ArticlePDF AvailableLiterature Review

Doing no harm in mindfulness-based programs: Conceptual issues and empirical findings

July 2019
Clinical Psychology Review 71

DOI:10.1016/j.cpr.2019.01.001

License
CC BY 4.0

Authors:

Ruth Baer

University of Oxford

Catherine Crane

University of Oxford

Edward Miller

University of Auckland

Willem Kuyken

University of Oxford

The benefits of empirically supported mindfulness-based programs (MBPs) are well documented, but the potential for harm has not been comprehensively studied. The available literature, although too small for a systematic review, suggests that the question of harm in MBPs needs careful attention. We argue that greater conceptual clarity will facilitate more systematic research and enable interpretation of existing findings. After summarizing how mindfulness, mindfulness practices, and MBPs are defined in the evidence-based context, we examine how harm is understood and studied in related approaches to physical or psychological health and wellbeing, including psychotherapy, pharmacotherapy, and physical exercise. We also review research on harmful effects of meditation in contemplative traditions. These bodies of literature provide helpful parallels for understanding potential harm in MBPs and suggest three interrelated types of factors that may contribute to harm and require further study: program-related factors, participant-related factors, and clinician- or teacher-related factors. We discuss conceptual issues and empirical findings related to these factors and end with recommendations for future research and for protecting participants in MBPs from harm.

Sources of harm in related approaches to health and wellbeing.

…

Figures - available via license: Creative Commons Attribution 4.0 International

Content may be subject to copyright.

Available via license: CC BY 4.0

Content may be subject to copyright.

Contents lists available at ScienceDirect

Clinical Psychology Review

journal homepage: www.elsevier.com/locate/clinpsychrev

Review

Doing no harm in mindfulness-based programs: Conceptual issues and

empirical ﬁndings

Ruth Baer

a,⁎

, Catherine Crane

, Edward Miller

, Willem Kuyken

University of Kentucky, USA

University of Oxford, UK

HIGHLIGHTS

•Potential harmful outcomes of mindfulness-based programs are under-researched.

•Harm occurs in psychotherapy, pharmacotherapy, physical exercise, and meditation.

•Potential harm may be related to participant, program, and instructor factors.

•Mindfulness practice can be unpleasant and challenging without causing harm.

•Understanding of harm in mindfulness programs requires monitoring individual data.

ARTICLE INFO

Keywords:

Mindfulness

Mindfulness-based programs

Harm

Adverse outcomes

ABSTRACT

The beneﬁts of empirically supported mindfulness-based programs (MBPs) are well documented, but the po-

tential for harm has not been comprehensively studied. The available literature, although too small for a sys-

tematic review, suggests that the question of harm in MBPs needs careful attention. We argue that greater

conceptual clarity will facilitate more systematic research and enable interpretation of existing ﬁndings. After

summarizing how mindfulness, mindfulness practices, and MBPs are deﬁned in the evidence-based context, we

examine how harm is understood and studied in related approaches to physical or psychological health and

wellbeing, including psychotherapy, pharmacotherapy, and physical exercise. We also review research on

harmful eﬀects of meditation in contemplative traditions. These bodies of literature provide helpful parallels for

understanding potential harm in MBPs and suggest three interrelated types of factors that may contribute to

harm and require further study: program-related factors, participant-related factors, and clinician- or teacher-

related factors. We discuss conceptual issues and empirical ﬁndings related to these factors and end with re-

commendations for future research and for protecting participants in MBPs from harm.

1. Introduction

Empirically supported mindfulness-based programs (MBPs) such as

mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990) and

mindfulness-based cognitive therapy (MBCT; Segal, Williams, &

Teasdale, 2013) are widely used in healthcare, educational, and

workplace settings. Meta-analytic reviews have found MBSR, MBCT,

and closely related programs to have beneﬁcial eﬀects on a range of

outcomes (Gotink et al., 2015). These include psychological disorders,

stress, and coping with illness and pain (Khoury et al., 2013); positive

moods and compassion for self and others (Khoury, Sharma, Rush, &

Fournier, 2015); and some forms of attention and memory (Chiesa,

Calati, & Serretti, 2011). Measurable eﬀects on neural structures and

systems have been documented (Tang, Hölzel, & Posner, 2015) and

eﬀects on blood pressure and immune function have been seen in some

populations (Carlson, Speca, Faris, & Patel, 2007;Nyklíček,

Mommersteeg, Van Beugen, Ramakers, & Van Boxtel, 2013). Compar-

isons with other interventions suggest that MBPs produce better out-

comes than psychoeducation and support groups and comparable out-

comes to cognitive-behavioral therapy and maintenance antidepressant

medication (Goldberg et al., 2018;Kuyken et al., 2016).

Although the beneﬁts of MBPs are well supported, less attention has

been paid to potential harm. The study of harm in MBPs is essential for

several reasons. First, any intervention powerful enough to have sub-

stantial beneﬁts might also cause harm (Dimidjian & Hollon, 2010). In

health-related professions, prevention of harm is the primary ethical

https://doi.org/10.1016/j.cpr.2019.01.001

Received 23 March 2018; Received in revised form 8 December 2018; Accepted 4 January 2019

⁎

Corresponding author at: Department of Psychology, University of Kentucky, USA.

E-mail address: rbaer@email.uky.edu (R. Baer).

Clinical Psychology Review 71 (2019) 101–114

Available online 07 January 2019

(http://creativecommons.org/licenses/BY/4.0/).

duty and requires knowledge of harms that might occur and how to

mitigate them. Second, psychotherapy researchers have long re-

cognized that the study of harmful outcomes can lead to improved

treatment methods (Dimidjian & Hollon, 2011;Mohr, 1995); the same

is likely true for MBPs. Third, meditation as practiced in Buddhist tra-

ditions (e.g., Vipassana, Zen), can elicit challenging and diﬃcult ex-

periences, some of which can be serious and long lasting (Lindahl,

Fisher, Cooper, Rosen, & Britton, 2017). It is therefore essential to ask

whether similar eﬀects might arise in evidence-based MBPs. Finally,

popular media articles about “mindfulness” (often not clearly deﬁned)

sometimes suggest that it can be harmful (Foster, 2016). The scientiﬁc

literature does not yet provide suﬃcient understanding of harm in

MBPs to inform evidence-based perspectives on such articles. Thus,

both the research literature and the public interest seem to require more

systematic study of the potential for harm in MBPs.

In this paper, we discuss conceptual and empirical work from the

scientiﬁc literature on mindfulness and related topics that bears on how

to understand and investigate the harm that might arise for participants

in evidence-based MBPs. Although too small for a systematic review,

the literature suggests that the question of harm in MBPs needs careful

attention, including greater conceptual clarity to facilitate more sys-

tematic research and interpretation of extant ﬁndings. After summar-

izing how mindfulness, mindfulness practices, and MBPs are deﬁned in

the evidence-based context, we examine how harm is understood and

studied in related approaches to health and wellbeing, including psy-

chotherapy, pharmacotherapy, and physical exercise. We also review

research on harmful eﬀects of meditation in contemplative traditions.

These diverse bodies of literature provide helpful parallels for under-

standing potential harm in MBPs and suggest three types of factors that

may contribute to harm: program-related factors, participant-related

factors, and clinician- or teacher-related factors. We discuss empirical

ﬁndings and conceptual issues related to these factors and end with

recommendations for future research and for protecting participants in

MBPs from harm.

2. Deﬁning mindfulness, mindfulness practices, and MBPs in the

evidence-based context

Evidence-based MBPs include ideas and practices adapted from

Buddhist traditions. Although discussion continues about the relation-

ship between the secular and the religious in MBPs (Brown, 2016;

Compson, 2017), most are transparent about the Buddhist roots of

mindfulness while aiming to be suitable for mainstream settings, ac-

cessible to diverse participants, and researchable within scientiﬁc dis-

ciplines related to health and wellbeing (Crane et al., 2017). To serve

these aims, central ideas and practices in MBPs are conceptualized

using contemporary scientiﬁc and discipline-speciﬁc language (Baer,

2011).

2.1. Mindfulness

In the scientiﬁc literature, mindfulness is usually deﬁned as a form

of present-moment attention and awareness that includes two elements:

the attention itself and the qualities of the attention (sometimes de-

scribed as the what and the how of mindfulness). Examples shown in

Table 1 indicate that mindfulness is understood to be open, nonjudg-

mental, friendly, curious, accepting, compassionate, and kind. Mind-

fulness can be further conceptualized as a state in which these qualities

of awareness are present, as a dispositional or trait-like general ten-

dency to pay attention in these ways, and as a set of skills that develop

with practice (Brown, 2016;Linehan, 1993). In all three of these forms,

mindfulness has been shown to be correlated negatively with mala-

daptive psychological processes and positively with health and well-

being (Levin, Hildebrandt, Lillis, & Hayes, 2012;Khoury et al., 2013;

Quaglia et al., 2016).

2.2. Mindfulness practices

In evidence-based MBPs, mindfulness practices are exercises that

cultivate the what and how elements of mindfulness. In most practices,

participants are invited to focus their attention on present-moment

phenomena, to notice when the mind wanders and return to the in-

tended focus, and to bring an attitude of friendly curiosity and non-

judgmental acceptance to whatever is observed. In informal practices,

these skills are applied to routine activities such as eating, walking and

washing dishes. In formal practices, time is devoted solely to cultivating

these skills. Some formal practices, such as sitting meditation, have

roots in Buddhist traditions but are adapted for mainstream settings.

Other practices were developed for more speciﬁc contemporary pur-

poses. For example, in mindfulness-based childbirth and parenting

(MBCP; Veringa et al., 2016), participants hold ice cubes for 60 s (the

average length of a contraction) while attending mindfully to their

breath and the sensations in their hands. This practice is intended to

reduce the fear and stress associated with childbirth by teaching a new

way of being present with sensations of pain.

2.3. Mindfulness-based programs

MBPs integrate theories and practices from contemplative traditions

with the scientiﬁc disciplines of psychology, medicine, and education

(Crane et al., 2017). They are based on a model of human experience

that places ways of relating and responding to distress (rather than the

distress itself) at the core of many problems and disorders. Through

intensive training in formal and informal mindfulness practices and

related exercises, MBPs teach a new relationship with present-moment

experience based on approach (rather than avoidance), compassion,

and decentering. The learning process is highly experiential. Mind-

fulness practices are followed by an interactive process known as in-

quiry that helps participants learn to identify their thoughts, emotions,

and sensations, recognize habitual patterns of reacting to them, and

respond with greater awareness and ﬂexibility. Intended outcomes in-

clude attentional, emotional, and behavioral self-regulation as well as

equanimity, compassion, and wisdom.

The ﬁrst MBP to appear in the research literature was MBSR (Kabat-

Zinn, 1982), an 8-week group program for adults with stress, pain, and

health concerns. According to Kabat-Zinn (2011), one intention of

MBSR was to recontextualize mindfulness within science, medicine, 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”

(p. 288). MBSR is a skills training and psychoeducational program that

uses formal and informal mindfulness practices suitable for con-

temporary non-Buddhist settings.

In deﬁning the essential features of MBPs, Crane et al. (2017) in-

clude programs derived from or inspired by MBSR, such as MBCT,

MBCP, mindfulness-based relapse prevention (Bowen et al., 2009),

mindfulness-based eating awareness training (Kristeller, Wolever, &

Sheets, 2014), and others, but not programs such as dialectical behavior

therapy (DBT; Linehan, 2015) and acceptance and commitment therapy

(ACT; Hayes, Strosahl, & Wilson, 2012). DBT and ACT integrate

mindfulness exercises with a variety of other therapeutic strategies,

place less emphasis on formal meditation, and are generally identiﬁed

as forms of psychotherapy, whereas MBPs are often described as edu-

cational and skills training programs. For these reasons, this paper

addresses the MBSR-inspired family of MBPs but not DBT, ACT, or other

psychotherapies with mindfulness elements.

3. The study of harm in related ﬁelds

Little is known about the potential for harmful outcomes in MBPs. In

contrast, other approaches to health and wellbeing, including psy-

chotherapy, pharmacotherapy, and physical exercise, have examined

the issue in more detail. In the following sections, we summarize

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

102

research on harm in these ﬁelds and draw parallels that may be helpful

in understanding how the risk of harm from MBPs can be con-

ceptualized and studied. We also summarize recent work on the po-

tential for harm from meditation in contemplative traditions and con-

sider its applicability to the question of harm in MBPs.

3.1. Psychological treatment

Duggan, Parry, McMurran, Davidson, and Dennis (2014) deﬁne

harm as “a sustained deterioration that is caused directly by the psy-

chological intervention” (p. 2). Dimidjian and Hollon (2010) state that

harmful psychological treatments are damaging and injurious and cause

worse outcomes than would have occurred without treatment. The

potential for psychotherapy to cause harm has been recognized for

many years (Bergin, 1966). Large scale studies and reviews have con-

sistently concluded that between 3% and 10% of psychotherapy clients

get worse with treatment (Lambert, 2013;Mohr, 1995;Strupp, Hadley,

& Gomez-Schwartz, 1977). For example, in a sample of over 6000

psychotherapy clients in the US, Hansen, Lambert, and Forman (2002)

found that 8.2% showed reliable deterioration on a well-validated

outcome questionnaire. Crawford et al. (2016) surveyed over 75,000

recipients of psychological treatment through the National Health

Service in England and Wales and found that, of the 14,587 who re-

turned the survey, 763 (5.23%) agreed (slightly or strongly) that they

had experienced “lasting bad eﬀects from the treatment.”

Harm in psychotherapy can take many forms. The target problem

may get worse or a new problem may arise while the target problem

improves or remains unchanged (Dimidjian & Hollon, 2010). Linden

(2013) proposed deﬁnitions for several unwanted outcomes of psy-

chotherapy including adverse reactions (unwanted events caused by the

treatment), side eﬀects (unwanted events caused by an eﬀective treat-

ment), malpractice eﬀects (unwanted events caused by inappropriate

treatment), and contra-indications (serious side eﬀects rendering a

treatment inappropriate for some people). Linden and Schermuly-

Haupt (2014) further noted that unwanted events can be mild (no

consequences), moderate (distressing), severe (in need of counter-

measures), very severe (lasting negative consequences), or extremely

severe (hospitalization required or life threatening). Mild-to-moderate

events should be understood and avoided when possible but do not

appear to meet deﬁnitions of harm, whereas events higher in the scale

are clearly harmful.

When deterioration over a course of therapy is observed, its causes

may not be clear. In some cases, the deterioration might not be attri-

butable to the treatment, which may be inert or may slow but not re-

verse an ongoing worsening of symptoms. Even so, Lambert (2013)

noted that when deterioration is monitored in controlled studies, it is

often worse in treatment groups than in no-treatment controls, sug-

gesting that aspects of treatment may be responsible. Empirical work on

harm in psychotherapy has examined three types of variables that are

correlated with negative outcomes: client, therapist, and treatment

variables.

Client variables related to negative outcomes include severity of

symptoms, poor interpersonal skills (Mohr, 1995), diagnostic co-

morbidity, severe stressors (Dimidjian & Hollon, 2011), and demo-

graphic variables. Crawford et al. (2016) found that clients older than

65 years were less likely to report negative eﬀects whereas sexual and

ethnic minorities were more likely to report them. Therapist variables

include lack of skill in conducting an eﬀective therapy (Lilienfeld,

2007), lack of empathy, underestimating the severity of the client's

problems, and poor communication about the process and content of

therapy (Crawford et al., 2016;Mohr, 1995). Treatments themselves

can also be harmful. Lilienfeld (2007) identiﬁed therapies shown in

randomized trials to produce worse outcomes than comparison groups.

