The portability of mantram repetition gives it potential for integration into almost every person’s daily routines, as reflected by the breadth of groups in which the MRP has been studied, ranging from healthcare workers to homeless populations. Methods for training MRP instructors have been developed as part of ongoing research work at the VA (e.g., Buttner et al.
2016). Importantly, beginners typically learn the three MRP practices most effectively when its presentation to them is tailored to their own individual, cultural, social, and material settings and needs. In particular, mantram repetition can be learned most easily when people hear examples of how to utilize the mantram that are relevant to their own daily personal and work environments. Beginners can benefit, for example, by learning examples of how to use the mantram for managing stressors common in their workplaces; learning examples of neutral cues to use for remembering the mantram in non-stressful times; and learning anecdotal accounts that link such mantram utilization with experienced results (see Bormann et al.
2020).
Application of MRP during the COVID-19 Pandemic
Around the world in 2020, daily life has been transformed by the expanding coronavirus disease pandemic, which is posing new challenges for health providers, patients, families, health systems, and ordinary citizens. Daily news reports from many countries have made it abundantly clear that the COVID-19 pandemic creates highly distressing and sometimes life-threatening challenges for healthcare workers, patients, patients’ families, and the general public (e.g., Shanafelt et al.
2020; Wang et al.
2020a,
b; Zhang et al.
2020). These coping challenges require both technical and psychosocial responses. Urgent on the technical side is providing lifesaving treatment and diagnostic testing, building emergency health system capacity, and implementing curve-bending preventive measures such as social distancing. These technical efforts should be accompanied by mental health supports to help sustain efforts by health-care workers and first responders, heal patients, foster social cohesion, and support better decision-making by individuals, organizations, and communities. No single mental health or stress management approach can be optimal for everyone. But based on evidence and experience, portable mantram repetition holds promise to benefit all major groups affected by the pandemic. The following paragraphs illustrate how the mantram may be used by three key groups: healthcare workers, patients, and the general population.
Healthcare workers working with COVID-19 patients, for example, must adhere to life-saving hygiene procedures. Such adherence demands heightened presence of mind and
one-pointed attention for safe donning and doffing in proper sequence to avoid contamination. In particular, doffing contaminated equipment requires handwashing several times (Centers for Disease Control and Prevention (CDC),
2020) and careful removal of potentially life-threatening equipment such as contaminated goggles, hoods, and gloves. Such doffing must often be done rapidly in order to respond to other emergent situations. Prior
repetition of the mantram can be used to support the focus needed to adhere to these and other mandated procedures (Bormann et al.
2006c).
Similarly, in COVID-19 “hot spots,” some healthcare workers face the emotionally wrenching challenge of delivering care to individuals who are their close friends and were colleagues only days prior. In such circumstances the MRP’s portable practices can be used to calm emotions while maintaining focus, mindfulness, and compassion. COVID-19 patient care may also demand emotionally draining conversations with patients’ families about end of life issues. Such conversations require focus, clarity, and sensitivity to emotions and to a family’s practical and spiritual concerns. These qualities are supported by MRP practices, which can also facilitate dealing with the healthcare worker’s own emotional sequelae from such conversations. The mantram also can be used to steady the mind when dealing with deaths, rationing, or other existentially challenging issues Table
1 offers numerous examples of stressor and self-cueing occasions that could be mentioned in an MRP training for health professionals engaged in COVID-19-related patient care.
Table 1
Examples of healthcare workplace situations usable as cues for mantram repetition
When tackling a routine yet unpleasant or difficult task | To pause, to center oneself, to clear mind of any judgment, fear, distaste |
While waiting for anyone or anything soon to arrive | To allow a moment of respite |
Walking down the hall | To allow a short respite from external chaos |
Handwashing | To strengthen mental concentration in support of essential hygiene; to “own these 20 seconds” |
Before donning personal protective equipment (PPE) | To support one-pointed focus, and clear mind for next task |
Before doffing PPE | To refocus attention, attend carefully to critical safety procedures, and transition to next task |
Upon opening a door when grasping any doorknob or handle | To pause, and to clear and re-center one’s mind |
Prior to making eye contact when greeting a new patient | To allow feeling a calm presence prior to conversations |
Before speaking with a patient’s family or friends | To clear mind, re-center, remain calm and present |
During a challenging team interaction | To maintain calm, and ensure listening and engaging productively; to sustain relationships for future |
Prior to having to enforce uncomfortable rules | To help sustain composure, listening, and focusing on the important priority of the regulation; to assist in avoiding unnecessary conflict |
When providing healthcare or other caring to a fellow colleague | To clear mind, re-center, remain calm and present |
When calling or preparing for an emergency procedure such as resuscitation [Code Blue] | To keep calm, perform accurately, stay mindful |
When further treatment is futile and a healthcare worker is the sole attendee at a patient’s dying | To be fully present and support one’s personal resilience; to cope with one’s impotence to prevent death |
For patients, COVID-19 also presents distinctive challenges for which MRP practices may be helpful. Respiratory distress is one COVID-19 presenting symptom that is common in more severe cases and can produce hypervigilance to bodily changes (Harrison et al.
