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Current Tensions and Challenges in Mindfulness Research and Practice

Current Tensions and Challenges in Mindfulness Research and Practice The field of mindfulness practice and research has expanded over recent years and become more established in the public consciousness. In this paper we explore four key tensions for the mindfulness community to hold in awareness. These include: Mindfulness for me vs. mindfulness for others (an awareness of the loss of the spiritual and collective elements historically essential to mindfulness), Mindfulness for some vs. mindfulness for all (understanding why mindfulness may be more appealing for some more than others), The whole vs. the sum of its parts (the need to understand the mechanisms of mindfulness and still preserve its integrity), and Improving access vs. preserving fidelity (balancing modifications to address issues such as accessibility with retaining core components). Recognising such challenges is a vital aspect of ensuring that mindfulness researchers and practitioners continue to work in a way that retains authenticity and trust within this burgeoning field and helps to support engagement from a diverse range of people across the modern world. Keywords Mindfulness · Meditation · Wellbeing · Compassion · Community The purported benefits of mindfulness, in terms of reducing Tensions suffering, increasing connection, and cultivating compas - sion have never been more important. We are living through Mindfulness for Me vs. Mindfulness for Others difficult times: climate and biodiversity crises, violent con - flict, rising costs of living, and a global pandemic. Whilst In pursuing a “secular” contemporary mindfulness practice not all nations have been exposed to all these challenges in the West, much of its broader context (spiritual, philo- to the same degree, as awareness about these global threats sophical, cultural) has been lost. It tends to be offered as a grows, so does universal concern and distress. Key to mak- clinical treatment for symptom reduction or enhancement of ing ongoing progress in terms of mindfulness being able to individual well-being. This is in distinct contrast to the his- meet some of these challenges will be the ability to bring torical origins of mindfulness, in which it was one compo- curiosity and compassion to current areas of tension in the nent of a set of contemplative practices based within a clear field. With this in mind, we present several areas of tension ethical framework and practised collectively (Van Gordon in this paper, to inform thinking and development in these & Shonin, 2020). A tension arises when contemporary areas for those in the mindfulness community and beyond. mindfulness is applied in a way that focuses solely upon benefits to the individual practitioner, rather than the com - munal benefits of practitioners in a group or community. Mindfulness was traditionally practised in community All authors are equal first authors, with order of names determined by alphabetical order. (sangha), with dedication to developing awareness, har- mony, loving-kindness, and acceptance, to transform and Tom A. Jenkins heal both the self and society (Hanh, 2002). When learn- tj260@bath.ac.uk ing Mindfulness Based Interventions (MBIs) within a group Bath Centre for Mindfulness and Community, University of setting, connections and a sense of safety can be facilitated Bath, Bath BA2 2AY, UK (Cormack et al., 2018). A meta-synthesis of qualitative stud- School of Psychology, University of Southampton, ies of Mindfulness-based Cognitive Therapy (MBCT) has Southampton SO17 1PS, UK 1 3 Journal of Contemporary Psychotherapy shown that a supportive group is experienced as helpful others. This can be balanced through supportive commu- and therapeutic (Cairns & Murray, 2015), since participant nity, cultivating self-care, recognising care from others, and experiences of distress were validated and normalised by being realistic about what differences can be made by an recognition of a shared experience. The group setting also individual. helped increase participants’ determination and motivation and contributed to the cultivation of their relationships, both Mindfulness for Some vs. Mindfulness for All within the group and in their personal lives. It is possible, therefore, that such benefits are lost when mindfulness is The idea of trying out a mindfulness course is more appeal- largely practiced at an individual, rather than community, ing to some people than others. Even for those who actively level. seek out mindfulness, or accept the invitation when it is In today’s world, we urgently need significant social offered, people vary in the degree to which they engage transformation to adapt to global challenges like the climate with regular practice and derive benefit from it (Crane et al., and related crises. This includes developing community 2014; Montero-Marin et al., 2022). engagement, becoming more attuned to relevant local and In a randomised controlled trial of MBCT for depres- global issues, building emotional resilience, and enhanc- sion, Crane and colleagues (2014) collected data on partici- ing our motivation to care for, and protect, other beings. pant’s frequency of home practice. They found a significant Research shows that mindfulness may be positively associ- association between amount of home practice and treat- ated with