Brief mindfulness-based interventions (MBIs) show promise for mental health support. However there is wide heterogeneity across intervention types, and a lack of systematic stakeholder involvement in their development. Our objective was to use INDIGO, a novel mixed method, to explore stakeholder perspectives on what a brief MBI should comprise.
Method
INDIGO combines timelining and storyboarding, and was used to collect data. Twenty-one participants (mean age 42.2 years, 15 female, 13 mindfulness teachers or trainee teachers, average 11 years’ experience of mindfulness practice) returned completed INDIGO charts. There were two data analysis stages: Descriptive analysis of qualitative and quantitative data (including qualitative content analysis); Interpretive analysis of visual and textual data using polytextual thematic analysis.
Results
The mean number of sessions suggested for a brief MBI was just over five. The most frequently suggested elements to include were focused attention practice, inquiry, three-step breathing space and psychoeducation. There were different interpretations of some practices, such as “open monitoring”. Three themes were generated from the polytextual thematic analysis: “Starting Where You Are” focussed on the needs and capacities of individual participants; “Surfing the Waves” described dynamic processes that need to be managed within a brief MBI, including holding the group; “The Deep and The Wide Path” connected the course formats suggested in this study to existing MBIs.
Conclusions
The visual aspect of INDIGO highlighted the influence of existing approaches that otherwise may be overlooked. The development and implementation of new, brief MBIs should take a person-centred approach, consider social common factors, and include training to increase the scientific literacy of teachers.
Mindfulness-based interventions (MBIs) are complex interventions that comprise multiple interacting components (Craig et al., 2008; Demarzo et al., 2015). These components typically include a variety of formal and informal mindfulness practices (including meditation), facilitator-led discussion of practice experience known as “inquiry”, psychoeducation, and mindfulness practice outside of class-contact hours. A significant body of research has demonstrated the effectiveness of MBIs such as Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 2004) and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2013) for improving physical and mental health. For example, Türkoğlu and Kavuran (2024) reported improved levels of perceived stress and quality of life in caregivers of people with cancer who attended an online MBSR course. A systematic review and meta-analysis of MBSR, MBCT and adapted mindfulness interventions for patients with breast cancer reported lower levels of depression in women who attended MBI groups (Reangsing et al., 2023). Additionally Khoo et al. (2019) reported clinically important changes in physical functioning, pain intensity, and depression symptoms in people with chronic pain who attended MBSR compared to control groups. There is also evidence that MBSR and MBCT can improve psychological health and wellbeing in nonclinical populations (Querstret et al., 2020).
There are, however, challenges associated with MBIs. MBSR and MBCT are intensive 8-week interventions that require weekly attendance at class sessions of 2–2.5 hr duration, and daily home practice of approximately 45 min per day for the duration of the course. This is a substantial time commitment which can be difficult for some participants to maintain, and many individuals practice less than the recommended duration outside of scheduled classes (Allen et al., 2009; Birtwell et al., 2019; Parsons et al., 2017; Quach et al., 2017).
Brief MBIs that are less demanding on the time and energy of participants may be a viable alternative to more intensive eight-week MBIs, or for some participants, they could be an important first step before attending a more intensive programme. There is growing evidence for the effectiveness of brief MBIs. For example, Martorella et al. (2024) reported findings from a pilot randomised controlled trial of a 4-week online MBI for 36 participants, delivered after total hip or knee replacement surgery. The MBI consisted of a pre-recorded video that participants could watch multiple times. Participants in the brief MBI group reported reductions in pain intensity, pain interference, and pain medication use. In a recent randomised controlled trial of 486 university students (Barcaccia et al., 2024), participants in the intervention group attended a weekly thirty-min mindfulness class delivered by a clinical psychologist who was an experienced mindfulness teacher with training in MBSR. The class comprised a 10-min breathing meditation, and group discussion of practice experience with feedback from the class instructor. The intervention duration was 28 days and participants were asked to complete a breathing exercise each day. The authors reported significant reductions in depression, rumination, and trait anxiety in the brief MBI participants (Barcaccia et al., 2024). Findings from systematic reviews further support the potential of brief MBIs for improving physical and psychological outcomes (Howarth et al., 2019; Jimenez et al., 2020; McClintock et al., 2019; Schumer et al., 2018).
While there is evidence to support the use of brief MBIs, there is considerable variation in terms of intervention content and duration (e.g., Birtwell et al., 2021). Some brief MBIs vary in duration from 30 min or fewer to more than 12 hr over six sessions, and some are abbreviated forms of MBSR or MBCT and include similar components while others include a smaller number of selected practices or do not provide a clear description of the intervention content (Birtwell et al., 2021). The recommended “dose” or amount of mindfulness practice varies across brief MBIs, and for MBIs generally (of any duration) the evidence is mixed regarding the amount of mindfulness practice required to achieve positive outcomes. There is some evidence to suggest that frequency of mindfulness practice rather than duration of practice is associated with improved outcomes. For example, Britton et al. (2010) reported a correlation between practice frequency (but not duration) and improved sleep in drug abusing adolescents. In a study of 60 employees, Manigault et al. (2021) reported that more frequent mindfulness practice in daily life was associated with reduced stress, as was more frequent audio-guided mindfulness practice. With regard to duration of mindfulness practice, there is evidence that both short and long practices can lead to improved outcomes (Strohmaier, 2020; Strohmaier et al., 2021). This heterogeneity and lack of clarity regarding intervention content may limit the transferability of findings from brief MBI research into practice.
