We have one minute left. So rather than, I know you guys are all busy on social media, but I was curious about something. How many of you meditate? One, two, three, four, please keep your raised hand. Six, seven, eight, nine, ten, eleven, twelve, yes, excellent. That was my starting point. Now is a trick question. I'm going to give you first one scenario and the other one, tell me which one you believe in when you say meditation. Do you believe that it must be with closed eyes, in a particular pose, in a particular sitting pose, with eyes open or closed? How many yes? So how many yes? We got at least one yes. And everybody's nodding no. Okay, so, sorry, no, no, no, just five minutes. Oh, time up now. My question is over. And I'm only going to trouble you for five minutes, Chetro. Sorry, Dr. Navarro. After that, your younglings are here. So we're talking about battle-tested meditation. And I have to acknowledge something that I have told Dr. Hart, I will not embarrass you. He's the reason I'm here. I used to present years ago and then kind of fell through the whole concept and I stopped doing presentations. And he, being my resident, one day said, Dr. Bharu, I'm presenting this topic, will you be my co-presenter? And I thought, okay, I'm getting assigned somewhere that maybe I need to resume what I once left off. He was the chair. I was one of his co-presenters. This very same place, Moscone Center, 2019. Almost the same topic, with a little bit of a variation. So he's put me on that path of presenting. And since then, I've not looked back. Every year, I've been presenting. Except the year of the pandemic, which they accepted and we couldn't do it. And this time, I had five presentations, one on each day. This is the fifth, the last one. So thanks, Dan. You're welcome. I had to say that out. I couldn't keep it on me anymore. Okay. So whatever we are going to talk about is our opinion alone. After a great amount of research, nobody else has any policy or anything else to say about it. All right? I'm not going to read that whole thing. And I'm also going to tell you the four presenters have no financial relationships to disclose. Now, you might be wondering, the fourth one over there is actually invisible right now. He will become visible shortly. There's a story behind that. What we are describing today, our objectives are quite simple. What are the types of meditation? As I already attuned to the, or alluded to the fact that we all believe in one type of meditation, whereas there are many. And most of you agreed with me. We're going to identify what these practices are. How do we incorporate them in our treatment plans? After all, that's what we are here for. We're all providers. And we need to do right by our patients. Also, we will come with a new topic, which we did not discuss last time. And that was the idea of discussing spiritual topics with patients and our own discomfort in doing that. And then finally, we'll talk about how to improve patients' health literacy and understand the benefits of many other things, including medicine, therapies, nutrition, one of my other favorite topics. These are the topics for today. I'm going to start. And that's me. And this is also me. I dabble in a little bit of art. And in one of those art classes a few years ago, I did this. And then I just added my hands in it. And here it is. This is also me. I do this every morning. So I preach what I practice. All right, coming to origins and history of meditation. It's not very clear. As we all know, the term mediatum came from to ponder in Latin. However, if we go back in history, we find that the concept has existed in most ancient civilizations and faiths and religions. How do we define meditation? It's not so simple either. If you look at the journal articles, and we came across a lot of them, there are six different definitions which stood out. And believe you, they are quite different, sometimes even contradictory to each other, much like the contradiction I saw amongst you when I said eyes closed or open. That was a simple thing, eyes closed or open. This is much more detailed. The first one refers to meditation as a self-regulation practice amongst many practices that focus on training attention and awareness to bring mental processes under greater voluntary control and thereby foster general mental well-being and development. Excellent. Right on the dot. Second one just says the fact that it's an art being serene and alert in the present moment. The third one has three criteria. What are those three criteria? Define technique. So here's the person who believes you should have your hands this way and your eyes that way and your legs that way. Three more. It's a complex neural practice. This one goes into the neuroscience. Fifth one says it's an exercise in which an individual turns attention and awareness to dwell upon a single object, concept, sound, image or experience. Quite a nice variety, which is what I tell many people. You can have a closed meditation or an open meditation. One of them told me how difficult it is to empty your mind. I said, who's asking you to empty your mind? You don't need to empty your mind at all. Nobody can. The idea is for you to be serene. Welcome the thoughts, even if they are unwelcome. Find out why they are coming to you at that moment. Banish them if you can, if they're too troubling or uncomfortable. If they're good, work with them, entertain them. And finally, it's a contemplative practice with certain features, which include an alteration of the body and mind and a purpose and goal. Six definitions. Three are specific, three are not. Coming to my tradition. As you must have guessed, I'm from India. But lived longer in the United States than in India. However, this is kind of... Somebody's heard of Ashtanga Yoga? Okay, eight limbs. So the first four limbs are more physical. These four limbs are more mental. And they are in a hierarchy. You can't go straight to Samadhi. They follow in that pattern. And if you will see, the first one, Pratyahara, is you stop the flow of information from outside. Turn your mind inwards. Plain and simple. Just close your eyes or not. But just forget everybody around you is there and you're thinking of anything. Dharana. That means, now you're thinking not just inwards, but you're thinking of a single focus. Dhyana. That focus, you have to be very aware of it, why it is there. And finally, Samadhi, which is almost impossible to achieve, is when you become that object. There's a nice little stamp of the guy who was supposed to have been attributed with having made Ashtanga Yoga. His name is Patanjali. So meditation ends with anatomical changes in the brain. Excellent. Now we have proof that there are things, these are not just abstract situations, but actually they will lead to changes in the brain. And all of those are towards a healthy path. By the way, our slides are also on your PDF. On that particular mode, if you go, you can see all the slides. We haven't changed anything. Also, physiological changes. It follows. If there's anatomical change, there has to be physiological change. And now we know that attention becomes better. Irrelevant information is shielded. Distraction becomes less. And self-awareness is better. Can you think of a couple of items here which you see amongst patients and you try to give them Adderall, Ritalin? Yes? All right. As I told you earlier, my passion, besides being meditation, is also nutritional psychiatry. That doesn't mean I do not prescribe medications. I prescribe in plenty. I also tell them for therapies. But I think there's a third prong which we are missing is good, healthy living. Sleep, nutrition, meditation, activity. And there now we have a commonality. This is a new research that came out early this year, and they found out that the fecal microbiota in those who do long-term deep meditation, and they took the example of the Tibetan Buddhist monks and had a good control group amongst those who don't meditate, and found out that the gut microbiota were very different. We all know by now that gut microbiota is one of the chief components in the PNEI axis. Anybody can name what that PNEI stands for? Psychoneuroendocrinal immunological axis. The gut microbiota has a direct implication on all these four systems. You can call it a whole new organ that has been not given importance, and that affects the mind. How do we utilize this? We can utilize it with patients who come for depression, ADHD, PTSD. Some even go as far as saying that schizophrenia patients who come to us do get help by this as an additional treatment plan. And finally, emotional distress, addiction, particularly in withdrawals. These are my references. And now I was supposed to introduce Captain Michael McCarthy, who was diagnosed with COVID on Saturday. He could not fly out of Washington, D.C., but he's recovering, and we are in touch with him every day. And he has sent us a video and an audio, and his slides are with us. So feel his presence, all right? As much as those characters in Star Wars sometimes feel the presence of others. And I'm going to introduce Dr. Kellen Meyer, who's going to do his talk after he has done Dr. McCarthy's talk. Thank you all. Applause So, unfortunately, Dr. McCarthy could not be here in person, but we do have him, and we'll get to hear his voice, if I can figure out how to get the mouse on the screen. And then I'll be back. Unknown, or better described as my own, I'm Captain Michael McCarthy, and I was supposed to be at this presentation in person. Through either some dumb luck or from some divine intervention, I actually got COVID a few days before I was supposed to leave out for San Francisco. Usually a little bit late on all fads, but this one was a little bit unfortunate. So I will be doing this presentation virtually, and hopefully can convey everything I was planning to in person through this. No one tells you that when you're doing these presentations, you start to really sort of analyze what's going on in your room. So I was thinking about taking down some of my artwork, but I thought you might just get a better idea of who I am and where I'm coming from for my presentation. And I have yet to find a way to do my presentation without my dogs roaming around, so you might actually see a disappearance from