This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Smith, J. C. Articles by Kabat-Zinn, J. Search for Related Content PubMed PubMed Citation Articles by Smith, J. C. Articles by Kabat-Zinn, J. Related Collections Letters to the Editor

ALTERATIONS IN BRAIN AND IMMUNE FUNCTION PRODUCED BY MINDFULNESS MEDITATION: THREE CAVEATS

Distinguished Professor of Psychology, Roosevelt University, Chicago, Illinois

Recent research of Davidson and his colleagues on brain processes and mindfulness meditation (1) has generated substantial media and popular attention. In this research, participants randomly assigned to 8 weeks of mindfulness meditation (compared with nonmeditating controls) displayed significant increases in left-sided anterior activation (previously associated with positive affect) and increases in antibody titers to influenza vaccine. Meditators practiced 45 minutes a day, met weekly for up to 3 hours, and completed a silent 7-hour retreat at week 6. These are exciting and promising findings that merit comment.

Having studied and taught meditation and relaxation for over three decades (2–11), I note similarities between the current burst of interest in Buddhist techniques and interest in a Westernized Hindu approach in the 1970s—transcendental meditation (TM). For both, media attention has been considerable, including major articles in the New York Times, several feature articles in theNew York Times Magazine, cover articles in Time, and significant coverage on network television. Interestingly, for both, heightened interest was preceded by major articles in Psychosomatic Medicine. Unfortunately for both, the popular press has generally overstated the significance of reported findings. This in turn has provided considerable misleading "expert recommended" advertising copy for technique advocates and exaggerated promise of symptom relief and psychological gain to those in distress. Ordinarily, scholars look the other way when the media mangles their work. However, given that serious journalists have described current mindfulness studies as "milestone" (13), and researchers, through frequent interviews, have done little to temper such exuberance, it is time to take a deep breath and bring to light three caveats.

First, most research on mindfulness has examined Kabat-Zinn’s approach. Few, if any, studies have cautioned that the Kabat-Zinn system is not pure mindfulness, but an amalgam of mindfulness meditation, concentrative meditation, passive breathing exercises, yoga stretching, and even a bit of imagery, autogenic training, and Buddhist psychology. Elsewhere I have proposed that this system should be viewed as a "combination approach" (10, 11, 12) . The point is not minor, given the consistent finding that the different approaches Kabat-Zinn incorporates have different effects (8, 9, 12). Thus, it is impossible to determine if obtained benefits are the result of meditation, stretching, breathing, or a synergistic combination of all components. Likewise, it is impossible to identify elements that are unnecessary or needlessly long. We risk driving clients away with 1-hour daily meditations (most other programs use 20 minutes or less), 3-hour weekly meditations, and 7-hour silent meditation retreats every few months. Of the six major approaches to professional relaxation (progressive muscle relaxation, autogenic training, yoga stretching, breathing exercises, imagery, meditation), the Kabat-Zinn approach is truly unique in its demands. Such demands appear to be based on Buddhist religious tradition rather than scientific evidence.

Second, we know very little about the biological effects of activities that consistently evoke positive states. It is clear that positive states can be evoked by many activities, including sitting in a Jacuzzi, listening to music, taking nature walks, petting pets, and so on (12). Just what are the physiological effects of, say, basking in a Jacuzzi an hour each day, supplemented by a 3-hour visit to the pleasure spa every weekend, and a 7-hour marathon spa retreat after 6 weeks? I predict the lucky participants in such research would appear quite happy and healthy, especially if their retreats were led by a world-famous pleasure spa expert. Of course, it is not my purpose to promote pleasure spas. My point is that any consistent, prolonged, and enthusiastically promoted regimen of quiet and pleasurable activity could well evoke changes in dispositional positive affect as well as brain and immune function. This simply has to be checked before any mindfulness research can be described as "milestone." Until then, researchers must provide the appropriate caveat.

