Is mindfulness training old wine in new bottles?

Posted: January 11, 2024 | Author: erikpeper | Filed under: attention, behavior, biofeedback, Breathing/respiration, CBT, cognitive behavior therapy, healing, health, meditation, self-healing, stress management | Tags: anxiety, autogenic training, biofeedback, health, meditation, mental-health, mindfulness, pain, passive attention, progressive muscle relaxation, wellness, yoga | Leave a comment

Adapted from: Peper, E., Harvey, R., & Lin, I-M. (2019).  Mindfulness training has themes common to other technique. Biofeedback. 47(3), 50-57.  https://doi.org/10.5298/1081-5937-47.3.02

This extensive blog discusses the benefits of mindfulness-based meditation (MM) techniques and explores how similar beneficial outcomes occur with other mind-centered practices such as transcendental meditation, and body-centered practices such as progressive muscle relaxation (PMR), autogenic training (AT), and yoga. For example, many standardized mind-body techniques such as mindfulness-based stress reduction and mindfulness-based cognitive therapy (a) are associated with a reduction in symptoms of symptoms such as anxiety, pain and depression. This article explores the efficacy of mindfulness based techniques to that of other self-regulation techniques and identifies components shared between mindfulness based techniques and several previous self-regulation techniques, including PMR, AT, and transcendental meditation. The authors conclude that most of the commonly used self-regulation strategies have comparable efficacy and share many elements.

Mindfulness-based strategies are based in ancient Buddhist practices and have found acceptance as one of the major contemporary behavioral medicine techniques (Hilton et al, 2016; Khazan, 2013).  Throughout this blog the term mindfulness will refer broadly to a mental state of paying total attention to the present moment, with a non-judgmental awareness of the inner and/ or outer experiences (Baer et al., 2004; Kabat-Zinn, 1994).

In 1979, Jon Kabat-Zinn introduced a manual for a standardized Mindfulness-Based Stress Reduction (MBSR) program at the University of Massachusetts Medical Center (Kabat-Zinn, 1994, 2003).  The eight-week program combined mindfulness as a form of insight meditation with specific types of yoga breathing and movements exercises designed to focus on awareness of the mind and body, as well as thoughts, feelings, and behaviors. 

There is a substantial body of evidence that mindfulness-based cognitive therapy (MBCT); Teasdale et al., 1995) and mindfulness-based stress reduction (MBSR) (Kabat-Zinn, 1994, 2003) have combined with skills of cognitive therapy for ameliorating stress symptoms such as negative thinking, anxiety and depression.  For example, MBSR and MBCT has been confirmed to be clinical beneficial in alleviating a variety of mental and physical conditions, for people dealing with anxiety, depression, cancer-related pain and anxiety, pain disorder, or high blood pressure (The following are only a few of the hundred studies published: Andersen et al., 2013; Carlson et al., 2003; Fjorback et al., 2011; Greeson, & Eisenlohr-Moul, 2014; Hoffman et al., 2012; Marchand, 2012; Baer, 2015; Demarzo et al., 2015; Khoury et al, 2013; Khoury et al, 2015; Chapin et al., 2014; Witek Janusek et al., 2019).  Currently, MBSR and MBCT techniques that are more standardized are widely applied in schools, hospitals, companies, prisons, and other environments. 

The Relationship Between Mindfulness and Other Self-Regulation Techniques

This section addresses two questions: First, how do mindfulness-based interventions compare in efficacy to older self-regulation techniques? Second, and perhaps more basically, how new and different are mindfulness-based therapies from other self-regulation-oriented practices and therapies?

Is mindfulness more effective than other mind/body body/mind approaches?

Although mindfulness-based meditation (MM) techniques are effective, it does not mean that is is more effective than other traditional meditation or self-regulation approaches.  To be able to conclude that MM is superior, it needs to be compared to equivalent well-coached control groups where the participants were taught other approaches such as progressive relaxation, autogenic training, transcendental meditation, or biofeedback training. In these control groups, the participants would be taught by practitioners who were self-experienced and had mastered the skills and not merely received training from a short audio or video clip (Cherkin et al, 2016). The most recent assessment by the National Centere for Complementary and Integrative Health, National Institutes of Health (NCCIH-NIH, 2024) concluded that generally “the effects of mindfulness meditation approaches were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise especially when they include how to generalize the skills during the day” (NCCIH, 2024). Generalizing the learned skills into daily life contributes to the  successful outcome of Autogenic Training, Progressive Relaxation, integrated biofeedback stress management training, or the Quieting Response (Luthe, 1979; Davis et al., 2019; Wilson et al., 2023; Stroebel, 1982).