prosocial behaviours, across both correlational and ment outcome, in that people who practised mindfulness intervention studies (Donald et al., 2019). For example, the at home three or more days a week were significantly less results of a systematic review support the notion that MBIs likely to experience a relapse in depression, compared with increase empathy, compassion and pro-social behaviour those who practised less than three days a week. Our work (Luberto et al., 2018). In particular, MBIs led to a significant has shown benefits of mindfulness at follow-up rather than improvement in at least one pro-social outcome in 22 out directly following intervention (e.g., Atkinson & Wade of the 26 randomised controlled trials (RCTs). Examples of 2015), likely a consequence of continued practice and such pro-social outcomes include making a charitable dona- opportunity for application. These clearly show the benefit tion or giving up one’s seat for an injured person. In addi- of regular engagement with mindfulness, but despite recom- tion, MBIs that are practiced within an ethical framework mendations to practise daily, people do not always choose (such as highlighting notions of no-harm and interdepen- to do so. dence of all beings) have led to greater pro-social behaviour This leads to many questions regarding who is attracted when compared to practicing secular mindfulness (Chen & to mindfulness, what prevents or supports engagement, Jordan, 2020). Pro-social behaviours may also be positively what makes regular practice challenging, and what factors associated with mindfulness practice that involves aspects are associated with greater benefits. Understanding such dif - of loving-kindness or compassion (Perkins et al., 2022). ferences could lead to optimization of mindfulness for cer- Such findings could be extended into other mindfulness- tain groups and cautions us from assuming that ‘one size’ of based approaches including building communities of prac- mindfulness fits all. tice and cultivating ‘noble’ states of being (loving-kindness, Individual differences may play an important role in how compassion, appreciative joy, and equanimity). Emerging people engage with and benefit from mindfulness. Prefer - evidence supports these ideas; the cultivation of apprecia- ence for type of mindfulness practise has been found to be tive joy demonstrates benefit to self and others (Casioppo, predicted by trait mindfulness, empathy, and gender ((Tang 2020), which underpins environmentally-focused thera- & Braver, 2020a), which can predict therapeutic outcomes peutic approaches such as Active Hope (Macy & John- ((Tang & Braver, 2020b) and attrition (Anderson & Farb, stone, 2022). Furthermore, second generation MBIs which 2018) in mindfulness interventions. Furthermore, individual incorporate teachings on impermanence, interconnection differences in cognitive functioning, personality and emo - and ‘non self’ offer great potential (Van Gordon & Shonin, tion regulation have all been associated with mindfulness 2020). Emphasising interconnection between self and the training outcomes ((Tang & Braver, 2020b). Early experi- world could increase our empathy and compassion (Hick mental work within our group indicated negative affect, & Furlotte, 2009). Extending this to the more-than-human emotion regulation difficulty, and avoidant coping predicted (e.g., biospheric beliefs), could support adaptation to cli- sub-optimal engagement in brief mindfulness intervention, mate change (Helm et al., 2018). but also moderated intervention effects on negative affect Practising mindfulness ‘for others’ may also bring chal- (Atkinson & Wade, 2012). lenges. This may include feeling distressed, overwhelmed, In a secondary analysis of data from pupils in the MYR- or excessively responsible for alleviating the suffering of IAD School-Based Mindfulness trial Montero-Marin et al. 1 3 Journal of Contemporary Psychotherapy (2022) found adverse effects for those deemed as being at towards internal experiences in the context of reducing risk greater risk for mental health difficulties. A sub-group of factors for disordered eating (Osborne & Atkinson, 2022). participants who were deemed ‘high risk’ of struggling with Evaluating the degree to which individual components mental health problems in the intervention group scored contribute to change is essential to justify their inclusion more highly on depression scores than the same sub-group in effective, multicomponent interventions. Yet, the extent in the teaching as usual control group. Furthermore, they to which individual components interact with each other found adolescents responded less well than hypothesised within a complex intervention and a real-world system is to the mindfulness intervention, perhaps due to lesser currently unclear. This is particularly important given the metacognitive awareness at this key developmental phase. importance of non-specific therapy effects and the wide- Research therefore highlights that whilst mindfulness train- ranging nature of current mindfulness intervention delivery ing can be safe and effective, there are differences between modalities from in-person, group delivery (McKenna et al., heterogenous groups of people, and training must reflect 2017) to digital, individual access (Ainsworth et al., 2022). these specific needs. Such considerations should lead us to robustly define the Conversely to views on the appropriateness