them too. But this is a neuropsychiatric survey on the effects of meditation and military psychiatry's approach to meditative practices. And one more time, I'm Captain Mike McCarthy, and it's good to see you all. So I was initially going to do a sort of anecdote on my history with meditation itself. On the left there is my beautiful wife, Hannah. This is actually her at the American Psychological Association, so I always say the A, little P-A, in 2019. And she has been very helpful for me, and I think I actually sort of like reinforcing my meditative practices that I've gotten into more recently and in past years as well, so I wouldn't be able to do it without her. And then on the right is me actually when I made it down to the actual office for the American Psychiatric Association in D.C., so it was kind of just this happy surprise. But part of what I was thinking with my initial anecdote was that we don't make mistakes, we just have happy accidents. And I think there's probably no better sort of description for that than what's going on right now. Initially, I was very frustrated, angry, sad. With getting COVID, I think at this time, it just seemed like, why now of all the times? And it just seemed like this sort of perfect alignment of not only can I get sick and feel like crap, but it's also at like the worst possible time where I already had some clinical duties that I wanted to make sure I was keeping up to date on, but also getting to this sort of first-time experience at the APA. So it's a little unfortunate that that all had to happen. But what it did end up changing for me was that I had to get back into my meditation even harder now, I think, considering some of these feelings that I was having. I actually ended up doing more sort of meditation because of some of these really intense emotions I was feeling, as I previously mentioned. It was actually more helpful for me to get back into my meditation, doing it even like twice a day sometimes to really just be mindful and really focus on recovering, getting better, and actually still keeping up to date with trying to get some of the stuff done. So it was actually very helpful for that. And this next part, I'd like to sort of explore maybe some of the underpinning neuroscience behind what was going on in my brain and hopefully some other people's brains with meditative practices. To give you all a roadmap at this point, this is my agenda for my plan moving forward here. I was going to jump into a brief overview of the theory of mind to sort of at least lay the foundation for what it means to be mindful and sort of explore this idea of what is a sentience. Moving into and after that is sort of exploring the neurocircuits and neuroanatomy associated with some of the different psychopathologies and relevant structures we can look at for understanding more of what's going on with us and how meditation can help with that, and then rounding that out with the relevance for the military. So I think to just start off this conversation and briefly sort of jump into this, I really want to look into what is consciousness and how do we approach understanding it. So when I was jumping into the literature about this, we kind of take like two trains of thought, one being either sort of a bottom-up process where we're talking more about sort of brainstem activity, basic sort of alertness and arousal, a detection of activity that's going on outside of us versus a top-down sort of model where we're looking at higher function, cortical structures, other things going on with that, and sort of a better sort of understanding and a sort of sentience that's going on associated with those sort of structures. It was interesting to go into it, mostly because it's still, I think, highly debated, and with new evidence in evolutionary structures and other sort of progressions that we've seen through different sort of animalistic models, it's not as clear-cut as we would think it would be, and there are actually two halves to a whole. So to start off with the top-down model, this is as far as this half of this idea, I think this is one that is more sort of implicitly understood and maybe seen more in sort of general science classes, especially in our earlier education, but the idea being that our outside, higher-up, new for humans developed structures in the cortices are what's necessary for experiencing consciousness and our sort of understanding of our surroundings at this point. These sort of higher-functioning areas in our brains are what allow us to sort of integrate all this information and sort of bring it out into complex realms of understanding. We can sort things out either visually, smell, and the rest of our senses, we can sort of understand the information around us much easier, and when we start to do that, we can sort of parse through these pieces of information and start developing very complex schemas for understanding our world around us. And I also want to point out, too, that the higher activity in these cortal structures are indicated for consciousness, and impairment in these structures is where we start to see people losing their understanding. I think a good example of this is cases of neurodegenerative disorders, dementias in particular, where individuals have profound degeneration in their cortical structures where their deeper structures are still preserved, so they're able to be alert but not necessarily have an understanding of their surrounding. So I think this sort of explains the idea that our cortical structures are really kind of what give us some ideas of sentience, and maybe not necessarily alertness, but it can help us with being present, where our attention is at, and other sort of models within that. And contrasting with our top-down ideas, this bottom-up theory, which is not necessarily counter to the idea that cortical structures or higher-out, newer, humanly-evolved structures are necessary for consciousness, but just more that the half of this idea is that you cannot have an understanding of your outside world or anything else that's going on in consciousness without the basic brainstem functions as far as humans go. These lower structures are inherently necessary for us to be awake and sort of being able to appreciate that, and it sort of complements those outside cortical structures. As well as maybe having an understanding of very complex schemas, the basic sort of needs for emotions are really sort of like the building blocks for our schemas for consciousness. So without these sort of basic functions, we actually sort of miss an entire sort of underpinning for what it would mean to be sort of aware of what's going on with us and everything else that's going on. And also I thought what was interesting when I was reading some review articles on this was that there's newer evidence saying that the idea that the cortex was developed after these more primitive structures or brainstem functions is not true. There's a number of sort of other evolutionary trees from vertebrates that actually developed their cortical structures first and then had a deeper sort of evolution of their brainstem and lower function parts of their brains that helps to complement these cortical structures and drive this understanding of sentience. I was very excited to hear about this. This is a talk that I was going to sort of use to sort of I think further some of our ideas in meditation. I actually just heard about this in my intern years, this triple network model, and it seemed for me to really sort of tie together some ideas of neuroanatomy going into the brain circuitry because I've heard the term like brain circuits and these different ideas but never really had them sort of boiled down or sort of concentrated into this usable sort of format until I hit this sort of idea. But the bottom line up front is that there's three distinct networks that evolve adjusting human arousal and consciousness, namely the salience network, the central executive network, and the default mode network, all of which will be very critical to our treatment for psychiatric illness as well as the benefits that we can sort of glean from meditative practices. One thing with this recording, too, was that I had to find interesting places to stand for, I guess, for these recordings, so it might seem like I'm moving back and forth, but that was just the easiest way for me to, I think, adjust myself and my slides. But starting off with the salience network here, primary areas that are involved in this are going to be the dorsal anterior cingulate cortex and the frontal insular cortex. So the idea with this is that it's involved in the detection of relevant information and environmental cues that are going to sort of switch us over, and so it's kind of this switchboard that goes back and forth, so kind of like pinging us of like, hey, there's something important here, pay attention. Interestingly, there's some clinical relevance in frontal temporal dementia, schizophrenia, MDD, and many others. For the schizophrenia in particular, I found it very interesting that there is an impairment associated with the salience network, and there's some specific difficulty with the reward pathway that we're not getting pinged correctly for the environmental cues that would normally make us pay attention. And so there can be some ignoring of regular sort of cues, and then some cues that might not necessarily elicit a response from the rest of us would actually sort of ping them. So there's this sort of improper response going on with the salience network in these sort of psychopathologies. I hope you can all appreciate my shading in here. I had to do this on my own with some articles that I pulled from military-specific sites so I could use these images. But jumping into this next idea here is a central executive network. Primary areas here are gonna be the dorsolateral prefrontal cortex and the posterior parietal cortex. And this is our sort of like thinking brain or when we're actually paying attention to something, achieving tasks. When there's a heavy cognitive load where we have to pay attention and really sort of activate problem-solving skills, this is when this network is turned on. And so it's pinged on by an environmental cue, excuse me, from the salience network that switches us over from