A doctor puts his mind to mindfulness

A few summers ago during a week-long vacation, I started playing a mind game. In the mornings, I would sit outside on a comfortable deck chair, surrounded by the shrill call of cicadas, and gaze across the lawn into the trees. After getting settled, I would close my eyes and bring my body to complete stillness except for the rhythmic rise and fall of my chest with each breath.

Then I’d embark on what I think of as a journey with my thoughts: noticing them nonjudgmentally and letting them pass through my mind like white clouds moving across the blue sky. I was practicing the very popular relaxation technique known as mindfulness.

I wasn’t sure if this practice was helping me relax, making me healthy or just wasting my time. Some days I felt almost pleasantly lost, tension-free while sitting quietly for 20 minutes; at other times I struggled not to think about an upcoming meeting for my next writing assignment.

Experts define mindfulness as a state of moment-to-moment awareness that emphasizes attention without judgment, without thinking, for example, that the sound of the cicadas is irritating or that the lawn needs to be trimmed or “Why did I say that to so-and-so?”

Meditation practices vary, but the scientific literature presents three general categories: Focused attention is when you concentrate on a word, sound or activity (such as breathing or slowly repeating a mantra such as “om”); open monitoring is when you just observe your thoughts (mindfulness meditation); and self-transcendence is clearing your mind of thoughts (Transcendental Meditation).

Doctors, including me, haven’t universally embraced mindfulness and other forms of meditation as a therapy for our patients.

Studies have shown psychological and even some physical benefits. One 2015 meta-analysis of mindfulness-based interventions, which considered findings involving more than 8,500 participants, found that the interventions produced a decrease in depressive symptoms, anxiety and stress levels, as well as enhanced quality of life and physical functioning.

A small study in the Journal of the American Medical Association found that veterans with post-traumatic stress disorder who participated in an eight-week mindfulness course experienced a modest but significant decrease in symptoms compared with those given group talk therapy. And a 2012 study found that Transcendental Meditation practiced over five years in a group of African American men and women with cardiovascular disease resulted in nearly a 50 percent lower rate of heart attack, stroke and death compared with a control group.

Still, other studies have shown meditation to be little or no better at decreasing anxiety than, say, listening to music or relaxing on the couch.

Yet neuroscience studies on meditation are intriguing. During meditation, our brain waves are distinctly different from those during sleep or an awake state. One study found that long-term meditators had greater volume of gray matter in the insula and prefrontal cortices, regions of the brain activated during learning, memory processes and emotional regulation. Another found a decrease in the volume of the amygdala region, which is involved in processing the emotions of fear. Scientists say it is unclear what if any meaning these brain changes have in someone’s behavior or life.

Other studies have shown that meditation may diminish cell inflammation. Most captivating is a 2011 study that showed that intensive three-month meditation retreats increased the activity of telomerase, a protective enzyme that is linked to the aging process. If confirmed, this may mean that meditation could help slow the aging of cells.

Doctors in other countries have incorporated mindfulness in their guidelines. In the United Kingdom, for instance, the government’s National Institute for Health and Clinical Excellence recommends mindfulness for patients who have had three or more episodes of depression.

Given all this, why do I not regularly recommend mindfulness or other meditation to my patients, while I do advise them to exercise, eat right and take their medicines?

Maybe it’s that I fear some patients may see it as a fringe religious or spiritual practice and that my colleagues may see me as much too “touchy-feely” or lacking substance or scientific grounding.

Once while teaching medical students I talked about meditation and proposed we try it. “Close your eyes . . . clear your thoughts . . . focus on your breath . . . ,” I said. Of the 100 students, a half-dozen got up and walked out of the lecture hall.

Why? I wondered. “You were trying to get inside my head,” one medical student told me later. “I can’t sit still,” another one said.

Yet I have come to think that encouraging patients to adopt meditation as a way to mental well-being is as important as encouraging them to jog as a way to physical well-being. Half a century ago, only a small percentage of the population participated in aerobic exercises such as jogging regularly. A person jogging in the neighborhood often was viewed as downright weird. Today, the number doing aerobic exercise has increased to nearly 50 percent of adults, thanks in part to encouragement from government, corporations and health providers.

Some medical schools, including those at Harvard, Georgetown and Emory universities, have begun to integrate mindfulness and meditation into their curriculum. The Army has a course in mindfulness-based mind fitness training. Public schools in San Francisco are encouraging mindfulness under a program called Quiet Time.” Even the top doctor in the United States, Surgeon General Vivek Murthy, practices meditation daily.

