A Second Career Teaching the Benefits of Meditation and Yoga

DELANY DEAN, JD, PhD crimlawdoc@gmail.com INTRODUCTION: Recently there has been an explosion of interest in meditation among psychologists, neuroscientists, physicians, and mental health care providers of all stripes. It is being claimed that meditation, or mindfulness-based interventions, can cure just about any ill. What is the evidence that these claims might be (even partially) true? A recent large meta-analysis () reported that, overall, the state of the research on the use of meditation as a health care intervention is not yet in a place from which to strongly proclaim its efficacy (you can read a summary of the conclusions, ). Although meditation, and mindfulness-based interventions, have been subjected to the scrutiny of researchers during the past 20 years or so, there are myriad problems with the vast majority of the research protocols that have been used in the past. Lack of control groups, lack of an effective placebo condition, poorly chosen outcome variables, and lack ofconsensus definitions of “meditation” are a few of the problems that have plagued the field. This does not mean that meditation is ineffective, only that the proof (so far) is lacking. However, at just about the same time that the meta-analysis was published, the entire geography of meditation research appeared to be shifting in the direction of much more rigorous designs. Thanks, in large part, to the pioneering efforts of Jon Kabat-Zinn with his Mindfulness-Based Stress Reduction (MBSR), funding agencies have begun to look favorably on grant applications that would permit the really difficult and expensive work required to engage in high-powered research on mindfulness and meditation. Researchers at major universities are getting grants from the National Institute of Health (NIH), and we are beginning to see some amazing results. I suspect that when the next big meta-analysis is conducted about the state of the research in the area of meditation for health care, we will see adifferent (and much more positive) conclusion. In this page I present and summarize some of the recent research that I’ve seen. MBSR CONFERENCE: RESEARCH ON MEDITATION I want to highlight and provide very brief summaries of some of the very exciting research findings from the 6th Annual Mindfulness-Based Stress Reduction (MBSR) Research Conference, just completed a few days ago (in April of 2008). 1. Cendri Hutcherson, B.S. (now at Stanford University): The Effects of Loving-Kindness Meditation on Social Perception. Psychologists have long known that implicit judgments (these are instantaneous judgments, positive or negative, that take place in our brains outside of conscious awareness) can have a very large effect on our consciously experienced feelings about other people. In other words, sometimes we just don’t like someone we have just met, but we don’t know why; and, not knowing why, our minds tend to create explanations that may really have nothing to do with the actual person infront of us. Implicit judgments about persons of non-similar racial backgrounds are of this type. What Ms. Hutcherson and her colleagues were able to demonstrate, in a very rigorous and well-designed study, is that when people engage in only 7 minutes of compassion meditation (also called Metta, or Loving-Kindness Meditation), they display “increased positive mood, and [this practice] evoked feelings of positivity and social connection to novel individuals on both explicit and implicit levels.” [For more information about this type of meditation practice, see my previous post] 2. Charles Raison, M.D. (now at Emory University): Effects of Compassion Meditation on Autonomic, Neuroendocrine and Inflammatory Pathway Reactivity to Psychosocial Stress. Dr. Raison points out that it is important to study the possible pathways along which meditation practice is helpful for stress-related emotional and medical conditions. He notes that “Obvious targets in this regard are pathways such as theautonomic nervous system, HPA axis, and innate immune inflammatory system that mediate mind-body interactions directly relevant to health.” In other words, stressful events and circumstances set off alarms within our nervous system, our endocrine system, and also in the form of an inflammatory response; all of these can (especially if they occur frequently, or for a long time) cause havoc in our bodies and minds, contributing to or causing serious disease processes. Dr. Raison is particularly interested in seeing whether meditation results in reduced reactivity within the inflammatory pathways that are activated when we encounter psychosocial stress. In other words, it is understood within medicine that our social interactions (work and marriage!) can cause a great deal of stress, and that this stress creates inflammatory responses that can make us sick (inflammatory responses are linked to cancer, heart disease, diabetes, depression, and other diseases) In this study, participantswere randomized either to training in loving-kindness meditation (Metta, or compassion meditation) or an active control group (a health discussion group). They were then subjected to an intense social stressor. Physiological measures were interleukin (IL)-6 and cortisol. Dr. Raison and his colleagues found that “meditation attenuated inflammatory reactivity to psychosocial stress [and this] may have significant health relevance.” Summary: These