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709589PPSXXX10.1177/1745691617709589Van Dam et al.Critical Evaluation of Mindfulness Research
†These authors contributed equally to the present article and are listed in reverse alphabetical order.
*Cathy Kerr passed away, unexpectedly, during the revision of this article.
Nicholas T. Van Dam, Department of Psychiatry, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY 10029
Mind the Hype: A Critical Evaluation
and Prescriptive Agenda for Research
on Mindfulness and Meditation
Nicholas T. Van Dam1, Marieke K. van Vugt2†, David R. Vago3†,
Laura Schmalzl4†, Clifford D. Saron5†, Andrew Olendzki6†,
Ted Meissner7†, Sara W. Lazar8†, Catherine E. Kerr9†*,
Jolie Gorchov10†, Kieran C. R. Fox11†, Brent A. Field12†,
Willoughby B. Britton13†, Julie A. Brefczynski-Lewis14†, and
David E. Meyer15
1Department of Psychiatry, Icahn School of Medicine at Mount Sinai; 2Institute of Artificial Intelligence
and Cognitive Engineering, University of Groningen; 3Osher Center for Integrative Medicine, Departments
of Psychiatry and Physical Medicine & Rehabilitation, Vanderbilt University Medical Center; 4College of
Science and Integrative Health, Southern California University of Health Sciences; 5Center for Mind and
Brain, University of California, Davis; 6Integrated Dharma Institute; 7Center for Mindfulness, University of
Massachusetts Medical School; 8Massachusetts General Hospital, Harvard Medical School; 9Department of
Family Medicine, Warren Alpert Medical School at Brown University; 10Silver School of Social Work, New
York University; 11Department of Neurology and Neurological Sciences, Stanford University; 12Princeton
Neuroscience Institute, Princeton University; 13Department of Psychiatry and Human Behavior, Warren Alpert
Medical School at Brown University; 14Department of Physiology and Pharmacology, School of Medicine,
West Virginia University; and 15Department of Psychology, University of Michigan
During the past two decades, mindfulness meditation has gone from being a fringe topic of scientific investigation to
being an occasional replacement for psychotherapy, tool of corporate well-being, widely implemented educational
practice, and “key to building more resilient soldiers.” Yet the mindfulness movement and empirical evidence supporting
it have not gone without criticism. Misinformation and poor methodology associated with past studies of mindfulness
may lead public consumers to be harmed, misled, and disappointed. Addressing such concerns, the present article
discusses the difficulties of defining mindfulness, delineates the proper scope of research into mindfulness practices,
and explicates crucial methodological issues for interpreting results from investigations of mindfulness. For doing so,
the authors draw on their diverse areas of expertise to review the present state of mindfulness research, comprehensively
summarizing what we do and do not know, while providing a prescriptive agenda for contemplative science, with a
particular focus on assessment, mindfulness training, possible adverse effects, and intersection with brain imaging. Our
goals are to inform interested scientists, the news media, and the public, to minimize harm, curb poor research practices,
and staunch the flow of misinformation about the benefits, costs, and future prospects of mindfulness meditation.
mindfulness, meditation, psychotherapy, neuroimaging, contemplative science, adverse effects, media hype,
2 Van Dam et al.
Mindfulness is an umbrella term used to characterize a
large number of practices, processes, and characteris-
tics, largely defined in relation to the capacities of atten-
tion, awareness, memory/retention, and acceptance/
discernment. While the term has its historical footing
in Buddhism (cf. Bodhi, 2011; Dreyfus, 2011; Dunne,
2011; Gethin, 2011; Kabat-Zinn, 2011), it has achieved
wide-ranging popularity in psychology, psychiatry,
medicine, neuroscience, and beyond, initially through
its central role in mindfulness-based stress reduction
(MBSR; Kabat-Zinn, 1990)—an intervention/training
“package” introduced in the late 1970s as a comple-
mentary therapy for medically ailing individuals
(Kabat-Zinn, 2011). The term mindfulness began to gain
traction among scientists, clinicians, and scholars as the
Mind and Life Institute emerged in 1987 and facilitated
formal regular dialogues between the Dalai Lama and
prominent scientists and clinicians, as well as regular
summer research meetings, the latter starting in 2004
(Kabat-Zinn & Davidson, 2011). In the early 2000s,
mindfulness saw an exponential growth trajectory that
continues to this day (see Fig. 1). The term mindfulness
has a plethora of meanings; a reflection of its incredible
popularity alongside some preliminary support, con-
siderable misinformation and misunderstanding, as well
as a general lack of methodologically rigorous research.
Mindfulness has become an extremely influential
practice for a sizeable subset of the general public, con-
stituting part of Google’s business practices (Schaufenbuel,
2015), available as a standard psychotherapy via the
National Health Service in the United Kingdom (see
Coyne, 2015b) and, most recently, part of standard edu-
cation for approximately 6,000 school children in Lon-
don (Rhodes, 2015). In addition, it has become a major
area of study across subdisciplines of psychological sci-
ence, including social/personality (Brown & Ryan, 2003),
industrial/organizational (Dane, 2011), experimental
(Jensen, Vangkilde, Frokjaer, & Hasselbalch, 2012), clini-
cal (Dimidjian & Segal, 2015), cognitive (Tang, Hölzel,
& Posner, 2015), health (Jain etal., 2007), educational
(Britton, Lepp, etal., 2014), and many others. As such,
it is critical that we take the term (along with any ambi-
guities) and the methodological rigor (or lack thereof)
with which it has been studied very seriously.
Over the past two decades, writings on mindfulness
and meditation practices have saturated the public news
media and scientific literature (see Fig. 1). While this is
not an isolated case, much popular media fail to accu-
rately represent scientific examination of mindfulness
(see, e.g., Goyal etal., 2014), making rather exaggerated
claims about the potential benefits of mindfulness prac-
tices (Gibbs, 2016; Gunderson, 2016). There have even
been some portrayals of mindfulness as an essentially
universal panacea for various types of human deficien-
cies and ailments (see, e.g., Gunderson, 2016; Huffington,
As mindfulness has increasingly pervaded every aspect
of contemporary society, so have misunderstandings
about what it is, whom it helps, and how it affects the
mind and brain. At a practical level, the misinformation
and propagation of poor research methodology can
potentially lead to people being harmed, cheated,
Fig. 1. Scientific and news media articles on mindfulness and/or meditation by year from 1970
to 2015. Empirical scientific articles (black line) with the term mindfulness or meditation in the
abstract, title, or keywords, published between 1970 and 2015 were searched using Scopus. Media
pieces (dashed gray line) with the term mindfulness or meditation, published in newspapers, using
a similarity filter to minimize double-counting, published between 1970 and 2015 were searched
Critical Evaluation of Mindfulness Research 3
disappointed, and/or disaffected. At a philosophical level,
misunderstandings of the work and its implications could
limit the potential utility of a method that proposes
unique links between first-person data and third-person
observations (cf. Lutz & Thompson, 2003). Furthermore,
research into a potentially promising arena may be halted
for no reason other than that people have become tired
of hearing about it (and therefore disinclined to pursue
and/or fund it). While there have been many review
articles written on mindfulness (e.g., Davidson &
Kaszniak, 2015; Dimidjian & Segal, 2015; Farb, 2014; Tang
etal., 2015), they cannot, by virtue of their limited scope
(often focused on specific conditions or topics) and
authorship (often limited to a short list of investigators,
sometimes with clear conflicts of interest; see, e.g., Coyne,
2015b), offer a balanced, consensus perspective. Going
beyond prior reviews, the present work provides exposi-
tion of the varying definitions of mindfulness, reviews
the status of empirical assessment of mindfulness, reviews
potential adverse events, considers implications for con-
temporary clinical practice, discusses specific issues that
arise when doing neuroimaging with meditating samples,
and elaborates on potential neural differences associated
with meditation practices of varying durations.
Two main topics are considered herein: (a) the prob-
lem of defining mindfulness and thus delineating the
appropriate scope of research on mindfulness practices
and (b) methodological issues in mindfulness research.
We provide (a) an overview of the current state in sci-
entific knowledge, (b) a summary of consensus about
what the currently available empirical findings do or
do not conclusively show, and (c) a proposed prescrip-
tive research agenda for making future scientific prog-
ress in understanding the consequences of mindfulness
Our rationale for this expository approach stems
from multiple major a priori considerations. We believe
that much public confusion and media hype have
stemmed from an undifferentiated use of the terms
mindfulness and meditation. Each of these terms may
refer to an ambiguously broad array of mental states
and practices that are associated with a wide variety of
secular and religious contexts (Davidson & Kaszniak,
2015; Goleman, 1988). Valid interpretation of empirical
results from scientific research on such states and prac-
tices must take proper account of exactly what types
of mindfulness and meditation are involved. With cur-
rent use of umbrella terms, a 5-minute meditation exer-
cise from a popular phone application might be treated
the same as a 3-month meditation retreat (both labeled
as meditation) and a self-report questionnaire might be
equated with the characteristics of someone who has
spent decades practicing a particular type of meditation
(both labeled as mindfulness).
