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Modern Mindfulness 2.1 MINDFULNESS: AN OVERVIEW Mindfulness in perspective involves a realistic orientation of its place chronologically, historically, and culturally. The origins of mindfulness have profound roots in the meditative practices of religious traditions, Hinduism and Buddhism. The Orthodox Christian, Jewish, and Islamic faiths also have well-developed practices, although not discussed here. Their practices frame an inward stillness integrating mind with heart preparing for participation or meditative awareness, a “mindfulness” toward spiritual refinement. Throughout this book, terminological distinctions clarify ideas. Overlap in concept and practice is common in writings on the subject. Adding precision to a field where poorly explained and inconsistent definitions occur is difficult but useful. The relevant psychological significance is highlighted. In the traditional Eastern use, “meditation” and its practices are bhavana and dhyana. Meditation denotes both the process of attaining and the state of the mind’s clear attentiveness toward awareness of its awareness. This state of mental clarity, a clear mind, is “meditative” whether identifying with any detailed content of its conscious awareness. A meditative mind is engaged in mindful awareness. Often, the ideal intention is toward achieving “thoughtless” awareness. The classical meaning of “thoughtless” suggests realizing a mind that is awake, alert, and tranquilly active. This mental space approximates a relative emptiness or clarity of content. This condition is an intention to be approximated, possibly not reached by most meditators. The Eastern sense of “emptiness” of mental content is complex to fathom. It suggests a fluidity of mental contents in which no “object” such as thought rigidly binds a focus of attention. This state is a clear mind. Mental content traditionally refers to “objects” that populate the mind. These take forms such as sensations, emotions, feelings, images, thoughts, and imaginations. Using the expression, the knower and known, to explain this idea, “knower” is the ego or self that mindfully meditates. The “known” are the objects of attention used as anchors on which to meditate. Mindfulness meditation or “the establishment of mindfulness” is satipatthana. Insight meditation is

Learned Mindfulness. https://doi.org/10.1016/B978-0-12-816484-6.00002-6 Copyright © 2020 Elsevier Inc. All rights reserved.

vipassana bhavana. The state of awareness established by meditation is “mindfulness” or sati (from the Buddhist Pali language related to Sanskrit) and smriti (from the Hindu Sanskrit language). The term smriti connotes remembering, recalling, and bearing in mind values, viewpoints, and beliefs from the voluminous teachings of Buddhist dhamma and Hindu dharma. These are the corpus of sacred scriptures. The term sati thus suggests mindfulness memory, preferred in this book. Hindu Sanskrit or Buddhist Pali language sources, sometimes mixtures of both, make rigid distinctions difficult. However, in mindfulness and meditation contexts, each has nuances. For example, sati means mindfulness, dhyana means meditation, and Samadhi denotes profound meditative absorption. This in-depth level is a peak spiritual refinement in the Yoga system (discussed in Chapter 1). Mindfulness as a mode of awareness has also been described as present-centered and nonevaluative “bare attention.” The German-born monk Nyanaponika Thera (Siegmund Feniger, 1901e94) coined this term in his 1954 book, The Heart of Buddhist Meditation. Writers in the field question whether the implications unnecessarily exclude bearing in mind the respective admonitions and dharmas that are part of other practice perspectives. Chapter 4 discusses Learned Mindfulness as sati, mindfulness or mindfulness memory. Mindfulness, therefore, as a mode of awareness involves the self-regulation of attention. This focus maintains immediate experience orienting with curiosity, inquiry, openness, and acceptance (Bishop et al., 2006). Receptivity and acceptance with monitoring rather than active efforts to reach a goal characterize mindful awareness. The term mindfulness as sati or mindfulness memory is this book’s definition because memory implies effortless recall of embedded knowledge. Mindfulness orientation is experiencing present-centered assimilated knowing. Concentrated practices toward mindfulness clear and reboot the mind of involuntary mind wandering. This gap in flexible attention includes patterns of “fixedness” in thought and emotional processing. Current mindfulness defines “practice” to mean being

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purposefully aware for a specified time during the day or week. For example, mind wandering occurs on average about 46.9% of the waking time in most people (Fox & Christoff, 2018). Thus, mindfulness helps to recenter and refocus attention and minimize mind wandering. Mindfulness in the West does not denote the Eastern notion of emptying the mind wholly of its objects or contents. Instead, Western mindfulness aspires to a mind alert and aware for significant times during the day. Intensive practices periodically strengthen the ability to remain mindful between these exercisesda mindfulness readiness. In the West, commonly sought results are relaxation, reduced anxiety, more in-depth psychological composure, and calm. Mindfulness-based techniques are now part of psychiatric practices: in selected psychopathologies, substance use disorders, eating difficulties, and wellness psychoeducation programs (Zerbo, Schlechter, Desai, & Levounis, 2017). Accredited sources support the benefits of mindfulness for both physicians and patients. Health-promoting benefits stem from the modulation or cessation of discursive, rambling thoughts practitioners correlate with anxiety, mental distress, and suffering. Behavior change is part of this.

2.2 WHY MINDFULNESS? Mindfulness practices intend to make sense of one’s subjective experiencedand to better it. As seen from the ancestral origins of mindfulness, in former times those who engaged sought psychological and spiritual refinement. This achievement had several names: selfrealization, enlightenment, Nirvana, and Moksha (i.e., liberation). Mindfulness meditation had been inextricably entwined with religion. Now in the West, the emphasis is on stress reduction, relaxation, reduced anxiety, and greater peace of mind. Breaking addictive behaviorsdrepeating habits that are detrimental despite adverse consequencesdis also a significant goal. The challenge of physician burnoutdemotional exhaustion, cynicism with depersonalization, and a sense of professional inefficacydhas emerged and demands remediation. For example, 54.4% (n ¼ 3680) of the physicians in one study reported at least one symptom of burnout (Shanafelt et al., 2015). Mindful orientations and practices have provided a promising avenue to explore (Beckman et al., 2012; Krasner et al., 2009). Mind wandering occurs when thoughts are not focused on a single topic or task for an extended time. This “off-task” distraction is also task-negative network inattention. Multitasking is both a cause and effect of a less than mindful perspective. The stable trait of mind wandering is transient. It fluctuates in people with lower

