Category: Interviews with the Experts

Interview with
Dr. Linda Carlson

Dr. Linda Carlson Ph.D. C. Psych

Dr. Linda Carlson holds the Enbridge Research Chair in Psychosocial Oncology, is Full Professor in Psychosocial Oncology in the Department of Oncology, Cumming School of Medicine at the University of Calgary, and Adjunct Professor in the Department of Psychology. She is the Director of Research and works as a Clinical Psychologist at the Department of Psychosocial Resources at the Tom Baker Cancer Centre (TBCC). Dr. Carlson’s research in Psychosocial Oncology, Integrative Oncology and Mindfulness-Based Cancer Recovery has been published in many high-impact journals and book chapters, and she published a patient manual in 2011 with Michael Speca entitled: Mindfulness-Based Cancer Recovery: A step-by-step MBSR approach to help you cope with treatment and reclaim your life, in addition to a professional training manual in 2009 (2nd Edition 2017) with Shauna Shapiro entitled The Art and Science of Mindfulness: Integrating mindfulness into psychology and the helping professions.

Some parts of this interview have been edited for length and clarity.

What is psychosocial oncology and why is this field important? 

Psychosocial oncology is the study of the social, emotional, and interpersonal aspects of dealing with cancer from the point of diagnosis through treatment, post-treatment, survivorship, and end of life. We’re looking at the impacts of the cancer diagnosis with regards to things like symptoms and side effects, which are very common such as high levels of distress, anxiety, depression, and symptoms such as fatigue, difficulties with sleeping, and pain. These kinds of problems tend to be long lasting well after treatment completion. Even if people have been treated with curative intent, and there’s a good prognosis, many still suffer with a lot of these lingering problems including fear of cancer recurrence. That’s what led to the need to have psychosocial interventions to support people, typically through cancer, but often post cancer in the survivorship phase. 

What is Mindfulness-based Cancer Recovery (MBCR) and what led to its inception?

We need to step back a few decades first. I did my PhD in Clinical Psychology in the 1990’s, at McGill University. During that time, I became familiar with Jon Kabat-Zinn and his MBSR program. As a student, I also started meditating. I had an interest even though my PhD was in psychoneuroimmunology. So it was looking at the mind-body connection more broadly, and I had a personal interest in mindfulness and yoga. When I moved to Calgary and started working at the cancer center, there was a group of other clinicians who also had a personal interest in meditation and yoga. I brought some knowledge of the MBSR paradigm. We came up with this intervention, specific to people with cancer that addressed some of the issues I outlined earlier. 

In addition to the expected symptoms people are dealing with, there are also existential issues around uncertainty, loss of control and mortality. Those kinds of bigger picture issues, as well as just day-to-day coping with stress, pain, and fatigue, needed addressing. We adapted the MBSR model specifically for people with cancer, and just started doing clinical trials. This was about 1998. Our first study was published in the year 2000. That was actually the first study of mindfulness for people with cancer in the literature, and since then, through the next almost 25 years, we’ve just continued to do more and different types of studies,  as have other people all around the world. Now there’s a very strong evidence base to support mindfulness-based interventions for people with cancer.

What is Tai Chi and Qigong and what potential does it have for psychosocial oncology?

There are a whole range of different mind-body therapies or energy therapies that have been investigated for people with cancer, and these include mindfulness, yoga, imagery, relaxation, hypnosis, and another one from traditional Chinese medicine is Tai Chi, which was originally a form of martial art that was used in defense, but it’s since been adapted as a health practice. There’s also Qigong, which actually comes directly from traditional Chinese medicine. 

Tai Chi you might think of as older people in the park doing all this slow choreographed movement. Those are called forms. And in traditional Tai Chi, there’s something like 24 forms and it’s quite complex to learn them all. Qigong tends to be simpler.  Each move has a posture that might be flowing, or it might be static, and then there’s a breathing pattern that goes with it, and a focus on directing energy. And so the intervention we’ve been studying we call TCQ, for Tai Chi Qigong, it’s like a simplified version that my colleague Peter Wayne at Harvard developed as an adaptation. So in a study we’ve done (called the MATCH Study), we compared this TCQ program to our Mindfulness-Based Cancer Recovery program in over 600 cancer survivors in a multisite trial in Calgary and Toronto, looking at a really broad range of different outcomes- psychosocial, physical, and biomarker as well. The study is done but we haven’t published any of the results yet. 