For example, critical incident stress debrieﬁng can worsen symptoms of

post-traumatic stress (Litz, Gray, Bryant, & Adler, 2002), perhaps by

interfering with natural processes of recovery. Boot-camp approaches to

conduct problems in adolescents may cause increases in criminal be-

haviour (Weiss, Wilson, & Whitemarsh, 2005.

3.2. Pharmacotherapy

Adverse drug reactions (ADRs) are deﬁned as appreciably harmful

or unpleasant reactions to medications (Aronson & Ferner, 2005) re-

sulting from error, misuse, and oﬀ-label use, as well as authorised use in

normal doses (Coleman & Pontefract, 2016). ADRs are occasionally

fatal and often uncomfortable, costly, and damaging to the patient-

prescriber relationship. Incidence of ADRs has been estimated at 5–10%

of hospitalized patients (Lazarou, Pomeranz, & Corey, 1998). The three

types of variables related to harm in psychotherapy are also recognized

in pharmacotherapy. Patient factors and drug factors are often dis-

cussed in terms of pharmacokinetics and pharmacodynamics, or “what

the body does to the drug” and “what the drug does to the body”

(Meibohm & Derendorf, 1997, p. 401). Pharmacokinetics includes how

the body absorbs, distributes, metabolizes, and excretes the drug;

pharmacodynamics, are the biochemical and physiological eﬀects of the

drug on the body. Drug eﬀects, therefore, are mediated by a complex

interaction of drug factors and patient factors, including dosage and

frequency of administration, the patient's genetic proﬁle, the presence

of other drugs in the body, and tolerance to the drug.

Clinician factors are also important. Clinicians must identify pa-

tients who are likely to be susceptible to ADRs, modify the treatment

choice accordingly, and include in the treatment plan strategies for

mitigating ADRs that arise (Coleman & Pontefract, 2016). They must

explain the risks and beneﬁts of taking or not taking the drug and al-

ternative options. For patients who choose to take the drug, failure to

take it correctly can cause harm. Bosworth et al. (2011) noted that

thousands of deaths and hospitalizations each year are attributable to

medication nonadherence. A large literature suggests that clinicians can

reduce the risk of harm from nonadherence through information, ad-

vice, and counselling that increase patients' ability and willingness to

take medication as prescribed (Schulz, 2007).

Table 1

Contemporary psychological descriptions of mindfulness: what and how.

Author What How

Kabat-Zinn, 1994, 2003 Paying attention, or the awareness that arises

through paying attention

on purpose, in the present moment, and nonjudgmentally; with an aﬀectionate,

compassionate quality, a sense of openhearted, friendly presence and interest

Marlatt & Kristeller, 1999 Bringing one's complete attention to present

experiences

on a moment-to-moment basis, with an attitude of acceptance and loving-kindness

Bishop et al., 2004 Self-regulation of attention so that it is

maintained on the immediate experience

with an orientation characterized by curiosity, openness, and acceptance

Germer, Siegel, & Fulton,

2005

Awareness of present experience with acceptance: an extension of nonjudgment that adds a measure of kindness or

friendliness

Linehan, 2015 The act of focusing the mind in the present

moment

without judgment or attachment, with openness to the ﬂuidity of each moment

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

103

3.3. Physical exercise

Mindfulness is sometimes compared to physical exercise, with

analogies to training the attention through mindfulness exercises “ra-

ther in the same way that we go to a gym to train muscles” (Segal et al.,

2013, p. 97). The beneﬁts and harms of physical exercise are well re-

searched. The American College of Sports Medicine (Garber et al.,

2011) notes that the beneﬁts far outweigh the risks in most adults and

include reduced mortality from many causes, prevention of chronic

medical conditions, reductions in anxiety and mood disorders, and

improved wellbeing and quality of life (Warburton, Taunton, Bredin, &

Isserow, 2016). The most common risks are musculoskeletal, including

strains, sprains, tears, inﬂammation, and fractures. More serious risks

are cardiovascular, including arrhythmias, heart attacks, and sudden

cardiac arrest. Conn, Annest, and Gilchrist (2003) reported that 2.59%

of Americans annually receive medical attention for a sports or re-

creation-related injury. The risk of a cardiovascular event linked to

aerobic exercise varies with ﬁtness level and falls between 1 in 500,000

and 1 in 2,600,000 h of exercise (Franklin & Billecke, 2012).

As in psychotherapy, risks of physical exercise are often discussed in

terms of participant, program, and instructor factors. Participant factors

include age, health status, physical activity, and ﬁtness. Program fac-

tors include intensity of the exercise, tailoring to individual partici-

pants, screening procedures, and education about risks. Instructor fac-

tors include knowledge of the physiology of exercise, competence in

screening participants, adapting programs to individuals, and en-

couraging adherence (Garber et al., 2011). These factors interact in

interesting ways to inﬂuence risk/beneﬁt ratios. For example, the dose-

response relationship between exercise and health status is not linear.

For inactive people, small increases in exercise lead to substantial

health beneﬁts (Lollgen, Bockenhoﬀ, & Knapp, 2009). In contrast, ex-

tremely active people may experience diminishing returns for health

beneﬁts as well as cardiovascular damage (Patil et al., 2012).

Warburton et al. (2016) note that people engaged in intensive training

for “ultra-endurance events” are at increased risk for cardiovascular

disease and “should be cautioned about the perils involved” (p. 216).

3.4. Meditation in contemplative traditions

Case reports of one or a few individuals describe severe symptoms

induced by meditation, including psychosis (Kuijpers, Van der Heijden,

Tuinier, & Verhoeven, 2007), negative aﬀect (French, Schmid, &

Ingalls, 1975), mania (Yorston, 2001), depersonalization and dereali-

zation (Castillo, 1990), and traumatic memories (Miller, 1993). Such

outcomes have been associated with several types of meditation

(transcendental, Zen, mindfulness) and often occurred in the context of

intensive retreats (Lustyk, Chawla, Nolan, & Marlatt, 2009). Most of

these early studies did not address the prevalence of harmful outcomes

in meditating samples or account for pre-existing psychological diﬃ-

culties. None involved evidence-based MBPs.

Larger studies reporting percentages of meditating samples with

negative experiences are summarized in Table 2.Otis (1984) found that

4.5% - 13.5% of transcendental meditation practitioners (N= 574)

reported increases in anxiety, depression, confusion, and other symp-

toms. The more experienced meditators reported more symptoms, but

also more psychological problems prior to taking up meditation. In

long-term Vipassana practitioners (N= 27), Shapiro (1992) found that

while most reported more positive than negative eﬀects, 63% reported

at least one challenging experience such as confusion, alienation, or

negative emotion. Some described these experiences as learning op-

portunities rather than problems; however, two (7%) reported severe

eﬀects (disorientation and depression) that caused them to stop medi-

tating. In an internet survey of 342 meditation practitioners (Cebolla,

Demarzo, Martins, Soler, & Garcia-Campayo, 2017), 25.4% reported

unwanted eﬀects (UEs) including negative emotions, pain, depersona-

lization, and other symptoms. Many of these symptoms were described

as transitory, although missing data were extensive. In 1.1% of the

sample, UEs caused the person to stop meditating; 5.7% sought help

from a medical professional or therapist. Positive outcomes were not

addressed.

More detailed accounts are provided by Lomas, Cartwright,

Edginton, and Ridge (2015), who interviewed 30 male Buddhist med-

itators about the impact of meditation on their wellbeing. All were

regular practitioners of various types of meditation for durations ran-

ging from less than ﬁve to > 20 years. Three were receiving mental

health treatment at the time of the interview; 11 had done so in the

past. All described meditation as a valuable activity and conducive to

wellbeing. However, reports of substantial diﬃculties accounted for

about one quarter of the interview data and these reports became the

subject of the paper.

For example, most participants reported that meditation brought up

troubling thoughts and feelings that were hard to manage. Many stated

that depression, anxiety, and low self-esteem were exacerbated by

meditation. Six reported serious threats to their sense of reality; for

example, they felt unreal, disoriented, or alienated. The authors note

that “these episodes did not occur in relation to more conventional

practices like mindfulness or loving-kindness meditation” but arose

when “attempting advanced meditation practices while still being a

relative beginner” and doing so “without the guidance of an experi-

enced teacher and/or a supportive sangha” (p. 855). The most severe

diﬃculties were psychotic symptoms. One participant felt close to

psychosis when trying to resume normal life following a week of in-

tensive practice in isolation. Two others were hospitalized for psychotic

episodes; one of them, who was also suicidal, attributed this to medi-

tation. Five of the six who reported threats to their sense of reality

reported no mental health problems before starting meditation and four

attributed these experiences directly to the meditation practice. Despite

the diﬃculties, many of the participants said that they eventually

learned skills for managing them and came to see such experiences as

important to their wellbeing and psychological development. The au-

thors concluded that meditation can have substantial positive and ne-

gative eﬀects.

Overall, the studies in Table 2 suggest that unpleasant and diﬃcult

experiences in meditation are common. In three of the four studies,

many participants described these experiences as temporary and useful

in developing skills and insights. Quantitative data are not always

provided, making it hard to determine the prevalence of diﬃculties that

outweigh beneﬁts. However, severe and harmful eﬀects were reported,

with 1% - 7% of participants quitting meditation, seeking professional

help, or being hospitalized.

In the most detailed qualitative study to date of meditation-related

harm, Lindahl et al. (2017) interviewed 60 Western Buddhist practi-

tioners from the Zen, Theravada, and Tibetan traditions (57% male,

mean age = 49 years, all residing in North America or Europe). Parti-

cipants were eligible only if they reported diﬃcult, challenging, dis-

tressing, or impairing experiences related to their meditation practice

that could not plausibly be attributed to pre-existing psychological or

medical conditions or other factors. Thus, this study provides no in-

formation about base rates of diﬃculties in meditating samples and is

not included in Table 2. Most participants were White and held uni-

versity degrees; 60% were meditation teachers. For 72%, meditation-

related diﬃculties began during or shortly after a retreat. For 28%, they

were associated with daily practice. None had participated in evidence-

based MBPs.

Semi-structured interviews yielded 59 categories of meditation-re-

lated eﬀects that were clustered into seven domains: cognitive (change

in executive functioning, delusions), perceptual (hallucinations, dis-

tortions in time or space), aﬀective (positive or negative aﬀect), somatic

(pain, energy, sleep, movement-related), conative (motivation-related),

sense of self (self-other or self-world boundaries, sense of agency) and

social (social impairment, change in relationships). Most (73%) re-

ported moderate to severe impairment in at least one domain, 17%

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

104

reported suicidality, and 17% required inpatient hospitalization.

Median duration of impairment was 1–3 years, with a range of a few

days to > 10 years.

Analyses also yielded four types of factors potentially related to

diﬃcult meditation experiences, corresponding loosely to the three

factors identiﬁed in the previous sections (participant, program, and

clinician/instructor factors). Participant factors included psychiatric,

medical, and trauma history, motivations or goals for meditating,

worldview, and personality. Health behavior factors (which can also be

seen as participant factors) included diet, sleep, exercise, and use of

medications or recreational drugs. Practice factors included the

amount, intensity, consistency, type, and stage of practice. Relationship

factors included relationships with teachers, practice community, and

others, as well as their early life relationships. Teacher factors other

than relationship with the meditator were not discussed.

A striking ﬁnding of this study was the lack of consistency among

participants in whether speciﬁc meditation eﬀects were seen as adverse.

Many intense experiences, including aﬀect, pain, and paranoia, were

appraised in a variety of ways. The authors note that interpretive fra-

meworks in the Buddhist traditions are diverse, with diﬀerences “across

traditions, lineages, or even teachers” in whether speciﬁc meditation-

related experiences should be seen as “progress” or “pathology” (p. 25).

Diﬀerences between Buddhist and psychological or medical perspec-

tives are also evident. Experiences that seem pathological from a clin-

ical point of view (hallucinations, paranoia) might not be viewed as

harmful if understood by the practitioner and teacher as transitory

experiences that make sense within the conceptual framework of their

meditation tradition and can be managed constructively.

Participants in this study were recruited through “outlier sampling”

(p. 7) and represent the extreme adverse end of the distribution of

meditation-related eﬀects. This was intentional, as the purpose was to

study under-reported phenomena; however, it prevents conclusions

about the base rates of distressing or impairing eﬀects in the overall

population of Buddhist meditation practitioners. The extent to which

ﬁndings apply to participants in MBPs is hard to determine. Although

25% of participants who reported harm were practicing less than one

hour per day using practices similar to those in MBPs and for similar

purposes (mental health-related rather than spiritual purposes), they

may not have had the psychoeducational and structural supports typical

of MBPs (Lomas et al., 2015). We discuss these supports in more detail

in a later section.

3.5. Harm in related ﬁelds: parallels for the study of evidence-based MBPs

The literature just reviewed suggests several parallels for the study

of harm in evidence-based MBPs. First, interventions with established

beneﬁts can also cause harm. Between 3 and 10% of psychotherapy

clients get worse, 5–10% of hospitalized patients have adverse drug

reactions, a small percentage of participants in physical exercise are

injured, and an unclear percentage of meditators in contemplative

traditions experience harmful eﬀects. MBPs include meditation and are

provided in both psychotherapeutic and wellness contexts; it therefore

seems likely some participants may experience harmful outcomes.

Second, sources of potential harm in the four ﬁelds just reviewed

can be classiﬁed into three categories that may also apply to MBPs: 1)

program, treatment, or practice factors, 2) client, patient, or participant

factors, and 3) teacher, therapist, or clinician factors. Examples (not an

exhaustive list) are shown in Table 3. Although it is useful to consider

these factors separately, in many situations they probably work to-

gether. For example, some medications are hard to take correctly

(treatment factor); e.g., those that must be taken several times daily

under speciﬁc conditions. For a patient whose circumstances make this

diﬃcult or whose personality is low in conscientiousness (patient fac-

tors), help from the prescriber (clinician factor) with problem-solving

Table 2

Studies reporting percentages of meditating samples (none from MBIs) describing negative or unwanted eﬀects of meditation.

1st author, year Sample Percent reporting and types of negative eﬀects Comments

Otis, 1984 574 TM practitioners 4.5% - 13.5% reported anxiety, depression, confusion,

or other symptoms

More experienced meditators reported more negative eﬀects

and more problems prior to taking up meditation

Shapiro, 1992 27 long-term Vipassana

meditators

63% reported negative emotion, confusion, alienation,

or other symptoms

7% reported severe eﬀects (disorientation, depression)

that led them to stop meditating

Many described unpleasant experiences as temporary and as

learning opportunities

Over 80% reported positive outcomes (joy, conﬁdence,

acceptance, compassion, problem solving, resilience)

Psychiatric history not addressed

Cebolla, 2017 342 practitioners of many types of

meditation

25.4% reported unwanted events (anxiety, pain, mood

symptoms, other)

1% stopped meditating

5.7% sought professional help

Many described unwanted events as transitory

Positive eﬀects not addressed

Psychiatric history not reported

Extensive missing data

Lomas, 2015 30 male Buddhist meditators 100% described meditation as challenging (diﬃcult,

unpleasant thoughts and emotions)

25% of the interview data involved problems with

meditation

20% reported threats to sense of reality

7% hospitalized (1 suicidal)

100% described meditation as valuable and conducive to

wellbeing

Many described diﬃculties (even severe ones) as important to

their development

Table 3

Sources of harm in related approaches to health and wellbeing.

