Keywords

The Rise of Mindfulness-Based Therapy

The set of practices widely known as ‘mindfulness’ derive from ancient India and the Mahayana and Theravada schools of monastic Buddhism—with their traditional aims of seeking to free the mind and body of desire, aversion, and confusion (Crook 2009). Despite the popularity of the approach, the precise meaning of ‘mindfulness’ remains elusive: it is an English translation of the term ‘Sati, which, in the Pali language, as spoken by the historical Buddha, has many meanings—including ‘attention’, ‘memory of the present’, ‘clear understanding’, and ‘awareness’ (Stanley 2012). In contemporary usage, especially in the Western world, the word ‘mindfulness’ has been expanded (or appropriated) to encompass a lifestyle, a system of beliefs, a set of moral prescriptions, a social movement, and, above all, a brand of self-development (Davies 2015; Heffernan 2015). Perhaps the least contentious reading ascribes a dual meaning to the term: as the sustained absorption of one’s attention in the present moment, on the one hand, and as the set of practices and ethical teachings designed to cultivate this mode of being, on the other hand (Bachelor 1983; Claxton 1991; Flanagan 2011). For well over a century, Western imperialists, travelers, mystics, and academics have sought to introduce Buddhist ideas to a wider public. In the field of psychology, Gautama Buddha has sometimes been interpreted as the founder of the first systematic ‘school’ within the discipline, and almost every contemporary sect has claimed Buddhist thought as the seed of its own—from behaviourism to psychoanalysis (Crook 1980; Stanley 2012). In the present day, practitioners of cognitive behavioural therapy (CBT) and of cognitive neuroscience are among the most ardent (Flanagan 2011; Stanley 2013). They are joined by the American Jon Kabat Zinn—emeritus professor of medicine at the University of Massachusetts and, for his huge global readership, a charismatic writer and teacher (e.g. Kabat-Zinn 1991, 1994, 2001). Kabat Zinn first came across Buddhist doctrine and practice as an undergraduate molecular biologist. Impressed by the clinical potential of these methods to help people trapped in physical pain and emotional turmoil, he devised and then introduced his own programme in ‘mindfulness-based stress reduction’ (or MBSR), at the University of Massachusetts’ Medical Center in 1979. Participants were asked to commit to daily practice of mindfulness exercises, mostly in the form of sitting or vipassana meditation (in which attention is focused upon the breath) and also in regular movement awareness and ‘body-scanning’ exercises, taught in a series of weekly sessions. These exercises were intended to dispel physical and mental tension and to foster the relaxed state conducive to the pursuit of meditation.

This classroom-based format—familiar to anyone who has ever taken an introductory adult education course—has become the core of the many efforts to adapt Kabat Zinn’s ideas to the treatment of problems such as depression, anxiety, ‘borderline personality disorder’, psychosis, PTSD, obsessive compulsive disorder, and a host of other psychological maladies (Germer et al. 2013; Gaudiano 2014; Roemer and Orisillo 2009). One of the best known of these therapeutic packages is mindfulness-based cognitive therapy (MBCT), as developed by British psychologist John Teasdale and colleagues in the 1990s (Zindel et al. 2013). This approach is at the forefront of what is known as the ‘third wave’ of cognitive behavioural therapy (or ‘CBT’). In the ‘first wave’, the practitioners of the 1950s and 1960s sought to inculcate better mental health via relatively straightforward—(and for the critics—simplistic)—techniques of conditioning, derived from experiments with animals; in the second phase, they sought to ease distress by the application of behavioural procedures and of ‘rational’ arguments, calculated to challenge the presumptively mistaken pessimism of their clients (see, e.g. Beck et al. 1987; Ellis and Dryden  1987). In the 'third wave' of the early twenty-first century, these cognitive behavioural methods have been subsumed within a larger curriculum. This features elements of Freudian and ‘systemic’ thinking and—especially—mindfulness training: intended to help the sufferer to reconnect with their bodily experience of themselves and of their world and to face their distress with greater equanimity and fortitude (Germer et al. 2013; Fuchs 2013; Michelak et al. 2012). In its claimed basis in ‘cognitive science’ and quantitative clinical research, in its pragmatic willingness to combine disparate and (arguably) incompatible theories of mind and conduct, and, especially, in its optimistic promise of fundamental personal change—this most recent incarnation of CBT is far more traditional than might appear (see Fancher 1996; Moloney 2013a, b; Smail 1987). It is this continuity, together with the reduced costs that attend group treatment, that helps to explain why MBSR, MBCT, and related approaches—such as dialogical behaviour therapy (or DBT)—have been widely adopted within the British National Health Service since 2004 and are endorsed by the official clinical guideline giving bodies of the UK and the USA (see for example, NICE 2016; Gregoire 2015; NIMH 2016).

More than just a therapy, mindfulness is at the forefront of an official utilitarian ‘mental health’ movement, sweeping through the health and social sciences. Governments and corporate employers are seeking to use behavioural methods to measure and boost ‘happiness’, ‘nudging’ as many of us as possible—and especially the poor and the indigent—into the lifestyle choices deemed to be healthier and more sensible (Davies 2015; Moloney 2013a, b; Midlands Psychology Group 2014; Frawley 2015). Taught increasingly in schools, colleges, universities, and workplaces in Britain, the USA, and many other countries—mindfulness is widely seen as a way to reduce stress and to make people more resilient, productive, creative, and amiable: the natural graces said to accompany a quieter and more open and attentive state of mind (Davies 2015; Frawley 2015). It is reported that 70 % of British general practitioners would like to refer their patients to NHS-funded courses on this subject, if only the public health services could meet the demand (Mindful Nation). In the UK, the Centre for Mindfulness Research and Practice in Bangor has trained 2500 teachers, enough to transmit the method to 200,000 people each year, and the one thousand plus fee-paying mindfulness courses that have emerged in the UK sell-out within hours of their announcement (Booth 2014). The uptake of mindfulness in the USA is comparable. More than 200 clinics offer mindfulness training, some of them affiliated with prestigious medical centres and tens of thousands of Americans have signed up for these programmes (Barker 2014; Center for Mindfulness 2010). Academic interest in the subject is intense, with over 500 peer-reviewed academic papers issued every year (Barker 2014).

Mindfulness is also a success story for publishers. In the larger bookstores, on many tens of feet of shelf space, the works of Kabbat Zinn are joined by those of psychologists, life coaches, counsellors, Buddhist monks, New Age therapists, neuropsychologists, and celebrities (with some authors bidding to be all of these things). All of them promise that the path to full awareness and health is attainable as long as we make enough effort in every quarter of our daily round—from office routines, to gardening, to childcare—to mention just a handful of topics featured in the many hundreds of book titles. For those who are too anxious or bored to read, crayoning books with titles like Colour Your Way to Calm invite the mindful-infilling of intricate flower drawings, ‘groovy mandalas’ and ‘folk art birds’. In the spoof 1960s, children’s publication known as the…‘Ladybird Book of Mindfulness’ … ‘the large clear script, the careful choice of words, the frequent repetition and the thoughtful matching of text with pictures all enable grown ups to think that they have taught themselves to cope’ (Hazely and Morris 2015). Popular satire is a sure sign that a mass movement has arrived. Dedicated Websites and other online resources grow apace, including smartphone apps such as ‘Headspace’—designed to help its three-quarter of a million subscribers to meditate. In 2014, the global advertising giant JWT announced ‘mindful living’ as one of its ten trends to influence the world. Consumers had found ‘a quasi-Zen desire to experience everything in a more present, conscious way’ (Booth 2014).