the default mode network into the central executive network. And so we're actively paying attention. We're applying different sort of integrated neural networks from our memory to sort of problem-solve here. And see if we can kind of figure out the issue that our brain's trying to solve at this point. There's heavy indications for this in generalized anxiety disorder, MDD, unsurprisingly, ADHD, and others. And I think what's interesting about this is that most of these actual connections with the psychopathologies is a poor integration between the central executive network and the default mode network. And so it seems like the salience network itself has trouble switching them over. And in ADHD in particular, there's just a low sort of like pinging with the central executive network where with the psychopathology and ADHD, the network is just like underutilized and the default mode network sort of predominates at that point too. And finally jumping into the final network here is the default mode network, which I think is the sort of like highlight for a lot of the psychopathologies that are relevant for us here today. Because the default mode network is primarily involved in ruminative thought patterns, even like sort of daydreaming or just not actively thinking processes. The relevant structures here are highlighted primarily involving the posterior cingulate cortex, medial prefrontal cortex and the medial temporal lobe. So a lot of this comes down to like our self-referential memory and sort of other ruminative thought patterns. And so there's this connection between our emotions and our day-to-day sort of like thinking that we're kind of just doing all the time. This was the most like widely described neural network with other psychopathologies. And interestingly, it had a sort of high relevance in autism spectrum disorder as well. So I thought that was fairly interesting. So if we take all of the information that I just mentioned and sort of like wrap it all together and just sort of focus and bring it down to a few simple ideas, is that many of the psychopathologies we're looking at primarily mood disorders involve a predominance of the default mode network. Mainly that our ruminative thought styles and our daydreaming or sort of non-active thought processes are getting sort of improperly tethered to some other distressful emotional sort of like either memories or cues. And so we have this predominance of a either depressed mood, anxious mood with that sort of neural network. And so our new norm becomes just expressing and feeling that emotion all the time. And it gets fairly difficult to sort of untether that, but if we're looking at how we should sort of target the different sort of changes that we're aiming to do and maybe explaining some things a bit further to patients, it could sort of involve this idea that this sort of network is on too much. We need to activate the other network, the central executive network, through this aliens network, which could be a whole sort of challenge in of itself. But I think if we can sort of boil that down and get people to understand that and ourselves sort of understand what's going on here, we could help people out a bit more too. And one thing that I was really excited to see was the sort of large swathe of literature on the physiological and neural effects of meditation and how it can help us sort of down here regulate this default mode network and sort of untether the default mode network to these sort of distressful sort of emotional centers for our brain. One thing in particular is that there's this enhanced integration of this network. The idea of just practicing some Zen meditation and mindfulness in of to itself, is not a sort of daydreaming process, it actually can be much more sort of involved in the central executive network, where we're actively trying to stay at the forefront of our mind and activate that sort of side, but almost in a resting state too. And so when we do that, the salience network itself, just through mind watering has to ping more to just be like present. So the central executive network will be on just through that sort of pinging by it's sort of like employing those areas. Also with that too is learning to non judgmentally just be with ourselves can help sort of untether the default mode network from, excuse me, these other areas. And these things that we're doing on a day to day basis or meditative practices can be appreciated just like working out and get strong muscles, you can actually increase your overall brain white matter, particularly in the insula cortical areas of our brain with meditative practices. So that can be like one more sort of here to explore that further. Time back, this science that I've kind of gone through for us in uniform is the different sort of psychopathologies we see in military members and dependents as well compared to the general population. So unsurprisingly, we have a lower rate of severe mental illness, primarily schizophrenia and bipolar disorder compared to the U.S. population as those individuals will be med boarded out to the military if they're identified or on screening with recruitment basis so it won't get in in the first place. While I was looking at the literature, there was a sort of comparable amounts of mood disorders between the civilian and military population. Although there's high rates of post-traumatic stress disorder and alcohol use disorder in the military, I think which could be explained through the higher rates of military sexual trauma and then obviously combat exposure for other sort of service members as well. And then alcohol use disorder, unsurprisingly, I think the military has been a large sort of obstacle for many service members to sort of navigate through and trying to self-soothe and honestly down-regulate or at least sort of soothe out their default phone network through the use of a substance. But keeping these sort of ideas in mind actually sort of catapults us into the next point that meditative practices might actually be one of the best sort of targets for us as military psychiatrists because of a number of reasons and I think the forefront of that is the behavioral health conditions we're looking to treat for our service members. The military itself has its own set of unique challenges that we need to sort of navigate through that aren't seen or appreciated in our civilian sort of patient population as well. Our service members have standards of fitness that they need to keep up with. They need to be in a physical fit, ready to deploy manner. They have to go or could have to go to austere environments with higher levels of exposure to trauma as well as having lower access to care at that time because of either supply logistics or other sort of issues too for getting qualified individuals or expert individuals for care out there. So you can't really bring out some of these heavy hitting tools for people when you gotta be in the middle of the sandbox. Piggybacking off that is that you can be in a resource limited environment and finally just some other sort of stigma involved with receiving mental health care in the military. There's still kind of shaking off some of these ideas of receiving care especially for mental health that makes you weak or that you should just deal with it or some people even just rely more heavily on alcohol or other sort of substances to sort of like self-soothe at that point too where it's just easier that way and there's I think appropriate concern from their end for their career and other sort of issues. But it was sort of keeping those things in mind too and how meditative practices might actually be one more avenue that can be easier to explore and sort of navigate some of these challenges would be helpful as well. As far as the unique benefits for meditation goes for our service members, especially active duty members, the benefits I think will speak for themselves and be very apparent. You can basically use it in any sort of environment. Once you get trained on the general practices for it, there's not too many places you can't do meditation and it's usually when you have to be actively engaged or paying attention to something while you're on duty. But inevitably, you'll have a few minutes here and there or whenever to sort of come off of that and then sort of engage in these practices for a sort of mindset for you. It's also a great complimentary therapy that you can use in addition or as an adjunct to pharmacotherapy, other sorts of cognitive therapy and it can thereby sort of increase our readiness in overall lethality for the military at that point as well. It's extremely cost efficient. You can sort of implement these in a sort of pyramid tier sort of training process. You can quickly educate others to be experts on these things and sort of push out a bit more in sort of like group settings as well. And then the specific benefits for our population in particular for the military is that these mood disorders, trauma disorders, and substance use disorders all can respond fairly well to metadata practices. So it's extremely helpful for us, I think, exploring it through that. As far as some of the limitation goes with any sort of therapy, there's always patient resistance and a sort of reluctance to engage in this either through some avoidance defense mechanisms or other sort of issues. Sometimes this can take more time compared to pharmacotherapy. You're not just taking a pill. You have to actively engage in a practice and in many ways sort of exercise your brain which is why people might not wanna do it as much. And then the training education portion required with it is sort of like I think balanced for any sort of mental health care. But keeping that in mind that it's not just taking a tab or something like that to address your mood symptoms. You need to sort of actively engage with this and keep up to date with it. But when I'm looking at the benefits versus limitations, I think the limitations themselves are pretty sparse and easily navigated and comparable to almost any other therapy. Whereas the benefits are very clear. So from my perspective, meditation should be a practice that we should be doing very regularly almost for everybody, myself included. So that is all I have for right now. I'll hop over to