Mindfulness is a mental state that involves observing and allowing one’s thoughts and feelings as they arise in the present. It can be learned through directed attention exercises, and can be integrated with existing therapy methods and training programs for use with many psychological problems.
Central to this practical implementation of mindfulness is developing the ability to recognize old, engrained, and automatic emotional response patterns as they occur. This process requires focused attention on the body’s response to emotional patterns. The repeated bringing to awareness and allowance of these patterns gradually leads to acceptance, and creates room for behavioral adjustment. With practice, patients can learn to apply this skill to their own psychological symptoms.
This can be illustrated with an ordinary example. Imagine someone criticizes you. Instantly, you experience an unpleasant state of tension. Thoughts race through your mind as the area around your chest tightens and your heart rate jumps. You feel hot and start to blush, holding back whatever it is you really want to say. Hours later, the incident still lingers. You brood over the order of events, what you should have said but didn’t dare to, and how you will act differently next time.
Mindfulness helps you to become aware of these kinds of automatic patterns. You learn to recognize the recurring stories in your head, such as “I’m worthless,” “I’m incompetent,” or “I’m powerless.” You notice that the sensations arising in your body are sensations that you don’t want, and you discover that much of your thought and behavior is aimed at getting rid of those unpleasant and painful feelings.
We are perpetually in doing-mode; always busy thinking and acting toward some objective. Meditation teaches us to enter being-mode, and to remain there. We permit every experience, including those we do not want, repeatedly reacting out of habit or impulse. Through this process our old and engrained response patterns lose their power over us, and we cultivate the freedom to respond differently.
The mindfulness training presented and discussed in this book is derived from Mindfulness-Based Cognitive Therapy (MBCT). Beginning in 1995, MBCT was developed as a training program for groups of patients with recurrent depression. In recent years it has increasingly found application in individual settings and the focus of treatment has expanded to include other types of disorder (Teasdale, Segal, & Williams, 1995).
In the West, interest in meditation as a therapeutic approach began to emerge in the 1960s (Germer, 2005). Jon Kabat-Zinn was a pioneer who applied this form of meditation in a medical setting with patients experiencing pain and psychosomatic symptoms. Kabat-Zinn’s methodology, named Mindfulness-Based Stress Reduction (MBSR, Kabat-Zinn, 1990), involves an intensive mindfulness training program consisting of eight weeks of weekly three-hour sessions, in which patients learn assorted meditation techniques as well as yoga exercises.
Teasdale and colleagues (1995) have also performed pioneering work in this area. The lack of a successful system for treating recurrent depression motivated them to develop Mindfulness-Based Cognitive Therapy (MBCT). They integrated MBSR and cognitive-behavioral therapy techniques in order to help prevent relapse in patients with a history of three or more episodes of depression. Their program yielded positive results. In a post-treatment follow-up period of 60 weeks, the percentage of relapses of depression was reduced to approximately half, compared to the control group, which was given treatment-as-usual (Ma & Teasdale, 2004; Teasdale et al., 2000).
These early research findings have led to a surge of enthusiasm and optimism about potential applications of mindfulness techniques. Hundreds of popular books on mindfulness have been published, and the expanding body of research literature on mindfulness-based treatment covers a range of topics, including qualitative research, controlled clinical trials, and neuroscientific studies. Black (2013) appraises the number of scientific publications appearing each year, showing an increase from 28 articles in 2002 to as many as 397 by 2011. Many of these studies demonstrate the positive effects of mindfulness-based interventions.
The success of mindfulness in clinical practice coincides with the advent of a new paradigm in treatment methodology. This development is expertly illustrated by Hayes (2005), who distinguishes between three generations of behavioral therapy. The first generation saw the dawning of behavioral therapy. This form of treatment is typified by its emphasis on the psychological principles of learning, such as classical and operant conditioning. The arrival of the cognitive revolution in psychology paved the way for cognitive-behavioral therapy, the second generation. Its principal assumption is that psychological problems arise or are perpetuated by the disturbance of specific cognitive functions and schemas. Treatment is directed toward changing dysfunctional thoughts, with the goal of eradicating or gaining control of maladaptive behavior. The third generation of treatment approaches is not as much about changing dysfunctional thoughts, feelings, and behavior, as it is about changing one’s attitude toward them. This “third wave” is currently made up of four fully functioning systems of treatment that have been evaluated for effectiveness, and in which mindfulness plays an important role: Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Dialectical Behavioral Therapy (DBT), and Acceptance and Commitment Therapy (ACT).
Besides the above, there are several other mindfulness-based interventions (MBIs) and treatment protocols in which mindfulness is integrated with cognitive-behavioral therapy. Segal, Williams, and Teasdale (2002) predicted that mindfulness-based treatment programs would lead to sweeping changes in the therapy profession. Their prediction was more accurate than they had imagined: In the second, revised edition of the authoritative book, Mindfulness-Based Cognitive Therapy for Depression (2013), the authors indicate an unexpected explosion of interest in the use of mindfulness in treating a great number of physical and psychological conditions.
Simply stated, in the context of MBCT, mindfulness is defined as (a) being observant of all that is experienced (sensory perception, thoughts, and feelings), and (b) permitting all experience including thoughts (analyzing, planning, fantasizing, judging, reasoning), behaviors, and behavioral urges (avoidance behavior, distraction seeking) without reacting automatically to it.
