Mindfulness-Based Programs: Why, When, and How to Adapt?

Abstract

This paper provides a framework for understanding why, when, and how to adapt mindfulness-based programs (MBPs) to specific populations and contexts, based on research that developed and adapted multiple MBPs. In doing so, we hope to support teachers, researchers and innovators who are considering adapting an MBP to ensure that changes made are necessary, acceptable, effective, cost-effective, and implementable. Specific questions for reflection are provided such as: (1) Why is an adaptation needed? (2) Does the theoretical premise underpinning mainstream MBPs extend to the population you are considering? (3) Do the benefits of the proposed adaptation outweigh the time and costs involved to all in research and implementation? (4) Is there already an evidenced-based approach to address this issue in the population or context? Fundamental knowledge that is important for the adaptation team to have includes: (1) essential ingredients of MBPs, (2) etiology of the target health outcome, (3) existing interventions that work for the health outcome, population, and context, (4) delivery systems and settings, and (5) culture, values, and communication patterns of the target population. A series of steps to follow for adaptations is provided, as are case examples. Adapting MBPs happens not only by researchers, but also by MBP teachers and developers, who endeavour to best serve the populations and contexts they work within. We hope that these recommendations for best practice provide a practical framework for skilfully understanding why, when, and how to adapt MBPs; and that this careful approach to adaptation maximizes MBP safety and efficacy.

Full text

Intervention Fidelity in Mindfulness-Based Research and Practice –Feature Article
Global Advances in Health and Medicine
Volume 11: 1–12
© The Author(s) 2022
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DOI: 10.1177/21649561211068805
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Mindfulness-Based Programs: Why, When,
and How to Adapt?
Eric B. Loucks, PhD
1,2,3
, Rebecca S. Crane, PhD
4
, Menka A. Sanghvi, MAJ
5
,
Jes ´
us Montero-Marin, PhD
6,7
, Jeffrey Proulx, PhD
2,3
, Judson A. Brewer, MD, PhD
2,3
, and
Willem Kuyken, PhD
6,7

Abstract
This paper provides a framework for understanding why, when and how to adapt mindfulness-based programs (MBPs) to
specific populations and contexts, based on research that developed and adapted multiple MBPs. In doing so, we hope to
support teachers, researchers and innovators who are considering adapting an MBP to ensure that changes made are necessary,
acceptable, effective, cost-effective, and implementable. Specific questions for reflection are provided such as (1) Why is an
adaptation needed? (2) Does the theoretical premise underpinning mainstream MBPs extend to the population you are
considering? (3) Do the benefits of the proposed adaptation outweigh the time and costs involved to all in research and
implementation? (4) Is there already an evidenced-based approach to address this issue in the population or context? Fun-
damental knowledge that is important for the adaptation team to have includes the following: (1) essential ingredients of MBPs,
(2) etiology of the target health outcome, (3) existing interventions that work for the health outcome, population, and context,
(4) delivery systems and settings, and (5) culture, values, and communication patterns of the target population. A series of steps
to follow for adaptations is provided, as are case examples. Adapting MBPs happens not only by researchers, but also by MBP
teachers and developers, who endeavor to best serve the populations and contexts they work within. We hope that these
recommendations for best practice provide a practical framework for skilfully understanding why, when, and how to adapt
MBPs; and that this careful approach to adaptation maximizes MBP safety and efficacy.
Keywords
mindfulness, study design, implementation, dissemination
Received August 11, 2021. Accepted for publication December 3, 2021
Introduction
Case Example 1:Alejandro Zima is a bilingual
Spanish/English Licensed Mental Health Counselor
and Mindfulness-Based Stress Reduction (MBSR)
teacher. He specializes in grief counseling. Alejandro
was considering whether to offer MBSR in a hospice
setting to family members of hospice patients, par-
ticularly in their second year of grief or later as a “step
beyond”program. His hospice setting already offered
effective psychoeducational and counseling programs
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1
Department of Epidemiology, Brown University School of Public Health,
Providence, RI, USA
2
Department of Behavioral and Social Sciences, Brown University School of
Public Health, Providence, RI, USA
3
Mindfulness Center, Brown University, Providence, RI, USA
4
Centre for Mindfulness Research and Practice, School of Psychology, Bangor
University, Bangor, UK
5
The Mindfulness Initiative, Sheffield, UK
6
Department of Psychiatry, Oxford University, Oxford, UK
7
Oxford Mindfulness Centre, Oxford University, Oxford, UK
Corresponding Author:
Eric B. Loucks, Department of Epidemiology, Brown University School of
Public Health, 121 South Main St, Providence, RI 02912, USA.
Email: eric.loucks@brown.edu

