Why do we need to regulate mindfulness?

Self-organisation at work?

The UK Network of Mindfulness-based Teacher Training Organisations is committed to supporting and developing good practice and integrity in the delivery of Mindfulness-based approaches do they know what they are doing?

Mindfulness-based Cognitive Therapy (MBCT) was developed to prevent relapse in depression and has consistently been found to be effective in a series of randomised controlled trials. This kind of scientific evidence is required to validate a therapeutic intervention; be it a drug, psychotherapy, surgery or physiotherapy.

To be able to scientifically assess the effectiveness of any therapy, the first thing that needs to be established is that the therapy itself can be standardised so that the same treatment can be given to people with the same diagnosis to make sure that like is compared to like. This means that there has to be a high level of consistency in the expertise of the professional delivering the therapy. If the therapy is then going to be offered as a treatment after the trial, therapists have to be trained to the same standard as those who delivered the therapy in clinical trials. This is why there is a need for standardisation of profession training for practitioners to deliver MBCT.

This all seems very sensible but issues around the regulation and standardisation of mindfulness-based interventions and mindfulness teacher-training is not quite as straightforward as it may seem.

Firstly, while MBCT has been rigorously tested in clinical trials, very little work has been done to understand what elements of the programme are actually having a positive effect. Could the benefits just be down to the fact that people are coming together in a group over eight weeks and sharing their experiences? Could there be better ways of delivering the active ingredient of mindfulness meditation? Why does MBCT work for some people and not for others?

Kuyken et al (20010) found that people with low levels of self-compassion didn’t benefit from MBCT. Is there then a way to teach people self-compassion before they do an MBCT course? Do mindfulness-based interventions need to be refined for people with different psychological make-ups? Is mindfulness good for everyone? Do some people find it uncomfortable sitting in circle in a group therapy and does this have a negative effect on outcomes? If we don’t know many of the answers to questions like these, is it not too soon to say how mindfulness should best be taught and even how it would be best to train mindfulness teachers?

However, MBCT is just one form of “mindfulness”. MBCT adapts Mindfulness-based Stress Reduction (MBSR) to a cognitive model to prevent relapse of depression. These approaches to mindfulness are adaptations of a westernised form of a family of related Buddhist meditation techniques. The main influences come from simplified Buddhist meditation styles that were developed in the colonial period in Theravada Buddhism in South East Asia and in Zen Buddhism in China around a millennium after the Buddha lived and taught in Northern India.

Another form of meditation, which has significant similarities comes from Tibet, which goes back to meditation masters who lived around a thousand years ago. Again this style of meditation represents a third strand of Buddhist meditation that has had an influence on what we think of as mindfulness today.  Jon Kabat-Zinn, who developed MBSR even cites influences from non-Buddhist Indian philosophy. However, it is the style of mindfulness meditation that has come from South East Asia that is framed in thinking closest to a modern psychological understanding of how the mind works, that is probably the most significant influence in what we know of as mindfulness today: insight meditation.

So mindfulness, in various forms, some of which would seem quite strange to a cognitive therapist and some more familiar, has been taught for centuries and continues to be taught by Buddhists today. So there is a difference of understanding of what mindfulness is and how best to teach it, from various schools of Buddhism to cognitive therapy.

Now, as a result of the interest in mindfulness, all sorts of people from all sorts of backgrounds are teaching something they call “mindfulness” in all sorts of contexts. Because of the diversity of approaches to teaching mindfulness, old and new, it is never going to be possible to regulate mindfulness or its teaching across the board. It may well make sense to standardise mindfulness programmes and how they are taught in therapy, even if the actual scientific understanding of what mindfulness is and how it should best be taught is rudimentary.

The fact is that mindfulness training in the workplace has to be fit for purpose in the culture of the workplace. MBSR and MBCT are not a good fit. Businesses need shorter courses and courses that fit organisational culture. One recent large randomised controlled trial with an adapted form of MBSR (van Berkel et al, 2014) with weekly classed reduced from 2.5 hours to 1.5 hours over 8 weeks, with further coaching, failed to show any benefits whatsoever while a shorter online course adapted from MBSR with 6 weekly classes of 1 hour (Aitkins et al, 2014) produced projected possible cost savings of up to $22,580 per year per employee in decreased employee burnout.

Standardisation in therapy might be seen as the best option in an imperfect world, where a therapeutic intervention has undergone evaluation under trial conditions and repeatability is required to reproduce the observed benefits in spite of the fact that this may stifle adaptation and the development of better courses. However, there can be no valid grounds for regulating mindfulness outside this context at least until what mindfulness is and how best to teach it is better understood.

References

Aitkens, K. A., Astin, J., Pelletier, K. R., Bodnar, C. M. (2014). Mindfulness goes to work: Impact of on online workplace intervention. Journal of Occupational and Environmental Medicine, 56(7), 721-731

Jantien van Berkel, Cécile R. L. Boot, Karin I. Proper, Paulien M. Bongers, Allard J. van der Beek (2014) Effectiveness of a Worksite Mindfulness-Related Multi-Component Health Promotion Intervention on Work Engagement and Mental Health: Results of a Randomized Controlled Trial. January 28, 2014 DOI: 10.1371/journal.pone.0084118. Plosone.org online journal.

Willem Kuyken, Ed Watkins, Emily Holden, Kat White, Rod S. Taylor, Sarah Byrford, Alison Evans, Sholto Radford, John D. Teasdale, Tim Dalgleish (2010). How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy 48, 1105-1112

This article was previously published, except for minor edits, on http://www.heartfulmind.net/, on 16/11/2014