However, the term mindfulness is often used in different ways, which may lead to some confusion. Several definitions exist, depending on the context of its use: as a meditation technique (formal mindfulness meditation), as a state of mind (being mindful), as a trait, as a skill (mindful reaction), and as a treatment method (therapeutic application).
In light of the ambiguity of the construct, experts in the field of mindfulness-based therapy have organized consensus conferences aimed at establishing an operational definition of the term. Bishop et al. (2004) describe mindfulness as a continuum of mental processes that serves to understand how functional and dysfunctional thoughts, feelings, and behaviors arise, with the goal of strengthening the former and attenuating the latter. They propose an operational definition of mindfulness based on two components. The first component concerns the self-regulation of attention, which entails directing attention at sensory experiences and mental events arising in the present moment. The second component describes an orientation to experience that is open and inviting; every thought, feeling, and physical sensation is accepted, without expressing intentional judgment and without wishing to change it.
Directing attention is the first step. The aim is to maintain conscious awareness, from moment to moment, of that which presents itself in the form of thought and sensation. This may involve a broad and all-encompassing sort of attention, or a focus on specific phenomena, such as the body’s emotional response. Steady and constant concentration is required. A common device used to aid concentration is the centering of awareness in the breath. The experience of breathing thus becomes a focal point for attention.
An important element in this practice is the capacity to recognize when distractions occur, and then directly returning to the intended subject of awareness. The core skill to be developed in mindfulness is that of turning off the “automatic pilot,” circumventing the habitual tendency toward unconscious reaction (Segal, Williams, & Teasdale, 2002). Mindfulness effectively fosters meta-awareness: the human mind’s capacity to observe itself and its behavior, and to contemplate personal actions and situations as though from a distance. Meta-awareness allows us to switch from automatic pilot to manual control.
The second component of mindfulness is the cultivation of an open and accepting attitude toward thoughts, feelings, and physical responses. Acceptance happens when unpleasantness is allowed to exist, without limitation, without evaluation, and without attempts to hold on or to resist. Such an attitude stands in direct opposition to our usual orientation: judgment, leading to action. Segal, Williams, and Teasdale (2013) refer to this as the doing mode, which is automatically activated when the brain detects a discrepancy between our current state and a desired state. This becomes most apparent when unpleasant thoughts and/or feelings arise. Explanations for the discomfort are sought, along with solutions to the problem perceived, in an effort to avoid further distress. If more urgent tasks demand attention, the problem is dealt with later on, but only after a solution has been found will the unpleasantness cease. Keywords related to the doing-mode include analyzing, judging, evaluating, solving, achieving, testing, planning, pursuing goals, adjusting, and obsessing. The doing-mode is suitable for practical, technical, and intellectual tasks, but is also so entrenched that it is activated to handle emotional problems as well.
When emotions are involved, the being-mode, which in many ways represents the opposite of the doing-mode, is more appropriate. The being mode is characterized by non-judging, permitting, non-striving, acceptance, understanding through direct experience, and a broad focusing of awareness (Segal, Williams, & Teasdale, 2013).
In mindfulness-based therapy, treatment revolves around mindfulness training and its implementation in situations that trigger inadequate responses or psychological problems. MBSR, and MBCT in particular, routinely incorporate formal meditation exercises of up to 45 minutes per day. In contrast, ACT and DGT methods make use of psychoeducation and a host of exercises for promoting mindfulness, but involve little meditative practice.
This chapter covers several meditation exercises with practical applications, all of which have in common the same basic instructions and objectives. We will first discuss the most widely used mindfulness technique, breathing meditation, followed by a number of other meditation exercises and their application.
Sitting upright in a relaxed and alert position, attention is focused on the physical sensation of breathing. Attention tends to get sidetracked quite easily. When this occurs, instructions are simply to notice the distraction in a gentle, non-judging manner, and to bring awareness back to the principal object of attention. In this case, the objective is not exclusively to focus on the breath. In fact, the actual awareness of breathing becomes the primary medium for the development of an open and perceptive stance, from which everything is experienced without following habitual reactions. In other words, one’s thoughts, feelings, and impulses are merely observed. They are not ignored, analyzed, or suppressed, but are permitted—without subsequent action and without losing awareness of the breath. Unequivocally, this is an exercise in turning off the automatic pilot and stepping out of doing mode. Patients are encouraged to practice this skill in daily life as often as possible, especially when dysfunctional emotional patterns threaten to surface. In this way, mindfulness creates a time-out between an experience and the immediate reaction it provokes. It facilitates a switch, as it were, from automatic transmission to manual, granting the freedom and space to react differently to whatever happens. More detailed and precise descriptions of mindfulness meditation can be found in Gunaratana (2011), Smalley and Winston (2010), and Segal, Williams, and Teasdale (2013).
This involves focusing awareness on one’s perception of the body, which may present purely physical sensations, such as the body’s contact with the seat, or somatic emotional responses, such as tension around the chest.
There are two variants of this exercise. In the body scan meditation, awareness is progressively moved through parts of the body.
The other variant is based on a broad, open form of attention to the body as a whole. If one particular physical sensation is in the foreground, it remains the point of focus until another sensation attracts attention.
