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<!– =============== Front Matter (Metadata) ========== –> <book-part-meta> <book-part-id>Lapdeb-1</book-part-id> <book-part-id book-part-id-type=“publisher-id”>BITS-Book-Test-chap2</book-part-id> <subj-group> <subject>Large Dogs</subject> </subj-group> <title-group> <title>BITS Book DTD Test Book for DTD Testing</title> <subtitle>(Just a small one for parsing)</subtitle> <alt-title>Bits alternate title</alt-title> </title-group> <pub-date><year>2004</year></pub-date> <publisher> <publisher-name>Mulberry Technologies, Inc.</publisher-name> </publisher> <permissions> <copyright-year>2004</copyright-year> </permissions>

<abstract><p>All the good stuff</p> <sec> <title>Introduction</title> <p>And not for something completely different</p> </sec> <sec> <title>Discussion</title> <p>Or maybe not</p> </sec> <sec> <title>Conclusion</title> <p>All&rsquor;s well that ends well.</p> </sec> </abstract> </book-part-meta>

<!– =============== Body Matter (Content) =========== –> <body> <p>A Body, a book part body!</p> <sec sec-type=“intro”> <title>Introduction</title> <p>Geriatric day hospitals developed rapidly in the United Kingdom in the 1960s as an important component of care provision. The model has since been widely applied in several Western countries. Day hospitals provide multidisciplinary assessment and rehabilitation in an outpatient setting and have a pivotal position between hospital and home based services .… We therefore undertook a systematic review of the randomized trials of day hospital care.</p> </sec> <sec>

  <title>Background</title>
  <p>In the last two to three decades, the concept of mindfulness has received increasing
    attention, particularly in the health sciences. Mindfulness is about being aware of actual
    experiences from one moment to the next with gentle acceptance. This concept has been proposed
    to contribute to the coping and recovery process in many health conditions.</p>
  <p>Both clinical as well as basic science researchers have devoted a significant amount of
    study to this topic. Moreover, with rapidly
    mounting evidence regarding the therapeutic capacities of mindfulness practice, medical
    professionals are increasingly incorporating such techniques into their clinical repertoire.
    Probably the best known and evaluated mindfulness-based treatment is the Mindfulness-Based
    Stress Reduction (MBSR) that is used in many clinical settings in the US and Canada and
    evermore, in Europe </p>
  <p>Yet, integrating mindfulness into existing therapeutic concepts may challenge medical
    professionals' usual practices for number of reasons. First and foremost, mindfulness
    approaches do not aim at symptom reduction. Fundamentally, mindfulness is not intended to
    explicitly eradicate pain, distress, or unwanted emotions. However, philosophically and
    practically, medical professionals endeavor to reduce suffering. If mindfulness does not aim
    at reducing symptoms, then how can it be helpful? In this essay, we argue that while
    mindfulness is not meant to actively reduce symptoms, it may passively modify their impact
    by changing an individual's perceptions and mindset. Mindfulness is a set of practices, if
    not a "way of being" that may incur salutogenic (i.e., health-promoting) effects. This may
    lead to a misconception of what mindfulness is, and how it works. We believe that some of
    the apparently contradictory aspects of mindfulness can be best understood by taking a
    dialectical approach. It is not a new idea to explain psychological health-related processes
    through the use of paradoxical or dialectical approaches. Indeed, we propose that the dialectical structure of mindfulness hallmarks its
    essence, which may easily be misunderstood in clinical practice.</p>
  <p>The dialectical approach is quite different from the conventional approach of symptom
    evaluation. The conventional approach uses the current logic: a symptom is either good or
    bad; present or absent; relevant or not. The dialectical approach stresses that each thesis
    also has to be considered in the light of its opposite (the antithesis), and only both