Furthermore, there is a general failure among the
public to recognize that scientific consensus is a com-
plex process requiring considerable time, effort, debate,
and (most important) data. Throughout the scientific
process, the predominant view among scholars can
vacillate between being in support of, being agnostic
to, and being against a given idea or theory (Shwed &
Bearman, 2010). Eager journalists, academic press
offices, and news media outlets—sometimes aided and
abetted by researchers—have often overinterpreted ini-
tial tentative empirical results as if they were estab-
lished facts. Moreover, statistically “significant”
differences have repeatedly been equated with clinical
and/or practical significance (cf. Rosnow & Rosenthal,
1989). These critical considerations need to be incor-
porated constructively in the future development of
best practices for conducting mindfulness research, and
for promoting accurate scientific communication with
the general public (Britton, 2016).
The Problematic Meaning of
Despite how it is often portrayed by the media (e.g.,
Huffington, 2013) and some researchers (Brown & Ryan,
2003), there is neither one universally accepted technical
definition of “mindfulness” nor any broad agreement
about detailed aspects of the underlying concept to
which it refers (Bodhi, 2011; Dreyfus, 2011; Dunne, 2011;
Gethin, 2011). Frequently, “mindfulness” simply denotes
a mental faculty for being consciously aware and taking
account of currently prevailing situations (Kabat-Zinn,
1990; Langer, 1989). At other times, “mindfulness” may
refer to formal practice of sitting on a cushion in a spe-
cific posture and attending (more or less successfully)
to the breath or some other focal object. Considerable
disagreement about definitions is not uncommon in the
study of complex constructs (for discussion of intelli-
gence, see, e.g., Neisser etal., 1996; for discussion of
wisdom, see, e.g., Walsh, 2015) and mindfulness is no
exception. Mindfulness is typically considered to be a
mental faculty relating to attention, awareness, retention/
memory, and/or discernment (cf. Davidson & Kaszniak,
2015); however, these multiple faculties are rarely rep-
resented in research practice (Goldberg et al., 2015;
Manuel, Somohano, & Bowen, 2017). One of the most
thoughtful and frequently invoked definitions states that
mindfulness is moment-to-moment awareness, cultivated
by paying attention in a specific way, in the present
moment, as nonreactively, nonjudgmentally, and open-
heartedly as possible (Kabat-Zinn, 1990, 2011). However,
this definition has been described as one of convenience
regarding those constructs most readily comprehensible
to Western audiences (Kabat-Zinn, 2011).
4 Van Dam et al.
Alternative semantic interpretations
Although concerted efforts have been made to provide
consensus descriptions of mindfulness (Analayo, 2003;
Bishop et al., 2004; Bodhi, 2011; Brown, Ryan, &
Creswell, 2007; Grabovac, Lau, & Willett, 2011;
Gunaratana, 2002; Hölzel et al., 2011; Malinowski,
2013; S. L. Shapiro, Carlson, Astin, & Freedman, 2006;
Vago & Silbersweig, 2012), there continue to be con-
siderable variations regarding the meaning of “mindful-
ness.” The resulting debates within and across
complementary scholarly disciplines that encompass
the investigation and practice of mindfulness and medi-
tation more generally are diverse and complex (see
Contemporary Buddhism, 2011, vol. 12, no. 1; Psycho-
logical Inquiry, 2007, vol. 18, no. 4). Given such con-
siderations, one should not be especially surprised that
some people have refrained from accepting Kabat-
Zinn’s (1990) definition of “mindfulness,” or else have
interpreted it in different, sometimes conflicting, ways.
Kabat-Zinn (2011) himself has acknowledged that the
term represents (to him) a much broader scope of
concepts and practices than what his earlier (1990)
definition might suggest.
Scientific implications of semantic
ambiguity in the meaning of
The ramifications of considerable semantic ambiguity
in the meaning of mindfulness are multifarious. Any
study that uses the term mindfulness must be scrutinized
carefully, ascertaining exactly what type of “mindful-
ness” was involved, and what sorts of explicit instruction
were actually given to participants for directing practice,
if there was any practice involved. If the definition of
mindfulness is based on self-report measures, one
should be aware of the nuances of the various measures,
how they relate to each other and/or conceptualizations
of mindfulness (see Table 1; Bergomi, Tschacher, &
Kupper, 2013; Sauer etal., 2013), as well as how differ-
ent individuals might interpret the items on these mea-
sures (cf. Grossman & Van Dam, 2011). It should be
further noted that self-reported mindfulness may not
relate to the actual practice of mindfulness meditation
(cf. Manuel etal., 2017). When formal meditation was
used in a study, one ought to consider whether a spe-
cifically defined type of mindfulness or other meditation
(cf. Lutz, Slagter, Dunne, & Davidson, 2008) was the
target practice (see, e.g., Braun, 2013; McMahan, 2008).
Table 1. Mindfulness Measures
Publication Date Name Context
2001 Freiburg Mindfulness Inventory (FMI) Buddhist theory 565 1. General
2003 Mindful Attention and Awareness Scale
Self-determination theory 5,054 1. Attentiveness and
2004 Kentucky Inventory of Mindfulness
1,449 1. Observing
2006 Five Facet Mindfulness Questionnaire
CAMS-R, KIMS, FMI,
2,660 1. Nonreactivity
2006 Toronto Mindfulness Scale (TMS) Bishop etal. (2004) 648 1. Curiosity
2007 Cognitive and Affective Mindfulness
Scale, Revised (CAMS-R)
Buddhist theory and
530 1. Attention
2. Present Focus
2008 Philadelpha Mindfulness Scale
Bishop etal. (2004) 411 1. Acceptance
2008 Southhamptom Mindfulness
Kabat-Zinn (1990) and
297 1. General
2013 State Mindfulness Scale (SMS) Buddhist theory 35 1. Body Mindfulness
2. Mind Mindfulness
aGoogle Scholar, October 20, 2016.
Critical Evaluation of Mindfulness Research 5
In addition, while there is no single definition of mind-
fulness, it is important to examine whether the authors’
specified definition is consistent with their study
Consequences of semantic ambiguity
for empirical studies of “mindfulness”
Although most mindfulness training has been derived
from the original MBSR model (Kabat-Zinn, 1990), the
intensity (hours per day) and duration (total time com-
mitment) of participants’ formal practice have varied
considerably across different versions of training
(Davidson & Kaszniak, 2015; Tang etal., 2007; Zeidan
etal., 2011). The particular methods for teaching and
practicing “mindful” states have varied, too. However,
published journal abstracts and media reports about
obtained results often gloss over such crucial variations,
leading to inappropriate comparisons between what
might be fundamentally different states, experiences,
skills, and practices.
Different definitions of skilled expertise. The defi-
nitions of “novice” and “expert” or “adept” (with respect
to those with meditation experience) have varied consid-
erably from study to study. Some investigators have con-
sidered novices to be individuals with some but not
extensive prior formal meditation experience (e.g., up to
a few hundred hours of practice; Kozasa et al., 2012;
Lutz, Dunne, & Davidson, 2007). Others have applied a
much stricter criterion, deeming novices only to be indi-
viduals with absolutely no prior meditation experience
(e.g., Brewer etal., 2011). Further increasing this confu-
sion, some approaches to investigating “mindfulness”
(e.g., Hayes, Strosahl, & Wilson, 1999; Linehan, 1993) do
not require any systematic training to become “skilled” in
the practice, nor do they require participants to sustain a
given experiential state (e.g., present-moment focus, or
compassionate engagement) any longer than necessary
to achieve a putative beneficial effect.
Consequences of semantic
ambiguity for theoretical models of
According to proposed theoretical models of mindful-
ness, there are clear mental processes and brain mecha-
nisms that might facilitate insight and adaptive personal
change, such as psychological distancing/reperceiving
(S. L. Shapiro etal., 2006), decentering and inhibitory
control (Vago & Silbersweig, 2012), nonconceptual dis-
criminatory awareness (Brown etal., 2007), acceptance
and reintegration (Hayes etal., 1999; Linehan, 1993),
or focused attention, decentering, and meta-awareness
(Lutz, Jha, Dunne, & Saron, 2015; Meyer, 2009). Some
of these processes and/or outcomes may be evident on
a continuum, suggesting gradual growth with practice
over time, whereas others may emerge significantly
only in experienced practitioners (i.e., individuals who
have engaged in formal sitting meditation or other con-
templative practices such as hatha yoga, over a lengthy
period of time; e.g., van Vugt & Slagter, 2014). Potential
changes to various cognitive capacities as a result of
mindfulness practice are not specific to clinical con-
texts; it also informs the limits, capacities, and nature
of various cognitive functions and how those functions
might be modified. However, the aforementioned com-
plexity, confounding, and confusion that surrounds
empirical research on “mindfulness” limits the potential
of the method to inform broad questions and inform
specific theories. The extent to which a specific model
is supported or disconfirmed by particular sets of
empirical data or systematic observations depends on
the meaning of “mindfulness” that inspired data acquisi-
tion. For example, it is nearly impossible to test whether
decentering has occurred if one has not obtained a
measure of it. Support for a model will also depend on
compliance with experimenter/clinician instructions
(Davidson & Kaszniak, 2015). No one theoretical model
(e.g., Garland, Farb, Goldin, & Fredrickson, 2015;
Grabovac etal., 2011; Hölzel etal., 2011; S. L. Shapiro
etal., 2006; Vago & Silbersweig, 2012) can possibly
describe, explain, and predict all of the phenomena
stemming from the panoply of facets that “mindfulness,”
broadly construed, can have. Thus, it will be critical,
going forward, to generate new integrative models and
to track which data support which models.