mood or depression (Killingsworth & Gilbert, 2010). Colloquially termed a “psychological Sahara,” those in this off-task state report thinking about past or future. The brain’s default mode network (DMN) links to mind wandering and internally directed thought (Gruberger, Ben-Simon, Levkovitz, Zangen, & Hendler, 2011). The DMN is an essential consideration in mindfulness. It maintains an internally generated loop of selfreferential narratives. This self-world imagery fills the void when the mind idles between tasks. Dysregulation of the hippocampus via gamma-aminobutyric acid is involved in mind wandering (Schmitz, Correia, Ferreira, Prescot, & Anderson, 2017). Mind wandering is an inadvertent, involuntary nonfocused state of inattention. Although semantic difficulties arise when words such as daydreaming and reverie appear synonymous, their meanings differ. Daydreaming has more consciously intentional directedness toward diffuse attentiveness and a subtle pleasurable quality. Reverie suggests an almost dreamlike state of rapture in an affectionately engaged scenario. The discussions here restrict mind wandering to inadvertent, unintentional, nonfocused inattention (Seli, Risko, & Smilek, 2016). Boredom is perceiving the environment as dull, tedious, and lacking in stimulation. Goetz and colleagues describe calibrating boredom as the passive searching for new ideas. This condition is not unpleasant. It is open to new thoughts and boredom-reducing options (Goetz et al., 2014). “Attention” has been viewed as the “sixth” vital sign over the last decades. It joins blood pressure, heart rate, respiratory rate, temperature, and regrettably “pain.” Attention difficulties associate with symptomatic dysregulation, distress, and may need treatment. Different subspecialties describe inattention and its distressing effects differently; measuring this “sign” is seldom precise. This medicalization has led to an array of attentional disorder diagnoses and the prescription, sometimes over prescription, of psychostimulant medications, many with potentially adverse side effects. Many other behavioral impairments often present themselves as primary signs and complicate this inattention. The wise physician carefully rules out primary learning disorders and substantially lowered IQ scores while choosing a medication with minimal or no effects on appetite, sleep, and tendency to increase anxiety and mood instability (Ninivaggi, 2017a, 2017b). A range of long-acting adrenergic a-2 agonists or atomoxitene may be safe choices, if clinically needed. A certain amount of mind wandering or inattention is part of people’s normal waking state. Excessive mind wandering and bona fide inattention needs strident measurement to verify fidelity and correct

CHAPTER 2 Modern Mindfulness identification (Seli, Smallwood, Cheyne, & Smilek, 2015). Attention, executive control, and mind wandering relate, though differently (Smallwood & Schooler, 2006). Patients and parents seeking higher levels of intellectual performance often request aggressive management of attention with drugs. This practice may lead to unhelpful and unsafe treatment with endpoints ill-advised when not supported by other available, nondrug methods. These methods are more intensive educational curriculums and workarounds. They included modifications and adaptations to measured cognitive platforms and tracked potential for improvement (Catalá-López et al., 2015). Mindfulness offers an additional innovative option. Thus, why choose mindfulness to help center attention? Mindfulness as an aspirational antidote arises from the typical default of mind wandering and the rambling distractedness of thought contents. The wish to regulate this evokes the dialectic of opposites: mind wandering and its contrast with mindfulness. Trying to attain synchrony of opposite poles reflects the universal impulse toward selfmodulation, natural homeostasis. Moderation and the ideal of “the middle path” have always been adaptive goals in any rational endeavor. The emotional dimension, however, of feeling the tension of extremes and a challenge to master them involves exciting and pleasurable experiences. These include the excitement of the anticipation, the building of expectations, and the pleasurable satisfaction resulting from incremental approximations and final achievement. While this book centers on mindfulness comprehension and applicability, there is a growing literature on mindfulness used to enhance and modulate activities of everyday life: eating, exercise, leisure, child rearing, and more. Mindful approaches even address addictive behaviors (Brewer, 2018; Brewer, Elwafi, & Davis, 2013). Anxiety and harmful habits respond to mindfulness interventions. Mindful awareness once learned becomes part of everyday experience. Becoming mindful is an unfolding process of self-understanding, understanding others, and a fuller, consciously aware life with meaning.

2.3 MINDFULNESS APPROACHES IN THE WEST In the West, modern mindfulness practices originated formally in the early 1980s. Fundamental principles of

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mindfulness-based therapies continue to comprise attention regulation, openness to present experience, curiosity, acceptance of the present moment, and nonjudgmental awareness of sensations, emotions, thoughts, and the environment. Stress reduction and a more comfortable capacity to relax become nurtured. Efficacy correlates with increased ability to manage stressors, become more mindfully aware, and experience less anxiety and rumination. Westernizing Eastern systems has led to periodic tries to deemphasize connotations of mysticism and perceived “hocus-pocus.” The emphasis in “meditation” is about genuinely paying attention to mindfully present-centered awareness. The structured and repeatedly validated techniques of Mindfulness-Based Stress Reduction (MBSR) by the distinguished psychologist Jon Kabat-Zinn focused on the physical level of stress and supportive care for ailments such as cancer, chronic pain, heart disease, and fibromyalgia (Kabat-Zinn, 2000, 2005, 2011, 2013a, 2013b; Kabat-Zinn & Williams, 2011; Vago & Nakamura, 2011). A psychotherapy, MindfulnessBased Cognitive Therapy (MBCT), was used for depression relapse (Morgan, 2010). MBCT emphasized changing the awareness of and relationship to thoughts rather than the thoughts. A significant part of this process included the development of “decentering.” “Decentering” entails distinguishing rigid identification with one’s thoughts as personal facts identical with oneself (Bernstein et al., 2015). These therapeutic interventions occurred 45 minutes per day, 6 days per week over eight weekly sessions and a daylong retreat. Mindfulness systems regard mindfulness and its practices as a process, more a way of life than an occasional meditative exercise. Intimacy with the present moment, not bound by time, and a relaxation of the frenetic pace of routine activities characterize mindfulness. Mindfulness can counterbalance habitually experiencing life as an “emergency.” Mindfulness frequently likens itself to learning “nondoing.” Nondoing highlights the acceptance of oneself attentively at the “now” of the present moment. Chapter 1 discussed the theme of nondoing with its enormous Eastern significance. A by-product of judicious and measured nondoing is the reduction of the sense of pressure “to get things done.” Acceptance and Commitment Therapy (ACT) developed in the 1990s by Steven Hayes and Colleagues sought to increase psychological flexibility using mindfulness approaches. This mental flexibility involved engaging with the present moment fully as a consciously aware person and changing behaviors toward chosen values. An underlying premise was core

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distress resulting from avoidance and fear (Hayes, Strosahl, & Wilson, 2012). The acronym, FEAR, represented Fusion with your thoughts, Evaluation of experience, Avoidance of your experience, and Reason-giving for your behavior. In this system, a healthier alternative is to adhere to the guidelines shown by the acronym, ACT: Accept your reactions and be present-focused, Choose a valued direction, and Take action. Mindfulness meditation is the framework for several protocols. These include an occasional replacement for or addition to traditional psychotherapy, as a relevant part of Dialectical Behavior Therapy (Linehan, Comtois, & Murray, 2006), a tool for corporate well-being, an educational instrument, and a regimen for building more resilient soldiers (Van Dam et al., 2018). Mindfulness falls under the aegis of mind/body perspectives such as the fields of Integrative Medicine, Complementary and Alternative Medicine, and the American Consortium on Integrative Medicine associated with medical schools (Loizzo, 2000). Over the last decade, occupational burnout is prevalent in healthcare. Physician burnout is escalating. Most burnout prevention and restorative protocols recommend mindfulness as a worthwhile intervention. Chapter 4 discusses physician burnout as a modern medical challenge. The effectiveness of meditative techniques led to modifications of protocols and using mindfulness practices for stress reduction. Reducing distressing rumination and worry over life’s puzzling challenges was a significant enhancement. Gradually, the connections with Yoga and Buddhism led to various integrations, too many to detail in this brief review. Bringing into consideration compassion for self and others was another refreshing insight. Mindfulness practices enhance one’s sense of concern for suffering and evoke the desire to help. The benefits of becoming mindful, however, include stress reduction and reduced anxiety with mood stability. Greater mental clarity and focus are by-products sought. Mindfulness practice develops more significant self-knowledge and understanding. Behavior change, reduced anxiety, and adaptive coping strategies are parts of this.