Today, our lives are filled with stressors, from work, home, financial pressures and digital devices. Mindfulness is a low-cost, medication-free way to manage and reduce the ill effects of stress.

I have grown less shy in recommending meditation — along with exercise and nutrition — for physical and mental wellness to my patients. Last week I recommended mindfulness and meditation to two patients: one a middle-aged man with HIV and hypertension who is doing well on HIV meds but with hypertension out of control, and another elderly man with depression and insomnia. They both looked at me quizzically as if they were saying, “Really?” They had heard about meditation but never linked it to their illness or expected their doctor to recommend it.

So I didn’t oversell it — not everyone likes the feeling of sitting quietly with their eyes closed without judgment and observing the thoughts in their mind. I hope at least some of my patients will give it a try.

Meanwhile, I have taken my own advice. I am still at it: sitting on the deck, focusing on my breath, watching my thoughts, clearing my mind amid the shrill end-of-summer calls of the cicadas. I think I have noticed an effect — I feel a deeper sense of acceptance in my life, without losing a passion or resolve to change things for the better.

Meditation: A useful technique for achieving mindfulness

We sit in a conference room on red swivel chairs, quiet, motionless, eyes closed. We turn off our senses just like we turn down the house lights, switch off the television, and close the garage door at the end of the day. We become numb and detached from our bodies.

For the past eight weeks, I have been teaching a course on “Mindfulness” at the Meeman Center for Lifelong Learning at Rhodes College. Dr. Mark Muesse, a professor of philosophy at Rhodes and my co-instructor, tells the 18 adult students who are doctors, lawyers, professors and social workers, “We often live our lives in a state of mindlessness, constant generation of unnecessary thoughts and judgments which separate us from the present.” He adds, “We need to achieve a state of mindfulness, a state of moment-to-moment awareness.”

A student poses an obvious question: “How does one do this?”

“Through the techniques of meditation,” I explain. Practitioners have developed hundreds of types of meditation over millennia and across religious traditions. These practices can be lumped into three broad categories:

Focused attention: When we focus on an object or activity such as our breathing;

Open monitoring: When we observe our mind without any judgment;

Self transcendence: When we go into a state of no thoughts.

This is all too didactic and a bit mind-numbing, so we go on a test drive of a meditative experience.

We begin with a comfortable posture and gently close our eyes. We take deep breaths, focusing our attention on our breathing. Then, turning our attention to our mind, we observe and monitor our thoughts without judgment, as if we are sitting on a riverbank watching sailboats pass. Then we engross and transcend ourselves in the precious, almost blissful, moments of extreme serenity of the mind after the last thought is completed and before the next thought has generated.

At first it may seem hard, as our mind flips from one thing to another, but with just a few sessions, anyone can become comfortable.

“It is not hard to do,” I say, as I guide the class through the 10-minute meditative exercise.

Meditation is not an unnatural or a foreign practice; rather, it is a training.

Just as we are able to control our arm to throw a baseball or control our diaphragm to take three deep inhalations, so we can bring control to our mind.

But our mind is “smarter” than our arm or our diaphragm, so rather than forcing the mind to be still, the idea is first to observe it, and see how it moves, how it wavers, how it is ignited and elated, how it is dulled and depressed, and then not to pass judgment on it — in effect ignoring it.

In class, we talk about the benefits of meditation: health benefits such as longevity, lower blood pressure and a stronger immune system; academic benefits like better grades and test scores for school children; fewer effects of post-traumatic stress disorder among soldiers, and reduced rates of recidivism and violent crime among prisoners. Mindfulness is not a panacea to our troubled world, but it is a path to moving our individual selves thoughtfully, mindfully in the right direction.

In our class, we also play “mind games.” For three minutes, we sit quietly, eyes closed, with a pen in one hand and a notebook on our lap. We track and tally our thoughts by writing down a single word for each thought like an observer watching cars on a race course. The purpose is to watch and record our thoughts as they take us for a roller coaster ride, making us happy or sad, and how they link to one another like runners passing a baton. Anyone can try this exercise, and most often people come up with up with three to four thoughts per minute.

It’s funny how each day we take 30 minutes or more to get ready, by showering, dressing, putting on make-up, deodorant or fixing our hair — all this we do for our bodies, but what do we do each day for our minds? One student tells me, “After I meditate, I feel like I have just cleared my mind of clutter.” Another says it feels like “I have rebooted my mind.”