Third, there is the problem of happiness. For over a decade (6, 7, 12), I have argued that positive state researchers have restricted their attention to just one or two positive dimensions, usually happiness. Such a focus limits what meditation research can find. I predict that when brain researchers start comparing approaches, practitioners of different techniques will look uninterestingly similar when happiness is the only positive state examined. Our research, as described in over 30 published studies (7–9, 12, 14–16), has examined several dozen types of relaxation and meditation activities practiced by over 10,000 participants. We have found at least 15 positive factor states associated with the practice of relaxation, meditation, and mindfulness. In addition to Happiness, this comprehensive list includes: Sleepiness, Disengagement, Rested/Refreshed, Energized, Physical Relaxation, At Ease/Peace, Mental Quiet, Childlike Innocence, Love/Thankfulness, Mystery, Awe/Wonder, Prayerfulness, and Timeless/Boundless/Infinite/At One. Furthermore, whenever we have compared techniques (including mindfulness), we have found that different approaches evoke different positive states, even though they evoke the same degree of happiness. It remains for researchers to look beyond happiness for what may well be the true uniqueness of mindfulness.

In sum, I sense that we may be at the threshold of a new explosion of public and scientific interest in mindfulness meditation. Serious research on TM first appeared in the scientific literature about three decades ago, and inspired, as listed on PsycINFO, 147 articles from 1973 to 1982 (during this time, 88 studies focused on Zen and mindfulness). In the present decade (1993–2002), mindfulness research has been on the rise, with over 140 articles to date (75 for TM). It is my hope that a few simple caveats may prompt or provoke meditation researchers to carefully examine their methods and avoid the exaggerated claims uttered by TM advocates in the 1970s and 1980s. Those of us who do meditation research should be mindful that our findings and enthusiastic recommendations are grounded in fact, not faith.

REFERENCES

1. Davidson R, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli S, Urbanowski F, Harrington A, Bonus K, Sheridan J. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med 2003; 65: 564–70.[Abstract/Free Full Text]
2. Smith J. Meditation as psychotherapy: A review of the literature. Psychol Bull 1975; 32: 553–64.
3. Smith J. Psychotherapeutic effects of TM with controls for expectation of relief and daily sitting. Consult Clin Psychol 1976; 44: 630–7.[CrossRef]
4. Smith J. Personality correlates of continuation and outcome in meditation and erect sitting control treatment. J Consult Clin Psychol 1978; 46: 2272–9.
5. Smith J. Relaxation dynamics: Nine world approaches to self-relaxation. Champaign, IL: Research Press; 1985.
6. Smith J. Meditation, biofeedback, and the relaxation controversy: A cognitive-behavioral perspective. Amer Psychol 1986; 41: 1007–9.
7. Smith J. Cognitive-behavioral relaxation training: A new system of strategies for treatment and assessment. New York: Springer; 1990.
8. Gillani N, Smith J. Zen meditation and ABC relaxation theory: An exploration of relaxation states, beliefs, dispositions, and motivations. J Clin Psychol 2001; 57: 839–46.[CrossRef][Medline]
9. Matsumato M, Smith J. Progressive muscle relaxation, breathing exercises, and ABC relaxation theory. J Clin Psychol 2001; 57: 1551–7.[Medline]
10. Smith J. ABC relaxation theory: An evidence-based approach. New York: Springer; 1999.
11. Smith J. ABC relaxation training: A practical guide for health professionals. New York: Springer; 1999.
12. Smith JC. Advances in ABC relaxation. Applications and inventories. New York: Springer; 2001.
13. Hall S. Is Buddhism good for your health? NY Times Mag; September 14, 2003.
14. Smith J, Wendell A, Kolotylo C, Camille J, Lewis J, Byers K, Segin C. ABC relaxation theory and the factor structure of relaxation states and recalled relaxation activities, dispositions, and motivations. Psychol Rep 2000; 86: 1201–8.[Medline]
15. Smith J. Steps toward a cognitive-behavioral model of relaxation. Biofeedback Self Regul 1988; 13: 307–29.[Medline]
16. Smith J, Amutio A, Anderson J, Aria L. Relaxation. Mapping an uncharted world. Biofeedback Self Regul 1996; 21: 63–90[Medline]

Response

University of Wisconsin, Madison, Wisconsin, University of Massachusetts Medical School, Amherst, Massachusetts

We thank Professor Smith for his useful comments and cautionary notes, particularly regarding the response of the media to published research on meditation and for the opportunity to elaborate on the important issues he raises. As a clinician who has used various forms of meditation and relaxation for many years, he raises three caveats about our study that we will address in turn.