Consensus about the semantic ambiguity of “mind-
fulness.” “Mindfulness” does not constitute a unitary
construct, though it frequently includes aspects of paying
attention in a specific, sustained, nonjudgmental way
(Kabat-Zinn, 1990). Buddhist scholars suggest it often
entails attention, awareness, memory/retention, and dis-
cernment (cf. Bodhi, 2011; Dreyfus, 2011; Dunne, 2011;
Gethin, 2011). Self-report measures often highlight atten-
tion, awareness, and acceptance or nonjudgment (rather
than discernment; see Table 1). The field, broadly
defined, seems to agree that mindfulness entails attention
and awareness with some important qualifiers about the
nature of those faculties. It is also evident that mindful-
ness is part of some broader collection of goals and atti-
tudes (Gethin, 2011; Kabat-Zinn, 2011). From a historical
perspective, the attitudes qualifying attention and aware-
ness are those accompanying some higher pursuit (e.g.,
6 Van Dam et al.
enlightenment), including recognition/awareness, tran-
quility, concentration, equanimity, energy, joy, and dis-
crimination (Gethin, 2011). Ultimately, degree of fidelity
to historical definitions may not necessarily matter to
definitions of mindfulness applied in modern practice
(Dreyfus, 2011; Gethin, 2011), though historical defini-
tions can provide important context and insight into the
nature of mindfulness practice and its potential mecha-
nisms (cf. Kabat-Zinn, 2011). Finally, the type of mindful-
ness putatively measured by contemporary cross-sectional
research is not necessarily the same as what contempo-
rary mindfulness training/meditation seeks to cultivate
(see Manuel etal., 2017), which itself can differ from the
mindfulness practiced by long-term meditators in various
contemplative traditions relative to one another (Grossman
& Van Dam, 2011).
Prescriptive research agenda: Transcending the
prevalent ambiguity. Given current confusion sur-
rounding “mindfulness,” we urge scientists, practitioners,
instructors, and the public news media to move away from
relying on the broad, umbrella rubric of “mindfulness” and
toward more explicit, differentiated denotations of exactly
what mental states, processes, and functions are being
taught, practiced, and investigated. Toward this end, we
have provided a nonexhaustive list of defining features for
characterization of contemplative and meditation practices
(see Table 2). We have divided these features into primary
(i.e., critical to most practices) and secondary (i.e., only
critical to some practices). While this list is nonexhaustive,
common use of this list of descriptors (or a comparable
list) would permit the field to move beyond the many
ambiguities of definition it is currently facing. Other exam-
ples of fundamental feature lists can be found in both sci-
entific (e.g., Lutz et al., 2015) and contemplative (e.g.,
Analayo, 2003) literatures. For those studies using self-
report measures, we encourage users to list the exact mea-
sure and to discuss the aspects of “mindfulness” that the
utilized measure characterizes (see, e.g., Table 1). These
suggestions address only terminology and do not neces-
sarily provide ways to overcome the variation in the pano-
ply of contextual factors surrounding mindfulness and/or
meditation practice (e.g., type and training of instructor,
regularity of meetings, group vs. individual practice, home
practice type and amount, etc.). To resolve issues sur-
rounding the implementation of mindfulness and/or other
meditation-based training/intervention, we recommend
development of something similar to a CONSORT check-
list (Moher, Schulz, & Altman, 2001) that could be imple-
mented across studies (see Table 3).
Table 2. Nonexhaustive List of Defining Features for Characterization of Meditation Practice
Feature Definition Variation in Feature
Arousal Extent of alertness, awakeness, etc. Low, medium, high
Orientation (of attention) Where attention is directed Inward vs. outward vs. no orientation
Spatial “dynamic” (of attention) The quality of attention in space Fixed (e.g., on an object or location) vs.
moving (e.g., as in the body scan)
Temporal “dynamic” (of attention) The quality of attention in time Constant/stable vs. rhythmic/sporadic
Object (of attention) Attention can be fixed on none, one, two,
or many objects
Specific (i.e., defined object[s]) vs. aspecific
(i.e., no well-defined object[s]) vs. none
(i.e., no object of attention)
Aperture (of attention) How “sharply” the spotlight of attention is
Narrow vs. intermediate vs. diffuse
Effort The extent to which one exerts energy to
achieve other features
Low, medium, high
Complementary activity Physical activity to facilitate desired
Walking, mantra recitation, dancing,
rhythmic movement, etc.
Affective valence Emotional tone of practice Positive vs. neutral vs. negative
Emotional intention A desired emotional state (to be cultivated) Loving-kindness, compassion, forgiveness,
Motivation/goal The rationale/reason for the practice Wellness, mitigation of illness, self-
Proficiency required Level of skill or expertise necessary Low, medium, high
Posture Physical orientation of body during
Horizontal (e.g., lying down) vs. intermediate
(e.g., sitting) vs. vertical (e.g., standing)
Critical Evaluation of Mindfulness Research 7
Methodological Issues in Mindfulness
Complementing our commentary about the problematic
meanings of “mindfulness,” several major methodologi-
cal issues in mindfulness meditation research should
be considered as well. Such consideration is essential
to achieve the present goals of providing a more bal-
anced perspective on the pros and cons of practicing
mindfulness, and on the weaknesses of currently avail-
able empirical findings about its efficacy. Specifically,
we are concerned about four distinct but related types
of issue: (a) insufficient construct validity in measures
of mindfulness, (b) challenges to (clinical) intervention
methodology, (c) potential adverse effects from practic-
ing mindfulness, and (d) questionable interpretations
of data from contemplative neuroscience concerning
the mental processes and brain mechanisms underlying
Relation to the “replication crisis” in
Worries over scientific integrity and reproducibility of
empirical findings have recently come to the fore of
both psychological science and wider swaths of other
basic and applied sciences, receiving considerable
attention in both the scientific literature (Button etal.,
2013; Ioannidis, 2005, 2012; Miguel etal., 2014; Open
Science Collaboration, 2012; Pashler & Wagenmakers,
2012) and public news media (Freedman, 2010; Johnson,
2014a, 2014b; Lehrer, 2010; Nyham, 2014). As part of
these developments, debates regarding the efficacy and
safety of treatment interventions have also embroiled
the behavioral and neuropsychiatric sciences (Baker,
McFall, & Shoham, 2008; Button etal., 2013; Fanelli,
2010; Ioannidis, 2005; Munafò, Stothart, & Flint, 2009;
Simmons, Nelson, & Simonsohn, 2011; Yarkoni,
Poldrack, Van Essen, & Wager, 2010). Although our
present focus is on methodological issues to which
mindfulness research is especially vulnerable, it is impor-
tant to take account of this broader self-examination
currently underway in the scientific community. Contem-
plative science (i.e., the scientific study of contemplative
practices including, but not limited to, mindfulness medi-
tation) is particularly vulnerable to “hype” of various
sorts (i.e., tendencies to tout exaggerated positive and
Insufficient construct validity in
One of the disclaimers on offer here concerns construct
validity in measuring mindfulness. For obvious reasons,
Table 3. Nonexhaustive List of Study Design Features for a Mindfulness-Based Intervention
Teacher information Number/type of retreats attended?
Experience in contemplative instruction (general and specific)?
Formal contemplative training?
Formal clinical qualifications?
Blinded to experimental hypotheses?
Practice information Setting(s)?
Physical (e.g., hospital room, university lecture hall, etc.)
Social (e.g., individual vs. group—if group, cohesion, size)
Overall duration (e.g., 8 weeks, 12 weeks, 3 months, etc.)?
Frequency of meetings?
Average length of meetings?
Types of formal practice (e.g., body scan, breath meditation, walking meditation, etc.)?
Approximate total % of each type of practice?
Types of informal practice?
Logs maintained? Practice reviewed in session? Guided?
Types of instructional materials used (e.g., mindfulness-based stress reduction workbook)
General information Instructor adherence assessed?
Control group used?
Adverse events monitored?
Participant info Inclusion/exclusion criteria?
Prior meditation experience?
Conflicts of interest Formal: funding agency
Informal: Any possible financial benefit from results of study?
8 Van Dam et al.
this concern is crucial to our present objectives. Lacking
reasonably validated mindfulness measures, one can
neither properly determine how this mental faculty
changes through instructions and guided practice, nor
can one assess how increased mindfulness affects the
cognitive capacities and/or symptoms of various mental
and physical dysfunctions.
Difficulties in operationalizing and measuring
mindfulness. Given the aforementioned absence of
consensus regarding definitions of “mindfulness,” the
operationalization and measurement of mindfulness are
challenging endeavors. These difficulties have propagated
to affect both (a) mindfulness practice and (b) assess-
ments of mindfulness as a mental state or personality trait.
Different researchers have implemented varying mindful-
ness training approaches across studies (e.g., Davidson,
2010), creating challenges for identifying common effects.
