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

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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.
Intervention Fidelity in Mindfulness-Based Research and Practice Feature Article
Global Advances in Health and Medicine
Volume 11: 112
© The Author(s) 2022
Article reuse guidelines:
DOI: 10.1177/21649561211068805
Mindfulness-Based Programs: Why, When,
and How to Adapt?
Eric B. Loucks, PhD
, Rebecca S. Crane, PhD
, Menka A. Sanghvi, MAJ
Jes ´
us Montero-Marin, PhD
, Jeffrey Proulx, PhD
, Judson A. Brewer, MD, PhD
, and
Willem Kuyken, PhD
This paper provides a framework for understanding why, when and how to adapt mindfulness-based programs (MBPs) to
specic 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. Specic questions for reection 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 benets 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 efcacy.
mindfulness, study design, implementation, dissemination
Received August 11, 2021. Accepted for publication December 3, 2021
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
beyondprogram. His hospice setting already offered
effective psychoeducational and counseling programs
Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https:// which permits any use, reproduction and distribution of the work without further
permission provided the original work is attributed as specied on the SAGE and Open Access pages (
Department of Epidemiology, Brown University School of Public Health,
Providence, RI, USA
Department of Behavioral and Social Sciences, Brown University School of
Public Health, Providence, RI, USA
Mindfulness Center, Brown University, Providence, RI, USA
Centre for Mindfulness Research and Practice, School of Psychology, Bangor
University, Bangor, UK
The Mindfulness Initiative, Shefeld, UK
Department of Psychiatry, Oxford University, Oxford, UK
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.
for the rst 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 modications, 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 scientic 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
Long-term effects are not yet clear.
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.
He wondered
if MBSRs effects could be boosted, and MBSR be more
accepted by people with hypertension, if its curriculum
more explicitly directed mindfulness skill development
to participantshealth behaviors that affect blood
pressure (detailed elsewhere).
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.
The work has been developed,
implemented and researched as an in-person course.
There has been an explosion of interest in mindfulness-based
programs (MBPs).
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.
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.
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.
Nonetheless, there are several excellent examples of MBPs
adaptedtospecic populations and contexts, such as depression
binge eating disorder (Mindfulness-Based Eating
Awareness Training),
relapse prevention (Mindfulness-Based
Relapse Prevention),
cancer (Mindfulness-Based Cancer Re-
and blood pressure (Mindfulness-Based Blood Pres-
sure Reduction).
There are increasing adaptations to specic
demographic groups, such as young adults (Mindfulness-Based
military personnel (Mindfulness-Based Mind Fitness
Training, Mindfulness-Based Attention Training),
those with
trauma history,
expectant parents (Mindfulness-Based Child-
birth and Parenting Program),
and Native American commu-
nities (NativeMIND).
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 ndings for adaptations
to online delivery formats: for example, randomized controlled
trial showed online MBCT effectively prevents depression re-
; a pilot single-arm trial show the Eat Right Now app
improved emotional eating
; a systematic review of face-to-face
MBPs delivered through videoconferencing online suggests
benecial effects.
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,
MRC Guidelines on Complex Intervention Development,
Theory of Change,
National Institutes of Health Stage
Multiphasic Optimization Strategy (MOST),
2Global Advances in Health and Medicine
amongst others. The Fieldbook for Mindfulness Innovators is a
resource for making minor adaptations to existing MBPs,
It emphasizes
design thinking, prototyping, and offers steps for building ev-
idence. Some textbooks describe examples of MBPs that have
been adapted to specic populations and contexts.
Table 1. Established Models for Behavioral Intervention Development.
Model Description
NIH Stage Model
Strong emphasis on carrying behavioral clinical trials through all clinical trial stages, including
basic research for intervention development, research on mechanisms, efcacy 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)
Focuses on identifying mechanisms of behavior change rst 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 efcient interventions customized to target the mechanisms of behavior
change, while cleaving out superuous intervention content that does not impact health
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
Provides a framework for complex behavioral intervention development
A. Pre-Clinicalor 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 inuence 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-dened 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)
Interventions developed in collaboration with a wide variety of stakeholders
Encompasses strategic considerations such as including beneciaries, actors in the context,
sphere of inuence, 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 scienticndings, it argues that more efcient and
effective interventions can be developed
Community-Based Participatory Research
Focuses on active involvement of community members, organizational representatives, and
researchers in the entire research process
Several key principles, identied 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 benet 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 ndings and knowledge gained to all partners
Multiphasic Optimization Strategy (MOST)
Uses a three-phase design to identify the active and inactive components of interventions in
order to make them efcient 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 efciency (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 specic populations and contexts.
In response
to the proliferation in the eld, some of the rst- 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 eld.
