Mindfulness and its near-enemies: Opportunities and opportunism as psychology embraces the Big M

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1 Mindfulness and its near-enemies: Opportunities and opportunism as psychology embraces the Big M Paul Grossman Department of Psychosomatic Medicine University of Basel Hospital Basel, Switzerland

2 No. of mindfulness papers per year published in research journals (MEDLINE & Web of Science) Number of published papers per year in peer-rev iew ed j ournals Published papers/year to (W eb of Science & Medline) Year YEAR

3 Short-term clinical benefits upon well-being of MBSR (Effect size = standardized measure of improvement) 1.0 Effect Sizes 1.0 Effect Size Depression/Anxiety Fibromyalgia Pain Insomnia Heart Disease AIDS/HIV Organ Transplant pts Cancer Multiple Sclerosis Prisoners Students Volunteers 0.0 Expanded from Grossman et al, 2004

4 Effect Sizes (Measures of Well-Being) Long-Term Follow-up Studies (0.5-3 years follow-ups) Pain Syndromes Breast Cancer: Stage 1-2 n=111 n=34 Inner City Stress n=47 Varied Medical Pts. n=41 Fibromyalgia n=26 Major Depression n=198 Anxiety Disorder Multiple Sclerosis n=150 n=39 Major Head Trauma n=7

5 But there may remain some difficult issues in the mindfulness literature.

6 Rarely considered problems and inconsistencies in the scientific mindfulnessbased intervention (MBI) literature Surge of enthusiasm for research into MBIs is exciting but may bring with it certain difficulties Interest in mindfulness outpaces experience and knowledge Typical research methodologies may not always be optimal or appropriate for mindfulness studies Enthusiasm may cause us to overlook possible problems and limitations of approaches May affect further development of MBI's Some examples of inconsistencies

7 Own studies with MBSR for fibromyalgia patients Pre- to post-intervention effect sizes (52 women, MBSR vs. active control; quasi-randomized) EFFECT SIZES Total Group (n=144) SubGroups (n=80-91) Effect Size Grossman, Tiefenthaler et al. 2007, Psychother Psychosom

8 Effect Size 3-year follow-up fibromyalgia study 1 EFFECT SIZES Effect Size Quality of Life Total Group (n=144) SubGroups (n=80-91) Fibro2007 Fibro2007_3y FU Depression Grossman, Tiefenthaler et al. 2007, Psychother Psychosom

9 Effect Size Fibromyalgia study 2 with same intervention: Relatively small pre-post effect sizes (2nd RCT study 168 women, MBSR vs active control vs usual care) EFFECT SIZES Effect Size Quality of Life Total Group (n=144) SubGroups (n=80-91) Depression Fibro2007 Fibro2011 Grossman, Tiefenthaler et al. 2007, Psychother Psychosom Schmidt, Grossman et al., Pain, 2011

10 Effect Size Less than at 3-year follow-up of Study Effect Size Quality of Life Total Group (n=144) EFFECT SIZES SubGroups (n=80-91) Fibro2007 Fibro2007_3y FU Fibro2011 Depression Grossman, Tiefenthaler et al. 2007, Psychother Psychosom Schmidt, Grossman et al., Pain, 2011

11 Effect Sizes (Measures of Well-Being) Long-Term Follow-up Studies (6 month-3 year follow-ups) Pain Syndromes Breast Cancer: Stage 1-2 n=111 n=34 Inner City Stress n=47 Varied Medical Pts. n=41 Fibromyalgia n=26 Major Depression n=198 Anxiety Disorder Multiple Sclerosis n=150 n=39 Major Head Trauma n=7

12 Therapist MAAS 'Mindfulness' negatively correlated with psychotherapy outcome of patients (23 psychotherapists treated 144 clients) MAAS 'Mindfulness' End-of-therapy Estimated Improvement -.23* End-of-therapy Global Assessment of Functioning -.24** N = 144 (Stanley et al., Journal of Cognitive Psychotherapy 2006)

13 Improvement (pts) Client Improvements (SCL-90) as Consequence of Therapist Mindfulness Training * * * * * * * * * Mindful Therapists 10 * * * * * * * * * Usual Therapists 0 Som Obsess Insecur Depress Anx Hostil Phobic Paran Psychot GSI (18 therapists, 123 patients) (Grepmair et al. 2007, Psychother Psychosom)

14 Examples illustrate just a few of the inconsistencies in scientific literature The Buddhist concept of near-enemies may be helpful here to explore these conflicting findings.