We are especially concerned about attempts to measure
mindfulness via self-report (see, e.g., Grossman & Van
Dam, 2011) because, as Figure 2 indicates, a large fraction
of recent research studies has used questionnaires for
their primary assessment of mindfulness (consistent with
a broader trend toward measuring psychological con-
structs via self-report; e.g., Baumeister, Vohs, & Funder,
Problematic aspects of self-report questionnaires. A
major challenge to construct validity in psychological
assessment is due to reluctance of the field to move
beyond logical positivism, a philosophical position that
suggests theories are direct derivations of that which can
be empirically observed (Green, 1992). Fueled by the
prominence of behaviorism, which continues to play a
prominent role in contemporary psychology (see, e.g.,
Plaud, 2001), the logical positivistic approach posits that a
given measure is equivalent to the construct it purports to
measure. In contrast, an alternative, nonjustificationist
view suggests that a given measure is merely an approxi-
mation of a construct (Embretson, 1983; M. E. Strauss &
Smith, 2009). It is important that philosophical views on
construct validity can influence the ways that measures
are designed and validated. One contemporary extension
of logical positivism (which itself would reject the very
idea of a construct) seems to be that nomothetic span
(e.g., the extent to which a measure converges or diverges
from other measures that are related or unrelated, respec-
tively) is all that is needed for construct validity. In con-
trast to the positivistic view, construct representation (e.g.,
the psychological processes that give rise to responses on
instruments that purport to measure the construct) is criti-
cal to construct validity (Embretson, 1983; M. E. Strauss &
Questionnaire-based scales that purport to measure
mindfulness offer, at best, modest evidence of nomo-
thetic span. Mindfulness does reliably correlate with
other constructs such as emotional intelligence, self-
compassion, psychological symptoms, thought suppres-
sion, emotion regulation, alexithymia, dissociation, and
absent-mindedness (e.g., Baer, Smith, Hopkins, Kritemeyer,
& Toney, 2006). However, these findings may actually be
suggestive of a lack of differentiation from broad features
of personality and temperament; meta-analysis of mind-
fulness measures suggests a strong negative relation-
ship to neuroticism and negative affect (Giluk, 2009).
As an alternative, it may suggest that at least some
measures of mindfulness relate to general vulnerabili-
ties or skills that are developed across interventions. In
other words, these vulnerabilities and/or skills may not
be specifically related to mindfulness, an idea sup-
ported by increases in mindfulness across both MBSR
and an active control condition (Goldberg etal., 2015).
Additional psychometric concerns, largely relating to
construct representation, about self-report mindfulness
also exist. Notably, several of these scales exhibit differ-
ent factor structures and response properties between
meditators and nonmeditators (e.g., Christopher,
Charoensuk, Gilbert, Neary, & Pearce, 2009; Van Dam,
Earleywine, & Danoff-Burg, 2009), as well as before and
after mindfulness training (e.g., Gu etal., 2016). These
findings suggest lack of equivalence on a common
underlying latent variable, as well as change in how the
items are interpreted. One possible reason for this has
to do with demand characteristics; one who has prac-
ticed mindfulness meditation may understand and value
items differently than someone who has not practiced
Fig. 2. Articles in academic journals by content type. Scopus search
limited to articles in academic journals only, published between 1970
and 2014, keyword mindfulness or meditation for overall search;
Brain NOT Questionnaire and Questionnaire NOT Brain as additional
Critical Evaluation of Mindfulness Research 9
(though see Baer, Samuel, & Lykins, 2011)—a potential
conflation of desire to be “mindful” with actually being
“mindful” (cf. Grossman, 2011). Of additional concern,
mindfulness measures have not always favored the group
one might expect to be more mindful; in one case, expe-
rienced meditators were less “mindful” than binge drink-
ers (Grossman & Van Dam, 2011; Leigh, Bowen, &
Marlatt, 2005). Moreover, mindfulness questionnaires do
not always correlate with mindfulness meditation prac-
tice (Manuel etal., 2017) and the underlying latent vari-
able influencing item response on certain scales may be
reflective of some general feature such as inattentiveness
(Van Dam, Earleywine, & Borders, 2010).
Self-report-based measures of mindfulness may be
particularly vulnerable to limitations of introspection
because participants may not know exactly which
aspects of mental states should be taken into account
when making personal assessments. Moreover, making
“on-line” judgments about degrees of mindfulness
requires a special kind of multitasking (Meyer, 2009).
In addition, social-desirability biases may be especially
pronounced in self-reports about “mindfulness.” This is
because participants/patients often learn to expect/
value improved attention, equanimity, and so forth,
while experimenters often fail to hide their hopes that
participants will grow in their adeptness at these mental
faculties (cf. Jensen etal., 2012).
Consensus about construct validity in measuring
“mindfulness.” Some promise exists toward more accu-
rate mindfulness measures via subjective report of behav-
ioral indicators (e.g., breath counting; Frewen, Evans,
Maraj, Dozois, & Partridge, 2007; Frewen, Lundberg,
MacKinley, & Wrath, 2011; Levinson, Stoll, Kindy, Merry, &
Davidson, 2014). Yet potential pitfalls exist even in these
new measures (Ring, Brener, Knapp, & Mailloux, 2015).
Although some self-report questionnaire measures of
mindfulness seem to be effective in revealing particular
mental and physical changes associated with practicing
mindfulness (e.g., Baer, 2011), how closely these mea-
sures track exactly what is taught during practice remains
unclear. While some investigators have implied that
increased mindfulness improves the quality of partici-
pants’ introspections (Lutz etal., 2007; Mrazek, Smallwood,
& Schooler, 2012; Zanesco, King, MacLean, & Saron,
2013), this claim has not been well established (cf. Fox
etal., 2012; Levinson etal., 2014; Sze, Gyurak, Yuan, &
Levenson, 2010; Whitmarsh, Barendregt, Schoffelen, &
Jensen, 2014). Nor is it entirely obvious how one could
veridically establish such a claim, for doing so would
require accurate “third-person” evidence about the sub-
jective contents of an introspector’s “first-person” con-
sciousness (cf. Lutz, Lachaux, Martinerie, & Varela, 2002).
It is ironic that were it shown that mindfulness practice
improves the quality of participants’ introspections, this
might deepen other problems in mindfulness research. For
example, if mindfulness-based enhancements of intro-
spective accuracy are real, such enhancements could
increase honest responding, thereby exacerbating between
Perhaps because of such pitfalls in introspection,
many studies have focused instead on neurobehavioral
performance, attempting to assess mindfulness indirectly
(e.g., Brewer etal., 2011; Ferrarelli etal., 2013; Jha,
Krompinger, & Baime, 2007; Lao, Kissane, & Meadows,
2016; Lutz, Greischar, Perlman, & Davidson, 2009; Sahdra
etal., 2011). However, these studies have inconsistent
and sometimes contradictory empirical findings about
the effects of mindfulness training on various basic cog-
nitive and behavioral capacities (e.g., Jha etal., 2007;
Lao etal., 2016). Some promising preliminary examples
include studies that involved different types of mindful-
ness training leading to modest improvements in the
efficiency of attention, orienting, and executive cognitive
control after varying types of practice ( Jha etal., 2007;
Sahdra etal., 2011; Slagter etal., 2007; Tang etal., 2007;
Van den Hurk, Giommi, Gielen, Speckens, & Barendregt,
2010). Even when statistically significant, the magnitudes
of observed cognitive effects stemming from mindfulness
practices have been rather small (Chiesa, Calati, &
Serretti, 2011; Sedlmeier etal., 2012).
Prescriptive research agenda: Measuring aspects of
mindfulness. Given the cultural history and multitude
of contextual variations in the term mindfulness, scientific
research on the aggregate of mental states labeled by it
would benefit from redirecting attempts to directly mea-
sure mindfulness toward measuring supporting mental
faculties. The situation is similar to the psychological
study of “intelligence.” Because of complexities, historical
efforts to obtain a single unitary measure of general intel-
ligence evolved to studying particular cognitive capaci-
ties, that, in combination, may make people functionally
more or less intelligent (cf. Neisser etal., 1996).
Paralleling such evolution, we recommend that
future research on mindfulness aim to produce a body
of work for describing and explaining what biological,
emotional, cognitive, behavioral, and social, as well as
other such mental and physical functions change with
mindfulness training. There are two broadly useful con-
texts in which to approach this problem. The first is to
use a multimodal approach wherein first- and third-
person (i.e., neurobiological and/or behavioral) assess-
ments are used to mutually inform and identify one
another (cf. Lutz etal., 2015; Lutz et al., 2002). This
constitutes a more theory-driven approach to the prob-
lem of understanding mindfulness. A data-driven alter-
native might be comparable to how individuals in
10 Van Dam et al.
affective neuroscience have used advanced algorithms
to integrate physiological and neurobiological signals
toward understanding emotional states (cf. Kragel &
LaBar, 2014). A second context is to focus on the indi-
rect impact of mindfulness practice, such as how medi-
tation practice might lead to more effective therapists
via assessing patient outcome (cf. Grepmair etal., 2007)
or how mindfulness might improve caregiver efficacy
via assessment of significant others (cf. Singh etal.,
2004). Another approach within this domain might be
to examine how mindfulness practice can lead to
changes in observable behaviors such as eating patterns
or interpersonal exchanges (Papies, Pronk, Keesman,
& Barsalou, 2015), the latter especially as reported by
friends or partners of those undergoing mindfulness
and/or meditation training (e.g., Birnie, Garland, &
Carlson, 2010). In addition, researchers should situate
future process models of mindfulness within extant
rigorous theoretical frameworks for cognition and emo-
tion whereby empirical predictions and falsifiable con-
ceptual hypotheses can be tested (e.g., Meyer, 2009;
Vago & Silbersweig, 2012). Frameworks based on com-
putational modeling may be especially helpful for such
purposes (e.g., Anderson etal., 2004; Meyer & Kieras,
Challenges for clinical intervention
Numerous intervention studies have been conducted to
assess whether, and by how much, practicing mindful-
ness may help alleviate various undesirable mental and
physical conditions, including pain, stress, anxiety,
depression, obesity, addiction, and others. Dimidjian
and Segal (2015) estimate, using the NIH stage model
for clinical science (Onken, Carroll, Shoham, Cuthbert,
& Riddle, 2014), that only 30% of research using mind-
fulness-based interventions (MBIs) has moved beyond
Stage 1 (intervention generation/refinement). The major-
ity (20%) of research beyond Stage 1 has been con-
ducted at Stage 2a (efficacy in research clinic: compared
to wait-list control or treatment as usual), with a mere
9% (of the total) at Stage 2b (efficacy in research clinic:
compared to active control). Moreover, only 1% of all
research has been conducted outside research contexts,
a woefully inadequate research base to inform whether
MBIs are ready for use in regular clinical practice, as is
the case in the United Kingdom (Coyne, 2015b, 2016).
