Meditation Experience Predicts Less Negative Appraisal of Pain: Electrophysiological Evidence for the Involvement of Anticipatory Neural Responses

In a recent study, researchers in the United Kingdom examined the impact of meditation experience and the anticipation of and experience of pain. The control group consisted of 15 people with no previous experience in meditation. They were compared with 12 people who came from a variety of Buddhist and non-Buddhist meditative backgrounds. It was a pretty heterogeneous sample of meditators.

The researchers encountered difficulty developing a reliable estimate of meditation experience. They eventually disregarded the amount of hours per week of practice and instead looked at the overall lifetime experience with meditation. These ranged from less than 1 year to more than 30 years experience.

The researchers used a laser to induce a painful burning sensation in the participants. Anticipation of pain was created through a visual stimulus that indicated to the participants that they would be exposed to the laser within 3 seconds.  Because of the design, the researchers suggest they may have over-estimated the impact of the anticipation of pain on the actual pain response. In addition to self-report by the participants, the researchers used an EEG (e.g., brain scan) to measure participants' anticipation to and experience of pain.

Initially, the researchers found no significant difference in perceived pain between the mediation and control groups. Once the researchers dropped participants with less than 6 years of meditation experience from the analyses, however, participants with more meditation experience showed a lower response to anticipated pain unpleasantness.  This relationship was accounted for by the age of the meditators.  However, there was no correlation in the control group between pain response and age.  Although the relationship is not entirely clear, it appears that meditation experience may impact anticipation of pain.

In looking at the EEG results, an interesting pattern emerges. The researchers suggest that those with meditation experience were more likely to process and contextutalize the experience of pain before responding to it emotionally.

In summary, the researchers suggest that the cultivation of acceptance through practicing attentional control (i.e., through regular meditation practice) may allow people to show more equanimity in both in their anticipation of pain and their actual experience of it.

There are some limitations with the pain assessment in this study. As noted, researchers admitted that they had a difficult time determining if the pain assessment was in fact influenced by the anticipation of the pain. Also, because of the design of the study, we can't completely rule out that people who take up meditation are inherently different from those who don't meditate, and that these differences--rather than the actual meditation practice--better explain the results.

To download a  copy of the article, click on the full citation is below:

Brown, C.A., & Jones, A.K.P. (2010). Mediation Experience Predicts Less Negative Appraisal of Pain: Electrophysiological Evidence for the Involvement of Anticipatory Neural Responses. Pain, 150, 428-438.

I’d like to thank Molly Ellis for her help with drafting this post!

Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial

Mindfulness-based cognitive therapy (MBCT) studies generally focus on what’s sometimes called unipolar depression. The term “unipolar” is just a fancy way of distinguishing clinical depression from depression experienced in people with bipolar disorder. People with bipolar disorder may alternate between periods of depression and periods of elation called mania or hypomania (hypomania is less extreme than mania).

In earlier studies of MBCT, people with bipolar depression were screened out. More recently, researchers from Geneva University Hospital in Switzerland set out to determine if MBCT may be helpful for people with bipolar disorder.  They hypothesized that mindfulness may help break the vicious cycles of depression and mania.  This study is the first to pilot the use of MBCT for a sample comprised entirely of people with bipolar disorder.

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The intervention consisted of weekly, 2-hour, MBCT sessions for a total of 8 weeks. Each group met three months after the end of the 8-week program for a 2-hour refresher session. Little was changed to the program except that mania and hypomania were discussed in sessions and mentioned in handouts. Participants were assessed a month before the MBCT class, a month afterward, and at the 3-month follow-up. Of 23 participants, only 15 attended enough sessions to be included in the analyses, and only 9 were assessed at follow-up.

Overall, there were no significant improvements in mindfulness, depression, and hypomania between the beginning and end of the MBCT program. Interestingly, it didn’t look like the researchers included the 3-month follow-up in their analyses. Statistical analyses indicate no significant changes in depressive symptoms, mindfulness, and mania during the study. According to a table in the article, it even looks like depression may have increased at the follow-up! The good news is that 82% of the participants reported having benefited from the program. This point is emphasized by the authors.

A big limitation of this study is sample size: it’s hard to detect changes when working with such a small sample. That said, the study is spun a bit. The authors seem to downplay the nonsignificant changes in symptoms and mindfulness in favor of the participants’ self-report that they found the program beneficial. People says they liked the program, but there's no evidence it impacted depressive symptoms or mania, or that people improved in mindfulness.

In sum, the study suggests that people with bipolar disorder can participate in MBCT, but it provides little evidence that they benefited from it. However, because the sample size was small, it may be worth running another MBCT study for people with bipolar disorder with a larger sample.

The full citation is below:

Weber, B., Jermann, F., Gex-Fabry, M., Nallet, A., Bondolfi, G., & Aubry, J.-M. (2010). Mindfulness-Based Cognitive Therapy for Bipolar Disorder: A Feasibility Trial. European Psychiatry, 25, 334-337.

If you're interested in learning more about MBCT, the original book is one of the more readable therapist manuals out there:

Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2001). Mindfulness-Based Cognitive Therapy for Depression: A New Aproach to Preventing Relapse. New York: Guilford.

The core MBCT originators also created a self-help book called The Mindful Way Through Depression.

I'd like to thank Molly Ellis for her help with this post.

Neural Correlates of Focused Attention and Cognitive Monitoring in Meditation

A former classmate from graduate school sent me a nifty neuroimaging study by a group of researchers in Italy. The article compared 8 Buddhist monks against 8 novice meditators. The monks were part of the Thai Forest Tradition founded by Ajahn Chah. They averaged 15,750 hours of meditation experience! By contrast, the novice sample were people who expressed an interest in meditation but had no prior meditative experience. They were given 10 days of meditation practice prior to the study.

