Article first published in Yale Medicine by Kathy Katella on May 19, 2020
Yale experts say the practice helps patients cope with illness and the anxiety related to it.
To say that COVID-19 has been an emotional roller coaster is an understatement. While you’re busy juggling working at home, homeschooling your children, and disinfecting your groceries, your mind may be playing a constant chatter of worry on a loop. “What’s going to happen with my retirement savings?” “What if I lose my job and health insurance?” “How will I make my mortgage payment?” And the ultimate fear: “What if I develop a cough, fever, shortness of breath, or other symptoms of the disease?”
Now, for a moment, try to forget all of that. Breathe in and out a few times. If your mind wanders, just notice that, accept that your mind has wandered, and refocus on your breathing.
That’s a bare bones example of mindfulness, an approach to dealing with stress that can involve a simple form of meditation—although it doesn’t have to—or a variety of other techniques that help you slow down.
“Mindfulness is really important in times like this,” says Auguste H. Fortin VI, MD, MPH, a Yale Medicine internal medicine specialist who has recommended mindfulness practices to some of his patients to help them cope with their illnesses. With COVID-19 front and center of nearly every aspect of life, he believes that, under the surface, many people are grieving the loss of their former lives. “It’s not just the kind of grief you feel when a loved one dies—it’s grief created by so much uncertainty,” he says. “We liked the way things were.”
What is mindfulness?
Mindfulness can be a formal meditation. Though people might be intimidated at the thought of what’s involved with meditating, Dr. Fortin suggests that it may be easier to think of it as a gym for developing mindfulness. “In meditation, your only job is to follow your breath and notice what your mind is doing while that’s happening,” he says. “You’ll then learn how to use the muscles you develop.”
But mindfulness shouldn’t be confused with other types of meditation such as TM®, which stands for transcendental meditation, a popular kind of meditation that involves using a mantra, says Rajita Sinha, PhD, chief of psychology for the Department of Psychiatry. She is also the director of the Yale Stress Center, which offers mindfulness classes, trainings, and workshops, and also conducts research focused on developing and testing novel treatments to reverse the destructive effects of stress.
Dr. Sinha adds that a mindfulness practice doesn’t have to involve meditation. “It is really about being in the moment, observing what’s coming at you from the outside and what’s coming up inside—taking it in and observing, and not reacting to it,” Dr. Sinha says. “With extended practice, you can begin to let go of what’s coming at you. But that takes longer.”
It’s also important to refrain from judging yourself or anything that’s happening in the moment, Dr. Sinha says. “Being nonjudgmental is a critical part.”
This may sound easy, but maintaining a daily mindfulness practice can be difficult, says Dr. Sinha. “You can’t just pull mindfulness down from a shelf whenever you need it,” she says. It’s not just taking a relaxing break, nor is it a “state of mind”—and if someone says they had a mindful day, they probably didn’t, she adds. “We may think we are in the present moment, but our attention keeps going to where we have to be tomorrow or the pain that we are feeling, or to talking on the phone or looking at the computer. When you are staying in a moment fully, it means you observe what is happening and notice when your mind gets taken away to something else. Then, you bring it back. That’s when this becomes a skill.”
A variety of ways to practice mindfulness
Anne Dutton, MA, LCSW, is director of the Yale Stress Center mindfulness education program, where she teaches a Mindfulness-Based Stress Reduction (MBSR) course, a group program that was developed in the 1970s by Jon Kabat-Zinn and pioneered at the University of Massachusetts Medical School. Kabat-Zinn took mindfulness, which is part of an ancient Buddhist tradition of practices, and repackaged it as a secular intervention to help patients struggling with life’s difficulties, including physical and/or mental challenges. MBSR is used widely today in preventive and clinical programs.
Dutton says mindfulness is a practice that involves three components:
- Paying attention to what is happening in the present moment
- Doing this purposely and deliberately, with resolve
- Maintaining the attitude that you will stay with your mindfulness experience, whether it’s pleasant or unpleasant
“You can pick your practice,” says Dutton. A formal practice means specifying at least one time each day when you will put other concerns aside and focus only on the practice, be it meditation or another technique. (There are many apps available online that can be used for guidance, she says.) You can also do an informal practice, which could involve picking something you do anyway and approaching it with the three components (above) in mind.
Mindfulness and COVID-19
The Centers for Disease Control and Prevention (CDC) recommends washing your hands frequently to prevent COVID-19, and that can be done as a mindfulness practice, Dutton says. “Before you begin, set your intention that you are going to pay attention to the sensations associated with the experience, as well as any thoughts that arise and emotions you may feel while handwashing. Moment to moment, pay attention to the water, the application of soap to your hands, the smell of the soap, the rubbing of your hands together. If a thought pops into your head while you are doing that—or if you start to feel sad—notice that but go back to the sensations of washing your hands, which is your anchor.”
