Research is proving the value of awareness practices
It's hard to believe that just 20 years ago meditation was still widely considered something practiced only by Zen students, Yoga adepts, and New Age esoterics in Birkenstocks. True, in the '70s, a few outlander physicians, led by Herbert Benson, began studying the power of meditation to evoke a "relaxation response," which lowered blood pressure and alleviated stress. But for a long time, the scientific community considered the healing potential of meditation to be about as credible as that of faith healing and exorcism.
Since the early '90s, however, the idea that meditation might have a real, empirically measurable, impact on mental and physical health has become almost boringly mainstream. Dozens of research studies have now demonstrated that meditation can reduce anxiety, stress, blood pressure, chronic pain, insomnia, post-traumatic stress disorder symptoms, substance abuse, and health care visits. It also seems to enhance the immune system, increase longevity, and improve the quality of life. Who knows? We may soon discover that meditation cures baldness, removes warts, and sharpens math skills.
But until the last few years, relatively few credentialed, respectable, standard-issue psychotherapists seemed to have discovered meditation for themselves or for their clients. Hovering for years around the fringy edges of mental health care, it's only now beginning to enter the mainstream of psychotherapy practice. More and more workshops and conferences seem to have "mindfulness" or "meditation" in their titles, and increasing numbers of therapists are teaching their clients to sit quietly and follow their breath.
In spite of increasing support for meditation among practitioners and much anecdotal evidence that it works well for different clients in a variety of circumstances, formal research on the value of incorporating it into the clinical practice of psychotherapy has been sparse. Perhaps the philosophy of detachment, which is often seen to accompany meditation traditions, conflicts with the goal of endless improvement and progress, which characterizes Western science and, probably, most psychotherapy models. After all, the byword for most psychotherapies has been "change," rather than "acceptance."
Also the research community may be constrained by an inability to think outside the box. The most stultifying research box of all is the self-defeating assumption that there must already be some empirical evidence showing the value of an intervention before there can be more exploration of its value as an intervention!
In the case of meditation, this assumption is indeed myopic, since there's a growing body of research demonstrating the extraordinary power of mindfulness practice to affect the way the mind works. Granted, much of this research hasn't been done in the area of psychotherapy per se, but some studies have shown that meditation has such an astonishing impact on the mind and brain that even the most hard-nosed psychotherapy researcher should be impressed.
In one of the most remarkable partnerships in the history of research, Richard Davidson, a neuroscientist at the University of Wisconsin, collaborated with the Dalai Lama on an astonishingly innovative piece of research investigating long-term meditation's effects on the mind and brain. For this project, the Dalai Lama sent eight monks to Davidson's laboratory. Each one had meditated for between 10,000 and 40,000 hours over the preceding 15 to 40 years. In a randomized design, comparing the brain waves of these monks to those of novice meditators, Davidson and his colleagues found that the monks had substantially higher levels of gamma brain waves--brain activity indicating higher levels of consciousness--than the novices. The monks' brain waves were better organized and coordinated. Their brain activity was highest in the left prefrontal cortex, the area of the brain that's been associated with happiness. Furthermore, these differences in brain function continued even when the monks weren't meditating, indicating that the years of mindfulness practice had fundamentally changed how their brains operated. And like other dose-response effects, the monks who'd meditated the longest showed these effects the most.
Other major areas of research on meditation and mindfulness are more directly related to psychotherapy. Some studies have looked at the value of training in mindfulness techniques for increasing happiness and reducing levels of distress and psychopathology. The best known is a series of studies by Jon Kabat-Zinn of the University of Massachusetts Medical Center, who developed and evaluated a program for increasing mindfulness called Mindfulness-Based Stress Reduction (MBSR). Developed originally as a means of allaying chronic pain, MBSR is an 8- to 10-week course that includes an intensive, full-day mindfulness session. Following the course, participants practice mindfulness for at least 45 minutes per day, six days a week. Another prominent feature of MBSR training is teaching participants to observe their emotions, sensations, and cognitions--even the unpleasant and painful ones--calmly, dispassionately, and nonjudgmentally.
Kabat-Zinn's research has shown that MBSR significantly decreases pain and the number of medical symptoms reported, and reduces psychological distress in participants. Similar findings have emerged in studies that he and his colleagues have done on the impact of MBSR on generalized anxiety disorder and depression.
But what does it mean to be "mindful" or to do research on "mindfulness"? How do you take this deeply private, elusive experience and make it the focus of research aimed at studying how it can become part of replicable psychotherapy treatments? Rather than analyzing what's perhaps unanalyzable, researchers studying mindfulness have focused on two of its core features: remaining in the moment and developing one's ability to accept what's occurring. In this form, mindfulness practice is consciously and purposely initiated, but allows experience to unfold without evaluation or criticism.
