Introduction
Overview
Learned Mindfulness: Physician Engagement and MD Wellness is achieving authentic integrity—mindfulness for an integrated life. This book proposes mindful awareness as the art of being in the “now”—living fully in the present. Mindfulness is a way of living requiring transformation to a new future, not merely change from an incomplete past. Mindfulness as a lifestyle promotes a mindset galvanized by meaning. Learning to live with complexity as the fabric of wholeness is Learned Mindfulness. With this, embracing nutrition, exercise, breathing, relationships, and fitness exceeds routine expectations. Learned Mindfulness as a construct and set of propositions becomes an attraction toward wellness.
Mindfulness shifts attention from competitiveness and focuses on stabilizing oneself. This realignment is a step toward relaxation in the workplace. This stepping back has downstream effects on relations with others. Sharpened receptivity to human feedback is a central theme in Learned Mindfulness. The emphasis is on a continuous awakening. Human psychological intimacy and never taking this ultimate value for granted are emphasized. Empathetic mindfulness contours itself this way.
These preliminary definitions reflect Learned Mindfulness more as a perspective, a mindset with a major utility. First, it proposes a burgeoning set of propositions resembling a construct, hypothesis, even a manifesto of aspirations. Not new, these ideas anchor themselves in a rich history of world traditions. Second, Learned Mindfulness in its nascent entirety is a clinical tool both useful for the physician and for the physician to integrate into medical care. Such an integration needs specification depending on the subspecialties involved. However, the outstanding determinant of therapeutically mindful approaches entails communication hallmarked by empathy, astute perspective-taking, transparency, and iterative actions toward increasingly better outcomes.
The essential intention is awakening a hitherto sleeping realization: we are already where we are supposed to be—but unaware of its fullness. Written from a clinical perspective, Learned Mindfulness focuses on the individual. However, findings from modern science and evidence it works support this clinical emphasis. Thus, clinical utility arises. Targeted self-improvement occurs, and this precedes leading by example. Thus, a public contribution can result. This intention is central to the essence of mindfulness. Realizing this inflection from thought to act shines a light on meaning, purpose, and satisfaction. Mindfulness changes the caliber of the mind's habitual discourse. Nourishing one's inner life empowers choice. Not only is this clinical tool suitable for those seeking the betterment of already established health but also for those eager for new adventures toward improvement on current distress or distress in the making, e.g., potential burnout. One better selects the options about a lifestyle, diet, exercise, and, notably, relationships. Breaking old habits—mindsets leading to harmful behaviors, anxiety, and stress—becomes a learned skill.
Learned Mindfulness is the author's emotional intelligence (EI) and integrity version of mindfulness as a state of evolving awareness, orientation, and practice. Among the qualities, comprising an excellent physician's abilities is EI (Libbrecht, Lievens, Carette, & Cote, 2013; Shahid, Stirling, & Adams, 2016). Intrinsic to this is stable mood regulation—emotional equanimity and mental equipoise. The foundational knowledge offered here provides a roadmap integrating equanimity and equipoise into “the stuff of everyday life.”
Primary care doctors seeing many patients every day might welcome a one-volume text encapsulating the principles of mindful well-being. This book offers access, an approach to a formidable journey, millennia-rich wisdom now sorely needed. Primary care doctors are the first to test signs and symptoms, manage the prevention, and follow-up of chronic disease. Being mindful is a premium both personally and professionally.
Learned Mindfulness and EI bring clear awareness and authentic integrity to one's life. Authentic integrity is the consistent integration of emotion with thought resulting in integral, less divided mental functioning. This
assimilation brings greater awareness to previously unrecognized inclinations, aspirations, attitudes, and less mindful behaviors.
Learning is an uncovering, an awakening of dormant potentials. Central to these is learning to pay attention. Goals of mindfulness are expansions of awareness and acceptance of present experiencing. By-products include the benefits emerging from these psychological reconfigurations: attentional regulation, sensory clarity, emotional equanimity, and overall mental equipoise.
Personal mindfulness is the physician's in-depth knowledge of the causes and consequences of emotional thriving and resilience. These capacities counter cynicism, shutdown, and the challenge of burnout. Anxiety accompanies these feelings, increases stress, and elicits tendencies to deny the anxiety and make it go away. Instead of avoidance, mindfulness urges a gentle embrace and a curious exploration. Having this awareness—mindfulness as knowing, just here and now—helps minimize anxiety, conflict, and confusion. Erecting self-defense mechanisms against anxiety provoked by unresolved stressors subsides. Healthy habits replace broken, stress-provoking behaviors. There are recognized contributors to burnout. They include regulatory burdens, documentation requirements, compassion fatigue, obstacles to efficient communication, perceived lack of autonomy, inefficient workflows, and competing career priorities.
Compassion is concern for the suffering of others and the desire to help. Compassion fatigue is secondary traumatic stress and vicarious trauma lessening compassion to those in need. This diminishment of empathetic responsivity is common among nurses, mental health clinicians, and emergency workers treating trauma patients. Instead of their earlier sense of conscientiousness and wish to excel, those so dispirited experience hopelessness, demoralization, increased stress, and have disturbed sleep. Those with compassion fatigue continue to struggle with empathetic engagement. Those with burnout are prone to give up and withdraw. Integrity diminishes into despair. While differentiated from physician burnout, similar interventions focus on renewed self-care, community, and social supports.
Might it be hyperbole to suggest mindfulness is antithetical to a dystopian lifestyle with cynical and foreboding perspectives? Burnout is a tragedy affecting physicians and others in the workplace. Physician burnout leads to disengagement and eventual attrition because it creates distressing feelings that they are replaceable cogs in a business rather than meaningful human beings. This radical diminishment of autonomy erases purpose, meaning, and inspiration. It challenges a doctor's sense of intrinsic worth and expertise. Mindfulness is among the known interventions increasing purpose, meaning, and inspiration.
This book has a tapered focus, mindfulness, and integrated wellness for physicians—personally and professionally. Physician burnout makes this a timely consideration. However, what must neither be overlooked nor diminished is burnout across the entire healthcare community. Burnout is a human response to stress, allostatic load, avalanching technological complexities, and the escalating challenges of the last decades. Many individuals experience exhaustion, cynicism, and being overwhelmed in the workplace. This set of individually felt burnout wear and tear symptoms also affects the workforce. In speaking about physicians, their role in enhancing or diminishing the self-esteem and effectiveness of others needs consideration. Members of the healthcare team interact and influence one another and the entire system. When physicians are engaged and resilient, their influence on the collaborative enterprise is an asset and resilience support. Although addressed to physicians, the themes of mindfulness, integrity, interpersonal cooperativeness, and organizational collaboration apply to everyone.
Physician burnout is the personal side of a system in distress. The healthcare organization to advance technologically and become efficient may have lost the human side of its mission. Caregivers on the front lines of this industry-wide transformation are feeling dehumanized. While dehumanization and depersonalization pervade the system and the physician, high-quality healthcare for the most vulnerable—patients—diminishes. Burnout and strong physician engagement have the same dual sources: the healthcare system and the physician. Both appear at odds and stalled. Multiple targeted strategies need to identify, acknowledge, and discuss each so, meeting patient needs ensues. Chapter 6 details these.
Respect experienced by physicians for the value of their contributions—both professional services and participation in the organizational initiatives—has significant empowering value. Organizational physician respect counters the sense of loss of control and dignity clinicians experience. Feeling unsupported and not respected for who they are and what they contribute leads to physician burnout. Showing appropriate value and respect counteracts a sense of loss in self-value. It offsets a loss of autonomy and control in a physician's role.
Healthcare systems have a herculean task to change the current conversation between themselves and doctors. Physicians can also empower themselves as active
participants in that dialogue. The physician and healthcare system share common visions and missions. These include taking part mutually, equitably, and innovatively in transformed collegiality not seen before.