“I find it interesting that people seem so excited when you show that a mindfulness-based intervention can change cytokines like immune function, telomere length, or affect gene expression. That’s cool, but what’s important to me is that a person feels better; that their anxiety has gone down, they can cope, have a better quality of life, they’re sleeping better, and that their pain is managed.”

How can technology help deliver mindfulness interventions to cancer patients? 

There are issues around accessibility, scalability, sustainability, basically, access issues. In-person programs are only accessible to people who happen to live in a city where the programs are available. As we know, they’re not everywhere. There are also other barriers around cost and time and transportation. So really, if you want to get these types of interventions out to a lot of people at a low cost, technology is one way to do that. So we’ve developed both online interactive Mindfulness-Based Cancer Recovery as well as through an app, where weadapted the program into an app format. We’ve done studies on both of those. We have also developed and are testing a virtual reality version of mindfulness for pain management.

What is the AmDTx app?

It’s called AmDTx (like “I am“). It’s a larger generic mindfulness app that has been developed by a company we’ve worked with called Mobio Interactive . The Am app itself is really cool. It offers consecutive ‘journeys’ you can take, has a whole library of different meditations, teachings, as well as practices. It has ways to interact with the app like a feature where it uses the camera to measure blood flow, and comes up with a biological stress score. It also has a mood board where you can map your mood, and then it suggests meditations based on how you’re feeling. Within that, it’s got these series of journeys. And so ours is called the Mindfulness-Based Cancer Survivorship Journey. It’s within the larger AmDtx app.

Do you envision that mindfulness apps would eventually become a free tool for the public?

Many apps already are a free tool for the public. Everybody has access! What’s lacking is a rigorous investigation of who they help and in what ways do they help? Science is beginning to catch up with the commercialization of it. We’re starting to see some evidence that there may be benefits, but we still need to do a lot more research. You know, it’s not anywhere near the evidence base that we have for in-person programs right now. I’m from Canada, where healthcare is public and free. I believe that anything that’s part of our healthcare system should not be at cost. 

Do you think that mobile health (mHealth) mindfulness-based interventions will replace traditional in person mindfulness programs?

I hope not. There’s always a place for in-person programs. One of the questions around designing mobile apps is how much of that relationship with the teacher or the instructor can we incorporate, and is there a real need to incorporate that? In my opinion, it’s never going to be the same. If it’s just a series of guided meditations, that’s the very lowest common denominator. I feel like guided meditations are just the tip of the iceberg. The philosophy behind the practices are just as important. So apps that include that would likely be better.  

What we’re really doing is creating a shift in how people think about the universe, how they live their lives. It’s as Dr. Jon Kabat-Zinn would always say, ‘an orthogonal rotation of consciousness,’ like you are approaching life in a completely different way after you participate in a mindfulness-based intervention. If you just listen to some guided meditations on an app, it might be helping you regulate your level of physiological arousal but it may not be shifting your consciousness in the same way as practicing through a program does. In a program there is a lot more discussion around application and theoretical concepts around mindfulness, what causes suffering, and the intersection of a mindfulness-based approach and the cessation of suffering. It’s not something you necessarily get from doing a guided body scan. So you need to be experiential, but also understand the theoretical underpinnings. 

For the people who’ve been through our program, we follow them up years later. And many of them are not still practicing formally. But they still report lasting benefits because they live their life more in accordance with the attitudes that we teach: acceptance, letting go, and non-attachment, for example. Those things are fundamental, especially for people who are going to spend the rest of their lives worrying about cancer coming back. So I don’t see apps ever replacing that. Maybe there’s a possibility, but the digital health interventions would have to be quite different than the mindfulness apps are now.

“…many of them are not still practicing formally. But they still report lasting benefits because they live their life more in accordance with the attitudes that we teach: acceptance, letting go, and non-attachment, for example. Those things are fundamental, especially for people who are going to spend the rest of their lives worrying about cancer coming back.”

If there’s one scientific discovery that you hope to make in your lifetime, what would it be?

I don’t think about it that way, like there’s something out there to discover; it’s problems that need to be solved. I guess the fundamental problem I’ve been trying to solve my entire career is how to live your life in a way that is joyful, with ease, compassionately, that helps you get through whatever life throws at you, whether it’s a cancer diagnosis, or whether it’s a mental health problem, whatever it is. Those are the bigger problems I hope to address in my life’s work.