my reference pages. Here is reference page one, reference page two, and reference page three. I will turn it over to the next presenter. I wanna thank you all for tuning in or I guess like listening to me. I really wish I could have been there. Hopefully we'll get there next year. And thank you all very much. So some of you might be wondering what I was doing in the middle with this phone. And for sake of disclosure, I made a small one minute video of all of you and the screen and sent it over to him. And to which he has written my moment of glory. Thank you all. So the agenda, I'm gonna talk about some different ways to meditate. We're gonna talk about kind of identifying or breaking them down into categories. I'm gonna take an aside to differentiate mindfulness from meditation. And then talk about utilizing meditation in the clinic with some clinical vignettes. That will give us a jumping off point to discuss how and why we should work on optimizing our personal practice. And then talk about some additional ways to introduce meditation to our patients. So there are a bunch of different ways to categorize meditation. We're gonna really focus on to a more specific and then a broader categorization. So the types of meditation kind of all starts with, in my opinion, this focused attention meditation. That is the meditation that focuses on a specific stimulus. It is the returning to your breathing phase of meditation. It is often used as our jumping off point to the next stage, the open monitoring meditation, which is the nonjudgmental monitoring of your thoughts and feelings as they're occurring. And there is transcendental meditation, mindfulness meditation, body mind meditation, and loving kindness meditation. So the both focused attention and open monitoring meditation derive from traditional practices in Zen, Vipassana, and Tibetan Buddhism. The practice of focused attention, like I mentioned, it entails the sustained attention on a chosen object so that if your mind wanders, you constantly bring it back to your chosen object of attention. So it's a thought prevailing over thoughts. The open monitoring meditation maintains the state of insight and awareness, paying attention to anything as it occurs without taking the time to judge and evaluate the thoughts as they're occurring. Some of the more body mind meditation methods are things like Tai Chi, Qigong, and yoga. They promote mental concentration. They can also be useful for pain control and emotion regulation. It combines exercise as well as the focused attention and even the open monitoring methods of meditation. Transcendental meditation is not really widely used in a lot of psychiatric disorders yet. It has been applied in patients with PTSD. It attempts to prevent distraction and to reach a deep physical and mental relaxation by repeating a mantra is the typical tool used. Loving kindness meditation is designed to cultivate an unconditional kindness towards self and others, and it's been studied in both depression and schizophrenia. So we're gonna take those categories and kind of lump them together into another common way of categorizing meditation, especially on the internet, and especially I found this is a little bit more palatable to patients when we were first introducing the topic. So there's concentration meditation, which is just another word for our focused attention meditation. Insight meditation, which is another word for open monitoring meditation. And then the compassion meditation, which is kind of a hybrid of loving kindness meditation and transcendental meditation, depending on the patient's own background and needs at the time. So mindfulness is what a lot of people think about when they think meditation. It's what a lot of people get introduced to as kind of the stepping stone into meditation. Mindfulness is a component, but it may also be a standalone concept or paradigm to approach therapy in life. Mindfulness is taught to Navy SEALs and to special forces in the military. Mindfulness meditation is a separate, more intense practice. Mindfulness meditation itself integrates elements of focused attention and open monitoring meditation with a shifting focus between the two, depending on the session. The kind of classic example is you try to work on that insight meditation and observe your thoughts, and when you've noticed that you've wandered in your meditation, you try to focus on an object or a stimulus, most often breathing. You try to return to your breathing and reground yourself before trying to open back up to that insight phase. The techniques which form the primary basis of mindfulness-based interventions are implemented in clinical research and include things like mindfulness-based stress reduction, cognitive therapy, acceptance and commitment therapy, DBT, and even mindfulness-based relapse prevention for substance use disorders. Oops. So we're gonna kind of go back to the three broader categorizations of meditation that I used and discuss them with some clinical vignettes. So we'll start with concentration meditation. The goal is to focus. I say intense. If you start describing meditation as intense to people, they'll get confused. But your goal is to focus on a single object or concept. It can be on mental or physical objects. It doesn't have to be on breathing. It can use any of the body's senses. It can use touch, hearing, smell. The most common example is that breath meditation, but you can also meditate on your heartbeat. You can hold your attention to physical sensations like we see with body scanning or even progressive relaxation. You could focus on a mantra or prayer. You can use a visual object or a prop, candle flames as a visual stimulus or music, as long as the individual engaging the practice finds that music to be soothing, relaxing, or otherwise positively engaged. So my case example for this vignette is gonna be a patient that I had to work with as a fourth-year resident, so not too long ago, on somatic awareness. This is a 44-year-old retired military service member with a history of PTSD and multiple traumatic brain injuries. He was first met by me on an inpatient neuropsych unit where he was referred to us because he'd been experiencing episodic dissociation with agitation to the extent where he was starting to worry that he would hurt somebody without realizing it. He also was experiencing frequent falls, just walking, standing, going about his day-to-day business that resulted in significant injury to both of his legs. He actually required surgical repair on his right leg not too long ago. Medical workup, and the reason that he was sent to us originally in the neuropsych unit was that they were unable to identify any specific non-psychiatric contributors to his falls, which then, of course, made him more anxious about what was going on with him, more concerned as well as more hopeless, leading to thoughts of suicide. Psychological testing, which we did, suggested diminished psychological self-awareness with a tendency to focus on physical ailments to absolutely nobody's surprise. I was able to pick him up and see him in the clinic after his hospital discharge where we decided to focus on treatment for his PTSD-related symptoms. The initial ground laying of our sessions really focused on trying to build awareness. He would experience these episodes of dissociation and agitation, and he would come to pushing somebody up against the wall or having started taking steps towards somebody in public. And the falls, he would be feeling fine, and then all of a sudden, without any kind of prodromal dizziness, be on the ground. So we really wanted to focus on kind of getting him able to catch the situations that these things were happening and the environments, the cues that he may have been missing that his body was picking up on, but he consciously was unable to. The way that we did that was by introducing and really focusing first on body scanning, just getting his brain and body to communicate, getting him able to recognize how he is feeling mentally based off of the feedback his body is giving him. We were then able to turn that into progressive relaxation, where he really focused on holding that awareness on the physical stimulus that he was feeling, and then kind of treating or managing that with progressive, just the normal head-to-toe and toe-to-head muscle relaxation. This was actually surprisingly helpful for him in getting him able to localize and being able to recognize, oh, when I am mentally feeling this way, this is how my body is reacting. This is why my body has been doing this. This is how my body responds to situations that I find threatening. If I feel trapped, then I start to feel one way. This is what my body does when I am in a situation where I feel like I don't know who's around the corner or what might be coming through the door. The progress that we made has kind of been start and stop. The biggest thing that I think we've done for him is being able to provide him relief and just being able to build those connections. The last time I saw him, we were actually three or four months now without any falls, which was a pretty big deal for him to be able to say. He also, at our last session, told me that he thinks that some of the physical things he's been experiencing might be because of his PTSD. So the next kind of meditation we're gonna talk about is insight meditation. This is often used as like a next step past the concentration meditation where the focus is on developing and holding that awareness of all phenomena as they're occurring. It can seem a little bit more intimidating to people as they're kind of getting introduced to mindfulness and to meditation. It may, in some people, have a more spiritual connotation that may make them uncomfortable due to its association with some traditional Buddhist practices. But it's, if that is a door into getting them into practice, then I encourage that route of exploration. But there's also clinical kind of more dry, non-spiritual connotations behind it where it's used and useful in DBT and CBT modalities in order to train observation of people's patterns of thoughts. It may require skill and techniques from concentration meditation to kind of bring the mind back when it starts to wander, as it inevitably will. Another reason that