Learned Mindfulness is a new and reflective contribution to the actionable model of mindfulness. Its premise is achieving thought assimilated with full emotional resources. The shift in mode is from autopilot survival to engaged thriving. Anxiety festering at the center of burnout needs identification. Retraining to bring quality to a physician's work-life synchrony is required. These ideas are a foundation for integrating mindfulness, EI, work-life balance, and burnout prevention.
Learned Mindfulness
Learned Mindfulness is meeting yourself exactly where you are—a state of active, mindful alertness or mindfulness memory called sati in Sanskrit. This state contrasts with meditation, a practice toward attaining enduring mindful awareness. Being in “meditation” is nondirective inaction, a resting state of equipoise. Deep meditative states (i.e., dhyana, bhavana, and Samadhi in Sanskrit) are intermittent practices affording greater mindfulness (i.e., sati) between these intensive meditations. Chapters 1 and 2 elaborate these ideas.
The Learned Mindfulness introduced here lies in a basic framework of EI, its scaffolding. Emotion drives behavior. With authentically integrated thought and feeling, behaviors excel toward excellence. Mindfulness adapters take measured personal management in steering emotion toward active assimilation with thought. Effective decision-making results. Building on this cumulative achievement drives personal inspiration. Such courage helps a doctor to take intelligent risks from Learned Mindfulness tools resulting in manageable and successful outcomes.
Professionals and all concerned with stress reduction have an interest in novel approaches to mindfulness. In the current era of performance and achievement measured by external accomplishments, self-reflection and introspection as values have been obscured. The last decades have produced a virtual cottage industry of mindfulness programs. These have large-scale public appeal and promises of quick results—reduced stress and increased happiness. This perspective has never been part of the millennia-long history of mindfulness and its meditative practices. Mindfulness by serious meditative techniques has entailed well-structured programs for those earnest and intent on taking stock and working intelligently. The outcomes sought, though not by all, were “self-realization, “liberation,” “enlightenment,” and even “Buddhahood.” These were pursuits of a lifetime. Today, perspectives are different and goals less lofty. They include stress reduction, lowered anxiety, and equanimity. Mindfulness examines and changes older, ingrained cycles of negatively rewarding behaviors.
Learned Mindfulness is an “Integrity-based Mindfulness” model. Using this tool in clinical practice helps to improve emotional well-being and prevent emotional burnout. It thus broadens one's quality of life. This wellness perspective, if not only therapeutically preventive, is markedly relevant to all who care for patients, principally physicians.
Engagement is the opposite of burnout. Engagement is mindfulness of being aware and involved in the activities of daily living. The span is from the simplest to those needing greater focus, concentration, and skill. This book's ideas emerge from this base: a need for innovative perspectives on emotional well-being and robust tools aimed at upgrading one's quality of life. To accomplish this, Learned Mindfulness addresses well-being and self-care, the human side of medicine. The importance of balancing the social good with scientific progress and clinical excellence links these values together.
Entrainments to the natural cycle of emotion restore thought with quality reason. This synchronization of emotion and thought resets emotional processing through emotional modulation and regulation. Restoration is essential because perception is always incomplete. Perception's insufficient information base, if not enhanced, causes the anxiety of confusion leading to harmful behaviors and stress. Included here are the clinician's biases and even blind spots. Confusion takes shape as cognitive dissonance and emotional ambivalence. Thus, uncertainty predisposes to anxiety. The threat of error in decision-making becomes a risk. This vulnerability is a sensitive concern for physicians. As stress increases, it downgrades emotional and conceptual clarity and risks physiological impairments. These substantial limitations, significant and meaningful, mute the physician's effectiveness. Having perceptions improved by emotional lucidity makes thinking well-structured, focused, and purposefully directed. This even-mindedness enhances well-being.
The subjective side of well-being and wellness comprises psychological equipoise, a dynamic balance, often of antagonistic forces. This active moderation is a constructive and containing even-mindedness. Equipoise is the balance between extremes, a modulated equilibrium. This level-headedness supports refined emotional equanimity, mood stability. It yields a sense of quiet pleasure and lowered anxiety. It is calm,
tranquility, and peace of mind. Equanimity felt as composure is a platform for the mindful equipoise modulating impulsivity and reflexive reactivity toward extremes. Breaking the harmful loop of anxiety triggering poor choice and distress becomes available so that behavior change can occur. When change occurs and anxieties lessen, greater happiness, even joy, arises. Emotional equanimity and mindful equipoise are key performance indicators in work-life balance.
Learned Mindfulness is the emotional hygiene orientation in the Making Sense of Emotion model of EI (Ninivaggi, 2017). Understanding and practicing this restores the natural cycle launched by the inborn primacy of emotion—integration bridges the ambivalence of positive and negative emotionality. Integration also foresees normative contradictoriness in events not with avoidance but meeting these challenges with anticipatory enthusiasm for creative syntheses. For example, it shows itself in a greater synchronization of left (analytic) and right (esthetic/holistic) brain hemispheres (Luders, Clark, Narr, & Toga, 2011, Luders et al., 2012).
Thus, the mind's linearly harsh discourse, the “inner critic,” can mellow into more a poetry with meaning. The anchor in this mindfulness task entails the steps of EI. This intention promotes a significant sense of emotional knowing with wholeness and integrity. Learned Mindfulness enhances the self-observing potential now dormant. Once set into motion, self-observation learns to notice, explore, identify the body's sensations, and see how they evolve into feelings. This focus is especially sensitive to anxiety signals as bodily sensations. This sequence entails noting self-criticism and minimizing it. It replaces judgments with noting and mindful exploration. This periodic exercise in mindful curiosity helps to empty the mind of burdensome bias. This unblocking process relaxes emotion and frees creative thinking. Underlying anxieties hinder grasping knowledge. Integrity revitalizes interest, enthusiasm, and intelligent seeing. Fresh engagement in everyday experience becomes a baseline mode of interacting. Thus, motivation as a sparked threshold moment invigorates thinking toward executive action in real life.
Psychological Mindedness is one's self-observing capacity. This ability is a primary goal of all psychotherapies. This self-reflection entails observing one's inner experience primarily and also appreciating that others have similar inner experiences. Introspective self-awareness includes the simultaneous examination and insight from understanding nuances and meanings among the relationships of feelings, thoughts, motives, intentions, and behaviors. Self-reflection as psychological mindedness entails using this reflective capacity across changing moods in differing contexts at different developmental stages from about age 4
years in childhood through adulthood.
Empathy is core to psychological mindedness. It rests on a platform of self-observation having two components: (1) the emotional and affective comprehension of the inner experiences of another and (2) cognitive perspective-taking or theory of mind focusing on epistemic states of others such as their beliefs, intentions, and values.
Mindful Mindedness, introduced here, may be one step beyond psychological mindedness because it integrates in-depth self-observation with empathy and heightened perspective-taking in each experiential moment of paying attention. Learned Mindfulness builds the capacity for Mindful Mindedness.
Mindfulness is awareness of the embodied (i.e., participating in bodily experience) knowledge of one's experiencing at that moment. “Moment” emphasizes the immediacy of real-time, current experiencing—an in vivo occurrence alone or with another. While awareness can mean awareness of self or an object or both, Learned Mindfulness refers to the gentle blending of both.
Spontaneous “I am awareness” rather than a goal orientation or controlling (i.e., effortful) regulation is the meaning of “I am” awareness filling the mind in this dynamic model. This awareness is an intention toward a process, not an outcome. Here, using novel phraseology captures the dynamic sense of being in authentic mindfulness. Chapter 4 discusses this state of alert awareness to mean “I am aware of engaging in the immediacy of now.” For example, one does not issue a personal command: “I must now control my breathing” rather an inner poetry arises: “I am breathing.” This mindfulness generates itself more by design with implicit intention—effortlessly. Purposefully inducing this mental frame creates an active, paused space—neutral, tranquil, yet dynamically complete. It includes engaging bodily sensation, breath, perception, emotion, and spontaneity.
