Home practice in Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction: A systematic review and meta-analysis of participants' mindfulness practice and its association with outcomes

Abstract

Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) emphasize the importance of mindfulness practice at home as an integral part of the program. However, the extent to which participants complete their assigned practice is not yet clear, nor is it clear whether this practice is associated with positive outcomes.
For this systematic review and meta-analysis, searches were performed using Scopus and PubMed for studies published through to the end of 2015, reporting on formal home practice of mindfulness by MBSR or MBCT participants.
Across 43 studies (N = 1427), the pooled estimate for participants' home practice was 64% of the assigned amount, equating to about 30 minutes per day, six days per week [95% CI 60–69%]. There was substantial heterogeneity associated with this estimate. Across 28 studies (N = 898), there was a small but significant association between participants’ self-reported home practice and intervention outcomes (r = 0·26, 95% CI 0·19,–0·34).
MBSR and MBCT participants report completing substantial formal mindfulness practice at home over the eight-week intervention, albeit less than assigned amounts. There is a small but significant association between the extent of formal practice and positive intervention outcomes for a wide range of participants.

Full text

Home practice in Mindfulness-Based Cognitive Therapy and
Mindfulness-Based Stress Reduction: A systematic review and meta-
analysis of participants' mindfulness practice and its association with
outcomes
Christine E. Parsons, PhD
a
,
*
, Catherine Crane, PhD
b
, Liam J. Parsons, MA
c
,
Lone Overby Fjorback, PhD
d
, Willem Kuyken, PhD
a
a
Interacting Minds Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
b
Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford, England, United Kingdom
c
Department of Experimental Psychology, University of Bristol, England, United Kingdom
d
Danish Center for Mindfulness, Aarhus University, Aarhus, Denmark
article info
Article history:
Received 13 July 2016
Received in revised form
3 April 2017
Accepted 6 May 2017
Available online 10 May 2017
Keywords:
Mindfulness-based cognitive therapy
Mindfulness-based stress reduction
Treatment engagement
Treatment adherence
Homework
Adherence
Mindfulness practice
Meditation practice
abstract
Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR)
emphasize the importance of mindfulness practice at home as an integral part of the program. However,
the extent to which participants complete their assigned practice is not yet clear, nor is it clear whether
this practice is associated with positive outcomes.
For this systematic review and meta-analysis, searches were performed using Scopus and PubMed for
studies published through to the end of 2015, reporting on formal home practice of mindfulness by MBSR
or MBCT participants.
Across 43 studies (N ¼1427), the pooled estimate for participants' home practice was 64% of the
assigned amount, equating to about 30 minutes per day, six days per week [95% CI 60e69%]. There was
substantial heterogeneity associated with this estimate. Across 28 studies (N ¼898), there was a small
but significant association between participants’self-reported home practice and intervention outcomes
(r ¼0$26, 95% CI 0$19,e0$34).
MBSR and MBCT participants report completing substantial formal mindfulness practice at home over
the eight-week intervention, albeit less than assigned amounts. There is a small but significant associ-
ation between the extent of formal practice and positive intervention outcomes for a wide range of
participants.
©2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
Contemporary psychological treatments require active engage-
ment by participants, both in sessions with a therapist, and in
applying and practicing new skills in their lives. Between-session
development of these skills through ‘home practice’is an integral
component of treatment. Such home practice is viewed as neces-
sary for participants to gain the insights and skills for the intended
treatment outcomes. For cognitive behavioral therapy (CBT), this
takes the form of variable assignments, such as self-monitoring,
exposure to feared situations, or scheduling of behavioral experi-
ments that extend the therapeutic sessions. Several meta-analyses
have provided evidence for a small to moderate association be-
tween home assignment completion and CBT treatment outcomes
across different psychological disorders (Kazantzis, Whittington, &
Dattilio, 2010; Mausbach, Moore, Roesch, Cardenas, &Patterson,
2010).
Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-
Based Stress Reduction (MBSR) are manualized, group-based skills
training programs that teach mindfulness both in and between
sessions. Between-session practice consists of informal and formal
home mindfulness practice that trains attention and develops the
ability to respond to difficult mental and physical experiences
(Kabat Zinn, 1990; Segal, Williams, &Teasdale, 2012). Informal
practices encourage mindfulness in everyday life, for example, by
*Corresponding author.
E-mail address: Christine.parsons@clin.au.dk (C.E. Parsons).
Contents lists available at ScienceDirect
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
http://dx.doi.org/10.1016/j.brat.2017.05.004
0005-7967/©2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
Behaviour Research and Therapy 95 (2017) 29e41