“What we’re really doing is creating a shift in how people think about the universe, how they live their lives. It’s as Dr. Jon Kabat-Zinn would always say, ‘an orthogonal rotation of consciousness,’ like you are approaching life in a completely different way after you participate in a mindfulness-based intervention.”

Read her Books

Mindfulness-Based Cancer Recovery: A Step-by-Step MBSR Approach to Help You Cope with Treatment and Reclaim Your Life

If you have received a cancer diagnosis, you know that the hundreds of questions and concerns you have about what’s to come can be as stressful as the cancer treatment itself. But research shows that if you mentally prepare yourself to handle cancer treatment by getting stress and anxiety under control, you can improve your quality of life and become an active participant in your own recovery.

The Art and Science of Mindfulness: Integrating Mindfulness Into Psychology and the Helping Professions

Intention is fundamental to any project, endeavor, or journey. Related to intention is the concept of mindfulness – the awareness that arises through intentionally attending to oneself and others in an open, caring, and nonjudgmental way. Authors Shapiro and Carlson draw from Eastern wisdom and practices as well as Western psychological theory and science to explore why mindful awareness is integral to the therapeutic healing process and to show clinicians how to connect with this deeper awareness.

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Interview with
Dr. Sahib Khalsa

Dr. Sahib Khalsa, M.D., Ph.D.

Dr. Khalsa graduated from the Medical Scientist Training Program at the University of Iowa, receiving M.D. and Ph.D. (neuroscience) degrees. He is currently the Director of Clinical Operations at the Laureate Institute for Brain Research, and an Associate Professor of Community Medicine at the University of Tulsa. Dr. Khalsa’s research investigates the role of interoception in mental health, with a focus on understanding how changes in internal physiological states influence body perception and the functioning of the human nervous system. His studies utilize a variety of approaches to probe cardiovascular, respiratory, and gastrointestinal interoception including via pharmacological and non-pharmacological techniques, functional magnetic resonance imaging (fMRI), electroencephalography (EEG), and computational modeling.

Parts of the interview have been edited for clarity and length. 

What is interoception and why is it important for health?

Interoception refers to the process by which the nervous system senses, interprets, and integrates information about the internal state of the body. It’s a process that spans multiple levels of functioning within the nervous system, which includes the peripheral nervous system (the autonomic and somatic branches) as well as the central nervous system. Interoception also bridges multiple physiological states. For example, there are many physiological signals which we are not aware of.  For those signals which we are aware of, the degree to which we are aware or conscious of them is sometimes very meaningful, particularly in the context where homeostasis is disrupted and where the integrity of the body is threatened.

Interoception is important for physical and mental health because it is the primary way that we become aware of internal status of the body. For example, noticing your heart beating strongly in your chest might be called a palpitation. That could be indicative of potentially very serious medical condition like a heart attack or abnormal heart rhythm, so you can think of a major role of interoception is to act an early warning system. Noticing those symptoms could lead somebody to seek help and undergo and diagnostic evaluation, resulting in detection of this pathologic process in the body and, in ideal circumstances, lead to the appropriate treatment and resolution. Dyspnea or difficulty breathing during an asthma attack or pneumonia are other examples physical manifestations, that if left untreated, could have drastic consequences.

There are also a tremendous number of mental health conditions where the condition itself is diagnosed or characterized by abnormalities of interoception. Using the cardiac example, somebody might come to the Emergency Department complaining of heart palpitations. But at the end of the evaluation, the doctor says that they’re not having a heart attack and their cardiovascular system is intact. In this example, their symptoms might be better explained by a mental health condition such as panic disorder, where a person misinterprets the sensation of their heart beating faster as indicative of impending death. Appetite changes and fatigue in depression, autonomic hypervigilance in PTSD, abdominal fullness in eating disorders, and muscle tension in generalized anxiety disorder are some other examples.

What is interoceptive psychopathology and how would a specific intervention that targets interoceptive processing help?

It might be helpful to think of interoceptive psychopathology as the aspects of psychiatric illness or mental health that relate to abnormal processing of the body’s internal state. Interventions targeting the processing of interoceptive symptoms help to recalibrate the abnormal sensory experience. For example, interoceptive exposure therapy for panic disorder is a commonly employed intervention that helps people approach their feared internal body sensations, such as heart palpitations or dyspnea, and learn to avoid misinterpretations or abnormal expectations. No longer fearing or catastrophically misinterpreting body sensations allows people to experience their body and the world environment without hindrance and to ultimately experience a fuller life. While this is one example of a commonly used interoceptive intervention in current clinical practice, there are currently several others in various stages of development.  