2.4 MINDFULNESS: FOUNDATIONAL PERSPECTIVES Western thinking tends toward scientific, logical, organized, and rational approaches focusing on what is conscious and testable. While reasonable, a few classicists see it at odds with the sources from which

mindfulness practices arose. A realistic position approaches mindfulness using its evidenced-informed and scientifically researched mechanisms. Distinctions, therefore, among mindfulness, mindfulness meditation, and meditation clarify nuances. Most recognize mindfulness as a state of awareness that is (1) attentively single, (2) clear, and (3) emotionally poised. To achieve mindfulness, practitioners use mindfulness exercises. These procedures have several terms, each having nuanced emphases. The phrase “meditation practices” is used; less often, “meditation.” This book prefers the more psychologically oriented term “mindfulness” and “pause” to cover both the mindfulness systems and their attainment. The culturally oriented roots of mindfulness cannot be dismissed without losing something of the heart and soul of any practice. Western methods have tried to westernize mindfulness practices by minimizing these referencesdmostly, although there are exceptions. For example, David R. Vago PhD, a distinguished cognitive neuroscientist, has contributed seminal work on mapping modalities of selfawareness in mindfulness practice. Attempts to capture a definition of self-processing loom large but remain elusive. Self-processing typically entails attempts to make sense of perceptual images and mental concepts of oneself. His research offers much in the understanding of self-processing (Vago, 2013, 2014). Northoff (2011) also explains the self-processing theory as have Brewer, Garrison, and Whitfield-Gabrieli (2013), Brewer and Garrison (2013), Brewer, Davis, and Goldstein (2013). While adhering to Buddhist fundamentals, Vago uses Western scientific models to integrate his knowledge of mindfulness mechanisms as a triune of self-awareness, self-regulation, and self-transcendence. Vago and Silbersweig (2012) propose these mechanisms drive mindfulness practices. These intentions naturally strive toward a higher level of personal development and well-being. Self-transcendence may go beyond these. From a psychological perspective, however, it implies reduced egocentricity, narcissism, and more significant empathy and compassion. Part II of this book (Chapters 3 and 4) covers the author’s version of an emotional intelligence perspective of mindfulness. Mindfulness variations attest to the “problem of the one and the many.” These perspectives reflect “the beauty of the one and the many” as it has and continues to exist in diverse, creative efforts toward self-understanding.

CHAPTER 2 Modern Mindfulness

2.4.1 Seven Specific Prerequisites of Mindfulness Practices Becoming mindful presupposes a motivation for selfimprovement. For most, this involves clarity and stability of thinking and emotional experience. Behavior change follows. Formal practices are structured practices. Informal, less structured practices can weave themselves into routine activities throughout the day. One may practice alone or in groups, with or without an instructor. Beginners can seek formal instruction from a guide, at least at the beginning of the journey. Jon Kabat-Zin (2013a), a distinguished psychologist and originator of the MBSR Program, proposes seven attitudinal foundations of mindfulness practice. These guidelines ask the beginner to entertain several considerations.

2.4.1.1 Nonjudging Nonjudging is developing an attitude of becoming an impartial witness to one’s experiences. Learning to be an alert observer to what one is doing in thought, feeling, and action, and then noting the almost habitual, automatic evaluations given to these must be identified. Whether first attending to sensations, inner thoughts and feelings, or to outer behaviors, putting them together sets the stage for the next, automatic evaluation or judgment that follows. Judging can be a straightforward “good” or “bad.” It may involve more complex “ought to” variations. Judging arises spontaneously and needs to be noticed, gradually deemphasized, and minimized. Good and bad in judging are best minimized. Negative self-criticisms are common. When projected, they are negative judgments about others. This first step is essential because judging is a core quality of critical thinking whose function is to help make sense of sensory data. This sense-making is not de novo. It is based on earlier experience, memories. Thus, it is influenced by habit patterns with biased tendencies. Using the nonjudging technique is an effort to unlock the mind’s rigidity in stereotyped categorization. Eliciting one’s “inner critic” to negativize and “condemn” a thought or emotion is an unhealthy self-criticism. Nonjudging gives a fresh opportunity to view the data of experience with a less automatically biased lens. Remember: this nonjudging of thought occurs inside mindful practice. In everyday life, evenminded assessments are essential to critical thinking, problem-solving, and adaptive work-life balance. From a positive perspective, this way of approaching experience means accepting one’s apprehensions in how they present. Seeing things both in the environment and captured in their own right without projected

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attributions is the ideal aim. Mindful states minimize selective editing of content when in periodic states of intense practice. The enormous emphasis here is on minimizing the interpretations and meanings imposed. This imposed editing harkens to traditional psychological concepts such as the “projection” of personal biases on experiences. Nonjudging means identifying tendencies to impute harsh criticisms to oneself. Softening these with realistic mindful self-compassion is essential mindfulness. Learning to replace judgments with a gentle curiosity about ideas, feelings, and behaviors is the mindful option.

2.4.1.2 Patience Patience is central to all aspects of mindfulness. The term “pauses” shows the periodic enactment of patience. Both patience and pause are a slowing and time out from a more hurried pace. Quiet time provides the opportunity for reflection. In addition, patience permits additional time to elapse, so the natural course of events may continue permitting a more natural unfolding. While this is happening, one observes occurrences in more of a resting state than in an engaged “doing” state. This position is watching and witnessing so valued in the cultivation of mindfulness focusing on mental activity as it unfolds.

2.4.1.3 Beginner’s mind Beginner’s Mind is like having the eyes of a child seeing the world anew. The child repeatedly marvels at each new and awe-filled revelation. Beginner’s Mind builds on the previous attitudes of nonjudging and patience helping to configure a clear and uncluttered mental set. An essential benefit of Beginner’s Mind is readying the practitioner for the experience of what may be seen and felt as foreign and strange. This unsettling surprise happens when first encountering ideas and practices about mindfulness and its exercises. Many of these guidelines as prerequisites for mindfulness interface with and support one another. Nonjudging is foundational. Beginner’s Mind, as a prelude to an adventure, makes nonjudging a more straightforward task.

2.4.1.4 Trust Trust in mindfulness directs itself to develop trust in oneself. The entire process of mindfulness is personal. Trust pivots on trusting one’s capacities for knowing the right things to do for one’s betterment. This knowing with both conscious and subliminal dimensions comprises an integration of intellectual abilities, emotional sensibilities, and intuitive capabilities. These trusting foundations bridge understanding from

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conscious knowledge toward one’s sense of core being. Trusting oneself is a subtle and complex attitude needed to approach mindfulness. It taps unmeasurable and nonconscious motivating urges. Essential trust in oneself may be decisive in any mindfulness pursuit. It is a powerful counterbalance to the anxieties and fears that venturing into unknown territory, mind explorations, uncover. Trust means taking accountability for one’s decisions and the actions that follow. Often, what follows is the unexpected. When such unanticipated events, thoughts, or feelings arise, a poised, open mind that can graciously entertain a temporary acceptance is a skill. What follows from unforeseen circumstances creates frustration, perhaps anger, and momentary confusion. Trustfully meeting the unexpected as a fresh, welcomed adventure becomes more comfortable. This greeting elicits positive feelings making its management mindful instead of disturbing and cynical. Trust, therefore, is a significant choice with far-reaching consequences.

