During the past two decades, mindfulness meditation has gone from being a fringe topic of scientific investigation to being
- an occasional replacement for psychotherapy,
- tool of corporate well-being,
- widely implemented educational practice, and
- “key to building more resilient soldiers.
Yet the mindfulness movement and empirical evidence supporting it have not gone without criticism.
Misinformation and poor methodology associated with past studies of mindfulness may lead public consumers to be harmed, misled, and disappointed
Addressing such concerns, the present article
- discusses the difficulties of defining mindfulness,
- delineates the proper scope of research into mindfulness practices, and
- explicates crucial methodological issues for interpreting results from investigations of mindfulness
For doing so, the authors draw on their diverse areas of expertise to review the present state of mindfulness research, comprehensively summarizing what we do and do not know, while providing a prescriptive agenda for contemplative science, with a particular focus on assessment, mindfulness training, possible adverse effects, and intersection with brain imaging
Our goals are to inform interested scientists, the news media, and the public, to minimize harm, curb poor research practices, and staunch the flow of misinformation about the benefits, costs, and future prospects of mindfulness meditation.
Mindfulness is an umbrella term used to characterize a large number of practices, processes, and characteristics, largely defined in relation to the capacities of attention, awareness, memory/retention, and acceptance/discernment.
it has achieved wide-ranging popularity in psychology, psychiatry, medicine, neuroscience, and beyond, initially through its central role in mindfulness-based stress reduction
The term mindfulness began to gain traction among scientists, clinicians, and scholars as the Mind and Life Institute emerged in 1987 and facilitated formal regular dialogues between the Dalai Lama and prominent scientists and clinicians, as well as regular summer research meetings, the latter starting in 2004 (Kabat-Zinn & Davidson, 2011).
In the early 2000s, mindfulness saw an exponential growth trajectory that continues to this day (see Fig. 1). The term mindfulness has a plethora of meanings; a reflection of its incredible popularity alongside some preliminary support, considerable misinformation and misunderstanding, as well as a general lack of methodologically rigorous research.
Mindfulness has become an extremely influential practice for a sizeable subset of the general public, constituting part of Google’s business practices (Schaufenbuel, 2015), available as a standard psychotherapy via the National Health Service in the United Kingdom (see Coyne, 2015b) and, most recently, part of standard education for approximately 6,000 school children in London (Rhodes, 2015). In addition, it has become a major area of study across subdisciplines of psychological science, including social/personality (Brown & Ryan, 2003), industrial/organizational (Dane, 2011), experimental (Jensen, Vangkilde, Frokjaer, & Hasselbalch, 2012), clinical (Dimidjian & Segal, 2015), cognitive (Tang, Hölzel, & Posner, 2015), health (Jain et al., 2007), educational (Britton, Lepp, et al., 2014), and many others. As such, it is critical that we take the term (along with any ambiguities) and the methodological rigor (or lack thereof) with which it has been studied very seriously.
much popular media fail to accurately represent scientific examination of mindfulness (see, e.g., Goyal et al., 2014), making rather exaggerated claims about the potential benefits of mindfulness practices (Gibbs, 2016; Gunderson, 2016). There have even been some portrayals of mindfulness as an essentially universal panacea for various types of human deficiencies and ailments (see, e.g., Gunderson, 2016;Huffington, 2013).
As mindfulness has increasingly pervaded every aspect of contemporary society, so have misunderstandings about what it is, whom it helps, and how it affects the mind and brain. At a practical level, the misinformation and propagation of poor research methodology can potentially lead to people being harmed, cheated, disappointed, and/or disaffected. At a philosophical level, misunderstandings of the work and its implications could limit the potential utility of a method that proposes unique links between first-person data and third-person observations (cf. Lutz & Thompson, 2003).
Two main topics are considered herein: (a) the problem of defining mindfulness and thus delineating the appropriate scope of research on mindfulness practices and (b) methodological issues in mindfulness research. We provide (a) an overview of the current state in scientific knowledge, (b) a summary of consensus about what the currently available empirical findings do or do not conclusively show, and (c) a proposed prescriptive research agenda for making future scientific progress in understanding the consequences of mindfulness practices.
We believe that much public confusion and media hype have stemmed from an undifferentiated use of the terms mindfulness and meditation. Each of these terms may refer to an ambiguously broad array of mental states and practices that are associated with a wide variety of secular and religious contexts (Davidson & Kaszniak, 2015; Goleman, 1988).
Valid interpretation of empirical results from scientific research on such states and practices must take proper account of exactly what types of mindfulness and meditation are involved.
With current use of umbrella terms, a 5-minute meditation exercise from a popular phone application might be treated the same as a 3-month meditation retreat (both labeled as meditation) and a self-report questionnaire might be equated with the characteristics of someone who has spent decades practicing a particular type of meditation (both labeled as mindfulness).
