Although mindfulness is widely recognized in both the professional and popular literature, the state of the science in mindfulness research is still preliminary.
The good news so far is that mindfulness-based interventions work in the treatment of psychological disorders. A 2018 meta-analysis looked at 143 randomized controlled trials (RCTs), which are the gold standard research approach for testing interventions. The authors included any intervention that had mindfulness as a core component, such as Jon Kabat-Zinn's mindfulness-based stress reduction (MBSR) which has been studied since the 1970s, as well as mindfulness-based cognitive therapy (MBCT) which is a more recent adaptation of mindfulness techniques to fit within cognitive-behavioral therapy approaches. The treatments in this review generally involved individual or group work with a psychotherapist or coach, and lasted for multiple sessions. The authors excluded treatments that were based on mindfulness or other Eastern philosophies, but that didn't specifically teach people to implement mindfulness techniques - for example, Acceptance and Commitment Therapy (ACT) for various problems or Dialectical Behavior Therapy (DBT) for borderline personality disorder. Similarly, they excluded studies of meditation practices that didn't also teach mindfulness ideas.
In this review, mindfulness-based interventions were found to work better than no treatment. The average effect size was Cohen's d = 0.50, which reflects about half a standard deviation of improvement in symptoms or quality of life. This is a typical effect size for studies of active psychotherapies. Mindfulness-based interventions had positive effects for psychological problems including depression, chronic pain, and even the symptoms associated with schizophrenia. For addictions there were also positive effects, but with a wide range suggesting that some people benefitted much more than others from the treatment. Unfortunately, despite the intuitive appeal of "mindful eating" as a strategy for weight management, mindfulness interventions didn't work any better than comparison conditions in the treatment of eating disorders or obesity.
The average level of improvement for mindfulness interventions is similar to that produced by other forms of psychotherapy, and the direct head-to-head comparisons of mindfulness versus other psychotherapies that were included in this review found no differences between them. Mindfulness-based interventions did, however, outperform comparison conditions like brief 5- to 10-minute mindfulness coaching by a health care professional (d = 0.38) or supportive psychotherapy that used basic principles of empathy and listening without a strong theory of behavior change (d = 0.29). The fact that mindfulness outperformed other treatments without a strong theory basis suggests that something is unique about the approach. However, the fact that mindfulness failed to outperform interventions based on other unique theories of human behavior suggests that it is not the game-changer some of its advocates would like it to be. Mindfulness encourages people to accept and pay attention to symptoms, while cognitive-behavioral therapy in its classic form encourages people to logically challenge and use behavioral strategies to overcome their symptoms. The philosophical roots of these two approaches couldn't be farther apart. Yet, in practice, they work equally well.
As mindfulness has made its way into the mainstream, it has increasingly been paired with technology as a wide-scale delivery mechanism. Perhaps the marriage of mindfulness and technology goes back to Apple founder Steve Jobs, who studied meditation as a young man and promoted it as a philosophy for business. Technology-based mindfulness apps are now common, including popular options like Headspace, Calm, and 10% Happier. You might have seen the Insight Timer bell used to track duration during segments of meetings at work. The Breathe mindfulness app is built into the Apple Watch. Smiling Mind is an app for kids, tied to mindfulness education programs that are now found in many schools. And I have written previously about the Muse meditation app that works with an EEG headband to give biofeedback about one's brain waves during mindfulness practice. Even more immersive mindfulness interventions using virtual reality are currently being developed. Yet despite the proliferation of technology, some mindfulness experts have sounded a note of caution: If mindfulness helps us to disconnect from technology and reconnect with the real world, then technology-based delivery of mindfulness interventions is at best an oxymoron, or at worst a bait-and-switch by corporate interests that's designed to keep us even more plugged in. Others argue that the de-linkage of mindfulness methods from their Buddhist spiritual underpinnings has resulted in a "new capitalist spirituality" that supports further distraction and consumption rather than actual mindful practices. And the gamification of mindfulness -- e.g., trackers that encourage you to use the app or reach a certain number of mindful minutes -- might enhance competitiveness rather than Buddhist loving-kindness, or even feed Internet addiction in vulnerable individuals. There are a number of reasons, then, to wonder about the specific effects of technology-based mindfulness interventions.
A 2021 meta-analysis reviewed 83 randomized controlled trials (RCTs) of technology-based mindfulness interventions to determine their efficacy for a variety of life challenges. In this review, the authors excluded any mindfulness intervention that included contact with a coach or counselor, in order to focus only on mindfulness interventions that could be delivered at scale. All but 9 of the interventions were delivered via websites or smartphone apps; the few remaining ones involved much more prosaic delivery methods such as self-help CDs, worksheets, and books. The majority of studies in this review compared mindfulness interventions to either no treatment (e.g., a wait list) or usual care. About a third included a different self-help approach like participating in Internet discussion boards or receiving generic cognitive-behavioral self-help messages; these might be considered similar to the "non-theory-based psychotherapy" controls in the 2018 review. The number of days a participant used the program was correlated with how much they improved, but the number of days they actually practiced mindfulness during that time did not predict improvement, which suggests that some of the benefits of mindfulness might be separate from the actual mindfulness "sessions."
