In the spring of 1979, on Day 10 of a two-week meditation retreat,1 the then-34-year-old Jon Kabat-Zinn, a long-term practitioner of yoga and meditation, had “a vision” (his own words), which lasted for about “10 seconds.” In that vision, he saw what he later called his “karmic assignment”: a model for how to share the essence of meditation and yoga practices (an essence he labeled mindfulness) through hospitals and medical centers and clinics across the world—”a practical path to liberation from suffering.”
Kabat-Zinn’s 10-second vision was the humble beginning of the mindfulness-based stress reduction (MBSR) program, implemented first at the Pain Clinic (now the Center for Mindfulness) at the University of Massachusetts Medical School. Since 1979, more than 20,000 people have participated in MBSR programs; the U-Mass database contains more than 480 mindfulness-based health practitioners; a 2007 government survey found that more than 20 million Americans used meditation (often considered to be the tool that leads to mindfulness) for health reasons; and the mindfulness industry was estimated to be worth $4.2 billion in 2009 in the United States alone.2 Some—notably Time Magazine on its January 2014 cover—have called this “the Mindful Revolution.”3
There are plenty of books on mindfulness too. A casual search on Amazon brings up titles suitable for every area of life4: Mindful Work, The Mindful Way through Depression, The Mindful Way through Stress, The Mindful Way through Anxiety, Mindful Eating (there are at least eight different books with that title), The Mindful Diet, The Mindful Athlete, The Mindful Therapist, The Mindful Couple, which—we hope—experiences Mindful Loving (two titles) and The Joy of Mindful Sex, which results in The Mindful Mom-to-Be, Mindful Birthing, and Mindful Parenting (at least four titles), during which they can read their offspring the book Mindful Monkey, Happy Panda. Perhaps my favorite among those tomes is the Color Me Mindful series—a set of mindful coloring books for adults. It’s not hard to find curious commercial aberrations either: One condiment producer sells MindfulMayo® (dairy-free; “Dollop, mix and smear your way to spread-happy euphoria”); the Budhagirl [sic] jewelry line offers mindful glamour (“Turn the routine of getting dressed in the morning into the ritual of presence”), complete with a scientific explanation for why these bracelets work.
Since 2013, mindfulness aficionados even have their own popular magazine—Mindful, which comes with a board of advisors that includes academics from the University of Virginia, Duke University, Penn State, the University of Wisconsin, and UCLA; the director of executive development at Google is on this board as well. Since 2010, it even has its own high-impact5 scientific journal—Mindfulness—printed by the venerable Springer publishing house. Typing in the keyword “mindfulness” in my university’s library’s database of scientific articles produced no less than 50,330 hits. (In case you were wondering—No, I did not read all those papers.)
Big business then, but also serious business.
And, judging from the titles of those books, a concept with wide applicability and a lot of promises.
What is this mindfulness thing? Does it deliver?
Let’s start with the first question: What is mindfulness? The definition of mindfulness that seems to resonate most within the movement—just typing in the whole definition into Google resulted in 15,400 hits—is one that Kabat-Zinn coined, almost in passing, in the first pages of his 1994 book Wherever You Go, There You Are: Mindfulness is “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.”6
Maybe an example will help to show what is meant by this. The author of that 2014 Time Magazine’s cover story, Kate Pickert, opens her article with a description of a popular beginner’s mindfulness exercise—how to eat a raisin7 mindfully:
The raisins sitting in my sweaty palm are getting stickier by the minute. They don’t look particularly appealing, but when instructed by my teacher, I take one in my fingers and examine it. I notice that the raisin’s skin glistens. Looking closer, I see a small indentation where it once hung from the vine. Eventually, I place the raisin in my mouth and roll the wrinkly little shape over and over with my tongue, feeling its texture. After a while, I push it up against my teeth and slice it open. Then, finally, I chew—very slowly. I’m eating a raisin. But for the first time in my life, I’m doing it differently. I’m doing it mindfully.