Using an fMRI (e.g., functional brain scans), the researchers recorded brain patterns during an hour block involving alternating periods of focused attention (FA) and open monitoring (OM). For those familiar with Buddhist practices, FA corresponded to Samatha meditation (Pali: calm abiding) and OM was a form of Vipassana (Pali: clear seeing or insight), according the researchers. (Our garden variety mindfulness meditation is more or less based on Vipassana meditation.) Participants alternated between 6 minutes of Samatha and Vipassana with 3 minutes of non-meditative rest preceding and following these conditions.

The article is pretty technical. Since I can't really do it justice, I won't parrot back the specific results (e.g., which parts of neuroanatomy relate to which forms of attention). Overall, results suggest that meditation practice reorganizes brain activity. More simply, experienced meditators showed a different pattern of brain activity than novices on these tasks.

Reorganization of brain processes is called neuroplasticity. Previously researchers believed the brain doesn't change much after we're born. Recent research has shown that this isn't so--the brain can and does change--and regular meditation practice can re-map the way the brain processes stuff.

For the full citation:

Manna, A., Raffone, A., Perrucci, M.G., Nardo, D., Ferretti, A., et al. (2010). Neural Correlates of Focused Attention and Cognitive Monitoring in Meditation. Brain Research Bulletin, 82, 46-56.

How Does Mindfulness-Based Cognitive Therapy Work?

Mindfulness-Based Cognitive Therapy (MBCT) has demonstrated it reduces depressive relapse in those with three or more depressive episodes across several studies now. But why--what changes occur in MBCT that reduce relapse? The theory behind MBCT suggests increased mindfulness leads to reduced chance of relapse; however, treatments may be effective for reasons having little to do with why we think they're effective.

A recent article by Kuyken and colleagues examines processes of change in MBCT in order to assess the theory behind underlying it. The researchers used what are called mediational analyses. Mediational analyses look at whether changes in one factor (e.g., mindfulness) lead to changes in another (e.g. lower depression).

The authors used data from a previous study (Kuyken et al., 2008) in which 123 people with 3 or more depressive episodes who were currently prescribed antidepressant medication were randomly assigned to either 8-weeks of MBCT or were placed on a wait list. Those in the MBCT condition were weaned off their medication while those not assigned to MBCT remained on their meds. Participants were assessed every 3 months up to a 15 month follow-up. (In the original study, there was no difference in rate of relapse between MBCT and antidepressant meds; however, people in MBCT exhibited fewer depressive symptoms by the 15-month follow-up.)

Results of this study suggest increases in mindfulness and self-compassion mediated the effect of MBCT on depressive symptoms at follow-up. Researchers also looked at what they called cognitive reactivity. Cognitive reactivity was defined as changes in depressive thinking before and after a short piece of "sad" music (i.e., Prokofiev).

Curiously, people who participated in MBCT exhibited greater cognitive reactivity than those who remained on antidepressant medication. Here's the interesting part, though: whereas cognitive reactivity was associated with poorer outcome for people taking antidepressants, participation in MBCT appears to erase this relationship. Said another way, for people who participated in MBCT, cognitive reactivity no longer appeared to impact depressive symptoms. This reminds me of the Mindfulness-Based Relapse Prevention study in which the researchers found the relationship between depression and relapse appeared to disappear for those who participated in the program.

These results of the current study offer further evidence that mindfulness doesn't change patterns of thinking so much as it changes how people relate to thinking. Additionally, this is another study showing the useful in self-compassion in understanding mechanisms of change in mindfulness based treatments. (For another study indicating the importance of self-compassion, click here.)

As with any study, there are limitations. Mediational analyses don't definitively tell us that particular variables lead to change. However, the results largely supported the hypotheses of the researchers, offering additional evidence in support of the theory.

To download a copy of the article, click on the full citation below:

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R.S. et al. (2010). How Does Mindfulness-Based Cognitive Therapy Work? Behaviour Research and Therapy, 48, 1105-1113.

New York Times: How Meditation Changes the Brain

The New York Times published an article today on a recent study that provides further evidence that regular meditation practice  affects the brain. Compared to a control group, people who meditated 30 minutes a day for 8 weeks showed changes in brain gray-matter density. The affected regions of the brain are associated with memory, stress, empathy, and what they call "sense of self."

The research article was published in Psychiatry Research: Neuroimaging. Dr. Britta Hölzel, a psychologist at Mass General and Harvard Medical School, is first author. (Coincidentally, I printed out a copy of the article last week but haven't had a chance to look at it yet. I guess I'll move it up in my queue and will hopefully post a summary within the next few weeks.) According to the article:Times

M.R.I. brain scans taken before and after the participants’ meditation regimen found increased gray matter in the hippocampus, an area important for learning and memory. The images also showed a reduction of gray matter in the amygdala, a region connected to anxiety and stress. A control group that did not practice meditation showed no such changes.

I've written about changes in gray matter in meditators in a previous post, in which long-term meditators showed greater cortical thickness compared to non-meditators matched for age. A major difference between this study and those others is that the other studies looked at samples of experienced meditators whereas this study involved people who practed meditation for only 8 weeks! The article mentions a control group, but I wasn't clear if people were randomly assigned to either the control or meditation group. I'm really looking forward to reading the original article now! (UPDATE: I've since posted on the original article here.)

To read the Times article, click here.