Learned Mindfulness makes relaxation a remembered skill, something like a procedural memory. In states of active relaxation, mental processing opens itself to a more transparent awareness of emotion engaged with thought—burgeoning insights in personal evolution. Inherent intuitive, effortless abilities in self-understanding unleash themselves. Learned Mindfulness subtly educates one to the human core of hidden inwardness. This inspiration innovates purpose, meaning, and vision of one's values. As an unbroken
condition, a human birthright, it aims toward emerging from a zero point of merely surviving. Reaching the potential ability of wholeness—authentic integrity—is central to this theme.
Learned Mindfulness is best viewed not as mindfulness meditation but as an educational and clinical tool. This approach encapsulates an orientation toward mindful attitudes, neither meditation nor a structured technique. Mindfulness-based contemplation exercises comprise a method for thoughtfully pondering something for a short or longer time, examining, observing, surveying, and studying it with gentle exploration. This absorption requires deep reflective and self-reflective focus. It is experiencing things with an alert, conscious attention, not rote, mechanical, and nonconscious review. This practicing pause tool as a daily exercise may take seconds, minutes, or longer. After this intensified “practice,” shifting one's mode of attention to mindful everyday awareness complements the mindfulness enhancement process. This mindful engagement cultivates curiosity and sustainable interest. Retrospectively, critical thinking can see current attitudes and behaviors and make improved choices. Both nonconscious changing (self-modulation) and effortful direction (self-regulation) then coalesce to change behavior.
Learned Mindfulness is neither a straightforward solution nor meant to evoke unrealistic expectations for instant results. This program is part of an integrated health-promoting lifestyle. The ideas and methods introduced as “mindfulness” are distinct from ordinary, everyday thinking involving critical analysis and executive functions in novel situations. Chapters 2–4 clarify these distinctions.
Critical thinking is the normal mode of daily focused thought. It regulates decision-making and guides behavior. Executive functions such as highly concentrated attention, working memory, and the sequence of planning, problem-solving, and refining goals occupies most of a physician's waking hours besides family, social, leisure, and recreation. Not confusing discussions about thought processes and reconfigurations during mindfulness practices with those of critical thinking is necessary. Neither should mindfulness in isolation substitute for nor replace executive functions so essential in scientific pursuits. Mindfulness developed as an asset supports the effectiveness of critical thinking.
Learned Mindfulness makes clear the inner workings of this mindfulness model and uses its historical origins to explain its current appearance. This expanded link between the past and the present has been missing from mindfulness literature easily accessible to physicians.
While ahead of hard science now, these plausible invitations for exploration may be useful to integrate personally and in the clinical work of biopsychosocial care. Clinical theory and its application are difficult to separate from confounding biases where variables distort an exposure and outcome. With this squarely in mind, innovative ideas are options inspiring “speculations sparking thinking one galaxy over.” This leap may be a needed jumpstart launching the mindfulness journey. The elasticity of thought, not fixedness, is essential mindfulness.
A variety of well-established and validated mindfulness practices, techniques, and “mindfulness meditation” protocols are available and accessible. Systems of thought, models, and perspectives are best when rationally flexible and creatively porous. Learned Mindfulness, while a mindfulness perspective, overlaps and is honored to share with other valuable mindfulness and meditative endeavors. Practical tools complementary to Learned Mindfulness are already available. The Learned Mindfulness introduced here is new. Its intention has an “idiographic” and “population thinking” perspective—the individual within the group. Although united in our human psychology of universally shared themes, taking into consideration the variations, needs, and preferences of the individuals forming those groups are essential.
Learned Mindfulness, therefore, deemphasizes rigid guidelines. Instead, it can be taken, as needed, by each physician, to fill in self-identified gaps requiring mindful awareness, if not expansion. Many physicians have not taken or cannot take formal training. This concise volume can act as a personal coach. This portable coach becomes an inner voice and personal guide accessible “in-the-moment.” Thus, Learned Mindfulness is more of a mindful orientation as one moves through daily life rather than a structured practice.
A leading exercise is an informal practice called practicing pause. The technique entails times during the day where one stops routine activities for a few seconds, shifts attention to being in whatever moment of experience is at hand, noticing it, briefly labeling it, then moving attention onward. A few deep breaths complete this informal direct engagement. Just reading this is becoming familiar with it, the first steps of learning (see Section 4.5). Substantive change occurs through repeatedly applied learning by practice—here, using the tool of practicing pause.
The Quadruple Aim: Improving Physician's Quality of Life
Excellence in healthcare presumes a physician who is intelligent both in the clinical skills needed for patient care and as an emotionally competent person. In the last years, the Institute for Healthcare Improvement in Boston developed a framework of improvement describing an approach to optimizing health system performance focused on the patient. New designs pursue three dimensions called the “Triple Aim.” However, advances in medicine have expanded “The Triple Aim” to become “The Quadruple Aim” (Bodenheimer and Sinsky, 2014). With an overarching target of optimizing healthcare performance, the three aims have become four: (1) enhancing a patient's experience with high-quality care, safety, and satisfaction, (2) improving population health, and (3) reducing costs. Now added is a fourth aim: the goal of improving the work-life of healthcare providers, clinicians, and staff. Work-life balance enhances resilience to deepen safely and excellently. Physician burnout has added depth to this set of aims and the development of broader interventions. Mindfulness reflects emotional competence and work-life satisfaction.
This book, a theoretical exposition, is a clinical contribution of ideas. Here, the fourth aim—physician work-life balance—is central. Discussed is the need for an integrated, systematic clinical approach to planning research questions in the nascent development of mindfulness-based programs. Sections on empathy, perspective-taking, EI, integrity, and mindfulness are discussed. These provide a lexicon and framework with which to weave an integrated understanding and working knowledge of mindfulness. This contribution, more of a theoretical foundation than an evidenced-based protocol, makes mindfulness attractive, attainable, and accessible. Introducing novel terminology at selected junctures has been necessary to convey the relevant meaning of the material, which can be elusive because it deals with clearing the mind of “inattentional” clutter.
Learned Mindfulness written by a psychiatrist for physicians respects the intellectual demeanor and expectation of physicians without adding the salubrious niceties of New Age shibboleths. Instead, a contemporary EI model innovates a fresh, current, and evidence-informed platform for mindfulness as an intelligent lifestyle. The Learned Mindfulness perspective is the first approach by a physician—a meditator for five decades—written for physicians to lay bare the roots of a popular endeavor. While it may be deeper than most cursory and formulaic approaches available, its range is a sourcebook in one volume. Portions may be read in isolation; others require extended reflection. Thus, avoiding simplicity and targeting specificity makes the material direct and valuable. Mindfulness awareness and its integration by physicians thus enriches medicine's Quadruple Aim.
A key to this book's perspective is its clinical orientation. It bridges the history with the here-and-now realities of what mindfulness demands physicians attend and master. This empirical, experience-near approach means an overview of mindfulness for oneself and with patients. Thus, this contribution summarizes theory and is an orienting tool for use. It is not a research-oriented or studies-driven and extensively cited text. An abundance of journal papers is available for this purpose.
Learned Mindfulness is synonymous with the phrase “Integrity Mindfulness.” Integrity mindfulness orients one toward paying attention to one's experiencing intentionally free of polarized mind cluttering judgments. Judgmental thinking constricts the range of creative thought. Such a program of integrity supports authentic living by holistic awareness, transparency, personal honesty, and directedness in everyday life. Integrity supports consistent mental equipoise.
