ARTICLES

The practice of mindfulness has many benefits; how can we ensure it is safe?

 The benefits of mindfulness practice are increasingly well documented, but little attention has been paid to potential risks. The prevention of harm to people learning mindfulness skills requires the field to study both the benefits and the risks. We offer the following discussion with the understanding that perspectives may change as research on benefits and risks continues to evolve.  We begin with parallels between mindfulness practice and physical exercise, for which the risk/benefit analyses are better understood. We then describe factors to consider in understanding the safety of mindfulness practice and conclude with suggestions for ensuring safety of those undertaking mindfulness programmes, as well as directions for future research.

 Physical exercise: benefits and risks

 Physical exercise is a popular pursuit. Gyms and fitness classes are everywhere. Books, magazines, and blogs tell us how to get stronger and fitter. Public health campaigns encourage us to exercise more, and wearable devices and apps enhance motivation by keeping track of physical activity. There are good reasons for this enthusiasm. Research shows that exercise improves many aspects of physical and psychological health. It strengthens the heart, lungs, bones, and muscles. It helps people control their weight and manage diabetes and arthritis. It reduces the risk of colon and breast cancer, heart disease and stroke. Exercise improves sleep, increases energy levels, boosts mood, and reduces the risk of depression and the impact of stress. It sharpens thinking and concentration while helping to prevent dementia and Alzheimer’s disease. It increases confidence, self-esteem, and quality of life (Centers for Disease Control, 2015).

 Exercise also has significant risks (Garber et al, 2011). People sprain joints, tear tendons, and have painful muscle spasms while exercising. Some suffer from asthma, others from heat stroke or heart attacks. Occasionally these consequences are fatal. Deaths are most likely when people do vigorous activities that they aren’t accustomed to, particularly in hot weather, but sometimes in the cold. Shovelling snow, for example, causes at least 100 fatal heart attacks every winter in the US, mostly in people who don’t realize the intensity of this form of exercise. Not surprisingly, research also shows that working with a well-trained fitness professional reduces the risks of exercise, especially for people with medical conditions.

Physical exercise has important benefits, although the risks can be serious. Mindfulness practice is sometimes compared to physical exercise

 Experts have reached a consensus that physical exercise, when it’s done carefully, has numerous important benefits and prevents much more harm than it causes. The risks, though potentially serious, can be substantially reduced through consideration of three important factors: the intensity of the exercise, the vulnerability of the person, and the quality of the instruction.

 Mindfulness practice

 Mindfulness practice is sometimes compared to physical exercise. The analogy is not perfect and the science is at a much earlier stage. Nonetheless, experts often describe mindfulness practice as a form of mental exercise. Regular and sustained mindfulness practices are described as helping to strengthen our attentional muscles and change the way we think and behave.

 Like physical exercise, mindfulness practice has become a popular pursuit. Classes, books, magazines, blogs, and apps are widely available. Research shows that practicing mindfulness has many benefits. Although the empirical literature is much smaller than for physical exercise, we have strong evidence that mindfulness-based programmes reduce anxiety, depression, and stress and help people cope with illness and pain (Khoury et al., 2013). Some studies show that the practice of mindfulness increases positive moods and cultivates compassion for self and others (Eberth & Sedlmeier, 2012; Khoury, Sharma, Rush, & Fournier, 2015). It may also improve some forms of attention and memory, although findings are mixed (Chiesa, Calati, & Serretti, 2011). There is also preliminary evidence that practicing mindfulness has measurable effects on the brain (Tang, Holzel, & Posner, 2015).

 On the other hand, we have very little scientific information about the potential risks of mindfulness practice. Descriptions are emerging of problems brought on by mindfulness practice, including panic, depression, and anxiety. In some more extreme cases, mania and psychotic symptoms have been reported. These problems seem to be rare, but nonetheless significant, and require further investigation and guidance.

 Temporary discomfort versus lasting harm

 In psychological treatment research, harm, adverse events and risk are defined as follows:

 Harm is defined as a sustained deterioration in a person’s functioning that is caused by the treatment programme (Duggan et al, 2014), or an outcome that is damaging, injurious, or worse than it would have been in the absence of treatment (Dimidjian & Hollon, 2010).

 Serious Adverse events are specific occurrences, such as hospitalizations or suicide attempts; they might be caused by the programme, or they might be unrelated to the programme. For example, some patients with severe depression kill themselves during a course of treatment, but this does not necessarily mean that the treatment caused the suicide. In clinical trials, an independent committee evaluates the causes of adverse events and judges whether the events are attributable to the treatment(s) being studied.

