Doug Oman (2023) has written a very thoughtful and comprehensive piece about potential synergies between the mindfulness and the public health fields. We are grateful to him for having raised so many important points for discussion, and to the journal Mindfulness for stimulating this discussion by inviting other academics, us included, to contribute their thinking. As researchers who have successfully brought mindfulness to the attention of top tier public health journals (e.g. Galante et al., 2018), we hope that our perspectives are helpful to other mindfulness researchers less familiar with the public health field.
In the sections that follow, we use the term “public health” following the same definition that Oman has used: “all organized efforts of society to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases” (World Health Organization, 2015, p. 249). When we use the term “intervention,” we refer to a public health intervention, defined as an “organized set of means implemented in a specific context to meet one or several targets with respect to improving health and preventing disease” (Litvak et al., 2020, p. 67). We use the term “mindfulness” to refer to either the academic field, or to practices that draw upon Jon Kabat-Zinn’s (2011) broad definition, or the consensus definition by Bishop et al. (2004). We do not use the term “mindfulness” in isolation to refer to a psychological trait or disposition (or attempts to measure such a trait)—for this, we use the term “dispositional mindfulness.”
Mindfulness and Contemplative Practices
In the first section of the article, “What is Mindfulness? Emic and Etic Views,” Oman identifies and discusses multiple issues that arise when attempting to define what mindfulness is. For example, he cites Rosch who highlighted that her work should “bring up many research questions that are obscured if everything is called by the name mindfulness” (Rosch, 2015, p. 280). However, later on, Oman proposes that an even more diverse set of contemplative practices is included under the mindfulness umbrella term (see mentions of “mindfulness analogues,” and section “Employs Branding”). He cites Karl et al. (2021), who “offered evolutionary arguments and preliminary evidence that cultural practices with functional features overlapping with mindfulness may have ‘emerged independently,’ ‘in a wide range of cultures’, and that by examining ‘a wider range of cultural and philosophical practices across the world…we can identify practices that strongly resemble mindfulness in spirit and practice’” (p. 11). Crane et al. have also proposed such a widening recently: “Widening the underpinning roots of MBP [mindfulness-based program] research and practice to include indigenous, and global majority wisdom, is essential if we are to truly increase access and build equity into the MBP field” (2023, p. 9). Academic definitions and conceptualizations of mindfulness ought to be thoroughly discussed before any meaningful inter-cultural comparison can take place.
There is a long history of attempts to define mindfulness within mindfulness researcher and practitioner circles. While for pragmatic reasons mindfulness-based program researchers have settled on Kabat-Zinn’s definition (1990), and the framework by Crane et al. (2017), these are far from uncontested by psychology, philosophy, religion, and anthropology (Grossman & Van Dam, 2011; Stanley & Kortelainen, 2019; Van Dam et al., 2018). Notably, even Kabat-Zinn (2011) himself has noted that his use/definition of mindfulness was as a placeholder for a broader set of ideas and practices. In the public sphere, the divergence of views about mindfulness is even greater, and, as Oman notes, the market is full of mindful products. Among academics who study yoga, there are propositions that “it might be more helpful to think of ‘yogas’, with a multiplicity of definitions and interpretations, rather than of a single yoga that we would seek to define and circumscribe” (Singleton & Byrne, 2008, p. 5) as cited in Jain (2020)). Should we be talking about mindfulness-es?
Perhaps an academic definition of mindfulness is not worth pursuing. After all, mindfulness as a means to manage illness and promote health was popularized in the public sphere by Kabat-Zinn (2011) when he was trying to make Buddhist meditation practices more palatable to secular audiences. We would be remiss not to mention that mindfulness is a core component of Buddhist meditation practices and is a concept central to Buddhist ideology (Analayo, 2003). However, the version presented within Kabat-Zinn’s offering is not purely Buddhist (see, e.g., Kabat-Zinn, 2011) nor do Buddhists necessarily agree on a common definition (see, e.g., Van Dam et al., 2018). Kabat-Zinn, being a scientist, provided a fast and direct conduit for mindfulness to enter the academic world, so that mindfulness-based programs could be evaluated using scientific methods. Mindfulness then, in this context, has a Buddhist-inspired, albeit popularist origin, and as such it does not have a singular theoretical framework that supports the term. Since its introduction to the academic vernacular, mindfulness enthusiasts have been trying to retroactively build an academic theoretical and empirical framework around it, arguably with limited success due to the breadth of concepts to which it refers and is applied.