for the first year of grief (some that included basic
mindfulness training) but there was a gap in effective
programs beyond that time. In fact, most participants in
his MBSR programs had participated in prior grief
support programs and/or were currently receiving
ongoing counseling supports. Informed by his training
in MBSR, counseling theory, grief support method-
ologies, trauma-sensitive mindfulness, and post-
traumatic growth, Alejandro felt that MBSR would
likely be effective, but with a few tailored consider-
ations in the participant screening process and curric-
ular modifications, to help it better support people who are
healing following the passing of a loved one.
Case Example 2: Eric Loucks, a cardiovascular epi-
demiologist and MBSR teacher, was interested in
whether MBSR might reduce risk for cardiovascular
disease. Turning to the scientific literature, the effects of
MBSR in a systematic review and meta-analysis showed
reductions of systolic blood pressure of 6.6 (95% CI:
11.7, 1.5) mmHg at immediate post-intervention
follow-up.
1
Long-term effects are not yet clear.
1
He
already knew research showed that major drivers of
blood pressure are diet, physical activity, obesity, ex-
cessive alcohol consumption, and antihypertensive
medication adherence, which MBSR does not explicitly
address other than through yoga training.
2
He wondered
if MBSR’s effects could be boosted, and MBSR be more
accepted by people with hypertension, if its curriculum
more explicitly directed mindfulness skill development
to participants’health behaviors that affect blood
pressure (detailed elsewhere).
3
Case example 3. Mark Williams, a clinical psychologist
was interviewed about Mindfulness-Based Cognitive
Therapy (MBCT) for depression by a journalist, Danny
Penman, for an article in a UK national newspaper. They
got to talking about whether MBCT might go beyond
depression to help all of us who are struggling with the
everyday demands and challenges of life, including
whether it could support well-being in the wider pop-
ulation. They collaborated on answering these questions
andwroteabook,Mindfulness –A Practical Guide to
Finding Peace in a Frantic World, that has been read by
more than 1.5 million people and translated into more
than 30 languages.
4
The work has been developed,
implemented and researched as an in-person course.
5,6
There has been an explosion of interest in mindfulness-based
programs (MBPs).
7-9
MBSR, which teaches mindfulness practices
in group settings over an 8-week period using an established
curriculum, has undergone hundreds of randomized control trials
from which systematic reviews and meta-analyses show effects on
outcomes such as stress, anxiety symptoms, depressive symptoms
and chronic pain management.
7-11
MBCT integrates MBSR with
cognitive behavioral therapy (CBT) in ways that target the vul-
nerability factors for people at risk of recurrent depression. MBCT
and MBSR have increasingly demonstrated effectiveness and cost-
effectiveness, providing millions of people with choices about how
best to recover and stay well in the longer term.
8,12
Partially because of this careful work to develop and
research MBSR and MBCT, there is growing awareness of,
and demand for, MBPs in new populations and contexts. This
has led to a proliferation of MBP innovations with potential to
improve outcomes in target populations. However, there are
also costs and downsides to adaptations. Careful adaptation is
time and resource intensive. It requires research to investigate
the acceptability, effectiveness and cost-effectiveness, and
whether the adaptations work through hypothesized mech-
anisms. A key question is whether adaptations add value to
other already available evidence-based programs. Finally,
even if the adaptation proves to be acceptable and cost-
effective, real-world implementation is complex and time
consuming (such as training teachers, developing digital
platforms and persuading policy groups to recommend it).
Theory and research point to the facilitators and barriers
involved in navigating an evidence-based MBP to targeted
populations and new contexts.
13-16
Nonetheless, there are several excellent examples of MBPs
adaptedtospecific populations and contexts, such as depression
(MBCT),
8
binge eating disorder (Mindfulness-Based Eating
Awareness Training),
17
relapse prevention (Mindfulness-Based
Relapse Prevention),
18
cancer (Mindfulness-Based Cancer Re-
covery),
19
and blood pressure (Mindfulness-Based Blood Pres-
sure Reduction).
20
There are increasing adaptations to specific
demographic groups, such as young adults (Mindfulness-Based
College),
21
military personnel (Mindfulness-Based Mind Fitness
Training, Mindfulness-Based Attention Training),
22
those with
trauma history,
23
expectant parents (Mindfulness-Based Child-
birth and Parenting Program),
24
and Native American commu-
nities (NativeMIND).
25
There are many more, and the evidence
base and penetration of these MBPs varies greatly, from early
preliminary studies (e.g., NativeMIND), through to extensive
evidence and implementation around the world (MBCT). In some
cases, implementation far outstrips the evidence, for example,
with some mainstream mindfulness apps that are used by millions
internationally. There are early promising findings for adaptations
to online delivery formats: for example, randomized controlled
trial showed online MBCT effectively prevents depression re-
lapse
26
; a pilot single-arm trial show the Eat Right Now app
improved emotional eating
27
; a systematic review of face-to-face
MBPs delivered through videoconferencing online suggests
beneficial effects.
28
A growing number of resources are available to guide and
support MBP adaptation. These include established best practice
methods for developing behavioral change interventions (Table
1), including the Science of Behavior Change framework,
29
MRC Guidelines on Complex Intervention Development,
30
Theory of Change,
31
National Institutes of Health Stage
Model,
16
Multiphasic Optimization Strategy (MOST),
32
2Global Advances in Health and Medicine