Why is a mixed method approach to science important to your work?

I include mixed method and multilevel approaches in my work because interoception is a process that covers multiple levels of processing and many types of experiences. It may not be completely understood by focusing on one aspect of an organ system as it interacts with the nervous system, or by focusing only on nervous system signaling. Mixed method approaches which incorporate subjective experiences allow me to develop an integrated understanding of how the processing of interoceptive signals impacts the entire organism, across different levels of awareness. That kind of approach is incredibly important for any type of science, but especially contemplative neuroscience research, where there are many different ways of obtaining insight into the impact of contemplative practices on the human experience.

Is mindfulness practice able to improve interoception?

This is a complex question because mindfulness is one component of a contemplative practice, and because there are many types of contemplative practices that have been investigated with respect to their ability to alter interoception. Most studies have utilized cross-sectional approaches that compare those with some degree of meditative or contemplative experience against those without. Studies looking at the interoceptive processing of the heartbeat in practitioners with various levels of contemplative experience have generally found that the accuracy of their ability to sense that signal is no greater than that of people who’ve never meditated. Some studies have also begun to look at the longitudinal impact when you take somebody without any established training and then you give them exposure to contemplative practice, whether it’s in mindfulness practice such as Mindfulness-based Stress Reduction or another practice that has roots in a contemplative or spiritual tradition. This allows us to see what happens with the person’s experience in processing interoceptive signals over time. There is some evidence for changes in the experience of interoceptive signals that happens with these practices, but to my knowledge it’s not the kind of change that most people would think is happening.

For example, you might be surprised to hear that contemplative practices are not strongly associated with increased accuracy of heartbeat perception. On the other hand, one important point is that accuracy of heartbeat perception is only one aspect of interoceptive awareness, even if it is the most studied process. You can also ask people how often they attend to those the internal body signal like the heartbeat, and you tend to find practitioners endorsing that they feel very familiar with it, that it’s an easy signal for them to perceive, and over time, their sense of that has improved. It would not be a fair statement to say that there is no impact on cardiac interoception.

You might also be thinking that it is more important to study awareness of the breath since that is a more common focus of sensory processing in many traditions. But it turns out that it’s been very difficult to derive methods for rigorously ascertaining the degree to which somebody can perceive their spontaneously arising respiratory signals. This is partly because of the voluntary regulatory influence that they can exert over this system. For example, try to convince me that your breathing pattern did not change after I told you not to hold your breath. One of the things that I noticed in my initial study of interoceptive awareness in experienced meditators was that as soon as we asked participants to pay attention to their heartbeat sensation, many of them started to change their breathing pattern. In some cases, they felt like it helped them to get into a more focused state of mind. In other cases, they felt like they were able to manipulate the signal of their heartbeat signal better therefore perform better in the task.

In the ensuing years since we did that study, there have been a number of clever ways to study respiratory interoception. One approach is where you directly manipulate the experience of the breath. You might potentially have somebody breathe through an apparatus and temporarily restrict the airflow as a way of simulating this state of dyspnea, or difficulty breathing. There’s still a lot of unexplored territory in this area and there’s considerable value to moving forward with more sophisticated methods and models. Overall, we need better ways of measuring interoception and more rigorously designed studies to conclusively answer this question.

“Mixed method approaches which incorporate subjective experiences allow me to develop an integrated understanding of how the processing of interoceptive signals impacts the entire organism, across different levels of awareness. That kind of approach is incredibly important for any type of science, but especially contemplative neuroscience research, where there are many different ways of obtaining insight into the impact of contemplative practices on the human experience.”

Your study found that meditation is not associated with enhanced interoceptive awareness, yet there have been previous reports of higher subjective ratings and meditators. What might explain this difference

Some of the discrepancies between studies in this area may have to do with different ways of assessing interoception, and also the fact that studies of cardiac interoception find that most people have a hard time feeling their heartbeat sensations under resting physiological conditions. But we all know what it feels like to experience our heartbeat sensation, and often that happens during periods of increased arousal, excitement, or physical activity.