Authenticity is grounded in emotional genuineness and psychological depth. Implied in such integrity is an ethic toward error-free decision-making reliably enduring. Integrity supports increased performance and value creation. Physicians and those engaged in clinical care may profit from this psychological upgrade called mindfulness. Learned Mindfulness affords one the clinical orientation to function above baseline minimums toward optimums.
Value-based Mindfulness
Value-based mindfulness reflects the positive return of investing in mindfulness. This profitability bases itself on and measures the outcomes of how mindfulness shows up as a positive reward in one's life. Mindfulness is alert awareness, increased self-awareness, pause, and less erratic mental fluctuations. This psychological stability means less anxiety, worry and ruminations, ambivalence, and greater intentionality and decisiveness. Mindful equipoise as emotional–cognitive even-mindedness and equanimity as emotional composure result.
Value-based integrity arises with becoming more transparent, honest, and developing the ability for comprehensive task engagement. Mindful attention chooses one task and avoids multitasking traps. Value
-based transparency means sober acceptance of one's less than perfect traits and abilities. Appreciating the beauty and potential to improve self-identified “flaws” bolsters self-esteem and effort.
These intensifications in mindfulness and integrity bring about greater self-leadership. These strengths build an increasing self-activism. Helplessness and passivity transform to uncover judicious self-efficacy. Value-based self-leadership is the return from investing in leadership measured by high-reliable results from personal accountability in all spheres of life. A genuine sense of self-leadership encompasses the attributes: self-awareness, self-reflection, perspective-taking, ongoing self-reexamination, open sharing of aspirations and innovative ideas, fair-mindedness, and an ethical foundation of values and behaviors. Chapter 6 discusses value-based mindfulness as the personal side of professional value-based medicine. Core mindfulness is a platform on which physician engagement grows, unfolds, and develops.
Physician engagement of value is the doctor's emotional commitment and active participation in the entire team of operations taking place in the hospital and collaborative community of care. Engaged physicians commit to the organization's mission, vision, and values. Collaborated care delivery demands shared responsibilities between the individual physician and the aligned organization in forming and implementing value-building strategies. On the broadest levels, engagement transcends the physician to include the system and patients, all of whom engage with the resources available and even strive to create needed resources to optimize healthcare in its entirety.
The Relevance of This Book
An integrated perspective on mindfulness in all areas of one's life is not only interesting but now lacking. This fresh, innovative work aims to offer a small yet significant contribution to an understanding of our relationship with mindfulness. Mindfulness for physicians has often been relegated to increasing attentiveness or taking “time out” for relaxation or gentle meditation. The robust roots of in-depth and complexly detailed meditative practices, derived from Eastern cultures, has been simplified or entirely extracted perhaps to make it more palatable to Western tastes. Without an intelligent understanding of the backbone of mindfulness axioms and practices, its developmental history, much value has been lost in current translations.
The evolving approach used here arises from the author's intensive training at the Yale Child Study Center. Understanding the person meant digging deep into the longitudinal course of infancy, childhood, and adolescence. This genetic and developmental perspective not only considers the growth, unfolding, and interactional development of the individual but accounts for this within the family and social culture influencing its course. Now, working with other Yale doctors on the “Physician's Engagement and Burnout Prevention Committees” has sharpened a focus on doctors' work-life balance. Programs, protocols, and clinical redesign optimizing professional fulfillment and high-quality patient care are ongoing initiatives.
This book aims to remedy earlier gaps in the field by supplying additional propositions scaffolding Eastern systems of meditation. Eastern ideas are explained in terms Western-trained physicians can comprehend. Chapter 1 lays bare the mechanisms detailing those practical steps used to achieve mindful states. Trying to demystify Eastern concepts while not denuding them of their cultural meaning puts Buddhism and Yoga on straightforward yet respectful footings. Chapter 3 puts mindfulness in the light of contemporary EI. This innovation may be an unprecedented effort to join these hitherto distinct areas in a fresh, integrated perspective.
Because mindfulness has the mind as its observation, an intensive exploration of a significant sector of mind—emotions and emotional processing—is sorely needed. This demand requires the astute physician to have a working knowledge of emotions, feelings, and their processing from the behavioral perspectives to their neuroscience. Much of medical training steeps itself in technical skill building and diagnostic precision. Attention to one's emotional life is often eclipsed, even though it is the heart and soul of both physician and patient. This book discusses these needs in ways physicians trained in the sciences, including the behavioral and psychosocial, can appreciate. The way basic emotions directly interface with critical constructs in all mindfulness models from ancient to those today is made transparent.
With a millennia-old history in spiritual traditions, principally those of the East and now linked to the West, Chapter 2 describes how mindfulness today often takes shape as meditation or meditative practice. Learned Mindfulness has dug deep into the archeology of mindfulness and examined its origins, practices, and raison d'être. While deriving an inestimable wealth of information and insight from this exploration, Learned Mindfulness offers a Western model using an EI template as its scaffolding.
With origins as a spiritual practice for millennia, Learned Mindfulness as a modern innovation broadens
applicability to more pointedly psychological concerns. Thus, Learned Mindfulness as integrity mindfulness has central utility for personal development, increased self-awareness, and applicability as a clinical tool. Learning about mindfulness brings one in the authentic integrity zone. This ability uses the transparency of integral awareness of sensation, feeling, and thought consciously, consistently, and pragmatically. Emotions become more transparent and accessible. What in the East is self-realization can be translated into Western terms to signify integrated self-understanding, self-identified transparency, and holistic self-integrity.
Therefore, the relevance of this contribution includes not only introducing an innovation in modern mindfulness called Learned Mindfulness but also an applied discussion of mindfulness for physicians in healthcare systems. Chapter 6 expands physician wellness themes, the challenges of MD burnout, enhancing fuller engagement, upgrading organizational sensitivity to physician needs, and mindful equipoise as a lifestyle of engaged wellness. Equipoise is the balance between extremes, a modulated equilibrium. Anxiety quells. When emotional stability suffuses this refined equanimity, even-minded equipoise results.
Mindfulness: Its Home in the East
Mindful awareness and being alert are intrinsic to human survival. Mindfulness is new to our culture. Being alert and aware—a “second to second” situational awareness—must have been part of basic survival, exploration, and managing life on Earth. Today, mindfulness is a distillation of ancient practices toward self-development of awareness, understanding, and wisdom expansion: “enlightenment.” Its practical applicability now is similar but updated with contemporary terminology: shining a light on challenges and creating innovative strategies to manage stress reduction permitting relaxation in a busy world of technology and its demands.
Chapter 1 summarizes Eastern and Western ideas about the mind. A primer of contemporary psychology and psychiatry sets the context for understanding mind and mindfulness. Terms the East has used for thousands of years outline similar perspectives. Eastern perspectives emphasizing mind and the psychology of mind instead of pointedly religious themes comprise Yoga and Buddhist mindfulness. This psychological emphasis is most relevant to modern mindfulness discussed in this book. To be sure, the primer on Eastern thought merely brushes, sometimes oversimply, the complexities only in-depth studies over many years can even approach. Many Eastern terms remain in the original. Standard translations try to convey meanings although many of these are archaic and burdened with old biases.
An example is the term shunyata meaning emptiness. This notion is one of Buddhism's central presumptions about attaining successful mindful meditation. Left unexplained, the English word “emptiness” appears strange and off-putting. However, understanding it as a “clear mind” faithfully conveys its meaning, as explained in Chapter 1. Insights arise from seeing one's experiences as they are without judgments and preconceived ideas. Thus, context, East and West, and correlations help to make sense of primary ideas critical to both cultures.