The instruction is to continually observe and allow perceptions that arise, without doing anything about them.
Besides the breath and other bodily phenomena, attention can be focused on sounds, thoughts representing words or phrases (internal speech), or on thoughts in the form of images (memories and fantasies). Another kind of meditation exercise is choiceless awareness (or mindfulness without an object), in which attention is broad and all-encompassing. There is no focal point, and anything goes. Whatever appears in awareness also disappears, and does so without intervention.
Walking meditation is a widely practiced technique, and can be a valuable alternative to seated meditation. While walking, attention is initially turned toward the soles of the feet and gradually expanded to the rest of the body. Walking meditation, and other types of meditation involving movement, can be performed slowly or at the accustomed pace. These kinds of exercises are an effective way of involving mindfulness techniques in day-to-day life.
In addition to the aforementioned exercises, which are meant to be performed daily and at specifically allotted times, there are also ways to practice mindfulness during regular day-to-day activities and tasks. Special attention can be given to routine actions, like tooth brushing, showering, dish washing, walking up and down stairs, and eating. Spontaneous moments in the day may also provide opportunities for practice, for instance, while waiting in a queue, walking short distances, or answering the phone. Another mindfulness exercise calls for occasional breaks over the course of the day. One momentarily concentrates on the sensation of breathing, followed by a focus on whatever happens to be active in one’s experience at the time. The objective is not to react automatically and impulsively, but rather to notice stimuli before they are responded to.
Three Minute Breathing Space is a specialized mindfulness application developed by Segal et al. (2002, 2013). This exercise is meant to be employed when habitual patterns are triggered in daily life. The breathing space provides patients with an opportunity to step out of automatic pilot mode when situations require conscious consideration. The exercise is made up of three steps, each taking approximately one minute to complete. The first step is the bringing into awareness of any bodily sensations, thoughts, or feelings coming into being. In the second step, attention is focused as much as possible on the experience of breathing. In the third step, attention is expanded to the full physical presence, with the breath remaining in background awareness. A phrase that may be recited is “It’s okay … whatever it is, it’s already here: let me feel it” (Williams, Teasdale, Segal, & Kabat-Zinn, 2007).
An emotionally laden issue can also become the object of meditation (Segal, Williams, and Teasdale, 2013). In this exercise, the instruction is to divide attention between the sensation of breathing and locations in the body where emotional responses are most pronounced. If emotions become overwhelming, then awareness can be temporarily focused on the breath.
If any presently taxing experiences or traumatic memories come up, then the therapist can supervise an exercise in mindful exposure. An image is selected that best reflects the patient’s unpleasant experience. The therapist then asks the patient to report his or her physical sensations at 10- to 20-second intervals. The patient is instructed to accept everything that emerges, and to do nothing in response. Although behavioral therapy and mindful exposure have some procedures in common, their basic instructions differ on important points. The typical explanation for exposure in behavioral therapy is: “If you persist in the confrontation with your problematic (usually frightening) situation, you will notice that your emotional response will subside, and that your (usually anxiety-provoking) expectation will not materialize.” In other words, the unpleasant feeling is expected to fade through habituation and irrational thoughts to disappear accordingly. This is not the standpoint of mindful exposure. Just as with other mindfulness exercises, the instructions are to allow feelings to arise and to focus on their physical responses—to expect nothing, and to do nothing. In the long run, paradoxically, transformation is achieved by letting go. The goal, then, is not to regulate the frequency and intensity of emotions, but to foster an open and accepting attitude toward them.
The selection and planning of meditation exercises depend on the nature of the problem, the treatment plan, the patient’s wishes, and the options available. Bringing mindfulness-based techniques into therapy can take the form of a complete training program that incorporates all of the practices described above, or may be limited to the application of a small number of exercises in tandem with some existing treatment plan (Rapgay et al., 2013).
The recommended duration of mindfulness exercises in the context of training and therapy ranges from 30 to 45 minutes, both in session and on a daily basis between meetings. Also recommended is continuation of daily mindfulness practice after the training has ended. Carmody and Baer (2009) performed a meta-analysis of 30 studies which showed that practitioners advocate an average of 45 minutes of practice per day, 6 days a week. Training participants are also asked to practice mindfulness skills during daily activities, which is known as informal practice. Additionally, many MBSR training programs include a day of silence, and both practitioners and instructors are advised to regularly attend multi-day meditation retreats as a way to increase their expertise. These extended retreats are commonly practiced for spiritual purposes, but have been adopted in the field of mindfulness-based psychotherapy. There seems to be a common assumption that frequent and long-lasting meditation is necessary, yet scientific studies demonstrate that more is not always better.
Research findings suggest that the relationship between the duration and effect of mindfulness exercise (both formal and informal) is unclear or does not exist. Davidson et al. (2003) studied the neurological and biological changes that occur following mindfulness training and found no significant relationship between exercise length and associated changes. Nor was any such correlation found in Hölzel et al.’s (2011) study on mindfulness in the brain.
A recent study by Klatt, Buckworth, and Malarkey (2008) assessed a shortened MBSR training program for professionals. Participants meditated at work for 20 minutes at a time, 5 days a week, for a sum total of 6 hours, whereas the standard MBSR training program entails more than 20 hours of practice over 10 weeks. The shorter training was found to have significant effects on measures like stress and quality of sleep, and these effects were comparable to those of the standard training.