Unfortunately, there are few studies that compare the effective of mindfulness meditation to other sitting mental techniques such as Autogenic Training, Transcendental Meditation or similar meditative practices that are used therapeutically.  When the few randomized control studies of MBSR versus autogenic training (AT) was done, no conclusions could be drawn as to the superior stress reduction technique among German medical students (Kuhlmann et al., 2016).

Interestingly, Tanner, et al (2009) in a waitlist study of students in Washington, D.C. area universities practicing TM used the concept of mindfulness, as measured by the Kentucky Inventory of Mindfulness Skills (KIM) (Baer et al, 2004)  as a dependent variable, where TM practice resulted in greater degrees of ‘mindfulness.’ More direct comparisons of MM with body-focused techniques, such as progressive relaxation, or Autogenic training mindfulness-based approaches, have not found superior benefit.  For example, Agee et al (2009) compared the stress management effects of a five-week Mindfulness Meditation (MM) to a five-week Progressive Muscle Relaxation (PMR) course and found no meaningful reports of superiority of one over the other program; both MM and PMR were effective in reducing symptoms of stress. 

In a persuasive meta-analysis comparing MBSR with other similar stress management techniques used among military service members, Crawford, et al (2013) described various multimodal programs for addressing post-traumatic stress disorder (PTSD) and other military or combat-related stress reactions.  Of note, Crawford, et al (2013) suggest that all of the multi-modal approaches that include Autogenic Training, Progressive Muscle Relaxation, movement practices including Yoga and Tai Chi, as well as Mindfulness Meditation, and various types of imagery, visualization and prayer-based contemplative practices ALL provide some benefit to service members experiencing PTSD. 

An important observation by Crawford et al (2013) pointed out that when military service members had more physical symptoms of stress, the meditative techniques appeared to work best, and when the chief complaints were about cognitive ruminations, the body techniques such as Yoga or Tai Chi worked best to reduce symptoms.  Whereas it may not be possible to say that mindfulness meditation practices are clearly superior to other mind-body techniques, it may be possible to raise questions about mechanisms that unite the mind-body approaches used in therapeutic settings.

Could there be negative side effects?

Another point to consider is the limited discussion of the possible absence of benefit or even harms that may be associated with mind-body therapies. For example, for some people, meditation does not promote prosocial behavior (Kreplin et al, 2018). For other people, meditation can evoke negative physical and/or psychological outcomes (Lindahl et al, 2017; Britton et al., 2021).  There are other struggles with mind-body techniques when people only find benefit in the presence of a skilled clinician, practitioner, or guru, suggesting a type of psychological dependency or transference, rather than the ability to generalize the benefits outside of a set of conditions (e.g. four to eight weeks of one to four hour trainings) or a particular setting (e.g. in a natural and/or quiet space). 

Whereas the detailed instructions for many mindfulness meditation trainings, along with many other types of mind-body practices (e.g. Transcendental Meditation, Autogenic Training, Progressive Muscle Relaxation, Yoga, Tai Chi…)  create conditions that are laudable because they are standardized, a question is raised as to ‘critical ingredients’, using the metaphor of baking.  The difference between a chocolate and a vanilla cake is not ingredients such as flour, or sugar, etc., which are common to all cakes, but rather the essential or critical ingredient of the chocolate or vanilla flavoring.  So what are the essential or critical ingredients in mind-body techniques?  Extending the metaphor, Crawford, et al (2013, p. 20) might say the critical ingredient common to the mind-body techniques they studied was that people “can change the way their body and mind react to stress by changing their thoughts, emotions, and behaviors…” with techniques that, relatively speaking, “involve minimal cost and training time.”

The skeptical view suggested here is that MM techniques share similar strategies with other mind-body approaches that encouraging learners to ‘pay attention and shift intention.’ This strategy is part of the instructions when learning Progressive Relaxation, Autogenic Training, Transcendental Meditation, movement meditation of Yoga and Tai Chi and, with instrumented self-regulation techniques such as bio/neurofeedback.  In this sense, MM training repackages techniques that have been available for millennia and thus becomes ‘old wine sold in new bottles.’

We wonder if a control group for compassionate mindfulness training would report more benefits if they were asked not only to meditate on compassionate acts, but actually performed compassionate tasks such as taking care of person in pain, helping a homeless person, or actually writing and delivering a letter of gratitude to a person who has helped them in the past?  The suggestion is to titrate the effects of MM techniques, moving from a more basic level of benefit to a more fully actualized level of benefit, generalizing their skill beyond a training setting, as measured by the Baer et al (2004) Kentucky Inventory of Mindfulness Skills.