Overall, the technology-based mindfulness interventions' effects were weaker than those of the more intensive in-person mindfulness interventions from the 2018 review, with Cohen's ds ranging from 0.23 to 0.38 on measures of anxiety, depression, and wellbeing or quality of life. The type of comparison group did matter, with slightly stronger effects when mindfulness was compared to no treatment than to a generic-support intervention, but even in no-treatment comparisons the technology-based mindfulness interventions were much weaker than the effects demonstrated by in-person versions in the previous review. This weaker efficacy might be due in part to the fact that participants in the 2018 review were generally diagnosed with some form of mental health condition (major depression, anxiety disorders, etc.), while participants in the 2021 review were people simply experiencing symptoms of anxiety or depression without necessarily qualifying for a mental disorder. If participants in the 2021 review did in fact have less clinically severe problems than their counterparts in the 2018 review, this might mean (a) that they were easier to help which makes the technology-based mindfulness results even less impressive, but also (b) that they had less room for improvement, which might have artificially limited the amount of benefit that technology-based mindfulness interventions were able to provide.
In general, the concerns described above about mindfulness technologies were not substantiated: People reported that the interventions made them feel more mindful (d = 0.37) and less stressed (d = .41), rather than stressing them out more. A commentary on the issue of gamification suggests that technology can be helpful as long as it is viewed as a tool to assist with mindfulness rather than an end in itself. Perhaps that is in fact how people approach these new technologies. However, both reviews found a high level of variability in the results, suggesting that some mindfulness interventions work better than others for some people with some problem types under some set of circumstances. About a third of people dropped out of the mindfulness interventions before the end of the studies, suggesting that this tool is not for everyone. And one finding from the 2021 review is consistent with a view that technology is part of the problem rather than the solution: The small number of mindfulness interventions that used old technologies (e.g., books) actually had larger effects than the newer, app-based methods. This difference was more apparent for depression, self-reported mindfulness, and quality-of-life outcomes than for anxiety.
Another mindfulness review suggested several ways in which future studies need to improve. In some of these areas, Two Minds Theory may be able to help.
- First, future studies need to clearly define mindfulness. Definitions may include the cultivation of specific attitudes (appreciation, loving-kindness, etc.), the use of specific behavioral techniques (e.g., regular breathing, repetition of a mantra), or the intentional direction of attention (the most basic definition of mindfulness). Each of these aspects may correspond to different types of meditation that have been historically practiced by different religious or cultural groups, and the degree to which a mindfulness technique is grounded in a specific religious/philosophical tradition should also be specified by the researchers.
- Related to the issue of definitions, the theoretical model behind a mindfulness intervention should be described. Two Minds Theory suggests that mindfulness works primarily by training oneself to delay an initial behavioral response from the Intuitive mind, so that the Narrative mind has time to catch up. The delay has to be trained to the point where it becomes habitual — as always, one can’t simply tell oneself to wait, because the conscious mind arrives too late to the party. Once a person learns the behavioral response of “delay responding,” there is an opening for the Narrative mind to affect behavior. Essentially the person learns to pass on their turn the first time through the stimulus-response cycle of behavior, and the second time through (with Narrative input) is when an overt behavior actually occurs. Other accounts of mindfulness emphasize a more Narrative aspect of the approach - e.g., the idea that mindfulness is not just attention, but learning to see things through a lens of Buddhist loving-kindness. Alternately, mindfulness practice might increase body awareness (interoception) as a learned skill, which might reduce depression by correcting neurotransmitter deficits in the insular cortex. Different theoretical models of mindfulness will lead to different predictions about what moderators change during people's participation during an intervention, and ultimately this type of causal-path understanding could lead to different ways of designing a mindfulness intervention.
- Researchers need to clearly specify the dose and frequency of mindfulness interventions. From the second review article described above, we can see that the "dose" of an intervention might be defined in different ways: as the amount of time since the start of the intervention, as the number of sessions completed with a teacher or an app, or as the amount of mindfulness practice during that time. The right measures of dose and frequency will depend in part on the theoretical model of mindfulness that is proposed: If mindfulness techniques are conceptualized in terms of an Intuitively learned relaxation technique like regular breathing, then actual practice sessions might matter most. If mindfulness is more about the development of a new Narrative focused on loving-kindness, then perhaps a single exposure to new ideas plus the passage of time will do the trick.
- Researchers should also specify the specific type or modality of their mindfulness interventions. The contrast above between in-person and technology-based mindfulness interventions shows that the way these tools are delivered can matter quite a bit. For self-guided mindfulness interventions, it may matter whether a computer or a book is the medium of communication. The person-to-person interventions reviewed in the 2018 meta-analysis were probably conducted as live sessions, but in the new era of telehealth it might be important to examine in-person versus Zoom-based counseling as well.
- The specific target of interventions matters. Two Minds Theory suggests that it's easier to change people's beliefs or intentions than to change their behavior, and the 2021 meta-analysis showed stronger effects on people's self-report that they felt mindful or less stressed, which might be Narrative-level beliefs. Mindfulness interventions had weaker effects on measures of anxiety, depression, and quality of life, which might be more tied to people's actual behaviors and experiences. Furthermore, it's probably best to measure mindfulness in the context of everyday life, because daily measures are less biased by people's Narrative attitudes and beliefs.
- Finally, mindfulness researchers should include physiological as well as psychological measures to assess their interventions' effects. In general physiological measures (or sensor-based behavior measures) are less vulnerable to self-report biases and more credible metrics of change in response to mindfulness interventions. Some examples are measures of sleep or heart rate variability, outcomes for which there are credible reasons to expect change among people who learn mindfulness techniques. We explored physiological measures of mindfulness in a previous blog post, and suggested that there might be a difference between mindful responses and the mere absence of stress responses. Measures of synchronization -- e.g., the "coherence" measure used in HeartMath's proprietary algorithm -- might provide additional data beyond what can be gleaned from raw measures of heart rate or breathing.
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