Eastern psychological views are stunning for their contrasting approaches to theories of mind. The East used the vivid metaphors of its sages to convey mindfulness truths. Today, the West uses the lexicon and tools of science. Relaxation is key to implementing these ideas in a variety of mindfulness practices under the rubric of “meditation.” Thus, it may be safe to say modern mindfulness has its historical origins in Eastern meditative traditions.
How different are Buddhist, Yogic, and Western perspectives—at least those propositions derived from classical writings—about the experience and meaning of individual life and personhood. While most mindfulness-based programs allude to Eastern sources and Westernized translations, few to none make explicit the intriguing, often compelling, Hindu and Buddhist ideas behind these exercises. This book seeks to remedy this gap in the literature. It makes available more of the Hindu/Yoga foundations and Buddhist axioms from which mindfulness, as we know it today, have sprung. An open-airing examining these ideas is wise.
Mindfulness coupled with intelligent inquiry creates safe spaces to discuss issues often puzzling and perceived “illogical.” Knowledge is gained not by tolerating such perceived information as alien or enigmatic but by accommodating it. Making space for what may be innovative ideas and perspectives challenges but expands thinking. “Newcomers” to one's thinking later may become assimilated and integrated to enrich an earlier more constrained worldview.
The literature on mindfulness written by Western scholars openly and sometimes implicitly struggles with ideas of cultural appropriation, even recontextualizing mindfulness practices of their roots in those profoundly spiritual traditions (Dreyfus, 2011; Kirmayer, 2015; Sharf, 2015). While not endorsing any faith or belief system, an intelligent approach to mindfulness
perspectives is to understand them including their historical development. The competent physician must be sensitive to and respect the spiritual and faith traditions a subgroup of patients holds meaningful. This part of respecting presentations has clinical relevance as it influences adherence to any healthcare initiative. The “humanities” show how people comprehend and document the human experience using philosophy, literature, religion, art, music, history, and language to understand and record the world. Mindfulness respects and uses this base.
To clarify the vast field of mindfulness, conceptual distinctions are needed. A variety of fields discuss mindfulness while defining it in idiosyncratic ways. For example, religion addresses people's approach to faith, worship, and spiritual pursuits; philosophy discusses matters such as existence, knowledge, values, reason, mind, and language; psychology examines theories of mind such as emotions, thought, and behavior; and last, mysticism deals with the doctrines and practices of a direct and unmediated connection with the divine or ultimate source of reality. Each of these concerns has a mindful focus.
Most mindfulness practices today explicitly or implicitly allude to Buddhist religious tradition. This cultural undertone is understandable because both Buddhism and Hinduism as religions had and have meditation and mindfulness protocols integral to their practices. This religious base is mentioned for several reasons. This book offers a nonreligious perspective and calls it Learned Mindfulness. Learned Mindfulness is a psychological approach whose foundation is EI. Thus, Learned Mindfulness is mindful awareness whose premise is the human mind having inherent qualities that can be examined and understood in themselves. As mentioned earlier, this contribution is more of a manifesto of intentions, motives, and prescriptive notions founded on a clinical base of medical care. Learned Mindfulness is an orientation for carrying out changes to current perspectives on mindful living. This book builds a knowledge base. Actual practices and formulaic techniques need future development.
Another relevant consideration is the undergirding of current mindfulness practices rooted in Eastern traditions that are unfamiliar or may be unknown to Westerners. Since writing a textbook on Ayurveda: A Comprehensive Guide to Traditional Indian Medicine for the West (2010), the author is familiar with both Buddhist and Hindu medical and psychological concepts. Thus, their relevant parts will be discussed in understandable ways in terms correlating Eastern and Western ideas. This understanding acts as a backdrop to a more in-depth appreciation of mindfulness as it exists today. An intelligent understanding helps demystify what had been the perceived strangeness and now shows the universally human face of the East and their traditions.
Chapter 1 explains the traditional scaffolding from which modern mindfulness has emerged. To be clear, this is not intended to overemphasize Eastern views. Instead, it is a selective, historical review of the essentials leading to what has become mindfulness as a mindful lifestyle. Learned Mindfulness is not an isolated meditative technique. It is a psychological orientation reflecting basic human nature, most likely inherent in many cultural traditions. Therefore, Learned Mindfulness is more a clinical tool than a purely meditative exercise. Traditionally, establishing mindfulness required four components: mindfulness of body, emotions, mind, and the dhamma/dharma guidelines. Millennia ago, the fourth comprised the social and cultural doctrines needed for mindfulness success. This book gives physicians a new cultural fourth contemporary component: physical engagement and MD wellness as the context for mindfulness relevant to today's work-life balance.
Why Has Mindfulness Gained Popularity Now?
Mindfulness often takes the form of “mindfulness meditation.” Whether the context is religious, psychological, or relaxation technique, these practices aim toward stress reduction and more in-depth tranquility. These exercises clear and reboot the mind. They are restorative in affording the time to pause and relax. Many have termed this a “destressing” occasion.
Chapters 4 and 6 discuss burnout as a phenomenon of our current work climate. Physicians under stress suffer burnout (Shanafelt et al., 2015). The value proposition of this book is that Learned Mindfulness offers a timely, innovative, and focused approach targeting this emerging challenge. Burnout entails physical and emotional exhaustion, depersonalization, and having a sense of inadequate work accomplishment. An impending sense one's life as sputtering, on the verge of stalling, precedes the burnout syndrome. Generativity in productive work diminishes, and integrity fades into despair.
At least half, if not more, physicians suffer from burnout. Varieties of interventions both individually based and through the workplace improve burnout. Burnout unchecked contributes to medical error, high attrition rates, and physicians “moving on” hastily from current job positions. Therefore, exhaustion,
interpersonal disengagement, and a low sense of personal accomplishment negatively affect the physician, patient care, and the healthcare system. The financial damage and waste are inestimable (Schnapp et al., 2018; Shanafelt, Goh, & Sinsky, 2017).
Contemporary culture has invested faith in the net of technology and science hoping to elevate humanity's distress toward states of wellness. The electronic health records and “Big Data” platforms modern technology provides have become astonishing parts of the stress overload reported by physicians.
The contemporary infatuation with technology and its wonders has led to its becoming used as our “personal assistant.” Technology has launched an unprecedented merger between man and machine. Algorithms have become artificial brains automating choices and subtly eclipsing free will and mindful decision-making. There are differences between machine techno-generated options and decisions made by critical thinking, executive functions, and nonconscious indeterminate resources (e.g., nonconscious change leading to prudent intuition). Checks and balances and long-term impact on healthcare need monitoring. Artificial intelligence (AI) is not neutral.
AI and machine learning algorithms tend to rely on large quantities of data to be effective. This information needs people to analyze it—looking for trends and patterns and then making intelligent recommendations. The ethics of a decision, complex data, or one-off decision are beyond the present capabilities of AI. AI and machine learning are advantageous in refining clinical workflows and even physician training. Moreover, with the market growing the way it is, implementation is inevitable.
Now is the time for physicians to examine mindfully to what extent they will allow the machine-based medicine to be part of healthcare, at least as it now stands. To what extent is this automated reasoning a surrender of privacy or, at worst, dubious conformity to compliance with an algorithm-fed mechanical mind? Are we ready to reassess the role technology plays (with us) in our lives? These endure as intriguing questions. Lifestyle choice remains a leading option.