A meta-analysis by Vettese, Toneatto, Stea, Nguyen, and Wang (2009) incorporated 24 studies that provided data on exercise duration and outcomes. The average time spent on mindfulness practice was 31.8 minutes per day, with a range from 5 to 58 minutes. According to Vettese, nearly half of the studies showed no support for the hypothesis that longer exercises yield better results. Studies that did support the link between duration and outcome employed many self-selected participants and participants active in healthcare. This suggests that positive expectations and previous exposure to mindfulness may have been (partly) responsible for these results.
Perich, Manacavasgar, Mitchell, and Ball (2013) performed a study on the use of MBCT with bipolar disorder, in which pre- and post-training measurements indicated no relationship between duration of mindfulness practice and psychiatric symptoms. Furthermore, follow-up tests administered 12 months after training showed no significant improvement of symptoms in participants who continued practicing mindfulness compared to those who did not.
In their conclusions of a meta-analysis involving 39 studies and a total of 1,140 participants, Hofmann, Sawyer, Witt, and Oh (2010) wrote that mindfulness-based treatments had a robust positive effect on anxiety and mood disorders regardless of training duration. Most training programs consisted of eight meetings with a range of six to twelve sessions. Many programs also included a retreat lasting one day or half a day. Bowen and Kurz (2012) found that the amount of practice between sessions in an eight-week program was positively related to the degree of mindfulness measured upon conclusion of the training, but no such effect was found at two- and four-month follow-ups.
A recently published meta-analysis (Khoury et al., 2013) found no consistent relationship between the number of training sessions and assigned exercises and MBI outcomes. There was, however, a correlation between training outcomes and the therapist’s level experience with mindfulness. The authors list group cohesion and quality of practice as additional factors.
In practice, therapists frequently receive feedback from patients regarding their difficulty fitting extended exercises into their day-to-day schedules. Over the course of therapy and in follow-up sessions it typically becomes known that many patients do not carry out their longer exercises in full, whereas shorter exercises such as the Three Minute Breathing Space technique are more compatible with busy schedules. Shorter meditations (8 to 15 minutes) are thus more likely to meet practical considerations such as the need for regular practice and treatment compliance.
Scientific studies and practical experience point to a need for further research on the relationship between exercise duration and effectiveness, and on the necessity of continued practice subsequent to therapy or training. Additionally, there are few data on the effectiveness and duration of mindfulness practice in terms of specific disorders and populations. At present it appears most prudent to select more feasible—and thus shorter—mindfulness techniques in lieu of prolonged exercises that are difficult to combine with everyday life. Advising patients to continue practicing mindfulness once training or therapy has ended is not supported by the literature to date.
Finally, the specific nature of the client’s problems and (dis)abilities should be taken into account when selecting mindfulness exercises and exercise lengths. For beginner meditators, greater awareness is often accompanied by increased experience of unpleasant feelings. If this becomes problematic, for instance, when symptoms include anxiety around bodily phenomena (as in hypochondriasis and panic disorder), shorter exercises should be offered. In such cases attention can initially be restricted to external stimuli (sounds) or can focus on movement and/or mindfulness with daily activities. Exercises involving awareness of bodily sensations can be introduced at a later stage. Chadwick, Newman Taylor, and Abba (2005) describes the development of his mindfulness program for psychotic patients: Over the course of four years, the duration of mindfulness exercises had to be reduced from prolonged meditations to a feasible length of just four minutes.
Schema Therapy works in two stages: the assessment stage, in which schemas and modes are identified; and the transformation stage, in which empathic confrontation and reality testing are employed toward the transformation of schemas and modes. Techniques used for modifying schemas and modes are borrowed from cognitive-behavioral therapy (cognitive reorganization, creation of an internalized healthy voice, and behavioral exercises designed to disrupt dysfunctional behavior); from experiential therapy (practicing the expression of anger, sadness, or pain); from Gestalt therapy; and from interpersonal psychotherapy techniques.
The mindfulness-based approach introduces a third stage: through nonjudgmental attention to the inner experience of schema and mode activation, room is created for novel ways of responding. This attention-oriented process is illustrated in the example of Anna:
Most mindfulness training takes the form of MBSR or MBCT. In its initial development MBSR was geared toward people with physical symptoms (chronic pain/stress) and has therefore found broad application. MBCT was specifically developed for people with recurrent depression. Though primarily used within this population, it is increasingly implemented in the treatment of other mental disorders.
Research on the therapeutic action of mindfulness has gotten off to a strong start, but applications in the domain of several specific disorders have not yet been examined through randomized controlled trials (RCTs). Nonetheless, the literature contains many publications concerning other implementations, noncontrolled studies, and case studies (a recent overview can be found in Baer, 2010). Various studies, most of them RCTs and meta-analyses, are discussed in the following subsections.