This paper, entitled What De-
nes Mindfulness-Based Programs? The Warp and the Weft,
outlines both MBPsessential elements (the warp) and the
exible 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 specic populations and contexts. Cur-
rently, such a framework for MBP adaptation is absent in
the literature. We start by addressing the obvious rst
questions: Why is an adaptation necessary?”“When
should I adapt, and when shouldntI?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 eld 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
participantslearning, ne-tuning their teaching to ensure it
is inclusive and supports individual participants and the
needs of the whole group.
pression are experienced in both similar and unique ways,
and good MBP teaching accommodates this universality and
specicity. 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
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.
Warp: Essential ingredients
MBP MBP teacher
1. Is informed by theories and practices that draw from a conuence 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 experiencewhether pleasurable, neutral or
difcultinstead of away)
3. Has engaged in appropriate training and commits to ongoing good
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
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 specic contexts and
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 t 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 Reection 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 teachers
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 MBSRs acceptability and effectiveness
Case example 1 of teaching MBSR in a hospice setting illustrates these questions of ex or
adaptation. There is a substantial evidence-base showing MBSR reduces stress and
improves mental health.
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 grievers varied
Giving full attention to the grievers 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 Alejandros 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
C. Adapt some of the poetry to relate more specically to grief and impermanence
D. Offer exibility 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 condent 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.
However, sometimes an overlay of a more specic
theoretical formulation is required for particular issues or populations. For example, when
MBCT for depression was being developed, the challenge was nding 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
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 MBPsreach. 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
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
4. Do the benets 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
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.
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-Zinns original
formulation of MBSR was based on a universal model of the mind and body for
heterogeneous groups.
Work has focused on its effectiveness and implementation
around the world, and there have been numerous adaptations
But in contrast to CBT, the question of bespoke adaptations came second, with MBCT for
recurrent depression perhaps being the most extensively researched
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
benets unique from other existing interventions, dissemination of research ndings;
scalability of interventions in populations settings, advocacy for policy and health insurance
coverage, etc.) were not outweighed by the potential benets
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 rst developed it clearly met a particular need, lling a particular and
important nichehelping people in healthcare settings learn to manage and live with long-
term health conditions.
Similarly, MBCT for recurrent depression lls 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,
2014 systematic review and meta-analyses in participants diagnosed with an anxiety
disorder showed mixed ndings.
Other approaches, most notably CBT, are effective for
anxiety disorders, and what is needed now is more sophisticated questions of what works
for whom.
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
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 arent.
MBPswarp 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).
This is
an aspect of the essential theoretical DNAand 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 dening
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.
Once we know the modiable
determinants of the health outcome, we can design MBPs
to engage participantsrelationships 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 inuence blood pres-
It built upon prior theoretical work by Tang
et al.
suggesting that mindfulness impacts 3 domains
of self-regulation, specically attention control, self-
awareness, and emotion regulation. The theoretical
framework extended to applying these 3 mindfulness
skills to peoples relationships with their modiable
determinants of elevated blood pressure, such as diet,
physical activity, and antihypertensive medication ad-
herence. Example approaches used in MB-BP were
directing participantsimproved 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
The detailed conceptual framework is
described elsewhere.
(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 efcacy. 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.
MBCT integrates MBSR and
CBT. A challenge to this approach, particularly from a
scientic 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 efcient.
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,
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
efcient and understanding the mechanisms by which they
Figure 1. Fundamental knowledge domains required in the
developmental team in order to develop an effective MBP adapted
to specic 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.
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 understandingand
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.
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,
articial intelligence, social interaction, and mobile
sensing continue, there will be increasing opportuni-
ties to adapt digitally delivered MBPs in accessible,
scalable ways.
Other explorations include stepped
care models that would encourage the use of apps,
books, self-taught, or lightly supported interventions
in mild to moderate conditionsand more intensive
teacher/therapist led interventions for people with
more challenging issues. There can even be bidir-
ectionality where people may nd 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.
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 benecial, and found several
recommendations for culturally adapting it to them,
including (1) Focusing on stress relief and health
benets; (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.
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.
For example, in the community-based participatory re-
search being done for the NativeMIND study,
are explicitly naming how they are indigenizing and de-
colonizing MBSRas 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 metby the teaching process, the potential for
deeper engagement and transformation is signicant.
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 efcacy 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
reective 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 specic
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
to evaluate impacts on the primary
outcome of interest, and relevant mechanisms.
(8) If efcacy 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
Science of Behavior Change,
Related Behavioral Intervention Trials (ORBIT)
Multiphasic Optimization Strategy (MOST),
and MRC Guidelines on Complex Intervention De-
as summarized in Tab le 1.
Our three case examples have progressed through these
steps to differing degrees. Case example 1 moved
through steps 14 to see that a full adaptation of MBSR
was not needed, but instead MBSR was used with more
minor modications 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 exible (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,
Community-Based Participatory Research,
MRC Guide-
lines on Complex Intervention Development,
and others
described in Table 1. Limitations include that, while the warp
and weft are informed by theory and practice, the proposed
essential and exible 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
rst- and second-generation designers of MBSR and MBCT,
so reect 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 efcient
and effective programs to maximize public health. Our hope is
that this provides a useful framework for ensuring that further
developments in the eld 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 conicting interests
The author(s) declared the following potential conicts 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-protentity,hasanEd-
ucation Unit that provides mindfulness-based program delivery to the
general public for fees. Dr. Louckss 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 -
nancial interest has been disclosed to and is being managed by
Brown University, in accordance with its Conict of Interest and
Conict 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 conicts of interest.