deliberately focusing awareness on everyday activities and
savouring pleasant experiences. In a formal practice, participants
are given guidance as to the nature and content of the practice (e.g.,
suggestions as to the posture adopted, attitude and how attention is
directed).
Typically, participants’formal practices are supported by audio
recordings. In the early weeks of the intervention, participants are
gradually introduced to a range of formal meditation practices,
focusing initially on mindfulness of the body and the breath, and
later the body in movement and mindfulness of thoughts and other
mental events. Early practices are intended to support participants
in stabilising attention, beginning to notice patterns of mind
wandering and increasing the ability to return the mind to an
intended focus of attention when mind wandering occurs. Later
practices encourage participants to observe patterns of mind
wandering in more detail and approach difficult mental content or
unpleasant physical sensations with an attitude of curiosity,
acceptance and non-judgement. In the final weeks of these in-
terventions, participants are typically encouraged to develop a
pattern of formal meditation practice that fits in with their daily life
and which will be sustainable beyond the 8-week intervention. In
class, teachers review weekly home practice, inviting participants
to share their experiences to aid generalisation of learning. These
mindfulness home practices are assumed to be critical to thera-
peutic change. While a growing number of studies have explored
the relationship between practice and change, this research is still
at an early stage.
This systematic review and meta-analysis aimed to address two
key questions about participants' between-session practice in
MBSR and MBCT. First, we examined the extent to which partici-
pants report completing the assigned formal mindfulness home
practice. This is important because psychological ill-health can
compromise an individual's capacity to adhere to treatment
guidelines (Prince et al., 2007). Furthermore, where interventions
involve extensive behavioral components, adherence is often less
than ideal (DiMatteo, 2004). Second, we assessed whether there is
evidence that completion of formal practice, which is most
frequently recorded in MBSR and MBCT studies (Vettese, Toneatto,
Stea, Nguyen, &Wang, 2009), is associated with treatment out-
comes. It is widely accepted that the full benefit of many effective
treatments can only be achieved if the prescribed regime is fol-
lowed reasonably closely (Osterberg &Blaschke, 2005), but this has
not yet been established for mindfulness practice in MBSR and
MBCT.
1. Methods
This review followed procedures outlined in the Cochrane
Handbook for Systematic Reviews (Higgins &Green, 2008) and by
the Centre for Reviews and Dissemination (CRD, 2014). The review
protocol was registered with PROSPERO [CRD42015029959].
2. Search strategy
Searches were performed using Scopus and PubMed for studies
published through to the end of 2015, which reported on home
practice of mindfulness in MBSR or MBCT. The search terms were:
‘Mindfulness based stress reduction’or ‘mindfulness based cogni-
tive therapy’,or‘MBSR’,or‘MBCT’and ‘practice’or ‘homework’or
‘adherence’or ‘compliance’or ‘engagement’(see Supplementary
Materials for search strings). Only primary research presenting
novel data on mindfulness practice was included. Two independent
reviewers (CP, LP) performed title and abstract screening and full
text review using the web-based software platform Covidence,
(www.covidence.org; a Cochrane recommended primary screening
tool). At full text review, studies were checked to ensure reporting
of results from unique, non-overlapping participants. While Covi-
dence does not allow for post hoc calculation of Cohen's Kappa for
inter-rater reliability, agreement on screening and data extraction
was established between the first two reviewers through discus-
sion for all but 7 issues. These 7 disagreements were resolved with
referral to a third reviewer (CC).
We included studies that reported on MBCT or MBSR delivered
in line with the format described in the respective manuals, namely
an eight-week group program, with class time of 2-2$5 h and one
all-day retreat, requiring at-home mindfulness practice for about
45 min, six days per week (Kabat-Zinn, 1990; Segal, Williams, &
Teasdale, 2013). Studies were excluded if they reported substan-
tial deviations from the standard format such as shortened class
times or fewer than eight classes. However, we included studies
with reduced home practice requirements (less than the recom-
mended 45 min) as a separate subgroup. Studies were also
excluded if they did not report collecting data on participants’
home practice.
We included studies that reported formal home mindfulness
practice data (referred to throughout as mindfulness practice) in a
format that allowed calculation of average minutes of practice per
day, or average number of formal practice sessions per week, for the
duration of the course. If studies reported collecting home practice
data, but did not report these values, authors were contacted for
this information. If authors described the home practice re-
quirements of their intervention, but did not report any actual
home practice data, their study was not included in the review. In
total, 57 authors were contacted, and 26 responded. Eight authors
were able to provide information on formal home practice
completion amounts and ten were able to provide information on
home practice-outcome associations. Formal practice, defined as
the assigned, scheduled home mindfulness sessions (e.g., following
a guided meditation, 3-min breathing space), was the focus of our
analyses. Formal practice is arguably easier to record in a standard
way compared with informal practice, and is more widely reported
(Vettese et al., 2009).
In instances of missing or incomplete data, authors were first
contacted. Where standard deviations were unavailable after this
(12 studies), we compared two methods for SD imputation. The
first used an average pooled SD from all other included studies
1
and the second used the largest SD from the available studies.
Both yielded similar estimates, so the former method was imple-
mented (Furukawa, Barbui, Cipriani, Brambilla, &Watanabe, 2006).
To generate an aggregate estimate of the amount of home practice,
a random effects model was implemented with the mean per-
centage of recommended home practice time (% of 45 min or % of 6
sessions).
3. Data extraction and synthesis
Information was extracted from each study as follows (1) the
characteristics of the study, where relevant (design, randomization,
blinding, therapist qualifications, number of participants, class
attendance recorded, type of outcome measures, overall interven-
tion effects), (2) the characteristics of the intervention, including
target population (3) the characteristics of participants, including
people who did not complete the MBSR/MBCT program (4) home
practice details, including recording method, number of partici-
pants providing data, amount of formal practice in minutes (or if
practice amount was not reported, the number of formal sessions)
(M, SD) (5) data on the association between practice (across the
1
The average SD from the included studies was 31.7%.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e4130