Vipassana Meditation: Systematic Review of Current Evidence

In the 1980-1990's Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR) and Linehan's Dialectical Behavior Therapy (DBT) helped kick off the recent wave of mindfulness research. Prior to that, there had been an accumulating body of research on the usefulness of Buddhist meditation in the 1970's and 80's, which had begun to trickle in as early as the 50's.

Although research of mindfulness-based treatments such as MBSR and DBT make up the majority of the currently published literature, there remains an interest in particular Buddhist meditative traditions. Dr. Chiesa of the University of Bologna, Italy, who also authored a review of neuroimaging studies of mindfulness meditation, recently reviewed research on Vipassana Meditation. Vipassana is a Pali word commonly translated as "insight" or "clear seeing." It is a mindfulness meditation, and is distinguished from meditative practices that emphasize concentration. The counterpart to Vipassana is Samatha ("calm abiding"in Pali), which is a way to calm the mind and develop one's ability to focus through concentrating on a particular object, often the breath.

Although I'm not a Buddhist scholar by any means, Chiesa's understanding of Vipassana appears to be a little shaky. Contrary to Chiesa's claim thar Vipassana is the "most ancient of Buddhist traditions," it is perhaps more accurate to say that Vipassana is a style of meditation attributed to the Buddha, which he is said to have developed after finding that concentration meditation failed to bring about lasting transformation and enlightenment. Concentrative practices such as Shamatha are believed to have been practiced thousands of years before the Buddha.

Vipassana is a general term and encompasses a number of traditions such as the Insight Meditation Society that inspired Kabat-Zinn and S.N. Goenka's promulgation of the tradition of U Ba Khin. It is Goenka's program that Chiesa focuses on in his review. Goenka has been hugely influential in creating a network of rigorously organized 10-day Vipassana retreats all over the world.

Chiesa uncovered 18 articles on Vipassana in his search but found only 7 met his inclusion criteria. Three of them came out of Dr. Marlatt's lab and were briefly mentioned in a previous post on Mindfulness-Based Relapse Prevention (Bowen et al., 2007, 2008; Simpson et al., 2007). One is by Dr. Lazar, whose work was also briefly discussed in a previous post, which looks at differences in cortical thickness in meditators (Lazar et al, 2005). Two were by Dr. Holzel (Holzel et al., 2007, 2008), and the remaining one I had never heard of (Emavardhana & Tori, 1997).

A problem I have with the way the review is the set-up: Dr. Chiesa links Vipassana to Goenka's organization in his introduction but does not mention other Vipassana traditions such as Insight Meditation. This would be fine if Dr. Chiesa only included studies of participants in Goenka's retreats (i.e., Bowen et al., 2006, 2007; Holzel et al., 2007, 2008; Simpson et al., 2007); however, he includes two studies with meditators that appear to be from Vipassana traditions other than Goenka's (Emavardhana & Tori, 1997; Lazar, 2005). One is through the Young Buddhist Association of Thailand (i.e., Emavardhana & Tori); the other appears to be of Insight Meditation meditators (i.e., Lazar). None of this is necessarily a problem, but it should have been made clearer in the introduction.

Chiesa makes the important point that these initial studies show great promise for continued research of Vipassana meditation, but that more higher quality studies are needed. Given that Goenka's retreats are donation only (i.e., you pay only what you want and can for the retreat), they offer a potentially untapped resource for people who cannot afford ongoing psychotherapy. (However, they do require an initial 10-day investment.) Chiesa also suggests that Vipassana meditation be compared against Transcendental Meditation (TM) for treatment of addiction. Unless things have changed, however, my understanding is that the TM organization is open to research but has more rigid requirements to allowing itself to be studied; for example, it rarely allows TM to be compared to another technique (See Rao, 1998).

Overall, this review is useful in drawing attention to the growing body of research on Vipassana meditation. Because it is so standardized, Goenka's program would be a great resource for continued research; however, from what I've heard from Dr. Marlatt's lab, they found it impossible to secure grant funding for continuing their inquiries. For now, research on Buddhist meditation remains much less cohesive than research on particular mindfulness and acceptance-based treatments. I would love to see continued exploration of the benefits of these forms of Buddhist practice, but it may take commitment of a researcher or group of researchers to develop a series of studies that build upon one another.

For the full citation:

Chiesa, A. (2010): Vipassana Meditation: Systematic Review of Current Evidence. Journal of Alternative and Complementary Medicine, 1(16), 37-46.

For those interested, I've tracked down downloadable files of some of the articles Dr. Chiesa's review discusses. Just click on the citation:

Bowen, S., Witkiewitz, K., Dillworth, T. M., Chawla, N., Simpson, T. L., Ostafin, B. D., Larimer, M. E., et al. (2006). Mindfulness Meditation and Substance Use in an Incarcerated Population. Psychology of Addictive Behaviors, 20(3), 343-347.

Bowen, S., Witkiewitz, K., Dillworth, T. M., & Marlatt, G. A. (2007). The Role of Thought Suppression in the Relation between Mindfulness Meditation and Alcohol Use. Addictive Behaviors, 32(10), 2324-2328.

Holzel, B. K., Ott, U., Gard, T., Hempel, H., Weygandt, M., et al. (2008). Investigation of Mindfulness Meditation Practitioners with Voxel-Based Morphometry. Social Cognitive and Affective Neuroscience, 3(1), 55-61.

Lazar S. W., Kerr, C., Wasserman R. H, Gray, J. R., Greve D., et al. (2005). Meditation Experience is Associated with Increased Cortical Thickness. NeuroReport, 16, 1893-1897.

Simpson, T. L., Kaysen, D., Bowen, S., MacPherson, L. M., Chawla, N., Blume, A., Marlatt, G. A., et al. (2007). PTSD Symptoms, Substance Use, and Vipassana Meditation Among Incarcerated Individuals. Journal of Traumatic Stress, 20(3), 239-249.