MBIs are complex psychological interventions and guidance on the development of complex interventions recommends involving stakeholders throughout this development process (O’Cathain et al., 2019). Methods such as co-design, participatory approaches, or the Person-Based Approach to intervention development (Yardley et al., 2015) centre the views of stakeholders and future intervention users to increase the likelihood of interventions being acceptable to end users. However, such involvement is lacking in the development of many brief MBIs. We have employed a theory-, evidence-, and person-based approach (Yardley et al., 2015) to develop a brief MBI for a diverse population, e.g. primary care or the general population. The present study builds on the findings of our previous work, an online survey study (Birtwell et al., 2021). The findings from this previous study suggest a brief MBI could be five sessions long, and 80-min duration per session. We found differences of opinion regarding the inclusion of some practices such as the body scan and sitting with difficulty practice, and participants expressed concerns about insufficient content, curriculum adherence, teacher training and participant safety. Due to the limitations of the survey method we were unable to explore how participants thought the different components of a brief MBI should fit together to create a whole intervention.
The present study extended this work by supporting participants to consider the design of a brief MBI from a whole-intervention perspective. Participants included a range of stakeholders such as former mindfulness course attendees, mindfulness practitioners, mindfulness teachers and researchers. INDIGO (INtervention DesIGn with stakehOlders, Birtwell et al., 2022) was designed specifically for this study and is based on the techniques of timelining and storyboarding. It is a creative mixed method of data collection that enables participants to explore how elements of a complex intervention can be combined, giving consideration to how much of each element to include and in what order the elements should feature. While the present study is the first study to use INDIGO, it is based on established research methods (timelining and storyboarding) that have been used in a range of studies, including research with marginalised groups and participatory research (Birtwell et al., 2022). Further information about the development of INDIGO as a new mixed method and the benefits and challenges of its use can be found in Birtwell et al. (2022).
The aim of this study was therefore to use the novel INDIGO method (Birtwell et al., 2022) to explore what participants with experience and/or knowledge of mindfulness think a brief MBI should comprise. When we reviewed the INDIGO data it was clear that the INDIGO charts revealed more about participant perspectives than this aim addressed. We therefore decided to explore an additional aspect of the topic: how participants constructed brief MBIs using INDIGO. Our research questions were therefore as follows: (1) According to participants, what should a brief MBI comprise? (2) How were the interventions from participants constructed in terms of style or approach?
Method
Design
This study utilised an iterative mixed methods approach due to the exploratory and complex nature of the research. The purpose of combining qualitative and quantitative methods was complementarity, to enable us to gain a more complete understanding of the topic (Creamer, 2018; Greene et al., 1989). A combined convergent and explanatory sequential design was employed (Creswell & Creswell, 2018; Nicolson et al., 2011) with equal weighting given to the qualitative and quantitative aspects during data collection and the first stage of analysis, as indicated by the capitalized terms “QUAL” and “QUANT” in Fig. 1. Qualitative and quantitative data were collected concurrently via INDIGO and data were analysed in two sequential stages as illustrated in Fig. 1. In the Stage 1 analysis (the descriptive analysis stage), quantitative and textual data were analysed separately and the findings were then merged. The qualitative analysis of textual data helped to explain and elaborate on the findings from the descriptive quantitative analysis. In the Stage 2 analysis (the interpretive analysis stage) further qualitative analysis elaborated on the findings from Stage 1. There were multiple points of integration, as described in the next section.
Integration has been defined as “the linking of qualitative and quantitative approaches and dimensions together to create a new whole or a more holistic understanding than achieved by either alone” (Fetters & Molina-Azorin, 2017, p. 293). The present study involves integration within several of the dimensions described by Fetters and Molina-Azorin (2017), for example with the personal and professional experiences of the researchers (described below), the combination of the research team (described below), the rationale, the study purpose, aims and research questions, and the research design (described above). The study employed concurrent mixed methods convenience sampling whereby qualitative and quantitative data were collected from a single sample of participants (Creamer, 2018). Qualitative and quantitative data were collected concurrently using INDIGO, demonstrating integration of data collection through expansion (Fetters & Molina-Azorin, 2017). Integration within the interpretation dimension occurs through narrative using both a weaving and a staged approach (Fetters et al., 2013), i.e. the quantitative and qualitative findings of the Stage 1 analysis are woven together and reported first, followed by the findings of the Stage 2 analysis. Integration within the interpretation dimension also involves drawing metainferences (Fetters & Molina-Azorin, 2017).
Reflexivity
This study was conducted as part of the first author’s PhD. I am a counsellor and mindfulness teacher with experience of qualitative, quantitative, and mixed methods research. I have trained to teach Mindfulness-Based Cognitive Therapy as well as brief and person-centred approaches to mindfulness. My experience of teaching these different approaches has influenced my interpretation of the data provided by participants in this study. Personal subjectivity is known to contribute to analysis within qualitative research, for example Gleeson (2011) discusses this in relation to research with visual images: “The fact that we use a specific lens to view the images is precisely the thing that makes our interpretation culturally useful.” (Gleeson, 2011, p. 328). As researcher subjectivity is considered a resource that supports data analysis, measures to remove “bias” (such as inter-rater reliability measures) are considered unnecessary (Braun & Clarke, 2023). Our reflexive approach to analysis is in line with other reflexive qualitative approaches that emphasise the active role of the researcher in the analytic process (Braun & Clarke, 2023).