 Risk is the likelihood that particular adverse events will occur if the programme is undertaken.

 Just as physical exercise can cause soreness and fatigue, psychological treatment is often uncomfortable, because it requires psychological and behavioural change, confronting painful experiences, learning new skills, and applying the skills, often in challenging situations.  When treatment is successful, the discomfort is temporary and doesn’t mean that the programme is harmful, but rather that psychological change is difficult.

 Unfortunately, psychological treatment is not always successful and occasionally it causes harm. In fact, research consistently shows that 5-10% of clients get worse with psychotherapy (Crawford et al., 2016; Lilienfeld, 2007). In most studies, it is difficult to know why, because participants may have gotten worse with or without the therapy.  However, a few treatments have been shown in randomized trials to be worse than no treatment at all. For example, critical incident stress debriefing (CISD) is intended to prevent post-traumatic stress disorder in people exposed to extreme stressors, but has the opposite effect in some people, possibly because it interferes with natural recovery processes (Lilienfeld, 2007).

 Mindfulness practices will bring into awareness experiences that are pleasant, unpleasant, or neutral. It can lead to states of ease, joy, relaxation, peace and a sense of wellbeing. Unpleasant experiences such as agitation, physical discomfort, sleepiness, sadness and anger are also common. Such experiences are usually temporary. The theoretical models that mindfulness draws from state that these pleasant, neutral and unpleasant experiences are part of the normal human experience. Seeing them arise and pass away is part of the learning process (Williams & Penman, 2011).

 In people seeking help for stress, pain, or psychological disorders, unpleasant states are more likely to arise because they are part of the phenomenology of these problems. These unpleasant states are considered harmful only if they lead to sustained deterioration or some form of injury. Randomized trials consistently show that mindfulness-based programs are more effective than no treatment. However, it is possible that a small proportion of participants experience sustained deterioration or long-term harm. This question has not yet been adequately studied and is a priority for future research.

 Are mindfulness practices safe? How can we safeguard those teaching and learning mindfulness?

 Physical strength and fitness are generally healthy conditions that probably don’t cause harm in most circumstances. Harm is more likely to arise through unsafe or excessive forms of exercise. In a similar way, mindfulness is a natural human capacity that appears to be beneficial in many circumstances. Harm is more likely to arise through misguided or inappropriate forms of mindfulness practice. In thinking about how to teach and learn mindfulness safely, we offer three key dimensions: the intensity of the practice, the vulnerability of the person and the quality of the mindfulness instructor/instruction. Understanding these factors will help to ensure that protection against risk is in place for those practising mindfulness and that teachers of mindfulness-based programmes receive appropriate training and supervision.

The intensity of practice, the vulnerability of the person, and the quality of the instruction are three key issues in teaching and learning mindfulness safely

 The intensity of the practice

Some mindfulness practices are very low intensity, such as bringing friendly awareness to the tastes and textures of food, sensations in the body while walking, or sights, sounds and scents while washing the dishes. These practices invite people to orient their attention to their natural capacity for mindfulness in sensorial perception; what they see, taste, hear and touch. There is no evidence that such practices cause harm. In fact, they are likely to help people discern what they like and dislike and what leads to good and bad outcomes. For example, one of us had a participant who every day for years had eaten a particular instant food for lunch. When he brought awareness to the preparation (pouring water onto the dried food and adding a sachet of powder) and the eating he realised he did not actually like the taste, nor did it satiate his hunger.

 Low-intensity mindfulness practices are offered in many teacher-led programmes as well as through self-help books, downloadable recordings, and apps. Headspace, for example, provides short, low-intensity mindfulness exercises that are used by millions of people. Headspace was developed by a highly experienced mindfulness teacher and has been researched with attention to benefits and safeguarding, although the evidence to date is still very limited (Bostock & Steptoe, 2013; Mani, Kavanagh, Hides, & Stoyanov, 2015).

 Moderate intensity practices are used in mindfulness-based stress reduction (MBSR), mindfulness-based cognitive therapy (MBCT), and other evidence-based mindfulness programmes. Over 8 weeks, participants sit for up to 40 minutes each day practicing mindful observation of their thoughts, feelings and bodily sensations. They are invited to orient their attention both to the pleasant and the unpleasant. They are asked to bring their new skills and learning to the difficulties that brought them to the class (e.g., chronic pain or recurrent depression). For most participants, especially those with significant physical or mental pain, this will almost invariably bring to mind difficult or unwanted memories, emotions, and sensations. Learning to work skilfully with such experiences, which are understood to be normal, can lead to substantial improvements in mental health and wellbeing. In-session practices are followed by discussion with a mindfulness teacher who helps participants make sense of what they noticed during the exercise. Detailed guidance is also provided for practice between sessions.

