Learned mindfulness

Learned Mindfulness: Physician Engagement and M.D. Wellness discusses the original technique of "Learned Mindfulness" developed by Dr. Ninivaggi to combat stress and burnout. In this book, Dr. Ninivaggi uses his Integrity Mindfulness model as a tool to manage stress, prevent burnout, and broaden quality of life, ultimately promoting well-being. Helping physicians ultimately helps patients and extends to the public enhancement of greater equanimity. The book provides readers with background information on the origins of mindfulness and details step-by-step directions on how to use the original technique. First book to introduce the technique of learned mindfulness Useful to psychiatrists, psychologists, physicians, and all suffering from stress and burnout Provides step-by-step instructions on how to apply the model to their patients

Table of Contents

Cover imageTitle pageCopyrightList of FigureList of TablesAbout the AuthorForeword

Medical DisclaimerIntroduction

Part I Mindfulness in Perspective

Chapter 1 Consciousness and Awareness: East and West1.1 Consciousness and Awareness

1.2 One or Many: Self and World Around1.3 Western Perspectives on the Self

1.4 Thinking Architecture and the Mental Status

1.5 Eastern Perspectives: Buddhism, Hinduism, and Yoga1.6 Buddhist Perspectives on MIND

1.7 Hinduism: SELF as Atman, a Microcosmic Centration of Divinity1.8 Narcissism

1.9 Mindfulness: More than a Five-Minute Time-out Practice

Chapter 2 Modern Mindfulness2.1 Mindfulness: An Overview2.2 Why Mindfulness?

2.3 Mindfulness Approaches in the West2.4 Mindfulness: Foundational Perspectives2.5 Mindfulness Meditation Practices in the West2.6 The Role of Technology in Modern MindfulnessPart II Emotional Awareness and MindfulnessChapter 3 Emotional Intelligence and Mindfulness

3.1 Emotions as a Second Language—or Should They be our First?3.2 Emotions are our First Language

3.3 Emotional Processing3.4 A Primer of Emotions

3.5 Feelings with Privileged Status: Loss, Envy, Greed, Jealousy, and Guilt3.6 Emotional Literacy: The Refinement of Emotional Intelligence

3.7 The Developmental Psychology of Emotions in Infancy3.8 Cultivating Positive Emotions and Mindfulness

3.9 Emotions and Motivation3.10 Resilience

Chapter 4 Learned Mindfulness—An Emotional Intelligence Perspective4.1 Learned Mindfulness: The Memory of Wholeness

4.2 Burnout: the Need for Learned Mindfulness as a Stress Reduction Tool4.3 Mindfulness-Informed Tools

5.9 The High-Reliability Personality

Chapter 6 Physician Wellness: Engaging Mindfulness6.1 Enhancing Wellness and Physician Engagement6.2 Enhancing Professional Engagement

6.3 The Benefits of Physician Engagement

6.4 Merging Physician Engagement and Organizational Alignment6.5 Value-Based Self-Leadership Development

6.6 Mindful Equipoise: Integrity, Values, and Empathy6.7 Final Thoughts

Learned Mindfulness: Physician Engagement and MD Wellness is achieving authentic integrity—mindfulness for an

integrated life This book proposes mindful awareness as the art of being in the “now”—living fully in thepresent Mindfulness is a way of living requiring transformation to a new future, not merely change from anincomplete past Mindfulness as a lifestyle promotes a mindset galvanized by meaning Learning to live with

complexity as the fabric of wholeness is Learned Mindfulness With this, embracing nutrition, exercise,breathing, relationships, and fitness exceeds routine expectations Learned Mindfulness as a construct and set of

propositions becomes an attraction toward wellness.

Mindfulness shifts attention from competitiveness and focuses on stabilizing oneself This realignment is astep toward relaxation in the workplace This stepping back has downstream effects on relations with others.

Sharpened receptivity to human feedback is a central theme in Learned Mindfulness The emphasis is on a

continuous awakening Human psychological intimacy and never taking this ultimate value for granted areemphasized Empathetic mindfulness contours itself this way.

These preliminary definitions reflect Learned Mindfulness more as a perspective, a mindset with a major

utility First, it proposes a burgeoning set of propositions resembling a construct, hypothesis, even a manifesto

of aspirations Not new, these ideas anchor themselves in a rich history of world traditions Second, LearnedMindfulness in its nascent entirety is a clinical tool both useful for the physician and for the physician to

integrate into medical care Such an integration needs specification depending on the subspecialties involved.However, the outstanding determinant of therapeutically mindful approaches entails communicationhallmarked by empathy, astute perspective-taking, transparency, and iterative actions toward increasinglybetter outcomes.

The essential intention is awakening a hitherto sleeping realization: we are already where we are supposed

to be—but unaware of its fullness Written from a clinical perspective, Learned Mindfulness focuses on the

individual However, findings from modern science and evidence it works support this clinical emphasis.Thus, clinical utility arises Targeted self-improvement occurs, and this precedes leading by example Thus, apublic contribution can result This intention is central to the essence of mindfulness Realizing this inflectionfrom thought to act shines a light on meaning, purpose, and satisfaction Mindfulness changes the caliber of themind's habitual discourse Nourishing one's inner life empowers choice Not only is this clinical tool suitablefor those seeking the betterment of already established health but also for those eager for new adventurestoward improvement on current distress or distress in the making, e.g., potential burnout One better selectsthe options about a lifestyle, diet, exercise, and, notably, relationships Breaking old habits—mindsets leadingto harmful behaviors, anxiety, and stress—becomes a learned skill.

Learned Mindfulness is the author's emotional intelligence (EI) and integrity version of mindfulness as a state

of evolving awareness, orientation, and practice Among the qualities, comprising an excellent physician'sabilities is EI (Libbrecht, Lievens, Carette, & Cote, 2013; Shahid, Stirling, & Adams, 2016) Intrinsic to this isstable mood regulation—emotional equanimity and mental equipoise The foundational knowledge offeredhere provides a roadmap integrating equanimity and equipoise into “the stuff of everyday life.”

Primary care doctors seeing many patients every day might welcome a one-volume text encapsulating theprinciples of mindful well-being This book offers access, an approach to a formidable journey, millennia-richwisdom now sorely needed Primary care doctors are the first to test signs and symptoms, manage theprevention, and follow-up of chronic disease Being mindful is a premium both personally and professionally.

Learned Mindfulness and EI bring clear awareness and authentic integrity to one's life Authentic integrity is

the consistent integration of emotion with thought resulting in integral, less divided mental functioning.This assimilation brings greater awareness to previously unrecognized inclinations, aspirations, attitudes, andless mindful behaviors.

Learning is an uncovering, an awakening of dormant potentials Central to these is learning to pay attention.Goals of mindfulness are expansions of awareness and acceptance of present experiencing By-productsinclude the benefits emerging from these psychological reconfigurations: attentional regulation, sensory clarity,emotional equanimity, and overall mental equipoise.

Personal mindfulness is the physician's in-depth knowledge of the causes and consequences of emotionalthriving and resilience These capacities counter cynicism, shutdown, and the challenge of burnout Anxietyaccompanies these feelings, increases stress, and elicits tendencies to deny the anxiety and make it go away.Instead of avoidance, mindfulness urges a gentle embrace and a curious exploration Having this awareness—mindfulness as knowing, just here and now—helps minimize anxiety, conflict, and confusion Erecting self-defense mechanisms against anxiety provoked by unresolved stressors subsides Healthy habits replacebroken, stress-provoking behaviors There are recognized contributors to burnout They include regulatoryburdens, documentation requirements, compassion fatigue, obstacles to efficient communication, perceivedlack of autonomy, inefficient workflows, and competing career priorities.

Compassion is concern for the suffering of others and the desire to help Compassion fatigue is secondarytraumatic stress and vicarious trauma lessening compassion to those in need This diminishment of empatheticresponsivity is common among nurses, mental health clinicians, and emergency workers treating traumapatients Instead of their earlier sense of conscientiousness and wish to excel, those so dispirited experiencehopelessness, demoralization, increased stress, and have disturbed sleep Those with compassion fatiguecontinue to struggle with empathetic engagement Those with burnout are prone to give up and withdraw.Integrity diminishes into despair While differentiated from physician burnout, similar interventions focus onrenewed self-care, community, and social supports.

Might it be hyperbole to suggest mindfulness is antithetical to a dystopian lifestyle with cynical andforeboding perspectives? Burnout is a tragedy affecting physicians and others in the workplace Physicianburnout leads to disengagement and eventual attrition because it creates distressing feelings that they arereplaceable cogs in a business rather than meaningful human beings This radical diminishment of autonomyerases purpose, meaning, and inspiration It challenges a doctor's sense of intrinsic worth and expertise.Mindfulness is among the known interventions increasing purpose, meaning, and inspiration.

This book has a tapered focus, mindfulness, and integrated wellness for physicians—personally andprofessionally Physician burnout makes this a timely consideration However, what must neither beoverlooked nor diminished is burnout across the entire healthcare community Burnout is a human response tostress, allostatic load, avalanching technological complexities, and the escalating challenges of the last decades.Many individuals experience exhaustion, cynicism, and being overwhelmed in the workplace This set ofindividually felt burnout wear and tear symptoms also affects the workforce In speaking about physicians,their role in enhancing or diminishing the self-esteem and effectiveness of others needs consideration.Members of the healthcare team interact and influence one another and the entire system When physicians are

engaged and resilient, their influence on the collaborative enterprise is an asset and resilience support.Although addressed to physicians, the themes of mindfulness, integrity, interpersonal cooperativeness, andorganizational collaboration apply to everyone.

Physician burnout is the personal side of a system in distress The healthcare organization to advancetechnologically and become efficient may have lost the human side of its mission Caregivers on the front linesof this industry-wide transformation are feeling dehumanized While dehumanization and depersonalizationpervade the system and the physician, high-quality healthcare for the most vulnerable—patients—diminishes.Burnout and strong physician engagement have the same dual sources: the healthcare system and thephysician Both appear at odds and stalled Multiple targeted strategies need to identify, acknowledge, anddiscuss each so, meeting patient needs ensues Chapter 6 details these.

Respect experienced by physicians for the value of their contributions—both professional services andparticipation in the organizational initiatives—has significant empowering value Organizational physicianrespect counters the sense of loss of control and dignity clinicians experience Feeling unsupported and notrespected for who they are and what they contribute leads to physician burnout Showing appropriate valueand respect counteracts a sense of loss in self-value It offsets a loss of autonomy and control in a physician'srole.

Healthcare systems have a herculean task to change the current conversation between themselves anddoctors Physicians can also empower themselves as active participants in that dialogue The physician andhealthcare system share common visions and missions These include taking part mutually, equitably, andinnovatively in transformed collegiality not seen before.

Learned Mindfulness is a new and reflective contribution to the actionable model of mindfulness Its premise

is achieving thought assimilated with full emotional resources The shift in mode is from autopilot survival toengaged thriving Anxiety festering at the center of burnout needs identification Retraining to bring quality toa physician's work-life synchrony is required These ideas are a foundation for integrating mindfulness, EI,work-life balance, and burnout prevention.

Learned Mindfulness

Learned Mindfulness is meeting yourself exactly where you are—a state of active, mindful alertnessor mindfulness memory called sati in Sanskrit This state contrasts with meditation, a practice toward attaining

enduring mindful awareness Being in “meditation” is nondirective inaction, a resting state of equipoise Deep

meditative states (i.e., dhyana, bhavana, and Samadhi in Sanskrit) are intermittent practices affording greatermindfulness (i.e., sati) between these intensive meditations Chapters 1 and 2 elaborate these ideas.

The Learned Mindfulness introduced here lies in a basic framework of EI, its scaffolding Emotion drives

behavior With authentically integrated thought and feeling, behaviors excel toward excellence Mindfulnessadapters take measured personal management in steering emotion toward active assimilation with thought.Effective decision-making results Building on this cumulative achievement drives personal inspiration Such

courage helps a doctor to take intelligent risks from Learned Mindfulness tools resulting in manageable and

successful outcomes.

Professionals and all concerned with stress reduction have an interest in novel approaches to mindfulness.In the current era of performance and achievement measured by external accomplishments, self-reflection andintrospection as values have been obscured The last decades have produced a virtual cottage industry ofmindfulness programs These have large-scale public appeal and promises of quick results—reduced stress andincreased happiness This perspective has never been part of the millennia-long history of mindfulness and its

meditative practices Mindfulness by serious meditative techniques has entailed well-structured programs forthose earnest and intent on taking stock and working intelligently The outcomes sought, though not by all,were “self-realization, “liberation,” “enlightenment,” and even “Buddhahood.” These were pursuits of alifetime Today, perspectives are different and goals less lofty They include stress reduction, lowered anxiety,and equanimity Mindfulness examines and changes older, ingrained cycles of negatively rewarding behaviors.

Learned Mindfulness is an “Integrity-based Mindfulness” model Using this tool in clinical practice helps to

improve emotional well-being and prevent emotional burnout It thus broadens one's quality of life Thiswellness perspective, if not only therapeutically preventive, is markedly relevant to all who care for patients,principally physicians.

Engagement is the opposite of burnout Engagement is mindfulness of being aware and involved in theactivities of daily living The span is from the simplest to those needing greater focus, concentration, and skill.

This book's ideas emerge from this base: a need for innovative perspectives on emotional well-being and robust toolsaimed at upgrading one's quality of life To accomplish this, Learned Mindfulness addresses well-being and self-care, thehuman side of medicine The importance of balancing the social good with scientific progress and clinical excellence linksthese values together.

Entrainments to the natural cycle of emotion restore thought with quality reason This synchronization ofemotion and thought resets emotional processing through emotional modulation and regulation Restoration isessential because perception is always incomplete Perception's insufficient information base, if not enhanced,causes the anxiety of confusion leading to harmful behaviors and stress Included here are the clinician's biasesand even blind spots Confusion takes shape as cognitive dissonance and emotional ambivalence Thus,uncertainty predisposes to anxiety The threat of error in decision-making becomes a risk This vulnerability isa sensitive concern for physicians As stress increases, it downgrades emotional and conceptual clarity andrisks physiological impairments These substantial limitations, significant and meaningful, mute thephysician's effectiveness Having perceptions improved by emotional lucidity makes thinking well-structured,focused, and purposefully directed This even-mindedness enhances well-being.