Ms. Pickert is eating the raisin, and while she does so, she is paying attention to its visual appearance, its texture, the sensations of its skin bursting open under the pressure of her teeth, the tiny explosion of taste enveloping her mouth, the muscle contractions of swallowing, the aromatic lingerings. She pays attention to this on purpose—unlike most of the time when we snack and just pop the food into our mouths, she pays attention to every step of the process, deliberately slowing everything down. She does this in the present moment—this is all that fills her awareness—she is not doing anything else, and she lets no memories of raisins past or hankerings for (or maybe fears of) raisins future disrupt her communion with only and precisely this raisin, right here, right now. Finally, she does this nonjudgmentally—she is not comparing the raisin with any other raisin, or any other food, and she is not letting herself be swayed by likes or dislikes for the raisin’s appearance, texture, or taste; Ms. Pickert just is with the raisin. Put yourself in her place. When you are eating a raisin mindfully, there are just two things in the universe: you and the raisin. Maybe there is just one, actually: you—seeing, touching, chewing, tasting, swallowing.
In a very simple way, we can define mindfulness as actually being present in/for whatever it is you are doing, without letting your judging mind (Is this good or bad? Do I like or dislike this?) interfere. If you are listening to Bach, just listen to Bach; if you are dancing to Girl Talk, just dance to Girl Talk; if you are cooking, just cook; if you are sweeping, sweep. To be fully present. That is mindfulness.
This does not mean that every moment of your life should be lived nonjudgmentally in the present moment. Stuff needs to get done, so you need to plan; you might want to revisit that fight with your spouse to see how you can do better next time; and—on a grander scale—social or personal change isn’t possible without a critical eye filled with wisdom. What mindfulness teachers are saying is that it is good to have mindfulness as a tool in your toolbox, to be used when appropriate or opportune. Part of life’s wisdom is figuring out—that is judgment, or discernment, right there—what that appropriate or opportune moment is, and noticing when you have missed it. And then, nonjudgmentally, remind yourself not to miss it next time.
Why be mindful?
One simple and smartly selfish answer is that being present in the moment is associated with happiness, and happiness is one of those things most living beings are quite interested in. You can see this on a small scale: actually tasting a good piece of chocolate or a nice mouthful of wine, actually getting an earful of your favorite music, with full concentration, makes you enjoy it (or maybe even life) even more.
Let’s widen this up a bit. In a groundbreaking but very simple study, Matt Killingsworth and Dan Gilbert8 had more than 2,000 people from 83 different countries download an app on their iPhones. The app beeped people at random times during the day, asking them three questions: “How are you feeling right now?” (on a sliding scale from 0 [very bad] to 100[ very good]), “What are you doing right now?” (pick one or more from a list of 22 activities), and “Are you thinking about something other than what you’re currently doing?” (no; yes, something pleasant; yes, something neutral; yes, something unpleasant).
A first finding was that, generally speaking and as you would expect, some activities made people quite happy (in descending order of happiness: making love, exercising, talking, listening to music, and taking a walk), while others not so much (in descending order of unhappiness: sleep or rest—maybe because the beeps woke you up?—working, being at your home computer, commuting, and grooming). Another finding was that people’s minds wandered a lot: On average, people were not with the task 47% of the time. Unexpectedly, the activity people were doing did not have much bearing on whether their mind wandered or not (the one exception was making love—people like to be present for that).
Perhaps unsurprisingly, when people were daydreaming, their mind most often strayed to pleasant topics (42% of the time). You might be tempted to think they were doing this to escape the unhappiness of their present circumstances, but the interesting finding was that people were no happier thinking about pleasant topics than they were when they were simply present with their current activity. And, even more important, how people were feeling was much more related to their level of mindfulness than to the actual activity they were supposed to be engaged in. As the authors state it: “People were less happy when their minds were wandering than when they were not, and this was true during all activities, including the least enjoyable.” It really feels better to just be there.
In general, then, a mindful mind—or at least a mind that is present for the experience it is having—is a happy mind. (Killingsworth and Gilbert—in what may have been a moment of absent-mindedness—titled their paper with the negative conclusion: A Wandering Mind Is an Unhappy Mind.)
This paper raises an important question: If a mindful mind is a happy mind, why aren’t we simply mindful all the time?9 Why do we naturally stray away from this most rudimentary, uncomplicated form of happiness?