amongst others. The Fieldbook for Mindfulness Innovators is a
resource for making minor adaptations to existing MBPs,
throughtocreatingcompletelynewMBPs.
33
It emphasizes
design thinking, prototyping, and offers steps for building ev-
idence. Some textbooks describe examples of MBPs that have
been adapted to specific populations and contexts.
34,35
Dobkin
Table 1. Established Models for Behavioral Intervention Development.
Model Description
NIH Stage Model
15,16
•Strong emphasis on carrying behavioral clinical trials through all clinical trial stages, including
basic research for intervention development, research on mechanisms, efficacy and
effectiveness testing, as well as implementation and dissemination research in the actual
communities and settings the intervention ends up serving
Science of Behavior Change (SOBC)
29
•Focuses on identifying mechanisms of behavior change first as an early indicator of effect, and as
a potential target to customize interventions to engage with
•Emphasizes evaluating the degree to which changes in the mechanisms translate into meaningful
behavior change
•Can foster creating efficient interventions customized to target the mechanisms of behavior
change, while cleaving out superfluous intervention content that does not impact health
ORBIT Model
38
•Incorporates basic behavioral and social science insights into a four-stage model of sequential
intervention development and testing from phase I (intervention design) to phase IV
(intervention effectiveness) testing
MRC Guidelines on Complex Intervention
Development
30
•Provides a framework for complex behavioral intervention development
A. “Pre-Clinical”or Theoretical Phase: Identify theory to ensure best choice of intervention and
hypotheses, and pinpoint confounders and challenges in intervention design
B. Phase 1 or Modeling: Identify components of the intervention, and the underlying mechanisms
by which they influence health outcomes, in order to predict how the components are related
to, and interact with, each other
C. Phase 2 or Exploratory Trial: Describe the constant and variable components of an intervention
that should be replicable, and a protocol for comparing the feasibility of the intervention to an
appropriate control
D. Phase 3 or Main Trial: Compare the well-defined intervention to an appropriate control, using a
theoretically sound, reproducible, methodologically rigorous protocol
E. Phase 4 or Long-Term Surveillance: Determine whether others can reliability replicate the
intervention and results in controlled settings over the long-term
Theory of Change (ToC)
31
•Interventions developed in collaboration with a wide variety of stakeholders
•Encompasses strategic considerations such as including beneficiaries, actors in the context,
sphere of influence, research evidence supporting the ToC, timelines, and indicators
•Emphasizes developing the theory by which the intervention is expected to change clinically
relevant outcomes. By deeply understanding and developing the theory through recursive
feedback from key stakeholders and scientificfindings, it argues that more efficient and
effective interventions can be developed
Community-Based Participatory Research
(CBPR)
39
•Focuses on active involvement of community members, organizational representatives, and
researchers in the entire research process
•Several key principles, identified by Israel et al., 52 are
A. Recognizes community as a unit of identity
B. Builds on strengths and resources within the community
C. Facilitates collaborative partnerships in all phases of the research
D. Integrates knowledge and action for mutual benefit of all partners
E. Promotes a co-learning and empowering process that attends to social inequalities
F. Involves a cyclical and iterative process
G. Addresses health from both positive and ecological perspectives
H. Disseminates findings and knowledge gained to all partners
Multiphasic Optimization Strategy (MOST)
32
•Uses a three-phase design to identify the active and inactive components of interventions in
order to make them efficient and effective. The phases are
A. Preparation, in which a conceptual model is created, and pilot testing of intervention
components is performed. Careful consideration is given to balancing effectiveness,
affordability, scalability, and efficiency (EASE)
B. Optimization, where the investigators select the components and component levels within the
intervention, often using an optimization trial
C. Evaluation, using a randomized controlled trial comparing the optimized interventions to an
appropriate control group
Loucks et al. 3