The subjective side of well-being and wellness comprises psychological equipoise, a dynamic balance, often of

antagonistic forces This active moderation is a constructive and containing even-mindedness Equipoise is the

balance between extremes, a modulated equilibrium This level-headedness supports refined emotionalequanimity, mood stability It yields a sense of quiet pleasure and lowered anxiety It is calm, tranquility, andpeace of mind Equanimity felt as composure is a platform for the mindful equipoise modulating impulsivity and

reflexive reactivity toward extremes Breaking the harmful loop of anxiety triggering poor choice and distressbecomes available so that behavior change can occur When change occurs and anxieties lessen, greaterhappiness, even joy, arises Emotional equanimity and mindful equipoise are key performance indicators inwork-life balance.

Learned Mindfulness is the emotional hygiene orientation in the Making Sense of Emotion model of EI

(Ninivaggi, 2017) Understanding and practicing this restores the natural cycle launched by the inborn primacyof emotion—integration bridges the ambivalence of positive and negative emotionality Integration alsoforesees normative contradictoriness in events not with avoidance but meeting these challenges withanticipatory enthusiasm for creative syntheses For example, it shows itself in a greater synchronization of left(analytic) and right (esthetic/holistic) brain hemispheres (Luders, Clark, Narr, & Toga, 2011, Luders et al.,2012).

Thus, the mind's linearly harsh discourse, the “inner critic,” can mellow into more a poetry with meaning.The anchor in this mindfulness task entails the steps of EI This intention promotes a significant sense of

emotional knowing with wholeness and integrity Learned Mindfulness enhances the self-observing potential

now dormant Once set into motion, self-observation learns to notice, explore, identify the body's sensations,and see how they evolve into feelings This focus is especially sensitive to anxiety signals as bodily sensations.This sequence entails noting self-criticism and minimizing it It replaces judgments with noting and mindfulexploration This periodic exercise in mindful curiosity helps to empty the mind of burdensome bias Thisunblocking process relaxes emotion and frees creative thinking Underlying anxieties hinder graspingknowledge Integrity revitalizes interest, enthusiasm, and intelligent seeing Fresh engagement in everydayexperience becomes a baseline mode of interacting Thus, motivation as a sparked threshold momentinvigorates thinking toward executive action in real life.

Psychological Mindedness is one's self-observing capacity This ability is a primary goal of all psychotherapies.This self-reflection entails observing one's inner experience primarily and also appreciating that others have

similar inner experiences Introspective self-awareness includes the simultaneous examination and insightfrom understanding nuances and meanings among the relationships of feelings, thoughts, motives, intentions,and behaviors Self-reflection as psychological mindedness entails using this reflective capacity acrosschanging moods in differing contexts at different developmental stages from about age 4 years in childhoodthrough adulthood.

Empathy is core to psychological mindedness It rests on a platform of self-observation having twocomponents: (1) the emotional and affective comprehension of the inner experiences of another and (2)cognitive perspective-taking or theory of mind focusing on epistemic states of others such as their beliefs,intentions, and values.

Mindful Mindedness, introduced here, may be one step beyond psychological mindedness because it

integrates in-depth self-observation with empathy and heightened perspective-taking in each experiential

moment of paying attention Learned Mindfulness builds the capacity for Mindful Mindedness.

Mindfulness is awareness of the embodied (i.e., participating in bodily experience) knowledge of one'sexperiencing at that moment “Moment” emphasizes the immediacy of real-time, current experiencing—anin vivo occurrence alone or with another While awareness can mean awareness of self or an object or

both, Learned Mindfulness refers to the gentle blending of both.

Spontaneous “I am awareness” rather than a goal orientation or controlling (i.e., effortful) regulation is the

meaning of “I am” awareness filling the mind in this dynamic model This awareness is an intention toward aprocess, not an outcome Here, using novel phraseology captures the dynamic sense of being in authentic

mindfulness Chapter 4 discusses this state of alert awareness to mean “I am aware of engaging in the

immediacy of now.” For example, one does not issue a personal command: “I must now control my breathing”rather an inner poetry arises: “I am breathing.” This mindfulness generates itself more by design with implicitintention—effortlessly Purposefully inducing this mental frame creates an active, paused space—neutral,tranquil, yet dynamically complete It includes engaging bodily sensation, breath, perception, emotion, andspontaneity.

Learned Mindfulness makes relaxation a remembered skill, something like a procedural memory In states of

active relaxation, mental processing opens itself to a more transparent awareness of emotion engaged withthought—burgeoning insights in personal evolution Inherent intuitive, effortless abilities in self-

understanding unleash themselves Learned Mindfulness subtly educates one to the human core of hidden

inwardness This inspiration innovates purpose, meaning, and vision of one's values As anunbroken condition, a human birthright, it aims toward emerging from a zero point of merely surviving.Reaching the potential ability of wholeness—authentic integrity—is central to this theme.

Learned Mindfulness is best viewed not as mindfulness meditation but as an educational and clinical tool.

This approach encapsulates an orientation toward mindful attitudes, neither meditation nor a structuredtechnique Mindfulness-based contemplation exercises comprise a method for thoughtfully ponderingsomething for a short or longer time, examining, observing, surveying, and studying it with gentle exploration.This absorption requires deep reflective and self-reflective focus It is experiencing things with an alert,

conscious attention, not rote, mechanical, and nonconscious review This practicing pause tool as a daily exercise

may take seconds, minutes, or longer After this intensified “practice,” shifting one's mode of attention tomindful everyday awareness complements the mindfulness enhancement process This mindful engagementcultivates curiosity and sustainable interest Retrospectively, critical thinking can see current attitudes andbehaviors and make improved choices Both nonconscious changing (self-modulation) and effortful direction(self-regulation) then coalesce to change behavior.

Learned Mindfulness is neither a straightforward solution nor meant to evoke unrealistic expectations for

instant results This program is part of an integrated health-promoting lifestyle The ideas and methodsintroduced as “mindfulness” are distinct from ordinary, everyday thinking involving critical analysis andexecutive functions in novel situations Chapters 2– clarify these distinctions.

Critical thinking is the normal mode of daily focused thought It regulates decision-making and guidesbehavior Executive functions such as highly concentrated attention, working memory, and the sequence ofplanning, problem-solving, and refining goals occupies most of a physician's waking hours besides family,social, leisure, and recreation Not confusing discussions about thought processes and reconfigurations duringmindfulness practices with those of critical thinking is necessary Neither should mindfulness in isolationsubstitute for nor replace executive functions so essential in scientific pursuits Mindfulness developed as anasset supports the effectiveness of critical thinking.

Learned Mindfulness makes clear the inner workings of this mindfulness model and uses its historical origins

to explain its current appearance This expanded link between the past and the present has been missing frommindfulness literature easily accessible to physicians.

While ahead of hard science now, these plausible invitations for exploration may be useful to integratepersonally and in the clinical work of biopsychosocial care Clinical theory and its application are difficult toseparate from confounding biases where variables distort an exposure and outcome With this squarely inmind, innovative ideas are options inspiring “speculations sparking thinking one galaxy over.” This leap maybe a needed jumpstart launching the mindfulness journey The elasticity of thought, not fixedness, is essentialmindfulness.

A variety of well-established and validated mindfulness practices, techniques, and “mindfulnessmeditation” protocols are available and accessible Systems of thought, models, and perspectives are best when

rationally flexible and creatively porous Learned Mindfulness, while a mindfulness perspective, overlaps and is

honored to share with other valuable mindfulness and meditative endeavors Practical tools complementary

to Learned Mindfulness are already available The Learned Mindfulness introduced here is new Its intention has

an “idiographic” and “population thinking” perspective—the individual within the group Although united inour human psychology of universally shared themes, taking into consideration the variations, needs, andpreferences of the individuals forming those groups are essential.

Learned Mindfulness, therefore, deemphasizes rigid guidelines Instead, it can be taken, as needed, by each

physician, to fill in self-identified gaps requiring mindful awareness, if not expansion Many physicians havenot taken or cannot take formal training This concise volume can act as a personal coach This portable coach

becomes an inner voice and personal guide accessible “in-the-moment.” Thus, Learned Mindfulness is more of a

mindful orientation as one moves through daily life rather than a structured practice.

A leading exercise is an informal practice called practicing pause The technique entails times during the day

where one stops routine activities for a few seconds, shifts attention to being in whatever moment ofexperience is at hand, noticing it, briefly labeling it, then moving attention onward A few deep breathscomplete this informal direct engagement Just reading this is becoming familiar with it, the first steps oflearning (see Section 4.5) Substantive change occurs through repeatedly applied learning by practice—here,

using the tool of practicing pause.

The Quadruple Aim: Improving Physician's Quality of Life

Excellence in healthcare presumes a physician who is intelligent both in the clinical skills needed for patientcare and as an emotionally competent person In the last years, the Institute for Healthcare Improvement inBoston developed a framework of improvement describing an approach to optimizing health systemperformance focused on the patient New designs pursue three dimensions called the “Triple Aim.” However,advances in medicine have expanded “The Triple Aim” to become “The Quadruple Aim” (Bodenheimer andSinsky, 2014) With an overarching target of optimizing healthcare performance, the three aims have becomefour: (1) enhancing a patient's experience with high-quality care, safety, and satisfaction, (2) improvingpopulation health, and (3) reducing costs Now added is a fourth aim: the goal of improving the work-life ofhealthcare providers, clinicians, and staff Work-life balance enhances resilience to deepen safely andexcellently Physician burnout has added depth to this set of aims and the development of broaderinterventions Mindfulness reflects emotional competence and work-life satisfaction.

This book, a theoretical exposition, is a clinical contribution of ideas Here, the fourth aim—physician

work-life balance—is central Discussed is the need for an integrated, systematic clinical approach to planningresearch questions in the nascent development of mindfulness-based programs Sections on empathy,perspective-taking, EI, integrity, and mindfulness are discussed These provide a lexicon and framework withwhich to weave an integrated understanding and working knowledge of mindfulness This contribution, moreof a theoretical foundation than an evidenced-based protocol, makes mindfulness attractive, attainable, andaccessible Introducing novel terminology at selected junctures has been necessary to convey the relevantmeaning of the material, which can be elusive because it deals with clearing the mind of “inattentional” clutter.

Learned Mindfulness written by a psychiatrist for physicians respects the intellectual demeanor and

expectation of physicians without adding the salubrious niceties of New Age shibboleths Instead, acontemporary EI model innovates a fresh, current, and evidence-informed platform for mindfulness as an

intelligent lifestyle The Learned Mindfulness perspective is the first approach by a physician—a meditator for

five decades—written for physicians to lay bare the roots of a popular endeavor While it may be deeper thanmost cursory and formulaic approaches available, its range is a sourcebook in one volume Portions may beread in isolation; others require extended reflection Thus, avoiding simplicity and targeting specificity makesthe material direct and valuable Mindfulness awareness and its integration by physicians thus enrichesmedicine's Quadruple Aim.

A key to this book's perspective is its clinical orientation It bridges the history with the here-and-nowrealities of what mindfulness demands physicians attend and master This empirical, experience-near approachmeans an overview of mindfulness for oneself and with patients Thus, this contribution summarizes theoryand is an orienting tool for use It is not a research-oriented or studies-driven and extensively cited text Anabundance of journal papers is available for this purpose.

Learned Mindfulness is synonymous with the phrase “Integrity Mindfulness.” Integrity mindfulness orients

one toward paying attention to one's experiencing intentionally free of polarized mind cluttering judgments.Judgmental thinking constricts the range of creative thought Such a program of integrity supports authenticliving by holistic awareness, transparency, personal honesty, and directedness in everyday life Integritysupports consistent mental equipoise.

Authenticity is grounded in emotional genuineness and psychological depth Implied in such integrity is anethic toward error-free decision-making reliably enduring Integrity supports increased performance and valuecreation Physicians and those engaged in clinical care may profit from this psychological upgrade called

mindfulness Learned Mindfulness affords one the clinical orientation to function above baseline minimums

toward optimums.

Value-based Mindfulness

Value-based mindfulness reflects the positive return of investing in mindfulness This profitability bases itselfon and measures the outcomes of how mindfulness shows up as a positive reward in one's life Mindfulness isalert awareness, increased self-awareness, pause, and less erratic mental fluctuations This psychologicalstability means less anxiety, worry and ruminations, ambivalence, and greater intentionality and decisiveness.Mindful equipoise as emotional–cognitive even-mindedness and equanimity as emotional composure result.

Value-based integrity arises with becoming more transparent, honest, and developing the ability forcomprehensive task engagement Mindful attention chooses one task and avoids multitasking traps Value -based transparency means sober acceptance of one's less than perfect traits and abilities Appreciating thebeauty and potential to improve self-identified “flaws” bolsters self-esteem and effort.

These intensifications in mindfulness and integrity bring about greater self-leadership These strengths buildan increasing self-activism Helplessness and passivity transform to uncover judicious self-efficacy Value-based self-leadership is the return from investing in leadership measured by high-reliable results frompersonal accountability in all spheres of life A genuine sense of self-leadership encompasses the attributes:self-awareness, self-reflection, perspective-taking, ongoing self-reexamination, open sharing of aspirations andinnovative ideas, fair-mindedness, and an ethical foundation of values and behaviors Chapter 6 discussesvalue-based mindfulness as the personal side of professional value-based medicine Core mindfulness is aplatform on which physician engagement grows, unfolds, and develops.

Physician engagement of value is the doctor's emotional commitment and active participation in the entireteam of operations taking place in the hospital and collaborative community of care Engaged physicianscommit to the organization's mission, vision, and values Collaborated care delivery demands sharedresponsibilities between the individual physician and the aligned organization in forming and implementingvalue-building strategies On the broadest levels, engagement transcends the physician to include the systemand patients, all of whom engage with the resources available and even strive to create needed resources tooptimize healthcare in its entirety.

The Relevance of This Book

An integrated perspective on mindfulness in all areas of one's life is not only interesting but now lacking Thisfresh, innovative work aims to offer a small yet significant contribution to an understanding of our relationshipwith mindfulness Mindfulness for physicians has often been relegated to increasing attentiveness or taking“time out” for relaxation or gentle meditation The robust roots of in-depth and complexly detailed meditativepractices, derived from Eastern cultures, has been simplified or entirely extracted perhaps to make it morepalatable to Western tastes Without an intelligent understanding of the backbone of mindfulness axioms andpractices, its developmental history, much value has been lost in current translations.

The evolving approach used here arises from the author's intensive training at the Yale Child Study Center.Understanding the person meant digging deep into the longitudinal course of infancy, childhood, andadolescence This genetic and developmental perspective not only considers the growth, unfolding, andinteractional development of the individual but accounts for this within the family and social cultureinfluencing its course Now, working with other Yale doctors on the “Physician's Engagement and BurnoutPrevention Committees” has sharpened a focus on doctors' work-life balance Programs, protocols, and clinicalredesign optimizing professional fulfillment and high-quality patient care are ongoing initiatives.