15 Near-Enemies Concept derives from later Buddhist commentary around 410 AD (Buddhaghosa) Quality that seems the same or, at least, very similar to a particular characteristic but is actually very different. Near-enemies often masquerade as the real thing

16 "Noble States of Living" (Four Immeasurables)

17 Mindfulness

18 Compassion- feeling of deep sympathy and sorrow for another who is stricken by misfortune, accompanied by a strong desire to alleviate the suffering

19 Near-Enemy of Compassion Pity: Feeling sorry for someone without real empathy--maybe even with sense of relief, distancing and/or ambivalence, often more out of fear than concern for other.

20 Sympathetic Joy: True joy felt for the happiness of another

21 VS. Displays of joy covering envy Real joy or inauguration blues....?

22 ....or joy for others that means gains for self

23 Topics 1. Examine current attempts, particularly in psychology to characterize mindfulness, even to measure it. Do these approaches capture mindfulness, or more its near enemies? 2. Address certain issues more specifically related to scientific research on mindfulness-based interventions (MBI s) that may provide information that is the near-enemy to evidence about effectiveness

24 Topics 1. Examine current attempts, particularly in psychology to characterize mindfulness and even to measure it. and suggest that these approaches may be getting not at mindfulness, itself, but more at its near enemies. 2.Address issues specifically related to scientific research on mindfulness-based interventions (MBI s) that may provide information that is the near-enemy to evidence about effectiveness.

25 Coming to Terms with `Mindfulness A Brief Background and Description For further clarification, see Grossman, Psychological Assessment (2011) ; and Grossman & van Dam, Contemporary Buddhism (2011)

26 Major Elements of MBIs Based on 2500-year-old Buddhist meditation practices and sophisticated, descriptive phenomenological system of subjective experience Nonesoteric, nonreligious, entirely empirical BUT DOES DERIVE from very different paradigm of psychology and theory of knowledge Based on percept, not concept Central process is, therefore, Buddhist idea of mindfulness ('Sati'; and no other).

27 Mindfulness is basically just a particular way of paying attention. It is a way of looking deeply into oneself in the spirit of self-inquiry and self-understanding. It is open-hearted moment-to-moment, nonjudgmental awareness. Jon Kabat-Zinn (1990 & 2005)

28 Mindfulness is basically just a particular way of paying attention. It is a way of looking deeply into oneself in the spirit of self-inquiry and self-understanding. It is open-hearted moment-to-moment, nonjudgmental awareness. Jon Kabat-Zinn (1990 & 2005)

29 The kind of awareness involved in mindfulness differs profoundly from the kind of awareness at work in our usual mode of consciousness..with the practice of mindfulness, awareness is applied at a special pitch..the mind is trained to remain in the present, open, quiet and alert, contemplating the present moment. All judgments and interpretations have to be suspended, or if they occur, just registered and dropped. Bhikkhu Bodhi (1984) Noble Eightfold Path

30 The kind of awareness involved in mindfulness differs profoundly from the kind of awareness at work in our usual mode of consciousness..with the practice of mindfulness, awareness is applied at a special pitch..the mind is trained to remain in the present, open, quiet and alert, contemplating the present moment. All judgments and interpretations have to be suspended, or if they occur, just registered and dropped. Bhikkhu Bodhi (1984) Noble Eightfold Path

31 Qualities underlying and supporting mindfulness Self-ethical system Kindness Letting go Gentleness Generosity Empathy Courage Non-judging Non-striving Acceptance Patience Trust Openness

32 Some essential qualities of mindfulness a) Deliberate intention to pay attention to momentary experience b) Clear focus on aspects of active investigation of moment-tomoment experience c) Continuity of a precise moment-to-moment awareness of immediate experience d) Assumptions of importance of mindfulness training and its gradual acquisition e) A marked distinction from normal, everyday modes of consciousness f) Inherent interdependency, or melding, of mindfulness with attitudes of openness, acceptance, kindness, curiosity, and patience (underpinnings of nonjudgmentalness) The beginner's mind is the mind of compassion. S. Suzuki 1970, Zen Mind, Beginner s Mind

33 CONTRAST I can easily put my beliefs, opinions, and expectations into words. I m good at thinking of words to express my perceptions, such as how things taste, smell, or sound. It s hard for me to find the words to describe what I m thinking. I have trouble thinking of the right words to express how I feel about things. My natural tendency is to put my experiences into words. From 5 Facets Scale Baer et al. (2006) Subscale: Describing w/words

34 Most popular measure of 'mindfulness': Does it measure mindfulness at all? (Mindfulness Attention Awareness Scale [MAAS], Brown &Ryan, 2003) Almost never Almost always I drive places on automatic pilot and then wonder why I went there. I snack without being aware that I m eating. I forget a person s name almost as soon as I ve been told it for the first time. I break or spill things because of carelessness, not paying attention, or thinking of something else. I do jobs or tasks automatically, without being aware of what I m doing. I rush through activities without being really attentive to them..... Is absence of perceived lapses of attention or dissociation equivalent to mindfulness?

