Does Mindfulness Have a Role in the Treatment of Fibromyalgia Syndrome?

Does Mindfulness Have a Role in the Treatment of Fibromyalgia Syndrome?

Fibro 1

Fibromyalgia syndrome is a poorly understood chronic pain disorder. An estimated 3% of adults are reported to suffer from fibromyalgia, with higher levels of occurrence in females compared to males. The main symptoms of fibromyalgia syndrome are all-over body pain, tiredness, difficulty in sleeping, and cognitive dysfunction such as memory impairment. There is also a high level of association between fibromyalgia syndrome and poor quality of life, mental health issues such as depression and anxiety, irritable bowel syndrome, and unemployment.

Some of the reasons why fibromyalgia syndrome is believed to be a controversial illness are as follows:

  1. Individuals with fibromyalgia are reported to exert a higher burden upon healthcare resources when compared with individuals diagnosed with other chronic illnesses.
  1. Research has shown that individuals with fibromyalgia often experience difficulty in having their illness diagnosed, and often feel that their needs and symptoms are poorly understood by the medical profession.
  1. A diagnosis of fibromyalgia is primarily based upon the exclusion of other illnesses, the patient’s medical history, and their reaction to pressure being gently applied to ‘tender points’. In other words, there isn’t a reliable laboratory test for fibromyalgia syndrome (e.g., blood test, x-ray) and this means that it is difficult to be 100% certain that a given individual is genuinely suffering from the illness.

The current treatment-of-choice for fibromyalgia syndrome is the use of psychopharmacology (principally antidepressants) coupled with non-pharmacological approaches such as physical exercise, cognitive-behavioural therapy, self-help, and/or psycho-education. However, pharmacological treatments for fibromyalgia have shown only a limited degree of effectiveness, and many patients withdraw from treatment due to the side-effects of antidepressants as well as low levels of symptom reduction.

The lack of convincing treatment efficacy outcomes for existing pharmacological and non-pharmacological fibromyalgia interventions has led to the empirical evaluation of alternative treatment approaches. Since there exists evidence (which varies in quality and quantity) supporting the use of mindfulness in treating each of the individual symptoms of fibromyalgia syndrome (e.g., chronic pain, sleep disturbance, fatigue, depression, anxiety, and cognitive dysfunction), mindfulness-based interventions have been an obvious candidate in terms of investigating their effectiveness for treating the illness.

A systematic review and meta-analysis comprising six randomised and non-randomised controlled trials of mindfulness-based stress reduction (MBSR) for individuals with fibromyalgia (674 participants in total) found that individuals receiving MBSR experienced significant short-term improvements in quality of life and pain compared to individuals in the non-meditating control groups. A further systematic review (incorporating a range of intervention study designs) examined the findings from ten studies of mindfulness meditation (702 participants in total). The review concluded that mindfulness led to significant improvements in both physical symptoms (e.g., pain, sleep quality, functionality) and psychological symptoms (e.g. depression, anxiety, perceived helplessness).

In terms of the possible mechanisms by which mindfulness helps to alleviate the symptoms of fibromyalgia syndrome, the most widely proposed explanation is that mindfulness helps to increase perceptual distance from somatic pain and distressing psychological stimuli. By mindfully observing painful bodily sensations, it appears that individuals suffering from fibromyalgia (and other pain disorders) can begin to objectify and almost distance themselves from their pain. The same applies to feelings of psychological distress and fatigue that are often associated with musculoskeletal pain. Mindfully observing feelings of distress, frustration and low mood appears to weaken the intensity of such feelings, and to help create the ‘psychological space’ necessary for other – more psychologically adaptive – feelings and thought processes to arise.

Based on findings from a randomised controlled trial of an online mindfulness-based intervention, it has been suggested that stronger treatment outcomes can actually be achieved by using mindfulness not just as a means of improving patient’s ability to cope with pain and psychological distress, but as a means of helping improve patients’ ability to engage in effective social and interpersonal interactions. In other words, given the complexity of fibromyalgia syndrome, it appears that in order to maximise treatment effectiveness, mindfulness interventions targeting fibromyalgia should be purpose-designed and encourage participants to draw on both psychological and social resources.