Is Learning Mindfulness Associated with Improved Affect After Mindfulness-Based Cognitive Therapy?

 Research suggests mindfulness is a multifaceted construct. We know that people develop greater mindfulness during mindfulness-based interventions, but we are less sure what aspects of mindfulness are most important to improved outcomes. Two researchers in the Netherlands have an article just published in the British Journal of Psychological attempting to link changes in specific aspects of mindfulness with particular outcomes following involvement in a Mindfulness-Based Cognitive Therapy (MBCT) program.

Schroevers and Brandsma collected self-report measures from a heterogeneous community sample of adults at the beginning and end of 8-week MBCT programs. Post-interventions were collected for 64 of the 85 people who filled out pre-intention measures.

To measure mindfulness, the researchers used the Mindful Attention Awareness Scale (MAAS), and select items from the Kentucky Inventory of Mindfulness Skills (KIMS; "observing" and "accept without judgment" subscales) and the Self-Compassion Scale (SCS; "mindfulness" and "over-identification" subscales). (Click here for a post on self-compassion.)

At the end of the program, people showed an improvement in awareness of daily activities (MAAS), ability to observe experiences (KIMS), acceptance of experiences (KIMS), and being able to disengage from pleasant experiences (SCS), but there was no change in being open and curious about experiences (SCS).

What I found most interesting about this article are the more specific findings. Learning to engage in activities with a more present-centered focus was the most important aspect of mindfulness in increasing one's experience of positive emotions--although improvements were unrelated to reducing negative emotions. Learning to become more accepting and less judgmental of experiences was related to lower negative affect. These results suggest that the increase of positive emotions and decrease of negative emotions through the cultivation of mindfulness are related to the development of different skills to some extent. Acceptance was related to improvements in positive and negative emotions; increasing one's ability to mindfully engage in activity appeared to increase positive emotions but didn't impact the experience of negative emotions.

As the authors admit, there are some weaknesses in this study. As data was collected before and after an 8-week MBCT program, it's unclear whether these gains are maintained over time or whether more improvements may eventually emerge. Additionally, there was no control group, so we can't be certain these changes wouldn't have happened over time without the MBCT program--although there is enough research on MBCT to support its impact.

To download the article, click on the full citation below:

 Schroevers, M. J., & Brandsma, R. (2010). Is Learning Mindfulness Associated with Improved Affect After Mindfulness-Based Cognitive Therapy? British Journal of Psychology, 101, 95-107.

Differential Effects of Mindful Breathing, Progressive Muscle Relaxation, and Loving-Kindness Meditation on Decentering and Negative Reactions to Repetitive Thoughts

"Decentering" is a term used to describe a process in which individuals learn to take a step back and observe a thought more objectively as content, rather than perceiving thoughts as accurate reflections of reality. For example, a non-decentered stance might be something like, "I'm too anxious to attend thw party," believing the thought, and canceling plans to attend, even though one would like to go. A more decentered stance is, "I'm having the thought, 'I'm too anxious to attend the party,'" and attending anyway. Decentering came out of the Mindfulness-Based Cognitive Therapy camp (Click here for other SM MBCT posts), and is similar to "defusion" in Acceptance and Commitment Therapy (Click here for other SM ACT posts).

In a recent study published in Behaviour Research and Therapy, Dr. Greg Feldman of Simmons College and colleagues examined the impact of a 15 minute intervention on decentering, as measured by the Toronto Mindfulness Scale.

As Simmons College is an all girls' school, all participants were female. They were randomly assigned to one of three 15 minute guided exercises: 1.) mindful breathing, adapted from a MBCT script; 2.) a Buddhist loving-kindness meditation, adapted from Insight Meditation by Buddhist teachers Sharon Salzburg and Joseph Goldstein; and 3.) progressive muscle relaxation, a decades old relaxation practice that is just like it sounds.

Mindful breathing was related to greater scores on decentering compared to loving-kindness and progressive muscle relaxation. Also, even though people who practiced mindful breathing endorsed greater repetitive thoughts (e.g., worrying, making mental lists), mindful breathing was associated with a weaker relationship between negative affect and repetitive thoughts. This finding adds to a growing body of literature suggesting that mindfulness shift the way people respond to negative thoughts and feelings, making them less aversive. (Similarly, the MBRP study we recently wrote about had a similar finding with depression and relapse.)

Several years ago, I never would have thought we could find signficant changes from only 15 minutes of mindfulness, but there is a growing body of research using similarly short interventions. We still need to be careful of other confounds, such as demand characteristics (e.g., people responding a certain way because they feel expected to), but the research is very promising.

For the abstract, click here. For the full citation:

Feldman, G., Greeson, J., & Senville, J. (2010). Differential Effects of Mindful Breathing, Progressive Muscle Relaxation, and Loving-Kindness Meditation on Decentering and Negative Reactions to Repetitive Thoughts. Behaviour Research and Therapy, 48, 1002-1011.

MBCT for Individuals Whose Lives Have Been Affected by Cancer: A RCT

A recent issue of the well-respected Journal of Consulting and Clinical Psychology has an article on the use of Mindfulness-Based Cognitive Therapy (MBCT) for people with cancer. MBCT is an adaptation of Mindfulness-Based Stress Reduction (MBSR) and was developed to reduce depressive relapse. MBSR has already been used with good results in people with cancer across several studies (Carlson et al, 2003; Tacon et al., 2004), including one randomized controlled trial (RCT; Speca et al., 2000). Although it's not the first study employing a mindfulness-based treatment with an oncology population, this new study is the first controlled study of MBCT for people with cancer.

