For mindfulness programs, ‘with whom’ may be more important than ‘how’

A pair of Brown University studies on the effect of mindfulness-based meditation programs highlight the importance of the instructor and the group.

PROVIDENCE, R.I. [Brown University] — For people who feel stressed, anxious or depressed, meditation can be a way to find some emotional peace. Structured mindfulness-based meditation programs, in which a trained instructor leads regular group sessions featuring meditation, have been shown to be effective in improving psychological well-being.

But the precise factors for why these programs can help are less clear. A new study teased apart the different therapeutic factors of mindfulness-based meditation programs and found that the effects of the instructor and the group are often more significant than the type or amount of meditation practiced.

Willoughby Britton, an assistant professor of psychiatry and human behavior at Brown University who led the study, says that mindfulness-based meditation programs often operate with the assumption that meditation is the active ingredient, but less attention is paid to social factors inherent in these programs, like the group and the instructor.

“It’s important to determine how much of a role is played by social factors, because that knowledge informs the implementation of treatments, training of instructors and much more,” Britton said. “If the benefits of mindfulness meditation programs are mostly due to relationships of the people in the programs, we should pay much more attention to developing that factor.” This is one of the first studies to look at the significance of interpersonal relationships in meditation programs.

Interestingly, social factors weren’t what Britton and her team, including study author Brendan Cullen, set out to explore; their initial research focus was the effectiveness of different types of practices for treating conditions like stress, anxiety, and depression. Britton directs the Clinical and Affective Neuroscience Laboratory at Brown, which investigates the psychophysiological and neurocognitive effects of cognitive training and mindfulness-based interventions for mood and anxiety disorders. She uses empirical methods to explore accepted yet untested claims about mindfulness — and expand the scientific understanding of the effects of meditation. With a grant from the National Institutes of Health, Britton led a clinical trial that compared the effects of focused attention meditation, open monitoring meditation and a combination of the two (“mindfulness-based cognitive therapy”) on stress, anxiety and depression.

“The goal of the study was to look at these two practices that are integrated within mindfulness-based programs, each of which has different neural underpinnings and different cognitive, affective and behavioral consequences, to see how they influence outcomes,” Britton said.

The answer to the original research question, published in PLOS ONE in January, was that the type of practice did matter — but less than expected.

“Some practices — on average — seem to be better for some conditions than others,” Britton said. “It depends on the state of a person’s nervous system. Focused attention, which is also known as a tranquility practice, was helpful for anxiety and stress and less helpful for depression; open monitoring, which is a more active and arousing practice, seemed to be better for depression, but worse for anxiety.”

But importantly, the differences were small, and the combination of focused attention and open monitoring didn’t show a clear advantage over either practice alone. All programs, regardless of the meditation type, had large benefits. This could mean that the different types of mediation were largely equivalent, or alternatively, that there was something else driving the benefits of mindfulness program.

Britton was aware that in medical and psychotherapy research, social factors like the quality of the relationship between patient and provider could be a stronger predictor of outcome than the treatment modality. Could this also be true of mindfulness-based programs?

Homing in on social factors

To test this possibility, Britton, with researchers Kristina Eichel, Nicholas Canby and other Brown scholars, compared the effects of meditation practice amount to social factors like those related to instructors and group participants. Their analysis assessed the contributions of each towards the improvements the participants experienced as a result of the programs.

“There is a wealth of psychological research showing that community, relationships and the alliance between therapist and client are responsible for most of the outcomes in many different types of therapy,” said Canby, a senior research assistant at Brown and a fifth-year Ph.D. student in clinical psychology at Clark University. “It made sense that these factors would play a significant role in therapeutic mindfulness programs as well.”

Working with the data collected as part of the trial, which came from surveys administered before, during and after the intervention as well as qualitative interviews with participants, the researchers were able to correlate variables such as the extent to which a person felt supported by the group with improvements in symptoms of anxiety, stress or depression. The results were published Frontiers in Psychology in January.

The findings showed that instructor ratings predicted changes in depression and stress, group ratings predicted changes in stress and self-reported mindfulness, and formal meditation amount (for example, setting aside time to meditate with a guided recording) predicted changes in anxiety and stress — while informal mindfulness practice amount (“such as paying attention to one’s present moment experience throughout the day,” Canby explained) did not predict improvements in emotional health.

The social factors were stronger predictors of improvement in depression, stress and self-reported mindfulness than the amount of mindfulness practice itself. In the interviews, participants frequently talked about how their relationships with the instructor and the group allowed for bonding with other people, the expression of feelings and the instillation of hope, the researchers said.

“Our findings dispel the myth that mindfulness-based intervention outcomes are exclusively the result of mindfulness meditation practice,” the researchers wrote in the paper, “and suggest that social common factors may account for much of the effects of these interventions.”

In a surprise finding, the team also learned that amount of mindfulness practice did not actually contribute to increasing mindfulness, or nonjudgmental and accepting present moment awareness of thoughts and emotions. However, bonding with other meditators in the group by sharing experiences did seem to make a difference.

What I’ve learned from working on both of these papers is that it’s not about the practice as much as it is about the practice-person match.

Willoughby Britton Director of the Clinical and Affective Neuroscience Laboratory

“We don’t know exactly why,” Canby said, “but my sense is that being part of a group that involves learning, talking, and thinking about mindfulness on a regular basis may make people more mindful because mindfulness is on their mind — and that’s a reminder to be present and nonjudgmental, especially since they’ve made a commitment to cultivating it in their lives by signing up for the course.”

Britton said the findings have important implications for the design of therapeutic mindfulness programs, especially those offered via smartphone apps, which have become increasingly popular.

“The data show that relationships may matter more than technique and suggest that meditating as part of a community or group would increase well-being,” Britton said. “So to increase effectiveness, meditation or mindfulness apps could consider expanding ways that members or users can interact with each other.”

Another implication of the study, Canby said, “is that some people might find greater benefit, especially during the isolation that many people are experiencing due to COVID, with a therapeutic support group of any kind rather than trying to solve their mental health needs by meditating alone.”

The results from these studies, while unexpected, have provided Britton with new ideas about how to maximize the benefits of mindfulness programs.

“What I’ve learned from working on both of these papers is that it’s not about the practice as much as it is about the practice-person match,” Britton said. Of course, individual preferences vary widely, and different practices affect people in different ways. “In the end, it’s up to the meditator to explore and then choose what practice, group and teacher combination works best for them.” Meditation programs could support that exploration, Britton adds, by offering a wider range of options.

“As part of the trend of personalized medicine, this is a move towards personalized mindfulness,” she said. “We’re learning more about how to help individuals co-create the treatment package that matches their needs.”

This work was supported by the National Institutes of Health; the National Center for Complementary and Integrative Health and the Office of Behavioral and Social Sciences Research; the Mind and Life Institute; and the Brown University Contemplative Studies Initiative.

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