Mindfulness research –where are we here and now?

By | February 21, 2014

Let me share a few thoughts regarding the state of mindfulness research and also reflecting on mindfulness-based applications that, at least partially, justify their use by referring to scientific evidence of their effectiveness.

A recently published analysis of the available research regarding the effectiveness of meditation programmes for psychological stress and wellbeing inspired me to jot down some of the thoughts I have been carrying around for a while. This review concludes that the observed small improvements in negative affect resulting from mindfulness meditation “are comparable with what would be expected from the use of an antidepressant in a primary care population but without the associated toxicities”. With other words, the effects of mindfulness-based interventions are not worse than those of standard antidepressants for treating anxiety, depression and stress, but do not have the side effects that can result from taking antidepressants.

However, the review also highlights that the evidence for the effectiveness of meditation-based approaches for other conditions than anxiety, depression and stress is less clear and that overall the whole field still suffers from a lack of high quality research.

Considering this ‘verdict’ it may seem surprising how frequently mindfulness courses are offered with reference to the scientifically confirmed benefits often citing the fact that the UK’s National Institute for Health and Care Excellence (NICE) includes mindfulness in their guidelines for depression [download pdf here]. However, what tends to be omitted is that these guidelines are very specific; it is not mindfulness per se but Mindfulness-based Cognitive Therapy (MBCT) that is recommended by NICE! And more than that, also MBCT is not recommended as panacea but rather as treatment for one specific situation, namely when an individual is “at significant risk of relapse” into depression. In such cases “mindfulness-based cognitive therapy for people who are currently well but have experienced three or more previous episodes of depression” is the recommended treatment. To put it clearly, MBCT is not the recommended treatment for most cases of depression, but merely in the specific case of three or more episodes of depression and at a time when people are feeling well. This, of course, does not necessarily mean that mindfulness-based interventions do not work in other cases. It merely means that the evidence is not yet convincing enough to be considered by NICE and not as strong as some would make us believe. The consequence certainly is that current NICE guidelines should not be used for justifying anything else than relapse prevention for depression in the way stipulated above.

 

There are several other considerations that ask us to be careful.

For instance, the huge public presence of the mindfulness topic has fuelled a rapid increase in demand and one may wonder to what extent this demand can be met by sufficiently qualified mindfulness teachers or trainers. Furthermore, often the media are not very clear in showing that the evidence they are presenting actually relates to very specific programmes such as MBSR or MBCT, that are – I hope – carried out by practitioners fully qualified in offering mindfulness training and counselling, therapy or what else the context requires. As a result of this, people appear at the doorsteps of meditation centres hoping to get help with their depression, anxiety or OCD having decided to discontinue their medication without informing their doctors. With probably only few exceptions meditation centres will not have staff/volunteers/helpers with the appropriate level of professional training to deal in the required way with the different mental health issues visitors are presenting with – a situation that may significantly aggravate the mental health issues. The media also tend to neglect the fact that it is not meditation per se and on its own that is considered beneficial in these cases, but mindfulness meditation embedded within a complete and coherent therapeutic concept – something most meditation centres will not be qualified to offer.

 

We can observe further varieties of misunderstanding regarding mindfulness that can go to the core of the concept itself. Together with several other colleagues I was recently interviewed by a journalist who wrote a piece about the effects of mindfulness practice. The resulting article with the title “Breathing In vs. Spacing Out” appeared in January this year in the New York Times. I think it is an excellent example how mindfulness can be misinterpreted as the opposite of mind wandering. In a comment on this article I have argued that this is actually incorrect:

“It seems he partially misunderstood what mindfulness meditation is about; thinking it merely is a practice of focusing the mind, the opposite of mind wandering. I would rather say that mindfulness practice leads to more relaxed mind wandering and the psychological flexibility to either engage with the wandering thoughts or just let them play around. It’s a bit like the noise of playing kids: We just know that they are there, but only engage or jump in if something dramatic is about to happen. The article shows how difficult it is to grasp the actual experience of the practice without practising it.”