people will shy away from insight meditation is frustration, as they notice that it's really hard to just kind of observe their thoughts as they're happening without judgment, especially in our patient population where they often come in, as we'll discuss with the next vignette, with a lot of kind of preconceived notions of who they are and whether they're good or bad people. So the vignette for this one, in third year of residency at the clinic that I was working in, the residents would take turns running DBT and CBT groups, the way they had it set up. The first six months of the year, half of us would run our DBT group. The second half of the year, half of us would run our CBT group. So what we would do is the providers who weren't running the DBT group would refer to the CBT group, and the providers who were running the CBT group would send all of their patients to the DBT group that needed that particular therapy. So our DBT group that I helped to run, it was me and two other residents. The patient panel consisted of about a dozen active duty service members or their dependents. When we say dependents in the military, we don't necessarily mean children. When I say dependents, I usually mean spouses, siblings, sometimes adult parents. So in this particular case, it was service members and the spouses of service members. So in order to reinforce the mindfulness skills that we were trying to teach in DBT, after the first couple of sessions, we started to introduce the idea of a mindful minute. It wasn't a minute. It was usually 5, 10, sometimes 15 minutes. But we wanted to kind of give the patients that extra practice, as well as give the providers some time to kind of put the rest of the clinic behind us and to be able to be more present and focus on the 90-minute DBT group that we had coming up. What we would do is we would take turns finding just YouTube videos of guided insight meditation that would provide a soundtrack or constantly refer the listener to focus back on their breathing if they notice that they have started to wander. We would also use and take the opportunity ourselves to print off and read out insight meditation scripts to the patients and amongst ourselves. I don't know how helpful it was for the patients, but I can say as a provider, it was very useful just to be able to focus and to get prepared and to kind of bring myself to the moment and put everything else to the side. So the last major kind of meditation that I'm going to talk about with a clinical vignette is compassion meditation. This uses a deliberate, purposeful focus on positive human feelings, positive human experiences, feelings of compassion, joy, unity, and loving kindness. It can include prayers or mantras, but the focus is more on the subjective experience of the feelings rather than the process or the language. Rather than focusing on the prayer or on the words of the mantra, you're focusing on the feelings that you're evoking with them. This I have found in my own practice to be pretty easy to include religious imagery or culturally familiar approaches to spirituality in the individual's life, especially if that is something that they have kind of brought up independently as being important to them. I want to make sure that I capitalize on that source of meaning in using this technique. So my case for transcendent—sorry, for compassion meditation is transcendent compassion. So this was a 54-year-old male active duty. He had been in the military somewhere between 18 and 20 years. He had had a very storied career in that he had been doing four or five different major careers in his 18-year career. He had done so many different things that he, when he first showed up, knew—it was one of those patients where he could say, I know something's wrong, but I don't know what, and here's how it's kind of affecting my home life. So what we did is we kind of sat down and we had to explore each of these little chunks of his career in order to kind of figure out what kind of index traumas we might even be able to find. We did eventually, after maybe eight months of weekly visits, come up with what I called an ERR index trauma, kind of the first trauma that he was able to identify as having been the root of all of these other negative experiences that he'd had, as well as some of the lingering moral injury that he had carried with him the rest of his career. So with him, we tried a little bit of everything. I started with cognitive processing therapy. He didn't really connect very well with it. We did prolonged exposure therapy, but he was very busy slash avoidant and had a hard time keeping up with the homework. So it basically turned into weekly torture sessions because he would go all week trying not to think about it, and then I would force him to think about it for two hours. So we stopped that after I realized what I was doing to him. We did do written exposure trauma on one of his index traumas. While that was helpful, because of the kind of this repeated pattern that he had built up in his mind, it wasn't able to provide any kind of real significant reduction in symptoms. So I was able to work with another provider in getting him into some imaginal exposure, things like ART. So he did a session or two of that with them, and when he came back to me, he talked about how independently, on his own, he had been in a restaurant and had kind of a triggering event happen, and he went to mass that day, and while bawling his eyes out, kind of crafted this image of him with Jesus, Mary, and Joseph kind of all cradling him as he's experiencing this kind of catharsis after experiencing this triggering event, and he was able to utilize that in his future imaginal therapy sessions where he would kind of return to that as his re-scripting of the events when he was thinking about how scared he was, how, you know, all the feelings that he had in the event, he was able to reimagine that as he was being cradled through the event. I encouraged him to increase his skill with this ability, even though this was pretty far removed from my own spiritual practices, I was able to really sit down and talk with him about what kind of meaning it brought to his therapy, what kind of meaning it brought to his life, and what kind of meaning he was able to retroactively attach to the traumatic events that he had experienced. So hopefully, almost everybody raised their hands when asked if they were familiar with meditation, so hopefully I don't need to sell you guys on it too hard. More than the patient can benefit if the clinician is skilled in meditation. Meditation can be used in our own self-care practices to alleviate feelings of stress, discomfort, as well as to improve our somatic, our physical functioning. Mindfulness-based techniques, with or without meditation, are well known for having beneficial effects in a variety of psychiatric disorders. The best results for patients with this kind of therapy, or with this tool specifically, are likely to occur when providers are themselves proficient in the skills. It's kind of, it's not a therapy that we can very easily walk the patient through without having a lot of buy-in ourselves into this kind of practice. There does appear to be, in research, a direct correlation between time spent practicing meditation techniques and outcome measures. Basic meditation techniques are not inherently complex. Things as simple as that, body scanning and progressive relaxation, can be added to a clinic visit. They can be included in our educational toolkit alongside things like our, you know, our rope discussion on things like sleep hygiene, interpersonal communication skills, our Dear Man brochure that we hand out to all of our DBT patients. We can start including some meditation techniques into that toolkit that we have to hand patients in order to, one, to give them some homework, but also to build that rapport, to demonstrate some early successes in therapy as they're able to kind of start settling into this hopefully helpful routine. There is increased engagement potential for closer therapeutic alliance. It does not take long to get some initial benefits from these techniques. And then we're going to hold all questions and discussion to the end, but I hope that we have some. I'm going to turn it over now. I am not the only one who feels honored to know Lieutenant Colonel Hart. I don't know if he remembers, but I actually met him when I was a medical student rotating at Walter Reed, and I have looked up to him since then, so I'm really glad that I get to present with him today. Thank you. Well, as Dr. Baru mentioned, we had the opportunity to present a similar topic about four years ago, and that topic was resistance to meditation in the military. And one of the things that Dr. Mayer highlighted very well is the fact that as we address topics of meditation, there is a large population of people who very closely associate meditation with spirituality. And so there may be hesitancy, there may be love of meditative practices, but it may come with this overtone of spirituality. So that's what I'm going to be talking about. I'm Dr. Hart. I am an adult and child psychiatrist at Fort Bragg. Next week it'll be Fort Liberty, North Carolina on the 2nd of June. They're changing the name. And my agenda will be addressing spirituality and just talking about why should we address it in the first place. Like, you know, spoiler alert, I'm going to suggest that we should address it. Why? Spiritual conversations, how clients view spiritual conversations, and how we as physicians and as psychiatrists also, or mental health providers view spiritual conversations. I am going to talk about in the literature a few spiritual inventories that are already in existence, and I'm just going to share using a few vignettes and using a process that I've developed how I think we can all have spiritual conversations with anyone. I think any mental health professional can have a spiritual conversation with anyone. All right. So here's some definitions. I actually wanted to start off with, I think words matter, and so I actually tried to define the words myself. So in black are my definitions, in blue are Webster. So when we talk about spirituality, the way I approach spirituality is a connection through action, thought, or emotion to something