The simple answer is that we don’t know why we do that. In the next chapter, I discuss the finding that our mind, when asked to be at ease, does nothing of the sort but instead becomes restless and flits from association to association. Buddhist teachers call this “monkey mind”—just like a monkey swings from one branch to the next, lets go, then grabs another branch, lets go again and grasps for another branch, and so on,10 our minds tend to just go with whatever mental flow is flowing. It’s human. It’s what we do. In fact, we have a whole network of the brain—the default-mode network—dedicated to just that: to daydream or mind wander (or, as neuroscientists like to call it, “to engage in task-unrelated thought,” or—my favorite—“mental time travel”). But why that is, what deeper evolutionary origins can explain our mental restlessness, is an open question. I would assume—but I don’t know—that part of our restlessness has helped us, as a species, with survival: We’re forever pondering our mistakes so we don’t need to repeat them, and we’re forever wondering what lies behind the next hill, so that we actually get going, out into the world.
A quick look around you will teach you that people differ greatly in their ability to be in the moment. Psychologists have called this ability “trait mindfulness”11; in the past decade or so, quite a number of questionnaires have been designed to tap this quality.12 Typical questions to measure trait mindfulness are: “I watch my feelings without getting lost in them,” “When I take a shower or bath, I stay alert to the sensations of water on my body,” “I pay attention to how my emotions affect my thoughts and behavior,” “In difficult situations, I can pause without immediately reacting,” “I am aware of what thoughts are passing through my mind,” “When I do things, I get totally wrapped up in them and don’t think about anything else,” or the opposite of “I rush through activities without being really attentive to them,” and “I break or spill things because of being careless, not paying attention, or thinking of something else.”13
Kabat-Zinn’s insight was that although mindfulness may be a trait—a knack that certain people possess and others don’t—it is also very much a skill that can be learned, and thus taught, and that acquiring it would be very useful in people’s daily life. For Kabat-Zinn “useful” means what Killingsworth and Gilbert showed—that being mindful can make us happier or, in Kabat-Zinn’s more Buddhist terms, that mindfulness can relieve suffering; that is, it can make you feel less stressed, less anxious, less depressed, more open, more content, more joyful.
This is not a new or original idea. Kabat-Zinn’s work can be read—in fact he does so himself14—as an adaptation of Buddhist principles and techniques to modern Western concerns. Pickert sees this as a first example of smart marketing on Kabat-Zinn’s part (we’ll get to the second one in the next section): He avoids any talk of spirituality, which would be off-putting to many, but emphasizes that mindful attention is like a muscle—it can be trained. The goal is not to reach some nirvana but to become a little more present, a little less stressed, a little happier—a small, modest, gradual form of awakening: awakening to what you have been missing, to who you are, and to what life is all about.
How do you train your mind to do this?
Kabat-Zinn was not naïve; by the time he had his vision, he was exquisitely proficient in quite a number of contemplative techniques. He had been practicing Zen for 13 years; he was a yoga teacher; he had been director of the Cambridge Zen Center; he was a teacher-in-training under the Korean Zen Master Seung Sahn. He had also been extensively trained within the Theravāda tradition15—he was in fact attending a Theravāda retreat at the Insight Meditation Society in Barre, Massachusetts, when inspiration struck. All these traditions rely extensively on meditation as a tool to gain mindfulness, and when Kabat-Zinn started to build his own program, he freely borrowed techniques from each of those traditions.
Except for yoga, all of these traditions trace themselves back to the historical Buddha—teachings that are about 2,500 years old. One of the techniques the Buddha taught extensively16 was to build a foundation of mindfulness by becoming aware of, first, the body, in particular the breath and the posture; second, of sensations and feelings; third, of the current state of awareness; and, finally, of that what is held in awareness. In the Buddhist tradition, a steady focus on the breath—merely observing, without intervening, while suspending both your judgment and your potential urge to conceptualize, and without reacting to whatever comes up in the mind in the process—has remained one of the prime teaching tools for basic meditation. Meditation is the laboratory, so to speak, in which you learn to develop mindfulness, first by observing it as it occurs (or rather, in the early stages, by observing the seething of its absence), then by deliberatively cultivating it.