of mindful- targeted aspect of each research study. These efforts are ness for non-clinical population, it has long been posited made particularly difficult by the multitude of (sometimes that mindfulness should be contraindicated in people expe- competing) definitions of mindfulness itself (Van Dam et riencing psychotic symptoms, due to concerns it could exac- al., 2018). erbate their difficulties. However, it has since been shown Defining what is being studied is a starting point that that with appropriate adaptations, mindfulness for psychosis informs other aspects of research design, including opera- can be delivered safely and effectively (Böge et al., 2021; tionalisation of the targeted aspect and the selection of a López-Navarro et al., 2022). Practises are modified with suitable control group. Researchers can choose passive con- briefer 5–10 min meditations; frequent guidance avoid- trol groups (e.g., wait-list controls, treatment as usual) or ing prolonged periods of silence; and addressing psychotic active control groups (i.e., alternative intervention designed symptoms, along with other sensations in a normalising not to impact the targeted aspect such as sham mindfulness manner (Chadwick, 2014; Jacobsen et al., 2020). Careful or an attention-matched control; Au et al., 2020). No choice consideration of the needs of different populations can thus of control group is ever perfect and in pragmatic trials of promote mental wellbeing and broaden the reach of mind- complex mindfulness-based interventions, it may be dif- fulness from some to all. ficult to disentangle effects of the intervention from other Cultural considerations are also important, as engage- non-specific effects. ment with mindfulness has been found to be associated with There are challenges in translating findings from con - certain demographic characteristics, with people from some trolled experiments, focused on specific aspects of mind - groups being underrepresented. In the United States, for fulness, into understanding and applying mindfulness in example, women, white adults, and employed adults have complex interventions in real-world settings. Mindfulness been found to be most likely to engage in mindfulness prac- is a complex construct involving a range of elements, such tise (Simonsson et al., 2020). Factors such as language dif- as attention training, embodiment of key principles by a ferences, religious beliefs and mistrust in service-providers well-trained teacher (e.g. non-reactivity), and attitudinal could act as significant barriers to engaging with mindful - qualities of friendliness and curiosity. MBIs also require ness. These barriers can be addressed in part by using partic- significant commitment from the individual and repeated ipatory research and community involvement in developing practice often in the face of adversity. Such complexity, and mindfulness-based interventions that are more culturally the interaction effects between these elements will neces - appropriate (Remskar et al., 2022; Watson-Singleton et al., sarily be lost within controlled lab-based experiments and 2019). component studies, and with this we may risk losing a sense of the ‘whole’ of mindfulness by reducing it to the ‘sum of The Whole vs. The Sum of its Parts its parts’. Since the development and implementation of mindfulness- Improving Access vs. Preserving Fidelity based interventions, there have been attempts to understand the active components of mindfulness, through experimen- There is always an implementation gap in healthcare tal work and dismantling trials (Stein & Witkiewitz, 2020). between interventions with an established evidence base in Researchers have used experimental methodologies to the research literature, and reliable access to them in rou- examine specific cognitive mechanisms, such as our work tine services. For example, MBCT for depression is now in comparing decentred versus non-judgemental stances recommended in the National Institute for health and Care 1 3 Journal of Contemporary Psychotherapy Excellence (NICE; UK) guidelines. However, access to than fully committed, intensive in-person practice. An anal- mindfulness in mental health settings remains limited, and ogy might be trying to learn to swim by simply looking at a greater roll-out of mindfulness therapies requires extra swimming pool rather than getting in the water. Neverthe- investment in staff training and buy-in from commission - less, it is important to appreciate the unique upsides digi- ers and service leads (Rycroft-Malone et al., 2019). In tal self-guided mindfulness approaches offer (most notably their mixed methods framework analysis, Rycroft-Malone the improved accessibility and reduced perceived barriers and colleagues discuss a range of factors which contribute to engagement; Lyzwinski et al., 2018), and integrate them towards this gap in MBCT for depression. Financial con- into the selection of evidence-based resources on offer, if we straints may limit access to training, support, and facili- are to meet the needs of the broadest possible pool of practi- ties, leaving service managers understandably hesitant to tioners. A tension therefore arises between reducing barriers compromise the quality of the MBCT offering, yet unwill - to access to mindfulness, whilst retaining safeguards which ing to give the go-ahead to a reduced package that is not ensure ‘proper use’ of mindfulness practices so