2.4.1.5 Nonstriving Nonstriving may be a unique characteristic of meditation and mindfulness. It is a quintessentially Eastern idea. This phenomenon is a “nondoing,” a “goalless goal,” a “pathless path,” and an “inactive action.” This noninstrumental dimension has an equivalence in ideas such as noncraving, nondesiring, and nonattachment. When Learned Mindfulness describes non-“do-er” awareness in everyday living as “I am-ing,” it portrays this nonconscious, implicit mindful engagement with living. The above characterizations appear paradoxical and perhaps contradictory. They are challenging and elicit creative realizations transcending conventional thinking. The flavor of Zen Buddhism pervades their intentions. The sense implied in these ways of describing “nonstriving” is that the mindfulness endeavor is a process living in the “now.” Past and future mind wandering and concerns must redirect to the present. One begins the process freshly by opening attention at once in the immediacy of each moment. After that, remaining alertly aware of continuing in that immediacy is likely. Noticing and witnessing occurrences coming and going through the lens of experience is mindful awareness. Chapter 1 discussed that “I” as sovereign do-er must soften its rigidity. The nuance is the shift from being an action figure to one who mindfully witnesses actions. Initiative and performance enhance one another. The individual as sovereign agent and do-er filled with urgency and pressure loses its stringency. Chapter 4 will

discuss this critical quality of mindfulness as being a poised transactivity in its discussion of Learned Mindfulness. The proposed “paradigm shift” moves from dualistic frames toward interactive, engaging, participatory, and embodied interactivity. Embodied means inclusive awareness of mental and bodily experiencing. Mindful awareness thus reconfigures from experienced to become a continual experiencingdan “I am-ing,” an embodied awareness. This process of engagement of self and what it does and how it moves implies a coherence. Dualistic states characterized by previous trends toward splitting into contrasting opposites gradually integrate. In this assimilation, contrasts become more unified. Therefore, a person dynamically “being in” is not at either extreme but in mindful experiencing. The self is not at one end, the goal at the other. The gap of “becoming aware” is the center of mindful awareness. Difficult to grasp at first, it is not too complex. The “I am-ing” means that thinking learns to view its processing not as “I, the subject” experience this “feeling or thought as object” but rather as “I am experiencing this feeling, this thought.” Mindfully absorbing the moment of experience is “I am-ing.” The impermanence or fleeting quality of “be-ing” in an experience loses any fixedness to adhere to that one moment. Flow in the experience, and then move on. Put differently, “I am dynamically at one in this experiencednowdthen leave.” Thus, more dynamism and less rigidity infuse the process. The intention becomes “I am aware of engaging in the immediacy of now.” Rather than a static ego locked in a rigid relation with an object, one’s more fluid sense of awareness bathes objects that enter its field. Awareness as unifying not as splitting acts as a witness to this dynamic coming and going. Awareness does not take ownership or say “mine” as, for example, lower-order ego cognition is prone to do. “I” becomes the experience of a “witness,” observer, and permittor of experiencing, not a sovereign “do-er” or controller or owner. Chapter 1 discussed these ideas about the Eastern concept of asmita and the association of “I” or ego as perceived sole agent controlling consciousness and behavior. The psychological concept of agency or sense of control is the subjective awareness of starting, executing, and controlling volitional actions. It is the prereflective awareness or implicit sense it is “I” who is performing the bodily movements and thinking the thoughts. The sense of agency is the belief in the ability to cause one’s actions as the sole, responsible source. As with other complex psychological ideas, the sense of agency lies

CHAPTER 2 Modern Mindfulness on a dimensional spectrum. The range is from feeling passive and acted on to active and solely self-directed. Each person is a relatively active agent, not a fully conscious or “omnipotent” autocrat choosing then doing. People perform in social contexts that are interactive and cofacilitating. Having qualities of a personal agency on either extreme suggests impairments of initiative about arousal, intensity, and consequences in real life. In mindfulness, a sense of agency that is moderate, not sovereign, is optimal. Its intention shows a robust orientation toward the process as a “becoming,” not a frenetic striving toward achieving a future goal. It is living in a reasonably effective way. Gentle nonstriving is an essential core of mindfulness practice, awareness, and readiness throughout the day.

2.4.1.6 Acceptance Acceptance means seeing and acknowledging things as they are without adding qualifying adjectives or interpretations. This sense of “reality as it is” is a skill built on the previous five attitudinal foundations, mainly the first one, nonjudging. While nonjudging applies to all experience, it is essential to one’s acceptance of oneself. It is a willing surrender to see ourselves as we are. The importance of this self-acceptance is that it directly evokes the conscious and nonconscious intricacies of one’s narcissism. Healthy narcissism can refer to sublimated attributes of coping skills contributing to judicious, measured self-esteem, self-worth, self-efficacy, self-agency, and self-image. Therefore, acceptance is complex and comprises a considered and delicate self-reflection and self-analysis to ferret out the beneficial from what is less adaptive. As discussed in Chapter 1, the Eastern concept of asmita, roughly akin to Western notions of narcissism, is relevant. Acceptance presumes maintaining a realistic sense of self. This adaptively healthy sense of self implies recognizing tendencies to gravitate toward exaggerations, judgments, and criticisms. Refocusing on the middle path of moderation remains core to all mindfulness systems both Eastern and Western.

2.4.1.7 Letting go Letting Go is another quintessential phenomenon in mindfulness. Letting Go and attachment harken to central themes in Yoga and Buddhism. The term “attachment” refers to one’s default state of habitually clinging to objects on all levels of experiencedthe material objects in the environment and mental objects in mind. Understanding the meaning of attachment is complex because it is fundamental to survival and quality of life. The material dimension of attachment and

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clinging to material objects is clear as it can progress to excessively gathering, holding, and accumulating. This unyielding clench falls under the emotions of “greed” and “avarice.” However, in mindfulness, the attachments of concern are those of the thinking processes. How thinking is managed affects emotional processing. When unhealthy attachments are excessive, they configure the mind to develop anxiety, worry, fears of loss, depression, stress, and emotional strife as found, for example, in interpersonal and marital discord. Many attachments are the habit loops linking unhealthy reactions with their ingrained triggers. Mindfulness targets a disconnect replacing “bad” triggers and reactive behaviors with more internally generated positive triggers and their healthier rewards. Chapter 1 discussed the way traditional Eastern cultures held attachment and release as considerations in meditation and mindfulness. Modern mindfulness also regards the capacity to allow thoughts to release themselves and flow freely to be essential to any successful practice. For example, flow in engaged work performance mirrors joy in one’s work (Csikszentmihalyi, 1997). Remembering these seven mindsets facilitating mindfulness skills is fundamental. As discussed throughout this book, critical thinking is a mode the physician usesdoutside of mindfulness exercisesdto practice high-end medicine. Concentrated mindfulness practices are exercises building mental equipoise. When critical thinking arises, it may emerge in optimal ways suitable to needed contexts.