35 "...the low end of depression is not happiness but rather the lack of depression; the low end of physical problems is not athleticism but rather an absence of mobility concerns." Item Response Theory and Clinical Measurement Reise & Waller, Annual Review Clin Psychol (2009) 5:27 48

36 Some essential qualities of mindfulness FMI* Buchheld et al, (2001) MAAS Brown & Ryan (2003) FFMQ Baer et al., (2006) (a) A deliberate intention to pay attention to momentary experience (b) Clear focus on aspects of active investigation of moment-to-moment experience (c) Continuity of a precise momentto-moment awareness of immediate experience (d) Assumptions of importance of mindfulness training and its very gradual acquisition (e) A marked distinction from normal, everyday modes of consciousness (f) Inherent interdependency, or melding, of mindfulness with attitudes of openness, acceptance, kindness, curiosity, and patience *Freiburg Mindfulness Inventory

37 Western Psychology s (Re)Invention of Mindfulness Do deviations from Buddhist/MBSR meanings of mindfulness make it into something else? Rob us of a new view on things Deceive us into thinking something unique to be ordinary e.g. equating mindfulness with quite familiar constructs like feelings of being inattentive or careless Distort general understanding of what mindfulness-based interventions are or what they do!

38 Number of published papers with citations per year referring to validation studies of three of the most popular questionnaires purporting to measure mindfulness: (Baer et al & 2006; Brown & Ryan, 2003) Published papers/year YEAR Science Citation Index (2012) N= 766 Studies

39 Questionnaire research dominates much of psychology: Therefore mindfulness becomes defined & measured by the scales that claim to assess it % studies including behavioral measures Baumeister, Vohs & Funder (2007)

40 Problem 1: Incongruous findings of studies purporting to measure mindfulness If mindfulness meditators and nonmeditators don t differ consistently in predictable ways Scale is not a valid measure of mindfulness Does not measure mindfulness If observation shows that the predicted effect is definitely absent, then the theory is simply refuted. Karl Popper (1957), Science: Conjectures and Refutations

41 Problems with scales of mindfulness Can we define mindfulness by people briefly rating themselves in 5-10 minutes on statements? An Interesting Comparison: Leigh, Bowen & Marlatt (2006) Examined `mindfulness in relation to substance abuse Used Freiburg Mindfulness Inventory (FMI) Binge-drinking vs. Non-drinking U.S. college students (n=196) VS. Buchheld, Grossman & Walach (2002) Freiburg Mindfulness Scores among long-term mindfulness meditation practitioners after intensive multiday meditation retreats (n=100) (Grossman, J Psychosom Res 2008)

42 Comparisons of Binge-Drinking Students vs. Non-Drinking Students Freiburg Mindfulness Inventory (FMI) Average Per-Item Mindfulness Score (Max score = 4) p < Non-Drinkers Binge-Drinkers

43 Comparisons of Long Time Meditators vs. Non-Drinking Students Freiburg Mindfulness Inventory (FMI) Average Per-Item Mindfulness Score (Max score = 4) * p < Long-term Meditators Healthy Students (N=100) (N= (150)

44 Comparisons of Long Time Meditators vs. Binge-Drinking Students Freiburg Mindfulness Inventory (FMI) Average Per-Item Mindfulness Score (Max score = 4) * p < Long-term Meditators (N=100) Binge-Drink Students (N=40) "The FMI can be measured reliably and may assist in identifying an important relationship between substance use and mindfulness." (Leigh, Bowen & Marlatt, 2006)

45 The trouble is not only with the FMI:

46 Tango but not mindfulness training improves MAAS scores in depressives ** R. Pinniger (2010)

47 A sample of other often unmentioned MAAS findings MAAS scores not improved as consequence of MBSR (Brown & Ryan, 2003) Other MBSR studies also with no changes (e.g. Pradhan et al. 2006; Witek-Janusek et al., 2007) MAAS scores not correlated with meditation experience (r=-.04; Baer et al., 2006) No differences between meditators and nonmeditators in mean MAAS scores (means=4.0; Mackillop & Anderson, 2007) Psychotherapist MAAS scores negatively related to therapeutic success (r=-.26; Stanley et al., 2006)