that people empirically supported. The atmosphere of services may be can still benefit from them. juxtaposed with the equanimity of mindfulness practises, meaning that sessions can sometimes feel at odds with their environment. Furthermore, mindfulness training can often Conclusions rely on the enthusiasm of a teacher or ‘champion’ within the service, who may be making a significant personal or finan - The so-called ‘hype cycle’ is a well-known way of under- cial investment in facilitating the set up of groups. In ser- standing how new ‘technologies’ are regarded over time, vices where this champion is not present, mindfulness may with initial success and enthusiasm leading to a ‘peak of not be effectively rolled out. Whilst closing this implemen - inflated expectation’, often quickly followed by a ‘trough tation gap is a key priority, a tension often arises between of disillusionment’. It is up for debate where we currently increasing access whilst ensuring fidelity in delivery, so that are in this hype cycle in relation to mindfulness; however, the basis on which an intervention is evidence based is still there are indications that the initial peak of enthusiasm is valid. over. There is a growing backlash from some quarters in For example, the proliferation of mindfulness apps (both terms of criticisms of the overselling and overapplication free and for a subscription fee) means that people can easily of mindfulness. Furthermore, there are many challenges access mindfulness apps via their smartphones outside of whenever anything quickly grows in popularity, including a formal therapy or group (Schultchen et al., 2021). This misunderstandings of the aims, applications, and theoreti- can bring many benefits, particularly for people who may cal underpinnings of the approach. Likewise, people setting not have the time or resources to attend individual or group themselves up as mindfulness teachers with limited training therapy, or where it is not on offer locally. It increases the may lack the required skills, competencies, and supervision geographic reach of mindfulness for those living in remote to safely and effectively guide others to learn mindfulness. or under-served areas and increases flexibility for people This may lead to people having unhelpful or simply fruitless in terms of when and how often they practise mindfulness. experiences of trying mindfulness, which adds to the chorus This is particularly important for people with complex of criticism that it has been oversold. health needs, disabilities, or caring responsibilities. Maintaining the integrity of mindfulness requires clarity However, accessing mindfulness meditations using a and a systematic approach to research and practice across purely self-guided approach can also be challenging. For the mindfulness community (Crane et al., 2017). Part of this example, practitioners miss out on the communal aspects requires us to recognise various tensions and outstanding and shared experience of being in a group. Furthermore, questions in the field, encouraging us to move in a produc - apps do not offer the opportunity for learning through tive direction. In this way, our knowledge about for whom teacher-led enquiry after each experiential practice. The role and in what contexts mindfulness ‘works’ may be advanced. of the teacher is complex and multi-faceted, for example In time, this will allow us to climb out of the trough of dis- the concept of ‘embodiment’ of the attitudinal qualities of illusionment into the slope of enlightenment, reaching an mindfulness (e.g., non-reactivity). Likewise, the lack of a eventual plateau, where the view is clearer. group and teacher means reduced accountability mecha- Funding No funding was received to assist with the preparation of nisms, making it more likely that audio tracks could be this manuscript. used as a ‘background’ activity (e.g., something to be ‘lis- tened’ to passively whilst doing the washing up or walking Declarations the dog), rather than as active skills practice. Such reduced or passive engagement would likely lead to lesser effects Compliance with ethical standards The manuscript does not contain 1 3 Journal of Contemporary Psychotherapy clinical studies or patient data. Chadwick, P. (2014). Mindfulness for psychosis. The British Jour- nal of Psychiatry, 204(5), 333–334. https://doi.org/10.1192/bjp. bp.113.136044 Conflict of Interest The authors declare that they have no conflict of Chen, S., & Jordan, C. H. (2020). Incorporating Ethics into brief interest. The authors have no relevant financial or non-financial inter - mindfulness practice: Effects on Well-Being and Prosocial ests to disclose. Behavior. Mindfulness, 11(1), 18–29. https://doi.org/10.1007/ s12671-018-0915-2 Consent to participate The manuscript did not involve data collection Cormack, D., Jones, F. W., & Maltby, M. (2018). A “collective effort from participants. to make yourself feel better”: The group process in mindful- ness-based interventions. Qualitative health research, 28(1), Consent to publish The manuscript did not involve data collection 3–15.Qualitative health research, 28(1), 3–15. https://doi. from participants. org/10.1177/104973231773344 Crane, C., Crane, R. S., Eames, C., Fennell, M. J. V., Silverton, S., Open Access This article is licensed under a Creative Commons Williams, J. M. G., & Barnhofer, T. (2014). 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Abstract