For me, a good meditation session feels like a natural high, like I have done a good physical workout. But this natural high is blissful, tranquil and serene.

Taking Responsibility for Our Thoughts

One of the first insights of vipassanā practice is the recognition that the mind has a mind of its own. When we finally begin to attend to the dynamics of our thinking pro­cesses, we realize that thoughts often seem to arise of their own accord, with little or no apparent prompting or direction. Where do these thoughts come from after all? It might seem that our thoughts are thoroughly be­yond our control, that we have no choice about the kinds of things that drift across our minds. Are we simply at the mercy of a mind out of control? For most of us, most of the time, the answer is yes. But the teachings of the Buddha tell us it need not be this way.

In the Vitakkasaṇṭhāna Sutta [Majjhima Nikāya 20], the Buddha concisely outlines a discipline for the more conscious management of our thinking. Even experienced practitio­ners of vipassanā who are schooled in the techniques of non-judgmental awareness may be surprised to learn of this teaching of the Buddha. For this discourse encourages the yogi who would attain “the higher mind” not merely to observe thoughts dispassionately but to exercise deliberate thought mainte­nance. By following the regimen outlined in the Vitakkasaṇṭhāna Sutta, we are able to in­fluence our thinking patterns and gradually cultivate minds that have a greater tendency to generate thoughts more appropriate to wisdom and liberation. It is not necessary for us to be buffeted about by our own minds.

Like all phenomena, the mind is a condi­tioned reality. Its existence is interdependent with other factors. Although thoughts may seem to come out of the blue, other mental and physical processes prepare for their aris­ing. Following karmic principle, wholesome thoughts create the propensity for more wholesome thoughts; unwholesome thoughts set the stage for unwholesome thoughts. In this sense, at least, we are responsible for what we think. While we may not be in conscious control of each and every thought, we can choose which thoughts to entertain and de­velop and which to disregard and release. Cultivating a discipline for the selection and fostering of thoughts increases our capacities to care for our thoughts with wisdom. The Vitakkasaṇṭhāna Sutta provides five very prac­tical techniques for such a discipline. In this sutta, the Buddha speaks specifically about one feature of the care for the mind: the re­laxation of unwholesome thoughts.

It requires skill to recognize unskillful thoughts.

Yet before we are able to relax unwhole­some thoughts, they must be recognized as such. One characteristic of the unskilled mind, of course, is its inability clearly to dis­tinguish between wholesome and unwhole­some thoughts. Just as the unskilled mind has difficulty even knowing when it is absorbed in thought, it finds it hard to know when a thought is edifying or corrosive—or even the importance of this distinction. An apocryphal anecdote from the life of Sigmund Freud puts this difficulty in an amusing light. Freud sup­posedly asked one his patients if she were ever troubled by lustful thoughts. “No,” she re­plied, “I rather enjoy them.”

In the Vitakkasaṇṭhāna Sutta, the Buddha identifies the qualities of an unwholesome thought and explains its problematic nature. An unwholesome thought is akusala, “unskill­ful.” Put simply, it is a thought that is not conducive to liberation but rather promotes suffering. Unwholesome thoughts may be recognized by certain telltale traits. Specifically, they are connected to desire, hatred, or delusion. Thoughts associated with desire are predicated on pleasant experiences and our voracious appetite for pleasure. Thoughts of hatred arise out of aversion and our desire to avoid unpleasant experiences. Deluded thoughts are thoughts that are at odds with reality and result from our failure to see our­selves and the world as they really are. It re­quires skill, of course, to recognize unskillful thoughts, and the development of this skill requires practice and vigilance. Given time and diligence, we begin to realize when our thoughts are associated with desire, aversion, and delusion. Once they have been recog­nized, they can be disempowered.

The Buddha’s five techniques for relaxing unwholesome thoughts proceeds in a step-by-step manner. He begins with the simplest and easiest procedure. In the event that technique fails, he advises a second step; if that does not work, he offers a third, then a fourth, and finally the fifth. These methods proceed from those requiring the least amount of psychic energy to that those requiring the most.

Bhikkhus, when a bhikkhu is pursuing the higher mind, from time to time he should give attention to five signs.

What are the five?

Here, when a bhikkhu is giving at­tention to some sign, and owing to that sign there arise in him evil unwholesome thoughts connected with desire, with hate, and with delusion, then he should…give attention to some other sign connected with what is wholesome.