bigger than or longer lasting than oneself. One of the definitions from Webster talks more about sensitivity to religious values. When we talk about faith, the way I approach faith is a certainty in something not seen, a surety of that which is hoped for, and a system of many such certainties and sureties. Webster addresses complete trust or belief or loyalty to God. And then lastly, a religion. I view religion as a construct of beliefs, actions, attitudes that operationalize faith into practice. Webster says a cause principle or system of beliefs held to with ardor or faith. And so the reason why I'm bringing this up is you'll hear me using predominantly the word spirituality, and there's a reason behind that. So I'm going to start with, I'm going to have four vignettes. This patient of mine was a 28-year-old woman who I had been working with for about a year. She had treatment-resistant depression. She was currently on lithium around this time. We had done written exposure therapy, accelerated resolution therapy, and felt like we just weren't making a lot of ground. The index trauma had been the death of her four-year-old son while he was in the care of his grandfather, and this had caused a huge rift in the family, as you can imagine. Therapy was going nowhere until we brought up the idea of spirituality. And as it turned out, the patient was Wiccan. And I didn't know a lot about the Wiccan faith or the Wiccan system of beliefs, but she explained to me that there needed to be balance between good and bad. And all this effort, all of the therapy we had been doing was to try to alleviate the pain of the bad, but she couldn't let it go if she also wanted good things. And so what we ended up doing was together we devised a way of creating a mental imagery that included a shrine, and really it was just a shelf, an actual shelf on her house is what she imagined in her mind. But she put the image of her dead son on the shelf on this mental shrine, and then she was able to add other images that were much more pleasant, much better memories of her son, and brought her a lot of relief. And so it wasn't until we addressed her spirituality and specifically the Wiccan beliefs that I was able to make, or that we as a team, a dyad, were able to make any progress. So there is a mismatch, and there can be a mismatch between what we as behavioral health professionals are willing to engage in and what our patients are hoping for. And so a couple studies that talk about this, how much do our clients desire to speak about spirituality? One study highlights that 48% of them said they desire to talk about spirituality, 90% said they were never asked about their beliefs. And then looking at physicians and their hesitancy, there's a wonderful study that tries to break down the individual roots of why we are hesitant. The number one thing, which I think we can all agree with, is lack of time. How long is this going to take me? Is this another inventory that I'm going to spend 25 minutes doing a structured inventory? I don't have that much time. The next thing is lack of experience, and I think the final bullet talks about the vocabulary. What I would say is lack of experience is tied hand-in-hand with a lack of a vocabulary. We are afraid of using the wrong words, because the next thing is I'm afraid of offending you. All right. And then 56% said, I don't know, I have a hard time figuring out who would even want to talk about spirituality. And then lastly, about a third say, it is not our job. Okay? And so hopefully, you know, one of my hidden agendas for today is to convince you that it might be our job to actually broach spiritual subjects. So looking at a couple different sources, the DSM-5 does address very briefly that we could include thinking about religious affiliation amongst other things in terms of what impacts our clients. I would say the DSM-5 is not robust in its treatment of spirituality. There are, however, many models that can be very helpful for you, and so I've listed three here, the FICA model, the Open Invite, and the HOPE model, and with the references attached. And so these are looking at faith, the FICA model specifically looking at faith and belief, the importance of that faith to the client, the community that they're engaged in, and how to address their spirituality or their faith in care. The Open Invite uses more of an open series of questions and then invites them to share spiritual needs, and the HOPE model, as you can see, talks about what are your sources of hope, are you involved in organized religion, do you have personal spiritual practices, and how is this going to affect your medical care or your end-of-life or any end-of-life issues. Now one thing I'll say is that there is another way that people normally address spirituality, and it's saying, are you religious? And if yes, do you want me to call the chaplain? And that's it, if there even is a chaplain in the hospital system that you're working in. And I would argue that that is insufficient and that we actually miss out on a lot of depth that our clients hold very dearly if we don't do something more than just those two questions. So I know that we're the APA, we don't fall underneath the World Psychiatric Association, but there are some interesting things to look at in terms of their recommendations for bringing up religious and spiritual conversations, that's what the R slash S is on this slide. So these are, they argue that they should be like spiritual and religious discussions and how to have them should be part of our training, that it should be person-centered and not proselytizing, so that meaning we are not trying to convince somebody of a different faith or convert someone to a different faith, but simply to understand where our clients are, and that we should work with faith communities, especially if we find ourselves working in a community where we may be an outsider in terms of our faith, being aware of how religion and spirituality affects the staff and the volunteers around where we may be working, and then also understanding that there are benefits and there can be harms that come from spiritual or religious practices. So a second vignette, and this was a mental status exam that I wrote when I was a medical student, and I was sitting with a patient who had been on our inpatient ward, and she was a dependent, which as Dr. Mayer said is a spouse, when her, and she would often have dissociative attacks where she felt like someone was attacking her, except for when her husband was visiting on the ward, and during one such occasion I was sitting with the two of them and they were, there were multiple chairs available, they were sitting in the same chair, they were essentially entwined around one another, and it was a very physical representation of the enmeshment between the two of them. She noted that he goes away when you're here talking to her husband, and without the husband present it would be very difficult to console her, and she would be tearful during most encounters. So it just so happened that she had a name that was very unique, and it's actually a name that's associated with a specific world religion, and the meaning of the name means focusing on God's good qualities, and the second meaning of the name means focusing on one's own good qualities, and so I asked her if she'd be willing to do a therapy, and I just called it by her name, this therapy, which is not published, but I said let's do this therapy, and what it involves is you saying something that you notice that's worthwhile or good about yourself, and your husband giving an example of when he's seen it, and so we did multiple iterations of this, and the key point from this being that understanding and drawing from one's own, or from a client's spiritual background can actually be an effective way of bridging gaps. So I want to bring up the method that I use, and I'm actually going to ask you to do this in about seven minutes, okay? So I don't want the anxiety to go up really high. I will say this whole process can take as little as 20 seconds, and probably as most as like 75 seconds, unless spirituality happens to be a very important thing for your client, and then you may end up spending a little bit more talking about it, but I always, in every intake interview that I do with adults, I say do you consider yourself a spiritual person? When I'm working in child and adolescent, I ask the parents, do you consider yourselves a spiritual family? And then I ask them, does your child consider themselves a spiritual person? And it's interesting to see how parents view the spirituality of their children. There are families that are not spiritual, and then the parents say, oh yeah, my child is very spiritual, and so it's just interesting to see how spirituality is, you know, can certainly be inherited from parents, but it's not necessarily that way. So my first question, do you consider yourself a spiritual person? If yes, is your sense of spirituality supportive? And it's important for us to note that many people's spiritual or religious practices may have exposed them to risk or to harm or to abuse, and so we want to just not assume that everyone's experience is positive, and so this allows us to get a no answer that then can be explored. Now if someone says no, I'm not a spiritual person, my next question is going to be, is there a place where you derive a sense of hope and purpose? And this can be a wonderful question for people to ponder, and I would recommend silence after asking this question. So, if yes, going along the top line there, are there elements of spirituality or elements of spiritual practice that you find particularly helpful? And this is where you're going to start learning the client's vocabulary, and as soon as you hear the vocabulary, you use their vocabulary, and they will tell you about things like meditation, they'll tell you about prayer, they'll tell you about singing, they'll tell you about going on a hajj, they'll tell you about any number of things, and it's important at this moment to adopt their vocabulary. So if they feel like their spirituality was not supportive, I know I'm taking a step back here, I'll ask them, was there a time when spirituality, or depending on if they use the word religion, was hurtful to you? And that