005;
Thayer

& Brosschot,
2005).
Notably, trait mindfulness has been associated with lower levels of worry, rumination, thought suppression, experiential avoidance, and stagnant deliberation
(Baer, Smith, Hopkins, Krietemeyer, & Toney,

2006a;
Feldman et al., 2007).
In addition, formal training in mindfulness meditation has produced significant reductions in the tendency to ruminate

and to problem-solve using an inflexible cognitive style (Feldman, Hayes,

180

Jeffrey Greeson, Jeffrey
Brantley

& Greeson,
2006;
Jain et al., 2007;
Ramel, Goldin, Carmona, & McQuaid,

2004).
Based on these shifts in attention, awareness, and cognitive processing, one might also expect mindfulness to correlate with decreased physio-

logical arousal and somatic symptom manifestation.

A second line of scientific inquiry for the self-regulatory capacity of mind-

fulness practice involves the investigation of autonomic nervous system reg-

ulation. Preliminary evidence for such regulation was recently demonstrated

by a study in which mindful body scan meditation produced greater parasym-

pathetic activation than progressive-muscle relaxation (Ditto, Eclache, &

Goldman,
2006).
In a different study, practice of a mindful body scan meditation immediately prior to a standardized psychosocial stress task was asso-

ciated with normal stress-related activation of the hypothalamic-pituitary-

adrenal (HPA) axis among medical students trained in mindfulness-based

stress reduction
(Greeson, Rosenzweig, Vogel, & Brainard, 2001).
In addition to possible attenuating effects on stress-related physiological activation,

mindfulness and meditation may also induce a relaxation response, charac-

terized by relaxed alertness, passive disregard for internal stimuli or external

events, and low-level physiological arousal
(Benson & Klipper, 1975).

A third line of scientific inquiry into the self-regulatory effects of mind-

fulness practice is the rapidly growing field of contemplative neuroscience.