two sets of studies are absolutely amazing. In both sets of studies, the intervention (or active ingredient) was Metta, or Loving-Kindness Meditation (see and my earlier post on this type of meditation, ). And, in both, the practice of meditation apparently caused changes in the human mind and body that are of great importance. First, those who engaged in compassion meditation had a more positive outlook toward others, both consciously and unconsciously. Second, after engaging in compassion meditation, participants displayed lower inflammatoryresponse to a psychosocial stressor, indicating that they are at lower risk for the many and various medical disorders related to stress. Implications: Meditation practice apparently creates changes within us that we are totally unaware of, changes that can have a major impact on our emotions, our behavior, and our health. In other words, this meditation business is not just about relaxation, or generating good feelings within ourselves; this is much more about changing our deeply held attitudes about everything we encounter, and this, in turn, may reduce our body’s tendency to (essentially) self-destruct, in response to the stress and pain we encounter throughout our lives. Part 2, Issues about “dosage” One of the relatively unexplored areas in the implementation of mindfulness-based interventions involves the issue of “homework” practice. The traditional standard that arises out of Mindfulness-Based Stress Reduction (MBSR), as created by Jon Kabat-Zinn, is that participants areassigned to engage in 45 minutes of “formal mindfulness practice” daily throughout the 8 weeks of the MBSR program. So-called “informal” mindfulness practice (or “mindfulness in everyday life” is also very much encouraged; however, most MBSR teachers, and mindfulness teachers in general, believe that it is formal practice that creates the mental capacity for everyday practice. In other words, you really do need to set aside time for such practices as sitting meditation, the body scan, and mindful movement (mindful yoga), in order to be able to reliably and frequently bring your mindfulness capacities to the dynamic interactions of ordinary life. Just learning “about” mindfulness, or making efforts to “be more mindful” are probably not going to produce measurable benefits. [I have written about this previously; see the page on Meditation: Practice; “Why Meditate? Part 2: Are There Any Shortcuts?”] Nevertheless, the issues as to how much formal practice is really necessary, and howfrequent must it be, remain to be answered. Many teachers, and many participants in mindfulness-based intervention programs, believe that something less than 45 minutes per day (and fewer than 6 or 7 days per week) might very well provide an effective “dose” of formal practice. At this recent conference, two researchers presented their data on those very questions. 1. Ruth Baer, PhD (at the University of Kentucky): The Importance of Homework Practice in Mindfulness-Based Stress Reduction. Dr. Baer (who is a very prominent researcher in the field of mindfulness) studied 174 adults who completed the MBSR program at the University of Massachusetts. They closely monitored their at-home, between-session mindfulness practice time. Overall, the participants showed improvements on various symptoms, and on a measure of well-being; and, significantly, the amount of time they spent on “formal” mindfulness practices (sitting meditation, the body scan, and mindful yoga) was “significantly relatedto the extent of [their] improvement.” However, time spent on “informal” mindfulness practice was not related to improvements on any of the measures. 2. Willoughby Britton, PhD (at Brown University): Issues of “dosage” in meditation research: frequency, duration and intensity. Dr. Britton studied three different groups (2 groups of adolescents, and one group of adults); her outcome measures all involved variables related to sleep and sleep problems. Her findings (as to the relationships between types and amounts of formal practice, and changes in sleep variables) were mixed. Overall, subjects in all groups showed improvements on the sleep measures. The adolescents (who were in treatment for substance abuse problems) showed improvements in sleep variables with as little as 5-10 minutes of mindfulness meditation (formal practice), 2-3 times per week. The adults (who had histories of depression) meditated an average of 40 minutes per day; Dr. Britton found that those individuals whomeditated more than 40 minutes per day showed signs of “increased arousal” during sleep (e.g., more awakenings, and EEG readings associated with wakefulness or higher levels of brain arousal). Summary: Some individuals may derive measurable benefits (of some types, e.g., quality of sleep) with as little as 5-10 minutes of sitting meditation, 2-3 times per week; it is also possible that there is an optimum period of routine formal practice, above which benefits (of some types, e.g., quality of sleep) may stabilize or even decrease (perhaps at around 40 minutes per day). Implications: So-called “informal” mindfulness practice, by itself, is probably not sufficient to cause the sorts of changes in attentional skills and mental habits that can cause measurable improvements. On the other hand, teachers of mindfulness-based interventions should be sure that participants in their programs are not frightened away by what might seem to be overly daunting homework