What are the Active Ingredients of Mindfulness-based Interventions?

What are the Active Ingredients of Mindfulness-based Interventions?

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Mindfulness-based interventions typically comprise numerous elements, including some or all of the following: guided mindfulness exercises, guided loving-kindness and compassion meditation exercises, group discussion, psycho-education (sometimes in the style of a university lecture), yoga, one-to-one discussion with the programme facilitator, a CD of guided meditations to encourage at-home practice, and a full or half-day silent group retreat. Given that each of the above techniques arguably have therapeutic utility in their own right, ascertaining why MBIs are effective is problematic because they have numerous ‘active ingredients’.

Not controlling for other active ingredients is a common limitation of MBI intervention studies. Indeed, although scientific evidence demonstrates that certain MBIs are equally or more effective than other treatments for improving specific health conditions, it is currently unclear whether it is mindfulness, or mindfulness in combination with other therapeutic techniques, that results in health benefits. One way to overcome this methodological limitation is to employ a purpose-designed ‘active’ control condition. This is a control intervention that mirrors the main intervention in terms of its design, but does not include any mindfulness techniques. By conducting a randomised controlled trial that compares the effectiveness of an MBI against a suitably formulated active control intervention, we can determine that superior outcomes in the MBI versus control group are caused by mindfulness.

It could be argued that it doesn’t matter whether it is specifically mindfulness or other intervention components that make MBIs effective. If we are only interested in treatment outcomes and adhere to a ‘what works’ approach to alleviating illness symptoms, then establishing which intervention components are most effective becomes less important. However, from the point of view of advancing scientific understanding of how the human mind reacts to given psychotherapeutic techniques, it is useful to establish which ingredients are most active within a given intervention. Such knowledge can also help to inform the development of more effective and ‘therapeutically streamlined’ MBIs.

When designing an active control intervention for MBI efficacy studies, in addition to matching the design of the target and control interventions (i.e., minus the inclusion of mindfulness techniques), it is also important to match the ‘competency’ of the instructor or instructors delivering the two interventions. For example, a number of meditation intervention studies employing an active control condition have used an experienced clinician and meditation teacher to deliver the MBI, whilst leaving a relatively inexperienced student to administer the control intervention. Clearly, such an approach can introduce bias and weaken the strength of the evidence from MBI studies.

In order to overcome the above methodological limitation, in a recent randomised controlled trial that we conducted, the study was designed such that the same instructor delivered the MBI and comparison intervention. To control for potential bias on the part of the instructor, participants in each intervention condition were asked to rate the instructor’s levels of enthusiasm and preparation. Statistical tests were then performed to determine if there were significant differences between how participants from the intervention and control group rated the instructor’s performance.

We decided to control for an ‘instructor effect’ because in our opinion, the mindfulness instructor is one of the most active ingredients in MBIs. Part of our research has involved the development and empirical investigation of a ‘second-generation’ of MBI. Second-generation MBIs (such as Meditation Awareness Training) are designed slightly differently compared to ‘first-generation’ MBIs (such as Mindfulness-based Stress Reduction or Mindfulness-based Cognitive Therapy). More specifically, second generation MBIs are overtly spiritual in nature and teach a greater range of meditative techniques. Given that second-generation MBIs comprise different design elements compared to first-generation MBIs, it is reasonable to assume that these two types of MBIs will result in different outcomes. However, despite the design differences between first- and second-generation MBIs, it is our view that if a mindfulness teacher with authentic spiritual realisation was to administer a first-generation MBI, the outcomes would be very similar to them administering a second-generation MBI.

In other words, if the mindfulness teacher is genuinely rooted in the present moment, the specific design of the MBI becomes less important. As we discussed in our post on The Four Types of Psychologist, we would argue that the same principle applies to the majority of psychological therapies. If the clinician knows their own mind, has genuine compassion for the client, and is skilled in helping the client understand their problems, then the choice of therapy becomes less important.