The Theme of Mindfulness in Medicine
Mindfulness is a perspective addressing physician health and wellness—as an optimal state of physical, mental, and social well-being, and not just the absence of burnout. Short of an exhaustive review, this one-authored, clinically oriented volume by a psychiatrist has value as an applicable tool. The role of subjective experience in clinical practice needs careful consideration. Subjective reports have limitations, but they have unique strengths because they are crucial indicators of people's immediate experiences (Ericcson, 1993; Garrison et al., 2013; Wilson, 1994). Self-reports are now becoming recognized as valid measures of key constructs of interest—those of the patient and the physician treater. Effectiveness is achieving clinically meaningful outcomes. Meaning is a potent change agent springing from several sources. How the whole patient defines meaning reflects what they say, feel, and nonverbally communicate, by how the physician understands the process of improvement occurs, and by measurement. Good to excellent medicine bases itself on solid clinical reasoning (During, Artino, Schuwirth, & van der Vleuten, 2013; Mercuri et al., 2015).
Healthcare enterprises with high-value care missions safe and minimizing the risk of patient harm must have at least three vital components: physician engagement, organizational alignment, and a patient's perception of quality care. A patient's participation is influenced by trust, comprehending what is at stake, informed consent, and engagement in the healing process. The patient's perception of care comes from physicians spending ample time in the diagnostic and treatment planning dialogue. While good practice, this rapport provides healthcare with the highest value to the patient who recognizes the mindful attentiveness of the caregiver.
Therefore, highlighted in this book are vital features of mindfulness, mindfulness meditation, and meditation. The relevant, millennia-long factors leading up to today's understanding and practices are introduced as clinically useful. For example, pain is a universal symptom of human distress; suffering is the emotional side. Surveys show 91% of primary care physicians say Traditional Chinese Medicine (TCM) is effective, mainly acupuncture to treat pain (Murphy, 2018; Vickers et al., 2018). Chinese medicine considers qi, the body's vital energy, flows along meridians or channels in the body, and keeps a person's spiritual, emotional, mental, and physical health in balance. TCM aims to restore the body's balance between the complementary forces of yin and yang, which can block qi and cause disease. The Centers for Disease Control states 38.3% of patients use Complementary and Alternative Medicine (NCCI, 2008).
In Ayurveda, the Traditional Medicine of India, prana correlates with qi. Prana and qi are subtle vital forces in food and air maintaining physiological and psychological processes. These forces are both taken into and made in the body by the principal component of all
foods: rasa. Rasa means “taste” containing all the bioenergetic principles regulating body, mind, and spirit. Rasa is also the term for the body's plasma. In the Ayurvedic medical literature, rasa links itself with focused, mindful grasping—an engagement with the tastes of food so they can internalize beneficially. This conscious savoring leads to their ability to flow through and nourish the body effortlessly.
Besides the balancing and restorative functions of prana, prana, in the form of a primary bioenergetic regulating factor termed Vata, is “lord of the mind,” “lord of the five senses,” and even “the sixth sense.” Prana's psychological home lives in Manas, which correlates with mental functioning; its physical site is the lungs. Prana's highest concentration is in the brain. Prana Vata denotes the directing and focusing of attention. Therefore, pranayama or breathing exercises have played a crucial role in ancient systems of meditation as breathing does now in Western practices.
Thus, Eastern perspectives on health assume subtle mental functioning to be integral to overall well-being. In the East, mindfulness and meditative practices address the mind. Today, the West as well recognizes the mind as integral to the entire human being. Psychiatry and psychology as specialized fields attest to this recognition. Current emphasis is stressing the health-enhancing facets these specialties can contribute. Attention to mindfulness is now a significant focus in medicine. It may be time for physicians to become comfortable with these approaches. Hence, the timeliness of this book.
The term “biomental” (Ninivaggi, 2013, p. 5) was coined to transcend the Cartesian dualism of body-mind separateness. Biomental efforts capture the authentic integrity of the person as a biopsychosocial organism in flux yet in ongoing integration:
I have coined the innovative phrase biomental child development, in which the word “biomental” indicates a specific child development perspective. This term refers to the integrity—nonduality and emergent integration—of the whole individual at all ages in processes that are both psychological and physical. It connotes simultaneity, a responsiveness of the total organism, and the dynamic relatedness among its aspects. In states of health, this relatedness reflects a synergy that promotes emerging dynamic integration. The construct and phenomenon of integration—apparently split-off parts understood to be aspects of a primary whole—is axiomatic in the biomental perspective, and remains a golden thread running throughout this text. p.5.
Eastern perspectives have always recognized the intimate links between body and mind and the energies pervading them. A health span that linked wellness to a coupling of body and mind runs through that literature. The term “biomental” also illustrates this. Formalizing these forces by the terms qi and prana makes tangible the intangible. Such paradoxical thought is a quintessential part of Eastern worldviews. Thus, in discussing mindfulness, Eastern conceptions center attention on subtle psychological processes, often using concepts scientifically foreign to Western thought. This contribution aims at helping to bridge this gap in understanding, at least as it adds to explaining the roots of modern mindfulness.
Systems Psychology of Mindfulness
Systems psychology is about putting together rather than taking apart, integration rather than reduction. Systems mindfulness is speculative modeling of complex psychological networks, namely the person. It is a psychology-based field of study focusing on complex interactions within mental systems, using a holistic approach instead of a reductionistic perspective. Reductionist methods aim to identify components and interactions but offer less understanding of how primary human system properties—meaning and purpose—emerge. The heterogeneity of causes and effects in biomental networks, notably the mental dimension, is better approached by considering multiple components simultaneously. This richness must include its origins and historical roots.
Using this “systems” and integrative approach has been one motivation for making exact the historical origins of modern mindfulness. Chapter 1 offers the reader the context from which mindfulness emerged. Without knowing this heritage, any examination of mindfulness standing today would be bare, desolate of its inner fabric. While not underestimating the evolution of millennia-rich ideas and changing needs, this book has gone to great lengths to uncover the archeology, the phylogeny of mindfulness in the 21st century.
Multiple features delineate every system: its spatial and temporal boundaries, influences from its environment (past and present), structural descriptions, purpose or nature, and its functioning. Regarding its effects, a system can be more than the sum of its parts if it expresses synergy or emergent behavior. Changing one part affects other parts and the whole system in meaningful ways, with predictable patterns emerging. For human systems who are self-learning and self-adapting, adaptive growth depends on how well the system adjusts itself (e.g., mindfully) to its environment. Creative transformation arises when in-depth mindfulness is learned. This engagement then empowers an unanticipated novelty—alert conscious awareness available at each waking moment. This mindfulness spurs
further gratifying advancement. One mindful part of the system can change the entire system.
The Centrality of “Control”: Biomental and Interpersonal Perspectives
The entire matter of control in an individual's life is complex but central to a sense of self, meaning, and mindfulness. Coercion as forcefully threatening persuasion is linked to manipulative control. How “control” is key to mindfulness has roots in infancy. Control involves the package of modulated impulses, reactivity, feelings, ideas, decisions, behaviors, and direct relationships with oneself and others. Control seeks to influence or direct in an excessively authoritative way. Control intends to achieve a change. In speaking of this form of “control,” other varieties of nonmanipulative, nonforced directedness such as managing, handling, and regulating are not included. For example, effortful regulation is willful and voluntary managing and changing to activate and constrain attention and behavior. Such effortful “control” is the nonmanipulative, sound management of mental and behavioral issues needing direction for effectiveness. Although intentional, it does not have the quality of being a forced situation. Healthy intentions ask for permission and seek informed cooperation. Issues related to control are always issues of dependent relations. Dependency, independence, interdependence, and the nuances of linked relationships are broad.
Control has biomental and developmental features. One is the maturational capacities of the brain and neuromuscular system; another is the infant's emotional desire to hold on to what it is grasping. The sense of agency is the belief in the ability to cause one's actions as the sole, responsible source. A first material expression of control as a burgeoning agent appears in the infant's developing capacities for grasping and letting go. While grasping occurs much earlier in life at about four to 8
months, letting go or releasing happens later at about seven to 10
months.