Perhaps then it should be no surprise that in Britain, a cross-party group of MPs has issued an official report, entitled Mindful Nation, which indorses the application of these practices on a national scale. Disappointed by the lack of provision of MBCT across the country so far, this group of politicians urge that it be made available on the National Health Service to over half a million adults each year by the third decade of the century, especially to those struggling with anxiety and depression. This document recommends the creation of three national institutes to pioneer mindfulness teaching to children in the classroom and the founding of a million pound ‘Challenge Fund’, for which schools might bid in hopes of training their best teachers to become expert disseminators. All public sector workers—from nurses to librarians to police officers—should have the opportunity to become proficient in this art, as should the many criminal offenders who have experienced and inflicted suffering because of their impulsivity.

Whether or not this buoyant blueprint will ever be realized in this time of fiscal ‘austerity’ is an open question, but the reply might turn out to be ‘yes’—since its authors and main supporters are members of an influential political and metropolitan elite. In many cases, such as the economist Richard Layard, they are linked to powerful institutions such as the London School of Economics: one of the main motors behind the rise of the ‘new management’ and ‘market-led’ culture that has transformed health care and other public services in the UK, and beyond (see Rogers and Pilgrim 2014; Proctor 2009). Layard has been this way before. Via his co-authorship of ‘The Depression Report’ in 2006, he was a key instigator of the massive CBT-based Improving Access to Psychological Therapies programme (or ‘IAPT’, as it is more commonly known)—still underway in England and Wales (Midlands Psychology Group 2008). Like its predecessor, the Mindful Nation document builds its authority on what its authors take to be the solid scientific credentials of CBT. It blends a declared humanitarian commitment with a strong fiscal case for psychological treatment—(in this case, ‘mindfulness’)—as a means of reducing healthcare bills through the prevention of psychological distress, and by getting the disturbed and disabled back to work and off the state sickness benefits roster. In these and many other ways, the report harks back to IAPT as an unmitigated success (see Layard and Clark 2014). However, it ignores the ‘scandalously high’ rates of client drop out (McInnes 2011), the questionable methods of data collection and outcome measurement, and the accusations of the coercive use of ‘therapy’ against the unemployed and debilitated—all of which have pursued the scheme from the outset (Freidly 2013; Midlands Psychology Group 2008; Moloney 2013a, b; Watts 2016). The response of the British media to the growing legitimacy of mindfulness in general and to the Mindful Nation report in particular has been generally favourable, sometimes near ecstatic—and from some surprising quarters, including academics and journalists with a reputation for sceptical thinking: some of whom, not so long ago, saw political and social change (rather than meditation) as the most sensible retort to widespread malaise and civil decline (see for instance, Khaneman 2010; and Bunting 2014, respectively). The existence of Mindful Nation is a sign of unalloyed official approval for what amounts to a CBT–vipassana hybrid as a preventative and curative programme and on a scale that enthusiasts liken, unblushingly, to previous well-received national public health measures such as the introduction of fluoride to British tap water, sixty years beforehand (Booth 2015).

The Scientific Study of Mindfulness: Insights and Warnings from the Talking Therapy Research Field

With all of this excitement, it is not hard to see the appeal of mindfulness for those who suffer intractable personal torments, or for anyone who seeks refreshment in stillness: the perennial fantasy of the modern era of commerce and industry (Pietikainen 2007; Scull 2015), and even more so, for the globalized and wired-up world of the early twenty-first century (Sim 2004; and see Kabbat-Zin 2005). In the words of one British parliamentarian who took a course on mindfulness at Westminster…‘In today’s mad whirl, a few well-earthed, indeed profoundly common sense, contemplative insights are truly valuable.’ (Mindful Nation, p. 16). But does any of this hold up as good science? Given the popularity of mindfulness and the self-assurance of its promoters, it might seem odd to even pose this question. However, a clue to its logic can be found in the report from the All Party Parliamentary Mindfulness Group itself, which laments the ‘inadequate investment in high quality research needed to strengthen the evidence’ (Mindful Nation, p. 24). To encounter qualms like these in an official policy recommendation document is rather like finding stones in a pudding. It suggests a need to scrutinize the ingredients and how they got there—in this case, beginning with the connections between mindfulness-based therapy and the evidence in favour of other forms of psychological treatment upon which its exponents seek to base its credibility.

Before the middle of the twentieth century, clinical assessments of talking treatment focused on efficacy—its apparent helpfulness in ordinary day-to-day clinical practice, as measured by recovery rates. These early studies spotlighted mainly psychoanalytic treatment and suggested that two-thirds of patients improved. Therapists everywhere drew succour from these findings, until the behaviourist psychologist Hans Eysenck claimed to find exactly the same trajectory in groups of untreated people. This implied the near irrelevance of talking therapy and that patient betterment might be attributed instead to seasonal effects upon mood, the benefits of social support, and the dividends of maturation and experience (Eysenck 1952). Though Eysenck’s data and conclusions were later challenged, this phenomenon of ‘spontaneous recovery’ hovers over the field to this day. In consequence, researchers have sought surety in randomized controlled trails, or RCTs. These are clinical experiments, in which sufferers are allotted blindly to either the treatment of interest or one or more comparison groups—which may comprise people who stay on a treatment waiting list, those who get a genuine alternative therapy or, more rarely, a sham (or placebo) one.

RCTs of this kind are numbered in the thousands, with results that have been positive overall but fickle in magnitude. In pursuit of still greater authority, researchers have used the technique of meta-analysis, in which the data from many dozens of studies are blended and then distilled to capture the main trends. In the decades from 1980, a large number of these procedures imply that talking therapy is a reliable technology for achieving personal change (e.g. Smith et al. 1980; Wampold and Imel 2015). Historically, this has been especially so for CBT: the approach that has most readily embraced psychiatric nosology and quantitative outcome measurement, geared to the audit requirements of managed health care (House and Loewenthal 2008; Moloney 2013a, b; Rogers and Pilgrim 2014). In consequence, CBT dominates official treatment guidelines (see Newnes 2014; House and Loewenthal 2008). For the vast majority of therapy professionals, the question of effectiveness is settled. All that remains is to decide what kind of treatment is suited for what kind of problem—and for whom (see, e.g. Roth and Fonagy 2006).

But there are reasons to doubt this straightforward tale of medical and scientific progress. The technique of meta-analysis has always been hostage to the variable quality of the original studies and to the skill and judgment with which they have been selected and standardized (Charlton 2005; Healy 2013; Prioleau et al. 1983). Moreover, the popular tenet that there are specific treatments and techniques for specific problems—like keys and their locks—cannot be reconciled with what the research literature persists in showing: that for the vast majority of psychological problems, there is no solid evidence that any one type of therapy can consistently outperform another, or indeed a convincing placebo, and that treatment success depends neither upon practitioner qualifications and experience, nor therapeutic orientation (Dawes 1994; Feltham 2013; King-Spooner 2014; Moloney 2013a, b; Norcross and Wampold 2011; Wampold and Imel 2015).

It is much harder to scientifically gauge a talking treatment than most people realize. In part, this is because psychological problems do not lend themselves to objective or quantitative measurement in the same way as many physical disorders (Cromby 2015; Midlands Psychology Group, forthcoming). There are few reasons to think that we have direct access to our mental states in the way that is presupposed by many lay people and too often by talking therapists and those who assess their interventions (see for instance, Kahneman 2013; Moloney 2013a, b; Morgan 2008; Schwitzgebel 2011). Indeed, the bulk of the evidence with which psychologists deal are not observable facts but communications, which are prone, by definition, to misinterpretation, slippage, and distortion (Rickman 2009; Harre 2002; Shotter 1975).