et al. provide recommendations on staying true to core
MBSR teaching intentions and program components, when
adapting for specific populations and contexts.
36
In response
to the proliferation in the field, some of the first- and second-
generation MBP developers created a consensus statement
that describes the essential theoretical and curriculum ele-
ments of MBPs, and was written to support the sustainable
development of the field.
37
This paper, entitled What De-
fines Mindfulness-Based Programs? The Warp and the Weft,
outlines both MBPs’essential elements (the warp) and the
flexible elements that can be adapted for particular pop-
ulations and contexts (the weft) (Table 2 ).
This paper is a sequel to the warp and weft paper,
providing a detailed framework on why, when and how to
adapt MBPs to specific populations and contexts. Cur-
rently, such a framework for MBP adaptation is absent in
the literature. We start by addressing the obvious first
questions: “Why is an adaptation necessary?”“When
should I adapt, and when shouldn’tI?”We then go on to
address the question, “How should I adapt for this pop-
ulation or context?”Our intention is to support MBP
teachers (case example 1), researchers (case example 2)
and innovators (case example 3) in considering whether
and how to adapt MBPs. In doing so, we hope to support
participants and the wider field by ensuring MBP teaching
is acceptable, effective, cost-effective, implementable,
and underpinned by best professional ethical codes and
practices. While considering adapting MBPs, we encourage
qualities such as humility, curiosity, open-mindedness,
clarity about aims, embracing diverse and challenging
voices, listening, testing, iterating, improving, and contin-
ued engagement with personal mindfulness practice. In
these ways, we anticipate that adaptations will have the
greatest likelihood of being safe and helpful.
Why and When to Adapt an MBP?
Any MBP taught by a skillful teacher is continually being
tailored and responsively tuned moment-by-moment to the
individual, group and context. Teachers are always for-
mulating and reformulating what is needed to support
participants’learning, fine-tuning their teaching to ensure it
is inclusive and supports individual participants and the
needs of the whole group.
40
Forexample,stressorde-
pression are experienced in both similar and unique ways,
and good MBP teaching accommodates this universality and
specificity. The questions in Tabl e 3 critically analyze why
and when to go beyond these expected adaptations to more
systematically adapt an MBP to a particular context or
population.
How to Adapt an MBP?
In order to develop an effective adapted MBP, there are
fundamental knowledge domains required in the develop-
mental team (see Figure 1).
Table 2. Description of Essential (Warp) and Flexible (Weft) Ingredients of MBPs and MBP Teachers Adapted From Crane et al.
37
Warp: Essential ingredients
MBP MBP teacher
1. Is informed by theories and practices that draw from a confluence of
contemplative traditions, science, and the major disciplines of
medicine, psychology and education
1. Has particular competencies which enable the effective delivery of
the MBP.
2. Is underpinned by a model of human experience which addresses the
causes of human distress and the pathways to relieving it
2. Has the capacity to embody the qualities and attitudes of
mindfulness within the process of the teaching
3. Develops a new relationship with experience, characterized by
present moment focus, decentering and an approach orientation
(i.e., moving towards experience—whether pleasurable, neutral or
difficult—instead of away)
3. Has engaged in appropriate training and commits to ongoing good
practice
4. Engages the participant in a sustained intensive training in
mindfulness meditation practice, in an experiential inquiry-based
learning process and in exercises to develop insight and
understanding
4. Is part of a participatory learning process with their students,
clients or patients
Weft: Flexible ingredients
MBP MBP teacher
1. The core essential curriculum elements are integrated with adapted
curriculum elements, and tailored to specific contexts and
populations
1. Has knowledge, experience and professional training related to the
specialist populations that the mindfulness-based course will be
delivered to
2. Variations in program structure, length and delivery are formatted
to fit the population and context
2. Has knowledge of relevant underlying theoretical processes which
underpin the teaching for particular contexts or populations
4Global Advances in Health and Medicine

Table 3. Five Questions for Reflection in Considering Whether or Not to Adapt an MBP.
Question Description
1. Why is an adaptation needed? Does a current MBP not meet the population being
served? For example, is the adaptation minor (i.e., within the remit of the teacher’s
ability to dial up/down certain features of an extant MBP for the population/ context) or
is the necessary adaptation more major, and so requires the MBP curriculum and/or
teaching process itself to be adapted?
•MBSR teachers offer MBSR in numerous settings and populations. An extensive evidence-
base attests to MBSR’s acceptability and effectiveness
1
•Case example 1 of teaching MBSR in a hospice setting illustrates these questions of flex or
adaptation. There is a substantial evidence-base showing MBSR reduces stress and
improves mental health.
4
Alejandro reasoned, informed by his clinical experience and the
literature, that the practice of mindfulness during grief recovery could create space for
careful observation, self-awareness and compassionate engagement with a griever’s varied
emotions.
2
Giving full attention to the griever’s own emotional state may allow for greater
acceptance of these emotional ongoing changes as an important, though challenging, part of
the grief process. Overall, he discerned these practices could lead to more effective
integration of the sometimes overwhelming internal and external shifts associated with
loss. In Alejandro’s hospice setting, the people he considered for taking the MBSR program
were family members of hospice patients who had already participated in other individual
or group grief counseling programs, had concurrent psychosocial supports, had
participated in shorter mindfulness-based support sessions or had their own previous
mindfulness practice, were at least 9 months from the time of the loss (as other effective
programs were already in place in his hospice setting for more recent bereavement grief),
and were screened for standard mental health exclusion criteria. Alejandro felt that MBSR
was appropriate, but with some key adjustments to better meet this population, such as
A. Ensuring the class only includes those who were grieving, to create a safe environment
where everyone had a shared history
B. During the teaching on stress physiology, include more on the neurobiology of loss and
grief
C. Adapt some of the poetry to relate more specifically to grief and impermanence
D. Offer flexibility with the length of meditation practices
E. Ensure the program is led by a grief counselor within the hospice setting to meet any
clinical needs of participants as they arise
F. Emphasize self-compassion throughout
•By staying true to MBSR form but making minor shifts to the curriculum, teaching process,
and teacher experience, Alejandro felt confident he could draw on MBSR evidence and
practice while ensuring it skilfully met this population
2. Does the theoretical premise underpinning mainstream MBPs extend to the population
you are considering? If not, what theoretical adaptation is needed?
•MBPs share a theoretical formulation based in ancient wisdom and modern psychology that
provides a map of the foundational skills that any MBP curriculum addresses: attention,
perspective and self-regulation.
3
However, sometimes an overlay of a more specific
theoretical formulation is required for particular issues or populations. For example, when
MBCT for depression was being developed, the challenge was finding cost-effective
strategies that enabled people to stay well in the long term. The development process for
MBCT sought to use the theoretical formulation of reactivity at times of potential
depressive relapse alongside existing CBT strategies (such as behavioral activation and
psychoeducation), with intensive training in mindfulness. The rationale was that this would
target the mechanisms of depressive relapse more thoroughly than existing approaches
had achieved. The evidence has largely borne this out
4
(continued)
Loucks et al. 5