Discipline Program/intervention factors Participant factors Teacher/clinician factors

Psychotherapy theoretically unsound, interferes with natural

psychological processes, wrong treatment for

presenting problem

symptom severity, comorbidity, poor

interpersonal functioning, severe

psychosocial stressors

lack of empathy, underestimating severity of

client's problems, lack of clarity about process or

content of therapy, other lack of competence

Pharmacotherapy dosage, frequency of administration,

pharmacodynamics

genetic proﬁle, other drugs in body,

pharmacokinetics, nonadherence

lack of knowledge of drug eﬀects, lack of skills for

encouraging adherence

Physical exercise not tailored for individual, too intense, lack of

screening or education about risks

age, health status, ﬁtness level, physical

activity

lack of general competence, lack of skills for

encouraging adherence

Meditation in contemplative

traditions

amount, intensity, consistency of practice;

type or stage of practice

psychiatric, medical, or trauma history;

goals for practice, personality, health

habits, relationships

relationship with practitioner

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

105

or ﬁnding a diﬀerent medication may be necessary. An example from

psychotherapy is relaxation-induced anxiety (Ferguson & Sgambati,

2008), which may be related to fear of losing control (participant

factor) and can be addressed by trying a diﬀerent form of relaxation

(program factor) or providing enhanced explanation and guidance

(therapist factor). In both of these examples, skillful reduction of the

likelihood of harm integrates participant, program, and clinician fac-

tors. The same is likely true of MBPs.

The dose-response relationship and adherence to recommendations,

which have been studied in pharmacotherapy, physical exercise, and

psychotherapy, may also be important in evidence-based MBPs.

Whether higher doses of meditation can be harmful, within the range

recommended by MBPs, is unknown. Whether lack of adherence in

MBPs can cause harm (rather than unhelpfulness) through under- or

overdosing is also unknown. Clinician or instructor factors, such as

educating participants about rationales, risks, and beneﬁts, and tai-

loring programs for individual needs, may also be important in pre-

venting harm in MBPs.

Finally, it seems clear that many approaches to health and wellbeing

can be stressful and challenging. Eﬀective medications can have un-

pleasant side eﬀects. Physical exercise can cause soreness and fatigue.

Diﬃcult experiences in meditation are sometimes seen as learning op-

portunities or indications of progress along the meditative path.

Temporary discomfort also seems to be inevitable in psychotherapy

(Duggan et al., 2014) as participants confront painful issues, learn new

skills, and apply them in problematic situations. In the next section we

consider the important distinction between lasting harm and the dis-

comfort associated with psychological change. We focus on evidence-

based psychotherapies, where discomfort has been widely discussed,

and then consider how the issues apply to MBPs.

4. Stress and discomfort in psychological change

Many evidence-based psychological treatments include diﬃcult

activities. Behavioral experiments, for example, are designed to test

unhelpful beliefs, such as, “If I participate in conversation, I'll say stupid

things and people will reject me.” Testing these beliefs by engaging in

such behavior, even in carefully planned ways, is expected to induce

anxiety (Bennett-Levy et al., 2004). In fact, behavioral experiments that

induce too little anxiety tend to be ineﬀective because they create too

little change in clients' beliefs about what they can do. An eﬀective

behavioral experiment is a “challenge to prevailing perspectives” and

likely to seem “at least somewhat threatening” (Bennett-Levy et al.,

2004; p. 43). The same applies to exposure-based therapies. A client

with obsessive-compulsive disorder may be encouraged to touch a dirty

ﬂoor and then refrain from handwashing, a person with post-traumatic

stress to recount a traumatic experience in detail. Many clients ﬁnd

these procedures challenging.

Some mental health professionals believe that exposure-based

methods cause attrition or exacerbation of symptoms and that clients

are better oﬀ continuing with the disorder than participating in the

treatment (Becker, Zayfert, & Anderson, 2004;Richard & Gloster,

2007). These concerns are inconsistent with the strong empirical evi-

dence supporting the eﬃcacy of exposure-based therapies (Olatunji,

Deacon, & Abramowitz, 2009). Deacon and Abramowitz (2005) re-

ported that people with anxiety disorders perceive exposure-based CBT

as more acceptable than medications and more likely to be eﬀective in

the long term. Foa, Zoellner, Feeny, Hembree, and Alvarez-Conrad

(2002) found that prolonged exposure for PTSD caused temporary

worsening of symptoms in a minority of participants, but that this short-

term eﬀect did not increase the risk of attrition or reduce the beneﬁts

attained by the end of treatment.

Recommendations for avoiding harm in such treatments include: (a)

remembering that many clients are “vulnerable people whose con-

ﬁdence is readily shaken” (Bennett-Levy et al., 2004, p. 33), (b) pro-

viding a clear rationale for and explanation of the activity, (c) never

coercing a client to engage in the procedure, but encouraging the client

to collaborate in designing the exercises and make their own decisions

about participating in them, (d) using tasks that objectively are no more

risky than daily life (e.g., asking a stranger for directions may feel

terrifying to a client with severe social anxiety, but is generally not

dangerous), and (e) anticipating how the activity might go awry and

how this will be interpreted and managed. Olatunji et al. (2009) note

that the potential for discomfort makes exposure-based therapies

complex to implement and that their most substantial risk may be un-

skillful delivery by therapists with inadequate training and supervision.

4.1. Stress and discomfort in MBPs

Participation in MBPs also involves discomfort. Unwanted thoughts,

emotions, and sensations inevitably arise during practices. Segal et al.

(2013) recommend discussing these diﬃculties during a pre-class in-

terview and providing a clear rationale for how the program may help

with participants' concerns. During the course, teachers often remind

participants not to push beyond limits of safety or tolerance and suggest

ways to adapt practices if diﬃculties that feel overwhelming arise.

Within these limits, however, discomfort is generally approached

(with compassion) rather than avoided. In MBCT, a handout explains

that mindful awareness in daily life means “facing what is present, even

when it is unpleasant and diﬃcult” (p. 102) and that learning to do this

gently, with the support of the teacher and the group, is “the most ef-

fective way, in the long run, to reduce unhappiness.” To cultivate ac-

ceptance skills, several MBPs include a practice in which participants

are invited to bring a problem to mind and observe the associated

thoughts and feelings with friendly curiosity. Although no studies have

examined the eﬀects of this practice separately from the rest of the

curriculum, an extensive body of research shows the maladaptive ef-

fects of avoidance and suppression of thoughts, emotions, and sensa-

tions and the beneﬁts of accepting them as they are (Cameron &

Overall, 2018;Hayes, Wilson, Giﬀord, Follette, & Strosahl, 1996;

Kashdan & Rottenberg, 2010;Levin et al., 2012). Clinical observations

suggest that learning skills for facing diﬃculties is empowering (Sears,

2015).

4.2. Weighing the risk of discomfort against the potential for beneﬁt

In their discussion of uncomfortable but eﬀective therapies, Olatunji

et al. (2009) noted that the risks of engaging in them must be balanced

against the risks of not doing so. If alternative treatments are less ef-

fective, the risk that symptoms will continue may be worse than the

temporary discomfort caused by the treatment. The balance between

acceptable discomfort and potential beneﬁt may vary with the severity

of the participant's problems. A person with a severe disorder probably

feels much distress in daily life and may ﬁnd that diﬃcult therapeutic

exercises, though uncomfortable, are within the range of discomfort

caused by their symptoms and worthwhile in light of the likely beneﬁts.

In contrast, a psychologically healthy person who takes a mindfulness

course for personal growth and unexpectedly has an intensely un-

comfortable experience may ﬁnd the discomfort disproportionate to the

expected beneﬁts. Such discomfort may not qualify as harm, by current

deﬁnitions, if it doesn't lead to sustained deterioration. If the diﬃcult

experience is disclosed, a skilled teacher may be able to help the par-

ticipant work with it in beneﬁcial ways. On the other hand, the diﬃcult

experience may be suﬃciently distressing to qualify as an adverse

event. This term is deﬁned in the next section.

5. Harm and adverse events in MBPs: Deﬁnitions and current

ﬁndings

We suggest that the most useful deﬁnition of harm in MBPs is based

on the deﬁnitions used in psychotherapy. That is, after exposure to the

MBP (whether the participant completes it or drops out), harm has

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

106

occurred if the participant's symptoms or level of functioning are worse

than beforehand and this deterioration is sustained, attributable to the

program, and more severe than it would have been without the pro-

gram. As in psychological treatment, harm in MBPs can appear in a

variety of ways. We agree with Dimidjian and Hollon (2010) that harm

is worse than unhelpfulness. An unhelpful program confers no beneﬁt

and will not stop an ongoing process of deterioration, whereas a

harmful program makes matters worse than they would have been

otherwise.

The terms adverse events (AEs) and serious adverse events (SAEs) are

often used in healthcare research and have been adopted in some stu-

dies of MBPs. As deﬁned by the World Health Organization, an AE is an

untoward occurrence in a patient or research participant who is ad-

ministered a pharmaceutical product (Lineberry et al., 2016); an SAE is

such an event that threatens life or function (Ioannidis et al., 2004). In

behavioral health and psychotherapy trials, SAEs include events such as

suicidal behavior and psychiatric hospitalizations; AEs are less severe

changes in psychological, behavioral, or physical functioning (Peterson,

Roache, Raj, & Young-McCaughan, 2013). By deﬁnition, AEs and SAEs

are not necessarily caused by the intervention. The causes of these

events can be diﬃcult to determine. In clinical trials, AEs and SAEs are

monitored in treatment and control groups; a higher frequency in the

treatment group suggests that the treatment may be harmful.

A few trials have reported deterioration for participants in MBPs.

For example, Reynolds et al. (2017) found symptom increases in an

MBP for cancer patients. Johnson et al. (2016), in a school-based study,

reported worse post-treatment anxiety scores in the MBP than in no-

treatment for several subgroups of participants. Brooker et al. (2012), in

an uncontrolled study of work-related stress, reported mixed ﬁndings,

with deterioration on some outcome variables. These studies must be

seen in the context of meta-analyses concluding that most studies

support the beneﬁts of MBPs for these populations, including children

and adolescents (Dunning et al., 2018), cancer patients and survivors

(Piet, Würtzen, & Zachariae, 2012), and workers in various occupations

(Lomas, Medina, Ivtzan, Rupprecht, & Eiroa-Orosa, 2018).

We found four reviews addressing AEs and SAEs in MBPs; these are

summarized in Table 4.Goyal et al. (2014) reviewed 47 RCTs com-

paring a mindfulness or meditation-based program to an active control

condition. Of these, 19% (9 studies) reported on AEs; none of these

reported any harms. In a review of 12 studies of MBPs for post-trau-

matic stress, Banks, Newman, and Saleem (2015) found that two studies

did not report on AEs/SAEs, four reported that none occurred, and six

reported that some participants showed increases in symptoms that

were not clinically signiﬁcant. Collapsed across these six studies,

symptom increases occurred in 13 of 123 participants (10.6%). In two

studies, a few participants reported increased anxiety during meditation

practices but no signiﬁcant worsening of symptoms from pre- to post-

treatment. One participant reported that meditation triggered a

memory of an assault. Learning to work skilfully with such memories

was considered part of the treatment. The authors concluded that ad-

verse eﬀects in these studies were minimal.

A meta-analysis of nine RCTs of MBCT for relapse prevention in

recurrent depression (Kuyken et al., 2016) reported that four of the

trials included no data on AEs or SAEs. In the other ﬁve trials, only SAEs

were reported. Percentage of participants in whom SAEs occurred

ranged from zero (2 studies) to 5.5% (1 study) with a mean of 1.94%.

SAEs were no more common in MBCT groups than in control arms of

the trials and none were judged to be related to participation in MBCT.

These studies did not report on broader indications of harm, such as

worsening of symptoms, appearance of new symptoms, or general de-

cline in functioning or wellbeing. Finally, a systematic review of RCTs

of MBSR and MBCT (Wong, Chan, Zhang, Lee, & Tsoi, 2018) found that

195 of 231 trials (84%) did not report on AEs. When summed across the

other 36 trials, AEs occurred in 1.0% and 0.9% of participants in MBI

and control groups, respectively; these proportions were not sig-

niﬁcantly diﬀerent. The authors concluded that MBSR and MBCT

Table 4

Reviews of evidence-based MBPs that include data on adverse events.

First author, year Number and type of studies in the review Percentage of studies in the review that

reported data on AEs/SAEs

Findings for AEs/SAEs Comments

Goyal, 2014 47 RCTs comparing MBPs or other

meditation-based programs to active controls

19% None reported

Banks, 2015 12 studies (various designs) of MBPs for

PTSD

83% AEs in 10.6% of participants symptom increases not clinically signiﬁcant, anxietyduringmeditation practices did not

lead to pre-post deterioration, 1 trauma memory triggered seen as within purpose of

intervention

Kuyken, 2016 9 RCTs of MBCT for depressive relapse 56% SAEs in 1.94% of participants (range:

0 to 5.5%)

SAEs no more common in MBCT than in control groups; SAEs unrelated to participation

in MBCT

Wong, 2018 231 RCTs of MBSR or MBCT 16% AEs in 1% of MBP participants, 0.9%

of control participants

AEs no more common in MBPs than in control groups

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

107

appear to be relatively safe but strongly recommended more consistent

reporting of AEs and SAEs.

Qualitative studies of diﬃculties in MBPs suggest that they are

common but tend to be short-term. A meta-ethnography (Malpass et al.,

2012) reported that increases in participants' awareness of their mala-

daptive coping habits could feel temporarily overwhelming, that pre-

sent-moment awareness was occasionally frightening, and that mis-

taken expectations that mindfulness should rid the mind of all

depressive thoughts led to self-devaluation when this did not happen.

Despite these diﬃculties, the general pattern was a shift from mala-

daptive coping strategies to more adaptive forms of self-understanding.

Overall, ﬁndings show that when reported, AEs/SAEs have occurred

in 0 to 10.6% of participants in evidence-based MBPs. When compared

in MBPs and controls, AEs/SAEs occur at similar rates, suggesting that

they are unrelated to participation in the MBP. These ﬁndings must be

interpreted cautiously for several reasons. First, few studies have report

on AEs/SAEs. Second, AEs/SAEs are sometimes narrowly deﬁned, such

that general deterioration or the appearance of new symptoms might

not be included. Finally, although meta-analyses and qualitative studies

show strong evidence of improvement with MBPs, it remains unclear

whether group averages mask deterioration in some participants.

6. Potential sources of harm in MBPs

As noted earlier, sources of harm commonly discussed in other ap-

proaches to health and wellbeing include program factors, participant

factors, and teacher/clinician factors. In the following sections, we re-

view empirical ﬁndings and conceptual discussion of how these sources

may apply to MBPs.

6.1. Program factors

Here we address factors that have been studied or discussed in the

mindfulness literature: the importance of what and how elements of

mindfulness, the soundness of the programs' conceptual foundations,

the intensity of the mindfulness practices, and the adequacy of the

psychoeducational or structural support provided by the program.