In the field of psychotherapy research, the rewards and the scope for unconscious dissimulation and exaggeration on the part of the client are very high—perhaps uniquely so. This is because, for most people, success or failure in the task of therapy has become a tacit index of self-worth. In the early twenty-first century, people in Western societies are encouraged to believe more strongly than ever in the individual’s power—indeed their moral obligation—to overcome whatever problems life thrusts upon them. This outlook has much to do with globalization and consumer capitalism, which place a large economic premium upon personal flexibility and competitiveness (Aschoff 2015; Cushman 1995; Pietikeinen 2007; Throop 2009), and with the influence of the psychology industry itself: which has encouraged us to gaze anxiously inwards in pursuit of the roots of our unease and has profited from the myth of easy personal change attainable via expert help (Illouz 2008; Rose 1989). For the client sitting under the earnest gaze of their therapist, in a scenario reminiscent of the religious confessional—(and with all that that implies)—there is every reason to exaggerate the benefits of treatment, above all to themselves. It is hard to know how common such self-deception might be—the whole topic is poorly researched. However, accounts of failed or abusive therapy (e.g. Bates 2005; Sands 2000; Zilbegeld 1982), painstaking investigations of how client’s seek to present themselves in treatment (Kelly 2000; Illouz 2008), and anthropological insights into the power of cultural myths to shape personal narratives of illness and recovery (Fuchs 2013; Lutz 1985; Throop, ibid)—all imply that such distortion is commonplace. Even more so, perhaps, for mindfulness training which can bear a heavy load of expectation, compounded of the latest ‘neuropsychological science’ and of popular new age-spirituality (Coward 1991; Davies 2015).

Should these arguments prove hard to digest, it is worth recalling that for decades psychologists have shown that in experiments involving human subjects, researchers must take great care if they are to avoid inadvertently sending out subtle but demanding cues that systematically distort the results. These signals involve more than facial expression, gesture, posture, eye contact, and voice timbre; for example, they are also about the prestige of the researcher and of the institution in which they work. Unconscious messages like these can powerfully shape participant conduct in the direction preferred by the investigator: whether we are considering the answers given to questions on ethical and political issues, for instance, decisions made by juries, or patient’s judgments of the potency of inert placebo tablets or of genuine medicines. Even laboratory animals can be systematically swayed by unconscious minute gestures or subtle differences in handling (Sutherland 1992). For humans, these effects are strongest when both parties are unaware of them and when the one directing holds some authority (Caldini 1993; Fisher and Greenberg 1997; Sutherland 1992). Moreover, researchers themselves can get snared into seeing what they want to see when testing a favoured hypothesis and especially where the data are elusive or ambiguous (Rosenthal and Rubin 1978). Expectancy biases, as they are known, may account for the recent failure to replicate many classic experiments and observational studies in psychology and other sciences. The original findings were probably artefacts created by overzealous investigators (Lowe 2011).

If it is not be compromised by such issues, the design and conduct of any clinical investigation into a psychological therapy needs to be of a very high standard. The long list of minimum desiderata begins with participants who fully represent the clinical population of interest, experimental and control (or placebo) treatments that are equally compelling for everyone involved, careful double-blind assessment—in which neither the assessors nor the participants know who has received the genuine or fake remedy, and long-term post treatment follow-up. Unfortunately, as thoughtful observers down the years have pointed out, such conditions have rarely, if ever, been met (Erwin 2000; Dineen 1998; Holmes 2002; Kline 1987; Mair 1992; Newnes 2014; Moloney 2013a, b; Pietikainen 2007; Smail 2005; Shedler 2015; Zilbegeld 1982).

Perhaps the most comprehensive and detailed of these critiques has come from the American academic William Epstein. In the early 1990s, he scrutinized some of the most reputable research in this field and found it to be badly wanting on methodological grounds (Epstein 1993, 1995). Ten years later, Epstein repeated the procedure for the top three international journals for the scientific assessment of the leading therapies, including CBT and behavioural and psychodynamic treatments. Once more, this literature could not sustain its own claims. Placebo treatments, for instance, were either absent or unconvincing, sample sizes were in many cases too small, and the systematic abdication of clients from key groups was downplayed or ignored. The questionnaires used to assess outcome were of dubious validity or prone to second-guessing by clients, and the statistical methods employed to analyse the data tended to inflate the power of treatment and to smooth over its uneven effects, including the likely deterioration of some participants. Finally, this research was compromised by the doubtful independence of the researchers and by their near total reliance upon what clients said about the helpfulness or otherwise of the intervention—as opposed to attempts to observe how it might shape their well-being and conduct, beyond the walls of the consulting room. Epstein concludes that, despite decades of being trumpeted as a success, the leading brands of psychological therapy remain unverified and are probably ineffective. This is especially so for patients who are struggling with harsh social and economic circumstances: the main clientele of the publicly funded health and care services in which most therapists work (Esptein 2006, 2013; and see Moloney 2016). These observations, which echo those of earlier critics such as Zilbegeld (1982), have been largely ignored within the professional literature (see Feltham 2013; Moloney 2013a, b; Newnes 2014), although a minority of psychological healers have persisted in reaching similar judgments, on the grounds of their own clinical experience (Davies 1996; Dineen 1998; Hagan and Donnison 1999; Holmes 2010; Lomas 1998; Moloney and Kelly 2008; Smail 1987). While Epstein’s reviews have focused mainly upon second-wave CBT, the supporters of mindfulness-based interventions imply (and sometimes claim) that the latter promise to be more effective than previous approaches, owing to their radically new integration of mind, body, and Eastern psychology.

Mindfulness-Based Therapy for Psychological Problems: A Brief Look at the Evidence

Since the introduction to the West of the Hindu practice of transcendental meditation in the 1960s by the Maharishi Mahesh Yogi (Russell 1976)—apparently for commercial reasons (Wheen 2004)—psychologists have tried to show that such techniques, including mindfulness, reliably yield changes in well-being, mental function, and behaviour superior to standard relaxation methods. The results have been wholly equivocal (Blackmore 1993, 2010; Farias and Wikholm 2015; Holmes 1984). The most recent comprehensive meta-analyses of studies looking at this question do little to challenge the original picture. Sedlmeier et al. (2012) took 163 separate trials involving people deemed to be mentally healthy (or ‘non clinical’) and assayed them for the reported effects of mindfulness and TM on a range of outcomes—including subjective well-being, intelligence, and negative emotions. Both types of mind training emerged as ‘moderately beneficial’, however, less than a dozen of these studies used any kind of active control therapy. For these investigations, no extra benefit from meditation emerged.

Of course, this does not imply the irrelevance of techniques of mental concentration to the treatment of clinical problems. In the last two decades, a growing number of reviews have weighed the effectiveness of mindfulness therapy in the reduction of stress and in the management of chronic physical and mental conditions, including autoimmune disorders, persistent pain, anxiety, depression, psychosis, eating disorders, and ‘borderline personality disorder’, to name but a few (Farias and Wikholm 2015). The results have been favourable on the whole, but with large disparities in the size of the treatment effects. Alongside their optimistic reading of the future of these methods, many researchers acknowledge that little is known about the active ingredients that account for the claimed improvements, how long these effects might last, and how they might be shaped by additional therapeutic procedures and by the circumstances in which the clients live. If caveats like these are not hard to find in the research literature (see, for instance, Baer 2003; Gaynor 2014; Khoury et al. 2013; Piet and Houghard 2011), they seldom survive the journey into the pronouncements of the policy analysts and interest groups and still less into popular works on mindfulness (Davies 2015; Barker 2014).

To take just one instance, the Mindful Nation report enthuses about Khoury et al.’s meta-analysis of 209 studies, covering more than 12,000 participants. By the standards of the field, this is a big survey. According to Mindful Nation, it showed ‘large and clinically significant effects in treating anxiety and depression, and the gains were maintained at follow-up’ (16). But this large-scale meta-analysis rests upon a painfully slender column of reliable evidence. The measured helpfulness of contemplative therapy wobbled considerably across the different studies and declined in close step with the level of experimental control (or care) that was exerted.