Note that because MBSR and other such programs are derived from Buddhism, they have also inherited some of the lingo. To meditate is often called “to sit”; a meditation session itself can be called “a sit.” A meditator is sometimes called “a yogi.” What you do to foster your mindfulness is often called “the practice”; this term can also be applied more narrowly, so that meditating is also called “practicing.” I personally like this concept, because of its inherent double meaning in English—you practice mindfulness both like a musician practices the piano (if you’ve been meditating for a while, you know that there is definitely artistry involved, and no end in sight) and like a doctor practices medicine (with diligence, aplomb, and selflessness).
Typically, meditation practices that are derived from Buddhist traditions, at least as taught within the context of mindfulness training programs, fall into three categories or styles: focused-attention practices, open-monitoring (also called open-awareness, or choiceless-awareness) practices,17 and the heart practices. All three of these train or incorporate elements of mindfulness.
In focused-attention meditation, the meditator focuses (or tries to focus) his mind on a single object, unwaveringly and clearly. Often, especially for beginners, that object is the breath. You concentrate on a region of your body where it is easy for you to pick up the breath (the nostrils, the chest, the abdomen) and simply stay with it. This, it turns out, is hard: The mind starts to wander, sudden itches and twitches and aches pop up and vie for attention, sleepiness creeps in—all sorts of distraction or dullness appear. When that happens, you simply notice them and go calmly back to the breath—over and over again, without judging, without reacting. Sometimes, counting the breath helps—count each outbreath, up to 10, and then back to 1. If you notice you are getting distracted, start again at 1. See how far you get. (Not far. Not to 10.) The goal here is to calm the mind, and to teach it to stay a particular course for a period of time, thus practicing concentration and sustained attention. By doing focused-attention meditation you also learn to observe and monitor the mind, that is, to check for distractions and the absence of distractions. If all goes well, you ultimately learn to be where you are.
Another popular form of focused-attention meditation is the body scan.18 You go on a mental walk through your body, either head to toe or toe to head, and take a few seconds to stay with each body part and note the sensations that are present there—pressure, temperature, vibrations, itches, whatever the particular body part feels like at that moment.19 The body scan is often an easier practice for beginners because it is a bit more concrete, and the shifting of attention to different regions of the body gives you something more concrete to do.
In all forms of focused-attention meditation, distractions, emotions, memories, or projections will arise. The training consists in meeting those with calm, patience, and kindness and then returning to the object of concentration.
In open-monitoring meditation, you open up your awareness to whatever is present in experience, moment to moment, inside the mind. (In Zen, this is called “just sitting.”) An open-monitoring meditation typically starts with a few minutes of focused-attention practice to build concentration and calm; then you broaden your focus and wait for whatever arises to arise. The main idea is to make attention become effortless, so that whatever arises—an emotion, the hearing of a sound, a memory, a thought—is simply observed from a distance, like you would observe a cloud in the sky or a leaf on a stream, watching it float by without grasping. In some traditions, experiences are “noted”; that is, a simple label is attached to the moment-to-moment contents of awareness (“itch,” “memory,” “thinking,” “pleasant feeling,” “planning,” “thinking,” and so on). Along the way, you learn to cultivate “reflexive awareness,” that is, awareness that refers back on itself. Your mind bears witness to your mind.
The heart practices distinguish themselves not by the type of attention that is being cultivated but by the kind of attitude (toward oneself, toward others, toward life) they try to foster—an attitude of positivity, of warm approach, and of interpersonal wisdom. Two flavors have been popular.
The first, in essence a focused-attention practice, is loving-kindness meditation, or metta meditation (metta is the Pali word—Pali is the language of the earliest surviving Buddhist texts—that is translated as loving-kindness; it could also be translated as goodwill, benevolence, or befriending). In this type of meditation, you conjure up a visual image of a series of people, one at a time, and you stay with each of them for a few minutes. The series typically starts with yourself, then a friend, then a neutral person (someone you don’t know very well and have no particular feelings toward, maybe the mailman or your bus driver?), then a “difficult” person (someone you have a bit of a hard time with), then an ever-widening circle of people, ultimately encompassing the whole planet.20 As you stay with the mental image of those people, you repeat phrases of goodwill, directing them toward these people—phrases like “May you be happy; may you be safe; may you be free from harm; may you be at ease.” The ultimate goal here is to allow yourself to experience an open benevolence toward everyone you meet, including those people in your life you find difficult to deal with.
