The science of mindfulness, a process under construction
The Science Of Mindulness
Several articles published recently in specialized journals have highlighted the debate that exists within the scientific community about the tack of research on mindfulness and other forms of meditation. The controversy questions central issues not only for research in this area, but also for science in general. Perhaps, deep down, there is the process of strengthening a discipline, until now incipient, that is coming of age
“If you are a scientist, you should be your biggest critic. Do not believe in your ideas, prove them to yourself”. These were the words with which Jon Kabat-Zinn, one of the people who most strongly introduced mindfulness in the West, underlined in his last visit to Madrid [i] an issue that is at the center of the challenges and opportunities that faces a young science, which just began to take its first steps in the late 70s. The scientist, professor emeritus of Medicine at the University of Massachusetts, recalled one of his works [ii] in which he showed how people with psoriasis, and subjected to a treatment with ultraviolet light, cured four times faster if, in addition, they meditated. “In one way or another, through mechanisms that we do not know, we are talking about how the mind affects the expression of certain genes or how certain cells replicate. (…) If you are really skeptical, and I hope that most of you are, because I do not address believers or meditation fans, there are very important questions regarding these issues.”
At the time of the first interventions of eight weeks (the Mindfulness Based Stress Reduction or MBSR programs), the intention of the founders of the Stress Reduction Clinic of the Medical School of Massachusetts was to welcome “the people who were falling through the cracks of the health system” and “see what happened after eight weeks of training to exercise the ‘muscle’ of mindfulness”. The truth is that since then the scientific interest in the subject has been such that the number of specialized articles with the word “mindfulness” in its title has increased exponentially, and scientists from around the world try to unravel the mechanisms of the action and the clinical applications of the mindfulness based protocols.
We can’t forget, however, that this systematization of the meditative practice and what it implies (that is, the creation of protocols that can be replicable and, therefore, validated according to the scientific method) was taking its first steps less than 40 years ago, and that the largest increase in research in the field began just 10 years ago. Science, all of it, is a science in construction. An open process in which the real work is to explore reality and obtain approximations to the “truth” that, later, can be nuanced or completed. The science about mindfulness, in particular, is a young, emerging discipline and, therefore, in a moment of effervescence and delimitation of operational definitions, the most efficient methodology and the most effective protocols to be used in the therapeutic context.
Some recent research have put on the table a debate about how to increase the rigor in this area. What is fascinating about the issue is, precisely, to observe live the establishment of a branch of science that has passed, in less than 40 years, of scarcely existing to have a scientific corpus of more than 3,000 articles. Mindfulness began its journey at the United States, in one of the basements of the Faculty of Medicine of the University of Massachusetts. Recently, the field has got its own Division, the first of its kind. With the creation of this body, the need for long-term research for the development of more effective treatments is underlined. According to Judson Brewer, chief of Division of Mindfulness at the Center For Mindfulness (CFM-UMass) the new recalls when “a young man reaches the age of majority and leaves the family home [iii]”.
The wide dissemination of what the discipline has enjoyed in recent years has given rise to the idea that mindfulness is the “panacea”, and the truth is that this idea is as inaccurate as the opposite. In fact, it is possible that the practice of mindfulness is contraindicated in some cases, such as hypochondria. This is, precisely, one of the great challenges facing the science that studies mindfulness in particular and the mind-body disciplines in general: to define in which cases the benefits are greater and in which there can be adverse and even harmful effects, as well as which are the most effective protocols and how they should be transferred to the population.
One of the articles that has reflected on this issue is the so-called “Mind the Hype: A Critical Evaluation and Prescriptive Agenda for Research on Mindfulness and Meditation” [iv]. The article, written by a team that includes both neuroscientists and psychiatrists, psychologists and experts in Buddhist philosophy, most of them specialized in precisely this field, mindfulness and meditation, wants to be a call to a more rigorous research: a way of channeling a nascent discipline towards more effective, safer and more scientifically based mechanisms of action.
