The relationship between mindfulness and well being

Although the amount of literature on mindfulness is vastly growing, relatively little has been written about the mechanisms underlying the relationship between mindfulness and well-being. Both theoretical frameworks as well as randomized empirical research seem sparse. This is remarkable when looking at the popularity of mindfulness amongst lay public and the many claims made by practitioners about the wholesomeness of Mindfulness. And although the efficacy of several mindfulness-based interventions on well-being seems to have been demonstrated, insufficient light has been shed on the constructs possibly mediating this relationship. An indication of such mediating constructs would stimulate research on mindfulness and well-being and would provide building material for a framework that outlines mindfulness and maximizes efficient deployment of mindfulness in the professional setting.

1.1 Mindfulness

To be able to define the concept of mindfulness, it is necessary to see how it is embedded in Buddhist literature. The concept of mindfulness originates from the realization of the four noble truths by Siddhartha Gautama, a spiritual teacher and founder of Buddhism. The four noble truths mark the beginning of Buddhist teachings and the spread of Buddhism throughout Asia (13), and contain the central principles of Buddhism which have been adopted by all Buddhist schools that have emerged ever since. The four noble truths explain the fact of suffering, the opposite of well-being, and propose the means to end this suffering, which is the ultimate goal of Buddhism. The first noble truth, Duhkha, explains the concept of suffering. It encompasses all suffering, both physically and mentally, and adds an extra dimension to suffering as usually conceptualized in Western societies by explaining that all suffering can be looked upon as holding on to something, whether it be health, perceptions, or feelings, with the hope that these will exist permanently. From this viewpoint, anything that a person wants and does not have is suffering, but also anything that a person has, for example an illness, trait, or a job, but does not want to have, is suffering. Once this is understood, the second noble truth, samudaya, teaches us where this suffering comes from, which is from desire and attachment. For example, the attachment to ideas and principles might be the cause of suffering for a person. The third noble truth, nirodha, follows naturally from the second one and simply sais that if one wants to end suffering, one needs to stop desiring. Finally, the fourth noble truth, marga, shows us the means to end this suffering, with the eightfold path. This path contains eight parts: “right view”, “right intention”, “right speech”, “right action”, “right livelihood”, “right effort”, “right mindfulness”, and “right concentration”. These behavioral components are inseparable and interwoven with each other. They are not sequential, as the four noble truths are. For example, when one practices right concentration, one cannot do it without also practicing for example right mindfulness, and when practicing right mindfulness, one cannot do it without also practicing the seven other parts of the eightfold path. True mindfulness is described as a diligent awareness with a presence of mind and aware of the activities of the body, mind, ideas and sensations (14). Thus, according to Buddhist tradition, the concept of mindfulness is interwoven with firstly having a right view. Right view can be seen as seeing the true nature of things, free of interpretations and labels (14). Secondly, it is connected with having the right intention, To have the right intention means that one must have the right thoughts, because thoughts precede actions. These right intentions consist amongst others of the intention of good will, harmlessness and the intention of renunciation, which encompasses the will to detach yourself, and is opposite to desire (15). The third part of the eightfold path, right speech, is about realizing that through speech, like for example gossip and unfounded critique, we can hurt others. When we perform right speech, we try to speak truthfully and positively (16). Fourthly, mindfulness is interwoven with right action, which constitutes of  acting kindly and honestly, with respect to others’ belongings and sexual desires. The fifth of the eightfold path, is called right livelihood and it means that one should earn one’s living in a legal, peaceful and righteous way. Sixthly, right effort means that one should have a positive mental energy or will to achieve. Right concentration in the context of the eightfold path, means a mental state where one concentrates on wholesome thoughts. The eight parts of the eightfold path can be divided into three separate groups: (a) wisdom, which contains “right view” and “right intention”; (b) ethical conduct, which contains “right speech”, “right action”, and “right livelihood”; and (c) mental discipline, which contains “right effort”, “right mindfulness”, and “right concentration”. The four noble truths and with it, the eightfold path, in which mindfulness is included, is at the center of Buddhism, and must be seen as a way of life (14). It has been incorporated in most of the Buddhist schools that were founded since this first teaching.

