“Diluting Its Value as a Word by Applying It to Everything”: A Qualitative Study Exploring Perspectives and Practices of Mindfulness Practitioners

Background

Mindfulness is a form of meditation practice used in both traditional and healthcare settings that aims to facilitate present moment awareness. The concepts and practices of mindfulness originated in 5th century BCE in India, which arose from Buddhist contemplative practices that focus on spiritual growth, psychological health and wellbeing.¹ While mindfulness existed within Buddhism, mostly within Asian communities, it then evolved into a secular therapeutic intervention with the development of mindfulness-based stress reduction (MBSR) in 1979.²

Jon Kabat-Zinn developed MBSR as a structured intervention to be used within healthcare settings for the management of chronic pain.³ Since the advent of MBSR, the popularity of mindfulness has continued to grow, and with this came the development of variations to mindfulness practices.⁴ These adaptations came largely from combinations of MBSR and cognitive behavioural therapies, which saw the development of mindfulness-based cognitive therapy (MBCT).⁵ Collectively, these systems of practice are commonly referred to as Mindfulness-based interventions (MBI).⁶

Although modern and traditional forms of mindfulness practice are often presented separately, they do share many commonalities in their origins. While MBI such as MBSR and MBCT are thought to have been developed from Buddhist practices, particularly Theravāda and Japanese Zen Buddhism, they are not believed to be the same.^7–9

Although the term “mindfulness” is often taken for granted as denoting a very specific concept, its use has been applied to a wide scope of practices. The term “mindfulness” was originally translated from the Pali word “Sati”, which is a term that may be more literally translated to mean memory.¹⁰ However, just as we have used the pre-existing word “mindfulness” in our English interpretation, the historical Buddha, drawing on the available language of the time, also appears to have adapted the term “Sati” for his own purposes and uses, showing that the terminology surrounding the concepts of mindfulness have been evolving from the very beginning.¹⁰

Existing literature has discussed an ever-developing context for mindfulness regarding its application as a term over the past several decades.¹¹ This progression has seen adaptations from its traditional Buddhist origins, into its use as a modern intervention where it is being applied in several different therapeutic settings. Along with the increase in the popularity of mindfulness, the term is now often used as a “buzzword” that is deemed by some as inappropriate to the original concepts of mindfulness, a development which has spawned the term “McMindfulness”, which suggests a reduction in quality and proper therapeutic rigor, similar to the invent of fast food.¹¹

The ever-changing understanding and use of mindfulness is not necessarily a new phenomenon.¹² The popularity of mindfulness and meditation in general, within the Buddhist context, has changed over time, and differs across the various schools of Buddhist doctrine, which are not in themselves homogenous.^12,13 There is disagreement in the literature about the most desirable progressions in mindfulness. For example, in a recent article, Oman suggests the need for inclusion of a more diverse set of practices under the umbrella term mindfulness.¹⁴ This was later supported by Knabb and Vazquez.¹⁵ However, in response to this, Galante and Van Dam presented an opposing argument as to why mindfulness should be simplified and clarified as a term with more specific meaning.¹⁶ It seems therefore that consensus has yet to be reached regarding even the most basic of questions related to mindfulness - “what is it?” and “should we apply it to more or less practices?”.

Recent discourse^17–19 on mindfulness-based practices has pointed to considerable heterogeneity regarding the definition, descriptions, practices, and intervention protocols of mindfulness. There are a broad range of terms used to describe mindfulness that consist of words such as “open”, “curious”, “present”, “accepting”, “compassionate” and “contemplative”; while some terms, such as “judgemental” and “non-judgemental”, appear contradictory and controversial.^6,19–21 A recent umbrella review examining the use of MBI for the management of chronic musculoskeletal pain similarly reported significant heterogeneity related to the protocols (eg, treatment duration, number of sessions) and definitions of mindfulness,¹⁷ as well as how professions practice mindfulness. The review findings suggested that the term “mindfulness” can mean different things to different groups of people.

Although a small body of research has investigated the perspectives of mindfulness amongst providers, to date, this research has focused on individual professions, such as psychology, and has generally defined the term mindfulness to include only a few specific interventions, such as MBSR, and MBCT.²² This means that primary, qualitative research has yet to capture how mindfulness is understood and practiced in diverse clinical and professional settings.

Based on recommendations from the abovementioned umbrella review, and recognising the current knowledge gap in the literature, the aim of the current research was to explore the perspective, language, description, and practices of practitioners who identify themselves as using mindfulness techniques for a range of health and clinical conditions.

Methods

Design

A qualitative descriptive (QD) approach, together with semi-structured interviews, were used to explore the beliefs and practices of mindfulness practitioners in a clinical or professional setting.²³ This approach and method was chosen to provide a rich description of participant’s experiences of mindfulness and to present the provider’s reality in everyday language.^24,25 A QD approach is appropriate when a firsthand description of a phenomena is desired that focuses on the who, what, when and where of events or phenomena.^26,27 QD can also provide a framework to carefully examine clinical interventions to ensure they are tailored to the needs of the populations that use them²⁸ Accordingly, QD is an appropriate methodology to investigate how mindfulness is understood and practiced in professional settings. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide the reporting of this study.²⁹

Research Questions

The study was designed to answer the following research questions:

1. What are the underlying philosophies/beliefs/aims of the practitioners of mindfulness?
2. How are the different types of MBI practiced in a clinical or professional context?

