Essentials of Complementary and Alternative Medicine (June 1999)

CHAPTER 30. M
EDITATION AND
 M
INDFULNESS
Michael J. Baime
Background
 
General Considerations
 
Definition
 
Types of Meditation
Mindfulness Meditation
Transcendental Meditation (TM)
Principal Concepts
 
Common Benefits of Meditation
 
Meditation and Stress Management
Physiology of Meditation
 
Metabolism
 
Endocrinology
 
Central Nervous System
 
Autonomic Nervous System
 
Clinical Research
Use of the System for Treatment
 
Major Indications
 
Adverse Effects
Organization
 
Training and Credentialing
 
Reimbursement
Prospects for the Future
Chapter References
BACKGROUND
General Considerations
Meditation is one of the oldest and most widely practiced mind–body therapies. An increasing enthusiasm for meditation as a therapeutic tool in Western medicine 
accompanies a new understanding of the mind's role in health and disease. A large body of knowledge suggests that subjective experience, quality of life, and 
psychosocial variables play a central role in health and healing. Depression, anxiety, personality traits, social support, and spirituality have all been associated with 
disease incidence and outcomes (
1
). This association has been proven strikingly in ischemic heart disease (
2
, 
3
 and 
4
), and there is intriguing evidence to suggest 
that the outcomes of diseases as dramatic as cancer (
5
) and as prevalent as the common cold (
6
) are influenced by psychosocial variables. These variables, which 
are largely subjective and difficult to measure except by self-report, are also difficult to influence by traditional Western medical approaches. Psychotherapy and 
psychotropic medications provide a tremendous benefit when they are indicated, but they are inappropriate, unavailable, or unacceptable for many patients. 
Meditation has been shown to improve some of the psychological and social variables associated with a poor outcome of many diseases. Meditation reduces stress, 
anxiety, and depression, and enhances quality of life.
Evidence that the mind has a meaningful role in health maintenance and disease recovery has fueled interest in meditation as a medical treatment. Meditation has 
been used as primary therapy to treat specific diseases, as adjunctive therapy in comprehensive treatment plans, and as means of improving the quality of life of 
individuals with chronic or debilitating illnesses. Meditation can teach patients how to cope more successfully with the stresses of illness and treatment (
1
). The extent 
to which the improvement of psychosocial variables will cure illness or prevent disease is unknown, but there is suggestive evidence and much ongoing research. A 
recent report to the National Institutes of Health on alternative medicine concluded the following:
More than 30 years of research, as well as the experiences of a large and growing number of individuals and health care providers, suggests that 
meditation and similar forms of relaxation can lead to better health, higher quality of life, and lowered health care costs.... Most important, meditation 
techniques offer the potential of learning how to live in an increasingly complex and stressful society while helping to preserve health in the process. Given 
their low cost and demonstrated health benefits, these simple mental technologies may be some of the best candidates among the alternative therapies for 
widespread inclusion in medical practice and for investment of medical resources (
7
).
The interest in meditation in health care has grown as our Western health care system has progressively emphasized and valued technology and procedures. This 
emphasis often results in treatments that depersonalize the personal aspects of illness and healing that accompany all disease. The objective, mechanistic approach 
of Western medicine may not always address a patient's anxiety about his or her illness. It is natural for people to fear pain, disfigurement, and death when they 
become ill. Anxiety can be heightened by many routine medical procedures. For example, a hypertensive patient may be full of apprehension from a simple blood 
pressure determination. This accounts for the phenomenon of white-coat hypertension, a well-described syndrome in which the patient's blood pressure is elevated 
only when a doctor or health-care professional measures it (
8
). Stress or anxiety may become particularly distressing when an individual faces chronic illness that 
affects quality of life (e.g., persistent pain, diagnosis of cancer, heart attack). In the time-pressured environment of modern medicine, it is difficult for most health care 
practitioners to fully address these concerns. Many busy clinicians do not have the training, tools, or time to help their patients cope with the stresses of their illness or 
of their lives in general. Patients can experience a demoralizing and frightening loss of control because of the intrinsic uncertainties of illness or the impersonal 
external demands of the health care system. Meditation practice can provide patients with self-directed and self-administered tools for cultivating mental and physical 
relaxation that helps return autonomy and control to the patient.
Definition
Meditation techniques originated as spiritual practices within traditional religious contexts, such as the contemplative reveries of the Jesuits or the Buddhist practice of 
sitting meditation. Most of the meditation techniques discussed in this chapter originated in the 3,000-year-old yogic practices of India (
9
). Over the centuries, 
hundreds of techniques have evolved. The original goal of these techniques was to lead the practitioner to a more absolute, unconditional, or sacred state of 
consciousness. In some traditional Eastern cultures, the full expression of this state of mind is termed  enlightenment. There is, however, nothing inherently religious 
or spiritual about meditation. Meditation can be taken from its traditional cultural or religious setting and used as a tool to improve health and quality of life. The same 
techniques that are used to promote personal or spiritual growth may be directed toward the relief of stress and physical discomfort.
Meditation techniques all share a structured mental process that steadies and deepens awareness by bringing it to rest on a stable focus. This process may be 
accomplished by resting the attention:
1. On a physical sensation, such as breathing; this is used as a focus in some forms of traditional Buddhist or mindfulness meditation.
2. On a thought or word that is silently repeated; this is used in some yoga practices and in transcendental meditation (TM).
3. On an external object, such as a candle's flame or a statue.
4. To the process of attention itself, as in some Tibetan Buddhist traditions.
By intentionally directing and regulating attention, the meditator modifies the functioning of the mind and its relationship to the body. The individual learns to rest the 
awareness in the present moment without struggle or wandering. This cessation of struggle is often experienced as deep mental and physical relaxation.

