New voices: Are we mindful of how we talk about mindfulness?

Mindfulness dates back 2500 years, originating in Buddhism. Right now it is everywhere. People are talking about it as a state of being and way of life, writing about it, broadcasting podcasts on it, developing phone-based apps, offering groups and online courses. A few years ago, I went to the 'Mindfulness in Society' conference organised by Bangor University's Centre for Mindfulness Research and Practice. There was a vibrant buzz: you would have understandably left feeling inspired and thinking we should all take up mindfulness practice. Yet I continue to find a lot of people are unaware of what mindfulness really is and what it involves. Some may assume it to be religious, conjuring up images of people chanting. Some believe it to be an alternative or complementary therapy, or that it is at best relaxation: 'Your PhD is about mindfulness?! That sounds calming, I could do with some of that.'

Mindfulness has been defined as 'paying attention on purpose, non-judgementally, and in the present moment' (Kabat-Zinn, 1982). One way of achieving this is through formal breathing or body-based meditation practices. Thoughts and feelings are acknowledged and accepted but not challenged as in cognitive behavioural therapy (CBT), for example. Mindfulness-based interventions (MBIs) have been developed for use in both mental and physical health, aimed at relieving symptoms of stress, depression, anxiety, eating disorders, and more. Jon Kabat-Zinn developed the first structured eight-week course, Mindfulness-based Stress Reduction (MBSR), for clients experiencing chronic pain (Kabat-Zinn, 1982), but you can now embrace mindfulness in workplaces (participating in 'mindful lunches' or 'mindful walks'), in schools (to help children with stress and general well-being: Kuyken et al., 2013) and beyond. To see mindfulness accepted and becoming integrated into people's lives is inspiring, but we need to be cautious with how we talk about and promote mindfulness, particularly so as to avoid creating unrealistic expectations in those new to mindfulness .

Increasing scientific research output has highlighted the growing interest and acceptance of mindfulness-based approaches. In the 1980s, only one or two academic papers were published. In the 1990s this increased to around 10–15 per year. In 2013 alone there were 475 publications on mindfulness (Black, 2014).

One particular field in which MBIs have been well researched is in depression. Despite both psychological and pharmacological treatments, many people continue to relapse into depression. Could the beauty of mindfulness lie in not only helping people to get better, but keeping them better? Mindfulness-based cognitive therapy (MBCT), developed in 1995 as an adaptation of MBSR (Teasdale et al., 2000), aims to provide people currently in remission from depression with skills in mindfulness supplemented with psychoeducational elements of CBT to help prevent further relapse. The first randomised controlled trial (RCT) shows that those who participated in the eight-week MBCT programme showed lower relapse rates 12 months later, compared with those receiving their normal treatment (Teasdale et al., 2000). In fact, 37 per cent of the MBCT group met relapse criteria compared with 66 per cent of the treatment-as-usual group. More recently RCTs have shown that MBCT is as effective as antidepressants in preventing depression and may be beneficial for those with higher childhood trauma (Kuyken et al., 2008; Williams et al., 2013). In terms of mechanisms underlying MBIs, MBCT has been shown to reduce rumination, worry and dysfunctional attitudes (Jermann et al., 2013; Williams, 2008). Both mindfulness and self-compassion have been reported to mediate the effects of MBCT on depressive outcome (Kuyken et al., 2010), and a qualitative study suggested that MBIs can lead to a greater sense of acceptance and control over symptoms of depression (Allen et al., 2009).

Additionally, research shows how mindfulness practice can alter brain structure and function in long-term experienced meditators compared with novices, but also following short-term mindfulness interventions of eight or just four weeks in those new to meditation (Tang et al., 2012). Studies investigating MBSR have shown that there are not only mood and well-being gains but also improvements in attention and in hippocampal and amygdala brain structure (Jha et al., 2010; Hölzel et al., 2010; Hölzel et al., 2011). My own PhD is attempting to identify the neuropsychological mechanisms through which MBCT works to prevent relapse in depression, targeting specifically mechanisms of self-compassion, rumination and brain structure.

