Being more than Mindful of Mindfulness – Part 1

This is the first of three posts titled “Being more than Mindful of Mindfulness”.

In this first post I will address Mindfulness as a treatment for clinical conditions. In the two posts that follow I will address Mindfulness as a way of life: What we might lose or gain in the process (Post Number 2), and why Listening to your Heart may be more productive than being Mindful (Post Number 3).

I do not consider this to be the final word on Mindfulness either as a strategy for clinical problems or Mindfulness as an approach to life. I see these posts as a contribution to an ongoing discussion that needs to take place – one that is ruled out by the practice of the strategy itself – one in which an appraisal of the practice takes place.

Mindfulness as a Clinical Practice

Summary

If you’re really excited about Mindfulness and it works for you, go for it. Mindfulness shows a lot of promise but it is too early to say that it is efficacious for serious mental disorders. Instead of helping the sick to flourish, it appears to help the well stay in a flourishing space.

People who practice Mindfulness impress me. The people I know that practice mindfulness are psychologically aware people. I’m not sure what came first – the awareness or the practice of mindfulness. I expect that much of the time their psychological awareness leads them to do Mindfulness. Sometimes though their insight is high because they have engaged themselves in the task of looking inward.

There is much excitement about it. Many practitioners call Mindfulness the “third wave” in behavioural therapies, it’s that significant. Others are more suspicious. A recent article in the New York Times said that, “Mindfulness has reached such a level of hipness that it is now suggested as a cure for essentially every ailment.”

I love the positioning that Mindful people take towards the machinations of their inner life. The distancing of themselves from their thoughts and emotions provides them with the opportunity to see the thoughts and emotions in a better light. Like when we sit back and take in a full vista, we can observe more of what is happening in a broader context.

Yet it is not just that. The people who practice it are typically smart and loving people. They are not all hippies or yogis or monks. They’re more typically professional people. They have kids and partners. It is the common decency of the practitioners that I like. They care for people and the planet. They’re trying to do the right thing by themselves, their partners, their families, and sometimes their God. They value traits like compassion and they often use Mindfulness because it lends itself to the development of that trait. They’re not lying when they tell me it works for them.

But does it work for all people? Should you be using Mindfulness? To answer this, I go to my main principle: that all therapy, whether clinical or self-applied, should lead to human flourishing. Let’s see if it does that.

In 2010 The Australian Psychological Society (APS) released a formal review of the literature regarding the treatment of psychological disorders. The review focussed on the efficacy of specific psychological interventions (Cognitive Behavioural Therapy, Motivational Interviewing, Hypnosis etc) for 24 different conditions found in adults and adolescents.

At the time of that publication there was no Level 1 evidence for Mindfulness Based Cognitive Therapy (MBCT) for any of the 24 disorders that they listed. “Level 1” evidence for efficacy of an intervention existed where there was a systematic review of all relevant randomised controlled trials. There was barely any Level 2 evidence for MBCT either, where “Level 2” was defined as at least one properly designed randomised control trial (except for MBCT for Bipolar, but this was used as a treatment approach in conjunction with medication).

So, according to the APS in 2010, there was no Level 1, nor was there any real Level 2 evidence for this intervention. Contrast this with Cognitive Behaviour Therapy (CBT). CBT had Level 1 evidence for 16 of the 24 disorders that were listed in the review. 16!

According to the Australian Psychological Society (APS) MBCT is a strategy that “was developed to interrupt patterns of ruminative cognitive-affective processing that can lead to depressive relapse. In MBCT, the emphasis is on changing the relationship to thoughts, rather than challenging them. Decentered thoughts are viewed as mental events that pass transiently through one’s consciousness, which may allow depressed individuals to decrease rumination and negative thinking.”

Now of course things may have changed in the last 5 years. So I got onto the Cochrane Database to check efficacy status for MBCT and the third wave. You check out the verdict here. Regarding these therapies, the authors conclude that the evidence is still weak.

That doesn’t mean to say there will be no other evidence to come. I expect that the next formal review by the Australian Psychological Society will contain different reports of evidence for all different sorts of therapy including MBCT. We will be able to evaluate the value of the intervention when there is better empirical support for it. Time will tell.

I don’t want to be the one to pour cold water all over MBCT. There are parts of the approach I find really appealing. Curiosity, separating the thoughts and emotions from the self (if practitioners can concede that there is one) is an admirable practice. And I deeply appreciate the push to remove inimical control strategies (for example, decreasing rumination). This is an MBCT strategy that’s proven to help the prevent of relapse. I also love the idealism (the belief that there is a non-material reality) because I’m an idealist and most psychologists are too (though they don’t always have the insight that they are, and they are unwilling to admit that they are, but they are).

Nor do I want to be an ambassador for CBT, as if this one strategy were close to my identity. Many of the studies on CBT have been conducted on people with only one disorder (like Panic Disorder), so six to eight sessions of CBT is an adequate dose of therapy, sufficient enough to bring about relief for the sufferer. But people are rarely like this (the average is 2.5 disorders roughly in the clinic), so CBT looks a lot more complicated in practice than it does in research. Yet, CBT has scientific backing, and we do well to acknowledge and understand this fact.

So, on the clinical side, it’s fair to say the therapeutic benefits of Mindfulness are yet to be proved. It may well be that mindfulness is very effective for non-disordered problems of living. So, it’s fine for normal people dealing with stressful events. It is quite clear that this is beyond the scope of the APS review and this may be what friends and family speak of when they talk about benefiting from this strategy.

Mindfulness sounds promising, but it seems that the level of evidence for treatment efficacy has been preceded and outstripped by the level of excitement for the intervention. At least for clinical disorders. There is a lot of excitement about Mindfulness, it may not lead to human flourishing but might sustain it. It appears to be good for the well, but not good for the sick. Not everyone sees it that way though. As one conference delegate explained to the touring Canadian researcher at a presentation I attended in Brisbane, “mindfulness is all the rage in Australia”. Despite my unwillingness to sound like a total wowser, I wanted to say to this delegate – “Easy tiger”. But even if it did work for everyone, and we all flourished as a result, why do we want to do that? So, we can feel content? Is it good to be content? Will being content help us keep our purpose and direction? How will Mindfulness keep our hearts in our minds? Those will be the issues that are considered in the next two posts.