Types of Meditation
The literature on meditation distinguishes between  mindfulness and concentrative meditation. Mindfulness meditation exemplifies the tradition of expansive, or 
opening-up, techniques (
11
). These techniques cultivate a meditative resting of the entire field of attention, including all sensory and mental contents. This meditation 
contrasts with concentrative, or restrictive, meditation, which directs awareness to a single thought or sensation, such as a  mantra, to the exclusion of all else. In 
practice, however, these theoretical types of meditation may be similar (
10
, 
11
). The most widely taught form of mindfulness meditation uses breathing as focus for the 
attention, just as concentrative meditation uses an object or a thought. In mindfulness meditation, the meditator is taught to allow sensations, thoughts, and emotions 
to arise and fade without provoking a mental or psychological reaction. Similarly, in concentrative meditation, when thoughts and emotions arise, the meditator is 
advised to gently direct the attention back to the object of concentration without suppression or struggle. One meditation researcher has concluded that “the more 
common versions of meditation, such as Transcendental Meditation and Zen (a mindfulness meditation tradition), use an integrated approach, i.e., they combine 
concentration and mindfulness elements, with the former tending to dominate–especially in the earlier stages. However, with increased adeptness, mindfulness plays 
a greater role"(
11
).
Individuals who practice meditation regularly have significant reductions in anxiety and depression; these reductions have been documented with many commonly 
used psychometric tools. There is also evidence that the regular practice of meditation improves a person's functional status and quality of life. Meditation has been 
shown to significantly reduce the number of somatic symptoms reported by a broad range of patients with medical diagnoses. Meditation also benefits individuals 
without acute medical illness or stress. People who meditate regularly report that they feel more confident and more in control of their lives. They say that their 
relationships with others are improved and that they experience more enjoyment and appreciation of life (
12
, 
13
).
MINDFULNESS MEDITATION
Mindfulness meditation has its origins in traditional Buddhist meditation. It was introduced into the medical setting by Jon Kabat-Zinn, who founded The Stress 
Reduction Clinic at the University of Massachusetts Medical Center in 1979. Since that time, Kabat-Zinn has been instrumental in promoting the use of meditation as 
a treatment in Western medicine. Mindfulness meditation has been used in medical centers and hospital-based stress management programs throughout the United 
States. It is integrated easily into the allopathic medical system and is now taught in several medical schools and hospitals.
Mindfulness teaches its practitioners to cultivate a nonjudgmental state of openness and relaxation that can be maintained throughout activity. In formal mindfulness 
meditation, practitioners are taught to place their attention on a simple event, such as  breathing, and to stabilize and evenly rest the awareness in the present 
moment. Mindfulness is the practice of resting steadily with “the clear and single-minded awareness of what actually happens  to us and in us at the successive 
moments of perception” (
14
). During this meditation, wandering thoughts and shifts in attention are noticed as they occur without the individual suppressing, resisting, 
or commenting on them. Mindfulness meditation cultivates “an intentionally non-reactive, non-judgmental moment-to-moment awareness of a changing field of objects” 
(
15
). Informal meditation practice, described as the application of mindfulness outside of formal meditation sessions, is also emphasized. Meditators are taught to rest 
their awareness on any event that occurs. This is said to cultivate both a balanced equanimity and a more full and rich experience of life. Kabat-Zinn says:
The key to mindfulness is not so much what you choose to focus on but the quality of the awareness that you bring to each moment. It is this investigative, 
discerning observation of whatever comes up in the present moment that is the hallmark of mindfulness and differentiates it most from other forms of 
meditation. The goal of mindfulness is for you to be more aware, more in touch with life and with whatever is happening in your own body and mind at the 
time it is happening—that is, the present moment. By fully accepting what each moment offers, you open yourself to experiencing life much more 
completely and make it more likely that you will be able to respond effectively to any situation that presents itself (
16
).
Mindfulness meditation provides cognitive learning as well as relaxation. Meditators are taught to recognize the repetitive patterns of their stressful thoughts and 
emotions and to inquire into them. Discovering that the thoughts and feelings accompanying stress reactions are often maladaptive or inaccurate leads one to more 
adaptive and skillful responses to stress.
TRANSCENDENTAL MEDITATION (TM)
TM is one of the most widely practiced forms of meditation in the West; somewhere between 2 and 4 million individuals have been taught the technique (
17
, 
18
). 
Numerous research studies have been performed to investigate its efficacy, and much of what is known about the physiology of meditation comes from the study of 