Psychological significance extends the meanings of control. Control may be a parallel phenomenon to wanting to maintain control over something precarious and not easily controllable and may be lost. Unreflectively feeling that one is an active “agent” may suggest unwarranted self-sufficient autonomy. Having a sense of power over one's actions being effective counters the natural helplessness of infancy and childhood. Warding off loss tempers the accompanying dissonance and anxiety and contributes to strengthening developing self-efficacy and confidence. The neural pathways becoming established remain contoured in mind, persist and express themselves in diverse ways throughout life. When the early controlling phenomenon develops appropriately, it forms the basis for waiting, pausing, expecting, and managing.
To a large extent, the ability for mentalization/perspective-taking comprises two factors: (1) empathetic understanding of another from their inner experience together with (2) mindful attentiveness to seeing oneself reflectively from the outside thus tempering one's raw control impulses. Evidence of this tempering appears at about four to 5
years old but has a long future for refined development. Reactivity to any event becomes modulated by subtle equipoise. Hope and optimism seed themselves.
In adulthood, the phenomenon of “loss aversion” is seen when one is more prone to gain and hold on than to let go of possessions, whether material or psychological. In all emotional life, an adhesiveness automatically sets up clinging between two objects. This attachment ranges from flexibly dissociable to rigidly adherent. All interpersonal relationships have a central theme of “psychological control.” When these emotionally charged urges of the impulsive need to change the ideas and behaviors of others remain flexible, mutually willing, and negotiable, relations are cooperative and agreeable. When this emotional control becomes stultified, it becomes a manipulative power struggle fraught with conflict. Thus, the relevance of continual return to mindful self-examination is crucial.
Clear-cut signs of those with manipulative control issues are people who speak continuously, almost uninterruptedly and issue directives about what others should and need to do on every level. Themes of “judgment” and “criticism” pervade these monologue orations. Themes of doing wrong and “bad” get highlighted. Evaluative and “ought to” statements resound. There is a pressured, compelling urgency in their voice as if the dictates were irrefutably valid and nonnegotiable. Such rigidity obviates dialogue and perspective-taking and feels overwhelming. This style of treating others is inimical to mindful conversations characterized by respect, pause, and mutuality.
Manipulative control issues appear in concentrated forms in intimate relationships such as family and marital discord. The readers of this book may also consider relations between physicians and organizations such as hospitals and universities. Loss of a sense of participatory control both triggers and pervades physician burnout. On a broader level, control conflicts embed themselves in all relationships where power and
power struggles are dominant—for example, between rival nations. Dominance-submission themes are central to control phenomena.
This broad view of control describes the attitudes and behaviors of, at least two people, or two camps of individuals with competing intentions. Mindfulness changes the perspective of such “control” to one centering on how one views, reacts to, and manages one's mind. Mindfulness centers on focusing and managing interior space—mental space. Rather than use the term “control,” the term “manage” is preferable. Chapter 4 will discuss concepts such as effortless modulation and effortful regulation. These ideas are crucial to a valid mindfulness perspective.
The core of mindfulness theory and practice is present-centered attention that is porous, fluid, and nonadherent. For example, trying to forcefully control anxiety and stress by using logic and reason alone seldom works. Changing harmful habits and replacing them with rewards that are helpfully sustainable is mindful behavior change. A mindful intrusion into unhealthy behavior patterns including addictive behaviors can change these etched-in stimulus–response reactions.
With practice, effortful regulation, e.g., behavior change, arises from its base in the effortless, nonconscious, implicit learning accrued. This reconfiguration has core emotional modulation as its nonconscious changing dynamic. Achieving such states of awareness means one's attachment to the “objects” of attention must be flexible. What comes into mind as thoughts about anything in the form of ideas, sensations, and feelings are not to be controlled—grasped, held, or clenched too forcefully. Managing mental contents is a preferable alternative.
Mindfulness is the ability to release, surrender, and “ungrasp” effortlessly. Whether rigid attachments to thought patterns or to the need for illicit substances (as found in addictive compulsions), ungrasping the triggering events and their outcomes is key to reconfiguration and distancing. Mindful coping is skillful problem-solving. It is decision-making acting as a resilience preparation preventing stress.
Control as an attachment and clinging relates to the Eastern meaning of “desire,” which means the desire to hold on, take possession of, and not let go. Desire in this sense means “I wish to be in control of this object; this object must be mine.” Thus, understanding this idea of “control” as attachment and desire is key to understanding Eastern perspectives when trying to grasp mindfulness. Central issues in modern mindfulness pivot around control versus suitable management using flexible acceptance and letting go—of thoughts, feelings, and attitudes in one's mindset.
The individual psychology of control can reconfigure itself to become a psychology of empathetic transactional reciprocity, more intentional and less reflexive. This social reciprocity can become a transactional sensitivity characterized by empathy and amplified perspective-taking. This respectful frame of mind is antithetical to forceful control and the wish to manipulate, or aggressively direct. Although this is an optimal form of constructive communication between any two people, its import in mindfulness is most relevant about managing one's mind—without rigid control and impulsive reactivity. It morphs just a business transaction to becoming an engagement of in-depth equipoise. Managing one's thoughts and feelings in a nonjudgmental and nongrasping manner is emotional equanimity.
Developing more significant emotional awareness and refined levels of emotional literacy empower one with the cognitive and emotional abilities intrinsic to empathy. Complex emotions, such as gratitude, support basic emotions like agreeableness and cooperative mutuality. These character strengths, notably integrity and empathy, are decisive in the mindful person. Asking permission not only relates to seeking agreement from others but also to permitting one's inclinations freedom to appear and move on. In addition, the inevitable experiences of sadness and suffering pondered and worked through amplify the development of empathetic feelings.
Character Strengths
Success in life involves developing a character of integrity. Learned Mindfulness holds integrity and empathy in high regard. These achievements are lifelong processes permitting one to live life the way one genuinely wishes. This experience is the enjoyment of satisfaction and admiration for achievements alone and shared. Character is personal excellence. Mindfulness enhances integrity bringing one's character strengths into action routinely.
Mindfulness means taking stock of oneself. Discerning what is important (e.g., maintaining positive health) from what is urgent (e.g., “putting out a fire”) is crucial. Writing aspirations and visions and mission statements are essential. Reviewing long-term goals helps to point toward the right direction and stay on track. Learning to become single-minded is fundamental. Self-optimism, self-discipline, and self-regulation comprise self-mastery, notably mindful equipoise and emotional equanimity. Self-regulation occurs on multiple levels supporting self-esteem, self-respect, and a healthy self-image.
Character comprises the nuanced super-refinements of one's personality. On basic temperamental predispositions, character develops from the consciously chosen values enthusiastically espoused. Motivation, learning from the environment, and random occurrences can change mental and behavioral “fixedness” in remarkable ways, especially if one is determined to change. Chapter 5 discusses Positive Psychiatry capturing such a broad array of ideas with the phrase “positive psychosocial characteristics.” This clustering encompasses individual character strengths and their social and environmental components. Active social engagement is vital to characterological well-being. Successful social engagement requires well-developed perspective-taking and empathetic rapport.
Authentic integrity correlates with high-value character strengths. Such positive psychosocial characteristics have empathy and communicative transparency as top values. Valuing one's life together with the lives of all humankind exemplifies reality-based perspectives on authentic empathy. “Keeping your word” verbally and in performance shows trustworthy integrity. One's character—resilient, optimistic, and socially engaged—is also reliable, accountable, and can forgive self and others. The wholeness of genuine, authentic integrity embodies empathy and mindful gratitude. Integrity supports increased performance and value creation. It is trustworthy and reinforces high reliability.
High-reliability performance amplifies a focused method harnessing ideas and leveraging improvements. Reliability refers to consistency, the ability to modulate toward effectiveness. Becoming a valid and genuine person, authentic and feeling real, depends on an implicit sense of being reliable.