The authors of this study, a group of Australian researchers lead by Dr. Elizabeth Foley, call MBCT a “refinement” of MBSR twice in the article, which I found a strange choice of words. It could imply that MBCT may be better suited to addressing the needs of cancer patients; however, the authors don’t actually say this and the design of the study doesn’t allow for these conclusion to be drawn. Instead, the authors suggest that because depression and anxiety are common in cancer patients, and because MBSR has been shown to be helpful in people with cancer, using MBCT may also be beneficial.

The sample consisted of 115 patients across a range of cancer types. They were randomly assigned to either MBCT or a wait-list condition. The wait-list group received MBCT after the data was collected.

MBCT involves 8 weekly 2-hour sessions in groups of 8-12 people. MBCT was modified in several ways for these participants. Didactic information focused on common problems associated with cancer, including depression, anxiety, and pain. One change that particularly struck me was the body scan. The body scan involves mindfully moving your attention from your toes to the crown of your head. Apparently this was very difficult for many participants, for whom bringing awareness to the cancerous part of the body was very painful and difficult. Consequently, participants had the option of a “graded practice,” which might begin with awareness of the sensation of one’s clothing in the cancerous area. Sensitivity was paid to the physical difficulties of practice and to fatigue. Lastly, 32% of participants had people who cared for them also participate in MBCT per invitation by the researchers. Overall, I was really impressed by the sensitivity in adapting this treatment for cancer patients.

The results of the study indicated that, compared to the wait-list group, people who participated in MBCT showed improvements in anxiety, depression, and distress. These improvements were maintained at a 3-month follow-up. One thing I found impressive is that at 3 months, 62% reported regular meditation practice and 31% reported occasional practice. This means that over 90% found value in continued mindfulness practice.

Given that MBSR has already been used successfully with cancer patients in previous studies, I personally think comparing MBCT to MBSR (as opposed to a wait-list) would have been much more interesting. The authors note that the impact of treatment is comparable to the MBSR RCT by Speca et al. (2000). Consequently, I don’t think this study is particularly groundbreaking. That said, it’s always interesting to encounter a RCT for a mindfulness-based treatment, and the study adds to the growing literature in the use of mindfulness-based interventions for cancer patients.

Full citation for the MCBT study:

Foley, E., Baillie, A., Huxter, M., Price, M., & Sinclair, E. (2010). Mindfulness-Based Cognitive Therapy for individuals whose lives have been affected by cancer: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 78(1), 72-79.

Citations for studies of MBSR with cancer patients (links are included to free PDF's of articles ):

Carlson, L. E., Speca, M., Patel, K. D., & Goodey, E. (2003). Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients. Psychosomatic Medicine, 65, 571-581.

Speca, M., Carlson, L E., Goodey, E., & Angen, M. (2000). A randomized, wait-list controlled clinical trial: The effects of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine, 62, 613-622.

Tacón, A. M., Caldera, Y. M., & Ronaghan, C. (2004). Mindfulness-based stress reduction in women with breast cancer. Families, Systems, & Health, 22(2), 193-203.

Mindfulness-Based Relapse Prevention: A Pilot Efficacy Study

In a previous post last week, I wrote a about Mindfulness-Based Relapse Prevention (MBRP), offering an introduction to the treatment and some background information. In this post, I’d like to report in detail about the results of the first randomized controlled trial of MBRP. (For those without a research background, randomized controlled trials or RCT’s are considered the gold standard of research.)

A few years ago, when I was a psychology intern at the Portland Veterans Affairs Medical Center in Portland, OR, I had the opportunity to conduct an MBRP group in the Substance Abuse Treatment Program. It was the first time MBRP had been offered at the VA. The veterans I worked with appeared to really like the program, and some continued to speak fondly of it for weeks after it ended. (I think my involvement may have even raised my own stature as an intern in their eyes!) I wasn’t able to collect any outcome data myself, but I’ve been interested in additional research on the effectiveness of MBRP.

From 2007-2008, a randomized pilot study was conducted with MBRP for the first time. Participants were recruited from a private, nonprofit agency, with 168 total. They were randomly assigned to either MBRP or the agencies standard treatment, which was process-oriented and based on the 12-step model (i.e., Alcoholics Anonymous). Outcome measures were administered at baseline, immediately after the 8-week MBRP program, and at 2- and 4-month follow-ups after the end of the 8 weeks.

Results were published across two articles.

According to Bowen (2009), people who completed MBRP had fewer days of use, fewer cravings, and greater awareness and acceptance compared to those who completed the agency’s standard program. However, when the researchers looked at the follow-up 4 months after MBRP ended, there was little difference in days of substance use between those who had completed MBRP and those who had completed the standard treatment. The authors suggest the reason for this is that those in MBRP returned to the standard program after completing the 8-week MBRP; however, it still doesn’t indicate the treatment gains of MBRP are maintained very well following the end of the 8-week program. In a sense, it suggests the gains associated with MBRP may not stick.

In the second article, Witkiewitz and Bowen (2010), the authors ran additional statistical analyses on the data from the first study to test some other hypothesis. The most interesting finding from these analyses related to differences in the experience of depression. For people who received standard care, there was a relationship between depressive symptoms and cravings; for example, more depressed people reported greater craving for drugs and alcohol. Additionally, as you might expect, those who were more depressed were more likely to use drugs and alcohol. For those who completed MBRP, however, there was no relationship between depression and cravings—those who were more depressed were no more likely to use than those who were less depressed.