    facets together (the synthesis) yield a full picture. In this light, depression might be a
    sign of a disorder that should be mitigated. But at the same time, it must be acknowledged
    that there are inner experiences that cannot be controlled or altered "at will". Hence,
    although the phenomenal quality of going through depression may not be altered, a patient's
      <italic>relation </italic>towards relevant inner states relevant to depression may be
    changed due to mindfulness or other forms of spiritual exercise [<xref ref-type="bibr"
      rid="B6">6</xref>,<xref ref-type="bibr" rid="B7">7</xref>].</p>
  <p>Herein, we first elaborate on the dialectical structure of mindfulness by providing an
    overview of 1) the theoretical foundation of the construct, 2) evidence of the clinical
    effectiveness, and 3) putative neurobiological correlates of mindfulness. We then introduce
    five dialectical positions that we believe are useful for resolving the apparent paradox
    associated with mindfulness and its relevant mechanisms of action. Finally, on the basis of
    this discussion, we derive the utility and implications of mindfulness for medicine, and
    address potential caveats.</p>
  <sec>
    <title>Roots of the concept of mindfulness</title>
    <p>Mindfulness is an old concept; its theoretical roots were formulated by the Buddha, who
      characterized himself as a physician. He stated that his primary work was to identify the
      maladies afflicting humankind, and to establish a way through which every individual could
      attain lasting absence from suffering rather than complete well-being [<xref
        ref-type="bibr" rid="B8">8</xref>]. He claimed that mere belief and rational reasoning
      were not sufficient to mitigate suffering. He proposed mindfulness as a "direct way" to
      confront suffering by transcending it. Interestingly, the Buddha did not aim to establish
      an institutionalized form for disseminating his insights, such as a sect or a religion.
      His devotion to the self-reliance and self-dependence of each individual also demonstrates
      the very essence of mindfulness: "Do not believe in anything because it is rumored and
      spoken by many" [[<xref ref-type="bibr" rid="B9">9</xref>] p. 137]. He called for
      accepting only what one has analyzed by direct and immediate experience. On this basis,
      mindfulness can be described by its two inter-related facets: (1) the capacity to
      dispassionately observe the present moment, through (2) a stance of non-judgmental and
      accepting openness [<xref ref-type="bibr" rid="B10">10</xref>,<xref ref-type="bibr"
        rid="B11">11</xref>].</p>
    <p>Unlike the contemporary practice of medicine that can be seen as "objective" and a
      mediated "third person perspective", mindfulness is experienced in the subjective and
      immediate "first person perspective", or by means of direct and unbiased introspection.
      Historically, this epistemological approach has also been part of the work of the
      psychologists Franz Brentano, William James, (and to some extent) Wilhelm Wundt and his
      disciple Edward Titchener, as well as by the phenomenologist Edmund Husserl [<xref
        ref-type="bibr" rid="B6">6</xref>,<xref ref-type="bibr" rid="B12">12</xref>]. The
      dialogical <italic>I-Thou </italic>philosophy of Martin Buber also evidences similarities
      to the concept of mindfulness [<xref ref-type="bibr" rid="B13">13</xref>].</p>
    <p>Some scholars claim that the methodology of the science of inner experiences is not well
      developed [<xref ref-type="bibr" rid="B14">14</xref>,<xref ref-type="bibr" rid="B15"
        >15</xref>] and that the phenomenological properties of inner experiences of
      consciousness cannot be shared. By contrast, the epistemological grounding of mindfulness
      - particularly to the Buddhist tradition - holds that great insight can be derived from
      first person approaches that are also valid from an intersubjective point of view [<xref
        ref-type="bibr" rid="B16">16</xref>]. For example, prolonged practice of mindfulness may
      develop the ability to dissect experiences into more subtle parts thereby revealing the
