Research reportMindfulness meditation practise as a healthcare intervention: A systematic review
Introduction
Mindfulness is a core construct of Buddhist teachings and lies at the heart of meditation.1 Meditation has been described as “a family of self regulation practices that focus on training attention and awareness in order to bring mental processes under greater voluntary control and thereby foster general mental well-being and development and/or specific capacities such as calm, clarity and concentration.”2 Formal and informal meditation practices whether they be sitting, walking, lying or in daily activity form a mental and attitudinal framework in which mindfulness may be established.3
Mindfulness is a state of consciousness in which the participant maintains a single pointed awareness focussed on mental, interoceptive and exteroceptive experiences; a quality of “bare attention” is attained where all elaborative and judgmental processes are suspended.4 Mindfulness is distinct from purposive outcome orientated self-management strategies. For example in relaxation exercises there is a definite aim or end point to be attained, however, mindfulness is characterised by a ‘beginners mind’ in which there is an inquisitive, embracing observation and a complete acceptance of all experience devoid of striving or attachment to any goal.3 Mindfulness has been characterised as a ‘crucible’ within which profound cognitive and behavioural changes may occur.5
The two principal strategies used to operationalise mindfulness as a healthcare intervention are Mindfulness Based Stress Reduction (MBSR) and Mindfulness Based Cognitive Therapy (MBCT). MBSR6 was developed by John Kabat-Zinn at the Department of Behavioural Medicine at the University of Massachusetts Medical Centre to address the cognitive and somatic dimensions of unmanaged stress associated with chronic pain and illness. In 1997 there were more than 240 programmes offering MBSR7 and since then interest has expanded exponentially.4, 8
MBSR is a multi-component group intervention programme consisting of 8 weekly two-hour group sessions and a final 8-hour whole day retreat. MBSR includes periods of sitting meditation and self-directed body scans to facilitate the impartial observation of sensation. Hatha yoga is included to generate increased musculoskeletal awareness and balance. Home practice and exercises are prescribed and are recorded in self-administered logbooks and diaries.
MBCT9 integrates aspects of Cognitive Behavioural Therapy (CBT) and MBSR. MBCT is intended to impart skills that empower patients in remission from recurrent major depression. MBCT teaches individuals to disengage from habitual depression-related ruminative mental patterns and adopt a more “decentred” perspective, where thoughts and feelings are viewed as transient negative or positive events rather than accurate representations of an objective reality. MBCT is delivered in 8 two-hour group trainings. Daily homework includes taped, guided or unguided exercises to promote mindfulness and additional exercises are designed to facilitate the incorporation of awareness skills in daily life.
There is an emerging debate on how the construct of mindfulness, embedded in an ancient spiritual and cultural heritage, may be evaluated by contemporary scientific analysis.2, 4, 10, 11, 12 The task of developing a scientific understanding of mindfulness is made problematic by the diffuse definitions that occur in the current literature where mindfulness is characterised as a collection of various techniques, a psychological process and sometimes as a distinct outcome in its own right.13 The development of a contemporary theory of mindfulness has been advocated as a spur to empirical work,11 but the utility of that work may in part depend on the development and use of validated mindfulness measures to assess outcomes in complex mindfulness based interventions.14 Moreover, when discussing mindfulness scholars must enter the “shadowy world of consciousness,”15 a notoriously difficult area.16, 17
It has been suggested that the non-judgmental observation of thoughts and their associated emotional sequelae may permit a state of detachment that could lead to the reduction of behaviours with adverse health implications.18 Mindfulness meditation has been shown to reduce habitual responding,19 and addictive behaviours have been modified in both injecting drug users and binge eaters.20, 21 Recently there has been an increase in the application of mindfulness techniques to a range of clinical and non-clinical populations including those suffering from cardiovascular disease, diabetes, prostate cancer and dermatomyositosis.22, 23, 24, 25
A growing number of studies appear to support the effectiveness of MBSR in a diverse range of patient populations. Some MBSR studies that have involved chronic pain26, 27 have shown statistically significant improvements in self-reported pain, psychological, and other medical symptoms that were largely maintained at follow up.18
Mindfulness based interventions have been used with those who have clinically defined psychiatric syndromes such as depression and substance abuse included in the Diagnostic and Statistical Manual of Mental Disorders 4th edition (DSM-IV,1995)28 as Axis 1 conditions. Axis 1 describes various categories of clinical disorders that cause significant impairment such as childhood developmental and adjustment abnormalities, adult anxiety, mood, sleep and sexual disorders. MBCT has produced positive results in patients with previous major depressive disorders.29, 30, 31, 32 Although many current studies have significant flaws4, 18, 33 and generalisability is limited, meta-analysis suggests that mindfulness interventions may have potential, particularly for chronic disease, pain and stress.34
The objective of this review was to systematically evaluate the literature related to the application of mindfulness-based interventions in healthcare and to draw conclusions based on the evidence from the highest quality randomised controlled trials. This study evaluates recent research not included in the review of mindfulness as a clinical intervention by Baer in 200318 or analysed in the extensive meta-analysis of MBSR conducted by Grossman et al. in 2004.34 In addition explicit methodological quality criteria were applied to provide new information on the quality of the current primary research literature on mindfulness.
Section snippets
Methods
The review protocol for this systematic review was formulated in accordance with the current guidelines for methodological best practice.35, 36, 37, 38, 39, 40, 41
Results
Computerised literature searches using the terms meditation, mindfulness and randomised controlled trial were conducted across 13 databases from the date of their inception to July 2006 (see Table 3).
Discussion
The 22 randomised controlled trials analysed in this review used a wide range of outcome measures to study a diverse range of patient populations, including Axis 1 conditions, diagnosed medical disorders and non-clinical populations. The methodologically strongest studies (11/22) demonstrated statistically significant changes following the application of mindfulness based interventions, as measured by 19 outcome variables. Improvements in psychological distress, spirituality, depressive relapse
Conclusions
Mindfulness may have potential as a positive healthcare intervention. The randomised controlled trials reviewed in this study have produced statistically significant results across a wide range of patient populations, including those with Axis 1 conditions, diagnosed medical conditions and non-clinical populations. The clearest indicators of the impact of mindfulness on health are those replicated in methodologically sound trials. The higher quality studies have shown statistically significant
Acknowledgements
TM acknowledges the cheerful example, patient guidance and deep wisdom of his mindfulness teacher Bhante Bodhidhamma. The authors would like to thank Tamar Pincus, Steve Vogel and Joanne Zamani (Research Department) and Will Podmore and Claire Baron (Library), British School of Osteopathy for their support and assistance. Also Lance McCracken for his critique of the manuscript and Brenda Mullinger, European School of Osteopathy for her editorial advice.
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