 Research on serious adverse events and harm from such programmes is just beginning. In trials where the population of clients are well defined and the mindfulness teachers well trained, preliminary research suggests there is no evidence of harm (Kuyken, Warren et al. & Dalgleish, 2016). Adverse events occasionally occur, but have not been attributable to participation in the mindfulness programme. However extensive qualitative research suggests that people do experience difficulties and challenges with their practice, and that learning to manage these difficult experiences can be empowering (Allen, Bromley, Kuyken, & Sonnenberg, 2009; Malpass et al., 2012). In a recent study of chronic low back pain, some participants in both MBSR and cognitive behavioural therapy (CBT) reported that pain temporarily got worse as they began to attend to it and learn to manage it. These increases in pain did not qualify as adverse events. By the end of the treatment programme, both the MBSR and CBT groups had improved significantly more than a group receiving usual care (Cherkin et al., 2016).

 The most intensive way to practice mindfulness is on meditation retreats, where participants typically meditate for many hours each day, often entirely in silence, for a week or more at a time. Contact with a teacher may occur only once every day or two. Most reports of adverse effects of mindfulness practice to date come from participants in intensive retreats. The best retreat centres are operated by meditation teachers with comprehensive knowledge of the retreat centre’s orientation (e.g., Christian, Buddhist etc.), extensive experience in offering the teachings in those settings, and knowledge of the difficulties that may arise during intensive mindfulness practice. Teachers at these centres will frame the difficulties they encounter within their own orientation and experience and the best will undertake some degree of screening, have a safeguarding policy and ways of referring to treatment centres when appropriate.  Clearly most retreat centres are not intended to be treatment centres and are therefore not staffed by people with mental health qualifications. Very little research has been conducted on the psychological effects of intensive retreats. Anecdotal evidence suggests that harm is rare, but a few participants have reported severe psychological problems lasting for months or years after the retreat has ended (Rocha, 2014).

 The vulnerability of the person

Consensus opinion is that the more vulnerable a person is, the greater the need to attend carefully to when, how and if mindfulness should be taught. Unfortunately, very little is known about why some people are more vulnerable than others to psychological problems brought on by mindfulness practice. Pre-existing mental health difficulties, such as a tendency to experience anxiety or depression, or a history of trauma or psychosis, may increase the risks.

 However, recent studies show that even highly vulnerable participants can practice mindfulness safely if their needs are carefully addressed. For example, Chadwick (2005) has developed ways for people who experience psychotic symptoms to practice mindfulness safely; he develops a strong relationship with the person he is teaching and a context of safety, assesses the person’s strengths and vulnerabilities and offers brief, focused mindfulness practices, with a great deal of support through the learning process and adaptation of the teaching based on feedback. Findings are promising, though preliminary. Two large trials of people with recurrent depression suggest that MBCT may be particularly indicated for those with a history of adversity (Williams et al 2014; Kuyken et al., 2015), but in these trials participants were carefully assessed and screened, pre-class interviews oriented them to the MBCT programme and the teachers were well trained and supervised in working with the difficult experiences that almost inevitably come up in these groups. The back pain study mentioned earlier (Cherkin, Sherman et al, & Turner, 2016) reported no serious adverse effects, despite temporary increases in pain during both MBSR and CBT. In combination, these studies are encouraging in suggesting that MBSR and MBCT can be used safely in participants with a variety of vulnerabilities. However, much more research on this question is needed.

 The quality of the instruction

Contemplative traditions have long recognized that intensive mindfulness practice can lead to challenging emotional or bodily experiences that require expert guidance. The developers of secular, evidence-based mindfulness programs also emphasize the importance of competent mindfulness teaching. Unfortunately, interest in mindfulness classes has become so widespread that not enough qualified teachers are available. Some teachers have very little training and may be unprepared to help participants with either the normal and expected unpleasant experiences that arise or the more atypical unexpected side effects of mindfulness practice. They may do little screening and assessment to determine if people are suitable and ready for programmes at different levels of intensity. Teacher training programmes are themselves still developing, including with regard to how best to ensure the protection of those learning mindfulness. The field is only just beginning to develop good practice guidelines and listings of qualified teachers. For teaching mindfulness at any intensity (e.g., MBSR and MBCT) and with vulnerable populations, we suggest that teachers must meet these good practice guidelines and ideally be able to independently evidence this by registering on a listing of qualified teachers.