      transient nature of perceptions [<xref ref-type="bibr" rid="B17">17</xref>].</p>
  </sec>
  <sec>
    <title>Clinical effectiveness and neurobiological correlates of mindfulness</title>
    <p>A body of research suggests that the facilitation of mindfulness has a positive impact on
      a variety of mental health symptoms, such as stress, anxiety, some personality disorders,
      chronic pain, and substance abuse. To date, several meta-analyses substantiate such
      clinical effects [<xref ref-type="bibr" rid="B1">1</xref>,<xref ref-type="bibr" rid="B18"
        >18</xref>,<xref ref-type="bibr" rid="B19">19</xref>]. Additionally, there is evidence
      that mindfulness has an impact on endocrinological and neurophysiological function. For
      example, Davidson and colleagues found a greater increase in antibody titers after
      vaccination in individuals practicing mindfulness on a regular basis as compared to
      non-practitioners [<xref ref-type="bibr" rid="B20">20</xref>]. More recently, in a
      randomized trial, Tang et al. [<xref ref-type="bibr" rid="B21">21</xref>] found that
      mindfulness practitioners showed more regional cerebral blood flow in the right anterior
      cingulate cortex (ACC), including the subgenual ACC (Brodmann area (BA) 25), and adjacent
      ventral ACC (BA 32), the left insula, occipital lobule, right posterior cingulate cortex,
      right precuneus, and subcortical structures of the putamen and caudate. These brain areas
      have been related to emotional regulation [<xref ref-type="bibr" rid="B22">22</xref>].
      Also, both Lazar et al. [<xref ref-type="bibr" rid="B23">23</xref>] and H&#246;lzel et al.
        [<xref ref-type="bibr" rid="B24">24</xref>] demonstrated that mindfulness may be
      associated with an increase of gray matter which persists longitudinally in certain brain
      areas. These researchers found that gray matter concentration in the left inferior
      temporal gyrus was correlated with meditative proficiency, corroborating the assumption of
      a positive impact of meditation training on gray matter concentration in this region
        [<xref ref-type="bibr" rid="B25">25</xref>,<xref ref-type="bibr" rid="B26">26</xref>].
      These results suggest that the ability of mindfulness to influence emotional state has not
      only a neurological base, but that mindfulness training - according to neuroplasticity
      paradigm - may actually influence the structural composition of the brain.</p>
  </sec>
  <sec>
    <title>Resolving the Paradox: The Dialectics of Mindfulness</title>
    <p>In the following sections we discuss five aspects of mindfulness that are all related to
      the underlying dialectical principle. In our view, these five dialectical aspects are a
      valuable way to address the apparent paradoxical structure of the construct.</p>
  </sec>
  <sec>
    <title>Dialectics of Activity vs. Passivity</title>
    <p>Mindfulness can be considered as a provokingly passive method. Mindfulness teachers
      explain the practice of mindfulness as "one simply examines every phenomenon" [[<xref
        ref-type="bibr" rid="B17">17</xref>] p. 95]. And, more illuminatingly, "the entire
      effort is to learn how not to react" [[<xref ref-type="bibr" rid="B17">17</xref>] p. 97].
      Mindfulness implies calmly observing unwanted inner or outer experiences. Psychologically,
      this means that the drives related to appetitive or aversive stimuli must be voluntarily
      suspended to the most possible extent. The first drive has been termed "approach
      motivation" and the latter "avoidance motivation" [<xref ref-type="bibr" rid="B27"
        >27</xref>]. Probably the most obvious difference to other treatments commonly employed,
      is that mindfulness advocates suspending cognitive, emotional or behavioral actions when
      facing negative experiences. In devising the antithesis, mindfulness seeks to engage a
      mechanism known as "apperception" a mental process that is responsible for perceiving,
      gauging, adopting and transforming an individual's experiences in order to create a new
      conscious concept based upon former experiences as well as inner states of the mind.