2.4.2 Attentional Regulation: Core of Mindfulness Practices The primary tool used to access and manage thoughts and feelings in mindfulness practices is attentional management. Working with one’s attention is the selfregulation of attention. Three protocols for mindfulness practice follow in further sections. Self-regulation has two components: (1) modulation that is a nonconscious, tacit, and implicit process of changing, reconfiguring, and stabilizing and (2) regulation that uses this nonconscious changing in a consciously, purposeful way to effortfully regulate how attention is selected and used thoughtfully and behaviorally. Thus, nonconscious changing with its broad impact expresses itself as accessible on everyday practical levels when consciously activated critical thinking uses its integrated nonconscious base. The platform of self-regulation of attention contains focused attention, clarity, and emotional poise.

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Attitudes open, curious, explorative, nonjudgmental, patient, trusting, intentional but not harshly goaloriented, accepting, nongrasping, and easy to release their objects of attention are best. Gracefully moving forward is conducive to ease in mindfulness practice. Another foundational attitude is surrender. Surrender is akin to acceptance. Surrender, however, in mindfulness meditation is nuanced with themes of permission, deference, nonresistance, and receptivity. One relaxes one’s active striving toward well-formed, logical, fixed goals. This is relaxing harshly analytic critical thinking. This relaxation opens the curious mind to receive the flow of streaming, apparently disorganized ideas and feelings. Letting the mind’s contents flow throughdjust noticing then accepting their fading is mindfulness. Implied here is surrender to one’s incompleteness. Less than optimal, well-understood, even undesirable characteristics become clearer, are labeled, and then left. This mindfulness practice helps to transform contracted awareness to expanded possibilities for future development. This Eastern perspective has entered Western practice in compelling suggestions. They include welcoming whatever arises in mind, lingering with it rather than adherently accepting or rejecting it even if distasteful, then graciously permitting it to dissipate and dissolve. For example, if one feels boredom, the suggestion might be to embrace the boredom with curiosity, feel it, linger with it without acting on it by getting up and walking around, and then permitting it to dissipate. This technique also applies to the feeling and managing of the discomfort of mild to moderate pain. When in a quiet state, if pain emerges, focus on it, examine its sensations, stay with it for a while, and hope it will subside. This self-regulating technique is using the problem creatively to solve the problem. While these examples may be difficult for the nonmeditator to imagine as ordinary ways to manage distress, meditators and those well versed in mindfulness have reported positive results with practice. Expert meditators state that relaxing into discomfort sometimes reduces pain intensity. Each person can manage thoughts by mindfully relating to instead of automatically resisting them. This nuanced ability to step out of a maladaptive thought cycle requires ongoing learning. Western systems of mindfulness put the selfregulation of attention in high regard. The term “regulation” presumes a conscious, effortful control over a vast area of neuropsychological processes having somatosensory and internally habit-laden conditioning. Selfregulation of attention is a management challenge but viewed as central to the mindfulness process.

Mindfulness teaches the skill of shifting modes of awareness from critical thinking to its temporary suspension. Effortfully relaxing consciously critical thinking enhances nonconscious modulation and change on implicit learning levels. This shift is a learned skill becoming activated with in-depth practice. Eastern perspectives have recognized this matter about variable states of attention and mind wandering. They describe this stabilizing task as one of steadying the constant fluctuations inherent in thinking processes. The attentional lability of the default mode is “mental chatter.” This flutter is a conglomeration of thoughts and feelings, back to back, clashing in an unending cacophony. It has been likened to the image of traffic “rush hour” with all its dissonance, confusion, frustration, and heated angry feelings. Self-regulation by nonconscious modulation and conscious regulation of attention builds emotional equanimity and mindful equipoise. For any attentional mindfulness work, the setting, one’s posture, and the time duration of each session are concrete details needing forethought. Many practice varieties are available. No standard guidelines can be given; each person and context offer unique situations to customize. Mindfulness practices are genuinely lifelong endeavors. However, there is evidence that positive changes can occur in 5e60 hours of formal training (Fox et al., 2014). Mindfulness training enhances brain and cognitive plasticity. These are process-specific events with wide-ranging effects (Slagter, Davidson, & Lutz, 2011).

2.4.3 Benefits of Mindfulness: SelfRegulation Self-regulation on many levels is the overarching benefit of attaining a mindful awareness in everyday life. Mindfulness is self-regulation. Three dimensions include (1) mindful attentional self-regulation that is alert and oriented, (2) emotional self-regulation that is curious, accepting, and can manage distress, and (3) self-awareness self-regulation that is insightful. Self-regulation involves a gathering of disparate and split experiences toward a biomental unification. The elements of attention, sensation, perception, thinking, and performance coalesce and integrate. This galvanization means a clear, openly receptive, balanced, poised, steady, and fluidly mobile state without a fixed bottom line. The caesura or splits in the natural flow of sensation, feeling, thought, and action thus diminish. For example, on the level of emotional regulation, mindfulness helps to enhance which emotions arise more efficiently and how suitably they are expressed

CHAPTER 2 Modern Mindfulness intentionally. This communicative facility is a byproduct of more refined empathetic skill. Self-regulation presumes a decentering of oneself to minimize unrealistic overemphases. This subtle modulating process involves identifying self-experience on several complex levels. These include I or ego as the active do-er, self-agency, self-image, body image, selfesteem, self-efficacy, self-confidence, and mood stability. These features describing personality are adaptive and healthy when in moderation and accord with reality testing. Only when one or more becomes pronounced and out of balance do challenges arise. Balance and decentering go together. A “decentering” of exclusivity of and on the selfddiminished narcissismdoccurs. Rigid identifications of all that transpires mentally and emotionally fade. Self-regulation on different levels of functioning involves managerial alignments that include 1. Self-regulation of attention. 2. Self-regulation of sensory awareness (e.g., raw, inchoate sensations become less coarse and more self-aware). 3. Self-regulation of perception (i.e., refinements of forming sensations, emotions, and thoughts). 4. Self-regulation of thinking. 5. Self-regulation of performance. Self-regulation associated with meditative experience diminishes mind wandering and by extension mind distress (Brewer et al., 2011). In everyday life, the benefits of mindfulness and overall self-regulation lead to more significant mindful listening and more responsive mindful speaking. Recent studies show that mindfulness programs improve self-compassion and lessen rumination. Neural correlates strengthen coupling between neural regions linked to sensory awareness perception, including the brain’s insula and the pregenual anterior cingulate (MacLean et al., 2010; Sevinc et al., 2018) (Table 2.1).

2.4.4 Stumbling Blocks to Mindfulness Practices Naturally occurring hindrances (i.e., Nivarana) inevitably arise. Being entrenched in everyday affairs, notably the details of medicine, the motivated physician needs intrinsic effort to step back and refocus temporarily. Multitasking must become the monotask of anchoring within, discovering, and bringing to salience bodily sensation and mental processing reconfigurations. Unfamiliarity with a mindfulness mindset is a block to be identified and embraced. It may be not knowing how to begin appropriately. This uncertain hesitation in focused self-observation is natural and understandable.