What’s really fascinating about this second article is that results suggest depressed people who completed MBRP were less likely to use substances than depressed people who completed the agency’s regular program. It indicates mindfulness may make people more resilient to using drugs or alcohol even when their moods drop. Additional analyses indicated that everyone from the MBRP group who continued meditating (63%) remained abstinent. Although we cannot make causal attributions of this latter finding—those who continue meditating may be more motivated in general than those who stopped—it is promising. This is evidence that MBRP may help to “erase” the relationship between depression and substance use for many who complete the program.

Overall, these results suggest that MBRP is different than standard substance abuse treatment, but it is not clear how much better it is. For me, the most interesting finding is that those who participated in MBRP were less likely to use when depressed. This suggests MBRP may be particularly useful in helping substance abusers learn to tolerate negative moods. I look forward to what additional studies of MBRO may find.

For full citation:

Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295-305.

Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78(3), 362-374.

Mindfulness-Based Relapse Prevention: An Introduction

The other day I came across a new article about an important emerging mindfulness-based treatment that we haven’t written about in SM yet: Mindfulness-Based Relapse Prevention (MBRP). MBRP came out of the lab of Dr. Alan Marlatt at the University of Washington. Dr. Marlatt is well-known for his substance abuse research, and he has had a personal and professional interest in mindfulness and meditation since he was a young professor decades ago. I first encountered mention of MBRP 5 years ago in a paper co-authored by Dr. Marlatt with Dr. Katie Witkiewitz, who was a student of Dr. Marlatt’s and is now at Washington State University-Vancouver.

My SC co-founder Jason Luoma and I are currently collaborating with Dr. Witkiewitz on a study of MBRP in a women’s inpatient substance abuse treatment program. During a meeting about the study, Dr. Witkiewitz talked about the genesis of MBRP. Marlatt’s lab had conducted a study of the impact of a 10-day Vipassana meditation course at a Washington jail. (The Vipassana retreat was in the style developed by S.N. Goenka.) Results of the study were extremely promising. Compared to inmates who didn’t participate in the Vipassana course, those who completed it showed significant reductions in substance use following release. Additionally, participants showed lower levels of psychiatric symptoms upon release.

Unfortunately, Marlatt’s lab couldn’t get funding for additional study of the Vipassana course. Apparently, it was considered a little unorthodox. In order to develop something that might be more palatable to potential grant reviewers, they took a cognitive behavioral Relapse Prevention program Dr. Marlatt had developed and combined it with Mindfulness-Based Cognitive Therapy, a well-supported mindfulness treatment for recurring depression. (MBCT in turn was based on Kabat-Zinn’s Mindfulness-Based Stress Reduction program.) In combining the treatments, Marlatt’s lab created MBRP!

MBRP is an 8-week group-based treatment. Participants are initially introduced to mindfulness through a body scan, a practice developed by Kabat-Zinn in his program. Sitting meditation is eventually introduced, and there is also some yoga. Throughout the treatment, participants learn to notice cravings for drugs and alcohol, identify triggers, and prepare for the possibility of relapse.

In my next post, I’ll write about a promising new study supporting the efficacy of MBRP. One article was just published in June in the Journal of Consulting and Clinical Psychology, an extremely prestigious publication. (UPDATE: click here for second post.)

For those interested, I’ve cited research I mention in this post. I’ve included links to PDF’s of the actual articles where possible. Specifically Bowen et al. (2006) and Simpson et al. (2007).

Citations:

Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., Grow, J., Clifasefi, S., et al. (2009). Mindfulness-based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30(4), 295-305.

Bowen, S., Witkiewitz, K., Dillworth, T. M., Chawla, N., Simpson, T. L., Ostafin, B. D., Larimer, M. E., et al. (2006). Mindfulness meditation and substance use in an incarcerated population. Psychology of Addictive Behaviors, 20(3), 343-347.

Simpson, T. L., Kaysen, D., Bowen, S., MacPherson, L. M., Chawla, N., Blume, A., Marlatt, G. A., et al. (2007). PTSD symptoms, substance use, and Vipassana meditation among incarcerated individuals. Journal of Traumatic Stress, 20(3), 239-249.

Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy, 19(3), 211-228.

Witkiewitz, K., & Bowen, S. (2010). Depression, craving, and substance use following a randomized trial of mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology, 78(3), 362-374.

Psych Central Article: Mindfulness for ADHD

I posted twice in April on research incorporating the use of mindfulness skills in the treatment of attention deficit/hyperactivity disorder (ADHD): a study using Metacognitive Therapy and a pilot study using mindfulness meditation. Psych Central posted an article by Lynda McCollough yesterday on this growing body of research. The article focuses on some of the work being done through the Mindful Awareness Research Center (MARC) at UCLA. They've developed a program called Mindful Awareness Practices for ADHD (MAP), and the article has comments by Lidia Zylowska, MD, a psychiatrist who founded MARC. It provides a nice overview of some of their work and has some useful links and citations.

You can read the Psych Central article here.

Integrative Body-Mind Training

A psychologist at the University of Oregon Michael Posner has teamed up with a group of Chinese researchers lead by Dr. Yi-Yuan Tang at Dalian University of Technology. They are studying a form of meditation called Integrative Body-Mind Training (IBMT) developed and adapted by Dr. Tang from traditional Chinese medicine.

IBMT involves mindfulness training, relaxation of muscle groups, and guided imagery, and it is accompanied by music played in the background. It's unclear to me how IBMT differs from mindfulness meditation--with the exception of the addition of background music--but there appears to be significant overlap in these types of meditation.

In a recent study using neuroimaging, changes in brain activity were observed in participants practicing IBMT after 11 hours of training compared to a control group who received only relaxation training. (More than 6 hours appear to be required for changes to be measurable.) Changes were most pronounced in the anterior cingulate, a part of the brain associated with the ability to regulate emotions and behavior.

