Can mindfulness be too much of a good thing? The value of a middle way

In the paper

“Indeed, high levels of the observing awareness facet of mindfulness have been repeatedly found to be associated with worse mental health, including increased depression, anxiety, dissociation, and substance abuse [8,16] and decreased ability to tolerate pain [17].”

What the sources say

• Not checked yetcites [8] Sahdra B, Ciarrochi J, Parker P, Basarkod G, Bradshaw E, Baer R: Are people mindful in different ways? Disentangling the quantity and quality of mindfulness in latent profiles and exploring their lnks to mental health and life effectiveness. European Journal of Personality 2017, 31: 347– 365. source
• Not checked yetcites [16] Eisenlohr-Moul TA, Walsh EC, Charnigo RJ Jr., Lynam DR, Baer RA: The “what” and the “how” of dispositional mindfulness: using interactions among subscales of the five-facet mindfulness questionnaire to understand its relation to substance use. Assessment 2012, 19: 276– 286. 22589412 PMC3715554 source
• Not checked yetcites [17] Evans DR, Eisenlohr-Moul TA, Button DF, Baer RA, Segerstrom SC: Self-Regulatory Deficits Associated with Unpracticed Mindfulness Strategies for Coping with Acute Pain. J Appl Soc Psychol 2014, 44: 23– 30. 25843972 PMC4383260 source

In the paper

“Increases in the size and activation of the insular cortex have been found to result from both short and long-term meditation training, and correlate with the amount of practice [20–22].”

What the sources say

• Not checked yetcites [20] Fox KC, Nijeboer S, Dixon ML, Floman JL, Ellamil M, Rumak SP, Sedlmeier P, Christoff K: Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neurosci Biobehav Rev 2014, 43: 48– 73. 24705269 source
• Not checked yetcites [21] Fox KC, Dixon ML, Nijeboer S, Girn M, Floman JL, Lifshitz M, Ellamil M, Sedlmeier P, Christoff K: Functional neuroanatomy of meditation: A review and meta-analysis of 78 functional neuroimaging investigations. Neurosci Biobehav Rev 2016, 65: 208– 228. 27032724 source
• Not checked yetcites [22] Gotink RA, Meijboom R, Vernooij MW, Smits M, Hunink MG: 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice -A systematic review. Brain Cogn 2016, 108: 32– 41. 27429096 source

In the paper

“In concluding “there is no such thing as an unmitigated good,” Grant and Schwartz [1] hypothesize that mindfulness is also likely to have non-monotonic effects and recommend that researchers study its boundary conditions more carefully.”

What the sources say

• Not checked yetcites [1] Grant AM, Schwartz B: Too Much of a Good Thing: The Challenge and Opportunity of the Inverted U. Perspect Psychol Sci 2011, 6: 61– 76. 26162116 source

In the paper

“Grant and Schwartz [1] demonstrate that even virtues and positive traits like curiosity and optimism are non-monotonic; they have an optimum level above or below which are minimal returns or undesirable effects.”

What the sources say

• Not checked yetcites [1] Grant AM, Schwartz B: Too Much of a Good Thing: The Challenge and Opportunity of the Inverted U. Perspect Psychol Sci 2011, 6: 61– 76. 26162116 source

In the paper

“Long-term meditators have also been found to have poorer sleep than non-meditators, with cortical arousal that is linearly correlated with lifetime meditation practice amount [52].”

What the sources say

• Not checked yetcites [52] Ferrarelli F, Smith R, Dentico D, Riedner BA, Zennig C, Benca RM, Lutz A, Davidson RJ, Tononi G: Experienced mindfulness meditators exhibit higher parietal-occipital EEG gamma activity during NREM sleep. PLoS One 2013, 8: e73417. 24015304 PMC3756031 source

In the paper

“High levels of a specific MRP may produce negative effects on its own, but can be counterbalanced by supplementing with other MRPs.”