The second author is a social sciences researcher and the third author is a Health Psychologist. Both have expertise in patient safety and intervention development, and neither practices mindfulness. The second author has knowledge and experience of qualitative methods and the third author has knowledge and experience of qualitative and quantitative methods. Within this mixed methods approach to inquiry we were able to combine our different experiences and perspectives to explore the topic comprehensively.
At the time of writing the first author holds a critical realist view. More specifically, I align myself with the type of critical realism described by Maxwell (2012), where critical realists “retain an ontological realism (there is a real world that exists independently of our perception, theories and constructions) while accepting a form of epistemological constructivism and relativism (our understanding of this world is inevitably a construction from our own perspectives and standpoint)” (Maxwell, 2012, p.5). Thus, critical realism allows for the idea of multiple perspectives (Maxwell & Mittapalli, 2010) and is compatible with a mixed methods approach to research. The second and third authors also hold critical realist perspectives.
Participants
Twenty-one people took part in this study. The mean age of participants was 42.2 years (SD = 13.1, range = 26–71). All were university graduates and 15 (71.4%) were female. With regard to mindfulness experience, participants self-identified in a range of ways: mindfulness teacher or trainee teacher (9); mindfulness teacher or trainee teacher, and researcher (4); mindfulness course attendee and researcher (3); mindfulness course attendee (1); mindfulness researcher (2); mindfulness practitioner (2). On average, participants had 11.4 years’ experience of mindfulness practice (SD = 14.9, range = 1–67).
As this was a mixed methods study and the analysis of quantitative data was intended to be descriptive only, our sample size was guided by principles of qualitative research, specifically information power (Malterud et al., 2016). A sample size of 21 is considered a medium to large sized qualitative study (Braun & Clarke, 2013) and we considered this sample to have sufficient information power to answer our research questions. For example, the aim of the study was narrow (focused on the content of a brief MBI); the sample included participants with experiences and knowledge that were specific for the study aim while also including some variation of experience; data were rich; and cases were considered individually as well as across the dataset (Malterud et al., 2016).
Procedures
Recruitment was conducted by the first author using convenience sampling. Participants with prior experience or knowledge of mindfulness were recruited from a leading international mindfulness-focused conference in Europe (n = 11) and a locally organised conference in the UK (n = 10). Permission to recruit participants was provided by the conference organisers. The conferences were selected as recruitment sites due to the variety of conference delegates, who were expected to have a diversity of mindfulness experience. The international conference had a broad scientific remit and was attended by almost 700 participants over three days. The local conference had a theme of Trauma Sensitive Mindfulness and Compassion and was attended by approximately 100 people over one day. Sixty INDIGO kits (chart, worksheet and consent form; see materials section below) were distributed to conference delegates across the two conferences and 21 completed kits were returned.
Participants were provided with task instructions that asked them to create a brief mindfulness course using the INDIGO kit (see “INDIGO chart” section below for task instructions). Initially, participants were asked to return the completed INDIGO kits on the day of the conference. However, some participants requested additional time, so they were advised to either return the completed kit by post or send scanned or photographed copies via email. For the second conference an instruction sheet was included that advised participants how to return the kit in person, by post, or via email.
Participants were contacted individually by email if clarification was required about any element of the chart, e.g. if the handwritten notes were not clear either due to scanning or handwriting, or if information was missing. Explanatory comments from emails were included in the data analysis.
Materials
Each participant was provided with one INDIGO kit comprising a participant information leaflet, consent form, worksheet, INDIGO chart, tokens representing intervention elements, and a key explaining the meaning of the tokens. Delegates at the international mindfulness conference were also given an instruction sheet explaining the process for returning the consent form, worksheet and INDIGO chart to the researcher. Due to the time and resource constraints of the first author’s PhD INDIGO was not pilot tested. Further information about the development of INDIGO and its application to this and another empirical study, including a discussion of the practicalities and challenges of using INDIGO, can be found in Birtwell et al. (2022).
Worksheet
The participant worksheet contained demographic questions including country of residence, age, gender, ethnicity, level of education, year of beginning to practice mindfulness, and role in relation to mindfulness, e.g. mindfulness teacher, researcher or past mindfulness course attendee. The worksheet also provided space for participants to write explanatory notes about the task.
INDIGO Chart
The INDIGO chart was an A4-sized card printed with a blank timetable grid split into seven sections to represent distinct intervention sessions (Fig. 2). The following task instructions were printed at the top of the card: “Below is an empty timetable grid for a brief mindfulness course. We would like to know what you think should be included in a brief mindfulness course. Please use the tokens provided to show where you would put which practices and activities and how long you would like each element to be.
You can choose the length of the course- from one to seven sessions, and how long each session should be- from ten minutes up to 110 min (just under two hours). You can vary the length of the sessions if you wish, e.g. if you want the first session to be longer than the others. You can add notes here or on the accompanying worksheet to explain your choices. Please note there are no right or wrong answers, we would just like to know what you think. We understand the format of the course could vary if you have a particular client group in mind, so please say if this is the case.”