Such trends are the norm within meta-analyses of this kind (see, for instance, Goyal et al. 2014). They suggest that distortion from expectancy effects and other biases must be common throughout the mindfulness health treatment literature. Most researchers are unable or unwilling to apply the proper controls (Khoury et al., p. 769), perhaps in part because of a widespread belief that mindfulness is clinically effective and no longer requires rigorous testing (Farias and Wikholm 2015). Indeed, only one in nine of the investigations in Khoury et al.’s review collected follow-up data or tried to use even basic blinding procedures: serious omissions, both. It is not necessarily reassuring that the reported benefits were larger for psychological than for physical or medical conditions, since, by their nature, mental ‘symptoms’ are among the most elusive and, as already noted, the easiest to deform at the reporting stage (see Morgan 2008; Schwitzgebel 2011, for a more detailed discussion of the perils of trying to accurately convey one’s subjective experience). In the end, the researchers believed there were grounds for cautious optimism, pending further, and stronger research. However, according to the independent Centre for Reviews and Dissemination, even these modest conclusions ‘may be over stated, given the poor quality and wide variation between studies’ (Database Abstract of Reviews of Effects (DARE) 2015, p. 1).

If the standards of the research in this area are often wobbly, then investigations into the application of mindfulness to severe depression tend to be among the more thorough, perhaps because the need for a demonstrable remedy is so high. Down the ages, there have been many accounts of those burdened with sadness and despair (Horwitz and Wakefield 2007; Scull 2015). Modern diagnostic systems attempt to capture this kind of suffering under the heading of ‘clinical depression’. There is still much debate about the precise elements that comprise the condition, to what extent they entail bodily as well as mental suffering and how they vary across different times and cultures and overlap with other kinds of distress (see, e.g., Fuchs 2013; Horwitz and Wakefield 2007). Nevertheless, there may be a core experience of dark and impacted misery, impervious to persuasion if not to comprehension—that would be recognizable to most people (Scull 2015; Smail 1996). As described by conventional psychiatric frameworks like the DSM, the lifetime risk of developing severe depression in a country like the USA is said to be almost one in four for women and just over one in ten for men. This form of distress recurs in around half of all sufferers, and it can have huge personal and social costs—including long-term debility and suicide (Horwitz and Wakefield 2007; Massouvi et al. 2007; WHO 2005). There is grudging but growing recognition that conventional therapies, such as antidepressant medication and ‘second-wave’ CBT, might not be as helpful as once believed (Healy 2013; Johnsen and and Friborg 2015; Moncrieff 2007). The search is on for new ‘adjunctive’ treatments to go alongside the psychiatric ones. Half a dozen recent clinical trials focusing upon MBCT as a bulwark against this debilitating form of melancholy have found it to be as good as or better than prescribed medication (e.g. Bondolfi et al. 2010; Kuyken et al. 2008; Ma and Teasdale 2004). The UK National Institute of Health and Clinical Excellence (NICE) has for some time featured MBCT in its list of recommended treatments (NICE 2016), although recent meta-analyses have suggested that it might work only for a subgroup of vulnerable patients who have struggled with exceptional emotional hardship in their formative years (e.g. Piet and Hougaard 2011).

A key problem is the paucity of studies that have sought to compare MBCT with an active psychological treatment, or better still, with a convincing placebo. Without this kind of multi-treatment trial, it is impossible to be confident that the claimed benefits derive from the core contemplative elements, as opposed to the more conventional parts of MBCT: including the teaching of cognitive behavioural ‘relapse prevention skills’ one the one hand, and the mixture of comfort, support, and hopefulness that comes with joining a therapeutic group, on the other hand (c.f. Frank and Frank 1991).

So far, only one enquiry has sought to address these issues (Williams et al. 2014). It is worth discussing this trial in some detail, because it is likely be seen as a landmark due to its large scale—it drew upon 274 participants—its claims to scientific rigour, and the international standing of its main authors. Both of them are academics at renowned UK universities and leading figures within the worlds of CBT and of mindfulness-based therapy research and practice.

The participants for this study were recruited through referrals from medical practitioners in primary care surgeries and mental health clinics, and via community advertisements. All of them had suffered from recurring attacks of depression, but were deemed to be coping—or ‘in remission’—for their worst symptoms. In true experimental fashion, they were randomly assigned to one of three groups, the first of which were given MBCT, while the second, regarded as the ‘active control’ set, were administered a very similar therapeutic package but with the mindfulness component filleted out. In other words, they were treated with cognitive–psychological education, or ‘CPE’, aimed at delaying the return of their condition. Finally, a third, ‘passive control group’ did not have the benefit of either form of psychological intervention, but, in common with the first two groups, were encouraged to continue to access their customary National Health Service outpatient treatment in the form of antidepressant medication, plus whatever advice and encouragement they could find.

Aside from the absence of mindfulness teaching for those in the CPE wing of the trial, Williams et al. strove for parity in everything else that was done with the two psychological therapy groups. To this end, they used their own specially adapted version of Kabat-Zinn’s mindfulness instruction manual as the framework for eight once weekly relapse prevention classes, followed by a single review meeting six weeks later, and a further one at six months. Every participant was given regular therapy-based assignments to be completed outside of the clinic, but with the difference that those in the MBCT wing were expected to perform mindfulness at home plus simple cognitive therapy assignments, such as keeping a daily diary of their thoughts and feelings. By contrast, the participants in the ‘active control group’ were neither instructed nor expected to practise the mindfulness itself, and as far as could be told, they did not do any.

As in the trials already described, this study sought to address two issues. First, how long would it take the people in the different groups to relapse to a state of major depression, once the main treatment had been completed? Second, would there be any subgroups of patients, as defined by the history or the severity of their problems, for whom mindfulness-based instruction might prove especially helpful?

The results were mixed, but encouraging. The more vulnerable participants, as defined by number of previous depressive episodes and disclosure of a troubled childhood, seemed to gain most from the MBCT package. When the relapse data for the two treated groups were blended together and considered as a whole—without regard to differences in psychological vulnerability—then the mindfulness-based package proved no better than cognitive treatment alone; predictably, both of these psychological interventions outdid the standard ‘pills and reassurance’ variety of outpatient care.

These findings might have justifiably been presented the other way around, given the exuberant claims for mindfulness-based therapies that have circulated in newspapers and other media and, with barely less restraint, in some of the clinical research and teaching literature (see Farias and Wikholm 2015). However that may be, the researchers felt that their study had clear strengths when compared with its forebears: client drop out rates were low and were spread evenly over the three groups. More than 90 % of the participants completed at least four treatment sessions—a respectable rate for this kind of trial. Fidelity to the treatment guidelines seemed to be high; every therapist followed the same tightly prescriptive manual under close supervision, based upon video recordings of each treatment session. The quality of therapist training and commitment appeared to be exceptional. Each practitioner had helped to write and pilot the treatment packages used in the study and held at least three years of experience in MBCT instruction. On the other side of the coin, the patients seemed to be convinced of the validity of both forms of psychological therapy: as confirmed by the results of a questionnaire, administered near the start of the trial.

Furthermore, this investigation boasted a total of six separate assessment interviews for each participant, the first one taking place just before the start of the therapy programme and the final one a year after its completion. These appraisals were done by trained personnel and with standardized questionnaires like the Structured Clinical Interview for the DSM IV (or SCID). To ensure that these assessors stayed blind as to the treatment received by their interviewees, the therapy and the appraisals took place in different buildings, to minimize possible cues. Furthermore, these interviewers were asked to report any treatment disclosures by their respondents. On ‘the rare occasions’ when this happened, the interviewer was replaced.

The authors assert that their findings ‘add to the growing body of evidence that psychological interventions, delivered during remission, may have particular beneficial effects in preventing future episodes of major depression, but may be especially relevant for those of highest risk of relapse’ (Williams et al. 2015, p. 285). Their tone is confident; but is it justified?