The field of mindfulness practice and research has expanded over recent years and become more established in the public consciousness. In this paper we explore four key tensions for the mindfulness community to hold in awareness. These include: Mindfulness for me vs. mindfulness for others (an awareness of the loss of the spiritual and collective elements historically essential to mindfulness), Mindfulness for some vs. mindfulness for all (understanding why mindfulness may be more appealing for some more than others), The whole vs. the sum of its parts (the need to understand the mechanisms of mindfulness and still preserve its integrity), and Improving access vs. preserving fidelity (balancing modifications to address issues such as accessibility with retaining core components). Recognising such challenges is a vital aspect of ensuring that mindfulness researchers and practitioners continue to work in a way that retains authenticity and trust within this burgeoning field and helps to support engagement from a diverse range of people across the modern world. Keywords Mindfulness · Meditation · Wellbeing · Compassion · Community The purported benefits of mindfulness, in terms of reducing Tensions suffering, increasing connection, and cultivating compas - sion have never been more important. We are living through Mindfulness for Me vs. Mindfulness for Others difficult times: climate and biodiversity crises, violent con - flict, rising costs of living, and a global pandemic. Whilst In pursuing a “secular” contemporary mindfulness practice not all nations have been exposed to all these challenges in the West, much of its broader context (spiritual, philo- to the same degree, as awareness about these global threats sophical, cultural) has been lost. It tends to be offered as a grows, so does universal concern and distress. Key to mak- clinical treatment for symptom reduction or enhancement of ing ongoing progress in terms of mindfulness being able to individual well-being. This is in distinct contrast to the his- meet some of these challenges will be the ability to bring torical origins of mindfulness, in which it was one compo- curiosity and compassion to current areas of tension in the nent of a set of contemplative practices based within a clear field. With this in mind, we present several areas of tension ethical framework and practised collectively (Van Gordon in this paper, to inform thinking and development in these & Shonin, 2020). A tension arises when contemporary areas for those in the mindfulness community and beyond. mindfulness is applied in a way that focuses solely upon benefits to the individual practitioner, rather than the com - munal benefits of practitioners in a group or community. Mindfulness was traditionally practised in community All authors are equal first authors, with order of names determined by alphabetical order. (sangha), with dedication to developing awareness, har- mony, loving-kindness, and acceptance, to transform and Tom A. Jenkins heal both the self and society (Hanh, 2002). When learn- tj260@bath.ac.uk ing Mindfulness Based Interventions (MBIs) within a group Bath Centre for Mindfulness and Community, University of setting, connections and a sense of safety can be facilitated Bath, Bath BA2 2AY, UK (Cormack et al., 2018). A meta-synthesis of qualitative stud- School of Psychology, University of Southampton, ies of Mindfulness-based Cognitive Therapy (MBCT) has Southampton SO17 1PS, UK 1 3 Journal of Contemporary Psychotherapy shown that a supportive group is experienced as helpful others. This can be balanced through supportive commu- and therapeutic (Cairns & Murray, 2015), since participant nity, cultivating self-care, recognising care from others, and experiences of distress were validated and normalised by being realistic about what differences can be made by an recognition of a shared experience. The group setting also individual. helped increase participants’ determination and motivation and contributed to the cultivation of their relationships, both Mindfulness for Some vs. Mindfulness for All within the group and in their personal lives. It is possible, therefore, that such benefits are lost when mindfulness is The idea of trying out a mindfulness course is more appeal- largely practiced at an individual, rather than community, ing to some people than others. Even for those who actively level. seek out mindfulness, or accept the invitation when it is In today’s world, we urgently need significant social offered, people vary in the degree to which they engage transformation to adapt to global challenges like the climate with regular practice and derive benefit from it (Crane et al., and related crises. This includes developing community 2014; Montero-Marin et al., 2022). engagement, becoming more attuned to relevant local and In a randomised controlled trial of MBCT for depres- global issues, building emotional resilience, and enhanc- sion, Crane and colleagues (2014) collected data on partici- ing our motivation to care for, and protect, other beings. pant’s frequency of home practice. They found a significant Research shows that mindfulness may be positively associ- association between amount of home practice and treat- ated with prosocial behaviours, across both correlational and ment outcome, in that people who practised mindfulness intervention studies (Donald et al., 2019). For example, the at home three or more days a