Such evidence is exciting and suggests that taking up mindfulness practice has wide impacts beyond psychological well-being. However, we must remain cautious that we do not talk about mindfulness as a quick fix or, worse, a panacea. Research to date has largely ignored negative side-effects, but one qualitative study reports how MBCT participants expressed difficulties when realising MBCT is not a cure-all and reporting feeling that they could not 'do' the mindfulness practice successfully (Allen et al., 2009). Such concerns are not uncommon and would normally be addressed during an MBCT course, particularly as there is no right way to 'do' mindfulness. This highlights the importance of raising realistic expectations of MBCT throughout the course, which may also help to ensure continued practice beyond the eight weeks. Development of mindfulness skills will inevitably require longer than an eight-week course, but the course is well suited to providing a foundation for further development of mindfulness techniques.

Recently an emerging area of research led by Willoughby Britton at Brown University has suggested that mindfulness practice may not be appropriate for all. Whilst scientific research has not yet uncovered many negative side-effects from meditation, there are texts hundreds of years old that do touch on negative experiences or the 'dark knight of the soul' (see tinyurl.com/jw4swbk), suggesting there are hardships in contemplative practices. Interestingly, whilst in medical studies side-effects would always be considered in RCTs, they have often been neglected in psychotherapy research (Dimidjian & Hollon, 2010), and thus far, in meditation research. We remain largely unaware of evidence on participants who may be more vulnerable to undertaking meditation practices or those who may experience negative emotions, paranoia, confusion or a loss of identity – some of the experiences reported in Britton's early research. This can of course all be a natural part of the meditative process, but, for some, such negative experiences can be heightened to an extent they can become very unwell. So there needs to be an awareness of undertaking mindfulness practices with a suitable level of insight and readiness to start meditation. Meditation may look and sound simple, but mindfulness practice involves a considerable amount of active effort – it is quite a commitment to achieve and maintain the benefits reported above. As psychologists, we need to exercise caution in promoting the use of mindfulness as a therapeutic intervention for clients. As above, there may be some who are more vulnerable or not at the right stage in their lives to face the emotions mindfulness can bring to the forefront.

Although there are not currently any formally recognised qualifications to teach mindfulness, and training pathways are not yet accredited, we must not forget that those teaching mindfulness should at the very least have their own established personal practice of mindfulness. Attendance at an eight-week course would not be sufficient for beginning to teach mindfulness techniques to others. We must encourage clients to seek teachers who have an established mindfulness practice, are appropriately trained and supervised and are following UK mindfulness teacher guidelines (Kuyken et al., 2012) to ensure continuation of credible and evidence-based courses.

Personally, I have practised mindfulness meditation for around four years; it is certainly not easy or a one-off practice. After all, you are connecting with inner thoughts and feelings you may have learned, over many years, to keep hidden under the surface. My practice has made me more self-aware and connected with my mind, my automatic reactions and behaviour around others, which has at times made me feel low or anxious. This is all a part of the process and is why mindfulness can be so powerful as a therapeutic tool. Whilst mindfulness practice for me has been a life-changing decision, it was not a simple, straight line journey and I'm sure I will have ups and downs as I continue to practise. As Jon Kabat-Zinn said at the mindfulness conference, it will not always be easy but 'you don't have to like it, you just have to do it'.

I am a strong believer in MBIs and can see the benefits it can bring. Yet we must remain 'mindful' of how we promote and talk about mindfulness to ensure we carefully promote its use and application to mental or physical health issues whilst in the early days of its research. If we can avoid overstating mindfulness as a gold standard or panacea, those new to mindfulness can start to practise with realistic expectations, under suitably qualified courses, and can begin to experience the wonderful world of mindfulness meditation.

Kate Williams is a PhD student in the Neuroscience and Psychiatry Unit at the University of Manchester
[email protected]

References

Allen, M., Bromley, A., Kuyken, W. & Sonnenberg, S.J. (2009). Participants' experiences of mindfulness-based cognitive therapy: 'It changed me in just about every way possible'. Behavioural and Cognitive Psychotherapy, 37(4), 413–430. 

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Hölzel, B.K., Carmody, J., Vangel, M. et al. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research, 191, 36–43.
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