Beginning in 1979, when Jon Kabat-Zinn went into the basement of the University of Massachusetts medical school and led a small number of patients through a program he dubbed Mindfulness-Based Stress Reduction (MBSR)—combining meditation with simple yoga movements—mindfulness was not a word you heard much. There were no studies of the effectiveness of mindfulness practices published in scientific journals, and your doctor was not likely to have heard of it, much less prescribe it.
—Editor-in-Chief Barry Boyce
Now, almost 40 years on, there are racks and racks of popular books on the subject and special publications galore in supermarket and bookstore aisles. Over 650 studies of the effects of mindfulness were published in 2016, which is more than double the number in 2013. Aetna, one of the world’s largest health insurers, now has a chief mindfulness officer; mindfulness is taught in grade schools, high schools, and colleges; and UMass has now become the first university whose medical school contains a Division of Mindfulness.
Judson Brewer—who is the acting director of the newly created Division of Mindfulness and has been the director of research at the Center for Mindfulness for several years—is both a medical doctor and a PhD. And he embraces mindfulness with the same inspiration that launched MBSR: Mindfulness practice is a methodology that has a place not just in monasteries and retreat centers but in doctor’s offices and hospitals. Brewer is proud to stand on the shoulders of pioneers like Jon Kabat-Zinn and Saki Santorelli, who ran the Center for several decades before his recent retirement.
Brewer also knows that while mindfulness has grown in popularity and acceptability, a mixed blessing lurks there. When something takes on the aura of a fad, in the way of Pet Rocks or Fidget Spinners, the very fact of popularity has a notorious way of trivializing something and reducing its credibility within established institutions. And in the rush to respond to the demand for something that promises some relief from suffering, breathless overpromotion inevitably ensues. In fact, a recent paper by a group of 15 researchers called for a halt to extravagant claims surrounding mindfulness, citing a need for more careful definitions of exactly what mindfulness is when it is studied, more rigorous clinical studies, and a check on media reports and advertising of mindfulness as a virtual cure-all.
In their recent book on the science of mindfulness, Altered Traits, Richard Davidson and Daniel Goleman emphasized that the mindfulness meditation practices generally under study were not “originally designed to treat illness” and that after decades of study there is “little we can say with certainty, given the great excitement (and okay, hype) about meditation as a way to boost health.” They speculated that mindfulness interventions for health care may not be worth the effort and perhaps focus should instead be aimed at generalized well-being.
The key to wider acceptance in the mainstream medical world is evidence that the methods work, but the nature of that evidence is critical. You can’t just put 25 people in a room once a week for eight weeks, teach them to meditate, and simply ask them how they feel at the end.
When I asked Brewer whether these sobering assessments of the state of mindfulness research, particularly in the area of health care, were discouraging to him, he said, “I am enthusiastic about mindfulness having a place within health care, but I am also very realistic about how much hard work that is going to take.” He echoed what Jon Kabat-Zinn, Amishi Jha, and many other prominent mindfulness proponents have said: The research into mindfulness is in its infancy. But he was also very firm on why mindfulness has a place in medical institutions: “Few places are as dedicated to increasing well-being as hospitals. Health-care institutions are excellent places to do responsible testing of methods of self-care.” The key to wider acceptance in the mainstream medical world is evidence that the methods work, but the nature of that evidence is critical. You can’t just put 25 people in a room once a week for eight weeks, teach them to meditate, and simply ask them how they feel at the end.
“The gold standard in medical research,” Brewer says, “is to identify a mechanism, a pathway, that is leading to the condition you are trying to cure or alter, and then to present evidence that you can interrupt that pathway, you can mess with that mechanism, in a way that changes the outcome.” Brewer cites the example of clinicians developing pharmaceutical treatments for a particular cancer. They look at a mechanism that prior research has identified—a protein pathway that has mutated—and they see if the drug they’re developing successfully attacks that pathway, resulting in the cancer abating. “That’s targeting,” Brewer says, “a step way beyond first-generation chemotherapy, which throws a grenade in there hoping that the widespread destruction will kill the cancer before it kills the patient. By understanding the mechanism that underlies the problem, you can treat the problem in a targeted way.”
How does this relate to mindfulness research? “We need to find the mechanisms, the pathways that mindfulness targets. In my lab, we have been working with reward-based learning for some time—what is formally known as operant conditioning—and focusing on very measurable, observable behaviors, particularly smoking and overeating. If someone binge eats, we can trace back and map how they got there, and we find that they sought and received a particular reward. However fleeting it might be, they report feeling a bit better or numbed out for a while. What took them there in the first place? A trigger, usually stress. It’s been amply demonstrated that if you stress people out and put a bunch of food in front of them, they will do the obvious to relieve their stress.”
Brewer points out that “reward-based learning” that leads to habit formation is a well-accepted mechanism in mainstream medical contexts. What he and his researchers need to do is to show, with specific interventions, that they can interrupt that pathway and achieve an observable result. (See “Constant Craving” for a diagram outlining how mindfulness may work as an intervention that can alter habits by influencing the reward-based learning cycle.)
They also need to compare their results to a control, a group that ideally takes another kind of training aimed at the same result. In the case of smoking, they compare their mindfulness intervention to a program from the American Lung Association. For overeating, they intend to compare their intervention to a well-documented calorie-counting method.
Results are already promising. For example, in a pilot study of obese women, led by Ashley Mason, PhD, the team found that mindfulness training delivered through a smartphone was able to target and affect the reward-based learning pathway, leading to a 40% reduction in craving-related eating.
Brewer and his lab are also working on the “mindfulness definition” challenge. “It seems like at this stage of development in the field,” he says, “we are going to need more granular definitions, more specificity. There are too many definitions of mindfulness floating around and it gets very conceptual very fast as you try to describe concrete experience in abstract terms. Drawn from user-centered research, we are working with the phrasing unforced freedom of choice emerging from embodied awareness as a measurable metric for mindfulness training as related to behavior change. It’s a little technical sounding, but we’re basically saying that someone learns how a habit forms from paying attention to the results of their actions, which leads to a wisdom base that guides future behavior. When triggers for habitual behavior arise, drawing not from concept, but from their own previous experience, they see the possibility of making their own choice about whether to continue the habit loop or to interrupt it and go to a fresh place. It brings together mindfulness, equanimity, and reward-based learning.”
Brewer has very consciously begun with habits where you can observe the behavior. As an evidence base develops, he believes it will become easier to venture into areas, such as anxiety, that cannot be observed in the same concrete way as smoking or overeating. “As we demonstrate changes in habits that stick over the long term and lead to obvious health improvements, we will not have to make big speeches about how great mindfulness is. The evidence will be there for doctors and patients to see. They can make their own choice.”
Mindful asked health reporter Peter Jaret to investigate a few other areas in the health-care landscape where mindfulness may make a difference. Here, he presents the results of his reporting.
Helping Cancer Patients Cope
At the Tom Baker Cancer Centre in Calgary, Canada, doctors use the full arsenal of conventional weapons to fight cancer, from chemotherapy to the latest cellular and genetic therapies. They also use mindfulness practice