entire course) and intervention outcomes. Table 1 presents study
characteristics related to the recording of mindfulness practice,
class attendance, teacher training and inclusion of a one-day
retreat.
To analyse the association between practice and outcomes, we
used the primary outcome at the end of the intervention (around
eight weeks), as reported by the study investigators. If this was not
specified, we used the most frequently reported measures across
studies (BAI, GAD-7, and BDI, PHQ-9, DASS-21 depression subscale,
consistent with (Newby, McKinnon, Kuyken, Gilbody, &Dalgleish,
2015). For the two studies reporting longer-term primary out-
comes (e.g., hazard of relapse to depression), we obtained outcome
measures recorded at the end of the intervention. This decision was
made in order to synthesise as much available comparable data as
possible. In some instances, authors reported related measures of
one physical outcome (e.g., for sleep, sleep initiation, frequency of
awakening) and we computed a composite variable (as outlined by
Borenstein, Hedges, Higgins, &Rothstein, 2009).
If authors reported standardized regression coefficients, these
were used to estimate correlation coefficients (as described by
Peterson &Brown, 2005). For two studies (Carmody, Reed,
Kristeller, &Merriam, 2008; Gross et al., 2011), Spearman's rho
values were reported and these were converted to Pearson's r
(Gilpin, 1993). Where authors reported only that correlations did
not reach significance (n ¼6), a correlation coefficient was esti-
mated using the study sample size and a conservative p-value of
0$5. Heterogeneity was investigated using forest plots and the I
2
statistic.
4. Subgroup analyses
To assess the differences between a priori identified subgroups
of interest (participant group: clinical or nonclinical; intervention
primary outcome: physical functioning, psychological functioning
or mixed), we conducted subgroup analyses using the mixed effect
model approach. We also examined differences across study design
(RCTs, non-randomized trials, before and after studies) and differ-
ences between MBCT and MBSR.
5. Study quality
We examined the risk of bias of included RCTs using the
Cochrane ‘Risk of Bias’tool (Higgins &Green, 2011) and for other
study designs, we recorded applicable information. Assessment of
study quality was conducted by two independent reviewers (CP, LP)
and disagreements were resolved through discussion. Table 2
presents the characteristics related to these quality indices.
6. Study characteristics
Fig. 1 presents the PRISMA flow chart for the included studies. A
total of 49 studies were identified that reported mindfulness
practice in MBSR/MBCT with standard home practice requirements
(45 min). An additional 10 studies were identified that had reduced
home practice requirements (N ¼141). Two of the 49 studies re-
ported on associations between mindfulness practice and out-
comes (Carmody et al., 2008; Eisendrath et al., 2015) but the mean
mindfulness practice data were not available. For the ‘standard’
interventions, 28 studies (N ¼898) reported associations between
practice and intervention outcomes, or provided this data when
contacted. For the ‘reduced practice’interventions, three studies
reported information on the correlation between practice and
outcomes, or provided this data when contacted (see Fig. 2).
Of the 49 studies included with standard home practice re-
quirements, 28 were RCTs, 15 were uncontrolled ‘before and after’
studies and six were non-randomized controlled trials. The ma-
jority of studies reported on clinical populations (clinical n ¼41;
nonclinical ¼8). Most reported on MBSR groups (n ¼34), while 12
reported on MBCT, and a further two reported on mixed MBCT and
MBSR groups. There were a variety of populations treated in these
studies, but the most common were depression/anxiety (n ¼10),
cancer (n ¼5) and insomnia (n ¼4). The majority examined pri-
mary outcomes related to psychological functioning (e.g., depres-
sion, anxiety, stress; n ¼33), but a substantial proportion examined
physical functioning (e.g., blood pressure, sleep, BMI; n ¼12), and a
smaller number reported ‘mixed’outcomes (e.g., quality of life;
n¼4). Of the 10 studies included with reduced home practice re-
quirements, 6 were RCTs, 3 were uncontrolled ‘before and after’
studies and one was a non-randomized controlled trial. All of these
studies examined MBSR participants (see Table 1).
In general, studies reported on the training of the intervention
teacher (36/49 of standard format studies, 6/10 reduced practice
format) and number of classes attended by participants (37/49 of
standard format studies, 7/10 reduced practice format). Only a
small number of studies reported using a scale to assess interven-
tion adherence by the teacher (5/49 standard format studies).
7. Risk of bias within randomized controlled trials
The methodological quality of the studies reporting RCTs varied
widely (see Table 2). Twenty-six (76%) reported adequate genera-
tion of random sequencing, 6 (17%) reported adequately concealing
group allocation, and 18 (51%) reported appropriate blinding of
outcome assessments. Dropouts were reported for 31 studies (86%),
but only a minority reported dropout reasons (46%). Twenty-two
studies (63%) reported intent to treat analysis. Seventeen studies
reported power calculations, but two of these reported that the
sample size was underpowered.
8. How much practice do participants complete in standard
format MBSR/MBCT?
Mindfulness practice was typically recorded in paper diaries and
collected during the weekly classes (Table 1). Practice records were
described as logs, diaries, calendars, or forms (e.g., “Tick boxes were
used by participants to record each element of home practice
alongside a space to make any free response comments on their
home practice for their own benefit and that of the class instructor”
from Crane et al., 2014.). One study used an online daily diary
recording method (Day et al., 2014), one used electronic loggers
(Gross et al., 2011) and one used weekly phone calls to monitor
practice (Jazaieri, Goldin, Werner, Ziv, &Gross, 2012). Most studies
reported participants’practice as an average amount (minutes,
hours) per week or per day, allowing calculation of an overall
percentage of recommended practice completion. Four studies re-
ported only the frequency of practice per week (see Table 1), and
this was expressed as a percentage of the recommended 6 times
per week.
Four studies were identified as extreme outliers. Three studies
reported that participants completed more than 45 min (>100%) of
practice and it was not possible to establish if this was combined
reports of formal and informal home practice for two cases (Cole
et al., 2015; Pradhan et al., 2007). One study was an outlier in the
other direction (Del Re et al., 2013), with participants reporting an
average of 14% of home practice (SD ¼3$14%). These studies were
excluded from pooled estimates because of the uncertainty
involved in these participant reports, but their exclusion did not
impact on the pattern of results.
Across the 43 included studies, the pooled estimate for partici-
pants’practice was 64% of the recommended amount (which
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e41 31

