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Binary Model of the Dynamics of Active versus Passive Mindfulness in Managing Depression


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Background: Meditation has developed over many centuries within a diverse range of religious traditions including Middle-Eastern, Indian, and East-Asian. Of these, mindfulness meditation from the Buddhist (Indian) tradition, has been the most extensively adopted in the Western secular world primarily with applications in health and well-being as pioneered by Jon Kabat-Zinn. Review: While originally developed to treat chronic pain and stress in the U.S., mindfulness training was later coupled with cognitive-behavioral therapy to treat depression in the U.K. and beyond. The present review of the literature confirms the effectiveness of mindfulness meditation in these medical applications. The various models of mindfulness that have been advanced are here reviewed and are shown to be generally based on an underlying unitary model of the human psyche. By contrast, the present model distinguishes between two modes of mindfulness, an active form and a passive form. Theory: The foundations of these two modes of mindfulness are two of three posited types of self comprising the tripartite psyche, namely, the 'intra-self' (underpinning 'active mindfulness') and the 'supra-self' (underpinning 'passive mindfulness'). The binary model of mindfulness advanced here shows how these two types of self can potentially form the basis of an effective two-stage approach to managing depression. Application: By combining both cognitive decentering using active mindfulness and existential disidentification using passive mindfulness, individuals can learn to manage their cognitive dysfunction and distorted self-identity and thereby reduce the effects of depression in their lives. A design for an empirical study is provided to test the proposed model.
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Open Access
OBM Integrative and
Complementary Medicine
Binary Model of the Dynamics of Active versus Passive Mindfulness in
Managing Depression
Andrew J Hede *
Professor Emeritus, University of the Sunshine Coast, Queensland, Australia; E-Mail:
* Correspondence: Andrew Hede; E-Mail:
Academic Editor: Sok Cheon Pak and Soo Liang Ooi
Special Issue: Health Benefits of Meditation
OBM Integrative and Complementary Medicine
2018, volume 3, issue 4
Received: July 27, 2018
Accepted: December 20, 2018
Published: December 24, 2018
Background: Meditation has developed over many centuries within a diverse range of religious
traditions including Middle-Eastern, Indian, and East-Asian. Of these, mindfulness meditation
from the Buddhist (Indian) tradition, has been the most extensively adopted in the Western
secular world primarily with applications in health and well-being as pioneered by Jon Kabat-
Review: While originally developed to treat chronic pain and stress in the U.S., mindfulness
training was later coupled with cognitive-behavioral therapy to treat depression in the U.K. and
beyond. The present review of the literature confirms the effectiveness of mindfulness
meditation in these medical applications. The various models of mindfulness that have been
advanced are here reviewed and are shown to be generally based on an underlying unitary
model of the human psyche. By contrast, the present model distinguishes between two modes
of mindfulness, an active form and a passive form.
Theory: The foundations of these two modes of mindfulness are two of three posited types of
self comprising the tripartite psyche, namely, the intra-self’ (underpinning ‘active mindfulness’)
and the ‘supra-self’ (underpinning ‘passive mindfulness’). The binary model of mindfulness
advanced here shows how these two types of self can potentially form the basis of an effective
two-stage approach to managing depression.
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Application: By combining both cognitive decentering using active mindfulness and existential
disidentification using passive mindfulness, individuals can learn to manage their cognitive
dysfunction and distorted self-identity and thereby reduce the effects of depression in their
lives. A design for an empirical study is provided to test the proposed model.
History of mindfulness meditation; mindfulness training; models of mindfulness; binary
model of self; cognitive decentering; existential disidentification; depression management
1. Introduction
It has long been recognized that depression is the most widespread mental illness impacting on
human beings in modern times [1]. The World Health Organization (WHO) estimates that
depression is the leading cause of disability worldwide Globally, more than 300 million people
of all ages suffer from depression …” [2]. According to the American Psychiatric Association (APA):
Depression (major depressive disorder) is a common and serious medical illness that negatively
affects how you feel, the way you think and how you act. Fortunately, it is also treatable.
Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed.” *3+. It is
notable that the APA website as cited does not mention mindfulness despite the growing
literature suggesting its effectiveness with depression and other conditions as will be shown.
The present paper aims to review the nature of mindfulness meditation and its development in
Western medical applications (specifically, Mindfulness-Based Stress Reduction [MBSR] and
Mindfulness-Based Cognitive Therapy [MBCT]), in particular, as they relate to depression. The
paper also aims to review the various models that have been advanced for mindfulness efficacy by
placing the proposed binary model of mindfulness in the context of other models in the
established literature. After presenting the new binary model of mindfulness including an
illustration of their distinct conceptual elements and also their key dynamic connections, the
paper aims to provide a discussion of how this model compares with other models of mindfulness
and the psyche. Finally, the paper aims to consider how the new binary model of mindfulness
could be tested empirically with a field experiment based on the established MBCT program.
The predominant treatment for depression globally is currently antidepressant medication
which has been increasing in usage throughout the modern era. Total antidepressant use in the
U.S., for example, was reported in 2011 by the National Center for Health Statistics as having
increased by 400% over the previous two decades such that 11% of Americans are currently
estimated to be using antidepressants [4]. This is despite the fact that mindfulness meditation has
been verified in many studies and reported in top medical journals as an effective alternative to
medication for the treatment of depression [5, 6]. While mindfulness training was introduced in
the West initially to assist people in managing stress [7-9], this form of meditation has since been
expanded in its application to a range of mental illnesses [10] including depression [11, 12],
anxiety [13, 14] and bipolar disorder [15, 16]. In addition, there is some expirical evidence that
mindfulness meditation may play a positive role in ameliorating some non-neurological aspects of
various neurological conditions such as chronic pain [17, 18], Parkinson’s disease [19, 20],
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dementia [21], epilepsy [22] and multiple sclerosis [23, 24]. However, it is not yet known how
mindfulness might alter the course, prognosis, or underlying pathophysiology of such neurological
conditions [Anonymous reviewer, Email, December, 2018].
2. Review of Mindfulness Meditation
Meditation, as it is currently practiced across both the spiritual and secular worlds, originated
with religious observances in India dating to before recorded history. Contemporary scholars have
observed that there are strong similarities among the various religious traditions in their
meditation practices including: those of Biblical origin in the Middle-East (viz., in chronological
order Judaism, Christianity and Islam) [25]; traditions of Indian origin (e.g., Hinduism, Buddhism,
Jainism and Sikhism) [26, 27]; and also those of East-Asian origin (e.g., Daoism, Confucianism and
Shintoism) [27]. Within each of these traditions there have arisen variations in meditation
practices that are relevant today. To elaborate on one pertinent example, the main active
Buddhist meditation tradition contains two distinct sub-traditions which spread over many years
as part of the cultural growth of a number of Indian and Asian countries. The first of these sub-
traditions is Mahayana meditation (including Zen) which developed in China, Korea, Japan, Tibet
and Vietnam [28]. The second Buddhist sub-tradition is Theravada meditation which spread
mainly in Sri Lanka, Thailand, Myanmar, Laos and Cambodia [28]. These two meditation practices
have spread widely including to Western countries. For example, the Vietnamese Zen Buddhist
monk, Thich Nhat Hanh, has been successful in promoting a blend of both Mahayana and
Theravada meditation practices in the English-speaking world, principally in America [29].
Observances in meditation practice have not always been consistent within the various
traditions over the centuries. An informative example is a type of meditation which was developed
in the 4th Century CE by the Christian hermits of the Mediterranean. This meditation practice was
based on focusing attention on the unceasing repetition of a short exhortation [30]. Such a
prayerful exclamation functions in this form of meditation as a focal point for the ‘busy mind’
somewhat like the mantra in Hindu practice and related forms of meditation [31]. Following the
so-called ‘East-West Schism’ in the Christian Church (from 1054 CE) [32], this meditation practice
continued to be promulgated throughout the Eastern (Orthodox) Church through to the present
day [33], but was largely ignored for nearly a millennium within the Western (Roman) Church [34].
There was a revival of this desert meditation tradition late last century led by Benedictine monk,
John Main. It is significant that he was initially trained in Hindu meditation practice and that he
promoted what he called ‘Christian Meditation’ with the personal support of his friend the Dalai
Lama, world leader of Buddhism [35]. It should not be surprising that Christian, Buddhist and
Hindu meditation influences all converged in this contemporary meditation movement which is
thriving in the 21st Century. It would appear that meditation practices have been at the core of
human experience across the ages linking diverse religions and cultures. We can only speculate
about the possible health benefits ancient peoples might have gained incidentally from their
spiritual practice of meditation thousands of years ago.
Of the many Buddhist meditation traditions and practices, the one that has attracted most
attention and acceptance in the Western world is mindfulness (called ‘sati’ in the Pali language as
used in the Theravada tradition and called ‘smrti’ in the Sanskrit language as used in the
Mahayana tradition) [36]. This is the main Buddhist form of meditation and can be traced to the
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original Buddha (Siddhartha Gautama, c.500 BCE). The English translation of ‘sati’ as ‘mindfulness’
is credited to Rhys Davids in 1881 [37]. From the earliest times of Buddhism, distinctions were
drawn between different forms of meditation, namely, mindfulness (sati), concentration
meditation (samadhi), supramundane powers (abhijñā), tranquillity meditation (samatha) and
insight meditation (vipassanā) *37].
2.1 Spread of Mindfulness Meditation in the West
Mindfulness meditation was already being taught in the U.S. as part of various international
Buddhist education programs from the mid-20th Century [38-41]. But it was not until Jon Kabat-
Zinn established the Centre for Mindfulness at the University of Massachusetts Medical School in
1979 that this approach engaged reputable institutions in the West [7-9]. This was evidently due
to the program’s scholarly reputation, its effective marketing and its high participant satisfaction.
A major factor in the acceptance of mindfulness meditation in America was that it was promoted
with few religious trappings [42].
A recent popular article has claimed that Rhys Davids original translation of ‘mindfulness’ was
not entirely accurate, suggesting to the contrary that ‘mindfulness’ really means memory of the
present’ [43]. However, a more authoritative Buddhist source asserts that ‘mindfulness’ as traced
to its original roots would best be characterized as ‘lucid awareness’ or more precisely “the
element of watchfulness, the lucid awareness of each event that presents itself on the successive
occasions of experience” [44]. Kabat-Zinn promoted the following definition which has been
widely adopted: "Mindfulness means paying attention in a particular way: on purpose, in the
present moment, and nonjudgmentally." [8]. The author can vouch for these three simple defining
features being very effective in teaching mindfulness to executives in university courses. Thus,
with its accessibility in practice, its hints of exoticism and its lack of emphasis on religion,
mindfulness has proved very marketable to a Western secular audience especially when used for
respectable university medical purposes.
As well as establishing an educational base for mindfulness in the U.S., the University of
Massachusetts Center for Mindfulness quickly became the springboard for mindfulness training in
other English-speaking countries especially in the U.K. where leading researchers applied it to
treating mental illness principally relapses in depression [45, 46]. In the almost 40 years since the
original centre was launched, the Centre’s website indicates that more than 24,000 people have
completed at one or other of their courses including the original 8-week Mindfulness-Based Stress
Reduction (MBSR) course and more recently, various online mindfulness courses [47]. Significantly,
many of these course alumni would have gone on to conduct their own mindfulness courses in
their own country thereby continually spreading this approach. For example, the website of Dr
Russ Harris in Australia reports that the 30,000 individuals who have undertaken short courses in
Acceptance and Commitment Therapy (incorporating mindfulness) since 2005, have almost all
been health professionals [48]. Further, there appears to be a clear trend of incorporating
mindfulness as a mainstream topic into university psychology courses around the world and this
will presumably ensure the ever-growing adoption of mindfulness in future clinical psychology
practice [49].