The explanation of a brief MBI was left intentionally broad (fewer than seven sessions and fewer than 110 min per session, i.e. shorter than a standardised 8-week MBI) so that participants would not be unduly influenced by the researchers in deciding the intervention duration.
Tokens
Participants were provided with card tokens (approximately 2 × 2 cm square) that contained images or letters to represent specific elements of a mindfulness course. See Table 1 for the “key for tokens” which lists all elements and descriptions as provided to participants. These intervention elements were selected by the first author because they feature in a range of widely available MBIs such as MBCT (Segal et al., 2013), MBSR (Kabat-Zinn, 2004) and mindfulness-based programmes such as those acknowledged by the International Panel for Acknowledgement (IPA; https://www.eamba.net/ipa-acknowledged-mbps/) and recognised by the British Association of Mindfulness-Based Approaches (BAMBA; https://bamba.org.uk/new-mindfulness-based-programme-acknowledgement/).
The intervention elements included focused attention practice, informal mindfulness, and open monitoring practice, which are associated with aspects of dispositional mindfulness (Cebolla et al., 2017). Dispositional mindfulness is associated with subjective and psychological wellbeing (Hanley et al., 2015) and it could be hypothesised therefore, that including these elements in a brief MBI should increase wellbeing. Definitions of these and other elements (as provided to participants) can be seen in Table 1.
Table 1
Key for tokens
Note: the term “Education and Knowledge Sharing” was used to refer to psychoeducation as it is a more accessible term. Within the element descriptions, examples of specific activities or practices from a range of MBIs were provided, in order to help participants relate the elements to their own experiences
For the focused attention practice element (labelled “FA”) participants could add their own choice of focus for the practice (a “focusing anchor”), such as the breath or sounds etc. Participants could add further elements beyond those specified on the pre-set tokens through the use of a “wild card”. Tokens could be combined in any way by participants, to create a visual representation of a brief mindfulness course.
Key for Tokens
The key for tokens is shown in Table 1. This displays all images and letters that were printed on the tokens along with the element descriptions, as provided to participants. The key for tokens contained further task instructions, as follows:
“The key below explains the parts of a mindfulness course that the tokens represent. Please note the tokens are mainly in squares that represent 10-min blocks, with some half-squares as 5-min blocks. If you would like the practices or activities to be longer (e.g. 15 min, 20 min etc.), please add extra squares to the grid, or draw an arrow on the grid to indicate how long you would like the activity to last for. If you would like the activity to be shorter (e.g. 5 min), then use half a token or make a note on the grid about the duration. If you have any questions about the activity please ask the researcher.” The key then explained the meaning of each intervention element.
Data Analyses
Data analysis was conducted by the first author and discussed with the other authors. The first author had a dual role of method developer and analyst so the data analysis discussions helped to ensure the analysis reflected the data and was not unduly influenced by the first author’s role as method developer. Data analysis comprised two stages: (1) Descriptive analysis; (2) Interpretive analysis. Stage 1 involved descriptive analysis of quantitative data and qualitative description of textual data using content analysis (Elo & Kyngäs, 2008; Sandelowski, 2000). The aim of Stage 1 was to answer the first research question about what a brief MBI should comprise. Stage 2 involved Polytextual Thematic Analysis (Gleeson, 2011) of visual and textual data in order to answer the second research question about how the interventions were constructed in terms of style or approach.
Descriptive Quantitative Analysis
The duration of the elements, the duration of the sessions, and the duration of the complete courses were calculated. Frequency of use both within and across participants was then calculated for each type of token. For example, the number of each type of token used within each chart, the number used by each participant, and the number used at specific points such as the start and end of course sessions.
Textual data from the INDIGO charts, worksheets, and follow-up emails were analysed using inductive content analysis. This was an iterative process that involved reading through all the data, coding the comments and sorting them into categories, reviewing all the data again, and revising codes and categories (Elo & Kyngäs, 2008). The analysis stayed close to the data, coding and categorising at the manifest level with a low level of abstraction and interpretation (Graneheim et al., 2017; Sandelowski, 2000). To reflect this level of analysis, the term “category” is used rather than “theme” (Graneheim et al., 2017).
Polytextual Thematic Analysis was employed to expand on the findings of the prior analyses by considering the style or approach of the interventions that were created. Polytextual Thematic Analysis was developed by Gleeson (2011) primarily as a method for analysing visual data. However, analysis can also incorporate different types of related data, as in the current study. The visual INDIGO charts were analysed in conjunction with the textual data at a more in-depth latent level to try to understand each intervention as a whole. As part of the analytic process data were interpreted in relation to other images and texts (intervisuality and intertextuality). The visual data represent elements of MBIs as well as whole constructed interventions, and the analysis therefore drew on the first author’s knowledge and experience of MBIs as well as the literature that describes and discusses mindfulness and MBIs. The findings from this analysis therefore include reference to the relevant literature where appropriate.
Analysis followed the steps outlined by Gleeson (2011) and involved repeatedly viewing the INDIGO charts, worksheets and emails individually and in groups, in different orders, and making notes about features of the data (e.g. course characteristics) and potential themes; returning to the images and text, adding further notes, reviewing and adding to the notes made; drawing together the material relevant to potential themes; briefly describing the initial or “proto-themes”; returning to the data and revising themes; reviewing the themes in relation to each other and further refining the themes. This was an iterative process that involved returning to the data several times, drawing on the mindfulness literature to identify patterns of meaning across the data and discussing the themes with the co-authors.