Despite the strong associations between mindfulness-based programs and health outcomes, it is still very unclear what the specific components, outcomes, and mechanisms of this intervention are (Galante et al., 2023; Goldberg et al., 2018). Measures of dispositional mindfulness were created to provide an operationalization of what changes in mindfulness-based programs (see e.g., Baer, 2011). However, as an intervention with an ambiguous theoretical background, it may not be surprising that there is very little empirical support for dispositional or trait mindfulness as a psychological construct, nor is their adequate evidence to suggest dispositional mindfulness is the core mechanism by which mindfulness-based programs have their effects (Altgassen et al., 2023; Goldberg et al., 2019; Van Dam et al., 2018). Existing psychological constructs with a stronger theoretical and empirical basis, such as emotion regulation and decentering, may do a better job explaining how mindfulness meditation improves mental health than dispositional mindfulness (see, e.g.,Goldberg et al., 2019). In this, we agree with Oman, who says that “Some of these [dispositional mindfulness] measures might be beneficially reframed as assessing facets of attentional health” (p. 11). This reframing would make it much easier to integrate mindfulness training with other contemplative practices, and public health interventions within complex multilevel interventions.
Therefore, rather than expand the use of the term mindfulness as Oman suggests, we think it may be more productive to question the value of mindfulness as an academic term in relation to the interventions themselves. Religious studies scholar Andrea Jain proposes that instead of arguing over what terms such as yoga or mindfulness are, academics may find it more productive to analyze how the different definitions of these terms in the public sphere are shaped by power structures dominant in the different historical and cultural contexts (Jain, 2020). She encourages “attention to the ideologies, discourses, and practices within which identities, such as yoga or mindfulness, are ‘animating, constitutive figures’ that are deployed within ‘situated networks of power and knowledge’ in order to produce certain types of moral communities” (p. 65).
If mindfulness is a term that came to prominence in the popular culture, perhaps that is where it should remain. While we agree with the effort to be inclusive, widening the conceptual basis of a concept that is already ill-defined (i.e., mindfulness) runs the risk of forcing disparate worldviews into alignment and potentially missing critical differences; a problem that could easily be addressed with a broader term, such as “contemplative practices.” If mindfulness-based practices are conceptualized as a type of contemplative practice, including mindfulness within the contemplative studies field may be more fruitful than attempting to include more practices under the mindfulness banner, no matter how popular the term may be. Rather than trying to find academic anchors to the term and provide definitions that tie up its cultural evolution, perhaps we should acknowledge the role of popular culture in shaping and reshaping definitions, while we create and work with different, more stable and better delineated, academic terms in order to maximize the contribution that contemplative practices such as mindfulness can make to public health.
Can Mindfulness and Public Health Fields be Compared Head-to-Head?
It is important to realize that, as a research and practice field, public health is vastly larger, wider, and more complex than mindfulness. Public health is not even in the same category of fields, because mindfulness is defined by a limited set of specific processes and practices while public health is a field defined by its application, irrespective of the interventions used. Thus, the head-to-head comparison presented in Oman’s article section “Are Mindfulness and Public Health Aligned?” incurs a category error. The whole discussion would be more accurately framed around how mindfulness could contribute to public health, as one of many fields of similar category to mindfulness. Framing the discussion in this way can also bring more clarity to some confusing or problematic issues in the mindfulness field, as follows.