However, considering this high rate of adoption of mindfulness in the secular world, the
question arises as to how this compares with the original spiritual meditation practice handed
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down within Buddhism. According to one learned source, some modern Buddhists are concerned
that modern mindfulness is becoming alienated from the traditional Buddhist approach [37]. Not
surprisingly, many medical and psychological practitioners endeavour to teach mindfulness
divorced from spiritual meditation as alluded to previously. Indeed, an influential article titled
Mindfulness Without Meditation’ asserts: “’Mindfulness’ can be defined in a variety of different
ways, but they all basically come down to this: paying attention with flexibility, openness, and
curiosity.” [50].
As an indicator of Western acceptance of mindfulness, it is worth considering that the American
Mindfulness Research Association (AMRA) has been collating all the scholarly journal articles on
mindfulness which have been published worldwide since 1980. Their latest official records [51]
yield the following figures up to 2017: in the 20 years between 1980 and 2000, there were a total
of only 58 publications on mindfulness; in the decade between 2001 and 2010, there were a
further 578 publications; and between 2011 and 2017 there were 3,149 mindfulness publications.
The cumulative total to 2017 was 3,785 publications which is currently increasing at almost 700
publications per year.
In his recent recollections long after establishing the Centre for Mindfulness, Kabat-Zinn
commented that in his first book on mindfulness published in 1990 [9], his intention was to
“embody to whatever degree possible the dharma essence of the Buddha’s teachings put into
action and made accessible to mainstream Americans facing stress, pain, and illness.” [7]. Kabat-
Zinn further elaborated on his use of the Buddhist concept of ‘dharma’ in the following words:
“The intention and approach behind MBSR *Mindfulness-Based Stress Reduction] were never
meant to exploit, fragment, or decontextualize the dharma, but rather to recontextualize it within
the frameworks of science, medicine (including psychiatry and psychology), and healthcare so that
it would be maximally useful to people who could not hear it or enter into it through the more
traditional dharma gates, whether they were doctors or medical patients, hospital administrators,
or insurance companies.” [7].
We see then that Kabat-Zinn openly employed the spiritual/religious language of Buddhism in
launching mindfulness in the U.S. (particularly in promoting ‘dharma’ as illustrated in the
quotations above). Thus, Kabat-Zinn found a way of promoting Buddhism in a secular Western
medical framework almost four decades ago, without diluting its essential Eastern message and
without alienating potential Western converts to mindfulness meditation. In the words of an
American radio interviewer, Kabat-Zinn was promoting the concept of “Buddhist meditation
without the Buddhism”. In a broadcast interview in 2010, Kabat-Zinn succinctly summarized his
own position in these terms: “You understand that I myself am not a Buddhist, right? I don’t see
what I do as Buddhism so much as I see it as Dharma expressing itself in the world in its Universal-
Dharma-way” *52].
3. Mindfulness Meditation Applications in Health & Well-Being
3.1 Mindfulness-Based Stress Reduction (MBSR)
The MBSR (Mindfulness-Based Stress Reduction) training programs dating from the early 1980s
in the U.S., were initially designed to treat patients with chronic pain and typically comprised eight
weeks of group instruction weekly, plus an all-day retreat, coupled with daily mindfulness practice
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individually [53]. This 8-week blueprint became the basic formula for medical mindfulness training
that has persisted in the West till today. A concise summary of the underlying foundation of
medical training in mindfulness within and beyond the U.S., was provided in a recent article by
Dutch researchers as follows: “The MBSR- and MBCT protocol comprises both focused attention,
open monitoring, and breathing meditation but without the transcendental atmosphere of
traditional meditative practice.” [54].
The structure of the original MBSR training course (that was adapted for MBCT) is presented on
the website for Kabat-Zinn’s first book [9], and comprises:
Eight weekly classes, 2 1/2 hours each (totalling 31 hours direct instruction);
One All-Day class on a Saturday or Sunday [7.5 hours], between classes 6 and 7;
Daily home practice assignments for 45-60 minutes each day;
Guided instruction in mindfulness meditation practices;
Gentle stretching and mindful yoga;
Group dialogue and discussions aimed at enhancing awareness in everyday life;
Systematic instruction in formal MBSR meditation practices, with opportunity to check in
with teachers;
Daily home assignments;
Downloadable home practice audio files (or CDs) and a home practice workbook [55].
Before examining MBCT and its application in the treatment of depression, it is worth briefly
reviewing the key studies assessing the original medical mindfulness program, MBSR. Specifically,
we will review three meta-analyses each of which assessed the results of multiple studies [10, 56,
57]. First, a review by Grossman et al. in 2004 identified 64 relevant studies of MBSR but found
that only 20 studies covering 1,605 subjects met their stringent criteria for inclusion. Their results
indicated that both controlled and uncontrolled studies had comparable effect sizes (i.e., Cohen’s
d values 0.5). Although warning that their results are not definitive because of deficiencies in the
rigour of the 20 studies included, the investigators concluded that their meta-analysis showed that
“Mindfulness training may be an intervention with potential for helping many to learn to deal with
chronic disease and stress.” *10].
The second meta-analysis worth considering here is that conducted in 2009 on 10 studies of
MBSR that qualified out of 150 relevant publications identified [56]. According to the researchers,
these studies were of ‘mainly low quality’ because of deficiencies in their control conditions.
Across these 10 studies the pre-post comparison effects of mindfulness on stress levels as
measured by the Cohen’s d statistic, were in the range between 0.5 and 1.00 which is accepted as
statistically significant. This study also included a specific comparison of MBSR with standard
relaxation training and found that the two behavioral conditions were equally effective in reducing
stress. Nevertheless, this study is limited in its outcomes because of the lack of precision in the
controls of its component studies which point to the need for further research. The third and most
recent meta-analytic study, dating from 2015, initially examined 400 published articles and
ultimately selected 29 studies of MBSR interventions which met their rigorous inclusion criteria.
Note that these studies included a total of 2,668 individual subjects [57]. Effect sizes were
measured using the statistic Hedge’s g with individual studies showing effect sizes around 0.5
which is considered moderately large. The researchers note that despite limitations arising from
various methodological issues, this meta-analysis is consistent with several previous ones they had
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published which provide evidence for the effectiveness of MBSR interventions [57]. Again,
however, these researchers stress that further research is needed.
A variant on the above meta-analysis was conducted by researchers who investigated different
systematic reviews of studies which employed randomized control trials (RCTs) to assess the
effectiveness of mindfulness interventions (viz., MBSR and MBCT) [58]. They initially identified 187
relevant reviews of which 23 qualified for inclusion and yielded 115 different RCTs covering 8,683
patients suffering various conditions, physical and psychological. This research is distinctive for its
methodological rigour in that all of the studies selected used randomization as well as a control
group. By making comparisons with suitable control groups, the researchers found there were
significant improvements due to mindfulness in a number of conditions, namely, stress,
depression, anxiety, quality of life, and general physical functioning [58]. Clearly, this broad study
shows there is considerable evidence for the effectiveness of MBSR and MBCT across a range of
health conditions, though there is some null evidence in the literature as well.
3.2 Mindfulness-Based Cognitive Therapy (MBCT)
Mindfulness-Based Cognitive Therapy (MBCT) can be considered a blending of mindfulness
training from MBSR together with the long-established approach to treating mental illness known
as cognitive-behavioral therapy (CBT) [59]. The MBCT course in general use is directly comparable
to the 8-week MBSR course (outlined above). According to the official MBCT website, the course
“allows participants to become aware of how conditioned patterns of mind and mood can trigger
depression relapse and sustain current symptoms of depression. Through the practice of mindful
awareness, they develop the capacity to mindfully disengage from distressing moods and negative
thoughts.” [60]. The origins and development of CBT are comprehensively reviewed in Dobson’s
definitive handbook [61]. The precursors to the emergence of MBCT comprised studies in the
1980s such as a study that compared the effectiveness of CBT with that of relaxation training
(similar to mindfulness) [62]. The subjects in this case were 30 moderately depressed adolescents
as assessed on the validated instrument, the Beck Depression Inventory (BDI) [63]. Subjects were
randomly assigned to either the CBT or relaxation treatment groups or else to a ‘wait-list’ as a
standard though not ideal (as compared with active) control. Subjects who underwent either form
of treatment experienced a lowering of their depression from an average of moderate to non-
depressed and maintained this improved level at a follow-up assessment. The results indicated
that after five weeks treatment, there was no significant difference between the CBT and
relaxation conditions thereby providing a basis for a combined treatment approach [62].
3.3 Research on MBCT and Depression
After the U.S. Mindfulness Centre had been operating for 20 years training people via the 8-
week MBSR course as outlined above, investigators in the U.K. combined this mindfulness
program with the already established cognitive-behavioral therapy (CBT) in the treatment of
depression [45, 46]. In what is generally accepted as the inaugural research study of MBCT by
Teasdale and colleagues in 2000, 145 individuals in remission or recovery from major depression
were randomly allocated to either a group undergoing an 8-week course based on MBSR or to a
treatment-as-usual (TAU) group [46]. When tested after one year, 40% of those in the MBCT group
were found to have suffered depressive relapse whereas 60% of the TAU group experienced
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depressive relapse, a significant difference. These results have been replicated in subsequent
studies [11, 64-66].
A further example of the extensive research on this moderately new method (MBCT) is a major
study published in 2016 in which researchers initially located 286 studies of MBCT in the relevant
databases (n=5), and then identified 41 of these articles for detailed evaluation and finally
selected 16 studies as fully qualifying for analysis [11]. The main outcome measures were possible
differences in 1-year relapse rates and possible pre-post differences in scores on the Beck
Depression Inventory (BDI). The 16 selected studies were subjected to detailed analysis and were
reported in depth in the published article. An important finding of this meta-analysis was that the
combination of MBCT plus gradual withdrawal from anti-depressant medication did not
significantly lower depression relapse rates [11]. Although not emphasised by the researchers, the
results of this study showed that in treating depression, there are complex interactions among the
so-called ‘active ingredients’ of MBCT and other medical and non-medical factors in patients’ lives
Another relatively recent study examined research which investigated individuals who had
undergone non-pharmacological treatment after they had recovered from depression. In this
meta-analytic study, a search of the major databases revealed 29 eligible published interventions
comprising 2,742 individuals [65]. The results were compared after 12 months of treatment (viz.,
either cognitive-behavioral therapy [CBT], mindfulness-based cognitive therapy (MBCT) or
interpersonal psychotherapy (IPT). The findings indicated that these three primary treatments
were associated with a 22% reduction in depressive relapse as compared with individuals in the
control conditions. After 24 months these effects were maintained for treatments involving
cognitive-behavioural therapy but not for that with IPT alone. The researchers conclude that
interventions using psychological treatments may assist in the recovery of depression sufferers
experience because of pharmaceutical treatment or acute psychological therapy [65].