Each generation of clinicians and educators rediscover principles without always recognizing that the similar principles were part of the previous clinical interventions. The analogies and language has changed; however, the underlying concepts may be the same.   Mindfulness interventions are now the new, current and popular approach. Some of the underlying ‘mindfulness’ concepts that are shared in common with successfully other mind-body and self-regulation approaches include: 

The practitioner must be self-experienced in mindfulness practice. This means that the practitioners do not merely believe the practice is effective; they know it is effective from self-experience.  Inner confidence conveyed to clients and patients enhances the healing/placebo effect. It is similar to having sympathy or empathy for clients and patients that occurs from have similar life experiences, such as when a clinician speaks to a patient.  For example, a male physician speaking to a female patient who has had a mastectomy may be compassionate; however, empathy occurs more easily when another mastectomy patient (who may also be a physician) shares how she struggled overcame her doubts and can still be loved by her partner.   

There may also be a continuum of strengthening beliefs about the benefits of mindfulness techniques that leads to increase benefits for the approach.  Knowing there are some kinds of benefits from initiating a practice of mindfulness increases empathy/compassion for others as they learn.  Proving that mindfulness techniques are causing benefits after systematically comparing their effectiveness with other approaches strengthens the belief in the mindfulness approaches.  Note that a similar process of strengthening one’s belief in an approach occurs gradually, over time as clients and patients progress through beginner, intermediate and advanced levels of mind-body practices.

Observing thoughts without being captured. Being a witness to the thoughts, emotions, and external events results in a type of covert global desensitization and skill mastery of NOT being captured by those thoughts and emotions. This same process of non-attachment and being a witness is one of the underpinnings of techniques that tacitly and sometime covertly support learning ways of controlling attention, such as with Autogenic Training; namely how to passively attend to a specific body part without judgment and, report on the subjective experience without comparison or judgment.

Ongoing daily practice. Participants take an active role in their own healing process as they learn to control and focus their attention. Participants are often asked to practice up to one hour a day and apply the practices during the day as mini-practices or awareness cues to interrupt the dysfunctional behavior.  For example in Autogenic training, trainees are taught to practice partial formula (such my “neck and shoulders are heavy”) during the day to bring the body/mind back to balance. While with Progressive Relaxation, the trainee learns to identify when they tighten inappropriate muscles (dysponesis) and then inhibit this observed tension.

Peer support by being in a group. Peer support is a major factor for success as people can share their challenges and successes.  Peer support tends to promote acceptance of self-and others and provides role modeling how to cope with stressors.  It is possible  that some peer support groups may counter the benefits of a mind-body technique, especially when the peers do not provide support or may in fact impede progress when they complain of the obstacles or difficulties in their process.

These concepts are not unique to Mindfulness Meditation (MM) training. Similar instructions have been part of the successful/educational intervention of Progressive Relaxation, Autogenic Training, Yogic practices, and Transcendental Meditation. These approaches have been most successful when the originators, and their initial students, taught their new and evolving techniques to clients and patients; however, they became less successful as later followers and practitioners used these approaches without learning an in-depth skill mastery. For example, Progressive relaxation as taught by Edmund Jacobson consisted of advanced skill mastery by developing subtle awareness of different muscle tension that was taught over 100 sessions (Mackereth & Tomlinson, 2010).  It was not simply listening once to a 20-minute audio recording about tightening and relaxing muscles.  Similarly, Autogenic training is very specific and teaches passive attention over a three to six-month time-period while the participant practices multiple times daily.  Stating the obvious, learning Autogenic Training, Mindfulness, Progressive Relaxation, Bio/Neurofeedback or any other mind-body technique is much more than listening to a 20-minute audio recording.

The same instructions are also part of many movement practices. For many participants focusing on the movement automatically evoked a shift in attention.  Their attention is with the task and they are instructed to be present in the movement.

Areas to explore.

Although Mindfulness training with clients and patients has resulted in remarkable beneficial outcomes for the participants, it is not clear whether mindfulness training is better than well taught PR, AT, TM or other mind/body or body/mind approaches.  There are also numerous question to explore such as: 1) Who drops out, 2) Is physical exercise to counter sitting disease and complete the alarm reaction more beneficial, and 3) Strategies to cope with wandering attention.

• Who drops out?