In the paper

“Avoidant individuals have been shown to benefit from exposure (attending to threat), while those with bias toward threat benefit most from cognitive bias modification (CBM), or training attention away from threat [41,42].”

What the sources say

• Not checked yetcites [41] Barry TJ, Vervliet B, Hermans D: An integrative review of attention biases and their contribution to treatment for anxiety disorders. Front Psychol 2015, 6: 968. 26217284 PMC4495309 source
• Not checked yetcites [42] McNally RJ: Attentional bias for threat: Crisis or opportunity? Clin Psychol Rev 2018. 29853421

In the paper

“Farb et al. [39] hypothesizes that mindfulness training recruits the IPL’s dissociative functions (out-of-body experiences and depersonalization) to create mindfulness’s “detached or objective mode of self-focus” or the ability to switch from a 1st to 3rd person perspective.”

What the sources say

• Not checked yetcites [39] Farb NA, Segal ZV, Mayberg H, Bean J, McKeon D, Fatima Z, Anderson AK: Attending to the present: mindfulness meditation reveals distinct neural modes of self-reference. Soc Cogn Affect Neurosci 2007, 2: 313– 322. 18985137 PMC2566754 source

In the paper

“For example, re-appraising or accepting a situation can ease distress when there are no other options, but failing to take corrective action in a situation one could have changed can cause depression [47].”

What the sources say

• Not checked yetcites [47] Troy AS, Shallcross AJ, Mauss IB: A person-by-situation approach to emotion regulation: cognitive reappraisal can either help or hurt, depending on the context. Psychol Sci 2013, 24: 2505– 2514. 24145331 source

In the paper

“However, anxiety and other disorders can be caused and maintained not only by attentional bias away from (avoidance of) threat, but also by attentional bias toward threat [41,42].”

What the sources say

• Not checked yetcites [41] Barry TJ, Vervliet B, Hermans D: An integrative review of attention biases and their contribution to treatment for anxiety disorders. Front Psychol 2015, 6: 968. 26217284 PMC4495309 source
• Not checked yetcites [42] McNally RJ: Attentional bias for threat: Crisis or opportunity? Clin Psychol Rev 2018. 29853421

In the paper

“Drawing from empirical evidence that many disorders are caused and maintained by high levels of experiential avoidance, exposure theory predicts and has verified that those who benefit the most reduce high levels of experiential avoidance by deliberately attending to threat [41].”

What the sources say

• Not checked yetcites [41] Barry TJ, Vervliet B, Hermans D: An integrative review of attention biases and their contribution to treatment for anxiety disorders. Front Psychol 2015, 6: 968. 26217284 PMC4495309 source

In the paper

“While present-moment awareness may constitute the “what” of mindfulness, mindfulness qualities constitute the “how” [16] by balancing that awareness with qualities of nonjudgment, acceptance, curiosity, open-mindedness, optimism, self-efficacy, courage, trust, patience, persistence, kindness, empathy, generosity, gratitude, social intelligence, freedom, autonomy and choice.”

What the sources say

• Not checked yetcites [16] Eisenlohr-Moul TA, Walsh EC, Charnigo RJ Jr., Lynam DR, Baer RA: The “what” and the “how” of dispositional mindfulness: using interactions among subscales of the five-facet mindfulness questionnaire to understand its relation to substance use. Assessment 2012, 19: 276– 286. 22589412 PMC3715554 source

In the paper

“Mindfulness qualities are attitudinal factors that are considered an essential foundation for mindfulness practice [31].”

What the sources say

• Not checked yetcites [31] Kabat-Zinn J: Full catastrophe living Using the wisdom of your body and mind to face stress, pain, and illness: Delta; 1990.

In the paper

“An essential part of mindful emotion regulation is decentering—the ability to “step back” or to have psychological distance from instead of fusion with one’s experience, especially one’s thought and emotions [13,37].”