Flowing from such a focus, researchers have developed the means for assessing mindfulness. One of these is the Mindfulness Attention Awareness Scale, developed by Kirk Brown and Richard Ryan of University of Rochester. Another is the Kentucky Inventory of Mindfulness Skills, developed by Ruth Baer, Gregory Smith, and Kristen Allen of the University of Kentucky. Such scales track clients' self-reports of their mindful experiences, such as their ability to remain nonjudgmental. Although such brain technologies as MRIs and EEGs, as utilized in the Davidson research assessing the monks' brains, show promise for tracking levels of mindfulness, research on the extent to which mindfulness is present remains principally the product of self-reports.
Particularly promising, as well as unexpected, is a surge in research on mindfulness conducted by clinicians practicing cognitive-behaviorial therapy (CBT)--a group of researcher/practitioners who often seem to dismiss all techniques outside of their usual methodologies. Now a growing number of the most prominent CBT researchers have become convinced of the value of mindfulness practices and have come to see them as consistent with and complementary to CBT.
This may not be as strange at it appears at first. CBT therapists have always employed relaxation and imagery techniques that overlap with mindfulness practice. Both CBT and mindfulness share a focus on directing awareness to one's inner processes and to how we automatically react to situations and get carried away by our feelings. Furthermore, several of the leaders in the CBT movement, such as Steve Hayes of the University of Nevada and Andrew Christenson of UCLA, have written and spoken extensively about the need for self-acceptance and acceptance of others as a feature effective change.
A variant of Kabat-Zinn's MBSR is currently being developed by John Teasdale and his colleagues in Cambridge, England. Called Mindfulness-Based Cognitive Therapy (MBCT), it's been shown to help reduce recidivism in depression. Teasdale and his colleagues have developed an eight-week course to help depressed people acquire a sense of detachment from the thought patterns that trigger their depression. MBCT incorporates simple breathing meditations and yoga stretches to help participants become more aware of the present moment. Teasdale and his colleagues have documented a relapse rate of 37 percent in depressed patients who'd had a major depressive disorder and received this intervention, as opposed to a rate of 66 percent among those who didn't receive this special treatment. The difference in relapse rate was even greater in those who'd had three or more previous episodes of depression.
In another example of the potential uses of meditation in the treatment of a difficult population, Alan Marlatt of the University of Washington examined the impact of Vipassana meditation on prisoners' behavior. In this experiment, groups of minimum-security prisoners in Washington State either participated in a 10-day course of meditation or received standard treatment. He found that even in this highly recidivist population, participating in this program instead in treatment as usual resulted in reduced levels of arrest, alcoholism, and drug use. For example, alcohol use in the meditation group decreased from 50 days out of the previous 90 to 10.
We're also beginning to see mindfulness practice incorporated into multimethod approaches intended for clients with problems that are notoriously resistant to treatment. Dialectical Behavior Therapy (DBT), for example, originally developed by Marsha Linehan of the University of Washington for clients with borderline personality disorder, incorporates mindfulness training as part of a complex treatment strategy. In DBT, clients are taught to observe their own emotions, for instance, to help them learn to calm down and detach themselves from their own inner turmoil. The mindfulness component of DBT is more flexible and less demanding than that of some other approaches, to avoid the difficulty that borderline clients often have with rigid structures and high performance expectations. The DBT program encourages clients to become comfortable with meditation techniques in a nondemanding environment, so they can experience its soothing effects and learn to increase mindfulness practice gradually. DBT has been the subject of several successful clinical trials. It is now the most widely circulated treatment for borderline personality disorder.
Enough research on the efficacy of mindfulness practice has been done in recent years that a metanalysis of these studies recently appeared in Clinical Psychology In that analysis, Ruth Baer assessed the impact of mindfulness practice on the kinds of problems most frequently encountered in psychotherapy, such as depression and anxiety. She found a mean effect size of 0.74 in mindfulness treatments, meaning that 74 percent of those in the groups receiving mindfulness training did better than those receiving another treatment or no treatment. This is a statistically "large" effect for these interventions. Baer also found that mindfulness treatments are highly acceptable to clients: 85 percent of participants complete these programs.
So where is this research taking us? It seems clear that the research has already demonstrated how powerful mindfulness techniques can be in the treatment of pain, anxiety, depression, and more complex problems, like borderline personality disorder. Basic questions still remain, however, about the most useful ways to incorporate these techniques into psychotherapy (particularly, how and when they should be integrated with other techniques) and for which clients these methods are most useful.
Furthermore, as Sona Dimidjian and Marsha Linehan of the University of Washington have pointed out, research has so far only focused on the secular types of mindfulness, leaving unexplored the role that spirituality plays in traditional mindfulness traditions. That raises the question to what extent, if at all, are the beneficial aspects of mindfulness connected to the spiritual or religious meanings ascribed to such practices by traditional cultures? For now, however, research has revealed that there is real value in helping therapists learn mindfulness skills and teach them to their clients.
Follette, Victoria, Steven Hayes, and Marsha Linehan. Mindfulness and Acceptance. New York: Guilford, 2004.
Germer, Christopher, Ronald Siegel, and Paul Fulton. Mindfulness and Psychotherapy. Washington, D.C.: APA Books, 2005.
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