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Beware mindless mindfulness

Written by Koen Smets (5 May 2016)

'Mindfulness' has gone from a relatively obscure term, originating in Buddhist vernacular, to one that is bandied around all over the place. More often than not it is presented as a panacea for all manner of ills, in our work as well as in our private life.

Is there any substance to this hype?

There certainly is a huge amount of academic interest in mindfulness, in particular in its use for the treatment of mental illness (such as depression, stress and anxiety). According to the National Center for Biotechnology Information's Pubmed database, more than 330 peer-reviewed studies have been published in the first four months of 2016. This continues a rising trend that started in 2000 with just seven studies, to about 800 in 2015.

Many studies of mindfulness-based interventions report positive results on mental health, but that should perhaps be taken with a pinch of salt. A review of 124 randomized controlled trials (RCTs) by a team from McGill University in Montreal raised concern that there may be more than a little bit of publication bias involved: as many as 109 trials (88%) concluded that mindfulness-based therapy was effective.

This is a very high proportion according to the researchers. Taking into account the sample sizes in the RCTs, they calculated that the expected number of positive studies is 66. And that was not the only issue: in addition, a mere 4 (3%) of the RCTs were unequivocally negative, again an unexpectedly extreme number. Finally, they also found that 13 out of 21 registered trials remained unpublished 30 months after registration, while all the published trials conveyed a positive conclusion. This is a strong indication that negative results are simply remaining unpublished.

Unfortunately the research seems to give us a potentially seriously biased picture.

Mindfulness in the wild

Mindfulness is an important component of established, evidence based psychotherapeutic methods – including Mindfulness-based Cognitive Therapy (MBCT), Mindfulness-based Stress Reduction (MBSR), and indeed Acceptance and Commitment Therapy (ACT). But while there is considerable evidence of the efficacy of MBCT, MBSR and ACT, this does not necessarily say anything about the specific role the mindfulness elements play in the therapy. It says even less about the benefit mindfulness-based interventions bring in isolation, i.e. outside a psychotherapeutic context, and outside controlled research studies.

Yet this is precisely where there has been a lot of excitement. The number of Google searches for "mindfulness" and "what is mindfulness" has shot up over the last five years. A search for 'mindfulness courses' in the UK produces more than 300 results; 'mindfulness workshops' yields another 200.

These are generally aimed at individuals, but employers too are increasingly looking at mindfulness as an instrument to improve staff wellbeing. (And, let’s be clear, control their costs – there is a business case to be made about employee health and wellbeing.) According to a CEBR report from 2013, "lack of motivation and sub-optimal health" reduces the potential of the UK economy by £6 billion. Furthermore, a study for NICE provides evidence statements claiming that mental wellbeing interventions produce a net benefit to employers estimated at between £130 and more than £5,000 per employee per year.

That represents a significant carrot for an organization – but can mindfulness on its own deliver the benefits that are anticipated? In a 2015 review of mindfulness at work, Darren Good and colleagues focus not only on wellbeing, but also on whether mindfulness can affect performance and interpersonal relationships. That is a challenging task, not least because – as the authors admit – mindfulness lacks a clear, unambiguous definition. There are multiple measures – David Vago, a psychologist at Harvard Medical School and an expert in mindfulness, lists no less than 13 scales. And mindfulness is effectively an internal state of mind, which is hard to observe and capture, so that there is a heavy reliance on self-reporting. This makes drawing unequivocal conclusions rather difficult.

But what are the mechanisms?

The researchers discover some evidence of a positive correlation between mindfulness and performance, but the way in which this happens is not clear. Likewise, there are indications that mindfulness improves interpersonal relationships. Yet how this could be translated into better relational management processes, like leadership and teamwork, is yet to be investigated.

However, wellbeing is the biggest ticket for mindfulness in organizations. There is a growing body of evidence that staff wellbeing is associated with significant benefits to employee and organizational performance. So if mindfulness really can help boost staff wellbeing, then that would be a major driver of its integration in corporate life. And in this third area too, the researchers find a correlation, but a lack of insight in the mechanisms by which specific mindfulness interventions might influence workplace wellbeing.

There is some tentative research on mediation in a therapeutic context, but that is inconclusive. In a systematic review and meta-analysis Jenny Gu and colleagues at the University of Sussex examined 20 mediation studies around MBCT and MBSR. They observed that "[m]ost reviewed […] studies have several key methodological shortcomings which preclude robust conclusions regarding mediation."

A healthy dose of scepticism

How to make sense of all this? It is important to distinguish between mindfulness in a psychotherapeutic context, and as a standalone intervention. Establishing the efficacy of a psychological therapy happens according to robust criteria, independent of the therapeutic approach, and focuses on the condition under treatment. The use of mindfulness (e.g. in ACT, but also in MBSR or MBCT) cannot easily be separated out in any evaluation.

Mindfulness applied on its own is a different affair. The evidence that it can have a positive influence in the workplace is promising, but the lack of understanding of the underlying mechanisms suggests that caution is needed. Buzzwords tend to attract a variety of people, from bona fide, well-trained and knowledgeable practitioners to snake-oil sellers. It is better to be sceptical than to go for mindless application of mindfulness at work.