When 16-year-old Kirsten White is in class and feels distracted, frustrated or angry, she looks at the tiles on the ceiling or the bricks on the walls and counts them.
It gives her the chance to pause and think before she acts.
"I take a minute, and no one realizes it," the Annapolis teenager says. "It calms me."
The mindfulness exercise is one of many she's learned and embraced in a residential program at Sheppard Pratt, a psychiatric hospital in Towson, where she has been living and going to school since November. The training has helped her cope with the burdens of her young life, which have included bullying, emotional problems and self-harm.
Mindfulness meditation is an ancient spiritual practice that was introduced into health care in the 1970s by a University of Massachusetts professor of medicine who believed it could help patients reduce stress. The practice continues to spread, with classes offered in offices, universities, hospitals and online to help promote relaxation and focus.
Now, as science begins to back up the benefits, mindfulness is being adopted in clinical settings to help providers and patients manage a host of disorders.
The idea is to focus intensely on the present, emptying the mind of outside influences, judgments or stressors, says Tess Carpenter, clinical director of residential programs at Sheppard Pratt.
Mindfulness is the core of the institution's Mann Residential Treatment Program, the behavioral training program launched in 2011 to help troubled teens tolerate distress and improve emotional and interpersonal responses in situations they find overwhelming.
The patients have diagnoses that include attention-deficit hyperactivity disorder, post-traumatic stress disorder, depression and anxiety.
Carpenter calls mindfulness "very abstract in nature" and tough to teach. Research shows it doesn't work on everyone. Some people don't take to it, just as plenty of people don't get the benefits of yoga, which embraces similar themes.
Kirsten, who's in 10th grade, says she was one of those people. When a counselor proposed the therapy, she was hesitant. She ultimately decided to give it a try.
Students in the treatment center repeat the exercises daily while also participating in more traditional therapy.
Counselors have the teens stare at their thumbs, or blow up balloons and bat them in the air for a few minutes.
That teaches them to concentrate on an activity, Carpenter says, filtering out distractions. In the real world, it could snap them out of an overly emotional situation and give them a window of time to rethink their response.
Dr. Carl Fulwiler, medical director and associate research director for the Center for Mindfulness in Medicine, Health Care and Society at the University of Massachusetts Medical School, says there's now a critical mass of studies showing mindfulness exercises are effective in helping to control stress, pain, weight and depression.
There are some problems, such as anxiety disorders in which patients can't focus, where the practice hasn't been proved effective, Fulwiler says. Outside a clinical setting, mindfulness can be harmful — as when it brings up buried memories or repressed feelings.
But with pain, for example, mindfulness may reduce suffering by making the brain less sensitive to what's happening in the body, he says. In other cases, such as when people cope with stress by eating, drinking alcohol or taking drugs, mindfulness can help people become more aware and make different choices.
"It's how we react to things that mindfulness can help," Fulwiler says."It's not a total panacea."
In a 2014 study of 47 mindfulness-based trials, researchers at the Johns Hopkins University said they found enough evidence of its benefits that doctors should be prepared to talk to patients about it. They also concluded that more study into who would benefit is warranted.
Fulwiler is looking at the benefits to minorities, who have not traditionally been included in studies. Hopkins researchers are examining the effects of mindfulness on Baltimore's urban youth.
Fulwiler is using brain imaging to determine which patients would gain from mindfulness training. Several researchers have found the practice changes the brain.
In one study, published in January in the journal Biological Psychiatry, 35 adults who were experiencing the stress of unemployment were either taught mindfulness meditation or general relaxation techniques over three days.
Using brain scans, researchers found only mindfulness exercises caused an increase in activity in the part of the brain responsible for reactions to stress and cognition. By looking at blood samples, they discovered a reduction in a chemical that causes inflammation, which can harm the immune system and lead to disease. Those benefits seemed to endure for months.
It's that kind of science that is propelling mindfulness into the mainstream, says lead researcher J. David Creswell, associate professor of psychology at Carnegie Mellon University in Pittsburgh.
While counselors believe everyone has an innate ability to practice mindfulness, they say it's not easy for many people to master. People are accustomed to letting their minds wander, suppressing unwanted experiences and running on autopilot.
That's why the teens in the Sheppard Pratt program stay from six months to a year, Carpenter says. The Towson program focuses on teenagers and can accommodate up to 63 at a time..
Carpenter's team is just starting to collect data on the outcomes for those who go through the program. But anecdotally, she says, they appear to be handling the real world as well as the therapy world. They are not returning to the program, or to the social service or criminal justice systems that initially referred many of them.
Other students are referred to the program by private psychiatrists or taken there by their parents.
Kirsten, whose newly red hair seems to reflect her growing confidence, now wants to become a counselor of some kind so she can help others change their path.
"I've been labeled and called names," she says. "I want to teach others that they can have a different life."
Corey Johnson Jr., an 18-year-old from Germantown, says he no longer wants people to look at him as a "negative influence." He went to Sheppard Pratt in December after handling his diagnoses of ADHD, PTSD and a mood disorder poorly.
Staff members now consider Johnson and Kirsten "honors" students for their level of dedication to improvement. The teens practice mindfulness daily at Sheppard Pratt and develop their skills in classes or activities with fellow students and when they go home on weekend passes.
"I'm working hard not to be defined by my past," Johnson said. "I don't want to be the person who is in and out of residential treatment centers for the rest of my life and is viewed negatively. I want to be viewed positively."
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