requirements; also, one shouldnot convey the idea that very long periods of meditation will necessarily result in more measurable benefits (depending, of course, on what sort of benefits one is seeking). Some researchers and clinicians have found that an “invitational” approach to homework is at least as effective as a more authoritarian “required homework” approach in gaining and maintaining adherence to acceptable frequencies and durations of formal mindfulness practice. In the Mindfulness-Based Wellness program conducted at my university in the Fall Semester of ‘07, we found that an invitational approach resulted in excellent compliance (around 15-25 minutes per day, most days every week) and very significant improvements for participants in a large number of wellness-related variables. Part 3, Mindfulness and the reduction (or alleviation) of harm resulting from stressful and/or traumatic events When humans are exposed to painful, highly distressing, or frightening circumstances, a cascade of physical/mentalevents occur. Many of these events are adaptive and even necessary means for addressing the situation (the nervous system, the endocrine system, the immune system all need to be mobilized in order to enable us to meet the threat at various levels of functioning). However, these responses to stress can develop, in effect, a life of their own, and can end up causing all kinds of problems, over and above the original stressful or traumatic event. There are many, many stress-related disorders. Can the practice of mindfulness meditation help to diminish the harm that these stress-responses can create? Two studies are very encouraging. 1. Melissa Rosenkranz (University of Wisconsin): Mindfulness-Based Stress Reduction effects on cutaneous inflammation following stress. Rosenkranz and her colleagues administered a real double-whammy to their research subjects. The subjects had to undergo a very stressful psychosocial task, and they had a strong pepper cream rubbed into their skin (resultingin blistering). Half the subjects completed a Mindfulness-Based Stress Reduction (MBSR) program; the other half engaged in a Health Enhancement Program (HEP), which included exercise, music, and various other components. The researchers found that the inflammation caused by the pepper cream “was significantly smaller in MBSR compared to HEP… [and] those individuals who spent more time practicing MBSR showed greater buffering effect on inflammation than those who practiced less.” The inflammatory response has been linked to numerous disorders, including cancer, diabetes, and depression. 2. Elizabeth Robinson, PhD (University of Michigan), and Tony King, PhD: A Pilot Study of a Mindfulness-based Group Therapy for Combat Veterans With Post-traumatic Stress Disorder. PTSD is (for obvious reasons!) classified psychiatrically as a stress-related disorder; perhaps, then, Mindfulness-Based Stress Reduction (MBSR) should be explored as a possibly effective mode of treatment (or at least as anadjunctive treatment) for these individuals. Robinson and her colleagues created a program, adapted for PTSD patients, that included the elements of MBSR and Mindfulness-Based Cognitive Therapy (MBCT). Veterans who completed the program showed significant “improvement in PTSD symptom severity…, decreased ‘avoidant’ cluster symptoms… [and] a significant improvement in self-blame cognitions… [as well as] a trend of reduced heart rate and skin conductance reactivity to trauma recall.” Summary: Interventions that included the practice of mindfulness meditation appear capable of reducing the toxic effects of stress responses, both at the time of onset (in the case of applying pepper cream to the skin, and undergoing a stressful interpersonal situation), and also long afterward (in the case of combat veterans with PTSD). Implications: These findings (along with other recent research) provide initial support for the teaching of mindfulness meditation in new settings, and especially in schoolsand veterans’ facilities. We might consider the school setting as a location in which children and adolescents can be, in effect, “inoculated” against harmful over-activation, or chronic activation, of physiological and mental stress responses. This could have a huge long-term impact on the overall health of the human population. And, for those who never received this type of protection from the negative effects of severe stressors (think about the massive traumas now being suffered and inflicted in Iraq, Afghanistan, the Middle East, and so many other locations, including our own cities and homes), effective remediation might very well include the use of mindfulness meditation training and practice. Overall Summary and Comments I have summarized (above) the research designs and results from 6 of the many impressive presentations at the 2008 MBSR Research Conference; I regret that there were a lot more research presentations that I was unable to attend. But in conclusion, and overall,what I want to say is this: the research on meditation has taken a quantum leap forward. It is so much more advanced, now, than it was (even) a couple of years ago! Previously (during the past 30 years), research has certainly been conducted, and results have steadily been accumulating; but this earlier research was typically in the form of a very simple protocol, in which people who went through the MBSR program were assessed, before and after the program, on a number