Perhaps the first thing to note is coyness in the presentation of the data from this trial. The main outcomes for this study were measured via the mean SCID scores for each treatment group. This information is presented in terms of the percentages of individuals in each group who scored high enough on the SCID to qualify as clinically depressed—as having relapsed. However, the mean SCID scores for each group are not given. A pattern of numbers like this can be statistically significant but far more ambiguous, when it comes to gauging the participants’ freedom from distress and their ability (or otherwise) to get on with their lives. In the absence of this basic information, the reader is left to ponder, given the widespread tendency within the field for inconvenient or lackluster findings to be elided or buried within abstruse statistical jargon (Dalal 2015; Epstein 2006; Postle 2007; Shedler 2015).

This study also followed its predecessors, in its exclusive reliance upon the participants’ own reports about their improvement, as told to their interviewers. There was no attempt to collect commentaries from relatives, carers or associates, nor was there any attempt to make direct observations of the participants’ daily activities—including patterns of sleeping, eating, self-care, physical activity, social contact, leisure, and changes in employment status. Hard as they might be to carry out, detailed real-world assessments of this sort are essential if a psychotherapy study is to hold up as good science (Epstein 1995; Kline 1992).

Indeed, the possibility cannot be discounted that the more vulnerable group of participants—the ones who seemed to gain most from the mindfulness exercises—might also have enjoyed better support and encouragement from family, friends, neighbours, colleagues, and other contacts: perhaps enough to boost their commitment to the otherwise marginally helpful practice of mindfulness therapy to the point where it crossed the threshold of apparent clinical effectiveness—at least as measured via the questionnaires used for this study (see Epstein 1995; 2010). It is impossible to say whether something like this happened for sure, since Williams and collaborators collected minimal data on the social and economic circumstances of their participants.

A further difficulty concerns this study's partial reliance upon self-selected clients, recruited via local adverts, whereas people with a history of more severe or protracted mental health problems—(the official targets of this particular RCT)—are often the least inclined to respond to such appeals (Epstein 1995; 2010). More generally, the participants in this study appear to have been aware of their treatment allocation at the outset. Patients taking part in the control section of a study like this one—and who either learn or infer that they are receiving humdrum regular outpatient care alone—can be tempted to overstate their clinical symptoms, in hopes of being reallocated to the presumptive cutting edge therapies that comprise the focus of the study. By embellishing their distress, the 'waiting list' control clients can make the experimental intervention look more helpful, by comparison, than it really is (Epstein 1995, 2006; Kline 1992).

Still more problematic is the question of the allegiance of the therapists themselves. For this kind of project, it is vital that practitioners providing the treatment under test are not tempted to deliver it with more brio than the standard form of help against which it is being compared:—lest they transmit their enhanced expectations for improvement to their patients (Epstein 1995; Goldacre 2009; Kirsch 2009). As veteran MBCT instructors, the therapists in this trial also helped to create the cogntive therapy packages that were used for both of the treatment groups. Williams and colleagues cite this involvement as proof of the instructors’ even-handedness in furnishing the treatments. But just the opposite conclusion seems warranted, since these teachers were so evidently immersed in the practice and theory of mindfulness-based therapy: the latest and ‘most advanced’ phase in the development of CBT. It stretches credulity to think that they did not therefore have a larger personal investment in the meditation-based element of this study, in comparison with the more mundane ‘cognitive relapse prevention’ part of the trial. Mindfulness teachers, including Kabat Zinn himself, can sometimes evince a quasi-religious belief in the power of the method, running alongside their professed commitment to scientific rationalism (Barker 2014; Davies 2015; and see Kabat-Zinn 2001). In the context of Williams et al. s’ study, it is plausible that when administering the CPE treatment, the instructors were less sanguine and might have unintentionally conveyed their diminished expectations to their patients, however subtly (see Caldini 1993; Epstein 1995; Rosenthal and Rubin 1978). While the rating scales completed by the participants did not suggest any real difference in the credibility of the two types of therapy from their point of view, this grading was done just once near the start of the program: perhaps well before most of them could reflect deeply on what they were being taught.

In this kind of research, the question of allegiance applies equally to those who are trying to gauge the effectiveness of the therapy: they should have as little personal and professional stake in the outcome as is humanly possible. This requirement likewise seems to have been violated. The evaluators—the people upon whose judgments the whole study crucially depends—appear to have had strong connections with the primary research team and might even have belonged to it. In which case, they would have been in a position to unknowingly communicate their hopes and expectations to the patients that they interviewed. The audio recording and verification of a sample of these interviews by a separate team of psychiatrists cannot remove this problem. Such a procedure can only confirm that the interviewer wrote down what the patient said. It cannot answer the key question of unintentional inducement or guidance. Moreover, the impartiality of even these ancillary assessors might be doubted. If they belonged to the same mental health services in Oxford and Bangor with which the key researchers were professionally associated, as seems likely—then they may well have shared a similar commitment to the promise of mindfulness. 

In sum, the most serious methodological problems boil down to sampling issues and poor control of expectancy bias and of demand characteristics, but magnified by the nature of this study as a demonstration project: a clinical trial in which every mental health professional was far more intensively coached, supervised, monitored, accountable, and (probably) inspiring—than would be the case in routine clinical practice (Epstein 1995, 2006; Kline 1992; Zilbegeld 1982). Situations like these are likely to yield superior results, even with the most pedestrian of interventions. The relevance of this highly optimized trial to the conditions encountered by clinicians in the workaday world of over stretched public health services is moot (see Davies 1996). If the research into mindfulness as a clinical treatment is less than encouraging, then it is worth recalling that its advocates see the latter as more than a therapy, and it is a valid means of building strength and ‘character’ in anyone who practises it, starting with the most vulnerable members of society.

‘Are You Paying Attention?’ Mindfulness in the Classroom

Interest in the use of mindfulness-based methods on youth and in schools has been growing in the last twenty years and more in the UK especially, under the unofficial banner of what has been described as the therapeutic turn in the education system as a whole. In this new regime, students and educators are encouraged to obsess not merely about their academic performance, but about their emotional lives and vulnerabilities—both real and imagined (Ecclestone and Hayes 2011; Furedi 2004). In contrast to the prescriptive and near hymnal tones of the Mindful Nation document, however, the lessons to be derived from the most comprehensive research reviews in this field are speculative at best. For instance, Felver et al. (2015) inspected 28 studies that sought to assess the value of MBIs in school settings—mainly in the USA. Happily, many of these drew upon suitably large samples, but only a third used randomization or a control condition, and of these, a mere four attempted a matched active control. There were no attempts to use fully autonomous evaluators or, oddly enough, the school system’s routine administrative data on student performance and conduct, which would have been a small step towards greater objectivity. Neglect of vital demographic information on disability and social and economic status of individuals and their communities was near total, making it difficult to interpret such findings as there were. Soberingly, the effects of the training were measured only during the brief lifetime of each intervention, undercutting one of the main justifications for mindfulness practice within the educational field: as a crucible of self-discipline and lifelong resilience (Mindful Nation 2015). The reviewers’ warm verdict on the promise of mindfulness for schools sits awkwardly next to their final (but familiar) plea that the standards of the research need to be a lot taller.