As a result, some have blatantly stated that “widespread
use is premature” (Greenberg & Harris, 2012).
Haphazard variability across MBIs. Given the lack
of consensus about what “mindfulness” means and how
it should be operationalized, MBIs have varied greatly in
the diverse types of practice, methods of participant
training, and duration of instructional courses associated
with them. The “gold-standard model” of an MBI has
been the 8-week mindfulness-based stress reduction
(MBSR; Kabat-Zinn, 1990) course, involving 20 to 26
hours of formal meditation training during 8 weekly
group classes (1.5–2.5 hours/class), one all-day (6 hours)
class, and home practice (about 45 minutes/day, 6 days/
week). Throughout the 8 weeks, formal MBSR training
has included an eclectic set of specific mindfulness
practices—focused attention on the breath, open moni-
toring of awareness in “body-scanning” (cf. Lutz etal.,
2008), prosocial meditation (e.g., loving kindness and
compassion), and gentle hatha yoga.
“Spin-off” MBIs vary in content and form depending
on the participant populations for which they were
adapted and the accompanying idiosyncratic objectives
of individual investigators (cf. Shonin, Van Gordon, &
Griffiths, 2013). For example, interventions such as
mindfulness-based cognitive therapy (MBCT; Segal,
Williams, & Teasdale, 2002) have incorporated aspects
of cognitive behavioral therapy (CBT, widely consid-
ered the most researched and empirically based psy-
chotherapy, focuses on the relationship between
thoughts, emotions, and behaviors, most commonly
with a focus on changing thought and behavioral pat-
terns; Tolin, 2010). Notably, there are also a number of
psychotherapies that draw on “mindful” principles, but
are more commonly associated with traditional CBT (cf.
Hofmann & Asmundson, 2008); these include accep-
tance and commitment therapy (Hayes etal., 1999) and
dialectical behavior therapy (Linehan, 1993). We focus
our discussions of MBIs on those interventions that
utilize formal meditation techniques (namely, derivatives
of MBSR), as they arguably differ in origin from those
interventions more closely tied to cognitive and/or
behavioral therapy (cf. Dimidjian & Segal, 2015; Hayes,
2002; Kabat-Zinn, 2011; Robins, 2002). Moreover, inter-
ventions that formally employ meditation practices differ
in therapeutic delivery from those that do not formally
employ such practices, though this distinction has
become muddied as mindfulness and meditation have
enjoyed greater mainstream popularity.
The duration of MBIs have been altered dramatically
to conform with brief training regimens that may involve
as few as four 20-minute sessions (e.g., Papies, Barsalou,
& Custers, 2012; Zeidan etal., 2015). Some newer MBIs
have even implemented web-based or mobile applica-
tions for treatment delivery (Cavanaugh etal., 2013;
Dimidjian etal., 2014; Lim, Condon, & DeSteno, 2015).
Given the variety of practices that fall under the
umbrella of MBI, the adoption of mindfulness as a
prescriptive clinical treatment has not entailed a con-
sistent type of intervention. While there is considerable
Critical Evaluation of Mindfulness Research 11
variability in other practices of psychotherapy as well,
specific classes of intervention (e.g., CBT) at least tend
to have sufficient consistency with one another (in
terms of content and format) to provide a basis for
broad evaluation of their efficacy (cf. Tolin, 2010). In
contrast, the varieties of interventions labeled as “mind-
ful” are as varied as the definitions of the construct
(differing in content, meeting type/frequency, instruc-
tions, homework, readings, instructor/therapist training
and accessibility, etc.). Extreme caution must be exer-
cised when considering mainstream implementation of
minimally tested adaptations of more traditional MBIs
(Dimidjian & Segal, 2015).
Misperceptions of therapeutic efficacy. Despite the
preceding list of concerns, there is a common mispercep-
tion in public and government domains that compelling
clinical evidence exists for the broad and strong efficacy
of mindfulness as a therapeutic intervention (e.g., Coyne,
2016; Freeman & Freeman, 2015). Results from some
clinical studies conducted over the past 10 years have
indicated that MBCT may be modestly helpful for some
individuals with residual symptoms of depression
(Eisendrath etal., 2008; Geschwind, Peeters, Huibers, van
Os, & Wichers, 2012; van Aalderen etal., 2012). As a con-
sequence of select results, published in high-profile jour-
nals, MBCT is now officially endorsed by the American
Psychiatric Association for preventing relapse in remitted
patients who have had three or more previous episodes
of depression. Moreover, the U.K. National Institute for
Health and Clinical Excellence now even recommends
MBCT over other more conventional treatments (e.g.,
SSRIs) for preventing depressive relapse (Crane &
Kuyken, 2012). Mitigating such endorsements, a recent
meta-analysis found that MBSR did not generally benefit
patients susceptible to relapses of depression (C. Strauss,
Cavanagh, Oliver, & Pettman, 2014). Other meta-analysis
have suggested general efficacy of MBIs for depressive
and anxious symptoms (Hofmann, Sawyer, Witt, & Oh,
2010), though head-to-head comparisons of MBIs to
other evidence-based practices have resulted in mixed
findings, some suggesting comparable outcomes, others
suggesting MBIs might be superior in certain conditions,
and others suggesting CBT is superior in certain condi-
tions (e.g., Arch et al., 2013; Goldin et al., 2016;
Manicavasgar, Parker, & Perich, 2011). There is also mixed
evidence comparing MBIs to interventions such as pro-
gressive muscle relaxation (e.g., Agee, Danoff-Burg, &
Grant, 2009; Jain etal., 2007). Direct comparisons of MBIs
to empirically established treatments are limited.
In a recent review and meta-analysis commissioned
by the U.S. Agency for Healthcare Research and Quality,
MBIs (compared to active controls) were found to have
a mixture of only moderate, low, or no efficacy,
depending on the disorder being treated. Specifically,
the efficacy of mindfulness was only moderate in reduc-
ing symptoms of anxiety, depression, and pain. Also
efficacy was low in reducing stress and improving qual-
ity of life. There was no effect or insufficient evidence
for attention, positive mood, substance abuse, eating
habits, sleep, and weight control (Goyal etal., 2014).
These and other limitations echoed those from a report
issued just 7 years earlier (Ospina etal., 2007). The lack
of improvement over these 7 years in the rigor of the
methods used to validate MBIs is concerning; indeed
if research does not extend beyond Stage 2A (compari-
son of MBI to wait-list control), it will be difficult, if
not impossible, to ascertain whether MBIs are effective
in the real world (cf. Dimidjian & Segal, 2015). On bal-
ance, much more research will be needed before we
know for what mental and physical disorders, in which
individuals, MBIs are definitively helpful.
Consensus about clinical intervention methodol-
ogy. MBIs are sometimes misleadingly described as
“comparable” to antidepressant medications (ADMs)
(Goyal etal., 2014). Such comparability has been tenta-
tively supported by results from studies examining MBIs
versus ADMs for depressive relapse in recurrent depres-
sion (Kuyken etal., 2015; Segal et al., 2010). Notably,
there are large individual differences in efficacy: MBIs
may be beneficial for some people, but may be ineffec-
tive or contraindicated for others (Dobkin, Irving, &
Amar, 2011). Special care is therefore needed when inter-
preting results from clinical studies employing MBIs,
many of which have lacked “active” control conditions.
Given the absence of scientific rigor in clinical mindful-
ness research (Davidson & Kaszniak, 2015; Goyal etal.,
2014), evidence for use of MBIs in clinical contexts
should be considered preliminary.