1. "Kabat-Zinn’s system is not pure mindfulness, but an amalgam of mindfulness meditation, concentrative meditation, passive breathing exercises, yoga stretching, and even a bit of imagery, autogenic training and Buddhist psychology."
      Professor Smith notes that it is impossible in light of the complexity of the intervention to know precisely which ingredient produced the effects that we observed. He also notes that is it not possible to know which components may be needlessly long and unnecessary, and he makes the good point that some individuals might be dissuaded from engaging in the Mindfulness-Based Stress Reduction (MBSR) intervention because of its high-demand characteristics.
      We view all of these as important issues, ones that we have obviously considered over the years. Our study must be placed within its appropriate context. While Professor Smith notes that research on MBSR has been increasing, our study was the first to examine brain and immune function changes produced by this intervention. Thus, in this initial study, we simply wished to determine whether there is any effect of the intervention as it is typically administered. Our goal was explicitly not to identify one particular component as "the" active ingredient, if indeed there is any. This would require the use of several different types of control groups, and our goals for this initial study were considerably more modest.
      While we agree with Professor Smith in his characterization of the intervention as complex and multi-componential, viewed along one axis, we believe he is overlooking another vital perspective, namely that mindfulness, defined as moment-to-moment nonjudgmental awareness, serves as the overarching unifying factor across the various elements of the intervention, which, we emphasize, do not include what he characterizes as "passive breathing exercises, autogenic training, and Buddhist psychology." Also, it should be understood in this context that there is no such thing as "pure mindfulness" meditation, even within the Buddhist tradition; we have emphasized the multi-modal nature of its cultivation in all our characterizations of MBSR, beginning in 1982 (1). Mindfulness as taught originally by the Buddha is practiced formally in the sitting, lying down, and standing positions, as well as walking. There are four foundations of mindfulness in the classical formulation (Mahasatipatana sutra) (2): body; perceptions of pleasant, unpleasant, and neutral; thoughts and emotions; and the characteristics of experience described as dis-satisfactoriness, impermanence, and emptiness of inherent self-existence. There are 16 cultivations of mind states in relation to awareness of breathing alone (Anapanasati Sutra) (3). Moreover, mindfulness is taught and practiced classically across all activities of daily living, and a good deal of the curriculum in MBSR concerns itself with this cultivation. We feel it is an accurate first-approximation characterization to say that training in mindful awareness across a number of different practices is the salient and overarching characteristic of MBSR.
      While it is true that at this point in time we do not know what the active ingredient in the intervention might be for producing the changes we observed on measures of brain and immune function, it is a far more complex and interesting question than it appears to be at first blush, and it will require multiple complex studies in the future to elucidate.
      In commenting on the demands made on clients by MBSR, Professor Smith notes that "of the six major approaches to professional relaxation (progressive muscle relaxation, autogenic training, yoga stretching breathing exercises, imagery, and meditation), the Kabat-Zinn approach is truly unique in its demands." If true, this is merely a reflection of the fact that MBSR is not aimed at achieving a state of clinical relaxation, but more at the cultivation of insight and understanding of self and self-in-relationship via the cultivation of a moment-to-moment, nonjudgmental but highly discerning awareness, as described by Kabat-Zinn (4). This orientation is likely to require a more extensive and intensive intervention strategy than the cultivation of relaxation in a clinical context. Relaxation may be a byproduct of this approach for some people under some circumstances, but it is not the goal of MBSR training. Indeed, Professor Smith seriously mischaracterizes mindfulness meditation and MBSR in suggesting that they promote quiet and pleasurable activity, as might many other regimens, including Jacuzzi time and spa sessions. A good deal of the time, the practice of mindfulness may mean being with and observing states of mind and body that are extremely painful or dysphoric, including fear, loneliness, anger, bodily discomfort, impatience, boredom, and the like. These are to be experienced as best as one can with the same nonjudgmental attitude as pleasant or neutral experiences. Meditation, and particularly mindfulness meditation, is not an isomorphic translation for relaxation, but rather for greater awareness, self-knowledge, equanimity, and self-compassion. It is hardly a trip to a luxury spa, as our patients can readily attest. The fact that over 15,000 people have completed MBSR training in the UMass Stress Reduction Clinic suggests that, whatever the demand characteristics of the program and perhaps because of them, large numbers of people are willing to engage in such an intensive process over 8 weeks and report significant benefits from doing so across a wide range of medical and psychiatric diagnoses.
      Professor Smith also notes that the demands of MBSR "appear to be based on Buddhist religious tradition rather than scientific evidence." While we agree with Professor Smith that much more scientific evidence is required for understanding all the potential combinatorial possibilities for an optimal generic MBSR intervention, we do not at all agree that the demands are based on Buddhist religious tradition, except in the sense that mindfulness meditation received its most elaborate and coherent articulation within that tradition and MBSR certainly makes use of lessons learned within such contexts as appropriate and in the absence of defining scientific information on the issue. As we have stated in many different contexts (1, 4–6), MBSR is an attempt to draw on whatever universal elements might be present within that tradition and others that cultivate mindfulness (since in the final analysis, mindfulness meditation is about the refining of attention and the cultivation of openhearted presence, both of which have nothing particularly Buddhist about them) and see if they can be made accessible and relevant to the needs of medical patients and others suffering from those aspects of the human condition subsumed under the terms stress, pain, and illness. MBSR is the outgrowth of that intention and exploration, shaped by extensive clinical experience delivering the intervention on the part of Kabat-Zinn and his colleagues, and drawing on their own first-person experience with a wide range of meditative practices. It is important in this context to clarify that the structure and components of MBSR have nothing to do with Buddhist religious beliefs. In fact, belief itself is a notion that is foreign to Buddhist meditative practices, which emphasize empiricism via direct personal experience rather than catechism or dogma. The MBSR curriculum is based on that kind of empirical attitude and approach and is entirely open to refinement on the basis of both clinical experience of what seems most effective and evidence from well-designed studies. Professor Smith is correct in pointing out that a great many interesting questions and research agendas can be brought to bear on the matter of demand characteristics and curriculum issues in mindfulness-based interventions, and this is an area of growing interest. It may be important to note that MBSR ordinarily requires 6 days each week of 45 minutes of formal guided meditation practice per day, not 1 hour, as Professor Smith states, and this was the case in the present study.
   