10 Global Advances in Health and Medicine
The author(s) disclosed receipt of the following nancial 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.
Eric B. Loucks
Rebecca S. Crane
us Montero-Marin
Willem Kuyken
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12 Global Advances in Health and Medicine
... Its journey from ancient wisdom to contemporary psychology underscores its adaptability and relevance in addressing the challenges of the modern world, including the pressing issue of cyberbullying. In the context of cyberbullying, mindfulness offers a potential pathway for individuals to navigate the emotional and psychological complexities of online aggression with greater resilience and self-compassion (Loucks et al., 2022). ...
Full-text available
In the rapidly evolving digital society, people’s daily lives have become intricately woven with online activities, driven by an ever-increasing demand for digital interconnectedness. The internet has bestowed upon them the gift of instantaneous communication with their loved ones, while simultaneously opening doors to global connections. This transformative power of the internet has also spawned a disconcerting issue—cyberbullying. Within the vast expanse of the online world, they witness the proliferation of various forms of harassment and abuse. This not only psychologically but also physically harms on a distressing number of individuals. This study thoroughly explores this disconcerting phenomenon, drawing upon established theories such as the spiral of silence theory and social cognitive theory to unveil the underlying causes of cyberbullying. It embarks on a detailed study into mindfulness, recognizing it as a potential tool to regulate the pernicious effects of cyberbullying. However, a significant knowledge gap persists concerning the cultivation of mindfulness and the intricate factors influencing its effectiveness within the context of cyberbullying. The paper conducts a questionnaire survey encompassing 529 participants to bridge this chasm of understanding. This survey not only provides valuable insights into the repercussions of cyberbullying on internet users but also unveils the potential moderating role of mindfulness in this complex dynamic. The findings unearthed through this study carry profound implications, serving as a clarion call for heightened societal awareness and informed governmental interventions to combat the scourge of cyberbullying.
... (Mindfulness programs are frequently adapted for specific populations, and guidelines exist to help practitioners make appropriate changes. 27 ) The course was delivered over Zoom for several reasons. First, it allowed a greater number of participants from the niche population. ...
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Objectives. Nearly every modern textbook on the etiology and treatment of voice disorders (VD) recommends stress reduction for VD patients. The benefits of mindfulness for stress reduction are well documented , but published literature on mindfulness and VD is sparse. Our objective was to determine whether an 8-week mindfulness course could increase mindfulness and lower stress in people with VD, leading to a decrease in vocal handicap. Study Design. Mixed methods study. Methods. Participants: 69 individuals with VD: 39 were mindfulness course participants (MCP), 30 were in a waitlist control group (WCG). Exclusionary criteria: patients in voice therapy. Before and after the 8-week timeframe, participants took the Mindful Attention and Awareness Scale (MAAS), Perceived Stress Scale-10 (PSS-10), Voice Handicap Index (VHI), and-for singers (n = 36)-the Singing Voice Handicap Index (SVHI). Follow-up interviews were conducted with select participants. Results. In the MCP, each of the outcomes significantly changed in the direction hypothesized, resulting in increased MAAS (P = 0.000) and decreased PSS-10 (P = 0.007), VHI (P = 0.000), and SVHI (P = 0.021, n = 22) scores. Using a 2 × 2 Repeated Measures ANOVA, two outcomes were statistically different for the MCP from pre to postcourse-MAAS increased (P = 0.006, ES = 0.107) and VHI decreased (P = 0.034, ES = 0.065)-in comparison to no change in the WCG. Follow-up interviews revealed increased acceptance of the VD; reduced stress, physical tension, and pain/discomfort; increased somatic (or interoceptive) awareness; community with other VD patients; and positive speaking and singing voice changes. Conclusions. An 8-week mindfulness course shows promise for reducing stress in people with VD, lowering voice handicap, and improving quality of life. Future research should evaluate mindfulness in patients with specific voice disorders; patients with higher and lower VHI scores; singers; and patients who experience throat pain. Mindfulness should also be evaluated within a standard voice therapy protocol.
... Mindfulness-based programs (MBPs) are often adapted for specific populations (Loucks et al., 2022), and there are extant MBPs that have been adapted to better serve the needs of parents (e.g., Behbahani et al., 2018;Jones et al., 2017). Mindfulness is defined as deliberately paying attention to the present moment experience, in a nonjudgmental way (Kabat-Zinn, 2013). ...