Another teaching that is central in all Buddhist schools, is the teaching of conditioned arising, or co-dependent origination, which is the realization that all things are interdependent of each other and are interwoven in a complex web of cause and effect, stimulating the insight that all are equal, and in this way encouraging the development of compassion and empathy. The concept of co-dependent origination is in accordance with the four noble truths and the incorporated eightfold path, which in turn includes mindfulness, because it emphasizes that whatever a person sends out, they receive it back [ te vaag???] (18). So if one lives with desire and tries to hold on to things whilst wishing they are permanent, then suffering will occur as an effect of this desire. This principle of conditioned arising is fundamental to all Buddhist schools, and has strong connections to the concept of mindfulness. [waarom??? Specificeer.] However, since the four noble truths are broadly formulated and no instructions as how to reach these truths were incorporated in the original discourse about the four noble truths, there are also some differences in viewpoints between schools in how this eightfold path should be practiced. These differences might place the concept of right mindfulness into a different.

1.1.2 Compassion in Buddhism

The two mainstream Buddhist schools are called Mahayana and Theravada. From these two mainstreams, many schools have derived. Theravada is looked upon as the older school, with an emphasis on practice. It believes that enlightenment, the complete end of suffering, is only meant for monks and cannot be reached by laymen. The Mahayana school, of which Tibetan and Zen Buddhism are part of, believes that the achievement of Buddha nature is possible for everyone, and gives place to rites and ceremonies. The two main streams have in common that they see both wisdom and compassion as the means to end suffering. Compassion is widely described both in the Theravada’s Pali Canon, assumedly the eldest and most original script of Buddhism, and is cultivated as one of the practices without which the end of suffering is deemed impossible. In the Mahayana school compassion is seen as one of the pillars of Buddhism, and it is being cultivated through the many sutras and mantras, like the NÄ«lakaṇṭha DhāranÄ«, that form the basis of Mahayanan literature.

Although both Buddhist schools put forward compassion as a vital ingredient that needs to be cultivated in the path to end suffering, some nuances are made in Zen tradition. D.T. Suzuki, a Japanese author of books and essays on Zen and Buddhism that were influential in the introduction of Zen to the Western world, even puts forward the idea of Zen being in some sense amoral. However, he states that the Japanese might have placed wisdom above compassion, with which he implicates the equal importance of both compassion and wisdom in Zen Buddhism (20). At the same time, Dōgen, a Japanese Zen-teacher and founder of Soto Zen in Japan, one of the mainstream Japanese Zen schools, emphasizes that practicing good and doing good things for others without benefit to yourself is a prerequisite for breaking free of the self (21). The impression that wisdom has been placed over compassion in Japanese Zen Buddhism might have been influenced by the fact that Zen Buddhism was thoroughly integrated in Japanese culture during wartime, in which the element of dis-identification with the self, as opposed to the concept of compassion, fitted perfectly. As a new class in Japanese society, the Samurai warriors, grew large, a separate Buddhist school named Rinzai came into existence, in which the practice was more martial and less compassionate than the Soto Zen school. It might be possible that Western society, a society who is much more focused on the individual as compared to the focus on society as a whole in Eastern cultures, in learning about Zen through D.T. Suzuki, who has been much criticized by scholars for his work, is understating the role of compassion in Buddhism.

The Vietnamese Zen monk Thich Nhat Hanh seems to explain that compassion follows from having the right view. He explains that only when we are able to look upon both positive and negative aspects of life without labeling them, we can see the causes of suffering. In this moment we begin to grasp compassion, he sais. He also emphasizes that compassion needs to be developed and he cites the Lotus Sutra describing Avalokiteshvara who practices ‘looking with the eyes of compassion and listening deeply to the cries of the world.’ (22)

We might conclude that the feeling of compassion is a central concept in Buddhism and that together with wisdom it is being placed parallel to the cognitive and behavioral paths as described in the eightfold path, which involve no affect, but only actions. To promote well-being, the qualities of wisdom and compassion must be developed equally (14). The great importance of compassion can be inferred from the fact that it is not merely looked upon as a product of the eightfold path, but that it is being actively cultivated through different kinds of meditation throughout all the Buddhist schools, including Zen, and is being emphasized in the motivation of the Buddha to start this teaching, namely ‘for the good of the many, for the happiness of the many, out of compassion for the world’ (14).

[ Leg uit : Mindfulness Meditation ]

Summarizing, we can say that Mindfulness is defined in Buddhist tradition as is described as diligent awareness with presence of mind, and that it is included in the four noble truths, which are inseparable from each other and are to be realized in a sequential way. Mindfulness is part of the fourth step, the eightfold path, of which the components are again inseparable from each other, and each component is interwoven with the other. Next to that, it is clear that this path cannot be taken without realizing conditioned arising, wisdom and compassion.