The rise of MBCT followed the success of two randomized trials demonstrating the effectiveness of MBCT as a method for relapse prevention in recurrent depression. Teasdale et al.’s (2000) study involved 145 patients with two or more depressive episodes, with the control group receiving “treatment as usual (TAU).” The mindfulness-based intervention was not found to be more effective than TAU for patients with only two episodes, but showed a significantly greater effect in patients with three or more episodes. Over a period of 60 weeks, 37% of the MBCT group experienced a relapse, compared to 66% relapse in the control group. The second study by Ma and Teasdale (2004) involving 75 patients yielded similar results: a 36% relapse rate in the MBCT group and 78% in the control group. Numerous studies have replicated these results since 2000, all supporting the effectiveness of mindfulness with recurrent depression. A recent RCT involving patients with three or more previous relapses (both with and without current episodes) compared MBCT to a control group (Van Aalderen et al., 2012). Depressive symptoms were significantly reduced by the end of the treatment. Patients reported significantly less worrying and rumination, demonstrated significantly improved mindfulness skills, and reported significantly higher scores for quality of life. MBCT resulted in similar symptom reductions in patients both with and without current depressive episodes.
Piet and Hougaard (2011) performed a meta-analysis of six RCTs with MBCT. Patients with recurrent depression in the MBCT group had a significantly smaller probability of relapsing than controls; the greatest difference was found among patients with three or more depressive episodes.
Eight of the studies included in Klainin-Yobas, Cho, and Creedy’s (2012) meta-analysis examined the effects of MBSR on depressive symptoms in people with mental disorders. MBSR appears to be an effective treatment for reducing depressive symptoms in people with mental disorders, demonstrating outcomes similar to those of cognitive-behavioral therapy. Klainin-Yobas et al.’s (2012) study also included 22 studies on the effect of MBCT on depression in people with diverse mental disorders. MBCT was found to have a medium effect size in reducing depressive symptoms.
An RCT by Geschwind, Peeters, Huibers, van Os, and Wichers (2012) looked at residual depression symptoms following at least one depressive episode. Patients were assigned either to an MBCT group (plus standard treatment) or to a control group (waitlist or continued standard treatment). MBCT was found to be significantly better at reducing residual depressive symptoms than the control group. No significant difference was found between persons with one or two episodes and those with three or more.
Vøllestad, Nielsen, and Nielsen’s (2012) meta-analysis incorporated four studies that examined the effect of MBSR on anxiety symptoms in people with diverse anxiety disorders (social phobia, panic disorder, generalized anxiety disorder, concurrent depression and anxiety). Each of these studies supported the effectiveness of MBSR in reducing anxiety symptoms; this effect was significant in three of the four studies. Vøllestad et al. (2012) also examined the effects of MBCT on anxiety. Their meta-analysis included nine studies in which anxiety symptoms were reduced as a result of MBCT, with significant effects in four of these studies.
Jazaieri, Goldin, Werner, Ziv, and Gross (2012) led an RCT on MBSR for people with social phobia, comparing the effects of MBSR to an active control group in which participants exercised at a gym at least twice a week for eight weeks. MBSR led to reductions in self-reported anxiety, depression, and stress symptoms upon completion of the training and at a three-month follow-up; increases in well-being were recorded at the same measurement times. Exercise also resulted in reductions in self-reported anxiety, depression, and stress symptoms upon completion of the training and at a three-month follow-up; increases in well-being were recorded at these same measurement times. No significant differences were found between the two interventions. The authors conclude that both MBSR and exercise can contribute to reduction of clinical symptoms in adults with social phobias.
McManus et al. (2012) researched the effects of MBCT (along with standard treatment) on health anxiety, comparing it to a control group that received standard treatment only. MBCT participants showed significantly lower health anxiety than controls, both directly post-intervention and one year after. Significantly fewer participants in the MBCT group than in the control group fulfilled diagnostic criteria for hypochondriasis directly post-intervention as well as one year later (36.1% vs. 76.3%). The authors conclude that MBCT can be a useful supplement to standard treatment for people with health anxiety.
Biegel, Brown, Shapiro, and Schubert’s (2009) RCT investigated the effect of MBSR on heterogeneous mental disorders (mood disorders, anxiety disorders, V-code disorders, and other disorders) in adolescents. In this study, MBSR (in addition to standard treatment) was compared to standard treatment alone (individual or group therapy and/or medication). Compared to controls, the MBSR group demonstrated a significantly greater reduction in diagnoses (percentage change) over the course of the five-month study, along with significantly increased Global Assessment of Functioning (GAF) scores. Participants in the MBSR group also indicated significantly fewer self-reported symptoms of anxiety, depression, and somatization, along with increased self-confidence. Effect sizes for these changes in self-reported symptoms were consistently large. The authors conclude that MBSR can be an effective supplement to treatment of adolescents with heterogeneous mental disorders.
A meta-analysis by Hofmann et al. (2010) incorporated 39 studies with a total of 1,140 participants who received mindfulness-based treatment for a variety of complaints, ranging from cancer-related psychological problems, generalized anxiety disorder, depression, and other psychiatric symptoms. The authors report the following results: mindfulness-based therapy had on average a strong, positive effect on anxiety and mood symptoms in all of the studies included in the meta-analysis. Large effects were measured in patients with anxiety and mood disorders as their primary diagnoses, and these effects remained when measured at (on average) 12-week follow-ups.
A recent meta-analysis by Khoury et al. (2013) reviewed 209 studies with a total of 12,145 participants engaging in mindfulness-based therapy (MBT) for various psychological problems. The results indicated that MBT had a medium effect size overall. MBT was not found to be more effective than cognitive-behavioral therapy. However, MBT showed large and clinically relevant effects in treating anxiety and depression, and these effects were maintained at follow-up measurement. Additionally, MBT had fewer dropouts compared to cognitive-behavioral therapy, which suggests greater motivation among MBT participants.