…Just as a skilled carpenter or his apprentice might knock out, remove, and extract a course peg by means of a fine one, so too…when he gives attention to some other sign connected with what is wholesome, then any evil un­wholesome thoughts connected with desire, with hate, and with delusion are abandoned in him and subside. With the abandoning of them his mind be­comes steadied internally, quieted, brought to singleness, and concen­trated.

Replacement

Perhaps the easiest means for ridding ourselves of problematic thoughts, once they have been identified, is replace­ment. Just as woodworker might knock out a coarse peg with a fine one, says the Buddha, so should we supplant the unwholesome thought with a wholesome one. The most ef­fective approach is to match the unskillful thought with an appropriate skillful one. Thoughts of desire, then, can be substituted by thoughts of the impermanence of the ob­ject of desire. Thoughts of hatred are replaced with notions of friendliness and compassion. Deluded thoughts are overcome by an accep­tance of reality. Initially, the technique of re­placement may seem awkward and artificial. It may appear, as the metaphor suggests, rather wooden. With practice, however, it becomes habitual, thus needing only the slightest expenditure of mental energy.

If, while he is giving attention to some other sign connected with what is wholesome, there still arise in him evil unwholesome thoughts con­nected with desire, with hate, and with delusion, then he should exam­ine the danger in those thoughts thus: “These thoughts are unwholesome, they are reprehensible, they result in suffering.”

…Just as a man or a woman, young, youthful, and fond of orna­ments, would be horrified, humili­ated, and disgusted if the carcass of a snake or a dog or a human being were hung around his or her neck, so too…when he examines the dan­ger in those thoughts thus: “These thoughts are unwholesome, they are reprehensible, they result in suffering,” then any evil unwholesome thoughts connected with desire, with hate, and with delusion are aban­doned in him and subside. With the abandoning of them his mind be­comes steadied internally, quieted, brought to singleness, and concen­trated.

Reflection on Results

If, while he is examining the danger in those thoughts, there still arise in him evil unwholesome thoughts connected with desire, with hate, and with delu­sion, then he should try to forget those thoughts and should not give attention to them. If replacing unskillful thoughts with skillful thoughts proves unsuccessful, the Buddha recommends that we contemplate the consequences of the unwholesome thought. We might ponder the effects of holding this unwise notion. It helps me to consider the kind of person I become when I entertain and foster a particular unwholesome thought. If, as the first verse of the Dhammapada has it, mind shapes reality, that as we think so we become, then our thoughts have ineluctable consequences, not unlike the way high caloric foods have consequences for our physical health. Just as I might reflect on my clogged arteries as I contemplate eating a slice of cheesecake—as pleasurable as it might be—so I follow the trajectory of an unwhole­some thought. I envision where a diet of such thoughts might lead. Do I really want to be­come the kind of person whose life has been shaped by thoughts of greed and hatred? In the Vitakkasaṇṭhāna Sutta, the Buddha likens the yogi’s unwholesome thought to a snake or animal carcass around the neck of a well-dressed person. Such a thought is unbecom­ing to a wise and compassionate person.

If, while he is examining the danger in those thoughts, there still arise in him evil unwholesome thoughts connected with desire, with hate, and with delu­sion, then he should try to forget those thoughts and should not give attention to them.

…Just as a man with good eyes who did not want to see forms that had come within range of sight would either shut his eyes or look away, so too…when he tries to forget those thoughts and does not give attention to them, then any evil unwholesome thoughts connected with desire, with hate, and with delusion are abandoned in him and subside. With the abandoning of them his mind be­comes steadied internally, quieted, brought to singleness, and concen­trated.

Redirecting

If the previous techniques are unable to relax the troubling thought, the Bud­dha encourages redirecting attention away from the thought to something more whole­some. To clarify this technique, the Buddha uses the metaphor of averting one’s gaze to avoid seeing certain objects. This method, of course, is familiar to meditators. When the mind has been distracted by thought, we sim­ply return attention back to the breath. Once again, the practice of meditation strengthens our ability to employ this technique. Redi­recting attention relies on the fundamental impermanence of reality to achieve success. If we can simply divert attention to more wholesome objects, the distracting thought, given its impermanent nature, will dissolve of its own accord. All things that arise must fall.

That wonderful but almost extinct Chris­tian community, the Shakers, has an old ex­pression that nicely reflects the wisdom of re­directing attention. “Hands to work,” they say, “and hearts to God.” This Shaker admon­ishment recognizes the importance of con­tinually redirecting attention to wholesome activity and thoughts. The undisciplined at­tention becomes the workshop of the devil. Far better to keep one’s self diligently occu­pied with wholesome activity lest the straying mind comes to dwell in greed, aversion, and delusion.