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TABLE 2.1

Benefits of Mindfulness: Self-regulation Managerial Alignments of Attention. Benefits of Mindfulness

Self-regulation Outcomes Self-regulation as (1) nonconscious modulation and (2) conscious regulation enhances containment, structure, and focused direction that minimizes anxiety.

Self-regulation of attention

Diminished mind wandering. Diminished boredom.

Self-regulation of sensory awareness

Sensation is identified and refined with practiced noticing, then “moving on.”

Self-regulation of perception

Perceptions become “labeled” sensations, emotions with a readiness for meaning, i.e., feelings.

Self-regulation of thinking

Attention, sensation, and perception align to reconfigure with meaning and in-depth relevance from thought, e.g., greater insight.

Self-regulation of performance

With attention, sensation, perception/feeling, and thinking aligned, both effortless and effortful choices lead to adaptive behaviors.

Adequate preparation may entail preliminary reading or instruction with a qualified professional. The most common difficulty is mind wandering. Mind wandering involves thinking of the past or the future instead of remaining in the present. Often, personal guidance is the preferred intervention. This personalized step-by-step analysis of the process shows a living example of the experience. It offers reframing tips specific to the one having the challenge. Feeling bored is common. Recalling the character strength of perseverance and being open to new experiences while seeing the broader perspective of the present endeavor helps refocus attention. Thus, the urge to avoid becoming mindful loses harshness. Chapter 5 discusses

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the concept of character strengths and their use to help overcome temporary impasses.

2.5 MINDFULNESS MEDITATION PRACTICES IN THE WEST In all practices and mindfulness, a specific intersection of change is self-processing. As mentioned in Chapter 1, the concept of “self’ is central to the entire field of mindfulness as it sits embedded in any of its cultural traditionsdEastern or Western. How one understands the self and defines its nature, processing, and functions are crucial to a solid understanding of mindfulness and the methods used. An overview of relevant neuroscience ideas related to mindfulness practices is warranted. The intimate associations between brain and mind are unavoidable. They remain a focus of interest in many research studies. Focusing on mindfulness practice will follow an overview of neuroscience perspectives. In cognitive neuroscience, the concept of selfreferential processing defines and explains how the self apprehends and manages an understanding of itself using its mental contents. Because this is a complicated issue, no consensus has reached final status (Nejad, Fossati, & Lemogne, 2013). Many proposals approximating a reasonable, if not hypothetical and working understanding, exist. Imaging studies associate functional areas of the brain with their presumed actions. Vago (2014) discusses neural mechanisms for changes in mindfulness by mapping modalities of awareness on brain networks for self-processing. Others have drawn attention to the DMN. This set of brain regions is more active when one rests than when engaging in goal-directed tasks. Mind wandering, antithetical to mindfulness, associates itself with processing in the DMN. These cortical regions coherently fluctuating are called “functional connectivity.” The DMN, mental fluctuations, and distractibility into past and future concerns are active areas of neuroimaging studies related to mindfulness (Molnar-Szakacs & Uddin, 2013). A metaanalysis study on relevant neuroimaging findings, for example, shows self-referential processing associated with these brain areas: medial prefrontal cortex, anterior and posterior cingulate cortex, insula, temporal lobe, hippocampus, and amygdala. Cortical midline structures such as these overlap with the brain’s intrinsic DMN (Brewer et al., 2011; Raichle et al., 2001; Qin and Northoff, 2011). With noting the above neuroscience, basic practices follow. Mindfulness-Based Interventions may be formalized practices, or informally integrated into everyday living

(Crane et al., 2017). Two mainstream formalized practices targeting medical and psychological disorders, also mentioned before, are the MBSR and MBCT. These two well-researched, validated, widely used protocols are available in books, manuals, and online. Many informally based meditations and mindfulness practices too many to discuss here abound. The outer trappings and logistics for these techniques vary. A basic format known as sitting meditation is common. Variations include lying down, walking, body scan practice, Hatha Yoga postures, and others. Three typical protocols for mindful awareness “Sitting practice” are as follows: 1. Task-focused Attention Practices to steady attention on a single event, 2. Open-monitoring (OM) practices to change one’s reactions to the flow of multiple mental experiences thus calming and balancing the mind, and 3. Ethical Enhancement Practices. These are “Lovingkindness” and “Compassion Meditation” practices. They evoke, support, and reinforce attitudes of care and tender-heartedness toward self and all others.

2.5.1 Task-focused Attention Practice Task-focused practices use a specific “anchor” to stabilize attention. Mindfulness anchors may use sound (e.g., a chime, running water, or the wind), the breath, or sensations felt in the body. This practice chooses one class of phenomena, specific and concrete. This technique highlights attentiveness to the sensory and bodily awareness of the anchor. Anchors close to oneself such as the breath are familiar. For example, if a sound is chosen, one might sit in a quiet location for 5e10 minutes, relax the body, close the eyes, and then focus attention on listening to the sounds. One only notes the perception as sound and then allows it to fade and pass. If the mind fixes on the sound, labeling it with a few words follows. This exercise takes practice and trial and error. Another anchor for task-focused practice mindfulness awareness is using one’s breath. Sitting in a quiet location for up to 10 minutes, relaxing the body, one focuses on the breathing process of inhalation and exhalation. Noting how the abdomen rises and falls helps anchor attention. Meditators can become absorbed in this. Thus, using a timer helps signal the time allotted. With focusing on the breath, attention to the sensory aspect of the felt experience is important. This visceral experiencing is a subtler tool that is more innerdirected (i.e., the internal physiosomatic environment). When mind wandering occurs, a guided return to focusing on breathing helps restore task orientation.

CHAPTER 2 Modern Mindfulness Typical beginning timeframes are 3 to about 10 minutes. When experiences enter awareness, rather than pin them down, fixate, and dwell on them, they are handled gently. Two techniques are common. A curious mindset is primary. First, noting is the process of turning toward the experience, witnessing it, then returning to the original anchor. Noting is decisive here. One notices, makes a mental note of what one is experiencing without getting caught in the emotional reaction to that object, then moves ahead. Second, labeling is the process of giving a specific word to the experience recently witnessed. It may be abstract: “this is thinking.” It may be more specific: “this feeling is boredom.” Quickly after labeling, one returns to one’s original meditative anchor. The ability to recognize attachment of attention to an object by how one can engage and effortlessly disengage is part of this practice. Selective editing of mental content needs to remain low. Guiding attention to gently focus on details of sensation, noting them, and then moving on is key. This expanded awareness unblocks points of bodily tension. Attachment of thought to one’s sense of self and awareness is often sticky and adherent. The letting go capacity (i.e., getting caught in and releasing) must be recognized and learned as a skill. This liberating process takes time and practice. How one manages attachments to thoughts is crucial. Dwelling for long periods on them or briefly noticing, noting, and permitting dissipation is decisive in skilled mindfulness abilities. Skill in realizing that you and the thought are not identical, decentering is essential mindfulness. For example, on a consciously aware intentional level, the ego carries on a mental dialogue between itself and what it is thinking. This narrative is higherorder mentation containing evaluation, judgments, and identifications of self with contents of the mind. In intensive mindfulness or meditative states, the configuration mentioned above transforms. Ego becomes an observer noting and labeling mental contents without appraising them. On even more in-depth levels, labeling and noting diminish. At this rarely reached stage, the self becomes experientially “enactive.” This engagement means living fully inside “the experiencing moment.” The work of Vago (2014) has detailed studies showing the theory and neuroscientific bases of these shifts in self-processing. He relates them to the frontoparietal brain control network. These scientifically measured changes are significant findings of the actual ability to shift modes of mindfulness. Salience, switching attention, and mental shifts also associate to the

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brain’s insular (Craig, 2009; Menon & Uddin, 2010). This evidence emphasizes the distinction of mindfulness practice from daily, conventional critical thinking more related to the dorsolateral prefrontal cortex.