A full description of the effects of mindfulness with all possible disorders lies beyond the scope of this chapter. An up-to-date overview of virtually all relevant studies can be found on the website http://www.mindfulexperience.org. The Mindfulness Research Guide on this website is a comprehensive electronic resource and publication database that provides information to researchers, practitioners, and the general public on the scientific study of mindfulness, including a database of research publications in the area of mindfulness, measurement tools to operationalize mindfulness, interventions incorporating mindfulness techniques, and universities and centers conducting mindfulness research.
In sum, research findings to date support mindfulness-based interventions as an effective supplement to existing treatment methods.
A number of questionnaires have been developed toward the study of specific aspects of mindfulness and for the assessment of mindfulness-enhancing exercises. At present there are at least seven different questionnaires for measuring mindfulness, of which the most prominent are listed below. The Mindfulness Attention and Awareness Scale (MAAS; Brown & Ryan, 2003) is a self-report questionnaire designed to measure an individual’s capacity for maintaining attention and resisting distraction. The Toronto Mindfulness Scale (TMS; Bishop, 2004) is administered directly after meditation and measures attention to internal stimuli and responsiveness. The Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004) measures four factors: observing, describing, acting with awareness, and accepting without judgment. The Freiburg Mindfulness Inventory (FMI; Buchheld, Grossman, & Walach, 2011) measures awareness of the present moment, nonjudging acceptance of self and others, openness to negative mental states, and insight.
Although there is consensus among researchers regarding the two most important factors of mindfulness (attention and an accepting attitude), it remains debated how these factors can be measured reliably. For research on the psychometric qualities of various mindfulness-questionnaires, refer to Baer, Smith, Hopkins, Krietemeyer, and Toney (2006).
Baer et al. (2006) investigated the structure of the mindfulness construct on the basis of five recently developed questionnaires. They conclude that there are five facets to mindfulness: describing, acting with awareness, nonjudging, nonreactivity, and observing. Describing is the labeling of experience using words. Acting with awareness means performing actions with active attention. Nonjudging is the absence of positive or negative commentary on thoughts and feelings. Nonreactivity is the permitting of feelings and thoughts without responding to them on automatic pilot. Observing entails remaining conscious of experiences, even when unpleasant or painful. Acceptance is regarded as a result, rather than a facet of mindfulness. Acceptance of anxiety, for instance, develops under the conditions of nonjudging and the absence of impulsive, anxiety-based reactions.
Items in the instruments examined by Baer et al. which best measured the five facets of mindfulness were combined to form the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006). According to the authors, this questionnaire is internally and conceptually consistent with the elements of mindfulness as described in published literature. The FFMQ’s ability to separately measure distinct facets of mindfulness lends itself to research investigating the determinants of positive psychological change in mindfulness-based interventions (Baer, 2010). Empirical research on the different facets of mindfulness is also beneficial because of the clear, intelligible descriptions it produces, which make it easier to explain mindfulness to patients.
Scientific research into the functional mechanisms behind mindfulness is fairly recent. A detailed discussion of various explanatory models is provided by Baer (2010), who lists mindfulness, decentering, psychological flexibility, values, emotion regulation, self-compassion, spirituality, brain change, and changes in attention and working memory as relevant factors.
In addition to the above, there are three other significant explanatory models: Interacting Cognitive Subsystems (ICS) theory, the Buddhist Psychological Model (BPM) of mindfulness, and therapeutic empathy.
The developers of MBCT (Teasdale et al., 1995) offer an explanation for the effects of mindfulness that is based on the information-processing model of Interacting Cognitive Subsystems (ICS). The model is predicated on multi-layered memory systems, in which all incoming stimuli, internal and external, are encoded in two ways: propositional (“knowing that…”) and implicational (“feeling that…”). Propositional memory storage contains cognitions that can be expressed and understood linguistically. Implicational storage is more broad and can take the form of emotional experiences not directly expressible in language. At the implicational level, rational-based interventions like psychoeducation and the challenging of irrational thought become ineffectual. An oft-heard difficulty is that patients know what it is they should do, but that their feelings compel them to do otherwise. Rather than relying on verbal meaning attributions at the propositional level, mindfulness interventions emphasize working with emotions at the implicational level (Baert, Goeleven, & Raedt, 2006).
Grabovac, Lau, and Willet (2011) have introduced an interesting conceptualization of mindfulness based on the Buddhist Psychological Model (BPM). The BPM is a stepwise description of the way in which our habitual reactions—that is, attachment to pleasant feelings and rejection of unpleasant feelings—lead to suffering. The stream of subjective experience is actually a rapid sequence of sensory impressions, feelings, and thoughts of which we are mostly unconscious. Each experience carries an immediate, spontaneous “feeling tone,” which can be neutral, pleasant, or unpleasant, and which precedes all emotions, such as fear or anger, and their associated behavior. This process can be short-circuited in two ways: through mindfulness training and through insight. Increased mindfulness allows one to recognize dysfunctional processes more quickly, disengage attention from performing habitual emotional reactions, and focus on goal-driven behavior. Insight occurs when, through direct experience, one becomes aware of the three most fundamental attributes of existence, which are present throughout all experience: impermanence, suffering, and not-self.