With its very broad set of tools, the research and practice of public health is able to modify, if there is political will, the social determinants of health such as housing, employment, or sanitation, often referred to as “upstream” determinants. Oman makes the case that “modern mindfulness approaches resonate with the public health field’s emphasis on causally ‘upstream’” approaches to foster salutary health behaviors and other protective factors that build resilience and prevent disease before it arises” (p. 1). We believe that while both think upstream, public health places the emphasis on systemic issues, and mindfulness on individual ones. We disagree with Oman’s assertion that “in addressing social and cultural factors, mindfulness has lagged in comparison to public health” (p. 10). Applying mindfulness training on its own is unable to tackle systemic issues. In order to address systemic issues, public health needs to target systems, for example, adding cycle lanes in a city to encourage individual and systemic-level outcomes such as improved citizen health and reduced carbon emissions respectively. Mindfulness can have a variety of effects on the individuals who learn the practices, but mindfulness training will always target individuals, not systems. Continuing with the analogy, adding cycle lanes encourages cycling by making it easier and safer—there is no obvious systems equivalent of mindfulness, which relies on individuals being transformed and then acting on the system.
Systemic issues also typically need coordinated intervention at many levels, using more than one technique, and often targeting individuals as well as systems (Lo Moro et al., 2020). Oman acknowledges that mindfulness-based multilevel interventions are hard to find. As an example of such an intervention, he describes that used by Meischke et al. (2018), “who provisioned individual workers with mindfulness training, while simultaneously provisioning managers with toolkits for ‘organizational stress reduction’—toolkits containing modules on issues such as ‘conflict management,’ ‘bullying in the workplace,’ and ‘health and wellness’” (p. 12). We agree that this is a multilevel intervention, but mindfulness is only used at one level. The other levels of this complex intervention consist of components other than mindfulness training. One could think of a program teaching mindfulness to individuals with different levels of responsibility within an organization, such as managers and clerks, as a multi-level mindfulness-based intervention. However, if the intervention is the same and the intention is to, for example, reduce psychological distress across the board, the intervention is not multilevel, just inclusive of individuals with different roles. For the intervention to be multilevel, there has to be different actions and different aims to be implemented at each level. To truly offer intervention at multiple levels, the causes of suffering would need to be diminished, the acute management of suffering would need to be better and more accessible, and the long-term follow-up would need to be improved. In other words, it cannot just be on the individual to deal with their own experience of the situation. While such an approach is helpful, it is not the same as a truly multi-level systemic intervention.
There is also the idea that targeting powerful individuals with interventions that may make them more prosocial will produce a trickle-down effect on dependent individuals, indirectly improving their well-being. For example, leaders at an organization might learn mindfulness with the aim of improving their team’s well-being, while the team members learn stress reduction for themselves. However, Oman himself acknowledges that the trickle-down effects from organizational leadership mindfulness training are merely speculative, with limited, if any, support. If anything, the existing evidence for trickle-down effects is discouraging. The MYRIAD trial, the largest ever mindfulness experiment, facilitated training in mindfulness to teachers who were then also trained to teach mindfulness to their secondary school students (Kuyken et al., 2022). This strategy had some positive outcomes for teachers, but there were no effects, either direct or trickle-down via teacher well-being, on students up to one year later. Even if teachers had been more mindful, they may have had have limited ability to change the classroom environment or home context of their pupils.
Framing this proposal around how mindfulness, as one of many interventions, could contribute to public health, can also shine a light on whether mindfulness practices are genuinely aiding individuals vs. helping perverse systems create more harm by masking the effects of poor social and structural conditions on health while making people more accepting of these conditions (Purser, 2019). As interventions seek to increase individual resilience, they put the onus for improvement on the individual, which, if not embedded within suitable cultural frameworks and accompanied by other interventions, may make them feel as if the problem is theirs and theirs alone. A perspective where mindfulness is seen within a large ecosystem of ideas and potential actions might remind researchers that mindfulness was not the only “intervention” in the societies in which it originated. For example, Right Mindfulness is only one of eight Buddhist factors listed in the Noble Eightfold Path, a prescription for how to go about living one’s life. In the same way, mindfulness may only be an instrument in the orchestra of actions that need to be taken for advancing the public health agenda in current societies. We agree with the author in that social movements are needed to “stop the people pouring itching powder on us” (p. 14), and that mindfulness and contemplative practices could have an important role in social movements to reduce health inequity and effect structural change—but they cannot be the social movement. They can instead be individual-level components of broader interventions, where they may help individuals not just to be more resilient but also to connect with their motivations, values, and communities (Caggiano et al., 2023; Koppel et al., 2023).