2.5.2 Open-Monitoring Practice OM practices use methods that change reactions to the normal, manifold flow of experienced sensations, emotions, and thoughts. The intention is a change toward nonreactivity, calm, and balanced mental activity. OM practices have no anchor and a duration of from 3 to 10 minutes. The essential endeavor is “noticing alone.” This technique is choiceless awareness. This form of mindfulness practice is subtler and more abstract than task-focused practice, which is more tangible. Thus, OM may be more difficult for beginners. Orienting to OM is challenging. Its premise rests on many Eastern axioms: the mind as a stream of constant, ever-changing fluctuations of many thoughts, feelings, and sensations; the nonsingle-mindedness that attention has as its default; and the intention toward modulating attention toward resting comfortably in states of choiceless awareness. Choiceless awareness is a significant intention that OM practice tries to approximate. It entails one’s awareness hovering around and noticing whatever arises in experiences without attaching or rejecting. Instead, curious awareness notes and allows all experiences to float away. When a thought, feeling, sensation, or “object” of awareness enters the field of experience, no narrative of agreement or disagreement occursdno judgment. Consistent with Eastern perspectives, anything filling awareness is a “thing” or an “object.” Choiceless awareness intends to deemphasize the mind’s sharp demarcation of its mental “things” and object content. OM practice aims to change reactions to the inevitable flow of sensations, feelings, thoughts, and imaginations experienced. Changing reactivity releases tension permitting relaxation. Practitioners expert in meditative techniques suggest that if one has difficulty using OM practice, it may be wise to use task-focused techniques until greater confidence builds before returning to OM.

2.5.3 Ethical Enhancement Practices: Loving-Kindness and Compassion Practices Loving-kindness and compassion practices are singlefocus meditations. They intend to promote care and tender-heartedness toward self and all others. Thus,

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loving-kindness emphasizes optimizing happiness; compassion points to the ubiquity of suffering and its amelioration, enhancing ways to ease this distress. These meditation practices imply moral and humanitarian values. This emphasis shows how concern for others edifies one’s personal development; the two may be inseparable. When the word “others” appears, terms such as “all-embracing,” “all-beings,” and “goodwill in the world” follow. Even “neutral,” “strangers,” and “difficult” people are recipients of Lovingkindness and Compassion concerns. Fundamental to both these forms of caring is empathy and an unbiased perspective-taking. These positive attributes counter self-centered and privileged egoism prone to devalue others with excluding qualifiers such as race, sex, socioeconomic status, religion, class, physical appearance, and so forth. Physicians, however, may have harsh selfjudgments. Identifying these long-term ways of feelingdperfectionism and nonconscious selfcriticismsdis a step to breaking the cycle. Loving practice exercises help build recognition of the naturalness of human frailty and soften the inner critic. They use specific single phrases, sometimes visualizations, and often are spoken out loud. They may last up to 20 min. Both are similar but have distinct characteristics. The Buddhist Pali term Metta and the Sanskrit term Maitri both translate as kindness and benevolence. Loving-kindness meditation practice intends to consciously use verbal anchor statements to express ideas emphasizing safety, happiness, friendliness, health, love, and kindness to self and all others. These vivid affirmations

are phrases including “May I/you be safe;” “May I/you be happy;” and “May I/you live with health, ease and self-care.” Compassion meditation practice is also a single-focus meditation using anchor statements specifically of compassion to self and all others. Karuna is the Sanskrit and Pali term meaning compassion and action to diminish the suffering of others. It, along with Prajna (ultimate wisdom), is one of the two principal virtues highest in Mahayana Buddhism. Compassion practice intends to transform one’s relationship to suffering. Often, the meditator speaks only two phrases: (1) “May you be free from inner and outer harm” and (2) “May you know peace.” All affirmations address six categories of people: (1) self, (2) benefactor, (3) friends, (4) a neutral person, (5) a problematic person, and (6) groups. Formalizing these sets is a clear-cut reminder that genuine care and authentic concern must transcend one’s in-group boundaries in a noble and humanely decent way. These practices support a mindset with enhanced willingness to help Table 2.2.

2.6 THE ROLE OF TECHNOLOGY IN MODERN MINDFULNESS Modern mindfulness can take advantage of all the technological resources now available despite the complexities of practicing medicine in the digital age. Due diligence to cybersecurity, online behavior, and patient privacy is fundamental. One trend in assistive means is the array of devices found on apps. Familiarizing oneself with technology is useful in the beginning.

TABLE 2.2

Sitting Practice Meditation: Three Types and Their Distinctions. Three Types of “Sitting Practice” Meditation

Task-Focused Practice

Open-Monitoring Practice

Loving-Kindness Practice

Technique

Focused attention on a single event using noting, labeling, then letting go.

Noticing alone; free-floating attention.

Evoking caring and tenderhearted feelings to self and others.

Anchor

An external object or the breath.

None.

Positive affirmations of safety, compassion, and peace.

Duration

Up to 10 min.

Up to 10 min.

Up to 20 min.

Intention

To steady attention.

Changing one’s reactions to the contents of mind; increasing mental nonreactivity.

Reducing self-criticisms, judgmental attitudes, and ill will.

CHAPTER 2 Modern Mindfulness A few words of caution need consideration. Although modern technology has value and benefits, misuse and an overreliance on it can have the potential to downgrade mindfulness, notably, face-to-face human interaction (Schulte-Rüther, Markowitsch, Fink, & Piefke, 2007). Physicians need to see patients as more than mere icons or avatars represented in the electronic medical record as virtual entities. Healthcare is neither a simulation nor an assembly line endeavor. Physicians need as much of a personal touch as possible. Mindfulness strives for greater intimacy with selfprocessing and a broadening of empathetic sensitivity toward people. The emphasis is on heightened awareness of sentience. Sentience is feeling and experiencing self and others in deeply subjective ways. It might also extend to experiences outdoors in nature e.g., “green spaces” instead of restricted to isolated, sequestered relations with devices. Sentient awareness highlights human contours. It counters synthetic and mechanical inclinations made blunt by nonhuman feedback. As one embraces the centrality of sentient experience, mindfulness skill develops. Periodic shifts of mental modes from critical, evaluative thinking toward circumscribed periods of suspended conventional thought occur. Critical thinking and the executive functions emphasizing measurement are higher-order ego skills. Periodic pauses from this toward more relaxed mindfulness, notably with others, are restorative. Human to human feedback conveying the bodily data of emotional communication is essential to enhancing transparent communication. This reequilibration adds to the sustainable platform of mental equipoise. Mindfulness exercises relax the mind: ego, thinking, and measurementdfor a limited time. Assistive technology as an aid to decision-making, however, must not become addictive technology. Thus, too high a reliance on technology in isolation can offset and deter ease into mindfulness approaches. Technology toward facilitating efficient care, not impeding it, augments clinical utility and optimal outcomes. Using technology mindfully in the already hyperconnected environment requires pause, judiciousness, and deliberation. Apps, websites, and social media can be helpful in connecting with online communities of mindfulness resources. Smartphone, mobile, and Internet-based technologies have converged into an Internet of things, a network of devices, vehicles, buildings, and other objects embedded with electronic sensors, software, and connectivity components still expanding. Fifty billion smart devices all interconnecting are expected by 2020 (Iyer, 2016).