We wonder if mindfulness is appropriate for all participants as sometimes participants drop out or experience negative abreactions. It not clear who those participants are. Interestingly, hints for whom the techniques may be challenging can be found in the observations of Autogenic Training that lists specific guidelines for contra-, relative- and non-indications (Luthe, 1970).

• Physical movement to counter sitting disease and complete the alarm reaction.

Although many mindfulness meditation practices may include yoga practices, most participants practice it in a sitting position.  It may be possible that for some people somatic movement practices such as a slow Zen walk may quiet the inner dialogue more quickly. In our experience, when participants are upset and highly stressed, it is much easier to let go of agitation by first completing the triggered fight/flight response with vigorous physical activity such as rapidly walking up and downs stairs while focusing on the burning sensations of the thigh muscles.  Once the physical stress reaction has been completed and the person feels physically calmer then the mind is quieter. Then have the person begin their meditative practice.  

•  Strategies to cope with wandering attention.

Some participants have difficulty staying on task, become sleepy, worry, and/or are preoccupied. We observed that first beginning with physical movement practices or Progressive Relaxation appears to be a helpful strategy to reduce wandering thoughts.  If one has many active thoughts, progressive relaxation continuously pulls your attention to your body as you are directed to tighten and let go of muscle groups.  Being guided supports developing the passive focus of attention to bring awareness back to the task at hand. Once internally quieter, it is easier hold their attention while doing Autogenic Training, breathing or Mindfullness Meditation.

By integrating somatic components with the mindfulness such as done in Progressive Relaxation or yoga practices facilitates the person staying present.  Similarly, when teaching slower breathing, if a person has a weight on their abdomen while practicing breathing, it is easier to keep attending to the task: allow the weight to upward when inhaling and feeling the exhalation flowing out through the arms and legs.

Therapeutic and education strategies that implicitly incorporate mindfulness

Progressive relaxation

In the United States during the 1920 progressive relaxation (PR) was developed and taught by Edmund Jacobson (1938). This approach was clinically very successful for numerous illnesses ranging from hypertension, back pain, gastrointestinal discomfort, and anxiety; it included 50 year follow-ups. Patients were active participants and practiced the skills at home and at work and interrupt their dysfunctional patterns during the day such as becoming aware of unnecessary muscle tension (dyponetic activity) and then release the unnecessary muscle tension (Whatmore & Kohli, 1968).  This structured approach is totally different than providing an audio recording that guides clients and patients through a series of tightening and relaxing of their muscles.  The clinical outcome of PR when taught using the original specific procedures described by Jacobson (1938) was remarkable. The incorporation of Progressive Relaxation as the homework practice was an important cofactor in the successful outcome in the treatment of muscle tension headache using electromyography (EMG) biofeedback by Budzynski, Stoyva and Adler (1970).

Autogenic Training

In 1932 Johannes Schultz in Germany published a book about Autogenic Training describing the basic training procedure. The basic autogenic procedure, the standard exercises, were taught over a minimum period of three month in which the person practiced daily.  In this practice they directed theri passive attention to the following  cascading sequence: heaviness of their arms, warmth of their arms, heart beat calm and regular, breathing calm and regular or it breathes me, solar plexus is warm, forehead is cool, and I am at peace (Luthe, 1979). Three main principles of autonomic training mentioned by Luthe (1979) are: (1) mental repetition of topographically oriented verbal formulae for brief periods; (2) passive concentration; and (3) reduction of exteroceptive and proprioceptive afferent stimulation.  The underlying concepts of Autogenic Therapy include as described by Peper and Williams (1980):

The body has an innate capacity for self-healing and it is this capacity that is allowed to become operative in the autogenic state. Neither the trainer nor trainee has the wisdom necessary to direct the course of the self-balancing process; hence, the capacity is allowed to occur and not be directed.

• Homeostatic self-regulation is encouraged.
• Much of the learning is done by the trainee at home; hence, the responsibility for the training lies primarily with the trainee.
• The trainer/teacher must be self-experience in the practice.
• The attitude necessary for successful practice is one of passive attention; active striving and concern with results impedes the learning process. An attitude of acceptance is cultivated, letting be whatever comes up. This quality of attention is known as “mindfulness’ in meditative traditions.