of variables (e.g., psychological symptoms, medical symptoms). During that earlier research, and almost always using that simple design, it has been repeatedly demonstrated (with tens of thousands of people) that there have been significant and consistent improvements across a number of variables for people who complete the MBSR program. But now, suddenly (in the past 2-3 years), there are highly sophisticated studies being funded and implemented (some of them funded by NIH and NIMH grants), in which we are beginning tosee genuinely impressive methodology, and (again) significant positive results. After having just participated in, and having completed the research on a very small-scale research project, myself, at a small university, I admit that I found it daunting and even intimidating to see what the “big guys” are now doing with complicated designs (active control groups!), amazing measuring devices (fMRI! stress hormones! EEG! unconscious priming!), creative ways of setting up and manipulating variables, and large numbers of subjects. Nobody could call this work flaky or fringe-y; research on meditation has definitely entered the mainstream. I find it incredibly exciting. And I realized, as I attended this meeting with so many other highly competent people who are committed to studying and implementing meditation-based interventions in standard clinical settings, in schools and universities, and in business settings, that I am really proud to be engaged in this work, in the company of thesepeople. I would not want to be involved in or associated with (for example) a clinical or wellness program in which the the term “mindful” is used, but only in some vague or theoretical way, divorced from the actual teaching and practice of meditation. I can’t get enthusiastic about what I have heard called “non-meditative mindfulness” (or the “Ellen Langer model”), because (as yet) there is no body of research indicating that it can create genuine and enduring positive changes in people’s lives. And, from my understanding of the mechanisms of change that appear to underlie the positive effects of meditation, you just can’t get the changes you want unless you do the practice involved, which requires some time and some mental effort. It is the repeated practice of compassionate observation and attentional shifting that seems to result in changes in brain circuitry and, consequently, better emotion regulation and capacity to engage in effective action. The programs that arose out of theCenter for Mindfulness (MBSR, MBCT, and other mindfulness-based interventions) are “the real deal”: they really respond effectively to human suffering in this world. I would not want to offer something less than that to anyone who came to me for help. Image via I got the word yesterday from the (APS) that a research I submitted for the annual convention has been accepted! I will be going to Chicago (along with co-author, Ian Butterbaugh) in May to display the method and results of the Mindfulness-Based Wellness program we ran at Avila University in the fall semester of 2007. Here’s what the program entry looks like: Mindfulness-Based Intervention Enhances Wellness on University Campus Time and Location Brain, Body, Behavior, and Health Friday May 23, 2008, 12:30 PM – 1:30 PM Chicago Delany Dean Avila University Maria Hunt Avila University Ian Butterbaugh Avila University Abstract A semester-long program for students, faculty, and staff at a small university combined Mindfulness-BasedStress Reduction with values-based behavioral activation. Participants showed significantly improved scores on measures of: depression, anxiety, attention, overall psychological discomfort, psychological/emotional sensitivity, impulsivity, attentional deficits, mindfulness, and overall quality of life. MEDITATION (AND MBSR) FOR SPECIFIC CONDITIONS Image via The inflammatory response to physical (and emotional) stressors has become a very hot topic in medicine, psychiatry, and neuroscience. The Wikipedia entry () provides a good overview of inflammation: “Inflammation (, inflammatio, to set on fire) is the complex biological response of tissues to harmful stimuli, such as , damaged cells, or irritants. It is a protective attempt by the organism to remove the injurious stimuli as well as initiate the healing process for the tissue. Inflammation is not a synonym for … In the absence of inflammation, wounds and infections would never heal, and progressive destruction of the tissue wouldcompromise the survival of the organism. However, inflammation which runs unchecked can also lead to a host of diseases.” It is increasingly being recognized that there are intriguing parallels between physical stressors and irritants (a cut or bruise; exposure to toxic substances) and mental or emotional stressors and symptoms (traumatic events; depression). Previously I have written () about Dr. Charles Raison’s new research into the effects of meditation (specifically, so-called “compassion meditation”) on the inflammatory response process. Here is a summary of what I wrote: Dr. Raison points out that it is important to study the possible pathways along which meditation practice is helpful for stress-related emotional and medical conditions. Likely pathways are: the autonomic nervous system, the hippocampus-pituitary-adrenal (HPA) axis, and the innate immune inflammatory system; each of these systems influences mind-body interactions that are directly relevant