Mindfulness-based programs can help lower psychological distress among parents of children with developmental disabilities. However, less is known about the functions of mindfulness in relation to parental outcomes. In a cross-sectional survey, mothers of children with developmental disabilities (N = 313) reported on their child’s behavior problems, trait mindfulness, mindful parenting, and a range of outcomes (anxiety and depression symptoms, parenting stress, family satisfaction, and positive gain). Neither trait mindfulness or mindful parenting acted as moderators between child behavior problems and outcome variables, although both had main effect (compensatory) associations with parent outcomes. Benefits of mindfulness-based programs may be general rather than specifically in the context of high child behavior problems, given the lack of evidence for the moderating function of mindfulness.
... It is a field of science that intersects psychology and neurophysiology, which studies meditation as a practice of human awareness at the present moment. Meditation is one of the tools of this method (Loucks, 2022). Mindfulness is the ability to perceive everything that is happening right now as it is, without trying to understand or analyze what is happening. ...
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The present article used a pilot study to determine the effectiveness of digital cognitive mindfulness training developed based on dialectical behavioral therapy (DBT) in reducing attention deficit hyperactivity disorder (ADHD) symptoms in children. The sample consisted of 90 children (8–10 years old) diagnosed with ADHD. The participants were randomized into two groups: an experimental group (n = 45) and a control group (n = 45). Results were assessed at three time points: before, after the study, and one month after the end of the study. Regarding ADHD symptoms, the ANCOVA results showed that there were no statistically significant differences between the study groups for inattention and hyperactivity/impulsivity after testing. One month after completion of the program, there was a significant alleviation in symptoms of inattention, executive functioning, learning problems, aggression, and peer relationships. Hyperactivity was the only variable that showed a decrease both post-test and during follow-up. These results suggest that a DBT-based mindfulness program is a promising method of reducing ADHD symptoms in children.
... Digitalised methods of brief mindfulness intervention delivery have unique advantages over traditional delivery methods as they have been proven to increase accessibility while also providing participants with unique opportunities for personalisation of such courses (Mrazek et al., 2019). That said, recent research addressing the digitalisation of course delivery suggests that course adaptation should be determined based on the needs of the demographic group involved and the desired outcome of the course while maintaining course integrity (Loucks et al., 2022). ...
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As a result of the COVID-19 pandemic, many university courses transitioned to online delivery, therefore, educators and students faced new challenges associated with the delivery of modules and the provision of necessary student supports. Given the scale of this transition, it is likely that many universities will continue to teach remotely far beyond the reach of any pandemic specific restrictions. This study sought to explore the impact and efficacy of a five-week online mindfulness course to a cohort of first-year university students (n = 25) at Technological University Dublin (TU Dublin), Ireland. Results demonstrated that participation in the course led to decreased levels of perceived stress for students and increased levels of resilience. Students who took the course reported that it provided emotional support, aided them in finding a healthy work-life balance and that ultimately, they felt the course broadened their perspective and helped them be more aware of positive coping mechanisms.
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Importance Hypertension is a major cause of cardiovascular disease, and although the Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure (BP), adherence is typically low. Mindfulness training adapted to improving health behaviors that lower BP could improve DASH adherence, in part through improved interoceptive awareness relevant to dietary consumption. Objective To evaluate the effects of the Mindfulness-Based Blood Pressure Reduction (MB-BP) program on interoceptive awareness and DASH adherence. Design, Setting, and Participants Parallel-group, phase 2, sequentially preregistered randomized clinical trials were conducted from June 1, 2017, to November 30, 2020. Follow-up was 6 months. Participants with elevated unattended office BP (≥120/80 mm Hg) were recruited from the population near Providence, Rhode Island. Of 348 participants assessed for eligibility, 67 did not meet inclusion criteria, 17 declined, and 63 did not enroll prior to study end date. In total, 201 participants were randomly assigned, 101 to the MB-BP program and 100 to the enhanced usual care control group, with 24 (11.9%) unavailable for follow-up. Outcome assessors and the data analyst were blinded to group allocation. Analyses were performed using intention-to-treat principles from June 1, 2022, to August 30, 2023. Interventions The 8-week MB-BP program was adapted for elevated BP, including personalized feedback, education, and mindfulness training directed to hypertension risk factors. Both MB-BP and control groups received home BP monitoring devices with instructions and options for referral to primary care physicians. The control group also received educational brochures on controlling high BP. Main Outcomes and Measures The primary outcome was Multidimensional Assessment of Interoceptive Awareness (MAIA) questionnaire scores (range 0-5, with higher scores indicating greater interoceptive awareness), and the secondary outcome was DASH adherence scores assessed via a 163-item Food Frequency Questionnaire (range 0-11, with higher scores indicating improved DASH