This book aims to remedy earlier gaps in the field by supplying additional propositions scaffolding Easternsystems of meditation Eastern ideas are explained in terms Western-trained physicians cancomprehend Chapter 1 lays bare the mechanisms detailing those practical steps used to achieve mindful states.Trying to demystify Eastern concepts while not denuding them of their cultural meaning puts Buddhism andYoga on straightforward yet respectful footings Chapter 3 puts mindfulness in the light of contemporary EI.This innovation may be an unprecedented effort to join these hitherto distinct areas in a fresh, integratedperspective.

Because mindfulness has the mind as its observation, an intensive exploration of a significant sector of mind—emotions and emotional processing—is sorely needed This demand requires the astute physician to have aworking knowledge of emotions, feelings, and their processing from the behavioral perspectives to theirneuroscience Much of medical training steeps itself in technical skill building and diagnostic precision.Attention to one's emotional life is often eclipsed, even though it is the heart and soul of both physician andpatient This book discusses these needs in ways physicians trained in the sciences, including the behavioraland psychosocial, can appreciate The way basic emotions directly interface with critical constructs in allmindfulness models from ancient to those today is made transparent.

With a millennia-old history in spiritual traditions, principally those of the East and now linked to theWest, Chapter 2 describes how mindfulness today often takes shape as meditation or meditative

practice Learned Mindfulness has dug deep into the archeology of mindfulness and examined its origins,

practices, and raison d'être While deriving an inestimable wealth of information and insight from this

exploration, Learned Mindfulness offers a Western model using an EI template as its scaffolding.

With origins as a spiritual practice for millennia, Learned Mindfulness as a modern innovationbroadens applicability to more pointedly psychological concerns Thus, Learned Mindfulness as integrity

mindfulness has central utility for personal development, increased self-awareness, and applicability as aclinical tool Learning about mindfulness brings one in the authentic integrity zone This ability uses thetransparency of integral awareness of sensation, feeling, and thought consciously, consistently, andpragmatically Emotions become more transparent and accessible What in the East is self-realization can betranslated into Western terms to signify integrated self-understanding, self-identified transparency, andholistic self-integrity.

Therefore, the relevance of this contribution includes not only introducing an innovation in modern

mindfulness called Learned Mindfulness but also an applied discussion of mindfulness for physicians in

healthcare systems Chapter 6 expands physician wellness themes, the challenges of MD burnout, enhancingfuller engagement, upgrading organizational sensitivity to physician needs, and mindful equipoise as alifestyle of engaged wellness Equipoise is the balance between extremes, a modulated equilibrium Anxietyquells When emotional stability suffuses this refined equanimity, even-minded equipoise results.

Mindfulness: Its Home in the East

Mindful awareness and being alert are intrinsic to human survival Mindfulness is new to our culture Beingalert and aware—a “second to second” situational awareness—must have been part of basic survival,exploration, and managing life on Earth Today, mindfulness is a distillation of ancient practices toward self-development of awareness, understanding, and wisdom expansion: “enlightenment.” Its practical applicabilitynow is similar but updated with contemporary terminology: shining a light on challenges and creatinginnovative strategies to manage stress reduction permitting relaxation in a busy world of technology and itsdemands.

Chapter 1 summarizes Eastern and Western ideas about the mind A primer of contemporary psychologyand psychiatry sets the context for understanding mind and mindfulness Terms the East has used forthousands of years outline similar perspectives Eastern perspectives emphasizing mind and the psychology ofmind instead of pointedly religious themes comprise Yoga and Buddhist mindfulness This psychologicalemphasis is most relevant to modern mindfulness discussed in this book To be sure, the primer on Easternthought merely brushes, sometimes oversimply, the complexities only in-depth studies over many years caneven approach Many Eastern terms remain in the original Standard translations try to convey meaningsalthough many of these are archaic and burdened with old biases.

An example is the term shunyata meaning emptiness This notion is one of Buddhism's central presumptions

about attaining successful mindful meditation Left unexplained, the English word “emptiness” appearsstrange and off-putting However, understanding it as a “clear mind” faithfully conveys its meaning, asexplained in Chapter 1 Insights arise from seeing one's experiences as they are without judgments andpreconceived ideas Thus, context, East and West, and correlations help to make sense of primary ideas criticalto both cultures.

Eastern psychological views are stunning for their contrasting approaches to theories of mind The East usedthe vivid metaphors of its sages to convey mindfulness truths Today, the West uses the lexicon and tools ofscience Relaxation is key to implementing these ideas in a variety of mindfulness practices under the rubric of“meditation.” Thus, it may be safe to say modern mindfulness has its historical origins in Eastern meditativetraditions.

How different are Buddhist, Yogic, and Western perspectives—at least those propositions derived fromclassical writings—about the experience and meaning of individual life and personhood While mostmindfulness-based programs allude to Eastern sources and Westernized translations, few to none makeexplicit the intriguing, often compelling, Hindu and Buddhist ideas behind these exercises This book seeks toremedy this gap in the literature It makes available more of the Hindu/Yoga foundations and Buddhist axiomsfrom which mindfulness, as we know it today, have sprung An open-airing examining these ideas is wise.

Mindfulness coupled with intelligent inquiry creates safe spaces to discuss issues often puzzling andperceived “illogical.” Knowledge is gained not by tolerating such perceived information as alien or enigmaticbut by accommodating it Making space for what may be innovative ideas and perspectives challenges butexpands thinking “Newcomers” to one's thinking later may become assimilated and integrated to enrich anearlier more constrained worldview.

The literature on mindfulness written by Western scholars openly and sometimes implicitly struggles withideas of cultural appropriation, even recontextualizing mindfulness practices of their roots in those profoundlyspiritual traditions (Dreyfus, 2011; Kirmayer, 2015; Sharf, 2015) While not endorsing any faith or belief system,an intelligent approach to mindfulness perspectives is to understand them including their historicaldevelopment The competent physician must be sensitive to and respect the spiritual and faith traditions a

subgroup of patients holds meaningful This part of respecting presentations has clinical relevance as itinfluences adherence to any healthcare initiative The “humanities” show how people comprehend anddocument the human experience using philosophy, literature, religion, art, music, history, and language tounderstand and record the world Mindfulness respects and uses this base.

To clarify the vast field of mindfulness, conceptual distinctions are needed A variety of fields discussmindfulness while defining it in idiosyncratic ways For example, religion addresses people's approach to faith,worship, and spiritual pursuits; philosophy discusses matters such as existence, knowledge, values, reason,mind, and language; psychology examines theories of mind such as emotions, thought, and behavior; and last,mysticism deals with the doctrines and practices of a direct and unmediated connection with the divine orultimate source of reality Each of these concerns has a mindful focus.

Most mindfulness practices today explicitly or implicitly allude to Buddhist religious tradition This culturalundertone is understandable because both Buddhism and Hinduism as religions had and have meditation andmindfulness protocols integral to their practices This religious base is mentioned for several reasons This book

offers a nonreligious perspective and calls it Learned Mindfulness Learned Mindfulness is a psychologicalapproach whose foundation is EI Thus, Learned Mindfulness is mindful awareness whose premise is the human

mind having inherent qualities that can be examined and understood in themselves As mentioned earlier, thiscontribution is more of a manifesto of intentions, motives, and prescriptive notions founded on a clinical base

of medical care Learned Mindfulness is an orientation for carrying out changes to current perspectives on

mindful living This book builds a knowledge base Actual practices and formulaic techniques need futuredevelopment.

Another relevant consideration is the undergirding of current mindfulness practices rooted in Eastern

traditions that are unfamiliar or may be unknown to Westerners Since writing a textbook on Ayurveda: AComprehensive Guide to Traditional Indian Medicine for the West (2010), the author is familiar with both Buddhistand Hindu medical and psychological concepts Thus, their relevant parts will be discussed in understandableways in terms correlating Eastern and Western ideas This understanding acts as a backdrop to a more in-depthappreciation of mindfulness as it exists today An intelligent understanding helps demystify what had been theperceived strangeness and now shows the universally human face of the East and their traditions.

Chapter 1 explains the traditional scaffolding from which modern mindfulness has emerged To be clear,this is not intended to overemphasize Eastern views Instead, it is a selective, historical review of the essentials

leading to what has become mindfulness as a mindful lifestyle Learned Mindfulness is not an isolated

meditative technique It is a psychological orientation reflecting basic human nature, most likely inherent in

many cultural traditions Therefore, Learned Mindfulness is more a clinical tool than a purely meditative

exercise Traditionally, establishing mindfulness required four components: mindfulness of body, emotions,

mind, and the dhamma/dharma guidelines Millennia ago, the fourth comprised the social and cultural doctrines

needed for mindfulness success This book gives physicians a new cultural fourth contemporary component:physical engagement and MD wellness as the context for mindfulness relevant to today's work-life balance.Why Has Mindfulness Gained Popularity Now?

Mindfulness often takes the form of “mindfulness meditation.” Whether the context is religious, psychological,or relaxation technique, these practices aim toward stress reduction and more in-depth tranquility Theseexercises clear and reboot the mind They are restorative in affording the time to pause and relax Many havetermed this a “destressing” occasion.

Chapters 4 and 6 discuss burnout as a phenomenon of our current work climate Physicians under stresssuffer burnout (Shanafelt et al., 2015) The value proposition of this book is that Learned Mindfulness offers a

timely, innovative, and focused approach targeting this emerging challenge Burnout entails physical andemotional exhaustion, depersonalization, and having a sense of inadequate work accomplishment Animpending sense one's life as sputtering, on the verge of stalling, precedes the burnout syndrome Generativityin productive work diminishes, and integrity fades into despair.

At least half, if not more, physicians suffer from burnout Varieties of interventions both individually basedand through the workplace improve burnout Burnout unchecked contributes to medical error, high attritionrates, and physicians “moving on” hastily from current job positions Therefore, exhaustion, interpersonaldisengagement, and a low sense of personal accomplishment negatively affect the physician, patient care, andthe healthcare system The financial damage and waste are inestimable (Schnapp et al., 2018; Shanafelt, Goh, &Sinsky, 2017).

Contemporary culture has invested faith in the net of technology and science hoping to elevate humanity'sdistress toward states of wellness The electronic health records and “Big Data” platforms modern technologyprovides have become astonishing parts of the stress overload reported by physicians.

The contemporary infatuation with technology and its wonders has led to its becoming used as our“personal assistant.” Technology has launched an unprecedented merger between man and machine.Algorithms have become artificial brains automating choices and subtly eclipsing free will and mindfuldecision-making There are differences between machine techno-generated options and decisions made bycritical thinking, executive functions, and nonconscious indeterminate resources (e.g., nonconscious changeleading to prudent intuition) Checks and balances and long-term impact on healthcare need monitoring.Artificial intelligence (AI) is not neutral.

AI and machine learning algorithms tend to rely on large quantities of data to be effective This informationneeds people to analyze it—looking for trends and patterns and then making intelligent recommendations Theethics of a decision, complex data, or one-off decision are beyond the present capabilities of AI AI and machinelearning are advantageous in refining clinical workflows and even physician training Moreover, with themarket growing the way it is, implementation is inevitable.

Now is the time for physicians to examine mindfully to what extent they will allow the machine-basedmedicine to be part of healthcare, at least as it now stands To what extent is this automated reasoning asurrender of privacy or, at worst, dubious conformity to compliance with an algorithm-fed mechanical mind?Are we ready to reassess the role technology plays (with us) in our lives? These endure as intriguing questions.Lifestyle choice remains a leading option.

The Theme of Mindfulness in Medicine

Mindfulness is a perspective addressing physician health and wellness—as an optimal state of physical,mental, and social well-being, and not just the absence of burnout Short of an exhaustive review, this one-authored, clinically oriented volume by a psychiatrist has value as an applicable tool The role of subjectiveexperience in clinical practice needs careful consideration Subjective reports have limitations, but they haveunique strengths because they are crucial indicators of people's immediate experiences (Ericcson,1993; Garrison et al., 2013; Wilson, 1994) Self-reports are now becoming recognized as valid measures of keyconstructs of interest—those of the patient and the physician treater Effectiveness is achieving clinicallymeaningful outcomes Meaning is a potent change agent springing from several sources How the wholepatient defines meaning reflects what they say, feel, and nonverbally communicate, by how the physicianunderstands the process of improvement occurs, and by measurement Good to excellent medicine bases itselfon solid clinical reasoning (During, Artino, Schuwirth, & van der Vleuten, 2013; Mercuri et al., 2015).

Healthcare enterprises with high-value care missions safe and minimizing the risk of patient harm musthave at least three vital components: physician engagement, organizational alignment, and a patient'sperception of quality care A patient's participation is influenced by trust, comprehending what is at stake,informed consent, and engagement in the healing process The patient's perception of care comes fromphysicians spending ample time in the diagnostic and treatment planning dialogue While good practice, thisrapport provides healthcare with the highest value to the patient who recognizes the mindful attentiveness ofthe caregiver.

Therefore, highlighted in this book are vital features of mindfulness, mindfulness meditation, andmeditation The relevant, millennia-long factors leading up to today's understanding and practices areintroduced as clinically useful For example, pain is a universal symptom of human distress; suffering is theemotional side Surveys show 91% of primary care physicians say Traditional Chinese Medicine (TCM) iseffective, mainly acupuncture to treat pain (Murphy, 2018; Vickers et al., 2018) Chinese medicine considers qi,

the body's vital energy, flows along meridians or channels in the body, and keeps a person's spiritual,emotional, mental, and physical health in balance TCM aims to restore the body's balance between the

complementary forces of yin and yang, which can block qi and cause disease The Centers for Disease Control

states 38.3% of patients use Complementary and Alternative Medicine (NCCI, 2008).

In Ayurveda, the Traditional Medicine of India, prana correlates with qi Prana and qi are subtle vital forces

in food and air maintaining physiological and psychological processes These forces are both taken into and

made in the body by the principal component of all foods: rasa Rasa means “taste” containing all thebioenergetic principles regulating body, mind, and spirit Rasa is also the term for the body's plasma In theAyurvedic medical literature, rasa links itself with focused, mindful grasping—an engagement with the tastes

of food so they can internalize beneficially This conscious savoring leads to their ability to flow through andnourish the body effortlessly.

Besides the balancing and restorative functions of prana, prana, in the form of a primary bioenergeticregulating factor termed Vata, is “lord of the mind,” “lord of the five senses,” and even “the sixthsense.” Prana's psychological home lives in Manas, which correlates with mental functioning; its physical site isthe lungs Prana's highest concentration is in the brain Prana Vata denotes the directing and focusing ofattention Therefore, pranayama or breathing exercises have played a crucial role in ancient systems of

meditation as breathing does now in Western practices.