What the sources say

• Not checked yetcites [13] Holzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U: How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Sci 2011, 6: 537– 559. 26168376 source
• Not checked yetcites [37] Crane RS, Brewer J, Feldman C, Kabat-Zinn J, Santorelli S, Williams JM, Kuyken W: What defines mindfulness-based programs? The warp and the weft. Psychol Med 2017, 47: 990– 999. 28031068 source

In the paper

“Low practice amounts in MBCT participants increased sleep duration, but as practice amount approached 30 minutes per day, sleep duration and depth began to decrease and cortical arousal (awakenings and microarousals) began to increase.”

What the sources say

• Not checked yetcites [50] Britton WB, Lindahl JR, Cahn BR, Davis JH, Goldman RE: Awakening is not a metaphor: the effects of Buddhist meditation practices on basic wakefulness. Ann N Y Acad Sci 2014, 1307: 64– 81. 24372471 PMC4054695 source
• Not checked yetcites [51] Britton WB, Haynes PL, Fridel KW, Bootzin RR: Polysomnographic and subjective profiles of sleep continuity before and after mindfulness-based cognitive therapy in partially remitted depression. Psychosom Med 2010, 72: 539– 548. 20467003 source

In the paper

“While it’s hard to imagine ever having too much of any of these qualities, Grant and Schwartz [1] demonstrate that all of these usually beneficial qualities are non-monotonic, or can have undesirable costs in certain situations, for certain people or when taken too far.”

What the sources say

• Not checked yetcites [1] Grant AM, Schwartz B: Too Much of a Good Thing: The Challenge and Opportunity of the Inverted U. Perspect Psychol Sci 2011, 6: 61– 76. 26162116 source

In the paper

“The non-monotonicity model also predicts that both positive and negative effects will be more likely to occur in practitioners with particular baseline conditions: Positive effects would be most likely to occur in those with low levels (deficits) in MRPs, while negative effects would be most likely to occur in those with high baseline levels of MRPs.”

In the paper

“By intentionally and consistently using an “approach orientation” [37], “turning towards the difficult,” and experiencing one’s negative emotions fully, mindfulness is thought to exert transdiagnostic benefits by “facilitating extinction of distress in response to strong emotions, leading to reduced emotional avoidance and, consequently, disorder symptoms” [40].”

What the sources say

• Not checked yetcites [40] Brake CA, Sauer-Zavala S, Boswell JF, Gallagher MW, Farchione TJ, Barlow DH: Mindfulness-Based Exposure Strategies as a Transdiagnostic Mechanism of Change: An Exploratory Alternating Treatment Design. Behav Ther 2016, 47: 225– 238. 26956654 PMC8177505 source

In the paper

“This model would predict that negative effects could occur with correct practice, and would be more likely at higher doses of practice or MRP.”

In the paper

“Mindfulness training has been found to increase prefrontal control over the limbic system and amygdala, which is associated with improved emotion regulation, anxiety, depression and emotional reactivity [22,32].”

What the sources say

• Not checked yetcites [22] Gotink RA, Meijboom R, Vernooij MW, Smits M, Hunink MG: 8-week Mindfulness Based Stress Reduction induces brain changes similar to traditional long-term meditation practice -A systematic review. Brain Cogn 2016, 108: 32– 41. 27429096 source
• Not checked yetcites [32] Tang YY, Holzel BK, Posner MI: The neuroscience of mindfulness meditation. Nat Rev Neurosci 2015, 16: 213– 225. 25783612 source

In the paper

“Mindful emotion regulation seeks to increase adaptive approach-related strategies like acceptance and reappraisal, and seeks to decrease maladaptive, avoidant strategies like distraction and suppression [13,37].”

