Mindfulness, a meditative practice based on Buddhist thought, is a growing movement in the mental health field used to assist patients in cultivating skills of emotional regulation and stress relief. Adapted to its present Western form by Jon Kabat-Zinn, mindfulness is a form of complementary medicine currently being integrated into health care settings throughout the country. Research is still emerging, and studies funded by the National Institutes of Health are looking at mindfulness techniques to aid in treating stress, addictions, anxiety and depression. (http://nytimes.com/2008/05/27/health/research/27budd.html)

Mindfulness is a simple technique for increasing awareness of the present moment, moving away from the past or future to pay attention to thoughts, feelings and sensations with objectivity as they unfold in the present moment. Mindful meditation generally involves a variation of the following steps:

1. Setting aside time to meditate or focus (the beginning of a treatment session, for example);

2. Relaxing and paying attention to body sensations, sounds, thoughts or feelings (paying attention to the breath is a common strategy); and

3. Noticing sensations without judgment and returning attention to breathing as a focal point (the goal is to quiet the mind so that one can observe with objectivity how emotions and sensations manifest in body and mind).

Mindfulness and Disability

Mindfulness can be adapted and modified for working with people with complicated chronic or progressive disabilities. From my own clinical work, I suggest the following points to consider:

First, mindfulness can be utilized in two ways: as a formal meditative practice (inward focus) or as a specific -strategy for dealing with stress or quality of life issues (outward focus). Inwardly focused mindfulness can help improve self-awareness or tame self-defeating self-talk (see "Anxiety Management Training," May 26). The goal is to teach patients how to pay attention to their minds and bodies with compassionate curiosity and without -getting caught up in every emotion, thought or sensation.

However, disabled or chronically ill patients may already be overly mindful of pain, sensations and distressing thoughts, due to the subjective stress their condition or medical treatment may inflict. As an alternative, exploring outwardly focused mindful activities can help relieve stress and improve quality of life, as they can be individualized, based on the patient's lifestyle and resources (see above box).

The point of either type of mindful strategy is the same: to pay attention when engaging in the meditation or mindful activity and become aware of the positive sensations, thoughts or feelings that result.

Dr. Rose Mathew, a neurologist with fellowship training in neuro-oncology, shares how she has fostered a mindfulness mindset with her patients:

"Many of the brain tumor patients I cared for had to undergo difficult regimens of chemotherapy and radiation, which resulted in extreme fatigue, nausea and changes in functional status. I would make it a point to encourage patients to engage in mindful activity to manage the stress. For some patients it was spending time with grandchildren; for others it was taking a walk, or cooking, or eating at their favorite restaurant."

As with any intervention, timing is critical. Patients first need to adjust to medical traumas and cycle through expected feelings of grief or loss. While it does not always play out this way, it is important to be in tune to where patients are in terms of their journey with their bodies before implementing new strategies.

Identity and Mindfulness

When people are confronted with disability or illness, the most profound level it affects is the level of identity. At such turning points, taking a moment to mindfully explore the seeds of rebuilding identity is the first step.

Brooke Ellison, 29, a public disability advocate, is a model of the mindfulness mindset when negotiating the stresses and demands of her quadriplegia and ventilator dependence. After being hit by a car at age 11, Brooke had to redefine her sense of self.

"When I was a child... I was in little league baseball and soccer. I was also a dancer. My sense of self was connected to physical activity. After my accident, I had to explore the question, 'What is still recognizable in me?' Just because I danced most of my childhood does not mean that I would have always. Everyone's lives change and not just because of disability."

Brooke went on to earn both bachelor's and master's degrees from Harvard University. She is currently on sabbatical from her doctoral work in political psychology at Stony Brook University to launch her foundation, The Brooke Ellison Project. Her life story has been made into a memoir and also a film directed by the late Christopher Reeve.

"When my life changed, it challenged me to look at other ways to re-direct my energy-to other activities, in other domains. A change of course in your life does not have to be seen solely as a restricting event; it can also be an opportunity. For me that has been through education, and I have gotten a lot of satisfaction out of this path - making my life meaningful."