Table 3. (continued)
Question Description
3. Does the existing MBP curriculum extend to the population and context you are
considering? If not, what adaptation (weft) is needed?
•Beyond theory, it is also important to consider both the MBP curriculum and how it is
delivered. For example, many settings do not provide two-hour time windows for classes
(e.g., schools), so different formats are needed
•Adaptations may be required to increase MBPs’reach. For example, when Dr. Brewer, an
addictions psychiatrist and mindfulness researcher was leaving work one day, he saw a group
of people in the parking lot smoking and looking at their smart phones. Dr. Brewer thought,
“If I could bring mindfulness training to them through their smartphones, it could serve so
many more people.”He developed an app-delivered MBP for smoking cessation, named
Craving to Quit. While much of the learning is asynchronous via a smartphone app, trained
MBP teachers are also available to provide live, synchronous mindfulness practices followed
by inquiry-based learning for participants to give feedback and guidance on their learning and
development. Preliminary and RCT evidence suggests it is acceptable and effective
5
•There are many examples where adaptations are necessary to make the curriculum
accessible and maximally potent. A UK review of MBPs in healthcare, workplaces, prisons
and educational settings provided exemplars, as well as recommendations for research and
implementation
6
4. Do the benefits of an adaptation outweigh the time and costs involved to all in research
and implementation? Is the adaptation likely to be sustainable and create long-term
value?
•The work on CBT over 50 years is an instructive model. When Beck started this work on
CBT for depression there were few evidence-based approaches to depression, let alone
other common mental health problems. The case for accessible, evidence-based, scalable
psychological treatments was easy to make. Beck and colleagues developed CBT adaptions
for anxiety disorder, substance abuse disorders, personality disorders, eating disorders
and psychosis.
7
Each adaptation involved at minimum the publication of a therapist manual,
randomized controlled trials demonstrating effectiveness, both against usual care and
superiority trials against other treatments, bespoke therapist training and sustained
implementation. This extensive and sustained programmatic work means that CBT is now
widely available around the world, and in many countries is part of primary care public
health service
•MBPs have gone through their own developmental process. Kabat-Zinn’s original
formulation of MBSR was based on a universal model of the mind and body for
heterogeneous groups.
35
Work has focused on its effectiveness and implementation
around the world, and there have been numerous adaptations
1,8
•But in contrast to CBT, the question of bespoke adaptations came second, with MBCT for
recurrent depression perhaps being the most extensively researched
4
and implemented
over the last 20 years. MBCT for recurrent depression is now recommended in clinical
guidelines in numerous countries and is becoming increasingly accessible. However, many
other MBP adaptations have not been subjected to the same process leaving major
research and implementation gaps; arguably this is in part because the time and costs of
developing a new adaptation (e.g.,, effort and time to garner research funding, performing
research through all stages such as those shown in Table 1, determining if adaption has
benefits unique from other existing interventions, dissemination of research findings;
scalability of interventions in populations settings, advocacy for policy and health insurance
coverage, etc.) were not outweighed by the potential benefits
16
(continued)
6Global Advances in Health and Medicine