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Therefore, discretion is advised in using these resources discriminately. Mindful use is the preferred use. For example, researchers examined over 700 mindfulness apps on the iTunes and google play stores. They found only 4% provided acceptable mindfulness training and education (Mani, Kavanagh, Hides, & Stoyanov, 2015; Torous, Luo, & Chan, 2017). Thus, technology has value, but discernment needs to identify constructive technoinnovations. High-quality apps centered on managing anxiety using mindful techniques are now available. See references and bibliography for resources.

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Linehan, M. M., Comtois, K. A., & Murray, A. M. (2006). Twoyear randomized controlled trial and follow-up of dialectical behavior Therapy vs Therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757e766. Loizzo, J. (2000). Meditation and psychotherapy: Stress, allostasis, and enrichment learning. In J. M. Oldham, M. B. Riba (Series Eds.) & P. R. Muskin (Ed.) Review of psychiatry: Vol. 19 (1). Complementary and alternative medicine and psychiatry (pp. 147e197). Washington, DC: American Psychiatric Press. MacLean, K. A., Ferrer, E., Aichle, S. R., Bridwell, D. A., Zanesco, A. P., Jacobs, T. L., et al. (2010). Intensive meditation training improves perceptual discrimination and sustained attention. Psychological Science, 21(6), 829e839. Mani, M., Kavanagh, D. J., Hides, L., & Stoyanov, S. R. (2015). Review and evaluation of mindfulness-based iPhone apps. JMIR Mhealth Uhealth, 3(3), e82. Menon, V., & Uddin, L. Q. (2010). Saliency, switching, attention and control: A network model of insula function. Brain Structure and Function, 214, 655e667. Molnar-Szakacs, I., & Uddin, L. Q. (2013). Self-processing and the default mode network: Interactions with the mirror Neuron system. Frontiers in Human Neuroscience, 7, 571. Morgan, D. (2010). Mindfulness-based cognitive Therapy for depression: A new approach to preventing relapse. Psychotherapy Research, 13(1), 123e125. Nejad, A. B., Fossati, P., & Lemogne, C. (2013). Self-referential processing, rumination, and cortical midline structures in major depression. Frontiers in Human Neuroscience, 10(7), 666. Ninivaggi, F. J. (2017a). Adhd: A bundle of deplorable problems masked in plain view? Performance deficits: The ADHD calling card. Psychologytoday.com. Ninivaggi, F. J. (2017b). Literacy rampage: So, you wanna be literate? Learning disorders/disabilities explained. Psychologytoday.com. Northoff, G. (2011). Self and brain: What is self-related processing? Trends in Cognitive Sciences, 15(5), 186e187. Qin, P., & Northoff, G. (2011). How is our self related to midline regions and the default-mode network? Neuroimage, 57(3), 1221e1233. Raichle, M. E., MacLeod, A. M., Snyder, A. Z., Powers, W. J., Gusnard, D. A., & Shulman, G. L. (2001). A default mode of brain function. Proceedings of the National Academy of Sciences USA, 98(2), 676e82. Schmitz, T. W., Correia, M. M., Ferreira, C. S., Prescot, A. P., & Anderson, M. C. (2017). Hippocampal GABA enables inhibitory control over unwanted thoughts. Nature Communications, 8(1), 1311. Schulte-Rüther, M., Markowitsch, H. J., Fink, G. R., & Piefke, M. (2007). Mirror neuron and theory of mind mechanisms involved in face-to-face interactions: A functional magnetic resonance imaging approach to empathy. Journal of Cognitive Neuroscience, 19(8), 1354e1372. Seli, P., Risko, E. F., & Smilek, D. (2016). On the necessity of distinguishing between unintentional and intentional mind wandering. Psychological Science, 27(5), 685e691.

CHAPTER 2 Modern Mindfulness Seli, P., Smallwood, J., Cheyne, J. A., & Smilek, D. (2015). On the relation of mind wandering and ADHD symptomatology. Psychonomic Bulletin & Review, 22(3), 629e636. Sevinc, G., Hölzel, B. K., Hashmi, J., Greenberg, J., McCallister, A., Treadway, M., et al. (2018). Common and dissociable neural activity after mindfulness-based stress reduction and relaxation response programs. Psychosomatic Medicine, 80(5), 439e451. Shanafelt, T. D., Hasan, O., Dyrbye, L. N., Sinsky, Satele, D., Sloan, J., et al. (2015). Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings, 90, 1600e1613. Slagter, H. A., Davidson, R. J., & Luta, A. (2011). Mental training as a tool in the neuroscientific study of brain and cognitive plasticity. Frontiers in Human Neuroscience, 5, 17. Smallwood, J., & Schooler, J. W. (2006). The restless mind. Psychological Bulletin, 132, 946. Torous, J., Luo, J., & Chan, S. R. (2017). Mental health apps: What to tell patients. Current Psychiatry, 17(3), 21e25. Vago, D. R. (2013). Clarifying habits of mind: Mapping the neurobiological substrates of mindfulness through modalities of self awareness. Annals of the New York Academy of Sciences, 1e15. https://doi.org/10.1111/nyas.12270. Vago, D. R. (2014). Mapping modalities of self-awareness in mindfulness practice: A potential mechanism for clarifying habits of mind. Annals of the New York Academy of Sciences, 1307, 28e42.

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Vago, D. R., & Nakamura, Y. (2011). Selective attentional bias towards pain-related threat in fibromyalgia: Preliminary evidence for effects of mindfulness meditation training. Cognitive Therapy and Research, 6(35), 581e594. Vago, D. R., & Silbersweig, D. A. (2012). Self-awareness, selfregulation, and self-transcendence (S-ART): a framework for understanding the neurobiological mechanisms of mindfulness. Frontiers in Human Neuroscience, 6, 296. Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., et al. (2018). Mind the hype: A critical evaluation and prescriptive agenda for research on mindfulness and meditation. Perspectives on Psychological Science, 13(1), 36e61. Zerbo, E., Schlechter, A., Desai, S., & Levounis, P. (2017). Becoming mindful: Integrating mindfulness into your psychiatric practice. Arlington, VA: American Psychiatric Association Publishing.

FURTHER READING Buckner, R. L., Andrews-Hanna, J. R., & Schacter, D. L. (2008). The brain’s default network. Annals of the New York Academy of Sciences, 1124(1), 1e38. Nyanaponika Thera. (1954). [1964]. The heart of Buddhist meditation. York Beach, ME: Samuel Weiser. Stern, D. N. (2000). The interpersonal world of the infant. New York, NY: Basic Books.