What the sources say

• Not checked yetcites [13] Holzel BK, Lazar SW, Gard T, Schuman-Olivier Z, Vago DR, Ott U: How Does Mindfulness Meditation Work? Proposing Mechanisms of Action From a Conceptual and Neural Perspective. Perspect Psychol Sci 2011, 6: 537– 559. 26168376 source
• Not checked yetcites [37] Crane RS, Brewer J, Feldman C, Kabat-Zinn J, Santorelli S, Williams JM, Kuyken W: What defines mindfulness-based programs? The warp and the weft. Psychol Med 2017, 47: 990– 999. 28031068 source

In the paper

“Thus, the benefits and/or harms of exposure depend on the initial baseline level of the targeted problem (bias toward or away from threat), and can become either ineffective or iatrogenic when applied to people with levels different than the targeted one [29].”

What the sources say

• Not checked yetcites [29] Treleaven DA: Trauma-Sensitive Mindfulness: Practices for safe and transformative healing New York: Norton; 2018.

In the paper

“However, treating any one strategy as either consistently adaptive or maladaptive has been called “the fallacy of uniform efficacy” [45].”

What the sources say

• Not checked yetcites [45] Bonanno GA, Burton CL: Regulatory Flexibility: An Individual Differences Perspective on Coping and Emotion Regulation. Perspect Psychol Sci 2013, 8: 591– 612. 26173226 source

In the paper

“Depending on the context and the person, favored strategies like acceptance and reappraisal may be superior, inferior, or equal to disfavored strategies like suppression and distraction [46] and are sometimes associated with adverse effects [47,48].”

What the sources say

• Not checked yetcites [46] Kohl A, Rief W, Glombiewski JA: How effective are acceptance strategies? A meta-analytic review of experimental results. J Behav Ther Exp Psychiatry 2012, 43: 988– 1001. 22561050 source
• Not checked yetcites [47] Troy AS, Shallcross AJ, Mauss IB: A person-by-situation approach to emotion regulation: cognitive reappraisal can either help or hurt, depending on the context. Psychol Sci 2013, 24: 2505– 2514. 24145331 source
• Not checked yetcites [48] Dunn BD, Billotti D, Murphy V, Dalgleish T: The consequences of effortful emotion regulation when processing distressing material: a comparison of suppression and acceptance. Behav Res Ther 2009, 47: 761– 773. 19559401 PMC2764381 source

In the paper

“Most MBI studies use data only from the treatment completers and lack data from long-term follow-ups and dropouts—the groups most likely to have negative effects [56,60].”

What the sources say

• Not checked yetcites [56] Coronado-Montoya S, Levis AW, Kwakkenbos L, Steele RJ, Turner EH, Thombs BD: Reporting of Positive Results in Randomized Controlled Trials of Mindfulness-Based Mental Health Interventions. PLoS One 2016, 11: e0153220. 27058355 PMC4825994 This review of mindfulness-based intervention RCTs found that nearly 90% of the trials reviewed reported positive results in favor of mindfulness, which the authors concluded is suggestive of reporting bias. Only 25% of studies that found negative results reported them in a straightforward way. Instead, 75% of studies “spun” negative findings to appear equivoc source
• Not checked yetcites [60] Ioannidis JP, Evans SJ, Gotzsche PC, O’Neill RT, Altman DG, Schulz K, Moher D: Better reporting of harms in randomized trials: an extension of the CONSORT statement. Ann Intern Med 2004, 141: 781– 788. 15545678 source

In the paper

“In addition, very few MBI trials actively measure adverse effects [58], relying instead on passive monitoring, which can underestimate the actual frequency by more than 20-fold [59,60].”