Although preliminary findings (including from some of our own clinical case studies and qualitative studies) support the notion that the mindfulness teacher is one of the (if not the) most important ingredients of MBIs, there is clearly a need for further research investigating how the instructor influences outcomes. However, in the absence of extensive empirical investigation into this subject, we hypothesise that what participants of MBIs need most (and therefore respond best to), is the unconditional love and spiritual wisdom of a teacher who is without a personal agenda, and whose mind is saturated with meditative awareness.

 

Ven. Edo Shonin and Ven. William Van Gordon

Further Reading

Baer, R., Smith, G., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27-45.

Chiesa, A. (2013). The difficulty of defining mindfulness: Current thought and critical issues. Mindfulness, 4, 255-268.

Chiesa, A., & Malinowski, P. (2011). Mindfulness-based approaches: Are they all the same? Journal of Clinical Psychology, 67, 404-424.

MacCoon, D., Imel, Z., Rosenkranz, M., Sheftel, J., Weng, H., Sullivan, J., . . . Lutz, A. (2012). The validation of an active control intervention for Mindfulness Based Stress Reduction (MBSR). Behavior Research and Therapy, 50, 3-12.

Shonin, E., Van Gordon, W., Dunn, T., Singh, N. N., & Griffiths, M. D. (2014). Meditation Awareness Training for work-related wellbeing and job performance: A randomised controlled trial. International Journal of Mental Health and Addiction, 12, 806-823.

Van Gordon, W., Shonin, E., & Griffiths, M. (2015a). Towards a second-generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49, 591-591.

Shonin, E., & Van Gordon, W. (2015). The lineage of mindfulness. Mindfulness, 6, 141-145.

Shonin, E., Van Gordon, W., & Griffiths, M. D. (2013). Meditation as medication: Are attitudes changing? British Journal of General Practice, 63, 654.

Van Gordon, W., Shonin, E., & Griffiths, M. (2015). Towards a second-generation of mindfulness-based interventions. Australia and New Zealand Journal of Psychiatry, 49, 591-591.

Shonin, E., Van Gordon, W., Compare, A., Zangeneh, M., & Griffiths, M. D. (2015). Buddhist-derived loving-kindness and compassion meditation for the treatment of psychopathology: A systematic review. Mindfulness, 6, 1161-1180.

Shonin, E., & Van Gordon, W. (2013). Searching for the present moment, Mindfulness, 5, 105-107.

Calling a Spade a Spade: The Need for Authentic Meditation Teachers

Calling a Spade a Spade: The Need for Authentic Meditation Teachers

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Some time ago, we uploaded a post that featured a vajragiti that we wrote called Hearken to the Dharma. A vajragiti is a type of spiritual song or poem. The Sanskrit word vajra means ‘diamond’ or ‘indestructible’ and the word giti means song. Some of our vajragitis have been spoken or written spontaneously, while others have been written at the request of a particular person or for a particular occasion. Since the post was published, we have received several enquiries as to what some of the terms means. Today’s post provides information on the meaning of these terms, and on the theme of the vajragiti more generally.

Hearken to the Dharma’ is a four-verse vajragiti written in the style of the spiritual songs of certain yogic traditions of Vajrayana Buddhism. In essence, it refers to the view of certain systems of Buddhist thought that we are currently in an era in which the Buddhist (and spiritual teachings more generally) are degenerating. More specifically, it refers to the fact that not all individuals who are currently teaching mindfulness, meditation and Buddhism have the ‘right intention’. When people with a selfish intent and who are without authentic spiritual realisation choose to teach meditation or Buddhism, it can result in negative consequences.

It could be argued that by writing a spiritual song such as the below, we are being judgemental. However, we wouldn’t agree with this because it is not judgemental to call a spade a spade. If things aren’t right, sometimes we need to speak up and raise awareness about the issue.