Its publication has led to a debate that shows that the discipline is at a turning point in which a greater consensus is needed on the methodology, the operational framework and the course to be followed. Next, we expose some of the points that this and other publications have put on the table.
Effectiveness: how much, how and for what
Numerous studies suggest that the practice of mindfulness can be beneficial in reducing anxiety, stress, chronic pain and mood improvement [v]. There is evidence that contemplative practices influence behavior and measurement of various physiological markers. It has also been shown to be effective in improving levels of well-being in healthy people. The question is that only 20% of the studies that have been done have been carried out in phase IIa, that is, with a control group on the waiting list, and even less (9%) have passed to Phase IIb which implies a comparison of the results with an active control group, thus discarding a possible placebo effect.
According to one of the co-authors of Mind the Hype, Julie Brefczynski-Lewis (Institute of Neuroscience WVU Rockefeller), programs based on mindfulness can have an efficacy similar to that of antidepressants such as Prozac. What happens, he explains [vi], is that “people who sign up for mindfulness are more likely to select themselves. In other words, they want to try mindfulness”. Therefore, “we do not know if it will have a significant benefit in those who are not so open to it and in other conditions”.
Along the same lines, another of the co-authors [vii], Marieke van Vugt, assistant professor in Cognitive Modeling at the Groningen University in the Netherlands, points out that “most of the studies do not have an active control group, so many of the ‘effects’ could actually be a placebo effect”. To this, Van Vugt adds: “I think that many of the quality problems come from the scarcity of funds available for this type of research in the first years. For example, I received a Varela Award in 2007 that allowed me to investigate the cognitive mechanisms of meditation, but I could not afford to have an active control group, and therefore we only used a passive control group”.
On the other hand, interventions based on mindfulness have an increasing diffusion, which could have repercussions on their quality. The effects can not be the same if the program includes eight weeks with 40-45 minutes of practice each day, than when there are four weeks with 20 minutes of practice. What, on the one hand, contributes to its diffusion, on the other hand, reduces the effectiveness of the intervention.
Richardson and Dahl [viii], in response to the “Mind the Hype” article, provide another approach to this discussion, namely that traditional contemplative practice was not conceived to treat the disease but, rather, as a way to contribute to the human flourishing and increase the well-being of people who do not have pathologies, but “only” experience the habitual and inherent difficulties of life. They also point out that the “dose” of practice required by clinical interventions is one of the most important issues to optimize its effectiveness and that it is an issue that requires, in fact, more research.
They also point out how mindfulness research has considered mainly one type of meditative practice - attention and awareness as the main focus in the learning process- while contemplative practices are varied and focused, rather than on the therapeutic process, in the broader context of the quest for optimal well-being or self-realization. Exercises such as interpersonal dialogue can constitute a form of self-inquiry, and body awareness practices or attention to everyday routines can be a way of cultivating qualities such as patience or kindness. In this sense, research in mindfulness has closed the focus of research and has left out different forms of mind training that are worth exploring.
Defining is delimiting
One of the problems that researchers address in the article “Mind the Hype” is the lack of consensus on the operational definition of mindfulness. It is a discussion more complex that it may seem at first sight. Let’s take as an example a common concept: intelligence. Everyone knows what this concept implies, at least as an idea. However, over time there have been considerable disagreements among researchers about which elements that construct includes and which do not. A question that is not banal because, according to what we understand by “intelligence”, some or other measurements will be made and even some people will be labeled as “more” or “less” intelligent (to know more about it, see Neisser et al. ., 1996 [ix]).
Therefore, the problem of the operational definition of certain particularly complex constructs is a question that affects other areas of science and on which research in general, and psychology and neuroscience in particular, must be especially alert (Davidson, Dahl, 2018).
In the same way it happens with mindfulness, a novel concept in our culture that we can’t simply match with what has usually been understood in the East, since the delimitation of concepts varies enormously even within the same culture or region, let alone from one to the other side of the world.