The clinical outcome for autogenic therapy is very promising. The detailed guided self-awareness training and uncontrolled studies showed benefits across a wide variety of psychosomatic illness such as asthma, cancer, hypertension, anxiety, pain irritable bowel disease, depression (Luthe & Schultz, 1970a; Luthe & Schultz, 1970b). Autogenic training components have also been integrated in biofeedback training.  Elmer and Alice Green included the incorporation of autogenic training phrases with temperature biofeedback for the very successful treatment of migraines (Green & Green, 1989).  Autonomic training combine with biofeedback in clinical practices produced better results than control group for headache population (Luthe, 1979). Empirical research found that autonomic training was applied efficiently in emotional and behavioral problems, and physical disorder (Klott, 2013), such as skin disorder (Klein & Peper, 2013), insomnia (Bowden et al., 2012), Meniere’s disease (Goto, Nakai, & Ogawa, 2011) and the multitude of  stress related symptoms (Wilson et al., 2023).

Bio/neurofeedback training

Starting in the late 1960s, biofeedback procedures have been developed as a successful treatment approach for numerous illnesses ranging from headaches, hypertension, to ADHD (Peper et al., 1979; Peper & Shaffer, 2010; Khazan, 2013).  In most cases, the similar instructions that are part of mindfulness meditation are also embedded in the bio/neurofeedback instructions. The participants are instructed to learn control over some physiological parameter and then practice the same skill during daily life. This means that during the learning process, the person learn passive attention and is not be captured by marauding thoughts and feeling.  and during the day develop awareness Whenever they become aware of  dysfunctional patterns, thoughts, emotions, they  initiated their newly learned skill.  The ongoing biological feedback signals continuously reminds them to focus.

Transcendental meditation

The next fad to hit the American shore was Transcendental Meditation (TM)– a meditation practice from the ancient Vedic tradition in India.  The participant were given a mantra that they mentally repeated and if their attention wanders, they go back to repeating the mantra internally.  The first study that captured the media’s attention was by Wallace (1970) published in the Journal Science which reported that “During meditation, oxygen consumption and heart rate decreased, skin resistance increased, and the electroencephalogram showed specific changes in certain frequencies. These results seem to distinguish the state produced by Transcendental Meditation from commonly encountered states of consciousness and suggest that it may have practical applications.” (Wallace, 1970).

The participants were to practice the mantra meditation twice a day for about 20 minutes. Meta-analysis studies have reported that those who practiced TM as compared to the control group experienced significant improved of numerous disorders such as CVD risk factors, anxiety, metabolic syndrome, drug abuse and hypertension (Paul-Labrador et al, 2006; Rainforth et al., 2007; Hawkins, 2003).

To make it more acceptable for the western audience, Herbert Benson, MD, adapted and simplified techniques from TM training and then labelled a core element, the ‘relaxation response’  (Benson et al., 1974) Instead of giving people a secret mantra and part of a spiritual tradition,  he recommend using the word “one”  as the mantra. Numerous studies have demonstrated that when patients practice the relaxation response, many clinical symptoms were reduced. The empirical research found that practiced transcendental meditation caused increasing prefrontal low alpha power (8-10Hz) and theta power of EEG; as well as higher prefrontal alpha coherence than other locations at both hemispheres. Moreover, some individuals also showed lower sympathetic activation and higher parasympathetic activation, increased respiratory sinus arrhythmic and frontal blood flow, and decreased breathing rate (Travis, 2001, 2014). Although TM and Benson’s relaxation response continues to be practiced, mindfulness has taking it place.

Conclusion

Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT) are very beneficial and yet may be considered ‘old wine in new bottles’ where the metaphor refers to millennia old meditation techniques as ‘old wine’ and the acronyms such as MBSR or MBCT as ‘new bottles’.  Like many other ‘new’ therapeutic approaches or for that matter, many other ‘new’ medications, use it now before it becomes stale and loses part of its placebo power.  As long as the application of a new technique is taught with the intensity and dedication of the promotors of the approach, and as long as the participants are required to practice while receiving support, the outcomes will be very beneficial, and most likely similar in effect to other mind-body approaches. 

The challenge facing mindfulness practices just as those from Autogenic Training, Progressive Relaxation and Transcendental Meditation, is that familiarity breeds contempt and that clients and therapists are continuously looking for a new technique that promises better outcome. Thus as Mindfulness training is taught to more and more people, it may become less promising.  In addition, as mindfulness training is taught in less time, (e.g. fewer minutes and/or fewer sessions), and with less well-trained instructors, who may offer less support and supervision for people experiencing possible negative effects, the overall benefits may decrease.  Thus, mindfulness practice, Autogenic training, progressive relaxation, Transcendental Meditation, movement practices, meditation, breathing practices as well as the many spiritual practices all appear to share common fate of fading over time.  Whereas the core principles of mind-body techniques are ageless, the execution is not always assured.

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