adherence), all compared using regression analyses. Results Among 201 participants, 118 (58.7%) were female, 163 (81.1%) were non-Hispanic White, and the mean (SD) age was 60.0 (12.2) years. The MB-BP program increased the MAIA score by 0.54 points (95% CI, 0.35-0.74 points; P < .001; Cohen d = 0.45) at 6 months vs control. In participants with poor baseline DASH adherence, the MB-BP program also significantly increased the DASH score by 0.62 points (95% CI, 0.13-1.11 points; P = .01; Cohen d = 0.71) at 6 months vs controls. The intervention was also associated with a 0.34-point improvement in the DASH diet score in all MB-BP participants from baseline (95% CI, 0.09-0.59 points; P = .01; Cohen d = 0.27), while the control group showed a −0.04 point change in DASH diet score from baseline to 6 months (95% CI, −0.31 to 0.24 points; P = .78; Cohen d = −0.03). Conclusions and Relevance A mindfulness program adapted to improving health behaviors to lower BP improved interoceptive awareness and DASH adherence. The MB-BP program could support DASH dietary adherence in adults with elevated BP. Clinical Trial Registration Identifiers: NCT03859076 and NCT03256890
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Objectives Prenatal mindfulness programs can improve mental health, yet access to and cultural and linguistic relevance of existing programs in the United States are limited for people who do not speak English and/or face major life stressors such as migration, housing instability, limited income, and racism. In response, mindfulness skills training drawn from Mindfulness-Based Childbirth and Parenting (MBCP) was integrated into Medicaid-covered CenteringPregnancy (CP) group prenatal healthcare, delivered in Spanish and English by certified nurse-midwives and community co-leaders, and tested in a pragmatic pilot trial. Method A provider survey of 17 CP clinics informed development of the enhanced program. Next, it was tested with 49 pregnant people who chose CP prenatal care. All of the sample identified as women; 4% as LGBTQ + ; 90% as Black, Indigenous, and People of Color (65% as Latina/e/x); 10% as White; and 63% as Spanish-speaking. Groups were allocated 1:1 to CenteringPregnancy or CenteringPregnancy with Mindfulness Skills (CP +). Results Intent-to-treat analysis of self-report interview data indicated CP + yielded lower postpartum depression (the a priori primary study outcome) with a large effect size (Cohen’s d = 0.80) and a trend toward lower postpartum anxiety (Cohen’s d = 0.59) compared to CP. Hypothesized effects on mindfulness, positive/negative affect, and perceived stress were only partially supported at post-birth follow-up. Satisfaction with care was high across conditions. Conclusions Augmenting group prenatal healthcare with mindfulness training in Spanish and English appears feasible, did not reduce satisfaction with care, and may have additional mental health benefits. Key questions remain about structural supports for perinatal well-being. Preregistration This trial was registered with (NCT01646463).
High levels of stress and burnout, low help-seeking behaviour and unhealthy coping in healthcare professionals (HCPs), are a critical concern globally. Mindfulness-based interventions (MBIs) reduce stress, are a healthy coping mechanism and have become increasingly popular among HCPs, especially during the Covid-19 pandemic. Nevertheless, HCPs' busy schedules require the intervention to be accessible, pragmatic, and context specific. Key to this goal is approaching mindfulness from a multicultural perspective, especially in diverse settings such as Africa. This paper aims to provide practical tips to ensure that the MBI offered is effective with multicultural HCPs during intense stress. Four tips each discuss the curriculum, implementation, and sustainability, respectively. The tips are elucidated by practical examples of regulating stress in healthcare settings and to offer a guideline to help structure future MBIs to be culturally and context appropriate.
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A randomized-controlled-trial study (N = 219) tested two pre-registered hypotheses that mobile-phone app-based mindfulness training improves wellbeing and increases self-transcendent emotions: gratitude, self-compassion, and awe. Latent change score modeling with a robust maximum likelihood estimator was used to test how those changes are associated in the training versus the waiting-list group. The training increased wellbeing and all self-transcendent emotions regardless of interindividual variance in the changes across time. Changes in all self-transcendent emotions were positively associated with changes in wellbeing. The strength of those associations was comparable in the waiting-list group and the training group. More studies are needed to test whether the effects of mindfulness practice on wellbeing are driven by increases in self-transcendent emotions. The study was conducted over 6 weeks during the COVID19 pandemic. The results indicate that the mindfulness training can be an easily accessible effective intervention supporting eudaimonic wellbeing in face of adversity.
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Mindfulness-informed school-based mental health curricula show much promise in cultivating a positive school climate which supports the well-being and mental health of pupils and staff. However, non-positive pupil outcomes and experiences of school-based mental health interventions are often under-recognised and under-reported. This study sought to capture non-positive pupil experiences of a popular mindfulness-informed curriculum. Some pupils across all schools in the study described non-positive experiences, including having troubling thoughts and emotions, and not finding the programme effective. Contexts surrounding these experiences are explored and linked to existing literature, and subsequent recommendations for improvements are made, including the importance of having clear programme structure, definitions and aims, acknowledging and accommodating fidelity issues as best as possible, and better highlighting the potential for non-positive experiences and how they may be reduced.