1.2 Mindfulness in Western society

There has been a diverse conceptualization of mindfulness in Western literature, and it is being practiced in significantly different ways in different mindfulness-based interventions strategies (25). Most conceptualizations stem from one of the earliest definitions of mindfulness in psychology by Jon Kabat-Zinn, who conceptualized mindfulness as ‘paying attention in a particular way, on purpose, in the present moment, and nonjudgmentally’. [Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York: Hyperion. p. 4, via (25))[how to cite???]. Building on this definition, in order to concretize it and stimulate further research, Shapiro & Carlson (2009) have broken down the construct into three components that altogether constitute mindfulness, which they define as ‘Intention’, ‘Attention’ and ‘Attitude’. One must know why one is practicing Mindfulness, i.e. liberation from a specific kind of suffering, while paying attention to the moment-to-moment content of consciousness, and at the same time having an open, curious and kind attitude (9). However, questions have been raised about the validity and necessity of breaking up mindfulness in separate components (24), and the describing of the concept in terms of behaviors instead of a quality of awareness (4). It’s clear that a definition of mindfulness has not been agreed upon, yet, there have been many implementations of mindfulness. The differences in conceptualization and operationalization might account for the differences in how mindfulness has been integrated in clinical practice (23).

Within the many different practices of mindfulness in western psychology, there are four established mainstream therapies to be discerned, the eldest of them being Mindfulness Based Stress Reduction (MBSR), which has been developed by Jon Zabat-Kinn in 1979, and which overtly states that its roots are in Buddhist tradition. Based on MBSR, mindfulness based cognitive therapy (MBCT) was developed by Zindel Segal, Mark Williams and John Teasdale (ref!!!!), integrating components of the MBRS therapy with cognitive behavioral therapy. The focus of MBCT is on depressive patients. Similarly, dialectical behavior therapy (DBT) was developed by Marsha Linehan in the 1980’s, as a treatment for suicidal, difficult-to-treat patients, which combines elements of mindfulness with behavioral therapy (25). Next to that, acceptance and commitment therapy (ACT) is a relatively new therapy, although its principles’ were already known in psychology. ACT can be categorized as post-Skinnerian, and it openly incorporates elements of mindfulness. The integration of mindfulness has not been limited to the clinical practice however.

Mindfulness has earned great publicity amongst general public through various channels in the alternative circuit. Deepak Chopra, the author of more than fifty books translated into over thirty-five languages and a member of several scholarly organizations, has been appointed one of the top 100 heroes and icons of the century by Time magazine. The spearhead of his teachings revolve around learning mindfulness and mindful living techniques (26). Another spiritual teacher and bestselling writer is Eckhart Tolle, a former postgraduate research student at Cambridge University. Tolle has sold millions of copies of his books and teaches about topics central to mindfulness, like living in the moment, the end of suffering and transcendence of duality. Although these spiritual ‘leaders’ are often are looked upon by scholars with Argus’ eyes, the popularity of mindfulness as it is being conveyed through these alternative channels cannot be overlooked as this public interest signals a social development of the perspective on well-being and sheds light on the extent to which the concept of mindfulness is known in the western world.

1.3 Challenges to the integration of mindfulness in the western clinical setting

Although we might conclude that the concept of mindfulness is relatively well-known in the western world, there are some challenges in integrating the concept into the western clinical setting.

First of all, a point that is being made by several scholars is that the eastern Buddhist theories on cultivating well-being originate from a pre-scientific era, and therefore have no western empirical foundation. In other words, introducing Mindfulness into the realm of western science is problematic, because it has not been founded on western scientific reasoning (7). Harrington & Pickles even find mindfulness antirational (8). Perhaps a refinement of such conclusions puts this view in a different perspective. In science as we know it, information is always obtained through a detector, which is a person or a device, and the results need to be demonstrable, unbiased and objective and as such a relation to consciousness is being avoided. As a result, measurable effects make up the concept of science, and therefore subjective concepts like joy, ideas and thoughts are deemed subjective and suspicious topics. The result is that science has not taken the opportunity to research consciousness itself. This is surprising, while our consciousness forms our daily reality. While consciousness is being explained in terms of brain function, research of the unique nature of consciousness, in other words, consciousness and its character, is being ignored (27). Mindfulness’ aim is to explore exactly this. And although the quality of our consciousness cannot be recorded by a detector, let alone be objectively judged by a third person, this does not mean that we can exclude mindfulness from the scientific realm. Rather, the ‘science’ of consciousness should be a point of particular interest to science, as it has been in eastern traditions for centuries.