Results
One INDIGO chart was created by each participant. Each chart represented a MBI that comprised multiple sessions and multiple elements. The findings are presented according to the research questions (What should a brief MBI comprise? How were the interventions constructed in terms of style or approach?) and in line with the two stages of analysis (1 descriptive; 2 interpretive).
What Should a Brief Mindfulness-Based Intervention Comprise?
Two categories were generated from the qualitative content analysis: “Content Matters” and “Keeping it Brief”. The Content Matters category relates to the choice of elements and participants’ interpretation and understanding of those elements. The category name denotes issues relating to content as well as the importance of appropriate content selection. The category Keeping it Brief reflects the different interpretations of what constitutes “brief”, and includes the duration of intervention elements, sessions, and the intervention as a whole, as specified by participants. The qualitative findings help to explain and elaborate on the quantitative findings, and thus are integrated through a weaving of the narrative in the following sections. The participant ID stated after quotations indicates the recruitment site of participants: “IN” refers to the international conference, and “LC” refers to the local conference.
Content Matters
All 21 participants used focused attention practice and inquiry in the courses they created, and 20 participants used the three-step breathing space and psychoeducation. Across all the courses, inquiry, psychoeducation, and focused attention practice were the elements used most frequently. The number of participants who used each element, and the number of times each element was used across all the courses are displayed in Table 2. As indicated in the written comments, wild cards were used to represent the following: an introduction to the course, icebreakers, “check-in”, being with neutral experiences, relational mindfulness, and managing the course ending. A variety of focusing anchors were suggested for the focused attention practices, for example the breath, body (e.g. feet, body scan), sounds, holding an object. Suggestions for informal mindfulness practices included taste, smell, creative doodling, noticing physical sensations during art activities, and savouring pleasant experiences, “e.g. heat pad or ice cube” (LC06).
Table 2
Use of each element
Element
n of participants who used each element
Number of times each element was used across all courses
Focused attention practice
21
113
Informal mindfulness
16
43
Three-step breathing space
20
80
Compassion meditation
14
43
Open monitoring practice
16
46
Inquiry
21
232
Psychoeducation
20
134
Practical exercises
14
56
Being with pleasant experiences
14
30
Being with unpleasant experiences
16
26
Poem
12
38
Wild card
12
54
Across the 21 courses, nine of the first sessions started with the psychoeducation element, and five started with the wild card element, used here to indicate a course introduction, ice-breaker, contracting, or “check-in”. Inquiry was the element used most frequently to end a session (used to end 27 sessions). Further information on the elements used to start and end sessions can be found in supplementary file one.
There were mixed opinions regarding open monitoring practice. Of the 16 participants who included this practice, five participants used it regularly (either four or five times within their courses), and 11 participants used it within the first two course sessions. However, five participants did not use this element at all and one participant expressly cautioned against its use: “I don’t think OM [open monitoring] practices are necessary or appropriate for a short course as I believe they take longer to acquire the skills for.” (IN08). One participant added “notice thoughts” next to the OM symbol when used in session two of their course (IN09), and another participant who used open monitoring practice to begin their course sessions explained “I always thought of FA [focused attention] on the breath while OM will include body sensations, sounds, thoughts, etc.” (IN06). This indicates participants had different interpretations of open monitoring practice. Indeed, participant IN05 stated “The techniques overlap somewhat. … even the distinction between insight and concentration meditation is a bit hard to make”. Insight meditation, also known as Vipassana meditation, is similar to open monitoring practice (Lippelt et al., 2014) and concentration meditation is another term for focused attention practice.
There were similar differences in opinion regarding compassion meditation and being with unpleasant experiences, used by 14 and 16 participants respectively. Some participants considered these elements to be essential: “I think compassion and working with difficulty are really essential for working with emotions” (IN08) and “compassion based meditations should be introduced in all sessions- I prefer to end with compassion as this is the meditation I get the most out of and use the most- having had adverse effects on a mindfulness course myself.” (LC01). Whereas other participants thought they would not be necessary for a brief mindfulness course: “I have omitted (as it is a ‘low intensity’ intervention): 1. Compassion practices- my experience is that this takes a lot of pre-work. 2. Practicing being with the unpleasant- while this may be there in discussion i.e. practicing being with an ‘itch’ etc.- not deliberately bringing the attention to the unpleasant at this point.” (LC05). Being with unpleasant experiences was the least used element across all of the courses created by participants, suggesting caution regarding the inclusion of this element in a brief MBI.
Keeping It Brief
Across the 21 MBIs created, the mean number of sessions per course was 5.48 (range = 4–7) and the mean session duration was 87 min (range = 40–120). One participant included an extra half hour in addition to their 1.5-h course sessions to allow for people arriving: “First half hour meet up/socialise- refreshments” (LC03).