A second heart practice, based on the Tibetan tradition of lojong21 (which translates as “mind training”) is compassion training. This is a more analytical form of meditation—one in which you ponder rather than concentrate. Unlike loving-kindness practice, which is simply the same meditation repeated over and over again until things seep into (and then from) the heart, compassion training typically takes time, unfolding slowly, step by step. For instance, one such program, Cognitively Based Compassion Training,22 consists of six modules, each taking a week of guided meditations and reflections, moving from focused-attention and open-monitoring basics to reflecting on and cultivating impartiality, gaining appreciation of and affection for others, and generating the skill of empathy, to finally start opening the heart for engaged compassion.
Kabat-Zinn’s MBSR program23 stretches over eight weeks, with about three hours of class time once a week and a silent one-day retreat during the sixth week. Participants learn four “formal” meditation methods: (a) body scan meditation, (b) sitting meditation (with a mixture of focused-attention and open-monitoring techniques: mindfulness of breath, body, feelings, thoughts, and emotions, and choiceless awareness, as well as some loving-kindness meditation), (c) walking meditation (mindful walking with a focus on the breath, on the sensations in your body as your limbs move, and/or on the outer world), and (d) gentle yoga exercises to be performed mindfully. Informal techniques are added to this, including awareness of pleasant or unpleasant events during the day, awareness of breathing, and mindful awareness of daily activities (eating mindfully, drinking your coffee mindfully, brushing your teeth mindfully, and so on). Homework is 45 minutes of formal and 15 minutes of informal practice per day, six days a week. (As we will see later, the reality is slightly different; in practice, there are fewer contact hours, and participants tend to practice less than recommended.)
The success of the MBSR endeavor has inspired others to build similar programs with different emphases or with additions. A very successful twist is the mindfulness-based cognitive therapy program (MBCT), designed by Zindel Segal, Mark Williams, and John Teasdale.24 This program, which fuses MBSR with cognitive therapy, is intended for the treatment of depression; its explicit goal is to reduce relapse rates. It includes the same formal techniques as MBSR and adds an emphasis on acceptance, allowing, letting be, with explicit classes focusing on how you can recognize and let go of the downward spirals of thought (psychologist call these “rumination”) that often start or keep depression alive.
Other therapy-oriented mindfulness programs include dialectical behavior therapy (DBT),25 intended for people living with borderline personality disorders, and acceptance and commitment therapy (ACT).26 These do not include MBSR’s formal meditation exercises but work on mindfulness in daily life through the skills of observing, describing, and accepting. ACT explicitly encourages patients to develop an observing self that remains at a nonjudgmental distance from the thinking and feeling self—seeing your mere thoughts as mere thoughts and not taking them so personally (i.e., observing yourself thinking that you are a bad person as opposed to concluding that you are a bad person).
Finally, note that there is a recent wave of programs (notably the ReSource Project,27Compassion Cultivation Training,28 and the aforementioned CBCT) that have gone beyond traditional approaches to mindfulness to include an explicit ethical component. These programs are still mostly grounded in a basic training in mindfulness but have been designed to explicitly promote the skills of empathy and compassion.
There are, of course, countless other classes, courses, workshops, and self-help books that have introduced these or similar techniques to an ever widening audience.
This brings me to the second question I asked at the beginning of this chapter: “Does mindfulness deliver?”
This is the core question that this book tries to answer, and I will need all the remaining chapters in the book to do so.
Before I start this journey, I would like to briefly focus on a preparatory question: How can we find out if mindfulness delivers?
In her Time Magazine article, Pickert mentions a second smart marketing move on Kabat-Zinn’s part: He started explicitly studying the effects of mindfulness on people’s lives, more specifically on stress, psychological symptoms, and different aspects of well-being. Pickert formulates this perhaps a bit too much as a deliberate, shrewd move on Kabat-Zinn’s part; to me, the therapeutic and research community that has developed around mindfulness really seems to be driven by a sincerely felt, natural curiosity to find out what mindfulness does and does not do.