to health. In otherwords, stressful events and circumstances set off alarms within our nervous system, our endocrine system, and also in the form of an inflammatory response; and all of these can (especially if they occur frequently, or for a long time) cause havoc in our bodies and minds, contributing to or causing serious disease processes. Dr. Raison is particularly interested in seeing whether meditation results in reduced reactivity within the inflammatory pathways that are activated when we encounter psychosocial stress. In other words, it is understood within medicine that our social interactions (work and marriage!) can cause a great deal of stress, and that this stress creates inflammatory responses that can make us sick (inflammatory responses are linked to cancer, heart disease, diabetes, depression, and other diseases) In this study, participants were randomized either to training in (Metta, or compassion meditation) or an active control group (a health discussion group). They were thensubjected to an intense social stressor. Physiological measures were interleukin (IL)-6 and cortisol. Dr. Raison and his colleagues found that “meditation attenuated inflammatory reactivity to psychosocial stress [and this] may have significant health relevance [emphasis added].” In other words, the people who were trained in compassion meditation displayed a reduced inflammatory response when they underwent an emotionally stressful event. There is also recent research on possible genetic differences that might explain the different responses people may exhibit to stressful situations. A recent report () in states that early indicators are showing some of these individual genetic differences: “there are clinical parallels between depressive symptoms and the symptoms of certain inflammatory disorders. In findings published electronically in Molecular Psychiatry, researchers from University of Miami found [differences] in inflammation-related genes that are associated with susceptibilityto major depression and antidepressant response.” I find all of this incredibly intriguing, especially during a time in our culture and environment when we are seeing so many people who are exposed to (and suffering from) a wide range of traumatic events, some of them quite severe (natural disasters, war, child abuse). We need to be engaged in looking for and researching multiple modalities for the prevention and treatment of stress-related and trauma-related disorders and symptoms. And it appears that one pathway that shows promise, both for prevention and treatment, is training in meditation. MBSR for Alcoholism This is an interesting (but not entirely new) application of MBSR. (Note that previous researchers and clinicians have used mindfulness-based approaches for prevention of relapse in alcohol and drug dependence/abuse disorders [see Marlatt et al.].) MBSR in Treating Alcohol Abuse: ScienceDaily (Oct. 28, 2007) — A researcher at the University at Buffalo’s Research Institute onAddictions (RIA) is initiating a study of “mindfulness-based stress reduction,” a technique often used in behavioral medicine for stress reduction but not before as an adjunct in the treatment of alcohol use disorders. “By adapting and applying mindfulness-based stress reduction or MBSR in alcoholism treatment, we hope to develop an increased ability to cope with stress and enhanced psychological well-being among alcohol-dependent individuals,” said Gerard J. Connors, Ph.D. “For people who often deal with stress in their lives by turning to alcohol, this could be a very positive alternative.” The four-year investigation on MBSR will be conducted with support from a $1.9 million grant from the National Institute on Alcohol Abuse and Alcoholism. The MBSR intervention provides intensive training in mindfulness practices and their applications for daily living and coping with stress. MBSR emphasizes self-observation and self-responsibility, which is expected to facilitate thealcohol-dependent individual’s management of the stressors that place the person at increased risk for drinking. The long-term goal is to decrease relapse to drinking following treatment, thereby providing significant health benefits to people being treated for alcohol dependence, with corresponding benefits for their families and the community-at-large. Adapted from materials provided by . Meditation and Fibromyalgia Below find excerpts from an article about a new study that indicates that Mindfulness-Based Stress Reduction (MBSR) can be an effective intervention for people diagnosed with fibromyalgia: — “Fibromyalgia has emerged as a common, yet difficult to treat disorder. A group of investigators of the University of Basel has proposed a new modality of treatment in the July issue of Psychotherapy and Psychosomatics. Mindfulness-based stress reduction (MBSR) proposes a systematic program for reduction of suffering associated with a wide range of medical conditions. “Studies suggestimprovements in general aspects of well-being, including quality of life (QoL), coping and positive affect, as well as decreased anxiety and depression. A quasi-experimental study examined effects of an 8-week MBSR intervention among 58 female patients with fibromyalgia (mean, 52 ± 8 years) who underwent MBSR or an active social support procedure. Pre- and postintervention measurements were made. Additionally, a 3-year follow-up was carried out on a subgroup of 26 participants. Pre- to