In terms of other potential mechanisms of action, there is evidence to suggest that mindfulness leads to changes in neurological pain pathways, reduced levels of ruminative thinking and self-preoccupation, and improvements in spirituality. This latter potential mechanism is important because cross-sectional studies involving individuals with fibromyalgia have specifically identified a positive correlation between spirituality and positive affect (i.e., as levels of spirituality increase so do positive mood states), and a negative association between spirituality and symptoms of depression and anxiety (i.e., as levels of spirituality increase in individuals with fibromyalgia, their levels of depression and anxiety decrease).

Findings indicate that purpose-designed mindfulness-based interventions may have a role to play in the treatment of fibromyalgia syndrome. However, at present the overall quality of the evidence is weak and there is a need to replicate and consolidate findings using methodologically robust randomised controlled trials.

Ven Edo Shonin and Ven William Van Gordon

 

Further Reading

Branco, J. C., Bannwarth, B., Failde, I., Abello Carbonell, J., Blotman, F., Spaeth, M., … Matucci-Cerinic, M. (2010). Prevalence of fibromyalgia: a survey in five European countries. Seminars in Arthritis and Rheumatism, 39, 448-55.

Cramer, H., Haller, H., Lauche, R., & Dobos, G. (2012). Mindfulness-based stress reduction for low back pain. A systematic review. BMC Complementary and Alternative Medicine, 12, 162.

Davis, M. C., & Zautra, A. J. (2013). An online mindfulness intervention targeting socioemotional regulation in fibromyalgia: results of a randomized controlled trial. Annals of Behavioural Medicine, 46, 273-284.

Dennis, N. L., Larkin, M., & Derbyshire, S. W. G. (2013). ‘A giant mess’ – making sense of complexity in the accounts of people with fibromyalgia. British Journal of Health Psychology, 18, 763-781.

Häuser, W., Wolfe, F., Tölle, T., Üçeyler, N., & Sommer, C. (2012). The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs, 26, 297-307.

Henke, M., & Chur-Hansen, A. (2014). The effectiveness of mindfulness-based programs on physical symptoms and psychological distress in patients with fibromyalgia: a systematic review. International Journal of Wellbeing, 4, 28-45.

Hickie, I., Pols, R. G., Koschera, A., & Davenport, T. (2004). Why are Somatoform Disorders so Poorly Recognized and Treated? In: G. Andrews & Henderson S. (Eds). Unmet Need in Psychiatry: Problems, Resources, Responses (pp. 309-323). Cambridge: Cambridge University Press.

Hughes, G., Martinez, C., Myon, E., Taïeb, C., & Wessely, S. (2005). The impact of a diagnosis of fibromyalgia on health care resource use by primary care patients in the UK: an observational study based on clinical practice. Arthritis and Rheumatism, 54, 177-183.

Jones, K. D., Sherman, C. A., Mist, S. D., Carson, J. W., Bennett, R. M., & Li, F. (2012). A randomized controlled trial of 8-form Tai chi improves symptoms and functional mobility in fibromyalgia patients. Clinical Rheumatology, 31, 1205-1214.

Langhorst, J., Klose, P., Dobos, G. J., Bernardy, K, & Häuser, W. (2013). Efficacy and safety of meditative movement therapies in fibromyalgia syndrome: a systematic review and meta-analysis of randomized controlled trials. Rheumatology International, 33, 193-207.

Lauche, R., Cramer, H., Dobos, G., Langhorst, J., & Schmidt, S. (2013). A systematic review and meta-analysis of mindfulness-based stress reduction for the fibromyalgia syndrome. Journal of Psychosomatic Research, 75, 500-510.

Moreira-Almeida, A., & Koenig, H. G. (2008). Religiousness and spirituality in fibromyalgia and chronic pain patients. Current Pain and Headache Reports, 12, 327-332.

Nüesch, E., Häuser, W., Bernardy, K., Barth, J., & Jüni, P. (2013). Comparative efficacy of pharmacological and non-pharmacological interventions in fibromyalgia syndrome: network meta-analysis. Annals of the Rheumatic Diseases, 72, 955-962.

Peterson, E. L. (2007). Fibromyalgia – Management of a misunderstood disorder. Journal of the American Academy of Nurse Practitioners. 19, 341-348.

Rimes, K. A., & Wingrove, J. (2013). Mindfulness-based cognitive therapy for people with chronic fatigue syndrome still experiencing excessive fatigue after cognitive behaviour therapy: a pilot randomized study. Clinical Psychology and Psychotherapy, 20, 107-117.

Scott, M., & Jones, K. (2014). Mindfulness in a fibromyalgia population. The Journal of Alternative and Complementary Medicine, 20, A94-A95.