In a similar vein, Zenner et al. (2014) present their assay of two-dozen studies into the application of contemplative science to the school arena: half of which were never published—presumably because they were originally deemed to be too small to yield firm conclusions. In contrast to the preceding meta-analysis, this one drew upon publications outside of the USA—some of which looked for gains in students’ thinking skills and in other academically relevant markers, months or more after the mindfulness training had ended. The reviewers judged that mindfulness-based applications hold the promise of boosting these capabilities, including emotional resilience. Nevertheless, the flaws within this particular meta-analysis resemble those in the previously discussed one. There was the same unwillingness to review progress in the ensuing months and years, the same absence of convincing placebo control groups, of independent assessment, and finally, of the demographic data needed to make sense of what made a programme acceptable or otherwise within a particular school or educational district. On top of which, the wide differences among the studies in ethos and methods of training and assessment made it impossible to identify which aspects were the most useful. Zenner and colleagues admit that…‘the precise role that the element of mindfulness plays [in the reported improvements in student wellbeing] is unknown, as is the extent of the effect that can be attributed to non-specific intervention factors, such as perceived group support, the speciality, and the novelty of the intervention’ […] (17). The findings of studies such as these—dogged by messy and complex situational variables—are even more inconclusive than the clinical research in this field and indeed are echoed in the extremely poor quality of those studies which purport to show the benefits of mindfulness practice for corporate workplaces and boardrooms (see Davies 2015). Perhaps then investigators should seek more tangible evidence for the transformative power of mindfulness—in the form of unique neurological changes wrought by the practice?

Meditation and Well-being: Experimental and Neuropsychological Studies

Cognitive neuroscience is often presented as a brand new enterprise. In truth, written accounts of the relationship between brain and mind stretch back to far antiquity and have been driven down the centuries by the development of new diagnostic instruments (Rose 2005; Uttall 2016). Since the 1960s, interest in the neuropsychological effects of meditation has been strong, and in the last quarter century, neuroimaging studies based upon fMRI and PET scanning devices have started to yield intriguing results. Some of the key changes in subjective experience that are said to accompany mindfulness practice—including the fading away of the narrative based ‘self’—have been tracked within the brains of practitioners, as their meditation unfolds (Tagini and Raffione 2010; Stanley 2012). To take another example, fMRI and PET scans seem to confirm that Buddhist meditation practices designed to foster compassion can do just that: as measured in fronto-temporal brain activation which also predicts improvements in generosity—or at least in the willingness to share a small monetary reward more equitably, in the laboratory (Crook 2009; Flanagan 2011). Similar studies of the effects of noise and other surprises upon long-term meditators suggest that the equanimity for which many Buddhist monks are renowned may not be altogether mythical (Austin 2014; Flanagan 2011). The colourful computer images that convey results like these are often compelling and persuasive for many (Weisberg 2008; Wiseman 2016). Once again, however, we have to be careful: both about the procedures that create these findings and especially how they are interpreted and generalized beyond the compass of the laboratory.

Rather than real-time images of the brain in action, brain scans are colour-coded computer-generated inferences about what might be happening beneath the skull. fMRI images specifically are based upon surges in detected levels of oxygenated blood within the brain, which occur when the iron within blood-borne haemoglobin interacts with the magnetic fields generated by the device, to produce what is known as the BOLD signal. However, the final image comes at the end of a long chain of statistical and logical inference in which there is ample room for best guesses and outright mistakes to be turned into apparent truths. At the most fundamental level, there are persistent doubts about the validity of the BOLD signature itself. Cerebral blood flow does not always straightforwardly match brain activity, and it appears increasingly likely that the spatial and temporal resolution of the resulting images is far too wide to grasp the activities of the subtle and widely distributed neural networks that are considered by many to be the most likely source of our mental activity (Cacioppo, et al. 2003; Noe 2009; Rose and Abi-Rachid 2013; Uttall 2011, 2016; Wiseman 2016). The problems do not end here. In most published investigations, the pictures are a distillation of data harvested from a group of participants, which are then projected onto a map of a notional ‘average human brain’. Since few of us have such a nervous system, these representations can be misleading, and because they draw upon vast amounts of composite data, they are also prone to distortion by chance events and can even suggest areas of apparent neural activation where none took place in the central nervous system of any individual participant (Choudhury and Slaby 2012; Wiseman 2016; Uttall 2011, 2016). For all of their fascination, these images are simulations of cerebral action and are necessarily crude, whereas the brain is intricate, subtle, and vital.

As is the case for the investigation of talking therapy, the overall circumstances in which the research is conducted are far from irrelevant. The fMRI scanning suite is a very singular situation. Participants have to be inducted and managed. They are required to lie prone and isolated within the machine and not everyone can tolerate the procedure, which can be noisy, claustrophobic, and boring (Cromby 2015). All of these factors are suspected of altering the blood flow profiles detected by scanning machines, which perhaps accounts for the finding that the same adults performing the same cognitive assignment can show completely different outcomes in different research centres (Kagan 2012).

Like every other scientific tool, the results yielded by brain-scanning equipment depend heavily upon the assumptions shared by the people who use it. Generations of psychology undergraduates operating EEG equipment were warned that it is possible to get an apparently meaningful EEG signal from a bowl of porridge. Things are no different in the case of neural scanners, as revealed by one celebrated study which purported to find ‘emotional activity’ in the brain of a salmon exposed to pictures of people arguing, and the fish was dead (Bennett et al. 2010). How often in the neuropsychology field have scanning devices been misused in this way—albeit with far more innocence? Very often, according to Craig Bennett and colleagues, who achieved their notable result by following the minimal standards of software calibration that in the rush to obtain publishable results have been commonplace within the field. Exact replication of findings within this field is a rarity, because of the practical limits upon the reporting of complex experimental protocols, and because researchers often use different statistical procedures to analyse their results (Uttal 2016). As a whole, the area suffers from a dearth of control for demand characteristics and participant expectations which even exceeds that for the study of talking therapy (Moloney 2013b; Sanders 2009; Uttall 2011, 2016; and see Horvath et al. (2015a, b), who find similar doubts in regard to the widely reported results of studies of trans-cranial magnetic stimulation—the application of ‘mind altering’ electrical fields to the brain).

Besides these technical and procedural obstacles, investigators often take a naïve view of emotion as a natural, biological entity, tightly sealed away inside of the central nervous system. But this is questionable science and poor history (Choudhury and Slaby 2012; Kagan 2007, 2012). Even if stable changes in brain functioning could be shown to clearly flow from cumulative meditational practice, it is not clear what the implications might be when it comes to the promised attainment of more happiness or altruism in daily life. Laboratory-based studies that seek to relate changes in brain functioning to decision-making at work or at play are forced to swap relevance for simplicity. For the people and the situations that count the most, neither our subjective experience nor our conduct can be reduced to predictive models of neural activity (Cromby 2015; Uttal 2016; Wiseman 2016).

This observation applies even to animal studies, devised to uncover the fundamentals of feeling and emotion. In the first half of the twentieth century, for instance, neuroscientists had experimented extensively upon caged laboratory monkeys and other vertebrates, cutting out their amygdalas to produce what became known as Kluver-Bucy syndrome, a state of striking tameness and hypersexuality. Experiments like these implied that this small part of the brain must be the locus of emotions such as fear and rage and warranted a seemingly clear clinical logic: cut out the offending bit of nerve tissue and the distressing emotions will vanish: a sensible enough conclusion, perhaps, until the effects of these operations were seen in animals living in their natural forest environments and communities, rather than in the solitary confinement of the laboratory cage. In these settings, Kluver-Bucy syndrome melts away. Vivisected rhesus monkeys are neither docile nor oversexed, but can be unusually fearful of their compatriots (Brothers 2002). Brains do not exist in bottles. What goes on inside of them has a lot do with the communal and physical world—and with the body in which that brain is situated: whether it be healthy or damaged, animal, or human. For our own kind, the social and material environment has even richer significance, because of the huge role played by language and symbolic thought in our daily lives (Brothers 2002; Pilgrim and Bentall 1999).