      Mindfulness involves meticulous and continuous observation of the prevalent sensory and
      mental processes by means of being fully present: Every moment and detail of a given
      experience is to be observed scrupulously, without cognitive and emotional evaluation of
      the respective event. This process involves a high degree of alertness and activity [<xref
        ref-type="bibr" rid="B28">28</xref>]. Hence, we claim that mindfulness is at the same
      time a way of being passive (with regard to gauging and reacting towards external stimuli)
      and of being active (with regard to observing the present moment and the accompanying
      inner states of mind). By means of reconfiguring the cognitively active and passive
      components, the thesis and antithesis of seemingly contradicting processes are resolved,
      and mindfulness can be regarded as a synthesis.</p>
  </sec>
  <sec>
    <title>Dialectics of Wanting vs. Non-wanting</title>
    <p>Some authors argue that mindfulness is a "non-striving" state of being, thereby
      precluding goal-oriented behavior [<xref ref-type="bibr" rid="B29">29</xref>]. In other
      words, it is held that being mindful contradicts wanting, aspiring, or desiring something.
      These authors state that during a deep state of mindfulness, a person has no goals and
      does not want for anything during the time of practice. Although this concept may be
      appealing, we doubt that an individual can be in a state in which she does not want
      anything at all, at least in situations that entail active behavior. How could a person be
      motivated to begin and stay within a mindful state? The fact that an individual starts or
      continues a mindfulness exercise from one moment to the next explicitly shows that she
        <italic>does </italic>aspire to be mindful. Additionally, why should one engage
      mindfulness meditation at all? Would she not aspire to achieve a certain goal implicitly
      or explicitly associated with this technique? Hence, upholding mindfulness practice cannot
      be simply equated with "non-wanting", but rather implies wanting to achieve something such
      as reducing suffering and distress or gaining essential insights to phenomenological
      experience. At the same time, we admit that the mindfulness antithesis is at odds with a
      certain understanding of what "wanting" comprises. To be more precise, "unconditional
      wanting" is the opposite of mindfulness as it refers to a mental state where something is
      sought after to such a degree that not achieving the desired state would lead to
      dissatisfaction. It has been argued that unconditional wanting leads to breakdown of inner
      balance if the desired state is not achieved [<xref ref-type="bibr" rid="B17">17</xref>].
      In fact, even if a person reaches the intended goal, the mind cannot be balanced,
      according to the theory of mindfulness, if the wanting is too strong. Both unconditional
      wanting or craving ("I must have this!") and aversion ("This must go away!") are forms of
      non-mindful states. Hence, the synthesis of the wanting-non-wanting dialectics reveals
      that a "gentle" form of wanting reflects the volitional processes underlying mindfulness,
      whereas "unconditional" wanting (both craving and aversion) cannot conform to the
      philosophy of mindfulness.</p>
  </sec>
  <sec>
    <title>Dialectics of Therapeutic Change vs. Non-Change</title>
    <p>Medical professionals strive to alleviate suffering. Many medical professionals have used
      mindfulness techniques in order to lessen the suffering of the patients they treat [<xref
        ref-type="bibr" rid="B30">30</xref>]. Yet, mindfulness theory claims that pain and
      related symptoms must be accepted by embracing them with an attitude of equanimity.
      Accordingly, if this aspect of mindfulness is cultivated, there is no longer any real
      argument for changing inferior and negative sensations, emotions, or symptoms. This is a
      critical but often misunderstood aspect of mindfulness that rests upon the fact that
      changing one's relation to the symptom has been mistaken for changing the symptom.