Sicras-Mainar, A., Rejas, J., Navarro, R., Blanca, M., Morcillo, A., Larios, R., … Villarroya, C. (2009). Treating patients with fibromyalgia in primary care settings under routine medical practice: a claim database cost and burden of illness study. Arthritis Research & Therapy, 11, R54. DOI:10.1186/ar2673.

Wolfe, F., Brähler, E., Hinz, A., & Häuser, W. (2013). Fibromyalgia prevalence, somatic symptom reporting, and the dimensionality of polysymptomatic distress: results from a survey of the general population. Arthritis Care and Research, 65, 777-785.

Wolfe, F. (2009). Fibromyalgia wars. Journal of Rheumatology, 36, 671-678.

Wolfe, F., Anderson, J., Harkness, D., Bennett, R. M., Caro, X. J., Goldenberg, D. L., … Yunus, M. B. (1997a). A prospective, longitudinal, multicenter study of service utilization and costs in fibromyalgia. Arthritis and Rheumatology, 40, 1560-1570.

Wolfe, F., Anderson, J., Harkness, D., Bennett, R. M., Caro, X. J., Goldenberg, D. L., … Yunus, M. B. (1997b). Work and disability status of persons with fibromyalgia. The Journal of Rheumatology, 24, 1171-1178.

Shonin, E., & Van Gordon, W. (2013). Searching for the present moment, Mindfulness, 5, 105-107.

Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6, 1161-1180.

Van Gordon, W., Shonin, E., & Griffiths, M. (2015). Towards a second-generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49, 591-591.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice, 63, 654.

Shonin, E., & Van Gordon, W. (2015). The lineage of mindfulness. Mindfulness, 6, 141-145.

Tips for using Mindfulness in Psychotherapy Contexts

Tips for using Mindfulness in Psychotherapy Contexts

psychotherapy 2

Recently, we were joined by our friend and academic colleague Professor Mark Griffiths in writing a paper on ‘Meditation as Medication: Are Attitudes Changing?’ (the paper is currently in press with the British Journal of General Practice).1 The paper discusses how, amongst both patients and clinicians, the prospect of using mindfulness and meditation as a mainstream medical intervention is becoming increasingly acceptable. Over the last 12 months or so, in addition to mainstream research journals such as the above, we have also published (or had accepted for publication) a series of articles in more practitioner-based and/or professional journals where we offer suggestions on how best to use and teach mindfulness (and other meditative techniques) within medical and/or mental health settings. Examples are articles published in Corrections Today (a journal of the American Correctional Association),2 Thresholds (a journal of the British Association for Counselling and Psychotherapy), 3 Addiction Today (a practitioner-focused journal focusing on addiction recovery), 4 Education Today (the nationwide journal of the School and Student Health Education Unit), 5 and the quarterly publication of the National Council on Problem Gambling.6

Based on a synthesis of the recommendations outlined in the abovementioned professional/practitioner journals, and based on insights from our own and others’ research and practice of meditation, today’s post outlines what we consider to be helpful strategies for the effective use of mindfulness techniques within client-therapist settings:

1. Therapist-led practice: Findings from our own empirical research into Meditation Awareness Training (MAT) indicate that clients and patients place tremendous importance on the extent to which the therapist’s own thoughts, words, and actions are infused with mindful awareness.7 A therapist who is ‘well-soaked’ in meditation naturally exerts a reassuring presence that helps clients to relax and connect with their own capacity for spiritual awareness. As we discussed in our posts on ‘Teaching Mindfulness to Children and ‘Predicting your Enlightenment, if a meditation teacher (or a therapist) is going to instruct others on how to practise mindfulness correctly, then it is essential that they do so from an experiential standpoint. Furthermore, clinicians and psychotherapists are particularly at-risk for compassion fatigue – a type of secondary traumatic stress caused by working with clients who have an illness of a distressing nature or who have directly experienced a traumatic event.3 Therapist mindfulness practice has been shown to exert a protective influence over compassion fatigue and therefore helps to improve the therapeutic experience for client and therapist alike.8