allows us to explore more their background. And then lastly, if we've had yes answers all across the board, then is there a way to increase the use of those supportive elements? And oftentimes people find, you know, if someone moved to San Francisco, and they are totally detached from their spiritual community, they may be very rich from a spiritual standpoint, but be detached from the community, and they just may need a little bit of encouragement to get back into the community, that might be what they need. Again, if they want to talk about a time that spirituality has been harmful, you can always ask, do you care to share about that experience? And again, the whole idea being, all the way through this process, the patient has the opportunity to close the door. That's why I call it the open door. They can close the door at any point. And then lastly, can I refer you to someone who can talk to you or explore hope and purpose? And you could use this question at any point in time. If you feel like you are suddenly out of your element, you know, can I refer you to someone that can explore this with you? And for the military people in the room, I have sent atheists to chaplains, because chaplains are trained in addressing the ideas of hope and purpose. And I'm not trying to proselytize, and the chaplains don't either. But who better to answer questions about hope and purpose, the afterlife, some of these major existential questions of life? And so just a couple notes here, again, use the patient's language as soon as they identify it. Be open to saying, I'm not familiar with that. And then ask clarifying but open-ended questions just to allow your client to be able to share. And so one more vignette, or I have a couple more vignettes, actually. But this vignette, 35-year-old, very high anxiety, and came to me with a vocal tick, a very prominent vocal tick of like swallowing or kind of like a deep cough. But he was wearing a very unique necklace. And right towards the beginning of the encounter, I asked him about his necklace, and it was Thor's hammer. And so I asked him, you know, does it have a special significance for you? And he let me know that he was a leader in his pagan community. And this is an individual that had very low sense of self in my office and was very anxious. And yet when we started talking about his community, he lightened up and seemed to really enjoy talking about it. One of the things I learned from him is that in his section of the pagan belief, hell is not a place of judgment but a place of community. And so that was an important distinction that he emphasized to me on two different occasions. Later on in our relationship together, he ended up losing a teen in his community to suicide, and we were able to process that and address how despite the fact that in the military he might not have been winning at everything he was doing and he really had a low sense of self in the military, he was a very valued leader in his community and was able to help in a time of need. So we're ramping up in level of anxiety here. So this is probably one of the hardest questions to address as behavioral health providers. Doctor, will you pray for me? And so I did want to address this because I think it's something that as we saw in the screening beforehand, it is an important thing to address. Are we going to even talk about spiritual things with our patients? They kind of want to talk about spiritual things. What if they say, will you pray for me? And I think this question is second only, second in difficulty to another question that I've had is, doctor, will you help me die? That was hard. This is also hard. And so there are different ways you can respond. You can respond by pretending they just didn't ask the question and making no comment at all. Not the best response. You can respond by asking strictly medical questions. So let's get the topic back into known territory. You can respond by referring to the chaplain. Or you can respond by commenting on the patient's remark and maybe asking them what their need is at the moment. Here's a couple of suggestions that I have. And again, this is now going to be more dependent upon your own personal spirituality slash religion and your comfort level. But asking, how would you like to pray? Or how do you pray? Or can I pray silently while you're praying? Or can I be with you while you pray? So there's lots of ways to approach this without just kind of running out of the room. What should be prayed about? And this is often interesting because clients don't always want to pray about the proximal thing that you think they might want to pray for. There may be other things on their mind that are way more weighty, things going on with their family or in other parts of the country, not even the proximal reason why you're meeting with them. You can say, I'm uncomfortable praying in this setting, but I'll consider you in my own way later on. I would say, only make that promise if you actually intend to consider them later on. You can let them know, I usually pray in a certain way, do you mind if I use my way of praying? And I think that's a fair question to ask because there's no two ways of praying that are alike. And then, or saying, would you mind if I pray for you as you come to mind today? So there are many different ways of not sidestepping a very tough question, and I would challenge you to come up with one that way, one that you feel is true to the way that you practice. So this is my last vignette. I met this individual. He was a captain in the Army, and he was a company commander, meaning he was in charge of multiple Black Hawk helicopters and about 100 people. He was in charge of a training mission of two helicopters, and he was also in charge of his helicopter when it crashed on a training mission. And so when it crashed, there were only three people aboard. He was the pilot. He had his co-pilot, and the youngest person in his company was what we call the crew chief. He was in the back. And the crew chief was crushed and killed underneath the helicopter when it crashed into a golf course. So when I met him on the consulate liaison service, he was lying uncomfortably in his bed. He had scars from head to foot. He was mourning. He was weeping, like actively weeping, and just overwhelmed with grief. He would talk briefly about what was going on, but then he would erupt into tearfulness. He had a linear logical thought process, but it always came back to extreme guilt. And he, I will add, he was having hypnopompic and hypnagogic, so hallucinations when falling asleep and when waking up, of his crew chief at the end of his bed, which would just rock him into another round of grief. And so in that setting, I did ask them about spirituality. He was with his wife. His wife's name was Faith, as it should be. So he was with his wife, Faith. And I asked them the question, do you consider yourselves to be a spiritual couple? And they laughed and kind of looked at each other, and they explained that they thought they were spiritual, but they had just come out of a cult. And they really wanted nothing to do with religion at the moment, but they were really searching for something. So it was a very strong, powerful duality in their approach to spirituality. At the end of this interaction, I did actually end up asking if I could pray for him, and I did pray for him by the bedside. And I contacted him about a year later as I was preparing for Dr. Brew and I's first time talking here, and he made this comment to me in an email. He said, I can simply correlate my existence and the presence as a person equal to the image of how my helicopter must have looked. He's talking about what it was like to be in the room recovering at that time. Physically, mentally, and emotionally, I was a person laying in a hospital bed in pieces, literally pulling shards of glass out of my teeth and hair. I'm going to skip down. One of the clearest memories of that time was when my doctor began discussing faith with a genuine concern about the health of my spirit. And he ended up noting later on that this was a pivotal time in his recovery because to that point forward, he felt like everything was in shambles. He had lost the youngest person in his unit. He might not have been able to walk. There was a lot going on that was not in his favor. And he really had literally just experienced kind of a severing from God or a severing from a spiritual community. I don't share that to share that I'm anything special. I hope you don't get that picture. I think anyone, that's why I'm arguing, anyone can have a spiritual conversation with anyone. And you don't have to pray with your patients. I know that's very controversial. You don't have to do that. I don't do it all the time. But I would say that there are certainly appropriate times to interact on a spiritual level with your patients. And so next steps, I do ask you, we should all be considering our own spirituality from two aspects. We should not let it get in the way of our care for other people. We should not let it get in the way of how we provide care or if we have bias along spiritual lines, being aware of that bias and ensuring that it doesn't impact the quality of our care. I would also ask you to consider what might prevent you from engaging in conversations like this and then thinking about using some of the spiritual inventories that I mentioned earlier or doing a spiritual assessment like what I've explained with the open door process. And so now comes time for the practical exercise and I am looking at the time. We have 10 minutes left. So like I said, this is very short. I'm actually going to demonstrate it very quickly. Do you mind if I do it with you? Okay. Why don't you get the microphone? So Dr. Mayer, do you consider yourself a spiritual person? Not especially. No. Okay. Is there a place in your life where you feel like you derive a sense of hope and purpose from? My work, my family. Okay. So work and family. All right. That's it. Okay. So it could go longer than that, but I would ask you, I'd like you to, I'm going to keep this slide up. I'd like you to turn to someone to your right or left. There is, there's going to be a secret sign. If you absolutely do not want to do it, the secret sign is, I don't care to do this. Okay. Just, you