postintervention analyses indicated MBSR to provide significantly greater benefits than the control intervention on most dimensions, including visual analog pain, QoL subscales, coping with pain, anxiety, depression and somatic complaints (Cohen d effect size, 0.40-1.10). “Three-year follow-up analyses of MBSR participants indicated sustained benefits for these same measures (effect size, 0.50-0.65). Based upon a quasi-randomized trial and long-term observational follow-up, results indicate mindfulnessintervention to be of potential long-term benefit for female fibromyalgia patients.” Reference: Paul Grossman, Ulrike Tiefenthaler-Gilmer, Annette Raysz, Ulrike Kesper. Mindfulness Training as an Intervention for Fibromyalgia: Evidence of Postintervention and 3-Year Follow-Up Benefits in Well-Being. Psychotherapy and Psychosomatics 2007;76:226-233 Meditation and Blood Pressure I think it was nearly 25 years ago, while I was still working as a prosecuting attorney, that I had a conversation with my physician. He noticed that my blood pressure was a little higher than it should be, and he suggested that I might want to begin the practice of meditation. My response? Privately, I scoffed. I figured he was one of these guys who was into fringe treatments, and I wanted no part of that. Besides, meditation really did not fit my own self image, which at that time was very much that of a tough, no-nonsense, prosecutor. For some reason (now that I look back on it, I can’t figure out what exactlythe reason was!), people like me just didn’t do meditation, or yoga, or any of “that” stuff… A lot of years (and, for me, many life changes) have gone by since then. Now, I’m a psychologist, and I have been practicing meditation for about 10 years. I teach meditation, as well, and I keep an eye on the research literature about its apparent health benefits. One wellness-related area in which research is being carried out is on high blood pressure, or hypertension (my doctor may have been on target, and ahead of his time!). Some recent research can be found and (specifically, using “Transcendental Meditation,” or TM); and also a indicating that, overall, the evidence indicating that meditation actually significantly lowers blood pressure is not yet very strong. The studies, so far, tend to have various flaws; we will know more when better studies are designed and carried out, but preliminary indications are encouraging. Why might the practice of meditation lower blood pressure? There areno definitive answers, yet, to this question, but at least a couple of good ideas. Most recently, there has been a new focus on the “slow breathing” aspect of meditation. It’s true that, in most schools of meditation, there is no conscious effort made to alter the rate or rhythm of the breath; however, during a typical period of sitting meditation, in most individuals, the breathing naturally slows. Some researchers have honed in on this fact, and have measured what happens to the blood pressure when people deliberately make their breathing slower and deeper (you can use music, or recorded tones, to easily accomplish this) for 10 or 15 minutes per day. They found that blood pressure becomes significantly lower, and actually remains lower throughout the rest of the day. The reason for this is unclear; one hypothesis has to do with the physiology of breathing and its impact on sodium levels in the body. See my earlier post about this, , and an article, . A second idea has to do with the(at least superficial) similarity between “progressive relaxation training” (sometimes used in cognitive-behavioral therapy) and the practice of meditation. Many people (lay and professional, both) tend to confuse the two. Actually, the two practices are quite different in important ways. In progressive relaxation, one systematically engages in a tensing and relaxing of muscles throughout the body; there is little, if any, instruction given about the quality of attention paid to physical sensations, nor do the instructions typically address the issue distractions of attention from the task, and non-judgmental return of attention to a chosen anchor, or focus point. In meditation training, on the other hand, relaxation is not an explicit goal, and one does not deliberately tense or relax the muscles. Rather, the task is to non-judgmentally notice whatever may be present in the moment (and that might include muscular tension, bodily discomfort, etc.) without trying to change it. However,another persuasive idea as to why meditation lowers blood pressure has more to do with our emotions and thoughts. The practice of meditation is, in part, an exercise in training the attention. A person practices meditation by repeatedly focusing and re-focusing his or her attention to a particular object: that may be the ever-changing sensations of breathing, or the sounds that naturally occur while one is meditating; or on a phrase that one silently repeats (a “mantra,” as in TM or Centering Prayer). Upon noticing that s/he has become distracted from a focus on the present moment (whether it be the breath, or physical sensations), s/he simply takes note that attention has been lost, and (compassionately) re-focuses attention on the chosen object. Within any particular session of meditation, this cycle of focusing the attention, losing focus, and re-focusing, may occur a hundred times. And, each time, the act of re-focusing, of bringing attention back to a chosen object, strengthens