More than 80% of the mindfulness practice elements included in the courses were 10 min long. Other practice durations were 5, 15, 20, 30 and 40 min. One participant explained their course would include “lots of short practices (reinforced by repetition…)” (LC05). Another participant explained their rationale for short practices: “I have focussed on short practices as the patients I have encountered struggled and some were put off by long body scans.” (LC08). Five participants favoured practices that were 20, 30 or 40 min long, and one participant interpreted “brief” as referring to home practice and preferred to have an intensive start to a course: “Briefness to me also applies to the amount of practice we are asking people to do outside the sessions. … Ideally I would do one day session (so people have an initial fairly intense introduction to the group and the practice) followed by minimum of 6, max of 8 sessions” (IN07). While most participants favoured short practices, this was not universal and the findings point to the different interpretations of what makes a “brief” course brief.
The duration of non-practice elements followed a similar pattern, with more than 80% of the elements used being 10 min long and others at 5, 15 and 20 min. Two participants included longer non-practice elements. For example, participant LC03 included 30 min of psychoeducation at the start of the first session, and 30 min of inquiry (group discussion) at the end of session two. Participant IN10 suggested 60 min of inquiry following a 40-min mindfulness practice for each of their four course sessions. Some participants explained that durations were not strictly set: “sessions will need to be somewhat fluid to allow for discussions that either end up being quite short or drag on. Rather than prescribing a rigid order minute by minute, I think it will be better to have a list of content that you intend to cover” (IN05).
Participants were not explicitly asked to make suggestions for home practice although two participants did suggest it and one participant cautioned against home practice (LC09). Data regarding home practice can be found in supplementary file one.
How Were the Interventions Constructed in Terms of Style or Approach?
Three themes were generated from the polytextual thematic analysis, which elaborate on the findings above and reveal different ways of constructing brief MBIs. The theme Starting Where You Are has a focus on the needs and capacities of individual participants; the theme Surfing the Waves describes the dynamic processes that need to be managed within brief MBIs; and the final theme The Deep and The Wide Path describes the courses created in this study in relation to existing MBIs. The three themes are described below.
Theme 1: Starting Where You Are
This theme represents courses that focus on the individual needs and capacities of those attending the course. Participants emphasised choice and supporting course attendees to find their own ways of practicing mindfulness, as well as demonstrating an awareness of adverse effects and ways of practicing mindfulness safely.
Choices were offered within some of the mindfulness practices, for example participant LC07 stated “choose” for the focused attention practice indicating participants should choose their own focusing anchor (see Fig. 3). Participant LC05 offered a choice of anchor for focused attention practices and the three-step breathing space (see Fig. 4). Their handwritten notes explain: “offering a variety of options of focussing attention points” and “info about theory and introduce 3MBS (with caution re breath) or invitation for other anchors” (3MBS indicates the three-step breathing space). Another participant described how they would explain focused attention practice to course attendees with a view to tailoring the course to their needs: “some people find breath anxiety provoking and rather focus on feet… I’d frame what FA [focused attention practice] means and let them decide” (LC10). As well as advocating choice, these quotes also highlight the difficulties that could be experienced when focusing on the breath and the potential for adverse effects.
The course structure was used as a way to mitigate such difficulties and minimise the potential for adverse effects. For example: “earlier on in programme I’d focus outside of body to exercise and feed the soothing system a bit and midway through onwards shift focusing on areas of the body” (LC10). This move from external (e.g. sounds or a visual object) to internal (e.g. the breath or the body) focusing anchors also occurs within the seven-session course created by participant IN11, which includes a focused attention practice using sounds in session three, then a practice using the feet in session four, moving on to the breath in session five, and a body scan in sessions six and seven. This indicates an awareness of the challenges that can be associated with internal focusing anchors.
Theme 2: Surfing the Waves
Within this theme brief MBIs are represented as a dynamic process with a structure that may build or flow in a particular way. This theme highlights the importance of holding the group and supporting course attendees as they progress through the course.
Some participants used the wild cards to include specific activities to support attendees across the course sessions. For example, introductions, ice-breakers, contracting, check-ins, and time for endings are all ways of holding the group. Participant LC08 explained they would include: “Time allocated for if–then plans and trouble shooting each session.” Time to process the ending of the course was considered important, for example participant IN04 included a compassion meditation as a “5 min “goodbye practice” where participants wish well to others in the group as they now part” (IN04).
There was variation in the structure of courses, with some courses featuring longer practices and what might be considered more challenging or complex practices (such as open monitoring) right from the beginning. Whereas other courses seemed to build, either in the duration of practices or in the perceived difficulty or complexity of practice. The 5-session course from participant IN09 illustrates a course building: the duration of practices gradually increases from the three-step breathing space in session one, up to a 20-min mindfulness practice in session five. The practicing being with unpleasant experiences element is not used until session four. The course also includes an introduction (Fig. 5), breaks in the sessions, and an end of course reflection. For some participants a repeated structure was considered important: “Any structured course will give a ‘safe’ ‘secure’ environment for learners if the sessions have a structure (similar in nature) each time” (LC04). This could be combined with an increase in duration of mindfulness practice, or a change to the type of practice. The course from participant LC04 contains sessions that follow a similar structure (see example in Fig. 6), although the duration of practice increases and there is a change to the type of practice in later sessions.