According to the BPM, the immediate, tangible, and repeated experience of these three interrelated qualities of existence leads to alleviation of psychological problems and improved psychological functioning. In the Buddhist tradition this eventually culminates in spiritual enlightenment.
The last few decades have seen an increased emphasis on protocol-based treatment, evidence-based medicine, and randomized clinical trials, all predicated on the assumption that the effectiveness of a treatment is fully or primarily afforded by specific therapeutic or psychopharmacological interventions. However, meta-analyses (e.g., Lambert & Barley, 2002; Wampold, 2001) have increasingly indicated that the effectiveness of therapy is due only in part to specific therapeutic techniques. Although many interventions seem relevant—or even crucial—in the treatment of particular disorders (e.g., exposure and response prevention for obsessive-compulsive disorder), their specific effects tend to be overestimated. The degree of influence of factors determining therapeutic success is estimated as follows: 15% therapeutic techniques, 40% extraneous factors (life situation, job, relationship, etc.), 15% placebo effects (positive expectations, faith), and 30% the therapeutic alliance and the therapist’s personal qualities (Lambert & Barley 2001). The most positive features reported by patients when describing their interaction with therapists are empathic capacity, warmth, understanding, and acceptance, along with the absence of criticism, neglect, and rejection. These positive aspects are encapsulated in the term empathy. Empathy is an innate potential and a skill that can be developed.
Davidson et al. (2003) found that mindfulness meditation gave rise to brain activation in areas associated with compassion. Grepmair et al. (2007), using SCL-90 and other measures, evaluated the results of treatment provided by therapists in training, and found that therapists who meditated scored significantly higher than the nonmeditating control group. According to Lutz, Slagter, Dunne, and Davidson (2008), heightened awareness of one’s bodily sensations and reactions is associated with increased empathy. A number of authors, such as Fulton (2005, 2008), hold that a therapist’s practice of mindfulness meditation cultivates not only empathy but other components of the therapeutic alliance as well. Benefits include increased attention in therapy, higher tolerance of patient emotions, greater acceptance, and a more open attitude.
The diversity of explanatory models of mindfulness complicates matters for practitioners and patients. There is a practical need for a straightforward explanatory model that is clear and compatible with existing knowledge about psychological interventions. An explanation on the basis of attention and emotion regulation satisfies these criteria.
Attentional processes are in almost all cases pivotal in the processing of information and typically precede other types of processes in the brain. Dysfunctional attentional processes play a sizable role in many psychiatric conditions. How this works in anxiety and depression is described by Koster, Baert, and De Raedt (2006). People with a biological predisposition to anxiety disorders are excessively alert, which leads to: (a) elevated distractability in general; (b) increased scanning of the environment for threatening information; (c) selective attention to threatening information; (d) a broad field of attention prior to threat detection; (e) narrowed attention subsequent to threat detection. These attentional biases result in the world being experienced as an unsafe place. Moreover, such biases restrict attentional access to information that may contradict anxious expectations.
Similarly dysfunctional attentional processes play a role in depression. Information that confirms a somber outlook is more likely to be selected, negative memories are more likely to arise, and less attention is allocated to positive information. People with depression tend to place insufficient attention on positive experiences (McCabe & Toman, 2000), and people in somber moods are less likely to shift attention away from negative information than normal controls. In contrast, positive emotions correlate with more broad and open attention (Fredrickson, 2004). Changes in the range of attention are linked to behavior change: broad and distributed attention corresponds to approach behavior, and narrowed attention to avoidance behavior (Förster, Friedman, Özelsel, & Denzler, 2006, Förster & Higgins, 2005).
For most people, attention is something you either have—to whatever degree—or you don’t. It is something to be directed (active attention) or followed (passive attention). Yet attention is a complex phenomenon that has been studied by psychologists for over a hundred years. There are, in fact, several overlapping forms of attention: focused, sustained, selective, and divided attention. Training these capacities serves to enhance meta-awareness.
These distinct attentional processes are inherently tied to the control and maintenance of desired behavior.
Training the aforementioned attentional processes serves to enhance meta-awareness. This is also referred to as metacognitive awareness, which relates specifically to cognition: knowing what one is thinking. The term meta-awareness, however, encompasses awareness of all that is experienced through thought and the senses. Meta-awareness means acting on manual pilot, rather than automatic pilot. Myriad terms have been put forward to identify this metaposition in the literature: disidentification, neutral observer, reperceiving, decentering, defusion, distancing, and impartial spectator (Smalley & Winston, 2010). Various studies support the notion that mindfulness works in part due to the augmentation of meta-awareness (Carmody, 2009; Hargus, Crane, Barnhofer, & Williams 2010; Rapgay, Bystritsky, Dafter, & Spearman, 2011; Teasdale et al., 1995, 2000).
The brain responds to external and internal stimuli in different ways. One way is known as bottom-up (or stimulus-driven attention) in which the flow of attention is directed by stimulus features, such as when an unexpected sound or pain automatically and involuntarily draws our attention. The other way is top-down, also known as goal-driven or executive attention, which is controlled by the individual. The bottom-up processes involve areas of the brain that are, in evolutionary terms, as old as the brainstem. Top-down attention involves control mechanisms associated with newer areas of the brain, such as the frontal cortex (Posner & Petersen, 1990; Posner & Rothbart, 1998).