Learned Mindfulness is remembering to remain awake to oneself thus enabling the process of active self-remembering mobilizing character strengths. Becoming sensitized to the personal experience of flesh, blood, sensations, feelings, thoughts, and contact with others made up in similar ways thus takes on vibrant embodied meaningfulness. The resilience of bouncing back from stress and recuperating from burnout powerfully expands.
Learned Mindfulness presents learning the resources preventing and protecting from exposure and negative engagement in stressful events. This skill creates resilience. In addition, mindful people endure unforeseen stressors with substantive coping strategies enhanced by character strengths. These skills lay the foundations for quick recovery and newfound abilities enhancing prevention.
Authentic Integrity
Authentic integrity is a peakless mountain. As wholeness, it is personal freedom from self-deceit because hidden parts of oneself can now be accessed and brought to the light of mindful awareness. Integrity brings entirety, soundness, transparency, and a sense of being undiminished. The wholeness of authentic integrity involves being true to oneself. This ability entails honestly detecting what one genuinely senses and knows to be part of their inner being, even if underdeveloped or counter to earlier self-perspectives.
Integrity is an unimpaired quality of life. It is a biomental integration. Learned Mindfulness is entering the “Into Integrity Zone.” Authentic integrity is an achievement of self-determination, self-activism, and prudent self-agency bringing more consistency to temperament, personality, and character. Such self-regulation is an actionable pathway to becoming whole and complete, an integrated person.
Learned Mindfulness keeps attention dynamically alive. Cynicism—emotional distrust—shatters values and blocks empathy; callousness to self and others increases. Cynicism, callousness, and depersonalization are features of the burnout syndrome and alien to health and well-being.
Cynicism profoundly questions the genuineness and sincerity of other's motives thus impairing belief in communicative validity. Integrity mindfulness continuously disables this deception and self-cleanses the fluid alignment of emotion with thought. Reconfiguring the mind in this way creates a newly experienced mindfulness readiness. This readiness graciously allows renewed interest, inquisitiveness, curiosity, and openness. This sequence is the path for acceptance of the natural flow of sensation, perception, emotion, and thought. Wholeness enhances integrity and generativity in work-life. The emotional cascade leading to multidimensional empathy is the crux of EI.
Learned Mindfulness is self-regulation. Self-regulation has two components: (1) nonconscious modulation of emotion and thought that underlies nonconscious changing and (2) a conscious regulation that is the intentional and purposeful work of critical thinking—tangible on a practical level. Three dimensions of self-regulation include
All these bring about and support self-esteem, self-respect, and a healthy self-image.
With practice, implicit emotional modulation (i.e., noneffortful) enables oriented attention to be present to each moment unfolding but not restrictively lingering in a rigidly fixed way on any experience (Garrison et al., 2013). Learned Mindfulness understands “presence in the moment” to be awareness characterized by immediacy. Attention with immediacy is mindful attention. Integrity embraces one's capabilities and skills and makes their potential available in the mindful moment.
Emotional hygiene is both awareness and literacy promoting the active engagement of emotion, decision-making, and its implementation in real life. The intention and dynamic act of welcoming emotion to become optimally humanized by clear thinking is precision self-medicine. Learning can enhance this alignment of feeling with thought and its application in productive ways. Emotion must be discovered, recovered, and joined with ideas. Learned Mindfulness is a psychological orientation and tool with steps. They outline the process of enacting this engagement of awareness with EI. This approach aims to expand emotional awareness by teaching the conscious awareness (i.e., Learned Mindfulness) of the identification of emotion—(1) sensation, (2) perception, and (3) the readiness of conceptual elaboration.
These three preparatory stages to EI by noting, labeling, and embracing one's biomental capacities are the foundation for effective action in everyday living. These three steps of EI become a prelude to their target: emotion performance utilization. This decision-making performance may happen “now” or later when circumstances call for more intensive critical thinking, executive functioning. It is mindful behavior in real life.
While Learned Mindfulness aims to increase genuine emotional awareness, its definitive aim is emotional literacy: mindful listening, speaking, and doing. This cognitive-affective reconfiguration is an equipoise-promoting skill sustaining health and well-being via achieving the character strength of authentic integrity.
Integral Empathy
Inner character strengths pivot on Integral Empathy: cognitive perspective-taking and emotionally grasping and outwardly responding to another's sentient inner experience. Integral empathy comprises the refinement of emotions for the effective comprehension of self-experience and that of others. These experiences entail emotions, thoughts, and even bodily sensations. Performing this skill enhances empathetic interpersonal relations. Empathy includes attunements to nonverbal communications such as facial expressions and body language. This transpersonal conduit adds meaning to the biomental perspective of Learned Mindfulness of body-mind synchrony.
Work-life balance is crucial, but life management is more than avoiding unhappiness, it is reclaiming forgotten emotions, including joyful engagement empowered by meaning. This book empathizes with Eastern perspectives, giving them homage for their enduring contributions to mindfulness in theory and practice.
Learned Mindfulness: Wellness for a New Generation of Physicians
Traditionalists and baby boomers, now over 60
years old, had experience with the era of the 1960s when Yoga and a myriad of other Eastern traditions flooded America. Many aspiring physicians, including the author, engaged with varying involvement in these pursuits. Exposure then was on personal terms, close contact with a teacher and guide. High levels of motivation, endurance, and enthusiasm characterized training. There was a joy in transforming and creating fresh versions of oneself. Some meditators dropped out; some continued the practices.
Today, generations of millennials and Gen X physicians are becoming reacquainted with the East. This wave of concern with stress reduction and relief from burnout has reinvented what had been traditional meditation into the arena of modern mindfulness.
A recent survey of 1900 US medical residents in 29 specialties showed three outstanding professional challenges:
Depression was reported in 10% as ever-present and sometimes present in 33%. Stigmas against seeking help were prevalent in 68%. Many respondents (35%) reported no time for personal wellness (Levy, 2018).
The intention of Learned Mindfulness is a self-regulating orientation of receptive curiosity and nuanced noticing: a restoration of the primacy of emotion in the natural cycle of rational thinking. Active self-observation and remembering foster turning invisible emotion to palpable perception. This awareness transforms into evaluative thought and intelligent decision-making. One's moral compass then spins toward relevant and socially beneficial performance.
The transparency unveiled by refined EI refreshes eagerness to work. The prospects of a task thus elicit excitement in planning and completing steps advancing
accomplishment. What at first was deliberate intention modulates itself in implicit awareness to become effortless and spontaneous. Thus, the mindful physician feels energized, engaged, and accomplished in his and her respective medical fields with a clarity of purpose. Mindful awareness is a foundation for wellness pervading one's lifestyle.
Learned Mindfulness supports the modulated engagement of sensation, perception, conception, decision-making, and their implementation in real life. This integral strength toward an equipoise-building alignment must be learned. The application of Learned Mindfulness is an example of “translational medicine,” i.e., from bench side (i.e., theory) to bedside (i.e., individual application), and ultimately to community well-being. Learned Mindfulness and achieving authentic integrity can be integrated into any existing psychotherapy, counseling, organization, business, hospital training, or school upgrade format on a one-to-one or group basis.
The relevance of mindfulness for physicians to use personally, above all, the newer generation of medical doctors is enormous, if not inestimable. For example, Chapter 6 integrates mindfulness principles, practice, and policy guidelines into the real-life healthcare area. Here physicians and organizational leaders live, work, and aspire toward quality professionalism with emotional equanimity and mindful equipoise. Physician engagement and organizational alignment thus enable themselves to enhance one another—mindfully. Mindful mindedness is a premier self-observing capacity enriching work-life balance. Psychological mindedness thus reaches quantum proportions.
Frank John Ninivaggi, MD
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