A recent meta-analysis updated a previous study by screening 2,555 new studies of which only
9 studies met all the inclusion criteria thereby yielding 1,258 eligible patients [66]. The meta-
analytic results indicated that those patients who had undergone MBCT were significantly less
likely to experience a depressive relapse within 60-weeks of treatment in comparison with
patients who did not undergo MBCT. In addition, the results showed a reduced risk of depressive
relapse with MBCT as compared with active treatments within a 60-week follow-up. The
researchers concluded that MBCT can be efficacious in preventing relapse for those suffering
recurrent depression [66]. This study was included in a review by Oxford University’s Mindfulness
Centre published on their website in 2016 in which they asserted: “Consistent with the findings of
previous meta-analyses, our work indicates that MBCT provides clear benefit over control
conditions (comprising usual care in some studies and active controls in others), through reducing
rates of relapse to depression over 60 weeks follow-up.” *67]. The Oxford University review
concluded that: “The results of this meta-analysis are promising and suggest that MBCT can
provide a viable relapse prevention intervention for people with a history of recurrent
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4. Review of Models of Mindfulness Efficacy
Having established that mindfulness meditation can be effective in a number of important
areas of mental health, it’s appropriate to consider what are the theoretical models which explain
the underlying mechanisms of mindfulness, a topic that has been subjected to extensive analysis
over the past two decades. One of the earliest reviews of mindfulness models was that by Baer in
an influential paper that also reviewed the meta-analytic studies that had been published at the
time (2003) [68]. From the empirical viewpoint, this investigation concluded that despite many
methodological flaws, the available research indicated that mindfulness-based interventions can
be effective in treating a number of disorders. From the conceptual viewpoint, Baer also showed
that there were a variety of theoretical models (explicit and implicit) which aimed to explain the
efficacy mechanisms of mindfulness in health applications [68].
A relatively early attempt to conceptualize the efficacy mechanisms involved in mindfulness
interventions, was an article by Bishop and associates which presented a two-component model
to provide an operational definition of mindfulness [69]. As the researchers described their model:
the first component is that of self-regulation of attention based on immediate experience which
allows for increased recognition of mental events in the present moment. The second component
refers to an individual’s ability to orient themselves toward their experience in the present
moment, an orientation that involves curiosity, openness and acceptance [69]. While Bishop’s
model posits two operational components in mindfulness, it is worth noting that this differs from
the binary model advanced in this paper which is based on there being two mindfulness processes
(active versus passive) underpinned by two structural elements (‘intra-self’ versus supra-self)
(see Figure 1).
Some of the important conceptual models of mindfulness are associated with the various
instruments developed to measure mindfulness competencies in individuals. In other words, the
dimensions or factors of the instrument correspond with the constructs in the model. For example,
the empirically validated ‘Five Facet Mindfulness Questionnaire’ advanced by Baer and colleagues,
is designed to assess five component skills yielding a five-factor conceptual model of mindfulness
(viz., “observing, describing, acting with awareness, nonjudging of inner experience, and
nonreactivity to inner experience” *70]. Another example from those available is a conceptual
model that posits two basic components of mindfulness, specifically, 1) present-moment
awareness, and 2) non-judgmental acceptance of thoughts and emotions. These two components
are proposed to operate iteratively so as to promote executive control which leads to an
improvement in the regulation of emotion [71]. A comprehensive conceptual review worth noting
in this context is one by Brown and associates that compared the mechanisms of mindfulness
proposed in ancient Buddhist versus contemporary secular scholarly sources [72]. They review the
mindfulness mechanism of attention and the role it plays in the regulation of both physical and
psychological health. In addition, they review the main theories of behavioral regulation (e.g., self-
control) and evaluate the importance of paying attention here and now, a key mindfulness
A recent pivotal paper which investigated six different models of the efficacy mechanisms
involved in mindfulness-based interventions (MBI) [73]. This study analysed 20 methodologically-
acceptable published articles (out of 169 relevant full-text publications) relating to MBSR
(mindfulness-based stress reduction) and MBCT (mindfulness-based cognitive therapy). Using two-
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stage structural equation modelling the research identified four main mechanisms that proved
effective, namely: mindfulness (present moment awareness with non-judgmental acceptance),
repetitive negative thinking (comprising rumination about the past and worrying about the future),
self-compassion (including self-acceptance) and cognitive and emotional reactivity (which entails
stress triggering negative thinking and emotional behaviors). The researchers concluded that their
study indicated the evidence for cognitive and emotional reactivity was stronger than the other
mechanisms investigated [73].
A somewhat different model of mindfulness emphasizes the role of ‘positive reappraisal’ of
conditions which pose either a stressor or a threat to an individual [74]. The function of positive
reappraisal is to operate as an active coping strategy which re-evaluates the stressor and alters
how it is experienced. This model of mindfulness posits that in order to obtain a state of positive
reappraisal, an individual has to retreat from their initial appraisal of an event into a momentary
state of metacognitive awareness that discards the original semantic evaluations one made and
replaces them with positive evaluations [74]. Thus, positive reappraisal is the central mechanism
in this so called ‘mindful coping model’ which is posited to result from the instrumentation of
mindfulness. This model, while primarily focusing on the effect of mindfulness on stressors, can be
extended to explain the dynamics of depression.
A recent systematic review by van der Velden and associates focused specifically on the
mechanisms in MBCT which produce change in patients suffering major depressive disorder [75].
The researchers initially identified 476 relevant studies of which 23 were eligible for analysis. Of
these, 12 studies indicated that changes in mindfulness, rumination, worry compassion or meta-
awareness were associated with the treatment effect of MBCT. In addition, there were a number
of other mechanisms (including alterations in attention and emotional reactivity) that were
identified as possibly playing a role in the efficacy of MBCT subject to further research. Another
recent model of the mechanisms of mindfulness has been called ‘monitor and acceptance theory’
(MAT) which succinctly describes the two constructs on which it is based [75]. This theoretical
approach adopts the widely accepted definition of mindfulness as its core (viz., present moment
attention plus non-judgmental acceptance), specifically, attention monitoring and acceptance [76].
According to MAT theory, the initial efficacy mechanism in mindfulness practice should be an
increased capacity for attention monitoring. Such a capacity should enable an individual to be
more aware of affective information and if they are operating alone, this skill should reduce their
negative experiences and increase their positive experiences. Note that the MAT model is
comparable to that offered by Bishop et al. as considered above, in that both are based on two-
components (attention and acceptance) [69].
A significant review published recently, systematically examined the various ‘mechanisms of
action’ that have been advanced to explain the efficacy of the main mindfulness-based
interventions, (MBCT and MBSR), while adopting the definition of ‘mechanism’ as a process that
can bring about change in a patient’s physical or psychological condition [77]. The researchers
scanned 7 major databases and initially identified 3,290 studies of which 3,234 were removed for
various reasons leaving 41 possible studies for further consideration. After further exclusions, they
finally selected 4 studies of mindfulness treatments for combined physical and psychological
conditions and a further 14 studies of various psychological conditions. The researchers
commented on the general lack of methodological rigour in the studies analyzed but concluded
that overall there was clear evidence for the efficacy of mindfulness interventions. However,
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regarding the mindfulness mechanisms at work in treating depression, they found that of the 14
studies of psychological conditions, most related to depression and that the key mechanisms in
addition to mindfulness were “rumination, worry and self-compassion” as well as “attention and
emotional reactivity” *77]. Again, the authors state that further research is needed to clarify the
dynamics involved.
Finally, in a novel study published this year, Britton and colleagues observed that mindfulness-
based interventions (viz., MBSR and MBCT) employ two distinct practices, namely, focused
attention (FA) and open monitoring (OM) [78]. These two meditation practices were identified
previously by Lutz and associates [79] as being central to mindfulness-based programs. Britton et
al. assert that FA involves four interrelated skills: “1) sustaining attention on a chosen object; 2)
identifying distractions without destabilizing the intended forms; 3) disengaging from a distracting
object without further involvement and 4) redirecting focus promptly to the chosen object.” [78].
The second type of meditation, OM (open monitoring), is claimed to involve the cultivation of non-
reactive awareness of the automatic cognitive and emotional responses one has to the continual
barrage of stimuli they receive.
Using samples matched on relevant variables, this research compared a mindfulness-based
intervention that was primarily based on focused attention (FA) with one based on open
monitoring (OM) and also using the standard MBCT program as a third treatment functioning as
an active control group [78]. After 506 potential participants were initially assessed, a total of 104
subjects were selected and randomly assigned to one of the three treatment groups. Each group
underwent approximately 3 hrs/week of group instruction in the relevant meditation practice plus
comparable times in directed daily meditation practice and reading. With a number of drop-outs
from the 8-weeks training, 96 subjects were finally judged eligible for analysis spread roughly
equally across the three treatment groups. At the end of their respective 8-week course, each
subject completed 7 different self-report instruments including one scale, the Therapeutic Factors
Inventory, comprising 99 items. The results indicated that the three treatment groups (FA, OM
and MBCT) differed in the skill levels subjects acquired on the various instruments [79]. Essentially,
this research demonstrated that the two primary components of mindfulness practice can be
differentially enhanced by training directed at either focused attention or open monitoring. In the
present context, this means that a two-component model of mindfulness (FA versus OM) can have
practical application.
The above overview of models of mindfulness which is based on a diverse selection from the
many published conceptualizations of mindfulness efficacy, shows that there has been a variety of
mechanisms postulated to explain how mindfulness can produce beneficial physical and
psychological health effects. Coupled with the extensive empirical evidence reviewed previously,
there is considerable evidence for the effectiveness of mindfulness interventions in the treatment
of depression and other mental conditions. One feature that all the models share, albeit without
specifying the fact, is that they postulate that the human psyche is unitary and, consequently, that
mindfulness is a unitary process. The binary model of mindfulness proposed in this paper is based
on the concept of two distinct processes (‘active mindfulness’ versus ‘passive mindfulness’)
occurring in a tripartite human psyche comprising three distinct selves as described (viz., the ‘sub-
selves’, the intra-self and the supra-self). The present model (see Figure 1) is developed from
that proposed some years ago in relation to executive stress [80] and more recently applied to
environmental noise stress [81].
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Despite the considerable evidence for the efficacy of mindfulness as reviewed above, there is a
new literature that is critical of mindfulness and cautions scientists, the public and the media to
“mind the hype” *82]. Van Dam and associates recently published a detailed critique with the
objective of addressing the “Misinformation and poor methodology associated with past studies
of mindfulness [which] may lead public consumers to be harmed, misled and disappointed” [82].
These critics place particular emphasis on the difficulties in defining mindfulness as well as the
alleged deficiencies in the methodology of mindfulness research. Regarding the definition of
mindfulness, there is certainly a need for an international standard classificatory system to ensure
that therapeutic practices and comparative research studies are consistent. As well as the issue of
defining mindfulness, the van Dam group questions the construct validity of mindfulness and also
the problems of operationalizing and measuring mindfulness especially via self-report
questionnaires. In addition, they advocate a new prescriptive protocol for therapeutic
interventions involving mindfulness.
A reply to the above critics was recently presented by Davidson and Dahl [83] who reported
that they accepted van Dam’s main points, but that there are a number of issues regarding future
mindfulness research that need to be considered. The main issues Davidson and Dahl raise include
the fact that mindfulness is not the only research area to face problematic methodological
concerns especially the use of self-report measures [83]. Further, as has been shown in the
present paper, the term mindfulness has a long history and has come to be applied to a diversity
of meditation practices. Both groups of evaluators warn of the tendency for previous research
studies to mismatch diverse meditation training under the single rubric of mindfulness [82, 83]. I
would observe that such an approach is likely to confound ‘what causes what’ when accounting
for research results. The van Dam group continued the debate by offering a rejoinder to Davidson
and Dahl [83, 84]. While conceding that methodological issues are not unique to mindfulness
research, van Dam and colleagues stress that they are still of great importance even allowing for
the relative youth of the discipline [84]. It is worth noting that mindfulness applications in health
and wellbeing can be traced only four decades to around 1980 (for MBSR [17]) and two decades to
2000 (for MBCT [46]). The key lesson from the recent van Dam debate would seem to be that
mindfulness research over the next 20 years needs to focus on systematically assessing the
efficacy of the various relevant mindfulness practices and also to apply more standardized and
more objective measures with less reliance on self-report.