2. "We know very little about the biological effects of activities that consistently evoke positive states. It is clear that positive states can be evoked by many activities...any consistent, prolonged, and enthusiastically promoted regimen of quiet and pleasurable activity could well evoke changes in dispositional positive affect as well as brain and immune functioning."
      Here again Professor Smith calls our attention to a very important issue, and that is the possibility that other forms of leisure activity might promote changes that may or may not be similar to those we found produced by MBSR. Our purpose in performing this study was not to demonstrate the unique capability of MBSR in producing these effects. This would have required a comparison of MBSR to many other activities and strategies for the promotion of positive affect. Rather, our purpose was to determine if changes in brain and immune function could be uncovered as a consequence of the intervention. If our results were positive, as indeed they were, we and other researchers could begin the painstaking task of exploring the entire question of active ingredients and their interactions within the MBSR intervention and whether any feature of the intervention is truly unique or whether similar effects could be produced by other, very different forms of intervention. As suggested in our response to point 1 above, there may be fundamental differences in conceptualization and delivery between relaxation-oriented interventions and mindfulness-based interventions that may be relevant in this regard. These are all questions that await future research, and it is our sincere hope that this study and others like it will encourage precisely this kind of research and dialogue within the scientific community.
      There is one important issue with respect to this point of Professor Smith that we must not leave untouched. As we note both in our Results and Discussion sections, we failed to find any significant increase in self-reports of Positive Affect as a consequence of our MBSR intervention. We did find reliable reductions in self-reported anxiety. This fact raises several important issues. First, self-report measures are inadequate by themselves to capture positive-affect related changes in brain function. Second, the kind of interventions noted by Professor Smith, such as attending a "pleasure spa" are likely to produce changes in self-reported positive affect and thus appear different from the kind of change produced by MBSR. It is very important to note though that we made no claims about the uniqueness of MBSR or meditation more generally in promoting positive affects in brain and immune function. It is our firm intuition that there are likely many types of activities in which people engage that may promote similar changes. One of the critical questions that must be tackled in future research is how to best "match" a given individual to activities or interventions that will be most effective in promoting salubrious neural and immune function, if that is indeed a goal rather than an indicator of underlying psychological changes. We suspect that there will considerable individual variation in the nature of the activities that are most effective in this regard. As for its characterization in the press as a milestone, what is a milestone is the very fact that such studies are being undertaken at all. In our paper, we emphasized in considerable detail the limitations of the present study; when speaking with the press, we take pains to make sure that these limitations are understood.
   