Working “as” or “with” Public Health
Contemplative practitioners may have the best intentions when they approach a community with the aim of imparting their knowledge to improve health, but they may not have in their toolbox what that community actually needs. This problem is expressed most acutely when attempting to roll out mindfulness-based interventions to whole populations universally, that is, when intervening on many groups at the same time using the same intervention. Again, the recent MYRIAD study is a great lesson on this: it found that embedding a mindfulness-based intervention in UK school curricula not only did not help the average adolescent, but it also harmed some groups (Kuyken et al., 2022).
Apart from not having a wide perspective of the many interventions that could be applied in different settings and how to combine them, people who work delivering specific interventions may have strong allegiances and conflicts of interest that will bias their research efforts to evaluate those same interventions. This is a known problem with research on mindfulness (Galante et al., 2021; Goldberg & Tucker, 2020), meditation (Kreplin et al., 2018), and other psychosocial interventions (Cristea & Ioannidis, 2018; Dragioti et al., 2015). Researcher allegiance occurs when researchers testing an intervention are already convinced that the intervention is superior, while conflicts of interest arise when an individual’s interests (personal, social, or financial) could consciously or unconsciously compromise their judgment, decisions, or actions in the research. Going back to the differences between public health and mindfulness, here lies one of the key elements that undermines head-to-head comparisons: public health’s only agenda is to improve health for as many people as possible, independently of the types of interventions used (as long as they are ethical). The mindfulness field, by choosing to define itself via the use of a specific intervention, inherently implies a conflict of interest: mindfulness experts would lose status and power if mindfulness proves ineffective.
In mindfulness research, on top of the limited perspective, allegiances, and conflicts of interest that apply to psychosocial interventions in general, there is a further issue. While mindfulness researchers are strongly advised to be trained in meditation (Desbordes & Negi, 2013), there is very little talk about the benefits of also having within mindfulness research teams investigators who are not trained in meditation. The latter, less invested in the practices (Smolka, 2019), could bring in fresh perspectives and reduce group-think effects, ultimately increasing overall research quality (Smolka, 2019).
All these limitations are, in our view, strong reasons why the practitioner-researcher model—i.e., practitioners accessing a community on their own and evaluating the implementation of their intervention—is not the best model for public health purposes. Interventions will be richer and results more reliable if practitioners work with independent researchers that have complementary expertise. The latter can do the listening work first to see what the actual needs are, match needs with specific interventions, invite practitioners to develop and/or deliver them, and assess results. For example, a public health researcher liaises with a local community and detects that there is a need for an intervention to reduce loneliness and prevent its negative effects on mental health. Interviewing local residents to understand what sort of intervention might be acceptable, they conclude that a council-sponsored group-based teacher-led mindfulness-based program offered at the local community centre combined with a door-to-door approach to invite residents might be helpful. They then investigate which mindfulness program providers in the market might be best for this community (e.g., teachers who are already known to residents), and liaise with them to organize implementation and any superficial adaptation needed (e.g., class duration). Finally, the public health researcher designs and runs an evaluation of the effects of this program on this community (if not known already). A less straightforward example would be that while the public health researcher sees the potential for a contemplative practice to help, they deem a pre-existing mindfulness program not suitable because this particular community would not find it acceptable. Rather, a new contemplative practice program is deemed appropriate, building on contemplative practices already used by this community, and co-designed with the community.
In sum, there is plenty of potential for inclusion of contemplative practices within public health initiatives that aim at addressing upstream determinants of health, improving health and tacking health inequity. However, for this potential to realize fully, we think that the mindfulness field will need to work “with” rather than “as” public health.