      Empirical research indicates that mindfulness training leads to a reduction of pain and
      anxiety [<xref ref-type="bibr" rid="B31">31</xref>], not by directly lessening symptoms,
      but by changing patients' attitudes toward them. Hayes et al. [<xref ref-type="bibr"
        rid="B32">32</xref>] describe that mindfulness aims at establishing a psychological
      stance of preparedness in which formerly unwanted feelings can be accepted. To give an
      example, anxiety is not necessarily a problem, if anxiety is embraced with the right state
      of mind. Simply, if one is able to accept anxiety, anxiety gradually loses its effect,
      simply because it can be contained; finally, the degree of fear will decrease as a result
      of reduced emotional impact. Thus, mindfulness is about being aware of experience, and
      gently accepting it. The finding that mindfulness reduces psychosomatic symptoms may be
      explained by two mechanisms. First, if a symptom of distress, such as anxiety, is
      subjectively accepted and embraced rather than resisted, it becomes less threatening. This
      is likely the reason why decreased levels of distress, anxiety, and depression are
      reported after mindfulness interventions. Second, as such symptoms become less important,
      behavioral changes associated with decline of symptoms become more probable [<xref
        ref-type="bibr" rid="B33">33</xref>].</p>
    <p>Recent research has shed light upon the possible mechanisms of mindfulness. Kohls, Sauer,
      and Walach described two main aspects of mindfulness, i.e., "presence" (attending to the
      present moment) and "acceptance" (non-judgmental attitude) [<xref ref-type="bibr"
        rid="B10">10</xref>]. Their work suggested that presence is a way to instill an attitude
      of acceptance, which is in turn responsible for buffering distress. It appears that
      presence itself does not buffer distress but allows one to build the non-judgmental
      attitude that seems to be responsible for health-relevant effects.</p>
    <p>Taken together, the synthesis of change and no-change distinguishes between what is
      changed through the practice of mindfulness - an emotional connection with the symptom -
      and what is (primarily) unchanged - the symptom itself. As changes in the symptom itself
      are not intended, mindfulness may be understood as a transformation of the
        <italic>relationship </italic>between self and symptom.</p>
  </sec>
  <sec>
    <title>Dialectics of Non-judging vs. Non-Reacting</title>
    <p>A facet of the definition of mindfulness is "non-judging", which has been advocated by
      Kabat-Zinn [<xref ref-type="bibr" rid="B34">34</xref>,<xref ref-type="bibr" rid="B35"
        >35</xref>] and subsequently more widely accepted [<xref ref-type="bibr" rid="B29"
        >29</xref>,<xref ref-type="bibr" rid="B36">36</xref>,<xref ref-type="bibr" rid="B37"
        >37</xref>]. However, we suggest a word of caution here. Let us start by posing a
      question. Is it possible to cognitively perceive something and concomitantly to abstain
      from all judgments? To answer this question, it is necessary to understand judging.
      Literature on perception and cognitive psychology suggests that judging primarily entails
      identifying a perception as representative of a certain mental category (e.g., sparrow as
      a bird) [<xref ref-type="bibr" rid="B38">38</xref>]. The relevant category has different
      attributes including a valence continuum (from "I like it" to "I don't like it") with
      various degrees of intensity. It is unlikely that a well-learned category attribute
      ("weapons - not good") can be easily abandoned, if at all. We suggest that mindfulness in
      the first instance should not be equated with the <italic>cognitive </italic>aspect of
      non-judging.</p>
    <p>Rather, we propose that mindfulness is primarily concerned with the
        <italic>emotional-motivational </italic>component of non-judging. Consider the following
      thought experiment. Imagine the possibility that you will not be eating your favorite food
      in the next months. This is not something agreeable; yet, although one would not want this
      to happen (i.e., cognitive judging occurs), it is possible to stay emotionally calm, and
      to remain contented despite this unwanted imagination (i.e., no emotional reaction). This
      emotionally calm state has been termed "balanced mind" - the fact that one does not react
      emotionally when facing an unfavorable experience [<xref ref-type="bibr" rid="B17"
        >17</xref>]. The opposite behavior would imply generation of emotions of dislike or
      craving. As a result, an urge - a specific emotional-motivational tendency - to