If you browse the comment section to the NYT article you will find that many share this concern.

research line graph

So, what to do about it? Well, the simple answer is that more high quality research is desperately needed and that until evidence is strong one would be well-advised to be modest and careful with our claims. In addition to conducting more high quality studies that evaluate the effectiveness of existing mindfulness programmes there are a host of other questions that will need to be answered. Here are just a few of those questions, some of which are crucial for offering mindfulness programmes in an appropriate way and making sure that there will be a lasting legacy:

  • How much personal experience with mindfulness/meditation practice is required before somebody can be considered to be qualified to guide others through the process?
  • Are there ways of evaluating whether somebody is a good and reliable meditation/mindfulness guide?
  • Is mindfulness an approach that can benefit anybody or do certain personal prerequisites need to be there?
  • The dosage: How much practice is needed to get the expected results?
  • What happens once a mindfulness course has ended? Does participation in one 8-week course suffice or is a minimum dosage of practice required to maintain what has been achieved?
  • Related to the previous question: Where to turn once the course is over? From where to get further guidance if somebody wants to continue with their mindfulness practice?

 

And now back to work.

 

© 2014, Peter Malinowski. All rights reserved. You may republish this post in unaltered form – On republishing it you must provide the link to this original post.

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9 thoughts on “Mindfulness research –where are we here and now?

  1. Erik Behrends

    Thanks for sharing this summary, Peter. I really enjoyed reading this article.

    One more question related to the dosage came to my mind:
    “Is there a possibility that mindfulness practice could be applied in a way that has to be considered as potentially harmful?” For example, meditation teachers often warn that extensive periods of mindfulness practice could lead to increased states of dullness (sometimes called the “white wall effect”).

    Reply
    1. Peter Malinowski Post author

      Dear Erik, thank you for your comment / question.
      You are raising an important point here. It relates to the dosage question, as you say, but also to several other questions, such as the qualification required for guiding mindfulness practice. Possible dangers involved in practicing meditation in general and mindfulness in particular have so far not been at the centre of much research, so I am relying more on my understanding of meditation, on observations, explanations from experienced buddhist meditation teachers as well as on common sense.
      The possibility of cultivating dullness (aka the ‘white wall effect’) instead of mental freshness and clarity is very real. There can be various reasons for it and I think one central point is our ever present drive, albeit sometimes quite subtle, for pleasant experiences. Taking this into the meditation practice and expecting to have a peaceful, relaxing or calm meditation can strengthen the tendency for the mind to go for such states and “giving up” non-evaluative awareness in an unnoticed, subtle fashion. The snag is that such states of mind can feel very pleasant, so that one does not realise how the clarity of mind is obscured by some wooly clouds of pleasant peace. If this happens regularly and the mind ‘goes for it’, it is easily seen how a wooly, unclear state of mind is cultivated, while at the same time thinking that we are doing “something good” for our mind/ourselves.
      What can be done? First of all, I would think it needs a meditation teacher who is aware of this danger and does not fall into the trap. On a practical level, it is probably advisable to keep mindfulness meditations relatively short, as it is incredibly difficult to maintain clear awareness for more than a few minutes. Also, forms of meditation that include methods that allow the mind to engage with something (e.g. calling Buddha forms to mind as done in the different branches of Vajrayana Buddhism) generally offer more protection against the ‘white wall effect’ than merely focusing on the breathing. My view is that asking people to practice say 45-minute sessions of mindful breathing as home practice would require extremely detailed and profound groundwork to ensure that the practitioner would be able to appropriately fine tune their own awareness towards clarity rather than a pleasant dullness.
      But as I said at the beginning, there is – to my knowledge – currently no research on this ‘white wall effect’. It would, for instance, be cool to know how much meditation is required to really strengthen the ‘white wall effect’. Once we have established more fully what to expect from mindfulness meditation in psychological and neurophysiological terms, we may be able to address this question more directly. For now, my hope lies with mindfulness teachers and their level of insight and expertise. Fingers crossed!