If You Want to Help Them, Ask Them What They Need
Oman makes the case that in order to help diverse communities, it is important to tailor mindfulness-based interventions to national and local culture (e.g., by working with “cultural insiders”). There has been a growing conversation in the mindfulness movement about adaptation in the last decade (Crane et al., 2023; Loucks et al., 2022). However, we think that Oman and the mindfulness field in general are missing a key point in their quest to help diverse communities, particularly those underserved or underrepresented. There is an underlying assumption that local communities will benefit from a mindfulness-based program, and that the only work to be done lies in adapting its logistics or vocabulary, followed by community implementation. There is no mention of engaging with the community first to listen to what they have to say about their problems or their needs, and how they think these could be addressed. There seems to be a failure to consider the possibility that some do not want or need what mindfulness innovators are offering, and that others may want it but in very specific ways. There is extensive literature in the public health field about involving communities in intervention creation and implementation processes from inception (Durand et al., 2014; Greenhalgh et al., 2016). Without broad discussions about the types of problems faced by a local community, any efforts at adaptation may be surface deep at best and may represent a fundamental mismatch between what the community wants and/or is willing to do and what mindfulness innovators are offering.
The following examples illustrate this fundamental blind spot. Oman cites Proulx et al. (2018), who has observed that American minority communities “have well-developed coping mechanisms that are culturally specific and recognizable by community members” (p. 367). Both Proulx and Oman seem to concur in that what needs to be done is to explore “how spiritual and contemplative traditions in these communities resonate with mindfulness” (p. 362). The specific focus on mindfulness seems to overlook rich, cultural approaches to dealing with complex problems. Why only consider those local traditions that resonate with mindfulness? Community needs may be around contemplative practices that are not typically included in mindfulness-based programs, such as group chanting, prayer, and ritual (Crane et al., 2017); or perhaps interventions other than contemplative practices are needed. By presuming the solution prior to engaging the community, we may entirely miss the problem, fail to engage the community, and/or waste time and money. Oman may still be trying to force mindfulness into the equation when he defends the need for “deep” structural adaptation by framing mindfulness “within culture’s ‘values, customs, and traditions’” (p. 16) considering how the problem “is theorized or explained to clients” (p. 16), and/or including knowledge about cultural background in the intervention (Castellanos et al., 2019). The proposed solution is to adapt the existing offering rather than to explore whether there is a match between community needs and what the mindfulness innovator has to offer. Potential assumptions around singular core metaphysical truths or common origins and goals may actually obscure meaningful dialogue about why and how people do what they do to meet their needs.
Oman notes that “attention to mindfulness remains rare in major parts of the world—for example, in Africa” (p. 2). We interpret that this refers, at least in part, to the low availability of mindfulness-based programs and similar mindfulness training offers in African countries, compared to other areas of the world. And we wonder: should this change? We think that the only way to know is to work with the very diverse local communities in the African continent and listen to the specific local needs. There is some emerging work in this direction (Draper-Clarke & Green, 2023). Communities often already have their own local contemplative practices—is it wise to impose mindfulness (adapted or not) to them? If the community does not feel listened to and taken seriously, there will not be any room for empowerment, and barely any social capital growth—no matter what you teach them.
Conclusions
In summary, we think the article by Oman raises some essential topics for discussion and are grateful that it has provoked this exchange. However, we think it is a category error to compare mindfulness directly to public health, believe that mindfulness should be used “with” rather than “as” public health, that we need to explore what target populations actually want rather than pre-emptively thinking about the ways to adapt mindfulness, and suggest the field consider alternative, more inclusive terms for practices rather than trying to force other practices to fit under the umbrella of mindfulness. Such conversations are crucial as mindfulness research and the field of contemplative studies continues to grow. As the field matures, it is key that we integrate perspectives from multiple disciplines and cultures to ensure that we do not find ourselves in a “mindful echo chamber.”
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