Saturday, February 15, 2014

The Wild Frontier of Mindfulness

There's been some gushing about mindfulness recently following the publication of a mindfulness meta-analysis and a TIME magazine cover story, The Mindful Revolution. Perversely for an avowed "mindfulness evangelist," I will argue that this is a good time to check over-exuberant claims and expectations.

First, here's an abstract of the new report, and some links to articles in the lay press about it in Reuter's Health;  The Guardian's blog; and a Guardian editorial by writer Julie Myerson on how Mindfulness cured her lifelong anxietyThe story in TIME generated a loud rumble in the blogosphere, including one in The Huff Post mentioning a wide range of applications of mindfulness meditation.

The new meta-analysis, or "study of studies," analyzed 47 scientific reports on randomized controlled clinical trials of mindfulness programs to help people with physical or psychological problems or high stress.   Controlled in this case meant that mindfulness was compared to some other treatment program similar in duration and intensity -- such as an exercise-, muscle relaxation- or education program or cognitive-behavioral group therapy, for example. Having a control group for comparison helps to rule out placebo effects:  It's long been known that people tend to improve somewhat just from the belief that they are being treated, even when the "treatment" is completely inert.

Randomized means that participants in the studies weren't specially selected for one treatment versus another -- they were assigned randomly.  This helps eliminate bias that would result from deliberately or unknowingly assigning people likely to benefit from a new treatment to one arm of a trial and  tougher cases to the other. Random assignment to treatments can help reduce "self-selection bias." This happens when volunteers enroll in a study believing in advance that they'll benefit from it. With this bias, they may be more receptive to the treatment and more likely to notice and report benefits.

The 47 experiments covered in the meta-analysis included 3,515 people who participated in a trial of some type of meditation (mindfulness, transcendental meditation [TM], or mantra meditation). A large population like this is good-- small studies can yield fluke results due to chance or conditions unique to the trial setting, rather than real effects of mindfulness. Combining and comparing studies in a meta-analysis dilutes or cancels out some of these anomalies.

Sadly, the 47 studies were the few bits of cream that rose to the top of 1651 meditation research articles the meta-analysts could find. They had to discard 444 studies that did not include an active control group or randomization.

What the meta-analysis actually found was modest: "Moderately strong evidence" that mindfulness programs could improve anxiety and depression by 10-20% at eight weeks (i.e. at the end of a typical mindfulness training program) and after three to six months. The researchers wrote, "These small effects are comparable with what would be expected from the use of an antidepressant in a primary care population, but without the associated toxicities." There was also evidence that mindfulness meditation reduced pain. There was only slight evidence that it eased stress or improved quality of life related to mental health.

Clearly something about mindfulness works for some people. But there was insufficient evidence that meditation increased positive mood, attention, eating habits, or sleep. Nor did evidence show it helped with weight control or substance use. There was no evidence that meditation was better than active comparison treatments, such as prescribed drugs, exercise, or other behavioral treatments. The researchers found fewer studies of mantra meditation and TM than mindfulness, so support for the other types of meditation was even sketchier .

The conclusion of the study was appropriately low-key:  Clinicians were advised that meditation programs could yield small-to-moderate reductions in "negative dimensions of psychological stress" (i.e anxiety and depression). They added that better-designed studies are needed to "determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior" (i.e. substance use, sleep problems, weight control, etc.)

So is this mindfulness glass half-full or half-empty? Is Mindfulness really only modestly effective for a few conditions? Or is it only modestly proven because the studies aren't good enough yet? Is Mindfulness too fuzzy, too full of uncontrollable human factors to ever be proven more effective? Or is it that Mindfulness is still in its infancy -- still identifying key ingredients to make it more effective and still groping for the best ways to measure benefits?

If the answers lie in anecdotes, the abundance of positive personal testimony would paint Mindfulness as perfect already. For instance, scan the comments following the Guardian blog and you'll find plenty of folks saying mindfulness has improved -- even saved -- their lives.  But just as all the personal testimony in the world will never convince Richard Dawkins that God exists, so positive testimony from mindfulness evangelists won't nudge the science. 

But on the flip side, might there be constructive ideas for improving Mindfulness in the negative testimony -- or in comparisons of people who did vs. did not benefit from Mindfulness? 