6.1.1. What and how

Segal et al. (2013) state that mindfulness “cannot be reduced to

awareness or attention alone” and note that increased present-moment

awareness will not be helpful, and may even be harmful, unless

“friendliness and compassion can be brought to those elements of

present-moment experience to which we attend” (p. 137). In support of

this statement, several studies have found that the relationship between

present-moment awareness and adaptive functioning is moderated by

the quality of the awareness. Substance use, depression, rumination,

worry, and blood pressure have all been shown to be lower in partici-

pants who endorse high levels of present-moment awareness, but only if

the awareness is nonjudgmental or nonreactive (Desrosiers, Vine,

Curtiss, & Klemanski, 2014;Eisenlohr-Moul, Walsh, Charnigo, Lynam,

& Baer, 2012;Tomfohr, Pung, Mills, & Edwards, 2015). This work is

consistent with previous research showing that self-focused attention

(deﬁned as awareness of thoughts, emotions, and sensations) is adap-

tive when it is nonjudgmental and experiential but maladaptive when it

is judgmental and ruminative (Ingram, 1990;Mor & Winquist, 2002;

Watkins, 2008). These bodies of literature suggest that eﬀective

teaching of mindfulness must include both present-moment awareness

and its nonreactive, nonjudgmental qualities. Otherwise, increases in

awareness might lead to unintended increases in symptoms.

6.1.2. Conceptual foundations of the MPB

Crane et al. (2017) argued that without a sound theoretical for-

mulation of how mindfulness should help with a particular problem, an

MBP might be unhelpful. An interesting example to which this may

apply is insomnia. Ong, Ulmer, and Manber (2012) theorize that

mindfulness promotes decentering from insomnia-related thoughts and

feelings, equanimity and commitment to values, and reduced sleep-re-

lated arousal. This model was supported in randomized trial showing

improvements in self-reported sleep variables for people with insomnia

(Ong et al., 2014). On the other hand, Britton, Lindahl, Cahn, Davis,

and Goldman (2014) note that in Buddhist traditions, mindfulness is

described as a state of relaxed alertness that balances hyper- and hy-

poarousal. They summarize brain imaging studies suggesting that

“Buddhist meditation practices are associated with activation/en-

largement of the areas that underlie tonic alertness and/or prevent

sleep” (p. 69). A study of MBCT for people with partially remitted de-

pression and sleep disturbance (Britton, Haynes, Fridel, & Bootzin,

2010) found polysomnographic evidence of increased cortical arousal

post-MBCT that was correlated with amount of mindfulness practice,

although participants also reported better subjective sleep quality.

Britton et al. (2014) suggested that short-term, short-duration mind-

fulness practice may increase sleep propensity whereas longer-term,

higher-dose practice may lead to neurological changes producing

greater wakefulness. They did not discuss harm, but ﬁndings suggest

that intensive long-term practice might be unhelpful for people whose

goal is increased sleep. These ﬁndings highlight the necessity of a clear

understanding of how mindfulness meditation, as used in MBPs, should

be expected to improve sleep.

6.1.3. Intensity of the mindfulness practice

Though loosely analogous to intensity of physical exercise and do-

sage of medication, intensity of mindfulness practice is hard to deﬁne.

Participants in MBPs may have diﬀerent experiences of the intensity of

practice, perhaps related to previous meditation experience, the en-

vironment in which they practice, or other factors. The idea that in-

tensity of practice could be related to harm in MBPs comes most di-

rectly from Lindahl et al. (2017), who reported that for 72% of their

Buddhist practitioners, harmful eﬀects were associated with participa-

tion in residential retreats, which are often a week or more in duration

and involve many hours per day of meditation in a mostly silent en-

vironment removed from normal daily routines.

Most MBPs involve weekly group sessions and encourage up to an

hour per day of formal and informal home practice. Many also include a

mostly silent all-day session of about 6 h. Whether this level of intensity

can cause harmful outcomes is unclear. Lindahl et al. reported that 25%

of their participants who reported harm were practicing less than an

hour per day using practices similar to those in MBPs and for similar

purposes (mental health-related rather than spiritual purposes); ac-

cordingly, they argued that the harmful eﬀects they observed may also

occur in MBPs. While we agree that this possibility should be studied,

we also note that evidence-based MBPs include many psychoeduca-

tional and structural supports that may be less available in Buddhist

meditation settings where participants are practicing outside of mon-

itored interventions (Lomas et al., 2015). These supports may reduce

the potential for harm from challenging meditation experiences.

6.1.4. Psychoeducational and structural support for meditation practices

Many MBPs include a pre-course interview or information session

that helps participants anticipate and prepare for likely challenges. A

rationale for how mindfulness is expected to help with participants'

problems is often provided. Nearly all in-session practices are followed

by inquiry, when challenging experiences can be explored. Sessions also

include inquiry about home practice, when diﬃculties encountered at

home can be considered. Teachers are often available before and after

sessions for consultation. A range of practices, varying in duration and

focus, is introduced in a logical sequence in which learning builds from

week to week. Recordings to guide home practice are provided.

Sessions also include didactic information and non-meditative exercises

that supplement and support the meditation practices; many of these

speak directly to how to manage challenging experiences that arise in

meditation or at other times. Weekly handouts provide summaries of

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

108

session content and goals, rationales for the practices, descriptions of

previous participants' experiences, and worksheets for recording ob-

servations. The all-day session occurs late in the eight-week course,

allowing participants to build skills through several weeks of daily

practice and group sessions beforehand.

We identiﬁed only one example of empirical study of the eﬀects of

psychoeducational and structural supports. In a pilot trial for a study of

MBCT adapted for people at risk of suicide, Crane and Williams (2010)

found that participants who showed the greatest evidence of cognitive

vulnerabilities associated with depression and suicidality were most

likely to drop out. In the subsequent trial, the individual pre-course

interview was extended from 60 to 90 min to include more explicit,

personalised discussion of how to meet the program's likely challenges.

Use of the modiﬁed interview reduced attrition from 30% to 18%

(Williams et al., 2015), suggesting that evidence-based structural and

psychoeducational support for meditation may be helpful in high-risk

samples.

6.2. Participant factors

Table 2 suggests participant factors that could be related to the

potential for harm in MBPs. The mindfulness literature has focused

primarily on psychiatric and trauma history. Of the Buddhist medita-

tion teachers interviewed by Lindahl et al. (2017), 88% stated that a

psychiatric history is a risk factor for meditation-related challenges;

54% stated that a trauma history is important. Similarly, Lomas et al.

(2015) found that pre-existing depression and anxiety could be ex-

acerbated by Buddhist meditation. Several studies of MBPs suggest a

relationship in the opposite direction; i.e., under some circumstances,

participants with severe symptoms and traumatic backgrounds may be

more likely to beneﬁt. However, these studies have not included broad

assessments of harm. We summarize the ﬁndings here.

6.2.1. Participant vulnerabilities and response to standard MBPs

Several studies of MBCT for preventing depressive relapse have

shown stronger beneﬁts for participants with higher levels of various

vulnerabilities, including earlier onset of depression, more previous

episodes (Ma & Teasdale, 2004;Teasdale et al., 2000), unstable re-

mission (Segal et al., 2010), and childhood trauma (Kuyken et al., 2015;

Williams et al., 2014). In most of these studies, the participants with

fewer vulnerabilities showed eﬀects for MBCT that did not diﬀer from

TAU, placebo, or antidepressant medication (ADM). Several of these

studies found that participants with fewer previous episodes had non-

signiﬁcantly higher relapse rates in MBCT than in TAU. Ma & Teasdale

noted that the small sample made it unclear whether MBCT was causing

harm for the fewer-episodes subgroup (increasing the likelihood of re-

lapse) or was only unhelpful (providing no beneﬁt). An individual pa-

tient data meta-analysis (Kuyken et al., 2016) combined these and other

trials and found that in the larger sample (N> 1200) the only sig-

niﬁcant moderator of treatment eﬀect was severity of depressive

symptoms at baseline. Patients with more severe symptoms showed a

larger treatment eﬀect. No evidence of increased risk of relapse in

MBCT was seen; however, asymmetry in the funnel plot suggested the

possible existence of small unpublished studies showing this pattern.

Other MBPs have also shown better outcomes in participants with

more severe symptoms. Roos, Bowen, and Witkiewitz (2017) found that

MBRP was more eﬀective than CBT or usual care for participants with

high levels of substance use, anxiety, and depression, but similar to

these comparison groups for participants with fewer symptoms. Arch

and Ayers (2013) found that MBSR was more eﬀective than CBT for

people with comorbid anxiety and depression; CBT was more eﬀective

for those with anxiety only. These studies have not included detailed

assessments of harm.

6.2.2. MBPs adapted for speciﬁc vulnerabilities

MBPs have been adapted for psychosis, post-traumatic stress (PTS),

and suicide risk. For people with psychosis, Chadwick, Taylor, and

Abba (2005) reduced the number and duration of sessions, shortened

the meditation practices, and provided steady guidance during prac-

tices to prevent absorption in psychotic symptoms during stretches of

silence. Psychological functioning improved and no adverse eﬀects

were reported in post-treatment interviews. Since then, a meta-analytic

review of MBPs for psychosis (Khoury et al., 2013) reported a small-to-

moderate reduction in psychotic symptoms (g = 0.43) but did not

discuss harm or adverse events.

MBPs for PTS have also been studied. As noted earlier, Banks et al.

(2015) concluded that adverse eﬀects in 12 studies of MBPs for PTS

were minimal. A meta-analysis of 18 randomized trials (Hopwood &

Schutte, 2017) found a mean eﬀect size of g = 0.44 in favor of MBPs

over control conditions. For studies of MBSR, rather than unspeciﬁed

mindfulness programs, g = 0.49. There was no signiﬁcant diﬀerence

between MBSR adapted for trauma and standard MBSR. Most studies

did not mention whether AEs had been examined; a few reported that

there were none. One study reported that two participants (4.3%, one

each in the MBP and the control condition) required hospitalization for

worsening symptoms.

The adaptation of MBCT for people at high risk of suicide (Williams

et al., 2014) found that MBCT was more eﬀective than control condi-

tions in preventing depressive relapse for people with a history of

childhood trauma. Fifteen SAEs were reported: ﬁve in the MBCT arm

and 10 in the control conditions (5% and 6.4% of participants, re-

spectively). Most were overnight hospital admissions for physical

health problems; 14 of the 15 events (93%) were judged to be unrelated

to participation in the study. One episode of serious suicidal ideation

was potentially attributable to the active control intervention (Williams

et al., 2014).

Overall, the literature suggests that MBPs can be signiﬁcantly

therapeutic in groups with severe symptoms, comorbid conditions, and

other vulnerabilities. Speciﬁc vulnerabilities are sometimes associated

with better outcomes. Studies that monitored AEs/SAEs in these po-

pulations have reported that they occur in 0–10% of participants, are no

more common in MBPs than control groups, and are not attributable to

the MBP when they occur (Kuyken et al., 2016). However, many studies

have not monitored harm in any way. When negative outcomes are

reported, their relationship to participation in the MBP is not always

provided. In addition, most studies report only group data, making it

impossible to know whether promising averages mask deterioration in

some participants.

6.3. Teacher/clinician factors

The literature summarized in Table 2 suggests that risk of harm may

be related to characteristics of the provider, including empathy, un-

derstanding of the client's problems, communication about the nature

of the program, skillful implementation of the program, managing

diﬃculties that arise, and encouraging adherence to recommended

practice. Here we summarize recent work on assessment of similar

competencies in providers of MBPs.

6.3.1. Assessment of teacher competencies

Several methods for assessing teachers' delivery of MBPs are avail-

able. All use ratings of recorded sessions or live observation and have

shown adequate psychometric properties. The MBCT adherence scale

(MBCT-AS; Segal, Teasdale, Williams, & Gemar, 2002) is a list of es-

sential program elements; raters note the extent to which each element

is present. The mindfulness-based relapse prevention adherence and

competence scale (MBRP-AC; Chawla et al., 2010) is a similar measure

assessing the presence of required elements and the therapist's skills in

implementing them. The Mindfulness-Based Interventions – Teaching

Assessment Criteria (MBI-TAC; Crane et al., 2013) evaluates six do-

mains of competency: a) coverage, pacing, and organization of session

content, b) relational skills, c) embodiment of mindfulness, d) guiding

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

109

mindfulness practices, e) conveying course themes, and f) holding the

group learning environment.

Relationships between teacher competency scores and participant

outcomes have been examined in only a few studies. Using the MBRP-

AC, Chawla et al. (2010) found that therapists' adherence to required

elements of treatment was related to participants' development of

mindfulness skills. In MBCT for adults with recurrent depression,

Huijbers et al. (2017) found no signiﬁcant relationships between tea-

chers' MBI-TAC scores and any of the dependent variables. The null

ﬁndings may be related to the small sample of teachers (N= 15), re-

striction of range in competence scores, or the high level of standar-

dization of the intervention, which was provided in two clinical trials

by the same research team.

While substantial progress has been made in the assessment of

teacher competency, additional research is needed. To date, there is no

evidence that lack of competency is related to harmful outcomes.

Competency may have been assessed primarily in settings where tea-

chers are well trained, leading to restriction of range. Prevention of

harm may require skills not covered by existing measures, such as the

pre-course interview. In ostensibly nonclinical settings such as work-

places, where MBPs may be oﬀered by non-mental-health professionals,

harm might arise when teachers lack skills for screening participants for

psychological symptoms and managing mental health emergencies.

Finally, because harm can arise through ethical violations, knowledge

of professional ethics is necessary for managing issues related to in-

formed consent, conﬁdentiality, and other ethical concerns.

7. Recommendations for research

Perhaps the most basic unanswered questions are how often MBPs

cause harm, in what forms, and to whom. Answering these questions

requires detailed monitoring of potentially harmful eﬀects. Surveys of

participants about their experiences and measurement of a wide range

of participant characteristics and outcomes might help to clarify whe-

ther the target problem got worse or new problems arose, and for

whom. Attention to reasons for attrition may clarify whether dropping

out is related to harm. Examining individual-level data could clarify

whether group averages conceal the occurrence of harm in some par-

ticipants. Vagueness in existing deﬁnitions of harm (how much dete-

rioration is meaningful?) might be addressed with the reliable change

index (Jacobson & Truax, 1991), which classiﬁes participant outcomes

into three categories: reliable improvement, no reliable change, or re-

liable deterioration. At the same time, it seems important to consider

whether participants feel worse, even if their objectively measured

symptoms have not reliably decreased (Duggan et al., 2014). Qualita-

tive interviews with participants reporting harm or classiﬁed as having

deteriorated may be helpful in generating hypotheses for quantitative

studies.

More comprehensive monitoring may improve understanding of

participant, teacher, and program factors potentially related to harm.

For example, the study of moderators of outcome may clarify for whom

programs should be modiﬁed or contra-indicated. If an MBP has both

risks and beneﬁts for many participants, research could focus on for

whom the beneﬁts outweigh the risks and how to mitigate risks. Harm

that seems related to unskilful teaching may clarify essential teacher

competencies. These factors are likely to be intertwined; that is, parti-

cipant characteristics may require adaptations to programs and the

development of speciﬁc teaching skills.

