Mindfulness has many advocates: spiritual people seeking enlightenment; neuroscientists who study the mind; psychiatrists who want to cure depression, anxiety, and addiction; sports psychologists who want to improve performance; and physical therapists who want to help people with pain.
It's noteworthy when many different groups of people, working independently, with different agendas and conceptual models, all agree on something. All of these different fingers are pointing at the same thing: a certain quality of mind that can supposedly help reduce almost any undesirable state of consciousness that you happen to be in - worry, rumination, distraction, and even pain.
There is a growing body of science related to the study of mindfulness, examining its effect on mood, cognition, performance, and health. Brown University has a Department of Mindfulness and Contemplative Studies. The University of Oxford has a Mindfulness Research Center. There are similar departments at other elite academic institutions, and many credible experts who believe mindfulness can be studied scientifically, and that it has wide-ranging mental health benefits.
I've read a lot of these optimistic takes and find them to be plausible. Many claims are supported by RCTs, FMRI showing brain changes, and plausible scientific explanations. I've also personally found benefit in a variety of practices that involve some element of mindfulness, such as meditation, yoga, and the Feldenkrais Method. So I think the mindfulness craze may be a good thing, and I hope that it will help people.
On the other hand, I'm also a skeptical person who has been reading medical evidence for at least 15 years, and am therefore aware of certain patterns:
most treatments simply don't work, and this should be your default assumption about any new treatment, especially a treatment aimed at a complex health problem;
if a new treatment seems to work, the media will overhype it, even if the supporting evidence is weak;
scientists will be more skeptical, but still biased in favor of reporting positive results;
over time, as treatments are studied with more rigor, effect sizes will grow smaller, and may disappear entirely.
I have recently seen several articles arguing that the science of mindfulness is following this trajectory. They point out that the definitions of mindfulness are vague, that the mechanisms by which it works are poorly specified, and that the trials showing benefits have low methodological quality. Further, mindfulness is now a billion-dollar industry, the media loves to talk about it, and some scientists are acting more like advocates than referees.
With this background in mind, this post outlines some of the major concepts and claims from both the optimistic and skeptical perspectives. At the end, I'll provide a short summary of how I think about this topic. I am mostly ignoring the details and sticking more to a high-level overview.
What exactly is mindfulness?
In the scientific literature studying mindfulness, it is commonly defined as a state of non-judgmental focused attention on present experience. There are least three concepts in this definition that require further elaboration:
“Attention” means some form of effort to be aware of something.
“Present experience” might include physical sensations, thoughts, or emotions.
“Non-judgmental” means an attitude of openness, curiosity, calmness, and acceptance.
Some researchers note a further requirement: that there be some intention to increase well-being, or seek deeper self-knowledge.
Here’s how mindfulness is defined in a paper examining the effects of mindfulness-based stress reduction (MBSR), the most well-studied form of mindfulness practice, which was developed by John Kabat-Zinn, a professor of medicine and practicing Buddhist:
the non-judgmental acceptance and investigation of present experience, including body sensations, internal mental states, thoughts, emotions, impulses and memories, in order to reduce suffering or distress and to increase well-being.1
Critics of the science of mindfulness have pointed out that this definition is vague, and doesn’t make clear exactly which states of mind should be considered "mindful" and which should not. Further, different studies use different definitions, which makes it hard to interpret the meaning of the scientific literature as a whole.2
My reading of these criticisms is that the studies do need to be more precise in their language. But this does not imply that mindfulness is not a meaningful concept that can’t be studied scientifically. I note that similar challenges pertain to the study of many other subjective states, including love, fear, and anxiety. Even pain!
How is mindfulness practiced?
We can get a better idea about what mindfulness is by considering the different ways it is practiced. With that in mind, following is some discussion of how mindfulness relates to practices like meditation, yoga, and body scans. Each of these have been used in studies as the “vehicle” for a delivering a “dose” of mindfulness and studying the effects.
The most popular form of mindfulness practice is meditation. There are many different forms of meditation, but a common element to each is non-judgmental attention on present experience.