Since the time of MBSR’s inception, the scientific research endeavor has really taken off. There are now literally thousands of papers on how mindfulness affects the brain and mind—in a recent review paper, Madhav Goyal and colleagues29 retrieved an unbelievable 18,753 of those; an equally improbable 1,468 of those papers contained actual research (though only 47 of those met the most rigorous criteria, as we shall see in Chapter 7). The number of studies is also growing at an incredible clip—in 2006, 121 papers were published on the topic of mindfulness; in 2010, that number was 381; in 2012, there were 672; and in 2014, 1,004.30
This is a lot to read. It is certainly too much to comfortably keep up with.
This glut of studies has created its own problems; the biggest problem for anyone new to this field—whether observer or participant—is what to read, that is, where to begin and how to select.
One issue when trying to summarize a literature as vast as this is the possibility of bias. Researchers often come into this field with preconceived notions. Maybe they like the idea of mindfulness; maybe they’ve been closet meditators half their lives and now they finally see the day that meditation is taken seriously enough for research papers to be published in the highest-ranking journals. This bias may lead to some partiality, even if they’re not always aware of it.
The following quote from an interview with Willoughy Britton—one of the smartest and most successful researchers in this field—illustrates this conundrum well:
My first ten years of practice, when I was also a researcher, I was in that bright-faith phase of “Meditation can fix everything! Everybody should do it!” I wrote a mega-article, the precursor to my dissertation, on all of the neurological and biological concomitants to stress and depression. And then I cited all of the studies that suggested meditation could reverse those processes. And I submitted that mega-article to three different journals and it got rejected three times. It finally dawned on me that I was cherry-picking the data. I wasn’t actually being a scientist or doing a scientific review; I was writing a persuasive essay.31
This cherry picking also happens in the media. I am keeping my eyes open for this, and I often see mindfulness studies discussed on mainstream websites and news aggregators, and the news is invariably positive: Your local newspaper, the magazines you subscribe to, your news aggregator, the blogs you read—they all are much more likely to push a study that shows that meditation “works” than a study that shows it doesn’t. This may even just be for the simple reason that a study that doesn’t pan out doesn’t seem to be so newsworthy—positive results sell. When you read these sources, you will be slowly accumulating the impression that mindfulness is a cure-all and the ultimate route to happiness.32
There are two issues here. One is that these positive results are likely to stack, or sum, in your head. Imagine two studies. Study A finds that meditation helps you concentrate, but it doesn’t find any changes in stress. Study B finds that meditation destresses you, but it doesn’t find any changes in your ability to concentrate. Your favorite website will probably write up the first study under the headline: “Meditation Helps You Focus” and the second under the headline “Meditation Is a Mental Spa.” In your mind, meditation becomes a mental spa that helps you focus—you are stacking or summing the two findings. But the average of Study A and Study B on the ability to concentrate (one positive effect, one null effect) is not that meditation helps you concentrate—it’s that it “might” help you concentrate, or that it helps “a bit” with concentration, or, more precisely, that “one out of two studies shows that it helps with concentration.” The same goes true for stress: One study finds an effect, the other does not, and the one null finding should temper the enthusiasm generated by the one study that does find the effect. The issue is that the media tend to report only the positive results, not the negative results or the null result, and this risks creating a bias in the mind of the reader.
A second and related point is that reports in the media are more concerned with the presence of an effect (“Study X finds that …”) than with the size of the effect. But in research size does matter. For instance, imagine a study that finds that meditation does have an effect on stress. (It does, by the way—see Chapter 5.) But what does that mean? I would suspect that it almost never means that if you meditate long and hard enough, you will never ever experience stress in your life. (Even the Dalai Lama, by his own admission,33 feels anger from time to time.)
Let’s take a step back.