2. Insight-led practice: This point is closely related to the above point on therapist-led practice and refers to the importance of psychotherapists appreciating that there are many ‘activating agents’ that are essential for the development of ‘right mindfulness’. As outlined in our most recent post on ‘Exactly what is the Present Moment?’, an example of such an activating agent is cultivating insight into the ‘impermanent’, ‘non-self’, and ‘empty’ nature of reality. A firmly embedded understanding by therapists of the principles that underlie effective mindfulness practice (i.e., non-self, emptiness, impermanence, etc.) is likely to enhance therapeutic outcomes in the long term. Indeed, according to psychotherapists Maura Sills and Judy Lown, greater therapeutic connection and transformation can take place as client and therapist begin to acquaint themselves with the non-self construct and work in an “open and empty ground state”.9 Similarly, as Professor Seth Segall of Yale University School of Medicine acknowledges a firm understanding of non-self can improve therapeutic core conditions because “the more the therapist understands anatta [non-self], the less likelihood that the therapy will be about the selfhood of the therapist”.10

3. Deep listening: As with all psychotherapy modalities, the therapist’s ability to listen deeply to what the client is saying, as well as to what they are not saying, is a vital part of the therapeutic process. However, in the context of mindfulness-based therapy, the practice of deep listening takes on a slightly different meaning compared with the more conventional therapeutic modes. When the mindfulness practitioner (or therapist) listens deeply to another person, believe it or not, the emphasis is actually placed more on listening to oneself rather than the client. Let’s clarify what is meant by this statement. Normally, any kind of discussion with another person triggers various kinds of emotional and cognitive responses. The way we interpret the words of others, and the types of thoughts and feelings that are engendered by those words, is heavily influenced by our own conditioning and beliefs. In other words, it is through the lens of the conditioned mind that we experience ourselves and others. So as meditation practitioners, the reason why we make an effort to listen to our own mental chatter during dialogue with others, is to try to limit the extent to which our own conditioning might colour our interpretation of what the other person is actually saying. As we referred to in a short vajragiti (a type of spontaneous spiritual song or poem) called Simply Being with Nothing to Be, the best way to listen deeply to ourselves in this manner is by being fully present with ourselves. When we are fully present with ourselves and are perfectly content with where and who we are, when we are happy to simply experience the present moment without trying to modify it, the pain that has built up inside the other person begins to talk to us. This happens naturally and without us having to look too hard. We can see all of the person’s suffering, we can smile gently at it, and that person’s pain knows that it now has a friend and is no longer alone. Their suffering has exposed itself to us, and because we are not lost or caught-up in our own thoughts or ego-attachments, a true communion of compassion and loving-kindness can now occur.

4. Life integration: Although it is undoubtedly beneficial for a client to meet with the therapist once or twice a week, it goes without saying that emphasis should be placed on empowering the client to introduce mindfulness into all aspects of their lives. Many clients find a CD of guided meditations and written resources about mindfulness practice to be useful props in this respect. Another factor that can make a big difference to the success of the therapy is working with the client to establish a routine of mindfulness practice. Our personal preference is to do this on a case by case basis (i.e., rather than prescribing a blanket-amount of formal meditation practice time for all people). When working with patients or meditation practitioners as part of our research or monastic work, we generally encourage people to try to adopt a dynamic meditation routine. In this manner, people are dissuaded from drawing divisions between meditation during formal sitting settings and meditation during everyday activities.11 As referred to in our post on ‘The Top Ten Mistakes made by Meditation Practitioners’, the purpose of this is to reduce the likelihood of dependency on the need for formal meditation sessions.

5. Meditative anchors: Integral to effective mindfulness training, particularly at the beginning stages, is the use of meditative anchors.3 A good example of a meditative anchor is observing the breath. Full-awareness of the in-breath and out-breath helps clients ‘tie their mind’ to the present moment and to subdue ruminating thought processes. Where clients have noticeably low levels of concentration, then teaching them to count their breath can be quite helpful. However, when using breath awareness as a meditative anchor, it is important to discourage clients or patients from forcing their breathing. In other words, the breath should be allowed to follow its natural course and to calm and deepen of its own accord (i.e., as a regular consequence of it being mindfully observed).3

6. Mindfulness reminders: In addition to meditative anchors, the maintenance of mindfulness during everyday activities appears to be facilitated by the use of mindfulness reminders. An example of a mindfulness reminder is an hour chime (e.g., from a wrist-watch or wall clock), which, upon sounding, can be used as a trigger by the client to gently return their awareness to the present moment and to the natural flow of the in-breath and out-breath (and to the space and time between each in-breath and out-breath).3 Some clients seem to prefer a less sensory reminder such as a simple acronym. For example, in the aforementioned eight-week Meditation Awareness Training program, clients are taught to use the following SOS technique to facilitate recovery of meditative concentration by ‘sending out an SOS’ at the point when intrusive thoughts arise:

 

The three-step SOS technique3,4

 1. Stop

2. Observe the breath

3. Step back and watch the mind

 

7. Meditative posture: Although the focus of mindfulness practice should be directed towards its maintenance during everyday activities, formal daily seated-meditation sessions are an essential aspect of mindfulness training. As part of seated meditation practice, a good physical posture helps to facilitate the cultivation of a good mental posture. The most important aspect of the meditation posture is stability which can be achieved whether sitting up-right on a chair or on a meditation cushion. The analogy used in Meditation Awareness Training for the appropriate meditation posture is that of a mountain. A mountain has a definite presence, it is upright and stable yet at the same time it is without tension and does not have to strain to maintain its posture – it is relaxed, content, and deeply-rooted in the earth.3

8. Psychoeducation: In most psychotherapeutic approaches, a degree of psychoeducation regarding the mechanisms of action and projected hurdles to recovery is generally regarded as a means of augmenting client-therapist trust and therapeutic alliance. Mindfulness-based therapy is no exception to this, and clients generally welcome advance notice of the difficulties they are likely to encounter as their meditative training progresses. One such difficulty, particularly in the beginning stages, is the feeling by patients or clients that their mind is becoming more discursive than before. However, rather than an actual reduction in levels of mindfulness, our own research into meditation has shown that such feelings generally result from a greater awareness by clients of the “wild” nature of their cognitive and emotional processes that had hitherto remained unnoticed.7 Particularly within the context of mindfulness-based therapy, psychoeducation should be regarded as a two-way process. In other words, in working with the client to discuss and explore different dimensions of their mindfulness practice, a co-produced form of understanding or wisdom often emerges. This is something that both the client and therapist can benefit from and is consistent with the Buddhist technique known as ‘Dharma sharing’.

Although the above points are not exhaustive, we believe that when they are implemented as part of a therapeutic relationship based on trust, patience, loving-kindness, and compassion, they will help to add authenticity to the transmission that takes place between client and therapist.

 

Ven Edo Shonin & Ven William Van Gordon

 

References

  1. Shonin, E., Van Gordon, W., & Griffiths, M.D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice. In Press.
  2. Shonin, E., Van Gordon, W., & Griffiths, M.D. (2013). Mindfulness meditation in American correctional facilities: A ‘what-works’ approach to reducing reoffending. Corrections Today, In Press.
  3. Shonin, E., Van Gordon, W., & Griffiths, M.D. (2013). Mindfulness-based therapy: A tool for Spiritual Growth? Thresholds. Summer Issue, 14-18.
  4. Shonin, E., Van Gordon W., & Griffiths, M.D. (2013). Meditation for the treatment of addictive behaviours: Sending out an SOS. Addiction Today, March, 18-19.
  5. Shonin, E., Van Gordon, W., & Griffiths, M. D. (2012). The health benefits of mindfulness-based interventions for children and adolescents. Education and Health, 30, 94-97.
  6. Shonin, E., Van Gordon, W. & Griffiths, M.D. (2013). Mindfulness-based interventions for the treatment of problem gambling. Journal of the National Council on Problem Gambling, 16, 17-18.
  7. Shonin, E., Van Gordon W., & Griffiths M. D. (2013). Meditation Awareness Training (MAT) for improved psychological wellbeing: A qualitative examination of participant experiences. Journal of Religion and Health. DOI: 10.1007/s10943-013-9679-0.
  8. Christoper, J.C., & Maris, J.A. (2010). Integrating mindfulness as self-care into counselling and psychotherapy training. Counselling and Psychotherapy Research, 10, 144-125.
  9. Sills, M., & Lown, J. (2008). The field of subliminal mind and the nature of being. European Journal of Psychotherapy and Counselling, 10, 10: 71-80.

10. Segall, S.R. (2003). Psychotherapy practice as Buddhist practice. In S. R. Segall (Ed.), Encountering Buddhism: Western Psychology and Buddhist Teachings (pp. 165-178). New York: State University of New York Press.

11. Van Gordon, W., Shonin, E., Sumich, A., Sundin, E., & Griffiths, M.D. (2013). Meditation Awareness Training (MAT) for psychological wellbeing in a sub-clinical sample of university students: A controlled pilot study. Mindfulness. DOI: 10.1007/s12671-012-0191-5.