The official standards of practice for MBSR exclude
suicidality and the presence of any psychiatric disorder
(Santorelli, 2014). Case-by-case exceptions are permis-
sible by these standards if, and only if, an individual
participant is willing and able to simultaneously main-
tain adequate medical treatment for the exclusionary
condition or if an instructor has sufficient clinical train-
ing to manage the case at hand (Santorelli, 2014). The
American Psychiatric Association (D. H. Shapiro, 1982),
the U.S. National Institutes of Health (NIH; National
Center for Complementary and Integrative Health,
2016b), and leading researchers in the field (Dobkin
etal., 2011; Greenberg & Harris, 2012; Lustyk, Chawla,
Nolan, & Marlatt, 2009) have expressed concerns that
meditation may be contraindicated under several circum-
stances. Numerous authors have recommended that
schizophrenia spectrum disorders, bipolar disorder, post-
traumatic stress disorder, depression, and risk factors for
12 Van Dam et al.
psychosis (e.g., schizoid personality disorder) are con-
traindications to participation in an MBI that is not
specifically tailored to one of these conditions (Didonna
& Gonzalez, 2009; Dobkin etal., 2011; Germer, 2005;
Kuijpers, van der Heijden, Tuinier, & Verhoeven, 2007;
Lustyk etal., 2009; Manocha, 2000; Walsh & Roche,
1979; Yorston, 2001). The rationale for these contrain-
dications is that without sufficient clinical monitoring,
an intervention not designed to address these issues
could lead to deterioration or worse. Such contraindica-
tions should be considered exclusionary criteria for
regular clinical practice until substantially more evi-
dence about the efficacy of various MBIs becomes
Prescriptive research agenda: Strengthening clini-
cal intervention methods. Replication of earlier stud-
ies with appropriately randomized designs and proper
active control groups will be absolutely crucial. In con-
ducting this work, we recommend that researchers pro-
vide explicit detail of mindfulness measures (see, e.g.,
Table 1), primary outcome measures, mindfulness/medi-
tation practices (see Table 2), and intervention protocol
(see Table 3). While active control groups for MBIs can
be difficult to implement for a variety of reasons
(Davidson & Kaszniak, 2015), the problem is not insur-
mountable (see, e.g., MacCoon etal., 2012) and has been
resolved by those conducting more traditional psycho-
therapy research (e.g., Agee etal., 2009; Arch etal., 2013;
Goldin etal., 2016; Jain etal., 2007; Manicavasgar etal.,
2011). In addition, researchers must be explicit about the
exact hypothesis they are testing (noninferiority to an
established treatment, superiority to an established treat-
ment, etc.) and consider the various limitations that might
accompany treatment designs (see, e.g., Coyne, 2015a).
Because of potential confirmation biases (Rosnow,
2002) and allegiance effects (Martin, Garske, & Davis,
2000), clinical research ideally would involve multidis-
ciplinary teams of investigators. These teams should
consist of not only clinicians, but also basic research
scientists, scholars from within classical mindfulness
traditions, and scientists/scholars skeptical about mind-
fulness’s efficacy. An especially compelling research
strategy could involve adversarial collaboration (see,
e.g., Matzke etal., 2015). Moreover, future clinical stud-
ies should not rely merely on self-report and assess-
ments by clinicians, but also incorporate biological and
behavioral efficacy measures.
Harm, adverse effects, and fallout of
Much of the public news media has touted mindfulness
as a panacea for what ails human kind (e.g., Chan,
2013; Firestone, 2013), overlooking the very real
potential for several different types of harm. According
to directors of the National Center for Complementary
and Integrative Health (NCCIH) at the NIH, the biggest
potentials for harm of complementary treatments (e.g.,
meditation) are “unjustified claims of benefit, possible
adverse effects . . . and the possibility that vulnerable
patients with serious diseases may be misled” (Briggs
& Killen, 2013). Identifying “harm,” “side effects,” or
“adverse effects” is complicated by issues related to
definitions and measurement, which will be addressed
Coming to terms with meditation-related adverse
effects. An adverse effect or event (AE) is any unwanted,
harmful effect that results from but is not the stated goal
of a given treatment. A side effect is any unexpected
effect that is secondary to the intended effect of the treat-
ment (M. Linden, 2013). An event can also be categorized
a “side effect” if it is not described in the “product label-
ing,” “package insert,” “marketing or advertising” (NIA,
2011; Office for Human Research Protections, 2007)—
descriptions that are often lacking for meditation prac-
tices (and behavioral interventions more generally,
despite a comparable incidence of AEs to pharmacologi-
cal treatments; Crawford et al., 2016; M. Linden, 2013;
Mohr, 1995; Moos, 2005, 2012). Whether the result of cor-
rect or incorrect treatment, a treatment-emergent reaction
may include the appearance of novel symptoms that did
not exist before treatment, or the exacerbation or reemer-
gence of a preexisting condition. Treatment nonresponse
or deterioration of (target) illness may or may not be
caused by the treatment (M. Linden, 2013) but requires
both reporting and action.
Meditation-related experiences that were serious or
distressing enough to warrant additional treatment or
medical attention have been reported in more than 20
published case reports or observational studies. These
reports document instances of meditation-related or
“meditation-induced” (i.e., occurring in close temporal
proximity to meditation and causally attributed to medi-
tation by the practitioner, instructor, or both) psychosis,
mania, depersonalization, anxiety, panic, traumatic-
memory reexperiencing, and other forms of clinical
deterioration (Boorstein, 1996; Carrington, 1977;
Castillo, 1990; Chan-Ob & Boonyanaruthee, 1999;
Disayavanish & Disayavanish, 1984; Epstein & Lieff,
1981; Heide & Borkovec, 1983; Kerr, Josyula, &
Littenberg, 2011; Kornfield, 1979; Kuijpers etal., 2007;
Kutz etal., 1985; Lomas, Cartwright, Edginton, & Ridge,
2015; Miller, 1993; Nakaya & Ohmori, 2010; Sethi, 2003;
D. H. Shapiro, 1992; Shonin, Van Gordon, & Griffiths,
2014b, 2014c; VanderKooi, 1997; Van Nuys, 1973; Walsh
& Roche, 1979; Yorston, 2001). Many of the aforemen-
tioned were case studies, case series, or observational
studies, often without a control group. Only one was
Critical Evaluation of Mindfulness Research 13
prospective (D. H. Shapiro, 1992). Detailed clinical his-
tories were available for some of the subjects, but not
all, which makes the question of preexisting conditions
difficult to evaluate. While qualitative reports and case
studies are an appropriate and necessary first step in
identifying potential AEs (Dimidjian & Hollon, 2010),
the need for AE assessments within more rigorous
designs such as randomized controlled trials (RCTs)
would provide more conclusive information.
Issues in the measurement of adverse effects. Since
safety reporting is required for federally funded clinical
trials, one might expect that the many NIH-funded mind-
fulness or meditation trials would be a rich source of
information about potential AEs with causality assess-
ment inherent in an RCT design. However, most current
methods for assessing AEs in meditation-related research
are insufficient to produce an accurate estimate. Despite
CONSORT requirements (Moher etal., 2001), and com-
pared to 100% of pharmacology trials (Vaughan,
Goldstein, Alikakos, Cohen, & Serby, 2014), less than 25%
of meditation trials actively assess AEs (Goyal etal., 2014;
Jonsson, Alaie, Parling, & Arnberg, 2014), relying instead
on spontaneous reporting, which may underestimate AE
frequency by more than 20-fold (Bent, Padula, & Avins,
2006), and results in widely varying AE rates, even for
similar trials (Kuyken etal., 2015; Kuyken etal., 2016;
J. M. Williams etal., 2014). Different AE assessment meth-
ods (Vaughan etal., 2014) or specifically the lack of sys-
tematic AE assessment in meditation trials has led to the
hasty and erroneous conclusion not only that meditation
is free of AEs (L. Turner etal., 2011), but also that medita-
tion interventions can act as a replacement to medication
for mental illnesses such as depression and bipolar disor-
der (Annels, Kho, & Bridge, 2016; Strawn etal., 2016;
Walton, 2014) with slogans such as “meditate not medi-
cate” (Annels etal., 2016). Furthermore, meditation-related
AEs are discussed in many traditional (largely Buddhist)
meditation guides (Buddhaghosa, 1991; Sayadaw, 1965; B.
Wallace, 2011). Despite the assumption of “wide accep-
tance of minimal, if any, AEs associated with meditation”
(L. Turner etal., 2011), this assumption is largely based on
a lack of research rather than substantive evidence.
Other potential risks of mindfulness medita-
tion. The benefits and the safety of meditation are likely
exaggerated beyond available evidence in a manner that
increases “the possibility that vulnerable patients with
serious diseases may be misled” (Briggs & Killen, 2013).
In the face of such exaggerated claims, patients may be
diverted from pursuing other, more traditional activities
(e.g., regular aerobic exercising) that typically yield phys-
ical and mental benefits (Cotman, Berchtold, & Christie,
2007; Penedo & Dahn, 2005) or standard treatments (e.g.,
psychotherapy, pharmacotherapy) that are better suited
to dealing with particular psychiatric conditions. For
example, in a recent meta-analysis of MBIs, C. Strauss
etal. (2014) concluded, “given the paucity of evidence in
their favour, we would caution against offering MBIs as a
first line intervention for people experiencing a primary
anxiety disorder . . . findings from the current meta-anal-
ysis would suggest great caution if offering MBIs to this
population as a first line intervention instead of a well-
established therapy.” In economics, as well as recent dis-
cussions of psychotherapy, this effect has been labeled
an “opportunity cost” (i.e., time and money invested in a
treatment approach that has little to no therapeutic ben-
efit relative to the potential time/money that could have
been invested in a treatment more likely to yield improve-
ment; cf. Lilienfeld, Lynn, & Lohr, 2003). Given that relief
from anxiety is probably one of most widely promoted
benefits of mindfulness (see, e.g., Hofmann etal., 2010),
opportunity cost may be a widespread “side effect” of
Consensus about harm, adverse effects, and con-
traindications. To date, “official” clinical guidelines
about the state of meditation-related risks are in their
infancy and only a handful of organizations and regula-
tory agencies have issued any statements. The American
Psychiatric Association (APA) first showed concern about
meditation-related AEs in 1977 and commissioned a
report on the topic with treatment guidelines (D. H.