Consistent reporting of harm-related information in published pa-

pers is essential to developing this body of knowledge. A revised

CONSORT checklist (Ioannidis et al., 2004) includes 10 recommenda-

tions for reporting on harm-related issues in randomized trials. These

include listing and deﬁning all adverse events that were studied, noting

whether events that occurred were anticipated or unexpected, clar-

ifying how harms-related information was collected and analyzed,

presenting risk of each adverse event for each arm of the trial, and

providing a balanced discussion of beneﬁts and harms. Despite the

longstanding availability of this checklist, such reporting is rare, for

reasons that are unclear. Peterson et al. (2013) suggested that the pri-

mary reason is that a temporary increase in symptoms or discomfort is

understood to be part of the normal therapeutic process. However, they

also argued that greater reporting of this phenomenon would increase

understanding of the overall risk and safety of therapies, especially

those known to involve signiﬁcant discomfort such as exposure-based

treatments. More consistent reporting might also help to clarify the

boundary between expected discomfort and potential harm.

Another reason for lack of reporting of harms may be overreliance

on deﬁnitions of AEs and SAEs used in medical research (Duggan et al.,

2014). Some of these events (suicide attempts, hospitalizations) may be

uncommon in trials of psychological interventions or MBPs. Monitoring

events more relevant to the program being studied would be in-

formative. Duggan et al. (2014) also note that many adverse events are

not spontaneously reported and will not come to light without sys-

tematic assessment methods such as structured interviews.

Several additional questions seem important for future research.

First, what is the dose/response relationship for mindfulness practice in

MBPs? Can high doses be harmful? To date, the literature has examined

only whether extent of self-reported home practice predicts positive

outcomes; a meta-analytic review (Parsons, Crane, Parsons, Fjorback, &

Kuyken, 2017) found a small but signiﬁcant association. This review

did not report whether any of the correlations between home practice

and outcome were negative and did not address the issue of harm.

Second, a related issue is whether the type, timing and quality of

home practice inﬂuences outcomes and whether speciﬁc ways of

practicing might cause harm. Lomas et al. (2015) found that practi-

tioners of Buddhist meditation who used advanced practices before

they were ready for them experienced diﬃcult eﬀects. Lindahl et al.

(2017) referred to “incorrect ways of practicing meditation” (p. 23) that

might cause harm; these are not clearly explained but include excessive

striving, attachments to speciﬁc states, and misunderstanding or not

following directions. For MBPs, Del Re, Fluckiger, Goldberg, and Hoyt

(2013) developed a self-report measure of practice quality and found

that symptom reduction was related to the extent to which participants

returned their attention to present-moment experiences with curiosity,

willingness, and self-compassion. However, they did not address

harmful eﬀects.

Third, if harm occurs, how can it be remediated? In medicine and

exercise science, more is known about treatment of overdoses, adverse

reactions, and injuries; an analogous body of knowledge is needed for

the mindfulness ﬁeld. Lindahl et al. (2017) include discussion of po-

tential remedies for challenges arising in Buddhist meditation; how-

ever, little is known about how well these apply to diﬃculties arising in

evidence-based MBPs.

8. Recommendations for protecting participants in MBPs from

harm

Several steps can be taken before an MBP begins. Teachers must

understand the theoretical and empirical foundations for using the MBP

with their population. Without this understanding, they will be unable

to explain to potential participants how the MBP may be relevant to

them, what diﬃculties might arise, how these can be managed, and

whether the potential beneﬁts are likely to outweigh the diﬃculties

(Kuyken, Crane, & Williams, 2012). This information should be part of a

pre-program orientation and informed consent process in which the

theoretical rationale, evidence base, and potential beneﬁts and risks are

discussed.

Careful assessment of potential participants and well considered

exclusion criteria are important. Available lists of recommended ex-

clusion criteria for MBPs (Kuyken et al., 2012;Santorelli et al., 2017)

generally include substance dependence, suicidality, psychosis, PTSD,

severe depression, severe social anxiety, and recent bereavement,

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

110

divorce, or other personal crisis. Such conditions are likely to interfere

with ability to participate in the group or the practices, or to receive

any beneﬁt from doing so. However, because this is not true in every

case, these criteria are “subject to clinical judgement and experience of

teacher, and support available to and motivation of participant”

(Kuyken et al., p. 23). When working with the general population, as-

sessing psychiatric and trauma history as well as current functioning

and professional and personal support may facilitate sound decisions

about readiness to participate and the need for concurrent psycholo-

gical or psychiatric treatment (Dobkin, Irving, & Amar, 2012). As noted

earlier, MBPs adapted for conditions that typically appear on lists of

exclusion criteria (PTSD, suicidality, psychosis) have shown promising

results, suggesting that exclusion criteria must be viewed ﬂexibly.

Once the program begins, it is important to teach both the what and

the how elements of mindfulness and to be sure that the psychoeduca-

tional and structural supports described earlier are in place. Rationales

for the practices should be made clear and participants should feel in-

vited, rather than pressured, to engage in them. Distress and discomfort

are likely to arise as participants learn new skills and practice applying

them to the diﬃculties for which they sought help. Prevention of harm

requires understanding common types of uncomfortable experiences,

their usual range of intensity, and how to help participants respond to

them in ways that facilitate learning the desired skills. Systematic

monitoring and recording of deterioration and adverse events will in-

crease this knowledge in providers of MBPs.

Systematic monitoring may also help teachers to recognize when

unusual or unexpected distressing experiences have arisen and when

they are disproportionate to the expected beneﬁts, likely to interfere

with attaining beneﬁts, or require clinical intervention. Protocols for

responding to objective indicators of imminent harm have been used in

randomized trials for monitoring foreseeable risks; for example, referral

to a physician when a participant endorses suicidality on a ques-

tionnaire. While suicide risk is foreseeable in a depressed sample, other

potentially harmful outcomes may be harder to predict. The Oﬃce for

Human Research Protections (US Department of Health and Human

Services, 2007) notes that an event is unexpected if its nature, severity,

or frequency is inconsistent with the known or foreseeable risk asso-

ciated with the procedures involved, or if it is inconsistent with the

expected natural progression of an underlying condition. When such

events occur, prevention of harm may require adjustments in the par-

ticipant's practice, discontinuing the program, or referral to other ser-

vices. Mindfulness teachers need training in the mental health condi-

tions they are likely to encounter and how to recognize and work with

the meditation-related challenges that participants may experience. The

requirement that teachers of MBPs have their own mindfulness practice

may provide further experiential understanding of challenging mind

states that will help them work with participants' meditation-related

challenges.

9. Summary and conclusions

In well-established approaches to health and wellbeing, including

psychotherapy, pharmacotherapy, and physical exercise, some partici-

pants suﬀer serious harm or get meaningfully worse. The same appears

to be true for meditation in contemplative traditions. Evidence-based

MBPs have important commonalities with these approaches. They work

with cognitions, emotions, and sensations, some of which are distres-

sing and diﬃcult; they raise issues about adherence, dosage, and dose/

response relationships; they include a variety of exercises, which can be

uncomfortable; and they place the formal practice of meditation at their

core. Because of these commonalities, it is essential to consider the

possibility that some participants in evidence-based MBPs may get

worse.

The existing literature on harm in evidence-based MBPs is sparse. A

few studies have shown worsening symptoms in MBPs; however, meta-

analyses consistently report signiﬁcant beneﬁts for many outcome

variables in a wide range of samples. Research also suggests that par-

ticipants with severe symptoms, comorbid conditions, and other vul-

nerabilities (psychosis, trauma history, suicide risk) can beneﬁt from

MBPs in standard or adapted forms, and that some may show more

beneﬁt from MBPs than participants without such vulnerabilities. The

few reviews including data on AEs and SAEs in evidence-based MBPs

report that they have occurred in zero to 10.6% of participants

(Table 4), are no more common in MBPs than comparison conditions

(Kuyken et al., 2016;Wong et al., 2018), and are not attributable to the

MBP (Kuyken et al.) or not clinically signiﬁcant (Banks et al., 2015).

However, these ﬁndings must be viewed cautiously because most

studies report only group averages that might mask meaningful dete-

rioration in some participants. Only a small minority of studies have

monitored AEs and SAEs. Those that have may have deﬁned them

narrowly or failed to ask about them in ways that elicit detailed an-

swers.

The prevalence of harm from meditation in contemplative traditions

is unclear. Nevertheless, harm clearly occurs, and the possibility that

similar harm might arise in evidence-based MBPs, despite adaptations

for contemporary mainstream contexts and the presence of structural

and psychoeducational supports described earlier, needs further study.

If such harm is occurring, it might not be detectable without systematic

monitoring of individual-level data. The ethical obligation to do no

harm requires us to enhance our monitoring methods in order to better

understand the risks for participants in MBPs, including what forms of

harm might occur, how often they occur, who is most susceptible, and

how harmful eﬀects can be prevented or remediated.

Role of funding sources

This work was partially supported by the Wellcome Trust, Grant

Reference: 104908/Z/14/Z. The Wellcome Trust had no role in plan-

ning or writing the manuscript or the decision to submit the paper for

publication.

Contributors

All authors contributed to discussions about the goals and structure

of the paper. Ruth Baer wrote most of the ﬁrst draft. Catherine Crane,

Edward Miller, and Willem Kuyken wrote sections of the paper. All

authors contributed to editing and revising. All authors have approved

the ﬁnal manuscript.

Conﬂict of interest

Ruth Baer is an Associate of the Oxford Mindfulness Centre and

receives occasional payments for training workshops and presentations

related to mindfulness. She also receives royalties for several books

related to mindfulness. Catherine Crane is aﬃliated with the Oxford

Mindfulness Centre and funded by the Wellcome Trust on a strategic

award exploring the role of mindfulness training in adolescence.

However she does not receive additional remuneration for training

workshops or presentations related to mindfulness. Willem Kuyken is

the director of the Oxford Mindfulness Centre. He receives payments for

training workshops and presentations related to mindfulness and do-

nates all such payments to the Oxford Mindfulness Foundation, a

charitable trust that supports the work of the Oxford Mindfulness

Centre. Willem Kuyken was until 2015 an unpaid Director of the

Mindfulness Network Community Interest Company and gave evidence

to the UK Mindfulness All Party Parliamentary Group.

References

Arch, J. J., & Ayers, C. R. (2013). Which treatment worked better for whom? Moderators

of group cognitive behavioral therapy versus adapted mindfulness based stress re-

duction for anxiety disorders. Behaviour Research and Therapy, 51(8), 434–442.

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

111

Aronson, J. K., & Ferner, R. E. (2005). Clariﬁcation of terminology in drug safety. Drug

Safety, 28(10), 851–870.

Baer, R. A. (2011). Measuring mindfulness. Contemporary Buddhism, 12(1), 241–261.

Banks, K., Newman, E., & Saleem, J. (2015). Overview of the research on mindfulness-

based interventions for treating symptoms of posttraumatic stress disorder: A sys-

tematic review. Journal of Clinical Psychology, 71, 935–963.

Becker, C., Zayfert, C., & Anderson, E. (2004). A survey of psychologists' attitudes towards

and utilization of exposure therapy for PTSD. Behaviour Research and Therapy, 42(3),

277–292.

Bennett-Levy, J., Butler, G., Fennell, M., Hackmann, A., Mueller, M., & Westbrook, D.

(2004). The Oxford handbook of behavioural experiments. Oxford: Oxford University

Press.

Bergin, A. E. (1966). Some implications of psychotherapy research for therapeutic prac-

tice. Journal of Abnormal Psychology, 71(4), 235–246.

Bishop, S., Lau, M., Shapiro, S., Carlson, L., Anderson, N., Carmody, J., et al. (2004).

Mindfulness: A proposed operational deﬁnition. Clinical Psychology: Science and

Practice, 11, 230–241.

Bosworth, H. B., Granger, B. B., Mendys, P., Brindis, R., Burkholder, R., Czajkowski, S. M.,

... Kimmel, S. E. (2011). Medication adherence: A call for action. American Heart

Journal, 162(3), 412–424.

Bowen, S., Chawla, N., Collins, S., Witkiewitz, K., Hsu, S., Grow, J., ... Marlatt, A. (2009).

Mindfulness-based relapse prevention for substance use disorders: A pilot eﬃcacy

trial. Substance Abuse, 30(4), 295–305.

Britton, W., Haynes, P., Fridel, K., & Bootzin, R. (2010). Polysomnographic and subjective

proﬁles of sleep continuity before and after mindfulness-based cognitive therapy in

partially remitted depression. Psychosomatic Medicine, 72, 539–548.

Britton, W. B., Lindahl, J. R., Cahn, B. R., Davis, J. H., & Goldman, R. E. (2014).

Awakening is not a metaphor: The eﬀects of Buddhist meditation practices on basic

wakefulness. Annals of the New York Academy of Sciences, 1307(1), 64–81.

Brooker, J., Julian, J., Webber, L., Chan, J., Shawyer, F., & Meadows, G. (2012).

Evaluation of an occupational mindfulness program for staﬀ employed in the dis-

ability sector in Australia. Mindfulness, 4(2), 122–136.

Brown, C. (2016). Can secular mindfulness be separated from religion? In R. Purser, D.

Forbes, & A. Burke (Eds.). Handbook of mindfulness: Culture, context, and social en-

gagement. Springer.

Cameron, L. D., & Overall, N. C. (2018). Suppression and expression as distinct emotion-

regulation processes in daily interactions: Longitudinal and meta-analyses. Emotion,

18(4), 465–480.

Carlson, L., Speca, M., Faris, P., & Patel, K. (2007). One year pre-post intervention follow-

up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-

based stress reduction (MBSR) in breast and prostate cancer outpatients. Brain,

Behavior, and Immunity, 21(8), 1038–1049.

Castillo, R. J. (1990). Depersonalization and meditation. Psychiatry, 53(2), 158–168.

Cebolla, A., Demarzo, M., Martins, P., Soler, J., & Garcia-Campayo, J. (2017). Unwanted

eﬀects: Is there a negative side of meditation? A multicentre survey. PLoS One, 12(9),

e0183137.

Chadwick, P., Taylor, K., & Abba, N. (2005). Mindfulness groups for people with psy-

chosis. Behavioural and Cognitive Psychotherapy, 33(3), 351–359.

Chawla, N., Collins, S., Bowen, S., Hsu, S., Grow, J., Douglas, A., & Marlatt, A. (2010). The

Mindfulness-Based Relapse Prevention Adherence and Competence Scale:

Development, interrater reliability, and validity. Psychotherapy Research, 20(4),

388–397.

Chiesa, A., Calati, R., & Serretti, A. (2011). Does mindfulness training improve cognitive

abilities? A systematic review of neuropsychological ﬁndings. Clinical Psychology

Review, 31, 449–464.

Coleman, J., & Pontefract, S. (2016). Adverse drug reactions. Clinical Medicine, 16,

481–485.

Compson, J. F. (2017). Is mindfulness secular or religious, and does it matter? In L.

Monteiro, J. Compson, & F. Musten (Eds.). Practitioner's guide to ethics and mindfulness-

based interventions. Springer.

Conn, J., Annest, J., & Gilchrist, J. (2003). Sports and recreation related injury episodes in

the US population, 1997-99. Injury Prevention, 9, 117–123.

Crane, C., & Williams, J. M. G. (2010). Factors associated with attrition from mindfulness-

based cognitive therapy in patient with a history of suicidal depression. Mindfulness,

1(1), 10–20.

Crane, R., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorelli, S., Williams, J., & Kuyken,

W. (2017). What deﬁnes mindfulness-based programs? The warp and the weft.

Psychological Medicine, 47, 990–999.