Thus, Eastern perspectives on health assume subtle mental functioning to be integral to overall well-being.In the East, mindfulness and meditative practices address the mind Today, the West as well recognizes themind as integral to the entire human being Psychiatry and psychology as specialized fields attest to thisrecognition Current emphasis is stressing the health-enhancing facets these specialties can contribute.Attention to mindfulness is now a significant focus in medicine It may be time for physicians to becomecomfortable with these approaches Hence, the timeliness of this book.

The term “biomental” (Ninivaggi, 2013, p 5) was coined to transcend the Cartesian dualism of body-mindseparateness Biomental efforts capture the authentic integrity of the person as a biopsychosocial organism influx yet in ongoing integration:

I have coined the innovative phrase biomental child development, in which the word “biomental”indicates a specific child development perspective This term refers to the integrity—nondualityand emergent integration—of the whole individual at all ages in processes that are bothpsychological and physical It connotes simultaneity, a responsiveness of the total organism, and

the dynamic relatedness among its aspects In states of health, this relatedness reflects a synergythat promotes emerging dynamic integration The construct and phenomenon of integration—apparently split-off parts understood to be aspects of a primary whole—is axiomatic in thebiomental perspective, and remains a golden thread running throughout this text p.5.

Eastern perspectives have always recognized the intimate links between body and mind and the energiespervading them A health span that linked wellness to a coupling of body and mind runs through that

literature The term “biomental” also illustrates this Formalizing these forces by the terms qi and prana makes

tangible the intangible Such paradoxical thought is a quintessential part of Eastern worldviews Thus, indiscussing mindfulness, Eastern conceptions center attention on subtle psychological processes, often usingconcepts scientifically foreign to Western thought This contribution aims at helping to bridge this gap inunderstanding, at least as it adds to explaining the roots of modern mindfulness.

Systems Psychology of Mindfulness

Systems psychology is about putting together rather than taking apart, integration rather than reduction.Systems mindfulness is speculative modeling of complex psychological networks, namely the person It is apsychology-based field of study focusing on complex interactions within mental systems, using a holisticapproach instead of a reductionistic perspective Reductionist methods aim to identify components andinteractions but offer less understanding of how primary human system properties—meaning and purpose—emerge The heterogeneity of causes and effects in biomental networks, notably the mental dimension, is betterapproached by considering multiple components simultaneously This richness must include its origins andhistorical roots.

Using this “systems” and integrative approach has been one motivation for making exact the historicalorigins of modern mindfulness Chapter 1 offers the reader the context from which mindfulness emerged.Without knowing this heritage, any examination of mindfulness standing today would be bare, desolate of itsinner fabric While not underestimating the evolution of millennia-rich ideas and changing needs, this book hasgone to great lengths to uncover the archeology, the phylogeny of mindfulness in the 21st century.

Multiple features delineate every system: its spatial and temporal boundaries, influences from itsenvironment (past and present), structural descriptions, purpose or nature, and its functioning Regarding itseffects, a system can be more than the sum of its parts if it expresses synergy or emergent behavior Changingone part affects other parts and the whole system in meaningful ways, with predictable patterns emerging Forhuman systems who are self-learning and self-adapting, adaptive growth depends on how well the system

adjusts itself (e.g., mindfully) to its environment Creative transformation arises when in-depth mindfulness is

learned This engagement then empowers an unanticipated novelty—alert conscious awareness available ateach waking moment This mindfulness spurs further gratifying advancement One mindful part of the systemcan change the entire system.

The Centrality of “Control”: Biomental and Interpersonal PerspectivesThe entire matter of control in an individual's life is complex but central to a sense of self, meaning, andmindfulness Coercion as forcefully threatening persuasion is linked to manipulative control How “control” iskey to mindfulness has roots in infancy Control involves the package of modulated impulses, reactivity,feelings, ideas, decisions, behaviors, and direct relationships with oneself and others Control seeks to influenceor direct in an excessively authoritative way Control intends to achieve a change In speaking of this form of“control,” other varieties of nonmanipulative, nonforced directedness such as managing, handling, andregulating are not included For example, effortful regulation is willful and voluntary managing and changing

to activate and constrain attention and behavior Such effortful “control” is the nonmanipulative, soundmanagement of mental and behavioral issues needing direction for effectiveness Although intentional, it doesnot have the quality of being a forced situation Healthy intentions ask for permission and seek informedcooperation Issues related to control are always issues of dependent relations Dependency, independence,interdependence, and the nuances of linked relationships are broad.

Control has biomental and developmental features One is the maturational capacities of the brain and

neuromuscular system; another is the infant's emotional desire to hold on to what it is grasping The sense ofagency is the belief in the ability to cause one's actions as the sole, responsible source A first material expression

of control as a burgeoning agent appears in the infant's developing capacities for grasping and letting go.While grasping occurs much earlier in life at about four to 8 months, letting go or releasing happens later atabout seven to 10 months.

Psychological significance extends the meanings of control Control may be a parallel phenomenon towanting to maintain control over something precarious and not easily controllable and may be lost.Unreflectively feeling that one is an active “agent” may suggest unwarranted self-sufficient autonomy Havinga sense of power over one's actions being effective counters the natural helplessness of infancy and childhood.Warding off loss tempers the accompanying dissonance and anxiety and contributes to strengtheningdeveloping self-efficacy and confidence The neural pathways becoming established remain contoured in mind,persist and express themselves in diverse ways throughout life When the early controlling phenomenondevelops appropriately, it forms the basis for waiting, pausing, expecting, and managing.

To a large extent, the ability for mentalization/perspective-taking comprises two factors: (1) empatheticunderstanding of another from their inner experience together with (2) mindful attentiveness to seeing oneselfreflectively from the outside thus tempering one's raw control impulses Evidence of this tempering appears atabout four to 5 years old but has a long future for refined development Reactivity to any event becomesmodulated by subtle equipoise Hope and optimism seed themselves.

In adulthood, the phenomenon of “loss aversion” is seen when one is more prone to gain and hold on thanto let go of possessions, whether material or psychological In all emotional life, an adhesiveness automaticallysets up clinging between two objects This attachment ranges from flexibly dissociable to rigidly adherent Allinterpersonal relationships have a central theme of “psychological control.” When these emotionally chargedurges of the impulsive need to change the ideas and behaviors of others remain flexible, mutually willing, andnegotiable, relations are cooperative and agreeable When this emotional control becomes stultified, it becomesa manipulative power struggle fraught with conflict Thus, the relevance of continual return to mindful self-examination is crucial.

Clear-cut signs of those with manipulative control issues are people who speak continuously, almostuninterruptedly and issue directives about what others should and need to do on every level Themes of“judgment” and “criticism” pervade these monologue orations Themes of doing wrong and “bad” gethighlighted Evaluative and “ought to” statements resound There is a pressured, compelling urgency in theirvoice as if the dictates were irrefutably valid and nonnegotiable Such rigidity obviates dialogue andperspective-taking and feels overwhelming This style of treating others is inimical to mindful conversationscharacterized by respect, pause, and mutuality.

Manipulative control issues appear in concentrated forms in intimate relationships such as family andmarital discord The readers of this book may also consider relations between physicians and organizationssuch as hospitals and universities Loss of a sense of participatory control both triggers and pervades physicianburnout On a broader level, control conflicts embed themselves in all relationships where power and power

struggles are dominant—for example, between rival nations Dominance-submission themes are central tocontrol phenomena.

This broad view of control describes the attitudes and behaviors of, at least two people, or two camps of

individuals with competing intentions Mindfulness changes the perspective of such “control” to one centering onhow one views, reacts to, and manages one's mind Mindfulness centers on focusing and managing interior space—mental space Rather than use the term “control,” the term “manage” is preferable Chapter 4 will discussconcepts such as effortless modulation and effortful regulation These ideas are crucial to a valid mindfulnessperspective.

The core of mindfulness theory and practice is present-centered attention that is porous, fluid, andnonadherent For example, trying to forcefully control anxiety and stress by using logic and reason aloneseldom works Changing harmful habits and replacing them with rewards that are helpfully sustainable ismindful behavior change A mindful intrusion into unhealthy behavior patterns including addictive behaviorscan change these etched-in stimulus–response reactions.

With practice, effortful regulation, e.g., behavior change, arises from its base in the effortless, nonconscious,

implicit learning accrued This reconfiguration has core emotional modulation as its nonconsciouschanging dynamic Achieving such states of awareness means one's attachment to the “objects” of attention

must be flexible What comes into mind as thoughts about anything in the form of ideas, sensations, andfeelings are not to be controlled—grasped, held, or clenched too forcefully Managing mental contents is apreferable alternative.

Mindfulness is the ability to release, surrender, and “ungrasp” effortlessly Whether rigid attachments to thought

patterns or to the need for illicit substances (as found in addictive compulsions), ungrasping the triggeringevents and their outcomes is key to reconfiguration and distancing Mindful coping is skillful problem-solving.It is decision-making acting as a resilience preparation preventing stress.

Control as an attachment and clinging relates to the Eastern meaning of “desire,” which means the desire tohold on, take possession of, and not let go Desire in this sense means “I wish to be in control of this object; thisobject must be mine.” Thus, understanding this idea of “control” as attachment and desire is key tounderstanding Eastern perspectives when trying to grasp mindfulness Central issues in modern mindfulnesspivot around control versus suitable management using flexible acceptance and letting go—of thoughts,feelings, and attitudes in one's mindset.

The individual psychology of control can reconfigure itself to become a psychology of empathetictransactional reciprocity, more intentional and less reflexive This social reciprocity can become a transactionalsensitivity characterized by empathy and amplified perspective-taking This respectful frame of mind isantithetical to forceful control and the wish to manipulate, or aggressively direct Although this is an optimalform of constructive communication between any two people, its import in mindfulness is most relevant aboutmanaging one's mind—without rigid control and impulsive reactivity It morphs just a business transaction tobecoming an engagement of in-depth equipoise Managing one's thoughts and feelings in a nonjudgmental andnongrasping manner is emotional equanimity.

Developing more significant emotional awareness and refined levels of emotional literacy empower onewith the cognitive and emotional abilities intrinsic to empathy Complex emotions, such as gratitude, supportbasic emotions like agreeableness and cooperative mutuality These character strengths, notably integrity andempathy, are decisive in the mindful person Asking permission not only relates to seeking agreement fromothers but also to permitting one's inclinations freedom to appear and move on In addition, the inevitable

experiences of sadness and suffering pondered and worked through amplify the development of empatheticfeelings.

Character Strengths

Success in life involves developing a character of integrity Learned Mindfulness holds integrity and empathy in

high regard These achievements are lifelong processes permitting one to live life the way one genuinelywishes This experience is the enjoyment of satisfaction and admiration for achievements alone and shared.Character is personal excellence Mindfulness enhances integrity bringing one's character strengths into actionroutinely.

Mindfulness means taking stock of oneself Discerning what is important (e.g., maintaining positive health)from what is urgent (e.g., “putting out a fire”) is crucial Writing aspirations and visions and missionstatements are essential Reviewing long-term goals helps to point toward the right direction and stay on track.Learning to become single-minded is fundamental Self-optimism, self-discipline, and self-regulation compriseself-mastery, notably mindful equipoise and emotional equanimity Self-regulation occurs on multiple levelssupporting self-esteem, self-respect, and a healthy self-image.

Character comprises the nuanced super-refinements of one's personality On basic temperamentalpredispositions, character develops from the consciously chosen values enthusiastically espoused Motivation,learning from the environment, and random occurrences can change mental and behavioral “fixedness” inremarkable ways, especially if one is determined to change Chapter 5 discusses Positive Psychiatry capturingsuch a broad array of ideas with the phrase “positive psychosocial characteristics.” This clusteringencompasses individual character strengths and their social and environmental components Active socialengagement is vital to characterological well-being Successful social engagement requires well-developedperspective-taking and empathetic rapport.

Authentic integrity correlates with high-value character strengths Such positive psychosocial characteristicshave empathy and communicative transparency as top values Valuing one's life together with the lives of allhumankind exemplifies reality-based perspectives on authentic empathy “Keeping your word” verbally andin performance shows trustworthy integrity One's character—resilient, optimistic, and socially engaged—isalso reliable, accountable, and can forgive self and others The wholeness of genuine, authentic integrityembodies empathy and mindful gratitude Integrity supports increased performance and value creation It istrustworthy and reinforces high reliability.

High-reliability performance amplifies a focused method harnessing ideas and leveraging improvements.Reliability refers to consistency, the ability to modulate toward effectiveness Becoming a valid and genuineperson, authentic and feeling real, depends on an implicit sense of being reliable.

Learned Mindfulness is remembering to remain awake to oneself thus enabling the process of active

self-remembering mobilizing character strengths Becoming sensitized to the personal experience of flesh, blood,sensations, feelings, thoughts, and contact with others made up in similar ways thus takes on vibrantembodied meaningfulness The resilience of bouncing back from stress and recuperating from burnoutpowerfully expands.

Learned Mindfulness presents learning the resources preventing and protecting from exposure and negative

engagement in stressful events This skill creates resilience In addition, mindful people endure unforeseenstressors with substantive coping strategies enhanced by character strengths These skills lay the foundationsfor quick recovery and newfound abilities enhancing prevention.

Authentic Integrity

Authentic integrity is a peakless mountain As wholeness, it is personal freedom from self-deceit becausehidden parts of oneself can now be accessed and brought to the light of mindful awareness Integrity bringsentirety, soundness, transparency, and a sense of being undiminished The wholeness of authentic integrityinvolves being true to oneself This ability entails honestly detecting what one genuinely senses and knows tobe part of their inner being, even if underdeveloped or counter to earlier self-perspectives.

Integrity is an unimpaired quality of life It is a biomental integration Learned Mindfulness is entering the

“Into Integrity Zone.” Authentic integrity is an achievement of self-determination, self-activism, and prudentself-agency bringing more consistency to temperament, personality, and character Such self-regulation is anactionable pathway to becoming whole and complete, an integrated person.

Learned Mindfulness keeps attention dynamically alive Cynicism—emotional distrust—shatters values and

blocks empathy; callousness to self and others increases Cynicism, callousness, and depersonalization arefeatures of the burnout syndrome and alien to health and well-being.

Cynicism profoundly questions the genuineness and sincerity of other's motives thus impairing belief incommunicative validity Integrity mindfulness continuously disables this deception and self-cleanses the fluid alignmentof emotion with thought Reconfiguring the mind in this way creates a newly experienced mindfulness readiness Thisreadiness graciously allows renewed interest, inquisitiveness, curiosity, and openness This sequence is the path foracceptance of the natural flow of sensation, perception, emotion, and thought Wholeness enhances integrity andgenerativity in work-life The emotional cascade leading to multidimensional empathy is the crux of EI.