Shapiro, 1982). The APA also included descriptions of
meditation-induced depersonalization and other clini-
cally relevant problems in both the 4th and 5th editions
of their Diagnostic and Statistical Manual of Mental Dis-
orders (APA, 1994, 2013). The NIH states that “meditation
could cause or worsen certain psychiatric problems” but
does not provide any practice guidelines beyond a boil-
erplate disclaimer to “check with your doctor” before try-
ing meditation (NCCIH, 2016b).
Since neither meditation writ large nor meditation-
based interventions are overseen by any regulatory
agencies, most of the clinical guidelines and recom-
mendations regarding risk and safety have been issued
by the “Centers for Mindfulness,” creators of interven-
tions, as well as various experts in the field. Many
meditation researchers and clinicians have offered
reviews of meditation-related risks, AEs, or contraindi-
cations with recommendations for clinical guidelines
(Dobkin et al., 2011; Fenwick, 1983; Greenberg &
Harris, 2012; Hanley, Abell, Osborn, Roehrig, & Canto,
2016; Lustyk etal., 2009; D. H. Shapiro, 1982; Shonin,
Van Gordon, & Griffiths, 2014a). The MBCT Implementa-
tion Resources (Kuyken, Crane, & Williams, 2012) is one
of the first documents to list potential “risks to partici-
pants,” including increased likelihood of suicidality,
14 Van Dam et al.
depression, negative emotions, and flashbacks during
meditation for individuals with trauma histories. At pres-
ent, management strategies for potential risks have been
largely limited to exclusion and informed consent. Both
the University of Massachusetts Center for Mindfulness
and the Oxford Mindfulness Centre have published rec-
ommended exclusion criteria for standard MBSR and
MBCT, both excluding current suicidality and/or any
current psychiatric disorder (Kuyken, Crane, & Williams,
2012; Santorelli, 2014). In addition, many centers attempt
to make clear that mindfulness is not intended to replace
standard psychiatric care.
Prescriptive research agenda: Transcending adverse
effects. The current guidelines, while preliminary, repre-
sent substantial progress in assessing and promoting
safety of meditation-based interventions. On the mea-
surement front, there have been signs of progress. A few
MBI researchers have started to actively monitor AEs
either through questionnaires or through clinician inter-
views (Kuyken etal., 2015; Kuyken et al., 2016; J. M.
Williams etal., 2014). While these are typically limited to
serious AEs (life-threatening or fatal events) or “deteriora-
tion” on preexisting clinical outcomes that require clinical
attention, such as increased depression or suicidality, this
is a considerable improvement from passive monitoring.
In addition, a recent qualitative study of 60 Buddhist
meditators and meditation teachers (cf. Lindahl etal.,
2017) also sought to improve knowledge of meditation-
related experiences that are underreported, unexpected,
“adverse,” or associated with significant levels of distress
and functional impairment. While qualitative and retro-
spective, this study applied 11 of the 13 causality criteria
(as outlined by the World Health Organization [WHO],
Federal Drug Administration, and NIH; Agbabiaka,
Savovic, & Ernst, 2008; NIH, 2016; WHO, 2016), includ-
ing interviews with meditation teachers (expert
judgment). The study produced 60 categories of medi-
tation-related experiences and 26 categories of “influ-
encing factors” that may impact the duration, associated
distress, and impairment of the experience. While the
first study of its kind, it sets a foundation for testable
hypotheses in future research. In addition, the 60 cat-
egories of meditation-related experiences are being
converted into a measurement tool that can be used for
systematic assessment across multiple studies and condi-
tions. The codebook was inserted as an interview-based
assessment into a recently completed clinical disman-
tling trial of MBCT (NCT no. 01831362) that can assess
whether similar experiences occur in MBIs, as well as
address the question of biological gradient (i.e., whether
more exposure results in greater effects; Hill, 1965).
The large and growing body of empirical data on the
psychological and neurobiological effects of meditation
and related practices also represent a step forward to
identifying potential mechanisms by which meditation-
related effects, as well as AEs might occur. Knowledge
of mechanism may help identify who is at risk. For
example, there is some evidence that hyperconnectivity
of the prefrontal cortex and limbic regions may result
in affective and autonomic blunting which is charac-
teristic of dissociation (Ketay, Hamilton, Haas, &
Simeon, 2014; Sierra etal., 2002). Similarly, increased
activity in the inferior parietal cortex, a common out-
come of mindfulness training (Brefczynski-Lewis, Lutz,
Schaefer, Levinson, & Davidson, 2007; Farb etal., 2007;
Goldin & Gross, 2010; Hasenkamp, Wilson-Mendenhall,
Duncan, & Barsalou, 2012), might relate to deperson-
alization (disembodiment, loss of agency and self-
other/self-world boundaries; Bunning & Blanke, 2005).
Others have created neurobiological models for specific
meditation-related experiences, such as visual halluci-
nations, (Lindahl, Kaplan, Winget, & Britton, 2014),
sleep-related changes (insomnia; Britton, Lindahl, etal.,
2014), changes in sense of self (Dor-Ziderman, Berkov-
ich-Ohana, Glicksohn, & Goldstein, 2013), and altered
perceptions of space and time (Berkovich-Ohana,
Dor-Ziderman, Glicksohn, & Goldstein, 2013).
Research on AEs of treatments that share mecha-
nisms with meditation should also be considered. For
example, treatments that restrict environmental stimula-
tion or narrative processing through internal sensory
focus, such as qigong (APA, 2000; Shan, 2000), auto-
genic training (W. Linden, 1990), and relaxation (Edinger
& Jacobsen, 1982), can precipitate similar AEs, such as
autonomic hyperarousal, perceptual disturbances
(Lindahl etal., 2014), traumatic memory reexperiencing
(Brewin, 2015; Brewin, Gregory, Lipton, & Burgess,
2010; Miller, 1993), and psychosis (APA, 2000; Shan,
2000). Relaxation-induced panic or anxiety is perhaps
one of the most well-documented phenomena with
clear relevance to meditation (Adler, Craske, & Barlow,
1987; Cohen, Barlow, & Blanchard, 1985; Heide &
Challenges for investigating
mindfulness through contemplative
As part of the burgeoning trend in research on mindful-
ness and meditation more generally (Fig. 1), investiga-
tors have increasingly used methods from cognitive
neuroscience, especially functional magnetic resonance
imaging (fMRI). These methods yield visual depictions
of participants’ relative, regionally localized, brain acti-
vation during various types of cognitive task perfor-
mance as well as the integrated functional neural
networks of mental processing (including the default
mode network; cf. Power etal., 2011). The investigation
of mindfulness through such methods has also come
Critical Evaluation of Mindfulness Research 15
to be known as contemplative neuroscience (e.g.,
Davidson & Lutz, 2008).
Limitations in depictions of brain activity based
on neuroimaging. Representative pictures from fMRI
and other neuroimaging methods do not clearly convey
the complex—often fraught—chain of biological and
computational steps that lead to inferences about changes
in brain structure and function. They also neglect to high-
light the fact that such inferences are frequently derived
from averages obtained across groups of participants.
Thus, when also accompanied by numerous other diffi-
cult experimental, statistical, and inferential challenges
prevalent in psychological research, contemplative neu-
roscience has often led to overly simplistic interpretations
of nuanced neurocognitive and affective phenomena. For
example, psychologist Rick Hanson, in what is presum-
ably an effort to explain how meditation has been shown
to influence emotion regulation, correlated with altera-
tions in amygdala activity (e.g., Goldin & Gross, 2010),
has stated, “ In terms of amydgala activity, people seem
to belong to one of three groups . . . the ones with a joy-
ful amydgala—are more focused on promoting the good
than on preventing the bad” (Hanson, 2013, pp. 43–44).
As a result of such oversimplifications, meditative bene-
fits may be exaggerated and undue societal urgency to
undertake mindfulness practices may be encouraged
(e.g., Farias & Wikholm, 2015).
Problematic aspects of group-level neuroimaging
analyses. Furthermore, results from neuroimaging dur-
ing mindfulness practices and other types of meditation
may be subject to unique confounds. Despite variability
in different types of practice and meditative experiences,
it is not uncommon for neuroimaging data obtained from
diverse practitioners to be pooled in aggregated analyses
(e.g., Ferrarelli etal., 2013; Luders et al., 2012; Luders,
Kurth, Toga, Narr, & Gaser, 2013; Sperduti, Martinelli, &
Piolino, 2012). Also complicating theoretical interpreta-
tion of their results and further adding to confounds
associated with systematic individual differences, many
neuroimaging studies have used cross-sectional designs,
precluding possible inferences about underlying cause-
and-effect relationships (cf. Tang etal., 2015).
Ancillary physical artifacts in neuroimaging
data. Certain methodological confounds that plague
neuroimaging studies in general, are of particular con-
cern in studies of individuals who meditate. Physical arti-
facts involving head movements and cardiorespiratory
effects are especially notable (Holmes, Solomon, Cappo,
& Greenberg, 1983; Lutz etal., 2009; Reuter etal., 2015; Van
Dijk, Sabuncu, & Buckner, 2012; R. K. Wallace, 1970; R. K.