A second challenge with integrating mindfulness into the clinical setting, is the difference in perceiving information. In social sciences, we look at the content of consciousness, and try to change this content in order to achieve mental health. Disidentification from thoughts is often viewed as the means for changing the content of a thought. In eastern traditions, the aim is to look at the process of consciousness. The goal is not only to achieve mental health, but also to rise above a healthy state of consciousness, develop it, and understand the nature of it. Disidentification is the end-goal of this process (7). We might conclude that in western traditions we tend to look upon information in a top-down manner. We look at our stream of consciousness through the glasses of a specific theory and thereby inevitably change its appearance. In eastern traditions, information is looked upon in bottom-up manner. The streams of information, including the theories that are part of it, are viewed upon as processes and developments with disidentification as the end-goal and mindfulness as the means.

Another challenge to the integration of mindfulness in the clinical setting is that mindfulness, as part of Buddhism, is being viewed as a religion by some. It is often thought that the purpose of mindfulness is to cultivate a trance-like state (8). This viewpoint however is disputed by Buddhism. Central to the teachings are being human and becoming aware. There are no deities or supernatural states or powers involved, nor is it a goal to become detached from life by cultivating a trance-like state. The sole principle of Buddhism is human effort and intelligence, and it’s goal is to be human in the most pure and simple form (14), which gives us ground to integrate mindfulness in the clinical practice. Next to this, there are other reasons to justify the integration of mindfulness in clinical practice.

Psychology and essential Buddhism, that is, the teachings that are eldest and core to all Buddhist schools, show similarities not only in their goals but also in their means to achieve these goals. <<<<<(vul aan met Mikulas 2007). >>>>>

One of these essential teachings is conditioned arising, as discussed earlier, which can be looked upon as early scientific in the sense that it places all beings (living and non-living), thoughts and behaviors in a web of cause and effect, a thought that is central in science (18).

Next to these similarities with western psychology, the popularity of, and effects attributed to mindfulness give cause for more research and the development of a framework that can help integrate mindfulness in the clinical setting and improve well-being.

1.2 Well-Being

To be able to explore the possible mediating effects of mindfulness on well-being, we have to ask ourselves what exactly well-being is composed of. Well-being is being researched and measured under several domains. Apart from obvious components of well-being like income, emotional well-being can be measured as psychological well-being, which gives measures for psychologically healthy functioning and disability, i.e. depression and/or anxiety. A scale that is often used in healthcare, and that has been constructed by the World Health Organization (WHO), is the WHO (Five) Well-Being Index. Its focus is on screening for depression. If a certain raw score is under the cut-off point, then it is advised by the WHO to administer more specific questionnaires to be able to specify the depression (28). Intuitively, we might feel that this kind of measurement of emotional and mental well-being seems to be driven by existing theoretical psychological concepts of well-being which are aimed at restoring health, and we might ask ourselves if such measurements are complete enough to seat the whole concept of well-being.

Under the influence of positive psychology, which has the goal, as summed up in 1998 by amongst others Mihaly Csikszentmihalyi, to make normal life more fulfilling and is put forward in order to complement general psychology, the measurement of well-being has developed from a different perspective which has given rise to the concept of subjective well-being (SWB), a relatively new domain in psychology. SWB aims to measure both cognitive and affective states that people have when evaluating their lives and presents this as a measure for well-being. It analyzes the data stream of constructs that might make up well-being in a bottom-up manner, and through factor analysis has come up with core components that make up SWB. On the cognitive level, the domains of standard of living, health, achievements, relationships, safety, community and future security were isolated, while on the affective level the concepts of feeling energized, happy, content, satisfied, stressed and pleased correlated significantly with well-being (29). At the first glance, SWB seems to be able to take more broad measurements of well-being. However, it has received some criticism.

First of all, it has been criticized for its lack of theory. It is unclear what exactly justifies the split in cognitive and affective measures, and the measurements are less robust than measurements of psychological well-being like measured with the WHO-5. Next to that, the SWB measurements seem to give an impression of what a person finds pleasurable and typical about life, but does not measure having goals and challenges in life, which has been pointed out as being an important part of psychological human life in all cultures and may be seen as self-actualization (30).

