Intervention Fidelity in Mindfulness-Based Research and Practice: Developing Criteria to Acknowledge New Training Programs

Abstract

The field of mindfulness-based research and practice is expanding fast. This development calls for a careful evaluation of the merits and scientific underpinnings of newly developed mindfulness-based programs (MBP’s). In this viewpoint, we describe a process initiated by two professional mindfulness teacher training organisations (the Dutch Vereniging Mindfulness-based Trainers Nederland, VMBN, and the British Association of Mindfulness-based Approaches, BAMBA) to develop a framework for evaluating the integrity of newly developed MBP’s. The framework aims to articulate criteria describing the elements and processes required to ensure that a new MBP meets good practice, adheres to evidenced-based practice, and is attending to the challenge of implementation and scalability. The development and implementation of the criteria are still a ‘work in progress’. We hope that this initiative offers a foundation for supporting the MBP field to balance innovation and grassroot community development with aligning to the principles of evidence-based practice.

Introduction

In recent decades, societal and scientific interest in mindfulness and mindfulness-based programs (MBP’s) has grown exponentially. ¹ MBP’s integrate mindfulness teaching and practice with contemporary approaches and theories to meet the needs of contemporary society. This momentum is largely grounded in the scientific evidence-base of the two core mindfulness programs that were outlined, first by Kabat-Zinn from 1983 on (Mindfulness-Based Stress Reduction, MBSR ² ) and then by Segal, Williams and Teasdale who developed and researched an adaptation of MBSR tailored to depression prevention (Mindfulness-Based Cognitive Therapy, MBCT ³ ). These programs have been shown to be beneficial and often cost-effective when applied in a variety of societal settings, such as health care, education, business and politics. ⁴ As the application of MBP’s widens, the field is facing the challenge of enabling innovation and inclusion of diverse programs and populations, while balancing integrity, safety, and quality assurance, founded on a robust evidence base.

Research on MBP’s is strong and promising, but there are understanding gaps typical of an emerging field in clinical psychological science. ⁵ The rate at which new MBP’s are emerging exceeds the capacity for robust randomised controlled trials. However, MBP teachers have done much innovative field work and, through practice-based clinical observation, have valuable insights on how MBP’s may be developed and tailored to particular populations, contexts and cultures. For example, there are programs currently being developed, researched and implemented that support skilful responses to challenging societal themes such as social injustice, inequality, and the climate and nature emergencies; and that attend to the challenges of equality, diversity, and inclusion. Professional bodies represent MBP teachers and training organisations, uphold the integrity of MBP’s and promote MBP’s to potential stakeholders, such as policy makers and health insurance companies. They are therefore at the frontier of managing the tensions of safeguarding integrity, adhering to scientific evidence and being open to innovation. This paper offers perspectives on a process developed and currently being implemented in two European MBP professional organisations – the Dutch Vereniging Mindfulness-based Trainers Nederland, VMBN, ⁶ and the British Association of Mindfulness-based Approaches, BAMBA ⁷ – which aims to apply a systematic and consistent approach to deciding which MBP’s are given the status of recognition by these bodies.

Acknowledgement Process for Newly Developed MBP’s

A taskforce was formed to explore the development of MBP acknowledgement criteria. A questionnaire, and an application process have been developed, piloted, and subsequently revised. Developers of new MBP’s seeking recognition can be invited to submit responses, together with complementary materials, such as training manuals and scientific source material. In the pilot phase, the questionnaire was used to evaluate five MBP’s. Their responses were assessed against the criteria, and written feedback and requests for clarification were returned. Three fundamental questions that arose through this process are presented here:

1. How do we define an MBP?

2. What level of evidence for efficacy and safety is required for program acknowledgement?

3. How is it decided that there is a need for a new program?

Defining an MBP

The starting point for developing the MBP assessment criteria was the position paper by Crane et al ⁸ which outlines the core elements of an MBP (see Table 1). These essential, constant, and integral elements define an MBP regardless of the population and context. Integrated within the warp elements, each MBP includes unique elements to tailor the program to particular populations and/or contexts/cultures (the ‘weft’ elements). These core elements were translated by the task force into practical and assessable criteria for evaluating new MBP’s. The appropriateness of ‘warp’ features in forming the definition of whether a program can be defined as ‘mindfulness-based’ proved to hold ground throughout the development, piloting, and revision stages. The criteria are clear and allow for the acknowledgement of a wide range of innovative and accessible programs that diverge from the original form and structure of established programs such as MBSR and MBCT.

Table 1.

The essential (‘warp’) and flexible (‘weft’) ingredients of mindfulness-based program’s (used with permission ⁸ ).