Wallace, Benson, & Wilson, 1971; cf. Lazar et al., 2000;
Zeidan etal., 2011). If nonmeditators are more restless or
breathe more rapidly than experienced meditators during
MRI sessions, there could be spurious group differences
in some neuroimaging measurements (e.g., with respect
to meditators, seemingly more brain gray matter and brain
activation in particular neuroanatomical regions; cf.
Greene, Black, & Schlaggar, 2016). Systematic individual
differences in cardiorespiratory activity between nonmed-
itators and meditators are especially worrisome because
of the so-called “vein-drain problem” (R. Turner, 2002). It
prevails especially in typical regions of differential brain
activation. Enlarged blood vessels may lead to measure-
ment artifacts (e.g., Boubela etal., 2015), which can be
particularly pronounced in brain regions commonly iden-
tified as important for cognition and emotion (e.g., insular
and anterior cingulate cortices).
Partially mitigating these concerns, meta-analyses of
both structural and functional neuroimaging data have
revealed differences in brain regions that tend to be
consistent with the specific meditation practices under
study (e.g., changes in brain regions associated with
bodily awareness of mindfulness practitioners—for
example, the insula and somatosensory cortices—and
widespread recruitment of brain regions associated
with vision during meditative visualization). Such find-
ings, when supported by results from meta-analyses of
multiple studies, are less likely to have stemmed merely
from artifacts (Fox etal., 2016; Fox etal., 2014).
Practical versus statistical significance of neuro-
imaging data. Statistical and theoretical approaches to
calculating and interpreting effect sizes and associated
confidence intervals have been well developed in behav-
ioral and psychological research (Cumming, 2014). Yet
calculating valid estimates of effect sizes in neuroimaging
data is extremely difficult (Fox et al., 2016; Fox et al.,
2014; Friston, 2012; Hupé, 2015). Consequently, the prac-
tical significance and clinical importance (e.g., diagnostic
and/or therapeutic utility) of observed changes in brain
structure and neural activity associated with practicing
mindfulness is still elusive (cf. Castellanos, Di Martino,
Craddock, Mehta, & Milham, 2013). Moreover, despite
some agreement among investigators that mindfulness
and other types of meditation affect the brain, we still do
not know how the effects compare to other cognitive
training methods regarding practical significance.
Consensus about findings from contemplative neu-
roscience. Despite the many serious limitations men-
tioned previously, studies in contemplative neuroscience
do allow some preliminary conclusions. Meta-analyses of
neuroimaging data suggest modest changes in brain
structure due to practicing mindfulness (Fox etal., 2014).
Some concomitant modest changes also have been
observed in neural function (e.g., Fox etal., 2016; Sperduti
etal., 2012; Tomasino, Fregona, Skrap, & Fabbro, 2013;
16 Van Dam et al.
for a broad review, see Tang etal., 2015). Caution must be
exerted in interpreting these findings; similar changes
have been observed following other forms of mental and
physical skill acquisition, such as learning to play musical
instruments and learning to reason, suggesting that they
may not be unique to mindfulness or other popular types
of meditation practice (cf. Draganski & May, 2008; Hyde
etal., 2009; Mackey, Miller Singley, & Bunge, 2013; Münte,
Altenmüller, & Jäncke, 2002).
Prescriptive research agenda: Truth in advertising
by contemplative neuroscience. Rather than contrib-
uting to further media hype, researchers in contemplative
neuroscience must endeavor to communicate more accu-
rately with other scientists, journalists, and the public not
only about the potential benefits of mindfulness practices
for mental processes and brain mechanisms, but also
about the limitations of neuroimaging methods and data
collected through them. We encourage contemplative
neuroscientists to follow best practices in neuroimaging
methods generally (cf. Nichols etal., 2017), but also to
consider and accommodate unique issues that may arise
while collecting brain data from meditating populations.
These unique issues (e.g., different respiration rates, dif-
ferent cardiac activity, dramatically different demographic
and life-style characteristics) may warrant unique data
collection methods (e.g., cardiac-gated image acquisi-
tion) and/or analytic methods (e.g., removal of activity
due to respiratory artifact), as well as very detailed demo-
graphic information. Particular attention should be paid
to methodologically and/or statistically controlling poten-
tial contributions from potentially confounding variables
(e.g., participant motivation, placebo effects, cardiorespi-
ratory factors, head motion, history of psychopathology)
that may underlie apparent group differences. This will
be especially necessary where mindfulness studies compare
results from long-term practitioners versus meditation-
naïve participants. In contexts of comparing meditation
experience, either between groups, or within, some com-
mon metric should be used (cf. Hasenkamp & Barsalou,
2012). Researchers should stress specifically that individ-
uals who already have meditated over many years, or
who—though not yet experts—are personally attracted
to meditation, may have characteristics that differentiate
them from the general population even before experi-
mentation (Mascaro, Rilling, Negi, & Raison, 2013). Prom-
inent mention about the limitations and fraught nuances
of statistical neuroimaging analyses should not be
neglected either. No amount of sophisticated statistical
prowess can correct results from faulty or confounded
methods, a fact of which researchers, scientists, and the
public should regularly be reminded.
And, ultimately, the popular news media—inspired
by honest, forthright, thorough cooperation with
contemplative neuroscientists—must persuade the gen-
eral public together with government funding agencies
that multiple large, longitudinal RCTs that consider
participant preferences concerning mindfulness prac-
tices are required and should be funded. We need such
trials to definitively determine the full benefits and
costs of practicing mindfulness. Without future RCTs,
prevalent widespread uncertainties surrounding past
results from haphazard studies of mindfulness involv-
ing relatively small sample sizes (e.g., Button etal.,
2013) and considerable variation in how neuroimaging
methodologies have been implemented (Simmons
etal., 2011) make it difficult to know the neural effects
Contemplative psychological scientists and neuroscien-
tists, along with other researchers who study mental
processes and brain mechanisms underlying the practice
of mindfulness and related types of meditation, have a
considerable amount of work to make meaningful prog-
ress. Much work should go toward improving the rigor
of methods used, along with the accuracy of news
media publicity and eliminating public misunderstand-
ings caused by past undue “mindfulness hype.” These
efforts have to take place on several related fronts.
First, as mentioned before, the various possible
meanings of “mindfulness” have to be clarified. To deal
with prevailing inherent semantic ambiguities, research-
ers should adopt more nuanced, precisely focused, ter-
minology for referring to the various distinct mental
and physical states as well as overt behaviors often
associated with mentions of “mindfulness” (see Table
2). Insofar as future research involves self-report ques-
tionnaires about mindfulness, new ones that incorpo-
rate specific terminology (see, e.g., Table 2) ought to
be developed. Theoretical models formulated to account
for data need also consider these new key terms.
Second, future studies of mindfulness should con-
form to lessons being learned from the ongoing “rep-
lication crisis” in psychological science and other
related scientific disciplines. For example, preregis-
tered experiments and open-science replications of
mindfulness are desirable. Additional discipline is
especially needed in light of recent growing trouble-
some meta-analytic evidence that—like some other
“glitzy” popular topics of psychological and neural
investigations—past mindfulness research has suc-
cumbed to these questionable practices (Coronado-
Montoya etal., 2016).
Third, future clinical applications involving MBIs
must seek to attain more uniformity and better control
(see Table 3), especially where definitive answers have
Critical Evaluation of Mindfulness Research 17
yet to be found. It is critical that those who conduct
clinical research provide warnings regarding the extent
to which their research findings generalize to clinical
practice. Also researchers and clinicians have to be put
on guard, educated about, and encouraged to address
the potential AEs stemming from mindfulness practices.
Research on the nature and scope of potential AEs
should receive considerable further attention and gov-
ernment funding, due to the public’s rapidly increasing
involvement in practicing mindfulness.
Fourth, as they continue to emerge through tech-
nological advances in neuroimaging methods, new
findings from contemplative neuroscience about the
mental processes and brain mechanisms of mindful-
ness practices must be reported with all due modesty.
Their importation into protocols for future clinical
practice must await proper vetting of the potential
practical significance that may accompany them. This
vetting process will have to deal diligently with the
many aforementioned challenges that still remain to
be surmounted by the contemplative neuroscience
Only with such diligent multipronged future endeav-
ors may we hope to surmount the prior misunderstand-
ings and past harms caused by pervasive mindfulness
hype that has accompanied the contemplative science
We dedicate this article to our dear friend and colleague,
Cathy Kerr, who passed away unexpectedly during revision
of this work. Cathy was among the key driving forces that
led to this particular group forming and to our formal meeting
in Amherst, Massachusetts, in July 2014. Cathy touched so
many lives and had a profound influence on the variety of
ways that many of us approach mindfulness and meditation
research. She will be profoundly missed.
This article grew out of a series of conferences and work-
shops generously funded by the Mind and Life Institute. How-
ever, the views expressed here are those of the authors alone,
collectively, and do not necessarily represent the views or
policies of the Mind and Life Institute nor any other organiza-
tions with which the authors are affiliated. We would further
like to add that while all authors contributed to the article, it
should be read as a majority consensus; not all authors strictly
ascribe to all statements contained herein.
Declaration of Conflicting Interests
The authors declared that they had no conflicts of interest with
respect to their authorship or the publication of this article.
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