The most commonly cited definition of mindfulness alludes to the one given by Kabat-Zinn in 1990 [x] as the faculty of being intentionally aware of the present moment, without judgment. However, this operational framework, designed to disseminate the term in a very effective way, throws some questions that it would be convenient to have a consensus about in the field of research: is it necessary to differentiate more clearly, for its study, the meditative practice of the discrete state that an individual can experience day to day? Are traits such as being alert, decentering, opening, intention or proprioception included? How do we differentiate the emotional intention, that is, the fact of proposing to cultivate positive emotional states in practices such as loving kindness or compassion? What about body consciousness, intention, focus or openness? In short, what exactly do we measure when we want to conclude whether there is a greater or lesser degree of “mindfulness”? Consensus on these traits is crucial, researchers say, in order to draw parallels or elucidate underlying mechanisms.
The map (the answers) and the territory (the physical and behavioral)
In respect of the methodology, one of the issues that are attributed to research in this area is to base its results especially on the use of questionnaires. It is important to note that this issue affects not only the research in mindfulness but, rather, it is a trend that is also observed in other areas such as psychology and neuroscience. At the same time, precisely the fact that research in mindfulness is taking its first steps makes this a good time to strengthen the discipline through more research focused on the analysis of biomarkers and behavior, for example asking questions like, is a therapist more effective after training in mindfulness?
There are several problems derived from the use of questionnaires in the investigation. On the one hand, do the questionnaires reflect reality in a reliable way? Not necessarily. For example, and following the example of intelligence, the fact that someone says that he is now “smarter” than a few years ago does not mean that he actually is (and nor the other way around). This fact, by the way, implies inaccuracy, and not always overestimation of the effectiveness of mindfulness, since one of the effects of the practice that first arise is to become more aware of the moments of unconsciousness (and this is reflected in the questionnaires ).
On the other hand, and while it is true that the demand for research on mindfulness and the meditation based on the physical and behavioral is growing, at the same time it is necessary to improve the questionnaires used to increase their reliability in the measurement of this type of construction.
Adverse or harmful effects?
Until now, research on mindfulness has focused mainly on assessing possible therapeutic applications and investigating the underlying mechanisms. Although adverse effects have been recorded when they have been found in the course of the research, only less than 25% of the research in meditation has actively evaluated them.
There are guides that value and promote the safety of interventions based on mindfulness. For example, the official standards of the MBSR program exclude those with a history of suicide attempts or who present any psychiatric disorder (Santorelli, 2014 [xi]). There may be exceptional cases if the participant agrees to take a parallel medical treatment or if the instructor has clinical training in the care of people with that particular ailment.
The truth is that it has never been ignored that the contemplative path -and also other forms of personal change- includes traversing, on occasion, unpleasant or stressful episodes. In fact, the exposure to what the mind qualifies as “unpleasant” is precisely the way to acquire awareness about phenomena that at first do not want to see. The question, perhaps, would be not only if unpleasant or stressful episodes have been experienced, but rather, if the participant considers that this experience has been useful or, on the contrary, has been harmful in the medium term.
Different studies carried out to date indicate that the practice of mindfulness can have the same adverse effects as psychotherapy. Specifically, a research work carried out by Ausiàs Cebolla and Javier García Campayo, among others, and which has been published in the journal Plos One, has found that 25% of the participants in the study had experienced adverse effects, if well these were smooth and did not lead to the abandonment of practice [i]. In any case, it is important to go deeper into this question and, especially, to find out in which cases the damages can be greater than the benefits and how the former can be minimized.
The challenges of contemplative neuroscience
Increasingly, research on mindfulness participates of the great advances in neuroscience and, especially, functional magnetic resonance imaging (fMRI). This methodology has been crucial to better understand the functioning of the brain. It has allowed us to gaze into its interior and see it in action. However, the image is, again, only a map and in this case, not very precise. It does not represent the complexity of the phenomena, both biological and computational, that occur inside the mind. Sometimes, however, and in an attempt to transfer these discoveries to the general public, the results are simplified and certainty is expressed where what there is is a path of exploration.