Learned Mindfulness is self-regulation Self-regulation has two components: (1) nonconscious modulation of

emotion and thought that underlies nonconscious changing and (2) a conscious regulation that is theintentional and purposeful work of critical thinking—tangible on a practical level Three dimensions of self-regulation include

1 mindful attentional self-regulation that is alert and oriented,

2 emotional self-regulation that is curious, accepting, and can manage emotionaldistress, and

3 self-awareness self-regulation that is insightful leading to broader self-understanding.All these bring about and support self-esteem, self-respect, and a healthy self-image.

With practice, implicit emotional modulation (i.e., noneffortful) enables oriented attention to be present toeach moment unfolding but not restrictively lingering in a rigidly fixed way on any experience (Garrison et al., 2013) Learned Mindfulness understands “presence in the moment” to be awareness characterized by

immediacy Attention with immediacy is mindful attention Integrity embraces one's capabilities and skills andmakes their potential available in the mindful moment.

Emotional hygiene is both awareness and literacy promoting the active engagement of emotion, making, and its implementation in real life The intention and dynamic act of welcoming emotion to becomeoptimally humanized by clear thinking is precision self-medicine Learning can enhance this alignment offeeling with thought and its application in productive ways Emotion must be discovered, recovered, and

decision-joined with ideas Learned Mindfulness is a psychological orientation and tool with steps They outline the

process of enacting this engagement of awareness with EI This approach aims to expand emotional awareness

by teaching the conscious awareness (i.e., Learned Mindfulness) of the identification of emotion—(1) sensation,

(2) perception, and (3) the readiness of conceptual elaboration.

These three preparatory stages to EI by noting, labeling, and embracing one's biomental capacities are thefoundation for effective action in everyday living These three steps of EI become a prelude to their target:emotion performance utilization This decision-making performance may happen “now” or later whencircumstances call for more intensive critical thinking, executive functioning It is mindful behavior in real life.

While Learned Mindfulness aims to increase genuine emotional awareness, its definitive aim is emotional

literacy: mindful listening, speaking, and doing This cognitive-affective reconfiguration is an promoting skill sustaining health and well-being via achieving the character strength of authentic integrity.Integral Empathy

equipoise-Inner character strengths pivot on Integral Empathy: cognitive perspective-taking and emotionally grasping and

outwardly responding to another's sentient inner experience Integral empathy comprises the refinement ofemotions for the effective comprehension of self-experience and that of others These experiences entailemotions, thoughts, and even bodily sensations Performing this skill enhances empathetic interpersonalrelations Empathy includes attunements to nonverbal communications such as facial expressions and body

language This transpersonal conduit adds meaning to the biomental perspective of Learned Mindfulness of

body-mind synchrony.

Work-life balance is crucial, but life management is more than avoiding unhappiness, it is reclaimingforgotten emotions, including joyful engagement empowered by meaning This book empathizes with Eastern

perspectives, giving them homage for their enduring contributions to mindfulness in theory and practice.

Learned Mindfulness: Wellness for a New Generation of Physicians

Traditionalists and baby boomers, now over 60 years old, had experience with the era of the 1960s when Yogaand a myriad of other Eastern traditions flooded America Many aspiring physicians, including the author,engaged with varying involvement in these pursuits Exposure then was on personal terms, close contact witha teacher and guide High levels of motivation, endurance, and enthusiasm characterized training There was ajoy in transforming and creating fresh versions of oneself Some meditators dropped out; some continued thepractices.

Today, generations of millennials and Gen X physicians are becoming reacquainted with the East This waveof concern with stress reduction and relief from burnout has reinvented what had been traditional meditationinto the arena of modern mindfulness.

A recent survey of 1900 US medical residents in 29 specialties showed three outstanding professionalchallenges:

1 work-life balance (34%),

2 time pressures and work schedules (16%), and

3 fear of failure and mistake making (13%).

Depression was reported in 10% as ever-present and sometimes present in 33% Stigmas against seekinghelp were prevalent in 68% Many respondents (35%) reported no time for personal wellness (Levy, 2018).

The intention of Learned Mindfulness is a self-regulating orientation of receptive curiosity and nuanced

noticing: a restoration of the primacy of emotion in the natural cycle of rational thinking Active observation and remembering foster turning invisible emotion to palpable perception This awarenesstransforms into evaluative thought and intelligent decision-making One's moral compass then spins towardrelevant and socially beneficial performance.

self-The transparency unveiled by refined EI refreshes eagerness to work self-The prospects of a task thus elicitexcitement in planning and completing steps advancing accomplishment What at first was deliberate intentionmodulates itself in implicit awareness to become effortless and spontaneous Thus, the mindful physician feelsenergized, engaged, and accomplished in his and her respective medical fields with a clarity of purpose.Mindful awareness is a foundation for wellness pervading one's lifestyle.

Learned Mindfulness supports the modulated engagement of sensation, perception, conception,

decision-making, and their implementation in real life This integral strength toward an equipoise-building alignment

must be learned The application of Learned Mindfulness is an example of “translational medicine,” i.e., from

bench side (i.e., theory) to bedside (i.e., individual application), and ultimately to community

well-being Learned Mindfulness and achieving authentic integrity can be integrated into any existing psychotherapy,

counseling, organization, business, hospital training, or school upgrade format on a one-to-one or group basis.The relevance of mindfulness for physicians to use personally, above all, the newer generation of medicaldoctors is enormous, if not inestimable For example, Chapter 6 integrates mindfulness principles, practice, andpolicy guidelines into the real-life healthcare area Here physicians and organizational leaders live, work, andaspire toward quality professionalism with emotional equanimity and mindful equipoise Physician

engagement and organizational alignment thus enable themselves to enhance one another—mindfully Mindfulmindedness is a premier self-observing capacity enriching work-life balance Psychological mindedness thus

reaches quantum proportions.

Frank John Ninivaggi, MD

Bodenheimer T, Sinsky C From triple to quadruple aim: care of the patient requires care of the

provider Annals of Family Medicine 2014;12(6):573–576.

Dreyfus G Is mindfulness present-centred and non-judgmental? A discussion of the cognitive

dimensions of mindfulness Contemporary Buddhism 2011;12(1):41–54.

During S.J, Artino A.R, Schuwirth L, van der Vleuten C Clarifying assumptions to enhance our

understanding and assessment of clinical reasoning Academic Medicine 2013;88(4):442–448.Ericcson K.A, Simon H Protocol analysis: Verbal reports as data Cambridge, Mass: MIT

Press; 1993.

Garrison K.M, Santoyo J.F, Davis J.H, Thornhill IV T.A, Thompson, Kerr C.E, et al Effortlessawareness: Using real-time neurofeedback to probe correlates of posterior cingulate cortex

activity in meditators' self-report Frontiers in Human Neuroscience 2013;7:440.

Kirmayer L.J Mindfulness in cultural context Transcultural Psychiatry 2015;52(4):447–469.

Levy S Medscape: Residents lifestyle and happiness report Medscape; 2018 August 18,2018 https://www.medscape.com/slideshow/2018-residents-lifestyle-report.6010110?

src=WNL_physrep_180818_reslifestyle2018_10&uac=304349MN&impID=1714805&faf=1.

Libbrecht N, Lievens F, Carette B, Cote S Emotional intelligence predicts success in medical

guidelines Academic Medicine 2015;90(2):191–196.

Murphy, J (2018) 91% of PCPs say Oriental medicine ‘somewhat effective’ survey finds.

2018; https://www.mdlinx.com/family-medicine/article/1399.ya2018).

National Center for Complementary and Integrative Health [NCCI] CDC national healthstatistics report #8 2008 https://nccih.nih.gov/research/statistics/2007/cam-use-us-adults-children.

Ninivaggi F.J Ayurveda: A comprehensive guide to traditional Indian medicine for the

West Lanham, MD: Rowman & Littlefield; 2010.

Ninivaggi F.J Biomental child development: Perspectives on psychology and

parenting Lanham, MD: Rowman & Littlefield; 2013.

Ninivaggi F.J Making sense of emotion: Innovating emotional intelligence Lanham,

MD: Rowman & Littlefield; 2017.

Schnapp B, Sun J, Kim J, et al Cognitive error in an academic emergency

department Diagnosis 2018 doi: 10.1515/dx-2018-0011 Retrieved from 1 Aug 2018.

Shahid R, Stirling J, Adams W Assessment of emotional intelligence in pediatric and med-peds

residents Journal of Contemporary Medical Education 2016;4(4):153.

Shanafelt T, Goh J, Sinsky C The business case for investing in physician well-being JAMA

Internal Medicine 2017 doi: 10.1001/jamainternmed.2017.4340 Published online September 25,2017.

Shanafelt T.D, Hasan O, Dyrbye L.N, Sinsky C, Satele D, Sloan J, et al Changes in burnout andsatisfaction with work–life balance in physicians and the general US working population

between 2011 and 2014 Mayo Clinic Proceedings 2015;90(12):1600–1613.

Sharf R.H Is mindfulness buddhist? (and why it matters) Transcultural

Psychiatry 2015;52(4):470–484.

Vickers A.J, Vertosick E.A, Lewith G, MacPherson H, Foster N.E, Sherman K.J, et

al Acupuncture for chronic pain: Update of an individual patient data meta-analysis The

1.Chapter 1 Consciousness and Awareness: East and West2.Chapter 2 Modern Mindfulness

C H A P T E R 1

Consciousness and Awareness

East and WestAbstract

Consciousness is a state of being aware The experience of sensations, perceptions,feelings, and conceptions includes self-awareness mentally—in consciousness The wayhumans receive and react to experience outside and inside themselves embeds self-awareness, a communicative ability Self-awareness involves paying attention to oneselfand consciously knowing one's attitudes and dispositions In Western psychology,terms such as “ego,” “self,” “sense of identity,” and “I” describe the way individualsexperience themselves in their social context Meditation and mindfulness practiceshave complex historical origins in Eastern cultures Buddhism, Hinduism, and Yogadiscuss these approaches while centering on how the self manages its contents Westernattention to mindfulness derives from this but leaves out much cultural context Thischapter fills in those gaps.

Awareness; Buddhist mindfulness; Consciousness; Hindu and yoga mindfulness; Meditation; Meditativeawareness; Mindfulness; Self-awareness; Thinking architecture

1.1 Consciousness and Awareness

The existence of consciousness as a reactive or aware property, a broad concept, is plausible In mostdiscussions of mindfulness, consciousness is assumed to be a fundamental given however understood Itsnature and definitions remain imprecise if not elusive In both East and West, defining consciousness, even thevalue of the term, remains a continuing query A few distinguished theoreticians also advance argumentsexplaining it away (Dennett, 1986, 1992).

This chapter discusses consciousness and awareness from both Western and Eastern perspectives as ascaffolding for understanding mindfulness The mind uses methods to define experience; models are mentalstructures like templates or patterns aiming to organize disparate data making information meaningful anduseful Models of consciousness are among the most general semifinished examples that serve this purpose asthey are soft-coded, not overly definable, and dynamically modifiable While Eastern ideas can perplex, thischapter tries to survey core ideas in more than a superficial manner yet lucidly link their relevance to theorigins and backbone of modern, mindful themes and practices.

Consciousness is challenging to define because it emerges in different environments having differentsubstrates Thus, consciousness means not only being aware Plantlife, minerals, and technologies also react tostimuli, sometimes in complex ways Awareness and reactivity range from minimal to full responsiveness.Human consciousness entails subjective feelings accompanying awareness of sensory information Mindtypically signifies the container of mental life Subjective reactions may be virtually devoid of gross physicalreactivity On molecular levels, reactivity is always a part of life Mental sentience includes degrees of self-awareness in space, about and with other humans, and about time and, importantly, the future Self-awarenessis present in how the mind receives and reacts to experience—with an awareness of these activities.Consciousness is a communicative ability Whether consciousness, awareness, and self-awareness are identical,similar, or qualitative variants are subjects of discussion Scaffolding mindfulness with these reference pointsoffers tentative hypotheses.

Consciousness, for example, can be compared metaphorically to mental space housing objects filling thespace In Eastern thought, “objects” is the term for experiences occurring and registered in mind: sensations,feelings, thinking, images, and imaginations These mental contents or objects are representations of a concreteevent, abstract, or imagined idea Awareness is the ability to sense and perceive an object (e.g., sensation,feeling, thinking, and imagination) within the spectrum of nonconscious and conscious cognizance Thisprocess then results in gained knowledge stored as memory and used for decision-making.

Thus, consciousness leading to awareness comprises a cognitive act, emotions or feelings, and a resultantexperience Whether these processes are localized, generalized, diffuse, or combinations are unclear (Crick andKoch, 2005; Damascio, 2018; Dennett, 2018; Gazzaniga, 2018; Kaku, 2018; Pinker, 2018) Neuroscienceperspectives see consciousness arising from the embodied person having a base in the central nervous systemor brain To what extent this localizes consciousness (e.g., “one”?) or results in vast arrays of modules (e.g.,“many”?) to produce consciousness remains unsettled.

Searching for neural correlates associated with consciousness is ongoing Scientific work by Dresler et al (2012) at the Max Planck Institutes in studies on lucid dreaming hypothesize several ideas Lucid dreaming isthe sleeping subject's ability to know of the contents of a dream and recall them after becoming awake Thevalidity and reliability of this are measurable by magnetic resonance tomography The vivid descriptions fromlucid dreaming reflect one's inner state of mind or consciousness.

Studies postulate several neurologically associated linkages The right dorsolateral prefrontal cortexassociates with the function of self-assessment and self-focused metacognitive evaluation; the bilateral fronto-

polar regions with testing one's thoughts and feelings; and the precuneus with self-perception, self-referentialprocessing, first-person perspective, and the experience of agency or the conviction of ownership of intendedactions (Northoff, 2011) Chapter 3 on emotions discusses neuroscience studies associating Brodmann area 10,also called the frontopolar cortex or the anterior prefrontal cortex, with the higher-order capabilities of themind Using this biomental perspective, integrative mind-body psychotherapies are now mainstream (JohnsHopkins Medicine, 2018).

The psychological concept of agency underlies many mindfulness perspectives; here, body-mind distinctions

between doing and knowing interface one another Agency entails a sense of control over one's intendedthoughts and actions Agency means “I as the do-er.” This subjective awareness is the conviction of oneself or“I” as being the responsible launcher, executor, and controller of volitional acts Agency is one's conviction ofbeing a self-governing, self-ruling, and self-dependent person virtually free from external control andinfluence The agent has the implicit conviction; they are the sovereign decision-makers and performanceimplementers of their lives Agency correlates with the perception of willpower and free will Free will, forexample, has two broad components: (1) volition made up of motivation and planning and (2) agencycomprising the conviction of ownership and responsibility for intended thoughts and behaviors.