week were significantly less results of a systematic review support the notion that MBIs likely to experience a relapse in depression, compared with increase empathy, compassion and pro-social behaviour those who practised less than three days a week. Our work (Luberto et al., 2018). In particular, MBIs led to a significant has shown benefits of mindfulness at follow-up rather than improvement in at least one pro-social outcome in 22 out directly following intervention (e.g., Atkinson & Wade of the 26 randomised controlled trials (RCTs). Examples of 2015), likely a consequence of continued practice and such pro-social outcomes include making a charitable dona- opportunity for application. These clearly show the benefit tion or giving up one’s seat for an injured person. In addi- of regular engagement with mindfulness, but despite recom- tion, MBIs that are practiced within an ethical framework mendations to practise daily, people do not always choose (such as highlighting notions of no-harm and interdepen- to do so. dence of all beings) have led to greater pro-social behaviour This leads to many questions regarding who is attracted when compared to practicing secular mindfulness (Chen & to mindfulness, what prevents or supports engagement, Jordan, 2020). Pro-social behaviours may also be positively what makes regular practice challenging, and what factors associated with mindfulness practice that involves aspects are associated with greater benefits. Understanding such dif - of loving-kindness or compassion (Perkins et al., 2022). ferences could lead to optimization of mindfulness for cer- Such findings could be extended into other mindfulness- tain groups and cautions us from assuming that ‘one size’ of based approaches including building communities of prac- mindfulness fits all. tice and cultivating ‘noble’ states of being (loving-kindness, Individual differences may play an important role in how compassion, appreciative joy, and equanimity). Emerging people engage with and benefit from mindfulness. Prefer - evidence supports these ideas; the cultivation of apprecia- ence for type of mindfulness practise has been found to be tive joy demonstrates benefit to self and others (Casioppo, predicted by trait mindfulness, empathy, and gender ((Tang 2020), which underpins environmentally-focused thera- & Braver, 2020a), which can predict therapeutic outcomes peutic approaches such as Active Hope (Macy & John- ((Tang & Braver, 2020b) and attrition (Anderson & Farb, stone, 2022). Furthermore, second generation MBIs which 2018) in mindfulness interventions. Furthermore, individual incorporate teachings on impermanence, interconnection differences in cognitive functioning, personality and emo - and ‘non self’ offer great potential (Van Gordon & Shonin, tion regulation have all been associated with mindfulness 2020). Emphasising interconnection between self and the training outcomes ((Tang & Braver, 2020b). Early experi- world could increase our empathy and compassion (Hick mental work within our group indicated negative affect, & Furlotte, 2009). Extending this to the more-than-human emotion regulation difficulty, and avoidant coping predicted (e.g., biospheric beliefs), could support adaptation to cli- sub-optimal engagement in brief mindfulness intervention, mate change (Helm et al., 2018). but also moderated intervention effects on negative affect Practising mindfulness ‘for others’ may also bring chal- (Atkinson & Wade, 2012). lenges. This may include feeling distressed, overwhelmed, In a secondary analysis of data from pupils in the MYR- or excessively responsible for alleviating the suffering of IAD School-Based Mindfulness trial Montero-Marin et al. 1 3 Journal of Contemporary Psychotherapy (2022) found adverse effects for those deemed as being at towards internal experiences in the context of reducing risk greater risk for mental health difficulties. A sub-group of factors for disordered eating (Osborne & Atkinson, 2022). participants who were deemed ‘high risk’ of struggling with Evaluating the degree to which individual components mental health problems in the intervention group scored contribute to change is essential to justify their inclusion more highly on depression scores than the same sub-group in effective, multicomponent interventions. Yet, the extent in the teaching as usual control group. Furthermore, they to which individual components interact with each other found adolescents responded less well than hypothesised within a complex intervention and a real-world system is to the mindfulness intervention, perhaps due to lesser currently unclear. This is particularly important given the metacognitive awareness at this key developmental phase. importance of non-specific therapy effects and the wide- Research therefore highlights that whilst mindfulness train- ranging nature of current mindfulness intervention delivery ing can be safe and effective, there are differences between modalities from in-person, group delivery (McKenna et al., heterogenous groups of people, and training must reflect 2017) to digital, individual access (Ainsworth et al., 2022). these specific needs. Such considerations should lead us to robustly define the Conversely to views on the appropriateness of mindful- targeted aspect of each research study. These efforts are ness for non-clinical population, it has long been posited made particularly difficult by the multitude of (sometimes