5. Proposed Binary Model of Mindfulness
The current model draws on the vast literature reviewed above, to propose that mindfulness
can have a beneficial effect on depression firstly, by assisting patients in disengaging from their
negative thoughts and secondly, by helping them disidentify with the self that sustains their
depressive existence. The mechanisms involved in mindfulness meditation are posited to be as
indicated in the literature, namely, the active process of focused attention and also open
monitoring which is, as will be shown, not entirely passive [68, 77, 78] in contrast to the present
(active versus passive) model. The present binary model of mindfulness proposes that the human
psyche comprises a number of distinct mental components which give rise to two modes of
mindfulness to be considered later. The first mental component, the ‘sub-selves’, are the basic
operating elements of one’s psyche; they dominate an individual’s waking consciousness and
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comprise the ever-present ‘voices in one‘s head’ experienced by every person capable of thought.
The ‘sub-selves’, ‘intra-self’ and’ supra-self’ are not ontologically-distinct entities within the
human psyche and are in that respect parallel to Freud’s model of the psyche comprising the id,
ego and superego which are posited to be emergent entities [85]. Rather, the present tripartite
selves are theorized as constructs which emerge from distinct functions of the psyche. For
example, the ‘sub-selves’ emerge from the repeated patterns in the stream of mindchatter that
continually occupies our consciousness [80, 81].
In the case of depression, it is here posited that it is the sub-selves which feed one’s mind non-
stop with the negative thoughts that initially create the state of depression and subsequently
serve to maintain its hold over the individual’s life. Fortunately, however, it is the sub-selves which
respond to cognitive-based interventions in the treatment of depression [62, 63]. It has been
found to be beneficial in managing our sub-selves to label them with names which describe the
typical thoughts that each produces Voice Dialogue is a well-established therapeutic technique
for helping individuals understand the various components of their own psyche including their
various sub-selves [86, 87]. For example, while each person has their own set of sub-selves
approximately 4-6 of which are typically operative at any one time and which contribute either
positively and negatively to their ‘mindchatter’, most individuals share a sub-self that can be
labelled The Miserable (Poor Me) as well as another we can label ‘The Critic’ (‘You’re Pathetic)
[86]. It is here asserted that these are the two sub-selves that are the primary sources of constant
depressive thoughts such as: “You are hopeless; your life is a failure; you’re a loser; why don’t you
just give up! ... etc. (viz., The Critic sub-self), and also: Depressed is me; I’m so sad; I am
worthless; my life is meaningless; no-one cares about me; there’s no hope I might as well opt out
of this life etc. (viz., The Miserable sub-self). Cognitive therapy, with or without mindfulness,
aims to help patients firstly observe their negative thoughts, and then to recognize such thoughts
as erroneous, and eventually to detach from these thoughts as not being their own self [45].
Mindfulness teaches individuals to reach such detachment via open self-observation during
meditation [78]. Unless an individual can detach themselves from such negative thoughts, they are
likely to identify their very being with such thoughts and thereby to become identified with their
own negative thoughts. It’s as though they say in a variation of Descartes: “I think; therefore, I
am my thoughts”. As cognitive therapy has revealed over several decades, depressive individuals
tend to believe their own thoughts, including their illogical negative thoughts, and to regard them
as indubitable ‘inner truths’. The ever-present ‘mindchatter’ they experience, especially those
ongoing streams of negative thoughts from their sub-selves that criticize and undermine
everything they are and do, reinforces their sense of hopelessness. Such individuals come to
identify with their own depressive thinking without realizing that their true self is able to observe
their mind and that, consequently, they are a being beyond their mind and, therefore, they are
not subservient to the relentless ‘mindchatter’ of their mind, specifically, their negative but
persuasive sub-selves. Addressing this erroneous thinking is the key strategy proposed by the
present binary model in managing depression. The other key strategy is existential
disidentification to be considered later.
As well as the ‘sub-selves’, the human psyche comprises the structural component of the ‘intra-
self’ (intra = within the mind and among the sub-selves). The intra-self functions as each
person’s ‘managing ego’ or in an alternative framework, their ‘aware ego’ [86, 88]. This
component of the psyche is responsible for managing the challenges a person faces each day. The
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intra-self actively operates within the realm of the ‘mindchatter’ of the sub-selves and provides
the individual with constructive feedback contrary to the negativity of ‘The Critic’ and The
Vulnerable’ [86]. The intra-self is an active component of one’s psyche which plays two roles under
the main form of mindfulness, namely, ‘active mindfulness’. These active roles are: 1) to manage
the continuous focussing of attention in the present moment, and 2) to maintain an open state of
active monitoring of their own mind without any judgement, commentary or intervention [78].
This active form of mindfulness is generally regarded as the only type of mindfulness in modern
psychology and medicine, that is, as the active but neutral form of monitoring the processes of
one’s mind *67, 71].
The third and final structural component of the human psyche is the ‘supra-self’ (supra =
‘above’ …the mind). The supra-self is also aptly described as the ‘inner observer’ or ‘observing self’
[89 and that is how it plays a critical role in the mindfulness-based management of depression (as
will be shown later). The supra-self is one’s ‘higher self which functions above the mind, meaning
that it is completely neutral and totally detached from the ‘mindchatter’ of the sub-selves
including those that feed depressive thinking. However, most people identify with their mind such
that they regard their mind as their ‘true self’. Moreover, they are completely unaware of their
supra-self, much less of its ability to detach from the reactivity and the frequent chaos of their
sub-selves and their mindchatter’. From all that is known from 2,500 years of scholarly human
psychology, originating with the teachings of the Buddha and now widely accepted in Western
psychology and medicine, the mind and its vicissitudes can be well managed through mindfulness
[60, 67].
Significantly, the supra-self is almost invariably either unrecognized or disregarded not only by
individuals most in need, but also by entire disciplines within psychology and medicine. It is
notable that mindfulness meditation is currently regarded in psychology and medicine as a
legitimate and effective intervention in a range of illness conditions including depression However,
there is virtually no recognition in the literature of a higher form of self which operates passively
above the cognitive domain of the mind and which can foster true detachment from the negative
thought processes which feed depression. As far as is known, the supra-self can be engaged only
by ‘stillness meditation’ which enables one’s higher self to observe with passive detachment.
Repeated practice of stillness meditation eventually leads an individual to disidentify their
existence from their depressive self. This results from the following simple but compelling logic: “If
I can repeatedly observe my mind and its constant chatter as other, then my true self must exist
separately from my mind”. Disidentification from one’s mental illness can free a depressed
individual from the heavy burden of their unceasing negative thoughts and enable them to
experience increased self-affirmation [90].Thus, it is here proposed that the human psyche has
three structural components: 1) the ‘sub-selves’ responsible for one’s constant ‘mindchatter’, 2)
the ‘intra-self’ which performs the function of one’s managing ego, and 3) the ‘supra-self’ which is
one’s higher self and which operates above mind as one’s inner observer. Both the intra-self and
the supra-self participate in mindfulness activities, the former by performing active mindfulness
typically involving both focused attention and open monitoring, and the latter engaging in passive
mindfulness which is entered via stillness meditation. In addition to the structure of the psyche,
the present binary model of mindfulness hypothesizes about the way the psyche functions in
managing depression (see Figure 1).
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Figure 1 Binary model of the dynamics of mindfulness meditation in managing depression.
NB. The above binary model of active versus passive mindfulness is based on that advanced
originally by Hede [80] to explain mindfulness in reducing executive stress. The central processes
are posited to be the two modes of mindfulness, namely, active mindfulness and passive
mindfulness (re-labelled from ‘meta-mindfulness’ and supra-mindfulness’, respectively, which
comprised Hede’s recent model [81] to explain how mindfulness can reduce the health effects of
environmental noise on communities).
The following explanatory notes correspond with the numbered elements in the model above
(see Figure 1):
[1] The causality of depression is known to comprise a complex of sources including various
biochemical factors, sustained stress, as well as life factors including experiential traumas,
relationship and family problems, as well as other causes [91] (see No.1 ‘Complex Causality of
Depression’ in Figure 1).
[2] The first reactions that people experience in encountering depression are usually
physiological. Of these, most people are likely to experience neuro-chemical reactions, physical
fatigue, sleep disturbance, as well as a range of other physiological conditions. (see No.2 in Figure
1, ‘Physiological Reactions to Depression’).
[3] As well as physiological reactions, people suffering depression are prone to experience
psychological reactions especially incessant negative thinking including possibly, suicidal thoughts.
A useful summary provided by one source is as follows: “Most common symptoms of depression
include sadness, dissatisfaction, spontaneous crying, irritability, withdrawal, increased tiredness,
weight loss and lack of interest in sex” *92]. Note that psychological reactions may be subjectively
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experienced prior to or concurrent with physiological reactions but depression sufferers typically
lack reflective awareness. (see No.3 ‘Psychological Reactions’ in Figure 1).
[4] The ‘intra-self’ operates within the mind and functions as one’s ‘managing ego’ (equivalent
to the ‘aware ego’ [86]) which deals with manages the constant chatter of the ‘sub-selves’ (see
No.4 in Figure 1, ‘Intra-Self’). The present model postulates that when an individual learns
mindfulness, it is their ‘intra-self’ that acquires the capacity for active-mindfulness’. This entails
two mechanisms that assist with conditions such as depression, namely, focused attention and the
active but non-judgmental monitoring of one’s own mental processes [78, 89]. Thus, active
mindfulness as a key function of one’s ‘intra-self’ is equivalent to the conceptualization of
mindfulness which is dominant in the literature (see Section 4 above).
[5] As far as possible, the proposed binary model of mindfulness has been designed to
incorporate elements previously validated in the literature. Thus, the mechanism with the greatest
efficacy in relation to depression is here posited to be decentering [90] (see No.5 in Figure 1,
‘Decentering from Depressive Thinking’). The process of active mindfulness as proposed here,
has been shown in many studies reviewed above to develop an individual’s capacity to detach
from their own depressive thinking. The current model explains such thoughts as continuously fed
to an individual in their ‘mindchatter’ by elements of their own mind, specifically, their sub-selves.
[6] The ‘supra-self’ is the ‘higher self’ of the human psyche (see No.6 in Figure 1, Supra-Self:
Inner Observer’). Whereas the ‘intra-self’ functions as one’s ‘managing ego’ which is actively
involved in mental processes (as discussed in Point No.4 above), the supra-self is an individual’s
‘inner observer’ whose function is completely passive and operates detached from mind (viz., in a
state of ‘no mind’). This construct is comparable to Deikman’s notion of the ‘observing self’ [89].
[7] The primary mechanism whereby the supra-self effects permanent change in an
individual suffering from depression is via existential disidentification (see No.7 in Figure 1,
Existential Disidentification from Depressive Self-Identity). This construct is called ‘existential
disidentification’ because it relates to how one experiences one’s existence, to distinguish it from
‘cognitive disidentification’ which involves intellectual disengagement from one’s mental states.
[8] As depicted in the model (see No.8 in Figure 1, ‘Improved Managing of Depression’), it is
hypothesized that by training themselves in both active and passive mindfulness, individuals can
reduce the impact of depression in their lives. The use of the term ‘improved managing’ rather
than ‘cure’ is intended to convey that major depression is likely to persist or recur in some form,
but that the ongoing practice of mindfulness can prevent a serious relapse.