Table 1
Study characteristics related to recording of practice, class attendance, teacher training and adherence and inclusion of a one-day retreat.
Study How was practice recorded? Frequency of
practice form
collection
Teacher
training
reported
Did the authors use a scale/
measure to check intervention
adherence?
Class
attendance
reported?
All-day
retreat
Studies with standard home practice requirements
Baer, Carmody, and
Hunsinger (2012)
Weekly logs Weekly N N Y All-day
retreat
Barnhofer et al. (2009) Homework records Not specified Y N Y Not
specified
Blom et al. (2014) Weekly logs Weekly N N Y 6 h
Bluth, Gaylord, Nguyen,
Bunevicius, and Girdler
(2015)
Daily logs Weekly
collection
YN Y 4h
Britton, Haynes, Fridel, and
Bootzin (2010)
Weekly logs Weekly
collection
Y N Y All-day
retreat
Britton, Haynes, Fridel, and
Bootzin (2012)
Weekly logs Weekly Y N Y All-day
retreat
Campbell, Labelle, Bacon,
Faris, and Carlson (2012)
Daily logs collected at end of course End of course Y N Y 6 h retreat
Carlson, Speca, Patel, and
Goodey (2004)
Daily log Weekly N N Y 3 h retreat
Carmody and Baer (2008) Weekly collection Weekly class N N Y All-day
retreat
Carmody et al. (2008) Course folder with colour tabs Weekly class N N N All-day
retreat
Carmody et al. (2011) Weekly log collected Weekly Y N Y All-day
retreat
Cole et al. (2015) Practice logs, frequency not mentioned Not specified Y N Y All-day
retreat
Collard, Avny, and Boniwell
(2008)
Questionnaires at start and end Not specified N N N Not
specified
Crane et al. (2014) Daily log Weekly Y Y Y Not
specified
Day et al. (2014) Daily online log Daily Y Y Y Not
specified
Del Re, Flückiger, Goldberg,
and Hoyt (2013)
Record after each home practice End of course Y N Y All-day
retreat
Eisendrath et al. (2015) Weekly logs Weekly Y N Y Not
specified
Farb, Segal, and Anderson
(2013)
Daily log collected at End of course End of course N N Y All-day
retreat
Foley, Baillie, Huxter, Price,
and Sinclair (2010)
Daily log collected at End of course End of course Y N Y All-day
retreat
Geschwind (2012) Not specified Not specified Y N Y All-day
retreat
Goldsmith et al. (2014) Weekly logs Not specified N N N No retreat
Gross et al. (2011) Electronic loggers Daily Y N Y All-day
retreat
Hawley et al. (2014) Weekly logs Weekly Y Y N Not
specified
Hoffman et al. (2012) Weekly sheets Not specified Y N Y 6 h
H€
olzel et al. (2011) Daily logs Not specified N N N 6.5 h
Hou et al. (2013) Weekly collection Weekly class Y N, but sessions videotaped and
reviewed
Y no retreat
Jazaieri et al. (2012) Weekly phone calls to monitor practice Weekly Y N N All-day
retreat
Jensen et al., 2012 Daily logs Not specified Y N Y 7 h retreat
Johansson, Bjuhr, Karlsson,
Karlsson, and R€
onnb€
ack
(2015)
Daily log End of course Y N Y 7 h retreat
Kluepfel et al. (2013) Weekly log Weekly Y Y Y All-day
retreat
Labelle, Lawlor-Savage,
Campbell, Faris, and
Carlson (2015)
Weekly logs Weekly Y N Y 6 h retreat
MacCoon et al. (2012) Minutes and sessions recorded; frequency not
specified
Not specified Y N Y 7 h retreat
Nyklicek and Kuijpers (2008) Weekly logs Weekly N N Y 6 h retreat
Ong et al. (2014) Daily logs Not specified Y N Y 6 h retreat
Parkin et al. (2014) Asked weekly about practice time Weekly Y N N No retreat
Perich, Manicavasagar,
Mitchell, and Ball (2013)
Daily record Weekly Y Y Y Not
specified
Pickut et al. (2015) Weekly logs Weekly class N N Y no retreat
Pradhan et al. (2007) Daily logs Not specified Y N Y All-day
retreat
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e4132