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Objectives Meditation is an umbrella term for a vast range of contemplative practices. Former proposals have struggled to do justice to this variety. To our knowledge, there is to date no comprehensive overview of meditation techniques spanning all major traditions. The present studies aimed at providing such a comprehensive list of meditation techniques. Methods In a qualitative study, we compiled a collection of 309 meditation techniques through a literature search and interviews with 20 expert meditators. Then, we reduced this collection to 50 basic meditation techniques. In a second, quantitative study, 635 experienced meditators from a wide range of meditative backgrounds indicated how much experience they had with each of these 50 meditation techniques. Results Meditators’ responses indicated that our choice of techniques had been adequate and only two techniques had to be added. Our additional statistical and cluster analyses illustrated preferences for specific techniques across and within diverse traditions as well as sets of techniques commonly practiced together. Body-centered techniques stood out in being of exceptional importance to all meditators. Conclusions In conclusion, we found an amazing variety of meditation techniques, which considerably surpasses previous collections. Our selection of basic meditation techniques might be of value for future scientific investigations and we encourage researchers to use this set.
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Mindfulness training (MT) is considered appropriate for school teachers and enhances well-being. Most research has investigated the efficacy of instructor-led MT. However, little is known about the benefits of using self-taught formats, nor what the key mechanisms of change are that contribute to enhanced teacher well-being. This study compared instructor-led and self-taught MT based on a book (Penman & Williams, 2011) in a sample of secondary school teachers. We assessed expectancy, the degree to which participants believed the intervention was effective, their program engagement, well-being and psychological distress, and evaluated whether mindfulness and self-compassion skills acted as mediators of outcomes. In total, 206 teachers from 43 schools were randomised by school to an instructor-led or self-taught course ---77% female, mean age 39 years (SD=9.0). Both MT formats showed similar rates of participant expectancy and engagement, but the instructor-led arm was perceived as more credible. Using linear mixed-effects models, we found the self-taught arm showed significant pre−post improvements in self-compassion and well-being, while the instructor-led arm showed such improvements in mindfulness, self-compassion, well-being, perceived stress, anxiety, depression and burnout. Changes over time significantly differed between the groups in all these outcomes, favouring the instructor-led arm. The instructor-led arm, compared with the self-taught, indirectly improved teacher outcomes by enhancing mindfulness and self-compassion as mediating factors. Mindfulness practice frequency had indirect effects on teacher outcomes through mindfulness in both self-taught and instructor-led arms. Our results suggest both formats are considered reasonable, but the instructor-led is more effective than the self-taught. Trial registration: ISRCTN18013311 (24/11/2015).
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Background: Mindfulness-based programs hold promise for improving cardiovascular health (e.g. physical activity, diet, blood pressure). However, despite theoretical frameworks proposed, no studies have reported qualitative findings on how study participants themselves believe mindfulness-based programs improved their cardiovascular health. With an emphasis on in-depth, open-ended investigation, qualitative methods are well suited to explore the mechanisms underlying health outcomes. The objective of this qualitative study was to explore the mechanisms through which the mindfulness-based program, Mindfulness-Based Blood Pressure Reduction (MB-BP), may influence cardiovascular health. Methods: This qualitative study was conducted as part of a Stage 1 single arm trial with one-year follow-up. The MB-BP curriculum was adapted from Mindfulness-Based Stress Reduction to direct participants' mindfulness skills towards modifiable determinants of blood pressure. Four focus group discussions were conducted (N = 19 participants), and seven additional participants were selected for in-depth interviews. Data analysis was conducted using the standard approach of thematic analysis. Following double-coding of audio-recorded transcripts, four members of the study team engaged in an iterative process of data analysis and interpretation. Results: Participants identified self-awareness, attention control, and emotion regulation as key mechanisms that led to improvements in cardiovascular health. Within these broader themes, many participants detailed a process beginning with increased self-awareness to sustain attention and regulate emotions. Many also explained that the specific relationship between self-awareness and emotion regulation enabled them to respond more skillfully to stressors. In a secondary sub-theme, participants suggested that higher self-awareness helped them engage in positive health behaviors (e.g. healthier dietary choices). Conclusion: Qualitative analyses suggest that MB-BP mindfulness practices allowed participants to engage more effectively in self-regulation skills and behaviors lowering cardiovascular disease risk, which supports recent theory. Results are consistent with quantitative mechanistic findings showing emotion regulation, perceived stress, interoceptive awareness, and attention control are influenced by MB-BP.