Volition is the desire to act, and agency is the belief in responsibility for intended actions Recent studiesshow that volition is functionally connected to the anterior cingulate cortex, while agency functionally connectsto the precuneus cortex These two brain areas link to decision-making Brain injury causes impairmentsmarked by disorders such as akinetic mutism and alien limb syndrome (Darby, Juho Joutsa, Burke, & Fox,2018) In mindfulness, a sense of agency that is moderate is optimal A mindful orientation is toward the process

as a “becoming,” not a frenetic striving toward sovereignly achieving a future goal It is feeling effective.Gentle nonstriving is an essential core of mindfulness practice and mindful awareness.

Whether consciousness can be understood in a way not requiring a dualistic distinction between the mentaland physical body remains an open question This debate between unity and duality or one versus many iscommon to both Eastern and Western perspectives This consideration points to the way each tradition viewsand manages the physical body with the agency of mind, notably in meditation and mindfulness.

Western views of psychology fully acknowledge the value of the body They go to great lengths towardadvancing its health and well-being by diet, exercise, nutritional, and medical interventions Hindu andBuddhist systems have developed medical Ayurveda and Yoga to address the significance of the body.Recognizing its importance, Eastern views stress its value as a vehicle for mental and spiritual advancement.Buddhism stresses axioms such as suffering, impermanence, and the insubstantiality or nonexistence of apermanent human core In doing so, a greater emphasis on meditation arose, at least in the history ofBuddhism and its writings.

Human consciousness as the state of being aware of and containing sensations, perceptions, feelings, andconceptions includes self-awareness Even if it is an awareness of sensory phenomena or feelings, it is self-awareness When awareness rises to the level of perceptual and conceptual interpretation “about” content,fuller self-awareness arises “About something” is knowledge around the periphery Implicit here is anepistemological duality: the subject as “knower” is distinct from and observes the objectified that is to be“known.” Understanding this and remembering it is essential to unlocking the crux of mindfulnessmechanisms For example, in the West, self or ego is typically the processor of information as in criticalthinking In Eastern perspectives, the term “ego” strongly suggests its acting as a block to self-understandingas in egoistic self-centeredness and selfishness This recurrent theme runs through most Eastern perspectives.

Eastern traditions differentiate this “about-ness” from the immediacy of a more profound immersion intothe “knowing” process Many Eastern mindfulness perspectives regard being “in” or “at one with” experienceas a more valid and direct form of knowing—an authentic intelligence The intention is to bridge the gapbetween the knower and known This bridging establishes a mindful resonance embodying the entire range of

The Eastern view of being “in” or merged within an experience has less cognitive precision thanconventional Western ideas about cognitive processing and comprehension It is a critical nuance pervadingEastern thought Concepts about cognition reveal beliefs about self-understanding, introspection, self-reflection, agency, and the knowledge and behaviors generated Such varied epistemological views areunderpinnings of traditional mindfulness and meditative outlooks.

Table 1.1

Consciousness, Self-Awareness, and Ego.

Consciousness Consciousness means not only being aware but also the nature of reacting (mentallyand/or physically) to stimuli, sometimes in complex ways Awareness and reactivityrange from minimal to full responsiveness Human consciousness entails subjectivefeelings accompanying awareness of sensory information.

Self-Self-awareness is the way one experiences themselves This awareness involves payingattention to oneself and consciously knowing one's attitudes and dispositions.

West Ego signifies a group of mental functions mediating an individual's inner instinctualor biological drives with the real demands of the environment Ego mediatesthese responses as adaptations to survival in reality “Ego functions” includedistinguishing reality from imagination and fantasy Facilitating this arejudgment, evaluation, sense of reality, regulating impulses, emotions, cognition,interpersonal and social relations, defense mechanisms modulating anxiety, andintegrative abilities coordinating information Ego is often used interchangeablywith self.

The terms “implicit” and “tacit” in psychology and neuroscience denotenonconscious (i.e., preconscious and unconscious) mental activities Frombehavioral perspectives, the ego is a pattern of habits deeply etched on all levelsof memory with more of an automatic reactivity than consciously effortfulresponsiveness Conscious awareness as a prime ego function makes critical

thinking, learning, and effortful change possible Thus, ego in this sense haspositive value.

East In Buddhism, no ego or self as defined by the West exists What exists is a loosely

tied, impermanent group of fluctuating functions called skandas that comprise

the body, emotions, perception, conditioned habit loops of stimulus-response,and personal awareness of these.

In Hinduism and Yoga, five sheaths, body, energy breath, mind, wisdom, and

loving joy, comprise the person as self Atman or a spiritual core attend these.

Key to understanding mindfulness and consciousness is that the ideal state of consciousness rests solely onawareness or nonreactive witnessing Mindfulness practices target the reactivity inclination of humanconsciousness that becomes aware, then tests, forms judgments, and expresses them behaviorally.Mindfulness-based programs strive to decouple the automaticity of this habitual reactivity toward assessmentfollowed by action Table 1.1 .

1.2 One or Many: Self and World Around

Thinkers call the problem of discovering a presumed or hoped for unity behind all things “the problem of theone and the many” (Papay, 1963, pp 1–31) How this consideration first emerged is unclear but may have beenpart of Eastern and Western philosophical speculations about an idea (e.g., fruit) and its multiple expressions(e.g., apple, orange, and banana) in the concrete world Both objects exist but on qualitatively different levels,the mental and the material.

The problem of the one and the many begins with the assumption the universe comprises an intrinsicallyunified integration—“one thing.” By being one, everything must fall under one unifying cohesion Thisproperty could be material: water, air, cells, atoms, or an idea, such as number, or “mind.” The problem isfiguring out what is that one unifier For example, it could be divine, such as the concept of God or the Chinese

concept of Shang-ti, the Divine Evolutionary biology also speculates on “oneness.” For example, the

choanoflagellates are a group of free-living unicellular and colonial flagellate eukaryotes considered to be theclosest living relatives of the animals This model proposes the last unicellular ancestor of modern animalsexisted in the late Precambrian, greater than 600 million years ago In this evolutionary biology perspective,one cell was the original point of development into modern, multicellular animals (Cavalier-Smith, 1998).

Incompleteness is central in the history of humankind's pursuit of ideas and strivings behind all endeavors.

From incomplete satiation or hunger for nourishment to an incomplete sense of being alone and desiring a

companion, the list of desires to fill in the missing parts is unending Nonattainment of desires and accompanying

distress are universal human experiences Mindfulness too takes part in this quest It tries to expand its rangeof alert awareness to engage in an in-depth way toward greater wholeness and integrity with its focus.

These representative divisions are simplifications of a complex and nuanced history of humankind's effortto make sense of itself Their relevance to mindfulness rests on several concerns: What is mind? To what is the“I” we speak of referring? What is conscious awareness? Are our minds experienced as distressfully “many,”so we strive toward aspiring to a more peaceful, mindful “oneness”? These questions pose enormouschallenges Mindfulness is one approach toward managing such existential concerns.

1.3 Western Perspectives on the Self

Perspectives on self, mind, and embodied personhood in Western psychology have contrasts with Hindu andBuddhist traditions In conventional Western psychology, the self is a standard contemporary term for theclassical, traditional use of the concept of “ego” (Gusnard, 2017) Ego, originating in psychoanalyticpsychology, is referred to a group of mental functions mediating an individual's inner instinctual or biologicaldrives with the real demands of the environment These faculties called for processing information asreasonable adaptations to reality “Ego functions” included abilities to distinguish reality from imagination andfantasy Facilitating this were judgment, evaluation, sense of reality, regulating impulses, emotions, cognition,interpersonal and social relations, defense mechanisms modulating anxiety, and synthetic abilities tocoordinate and integrate information Functions ranged the span of being consciously available through ever-deepening degrees of nonconscious automaticity.

Contemporary neuroscience recognizes nonconscious aspects of mental functioning The terms “implicit”and “tacit” in psychology and neuroscience denote nonconscious (i.e., preconscious and unconscious) mentalactivities (Cozolino and Siegel, 2017) From behavioral perspectives, the ego functions as a pattern of habitsdeeply etched on all levels of memory with more of an automatic reactivity than consciously effortfulresponsiveness Mindfulness provides an opportunity to understand this It offers, not guarantees, a chance formeaningful change This change includes updating old habit patterns—both nonconsciously and consciously—with nonconscious changing and more adaptive thinking and behavior.

1.3.1 Man and Woman as Incomplete

All world traditions, Western and Eastern, view the psychological and spiritual dimensions of people asincomplete, as humans “in the making.” This perception of incompleteness relates to both the inevitable flawsappearing in everyday life and to the emergence of disease, pain, and suffering Vastly differing interpretationsexplain these concerns While some religious perspectives speak about men and women as having sinful or, atleast, flawed inclinations, psychological traditions emphasize growth and developmental perspectives Thispsychological view describes natural tendencies toward mistake making that can gradually self-mature andlearn from supportive personal and educational environments Many physical and cognitive faculties matureand unfold to show their native functions Much potential ability can be educated and developed toward anintended level of more sophisticated performance This growth toward greater completeness includes, forexample, muscular development, language, and literacy skills such as reading, writing, and mathematicalcalculation.

The East has likened the incomplete condition (e.g., helplessness) at birth to concepts such as mental“ignorance.” This “absence” covers incomplete human capacities as potential faculties needing growth,

maturation, and development Thus, a natural state of “ignorance” (i.e., avidya in Sanskrit or avijjā in Pali) or

nonknowledge is axiomatic in Eastern traditions (Bryant, 2009) This essential term and its implications have

emphasis here because the concept of avidya is a core idea in both Buddhism and Hinduism They consider it a

fundamental block to a mindful awareness (Wayman, 1957) Most English translations use terms like

“ignorance” or “nescience” to signify avidya These translated terms may be too harsh and misleading because

they fail to emphasize the potential of covered understanding or incomplete knowledge in the meaning

of avidya Avidya may be the underlying trigger eliciting curiosity, exploration, growth, and development.The term avidya translates as missing knowledge, nonknowing, nonunderstanding, or misunderstanding.The Sanskrit term vidya means “knowing,” and a means the “absence of.” Avidya as a concept originated in the

ancient Vedic texts (c 1700–1100 BC), the foundational scriptures of Hinduism Using the

word avidya contrasts purposefully with the opposite ideas of intelligence, knowledge, understanding,

wisdom, seeing clearly, and enlightenment Put differently, avidya means the absence of maturation—

incompleteness and incorrect discrimination.

Avidya is the quintessential missing part or incompleteness acting as a prominent gap needing filling Likescars, avidya or incompleteness makes one interesting and motivated to focus on and discuss what's missing.

This impulse to explore is the dynamism behind curiosity as a primary tool in mindful awakening.

Viewing avidya as a potential “seed” may be a generative insight Avidya as a presence is a potential requiring

input to facilitate its maturation and greater fulfillment toward completeness The Eastern terms for

self-realization and enlightenment are Moksha (aka freedom) and Nirvana (aka extinguishment) Could these ideasrefer to the elimination of avidya?

Many Zen scholars quote the classic Zen aphorism: “Not knowing is the most intimate.” Thisincompleteness signifies the ideal state of openness to experiencing insights (Wick, 2005, p 63) Easternwritings use negatives to highlight the potential for positive transformation This aspirational premise is acentral and recurring theme in mindfulness considerations Of interest is the psychologically minded Westchoosing to view the incomplete human condition as one of “helplessness” in contrast to the East preferring the

term avidya.

Eastern traditions emphasize that change is illusory or that substantial entities such as self or soul

(Sanskrit: atman) are eternal and changeless Eastern views about spiritual and mental change can be nebulous,

nuanced, and hard to define in Western concepts Thus, Western perspectives have clear-cut boundariesaround definitions inherently psychological Eastern traditions think differently They fluidly interspersespiritual, religious, and philosophical ideas into what the West regard as psychologically unambiguous.

The field of information technology has relevance here The phenomenon of “Big data” is common currencyon all levels of science and business Big data defines datasets increasingly voluminous They challengeavailable data-processing application software to manage them A principal focus is a predictive analysis anduser behavior because this can enable extracting the value of dissimilar material from properly analyzed data.Monstrous databases challenge this goal Healthcare systems try to work with Big data to manage risk, reducewaste, and refine personalized medicine While needed and laudable, the inherent challenge of “dirty data,”data corrupted in extracting it for usability, poses its detours to progress Inaccuracies inevitably increase asinformation expands.

Technology has not only been decisive in creating this dilemma but also in trying to master it.Incompleteness as a personal matter has projected and materialized into social and organizational networks.For example, data dashboards used as information management tools, visually track, analyze, and displaymetrics, and data points to monitor the “health” (e.g., productivity) of an organization Analytical dashboardshelp decision-makers establish targets and set goals A provocative understatement is saying one function oftechnology is adding ever-expanding arrays of completeness to the unfulfilled desire for human ignorance tobecome less ignorant, more complete, and knowledgeably satisfied It is not an understatement to usetechnology wisely Along with technological innovations, a strategy to manage the distress of“incompleteness” has been the ramping up of thinking to excess This ratcheting up of thinking simulates areflex to fill in the gaps in speech and answer what is unanswerable.

The burgeoning tendency of younger generations to speak at alarmingly fast rates suggests a need to get inas much information in brief periods Speed as a criterion of efficiency has risen not only to interpersonaldialogue but as part of the escalating advances in the processing speeds of technological devices The term“speed” was once used to refer to stimulant-like drugs These had qualities of tolerance and withdrawal when

discontinued (formerly called “addiction” and “dependence”) Can our culture's fascination with rapiditycorrelate with these ideas of overuse and adverse effects?

Excessive thought, principally intellectualization, is a mechanism of defense against anxiety Using aflourish of intellectually clever arguments is the armor blocking confrontation with disturbing conflict andemotional stress Excessive thinking avoids the unbearable anxieties associated with distressing emotions andfeelings Often, avoidance triggers reactive monologues with a rhythm that is mechanical, monotonous, andunconvincing The outcome of overthinking, however, is time-dependent Briefly, anxiety becomes appeased.Shortly thereafter, overthinking becomes addictive worrying and a self-sabotaging habit.