Returning to the comments following the Guardian blog, I found the following problems with Mindfulness--at least for some people: 
  • Some (as I predicted) don't like the Buddhist references in Mindfulness (see note #1 below). 
  • Some say it's just the latest in a long line of psychobabble fads, following neurolinguistic programming, transcendental meditation,  hypnosis, or other "neurobollocks (#2)"
  • Some say there's nothing to mindfulness -- they do it all the time already (#3)
  • Some are surprised to find you must continue to practice mindfulness meditation each day to enjoy its full benefits -- and it's hard to find the time (#4)
  • Others observe Mindfulness is not a cure for life-threatening depression and is incompatible or inappropriate in some settings where it's being tested -- such as the military (#5).
Below I address these issues  and consider the differences between my experience with an 8-week Mindfulness-Based-Stress Reduction (MBSR) Course and that of a close friend.  

Because I've written previously about including Buddhist or other spiritual references in Mindfulness, I won't say more, except to repeat that spiritual references may encourage some potential practitioners, but will close the door for others. Even a passing reference to ancient Eastern practices with the stipulation that "you don't have to be a Buddhist to benefit" from Mindfulness may put some folks off. The alienated won't try Mindfulness, may drop out, or, if they stick with it for some reason -- perhaps as part of a clinical trial -- they may be less likely to practice wholeheartedly. 

Mindfulness is just the latest psychobabble fadTime and subsequent research will tell. I would guess that an average of four scientific articles on mindfulness are added to the PubMed database at the U.S. National Library of Medicine each week. TIME reports,

"Altogether, in 2003, 52 papers were published in scientific journals on the subject of mindfulness; by 2012, that number had jumped to 477."
Academics are holding their first international conferences on mindfulness and there are now programs around the world to train teachers of mindfulness--and teachers of teachers of mindfulness. There's now a magazine devoted exclusively to mindfulness. The new meta-analysis is a sign that mindfulness is beginning to mature as a science. I'd say the best way to avoid Mindfulness becoming a disappointing fad is to be sure claims don't push past the most rigorous science.

In an interesting article in Mindful magazine, science writer Sharon Begley describes promising evidence that even the adult brain retains plasticity -- ability to rewire emotional responses. Unfortunately, she says, the study of emotional reprogramming (which includes mindfulness) is in its infancy. Meanwhile neuroplasticity is a bandwagon starting to roll.
It’s a shame to see something as scientifically significant as neuroplasticity— the ability of the adult brain to change its structure or function in an enduring way—overpopularized to the point that it could start losing its real meaning.
I agree. It would be a shame, and the danger is there: The TIME article cites an NIH report which found back in 2007, Americans were already spending $4 billion on mindfulness-related alternative medicine Lucrative practice for the merchants of mindfulness and feel-good popularity could entrench the young field, even without more solid scientific backup. This is what happened with the Myers Briggs Type Indicator,  a personality test taken by 2.5 million people per year.  An important money-maker for the company with rights to the test and for people who train and pay for a license to administer it, the personality test is widely popular in the business community, despite lacking  scientific validity.  

There's nothing to mindfulness. I think this is largely true -- or perhaps simple Mindfulness potentially lies in many things. You can pretty much summarize the practices and attitudes of mindfulness meditation in a few paragraphs. Conceptually easy-peasy. There are lots of books on it, and free talks about it on YouTube where Jon Kabat-Zinn, one of the fathers of Mindfulness, calls it "Much ado about almost nothing." The MBSR course and other Mindfulness™courses take eight weeks (and a few hundred dollars or pounds) to school you in a series of specific exercises, such as sitting or lying down and focusing kindly attention on each breath, or parts of your body, or walking, or yoga movements, or a poem, or sounds, or something you are gazing at, or just the thoughts passing through your mind. (You can find links to some of these guided meditation exercises at 

These Mindfulness™exercises are simply well worked-out, more-or-less standardized techniques to an end: strengthening healthy control of focus and attention. Homework exercises in the MBSR course ask you to do something mindfully in your everyday routine -- eating, showering, brushing your teeth, washing the dishes. This highlights the everyday aspect of mindfulness--almost anything that engages attention presents an opportunity for mindfulness practice, helping you be present in the present and bumping aside regrets and worriesDear Husband finds that paragliding or riding his motorcycle at high speed snap his mind into the present (thank goodness). Maybe music, exercise, photography, hiking, gardening, the tangotai chi, aikido, crossword puzzles, or playing Tetris offer informal practice for other folks, even without Mindfulness™ training.