TM. TM has its origins in the Vedic tradition of India and was introduced to the West by Maharishi Mahesh Yogi. In TM, the meditator sits with his or her eyes closed 
for 20 minutes, twice a day, and effortlessly attends to a syllable or word (i.e., a  mantra). Whenever thoughts or distractions arise, the attention is directed back to the 
mantra. One report states that TM “... is said to allow the individual to experience increasingly refined levels of mental activity until a state of ‘pure consciousness' is 
experienced in which the mind is fully alert, yet completely silent and settled. This distinctive experience of ‘restful alertness' has been distinguished from the aroused 
state of ordinary waking and the restful but inert state of sleep ... ” (
19
). The late Charles Alexander, a prominent TM researcher, writes that “during TM, ordinary 
waking mental activity is said to settle down, until even the subtlest thought is transcended and a completely unified wholeness of awareness beyond the division of 
subject and object is experienced. In this silent, self-referential state of pure wakefulness, consciousness is fully awake to itself alone with no objects of thought or 
perception” (
18
).
TM proponents claim that this state of rest and relaxation is more profound than that of other meditation techniques. The TM program now teaches another technique: 
the TM-Siddhi program. This more active form of meditative yoga also has its roots in Vedic tradition. More recently, Maharishi Mahesh Yogi has also recommended 
Ayurvedic medicine, the traditional health care system of India, and has promoted the use of Ayurvedic food supplements and products as a complement to TM (
20
).
PRINCIPAL CONCEPTS
Despite many theories, it is difficult to demonstrate how meditation works (just as it is often difficult to determine the mechanism through which many common medical 
treatments confer their beneficial effect). The development of the tradition of meditation has been largely empirical. Meditation is practiced because it produces a 
subjective effect that is valued by the meditator. Techniques that are subjectively beneficial have been handed down from teacher to student. Each generation of 
meditators refines these techniques and then passes them to the next generation. The meditation techniques that are being adapted for use in health care are the 
result of several thousand years of progressive development and refinement. These techniques are extremely sophisticated tools for working with experience and 
consciousness, but their evolution has been guided by subjective experience rather than objective medical data. Because of the largely subjective nature of 
meditation, it has been viewed with skepticism by medical scientists (
21
). An organized, scientific investigation of the physiological effects of meditation practice has 
only begun during the last 30 years. Well-designed clinical research into the benefits of meditation is just beginning to emerge. Meditation may have unique benefits 
that distinguish it from other self-regulation strategies, such as biofeedback or progressive relaxation (
10
).
Common Benefits of Meditation
Practitioners of all types of meditation consistently report some common effects. All forms of meditation generate a state of deep relaxation. This relaxation appears to 
be different from that induced by other more active or physical methods of relaxation, such as exercise or progressive muscle relaxation. Another frequently reported 
benefit is a sense of psychological balance or equanimity. Meditation cultivates an emotional stability that allows the meditator to experience intense emotions fully 
while simultaneously maintaining perspective on them. As described in the tradition of mindfulness meditation, “the practitioner of bare attention [i.e., mindfulness] 
becomes able to contain any reaction: making space for it, but not completely identifying with it because of the concomitant presence of nonjudgmental awareness” 
(
22
). TM also describes the development of this type of emotional balance and suggests that it is a consequence of the deep relaxation that meditation provides.
Some types of meditation—particularly, mindfulness meditation and TM—claim to enhance psychological insight or understanding. Through the sustained application 
of nonjudgmental awareness, the mediator sees repetitive patterns of behavior and cognition more clearly. In mindfulness meditation, individuals are taught to 
experience and explore thoughts and feelings as events that are allowed to occur without invoking habitual patterns of response; this allows the meditator to gain 
insight into the nature of their involuntary habitual reactions. Kabat-Zinn writes that the “element of constant inquiry characteristic of mindfulness practice, promoted 
not through thinking but through bare attending and a continual non-discursive questioning about what one is actually experiencing, lays the foundation for such 
insight to arise”(
15
). Although insight is not emphasized as strongly in TM as in other types of meditation, enhancement of autonomy and freedom from unhealthy 
patterns of behavior are frequently described. One prominent investigator of TM writes that “meditators become better able to see another person's perspective, yet 
they cannot easily be swayed by social pressure to do something which they judge to be wrong” (Orme-Johnson D. Summary of Scientific Research on Maharishi's 