Crane, R. S., Eames, C., Kuyken, W., Hastings, R. P., Williams, J. M. G., Bartley, T., ...

Surawy, C. (2013). Development and validation of the mindfulness-based inter-

ventions–teaching assessment criteria (MBI: TAC). Assessment, 20(6), 681–688.

Crawford, M., Thana, L., Farquharson, L., Palmer, L., Hancock, E., Bassett, P., ... Parry, G.

(2016). Patient experience of negative eﬀects of psychological treatment: Results of a

national survey. The British Journal of Psychiatry, 208, 260–265.

Deacon, B. J., & Abramowitz, J. S. (2005). Patients' perceptions of pharmacological and

cognitive-behavioral treatments for anxiety disorders. Behavior Therapy, 36, 139–145.

Del Re, A., Fluckiger, C., Goldberg, S., & Hoyt, W. (2013). Monitoring mindfulness

practice quality: An important consideration in mindfulness practice. Psychotherapy

Research, 23(1), 54–66.

Desrosiers, A., Vine, V., Curtiss, J., & Klemanski, D. H. (2014). Observing nonreactively: A

conditional process model linking mindfulness facets, cognitive emotion regulation

strategies, and depression and anxiety symptoms. Journal of Aﬀective Disorders, 165,

31–37.

Dimidjian, S., & Hollon, S. (2010). How would we know if psychotherapy were harmful?

American Psychologist, 65(1), 21–33.

Dimidjian, S., & Hollon, S. (2011). What can be learned when empirically supported

treatments fail? Cognitive and Behavioral Practice, 18(3), 303–305.

Dobkin, P., Irving, J., & Amar, S. (2012). For whom may participation in a mindfulness-

based stress reduction program be contraindicated? Mindfulness, 3, 44–50.

Duggan, C., Parry, G., McMurran, M., Davidson, K., & Dennis, J. (2014). The recording of

adverse events from psychological treatments in clinical trials: Evidence from a re-

view of NIHR-funded trials. Trials, 15, 335.

Dunning, D., Griﬃths, K., Kuyken, W., Crane, C., Foulkes, L., Parker, J., & Dalgleish, T.

(2018). Research review: The eﬀects of mindfulness-based interventions on cognition

and mental health in children and adolescents – A meta-analysis of randomized

controlled trials. Journal of Child Psychology and Psychiatry.https://doi.org/10.1111/

jcpp.12980.

Eisenlohr-Moul, T., Walsh, E., Charnigo, R., Lynam, D., & Baer, R. (2012). The “what” and

the “how” of dispositional mindfulness: Using interactions among subscales of the

Five-Facet Mindfulness Questionnaire to understand its relation to substance use.

Assessment, 19(3), 276–286.

Ferguson, K., & Sgambati, R. (2008). Relaxation. In W. O'Donohue, & J. Fisher (Eds.).

Cognitive behavior therapy: Applying empirically supported techniques in your practice

(pp. 434–444). Hoboken, NJ: Wiley.

Foa, E. B., Zoellner, L. A., Feeny, N. C., Hembree, E. A., & Alvarez-Conrad, J. (2002). Does

imaginal exposure exacerbate PTSD symptoms? Journal of Consulting and Clinical

Psychology, 70(4), 1022.

Foster, D. (2016). Is mindfulness making us ill? The Guardian. Retrieved from https://

www.theguardian.com/lifeandstyle/2016/jan/23/is-mindfulness-making-us-ill.

Franklin, B. A., & Billecke, S. (2012). Putting the beneﬁts and risks of aerobic exercise in

perspective. Current Sports Medicine Reports, 11(4), 201–208.

French, A. P., Schmid, A. C., & Ingalls, E. (1975). Transcendental meditation, altered

reality testing, and behavioral change: A case report. Journal of Nervous & Mental

Disease, 161, 55–58.

Garber, C., Blissmer, B., Deschenes, M., Franklin, B., Lamonte, M., Lee, I., ... Swain, D.

(2011). Quantity and quality of exercise for developing and maintaining cardior-

espiratory, musculoskeletal, and neuromotor ﬁtness in apparently healthy adults:

Guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43(7),

1334–1359.

Germer, K., Siegel, R., & Fulton, P. (Eds.). (2005). Mindfulness and psychotherapy. NY:

Guilford.

Goldberg, S. B., Tucker, R. P., Green, P. A., Davidson, R. J., Wampold, B. E., Kearney, D.

J., & Simpson, T. L. (2018). Mindfulness-based interventions for psychiatric dis-

orders: A systematic review and meta-analysis. Clinical Psychology Review, 59, 52–60.

Gotink, R., Chu, P., Busschbach, J., Benson, H., Fricchione, G., & Hunink, M. (2015).

Standardized mindfulness-based interventions in healthcare: An overview of sys-

tematic reviews and meta-analyses of RCTs. PLoS One, 10(4).

Goyal, M., Singh, S., Sibinga, E., Gould, N., Rowland-Seymour, A., Sharma, R., ...

Haythornthwaite, J. (2014). Meditation programs for psychological stress and well-

being: A systematic review and meta-analysis. JAMA Internal Medicine, 174(3),

357–368.

Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response

eﬀect and its implications for treatment delivery services. Clinical Psychology: Science

and Practice, 9(3), 329–343.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy:

The process and practice of mindful change. New York, NY: Guilford Press.

Hayes, S. C., Wilson, K. G., Giﬀord, E. V., Follette, V. M., & Strosahl, K. (1996).

Experiential avoidance and behavioral disorders: A functional dimensional approach

to diagnosis and treatment. Journal of Consulting and Clinical Psychology, 64(6),

1152–1168.

Hopwood, T., & Schutte, N. (2017). A meta-analytic investigation of the impact of

mindfulness- based interventions on post-traumatic stress. Clinical Psychology Review,

57, 12–20.

Huijbers, M., Crane, J., Kuyken, R., Heijke, S., Hout, W., Donders, L., & Speckens, I.

(2017). Teacher competence in mindfulness-based cognitive therapy for depression

and its relation to treatment outcome. Mindfulness, 8(4), 960–972.

Ingram, R. E. (1990). Self-focused attention in clinical disorders: Review and a conceptual

model. Psychological Bulletin, 107(2), 156.

Ioannidis, J., Evans, J., Gotzsche, P., O'Neill, R., Altman, D., Schulz, K., & Moher, D.

(2004). Better reporting of harms in randomized trials: An extension of the CONSORT

statement. Annals of Internal Medicine, 141(10), 781–788.

Jacobson, N., & Truax, P. (1991). Clinical signiﬁcance: A statistical approach to deﬁning

meaningful change in psychotherapy research. Journal of Consulting and Clinical

Psychology, 59, 12–19.

Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain

patients based on the practice of mindfulness meditation: Theoretical considerations

and preliminary results. General Hospital Psychiatry, 4, 33–47.

Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your mind and body to face

stress, pain, and illness. New York, NY: Delacorte.

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday

life. New York: Hyperion.

Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present and fu-

ture. Clinical Psychology: Science and Practice, 10, 144–156.

Kabat-Zinn, J. (2011). Some reﬂections on the origins of MBSR, skillful means, and the

trouble with maps. Contemporary Buddhism, 12, 281–306.

Kashdan, T., & Rottenberg, J. (2010). Psychological ﬂexibility as a fundamental aspect of

health. Clinical Psychology Review, 390, 467–480.

Khoury, B., Lecomte, T., Fortin, G., Masse, M., Therien, P., Bouchard, V., ... Hofmann, S.

(2013). Mindfulness-based therapy: A comprehensive meta-analysis. Clinical

Psychology Review, 33, 763–771.

Khoury, B., Sharma, M., Rush, S. E., & Fournier, C. (2015). Mindfulness-based stress re-

duction for healthy individuals: A meta-analysis. Journal of Psychosomatic Research,

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

112

78(6), 519–528.

Kristeller, J., Wolever, R., & Sheets, V. (2014). Mindfulness-based eating awareness

training (MB-EAT) for binge eating: A randomized clinical trial. Mindfulness, 5(3),

282–297.

Kuijpers, H. J., Van der Heijden, F. M. M. A., Tuinier, S., & Verhoeven, W. M. A. (2007).

Meditation-induced psychosis. Psychopathology, 40(6), 461–464.

Kuyken, W., Crane, R., & Williams, M. (2012). Mindfulness-based cognitive therapy (MBCT)

implementation resources. University of Oxford, University of Exeter, Bangor

University.

Kuyken, W., Hayes, R., Barrett, B., Byng, R., Dalgleish, T., Kessler, D., ... Causley, A.

(2015). Eﬀectiveness and cost-eﬀectiveness of mindfulness-based cognitive therapy

compared with maintenance antidepressant treatment in the prevention of depressive

relapse or recurrence (PREVENT): A randomised controlled trial. The Lancet,

386(9988), 63–73.

Kuyken, W., Warren, F., Taylor, R., Whalley, B., Crane, C., Bondolﬁ, G., ... Segal, Z.

(2016). Eﬃcacy of mindfulness-based cognitive therapy in prevention of depressive

relapse: An individual patient data meta-analysis from randomized trials. JAMA

Psychiatry, 73, 565–574.

Lambert, M. (2013). The eﬃcacy and eﬀectiveness of psychotherapy. In M. J. Lambert

(Ed.). Bergin & Garﬁeld's handbook of psychotherapy and behavior change (pp. 169–

218). (6

ed.). Hoboken, NJ: Wiley.

Lazarou, J., Pomeranz, B. H., & Corey, P. N. (1998). Incidence of adverse drug reactions in

hospitalized patients: A meta-analysis of prospective studies. JAMA, 279, 1200–1205.

Levin, M. E., Hildebrandt, M. J., Lillis, J., & Hayes, S. C. (2012). The impact of treatment

components suggested by the psychological ﬂexibility model: A meta-analysis of la-

boratory-based component studies. Behavior Therapy, 43(4), 741–756.

Lilienfeld, S. (2007). Psychological treatments that cause harm. Perspectives on

Psychological Science, 2(1), 53–70.

Lindahl, J., Fisher, N., Cooper, D., Rosen, R., & Britton, W. (2017). The varieties of

contemplative experience: A mixed-methods study of meditation-related challenges

in Western Buddhists. PLoS One, 12(5), e0176239.

Linden, M. (2013). How to deﬁne, ﬁnd, and classify side eﬀects in psychotherapy: From

unwanted events to adverse treatment reactions. Clinical Psychology and

Psychotherapy, 20, 286–296.

Linden, M., & Schermuly-Haupt, M. (2014). Deﬁnition, assessment, and rate of psy-

chotherapy side eﬀects. World Psychiatry, 13, 306–309.

Lineberry, N., Berlin, J., Mansi, B., Glasser, S., Berkwits, M., Klem, C., ... Laine, C. (2016).

Recommendations to improve adverse event reporting in clinical trial publications: A

joint pharmaceutical industry/journal editor perspective. BMJ, 355, I5078.

Linehan, M. (2015). DBT skills training manual (2

ed.). New York, NY: Guilford Press.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. NY:

Guilford.

Litz, B., Gray, M., Bryant, R., & Adler, A. (2002). Early intervention for trauma: Current

status and future directions. Clinical Psychology: Science and Practice, 9, 112–134.

Lollgen, H., Bockenhoﬀ, A., & Knapp, G. (2009). Physical activity and all-cause mortality:

An updated meta-analysis with diﬀerent intensity categories. International Journal of

Sports Medicine, 30(3), 231–234.

Lomas, T., Cartwright, T., Edginton, T., & Ridge, D. (2015). A qualitative analysis of

experiential challenges associated with meditation practice. Mindfulness, 6, 848–860.

Lomas, T., Medina, J., Ivtzan, I., Rupprecht, S., & Eiroa-Orosa, F. (2018). Mindfulness-

based interventions in the workplace: An inclusive systematic review and meta-

analysis of their impact upon wellbeing. Journal of Positive Psychology..https://doi.

org/10.1080/17439760.2018.1519588.

Lustyk, M., Chawla, N., Nolan, R., & Marlatt, G. (2009). Mindfulness meditation research:

Issues of participants screening, safety procedures, and researcher training. Advances

in Mind Body Medicine, 24(1), 20–30.

Ma, S. H., & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression:

Replication and exploration of diﬀerential relapse prevention eﬀects. Journal of

Consulting and Clinical Psychology, 72(1), 31.

Malpass, A., Carel, H., Ridd, M., Shaw, A., Kessler, D., Sharp, D., ... Wallond, J. (2012).

Transforming the perceptual situation: A meta-ethnography of qualitative work re-

porting patients' experiences of mindfulness-based approaches. Mindfulness, 3, 60–75.

Marlatt, G. A., & Kristeller, J. L. (1999). In W. R. Miller (Ed.). Integrating spirituality into

treatment (pp. 67–84). Washington DC: American Psychological Association

Mindfulness and meditation.

Meibohm, B., & Derendorf, H. (1997). Basic concepts of pharmacokinetic/pharmacody-

namics (PK/PD) modelling. International Journal of Clinical Pharmacology and

Therapeutics, 35(10), 401–413.

Miller, J. J. (1993). The unveiling of traumatic memories and emotions through mind-

fulness and concentration meditation: Clinical implications and three case reports.

The Journal of Transpersonal Psychology, 25(2), 169.

Mohr, D. (1995). Negative outcome in psychotherapy: A critical review. Clinical

Psychology: Science and Practice, 2(1), 1–27.

Mor, N., & Winquist, J. (2002). Self-focused attention and negative aﬀect: A meta-ana-

lysis. Psychological Bulletin, 128(4), 638–662.

Nyklíček, I., Mommersteeg, P., Van Beugen, S., Ramakers, C., & Van Boxtel, G. (2013).

Mindfulness-based stress reduction and physiological activity during acute stress: A

randomized controlled trial. Health Psychology, 32(10), 1110–1113.

OHRP (2007). Guidance on reviewing and reporting unanticipated problems involving risks to

subjects of others and adverse events. Oﬃce for Human Research Protections, US

Department of Health and Human Services.

Olatunji, B., Deacon, B., & Abramowitz, J. (2009). The cruellest cure? Ethical issues in the

implementation of exposure-based treatments. Cognitive and Behavioral Practice, 16,

172–180.

Ong, J., Manber, R., Segal, Z., Xia, Y., Shapiro, S., & Wyatt, J. (2014). A randomized

controlled trial of mindfulness meditation for chronic insomnia. Sleep, 37,

1553–1563.

Ong, J., Ulmer, C., & Manber, R. (2012). Improving sleep with mindfulness and accep-

tance: A metacognitive model of insomnia. Behaviour Research and Therapy, 50,

651–660.

Otis, L. S. (1984). Adverse eﬀects of transcendental meditation. In D. Shapiro, & R. Walsh

(Eds.). Meditation: Classic and contemporary perspectives (pp. 201–208). Hawthorne.

Parsons, C., Crane, C., Parsons, L., Fjorback, L., & Kuyken, W. (2017). Home practice in

mindfulness-based cognitive therapy and mindfulness-based stress reduction: A sys-

tematic review and meta-analysis of participants' mindfulness practice and its asso-

ciation with outcomes. Behaviour Research and Therapy, 95, 29–41.

Patil, H., O'Keefe, J., Lavie, C., Magalski, A., Vogel, R., & McCullough, P. (2012).

Cardiovascular damage resulting from chronic excessive endurance exercise. Missouri

Medicine, 109(4), 312–321.