Table 3. (continued)
Question Description
5. Is there already a good approach for this issue in the population/ context? •When MBSR was first developed it clearly met a particular need, filling a particular and
important niche—helping people in healthcare settings learn to manage and live with long-
term health conditions.
11
Similarly, MBCT for recurrent depression fills a particular need,
helping people at risk for depressive relapse learn psychological self-management skills to
stay well. There were already a range of evidence-based treatments for current
depression. Arguably, some adaptations have not paused to ask this question, “Is there a
need or niche for this adaptation?”For example, while MBSR reduces anxiety symptoms,
7
a
2014 systematic review and meta-analyses in participants diagnosed with an anxiety
disorder showed mixed findings.
58
Other approaches, most notably CBT, are effective for
anxiety disorders, and what is needed now is more sophisticated questions of what works
for whom.
59
It may be that CBT is already a good approach for anxiety disorders, and that
mindfulness is not needed. Alternatively, it could be that an adapted MBP might serve this
population better by addressing a particular sub-group, offering a more universal
preventative approach, or helping patients with particular issues such as working skilfully
with strong emotions or improving choices
41
Loucks et al. 7

Fundamental Knowledge Domains Needed to Skilfully
Adapt an MBP
(1) Essential ingredients (i.e., warp) of MBPs: It is im-
portant to either be, or work with, a highly experienced
MBP teacher who has deep knowledge of what MBPs
are and aren’t.
37
MBPs’warp includes a core theo-
retical basis that underlines the universal importance
of foundational psychological skills such as attention,
decentering and self-regulation (see Table 2).
42
This is
an aspect of the essential theoretical ‘DNA’and does
not need adaptation if it is to be considered an MBP.
The same applies to some of the vehicles of change
within MBPs, namely, experiential learning through
core mindfulness practices. These are defining
premises of how MBPs are expected to effect change,
even if the way they are offered is adapted.
(2) Etiology of target outcome: For many conditions and
diseases, we know a great deal about what causes,
maintains and exacerbates them. For example, blood
pressure is sizably affected by obesity, diet, physical
activity, alcohol consumption, and antihypertensive
medication adherence.
2
Once we know the modifiable
determinants of the health outcome, we can design MBPs
to engage participants’relationships with these, such as
through mindful eating or physical activity practices.
In Case Example 2, a theoretical framework was devel-
oped using a Theory of Change approach (Table 1) for
how mindfulness training could influence blood pres-
sure.
20
It built upon prior theoretical work by Tang
et al.
43
suggesting that mindfulness impacts 3 domains
of self-regulation, specifically attention control, self-
awareness, and emotion regulation. The theoretical
framework extended to applying these 3 mindfulness
skills to people’s relationships with their modifiable
determinants of elevated blood pressure, such as diet,
physical activity, and antihypertensive medication ad-
herence. Example approaches used in MB-BP were
directing participants’improved self-awareness to how
they felt before, during and after certain kinds of foods
and physical activities, and then being with what in-
sights arose from that awareness. In these scenarios,
participants also used their improved attention control
skills to redirect their attention to healthier choices (e.g.,
less reactive response to a stressor and healthier food
selection).
20,44
The detailed conceptual framework is
described elsewhere.
3,20
(3) Existing interventions that work for the health outcome,
population, and context: At times, it may serve the
MBP to weave evidence-based elements into extant
approaches, in order to maximize efficacy. MBSR
itself contains a variety of evidence-based intervention
characteristics, such as participatory medicine prac-
tices and elements of motivational interviewing, such
as during the last class where participants write a letter
to themselves setting goals, considering what might
get in the way of meeting those goals, and what they
will do if that happens.
11
MBCT integrates MBSR and
CBT. A challenge to this approach, particularly from a
scientific and mechanistic perspective, is that, as most
MBPs are complex behavioral interventions, this af-
fects our ability to understand what the most active
ingredients are. Hence, we must balance 2 consider-
ations: Firstly, the encouragement for more disman-
tling studies using techniques in Tab l e 1 such as the
MOST framework to understand the maximally active
elements, and cleave out unnecessary elements so that
interventions are more cost-effective and efficient.
Secondly, as MBP instructors often see during the end
of the program when asking participants which
practices they will continue with longer term, pro-
viding a panel of active elements within the program
appears to meet different people in different ways,
shown by the diversity of practices that participants
plan to practice longer term to support their well-being
(e.g., body scan, attentional focus meditation, yoga,
and loving-kindness meditation). A sizable range of
meditation practices was recently demonstrated in a
sample of diverse meditation practitioners,
45
recogniz-
ing different practices support well-being of individuals in
unique ways. It is a challenge for mindfulness intervention
developers to create interventions that are likely to be
accepted by a large segment of society while keeping them
efficient and understanding the mechanisms by which they
operate.
Figure 1. Fundamental knowledge domains required in the
developmental team in order to develop an effective MBP adapted
to specific populations or contexts.
8Global Advances in Health and Medicine