On the other hand, the theoretical and statistical approaches yield results that, although they are significant, may not be of clinical importance. That is, although there is agreement among the scientific community that meditation produces certain changes in the brain, there is still no evidence of what the practical effects of this transformation are. It would be necessary, say the authors of the Mind the Hype, to transfer that complexity to other researchers as well as to communicators and the general public, making them participants of both the fascinating advances of neuroscience and the limitations of neuroimaging techniques.
There is also another issue that Francisco Varela already addressed [xii], and it is the problem of the study of the first person experience. The complexity of the psyche and the human organism is such that it becomes necessary to use new technological tools and mathematical methods such as, for example, graph theory and machine learning, capable of drawing the network of relationships between the different points or nodes of the nervous system and discern the effects that a change in one or several points of the mind-body system has on others.
Mobile technology: threat and opportunity
Interventions based on mindfulness are carried out more frequently through the Internet and mobile technology. The question is, can this use result in a greater loss of quality of the interventions or, on the contrary, it is a way of increasing the scope and, in this way, benefit more people and facilitate research through the study of interventions with large samples?
For Davidson and Dahl, it’s use is a necessary step “both for the dissemination (of the interventions) and for the evaluation of its impact”. In addition, it is useful in order to “solve some of the key methodological challenges in this area, including standardized teaching in all places and addressing individual differences (which will require studies with a large number of participants)”. This technology will allow, the researchers say, the collection of data on a large scale and, with it, answer questions still unanswered.
Van Dam et al., meanwhile, point out that, while it is true that the use of mobile technology in the field of mindfulness application and research is promising, there are still some outstanding problems, among which adaptation to the different individual rhythms in terms of the acquisition of trained skills and motivation, in addition to the fidelity and effectiveness of the intervention compared to face-to-face training.
Many of the challenges addressed by the science that studies mindfulness are common to other subjects that analyze issues as elusive as consciousness or intention. The debate continues, and the exciting thing about it is the fact of being witness of how a branch of emerging science builds itself from the contributions of all those involved, and for that reason it puts limits, direction and intention.
In the background, perhaps, there is an awareness of an area of research that, indeed, “grows”, which implies abandoning some structures, a certain “form”, to embrace another one more useful when addressing the challenges that arise at this time. Perhaps all this movement that is taking place in the science that studies contemplative practices is only the transformation of a discipline that is heading towards an incipient maturity.
[ii] Kabat-Zinn, J; Wheeler, E; Light, T; Skillings, A; Scharf, M; Cropley, T; Hosmer, D; Bernhard, J. D. Influence of a Mindfulness Meditation-Based Stress Reduction Intervention on Rates of Skin Clearing in Patients With Moderate to Severe Psoriasis Undergoing Photo Therapy (UVB) and Photochemotherapy (PUVA). (1998) Psychosomatic Medicine, 60 – 5, pp. 625-632.
[viii] Davidson, R. J., & Dahl, C. (ene 2018). Outstanding challenges in scientific research on mindfulness and meditation. Perspectives on Psychological Science, 13, 1, pp. 66-69.
[ix] Neisser Neisser, U., Boodoo, G., Bouchard, T. J., Boykin, A. W., Brody, N., Ceci, S. J., Halpern, D. F., Loehlin, J. C., Perloff, R., Sternberg, R. J., & Urbina, S. (1996). Intelligence: knowns and unknowns. American Psychologist, 51, 77–101.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain and illness.
[xi] Santorelli, S. (2014). Mindfulness-based stress reduction (MBSR): Standards of practice. Worcester, MA: Center for Mindfulness in Medicine, Health Care, and Society, University of Massachusetts Medical School.
[xii] Cebolla i Martí, AJ; Demarzo, M; Martins, P; Soler, J; García Campayo, J. “Unwanted effects: Is there a negative side of meditation? A multicentre survey”. (2017) Plos One, 12-9.
[xii] Varela, F; Thompson, E; Rosch, E. (1992). The embodied mind. Cognitive Science and Human Experience.