During data analysis similarities were noticed between the mindfulness courses created in this study and existing approaches. There appeared to be a spectrum that was reminiscent of the five levels of meditation described by Goleman and Davidson (2017) as the deep and wide path. Pure Buddhist meditation (Level 1) and more accessible forms of meditation (Level 2) form the deep path. The wide path comprises Levels 3–5: Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) at level three; more widely accessible approaches such as mindfulness apps and minutes-long meditation at level four; and digital meditation-based approaches for wellbeing at level five.
The final theme therefore describes the courses created by participants in relation to this spectrum, beginning with courses that had a simple structure, longer practices, and tended to incorporate open monitoring practice early on (closer to Level 2); through to courses that appeared to resemble abbreviated versions of MBSR and MBCT (Level 3); and finally, courses that were characterised by shorter practices and more informal mindfulness (Level 4).
Examples of courses with a simple structure, longer practices, and early use of open monitoring practice can be seen in Figs. 7 and 8. Both courses include 40-min practices that comprise open monitoring combined with another type of practice (compassion meditation or focused attention) plus inquiry (group discussion). Participant IN10 explained their choice of elements as follows: “For a general audience the meditation sessions should focus on simple focused attention (breathing, body scan or a mixture) plus some OM”.
In contrast, courses at the other end of the spectrum (towards Level 4) tended to include shorter practices (with many at five minutes or under) and more informal practices and being with pleasant experiences. For example, “I’ve put a lot of breathing-spaces and informal practices in the course to make mindfulness easier to implement in daily life.” (IN09) and “Choices:-) inf. – relates to an informal practice where participants are invited to savour a pleasant experience. E.g. heat pad or ice cube, fragrances etc.” (LC06). Participant LC06 included informal practices that involved a choice of pleasant experience, and activities that (as noted on their worksheet) combined art with informal mindfulness (see Fig. 9).
The courses that were more closely related to MBSR and MBCT (Level 3) included elements that are typically found within those courses e.g. the body scan, focused attention practice, open monitoring, and being with unpleasant experiences. Practices tended to be around 20 or 30 min long, and some participants emphasised the experiential aspects of the course: “Mindfulness is all about experiencing. Which is why I didn’t start with a lot of teaching” (LC10). Figure 10 shows an example that includes different types of practice, psychoeducation (“teaching”), and being with unpleasant experiences.
The aim of the study was to use the INDIGO method to explore participant perspectives on what a brief MBI should comprise. Twenty-one participants provided completed INDIGO charts, and participant comments from worksheets and emails were also analysed. Through the INDIGO method, participants could take a “whole-intervention” perspective to consider not only “what” should be included, but how much, and in what order. This revealed important insights about participant perspectives on MBIs generally (of any duration) and their components.
The qualitative findings from this study helped to explain and expand on the quantitative findings, for example participants explained their rationale for choosing particular elements and provided more detail for some elements. The reasons given tended to be based on the personal or professional experience of the participant, or on their understanding of an element, rather than referring to specific evidence. In addition, enabling participants to show the type of content, durations, and sequencing (as mixed together on the INDIGO chart) revealed some of the “unseen” aspects of MBIs such as methods of supporting participants through the course journey. The sequencing also highlighted similarities with existing approaches, which has implications for the future implementation of a new brief MBI. For example, some individuals may have an attachment to existing models and require a strong, clear, rationale for a new approach in order for it to be implemented effectively.
Based on mean scores from participants in this study the findings suggest a brief MBI should comprise five 1.5-hr sessions, and include focused attention practice, inquiry, the three-step breathing space and psychoeducation. These findings reflect those of our previous survey findings (Birtwell et al., 2021). As indicated by the theme “Surfing the Waves”, time should also be allocated for supporting the group, for example through icebreaker activities and time to process the course ending. The group aspects of MBIs are important. Indeed, Canby et al. (2021) explored the role of social common factors and suggested a strong group and teacher alliance may support participants to engage with challenging experiences that arise through mindfulness practice. In their study they found social common factors to be a stronger influence on outcomes than the amount of mindfulness practice (Canby et al., 2021).
The duration of mindfulness practices selected by participants was typically 10 min long which is substantially shorter than the 30- and 40-min practices from Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy (Kabat-Zinn, 2004; Segal et al., 2013). Recent research has found that a daily 10-min breathing practice (focused attention) over a period of 14 days can significantly increase mindfulness and reduce stress (Berghoff et al., 2017), and in novice meditators, both short and long practices can improve trait mindfulness, depression, anxiety and stress (Strohmaier et al., 2021). Furthermore, a 2020 meta-regression reported nonsignificant relationships between “dose” of mindfulness and psychological outcomes (Strohmaier, 2020). Due to the mixed evidence regarding duration of practice it may be appropriate to take a person-centred approach and offer short practices as a starting point with options to extend these practices should participants wish to and if this could be beneficial for them.
A range of focusing anchors were suggested for the focused attention practices, as well as supporting course attendees to choose their own anchor. Choice was key to the theme “Starting Where You Are” and reflects calls in the literature for person-centred approaches to mindfulness and meditation, as evidence suggests that different amounts of different types of mindfulness practices may be required for different individuals to achieve their goals (Britton, 2019; Lindahl et al., 2019; Sahdra et al., 2017). The explicit references to external anchors, described as “safe”, as well as offering choice, are also in line with trauma-sensitive approaches to mindfulness (Treleaven, 2018). For some individuals the use of internal body-based anchors may dysregulate the nervous system, whereas external anchors may provide a stabilising effect (Treleaven, 2018). Moreover, experiences of trauma can take away the feeling of being in control so ensuring people have a sense of choice during mindfulness practice can help to restore feelings of control and autonomy (Treleaven, 2018). Using a variety of focusing anchors and allowing participants to choose their own anchor is also in line with research on focusing anchors, for example Anderson and Farb (2018) reported that more than 50% of participants in their study were partial to non-breath anchors.