In yoga and other kinds of mind/body practice, such as tai chi, or Feldenkrais, mindfulness plays a central role. In each of these practices, the student is directed to pay non-judgmental attention to certain postures and movements, as a way to perceive and control the mind.
Aspect of mindfulness can often be found in therapies designed to reduce stress, such as body scans, massage, or breathing techniques.
Cognitive-behavioral therapy (CBT) is the most popular and evidence-based form of psychotherapy, and there is evidence that it can be used as an effective treatment for anxiety, depression, and chronic pain. It focuses on identifying and changing negative patterns of thinking and behavior. This necessarily involves some degree of introspection, which is aided by mindfulness. The Oxford researcher Mark Williams has discussed the complementary nature of these practices, and has combined them in a therapeutic technique called Mindfulness-Based Cognitive Therapy.
There are many different wisdom traditions that emphasize the importance of introspection or metacognition as a pathway to personal development and psychological maturity. The idea that “knowing thyself” is a noble goal can be found in Greek philosophy (Socrates, Aristotle, and the Stoics), eastern philosophy (Buddhism), literature, myth, and just basic common sense. Because the value of self-discovery is embedded in many parts of the culture, most of us have some intuitive understanding of what mindfulness is, even without formal study. And we have all probably practiced it in some form at one time or another, even without intending to do so.
Mindful states are a common element in a wide variety of activities that people tend to find meaningful. Walking, exercising, gardening, hiking, fishing, or working with the hands all promote sustained focus on the present moment.
Further, mindfulness probably helps to promote a flow state, which is the deeply meaningful and mental-health promoting feeling of being “in the zone” during performance of a skilled activity like music or sport. As discussed by the psychologist Mihaly Csikszentmihalyi, one of the pre-conditions for flow is focused attention on the present moment.
Another way to understand the nature of mindfulness and its potential benefits is to consider its opposite, which is a state of distraction and emotional reactivity. Consider the effects of scrolling through social media posts on Twitter or TikTok, especially those that are designed to capture our attention and reflexively engage our emotions. Doesn’t feel good.
What does science say about the potential mental health benefits of mindfulness?
The central claim by advocates of mindfulness practice is that it can improve the mind’s ability to control itself, thereby becoming better able to inhibit negative thoughts and emotions, and focus attention on solving problems without distraction. As evidence for this theory, mindfulness practices have been shown to:
Reduce symptoms of depression: A meta-analysis of 39 studies found that mindfulness-based interventions were associated with significant reductions in symptoms of depression.3
Reduce symptoms of anxiety: A systematic review and meta-analysis of 29 studies found that mindfulness-based interventions were associated with significant reductions in symptoms of anxiety.4
Improve working memory: A randomized controlled trial found that individuals who completed a mindfulness-based cognitive therapy program showed significant improvements in working memory performance compared to a control group.5
Reduce symptoms of chronic pain: A systematic review and meta-analysis of 21 studies found that mindfulness-based interventions were associated with significant reductions in pain intensity, pain-related disability, and psychological distress in individuals with chronic pain.6
Reduce symptoms of PTSD: A randomized controlled trial found that mindfulness-based stress reduction was associated with significant reductions in PTSD symptoms in a group of veterans.7
Change gray matter density: Participants who completed an 8-week mindfulness-based stress reduction program showed increases in gray matter density in the prefrontal cortex, which is associated with attention and emotional regulation, as well as decreases in gray matter density in the amygdala, which is associated with the processing of emotional stimuli.8
It should be noted that these are highlights of positive results. I’ll examine a more negative view of the evidence below.
A skeptical view of the evidence
Some good reasons to be skeptical about the science of mindfulness were articulated in several published articles, including a 2015 paper titled Mind the Hype: A Critical Evaluation and Prescriptive Agenda for Research on Mindfulness and Meditation9, and a 2016 article asking Has the Science of Mindfulness Lost its Mind?10
Both articles express several concerns:
inconsistency in the way mindfulness is defined from study to study;
low methodological quality in many studies, especially the lack of a control group;
small effect sizes in many cases, and a failure to measure potential negative side effects;
low levels of skepticism about the benefits of mindfulness, not only in the media, but by the major scientists studying it.