Pronounced thinking, overthinking, information overload, mind wandering, and forms of intellectualizationhave long been recognized in Eastern views and mentioned in the traditional Hindu scriptures such as theVedas, Vedanta, and Yoga The Buddhist concept of conceptual proliferation, often to absurdity, correlates

with the distasteful phrase, “monkey mind.” Buddha termed this kapicitta This reactionary process involves

removing one's self, emotionally, from a stressful event by restless, capricious, fanciful, confused, indecisive,and uncontrollable thinking—fast-paced swinging from one thought branch to another This discursive

rambling, even if seemingly logical, has the label papanca and may be a common undercurrent causingobstructions (called klesha in Eastern systems) to mindfulness as a mode of awareness.

A maxim in Zen Buddhism is: “See right at once When you think, you miss Zen.” To the Western mind, thisBuddhist truth may appear fanciful and irrational, but in Zen, transcending the rational is achieving ineffableenlightenment The belief in the event of enlightenment is an uncovering—an awakening to what is present buthad been unrecognized Hence, Zen calls itself, “the pathless path” and “the effortless effort.”

Sections contrasting Western and Eastern views clarify how different the role of reason is as it isunabashedly baked in perplexing ways in classical Eastern writings On the surface, ideas may appear illogicaland paradoxical, yet have served mindfulness for millennia Keeping this distinction in mind is helpful to aWestern-trained physician Suspending rapid negative judgments and preconceived notions about the“science” used in Eastern thought helps enormously in understanding Eastern perspectives.

1.3.2 Self-awareness and Self-reflection

Self-awareness includes multiple dimensions of how one experiences the self (Duvall and Wicklund,1972; Northoff, 2011) Self-awareness involves paying attention to oneself and consciously knowing one'sattitudes and dispositions This mindful understanding comprises awareness of sensations, emotions, feelings,thoughts, the physical body, relationships with others, and how these interact.

Developmentally, in infancy, this awareness arises embryonically as a phenomenal state of diffuseconsciousness—being awake and directly experiencing things in a global, undifferentiated way No to littleself-awareness is detectable, although presumed developing Experts in the field propose the underlyingorganization of the emotion-recognition networks is an experience-expectant neural circuitry emerging at 5 to7 months (Aru & Bachmann, 2013) Rapidly, exposure to universal features of people's expressions during thefirst years of life refines itself into abilities to differentiate emotions At about 18 to 24 months, detectable self-awareness is recognizing oneself in a mirror and beginning to say “I.” Using one's first name is clear at about30 months Turning all these abilities toward a sense of self arises in the preschool years.

Self-reflection is the periodic turning of attention inward (Johnson et al., 2002) Focusing toward oneself helpsmake sense of attitudes and behaviors This clarity is a process of realizing one's subtle or implicit and clear-cut, explicit feelings and mental states Interactions with other people evoke implicit emotional reactions Self-reflection helps to bring these previously unrecognized feelings into effortful, conscious awareness Self-

reflection arises from refined self-awareness Self-reflection, self-evaluation, self-monitoring, and cognitiveperspective-taking are interconnected abilities Their roots develop in early childhood between 3 and 5 yearsold As self-awareness expands throughout adulthood, the capacity for self-reflection also deepens.

1.3.3 Ego, Self, Sense of Identity, “I,” and Mind

Fundamental concepts help to understand the nuances of the developmental perspective and emergingpersonhood In individual psychology, terms such as “ego,” “self,” “sense of identity,” and “I” refer to theoverall way individuals experience themselves in a social context, mainly in relation to others (Aronson,Wilson, & Akert, 2007, p 113) Although these terms denote self-reference, they ground themselves in aninteractive mode, the self with another.

Ego in Eastern thought also strongly connotes its functioning as an instrument of measurement It is that“special individualness” of one's separate mind constructing boundedness and giving shape to forms andcontent with mental images, sensations, feelings, thoughts, and imaginations This form-shaping processreflects the concept of time Hence, managing the ego and one's sense of time in mindfulness is an essential

skill in Eastern systems Mind, a broader concept, covers all emotional and cognitive processing and resulting

contents Seigel (2012) has given a formidable portrayal of mind in mindfulness.

A sense of identity is related to defining personalized parameters from socially perceived inputs This sense

articulates—explicitly and implicitly—individuality and characteristic attitudinal and behavioral styles (Learyand Tangney, 2013) One's sense of identity denotes a personal knowledge or belief about who one is, forexample, male or female, young or old, happy or unhappy Identity includes a persistent, continuingselfsameness felt within This perceived essential continuity reinforces itself by the belief its character sharesitself with similar others The developmental growth, maturation, and revisions making up a sense of identityalways depend on the context of relations to outside figures and situations.

While difficult to establish timeframes with chronological precision, by 18 months, toddlers can recognizethemselves in a mirror as they also use language to label external objects and needs By about 30 months, theyoung child confidently says “I” and often his or her name Saying “I” denotes self-assigned (i.e., labeled andnamed) personality characteristics distinguishing individuals from others “I” as one's self-identity is anindividual's conscious belief about who they are as separate individuals (Stern, 2000) A sense of self implies agreater emphasis on nonconscious self-experience These psychological events signal personal identity isforming Between three and five to six years old, emerging personality configurations organize Adultsrecognize children as distinct in a mood, attitude, demeanor, and social interactions.

Mind refers to the subjective awareness of self: how one experiences herself or himself as a person, and to

the contents of this awareness The mind is the full faculty of thoughts and emotions encompassing sensation,perception, conception, and information processing both nonconscious and conscious Mind is both a containerand a processor About the self, mind forms mental models—conscious knowledge about the perceived self:“self-concepts.” Self-concepts contain information about and show conscious self-awareness They arise byages three to five years Self-concept comprises beliefs, mostly conscious self-perceptions, whose elementsencompass gender, race, social, and academic status.

“I” and “mine” are pathognomonic terms of the ego The word “mine” importantly connotes possession andclinging Saying “mine” and “no” becomes clear at 15 to 24 months Clinging suggests one is not ready orprepared to let go then move forward Eastern perspectives see this clinging as attachment suggesting an“unripe” condition, as, for example, fruit on the vine not mature enough to let go then detach Concepts suchas attachment, clinging, inability to let go, and fixedness show how crucial they are in Eastern perspectives.

This emphasis on incompleteness may be one reason the term “ego” has maintained its negative connotations.Obstacles use mindfulness to complete their development to ripen, detach, and fall away.

1.4 Thinking Architecture and the Mental Status

Understanding the process and content of thinking drills deeply into the Western interpretation of mind Working

knowledge of these details provides the intelligent physician with a broader frame for understandingmindfulness as it fits in contemporary clinical thinking This descriptive analysis of thinking architecture andthe mental status broadens understanding mindfulness and the array of techniques used An understanding ofthinking processes from the clinical viewpoint complements understanding emotional intelligence (Matorin,Shah, and Ruiz, 2017).

For example, physicians in every specialty face increasingly complex and “difficult-to-diagnose” patients.Accurate diagnoses support effective treatments The form and content of thinking, its design, andarrangement not only reflect patterns that may be assessed as typical and reality-based but also aspragmatically maladaptive This understanding gives the evaluator a sense of the individual's capacity tolisten, remember, understand, and cooperate This attentive, empathetic understanding can foster cooperation,adherence, and influence clinical outcomes in any medical specialty In-depth knowledge of the typical versusatypical mental status helps one who journeys into mindfulness because it helps to keep a reliable mentalhealth alignment in mind A secure ballast distinguishing what is sane, adaptive, and conducive to wellness isessential For example, mindfulness orientations are useful for many seeking reduced stress and greater clarityof thought However, persons with severe psychiatric disorders such as psychosis, severe trauma, severedepression, and active substance use might not be suitable while they are impaired Hence, both a familiaritywith the mental status and using sound clinical judgment precede considerations of introducing mindfulnessprotocols.

This section presents a descriptive, phenomenological rather than etiological method (Berrios, 1996; Simms,1988) Historically, emphasis on such descriptive rather than interpretive diagnostic methods had its roots insectors of the Anglo-Continental psychiatric tradition of the early part of the 20th century (Bleuler,1951; Jaspers, 1962; Schneider, 1958) In the 1940s, American psychiatrists such as Cameron(1947) and Goldstein (1944) contributed to the clinical understanding of the thinking processes found inpsychosis by careful studies of the standard language patterns used by persons having schizophrenicconditions The contributions of these pioneers can still be seen in current descriptive nosologies found in theDiagnostic and Statistical Manual of Mental Disorders (DSM-5) (APA, 2013, p 669).

1.4.1 Elements of Thinking Architecture: Cognitive Units, Form, and ContentThinking architecture is complex in structure and functioning It refers to the broad sector of cognitiveoperations that provide, process, and store information Units of sensory perception and their integrationinto meaningful conceptions build the structure of thinking architecture Functional analysis of thisarchitecture aims to delineate the process or form thought takes This assessment includes its level oforganization or disorganization, the tightness and looseness of associations, the quality of logical connectionsbetween thoughts and groups of thoughts, and the flow or stream of thinking.

The content within a disordered architecture may include hallucinations, delusions, obsessions, ideas ofreference, and paranoid ideation Thinking structure, therefore, reflects the design and arrangement of mentalprocesses It provides a model or plan informing and motivating subjective experience and modes of behavior.Any journey into mindfulness demands a reality-based grasp of typical and adaptive thinking processes.

1.4.2 Structural Cognitive Units: the Two Building Blocks of Thinking

A simplified schema broadly conveys the complicated nature of thinking architecture Understanding theaverage and typical course of thinking and how it may deviate from a reality base and become maladaptive is areference against which any mindfulness endeavor must proceed.

Two fundamental levels of cognition are perception and conception Perceptual processes can be understood

both developmentally and in real time Concrete sensory perceptions start these More abstract mentalinterpretations structure these elemental percepts Perceptual recognition is complex It involves the receptionof stimuli, registration, processing, and reorganization through associations with memories, emotions, needs,intentions, and expectations It activates feedback loops and yields final evaluation and judgments Concretesensory perception occurs in the actual presence of external stimuli and is a simple given These acute,ephemeral, and transitory states of awareness act as concrete, direct mental presentations Awareness ofinternal bodily states (i.e., interoception) resulting from proprioception and kinesthesia is also a perceptualexperience.

Normal and relatively accurate perception occurs in the absence of disease, toxic states, and mental

disorders False perceptions may be illusions or hallucinations Illusions are misinterpretations of real stimuli.

When distortions in the intensity, quality, and spatial form of perceptions arise, these distortions (e.g., ocularmicropsia or auditory hyperacusis) reflect physiological disorders as found with retinal or lens damage, braintumor, or drug-induced toxicity An essential feature of such functional perceptual misinterpretations orillusions is their easy amenability to correction The average person, sensing a possible perceptual confusion,uses further checking to test further and reassess the likely misperception thus trying to correct it.

Abstract perceptual mental images, which may occur in the absence of real external stimuli, may be accurateor erroneous They may be real or false when tested against reality When erroneous and bizarre, these types of

false perceptions are termed hallucinations They may occur with more accurate, reality-based perceptions.

Hallucinations are pathological because their veracity and integrity when tested using external environmental,evidential reality is gravely mistaken Hallucinations are false perceptions An essential feature ofhallucinations is their obstinacy However, this stubbornness may be overcome by the therapeutic use ofantipsychotic, neuroleptic medication This remediation is an attenuation rather than elimination.

Higher level or more complex mental functioning based on an accumulation of sensory perceptions results

in the gradual formation of more abstract and enduring mental units termed concepts These representations are

the ground forming one's database, store of knowledge, operational comprehension, and crystallizedunderstanding At this complex level of conceptual association more complexly configured pathological,maladaptive, and distressing ideational events such as found in mental disorders occur These

include obsessions, compulsions, and delusions.

1.4.3 The Dynamic Process or Form Associated with How ThinkingAssembles

The structural units of thinking, its percepts, and concepts unite to form associations in complex ways Theseyield the structure, design, and style associated with an individual's unique thinking architecture.Understanding the mechanisms underlying this dynamic construction is essential to determining whether one

is sufficiently reality-oriented and, therefore, not psychotic A formal thought disorder is synonymous with

psychosis, notably schizophrenia, and the mania displayed in bipolar disorder.

Close attention to speech and language determines the dynamic process or form of a patient's thinkingarchitecture Verbal communication shows a representative sampling of an individual's store of perceptions,conceptions, and the formal relationships of these in the thinking process Concepts and ideas have discrete

boundaries acting to sharpen their meaning They permit them to connect with other ideational units logically.These clear margins and their links produce complex and meaningful ideational progressions,rational thinking Organized, linear, coherent, and intact mental associations reflect conventional or normalthinking.

Associations between thoughts are a crucial determinant of psychosis “Tight” associations describeconventional thinking, adaptive and realistic The term “tight” means substantially linked in a relevant andmeaningful way This meaning is decisive to understand because in both the mental status and in mindfulnesstraining, the adherence between the thinker and the thought, for example, is a target of examination Inmindfulness, the strength of the normative association is intentionally and skillfully softened to permit thethinker relative freedom from becoming locked fixedly into any thought or object of mental content.

Formal thought disorders are also characterized by the lack of adequate connections between mentalassociations This inadvertent thought disjunction gives rise to unclear concepts and unstable thoughtprocesses Loosening of associations is also termed “allusive thinking.” The meaningful quality of linksbetween thoughts weakens Others have proposed various mechanisms to describe these faulty conceptualassociations Tangential thinking never gets to its intended conclusion Circumstantial thinking may arrive atconclusions but does so in a tortuous, overly detailed, sometimes irrelevant manner.

A formal thought disorder may show features of “derailment” where one thought slides on to a subsidiarythought haphazardly “Desultory thinking” reflects the bizarre intrusion of sudden ideas appearing to forcetheir way into what had seemed to be a healthy flow of thought Formal thought disorders have both positiveand negative dimensions.

A positive formal thought disorder may result from the lack of adequate connections between successive

thoughts and is “asyndesis.” Disorganized thinking may result from the interpenetration of conceptual themes.It is the overinclusiveness of single ideas and in broader streams of ideas In a positive thought disorder, thepatient can generalize and shift from one hypothesis to another The generalizations are too detail-specific, tooinclusive, and too enmeshed with idiosyncratic fantasy Derailments, which include the gradual or abruptdeviation in the logical train of thought to irrelevancies, may occur.

“Metonyms,” which are imprecise approximations in which a substitute word or phrase instead of a moreexact one, are often seen These, coupled with an abundance of personal idioms, referred to as the “woollinessof thought,” leave the hearer baffled and confused when listening to an individual with a formal thoughtdisorder, e.g., “once in a colored moon.” “Neologisms” or the creation of invented words with personalmeaning may emerge For example, a patient from New York City visiting Connecticut in July and seen in theemergency department for a sudden exacerbation of mania referred to his visit to the state as a visit to “Corn-ecticut” as the many cornfields he encountered overwhelmed him.