Warp

1. Is informed by theories and practices that draw from a confluence of contemplative traditions, science, and the major disciplines of medicine, psychology and education

2. Is underpinned by a model of human experience which addresses the causes of human distress and the pathways to relieving it

3. Develops a new relationship with experience characterized by present moment focus, decentering and an approach orientation

4. Supports the development of greater attentional, emotional and behavioral self-regulation, as well as positive qualities such as compassion, wisdom, equanimity

5. Engages the participant in a sustained intensive training in mindfulness meditation practice, in an experiential inquiry-based learning process and in exercises to develop insight and understanding

Weft

1. The core essential curriculum elements are integrated with adapted curriculum elements, and tailored to specific contexts and populations

2. Variations in program structure, length and delivery are formatted to fit the population and context

As MBP’s adapt to suit a wide range of populations, developers are finding that many contexts require interventions with less teacher contact, shorter mindfulness practices and reductions in home practice. Some findings suggest that teacher led MBP’s with longer practices may be more effective ⁹ ; however, ‘light touch’ approaches have also been shown to be beneficial ¹⁰ and may make mindfulness accessible in areas where the length of sessions and home practice commitment is a barrier to participation. ¹¹ We do not yet know enough empirically to discount low intensity programs and instead propose to recognise the ‘dose’ or ‘intensity’ of the programme by presenting new MBP’s within the listing categories ‘mindfulness’ or ‘mindfulness-low-intensity’.

Evidence Requirements for Program Acknowledgement

The taskforce established a principle that acknowledgement of new MBP’s must be available to both those with and without access to academic funding and research training. Many innovative teachers are developing MBP’s for contexts and populations that their expertise best places them to understand and test adaptations. At the same time, the continuation of the field, in any meaningful way, is dependent on the safety and efficacy of new MBP’s, assurance of which comes from robust empirical examination. We sought to develop criteria that values both evidence-based practice and practice-based evidence. ¹²

In the early piloting of the criteria, the core components of MBSR/MBCT (such as, the balance between psychoeducation, inquiry, and meditation practice) were held as a model for comparison. New programs were assessed for their similarity and/or difference to these programs and categorised as ‘adapted’ or ‘rebuilt’, depending on the amount of divergence. The premise was that those with significant deviation would need additional evidence for safety and efficacy. Through piloting we learnt the limitations of this approach. We are aware that there may be a range of new approaches to teaching mindfulness on the horizon, and that there is a need to make space for programs that diverge significantly from traditional 8-week programs, whilst still having a foundation that meets criteria based on ‘warp’ components. The revised approach thus seeks to firstly ascertain whether a program is ‘mindfulness-based’ in that it contains ‘warp’ components, and then to review evidence for efficacy and safety. Creating criteria to assess efficacy and safety is complex and nuanced. One option is to categorise MBP’s hierarchically as having a robust, moderate, or emerging evidence base. While this provides a clear sense of what we know about a program empirically, it may be exclusive and unattainable for those without access to RCT funding. The task force is thus aiming to articulate non-preferential, descriptive categories so that programs resting on evidence from a different epistemological perspective than that of empirical science can also be acknowledged.

How to Decide if a New Program Is Needed?

The recent paper ‘how, why and when to adapt’ by Loucks et al. sets out helpful criteria to ensure adaptations are ‘needed and appropriate to specific populations and contexts’. ¹³ These criteria have informed a pre-screening process that precedes full submission. If an MBP is deemed to meet a need, population or context that has not already been addressed, developers are invited to apply for full acknowledgement. Pre-screening would also require new MBP’s provide evidence that considerations related to equality, diversity and inclusion are included in the program development (i.e., cultural sensitivity, accessibility of teacher training, course materials etc.). We also aim to offer resources to support the process of applying for acknowledgement to reduce barrier for those from diverse or non-academic background.

In practice, the application process will be as follows. Once a program progresses through pre-screening, developers are invited to submit a full application. This application will be considered by members of a review committee, consisting of experienced trainers and scholars who work in this field, whose recommendations will be presented to the executive board of the VMBN or BAMBA. The applicant will contribute a small fee for the acknowledgement process, which is used to compensate members of the review committee for their work. If successful, programs will be acknowledged for a period of 3 years by the boards of both organizations. In practice, two acknowledgement categories are possible: ‘emergent MBP’ for programs for which the scientific evidence base is still limited, and ‘established MBP’ for programs that have sufficiently demonstrated the validity and efficacy of their approach. This process will be reviewed on a regular basis and updated when deemed necessary by the boards of both organisations.

Conclusion

The collaboration of professional MBP organisations on areas of shared concern will hopefully support parity in expectations around program development internationally. We aim to widen this collaboration to include representatives from other professional mindfulness organisations. There is a need for professional organisations to change to stay relevant and to incorporate new societal themes. Developing within MBP professional associations flexible yet robust criteria for assessing the integrity and quality of new MBP’s is an important next step to support sustainable development in the MBP field. The implementation of such a structure needs careful evaluation to ensure that valuable innovations are not hindered in their development. We hope that new acknowledgement criteria may enable the general public access to MBP’s that are effective, have depth of integrity and are sensitively tailored to a diversity of contexts, populations, societal challenges, and cultures.