equates to approximately 29 min per day, Fig. 3, 95% CI 60e69%].
However, there was substantial heterogeneity associated with this
estimate, as reflected by I
2
¼89%.
There were no significant differences in practice for studies
examining clinical populations (n ¼35, 65$95%, 95% CI 62$06 -
69$83%) and nonclinical populations (n ¼8; 56$32%, 95% CI
36$67e76$33; Q ¼0$84, df ¼1, p ¼0$36). We compared studies
where primary intervention outcomes related to physical func-
tioning, psychological functioning or a ‘mixed’outcome (e.g.,
quality of life). Tau squared values were pooled across subgroups
because of the limited number of ‘mixed’outcome studies as rec-
ommended by Borenstein et al., (2009). There were no significant
differences in home practice between studies examining primary
intervention outcomes related to psychological functioning
(n ¼29; 67$93%, 95% CI 59$9e75$95%), physical functioning
(n ¼12, 67$95; 95% CI 59$83e76$07%), and mixed outcomes (n ¼3,
66$7%; 95% CI 49$87e83$53%; Q ¼1$35, df ¼2, p ¼0$51).
Comparing MBCT and MBSR, we found no significant differences
in home practice reports (MBCT: n ¼11, 61.08%, 95% CI
52$7e69$44%; MBSR: n ¼21, 64$4%; 95% CI 59.26e69.52%;
Q¼0.44, df ¼1, p ¼0$51).
Finally, three comparisons were performed related to practice
recording, study design and study quality. First, studies were
compared that asked participants to fill in ‘daily’logs of practice
(n ¼18) compared with ‘weekly’logs (n ¼18). While heterogeneity
was lower across studies reporting the use of daily logs (I
2
¼84%)
compared to weekly logs (I
2
¼93%), there was no evidence for
significant differences in home practice across these two groups
(daily: 64$6% 95% CI 59e70$3%; weekly: 65$6%, 95% CI
56$9e74$25%, Q ¼0$03, df ¼1, p ¼0$86). Second, there was also no
evidence for significant differences in home practice by study
design, comparing RCTs (n ¼26; 64$9%, 95% CI 59$4e70$47%), non-
randomized trials (n ¼7; 61$5%, 95% CI 49$1e73$9%) and before
and after studies (n ¼10; 64$3%, 95% CI 55$25e73$3%; Q ¼0$25,
df ¼2, p ¼0$88). Third, we also restricted analysis to RCTs with a
low risk of bias, as indicated by three criteria (see Table 2 reporting
of randomization procedure, blinding of outcomes, recording of
attrition). Heterogeneity remained high in this subgroup of RCTs
(n ¼13, 66%, 95% CI 55$76e77$1%, I
2
¼93%). Finally, we performed
a sensitivity analysis excluding studies with small sample sizes (less
than 20, n ¼14). The pooled estimate of participants' practice was
62$7% (CI 57$79e67$75%), but again heterogeneity was substantial
(I
2
¼90%).
9. Studies with reduced home practice requirements
In 10 studies (N ¼141), participants were asked to practice for
less than the standard amount (i.e., less than 45 min per day/6 days
per week or 270 min). We calculated the amount of practice par-
ticipants reported completing as a percentage of the amount
requested. On average, these studies asked participants to practice
for 180 min (SD ¼43) across the week (e.g., 30 min per day, 6 days
per week, or 45 min per day, 5 days per week). The pooled estimate
for participants' practice was 83.86% of the requested amount
(which equates to approximately 151 min per week, 95% CI
67.78e99.94%, see Fig. 4). However, there was substantial
Table 1 (continued )
Study How was practice recorded? Frequency of
practice form
collection
Teacher
training
reported
Did the authors use a scale/
measure to check intervention
adherence?
Class
attendance
reported?
All-day
retreat
Ramel, Goldin, Carmona, and
McQuaid (2004)
Weekly logs but only half participants filled in;
all estimated at follow-up. Data at follow up
used
Weekly class Y N N Not
specified
Rimes and Wingrove (2011) Not specified Not specified Y N Y Not
specified
Roland et al. (2015) Daily log Weekly class Y N Y 3 h retreat
Shallcross et al. (2015) Not specified Not specified Y Y Y Not
specified
Shapiro, Brown, and Biegel
(2007)
Daily log Not specified Y N N Not
specified
Shapiro, Jazaieri, and Goldin
(2012)
Daily log Weekly class Y N N half-day
retreat
Shapiro, Oman, Thoresen,
Plante, and Flinders (2008)
Daily logs Not specified Y N Y No retreat
Vøllestad, Sivertsen, and
Nielsen (2011)
Daily log Not specified N N Y Half-
daYretreat
Whitebird et al. (2013) Daily log Not specified Y N Y 5 h retreat
Wong et al. (2011) Weekly log Weekly class Y N Y 7 h retreat
Zernicke et al. (2013) Weekly logs Weekly class Y N Y 3 h retreat
Studies with reduced practice requirements
Astin (1997) Daily log Not specified N N N no retreat
Bakker et al. (2014) Calendar diary Weekly class Y N Y Not
specified
Creswell et al. (2012) Daily log Not specified N N Y 7 h retreat
Gross et al. (2011) Daily log Regular phone
calls
Y N Y Not
specified
H€
olzel et al. (2011) Not specified
a
Not specified N N Y All-day
retreat
Kimbrough, Magyari,
Langenberg, Chesney and
Berman (2010)
Daily log Weekly class Y N Y 5 h retreat
Rosenzweig et al. (2007) Not specified Weekly class N N N 7 h retreat
Walach et al. (2007) Daily log Not specified Y N N 6 h
Wells et al. (2013) Not specified Not specified Y N Y one day
retreat
Wells et al. (2014) Daily log Not specified Y N Y 6 h retreat
a
Reduced home practice requirements detailed in Hou et al., 2013.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e41 33

