PRIFYSGOL BANGOR / B
ANGOR UNIVERSITY
What defines mindfulness-based programs?
Crane, Rebecca; Brewer, J.; Feldman, C.; Kabat-Zinn, J.; Santorellli, S;
Williams, J.M.G.; Kuyken, W.
Psychological Medicine
DOI:
10.1017/S0033291716003317
Published: 01/04/2017
Peer reviewed version
Cyswllt i'r cyhoeddiad / Link to publication
Dyfyniad o'r fersiwn a gyhoeddwyd / Citation for published version (APA):
Crane, R., Brewer, J., Feldman, C., Kabat-Zinn, J., Santorellli, S., Williams, J. M. G., & Kuyken,
W. (2017). What defines mindfulness-based programs? The warp and the weft. Psychological
Medicine, 47(6), 990-999. https://doi.org/10.1017/S0033291716003317
Hawliau Cyffredinol / General rights
Copyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or
other copyright owners and it is a condition of accessing publications that users recognise and abide by the legal
requirements associated with these rights.
• Users may download and print one copy of any publication from the public portal for the purpose of private
study or research.
• You may not further distribute the material or use it for any profit-making activity or commercial gain
• You may freely distribute the URL identifying the publication in the public portal ?
Take down policy
If you believe that this document breaches copyright please contact us providing details, and we will remove access to
the work immediately and investigate your claim.
26. Aug. 2022
1
What Defines Mindfulness-Based Programs?
The warp and the weft
Rebecca S. Crane, Bangor University
Judson Brewer, University of Massachusetts
Christina Feldman, Totnes, Devon, UK
Jon Kabat-Zinn, University of Massachusetts
Saki Santorelli, University of Massachusetts
J. Mark G. Williams, University of Oxford
Willem Kuyken, University of Oxford
Keywords: Mindfulness-Based Program, Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive
Therapy, fidelity
Manuscript
2
There has been an explosion of interest in Mindfulness-Based Programs (MBPs) such as Mindfulness-
Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) in the last two decades.
MBSR has accrued a robust evidence base in improving mental health outcomes in those with chronic physical
health problems (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010). MBCT is an adaptation developed to teach
those at high risk of depressive relapse skills to stay well and has been shown to be effective (Kuyken et al.,
2016). There are multiple other MBPs with varying levels of research evidence at each stage of the research
journey (Dimidjian & Segal, 2015).
For the sustainable development of the field there is a need to pause and address some fundamental
questions. Dimidjian and Segal (Dimidjian & Segal, 2015) analyzed the status of the extant evidence using the
National Institutes of Health (NIH) Stage Model (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014). This is a
model of behavioral intervention development composed of six stages: basic science (Stage 0), intervention
generation, refinement, modification, and adaptation and pilot testing (Stage I); traditional efficacy testing
(Stage II); efficacy testing with real-world providers (Stage III); effectiveness research (Stage IV) and;
dissemination and implementation research (Stage V). The mapping of the MBP evidence base onto this model
by Dimidjian and Segal clarifies that the evidence is heavily saturated in Stage I, lightly represented in Stages 0
and II, and that to date there is minimal research in stages III, IV and V. Overall, in their analysis they identify
significant strengths (e.g. breadth of clinical problems and populations targeted), and significant weaknesses
(e.g. the need for an integrated and systematic approach to core research questions across all stages of the
research from basic through to implementation science). In this editorial we focus on a critical underpinning
issue throughout the Stage Model – namely the fidelity/integrity of the intervention itself. Fidelity is central to
all stages but has particular salience at Stages I and V. Stage I involves the development of the intervention,
which requires great clarity about for whom it is intended, and a theoretical exposition of what mechanisms
are being targeted. It also requires careful consideration of what clinician training and supervision is required
to deliver the intervention effectively. Stage V addresses implementation, which raises similar issues about
what key aspects of fidelity need to be maintained when implementing in real world settings.
Given the proliferation of MBP development and research, there is a need to re-clarify the core
ingredients of mindfulness-based programs, and the implications this has for professional training, supervision
and implementation. This clarity is important for the field so that existing research can be meaningfully
3
interpreted, future research uses agreed definitions and established protocols, MBP teachers are trained
appropriately, and the general public are assured that programs titles accurately describe what is delivered.