      behaviorally react may arise. This reaction may entail either behavior to strengthen the
      favored experience, or weaken it, if it is disliked. Together, the emotional and
      motivational reactions become mutually reinforcing in a positive feedback loop. This may
      explain how such urges gain strength. Associated cognitions will likely accompany this
      process.</p>
    <p>This is why a so-called unbalanced mind - primarily an emotional-motivational process -
      may lead to cognitions that are judging ("I hate this!"). This rationale provides some
      explanation why judging is incongruent with mindfulness, although judging is a secondary
      reaction or an epiphenomenon to mindfulness. Mindfulness is characterized by not showing
      reactive behavior or not indulging in emotions of craving and aversion. We do not argue
      for causal orders of evaluative cognitions and emotions. It may well be the case that
      specific cognitions exhibit associated emotions or vice versa [<xref ref-type="bibr"
        rid="B39">39</xref>-<xref ref-type="bibr" rid="B41">41</xref>]. Rather, our point is
      that a mindful state depends primarily on emotional calm, and only secondarily on the
      absence of evaluative cognitions. That means that one may calmly think "I don't like this
      at all" and still be mindful. Indeed, one cannot be upset and mindful at the same
      time.</p>
  </sec>
  <sec>
    <title>Dialectics of Active Acceptance vs. Passive Acceptance</title>
    <p>Most authors in the field of mindfulness research consider "acceptance" as one of the
      major aspects of mindfulness, together with a form of directing the attention to the
      present moment. In this light, some, such as Kabat-Zinn, hold that mindfulness "includes
      an affectionate, compassionate quality" [[<xref ref-type="bibr" rid="B34">34</xref>] p.
      145]. This conception may be interpreted as "active approval" of what is being
      experienced. This describes a stance of "the present experience is good" which includes
      emotional, motivational and evaluative aspects. But how can one approve <italic>all
      </italic>situations or experiences? This is seemingly illogical. In contrast to this
      assumption, we believe that mindfulness does not involve such "active" acceptance. We
      opine that the concept of "passive acceptance" is consistent with the essential idea of
      mindfulness, and simply suggests that one suspends or weakens evaluative cognitions and
      emotional reactions in a given situation. There is a subtle but crucial difference between
      the two concepts. The former assumes that one should actively strive to see the proverbial
      silver lining in all situations, although this may be contradictory to an individual's
      ethical or philosophical grounding. The latter view, in contrast, assumes that although we
      may not be able to escape a given situation, we may withhold our emotional or evaluative
      reactions, thereby possibly reducing the aversive character of a given situation. In other
      words, not accepting something does not necessarily imply rejecting it.</p>
    <p>Thus, the difference between active and passive acceptance can be formalized by the
      concept(s) of passive and active negation [<xref ref-type="bibr" rid="B42">42</xref>]. To
      give an example, the active negation of "I love you" is "I hate you", whereas the passive
      negation is "I don't love you". In more formal terms, the active statement "A is p" may be
      negated by the active negation "A is (not p)" as well as by its passive negation "Not (A
      is p)". In sum, the synthesis suggests that mindfulness is the absence of reacting towards
      a given experience, but not the unconditional and active, rather na&#239;ve acceptance of
      a given experience.</p>
  </sec>
</sec>

</body>

<!– =============== Back Matter (Ancillary) ======= –> <back>

<ack><p>We thank all of them as well .</p></ack> <notes></notes>

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<ref-list> <title>Additional Reading</title> <p>Just a reference or two for testing:</p> <ref> <!– ========== –> <mixed-citation>A citation ain't nothing but a sandwich &mdash; personal communication </mixed-citation> </ref> <!– ========== –> <ref> <mixed-citation> <name> <surname>Piggy</surname> <prefix>Ms.</prefix></name> <article-title>Can't Help Lovin&rsquo; That Frog of Mine</article-title>; <source>Swine Review</source>, <issue>145</issue>: <fpage>12</fpage>&ndash;<lpage>24</lpage>; <year>2003</year>. <trans-title xml:lang=“en”>Ant-cay Elp-hay Ovin&rsquo;-lay At-thay Og-fray of-ay Ine-may</trans-title> </mixed-citation> </ref> </ref-list> </back>

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