Table 2
Study characteristics related to quality indices.
Study Design Randomized Randomization
procedure
Treatment allocation
concealed
Similar at
Baseline
Blinded
Outcomes
Dropouts
recorded
Dropout
Reasons
ITT Power
Studies with standard home practice requirements
Baer et al. (2012) Before and after N N/A N/A N/A N Y N N N
Barnhofer et al.
(2009)
RCT Y Y N N Y Y N Y Y - but
underpowered
Blom et al. (2014) RCT Y Y Y Y N Y Y Y Y
Bluth et al. (2015) Non-randomized
controlled trial
N N/A N/A N N Y Y N N
Britton et al. (2010) RCT Y Y Y N Y Y N N N
Britton et al. (2012) RCT Y Y N/A Y Y Y Y N N
Campbell et al.
(2012)
Non-randomized
controlled trial
N N/A N/A Y N Y Y Y Y
Carlson et al. (2004) Before and after N N/A N/A N/A N/A Y Y N N/A
Carmody and Baer
(2008)
Before and after N N/A N/A N/A N Y N N N/A
Carmody et al.
(2008)
Before and after N N/A N/A N/A N Y N N/
A
N/A
Carmody et al.
(2011)
RCT Y Y N N Y Y Y Y N
Cole et al. (2015) Before and after N N/A N/A N/A N Y N/A N/
A
N/A
Collard et al. (2008) Before and after N N/A N/A N/A N/A Y N N/
A
N/A
*Crane et al. (2014) RCT Y Y N Y Y Y N N/
A
Y
Day et al. (2014) RCT Y N N/A Y N Y N Y Y
Del Re et al. (2013) Before and after N N/A N/A N/A N Y N/A N N/A
Eisendrath et al.
(2015)
Non-randomized
controlled trial
N N/A N/A Y N Y Y N N
Farb et al. (2013) RCT Y N N/A Y N N N N N
Foley et al. (2010) RCT Y Y N Y Y Y Y Y Y
Geschwind (2012) RCT Y Y N Y N Y Y Y Y
Goldsmith et al.
(2014)
Before and after N N/A N/A N/A N/A Y N N/
A
N/A
Gross et al. (2011) RCT Y Y N/A N N Y N N Y
Hawley et al.
(2014)
RCT Y NA N N/A Y N N N/
A
N/A
Hoffman et al.
(2012)
RCT Y Y N Y Y Y Y Y Y
H€
olzel et al. (2011) Non-randomized
controlled trial
N N/A N/A N/A N N N N/
A
N/A
Hou et al. (2013) RCT Y Y N Y Y Y Y Y Y
Jazaieri et al. (2012) RCT Y Y N Y N Y Y Y N
Jensen et al. (2012) RCT Y N Y N Y Y Y N N
Johansson et al.
(2015)
Non-randomized
controlled trial
N N/A N/A Y N Y Y Y N
Kluepfel et al.
(2013)
Before and after N N/A N/A N/A N/A Y Y N N/A
Labelle et al. (2015) Non-randomized
controlled trial
N N/A N/A N/A N Y N Y Y
MacCoon et al.
(2012)
RCT Y Y Y Y Y Y Y Y Y
Nyklicek and
Kuijpers (2008)
RCT Y Y N Y Y Y N Y Y
Ong et al. (2014) RCT Y Y Y Y N Y N Y Y
Parkin et al. (2014) Before and after N N/A N/A N/A N/A Y N N/
A
N/A
Perich et al. (2013) RCT Y N N Y Y Y N Y Y
Pickut et al. (2015) RCT Y N N/A Y Y Y Y N N
Pradhan et al.
(2007)
RCT Y Y N N Y Y Y Y Y
Ramel et al. (2004) Non-randomized
controlled trial
N N/A N/A Y N Y N N N
Rimes and
Wingrove (2011)
Before and after N N/A N/A N/A Y N N/A N/
A
N/A
Roland et al. (2015) Before and after N N/A N/A N/A N Y N N N/A
Shallcross et al.
(2015)
RCT Y Y N/A Y Y Y N Y Y
Shapiro et al.
(2007)
Non-randomized
controlled trial
N N/A N/A Y N Y N N N
Shapiro et al.
(2012)
Before and after N N/A N/A N/A N/A Y N/A N/
A
N
Shapiro et al.
(2008)
RCT Y Y N/A Y N Y N N N
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e4134

heterogeneity associated with this estimate, as reflected by
I
2
¼87.89%. We expressed the practice time of these intervention
participants as a percentage of the standard practice time, to
compare interventions with different practice requirements. A
subgroup comparison showed that participants in the ‘standard
practice’interventions reported completing more practice than
those in the ‘reduced practice’interventions (n ¼10, 52.24%, 95% CI
43.18e61.3%, Q ¼5.6, df ¼1, p ¼0$02).
10. Publication bias
We found evidence suggesting a publication bias for the studies
reporting on quantity of home practice (see Appendix 2, Fig. 1).
Duval and Tweedie's Trim and Fill method, testing for missing
studies to the left side of the mean effect based on a random effects
model, suggested five missing studies, with an imputed point es-
timate of 61% (95% CI 56$8-65$6%). However, given the substantial
heterogeneity associated with the home practice pooled estimate,
the Trim and Fill imputed estimate should also be interpreted
cautiously (Terrin, Schmid, Lau, &Olkin, 2003).
11. Is there an association between home practice and
intervention outcomes?
Across the 28 studies, there was a small but significant associ-
ation between participants’home practice and intervention out-
comes (Fig. 5,r¼0$26, 95% CI 0$19,e0$34, Z ¼6$74, p <0.0001).
Heterogeneity of effects between studies did not appear to be
substantial (I
2
¼17.43%; p ¼0$21).
Subgroup analyses showed no evidence of a difference in the
relationship between home practice and outcomes across clinical
(n ¼22, r ¼0$25, 95% CI 0$17e0$34) and nonclinical populations
(n ¼5, r ¼0$29, 95% CI 0$07e0$48, Z ¼2$5, Q ¼$09, df ¼1,
p¼0$76). There was also no evidence of an overall significant
difference in the home practice/outcome association across studies
grouped by intervention outcome type (Q ¼5$52, df ¼2, p ¼0$17).
However, the majority of available studies reported on primary
psychological outcomes (n ¼19, r ¼0$3, 95% CI 0$21 -$38, Z ¼6$37,
p<0$0001), while a smaller number reported on physical out-
comes (n ¼6, r ¼0$, 95% CI -0$001e0$31, Z ¼1$95, p ¼0$05). Only
two studies reported on the association between SHFP and ‘mixed’
(quality of life) intervention outcomes and neither study reported a
significant association between practice and outcome (r ¼0$13,
95% CI 0$17e0$411, Z ¼$85, p ¼0$39). There was also no evidence
of an effect of study design, comparing RCTs (n ¼15, r ¼$26, 95% CI
0$143e0$376, Z ¼4$21, p <0$0001), non-randomized trials (n ¼4,
r¼$19, 95% CI -0$04e0$4, Z ¼1$6, p ¼0$1), and before and after
studies (n ¼8, r ¼$29, 95% CI 1$48e0$42, Z ¼3$9, p <0$0001;
Q¼0$61, df ¼2, p ¼0$74).
Restricting analysis to RCTs only (n ¼15), the association be-
tween home practice and outcomes remained small, but significant
(r ¼0$26, 95% CI 0$143e0$376, Z ¼4$21, p <0$0001). Finally, a
meta-regression was performed to examine whether the strength
of the association between home practice and outcomes differed
dependent on the mean amount of home practice. There was no
evidence for a linear impact of mean home practice on the practice-
outcome association (Beta ¼0$0004, SE ¼$003, Z ¼0$16,
p¼0$86). We found no evidence for a publication bias for studies
examining home practice and outcome associations
(Supplementary Materials, Fig. 2).
Finally, for the 10 studies with reduced home practice re-
quirements, two reported that there was no significant association
between practice and outcomes, but did not report statistical de-
tails (Astin, 1997,n¼12; Kimbrough et al., 2010;n¼23). Another
study found no significant relationships between home practice
completion and post treatment changes in self-reported loneliness
(Creswell et al., 2012,r(13) ¼0.35, p ¼0.2
2
). The remaining 7
studies did not report on the association between home practice
and outcomes.
Table 2 (continued )
Study Design Randomized Randomization
procedure
Treatment allocation
concealed
Similar at
Baseline
Blinded
Outcomes
Dropouts
recorded
Dropout
Reasons
ITT Power
Vøllestad et al.
(2011)
RCT Y N N/A Y N Y Y Y N
Whitebird et al.
(2013)
RCT Y Y N Y N Y Y Y N
Wong et al. (2011) RCT Y Y Y Y Y Y N Y Y
Zernicke et al.
(2013)
RCT Y Y N Y N Y Y Y Y
Studies with reduced practice requirements
Astin (1997) RCT Y N N Y N Y N N N
Bakker et al. (2014) RCT Y Y N Y N Y N Y Y
Creswell et al.
(2012)
RCT Y Y N Y N Y N Y N
Gross et al. (2004) pre-post N N/A N/A N/A N Y N N/
A
Y
H€
olzel et al. (2011) RCT Y Y ? Y Y Y Y N N
Kimbrough et al.
(2010)
pre-post N N/A N N/A N Y Y N/
A
Y
Rosenzweig et al.
(2007)
pre-post N N/A N/A N/A N Y Y N N/A
Walach et al.
(2007)
non randomized N N/A N/A N/A N Y Y N N
Wells et al. (2013) RCT Y Y N N N N N N/
A
N
Wells et al. (2014) RCT Y Y N N N Y N/A Y Y - but
underpowered
Note: Randomized ¼Was the study randomized? PR ¼Procedure for randomization described? TA ¼Treatment allocation concealed? Baseline ¼Similar at baseline? BO ¼
Blind outcome assessments-if unclear note as N, Dropouts ¼Number of dropouts mentioned. If no mention, score N, DR ¼Withdrawal reasons stated for dropouts ITT ¼Intent
to treat analysis, Power ¼Power calculation described. * RCT details described in Williams et al., 2014.
2
Data provided by authors when contacted.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e41 35