can just say that. All right. So we don't mean to intimidate you, but let's just turn. Give us a chance. Okay. If I can have your attention back. I wish to thank three groups. First of all, my team, which we all came together and proposed the presentation. Second would be the APA scientific committee that accepted this proposal and more important and the best of all is all of you who, when the convention is almost coming to an end and most people are finding their way back home, you have been really loyal to yourselves and stood through all the sessions, including this one, the final session and come here and most of you have stayed, which shows that you're all very dedicated and I salute you. On another note, this is the session that was also live streamed. So APA has told us that the question will be alternate, one from the live audience, one from those on the computer and we have tons of questions here as well, already formed up. All right. So if you do have questions, feel free, or even just a reflection on what that was like, feel free to go up to the microphones. I'm going to start with one. Sarah online asks, Dr. Hart, how do you navigate self-disclosure faith alliance with the patient? So I don't disclose my faith. I normally say, if they ask, well, I say, well, I'm a praying person and I will consider you in my prayers or something like that. So I don't disclose my specific faith. There kind of keep an eye on anyone walking to the microphones, which there are none. There was a question about box breathing. So box breathing. I've heard the military uses box breathing as a certain meditation modality. How would you say this fits into the meditation intervention for folks? Are there certain studies? And then also, are there certain studies about the three network model? That was what Gus had talked about. What I will say with box breathing is Kellen and I talked about box breathing right before we started presenting because we were both a little bit nervous. So yeah, it's a box breathing is a wonderful way of centering and of reducing our sympathetic tone and kind of getting everything back under control. Let's go with the first microphone, please. Hi. My name is Emily. I'm a practitioner from Canada. So firstly, thank you so much for your presentation. It was very interesting. First I'm hearing about all of this since residency. So yeah, very, I had a good time. I wanted to know if in the military you have any specific type of meditation that are used in very high stress environment. So most commonly, so high stress, I immediately think like special forces. Yeah. I mean, trying to relate it to my practice, which is sometimes intensive care units. So yeah. Yeah. So mindfulness based techniques tend to be the most common. The yeah, like I had mentioned, I think the Navy SEALs actually train in mindfulness. So when people are kind of hesitant, they're not quite sure like, you know, is meditation going to help? So I think just box breathing is often the launching point for mindfulness based interventions. I'm sorry for my ignorance, but what is box breathing? So yeah, box breathing is just a four count breathing. So four counts in with a good diaphragmatic breath, four counts held, four counts out, and then four counts held out. And so yeah, it's viewed as a stabilizing. I mean, it does lower your like sympathetic tone. So it can be relaxing. Another one that I talked to a lot of people about is pursed lip breathing. You know, you see it in the boxing movies all the time. Just breathing out against pursed lips activates your parasympathetic nervous system. So those are good. And the focus on the breath is a very important route of meditation in general. Thank you so much. Thanks for your question. Let me address one that came in online. So this was for you. Yeah, they asked about one, Sarah online asked about coding for teaching, like doing psychoeducation in meditation. How would you code for that? Or is it just going to be lost? Do we get, could we even get compensated for it? So I've been lucky enough in my military training to kind of be isolated from a lot of the more commercial aspects of coding. We still do it to learn how, but I honestly don't know if it ever comes back with anything. What I have seen others do is just include it under their therapy coding. So especially if you're doing like a group mindfulness exercise, there are practices that will build that as a group therapy code. All right, second mic. Hey, Sean from Tripler Army Medical Center. One of the only things I've actually used chat GPT for was to, is to write custom meditation, sleep meditations for my kids to help them go to sleep at night. And I actually did start using it for soldiers though, for example, to write a, a guided meditation to help with breathing and trigger discipline on the range. And so I'm curious about your experiences with technology to help with, with guided meditation, if there are any resources that you recommend in particular. So I think that's a great question. If you didn't catch the very beginning that he mentioned chat GPT, I don't know if everyone knows what that is, but it's an artificial intelligence that you can ask questions to and it gives you great answers and very detailed answers. There is, there was an article put out recently about there will be chat GPT religions in the future where people will worship AI and that those religions should be protected. It's a little bit scary. So to answer your question, I think that the, you know, apps wise, calm, breathe are two that are very good. I would, I would also look at, you know, are they coming at it from a spiritual perspective because there, there may be more spiritually related meditations that, that can be more in concert with, with their faith. Anyone else want to answer that? Okay. Um, did I get all your questions, Sean? Okay. I love the chat GPT idea though. I'm going to look into that. Yeah. Uh, there was a question. Let's see if I make, make sure I get this right here. Okay. So any specific, Dr. Brew, this might be for you, any specific training programs for learning more about these meditative and mindfulness practices that you would recommend? And then they, they also asked about the apps here as well. Uh, they are all available all over the internet and in person everywhere. In fact, if you just Google them, you get a whole lot of them describing what their practices are. As Dr. Meyer mentioned, the six main types of meditations are what we discussed, but there are many other variations. In fact, even in the Buddhist tradition of two different varieties, I don't know if you are familiar with two different sects of Buddhism. There are so many different variations, but the point is go with the one you're more comfortable with. Not only that, hear what they have to say, what their goals are, what their path is, because that's more important. What you relate to. That's all I could say. Okay. I did want to let everyone know we are right at time. I'm happy to take other questions, but if you absolutely need to leave and other people have plane flights, um, we will not be offended. Uh, second microphone there. Yeah. First off, thanks so much for this topic. I've found both lived experience and in professional work that there's a big void there. I had two questions for you in terms of patterns that I've recognized as it pertains to barriers of bridging the gap between faith and mental health. One is, uh, a lot of folks that are on the front line when people are reactive dealing with mental health issues are leaders of faith. Do you have any point of direction or advice for how to advise priests, pastors, stuff like that who are fielding families and people dealing with mental illness and aren't necessarily equipped to give competent advice. So that would be question one. And then my second question was, I'm a former collegiate and professional football player and there's a group called Merging Vets and Players that, uh, former combat veterans and professional athletes get together at different places in the country. It's funded by the NFLPA and, um, you have a 60 minute workout and then a 30 minute mental health emphasis talking about life and a pattern that I've recognized is that, um, there's kind of a point of contention in terms of mutual exclusivity of both faith and the mental health side because of some, uh, controversial beliefs like within the Bible and stuff like that. Um, do you have any point of direction in terms of how to, have you experienced that before? How to, how to bridge that gap? Um, I hope that's not too much. Thank you. No, I'll take both of those if you guys don't mind. So the first question, um, let me go with the second question first. So second question about kind of running up against, uh, some of those like spiritual taboos. Um, I think it's like what Dr. Mayer said, allowing the patient to, or the client to bring in spiritual imagery or bring in their own practice into the meditation I think is an important thing in that case or asking them, you know, is there, is there, uh, you know, something about your spiritual tradition that kind of makes this not an okay thing to do? It's important to understand that, um, because there, there are people who, you know, are very prohibitive against meditation for, for religious reasons. With the first answer, first question, uh, talking about, um, advice to clergy who might not know how to help in those types of situations. So psychological first aid is probably the best go to for all comers. And so I think being familiarized with like the five principles of psychological first aid and, and, uh, being able to, uh, allow priests to come alongside of communities or individuals, um, clergy to come alongside of individuals or communities and exercise those principles can be very helpful. Thank you. Okay. And we're going to, Cynthia, we're going to end, but can you come up here and ask your question? So we're out of time and I appreciate everyone being here and, uh, please safe travels. There are some more questions.

meditation

spirituality

mental health

military psychiatry

therapeutic scenarios

compassion meditation

loving-kindness meditation

spiritual conversations

brain networks

stress management

guided meditation

patient-centered care

therapeutic efficacy