Furthermore, there is a general failure among the public to recognize that scientific consensus is a complex process requiring considerable time, effort, debate, and (most important) data.
Throughout the scientific process, the predominant view among scholars can vacillate between being in support of, being agnostic to, and being against a given idea or theory (Shwed & Bearman, 2010).
Eager journalists, academic press offices, and news media outlets—sometimes aided and abetted by researchers—have often overinterpreted initial tentative empirical results as if they were established facts.
Moreover, statistically “significant” differences have repeatedly been equated with clinical and/or practical significance (cf. Rosnow & Rosenthal, 1989).
These critical considerations need to be incorporated constructively in the future development of best practices for conducting mindfulness research, and for promoting accurate scientific communication with the general public (Britton, 2016).
The Problematic Meaning of “Mindfulness”
Mindfulness is typically considered to be a mental faculty relating to attention, awareness, retention/memory, and/or discernment (cf. Davidson & Kaszniak, 2015).
One of the most thoughtful and frequently invoked definitions states that
“mindfulness is moment-to-moment awareness, cultivated by paying attention in a specific way, in the present moment, as nonreactively, nonjudgmentally, and open-heartedly as possible.”
However, this definition has been described as one of convenience regarding those constructs most readily comprehensible to Western audiences (Kabat-Zinn, 2011).
The ramifications of considerable semantic ambiguity in the meaning of mindfulness are multifarious. Any study that uses the term mindfulness must be scrutinized carefully, ascertaining exactly what type of “mindfulness” was involved, and what sorts of explicit instruction were actually given to participants for directing practice, if there was any practice involved.
If the definition of mindfulness is based on self-report measures, one should be aware of the nuances of the various measures, how they relate to each other and/or conceptualizations of mindfulness (see Table 1; Bergomi, Tschacher, & Kupper, 2013; Sauer et al., 2013), as well as how different individuals might interpret the items on these measures (cf. Grossman & Van Dam, 2011).
It should be further noted that self-reported mindfulness may not relate to the actual practice of mindfulness meditation (cf. Manuel et al., 2017).
Although most mindfulness training has been derived from the original MBSR model (Kabat-Zinn, 1990), the intensity (hours per day) and duration (total time commitment) of participants’ formal practice have varied considerably across different versions of training (Davidson & Kaszniak, 2015; Tang et al., 2007; Zeidan et al., 2011).
The particular methods for teaching and practicing “mindful” states have varied, too. However, published journal abstracts and media reports about obtained results often gloss over such crucial variations, leading to inappropriate comparisons between what might be fundamentally different states, experiences, skills, and practices.
Different definitions of skilled expertise
The definitions of “novice” and “expert” or “adept” (with respect to those with meditation experience) have varied considerably from study to study.
According to proposed theoretical models of mindfulness, there are clear mental processes and brain mechanisms that might facilitate insight and adaptive personal change, such as
- psychological distancing/reperceiving (S. L. Shapiro et al., 2006),
- decentering and inhibitory control (Vago & Silbersweig, 2012),
- nonconceptual discriminatory awareness (Brown et al., 2007),
- acceptance and reintegration (Hayes et al., 1999; Linehan, 1993), or
- focused attention, decentering, and meta-awareness (Lutz, Jha, Dunne, & Saron, 2015; Meyer, 2009).
Consensus about the semantic ambiguity of “mindfulness.”
“Mindfulness” does not constitute a unitary construct, though it frequently includes aspects of paying attention in a specific, sustained, nonjudgmental way (Kabat-Zinn, 1990).
the type of mindfulness putatively measured by contemporary cross-sectional research is not necessarily the same as what contemporary mindfulness training/meditation seeks to cultivate (see Manuel et al., 2017), which itself can differ from the mindfulness practiced by long-term meditators in various contemplative traditions relative to one another (Grossman & Van Dam, 2011).
Prescriptive research agenda: Transcending the prevalent ambiguity
Given current confusion surrounding “mindfulness,” we urge scientists, practitioners, instructors, and the public news media to move away from relying on the broad, umbrella rubric of “mindfulness” and toward more explicit, differentiated denotations of exactly what mental states, processes, and functions are being taught, practiced, and investigated.
Toward this end, we have provided a nonexhaustive list of defining features for characterization of contemplative and meditation practices (see Table 2).
To resolve issues surrounding the implementation of mindfulness and/or other meditation-based training/intervention, we recommend development of something similar to a CONSORT checklist (Moher, Schulz, & Altman, 2001) that could be implemented across studies (see Table 3).
Methodological Issues in Mindfulness Meditation Research
Challenges for clinical intervention methodology
Numerous intervention studies have been conducted to assess whether, and by how much, practicing mindfulness may help alleviate various undesirable mental and physical conditions, including pain, stress, anxiety, depression, obesity, addiction, and others
Moreover, only 1% of all research has been conducted outside research contexts, a woefully inadequate research base to inform whether MBIs are ready for use in regular clinical practice, as is the case in the United Kingdom (Coyne, 2015b, 2016).