3. "...there is the problem of happiness. ... I have argued that positive state researchers have restricted their attention to just one or two positive dimensions, usually ‘happiness.’ We have found at least 15 positive affect factor states associated with the practice of relaxation, meditation, and mindfulness."
      Professor Smith is calling our attention to an important issue in emotion research. He argues that there are many different forms of positive affect, other than happiness, and that researchers who study the impact of meditation and related interventions should examine the diverse range of positive affective states that might be affected. While we strongly agree with Professor Smith that positive affect states other than happiness need to be considered, as indeed Davidson has strongly argued in many previous publications (7–8), Davidson has also provided evidence to suggest that self-report methods by themselves will be woefully inadequate to capture these different forms of positive affect. The "15 positive factor states" described by Professor Smith are based exclusively on self-report methods. While this evidence is useful and important, it is inadequate and must be complemented by measures of brain function. One of the central tenets of affective neuroscience, similar to its neighboring cousin cognitive neuroscience, is that constituent affective processes will be identified in the brain that are opaque to awareness but that are consequential for behavior.
      It should also be noted that the assessment of positive affect in our study was not restricted to "happiness," but included many of the various adjectives that comprise the PANAS positive affect scale (9), as noted in our article. This scale includes a number of different facets of positive affect, including the terms "enthusiastic," "interested," and "strong."
      We wish to thank Professor Smith for raising these interesting and important issues. We strongly agree with his plea for conducting research with the utmost rigor and care. As noted in our article, we have a paragraph in the Discussion section devoted to caveats and limitations of our study. We appreciate the opportunity for elaborating on the other issues raised by Professor Smith in his letter.
   

REFERENCES

1. Kabat-Zinn J. An out-patient program in Behavioral Medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. Gen Hosp Psychiatry 1982; 4: 33–47.[CrossRef][Medline]
2. Thera N. The heart of buddhist meditation. New York: Weiser; 1962.
3. Rosenberg L. Breath by breath. Boston. Shambhala Publications Inc.; 1998.
4. Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clin Psychol Science Pract 2003; 144–56.
5. Kabat-Zinn J. Full catastrophe living. using the wisdom of your body and mind to face stress, pain and illness. New York: Delacorte; 1990.
6. Kabat-Zinn J. Mindfulness meditation: health benefits of an ancient buddhist practice. In: Goleman D, Gurin J, eds. Mind/body medicine. Yonkers, NY: Consumer Reports Books; 1993.
7. Davidson RJ. Affective style, psychopathology, and resilience: brain mechanisms and plasticity. Am Psychol 2000; 55: 1196–214.[CrossRef][Medline]
8. Davidson RJ, Harrington A. Visions of compassion: western scientists and tibetan buddhists examine human nature. New York: Oxford University Press; 2002.
9. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: The PANAS scales. J Pers Soc Psychol 1988; 54: 1063–70[CrossRef][Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Smith, J. C. Articles by Kabat-Zinn, J. Search for Related Content PubMed PubMed Citation Articles by Smith, J. C. Articles by Kabat-Zinn, J. Related Collections Letters to the Editor