(4) Delivery systems and settings: The variety of settings
and methods by which MBPs can be delivered is wide.
Delivery can occur in distinct physical settings, such
as grade school classrooms, military barracks, cor-
porate workplaces, prisons, or local health centers.
MBPs are increasingly being delivered digitally.
26-28
A frontier of digital mindfulness research is deter-
mining the value of these universal elements of MBPs,
asking, “What is essential?”For example, Table 2
suggests that 2 essential elements of an MBP are:
“Engages the participant in a sustained intensive
training in mindfulness meditation practice, in an
experiential inquiry-based learning process and in
exercises to develop insight and understanding”and
the teacher “Is part of a participatory learning process
with their students, clients or patients.”Some MBP
apps have synchronous (i.e., live) elements with
teacher feedback, like Unwinding Anxiety and Eat
Right Now.
27,41
Is the synchronous element needed,
and does it maximize positive effects and minimize
adverse effects? Alternatively, is purely asynchronous
(i.e., static) content, such as that delivered by popular
apps like Headspace and Calm, or by books, enough?
As technological developments in machine learning,
artificial intelligence, social interaction, and mobile
sensing continue, there will be increasing opportuni-
ties to adapt digitally delivered MBPs in accessible,
scalable ways.
46
Other explorations include stepped
care models that would encourage the use of apps,
books, self-taught, or lightly supported interventions
in mild to moderate conditions—and more intensive
teacher/therapist led interventions for people with
more challenging issues. There can even be bidir-
ectionality where people may find themselves drawn
to different delivery systems at different times in their
lives. These are important domains to explore and
systematically research as there are sizable accessi-
bility and cost-effectiveness implications.
(5) Culture, values, and communication patterns of target
population: The importance of culture, race, gender,
sexual orientation, and age are increasingly recognized
in mindfulness research.
47,48
In terms of race and
culture, a qualitative study by Tenfelde et al, in pre-
dominantly low income African American women,
found the participants recognized that yoga and
mindfulness could be beneficial, and found several
recommendations for culturally adapting it to them,
including (1) Focusing on stress relief and health
benefits; (2) Changing the image of yoga to include the
Black community; (3) Peer to peer teaching; and (4)
Afro-centric history and connection to yoga.
49
Bringing forward the culture, values and communi-
cation patterns of target groups, whether it is by race,
ethnicity, age, gender, or disability status, to name a
few, and preferably taught by a member of that group,
are important ways to ensure that MBPs are accessible
to the broad diversity of people throughout the world,
as well as to diverse communities within countries.
47
For example, in the community-based participatory re-
search being done for the NativeMIND study,
25
participants
are explicitly naming how they are “indigenizing and de-
colonizing MBSR”as they adapt it to Native American
cultures and traditions. This, for example, in one tribal nation,
includes using a drum instead of bells to begin and end
meditations, and in other tribal nations doing slow ceremonial
dances instead of walking meditation. Clear feelings have
been expressed in focus groups that NativeMIND is now an
authentic expression of their culture and values. When par-
ticipants feel ‘met’by the teaching process, the potential for
deeper engagement and transformation is significant.
50
In
adapting MBPs, it is fundamental to adapt with rather than for
the communities and contexts.
Develop and Test Your Adaptation: 8 Steps
to Adaptation
Based on experience developing and adapting MBPs, we
offer recommendations on steps to adaptation. We recom-
mend researchers follow all steps, while mindfulness teachers
may consider following steps 1 through 5. Partnering with
researchers is encouraged so that the safety and efficacy of the
adaption can be understood, enhancing the chances that the
adaptation is evaluated and sustainably implemented. We
recommend adhering to best practices for behavioral inter-
vention development, outlined in Table 1. This includes
engaging stakeholders in every step of the path (e.g., patients,
clinicians, and health insurers) so that an intervention that
meets the needs of the population is developed. It is beyond
the scope of this paper to outline these steps in detail; a well
assembled collaborative team would cover the requisite
knowledge and skills to conduct these steps. Refer to the
reflective questions in Tabl e 3 while considering these 8
recommended steps for adaption:
(1) Determine if this work is needed. Perform a thorough
review of the literature, and engage with diverse
stakeholders, to establish what is already known about
MBPs in the target population and context, and de-
termine if there are already adaptations or alternative
non-mindfulness-based approaches being used.
(2) Articulate the aim and intention of the adaptation, and
the theoretical basis of why an MBP would be helpful
for this population or context. Include a theoretical
account of the issue of concern in the target pop-
ulation, and how an MBP would address the specific
mechanisms (e.g., using the Theory of Change ap-
proach in Table 1).
(3) Generate and develop ideas for the necessary adap-
tations. Work creatively with a group of MBP teachers
Loucks et al. 9