12. Discussion
The available evidence suggests that in standard format MBCT
and MBSR, participants complete about 60% of assigned formal
home practice, where it is recorded and reported. This equates to
around 30 min per day, six days a week and representsa substantial
time commitment, albeit less than suggested in standard inter-
vention formats (Kabat-Zinn, 1990; Segal et al., 2013). We found no
evidence for significant differences in practice completion across
clinical and nonclinical participant groups nor between studies
targeting psychological and physical health outcomes. We found
evidence for a small, significant association between practice and
outcomes across the 28 standard format studies. This significant
association held across clinical and nonclinical participant groups
and across physical and psychological treatment outcomes.
However, there was substantial heterogeneity associated with
the pooled estimates of participants' home practice. Even within a
priori subgroups, heterogeneity was high and we could not readily
identify its source using indices of study quality or study design.
Within individual studies, participants’practice reports were var-
iable, as were reports across studies. This suggests a need for a
greater understanding of the individual-level factors affecting re-
ports of mindfulness home practice, as well as study-level factors.
We also examined the small body of studies with reduced home
practice requirements, which comprised MBSR interventions only.
We found that participants in these studies practiced significantly
less overall than those asked to practice for the standard amount of
time (i.e., 151 min vs. 174 mins per week).
Participants’perception of treatment plausibility and expec-
tancy of positive outcome have been shown to have a small but
significant impact on treatment outcomes for psychological ther-
apies more generally (meta-analysis; Constantino, Arnkoff, Glass,
Ametrano, &Smith, 2011). However, such effects have not been
clearly established for MBCT or MBSR participants (Crane et al.,
2014, but see also; Snippe et al., 2015). Participant personality
traits such as compliance or conscientiousness may also be
important. Other factors implicated in CBT homework completion,
namely motivation to change (Helbig &Fehm, 2004), teacher
Fig. 1. PRISMA diagram of study inclusion.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e4136