Peterson, A., Roache, J., Raj, J., & Young-McCaughan, S. (2013). The need for expanded

monitoring of adverse events in behavioral health clinical trials. Contemporary

Clinical Trials, 34, 152–154.

Piet, J., Würtzen, H., & Zachariae, R. (2012). The eﬀect of mindfulness-based therapy on

symptoms of anxiety and depression in adult cancer patients and survivors: A sys-

tematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 80(6),

1007–1020.

Quaglia, J., Braun, S., Freeman, S., McDaniel, M., & Brown, K. (2016). Meta-analytic

evidence for eﬀects of mindfulness training on dimensions of self-reported mind-

fulness. Psychological Assessment, 28(7), 803–818.

Reynolds, L., Bissett, I., Porter, D., & Consedine, N. (2017). A brief mindfulness inter-

vention is associated with negative outcomes in a randomized controlled trial among

chemotherapy patients. Mindfulness, 8, 1291–1303.

Richard, D., & Gloster, A. T. (2007). Exposure therapy has a public relations problem: A

dearth of litigation amid a wealth of concern. In D. Richard, & D. Lauterbach (Eds.).

Comprehensive handbook of the exposure therapies (pp. 409–425). NY: Academic Press.

Roos, C. R., Bowen, S., & Witkiewitz, K. (2017). Baseline patterns of substance use dis-

order severity and depression and anxiety symptoms moderate the eﬃcacy of

mindfulness-based relapse prevention. Journal of Consulting and Clinical Psychology,

85, 1041.

Santorelli, S., Meleo-Meyer, F., Koerbel, L., Kabat-Zinee, J., Blacker, M., Herbette, G., &

Fulwiler, C. (2017). Mindfulness-based stress reduction (MBSR) authorized curri-

culum guide. Center for Mindfulness in Medicine, Health Care, and Society (CFM).

University of Massachusetts Medical School.

Schulz, R. (2007). The role of health professionals in inﬂuencing patient compliance. In J.

Fincham (Ed.). Patient compliance with medications: Issues and opportunities (pp. 155–

171). New York, NY: Haworth Press.

Sears, R. W. (2015). Building competence in mindfulness-based cognitive therapy: Transcripts

and insights for working with stress, anxiety, depression, and other problems. New York:

Routledge.

Segal, Z. V., Bieling, P., Young, T., MacQueen, G., Cooke, R., Martin, L., ... Levitan, R. D.

(2010). Antidepressant monotherapy vs sequential pharmacotherapy and mind-

fulness-based cognitive therapy, or placebo, for relapse prophylaxis in recurrent de-

pression. Archives of General Psychiatry, 67(12), 1256–1264.

Segal, Z. V., Teasdale, J. D., Williams, J. M., & Gemar, M. C. (2002). The mindfulness-

based cognitive therapy adherence scale: Inter-rater reliability, adherence to pro-

tocol and treatment distinctiveness. Clinical Psychology & Psychotherapy, 9(2),

131–138.

Segal, Z. V., Williams, J. M. G., & Teasdale, J. (2013). Mindfulness-based cognitive therapy

for depression: A new approach to preventing relapse (2

ed.). NY: Guilford.

Shapiro, D. H. (1992). Adverse eﬀects of meditation: A preliminary investigation of long-

term meditators. International Journal of Psychosomatics, 39, 62–67.

Strupp, H. H., Hadley, S. W., & Gomez-Schwartz, B. (1977). Psychotherapy for better or

worse: The problem of negative eﬀects. New York, NY: Wiley.

Tang, Y. Y., Hölzel, B. K., & Posner, M. I. (2015). The neuroscience of mindfulness

meditation. Nature Reviews Neuroscience, 16(4), 213–225.

Teasdale, J., Segal, Z., Williams, J., Ridgeway, V., Soulsby, J., & Lau, M. (2000).

Prevention of relapse/recurrence in major depression by mindfulness-based cognitive

therapy. Journal of Consulting and Clinical Psychology, 68, 615–623.

Tomfohr, L. M., Pung, M., Mills, P., & Edwards, K. (2015). Trait mindfulness is associated

with blood pressure and interleukin-6: Exploring interactions among subscales of the

ﬁve Facet Mindfulness Questionnaire to better understand relationships between

mindfulness and health. Journal of Behavioral Medicine, 38(1), 28–38.

Veringa, I., de Bruin, E., Bardacke, N., Duncan, L., van Steensel, F., Dirksen, C., & Bögels,

S. (2016). I've changed my mind’, mindfulness-based childbirth and parenting

(MBCP) for pregnant women with a high level of fear of childbirth and their partners:

Study protocol of the quasi-experimental controlled trial. BMC Psychiatry, 16, 377.

Warburton, D., Taunton, J., Bredin, S., & Isserow, S. (2016). The risk-beneﬁt paradox of

exercise. BC Medical Association Journal, 58, 210–218.

Watkins, E. R. (2008). Constructive and unconstructive repetitive thought. Psychological

Bulletin, 134(2), 163.

Weiss, R., Wilson, N. L., & Whitemarsh, S. M. (2005). Evaluation of a voluntary, military-

style residential treatment program for adolescents with academic and conduct

problems. Journal of Clinical Child and Adolescent Psychology, 34(4), 692–705.

Williams, J., Crane, C., Barnhofer, T., Brennan, K., Duggan, D. S., Fennell, M. J., ... Shah,

D. (2014). Mindfulness-based cognitive therapy for preventing relapse in recurrent

depression: A randomized dismantling trial. Journal of Consulting and Clinical

Psychology, 82(2), 275.

Wong, S., Chan, J., Zhang, D., Lee, E., & Tsoi, K. (2018). The safety of mindfulness-based

interventions: A systematic review of randomized controlled trials. Mindfulness.

Yorston, G. (2001). Mania precipitated by meditation: A case report and literature review.

Mental Health Religion & Culture, 4(2), 209–213.

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

113

Ruth Baer, PhD, is Professor of Psychology at the University of Kentucky and an

Associate of the Oxford Mindfulness Centre, Department of Psychiatry, University of

Oxford.

Catherine Crane, PhD, is Research Lead at the Oxford Mindfulness Centre, Department of

Psychiatry, University of Oxford.

Edward Miller, MD, is a psychiatrist and post-graduate student at the Oxford

Mindfulness Centre, Department of Psychiatry, University of Oxford.

Willem Kuyken, PhD, is Professor of Clinical Psychology and Director of the Oxford

Mindfulness Centre, Department of Psychiatry, University of Oxford.

R. Baer et al. Clinical Psychology Review 71 (2019) 101–114

114

Web-Based Intervention Using Self-Compassionate Writing to Induce Positive Mood in Family Caregivers of Older Adults: Quantitative Study

Article

Full-text available

Nov 2024

Background: Caregiver burden can impact the mental health of family caregivers, but self-compassion may help reduce this impact. Brief self-compassion interventions have been shown to be useful but have not been tested in family caregivers of older adults.

Mindfulness-Based Interventions and the Hypothalamic–Pituitary–Adrenal Axis: A Systematic Review

Article

Full-text available

Nov 2024

Background: Numerous studies have evaluated the effect that mindfulness-based interventions (MBIs) have on multiple health outcomes. For its part, stress is a natural response to environmental disturbances and within the associated metabolic responses, alterations in cortisol levels and their measurement in different tissues are a way to determine the stress state of an individual. Therefore, it has been proposed that MBIs can modify cortisol levels. Methods and results: The objective of this systematic review was to analyze and summarize the different studies that have evaluated the effect of MBIs on cortisol levels. The following databases were consulted: MEDLINE, AMED, CINAHL, Web of Science, Science Direct, PsycINFO, SocINDEX, PubMed, the Cochrane Library and Scopus. The search terms “mindfulness”, “mindfulness-based interventions” and “cortisol” were used (and the search was limited to studies from January 1990 to May 2024). In order to reduce selection bias, each article was scrutinized using the JBI Critical Appraisal Checklist independently by two authors. We included those studies with specified intervention groups with at least one control group and excluded duplicate studies or those in which the intervention or control group was not adequately specified. Significant changes in cortisol following MBIs were found in 25 studies, while 10 found no changes. The small sample size, lack of randomization, blinding, and probable confounding and interaction variables stand out in these studies. Conclusion: MBIs have biological plausibility as a means of explaining a positive effect on cortisol levels; however, the weakness of the studies and the absence of robust designs makes it difficult to establish a causal association between both variables. Registration number: INPLASY2024110017.

Differential explanations of psychological well-being according to clinical personality patterns

Article

Full-text available

Nov 2024
CURR PSYCHOL

The purpose of this study was to examine the explanatory power of a predictive model of psychological well-being, consisting of mindfulness, private self-consciousness with its two dimensions, self-reflection and insight, emotional regulation, psychological inflexibility and external shame. Also, it was the author’s intention to explore the mediating effect of insight on the relationship between emotional regulation and psychological well-being. The current research involved a nonexperimental, cross-sectional design exploring the presence of psychological well-being at clinical personality patterns. The quantitative methodology was used to collect and analyse the data obtained from all the respondents. Researchers adapted and pretested the questionnaire set (PWB, MAAS, AAQ-II, OAS-II, ERQ, SRIS) to the Romanian context before distributing it to 268 participants. SPSS (V. 20) and Hayes’s PROCESS tool were used to investigate the data. The research findings illustrated that the effectiveness of predictors varies depending on clinical personality patterns. Among participants without clinical personality pattern scores, psychological inflexibility, emotional regulation, and self-reflection emerged as significant psychological factors predicting psychological well-being. For those identified with a histrionic clinical personality pattern, emotional regulation and psychological inflexibility constituted the most robust explanatory model for psychological well-being. Similarly, for individuals exhibiting depressive clinical personality patterns, only emotional regulation and psychological inflexibility played pivotal roles in predicting psychological well-being. Furthermore, the study highlighted a significant indirect effect of emotional regulation on psychological well-being through insight. Elevated emotional regulation levels indirectly contribute to higher psychological well-being by enhancing insight, thus promoting overall psychological well-being.

COVID-19 Traumatic Stress, Working Memory Deficits, and Mindfulness

Article

Nov 2024

Evaluation of Academic Dissertations via Mindfulness in Children Using Content Analysis Method

Article

Nov 2024

Dancing With Difficulty: A Qualitative Study on Management of Emergent Difficulties in Mindfulness Group Sessions

Article

Oct 2024

Rachael Miller

In the last decade, research has highlighted the efficacy of mindfulness-based interventions in treating psychiatric and physical conditions. Moments of difficulty during sessions are known to occur and can serve as opportunities for therapeutic growth. However, while research has concentrated on mindfulness’s impact on clients, the role of the facilitator remains underexplored. This qualitative study examined how mindfulness facilitators manage emergent difficulties during group MBCT/MBSR courses. Semi-structured interviews were conducted with MBCT/MBSR facilitators ( n=15) to discuss how they defined and managed emergent difficulty. Emergent difficulty, as derived from the interview data, is defined by dysregulation that impedes engagement, unsettles the group container, and necessitates intervention. Using thematic analysis, three key themes emerged: (a) when common difficulty becomes emergent, (b) the facilitators’ embodiment of mindfulness principles plays a pivotal role in effectively managing emergent difficulties, and (c) participants and facilitators engage in a dynamic process of “dancing with difficulty,” wherein turning toward challenges with curiosity and compassion enhances participants’ ability to remain present. The findings underscore the importance of embodiment in recognizing and addressing emergent challenges, fostering better attunement. Effective facilitation benefits individual participants and enriches the entire group’s experience by extending strategies for approaching obstacles with acceptance, compassion, and equanimity.

Mindfulness-Based Therapies with Bipolar Disorder

Chapter

Dec 2024

Mindfulness-based interventions are increasingly considered as a treatment option to support those living with bipolar disorder (BD). There is an emerging evidence base for group-based mindfulness interventions, with little published research on how to apply this treatment philosophy in individual work. Part 1 provides an overview of BD, with links made between how BD presents and the implications for mindfulness work. Part 2 offers a review of the evidence base for group MBIs (focusing on Mindfulness-Based Cognitive Therapy (MBCT) and drawing from systematic reviews). In Part 3, assumptions and clarifications are shared to orient the reader to specific aspects of working within a mindful framework. Part 4 offers guidance for individual work, drawn from (i) insights from the group MBCT evidence, (ii) neurocognitive principles, and (iii) the author’s clinical experience working with clients with BD. The chapter concludes with considerations of diversity and suggestions for future research. While mindfulness shows great promise to support our clients, the work is nuanced and requires thoughtful adaptation.

The relationship between mindfulness and aggression for adolescence: Interplay of impulsivity and inhibition dysfunction

Article

Full-text available

Nov 2024
CURR PSYCHOL

Adolescent aggression is a significant public health concern, impacting interpersonal relationships, mental health, and academic performance. This study investigated the relationship between dispositional mindfulness and aggression in adolescents, exploring the mediating roles of impulsivity and inhibition dysfunction, guided by the I3 model of aggression and the General Aggression Model. A cross-sectional design was employed with 627 high school students (39.2% male) aged 14-19 (M=16.49, SD=1.05) in Sichuan province, China. Participants completed self-report questionnaires assessing the Reactive-Proactive Aggression Questionnaire, the Barratt Impulsivity Scale, the Teenage Executive Functioning Inventory, and the Five-Facet Mindfulness Questionnaire. Structural equation modeling and bootstrapping procedures were used to test the hypothesized mediation models. Mindfulness negatively predicted both impulsivity and inhibition dysfunction. Impulsivity and inhibition dysfunction, in turn, positively predicted both reactive and proactive aggression. Mediation analyses confirmed that impulsivity and inhibition dysfunction mediated the relationship between mindfulness and both forms of aggression. Furthermore, a chain-mediation effect was observed, where mindfulness influenced reactive and proactive aggression through impulsivity, which subsequently impacted inhibition dysfunction. Sex moderated the relationship between inhibition dysfunction and both types of aggression, with a stronger effect for males. The findings support the I3 model and the General Aggression Model, suggesting that interventions targeting mindfulness could be beneficial in reducing aggression among adolescents by reducing impulsivity and improving inhibition function, particularly for males.

Mindfulness-based stress reduction (MBSR) for improving hope and happiness in men with visual impairment

Article

Nov 2024

Hope and happiness are positive emotions that affect an individual’s thoughts, feelings, and behavior. These two variables also affect different aspects of an individual’s life such as physical health, lifespan, academic performance, socialization process, creative thinking, problem-solving ability, and mental health. This study seeks to examine the effectiveness of mindfulness-based stress reduction (MBSR) in improving hope and happiness in visually impaired people. Employing a quasi-experimental pre-test–post-test design with a control group, this study sought to examine the degree of the effectiveness of MBSR therapy in improving hope and happiness in visually impaired people. The participants were selected from all visually impaired men aged 20 and 40 living in Tehran in 2023, who were supported by the State Welfare Organization of Iran and were members of the White Cane Society. A total of 40 visually impaired people were selected as the participants and randomly assigned to intervention and control groups (each with 20 members). The data were collected using Snyder’s Adult Hope Scale (1991) and Oxford Happiness Questionnaire (OHQ; 1990). The participants in the intervention group attended eight 90-min MBSR intervention sessions once a week. One-way analysis of covariance (ANCOVA) was used to analyze the data. The mean hope scores in the pre-intervention and post-intervention stages were 20 ± 3.28 and 25.53 ± 3.138, respectively. The mean happiness scores in the pre-intervention and post-intervention stages were 66.86 ± 5.91 and 75.93 ± 4.47, respectively (mean difference = 75.93 – 66.86). The findings showed that MBSR was effective in improving hope ( F = 32.7; p = .01) and happiness ( F = 45.86; p < .001) in men with visual impairment. As a result, MBSR can be considered an effective intervention to enhance happiness and hope while reducing the psychological complications associated with visual impairment in affected individuals.