What the sources say

• Not checked yetcites [58] Wong S, Chan J, Zhang D, Lee E, Tsoi K: The Safety of Mindfulness-Based Interventions: a Systematic Review of Randomized Controlled Trials. Mindfulness 2018. In a review of 231 RCTs of mindfulness-based interventions (MBSR or MBCT), the vast majority (84.4%) did not contain any information about measuring or monitoring adverse effects. In the remaining 15.6%, fewer adverse effects in the MBI arm were more likely to be reported when MBIs failed to outperformed controls, or when authors reported conflicts of interest. Current MBI trial harms reporting is not adequate to produce an accurate estim source
• Not checked yetcites [59] Bent S, Padula A, Avins AL: Brief communication: Better ways to question patients about adverse medical events: a randomized, controlled trial. Ann Intern Med 2006, 144: 257– 261. 16490911 source
• Not checked yetcites [60] Ioannidis JP, Evans SJ, Gotzsche PC, O’Neill RT, Altman DG, Schulz K, Moher D: Better reporting of harms in randomized trials: an extension of the CONSORT statement. Ann Intern Med 2004, 141: 781– 788. 15545678 source

In the paper

“Mindfulness researchers and program developers have recognized that reversal of deficiencies in MRPs enhance wellbeing, but have paid less attention to how excesses in these processes could also undermine wellbeing.”

In the paper

“The framework values null and negative effects because they signify boundary condition violations or inflection points. These are important because they provide otherwise unavailable information about optimal versus ineffective or harmful doses of MRPs under different conditions or for different people.”

In the paper

“Mindfulness studies tend to over-represent positive results, while negative findings are either not published or obscured by post-hoc subgroup analyses or creative reinterpretations [55–57].”

What the sources say

• Not checked yetcites [55] Dimidjian S, Segal ZV: Prospects for a clinical science of mindfulness-based intervention. Am Psychol 2015, 70: 593– 620. 26436311 PMC5853107 source
• Not checked yetcites [56] Coronado-Montoya S, Levis AW, Kwakkenbos L, Steele RJ, Turner EH, Thombs BD: Reporting of Positive Results in Randomized Controlled Trials of Mindfulness-Based Mental Health Interventions. PLoS One 2016, 11: e0153220. 27058355 PMC4825994 This review of mindfulness-based intervention RCTs found that nearly 90% of the trials reviewed reported positive results in favor of mindfulness, which the authors concluded is suggestive of reporting bias. Only 25% of studies that found negative results reported them in a straightforward way. Instead, 75% of studies “spun” negative findings to appear equivoc source
• Not checked yetcites [57] Morone NE, Moore CG, Greco CM: Characteristics of Adults Who Used Mindfulness Meditation: United States, 2012. J Altern Complement Med 2017, 23: 545– 550. 28084788 Querying more than 100,000 adults as part of the 2012 U.S. National Health survey, this study represents the largest cross-sectional study to date that compares mindfulness meditators to non-meditators. The study found that mindfulness meditators had worse physical and mental health than non-meditators, including higher levels of pain, headaches, stress, depression, anxiety, insomnia and acute illness. Although cross-sectional studi source

In the paper

“Expert meditators with mental health issues are typically excluded from research, resulting in a selective representation of the effects from long-term practice [52].”

What the sources say

• Not checked yetcites [52] Ferrarelli F, Smith R, Dentico D, Riedner BA, Zennig C, Benca RM, Lutz A, Davidson RJ, Tononi G: Experienced mindfulness meditators exhibit higher parietal-occipital EEG gamma activity during NREM sleep. PLoS One 2013, 8: e73417. 24015304 PMC3756031 source

In the paper

“Because it is measuring mindfulness in the deficiency-reversal phase (Figure 1, Panel 1), but not in the excess phase of the inverted U-shaped curve, it is more likely to be highly and linearly associated with gains in wellbeing or functioning and show few negative effects.”

In the paper

“A non-monotonic framework will help to maximize effectiveness and minimize harms in mindfulness-based applications by providing a model that can chart a “middle way” between “not enough” and “too much of a good thing.””

In the paper

“In other words, the field of mindfulness has been primarily focused on the upward slope of the inverted U-shaped curve, with insufficient attention to the downward slope of the curve.”

In the paper

“A mindfulness research agenda that employs a non-monotonic framework—one that includes the entirety of the inverted U-shaped curve—may be better positioned to make sense of positive, null, and contradictory findings, differential outcomes for different subgroups, and negative effects.”