According to a Science Daily article, IBMT is not available outside of China, so I don't know much about it. As I noted, I'm unclear whether there are any fundamental differences between IBMT and mindfulness meditation. This is a danger of some of the neuroimaging research: so many different types of meditation have been examined using different kinds of equipment that it can be difficult to make sense of the results other than that meditation appears to affect the brain. (Click here for a previous post about a review of the literature, and here for a previous post about some of the problems of the neuroimaging literature.) That said, any attempts at controlled studies of meditation are exciting, and what is unique about this one is that the researchers observed changes after only 11 hours of training! A number of studies draw from either experienced Buddhist meditators or people who have completed an 8-week mindfulness meditation program (e.g., MBSR), so this is a pretty cool finding.

To download and read a PDF of the published scientific article, click here.

To read a Science Daily article about the study, click here.

For the full citation:

Tang, Y. Y., Lu, Q., Geng, X., Stein, E. A., Yang, Y., & Posner, M. I. (2010). Short-term meditation induces white matter changes in the anterior cingulate. Proceedings of the National Academy of Sciences.

Functional Neural Correlates of Mindfulness Meditations in Comparison with Psychotherapy, Pharmacotherapy, and Placebo Effect

In a recent issue of Acta Neuropsychiatrica, Chiesa and colleagues, a group of researchers in Italy, published a review article of neuro-imaging studies. They were interested in comparing neural correlates of mindfulness meditation with those of psychotherapy, pharmacotherapy (e.g., antidepressants), and placebo. The main areas of the brain the researchers focused on were the prefrontal cortex, the anterior cingulate cortex, and the amygdala.

I found the placebo piece of the review particularly interesting as there’s a huge research literature showing placebo effects are powerful enough to be a treatment in themselves. Like psychotherapy, it’s hard to create an adequate placebo substitute for something like meditation, especially as people know more about it today than they did decades ago when this research began.

The authors’ findings suggest that mindfulness meditation may help facilitate a greater flexibility in emotion regulation, and an improved ability to step back from negative mood states by engaging the frontal cortex (higher order functions) in order to dampen amygdala activation (emotion response, especially fear). The authors also found there’s a great deal of overlap in the brain structures activated by mindfulness meditation, psychotherapy, pharmacotherapy, and placebo effects.

They make a preliminary suggestion that mindfulness meditation, psychotherapy, and placebo act through “top down” regulation (i.e., through other processes), whereas antidepressants have a “bottom-up” effect (i.e., more directly). For example, they suggest mindfulness meditation may regulate the amygdala through frontal brain areas whereas antidepressants target the amygdala directly. I found this curious, as Irving Kirsch and others have recently suggested that much of the benefit from antidepressants is through placebo or expectancy effects (here's a short review of this debate). I am not trained as a neuroscientist nor am I an expert in this area of research, so I won’t directly challenge the authors’ conclusions. Nonetheless, I was left uncertain how much of the notion of grouping meditation, psychotherapy, and placebos into one category, and antidepressants in another, is based more on theory than on data.

Nonetheless, I think the authors did a nice job of trying to organize and summarize a growing but somewhat disparate body of research. Additionally, they’ve raised some important questions for other researchers to begin to explore in a more systematic manner. As I blogged about last week, Fletcher and colleagues (2010) recently suggested ways in which a neuroscientific understanding of mindfulness may be refined. This is a really exciting avenue of study, but I agree with the latter authors in that what researchers should really focus on is building our understanding of the neurological underpinnings of mindfulness and meditation in a very deliberate and step-by-step approach.

Full Citation:

Chiesa, A., Brambilla, P., & Serretti, A. (2010). Functional neural correlates of mindfulness meditations in comparison with psychotherapy, pharmacotherapy and placebo effect. Is there a link? Acta Neuropsychiatrica, 22(3), 104-117.

Searching for Mindfulness in the Brain

In the new journal Mindfulness, Fletcher, Schoendorff, and Hayes, researchers well known within the Acceptance and Commitment Therapy (ACT) community, published an article about refining the approach towards using neuro-imaging techniques (i.e., brain scans) to study mindfulness.

The authors point out some of the flaws in the current literature, such as the lack of precision about definitions of mindfulness and accompanying processes, and difficulty measuring subjective reports of different psychological states. The authors advocate greater precision in understanding and delineating the different processes that may underlie mindfulness before subjecting mindfulness to neurobiological study.

As they authors admit, the lens through which they seek to understand mindfulness is the behaviorist approach ACT. They readily acknowledge that this is but one way to understand mindfulness. Their main point is that some clearly defined model of mindfulness, whatever that may be, is necessary before a true neurological study of mindfulness can be undertaken. Otherwise, inquiry may lead to sloppy science.

I applaud the authors for this undertaking. Although I think there is a great deal of value in neuroscience, there is such a mystique surrounding it (e.g., “It’s the brain, so it must be true!”), that I think some of the methodological limitations get overlooked. For example, as with any research technique, there is random error in measurement. The authors note an amusing study by Bennett and colleagues (2009) that found the brain area of dead salmon reliably lit up when the fish were shown emotional scenes. It’s highly unlikely the dead fish were having an emotional reaction! Yet this is precisely the problem we face when we stick people in a scanner and ask them to meditate without first clearly defining the task (e.g., What does it mean to meditate?), and what we’re looking for.

Although it’s not my main area of training, I find the neuroscience research on mindfulness and meditation pretty interesting. I think there is a great deal of potential in this particular avenue of exploration. However, I agree wholeheartedly with Fletcher and colleagues that there should be a movement towards greater scientific rigor with studies executed in a more systematic fashion.