In the below vajragiti, the term ‘two accumulations’ refers to the Buddhist view that spiritual practitioners need to accumulate both spiritual merit and wisdom. Spiritual merit is accumulated by engaging in acts of generosity, patience, loving-kindness and compassion. Wisdom is accumulated by practising meditation, especially insight meditation. Spiritual merit and wisdom are necessary if we want to overcome the tendency of making our lives all about the ‘me’, the ‘mine’ and the ‘I’. Living a life that is always centred upon the ‘me’, ‘mine’ and ‘I’ is what is meant by the term ‘self-grasping’.

True renunciation’ means that we are no longer interested in mundane pursuits such as accumulating wealth or status. It means that we are aware that death is a reality that we will have to face, sooner or later. When we cultivate true spiritual renunciation, it is a liberating experience. However, it is important to remember that spiritual renunciation doesn’t mean that we turn our back on the world. Rather, it means that because we are free of selfish intentions, we can fully taste, enjoy and engage with the world.

In some Buddhist sutras, the Dharma is sometimes referred to as the ‘Law’. Therefore, the term ‘Law Holder’ means an authentic spiritual practitioner – somebody who has transcended the ego and given rise to a high level of spiritual awakening. A Law Holder could be a fully enlightened Buddha, or it could be somebody who is well on the way to attaining Buddhahood. A person who holds the Law of Dharma embodies and emanates spiritual awareness. They are not necessarily a Buddhist scholar.

In the context referred to in the vajragiti, our use of the term ‘Mara’ invokes the connotations that this term has with the notion of the Devil in Christianity. However, the term ‘Mara’ has several different meanings in Buddhism, which include negativity in its broadest sense. The ‘lower realms’ refer to realms of existence in which there are high levels of ignorance and suffering. The animal world is an example of a lower realm (i.e. when compared with the human realm), but Buddhism asserts that there are realms of existence that are lower than the animal realm (e.g. the hell realms).

The terms ‘View’, ‘Meditation’ and ‘Action’ in the final verse refer to the three components that comprise an authentic Buddhist spiritual path. For example, in the Noble Eightfold Path referred to previously on this blog, each of the eight individual components of the path are understood to be primarily concerned with the cultivation of either: (i) wisdom or a ‘view’ that transcends the notion of self and other, (ii) meditation, or (iii) ethical ‘action’. If each of these three aspects (i.e. wisdom/view, ethics/action and meditation) are present, then a particular Buddhist path can be considered whole and complete. The three path elements of wisdom, ethics and meditation are known in Sanskrit as ‘trishiksha’, which means the ‘three trainings’.

The term ‘three doors’ refers to the three ‘doors’ through which we interact with the world: (i) body (i.e. actions), (ii) speech (i.e. words), and (iii) mind (i.e. thoughts). Finally, the term ‘Mind as all’ refers to a view amongst certain Buddhist schools that existence unfolds within the expanse of mind. According to this view, waking reality is no more ‘real’ than what we experience while dreaming.

Hearken to the Dharma

All you great teachers and meditators,
Who mistake self-grasping and pride for the two accumulations,
In whom true renunciation and devotion never arise,
You, pleasure seekers, hearken to the Dharma that keeps death in mind.

Proudly claiming to be great Buddhists,
Judging others as ‘right’ and ‘wrong’,
Spreading doubt and disparaging the Law Holders,
You, Dharma destroyers, hearken to the Dharma beyond all concepts.

Practicing sophistry you deceive the foolish,
Competing for renown like Mara princes,
Dragging your followers to the miserable realms,
You, evil doers, hearken to the Dharma of karmic cause and effect.

For View you delight in ‘self’ and ‘other’,
For Meditation you indulge in scheming thoughts,
For Action you mindlessly vomit through your three doors,
You, delusion revellers, hearken to the Dharma that knows Mind as all.

Ven Edo Shonin & Ven William Van Gordon