The nervous system enables our experience and our agency, but this is not the same as claiming that it is the only—or even the best—place to look, if we wish to understand them (Harre 2002; Rose 2005). The attempt to elucidate consciousness and feelings by observing the brain’s neural activity is like trying to comprehend dancing by watching only the muscles (Noe 2009). Without the relevant brain structures, it might not be possible to feel afraid, but in the end, it is you who are frightened, not your amygdala.Footnote 1 Sociological and historical studies of emotional experience and expression agree that our interior lives are not just matters of biology. They are at also about the weight of our personal biography, of the relationships in which we are enmeshed, and of the differences in power and influence that set the terms of mutual engagement. Our feelings and moods echo our changing position in the world and what we are allowed to say and do. Kings have lots of room for showing and (thus for feeling) anger; slaves, women, and the poor—to take just three examples—have more often been consigned to worry and to apathy (Bourdieu et al. 2000; Cromby 2015; Gross 2006; Charlesworth 1999).Footnote 2

For all of its promise, brain scan science is still in its infancy. There are still no reliable criteria which allow brain-scanning methods to confirm consciousness in seemingly ‘vegetative’ patients, nor to diagnosing any form of so-called mental disorder. It is common for doctors and researchers to disagree about the value of functional imaging. The clinicians, who work every day with non-standardized patients, are frequently the more sceptical (Noe 2009).

Should brain-scanning methods one day show that mindfulness practice yields clear and stable shifts in the activity of the central nervous system, no one should be surprised. There are few grounds for believing that ‘emotion’, ‘self’, or ‘sati’ are non-material, ghostly substances. All that we do—including the act of sitting for long periods of quiet attention—must lead to some kind of neural change (Cromby 2015; Kagan 2012; Rose 2005). The most important question hinges upon the personal and social significance of these alterations. Will they show that we have been freed from our many vanities, fears, and worries once we have shut the door of the brain-scanning suite behind us, with its simple tasks and regimens, and have returned to our day-to-day life, with all of its complexities, ambiguities, and travails?

Monks and other very long-term and intensive meditators are unusual individuals. They may be reaping the accumulated rewards of a lifetime of concentrated practice within highly protected settings: beyond those within the reach of the average (or even above average) people who comprise the main readership of publications like Mindful Nation (see Blackmore 2010, for an honest and sometimes gruelling account of the personal challenges entailed in protracted mindfulness practice). To hope that the same results can be achieved by people rehearsing vipassana techniques, several times a week during the school term, say, might be the equivalent of expecting children playing hopscotch to become Olympic gymnasts.

Mindfulness: The Bottled Water of the Therapy Industry

According to their many advocates, mindfulness-based interventions hold great promise for curing distress and for crafting a kinder world. But these methods are unproven. Neither commitment to mindfulness practice nor even to monastic Buddhism itself has ever been able to guarantee compassionate or moral conduct. In Japan and China, techniques of mental and spiritual concentration have long been used to enhance the martial skills of warriors and to overcome their reluctance to kill, up until and including the period of the Second World War (Victoria 2004). More recently, the US armed forces have sought to use the technique to improve the efficiency and combat readiness of their soldiers (Farias and Wikholm 2015). In Tibet, a strong tradition of monastic Buddhism has gone hand in hand with autocratic rule and expropriation of the peasantry (Grimshaw 1992; French 2004). In Sri Lanka, Buddhist monks, as community leaders, have too often been the vanguard for implacable race and class hatred (McGown 1992). Even if it were as effective as its supporters claim, mindfulness could never be a treatment or method that ‘works’ in a relatively straightforward way, like swallowing a medicinal pill. Its effects, such as they are, depend intimately upon context and the aims and values of the user. In the light of these sobering conclusions, the widespread enthusiasm for the approach in the Western world begins to look more and more like an officially endorsed cult. How has this situation come about, and so quickly?

These questions are complex and have more than one answer. For the therapy professionals, the most edifying account might dwell upon a reluctant (but growing) recognition that conventional psychological therapies—committed to a Cartesian divide between mind, body, and world—have not proven to be as helpful in the treatment of enduring and deep-seated psychological problems as was once hoped. In their promise to unite these mental and somatic domains, mindfulness-based therapies seem to beckon towards a new era of more successful treatments (Fuchs 2013; and see Smail 1985).

Less flatteringly, the world of psychological therapy is an industry that, like any other, serves many needs. In the business environment that increasingly shapes health care in the UK and many other countries, reputation, prestige, and income can be secured or lost on the strength of new products and services (Moloney 2013a, b; Newnes 2014; Pollock 2009; Smail 1989). For its critics, second-wave CBT, the traditional market leader, owed its premier position to assiduous marketing and to its long-standing alliance with biomedical psychiatry (Fancher 1996; Pilgrim 2008), but as so often, ubiquity has given way to banality. Challenged by resurgent rivals such as psychoanalysis and humanistic therapy—which once seemed to be the deadest of ducks (Burkeman 2016; Miller 2012; Shedler 2010); faced with charges of disingenuous data manipulation (Dalal 2015; Shedler 2015; Midlands Psychology Group 2008); confronted with empirical evidence of declining effectiveness in the treatment of depression (Johnsen and and Friborg 2015); and recently deposed from its position as the official therapy of choice for public health services in Sweden (Miller 2012): the authority and mystique of second-wave CBT is starting to fray. The creation of mindfulness-based therapies as the third and latest phase of the cognitive behavioural revolution offers an answer to this unprecedented problem.

A further explanation for the rise of mindfulness may reside in the wider public’s ambivalence towards biomedicine and the pharmaceutical industry. Even as more and more of us take the drugs that are advertised and prescribed as remedies for our distress, we grow disenchanted with the impersonality and limitations of these supposed chemical cures (Burstow 2015; Healy 2013; Johnstone 2006). Our appetite for healing methods alternative to mainstream biomedicine is matched by our desire that these remedies enjoy some form of ‘scientific endorsement’ (Barker 2014; Carrette and King 2005). Mindfulness—with its lingering cachet of mystical and esoteric discipline, on the one hand, and with its seemingly solid foundation in neuroscience, on the other hand—seems to fit this dual requirement rather well.

There is nothing new about our yearning for magic. From at least the seventeenth century and the days of Anton Mesmer, there has been a demand in Europe and the USA for self-improvement and healing methods that supposedly awaken our slumbering will and trounce adversity, often with the promise of religious or personal fulfilment at the end (Thomas 2009; Sladek 1973). East Asian philosophies and spiritual practices—romanticized and homogenized by their Anglo-Saxon interpreters—have held an especially strong allure since the nineteenth century (Buruma 2011; Stanley 2012).

If the fascination with mindfulness is only the most recent episode in this dubious chronicle, then it presents one genuine puzzle in the extent to which, in the Western world, it has been endorsed by elite groups in government, academia, and the media. And like the core of a Russian doll, this conundrum sits insides inside a still bigger one. From the beginning of the twenty-first century, governments, think tanks, and transnational corporations have never been so keen to measure and improve what they take to be the ‘happiness’ of their subjects and with the help of psychological techniques—of which mindfulness is one of the leaders. And yet these same governments are subjecting their less privileged citizens to stringency and duress on a scale that would have been unthinkable, only a generation or two before.

Since 2008, the global economy has been in the worst economic slump since ‘the Dark Valley’ of the 1930s (see Brendon 1998). Millions of people in Europe, including the citizens of the UK, have been subjected to an official policy of ‘austerity’. Presented as a way to manage the bad debts incurred by previous social democratic governments—(the alleged main cause of the current crisis)—austerity can be better understood as an official catalyst for the free market or neoliberal polices that have helped to shape the politics of the Western world since the 1980s (Hatherley 2016; Mendoza 2015). By degrees, the democratic state has been relegated to helpmate for business interests, intent upon dismantling most of the barriers to the movement of money and markets: including many of the legal and fiduciary protections that formerly sheltered the rights and livelihoods of millions of ordinary citizens (Clark and Heath 2015; Harvey 2005; Judt 2010; Smail 1993; Stuckler and Basu 2013).