For Full Citation:

Fletcher, L. B., Schoendorff, B., & Hayes, S. C. (2010). Searching for Mindfulness in the Brain: A Process-Oriented Approach to Examining the Neural Correlates of Mindfulness. Mindfulness, 1(1), 41-63.

Science of the Mindful Brain

Dan Siegel, MD, author of The Mindful Brain has a short article on Kripalu. He talks about his work and his journey in understanding mindfulness.

The article is available here.

Mindfulness Intervention for Child Abuse Survivors

A group of researchers at the University of Maryland School of Medicine conducted a pilot study enrolling 27 adult survivors of childhood sexual abuse in an 8-week Mindfulness-Based Stress Reduction (MBSR) program. At the end of the program, participants exhibited significant reductions in depression, anxiety, and posttraumatic stress disorder (PTSD) symptoms. These gains remained significant when participants were tested again 2 months after the program ended.

Although I’ve talked to therapists who are using meditation-based groups for people with PTSD—and even co-led one myself on my internship—this is the first published study I’ve come across. For that reason, I was excited about this article; however, there were some major limitations to this study. For one, participants were required to also be in individual psychotherapy; consequently, results cannot be attributed to MBSR alone. Additionally, because there was no control group, the researchers cannot rule out natural decline in symptoms unrelated to the treatment, or a placebo effect.

Despite these concerns, improvements were quite large, suggesting that additional study of MBSR with trauma survivors is worthwhile. Moreover, that 85% of participants attended the final MBSR session suggests that the treatment was well tolerated and appropriate for survivors of childhood sexual abuse. Personally, I hope to see additional research on the use of mindfulness and meditation in addressing PTSD.

For the full citation:

Kimbrough, E., Magyari, T., Langenberg, P., Chesney, M., & Berman, B. (2009). Mindfulness intervention for child abuse survivors. Journal of clinical psychology, 66(1), 17-33.

Meditation Changes Body Temperature

This is an older article, but it remains fascinating if you’ve never encountered it. For those of you familiar with Tibetan Buddhism, you’ve probably of Tummo, an advanced Vajrayana practice in which practitioners raise their body temperatures enough to dry wet sheets in freezing temperatures.

Herbert Benson and Sara Lazar at Harvard have actually studied and recorded this process. Buddhist monks were able to dry 3 x 6 foot sheets dipped in cold water in 40°F temperatures in an hour.

Read the full article in the 2002 Harvard Gazette.

Studying Mindfulness in Experienced Meditators

Often studies of meditation are conducted using samples of people taking 8-week mindfulness meditation courses such as Mindfulness-Based Stress Reduction. Studies of experience meditators are less common. For this reason, I perked up when I came across Fredik Falkenström’s new study of experienced meditators.

The experimenter obtained a sample of Vipassanna meditators who had completed at least one retreat of one week or longer. He used a quasi-experimental design, which means that participants weren’t randomly assigned into groups. The experimenter collected assessments of mindfulness and well-being one-week prior and one-week following retreats of 5 and 7 days in 48 participants. These measures were compared to a control group of 28 experienced meditators who did not participate in a retreat during the time period that the assessments were collected. Mindfulness was measured using the Kentucky Inventory of Mindfulness Skills (KIMS) and Five Facet Mindfulness Questionnaire (FFMQ), which include subscales of observing, describing, acting with awareness, accepting without judgment, and nonreactivity to inner experiences. The findings are quite interesting and easiest to understand grouped by hypothesis:

1. Mindfulness was related to well-being, as predicted.

2. The prediction that meditation experience was related to mindfulness was partially supported. Only the acceptance scales and the KIMS acting with awareness scale were related to meditation experience. Moreover, when controlling for age, only the KIMS acting with awareness scale remained significantly correlated, suggesting that we cannot rule out that greater scores on acceptance were related to age rather than meditation experience.

The authors note that because all the participants were experienced, there may be some ceiling effects, as the entire sample scored higher on the observe scales than the average population.

3. Although mindfulness skills increased following the retreat for the experimental group, they also increased for the control group. Interestingly, the increase for the retreat group was not significantly greater than that for the control group. The author suggests that it is possible the retreat group may have been struggling with post-retreat life following a week in quiet solitude. However, this is conjecture and the results remain intriguing.

4. Although mindfulness didn’t increase in the retreat group any more than the control group, well-being did. The retreat group exhibited significant increases in well-being, and this was greater than the control group.

5. The increase in well-being was associated with increases in mindfulness, but the relationship was not particularly strong.

The author discusses the apparent paradox in the results: the retreat was related to greater well-being, and well-being was related to greater mindfulness, but meditators who completed a retreat didn’t appear to develop greater mindfulness than meditators who did not attend a retreat during that time. Consequently, the authors note, there may be other factors that lead to an increase in well-being during retreat other than mindfulness (e.g., insight); also, it does not rule out that well-being is related to a placebo effect or something more mundane (e.g., the retreatants simply had a break).

Overall, these are fascinating results with much food for thought. Hopefully, the future will bring similar studies with experienced meditators, but with larger samples and greater experimental control.

Full citation:

Falkenström, F. (2010). Studying mindfulness in experienced meditators: A quasi-experimental approach. Personality and Individual Differences, 48, 305-310.

Meditation and Empathy

The National Center for Alternative and Complementary Medicine has an interesting summary on some neuro-imaging research with Dr. Lutz out of the University of Wisconsin suggesting that meditation practice is associated with increased empathy. Check it out:

http://nccam.nih.gov/research/results/spotlight/060608.htm