Top-down processes are also linked to working memory, which functions optimally when the “noise” surrounding stimuli, such as emotions, is effectively regulated. Working memory is a limited-capacity system that, in order to operate efficiently, relies on the filtering of nonrelevant information, thereby allowing new information into the system. Working memory is enhanced by mindfulness (Chiesa, Calati, & Serretti, 2011) and thus improves the ability to handle emotions.
Onraedt, Koster, Geraerts, de Lissnyder, and de Raedt (2011) pose that dysfunctional working memory processes form a risk factor for depression. Difficulties ignoring and eliminating negative information from working memory keep people with depression stuck in a vicious cycle of negative thoughts and emotions. Training attention, particularly selective and divided attention, is therefore of particular significance. Siegle, Ghinassi, and Thase (2007) found support for the benefits of training working memory in people with depression. There has also been research on optimal working memory loads in the treatment of post-traumatic stress disorder (PTSD). Mindful breathing and eye movements (Eye Movement Desensitization and Reprocessing; EMDR) while focusing on unpleasant thoughts, images, or bodily sensations, both resulted in similar reductions in the immediacy and emotional impact of negative experiences (Van den Hout et al., 2010).
Sustained mindfulness training allows one to better understand, recognize, and regulate one’s attentional processes. This helps to gradually diminish one’s tendency to automatically attend to and identify with particular thoughts or feelings, and frees up more attention and energy for a broader spectrum of experiences which would otherwise go unnoticed. Through repeated practice, this can become habit (Carmody, Baer, Lykins, & Olendzki, 2009).
Emotion plays a pivotal role in virtually all mental disorders. Emotions are complex phenomena comprising cognition, physiological responses, and behaviors associated with internal and external stimuli. They provide crucial information about internal and external events, motivate our actions, and communicate information to others. Emotion regulation is the process by which we influence which feelings we want to experience and when, how we experience them, and how they are expressed.
Recent perspectives on mental disorder, particularly Transdiagnostic Theory and Acceptance and Commitment Therapy, assume that emotion dysregulation lies at the core of all psychopathology (Farchione et al., 2012; Hayes, Wilson, Gifford, Follette, & Strosahl 1996; Watson, 2005). Regardless of the nature of their intense negative emotions, patients habitually tend to rely on the same dysfunctional strategies, such as avoidance, repression, and rumination. Although these have some effect in the short term, they exacerbate conditions in the long term. This offers an explanation for comorbodity as well as the fact that treatment effects can generalize from one disorder to another (Barlow et al., 2011).
Mindfulness-based interventions differ from standard cognitive-behavioral therapies and other treatment models in a very important way: Rather than attempting to change emotions and/or thought content, mindfulness entails tolerance. Meditation teaches one to notice distractions but not to engage them. As emotions represent the most challenging form of distraction, mindfulness involves continual confrontation with unpleasant feelings in the body and thoughts in the mind. Furthermore, heightened awareness also leads to greater insight into information regarding underlying factors (i.e., emotional awareness), such as the causes of emotions and their connection to unpleasant memories of past experience. In other words, mindfulness works like exposure. Goleman (1988) therefore refers to the result of mindfulness as “global desensitization.” MBCT includes specific mindfulness exercises focusing on emotions, such as the Working with Difficulty Meditation (Segal et al., 2013).
Support for emotional regulation as the most significant functional mechanism in mindfulness can be found in Chambers, Gullone, and Allen (2009), Hill and Updegraff (2012), Rapgay et al. (2011, 2013), and Treanor (2011). Chiesa, Serretti, and Jakobsen (2013) offer a detailed description of structures and processes in the brain that are associated with mindfulness-based emotion regulation. Some researchers consider mindfulness a top-down process, while others consider it a bottom-up emotion regulation strategy. The hypothesis best supported by brain research is that, for beginning meditators, the benefits of mindfulness occur through top-down regulation from the prefrontal context to the limbic system. As meditators become more experienced, bottom-up processes acquire a greater role. Although there is a gradual shift from top-down to bottom-up processes, each continues to serve an important role in emotion regulation (Chiesa et al., 2013).
The fact that mindfulness works because it trains attention and emotion regulation provides a useful rationale for both practitioners and patients. It can be easily explained to patients using everyday examples or problematic events from the patient’s own lived experience. Emotional problems always involve some activating event, followed by unpleasant or painful feelings, which then result in a critical response: “This is uncomfortable,” “I don’t want this,” “this needs to stop.” This in turn leads to countermeasures, such as particular modes of thinking and behaving, which are intended to resolve unpleasant bodily sensations and thoughts.
Mindfulness training enables one to recognize this pattern sooner and to maintain goal-driven attention without impulsive or automatic reactions. One learns to observe one’s actions and situations as if from a distance, which provides not only insight but also the room and freedom to respond in different, more appropriate ways. Mindfulness training also develops one’s ability to recognize distractions and let them go. As emotions are the most challenging of distractions, meditation provides a continuous learning process through which one acquires the flexibility to deal with problematic thoughts and bodily sensations. The combined training of attention and emotion regulation leads to a reduction of psychiatric symptoms and to improved health.