[9] The final element in the proposed binary model of mindfulness (see No.9 in Figure 1,
‘Other Efficacy Mechanisms’) is included because of the many efficacy mechanisms that have been
identified in the literature (see Section 4 above). Also, future research is likely to further clarify
precisely how mindfulness achieves its health benefits, both physiological and psychological.
6. Discussion
In evaluating the above model, it is essential to consider that that there is a long tradition in
Psychology and Behavioral Medicine of ‘explaining’ a process by identifying its component
constructs and also by showing how they interact (usually indicated by means of connecting lines
in illustrative diagrams. This is exactly what the current proposed binary model does (see Figure 1
above). It is important to note that the proposed model is not attempting to explain all MBCT
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interventions but only the two-stage therapeutic intervention specified, namely, decentering via
active mindfulness by the ‘intra-self’ and existential disidentification via passive mindfulness by
the ‘supra-self’.
The binary model presented here is distinctive in that it posits a tripartite composition of the
human psyche (viz., sub-selves, intra-self, supra-self) as well as two distinct mindfulness processes
(active versus passive) by which these selves function in one’s everyday life. Like Freud’s famous
tripartite model of personality (id, ego, superego) [85], the self components of the psyche as here
proposed are definitely not internal little men (from ‘homunculus’ in Latin) as the well-known
philosophical theory argues [93]. Nor are they internal spirit beings but rather emergent functions
whose existence can be inferred from their capacity to determine an individual’s recurrent
behaviors rather like human functions such as intelligence, wisdom and selfishness. The proposed
components of the psyche comprise firstly, the sub-selves which are evidenced in every
individuals’ constant ‘mindchatter’, plus secondly, the ‘intra-self’ or ‘managing ego which enables
an individual to manage the complex activities of their mind especially the many voices of their
sub-selves and also to interact with the outside world. The third and ultimate structural
component of the psyche is posited to be the ‘supra-self’ which is every individual’s ‘higher self’
and which has the potential to function as their ‘inner observer’.
Whereas the ‘intra-self’ is postulated as an active entity, the ‘supra-self’ is a passive and largely
overlooked component of one’s psyche. That is, it is only when an individual surrenders all control
to the neutral observation by their supra-self (as during stillness meditation) that they can truly
achieve a state of being ‘above mind’ in the sense of being fully detached from all mental activity.
Importantly, the ‘supra-self’ either observes or it doesn’t. If it does observe, it takes no action for
its function is purely neutral and passive. However, if the ‘supra-self’ doesn’t observe, it is
completely non-functional and irrelevant to the individual’s life. In sharp contrast with
homunculus theory, the current tripartite model of the human psyche does not entail endless
levels of self ad infinitum. Rather, the proposed kinds of self (‘intra-self’ and ‘supra-self) are
capable of engaging in two different modes of mindfulness, namely, active mindfulness in the case
of the intra-self and passive mindfulness when it involves the supra-self. Note that the proposed
distinction between two modes of mindfulness should improve our understanding of mindfulness
in practice and may result in a more effective two-stage intervention for depression subject to
empirical validation.
The main existing binary conceptualization of mindfulness in the literature seems to be that
proposed 20 years ago by Martin who distinguished two forms of mindfulness based on their use
of attention [94]. The first is an open form of mindfulness involving open attention while the
second is a focused form of mindfulness involving focused attention. According to Martin: “The
open form is like a space ship that can freely hover and examine a landscape. Once on the surface
of a planet, focused-form attention is necessary to identify, spot, or follow a path to an alternate
landscape.” [94]. Martin compares his binary conceptualization with various constructs proposed
by others. For example, he draws an equivalence between his two attentional forms of
mindfulness (open versus focused) and the Buddhist distinction between insight meditation
(vipassanā) and concentration meditation (samadhi) [36, 94]. Another example cited by Martin is
Seeth’s distinction between two types of attention used by psychotherapists, namely, panoramic
attention (open) versus narrow-focused attention (focused) [94, 95]. Yet another binary
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classification is Deikman’s *89+ notion of the ‘observing self’ which is posited to be capable of
either a ‘receptive mode’ (= open) and an ‘object or action mode’ (= focused).
Let us adapt Martin’s spaceship analogy (see previous paragraph) in order to conduct a direct
comparative analysis of his notion of binary attentional forms versus the present binary model of
active versus passive mindfulness (see Figure 1). First, let’s summarize the two approaches starting
with Martin’s distinction between two attentional forms of mindfulness (viz., open versus focused)
which he provides without any information about the mental structures assumed to be involved
[94]. By contrast, the present model distinguishes between active mindfulness (conducted by the
‘intra-self’ or ‘managing ego’ which operates totally in the mind) and passive mindfulness (which
involves the presence of a completely passive ‘supra-self’ or ‘inner observer’ which operates
above and detached from the mindchatter of the mind). As proposed here, the alternative to
Martin’s spaceship hovers over the landscape within one’s mind actively searching for a landing
site and scanning for any hostile mental activity especially the mindchatter’ of the noisy locals
(‘sub-selves’). Once the alternative spaceship has landed under the supervision of its pilot
(‘managing ego’), it can close down all systems and allow its ‘neutral eye’ on its surveillance tower
to observe all activity both inside and around the spaceship such that ‘stillness prevails. Whenever
an emergency arises, as happens often, the neutral ‘inner observer disengages and the pilot takes
over full control initiating corrective mental activity as required. (see Figure 1).
The first thing to notice from the allegorical spaceship comparison above is that the two
attentional processes are opposites in the two models. Whereas Martin’s spaceship starts in open
attention mode hovering above the landscape, the present model starts in active mindfulness
mode searching for a landing site and scanning for local (mental) activity. Importantly, both
models involve activity though Martin’s model clearly views ‘focused attention’ as involving more
action than ‘open attention’ considering that he mentions action several times in relation to
focused attention (e.g., “A focused attentional form facilitates action…” [94]. The proposed binary
mindfulness model, by contrast, posits a clear distinction between the mental activity of the intra-
self (active mindfulness comprising both focused attention and open monitoring) as compared
with the total passivity from the supra-self (passive mindfulness, that is, neutral observation
without any form of mental activity).
As noted above, Martin cited a number of published conceptualizations equivalent to his notion
of open versus focused attention. Interestingly, in the two decades since his article first appeared
in 1997, there have been several other comparable models of mindfulness which distinguish
focused attention versus open monitoring (see Section 4). All six of the conceptualizations of
mindfulness reviewed here (viz., those proposed by: Martin [94], Speeth [95], Deikman [89],
Bishop [69], Britton [78], and Lutz [79]), involve two active functions both of which are
accommodated within the present construct of active mindfulness. Firstly, focused attention or
its equivalent in the other models cited above, is clearly an active process requiring mental effort
to sustain continuous focus and also to re-focus when the mind wanders [79, 94]. According to
Lutz et al., FA meditation (focused attention), “entails voluntary focusing of attention on a chosen
object in a sustained fashion” *79]. These researchers posit that OM meditation (open monitoring),
on the other hand, “involves nonreactively monitoring the content of experience from moment to
moment, primarily as a means to recognize the nature of emotional and cognitive patterns” *79].
This view is shared by all the other models under consideration in this paper. Significantly, in the
various models considered, open monitoring is viewed as less of an active process as compared
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with focused attention (see above), but is nevertheless an active process for as Lutz et al. point
out regarding open monitoring, there is also an increasing emphasis on cultivating (sic) a
‘reflexive’ awareness that grants one greater access to the rich features of each experience [79].
It is argued here, that this contrasts with the current binary model which hypothesizes that passive
mindfulness involves nothing but neutral inner stillness without any mental activity (see Figure 1).
As proposed in the current binary model, the two modes of mindfulness (active versus passive)
are primarily linked to two efficacy mechanisms involving the intra-self (managing ego) and the
supra-self (inner observer), namely, decentering and existential disidentification, respectively
(see Figure 1). These are two of the many related constructs proposed in the literature which
Bernstein et al. list alphabetically as follows: cognitive defusion (or deliteralization); cognitive
distancing; decentering; detached mindfulness; meta-cognitive awareness; metacognitive mode;
mindfulness; reperceiving; self-as-context; and self-distanced perspective [96,p.600]. While
diverse in their detail, these metacognitive processes all relate to the very human capacity “to
shift experiential perspective from within one’s subjective experience onto that experience”, a
capacity these researchers describe broadly as “decentering” *96]. Bernstein et al. also propose a
model of decentering which comprises three constructs, namely, 1) meta-awareness, (awareness
of subjective experience), 2) disidentification from internal experience (the experience of internal
states as separate from one’s self), and 3) reduced reactivity to thought content (reduced effects
of thought content on other mental processes) [96].
The second key mechanism endorsed in the present model is the efficacy process of existential
disidentification. It is notable that most of the psychological literature on disidentification deals
with self-identity in relation to social factors such as nationality, race, occupation, organization
[e.g., 98]. Bernstein et al. define disidentification as the capacity to experience one’s own internal
activities and states as distinct from one’s own existential self. As they assert: This experiential
disidentification contrasts with the human tendency to identify with subjective experience and,
therein, to experience internal states such as thoughts, emotions, and sensations as integral parts
of the self.” [96]. As an example, if a depressed person experiences the thought ‘I’m worthless’
they may be tempted to interpret this as confirmation that they are indeed, a worthless being,
and to further argue because my infallible mind tells me so and, therefore, it must be true).
Similarly for all the thoughts listed in the published automatic thoughts questionnaire [97] which
provides an authoritative measure of depressive thinking. Disidentification enables the person to
realise as they happen that their automatic (negative) thoughts are simply events in their mind,
indeed, that they are no different from the other ‘mindchatter’ that their ‘sub-selves’ voice
continually. But so-called automatic thoughtsbecome problematic for the depressed person not
so much when they are continuously repeated as intellectual assertions but more so when such
thoughts become integrated into one’s self-identity. There are many techniques aimed at reducing
the impact of negative thinking, for example, the long-established method of cognitive defusion
adopted by Acceptance and Commitment Therapy (ACT) entails the rapid repetition of a single
word [99]. Thus, a depressed person might identify the negative thought they find most disturbing
as being ‘I’m always sad’ and from this they might derive the word ‘sad’ for repetition. By
repeating this word its semantic meaning eventually becomes less dominant or ‘defused’ and their
attachment to the literal meaning of their unwanted thought becomes less believable and, hence,
more manageable [99].
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From the previous discussion, there appear to be two relevant types of disidentification which
are here labelled cognitive versus existential. The first, as addressed in the model advanced by
Bernstein and associates [96], is the capacity to process one’s mental experiences as they occur
such that they are interpreted as events and states that are happening in one’s mind rather than
as occurrences that directly reflect one’s existential self. In the present binary model, cognitive
disidentification is a mental skill that can be acquired, albeit with much training and effort, by
using the resources of the ‘managing ego’ (intra-self). For a depressed individual, it is primarily the
‘sub-selves’ (especially ‘The Miserable’ and ‘The Critic’ or similar see Section 5), who collude not
only in repeating negative slogans (such as those from the official list of automatic thoughts [97]),
but who are well-practiced at engaging the ‘intra-self’ in debate about how the person’s thoughts
are evidence of their depressed existence. Of course, it is a great cognitive skill to be able to
process one’s negative or unpleasant mental events in the present moment without their affecting
one’s self-identity and sense of being.