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Objective: To evaluate effects of a mindfulness-based program, adapted to the young adult life course stage (age 18-29), named Mindfulness-Based College (MB-College). The primary outcome was a young adult health summary score, composed of key health risk factors: body mass index, physical activity, fruit and vegetable intake, alcohol consumption, stress, loneliness, and sleep duration. Secondary outcomes were hypothesized self-regulation mechanisms, including attention control, interoceptive awareness, and emotion regulation. Methods: This was a Stage 1 randomized controlled trial of the 9-week MB-College program (n=47) vs. enhanced usual care control (n=49) including students from three universities. Assessments were at baseline, during the beginning of the college term when stress is typically lower, and at MB-College completion (three months follow-up), when term-related stress is typically higher. Intention to treat, linear regression analyses estimated the marginal effects of MB-College vs. control on the outcomes. Results: MB-College participants (mean age 20 y, 68% female, 37% racial minorities) demonstrated improved health summary scores at follow-up, compared to control participants whose health summary scores worsened (marginal effect for MB-College vs. control=0.23; p=0.004). Effects on loneliness were pronounced (marginal effect=-3.11 for R-UCLA score; p=0.03). Secondary analyses showed significant impacts of MB-College on hypothesized self-regulation mechanisms (e.g. Sustained Attention to Response Task correct no-go percent, p=0.0008; Multidimensional Assessment of Interoceptive Awareness, p<0.0001; Center for Epidemiologic Studies-Depression scale, p=0.03). Conclusions: Findings of this early stage clinical trial suggest that MB-College may foster well-being in young adults. Trial registration: NCT03124446.
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Background: Physician burnout is on the rise, yet little is known about its relationship to anxiety. Mindfulness-based stress reduction has demonstrated decreases in anxiety, yet physicians have reported reluctance to engage in it due to significant time commitments. Objective: The aims of this study are to assess whether app-based mindfulness training can reduce anxiety in physicians and to explore if anxiety and burnout are correlated, thus leading to a reduction in both anxiety and burnout. Methods: This was a nonrandomized pilot study comprised of 34 physicians who worked in a large US health care network and reported having anxiety. The intervention was an app-based mindfulness program. The main outcome measure was anxiety, measured by the Generalized Anxiety Disorder-7 (GAD-7). The secondary outcome measures assessed burnout: cynicism and emotional exhaustion items from the Maslach Burnout Inventory. Results: GAD-7 scores decreased significantly at posttreatment (1 month after treatment initiation, 48% reduction, P<.001) and at the 3-month follow-up (57% reduction, P<.001). There was a significant correlation between anxiety and burnout (cynicism: r=.43; P=.01; emotional exhaustion: r=.71; P<.001). There was also a significant decrease in cynicism (50% reduction, P=.003 at posttreatment; 50% reduction, P=.009 at follow-up) and emotional exhaustion at both time points (20% reduction, P<.001 at posttreatment; 20% reduction, P=.003 at follow-up). Conclusions: This pilot study is the first to test an app-based mindfulness training program targeted at reducing anxiety with physicians and to demonstrate that in physicians, anxiety is correlated with burnout. These findings suggest that this may be an effective tool to reduce anxiety and burnout in physicians. Trial registration: NCT04137081;
The mindfulness-based stress reduction program (MBSR) may reduce blood pressure (BP) in patients with hypertension or elevated BP. However, some important parameters (such as asleep BP) have not been investigated in previous reviews, and a well-conducted meta-analysis is lacking. This meta-analysis investigates the effect and acceptability of MBSR on patients with elevated BP or hypertension. Relevant articles were searched in multiple databases, including MEDLINE, EMBASE, and APA PsycInfo. Included studies were randomized controlled trials that involved patients with an elevated BP, had a control group, and investigated the effect of MBSR. The mean office and out-of-office (including 24-hour, daytime, and asleep) systolic BP and diastolic BP, psychological outcomes (depression/anxiety/stress), and dropout rate were compared between the MBSR arm and the control arm using a random-effects model. Quality assessment was conducted based on the Cochrane risk-of-bias tool. Twelve studies were included, and only one was considered having low risk of bias. MBSR decreased the office systolic BP and diastolic BP by 6.64 and 2.47 mm Hg at postintervention, respectively; the reduction in diastolic BP was sustained until 3 to 6 months after the recruitment. Our meta-analyses did not find a significant reduction in out-of-office BP after MBSR. MBSR reduced depressive, anxiety, and stress symptoms. The dropout rate from MBSR arm was 15% and was similar to that of control arm. The current evidence is limited by lack of high-quality and adequately powered trials with long-term follow-up. Furthermore, out-of-office BP was only reported by few trials.
This book presents a framework for development, optimization, and evaluation of behavioral, biobehavioral, and biomedical interventions. Behavioral, biobehavioral, and biomedical interventions are programs with the objective of improving and maintaining human health and well-being, broadly defined, in individuals, families, schools, organizations, or communities. These interventions may be aimed at, for example, preventing or treating disease, promoting physical and mental health, preventing violence, or improving academic achievement. This volume introduces the Multiphase Optimization Strategy (MOST), pioneered at The Methodology Center at the Pennsylvania State University, as an alternative to the classical approach of relying solely on the randomized controlled trial (RCT). MOST borrows heavily from perspectives taken and approaches used in engineering, and also integrates concepts from statistics and behavioral science, including the RCT. As described in detail in this book, MOST consists of three phases: preparation, in which the conceptual model underlying the intervention is articulated; optimization, in which experimentation is used to gather the information necessary to identify the optimized intervention; and evaluation, in which the optimized intervention is evaluated in a standard RCT. Through numerous examples, the book demonstrates that MOST can be used to develop interventions that are more effective, efficient, economical, and scalable. Optimization of Behavioral, Biobehavioral, and Biomedical Interventions: The Multiphase Optimization Strategy is the first book to present a comprehensive introduction to MOST. It will be an essential resource for behavioral, biobehavioral, and biomedical scientists; statisticians, biostatisticians, and analysts working in epidemiology and public health; and graduate-level courses in development and evaluation of interventions.