Interestingly, a number of participants included open monitoring practice early on in their courses and some participants included this practice regularly. Open monitoring practice is generally considered a more challenging practice than focused attention practice, and one that participants would progress to following sufficient experience with focused attention practice (Fujino et al., 2018; Lutz et al., 2008). Some of the comments revealed different interpretations of this practice, which has implications for clinical practice. We know anecdotally and through emerging evidence (e.g. Birtwell et al., 2021) that mindfulness teachers adapt existing MBIs. Yet if adaptations are based on misunderstandings about particular elements, this could undermine the efficacy of an intervention or potentially lead to participant harms. Britton (2016) has suggested scientific literacy as a core competency for MBI teachers and this is vital to ensure that any adaptations are consistent with existing evidence and support participant safety.
Findings from the current study have implications for intervention developers, mindfulness teachers, supervisors, and mindfulness teacher training organisations. When creating brief MBIs, we recommend intervention developers consider the following:
i)
Building time into the course curriculum for the typically unseen elements (e.g. social common factors) such as supporting the group, including introductions, ice-breakers, check-ins, and processing endings.
ii)
Person-centred approaches that offer participants choice. For example, a choice in practice duration of up to no more than ten minutes. Should participants express an interest in practicing for longer this should be discussed with the brief MBI teacher. Choice should also be offered regarding the type of mindfulness practice and the type of focusing anchor (e.g. internal or external, and if internal, offering other places in the body as well as the breath).
iii)
To support implementation of brief MBIs, intervention developers should create training materials for mindfulness teachers. This should include a clear scientific rationale for the intervention and its components, explanations for what the components are, and clarity regarding the intention for specific mindfulness practices. Such detail would support the needs of mindfulness teachers who may have gaps in knowledge or attachments to existing models, and would also inform any future adaptations they may wish or need to make.
For mindfulness teachers, supervisors and teacher training organisations we recommend the following:
i)
Training that supports mindfulness teachers to develop skills in scientific literacy. This could be offered as part of core training programmes or as continuing professional development (CPD). Such training would help mindfulness teachers to understand the evidence base for the MBIs they deliver, to better understand the intervention components, and to make evidence-informed adaptations that support participant safety.
ii)
For mindfulness teachers with prior experience of more established approaches (e.g. MBSR, MBCT etc.) teaching brief MBIs in a person-centred way might require a shift in approach and a degree of unlearning. This could be supported by teacher training organisations and through regular CPD and supervision.
iii)
Mindfulness teachers should engage in regular supervision with a mindfulness supervisor knowledgeable in the brief MBI they are delivering. Scientific literacy of supervisors is important in order to support evidence-based delivery of brief MBIs and evidence-informed adaptations where necessary.
In conclusion, findings from this study contribute to the evidence base for brief MBIs by highlighting the importance of person-centred approaches, the role of social common factors in brief MBIs, the potential attachment to existing approaches and differing interpretations of certain practices. These findings have implications for the development and implementation of new, brief MBIs, thus demonstrating the importance of involving stakeholders and taking a holistic perspective to intervention development.
Limitations and Future Directions
All participants in this study were university graduates and more than two thirds were female. Although this is typical of many mindfulness research studies (e.g. Cebolla et al., 2017; de Vibe et al., 2018) this could have affected the findings. In addition, participants were recruited via convenience sampling from two conferences and the conference themes could have influenced participants’ responses. Participants with different characteristics or interests may have created different types of brief MBIs. Furthermore, participant demographic characteristics along with recruitment via conferences in Europe limit the transferability of the findings to other countries and cultures, particularly where there are different conceptualisations of mindfulness, and different forms of practice and methods of teaching mindfulness.
Findings from this study have been combined with theory and other empirical evidence to develop a new, brief MBI. Further intervention development work has included using INDIGO to display a prototype of the intervention plan and presenting this to focus group participants for feedback in order to refine the intervention plan (Birtwell et al., 2022). The combination of data from a new method (INDIGO) with established methods (an online survey, Birtwell et al., 2021; focus groups, Birtwell et al., 2022) for data collection mitigates the risks of using a new untested method, and a method developed by one of the researchers.
Acknowledgements
We would like to thank the individuals and organisations that assisted with recruitment, and the participants for giving their time so generously.
Declarations
Ethics Approval
This study was given approval by the University of Manchester Research Ethics Committee (ref: 2018–3878-5778) and has therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.
Informed Consent
Informed Consent
All participants gave their informed consent in writing prior to taking part in the study.
Competing interests
Kelly Birtwell has received payment for teaching mindfulness and delivering training sessions related to mindfulness. Rebecca Morris and Christopher J. Armitage declare no conflicts of interest.
Use of Artificial Intelligence
The authors declare that this paper represents their original work. No artificial intelligence tools or large language models were used in the creation or composition of this manuscript, beyond standard tools for grammar and spelling checks.
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