There are essentially two ways in which the effectiveness of a treatment—mindfulness training, for instance—can be evaluated: as progress (i.e., do people feel less stressed out after having gone through MBSR?) and by comparison to other treatments or no treatment (e.g., do people who meditate regularly complain less about stress than people who do not meditate?). We can quantify this effect in many ways; the statistic psychologists prefer is called the mean standardized difference. It tells you how many standard deviations (SDs) separate the two scores. For instance, an effect size of 1 SD for the first type of comparison (progress) would mean that, after training, the average participant has moved down one standard deviation on the stress distribution.34 An effect size of 1 SD for the second measure (comparison with nonmeditators) would mean that the average meditator is one standard deviation less stressed than all nonmeditators.
If you’ve ever taken statistics, this should mean something to you. If you have not, do not despair. There are other ways to gauge what a particular effect size means.
One method is to give a general ballpark estimate of what a given effect size means. In psychology, the convention is that an effect size of 0.2 SD is small, 0.5 is medium, 0.8 is large, and 1.3 is very large.35
Another is to benchmark. The effect of aspirin on your risk for myocardial infarction is about 0.0436 SD; the effect of bypass surgery on mortality is 0.15 SD; the effect of drug therapy for arthritis is 0.60 SD; the effect of psychotherapy is 0.85 SD.37 We can compare the effects of mindfulness to these benchmarks. One very large study of studies on all kinds of psychological, educational, and behavioral treatments found an average effect size of 0.47 SD (compared to other treatment or no treatment). This latter number may be a natural benchmark for mindfulness and meditation studies.
A third method, the measure I prefer, is statistical: If the effect size is X, we know participants are now doing better than Y percent of people. (For the statistics aficionados, you can read these out from a z score table; the effect size is the z score, and you look up the area under the curve.) If the progress effect size for MBSR is 1 SD, this would mean that, after MBSR, the average participant would be less stressed than 84% of people who haven’t yet gone through MBSR. In the meditator/nonmeditator comparison, this would mean that the average meditator would be less stressed than 84% of nonmeditators.
The reason to discuss effect size is that when researchers say they “find an effect” or a media outlet mentions that a study found that something “works”—or words to that effect—they do not mean to say that the effect size is large. They mean that a result is “statistically significant.” Statistically significant is a technical term; it implies that the researchers have followed the rules of probability theory to make the bet that the results of a study, as they are, are due to chance less than 5% of the time. Statisticians are more willing to take that bet if the effect size is large (for obvious reasons) or when more people are enrolled in the study. If you have, say, 20 people in your study, the results are more likely to be odd than if you have 2,000 participants. (A good analogy might be political polling. I wouldn’t trust a presidential poll that used 20 people; 2,000 sounds a lot better.) These odds are calculated using precise formulas. The upshot is that in very large studies, even small effects can become significant; in small studies, the effect needs be whoppingly large (that is not a technical term) to become significant. “Statistically significant”—translated in the media as “mindfulness works”—is thus a term that has a very specific, technical meaning and has little to do with what we normally mean by the term “significant”—something that is meaningful, or large, or useful. For meaningful, large, or useful, we need to look at the actual effect size, which tells us the strength of the effect.
I am forcing all this technical baggage on you for a reason. Looking at effect sizes is very helpful when it comes to combatting the type of bias Britton was talking about. To see if mindfulness has an effect on X, Y, or Z, you could carefully read all relevant papers (good luck with that!), keep track of all the results, and distill those into a summary. That is what is called a “subjective” or “narrative” review—basically, you present an overview of a field in the form of a story. This story will be filtered, by necessity, through your sensibilities.
The alternative is a “quantitative” or “objective” review, or (the term I use in this book) a “meta-analysis”—an analysis of analyses. In this type of review, you use statistics to pool the results from all studies on a particular topic. Say you want to know what the effect of mindfulness on stress is: You gather all relevant studies, you calculate the effect size for each of those studies, and you average across them all, giving larger weight to the larger studies. If all goes well, anyone who would do the analysis would come to the exact same final number and thus the exact same final conclusion. (That is what makes this type of review objective.) You can also pool brain activation across studies, as we shall see in the next chapter; this allows us to see what brain regions are activated during meditation across multiple studies.
Focusing on effect sizes, then, kills two birds with one stone.38 First, it allows us to cut through the unconscious bias we might have when exploring the vast amount of studies out there. Second, it gives us an indication of how strong the effects actually are and how they compare to other interventions. In other words, it tells us not just whether mindfulness delivers but also how much it delivers.