If, while he is trying to forget those thoughts and is not giving attention to them, there still arise in him evil un­wholesome thoughts connected with desire, with hate, and with delusion, then he should give attention to stilling the thought-formation of those thoughts.

…Just as a man walking fast might consider: “Why am I walking fast? What if I walk slowly?” and he would walk slowly; then he might consider: “Why am I walking slowly? What if I stand?” and he would stand; then he might con­sider: “Why am I standing? What if I sit?” and he would sit; then he might consider: “Why am I sitting? What if I lie down?” and he would lie down. By doing so he would substitute for each grosser posture one that was subtler. So too…when he gives attention to stilling the thought-formation of those thoughts, then any evil unwholesome thoughts connected with desire, with hate, and with delusion are abandoned in him and subside. With the abandoning of them his mind becomes steadied internally, quieted, brought to singleness, and con­centrated.

Reconstructing

We might call the Buddha’s fourth technique reconstructing, which is analyzing the formation of the unskillful thought. In the second method, reflecting on results, we pursue the forward trajectory of such a thought. With reconstructing, we move in the other direction, examining the antecedents that have given rise to an un­wholesome notion in the first place. Since the mind is a conditioned phenomenon, these distracting thoughts are predicated on other thoughts. It is possible, then, carefully to ex­plore the roots of unskillful thinking. If I am having unkind thoughts toward another, for instance, I am often able to see that those thoughts emerge out of a feeling of envy. Pursuing this insight further, I notice that my envy derives from a sense of personal inadequacy, which in turn rests on the belief that this “I” is a substantial entity, separate from the rest of reality. By systematically recon­structing the formation of an unwholesome thought, one is able to return it to its antecedent causes to see how it is rooted in a false apprehension of reality. Such a process is of­ten effective in rendering the thought totally harmless.

If, while he is giving attention to stilling the thought-formation of those thoughts, there still arise in him evil un­wholesome thoughts connected with desire, with hate, and with delusion, then, with his teeth clenched and his tongue pressed against the roof of his mouth, he beats down, constrains, and crushes mind with mind.

…Just as a strong man might seize a weaker man by the head or shoul­ders and beat him down, constrain him, and crush him, so too…when, with his teeth clenched and his tongue pressed against the roof of his mouth, he beats down, constrains, and crushes mind with mind, then any evil unwholesome thoughts connected with desire, with hate, and with delusion are abandoned in him and subside. With the aban­doning of them his mind becomes steadied internally, quieted, brought to singleness, and concentrated.

Resistance

The most radical technique for removing distracting thoughts is re­sisting the “evil mind” by means of the “good mind.” As a final resort, the Buddha advises the yogi to clench her teeth and press her tongue against the roof of her mouth as she “beats down, constrains, and crushes mind with mind.” The Buddha compares this method to the way a stronger man might sub­due and control a weaker one, literally seizing him by the head and shoulders. This analogy seems uncharacteristically brutal for the Buddha’s teaching, and it might appear a rather inappropriate metaphor for “relaxing” thinking patterns. But the intensity of the analogy is instructive if taken in the proper spirit. Its radical nature is consistent with a similar saying of Jesus. In the Sermon on the Mount, Jesus admonishes his students: If your right eye causes you to sin, tear it out and throw it away; it is better for you to lose one of your members than for your whole body to be thrown into hell. And if your right hand causes you to sin, cut it off and throw it away (Matt. 5:29- 30a).

In these teachings, the Buddha and Jesus alike emphasize the seriousness of evil actions, whether those are the actions of the hand or eye or the actions of the mind. What may now seem small and insignificant over time determines who we become. The tyranny of unwholesome thoughts over our lives needs to be ended, even if we must finally resort to clenching our teeth and crushing the mind with mind. Our liberation depends upon it.

Thinking Responsibly

We may not be able to control particular thoughts, but we can influence the conditioned mind that gives rise to particular thoughts. We can prepare a fer­tile mental soil that increases the likelihood of germinating wholesome, skillful ideas and decreases the likelihood of growing distract­ing ones. But such mind must be tended with a watchful eye. A seasoned gardener once gave me this simple advice: “When you see a weed, pluck it.” In other words, it’s in the nature of weeds to grow fast and wild; don’t wait until the garden is overrun with un­wanted foliage before you try to remedy the situation. Unwholesome thoughts are the same. They grow fast and wild and leech vital nutrients from the thoughts that conduce to our liberation. We ignore them at our peril.