competence and reviewing of home assignments (Weck, Richtberg,
Esch, H€
ofling, &Stangier, 2013) might be investigated in MBCT/
MBSR. Study level factors including therapist adherence to MBSR or
MBCT protocols, or indeed an interaction between these factors,
might also be relevant. We could not examine these factors because
of infrequent investigation.
12.1. The association between home practice and outcomes
We found a small to moderate association between participants'
home practice and treatment outcome, where participants are
asked to practice for the standard amount of time. There was no
evidence of heterogeneity of effects. The strength of the association
was similar to that reported in meta-analyses of CBT homework
assignments and outcomes (Kazantzis et al., 2010; Mausbach et al.,
2010). This finding suggests that there is value in supporting and
encouraging participants’home practice in MBCT and MBSR.
Mindfulness practice is often conceptualized as a form of mental
training (Tang, H€
olzel, &Posner, 2015) and like physical training,
greater practice may confer greater benefit. Given the small size of
the practice and outcome association, exploration of additional
participant engagement variables, such as class attendance,
alongside home practice, may be fruitful. Finally, there was insuf-
ficient data from studies with reduced home practice requirements
to address the practice/outcome question.
These findings should also be considered in relation to the small
number of dismantling trials that have tested whether mindfulness
is the “active ingredient”in MBSR (MacCoon et al., 2012) and MBCT
(Williams et al., 2014). For MBSR, a trial with a nonclinical partic-
ipant sample suggests that it is no more effective than an active
control condition (health enhancement programme) in improving
well-being indices. For MBCT, evidence suggests that it is more
beneficial for patients with recurrent depression at increased
vulnerability (history of childhood trauma) than an active control
condition. However, there was no significant advantage for MBCT
over the active treatment in the overall patient sample. Overall,
these trials raise questions about the active components of treat-
ment, but they do not directly test the importance of home practice
itself in MBSR or MBCT.
12.2. Limitations
While our findings suggest that home practice is clinically
important, there are a number of caveats. We found some evidence
of underreporting of participants' home practice, with lower
practice amounts less likely to be reported. However, we did not
find any evidence of a publication bias for studies reporting on the
association between practice and outcomes. Nonetheless, it should
be noted that the majority of studies of MBSR/MBCT do not report
on participants' home practice. Furthermore, the home practice
reports examined here were from participants' who had completed
the 8-week interventions. This review draws attention to the need
to record and report where possible, home practice from all par-
ticipants (completers and non-completers). This would provide a
broader understanding of participants’behavior outside of class
time and its impact on outcomes.
The quality of the evidence included here is another limitation.
We did not restrict inclusion based on study design because the aim
was to examine home practice completion rather than the efficacy
of MBSR or MBCT as interventions. Nevertheless, many of the
included RCTs were at risk for bias from lack of outcome assessment
blinding, allocation concealment, high attrition and lack of
intention-to-treat analysis. These sources of bias have been iden-
tified in previous systematic reviews of RCTs of meditation in-
terventions generally (e.g., Goyal et al., 2014).
There is much potential for improved methodology in studying
home practice and outcomes in MBSR and MBCT. Current estimates
of mindfulness practice rely on participants’retrospective self-
reports, but it is unclear how this relates to their actual practice
behavior. Related to this, included studies typically reported asking
participants to complete daily diaries or weekly forms. We found no
differences between mindfulness practice recorded using either
form type. However, it is difficult to ascertain the actual frequency
with which participants completed these forms.
Furthermore, few studies provided details on the specific forms
filled in by participants (e.g., form by Crane et al., 2014). Develop-
ment and widespread use of standard home practice reporting
forms would be helpful in ensuring consistency in participant
experience and in reporting across studies. Future use of
Fig. 2. Number of studies reporting on home practice and the association between practice time and outcomes.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e41 37

Fig. 3. Mindfulness practice in standard format MBSR/MBCT: Mean percentage of recommended practice (45 min, six days per week) reported across 43 studies.
Fig. 4. Mindfulness practice in MBSR/MBCT with reduced home practice requirements: Mean percentage completed of requested practice reported across 10 studies.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e4138

smartphone apps, text message reminders to fill in practice diaries,
or online portals, may support participants in recording home
practice. In addition, this would provide researchers with a means
to assess the frequency and timing of practice recording. Smart-
phone apps may be particularly valuable as a method of recording
informal practices in real-time (e.g., when participant undertake
unscheduled ‘additional breathing spaces’in response to stressful
events, and ‘noticings’ebringing mindful awareness to moments
in daily life). Future studies may also examine whether specific
practices (e.g., body scan, yoga) are more robustly correlated with
treatment outcomes than others.
Furthermore, participants' practice ‘quality’may be crucial (Del
Re et al., 2013), but again this presents an inherent measurement
challenge. We also did not examine informal practice, which has
been investigated in two recent studies but was not found to affect
intervention outcomes (Crane et al., 2014; Hawley et al., 2014).
However, as has been widely discussed, informal practice is more
challenging to quantify when compared with formal practice,
which has a more standard duration with audio guidance. Teacher
competence in reviewing home practice, and providing formative
feedback, may be particularly important in obtaining insights into
practice behavior, in increasing engagement with practice, and
indeed in increasing the beneficial effects of practice on outcome.
A further limitation of the current evidence is that studies
investigating the formal home practice and outcome association
are correlational. An arguably better strategy to investigate
whether home practice is necessary for positive treatment out-
comes might involve randomly assigning participants to ‘MBSR/
MBCT as usual’compared with a ‘no formal practice’format. Finally,
we chose to focus our analysis on studies reporting outcomes
immediately post intervention and the majority of MBCT/MBSR
studies to date have been over a relatively short time frame. This
allowed us to synthesize a reasonably large body of studies. How-
ever, MBCT has been shown to protect against relapse to depression
(Kuyken et al., 2015), an outcome that requires longer assessment
periods. An important future avenue therefore will be to examine
practice, and its continuation beyond the eight-week intervention,
and longer-term effects.
Author contributions
All authors contributed to the study design and writing of the
manuscript. CP and LP performed the literature searches and data
extraction. CP performed the data analysis and CP and CC per-
formed the data interpretation.
Acknowledgements
CP received funding from TrygFonden Charitable Foundation
(ID: 117642). WK's research is funded by the Wellcome Trust
(104908/Z/14/Z &WT104908MA) &NIHR, Health Services and
Delivery Research Programme, (12/64/0412). CC is affiliated with
the University of Oxford Mindfulness Centre and is funded by the
Wellcome Trust, 104908/Z/14/Z (PI Professor Mark Williams).
Fig. 5. The association between home practice and intervention outcomes across 28 studies.
C.E. Parsons et al. / Behaviour Research and Therapy 95 (2017) 29e41 39

Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.brat.2017.05.004.
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