In the UK, services once owned by the public and for the common good—health care, education, disability and unemployment benefits, housing, and transport—have been hollowed out and asset stripped (Harvey 2005; Judt 2010; Meeks 2014). While a small percentage of the population has prospered, poverty and inequalities of wealth and health have rocketed to heights reminiscent of the Gilded Age (Dorling 2014, 2016; Wilkinson and Pickett 2012). For the poor, the sick, and the disabled, austerity boils down to an attack upon the state benefits that help them to survive, increased hardship, and the threat or reality of homelessness and of official vilification (Clark and Heath 2014; Desmond 2016; Taylor 2015).

The consequences for non-executive workplaces especially have been dismal. In recent decades in both the USA and Europe, many of them  have become regimes of outsourced employment, subcontracting, franchising, and third-party management. More than one in three American workers are hired by an external agency rather than by the company under whose auspices they labour, and Britain is not far behind. Former notions of an unspoken and joint obligation between employee and corporation have all but vanished, together with predictable careers, mutual trust, and expectations of loyalty (Kuttner 2014; Sennett 1998, 2006; Weil 2014). The places in which many of us have to earn our living have become more fraught and—thanks to the Kafkaesque power of new information technology—more bureaucratic and chaotic, at the same time (Bunting 2005; Donner 2014; Fleming 2015). In the early twenty-first century, work seems for most people to have become increasingly invasive and disruptive of private life through the imposition of flexitime, zero hours contracts, and of mobile communication and tracking devices (Fleming 2015; Schneier 2015). Recent surveys confirm widespread malaise, accounting for over a third of all job-related illness in the UK, for example (TUC 2015). In part, these figures may speak of disenfranchised employees having to resort to the language of psychological symptoms for their grievances to be heard (Newton 1998). However, rising self-harm and suicide rates in professions such as teaching and finance suggest that for many, probably most, the distress is real (Fleming 2015; Fisher 2009).

In the midst of this unsettling landscape, we should not be surprised that the wish for distraction or reprieve is strong. Witness the prevalent recourse to alcohol and recreational drugs, the popularity of escapist holidays, and leisure and national lotteries. The demand for quietude as a commodity is just a subtler instance (Sim 2004). Upmarket religious retreats have become popular in recent years, with their promise to unburden each punter of their dependency upon mobile phones, laptops, and similar devices (Carrette and King 2005; Lipton 2007). So-called artistic siestas invite their participants into a state of easeful drifting attention and then sleep, for which the reading of a poem is merely a backdrop. This movement, most evident on the European continent, echoes attempts to establish the afternoon nap as part of the official working day among the self-consciously creative sectors of the corporate elite, including the employees of Google (Pieiller 2014).

The need felt by so many people for mindfulness practice as a form of escape and self-soothing is consistent with these trends. Mindfulness temporarily cocoons the user against the rootlessness and incessant demands of contemporary life, giving them—literally—a breathing space, in which they can get back in touch with what is happening in their own body and find comfort in convivial group membership: an experience that seems to be growing rarer for many (Cromby et al. 2013; Stivers 2004). To their credit, Kabbat Zinn and his followers sometimes acknowledge that the practice cannot compensate for all of the harmful effects of having to get by inside hostile workplaces (see, for example, Mindful Nation, ibid.) and that no one should be blamed for supposedly having created their own illness out of wilful pessimism and other bad mental habits (Kabat-Zinn 2005). In both of these cases and many others within the literature, however, lone cautionary statements like these are overwhelmed by a swarm of research findings and personal testimonials which imply that negative attitudes equate to a lack of moral backbone and predispose to poor health (Barker 2014; Coward 1991; Friedly 2013). In the Mindful Nation document, this impression is increased by the authors’ failure to acknowledge the extent to which mental health problems and poor educational attainment can reflect impoverished circumstances, and dysfunctional communities and schools (Mombiot 2016; Thomas 2014).

In its relentless focus upon the internal world of the individual as the main answer to all personal and communal ills, mindfulness turns each practitioner into the neoliberal subject incarnate; their personal freedom in the marketplace guaranteed, together with full responsibility and accountability—not merely for their own conduct, but for their health and well-being, too (Aschoff 2015; Davies 2015; Purser 2015; Rose 2007; Smail 2005). No wonder so many employers, government agencies, and mental health experts are keen to promote the practice (see Carrette and King 2005).

The traditional teachings of Mahayana and Theravada schools valued meditation as one path among several that led to insight into the transience and contingency of the ‘self’, so cherished within Western culture. However, the enlightenment experience gained importance only through dogged practice—(a rarity even in the Buddhist homelands of South East Asia)—and within a set of institutions, rituals, and teachings intended to nurture the seeker as an ethical being. The canonical texts seldom saw mindfulness as an end unto itself, but rather as bridge towards larger moral purposes, including dedication to a wider community. Equanimity, well-being, and ‘happiness’ as the warm inward glow beloved of Western psychologists were not necessarily unwelcome, but they could be distractions, in the end (Cohen 2010; Crook 1980, 2009; Flanagan 2011; Purser 2014; Trungpa 1973).

For the more reflective of Western practitioners, mindfulness is a discipline that shows how our thoughts and feelings are inextricably intertwined with our physical embodiment and that mindfulness meditation—like consciousness itself—cannot happen exclusively inside of the meditators’ head. Rather, it is a social practice, dependent upon the guidance and support of compassionate people. This standpoint—based in part upon the pragmatist philosophy of William James and upon the insights of Wittgenstein and of various systems theorists—promises to correct some of the misguided optimism of people like Richard Layard (see, e.g., Fuchs 2013 ; Michelak et al. 2012; Crook 1980, 2009; Stanley 2012). However, there is still something missing from this account. Clinical experience and the critical realist tradition within the social sciences have yet more to say about the relationship between self, feelings, and the experience of having to live in a world in which most forms of dignity are undermined or denied (Burkitt 2011; Cromby 2015; Sennett and Cobb 1985; Smail 2005). Indeed, Buddhist teachings aver that the inequity and strife that is central to a neoliberal society will foment envy, greed, mistrust, and anger—the ‘poisonous emotions’—and hence personal distress on the widest scale: which is just what epidemiologists have been finding (Crook 1980, 2009; Dorling 2016; Wilkinson and Pickett 2012).

We live in a real world that resists wishful thinking and that is structured by social, economic, and material powers over which most of us have little control, and those with the least—the poorest and the most downtrodden—usually suffer the most (Bourdieu et al. 2000; Moloney 2013a; Smail 1996). Our physical embodiment is about more than the mere kindling of experience. It testifies to our common fragility as creatures of flesh and bone, bearing the ineradicable emotional scars of our passage through life—even as they attune us—exquisitely and vulnerably—to our surroundings (Cromby 2015; Bourdieu 1985; Burkitt 2008; Charlesworth 1999; Sennett and Cobb 1985; Smail 2005). To feel secure, to act with a measure of confidence and compassion, we need to have some assurance of belonging, meaning, and stability. When our world begins to crumble, then we undergo a corresponding personal disintegration (Cromby et al. 2013; Doris 2002; Midlands Psychology Group 2012; Smail 1993, 2005).

Intellectual illusions are often the most seductive and damaging of all. The officially endorsed notion of mindfulness as the answer to societal and personal malaise belongs to this category. The advocates of mass meditation invert the quest of Freud and other psychologists, who wanted to use the lessons of therapy to inform the creation of new institutions for the nurture of future generations more humane and capable than their own (Freud 1895; Smail 2005). Instead, the vision of the good society has been turned upside down and inside out. It has become a collection of individuals, sitting in earnest inward gaze. Techniques of meditation can offer temporary sanctuary from the demands and conflicts of a world that for too many has grown colder, and more frightening. But in the end this respite is a fake. Like the advertised promise of superior refreshment from a commercially supplied bottle of drinking water: an over-packaged and inferior product, the mass consumption of which has helped to undermine the willingness of governments to maintain the quality of communal aquifers (Szasz 2007). Rather than looking to mythical internal cures for our personal ills, we need to look outward. The task is to rebuild a public world in which all of us can find a purpose and a place.