Across two studies we found that meditators were not more accurately aware of their heartbeat signal than non-meditators. But we define interoceptive awareness as the entire process of consciously experiencing the internal state of your body, then it would necessarily span things like the ability to detect a sensation, to localize it to particular organ system, to discriminate it from another part of the body, to feel it with a certain level of or magnitude of intensity, in addition to a metacognitive experience of yourself proceeding through that feeling state.

In our most recent study, we used a pharmacologic stimulation with a medicine that acts peripherally to perturb heartbeat and breathing sensations. We did that in meditators, who had several years of Vipassana meditation experience relative to matched individuals who had did not have any meditation experience. We didn’t find clear evidence of differences in interoceptive accuracy, but we did see evidence that the meditators had a sizeable difference in how and where they experienced their heartbeat sensations in different parts of their bodies. There was also some preliminary evidence that perhaps they were more attentive to that signal.

Overall, in looking across multiple measures of cardiac interoceptive awareness we didn’t see the findings that we were predicting. I think what that leads to is a greater refinement of subsequent research questions.

“We didn’t find clear evidence of differences in interoceptive accuracy, but we did see evidence that the meditators had a sizeable difference in how and where they experienced their heartbeat sensations in different parts of their bodies. “

How can psychedelics enhance our understanding of the mind-body connection?

When you look at the impact that psychedelics have, it’s undeniable that there is a strong subjective experience that that they elicit. For some people, that’s incredibly powerful and positive and in others, it can be negative. The enthusiasm for investigating the role of psychedelic interventions for various mental health conditions is predicated on the notion that it’s possible to study them in a systematic and safe manner to achieve long-lasting clinical benefit.

In terms of how psychedelics might impact the mind-body connection, a common theme I’ve observed is that the onset of the psychoactive effect coincides with changes an interoceptive signals, like the heart rate, blood pressure, or breathing. That perturbation of the bodily state likely has an impact on neural activity in higher levels of the nervous system, but whether or not that’s tied to the psychedelic effect has not been examined. Certainly, you can posit that there’s an increased amount of internal bodily sensation that’s happening. For example, if you look at the subjective experience induced by MDMA (also known as ‘ecstasy’), there’s quite a lot of sensory signals from the skin that are acutely affected as part of the serotonergic effect. But there are other physiological aspects related to the pharmacological action of these drugs on the body. For example, nausea and vomiting can occur in some individuals following ingestion of psilocybin-containing mushrooms or ayahuasca.

More generally, if you look at how psychedelic interventions are currently delivered, a lot of them incorporate the attenuation of exteroceptive input the nervous system. For example, when people are experiencing the peak of the psychedelic effect, they might wear eyepatches or headphones to reduce or modify the visual and auditory signals received by the brain. One interpretation may be that blocking visual information from the outer world allows the images that are generated during the hallucinogen come to the forefront of the theater of consciousness without impedance by competing images. Whether that magnifies the effect or not I think is probably somewhat of an empirical question, but those are some of the thoughts that come to mind when I when I think of how psychedelics might alter the mind-body connection.

What is Floatation-REST and how does this expand our toolbox for clinical interventions?

Floatation-REST (Reduced Environmental Stimulation Therapy) is a non-pharmacological intervention that involves the systematic attenuation of certain kinds of exteroceptive signals to the nervous system, such as reducing visual and auditory input. It’s an intervention that’s delivered using sophisticated engineered environments involving a shallow pool of water that’s been hyper saturated with Epsom salts. When you lay down, your body floats effortlessly on the surface of the water and you don’t have to hold your breath or move your muscles to stay afloat. It’s also a thermally regulated environment where the air temperature and the water temperature are elevated and calibrated to reach the temperature of the surface of your skin. They’re also been colloquially called ‘float tanks’ (the older term is sensory deprivation). However, the intervention does not involve sensory deprivation but rather a form of sensory enhancement.

In our research studies with clinically anxious individuals, we’ve found that the float environment is incredibly stimulating. Both in terms of the intellectual and cognitive experiences that people have when they’re floating and in terms of the enhancement of interoceptive sensation. People routinely experience their heartbeats and their breathing sensations more intensely when they’re in the float environment relative to comparison conditions such as laying in a comfortable chair in a quiet and dimly lit room or watching soothing nature videos. But rather than feeling more anxious and panicked when feeling their heartbeat more intensely, they walk away from the experience feeling more relaxed.

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