Mindfulness-Based Programs in Context
MBSR was developed as an education and training vehicle for people with chronic health problems
and those suffering from the mounting demands associated with psychological and emotional stress, to learn
to relate in new ways to life challenges (Kabat-Zinn, 2013). Other programs based upon the foundational
approach and structure of MBSR have since been developed with particular aims across a broad range of
settings, including hospitals, schools and prisons, and are gaining interest from policy makers (Mindfulness All
Party Parliamentary Group, 2015; Ryan, 2013).
MBP developments are nested within a wider context of empirical developments within psychology,
medicine, health care and education which include ‘mindfulness-informed’ programs such as Acceptance and
Commitment Therapy (Hayes, Strosahl, & Wilson, 2011), Compassion Focused Therapy (Gilbert, 2009),
Dialectical Behavioral Therapy (Linehan, 1993), Mindful Self Compassion (Neff & Germer, 2013) and
developments in the field of Positive Psychology (Seligman & Csikszentmihalyi, 2000). These mindfulness-
informed developments are part of the third wave of empirically tested psychotherapies (first wave being
behavioral therapy; second wave being cognitive behavioral therapy). Third wave approaches have a
decreased emphasis on controlling internal experience, and an increased emphasis on themes such as
acceptance, metacognition and how people relate to their experiences. Mindfulness-informed programs share
several underpinning theoretical ideas with MBPs, and many include some mindfulness meditation practice in
their approach. However, a distinctive feature of MBPs is that systematic and sustained training in formal and
informal mindfulness meditation practices (for both teacher and participants) is central both to the
therapeutic approach and underpinning theoretical model. They are based on mindfulness.
It should also be noted that other MBPs exist alongside MBSR/MBCT which also share this emphasis
on the practice of mindfulness-meditation as a central pedagogical component. An important example are
‘second generation ’ mindfulness-based interventions which are openly spiritual in nature, make the linkage to
the Buddhist teachings explicit within the pedagogy and are more traditional in the manner in which they
construct and teach mindfulness (Van Gordon, Shonin, & Griffiths, 2015).These programs are at an earlier
stage of development and research is now underway. However, the boundary to the analysis in this paper are
4
what have retrospectively become termed ‘first-generation’ MBPs – i.e. MBSR and MBCT (which represent the
strongest evidence within the field), and the range of programs which have developed out of these (e.g.
Bowen et al., 2009; Duncan & Bardacke, 2010; Kristeller, Sheets, Wolever, & Bolinskey, 2012). These first
generation MBPs, whilst drawing aspects of their underpinning models and practices from aspects of
Buddhism, aim to clearly re-contextualise both the program content and theoretical underpinnings within the
mainstream. That is to say, the aim is to ensure MBPs are based in science and contemporary approaches to
managing mental and physical health and supporting well-being; that they are suitable for delivery in
mainstream public institutions across a range of settings and cultures; and that they are maximally accessible
to people with diverse values and religious affiliations.
It is also important to note that while MBPs have been developed for particular issues such as stress
and depression, there are other empirically supported approaches for such difficulties. There is as yet no
compelling evidence for specificity of hypothesized mechanisms or differential outcomes. This may be an
artifact of the many shared components between these approaches, or it may simply be that this work has not
yet been done. Our hope is that the clarity we aim to offer in this editorial will support measurement,
mechanisms, and mediators research, as a recent editorial has argued is needed (Davidson, 2016).
Development Trajectory for Mindfulness-Based Programs
In the context of high interest and rapid proliferation Dimidjian and Segal (2015) identify several key
challenges for the next phase of research developments. This editorial focuses on one of these challenges -
research and practice issues in the arena of MBP fidelity. If these challenges are not carefully addressed they
will undermine the developing science as well as the quality and integrity of implementation in routine
practice. Mindfulness training in various forms is rapidly being applied within different contexts and
populations, and morphing into multiple curriculums of differing lengths and teaching methods. Mindfulness
can be intuitively appealing to teachers and participants. There is consequently a grassroots spread of practice
into populations and contexts, which at times is ahead of the evidence. The word mindfulness has become a
word conveying a multitude of meanings and practices. This is a confusing context within which to
systematically build the science and the practice integrity of MBPs.
The Essential and Variable Elements of First Generation MBPs