Background Mindfulness applications are popular tools for improving well-being, but their effectiveness is unclear. We conducted a meta-analysis of randomized controlled trials (RCTs) that employed a mindfulness meditation app as the main intervention to improve users’ well-being and mental-health related outcomes. Methods A systematic search was conducted in PsycINFO, PubMed, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Library, Open Grey and ResearchGate through June, 2020. Effects were calculated as standardized mean difference (Hedges’ g) between app-delivered mindfulness interventions and control conditions at post-test and pooled with a random-effects model. Results From 2637 records, we selected 34 trials (N = 7566). Significant effect sizes were found at post-test for perceived stress (n = 15; g = 0.46, 95% CI [0.24, .68], I2= 68%), anxiety (n = 15; g = 0.28, 95% CI [0.16, .40], I2= 35%), depression (n = 15; g = 0.33, 95% CI [0.24, .43], I2= 0%), and psychological well-being (n = 5; g = 0.29, 95% CI [0.14, .45], I2= 0%). No significant effects were found for distress at post-test (n = 6; g = 0.10, 95% CI [-0.02, .22], I2= 11%) and general well-being (n = 5; g = 0.14, 95% CI [-0.02, 0.29], I2 = 14%). Conclusion and limitations Mindfulness apps seem promising in improving well-being and mental-health, though results should be interpreted carefully due to the small number of included studies, overall uncertain risk of bias and heterogeneity.
Importance Patients with residual depressive symptoms face a gap in care because few resources, to date, are available to manage the lingering effects of their illness. Objective To evaluate the effectiveness for treating residual depressive symptoms with Mindful Mood Balance (MMB), a web-based application that delivers mindfulness-based cognitive therapy, plus usual depression care compared with usual depression care only. Design, Setting, and Participants This randomized clinical trial was conducted in primary care and behavioral health clinics at Kaiser Permanente Colorado, Denver. Adults identified with residual depressive symptoms were recruited between March 2, 2015, and November 30, 2018. Outcomes were assessed for a 15-month period, comprising a 3-month intervention interval and a 12-month follow-up period. Interventions Patients were randomized to receive usual depression care (UDC; n = 230) or MMB plus UDC (n = 230), which included 8 sessions delivered online for a 3-month interval plus minimal phone or email coaching support. Main Outcomes and Measures Primary outcomes were reduction in residual depressive symptom severity, assessed using the Patient Health Questionaire-9 (PHQ-9); rates of depressive relapse (PHQ-9 scores ≥15); and rates of remission (PHQ-9 scores <5). Secondary outcomes included depression-free days, anxiety symptoms (General Anxiety Disorder–7 Item Scale), and functional status (12-Item Short Form Survey). Results Among 460 randomized participants (mean [SD] age, 48.30 [14.89] years; 346 women [75.6%]), data were analyzed for the intent-to-treat sample, which included 362 participants (78.7%) at 3 months and 330 (71.7%) at 15 months. Participants who received MMB plus UDC had significantly greater reductions in residual depressive symptoms than did those receiving UDC only (mean [SE] PHQ-9 score, 0.95 [0.39], P < .02). A significantly greater proportion of patients achieved remission in the MMB plus UDC group compared with the UDC only group (PHQ-9 score, <5: β [SE], 0.38 [0.14], P = .008), and rates of depressive relapse were significantly lower in the MMB plus UDC group compared with the UDC only group (hazard ratio, 0.61; 95% CI, 0.39-0.95; P < .03). Compared with the UDC only group, the MMB plus UDC group had decreased depression-free days (mean [SD], 281.14 [164.99] days vs 247.54 [158.32] days; difference, −33.60 [154.14] days; t = −2.33; P = .02), decreased anxiety (mean [SE] General Anxiety Disorder–7 Item Scale score, 1.21 [0.42], P = .004), and improved mental functioning (mean [SE] 12-Item Short Form Survey score, −5.10 [1.37], P < .001), but there was no statistically significant difference in physical functioning. Conclusions and Relevance Use of MMB plus UDC resulted in significant improvement in depression and functional outcomes compared with UDC only. The MMB web-based treatment may offer a scalable approach for the management of residual depressive symptoms. Trial Registration identifier: NCT02190968