that mindfulness should be contraindicated in people expe- competing) definitions of mindfulness itself (Van Dam et riencing psychotic symptoms, due to concerns it could exac- al., 2018). erbate their difficulties. However, it has since been shown Defining what is being studied is a starting point that that with appropriate adaptations, mindfulness for psychosis informs other aspects of research design, including opera- can be delivered safely and effectively (Böge et al., 2021; tionalisation of the targeted aspect and the selection of a López-Navarro et al., 2022). Practises are modified with suitable control group. Researchers can choose passive con- briefer 5–10 min meditations; frequent guidance avoid- trol groups (e.g., wait-list controls, treatment as usual) or ing prolonged periods of silence; and addressing psychotic active control groups (i.e., alternative intervention designed symptoms, along with other sensations in a normalising not to impact the targeted aspect such as sham mindfulness manner (Chadwick, 2014; Jacobsen et al., 2020). Careful or an attention-matched control; Au et al., 2020). No choice consideration of the needs of different populations can thus of control group is ever perfect and in pragmatic trials of promote mental wellbeing and broaden the reach of mind- complex mindfulness-based interventions, it may be dif- fulness from some to all. ficult to disentangle effects of the intervention from other Cultural considerations are also important, as engage- non-specific effects. ment with mindfulness has been found to be associated with There are challenges in translating findings from con - certain demographic characteristics, with people from some trolled experiments, focused on specific aspects of mind - groups being underrepresented. In the United States, for fulness, into understanding and applying mindfulness in example, women, white adults, and employed adults have complex interventions in real-world settings. Mindfulness been found to be most likely to engage in mindfulness prac- is a complex construct involving a range of elements, such tise (Simonsson et al., 2020). Factors such as language dif- as attention training, embodiment of key principles by a ferences, religious beliefs and mistrust in service-providers well-trained teacher (e.g. non-reactivity), and attitudinal could act as significant barriers to engaging with mindful - qualities of friendliness and curiosity. MBIs also require ness. These barriers can be addressed in part by using partic- significant commitment from the individual and repeated ipatory research and community involvement in developing practice often in the face of adversity. Such complexity, and mindfulness-based interventions that are more culturally the interaction effects between these elements will neces - appropriate (Remskar et al., 2022; Watson-Singleton et al., sarily be lost within controlled lab-based experiments and 2019). component studies, and with this we may risk losing a sense of the ‘whole’ of mindfulness by reducing it to the ‘sum of The Whole vs. The Sum of its Parts its parts’. Since the development and implementation of mindfulness- Improving Access vs. Preserving Fidelity based interventions, there have been attempts to understand the active components of mindfulness, through experimen- There is always an implementation gap in healthcare tal work and dismantling trials (Stein & Witkiewitz, 2020). between interventions with an established evidence base in Researchers have used experimental methodologies to the research literature, and reliable access to them in rou- examine specific cognitive mechanisms, such as our work tine services. For example, MBCT for depression is now in comparing decentred versus non-judgemental stances recommended in the National Institute for health and Care 1 3 Journal of Contemporary Psychotherapy Excellence (NICE; UK) guidelines. However, access to than fully committed, intensive in-person practice. An anal- mindfulness in mental health settings remains limited, and ogy might be trying to learn to swim by simply looking at a greater roll-out of mindfulness therapies requires extra swimming pool rather than getting in the water. Neverthe- investment in staff training and buy-in from commission - less, it is important to appreciate the unique upsides digi- ers and service leads (Rycroft-Malone et al., 2019). In tal self-guided mindfulness approaches offer (most notably their mixed methods framework analysis, Rycroft-Malone the improved accessibility and reduced perceived barriers and colleagues discuss a range of factors which contribute to engagement; Lyzwinski et al., 2018), and integrate them towards this gap in MBCT for depression. Financial con- into the selection of evidence-based resources on offer, if we straints may limit access to training, support, and facili- are to meet the needs of the broadest possible pool of practi- ties, leaving service managers understandably hesitant to tioners. A tension therefore arises between reducing barriers compromise the quality of the MBCT offering, yet unwill - to access to mindfulness, whilst retaining safeguards which ing to give the go-ahead to a reduced package that is not ensure ‘proper use’ of mindfulness practices so that people empirically supported. The atmosphere of services may be can still benefit from them. juxtaposed with the equanimity of mindfulness practises, meaning that sessions can sometimes