MINDFULNESS PRACTICE & THE LAW

RICHARD E. BERGER, MD

Criteria for Change

• Perceived need• Perception that work/change required will

produce desired result• Benefit Greater than Cost

PERCEIVED NEED?

(c) Lipsenthal 2011 Swank and Marchland 1946; redrawn from Mind-Body Medicine, Watkins 1997

0 10 20 30 40 50 60

Degr

ee o

f com

bat

Days in combat

Soldier becomes"battlewise"

Period ofmaximum efficiency

Combat exhaustion

Hyper-reactivestage

Emotional exhaustionstage

Period ofoverconfidence

Vegetative phase

Battle Stress / Efficiency and Exhaustion

Predictors of Job Dissatisfaction in Lawyers ( approx. 25%)

• Emotional Exhaustion and Burnout• Stress due to clients• Work load• Litigious > non-litigious• Female > Male

Sharma et al 2010, Tsai et al 2009

Law Practice & Secondary PTSDCriteria Attorneys (n=238) Support Staff (n=109)

PTSD 11% 1%

Depression 39.5% 19.3%

Functional Impair. 74.8% 27.5%

Burnout 37.4% 8.3%

Secondary TS 34% 10.1%

Pleasure from Doing Good Work

19.3% 27.5%

Levin et al. J Nerv Ment Dis 2011;199: 946Y955

Surgical Error & Burnout

Shanafelt et al Ann Surg 2010;251: 995

In Medicine

• Poor provider QOL proportional to burnout• Mistakes proportional to burnout• Patient dissatisfaction proportional to provider

burnout• MBSR improves provider burnout and patient

satisfaction and decreases medical mistakes.

Will Mindfulness Practice Produce Results?

Mental States

Mindfulness: To see Clearly

Intentionally paying attention in an open, accepting and discerning way

Mindfulness

• Paying attention in particular way

• On purpose • In present moment• Openly and non-

judgmentally

• Alerting, re-orienting, executive control

• Intention, motivation• Experiential approach• Acceptance, curiosity

Mindfulness-Based Stress Reduction (MBSR)

• Formal Mindfulness Practice– Breath focused– Body Scan– Attention Shifting– Compassion/Loving Kindness– Present moment awareness focus

• Informal Mindfulness Practice– Pauses– Present moment shifts

• Yoga

Mechanisms of Mindfulness Training

• Emotion Regulation• Attention Regulation• Self-Referential

Processing• Self as Awareness

Awareness

Reperceiving

• Rotation in consciousness from subject to object

• Disidentify with the contents of consciousnes, thereby seeing freshly and clearly

• Witness our storey rather than immersed in it

Physiological consequences of stress driven by catecholamines and cortisol

é heart rateé blood pressureé blood flow to musclesê blood flow to skin é metabolic rateê digestioné blood clotting and thickness

é blood sugaré respiratory rateé fluid retentioné alertnessé breakdown of fatstriglycerides and LDL

cholesterol

(c) Lipsenthal 2011

Effects Mindful Practices• weight• blood sugar• bp• Improved lipid profile• cortisone• inflammation• Improved well-being, alertness• pain with stress

• brain size, grey matter• quality of life• concentration• learning• sleep quality• body awareness• depression • Changes DNA activation• Burnout

NIH conference 2009 Mind/Body Med.

Emotional Response to Negative Self-Beliefs

Golden et al, Emotion 2009

Mindfulness Training and Memory

Jha et al, Emotion 2010

Pain Sensitivity in Meditators

Grant et al. Emotion 2010

Meditation

“Bhavana” = Meaning Cultivation

Brain Changes with Short Term Mindfulness Practice

• Increased Prefrontal Cortex size

• Increased white matter efficiency in Anterior Cingular Gyrus

• Right becomes Left Amygdala predominance

• Increased size insula• Increased hippocampus

size and activity

• Executive Function• Self-regulation• Positive emotional outlook

• Perception, self-awareness, cognition

• Memory

Posner and Tang 2012

Benefit Greater Than Cost?

The Mindful Professional

• Increased attention– Sustained attention and switching focus

• Increases Empathy– Predictive of positive relationships and communication

• Increased Self-Compassion– Compassion toward self improves compassion toward others

• Increased Creativity and Problem Solving– Improved thinking in multiple perspectives and OOB

• Improved Emotional Regulation– Emotions transitory and received without fear

Mindfulness Practice

• Results in 4-8 weeks• Practice 20-40 minutes daily• 12-24 hours of class (minimum amount

unknown)

END