In consequence, my own bias in this book will be to gravitate toward existing meta-analyses as objective overviews of specific questions in the field. Here and there, when no meta-analysis yet exists, I conduct my own.39
The drawback of this method is that it paints effects with a broad brush: Details of particular studies get lost. Especially in the chapters on the effects of meditation on the brain, I add some of the detail back in—there are lots of studies that have yielded fascinating results using very innovative methods that are simply too interesting to not discuss. In the chapters on the effects of mindfulness on the mind—attention, well-being, stress, and psychological problems—my instincts were to stay a little closer to the meta-analyses and so to use that broader brush.
A final caveat: All the effects reported here (and, in fact, in all research papers) are effects at the group level. They tell us what to expect for the average meditator or the average participant in this or that mindfulness curriculum. Your own mileage may, and will, vary. Even if the effect size for stress would be 1 SD (spoiler alert: it is much smaller than that), that doesn’t mean that all participants experience the same effect. Some of them might become much more relaxed than that, some of them only a little bit more, and some of them might actually be more stressed out. Some of this is due to chance; sometimes there’s a reason for this. Even a very large effect size cannot guarantee a positive outcome for any single participant.
Now that we know what mindfulness is and have some idea of how we can glean its effectiveness from the literature, what can you expect from this book?
When I was an undergraduate, way back in the previous century, my professors talked about meditation as “altered consciousness”—just like your consciousness is altered when you are dreaming or after you’ve ingested certain drugs, meditation is an experience that is different from your usual walking around in the world. Depending on how you meditate, the outside world may fade away, for instance; your attention may drift in and out of focus; your body sense may change; you may even experience your self and your awareness in a different light. Chapter 2 investigates how meditation, as it happens in real time, impacts the body and brain. What changes occur in your physiology as you sit? What goes on inside your brain as you meditate? Chapter 3 looks more closely at individual studies that investigate how meditation impacts attention, body awareness, and the sense of self as expressed in the brain.
One very old adage in neuroscience is that what fires together wires together. That is, if you activate particular brain regions and the connections between them a lot, chances are that you will craft some lasting changes in these regions and their connections. Chapter 4 looks at the findings. Are meditators’ brains wired differently? Do particular regions grow in size? How long does it take for changes in brain structure to take hold? Do they last?
Chapters 5 through 7 examine how these changes play out in daily life, or at least as close to daily life as psychological measures typically get. Chapter 5 focuses on changes in attention; Chapter 6 discusses changes in stress, sleep, personality, and well-being; and Chapter 7 gives an overview of mindfulness as medicine; that is, it examines the effects of mindfulness programs that are used as therapeutic endeavors, mostly for anxiety, depression, and pain.
Chapter 8 is an attempt at bringing this all to a conclusion and to finally answer the question: Does mindfulness deliver?
I hope to provide more than a mere catalog of effects. First, I think it is truly essential to be on the lookout for convergence between different levels of results—does activation in specific brain regions as it occurs during meditation leave lasting changes in gray or white matter that in turn lead to transformations in behavior and psychology? In my mind, the story that is so often spun, namely that mindfulness is a valuable life tool, would be all the more convincing if all of its parts were to fit nicely together. Do they?
Second, the question of how or why mindfulness works is just as vital as the question of whether it works. (Of course, we need to first establish that it works before we can bother with the why.) Within MBSR, Kabat-Zinn talks about the “wise, discerning, embodied, and selfless aspects of awareness itself.”40 This formulation may sound New Age-ish, but it points to two crucial aspects of a developing meditation practice—the training of basic awareness, coupled with the flourishing of trait mindfulness. This description also—implicitly but importantly—points away from another possible explanation, popular in the 1970s, namely that all there is to meditation is a calming, relaxed, parasympathetic antistress response. The question here—to be tackled in Chapters 6 and 7—is to what extent we can explain changes in well-being or psychological symptoms through changes in these two aspects—increased trait mindfulness and more tightly focused and/or lingering sustained and/or more open attention.
Third, I’d like to point to what is still missing in the story. What is it we do not know but should? Where are the explanatory gaps? What are the questions that are open still?