Clinically significant thought disorders are characterized by enduring irregularities in tempo, speed,prosody, continuity, regulation of flow, and by the patient's abnormal sense of the ownership of thought Thesestreams of thought irregularities characterize positive thought disorders Typical normal speech rhythms andtheir melodious modulation may be absent Pressured thinking, a flight of ideas, and expansive prolixity inthinking may reflect hypomanic or manic states In psychosis, the patient may believe thoughts are beinginserted, extracted, or even broadcast by forces alien to and forcefully acting on him or her.

A negative formal thought disorder may occur when there is a loss of the earlier ability to use abstraction and

developmentally appropriate symbol formation Thinking becomes literal and concrete It is adherence toinstance-specific details, and the absence of a developmentally appropriate capacity to generalize, which was

previously present A negative thought disorder reflects thought blocking and a consistent paucity of the

volume of thought These features are negative symptoms, typically of schizophrenic disorders.

1.4.4 The Content of Thinking

A patient's thought content is measured against their age, and developmentally appropriate ability to formconcepts and conceptual organizations used adaptively to convey relevant meaning This “reality sense” ispredicated on the capacity to distinguish idiosyncratic imagination and fantasy from facts tested by evidenceand subjected to consensual validation, several perspectives agreeing on the same meaning Normal orstandard thinking has a broad range of forms and contents Being realistically adaptive, thinking's overridingaim is to maintain continued survival and health within one's cultural context Destructive impulses, forinstance, aimed at self and others are kept in check.

Thought contents within clinically disordered thinking may include features such as illusions,hallucinations, delusions, obsessions, and compulsions These suggest degrees of significant impairment inhealthy adaptation and reality testing They may put the patient at risk for harm Recognizing at-risk signs andsymptoms enhances diagnostic assessments and treatment interventions.

An illusion is a misinterpretation of sensory experience, of stimuli arising from an external object Illusions

are distorted perceptions A normal illusion, for example, might occur when a healthy individual on a campingtrip mistakes a rope on the ground for a snake A healthy person will have a reaction of withdrawal butexamines the event and readily recognizes the mistaken sense deception Benign illusions are short-lived andeasily open to correction.

Hallucinations are perceptual experiences triggered by internal stimuli They are perceptions of an external

object when no object is present Hallucinations may involve any sense modality, but visual and auditoryhallucinations are common in psychosis They intermittently emerge and disrupt the ordinary course of dailyliving and social interaction Toxic substances such as poisons or psychoactive drugs may cause organicallybased hallucinations, which are usually visual and tactile In schizophrenic disorders, the persistenthallucinatory experience is a common finding Any form of hallucinatory experience suggests serious mental

illness A hallucination is a positive symptom of schizophrenia Hallucinations are often accompanied by

delusional interpretations of the idiosyncratic meaning the patient gives to the hallucinatory experience.

Delusions are false beliefs firmly maintained even though contradicted by realistic evidence and by social

and cultural norms Delusions are vigorously held despite a lack of reasonable confirmatory evidence They areunshakeable, idiosyncratic misinterpretations, which severely impair overall functioning because they are soextreme and nonreality based Thinking characterized by delusions may present with clinically significantfeatures of paranoia, jealousy, grandiosity, eroticism, ill health, guilt, or nihilistic despair They may becomeorganized, systematized, dominant, and entrenched in one's psyche.

Primary delusions and secondary delusions may be part of any psychotic condition such as schizophrenia,bipolar disorder, and severe psychotic depression Primary delusions are de novo events wherein a newmeaning spontaneously arises and is not a response to a preexisting event Secondary delusions may thenorganize and can be in response to a chronically depressed mood or a paranoid suspiciousness A delusion is

a positive symptom in the spectrum of psychotic disorders.

Obsessions are thought contents and recurring ideas that cannot be dismissed even though judged to be

senseless and unwarranted in their persistence Inordinate doubt, anxiety, and distress accompany them.Obsessions are experienced as occurring against the patient's will although believed to be owned, self-generated, and not introduced by an outside agent Obsessions may take the form of ideas, mental images,

impulses, fears, phobias, or ruminations This form of pathological persistence of an irresistible thought orfeeling cannot be eliminated from consciousness by logic or willpower.

Compulsions are mental contents reflecting a pathological need to act on an impulse that, if resisted, would

produce anxiety Often a repetitive motor behavior or ritual enacts the ideational component of a compulsionsuch as excessive checking, arranging, or cleaning Time-consuming compulsive motor enactments orcompulsive thought ruminations may be in response to mental obsessions Compulsions are performedaccording to specific rules, with no end other than to prevent a feared event from occurring thus feeblyreducing doubt and anxiety.

Any physician considering entering explorations into mindfulness personally or with patients must beknowledgeable about norms in mental functioning Mindfulness focuses on consciousness and the self-regulation of attention Clear-cut understanding of the average contents of thought is essential When thinkingis normalized, emotions and mood stabilize Keeping this in mind is essential to maintaining a healthyperspective and moderation in approach and monitoring of outcomes.

1.5 Eastern Perspectives: Buddhism, Hinduism, and Yoga1.5.1 “Mindfulness Meditation”: Historical Origins

Mindfulness as a practical lifestyle and attitude and meditation as a group of diverse practices both Hindu- andBuddhist-based are indigenous to Eastern cultures Western religious meditative traditions, orthodox andmystical, also have strong backgrounds, although discussing these is beyond this book While contemporaryWestern views differ in approaches to the details of meditation and mindfulness practices, the Eastern culturalcontext influences a unifying influence that emphasizes a steadying mental attitude (Gombrich and Scherrer-Schaub, 2008, pp 209–210; Jones and Ryan, 2006, p 57; Kirmayer, 2015).

Learned Mindfulness is a psychological approach and so has addressed the psychological emphases in both

Yoga and Buddhism Both these traditions focus on mind, its detailed operations and use in mindfulnessendeavors The worldviews of the different branches of Hinduism and Buddhism undoubtedly influence theease, effectiveness, and sustainability of the results of mindfulness Rather than consider mindfulness as amodern reinvention, its historical origins offer a contemporary contribution whose foundation establishes itself

on the spirit of Eastern traditions and enhanced emotional intelligence perspectives Learned Mindfulness is an

addition to the valuable existing mindfulness frames.

Traditional Eastern practices began with careful observation (aka “witnessing”) of phenomena experienced

in body and mind This mindfulness readiness was everyday attention to the moment as a prelude to deeperstates of meditative awareness This participation correlates to right mindfulness (i.e., samma-sati).

Progressively, these objects of attention were handled to shift their focus and return awareness to their origins,consciousness in Yoga and clear mind in Buddhism This section unpacks these complex ideas The millennia-old traditions of Eastern perspectives undoubtedly embed them with nuance and enormous diversity Thus,this review is a briefing aimed at broad but relevant coverage of ideas and practices Careful attention is givento terms and their meanings understood by each tradition (Fischer-Schreiber, Ehrhard, & Freidrichs, 1994).Eastern terms are conceptually nuanced, and only the more standard definitions and connotations are given.1.5.2 Buddhism

Buddhism originated in Ancient India sometime between the sixth and fourth centuries BC with the figure ofSiddhārtha Gautama born in Lumbini, Nepal He became known by the title “the awakened one, the Buddha.”Buddha's system spread through much of Asia and then declined in India during the Middle Ages Scholarstoday recognize two existing branches of Buddhism They are Theravada (Pali: “The School of the Elders”) andMahayana (Sanskrit: “The Great Vehicle”) (Conze, 2003; Williams, Tribe, & Wynne, 2012).

Sanskrit is a standardized dialect of Old Indo-Aryan originated in the second millennium BC as VedicSanskrit It traces its linguistic ancestry to Proto-Indo-Iranian and Proto-Indo-European about the thirdmillennium BC (Ramat, 1998) Though the Pali and Sanskrit language are related, Pali is not considered adescendant of Sanskrit The Pali language is a composite having several dialects, likely based on the languageBuddha spoke, a Magadhi dialect This variant occurs in Eastern India, a native Middle Indo-Aryan language,replacing earlier Vedic Sanskrit Both the Sanskrit and Pali languages have the same vocabulary and similargrammar, but Pali has a simplified grammar In this book, conventional Sanskrit renderings will be used(Monier-Williams, 1872, p 918; Ruppel, 2017).

Hinayana also called Theravada (aka “Teaching of the Elders”) developed between the death of the Buddha

(∼480–400 BC) and the end of the first century BC Emphasis was on meditation, monasticism, and the strivingto reach salvation, Nirvana.

Mahayana, which includes the traditions called Pure Land, Zen, Nichiren, Japanese Buddhism, Shingon, and

Tiantai (aka Tendai), is found throughout East Asia Arising in the first century AD, Mahayana aspires to

Buddhahood via the bodhisattva path where one remains in the cycle of rebirth (i.e., samsara) to help othersreach Buddha awakening Bodhisattva means “about to become a Buddha.” Vajrayana, a body of teachingsattributed to Indian Siddhas (i.e., holy men), may be viewed as a third branch or a part of Mahayana This

Tibetan Buddhism preserves the Vajrayana teachings of the eighth century India Its practice is in regionssurrounding the Himalayas, Mongolia, and Kalmykia.

This chapter will summarize Theravada/Hinayana and Mahayana Buddhism because they encapsulateBuddhist thought Zen Buddhism is the Mahayana Buddhism influenced by Taoism first brought to China in

the sixth and seventh centuries AD and called Ch'an Ch'an reached Japan in the 12th and 13th centuries and is

Zen Buddhism It differs from classic Theravada and Mahayana Its primary emphasis is on the direct methodsof a Zen master with a disciple using specific Zen devices These are often

contradictory koan statements Koans show the inadequacy of logic and were used to provoke sudden insights(i.e., kensho) and enlightened awakening (i.e., satori) Zen practices are zazen or meditation.

1.5.3 The Arhat: Lone Seeker of Self-development

Hinayana (aka “Small Vehicle”) Buddhism is the early form of Buddhism, also called Theravada (aka Teaching of

the Elders) It developed between the death of the Buddha (∼480–400 BC) and the end of the first century BC.

The individual aspirant and monasticism were central areas of focus The arhat (Sanskrit) or arahat (Pali) is the

“worthy one” who has attained the highest level of Hinayana aspirations—that of no more learning needed.

For the arhat, the defilements (i.e., asrava or klesha) as the roots of all suffering entail 1.) desire, 2.) craving to

continue in existence, and 3.) ignorance When the passionate emotions have been extinguished and will notarise again, the flow of karma dissolves The belief was “salvation” must occur in this lifetime, the last karmicrebirth.

Early Buddhism had the arhat/arahat as its ideal aspirant whose aim was working independently, in a

monastery but chiefly as a sole practitioner, seeking salvation Early Buddhism saw salvation as its aim rather

than later iterations whose terminology became more allied with enlightenment or Nirvana The earlier

emphasis on salvation suggested an end to the suffering felt in this world while subsequent considerations ofenlightenment put sustained focus on insight and “right” living in this world On a foundation of the Buddhist

Four Noble Truths, the arhat achieved this self-realization by recognizing the impermanence of all things and

following the moral code prescribed by Buddha's Eight Noble Paths thus ceasing the defilements.

The early Buddhist texts of the Pali canon do not explicitly enumerate the three root kleshas Across time,the three poisons (and the kleshas) came to be the roots of samsaric (i.e., the cycle of rebirth) existence.

Samsara (i.e., “journeying” as the cycle of rebirths) signifies repetition toward extinction Its three driving

forces were these basic propositions:

1 dukkha (i.e., suffering), unsatisfactory, painful, and hated sense of repulsion

perpetuated by desire; implied is the oppressive nature of continuous upkeep and thenonpermanent and fleeting sense of happiness.

2 avidya (i.e., nonknowing), and

3 trishna, unending desire and craving with its resulting karma (i.e., consequences for all

uncompleted actions needing eventual completion).

The attainment of Nirvana, achieved by practicing the Noble Eightfold Path (also known as the MiddleWay), is freeing one from bondage to a cycle of suffering and rebirth.

Theravada now has a widespread following in Sri Lanka and Southeast Asia.

A curious issue may be that some modern “mindfulness meditation” scholars consider theory and practicesto be at odds with traditional Theravada Buddhist doctrine and practices (Sharf, 2015) Scharf argues this is arelatively modern phenomenon, possibly a reform, controversial in the traditional Buddhist world Modernversions of this associate it with “bare awareness” almost in isolation Its origins come from the Burmeseteacher, Mahasi Sayadaw (1904–82) His technique did not require classical familiarity with Buddhist doctrine

(e.g., Abhidhamma), strict ethical observance, and arduous perseverance Traditional Buddhist practices, by

contrast, orient themselves with doctrines instead of “bare mind” alone, according to Scharf Buddhist scholarslike Scharf emphasize less present-centered, nonjudgmental mental contents They put higher weight onBuddhist doctrine in mindfulness (Dreyfus, 2011).

1.5.4 The Bodhisattva: Enlightened but Remaining with Compassion to Help

Mahayana (aka “Great Vehicle”) Buddhism is another distinguished school of Buddhism Mahayana arose in the

first century AD and was influenced by the renowned Buddhist priest and Ayurvedic physician, Nagarjuna (c.AD second to third century) Focus shifted from the individual pursuit of self-development to self-development in the service of others Self-development implies development of the person and effacement of

the ego The bodhisattva is the figure representing this ideal.

While the words of Buddha as evidenced by his writings and disciples have a distinctly mystical air, with anemphasis on silence, Nagarjuna's written contributions were philosophical and highly analytic His scholarly,often enigmatic, contributions used logic yet kept a quintessential balance on Buddhist themes The chief

principle was the axiom of shunyata or emptiness This fundamental conception is primary in Nagarjuna'swork Examining other Buddhist schools, primary “emptiness” also can be found Emptiness is clarity or a clearmind.

The Mūlamadhyamakakārikā (Sanskrit) or “Fundamental Verses on the Middle Way” is a crucial text ofthe Madhyamaka-school, written by Nagarjuna, and is his best-known work (Garfield, 1995; Lindtner,1997; Siderits & Katsura, 2013; Tachikawa, 1997).

Using the Buddha's theory of “dependent arising” (i.e., pratitya-samutpada), Nagarjuna showed his view of

discursive arguments and the futility of metaphysical speculations His method of discussing such matters is

the “middle way” (i.e., madhyama pratipad) It is the middle way that avoided substantialism (i.e., that reality

has an intrinsically real substance that can be rationally understood) and nominalism (i.e., that reality is justsignified by words pointing to insubstantial referents), each in isolation.