As a result, some have blatantly stated that “widespread use is premature” (Greenberg & Harris, 2012).
Haphazard variability across Mindfulness-Based Initiatives (MBIs)
Given the lack of consensus about what “mindfulness” means and how it should be operationalized, MBIs have varied greatly in the diverse types of practice, methods of participant training, and duration of instructional courses associated with them.
The duration of MBIs have been altered dramatically to conform with brief training regimens that may involve as few as four 20-minute sessions (e.g., Papies, Barsalou, & Custers, 2012; Zeidan et al., 2015).
Given the variety of practices that fall under the umbrella of MBI, the adoption of mindfulness as a prescriptive clinical treatment has not entailed a consistent type of intervention.
Misperceptions of therapeutic efficacy
Despite the preceding list of concerns, there is a common misperception in public and government domains that compelling clinical evidence exists for the broad and strong efficacy of mindfulness as a therapeutic intervention (e.g., Coyne, 2016; Freeman & Freeman, 2015).
As a consequence of select results, published in high-profile journals, MBCT is now officially endorsed by the American Psychiatric Association for preventing relapse in remitted patients who have had three or more previous episodes of depression.
Moreover, the U.K. National Institute for Health and Clinical Excellence now even recommends MBCT over other more conventional treatments (e.g., SSRIs) for preventing depressive relapse (Crane & Kuyken, 2012).
Mitigating such endorsements, a recent meta-analysis found that MBSR did not generally benefit patients susceptible to relapses of depression (C. Strauss, Cavanagh, Oliver, & Pettman, 2014).
In a recent review and meta-analysis commissioned by the U.S. Agency for Healthcare Research and Quality, MBIs (compared to active controls) were found to have a mixture of only moderate, low, or no efficacy, depending on the disorder being treated.
Specifically, the efficacy of mindfulness was only moderate in reducing symptoms of anxiety, depression, and pain. Also efficacy was low in reducing stress and improving quality of life.
There was no effect or insufficient evidence for attention, positive mood, substance abuse, eating habits, sleep, and weight control (Goyal et al., 2014). These and other limitations echoed those from a report issued just 7 years earlier (Ospina et al., 2007).
On balance, much more research will be needed before we know for what mental and physical disorders, in which individuals, MBIs are definitively helpful.
Harm, adverse effects, and fallout of meditation practices
Much of the public news media has touted mindfulness as a panacea for what ails human kind (e.g., Chan, 2013; Firestone, 2013), overlooking the very real potential for several different types of harm.
at the NIH, the biggest potentials for harm of complementary treatments (e.g., meditation) are
“unjustified claims of benefit, possible adverse effects . . . and the possibility that vulnerable patients with serious diseases may be misled” (Briggs & Killen, 2013).
Coming to terms with meditation-related adverse effects
Meditation-related experiences that were serious or distressing enough to warrant additional treatment or medical attention have been reported in more than 20 published case reports or observational studies.
These reports document instances of meditation-related or “meditation-induced” (i.e., occurring in close temporal proximity to meditation and causally attributed to meditation by the practitioner, instructor, or both)
- traumatic-memory reexperiencing, and
other forms of clinical deterioration (Boorstein, 1996; Carrington, 1977; Castillo, 1990; Chan-Ob & Boonyanaruthee, 1999; Disayavanish & Disayavanish, 1984; Epstein & Lieff, 1981; Heide & Borkovec, 1983; Kerr, Josyula, & Littenberg, 2011; Kornfield, 1979; Kuijpers et al., 2007; Kutz et al., 1985; Lomas, Cartwright, Edginton, & Ridge, 2015; Miller, 1993; Nakaya & Ohmori, 2010; Sethi, 2003; D. H. Shapiro, 1992; Shonin, Van Gordon, & Griffiths, 2014b, 2014c; VanderKooi, 1997; Van Nuys, 1973; Walsh & Roche, 1979; Yorston, 2001).
For example, in a recent meta-analysis of MBIs, C. Strauss et al. (2014) concluded,
“given the paucity of evidence in their favour, we would caution against offering MBIs as a first line intervention for people experiencing a primary anxiety disorder . . . findings from the current meta-analysis would suggest great caution if offering MBIs to this population as a first line intervention instead of a well-established therapy.”
In economics, as well as recent discussions of psychotherapy, this effect has been labeled an “opportunity cost” (i.e., time and money invested in a treatment approach that has little to no therapeutic benefit relative to the potential time/money that could have been invested in a treatment more likely to yield improvement; cf. Lilienfeld, Lynn, & Lohr, 2003).
Given that relief from anxiety is probably one of most widely promoted benefits of mindfulness (see, e.g., Hofmann et al., 2010), opportunity cost may be a widespread “side effect” of MBI hype.
The article continues with a longer discussion of the harms of assuming benefit from MBIs and forcing such interventions upon people.