One of these goals may be spiritual growth, which we can be seen as inner development and giving meaning to life, and is opposite to material growth. A recent review on the literature of studies that have researched the relationship between spirituality and emotional well-being, found that a majority of these studies find a positive correlation between the two constructs. However, there are too many methodological flaws in these studies to draw a firm conclusion on the relationship between spirituality and emotional well-being (31).

In summary, we can conclude that there are many theories on well-being, and one has not come to an agreement on what exactly should be measured when we measure well-being. It is clear however that emotional well-being comprises more than the absence of mental disfunctioning and that there are indications of a relationship with amongst others self-actualization and spirituality. When examining the possible mechanisms underlying the relationship between mindfulness and well-being, this should be taken into account.

1.3 Effects of mindfulness on well-being

The efficacy of mindfulness-based therapies has not yet been widely researched, but outcomes seem to demonstrate a positive effect of mindfulness on well-being.

A recent meta-analytic review on the effects of mindfulness-based therapy (MBT) on anxiety and depression by Hofmann et al. in 2010 (32), reveals moderate effects of MBT on a general population of subjects with conditions including cancer, anxiety disorder, depression, and other psychiatric or medical conditions for improving anxiety (Hedges’s g = 0.63) and mood symptoms (Hedges’s g = 0.59). On the population of patients with anxiety and mood disorders, the effect was associated with effect sizes (Hedges’s g) of 0.97 and 0.95 (32).

Chiesa et al. have reviewed the research on the effects of the MBRS program on stress management in healthy people, and found that ruminative thinking was lowered significantly with participants in the MBRS program. Stress reduction was reported in numerous studies, however, no specific active ingredient in the MBRS program was appointed as being responsible for this reduction. Also, empathy and self-compassion were reported significantly higher to those following an MBRS program as opposed to those in waiting list groups. Next to their research on healthy subjects, Chiesa et al. have systematically reviewed clinical features of mindfulness meditations, and reveal that MBSR shows efficacy for both psychiatric disorders, like depression and substance abuse, and physical conditions (5).

Mindfulness is also being connected with emotion regulation (ER), a relatively new field in psychology which has identified that a disturbed ability to regulate emotions underlies several psychological disorders. It is thought that mindfulness meditation (MM) facilitates ER, because the dis-identification of thoughts and emotions is being trained by the practice of MM. As a result, the effect of MM is that emotions are taken for what they are and are less intrusive, resulting in better mental health (4)(24).

The findings on the efficacy of mindfulness-based therapies may seem hopeful, but are to be used with great care. Results are still very diverse and not conclusive. Toneatto and Nguyen (2007), have reviewed 15 studies on the effectiveness of the MBSR program for the reduction of anxiety and mood symptoms, that used control groups, and found that it cannot be concluded that MBRS reliably alleviates anxiety and mood symptoms (34). The divergent results on the efficacy of mindfulness based therapies raise questions about the possible causes.

Several weaknesses arise when examinating the research on the effectiveness of mindfulness. First, due to the methodological differences in these studies, one cannot easily draw firm conclusions on results. There have been many studies that did not use control groups (34), and instead use mindfulness practitioners to research the effects of mindfulness, which is a challenge because in a within-subjects design the practitioner may not be able to avoid being mindful (18). Studies where control groups are used are relatively scarce, and when used, one should be critical in putting together the control group, because people who take up meditation seem more prone to anxiety, and people who give up seem to be more introvert and have a lower expectation of meditation (18).

Different operationalisation of constructs.

The influence of time is unclear. max 3 mnd opvolg.

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Spirituality have been met ??

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Dalai Lama zegt dat ieder een gevoel heeft dat hij persoonijk wil ontwikkelen, spiritueel, mind. ..

Following Shapiro & Carlson’s example of a cursory internet search (9), currently a Google search with the terms ‘mindfulness-based therapies’ yield approximately 3.970.000 results, and a search of scientific literature on PsycINFO (American Psychological Association, Washington, DC) with the term ‘mindfulness-based’ now yield 651 published scientific articles as compared to 260 that were found by Shapiro & Carlson in 2009 (9). In spite of this growth, little progress has been made in dismantling the concept of mindfulness and demonstrating its possible underlying mechanisms to well-being.