The second type of disidentification (viz., existential) is much more difficult to manage in
practice because it requires the depressive individual to acquire a profound existential insight
(specifically, a fundamental shift in one’s deep conviction about who one really is). As we have
seen, cognitive disidentification enables a person with depression, to learn various cognitive skills
(decentering, defusion etc.) which empower them to experience their mental states without
affecting their sense of existence [100, 101]. While existential disidentification, on the other hand,
is difficult to achieve in practice, but the underlying logic is straightforward, namely: I observe my
mind; therefore, I cannot be my mind’. As one practices stillness meditation, their supra-self (inner
observer) engages in passive mindfulness such that they eventually experience their mind as
being distinct from their existence. No amount of mental effort, intellectual repetition or cognitive
assertion can produce a shift in one’s sense of core identity. For a person who has lived many
years struggling with their self-identity as a depressive person, the best they can hope for is
metacognitive awareness involving active mindfulness. As Teasdale and colleagues proposed some
15 years ago, “Metacognitive awareness is a cognitive set in which negative thoughts/feelings are
experienced as mental events, rather than as the self” *102]. But even if new mental events are
not experienced as the self because of active mindfulness, the depressive person’s self-identity is
already locked in and cannot be changed except via an existential shift (specifically, via existential
However, because the supra-self is totally confined to passive observation during stillness
meditation, it is not able to actively intervene in the process of existential disidentification. It’s
rather like a child attempting to catch a soap bubble the very attempt simply bursts the bubble.
In practice, the main aim of disidentification in the treatment of depression is to change both
one’s way of dealing with negative thoughts (cognitive) as well as shifting one’s self-identity from
that of a depressive to that of a being who exists beyond one’s mind) (existential) (i.e., one’s ‘inner
observer’ – see Figure 1). With another nod to Descartes, any person may reason: ‘I think;
therefore, I must have a mind. This assertion makes a simple logical point, namely, that if I think, I
must have a mind which does the thinking. However, the person can take the next logical step of
realising another assertion that: Because I can observe my mind operating separately, therefore, I
am not my mind’. This second assertion, on the other hand, is not logically derived from the first
assertion but is rather a distinct insight gained from reflecting on one’s own mental experience,
that is, an ‘aha’ moment about one’s true existence as separate from one’s ‘mindchattery’ mind.
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The final issue to consider is how the present binary model of mindfulness stands up to
empirical investigation. Such a study could be designed by randomly assigning approximately 120
depression sufferers to one of three test conditions based on the 8-week MBCT course [60, 103],
namely, a) standard MBCT course (as an active control); b) MBCT course with special emphasis on
active mindfulness and defusion; c) MBCT course with special emphasis on passive mindfulness
and existential disidentification; d) MBCT course with special emphasis on both defusion and
existential disintegration (see Figure 1). The outcome measures could include the following: 1) pre
and post scores on the Beck Depression Inventory [63]; 2) relapse and recurrence rates of
depression across the test conditions after 6 and 12 months [63]; 3) other measures based on
specific literature review. Comparisons among the four test groups would indicate the specific
efficacy of the mindfulness mechanisms.
7. Conclusions
In order to introduce a new conceptual model comprising two modes of mindfulness (active
versus passive) within a new tripartite framework of the psyche-as-selves, the current review
aimed to assess mindfulness from the historical, empirical and theoretical viewpoints. It has been
shown that there exists evidence across many studies and empirical meta-analyses for the efficacy
of mindfulness in treating a range of physiological and psychological conditions, particularly
depression. Further, although there are a rich variety of conceptual models describing the
mindfulness efficacy mechanisms involved, there is no consensus yet in the literature. However,
this paper has acknowledged that there is a strong body of opinion which questions the overall
validity of the mindfulness approach to therapeutic intervention and points to the need for more
rigorous methodology in future [82, 84].
Nevertheless, it has been shown here that a number of themes are emerging regarding, for
example, types of meditation (focused attention versus open monitoring) and types of awareness
(meta-cognitive awareness and cognitive disidentification). This paper has presented a tripartite
model of the human psyche comprising: 1) the sub-selves which are responsible for the constant
‘mindchatter’ that clutter one’s mind, 2) the intra-self (one’s managing ego) which engages in
active mindfulness works to manage the ongoing chaos of one’s mind on a daily basis, and 3) the
supra-self (one’s inner observer) which engages in passive mindfulness to neutrally monitor all of
one’s mental activity without offering any judgment or control. The present binary model posits
that both active mindfulness and passive mindfulness need to be accessed in order to gain the
maximum benefit in managing depression. The various cognitive techniques which are becoming
accepted in psychological practice [103], are accessible to the intra-self (managing ego) via active
mindfulness (see Figure 1). But potentially the most effective efficacy mechanism in the case of
depression is existential disidentification which helps a depression sufferer to re-define their sense
of self-identity so that they can avoid interpreting everything in their lives as confirming their
depressive existence. This is the key hypothesis that needs to be tested in future research on the
proposed binary model of mindfulness by comparing the outcomes for depression sufferers
randomly assigned to different conditions of 8-week MBCT training.
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The University of the Sunshine Coast (Australia) supported this research by providing full access
to their library and database resources.
Author Contributions
The author is solely responsible for the writing, revising and approving of this manuscript for
Competing Interests
The author has declared that no competing interests exist in this work.
1. Pollitt J. Suggestions for a physiological classification of depression. Br J Psychiatry. 1965; 111:
2. World Health Organization. Factsheets Depression. 2018, 29 April; Available from:
3. American Psychiatric Association. What is depression? 2018, 11 June; Available from:
4. Wood J. Antidepressant use up 400 percent in US. PsychCentral. 2011, 30 October; Available
5. Kuyken W, Hayes R, Barrett B, Byng R, Dalgleish T, Kessler D, et al. Effectiveness and cost-
effectiveness of mindfulness-based cognitive therapy compared with maintenance
antidepressant treatment in the prevention of depressive relapse or recurrent (PREVENT): a
randomised controlled trial. Lancet. 2015; 386: 63-73.
6. Reimann D, Hertenstein E, Schramm E. Mindfulness-based cognitive therapy for depression.
Lancet. 2016; 387: 1054.
7. Kabat-Zinn J. Some reflections on the origins of MBSR, skillful means, and the trouble with
maps. Contemp Buddhism. 2011; 12: 281-306.
8. Kabat-Zinn J. Wherever you go, there you are: Mindfulness meditation in everyday life, New
York NY: Hyperion, 1994.
9. Kabat-Zinn J. Full catastrophe living: Using the wisdom of your body and mind to face stress,
pain and illness. New York NY: Bantam Dell; 1990.
10. Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health
benefits: A meta-analysis. J Psychosom Res. 2004; 57: 35-43.
11. Mackenzie MB, Kocovski NL. Mindfulness-based cognitive therapy for depression: trends and
developments. Psychol Res Behav Manag. 2016; 9: 125-132.
12. Mason O, Hargreaves I. A qualitative study of mindfulness-based cognitive therapy for
depression. Br J Med Psychol. 2001; 74: 197-212.
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 23/28
13. Blanck P, Perleth S, Heidenreich T, Kroger P, Ditzen B, Bents H, et al. Effects of mindfulness
exercises as stand-alone intervention on symptoms of anxiety and depression: Systematic
review and meta-analysis. Behav Res Ther. 2018; 102: 25-35.
14. Lo HH, Ng SM, Chan CL, Lam KF, Lau BH. The Chinese medicine construct ‘stagnation’ in mind-
body connection mediates the effects of mindfulness training on depression and anxiety.
Complement Ther Med. 2013; 1: 348-57.
15. Lahera G, Bayon C, Fe Bravo-Ortiz M, Rodriguez-Vega B, Barbeito S, Saenz M, et al.
Mindfulness-based cognitive therapy versus psychoeducational intervention in bipolar
outpatients with sub-threshold depressive symptoms: a randomized controlled trial. BMC
Psychiatry. 2014; 14: 215-22.
16. Ives-Deliperi VI, Howells F, Stein DJ, Mientjes EM, Horn M. The effects of mindfulness-based
cognitive therapy in patients with bipolar disorder: A controlled functional MRI investigation.
J Affect Disord. 2013; 150: 1152-1157.
17. Kabat-Zinn J. An outpatient program in behavioural medicine for chronic pain patients based
on the practice of mindfulness meditation: Theoretical considerations and preliminary results.
Gen Hosp Psychiat. 1982; 4: 33-47.
18. Hilton, L, Hempel S, Ewing B, Apaydin E, Xenakis L, Newberry S, et al. Mindfulness meditation
for chronic pain: Systematic review and meta-analysis. Ann Behav Med. 2017, 51: 199-213.
19. Fitzpatrick L, Simpson J, Smith A. A qualitative analysis of mindfulness-based cognitive therapy
(MBCT) in Parkinson’s disease. Psychol Psychother. 2010; 83: 179-192.
20. Advocat J, Russell G, Enticott J, Hassad C, Hester J, Vandenberg B. The effects of a
mindfulness-based lifestyle programme for adults with Parkinson’s disease: protocol for a
mixed methods, randomised two-group control study. BMJ Open. 2013; 3: 1-8.
21. Chan J, Clarke AC, Royan L, Stott J, Spector A. A mindfulness program manual for people with
dementia. Beh Modif. 2017; 41: 764-787.
22. Tang V, Wai SP, Kwan P. Mindfulness-based therapy for drug-resistant epilepsy: An assessor-
blinded randomized trial. Neurology. 2015; 85: 1100-1107.
23. Simpson R, Booth J, Lawrence M, Byrne S, Mair F, Mercer S. Mindfulness based interventions
in multiple sclerosis a systematic review. BMC Neurol. 2014; 14: 15-23.
24. Tavee J, Stone L. Healing the mind: Meditation and multiple sclerosis. Neurology. 2010; 75:
25. Eifring H. Meditation in Judaism, Christianity and Islam: Cultural histories. London:
Bloomsbury; 2015.
26. Eifring H. Hindu, Buddhist and Daoist Meditation: Cultural Histories. New York NY: Hermes
Academic; 2014.
27. Eifring H. Characteristics of East Asian meditation. Acta Orientalia. 2010; 71: 125-157.
28. Gunaratana BH. Mindfulness in plain English. Somerville MA: Wisdom Publications; 2002.
29. Nhat Hanh T. The Miracle of mindfulness: An introduction to the practice of meditation.
Boston MA: Beacon Press; 1975.
30. Chumley N. Mysteries of the Jesus prayer: Experiencing the presence of god and a pilgrimage
to the heart of an ancient spirituality. San Francisco CA: HarperOne; 2011.
31. Chan R. Mantra meditation as a bedside spiritual intervention. Medsurg Nurs. 2014; 23: 84-88.
32. Encyclopedia Britannica. Schism of 1054. 2018, 30 April; Available from:
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 24/28
33. Anonymous. The way of a pilgrim: And the pilgrim continues his way, 2nd ed. Pasadena CA:
Hope Publishing House; 1989.
34. Mathewes-Green F. The Jesus prayer: The ancient desert prayer that tunes the heart to god.
Orleans MA: Paraclete Press; 2009.
35. Main J. Word into silence: A manual for Christian meditation. Norwich England: Canterbury
Press; 2006.
36. Gethin, R. On some definitions of mindfulness. Contemp Buddhism. 2011; 12: 263-279.
37. Shonin E, Van Gordon W, Singh NN, eds. Buddhist foundations of mindfulness. Cham,
Switzerland: Springer International Publishing; 2015.
38. Kuan TF. Mindfulness in early Buddhism: New approaches through psychology and textual
analysis of Pali, Chinese and Sanskrit sources. London: Routledge; 2008.
39. Thera S. The way of mindfulness: The Satipatthana Sutta and its commentary. Kandy, Sri
Lanka: Buddhist Publication Society; 1967, 1949, 1941.
40. N namoli B. Mindfulness of breathing (Anapanasati). Kandy, Sri Lanka: Buddhist Publication
Society; 1952.