feel at odds with their environment. Furthermore, mindfulness training can often Conclusions rely on the enthusiasm of a teacher or ‘champion’ within the service, who may be making a significant personal or finan - The so-called ‘hype cycle’ is a well-known way of under- cial investment in facilitating the set up of groups. In ser- standing how new ‘technologies’ are regarded over time, vices where this champion is not present, mindfulness may with initial success and enthusiasm leading to a ‘peak of not be effectively rolled out. Whilst closing this implemen - inflated expectation’, often quickly followed by a ‘trough tation gap is a key priority, a tension often arises between of disillusionment’. It is up for debate where we currently increasing access whilst ensuring fidelity in delivery, so that are in this hype cycle in relation to mindfulness; however, the basis on which an intervention is evidence based is still there are indications that the initial peak of enthusiasm is valid. over. There is a growing backlash from some quarters in For example, the proliferation of mindfulness apps (both terms of criticisms of the overselling and overapplication free and for a subscription fee) means that people can easily of mindfulness. Furthermore, there are many challenges access mindfulness apps via their smartphones outside of whenever anything quickly grows in popularity, including a formal therapy or group (Schultchen et al., 2021). This misunderstandings of the aims, applications, and theoreti- can bring many benefits, particularly for people who may cal underpinnings of the approach. Likewise, people setting not have the time or resources to attend individual or group themselves up as mindfulness teachers with limited training therapy, or where it is not on offer locally. It increases the may lack the required skills, competencies, and supervision geographic reach of mindfulness for those living in remote to safely and effectively guide others to learn mindfulness. or under-served areas and increases flexibility for people This may lead to people having unhelpful or simply fruitless in terms of when and how often they practise mindfulness. experiences of trying mindfulness, which adds to the chorus This is particularly important for people with complex of criticism that it has been oversold. health needs, disabilities, or caring responsibilities. Maintaining the integrity of mindfulness requires clarity However, accessing mindfulness meditations using a and a systematic approach to research and practice across purely self-guided approach can also be challenging. For the mindfulness community (Crane et al., 2017). Part of this example, practitioners miss out on the communal aspects requires us to recognise various tensions and outstanding and shared experience of being in a group. Furthermore, questions in the field, encouraging us to move in a produc - apps do not offer the opportunity for learning through tive direction. In this way, our knowledge about for whom teacher-led enquiry after each experiential practice. The role and in what contexts mindfulness ‘works’ may be advanced. of the teacher is complex and multi-faceted, for example In time, this will allow us to climb out of the trough of dis- the concept of ‘embodiment’ of the attitudinal qualities of illusionment into the slope of enlightenment, reaching an mindfulness (e.g., non-reactivity). Likewise, the lack of a eventual plateau, where the view is clearer. group and teacher means reduced accountability mecha- Funding No funding was received to assist with the preparation of nisms, making it more likely that audio tracks could be this manuscript. used as a ‘background’ activity (e.g., something to be ‘lis- tened’ to passively whilst doing the washing up or walking Declarations the dog), rather than as active skills practice. Such reduced or passive engagement would likely lead to lesser effects Compliance with ethical standards The manuscript does not contain 1 3 Journal of Contemporary Psychotherapy clinical studies or patient data. Chadwick, P. (2014). Mindfulness for psychosis. The British Jour- nal of Psychiatry, 204(5), 333–334. https://doi.org/10.1192/bjp. bp.113.136044 Conflict of Interest The authors declare that they have no conflict of Chen, S., & Jordan, C. H. (2020). Incorporating Ethics into brief interest. The authors have no relevant financial or non-financial inter - mindfulness practice: Effects on Well-Being and Prosocial ests to disclose. Behavior. Mindfulness, 11(1), 18–29. https://doi.org/10.1007/ s12671-018-0915-2 Consent to participate The manuscript did not involve data collection Cormack, D., Jones, F. W., & Maltby, M. (2018). A “collective effort from participants. to make yourself feel better”: The group process in mindful- ness-based interventions. Qualitative health research, 28(1), Consent to publish The manuscript did not involve data collection 3–15.Qualitative health research, 28(1), 3–15. https://doi. from participants. org/10.1177/104973231773344 Crane, C., Crane, R. S., Eames, C., Fennell, M. J. V., Silverton, S., Open Access This article is licensed under a Creative Commons Williams, J. M. G., & Barnhofer, T. (2014). 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Journal of Contemporary PsychotherapySpringer Journals

Published: Dec 1, 2023

Keywords: Mindfulness; Meditation; Wellbeing; Compassion; Community

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