and representative key stakeholders, including those
with lived experiences of the issues of concern and the
delivery context, and those with expertise in the target
population and context.
(4) Evaluate feasibility: This can include qualitative in-
terviews with people from the target population/
context, single-arm pilot trials of the adapted pro-
gram monitoring acceptability and feasibility, along
with exploratory work about the impact on proposed
mechanisms and outcomes.
(5) Steps 3 and 4 continue iteratively until a theoretically
plausible, acceptable, feasible, and potentially safe and
potent adaptation, is ready to pilot.
(6) Pilot clinical trial, with meaningful measures of ac-
ceptability, feasibility, harms, adverse events, mech-
anisms and effectiveness, using a meaningful
comparison group.
(7) Perform an adequately powered preregistered ran-
domized controlled trial, adhering to CONSORT
guidelines,
51
to evaluate impacts on the primary
outcome of interest, and relevant mechanisms.
(8) If efficacy in step 7 is sizable, carefully proceed with
replication, scalability, dissemination, and implementation
studies, using stepped implementation science-informed
approaches such as those outlined in the NIH Stage
Model,
15,16
Science of Behavior Change,
29
Obesity-
Related Behavioral Intervention Trials (ORBIT)
model,
38
Multiphasic Optimization Strategy (MOST),
52
and MRC Guidelines on Complex Intervention De-
velopment.
30
as summarized in Tab le 1.
Our three case examples have progressed through these
steps to differing degrees. Case example 1 moved
through steps 1–4 to see that a full adaptation of MBSR
was not needed, but instead MBSR was used with more
minor modifications and screening considerations such
as those described in Tabl e 3. To establish if MBCT could
be accessible to the general population, the new Finding
Peace in a Frantic World (case example 3) passed through
steps 1 through 7. It is also emerging in step 8 through
book distribution and reader feedback). MB-BP (case
example 2) has advanced through steps 1 through 6, with
step 7 recently completed and analyses underway.
Strengths and Limitations of
This Framework
Strengths of the MBP adaptation system provided in this
paper include grounding it in the established theoretical
framework of the essential (warp) and flexible (weft) in-
gredients of MBPs. The recommendations on how to adapt
MBPs are linked to established behavioral intervention de-
velopment methods such as the NIH Stage Model,
15,16
Community-Based Participatory Research,
39
MRC Guide-
lines on Complex Intervention Development,
30
and others
described in Table 1. Limitations include that, while the warp
and weft are informed by theory and practice, the proposed
essential and flexible elements have not yet been empirically
tested to identify which are more active. These elements were
offered by a team of researchers that included some of the
first- and second-generation designers of MBSR and MBCT,
so reflect their best understanding of active and unique
components. Empirically validating the warp and weft ele-
ments remains an opportunity for future research.
Summary and Conclusion
Adapting MBPs is currently happening not only in research,
but also by MBP teachers and developers who endeavor to
best serve the populations and contexts they work within. This
paper provides a set of principles and criteria for when, why
and how to adapt MBPs. We suggest ways to ensure adap-
tations to MBPs are acceptable to populations and contexts,
and become potentially scalable, thereby creating efficient
and effective programs to maximize public health. Our hope is
that this provides a useful framework for ensuring that further
developments in the field of MBPs systematically consider
safety, acceptability, effectiveness, cost-effectiveness and
scalability so their potential to enhance public health and
well-being is maximized.
Declaration of conflicting interests
The author(s) declared the following potential conflicts of interest with
respect to the research, authorship, and/or publication of this article:
Dr. Loucks is the director of the Mindfulness Center at Brown
University. The Mindfulness Center, a non-profitentity,hasanEd-
ucation Unit that provides mindfulness-based program delivery to the
general public for fees. Dr. Loucks’s salary is not tied to quantity or
content of programs offered through the Mindfulness Center.
Rebecca Crane receives royalties from books on mindfulness
Judson Brewer owns stock in, and serves as a paid consultant for
Sharecare Inc. the company that owns the Eat Right Now and
Unwinding Anxiety apps mentioned in this manuscript. This fi-
nancial interest has been disclosed to and is being managed by
Brown University, in accordance with its Conflict of Interest and
Conflict of Commitment policies.
Willem Kuyken is the director of the Oxford Mindfulness Centre.
Since arriving in Oxford (2014) he has received no payments for
training workshops, presentations or consultation work related to his
MBCT work and donates any such payments to the Oxford
Mindfulness Foundation, a charitable trust that supports the work of
the Oxford Mindfulness Centre. He was until 2015 an unpaid Di-
rector of the Mindfulness Network Community Interest Company.
He receives royalties for several books on mindfulness published by
Guilford Press. He has advised and consulted various groups (e.g.,
evidence to UK NHS committees, the UK Mindfulness All Party
Parliamentary Group).
Other authors report no conflicts of interest.
10 Global Advances in Health and Medicine

Funding
The author(s) disclosed receipt of the following financial support for
the research, authorship, and/or publication of this article: This work
was supported by the National Institute of Aging and Mount Sinai
Health System.
ORCID iDs
Eric B. Loucks https://orcid.org/0000-0002-9962-0386
Rebecca S. Crane https://orcid.org/0000-0003-3605-0256
Jes´
us Montero-Marin https://orcid.org/0000-0001-5677-1662
Willem Kuyken https://orcid.org/0000-0002-8596-5252
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