The Yale Stress Center and Kabat-Zinn provide other tips and techniques:
- Take a moment or two to pause during the day. Put aside whatever you are working on or thinking about, and take in a few slow breaths. Notice the sensations of the air going in through your nose and exhaling out through your nose.
- Lie down, close your eyes, and slowly scan your body mentally from head to toe—or start from the opposite direction—bringing your awareness to each part of the body without judging or trying to change anything.
- Practice S.T.O.P.—this is an acronym that stands for Stop, Take a breath, Observe your feelings, and Proceed.
For people who want further guidance on how to practice mindfulness, Dutton leads a free weekly Zoom program every Wednesday afternoon called “Coping with COVID-19 Anxiety through Mindfulness.”
Mindfulness can stop the chatter, especially related to COVID-19
Dutton says the mind’s constant chatter can be stopped by mindfulness, which can be invaluable when people are worrying about everything from whether they wore their mask properly in the grocery store to how to help a loved one who is seriously ill.
“Strong emotions like fear, sadness, and anger—that we are all feeling right now—are perpetuated by ruminative thinking [thought patterns that go around and around], so sometimes we don’t even realize this is happening,” Dutton says. “Usually these thoughts are speculative,” she adds, explaining that they might be based on something in the news or a concern about what could happen in the future. For example, “You can really get caught up in getting furious about how the health care workers don’t have the personal protective equipment [PPE] they need.”
This loop of ruminative thinking perpetuates the emotions, Dutton says. “A mindfulness practice can help us connect with awareness and let things come and go without our attention getting stuck on it. It can also help us make better choices. Between the emotion and the action, there is a choice, so this can help you to respond rather than to react.”
Is there evidence mindfulness works?
In the last few years, there has been an exponential increase in mindfulness research, according to Dr. Sinha. “The research has just completely exploded. There have been lots of different studies,” she says. Various findings—some from National Institutes of Health (NIH)-funded research—have shown that mindfulness can help reduce stress and increase well-being, and help in the treatment of addiction, anxiety, high blood pressure, depression, cancer, chronic pain, heart disease, stress, and many other mental and physiological problems.
Hedy Kober, PhD, associate professor of psychiatry and psychology, and director of the Clinical & Affective Neuroscience Laboratory in the Yale School of Medicine, is interested in the benefits of brief mindfulness interventions. “A lot of mindfulness research—including some of my own early work—uses individuals who are experienced meditators. For some people that’s a lot of investment, and what they might want to know is that with a little effort they might start seeing a little bit of benefit, and that can help them to do even more,” she says.
One of Kober’s most recent studies involved recruiting people who had never meditated, teaching them to be mindful in a moment, and studying the effects of doing so on the brain. The effect was so pronounced that when participants were practicing mindfulness and subjected to physical pain (in this case, the application of heat to their forearm that was intense enough to cause pain, but not burn them), their brains responded as if they were experiencing a lower, less intense temperature.
While more research needs to be done on minimal mindfulness practice, Kober says, “My recommendation to patients is that any amount of mindfulness you bring into your day can yield benefits. What do you have to lose? You can at least try.”
Can mindfulness help you?
Dr. Fortin’s patients with serious illnesses have reported experiencing less suffering when they have practiced mindfulness techniques. One patient visited the emergency department three times within a couple of weeks partly because he had so much anxiety over COVID-19, even though he didn’t have any symptoms. During a telehealth appointment, “I was able to acknowledge the patient’s anxiety,” Dr. Fortin says. “He learned that it’s OK to be with what is, and to recognize how we bring suffering on ourselves because of our desire to want things to be different than they actually are.”
That kind of anxiety doesn’t surprise Dutton, who says many people are underestimating the emotional impact of COVID-19 and the changes it has caused in their daily lives. “Emotions are at much higher levels than we are used to,” she says, “and it’s not just anxiety. People are furious as well as incredibly sad, and many are really having trouble focusing on anything. I think we all have to slowly work on the ability to feel balanced in the face of these stressors.”
Dutton says people can use mindfulness as a tool. Depending on their level of anxiety, they may want to take advantage of other tools as well, possibly including some form of psychotherapy and medication, in addition to lifestyle habits such as sleep, exercise, and good nutrition, she says. “Find a good teacher who you feel comfortable with, invest time in it, and have faith that this is something that has helped people for thousands of years. It’s not a quick fix, but it can be really helpful.”