The hard part to mindfulness is actually doing it intentionally, and mastering the skill sufficiently that you can summon mind-refocusing when you really need to--when it's most difficult, and when you don't have your camera, garden, or tango partner at hand. I would guess that only the most disciplined informal mindfulness practitioners would be as facile as experienced meditators in commanding their focus in moments of crisis.

It's another question whether mindfulness courses should cost what they do for what you get from a "science" still in its infancy. I'd say if you're a highly disciplined person, you can probably get your 10-20% improvement in depression or anxiety by following a book. If you need the assistance of a class and can afford a course, do it.

Mindfulness requires everyday practice to be effective. True. As a mindfulness devotee, I find time spent practicing mindfulness is at least partially repaid through increased effectiveness and enjoyment in daily life. Done properly, mindfulness practice  should steer you away from rumination, irritation, worry, self-loathing, anxious fears, jealousy, and other habitual, automatic, and unproductive thoughts. The more you practice, the better you should be at intentionally refocusing. You may even discover your own personal uses of the skill, as I have.

But is there a decay curve for Mindfulness skills? Is this related to how well you acquire them in the first place? How often and how intensely do you need to refresh the skills? One of the shortcomings of Mindfulness research is neglect of how much, how well, and how long trial participants actually practice or how firmly they acquire the skill in the first place. Even less is known about what's needed to maintain skills. At this point it's assumed practice makes perfect. Given that, Mindfulness teachers should be upfront and emphatic about the importance of ongoing practice.

Mindfulness is not right for all people under all conditions. True. As a field in its infancy, mindfulness is still identifying its goals, legitimate claims, and target populations --the meta-analysis is important for this.

The young field has a lush crop of published studies showing mindfulness is beneficial in a wide range of conditions, measured many different ways--a broad, but thin frontier. The way you measure mindfulness effects in post-traumatic stress disorder is quite different than in smoking cessationinsomniaattention deficit disorderpanic attacksfibromyalgia, or provoked vestibulodynia, for example. Frequently benefits of mindfulness are supported by small, uncontrolled studies of non-randomized, selected, atypical groups.  Many studies are one-offs.  For all these reasons, at this time, most mindfulness studies can't be pooled and meta-analyzed to wash out biases and anomalies.

But as broad as the applications of mindfulness might be, there are some proscribed applications. As one comment on the Guardian blog noted, mindfulness is not appropriate for the severely depressed and other people in acute crisis -- they should get emergency psychiatric help. I would hope that mindfulness teachers and others speaking and writing about mindfulness make that clear.

That comment and one about mindfulness in the military making soldiers more efficient killers and manipulators gets at another set of fundamental questions about mindfulness--what does mindfulness really want to grow up to be? What are its real goals?

 The research papers covered by the meta-analysis assumed that the function of Mindfulness is to improve measurable well-being or reduce the impact of particular health problems.  But, the authors write,
Historically, meditation was not conceptualized as an expedient therapy for health problems. Meditation was a skill or state one learned and practiced over time to increase one’s awareness and through this awareness to gain insight and understanding into the various subtleties of one’s existence. . .  The interest in meditation that has grown during the past 30 years in Western cultures comes from Eastern traditions that emphasize lifelong growth. The translation of these traditions into research studies remains challenging.
Some Mindfulness teachers -- even if they avoid invoking Buddhist traditions -- still resist a physiological view of the practice. Consider this from mindfulness teacher and author Ed Halliwell:
 Scientific studies might show that mindfulness improves well-being in material terms, but can they do justice to the inner transformation that occurs for many people who practise it? Isn't something lost by presenting its effects purely as a physical or mental health benefit? Indeed, by setting up mindfulness as something that produces guaranteed results, isn't there a danger of distorting one of its key messages—that striving for a concrete future is antithetical to the practice, which is about staying with the uncertain present?
The question about use of mindfulness to make soldiers better killers also reflects a different view of fundamental goals. My understanding of MBSR in the military is that it is aimed at preventing psychological injuries from war ('mental armour' from Mindfulness training before deployment) or treating such injuries (PTSD etc.) post-combat. Whilst I would like to think Mindfulness may contribute to responsible, respectful behavior toward others and ultimately contribute to world peace -- those objectives actually go beyond inner-focused MBSR remit.