41. Bullen L. Buddhism: A method of mind training. Bodhi Leaves No: 42. Kandy, Sri Lanka:
Buddhist Publication Society; 1965.
42. Thurman RAF. Meditation and education: India, Tibet and modern America. Teachers College
Record. 2006; 108: 1765-1774.
43. Heffernan, V. The muddled meaning of ‘mindfulness’. The New York Times Magazine. First
Words. 2015, 14 April.
44. Bodhi, B. What does mindfulness really mean? A canonical perspective. Contemp Buddhism.
2011; 12: 19-39.
45. Segal ZV, Williams JM, Teasdale JD. Mindfulness-Based Cognitive Therapy for depression: A
new approach to preventing relapse. New York, NY: Guilford Press; 2002.
46. Teasdale JD, Segal ZV, Williams MG, Ridgeway VA, Soulsby JM, Lau, MA. Prevention of
relapse/recurrence in major depression by Mindfulness-Based Cognitive Therapy. J Consult
Clin Psychol. 2000; 68: 615-623.
47. Mindfulness-Based Stress Reduction MBSR. Centre for Mindfulness, University of
Massachusetts Medical School. May 2018; Available from:
48. Harris R. Medical practitioner, psychotherapist, life coach. August 2018, Available from:
49. McCabe JA, Freidman-Wheeler DG. Mindfulness and meditation in Psychology courses.
Society for the Teaching of Psychology: Division 2 of the American Psychological Association.
Dec 2017; Available from:
50. Harris R. Mindfulness without meditation. Healthc Counsel Psychoth J. 2009; Oct: 21-24.
51. AMRA. Mindfulness journal publications by year, 1980-2017. American Mindfulness Research
Association. March 2018; Available from:
52. Fisher D. Mindfulness and the cessation of suffering: An exclusive new interview with
mindfulness pioneer Jon Kabat-Zinn. October 2010; Available from:
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 25/28
53. Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-
regulation of chronic pain. J Behav Med. 1985; 8: 163-190.
54. Gotink RA, Meijboom R, Verwooij, MW, Smits M, Myriam Hunink. 8-week mindfulness-based
stress reduction induces brain changes similar to traditional long-term meditation practice A
systematic review. Brain Cogn. 2016; 108: 32-41.
55. Kabat-Zinn J. Full Catastrophe Living Summary. 2018 June; Available from:
56. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy
people: A review and meta-analysis. J Altern Complement Med. 2009; 15: 593-600.
57. Khoury B, Sharma M, Rush S, Fournier C. Mindfulness-based stress reduction for healthy
individuals: A meta-analysis. J Psychosom Res. 2015; 78: 519-528.
58. Gotink RA, Chu P, Busschbach JJV, Benson H, Fricchione L, Hunink MGM. Standardised
mindfulness-based interventions in healthcare: An overview of systematic reviews and meta-
analyses of RCTs. PLoS One. 2015; 10: 1-17.
59. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral
therapy: A review of meta-analyses. Clin Psychol Rev. 2006; 26: 17-31.
60. A mindful way through depression MBCT. Centre for mindfulness, University of
Massachusetts Medical School. June 2018; Available from:
61. Dobson KS, Duzois DJA. Historical and philosophical bases of the cognitive-behavioral
therapies. In: Dobson KS ed. Handbook of Behavioral Therapies. 3rd ed. New York, NY:
Guilford Press; 2009. p. 3-38.
62. Reynolds WM, Coats KI. A comparison of cognitive-behavioral therapy and relaxation training
for the treatment of depression in adolescents. J Consult Clin Psychol. 1986; 54: 653-660.
63. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory:
Twenty-five years of evaluation. Clin Psychol Rev. 1988; 8: 77-100.
64. Chiesa A, Serretti A. Mindfulness-based cognitive therapy for psychiatric disorders: A
systematic review and meta-analysis. Psychiat Res. 2011; 187: 441-453.
65. Clarke K, Mayo-Wilson E, Kenny J, Pilling S. Can non-pharmacological interventions prevent
relapse in adults who have recovered from depression? A systematic review and meta-
analysis of randomised controlled trials. Clin Psychol Rev. 2015; 39: 58-70.
66. Kuyken W, Warren FC, Taylor RS, Whaley B, Crane C, Bondolfi G, et al. Efficacy of mindfulness-
based cognitive therapy in prevention of depressive relapse: An individual patient data meta-
analysis from randomized trials. JAMA Psychiatry. 2016; 73: 565-574.
67. Oxford Mindfulness Centre. MBCT for recurrent depression: What do we know? What does it
mean? Where to next? October 2016; Available from:
68. Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review.
Clin Psychol-Sci Pr. 2003; 10: 125-143.
69. Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, et al. Mindfulness: A
proposed operational definition. Clin Psychol-Sci Pr. 2004; 11: 230-241.
70. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods
to explore facets of mindfulness. Assessment. 2006; 13: 27-45.
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 26/28
71. Teper R, Segal ZV, Inzlicht M. Inside the mindful mind: How mindfulness enhances emotion
regulation through improvements in executive control. Curr Dir Psychol Sci. 2013; 20: 1-6.
72. Brown KW, Ryan RM, Creswell JD. Mindfulness: Theoretical foundations and evidence for its
salutary effects. Psychol Inq. 2007; 18: 211-237.
73. Gu J, Strauss C, Bond R, Cavanagh K. How do mindfulness-based cognitive therapy and
mindfulness-based stress reduction improve mental health and wellbeing? A systematic
review and meta-analysis of meditation studies. Clin Psychol Rev. 2015; 37: 1-12.
74. Garland EL, Gaylord S, Park J. The role of mindfulness in positive reappraisal. Explore (NY).
2009; 5: 37-44.
75. Van der Velden AM, Kurken W, Wattar U, Crane C, Pallesen KJ, Dahlgaard J, et al. A systematic
review of mechanisms of change in mindfulness-based cognitive therapy in the treatment of
recurrent major depressive disorder. Clin Psychol Rev. 2015; 37: 26-39.
76. Lindsay EK, Creswell JD. Mechanisms of mindfulness training: Monitor and acceptance theory
(MAT). Clin Psychol Rev. 2017; 51: 48-59.
77. Alsubaie M, Abbott R, Dunn B, Dickens C, Kell TF, Henley W, et al. Mechanisms of action in
mindfulness-based cognitive therapy (MBCT) and mindfulness-based stress reduction (MBSR)
in people with physical and/or psychological conditions: A systematic review. Clin Psychol Rev.
2017; 55: 74-91.
78. Britton WB, Davis JH, Loucks EB, Peterson B, Cullen BH, Reuter L, et al. Dismantling
Mindfulness-Based Cognitive Therapy: Creation and validation of 8-week focused attention
and open monitoring interventions within a 3-armed randomized controlled trial. Behav Res
Ther. 2018; 101: 92-107.
79. Lutz A, Slagter HA, Dunne JD, Davidson RJ. Attention regulation and monitoring in meditation.
Trends in Cognitive Sciences. 2008; 12: 163-169.
80. Hede AJ. The dynamics of mindfulness in managing emotions and stress. J Manag Devel. 2010;
22: 25-39.
81. Hede AJ. Using mindfulness to reduce the health effects of community reaction to aircraft
noise. Noise Health. 2017; 19: 165-173
82. Van Dam NT, van Vugt MK, Vago DR, Schmalzl L, Saron CD, Olendzi A, et al. Mind the hype: A
critical evaluation and prescriptive agenda for research on mindfulness and meditation.
Perspect Psychol Sci. 2018; 13: 36-61.
83. Davidson RJ, Dahl CJ. Outstanding challenges in scientific research on mindfulness and
meditation. Perspect Psychol Sci. 2018; 13: 62-65.
84. Van Dam NT, van Vugt MK, Vago DR, Schmalzl L, Saron CD, Olendzi A, et al. Reiterated
concerns and further challenges for mindfulness and meditation research: A reply to Davidson
and Dahl. Perspect Psychol Sci. 2018; 13: 66-69.
85. Cherry, K. The structural model of personality. 2017 Aug; Available from:
86. Stone H, Stone S. Embracing our selves: The voice dialogue manual. Novato CA: New World
Library; 1989.
87. Dyak M. The voice dialogue facilitator’s handbook. Seattle WA: L.I.F.E. Energy Press; 1999.
88. Tolle E. The power of now. Sydney: Hodder; 1999.
89. Deikman, AJ. The observing self. Boston MA: Beacon Press; 1982.
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 27/28
90. Aronson J, Blanton H, Cooper J. From dissonance to disidentification: Selectivity in the self-
affirmation process. J Pers Soc Psychol. 1995; 68: 986-996.
91. Kanter JW, Busch AM, Weeks CE, Landes SJ. The nature of clinical depression: Symptoms,
syndromes, and behavior analysis. Behav Anal. 2008; 31: 1-21.
92. Barakoti B, Jaiswal M, Adhikari B, Shyangwa PM. Depression in medical students. Kathmandu
Univ Med J. 2012; 1: 45-46.
93. Lörincz A. Hebbian constraint on the resolution of the Homunculus Fallacy leads to a network
that searches for hidden cause-effect relationships. Second conference on artificial general
intelligence. Arlington VA: AGI-09; 2009, March.
94. Martin JR. Mindfulness: A proposed common factor. J Psychother Integr. 1997; 7: 291-312.
95. Speeth KR. On psychotherapeutic attention. J Transpers Psychol. 1982; 14: 141-160.
96. Bernstein A, Hadash Y, Lichtash Y, Tanay G, Shepherd K, Fresco DM. Decentering and related
constructs: A critical review and metacognitive processes model. Perspect Psychol Sci. 2015;
10: 599-617.
97. Hollon SD, Kendall PC. Cognitive self-statements in depression: Development of an automatic
thoughts questionnaire. Cogn Ther Res. 1980; 4: 383395.
98. Jasinskaja-Lahti I, Liebkind K, Solheim E. To identify or not to identify? National
disidentification as an alternative reaction to perceived ethnic discrimination. Appl Psychol.
2009; 58: 105-128.
99. Matsuda A, Hayes SC, Sackett CF, Twohig MP. Cognitive defusion and self-relevant negative
thoughts: examining the impact of a ninety year old technique. Behav Res Ther. 2004; 42:
100. Larsson A, Hooper N, Osborne LA, Bennett P, McHugh L. Using brief cognitive restructuring
and cognitive defusion techniques to cope with negative thoughts. Behav Modif. 2015; 40:
101. Naragon-Gainey K, DeMarree KG. Structure and validity of measures of decentering and
defusion. Psychol Assess. 2017; 29: 935-954.
102. Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV. Metacognitive awareness
and prevention of relapse in depression: Empirical evidence. J Consult Clin Psychol. 2002; 70:
103. Teasdale J, Williams M, Segal Z. The mindful way workbook: An 8-week program to free
yourself from depression and emotional distress. New York NY: The Guilford Press; 2014.
OBM Integrative and Complementary Medicine 2018; 3(4), doi:10.21926/obm.icm.1804037
Page 28/28
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... pre-) session pain scores on a 0-10 VAS scale decreased among 85% of those who received the intervention, and 96% reported decreased post-session pain scores when presession scores were >5; furthermore, median pain scores decreased by 40%, more so for older than younger children [36]. Our working hypothesis is that this intervention may reduce pain and cortisol levels through active engagement of intrinsic and extrinsic cognition/affective processing, compared with more passive and self-focused interactions [55]. Specifically, this therapist-assisted VR intervention led the OUD patient to modify his/her own internal psychobiological state and to believe that his/her success in this regard was also helping others (i.e., children with cancer). ...