2014; Ji et al.
2020; Sohrabi et al.
2020). Patients with dyspnea have reported that “I could not take my mind off breathing for fear my life would end” (Harrison et al.
2014, p. 39), and severe cases may cause PTSD symptoms that persist for many months (Davydow et al.
2008). Conventional mindfulness interventions generally use breathing as a focus of concentration, and evidence to date has not supported the efficacy of such interventions for reducing stress in patients with respiratory illnesses (Harrison et al.
2016; see also Clari et al.
2020). Such conventional mindfulness approaches may be ineffective or even contra-indicated for patients with respiratory distress, as “drawing attention to breathing in those with dyspnea [shortness of breath] could provoke hyper-vigilance of breathless symptoms resulting in emotional distress” (Harrison et al.
2016, p. 349). Instead, such patients may be taught use the mantram to redirect attention away from experiences of shortness of breath.
Similarly, patients with suspected or confirmed COVID-19 illness may use the mantram to manage mortality fears, and if necessary, the potential additional anxiety of undergoing a life-threatening illness when medical care systems could become overwhelmed and unavailable. MRP-fostered gains in spiritual well-being suggest that mantram repetition can help many people to manage illness-related death anxiety, as affirmed in many religious traditions, perhaps in part by mentally activating spiritual perspectives on mortality and longevity (Easwaran
2008; Grossman et al.
2018; Jong et al.
2018; Pargament
1997; Wachholtz and Pargament
2008). Family members who are supporting a patient may benefit by repeating a mantram themselves, and can also repeat a patient’s mantram with them, either aloud (when appropriate) or silently. Corresponding stress reductions may contribute to healing and immunity (Schakel et al.
2019; Taylor
2019).
Finally, in the general population, mantram repetition can support many people in adhering to mandated social distancing and hygienic practices. Mantram repetition can calm the mind and mentally activate psychospiritual frameworks that discount immediate frustration in favor of longer-term benefits and acceptance-based responding (Bormann and Carrico
2009; Carrico et al.
2007). The mantram can also help manage other widespread fears—fears that may sometimes possess validity. Besides the virus itself, people may legitimately fear scapegoating, loss of employment or other economic harm, scarcity of personal protective equipment, separation from family during quarantines and lockdowns, and the sequelae of all these events (Taylor
2019). By one month after the initial outbreak, a significant fraction of the Chinese population was showing posttraumatic stress symptoms (Boyraz and Legros
2020; Sun et al.
2020). By preventing counter-productive rumination about such fears, and by mentally activating spiritual perspectives, the mantram can help mitigate or control the related suffering. Mantram repetition can also be used for comfort by those who are physically separated from family members, whereas families living in close quarters for extended periods may find the mantram an aid to maintaining patience. Small children can be given a mantram to repeat during times of fear or frustration, and it can be sung to them as a lullaby. Entire families can even sing mantrams together.
Unfortunately, vaccine development timelines for COVID-19 are uncertain and may require years until availability is widespread (Arnold
2020; Bregu et al.
2011). Thus, the worldwide yet uneven pursuit of social distancing and other pandemic control efforts raises the possibility that many countries will experience multiple pandemic waves, akin to the 1918–1919 influenza pandemic (and many others, Miller et al.
2009). Indeed, a modeling report from Imperial College has warned that “the more successful a strategy is at temporary suppression, the larger the later epidemic is predicted to be in the absence of vaccination, due to lesser build-up of herd immunity” (Ferguson et al.
2020, p. 11). Irregularities and uncertainties in disease spread may in turn generate additional cascading economic, social, and cultural uncertainties, irregularities, and shocks. And evidence now suggests that COVID-19 has long-lasting effects for a significant fraction of those infected: a study of 143 COVID-19 patients discharged from hospital in Italy found nearly nine in 10 (87%) still experienced at least one symptom after 60 days, and shortness of breath was still reported by nearly half (dyspnea, 43%, Carfi et al.
2020; see also Mahase
2020). To prepare for multiple pandemic waves, public health and disaster preparedness principles indicate that societies should build both technical and mental health facets of resilience (Aiello et al.
2011; Pfefferbaum et al.
2012)—and there is reason to believe the mantram can play a useful role in preparing.