 What can we conclude about the safety of mindfulness practice?

 Any program with the potential to be therapeutic may involve risk. Ensuring participants’ wellbeing and minimising any chance of harm requires that mindfulness practices are offered with skill and care. Harmful effects of mindfulness practice appear to be rare but have not yet been thoroughly studied. Until we understand the risks more clearly, the wisest course for anyone interested in mindfulness is to begin with low to moderate-intensity practices. Self-help books, recordings, and apps can provide helpful instruction in introductory practices, especially if written or developed by people with recognized expertise. A popular programme is Mindfulness: A Practical Guide to Finding Peace in a Frantic World (Williams & Penman, 2011). This programme was developed to introduce mindfulness in ways that are believed to be safe and engaging and it shows promising evidence of effectiveness.

 People interested in more intensive practice should work with an experienced teacher offering evidence-based classes. Those with mental health difficulties should consult with a mental health professional before beginning a mindfulness program, and should only undertake a programme taught by someone who has the training and experience to support them. They should ask if teachers of such programmes have been appropriately trained. Ideally, those in the UK will be registered with the UK Network of Mindfulness-based Teachers.

 People interested in the very intensive practice of a meditation retreat should remember that retreats are operated primarily by meditation teachers, rather than mental health professionals, and psychological research to date tells us very little about their effects. It may be wise to consult with an experienced meditation teacher before undertaking an intensive retreat. For people with mental health difficulties it may be wise to consult with a mental health professional with expertise in mindfulness practice. This is especially for those with little experience with less intensive forms of mindfulness practice.

 Finally, participants in any form of mindfulness practice should remember three crucial points:

First, mindfulness is not intended to be a blissful experience. Like exercise, it can be uncomfortable. In fact, mindfulness is about learning to recognise, allow and be with all of our experiences, whether pleasant, unpleasant or neutral, so that we can begin to exercise choices and responsiveness in our lives.

Second, mindfulness practice is not a panacea. It’s not the only way to reduce stress or increase wellbeing, nor is it right for everyone. People should select an approach that matches their interests and needs, whether it be mindfulness, physical exercise, cognitive-behavioural therapy or some other approach.

Third, mindfulness practice is intended to be invitational and empirical. Participants are invited to experiment with the practices in an open-minded and curious way and to be guided by the evidence of their own experience, continuing with practices that seem helpful and letting go of those that don’t.

Over the last 50 years, research on physical exercise has provided a large body of knowledge about the likely benefits, the types of exercise best suited to people with particular conditions, the risks of different forms of exercise for different people, and how to minimize the risks. The result is a strong consensus across numerous medical authorities that most people will be healthier if they exercise in particular ways and with care. The mindfulness field has not reached this level of consensus because the research base is not yet sufficiently developed. We need more study of how to match the intensity of the practices to the vulnerability of the participants. We also need clearer information about the risks of mindfulness practices, how to minimize the risks, and how to train teachers to help participants manage the inevitable difficulties. As the field progresses, these questions should be a high priority for research on the effects of mindfulness training.

 http://www.oxfordmindfulness.org/is-mindfulness-safe/

Ruth Baer and Willem Kuyken

Declaration of interests

Ruth Baer is author of Practicing Happiness: How Mindfulness Can Free You From Psychological Traps and Help You Build the Life You Want and receives royalties from its sales. She is Professor of Psychology at the University of Kentucky and is spending a sabbatical year at the University of Oxford Mindfulness Centre.

 Professor Willem Kuyken receives no payment for public engagement or consultancy, and any remuneration is paid in full to the not-for-profit charity Oxford Mindfulness Foundation. He is Director of the Oxford Mindfulness Centre and Principal Investigator of several NIHR and Wellcome Trust grants evaluating MBCT. Willem is Professor of Clinical Psychology at the University of Oxford.

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 Oxford Mindfulness Centre

The Oxford Mindfulness Centre (OMC) is an internationally recognised centre of excellence at the University of Oxford, and has been at the forefront of research and development in the field of mindfulness. The OMC works to advance the understanding of evidence-based mindfulness through research, publication, training and dissemination. Our world leading research investigates the mechanisms, efficacy, effectiveness, cost effectiveness and implementation of mindfulness. We offer a wide range of training, education, and clinical services, all taught by leading experts and teachers in the field, who are training the next generation of MBCT researchers, teachers and trainers. We actively engage in collaborative partnership to shape the field and influence policy nationally and internationally. Through the charitable work of the OMC, we are improving the accessibility of MBCT for those most in need.