Goal ambiguity may also start to explain why Mindfulness worked for me, but did little for my dear friend.  In the absence of universally accepted and communicated goals and unequivocal areas of effectiveness, mindfulness is a wide-open frontier. Like the Wild West--there's gold in them thar' hills -- promise and opportunity, but also hype, bravado, claims that won't pan out, and maybe some snake-oil, fast-talk, smoke, and mirrors.

People come to mindfulness with different expectations. Their motivations may be strengthened or diminished by what they find, as colored by personal traits of different participants and mindfulness teachers. My dear friend didn't start with the same open attitude toward MBSR that I had. He didn't "click" with the MBSR teacher.  I don't think his class attendance was perfect--as mine was. I can't say the same for my homework practice, but I probably did more than my friend. My ongoing practice tends to be brief, but daily. I expected more of MBSR than my friend; I put in more effort; and I continue to get more out of it.

What's needed now, in my opinion, is improvement of mindfulness pedagogy. Learning the practice should be like learning a foreign language, Aikido, or the tango. People considering signing up should know what they'll get (subject to specified effort and practice, as with any learned skill) and what it's good for. This will first require taming the wild frontier --narrowing, unifying, and clearly defining goals and then assuring -- based on research -- that practices and benefits are conveyed as efficiently, effectively, and honestly as possible.

Some downsides of Mindfulness (from comments following the Guardian blog
#1-The Buddhist / Psychological Basis of Mindfulness are problematic for some: Kikichan: I don't find the religious associations with mindfulness or any kind of psychological therapy to be at all helpful. Perhaps I've just... seen too many priests trying to milk too much money out of grieving people by means of emotional manipulation ... When my husband was a child, his grandfather died, and he was sent to a Zen meditation camp, where he was walloped by a monk for moving to avoid a wasp. Living among Buddhists, I really can't credit the religion with any power to make people healthy mentally.
PatLux: As an atheist I find the links to Buddhism don't sit well with me. However I did do a short mindfulness course and as a result when I go out for a walk I do tend to notice more of the beautiful details of the world around me. It is like any selfhelp programme for me. I take from it small aspects that are useful and then move on but my personality does not allow me to buy into the complete package.

#2-Mindfulness is the latest psychobabble fad, a reincarnation of neurolinguistic programming etc: Amendall: Some folk will believe anything. A new fad, lacking in evidence but harmless if kept to oneself.
CrewsControl: ... I wonder if the attempted scientific explanation, the uncoupling of the insula, as Prof Williams describes in his presentation isn’t just the sort of neurobollocks we’ve seen before.  It also has the strange feel of an embryo cult, following the path beaten by NLP. Discobedient: I suspect that after mindfulness the next buzzword in psychology is going to be "cheer up, love-ness". Fieldeffects: The only meditation technique recommended by the American Heart Association is Transcendental Meditation as they said that it has the best scientific evidence. A meta-analysis of randomised controlled trials on TM and anxiety (which looked at 600 papers) found that it was better than controls.

#3-There's nothing to Mindfulness -- I'm doing it already! Mauinglionz: I don't get it. Based on the description in the article I feel like this is something I'm doing anyway?

#4-Mindfulness requires everyday practice to be effective: OxfordBiker: I've a friend who has suffered from lifelong depression and anxiety who got send on a mindfulness course by her GP. She enjoyed it but 'didn't realise' she had to go on doing it every day! 

#5-Mindfulness does not work to make all people happy under all conditions:
Elmondo2012: ...Speaking as someone who has been meditating and doing aikido for years (AKA Zen on Wheels) and who also has a hell of lot of experience with very severe depression mindfulness or whatever you ant to call it isn't that helpful when you're suicidally depressed. Jodro: ... One additional remark: mindfulness has become very popular in the US recently and now also is gaining a strong foothold in the UK. However, in Buddhist traditions mindfulness is always taught in conjunction with a set of values. These include respect for life, including of animals and plants, respect for the environment as a whole, not stealing, social justice, helping those in need and sharing our resources with them, and responsible sexual behaviour and responsible consumption. While very beneficial, IMHO mindfulness practice alone is not enough. Witness for example the fact that the US army has begun to use it. Becoming a more effective killing machine, or becoming more effective at exploiting the system and becoming rich, and so on, miss the point as these actions will not foster happiness or contentment, which is what it's about.

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