48 Differences in Kentucky Mindfulness Scale Mean Scores between 24 Thai Monks and American College Students/Community Members * * (p<.001) Thai M onks (15 yrs med experience, 70 min/day) American Students (6% with some med experience) KIMS Subscale Scores *(p<.03) * * (p<.001) **(p<.002) Observing Describing Awareness Accepting KIMS Subscales Christopher et al. (2009)

49 Problem 2 Items can be very differently interpreted by different people

50 I sense I pay my attention body, to whether whether eating, my cooking, muscles cleaning, are tense or talking* or relaxed* * Item from Observe subscale of Baer et al. (2006)

51 Problem 3 Popular scales are often quite poorly correlated with each other

52 Putative mindfulness scales often correlate poorly with each other FMI Baer Five-Facet Subscales MAAS Act/aware (r=.9) Observe Describe Nonjudge Nonreact Cognitive Errors From Baer et al. (2006) and Cheyne et al (2009)

53 Do you want to call this: absence of mindfulness? (some items from cognitive errors scale) I go into a room to do one thing (e.g., brush my teeth) and end up doing something else (e.g., brush my hair). I have absent-mindedly mixed up targets of my action (e.g., pouring or putting something into the wrong container). I fail to see what I am looking for even though I am looking right at it. (Cheyne et al., 2007)

54 Problem 4 Self-report questionnaires evaluating characteristics generally seen as positive are notoriously poorly related to actual behavior. Why should self-report of mindfulness be different???

55 Examples of questionnaires that fail to predict behavior Moral courage Ability for self-control in difficult situations Empathy Gaps in self-predictions of empathy occur when people do not fully appreciate how much emotions, cognitions and social circumstance fundamentally change them as persons, shaping their perceptions, preferences, and behavioral inclinations (v. Boven et al. 2010).

56 SUMMARY AND SOME OTHER ISSUES Lack of clear external referents (gold-standard measures) with which to define a mindful person. Little concern given that all essential aspects of mindfulness are included in definition. Lack of consensus even among psychologists about what mindfulness is. Self-predictions of own empathy, self-control or courage do not correlate with actual behavior. Should mindfulness be any different? Unconcern for obvious potential different interpretations of what items mean in different populations. Unconcern about whether respondents conflate aspirations with achievements in attaining mindfulness. Inappropriate populations used for primary validation of scales. Why name scales as mindfulness when they can be easily characterized in conventional psych terms and provide greater information?

57 There are alternatives (e.g.): Naming things by their descriptive properties and relating them to mindfulness practices Qualitative studies that explore how mindfulness practices affect the way people think and feel Experimental studies that explore how mindfulness affects how people actually behave

58 The Best Mindfulness Checklist

59 Good mindfulness research and possible near-enemies? What s MBI anyhow? Cognitive skills training? A manualized, scripted technique for stress reduction? OR something very different: Start of a radical retraining of awareness embedded in a gentle ethics of wholesomeness Enabling a shift in what people find important, meaningful, of value Depends on who is teaching, their experiences and their abilities to embody what they teach

60 Good mindfulness research and possible near-enemies? What s MBI anyhow? Who is teaching MBI? MBI more and more commonly taught by individuals with no or modest self-experience in meditation and/or little or no teaching experience What is the teacher's understanding of mindfulness The difference between a trained and an untrained person is the understood experience.

61 Good mindfulness research and possible near-enemies? What s MBI anyhow? Who is teaching MBI? A long forgotten fact: the research context is part of the intervention! Discrepancies between mindfulness embodied in MBI and treatment of patients by research team Neutral or cool interactions with participants as part of assessment Excessive burdening of patients with assessment instruments Many questionnaires; daily diaries; physiological measures Induction of serious distress in a laboratory situation violates basic foundation of kindness inherent in MBI's Often with highly vulnerable groups (e.g. depressives)

62 An attempt to consider these factors: Mindfulness intervention with multiple sclerosis pts. 150 multiple sclerosis pts provided information and volunteered for MBSR (i.e. all chose for MBSR) Aim to improve well-being (quality of life, depression & fatigue) Randomized to MBSR vs. Waitlist control Carefully considered contextual factors Research/medical staff selected and trained (as best as possible) for kindness & attentiveness Patient burden kept to minimum in assessing trial Highly experienced teachers with many years personal meditation practice & teaching exper.