Participants

This study aimed to capture diverse views and experiences by recruiting practitioners from various disciplines (ie biomedical, allied health, complementary and alternative medicine (CAM), traditional meditation, spiritual disciplines). Practitioners were eligible to participate if they were (a) aged 18 years and over, (b) resided in Australia, (c) completed training in mindfulness practice, and (d) practiced mindfulness as part of their routine service provision when managing any health condition. Excluded were practitioners for whom mindfulness was not a primary focus of their practice. To capture how mindfulness is provided to real consumers across the broad spectrum of what is considered mindfulness practice, we allowed participants to self-identify as mindfulness practitioners instead of defining what constitutes a mindfulness intervention ourselves. The word “practice” in this study referred to the specific mindfulness practices or strategies used by practitioners, and not to the practitioner’s clinical or professional practice overall, for example “Physiotherapy Practice”. The inclusion of Buddhist teachers in this study, alongside allied health, medical, and CAM practitioners, was important due to the belief that mindfulness-based interventions were originally developed from the Buddhist practice and concept of Mindfulness.^7,8 Although they are now thought to be different, there still appears to be little consensus regarding how closely Buddhist-based mindfulness and mindfulness-based interventions are related in terms of practice and conceptualization.^7–9 In fact, although MBSR may be thought of as separate from Buddhist philosophy, John Kabat-Zinn frequently references and quotes the Buddha within his own publications.⁹

Recruitment and Sampling

Participants were recruited using three sampling techniques: (a) Non-probability, purposive sampling (ie selecting participants based on their ability to provide information-rich data);³⁰ (b) Quota sampling (ie selecting participants from different biomedical and allied health streams, CAM disciplines, and other traditional backgrounds such as Buddhist teachers); and (c) Snowball sampling (ie identifying participants through personal recommendations by others working within the same discipline)³¹ Potential participants were identified via public directories of pertinent professional associations (eg Australian Traditional Medicine Society), social media sites (eg TCM Acupuncture South Australia, Women’s, Men’s and Pelvic Health Physiotherapy Group Australia, both on Facebook (See Appendix 1)), internet searches, and networks of the research team, and were subsequently invited to participate via email (See Appendix 2) or telephone. Each potential participant was provided with a Participant Information Sheet (See Appendix 3), which outlined the aims, purpose and nature of the research, and the background of each member of the research team. Participants were also informed that participation was voluntary, they could withdraw from the study at any time without consequence, and there was no payment for participation.

As there are no definitive guidelines for sample sizes in QD research,³² sample size was guided by similar research in other fields, as well as practical considerations (eg timeframe, and resource limitations). The appropriate sample size for the current study was estimated to be around 16 participants.^33,34

Interviews

Data were collected using semi-structured Interviews, which enabled flexibility with the phrasing and order of questions depending on the responses of each participant.³⁵ Interview questions were informed by recent reviews of MBI,^17,18 and discussions with the research team, which were subsequently drafted into an interview guide.³⁶ The interview guide outlined the list of open-ended questions, as well as prompt questions, to enable participants to convey the depth of their own understanding and personal experience with the clinical use of mindfulness. The interview questions were piloted prior to the start of the study.³⁷ No changes were made to the interview guide (see Appendix 4) following the pilot test.

Data Collection

Semi-structured interviews were conducted virtually via Zoom, or in person in a closed office, by the lead researcher (PC). Interviews were undertaken between 23rd May and 15th July 2023, and ranged in duration from 35 minutes to 135 minutes. All interviews were audio recorded with the participant’s consent. Field notes were also documented during and after the interviews.³⁸ Audio recordings of each interview were transcribed verbatim and de-identified using pseudonyms.³⁸

Data Analysis

NVivo 14 software^TM was utilised to manage data and assist with data analysis. Data were analysed using thematic analysis, in accordance with the six phases of Braun and Clarke (ie familiarisation with data, systemic coding of data, searching for themes, reviewing themes, defining themes, and production of the report).³⁹ Each phase of the analysis was reviewed by members of the research team to ensure the codes/themes were an accurate representation of the raw data. Rigour was maintained^40–42 by ensuring credibility (ie, using two coders [PC, YV]), transferability (ie, using rich description of the methods), dependability (ie, triangulation of the data and field notes) and confirmability of the data (ie, identifying the limitations and biases of the study), thus ensuring trustworthiness.⁴³

Researcher Role

The lead researcher (PC) is a Master of Research candidate with prior experience in mindfulness research and a Bachelor of Health Science. He also has considerable practical experience with meditation traditions, including the use of various forms of Buddhism, and internal Kung Fu traditions. PC is also an Acupuncturist and Wing Chun Kung Fu instructor. As these professional, experiential, and educational biases could not be eliminated or controlled for, strategies were put in place for their management. These included adhering to the study design and interview schedule, regularly consulting with the research team, and undertaking training in the appropriate conduct and reporting of QD research.