Despite these criticisms, both papers acknowledge that studies on mindfulness have shown at least some benefits, and that there is a good reason to study it further.
A study from 2017 seems like a good representative of the state of the evidence: it is a systematic review and meta-analysis of 37 studies examining the effect of mindfulness practice on chronic pain. It found low quality evidence for small reductions in pain and depression.11 The conclusion:
While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.
Concluding thoughts
Here are my major takeaways based on this high-level overview of the evidence.
My default assumption is that when this topic has been studied with more rigor, it will be found that:
well-designed formal mindfulness practices have small positive effects on a wide variety of mental health issues, including chronic pain, anxiety, and depression;
some people may get more dramatic benefits, some will not respond at all, and some will experience negative side effects;
“dosage” matters, so that the optimum amount of mindfulness practice will be some Goldilocks amount of “not too much and not too little.”
In this regard, I think mindfulness practices may eventually come to be seen as similar to other well-established general health interventions such as exercise, sleep, diet, and stress reduction. In fact, I see several potential analogies:
Each provides a wide range of health benefits, but are not magical cures for anything;
Each is more effective in preventing pathology than curing it;
Each will provide the highest levels of benefit when they correct a major deficiency. With higher dosages, there will be diminishing returns;
Responses to interventions will depend on the individual, and also the way in which the “medicine” is delivered.
Further, many people will already be getting a sufficient dose of mindfulness from their current lifestyle, and will not get much additional benefit from formal practices. For example, if you already spend a lot of time knitting, or have a general predisposition towards wise and calm introspection, you might not get much additional benefit from starting a formal meditation practice. On the other hand, if you are spending your days in a state of distracted emotional reactivity, and never have even a second to introspect on the chaotic content of your scattered mind with any kind of calmness and equanimity, you might get a lot of benefit from starting a formal program of mindfulness.
The only way to know is to explore. And I think the nature of your conscious experience is an area well-worth exploring.
That's all on mindfulness for now, which of course leaves a lot unsaid. I plan to do some future posts to fill in some of the blanks, including the different theories that might explain the mechanism by which mindfulness works, especially predictive processing.
References
Phan-Le NT, Brennan L, Parker L. The search for scientific meaning in mindfulness research: Insights from a scoping review. PLoS One. 2022 May 4;17(5):e0264924. doi: 10.1371/journal.pone.0264924. PMID: 35507587; PMCID: PMC9067662.
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Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., ... & Hofmann, S. G. (2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical Psychology Review, 33(6), 763-771.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78(2), 169-183.
Chambers, R., Lo, B. C. Y., & Allen, N. B. (2008). The impact of intensive mindfulness training on attentional control, cognitive style, and affect. Cognitive Therapy and Research, 32(3), 303-322.
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., & Newberry, S. (2017). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51(2), 199-213.
Kearney, D. J., McDermott, K., Malte, C., Martinez, M., & Simpson, T. L. (2016). Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: A randomized controlled pilot study. Journal of Clinical Psychology, 72(4), 311-328.
Hölzel, B. K., Carmody, J., Evans, K. C., Hoge, E. A., Dusek, J. A., Morgan, L., ... & Lazar, S. W. (2010). Stress reduction correlates with structural changes in the amygdala. Social Cognitive and Affective Neuroscience, 5(1), 11-17.
Van Dam, N. T., van Vugt, M. K., Vago, D. R., Schmalzl, L., Saron, C. D., Olendzki, A., Meissner, T., Lazar, S. W., Kerr, C. E., Gorchov, J., Fox, K. C. R., Field, B. A., Britton, W. B., Brefczynski-Lewis, J. A., & Meyer, D. E. (2018). Mind the Hype: A Critical Evaluation and Prescriptive Agenda for Research on Mindfulness and Meditation. Perspectives on Psychological Science, 13(1), 36–61. https://doi.org/10.1177/1745691617709589.
Farias M, Wikholm C. Has the science of mindfulness lost its mind? BJPsych Bull. 2016 Dec;40(6):329-332. doi: 10.1192/pb.bp.116.053686. PMID: 28377813; PMCID: PMC5353526.
Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., & Newberry, S. (2017). Mindfulness meditation for chronic pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51(2), 199-213.