63 Patients complaining of depression at baseline Pre-Interv ention Post-Interv ention p< CES-Depression Control Group Mindfulness

64 Patients complaining of fatigue at baseline Pre-Intervention Post-Intervention p<.0005 Fatigue Control Group Mindfulness

65 Effect sizes for groups (with depression, fatigue, reduced QoL) Effect Size Quality of Life Depression Fatigue

66 6-month follow-up Standardized Change from Pre-Intervention *** *** *** *** MBI Usual Care * * ** * -0.6 Generic QoL MS-specfic QoL Fatigue Depression Generic QoL MS-specfic QoL Fatigue Depression Pre to Post-Intervention Pre to 6-month Follow -Up

67 The Best Mindfulness Checklist

68 The fabrication of mindfulness in psychology and psychotherapy:

69 How to explain: Fundamental issues Semantic Interpretation: Different mindfulness scores in meditators vs non- meditators might stem from a different understanding of the items (equivalent interpretation of meaning require for different groups). I notice my bodily sensations during daily activities

70 How to explain: Fundamental issues Semantic Interpretation: Different mindfulness scores in meditators vs non- meditators might stem from a different understanding of the items (equivalent interpretation of meaning require for different groups). I notice my bodily sensations during daily activities Relationships between aspects of mindfulness may be different for meditators vs unexperienced people (e.g. factor structure). Observe dimension of the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) shows up in meditators but not in nonmeditators (factor analysis).

71 How to explain: Fundamental issues Semantic Interpretation: Different mindfulness scores in meditators vs non- meditators might stem from a different understanding of the items (equivalent interpretation of meaning require for different groups). I notice my bodily sensations during daily activities Relationships between aspects of mindfulness may be different for meditators vs unexperienced people (e.g. factor structure). Observe dimension of the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) shows up in meditators but not in non-meditators (factor analysis). Major mindfulness scales don t always correlate with each other MAAS Toronto Mindfulness scale (Carmody et al., 2008) (r=.15) Freiburg Mindfulness Scale MAAS (r=.3) (Baer, 2004) FFMQ observe MAAS (r=.02) (Baer et al. 2006), Etc. When there are meaningful correlations, almost always <0.6

72 How to explain: Fundamental issues Semantic Interpretation: Different mindfulness scores in meditators vs non- meditators might stem from a different understanding of the items (equivalent interpretation of meaning require for different groups). I notice my bodily sensations during daily activities Relationships between aspects of mindfulness may be different for meditators vs unexperienced people (e.g. factor structure). Observe dimension of the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) shows up in meditators but not in non-meditators (factor analysis). Major mindfulness scales don t always correlate with each other MAAS Toronto Mindfulness scale (Carmody et al., 2008) (r=.15) Freiburg Mindfulness Scale MAAS (r=.3) (Baer, 2004) FFMQ observe MAS (r=.02) (Baer et al. 2006), Etc. When there are meaningful correlations, almost always <0.6 Relations of a particular mindfulness scale and other measures of wellbeing differ among meditators and nonmeditators (Baer, 2008) FFMQ and psychological symptoms: r=.2 for students; -.5 for meditators

73 How to explain: Fundamental issues Semantic Interpretation: Different mindfulness scores in meditators vs non- meditators might stem from a different understanding of the items (equivalent interpretation of meaning require for different groups). I notice my bodily sensations during daily activities Relationships between aspects of mindfulness may be different for meditators vs unexperienced people (e.g. factor structure). Observe dimension of the Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006) shows up in meditators but not in non-meditators (factor analysis). Major mindfulness scales don t always correlate with each other MAAS Toronto Mindfulness scale (Carmody et al., 2008) (r=.15) Freiburg Mindfulness Scale MAAS (r=.3) (Baer, 2004) FFMQ observe MAS (r=.02) (Baer et al. 2006), Etc. When there are meaningful correlations, almost always <0.6 Relations of a particular mindfulness scale and other measures of wellbeing differ among meditators and nonmeditators (Baer, 2008) FFMQ and psychological symptoms: r=.2 for students; -.5 for meditators Differential response biases of meditators (or MBI participants) vs inexperienced folks Increased familiarity with mindfulness might make people value characteristics of mindfulness more and create bias on self-reports Recent work (Van Dam et al., 2009) indicated clear differences in response bias between meditators and non-meditators on 18/39 items of the FFMQ

74 The difference between a trained and an untrained person is the understood experience. Consequences Failure to recognize these problems may seriously compromise progress in mindfulness research. Facile operationalizations of the original Buddhist idea of mindfulness may serve to trivialize our understanding. It may also substantially alter meaning.

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