Transcendental Meditation and TM-Siddhi program. Unpublished material.).
Meditation and Stress Management
Meditation reduces more than just the stress of illness. Chronic stress is one of the most widespread maladies of our culture. Although life has undeniably always 
been stressful, present-day culture has its own unique stressors and demands. Many people think that these demands are more than they can reasonably manage. 
The relentless pace of time-pressured activity may be continuous, and unceasing activity and tension may become so deeply ingrained that a person may have 
difficulty relaxing when he or she has a moment to rest. Meditation has been used for a millennia as a way to calm and stabilize the mind. Initially, formal meditation 
periods provide a respite from the speed and turmoil of everyday life. Later, the meditator learns to remain in a state of relaxation even in the midst of activity or 
stressful surroundings. Meditators consistently report that they can handle difficult situations more easily as they become more adept at meditation. Ultimately, the 
path of meditation becomes a larger journey toward greater psychological stability and health. The initial need to deal with a stressful medical condition may be 
subsumed into the larger goal of learning to cope more skillfully with all of the stresses of life. A participant in the author's meditation-based stress management 
program states that:
I was sent here because I had a heart attack and I was afraid that my Type-A personality would cause another. I was shocked to find that there were more 
important things to face. I had spent years running away from my family and myself and really from everything that I cared for most. I worked harder and 
enjoyed myself less. Here I found that the most important question was not whether I would die from heart disease but if I could live more fully and 
appreciate it while I was still alive. This is the most important message that I could ever hear–that it is possible for me to live fully and enjoy my life. 
Meditation has taught me how. This program should not be called stress management. It should be called life management. The fact that my experience of 
stress has been reduced is almost insignificant in comparison to all else that has happened to me through this class.
PHYSIOLOGY OF MEDITATION
Western medical science began an organized study of the physiological changes associated with meditation in the early 1960s, and by 1970 there was a growing 
body of evidence that meditation alters physiology as well as the psyche (
23
). In some cases, specific findings varied among early studies and among different 
meditation techniques (
24
), although it was apparent that the physiological state produced during meditation differs from that which occurs during rest (
25
). 
Subsequent research has clarified many of these differences and has begun to show a consistent set of physiological changes that accompany meditation. It is 
hypothesized that meditation creates a unique physiological state that maintains a high level of central nervous system functioning and alertness while simultaneously 
allowing for deep rest and relaxation (
26
). Meditation affects many different physiological systems, and these biological changes provide part of the theoretical 
rationale for the use of meditation as a medical treatment.
Metabolism
Most studies have found that metabolic rate, respiration, and oxygen consumption decrease during meditation and that these changes are more marked than those 
that occur during other types of rest. One representative study documented a 50% decline in respiratory rate and a 40% decrease in oxygen consumption during 
meditation in experienced meditators (
27
). This study also describes brief periods of complete respiratory cessation that correlate with the meditators' report of peak 
meditative intensity. Another report documented that three Buddhist monks were able to vary oxygen consumption markedly using different advanced Tibetan 
Buddhist meditative techniques: oxygen consumption decreased as much as 64% and, during a different meditative practice that attempts to increase “inner heat,” 
increased as much as 61% (
28
).
Endocrinology
There is compelling evidence that the neuroendocrine system is significantly influenced by meditation. The effects of meditation on the pituitary–adrenal axis are 
particularly well studied. Numerous studies show an acute decrease in cortisol secretion during meditation (
29
, 
30
 and 
31
), and a recent preliminary study found that 
meditators had reduced cortisol, thyroid-stimulating hormone, and growth hormone secretion in response to an experimental stress (
32
). Other research has shown 
alterations in concentrations of beta-endorphin and corticotropin-releasing hormone (
33
), melatonin (
34
), dehydroepiandrosterone sulfate (DHEA-S) (
35
), and gamma 
aminobutyric acid (GABA) (
36
).