      Your comment also encouraged me to follow up on the idea of writing about some of the critical views concerning mindfulness and I hope to do so soon. A few interesting points have been raised recently. >> Watch this space!
      Thanks, Peter

      Reply
  2. DAVE VAGO

    Thanks Peter. … a very important caveat to the the enthusiasm for mindfulness research. As we continue to investigate the associated phenomena, we are likely to see requirements change. MBCT for example is starting to demonstrate effectiveness with active depression. The question of “white wall” is a matter of intensity and duration. MBCT only provides small amounts of both in terms of meditation practice, the bulk of the intervention or even other like ACT or DBT have very active behavioral/cognitive approaches.

    cheers,
    Dave

    Reply
    1. Peter Malinowski Post author

      Hi Dave, thank you for your thoughts. I agree fully on all points! Exciting to see more and more evidence in support of a broader use of MBCT. I think it has a lot more potential than the current evidence base is able to show.
      I am just returning from a weekend with a group of meditation teachers, where the point that meditation always needs to be embedded within a more complete context became quite prominent in discussions. It seems it is exactly what you are referring to regarding the “white wall effect” and how MBCT and other complete systems such as ACT or DBT are protected against this.
      And certainly the “white wall effect” needs quite a lot of time of persistent practice to develop.

      Best wishes,
      Peter

      Reply
  3. Justine Owens

    I don’t see any axis labels, title, or caption to the graph. Is there a citation?
    Re: mindfulness and meditation research I continue to wonder why individual differences are not considered in this research, specifically the effects of Mental Absorption (e.g., as measured by Tellegen’s scale). I think there is ample evidence that differences in Absorption (or openness or flexibility) are associated with differences in mind/body control yet these are not typically measured. I have studied people with chronic pain who report “instant success” with mind/body techniques and so they practice and get better quickly compared to others or have great difficulty calming the mind, focusing, observing, and stillness in general. They get frustrated and don’t practice much. In general I think the concept of graceful switching of attention, from one mode to another, across the the various states of consciousness is the key construct in evaluating MBSR etc. and some people are just naturally better at this.

    Reply
    1. Peter Malinowski Post author

      Hi Justine, apologies for the delay with approving your comment. It got caught in the spam filter (not quite sure why) and only now did I find the time to scroll through all the comments (most of them pretty pointless spam) to detect the serious ones.
      Regarding your first question (acis labels, title, caption, etc. ) there is non of this because the image is only meant as general illustration not to reflect specific data. You will see that the post does not refer to it at all. 🙂

      Some research does consider individual differences and there has been a bit on absorption, too – not much, though. It is a tricky construct and it is probably as difficult to measure in this context as mindfulness itself. Some researchers seem to consider absorption to be positively related to meditation practice, whereas I am sceptical and would rather think that in the way it is operationalsied by Tellegren it would to a certain extent contradict the (buddhist, mindfulness, ….) idea of meditation.
      In more general terms, there are of course always limitations what can be measured within a single study – for many reasons such as resource limitations (somehow also this work needs to be funded) or the burden on the participant.

      There is, of course, also a lot to be said about ‘instant success’ – and there a practitioner or mindfulness/meditation teacher will find a way how to deal with it. Meditation, up to very recently, has not been used as a quick fix, where we would expect instant success and indeed, such expectation would have been considered quite detrimental to the practice or any progress with it.
      Now, of course, when we are offering meditation as a tool for dealing with pain or other ‘problems’ such expectations are understandably awakened.
      I am not sure that considering individual differences and who is “naturally better at this” (the question: ‘Who is better in being non-judgemental?‘ almost seems a contradiction in terms 😉 ) is the complete answer. It is certainly worth considering it.
      And it may well be that those who have the largest difficulties will benefit most.

      Reply
  4. Justine Owens

    Thanks for your comments. As a cognitive psychologist I always come back to the construct of attention. High Absorption people are naturally gifted in controlling the focus of attention and even though Mental Absorption is a very complex trait – as indicated by the variety in items and its own factor structure – Tellegen tied the facets together with attention focus. People high in Absorption tend to cultivate positive attention control, except if they are also prone to negative beliefs and moods, in which case they are psychologically quite vulnerable, as Wickramasekera describes. I’ve come to think of it as a mind/body connectivity factor and it can go either way (e.g. placebo or nocebo), depending on the context. Re the non-judgmental aspect Absorption is correlated with Openness to Experience (NEO factor) and the pain people I have studied describe willingness to try new therapies – withholding judgement – and a general non-judgmental attitude toward life.. My studies on wisdom and adversity do support the idea that those who have the largest difficulties can benefit most and appreciating that paradox seems very much associated with growth and wisdom. If you are interested “Choosing Wisdom” is available on Amazon and includes a PBS documentary.

    Reply

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