Do mindfulness interventions cause harm? Findings from the Learning to Apply Mindfulness to Pain (LAMP) Pragmatic Clinical Trial

Article

Nov 2024

Background Although mindfulness-based interventions (MBIs) are widely used in clinical and nonclinical settings, there has been little systematic study of their potential risks. To address this gap, we examined differences in psychological and physical worsening among participants in the usual care and intervention conditions of a 3-group, randomized pragmatic trial (Learning to Apply Mindfulness to Pain [LAMP]) that tested the effectiveness of 2 approaches to delivering MBIs to patients with chronic pain. Methods The sample consisted of 374 male and 334 female patients with chronic pain enrolled in the LAMP trial who completed a 10-week follow-up survey, 61% of whom had a mental health diagnosis. Psychological and physical worsening was assessed by a checklist asking whether participants experienced specific symptoms since beginning the study. We used multivariable logistic regression models with imputed data to determine whether predicted probabilities of increased symptoms differed between usual care and the 2 MBIs. Results Participants in usual care were more likely to report experiencing increased psychological and physical worsening than were those in the MBIs, including an increase in disturbing memories; sadness, anxiousness, and fatigue; isolation and loneliness; and feeling more upset than usual when something reminded them of the past. Conclusions MBIs do not appear to cause harm, in terms of increased symptoms, for this population of patients with chronic pain and high levels of mental health comorbidities. Clinical trial registration Preregistration with an analysis plan at www.ClinicalTrials.gov: NCT04526158. Patient enrollment began December 4, 2020.

Research Review: The effects of mindfulness‐based interventions on cognition and mental health in children and adolescents – a meta‐analysis of randomized controlled trials

Article

Full-text available

Oct 2018
J CHILD PSYCHOL PSYC

Background Mindfulness based interventions (MBIs) are an increasingly popular way of attempting to improve the behavioural, cognitive and mental health outcomes of children and adolescents, though there is a suggestion that enthusiasm has moved ahead of the evidence base. Most evaluations of MBIs are either uncontrolled or nonrandomized trials. This meta‐analysis aims to establish the efficacy of MBIs for children and adolescents in studies that have adopted a randomized, controlled trial (RCT) design. Methods A systematic literature search of RCTs of MBIs was conducted up to October 2017. Thirty‐three independent studies including 3,666 children and adolescents were included in random effects meta‐analyses with outcome measures categorized into cognitive, behavioural and emotional factors. Separate random effects meta‐analyses were completed for the seventeen studies (n = 1,762) that used an RCT design with an active control condition. Results Across all RCTs we found significant positive effects of MBIs, relative to controls, for the outcome categories of Mindfulness, Executive Functioning, Attention, Depression, Anxiety/Stress and Negative Behaviours, with small effect sizes (Cohen's d), ranging from .16 to .30. However, when considering only those RCTs with active control groups, significant benefits of an MBI were restricted to the outcomes of Mindfulness (d = .42), Depression (d = .47) and Anxiety/Stress (d = .18) only. Conclusions This meta‐analysis reinforces the efficacy of using MBIs for improving the mental health and wellbeing of youth as assessed using the gold standard RCT methodology. Future RCT evaluations should incorporate scaled‐up definitive trial designs to further evaluate the robustness of MBIs in youth, with an embedded focus on mechanisms of action.

Mindfulness-based interventions in the workplace: An inclusive systematic review and meta-analysis of their impact upon wellbeing

Article

Full-text available

Sep 2018

Given the demanding nature of many professions, efforts are ongoing to develop initiatives to improve occupational wellbeing, including mindfulness-based interventions (MBIs). To assess the efficacy of MBIs, meta-analytic procedures were conducted on 35 randomized controlled trials derived from an earlier inclusive systematic literature search (covering all occupations, MBIs, and wellbeing-related outcomes). Mindfulness had significant moderate effects on deficit-based outcomes such as stress (SMD = −0.57), anxiety (SMD = −0.57), distress (SMD = −0.56), depression (SMD = −0.48), and burnout (SMD = −0.36), and significant moderate to small effects on asset-based outcomes like health (SMD = 0.63), job performance (SMD = 0.43), compassion and empathy (SMD = 0.42), mindfulness (SMD = 0.39), and positive wellbeing (SMD = 0.36), while no significant effects were observed for depression or emotional regulation. However, the quality of the studies was inconsistent, suggesting more high-quality randomised controlled trials are needed.

The Safety of Mindfulness-Based Interventions: a Systematic Review of Randomized Controlled Trials

Article

Full-text available

Oct 2018
Mindfulness

The rapid growth of mindfulness-based interventions (MBIs) has raised questions regarding their safety. This review aimed to quantify the adverse events of mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) reported in randomized control trials (RCTs) which included a statement of monitoring of adverse events. Literature was searched from the OVID databases until August 2017. A total of 36 RCTs were identified from 7931 search records, with 25 trials using MBSR and 11 trials using MBCT. A total of 19 (1%) and 19 (0.9%) adverse events were reported in the mindfulness intervention group and control group, respectively. In the MBSR group, none of them reported serious adverse event, and only three (12.0%) studies reported six (0.49%) intervention-related adverse events from among 1231 participants. No significant difference between the MBSR intervention and control groups was observed (6/1231 vs. 2/1244; risk difference (95% CI) = 0.0033 (− 0.01 to 0.01)). In the MBCT group, no intervention-related adverse events were reported, and only one trial reported ten (1.5%) cases of intervention-unrelated adverse events from 768 participants. No statistically significant difference in terms of the reported adverse events between the intervention and control groups was observed in the MBCT trials. Only a small proportion of trials reported monitoring of adverse events. Very few adverse events were reported in RCTs that used MBSR/MBCT. The MBSR/MBCT is regarded as relatively safe interventions. However, future studies are highly encouraged to report adverse events in mindfulness interventions for more affirmative conclusions.

Mindfulness-based interventions for psychiatric disorders: A systematic review and meta-analysis

Article

Full-text available

Nov 2017
CLIN PSYCHOL REV

Despite widespread scientific and popular interest in mindfulness-based interventions, questions regarding the empirical status of these treatments remain. We sought to examine the efficacy of mindfulness-based interventions for clinical populations on disorder-specific symptoms. To address the question of relative efficacy, we coded the strength of the comparison group into five categories: no treatment, minimal treatment, non-specific active control, specific active control, and evidence-based treatment. A total of 142 non-overlapping samples and 12,005 participants were included. At post-treatment, mindfulness-based interventions were superior to no treatment (d=0.55), minimal treatment (d=0.37), non-specific active controls (d=0.35), and specific active controls (d=0.23). Mindfulness conditions did not differ from evidence-based treatments (d=-0.004). At follow-up, mindfulness-based interventions were superior to no treatment conditions (d=0.50), non-specific active controls (d=0.52), and specific active controls (d=0.29). Mindfulness conditions did not differ from minimal treatment conditions (d=0.38) and evidence-based treatments (d=0.09). Effects on specific disorder subgroups showed the most consistent evidence in support of mindfulness for depression, pain conditions, smoking, and addictive disorders. Results support the notion that mindfulness-based interventions hold promise as evidence-based treatments.

Baseline Patterns of Substance Use Disorder Severity and Depression and Anxiety Symptoms Moderate the Efficacy of Mindfulness-Based Relapse Prevention

Article

Full-text available

Nov 2017

Objective: Few studies have evaluated moderators of mindfulness-based relapse prevention (MBRP) for substance use disorders (SUDs). We tested whether baseline patterns of scores for SUD symptom severity and depression and anxiety symptoms moderated the efficacy of MBRP. Method: We used a latent class moderation approach with data from a randomized trial of MBRP compared to cognitive-behavioral relapse prevention and treatment as usual (TAU; Bowen et al., 2014; N = 286, 71.8% male, 48.4% non-White, mean age = 38.44 years, SD = 10.92) and a randomized trial comparing MBRP to TAU (Bowen et al., 2009; N = 168, 63.7% male, 44.6% non-White, mean age = 40.45, SD = .28). Indicators for the latent class models were measures of SUD severity (Severity of Dependence Scale and Short Inventory of Problems), depression symptoms (Beck Depression Inventory), and anxiety symptoms (Beck Anxiety Inventory). Results: In both trials, 3 latent classes provided the best fit: a high-high class characterized by high SUD severity and depression and anxiety symptoms, a high-low class characterized by high SUD severity and low depression and anxiety symptoms, and a low-low class characterized by low SUD severity and depression and anxiety symptoms. In both trials, we found significant latent Class × Treatment interaction effects: There were significant and large effects of MBRP on substance use outcomes in the high-high and high-low classes, but no MBRP effect in the low-low class. Conclusion: MBRP may be an optimal treatment for preventing relapse among clients with severe levels of SUD symptoms and depression and anxiety symptoms, as well as clients with only severe SUD symptoms. (PsycINFO Database Record

Unwanted effects: Is there a negative side of meditation? A multicentre survey

Article

Full-text available

Sep 2017
PLOS ONE

Objectives Despite the long-term use and evidence-based efficacy of meditation and mindfulness-based interventions, there is still a lack of data about the possible unwanted effects (UEs) of these practices. The aim of this study was to evaluate the occurrence of UEs among meditation practitioners, considering moderating factors such as the type, frequency, and lifetime duration of the meditation practices. Methods An online survey was developed and disseminated through several websites, such as Spanish-, English- and Portuguese-language scientific research portals related to mindfulness and meditation. After excluding people who did not answer the survey correctly or completely and those who had less than two months of meditation experience, a total of 342 people participated in the study. However, only 87 reported information about UEs. Results The majority of the practitioners were women from Spain who were married and had a University education level. Practices were more frequently informal, performed on a daily basis, and followed by focused attention (FA). Among the participants, 25.4% reported UEs, showing that severity varies considerably. The information requested indicated that most of the UEs were transitory and did not lead to discontinuing meditation practice or the need for medical assistance. They were more frequently reported in relation to individual practice, during focused attention meditation, and when practising for more than 20 minutes and alone. The practice of body awareness was associated with UEs to a lesser extent, whereas focused attention was associated more with UEs. Conclusions This is the first large-scale, multi-cultural study on the UEs of meditation. Despite its limitations, this study suggests that UEs are prevalent and transitory and should be further studied. We recommend the use of standardized questionnaires to assess the UEs of meditation practices.

The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists

Article

Full-text available

May 2017
PLOS ONE

Buddhist-derived meditation practices are currently being employed as a popular form of health promotion. While meditation programs draw inspiration from Buddhist textual sources for the benefits of meditation, these sources also acknowledge a wide range of other effects beyond health-related outcomes. The Varieties of Contemplative Experience study investigates meditation-related experiences that are typically underreported, particularly experiences that are described as challenging, difficult, distressing, functionally impairing, and/or requiring additional support. A mixed-methods approach featured qualitative interviews with Western Buddhist meditation practitioners and experts in Theravāda, Zen, and Tibetan traditions. Interview questions probed meditation experiences and influencing factors, including interpretations and management strategies. A follow-up survey provided quantitative assessments of causality, impairment and other demographic and practice-related variables. The content-driven thematic analysis of interviews yielded a taxonomy of 59 meditation-related experiences across 7 domains: cognitive, perceptual, affective, somatic, conative, sense of self, and social. Even in cases where the phenomenology was similar across participants, interpretations of and responses to the experiences differed considerably. The associated valence ranged from very positive to very negative, and the associated level of distress and functional impairment ranged from minimal and transient to severe and enduring. In order to determine what factors may influence the valence, impact, and response to any given experience, the study also identified 26 categories of influencing factors across 4 domains: practitioner-level factors, practice-level factors, relationships, and health behaviors. By identifying a broader range of experiences associated with meditation, along with the factors that contribute to the presence and management of experiences reported as challenging, difficult, distressing or functionally impairing, this study aims to increase our understanding of the effects of contemplative practices and to provide resources for mediators, clinicians, meditation researchers, and meditation teachers.

The Role of Health Professionals in Influencing Patient Compliance

Chapter

Apr 2020

Richard Schulz

Practitioner's Guide to Ethics and Mindfulness-Based Interventions

Book

Jan 2017

This book focuses on the role of ethics in the application of mindfulness-based interventions (MBIs) and mindfulness-based programs (MBPs) in clinical practice. The book offers an overview of the role of ethics in the cultivation of mindfulness and explores the way in which ethics have been embedded in the curriculum of MBIs and MBPs. Chapters review current training processes and examines the issues around incorporating ethics into MBIs and MBPs detailed for non-secular audiences, including training clinicians, developing program curriculum, and dealing with specific client populations. Chapters also examine new, second-generation MBIs and MBPs, the result of the call for more advanced mindfulness-based practices . The book addresses the increasing popularity of mindfulness in therapeutic interventions, but stresses that it remains a new treatment methodology and in order to achieve best practice status, mindfulness interventions must offer a clear understanding of their potential and limits. Topics featured in this book include: • Transparency in mindfulness programs. • Teaching ethics and mindfulness to physicians and healthcare professionals. • The Mindfulness-Based Symptom Management (MBSM) program and its use in treating mental health issues. • The efficacy and ethical considerations of teaching mindfulness in businesses. • The Mindful Self-Compassion (MSC) Program. • The application of mindfulness in the military context. Practitioner’s Guide to Mindfulness and Ethics is a must-have resource for clinical psychologists and affiliated medical, and mental health professionals, including specialists in complementary and alternative medicine and psychiatry. Social workers considering or already using mindfulness in practice will also find it highly useful.

A meta-analytic investigation of the impact of mindfulness-based interventions on post traumatic stress

Article

Aug 2017

A number of studies have investigated the impact of mindfulness-based interventions on symptoms of post-traumatic stress (PTSD) compared to control conditions. The current meta-analysis consolidated findings from 18 studies reporting results for 21 samples of participants. Across studies, mindfulness-based treatments compared to control conditions were effective in ameliorating symptoms of PTSD, with Hedges' g = − 0.44. Hedges' g was − 0.59 for comparison of mindfulness-based interventions to waitlist control conditions. Changes in mindfulness may underpin the effect of mindfulness-based interventions on PTSD symptoms and thus the meta-analysis examined findings regarding increases in mindfulness. The 12 studies that assessed mindfulness found that the interventions significantly increased mindfulness, Hedges' g = 0.52. Moderator analyses indicated that interventions with longer mindfulness training were more efficacious in reducing symptoms of PTSD. Across studies, gender, age, veteran status, or length of time between the intervention and assessment of PTSD symptoms did not moderate the impact of mindfulness-based interventions. The results provide a foundation for future research directions and have implications for work with those impacted by trauma.

Doing no harm in mindfulness-based programs: Conceptual issues and empirical findings

Abstract and Figures

Recommended publications

Psicoterapia y farmacoterapia en el tratamiento de la depresión mayor

Review of The pharmacologic basis of therapeutics: An introduction for psychologists.

Antidepressants vs. psychotherapy in the treatment of bulimia nervosa

Normal and abnormal anxiety in the age of DSM-5 and ICD-11