Objective: Standard-of-care for opioid use disorder (OUD) includes medication and counseling. However, there is an unmet need for complementary approaches to treat OUD patients coping with pain; furthermore, few studies have probed neurobiological features of pain or its management during OUD treatment. This preliminary study examines neurobiological and behavioral effects of a virtual reality-based meditative intervention in patients undergoing methadone maintenance treatment (MMT). Design: Prospective, non-blinded, single-arm, 12-week intervention with standardized assessments. Setting: Academic research laboratory affiliated with an on-site MMT clinic. Methods: Fifteen (11 female) MMT patients completed a virtual reality, therapist-guided meditative intervention that included breathing and relaxation exercises; sessions were scheduled twice weekly. Assessments included functional magnetic resonance imaging (fMRI) of pain neuromatrix activation and connectivity (pre- and post-intervention), saliva cortisol and C-reactive protein (CRP) at baseline and weeks 4, 8 and 12; and self-reported pain and affective symptoms before and after each intervention session. Results: After each intervention session (relative to pre-session), ratings of pain, opioid craving, anxiety and depression (but not anger) decreased. Saliva cortisol (but not CRP) levels decreased from pre- to post-session. From pre- to post-intervention fMRI assessments, pain task-related left postcentral gyrus (PCG) activation decreased. At baseline, PCG showed positive connectivity with other regions of the pain neuromatrix, but this pattern changed post-intervention. Conclusions: These preliminary findings demonstrate feasibility, therapeutic promise, and brain basis of a meditative intervention for OUD patients undergoing MMT.
... With the inclusion of 16 randomised controlled trials that utilised MBSR, MBCT, or their variations, this review found evidence supporting the treatment efficacy for depressive symptoms. To explain the dynamics of mindfulness in managing depression, Hede [13] proposed a binary model centred on the two modes of mindfulness (active and passive) with a tripartite human psyche ("sub-self", "intra-self", and "supra-self") as the posited underpinning of selves. A combination of both cognitive decentring with active mindfulness to manage cognitive dysfunction and existential dis-identification with passive mindfulness to manage distorted selfidentity was shown to help reduce the effects of depression. ...
Full-text available
The aim of this article is threefold: It attempts to 1) identify the characteristics of East Asian forms of meditation, as compared to meditation in other parts of the Eurasian continent; 2) test the usefulness of a definition of meditation as a self-administered technique for inner transformation; and 3) test the usefulness of a classification of meditation techniques based on generic features of the meditation object, in particular location (external vs. internal), agency (spontaneous vs. produced), and faculty (cognitive vs. sensory). While the variation among East Asian forms of meditation is considerable, they (along with Indic forms) are often more technical and less consistently devotional than their Western counterparts, and less often sound-based than their Indic counterparts. In a number of ways, both the definition and classification system suggested turn out to be helpful in the analysis of East Asian forms of meditation.
Full-text available
Aim This paper investigates whether mindfulness-based interventions might ameliorate the detrimental health effects of aircraft noise on residential communities. Review Numerous empirical studies over the past 50 years have demonstrated the increasing negative impact of aircraft noise on residents worldwide. However, extensive database searches have revealed no published studies on psychological interventions that reduce residents’ reactivity to environmental noise. By contrast, there has been extensive research over several decades confirming the effectiveness of mindfulness-based stress reduction training in lowering people’s stress from work and life. Considering that stress is a major component of aircraft noise reaction, it would seem worth assessing whether mindfulness-based interventions might be effective in reducing the health effects of aircraft noise. It appears that no existing conceptualization of mindfulness specifically accounts for noise as a stressor. Conceptual Analysis A new conceptual model is presented here which explains how mindfulness can reduce noise reactivity. Two types of mindfulness are distinguished: an active form (meta-mindfulness) and a passive form (supra-mindfulness). It is posited that meta-mindfulness can facilitate “cognitive defusion” which research has confirmed as enabling people to disconnect from their own dysfunctional thoughts. In the case of aircraft noise, negative thinking associated with residents’ reactive experiences can exacerbate the health effects they suffer. The present model further proposes that supra-mindfulness can enable an individual to disengage their own sense of identity from the often overwhelming negative thoughts which can define their existence when they are consumed by extreme noise annoyance. Conclusion The mindfulness processes of defusion and disidentification are postulated to be the key efficacy mechanisms potentially responsible for reducing reactivity to aircraft noise. This approach can be evaluated by extending previous research on the health benefits of mindfulness training.
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Despite evidence linking trait mindfulness and mindfulness training with a broad range of effects, still little is known about its underlying active mechanisms. Mindfulness is commonly defined as (1) the ongoing monitoring of present-moment experience (2) with an orientation of acceptance. Building on conceptual, clinical, and empirical work, we describe a testable theoretical account to help explain mindfulness effects on cognition, affect, stress, and health outcomes. Specifically, Monitor and Acceptance Theory (MAT) posits that (1), by enhancing awareness of one's experiences, the skill of attention monitoring explains how mindfulness improves cognitive functioning outcomes, yet this same skill can increase affective reactivity. Second (2), by modifying one's relation to monitored experience, acceptance is necessary for reducing affective reactivity, such that attention monitoring and acceptance skills together explain how mindfulness improves negative affectivity, stress, and stress-related health outcomes. We discuss how MAT contributes to mindfulness science, suggest plausible alternatives to the account, and offer specific predictions for future research.
Mindfulness-based interventions (MBIs) are currently well established in psychotherapy with meta-analyses demonstrating their efficacy. In these multifaceted interventions, the concrete performance of mindfulness exercises is typically integrated in a larger therapeutic framework. Thus, it is unclear whether stand-alone mindfulness exercises (SAMs) without such a framework are beneficial, as well. Therefore, we conducted a systematic review and meta-analysis regarding the effects of SAMs on symptoms of anxiety and depression. Systematic searching of electronic databases resulted in 18 eligible studies (n = 1150) for meta-analyses. After exclusion of one outlier SAMs had small to medium effects on anxiety (SMD = 0.39; CI: 0.22, 0.56; PI: 0.07, 0.70; p < .001, I2 = 18.90%) and on depression (SMD = 0.41; CI: 0.19, 0.64; PI: -0.05, 0.88; p < .001; I2 = 33.43%), when compared with controls. Summary effect estimates decreased, but remained significant when corrected for potential publication bias. This is the first meta-analysis to show that the mere, regular performance of mindfulness exercises is beneficial, even without being integrated in larger therapeutic frameworks.
Van Dam et al. raise a number of critical issues in contemporary research on mindfulness and meditation and offer a prescriptive agenda for future work in this area. While we agree with all of the key points made in their article, there are a number of important issues omitted that are central to a comprehensive agenda for future research in this area. This commentary highlights five key points: (a) Many of the key methodological issues the article raises are not specific to research on mindfulness; (b) contemplative practices are varied, and the landscape of modern scientific research has evolved to focus almost exclusively on one or two types of practice to the exclusion of other forms of practice that are potentially highly impactful; (c) mindfulness and related contemplative practices were not originally developed to treat disease; (d) key issues of duration, intensity and spacing of practice, and the extent to which formal meditation practice is required or whether practice can be piggybacked onto other non–cognitively demanding activities of daily living (e.g., commuting) remain as among the most important practical questions for disseminating these practices more widely, yet have received scant serious research attention; and (e) the use of mobile technology in both disseminating contemplative training and assessing its impact is going to be required to solve some of the key methodological challenges in this area including standardizing training across sites and addressing individual differences (which will require very large-N studies).
Background: While mindfulness-based interventions (MBIs) employ two distinct practices, focused attention (FA) and open monitoring (OM), the integrated delivery of these practices in MBIs precludes understanding of their practice-specific effects or mechanisms of action. The purpose of this study is to isolate hypothesized active ingredients and practice-specific mechanistic target engagement by creating structurally equivalent interventions that differ only by the active ingredient (meditation practice) offered and to test whether the hypothesized components differentially engage the mechanistic targets that they are purported to engage. Methods: Participants were intended to be representative of American meditators and had mild to severe affective disturbances. Measures of structural equivalence included participant-level (sample characteristics), treatment-level (program structure and duration, program materials, class size, attendance, homework compliance, etc.), and instructor-level variables (training, ratings and adherence/fidelity). Measures of differential validity included analysis of program materials and verification of differential mechanistic target engagement (cognitive and affective skills and beliefs about meditation acquired by participants after the 8-week training). Results: The results indicate successful creation of structurally equivalent FA and OM programs that were matched on participant-level, treatment-level, and instructor-level variables. The interventions also differed as expected with respect to program materials as well as mechanistic targets engaged (skills and beliefs acquired). Conclusions: These validated 8-week FA and OM training programs can be applied in future research to assess practice-specific effects of meditation.
This article describes a 10-session group-based Mindfulness Program for people with mild to moderate dementia. It aims to equip people with dementia with skills to manage psychological distress, with support from carers. The Mindfulness Program was developed through reviews of existing literature, consultation with experts, and a focus group with people with dementia. In a randomized controlled feasibility and pilot trial with people with mild to moderate dementia in care homes, it was found to significantly increase quality of life. The manual presented here is designed to be administered flexibly to promote participants' personhood. The protocol is designed for use by therapists with experience in practicing mindfulness meditation.
Background: Recently, there has been an increased interest in studying the effects of mindfulness-based interventions for people with psychological and physical problems. However, the mechanisms of action in these interventions that lead to beneficial physical and psychological outcomes have yet to be clearly identified. Purpose: The aim of this paper is to review, systematically, the evidence to date on the mechanisms of action in mindfulness interventions in populations with physical and/or psychological conditions. Method: Searches of seven databases (PsycINFO, Medline (Ovid), Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, AMED, were undertaken in June 2014 and July 2015. We evaluated to what extent the studies we identified met the criteria suggested by Kazdin for establishing mechanisms of action within a psychological treatment (2007, 2009). Results: We identified four trials examining mechanisms of mindfulness interventions in those with comorbid psychological and physical health problems and 14 in those with psychological conditions. These studies examined a diverse range of potential mechanisms, including mindfulness and rumination. Of these candidate mechanisms, the most consistent finding was that greater self-reported change in mindfulness mediated superior clinical outcomes. However, very few studies fully met the Kazdin criteria for examining treatment mechanisms. Conclusion: There was evidence that global changes in mindfulness are linked to better outcomes. This evidence pertained more to interventions targeting psychological rather than physical health conditions. While there is promising evidence that MBCT/MBSR intervention effects are mediated by hypothesised mechanisms, there is a lack of methodological rigour in the field of testing mechanisms of action for both MBCT and MBSR, which precludes definitive conclusions.
Defusion and decentering are related constructs that describe an objective, distanced, and open approach toward one's internal experiences. These constructs are thought to play important protective roles in models of psychopathology, and several common therapeutic interventions include techniques to increase levels of defusion and decentering. However, little research has examined the construct validity or the underlying structure of measures of these constructs. Across 4 samples-3 unselected student samples and 1 clinical sample-we examined 5 self-report measures of defusion/decentering. We found that measures of decentering and defusion were only weakly to modestly associated with each other. Item-level analyses revealed a 2-factor structure, consisting of "Observer Perspective" and "Reduced Struggle with Inner Experience," which generally showed expected and distinct patterns of convergent and discriminant validity, although the latter factor had questionable discriminant validity namely a-namely indices of psychological distress (e.g., neuroticism, negative affect, internalizing symptoms, rumination). The factors also related differently to believability of positive versus negative thoughts, which was partially explained by the overrepresentation of negative items in the measures. Implications for the structure and validity of these constructs, as well as for their assessment and use in clinical settings, are discussed. (PsycINFO Database Record