Mindful Outlets

All disability-whether chronic, progressive, temporary or permanent-imposes practical limits of some kind. Exploring accessible outlets that do not put too much exertion on the mind and body can can also provide stress relief or emotional comfort (see "Solution-focused Techniques," June 28). Brooke provides an example from her own life:

"I can't enjoy the beach, swim or the ocean. When my parents modified the house, they were mindful about the outdoors as a resource for me. They made a big deck, so I can go outside often. There is a path around the house from the deck to the front porch. When I do get out, and sometimes I don't as much as I could, I am mindful of the sense of oneness I feel with nature... Also, my office has four skylights and is light and airy; I am able to access this natural resource from indoors as well."

Mindfulness with Feelings

Managing the demands of disability and illnessoften comes with ongoing emotional stressors-loss, facing limitations, adapting to ongoing emotional and practical barriers. Mindfulness strategies can help patients develop self-compassion about expected emotional highs and lows. Brooke shares how she navigates such difficult moments:

"Difficult moments are intermittent for me. I allow myself to feel frustrated or gypped. But I don't let myself go beyond a few days, because there is so much I can do. I try not to focus on things I can't do, which is a lot of wasted time. I also keep a check in at what point are my feelings constructive versus self-defeating."

Mindful Parts of the Day

It is critical to help each patient discover mindful moments in the course of each day when they can take a break from the daily demands of their disability or illness. For each patient the resources may vary, and it can be interesting to mindfully explore a day in the life of a patient, seeking out mindful rituals or time slots (see "Stress Management," April 28).

Brooke's morning routine starts with an interesting strategy:

"My morning routines take 4.5 hours, which includes my personal care and medical needs. Before I start the day I try to plan out the day or schedule my time in my head. This is a grounding exercise for me. It gives me a sense of structure."

Brooke's evening routine takes about two hours. She shares a creative solution to help her wind down skillfully:

"Reading in the standard way is challenging due to the brightness of the computer screen, and also turning pages can be a stressor. I strongly advocate books on tape. It challenges me to create the mental imagery in my head. This is how I fall asleep. It is a great escape; it helps me to relax and takes me out of the demands of the day. This month I listened to Bridge of Sighs and Empire Falls by Richard Russo."

Mindful Activity

Finding the balance between work and rest is a challenge for everyone, but for people with disabilities, the particular limits or demands of a condition can present additional challenges. Brooke has learned to strike a balance between her desire to work and the essential need for rest (see "Integrating Behavioral Skills," March 31).

"When I am working, I can try to put out my best effort and I can work intensely. When I remove myself from my work, I can rest and I don't have to feel guilty. The rest will help me to go back and work again.

"When you find work that is productive to do, when you gain a sense of motivation out of your work, it is not as tiring. Also, bring in people to inspire you and shoulder the burden. The people around me have inspired me to do more."

Mindfulness Through Relapses

Most often, patients are unprepared skill-wise to navigate setbacks, relapses and vulnerability to stress. Brooke shares how she learned to cope with the medical risks of being ventilator dependent:

"The hardest thing for me medically is that my body temperature drops. When this happens, it is hard to articulate myself in any effective way or think clearly I take steps to avoid these episodes. I have to bundle up, and I don't worry about how that looks. When it does happen, I accept it and take the time I need to rest and recover."

Mindful Patient Care

Mindfulness is not only for patients. Mindful care starts with the practitioner. Currently, there are programs around the country that offer training to practitioners on how to provide mindful heath care. Brooke offers her own thoughts about what it means to be a mindful practitioner:

"I can't emphasize enough that the two most important qualities when working with patients with disabilities [are] compassion and patience. Let patients cycle through their feelings. It is not ok to put out platitudes. It is important to acknowledge the feelings when patients are going through a devastating, life-altering event."

Also, Brooke comments on attitude and the way we relate to our patients:

"The one thing I did not like was when I would be referred to as a quadriplegic. I am a person. I want to tell professionals to try to express things to patients in terms of ability versus limitations. Once a patient hears that enough times from enough people, they will begin to believe that about themselves."

From the broadest vantage point, mindful clinical practice holds possibilities when used in conjunction with other strategies. It helps patients to take a step back, assess their experiences and move toward compassionate self-care. We owe it to our patients to help them discover their own pockets of rest, relief and comfort.

Dr. Reji Mathew is a psychotherapist/clinical instructor at the New York University. Her clinical expertise is in integrative psychotherapy, particularly cognitive behavioral skills training. Reach her via email at rqm3463@nyu.edu.

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