Ethics

Ethical approval was obtained from the University of South Australia Human Research Ethics Committee [Protocol number – 205109]. Participants all gave both written and oral consent. The participants informed consent included publication of anonymized responses.

Results

Participant Demographics

Sixteen individuals participated in the interviews (Table 1), and fourteen participants returned the demographics questionnaire (see Appendix 5). Most of the participants were female (56.25%). Participants represented several disciplines and backgrounds, which were categorised into four groups of practitioners: Medical, Allied Health, CAM, and traditional Buddhism. Ages of the participants ranged from 31 years to over 60 years. Seven participants reported holding a master’s degree or doctorate (43.75%) and six reported holding bachelor’s degree (37.5%). More than one-half of participants (56.25%) had been practicing mindfulness for 11 years and more. Participants comprised a mix of practitioners that identified with biomedical and allied health disciplines (50%) and traditional practices (50%), with several participants indicating that they practiced across multiple modalities.

Table 1 Participant Demographics (n = 16)

Findings

Analysis of the data resulted in the identification of two broad themes: Plurality of understanding, and Multiplicity in use. Plurality of understanding refers to the varied perspectives of the theoretical underpinnings of mindfulness, and the transformation of mindfulness over time. Multiplicity in use relates to the varied perspectives of the indications and contraindications for mindfulness, and the adaptation of mindfulness to clinical practice.

Plurality of Understanding

Plurality of understanding relates to the range of theories that underpin the practice of mindfulness in a clinical or professional context; it also refers to the associated breadth of interpretations that may transform in a variety of ways based on the background of the professional, their personal journey and the evolution of mindfulness over time.

Theoretical Underpinnings of Mindfulness

Participants shared a variety of perspectives on their understanding and use of mindfulness. Concepts ranged from those that aligned with Jon Kabat-Zinn’s (JKZ) definition of mindfulness, to specific traditional Buddhist scriptures, and physiological or practice-based explanations.

The definition of mindfulness coined by JKZ was mostly used by allied health and medical practitioners as compared with CAM practitioners or traditional mindfulness practitioners. The most polarised views on definitions were between allied health or medical practitioners and Buddhist teachers. One psychiatrist expressed her belief that we should be very precise in using the JKZ definition verbatim,

Jon Kabat-Zinn’s definition of mindfulness was paying attention in a particular way on purpose in the present moment and non-judgmentally…the idea is that you’re being non-judgmentally accepting of whatever’s happening in the present moment, in your experience in the moment…you’ve got to be really specific about…what you mean by mindfulness and how you’re applying it to a condition and is there a theoretical rationale for that, and then does it work? (Participant 7)

Another allied health practitioner who reported using JKZ’s definition also adapted and added her own understanding of the JKZ definition, citing additional characterisations that she had developed through personal experience,

…an extra provision I often put on that…is…bringing attention to what is happening in your body, in your mind, in the world around you with curiosity and kindness. So that’s my little extra bit…I think the curiosity and kindness are really important elements (Participant 15)

Five participants from a Buddhist background characterised mindfulness in a traditional context. Of these, three practitioners were teachers of Buddhism and taught mindfulness within the Buddhist context, and two participants were trained to provide mindfulness within the Buddhist context but not trained to provide other Buddhist practices or philosophies. The former group reported using definitions from certain traditional Buddhist scriptures (Sutras and Tantras), primarily the Satipatthana sutra, which literally translates to “awareness of mindfulness” (Participant 3). This group reported a traditional definition using 4 levels or foundations of mindfulness,

the four foundations of mindfulness…are contemplation of body, contemplation of feeling…contemplation of mind…and…contemplation of objects of mind (Participant 3)

Interestingly, the group that taught mindfulness at Buddhist centres without necessarily incorporating Buddhist doctrines, had a slightly different approach and were more likely to characterise mindfulness using rich descriptive terms. For participant 1, this was to create a quiet, relaxed and calm mind to optimise the likelihood of students having an experience of mindfulness,

in those first few sessions…my aim…is to get them in a state of physical and mental relaxation so that they can experience what it’s like to have a mind that’s not buzzing with thoughts…and emotions. And if we can achieve that within an hour…we’ve given people a taste of, what it might be like to be mindful…it’s a very slow process, and you’ve really got to start with the first few steps (Participant 1)

For participant 8, this approach was to understand mindfulness in the context of life in general,

…Buddhism is a truth that we as human beings have this innate wisdom and insight already…It’s all there…what happens as we journey through life, …the world out there is uncontrollable, unknowable…vast and could be pretty scary… the adaptation … as human beings…from a very early age, is to find ways to adapt to the kind of insults and… experience of injuries. And so…for me mindfulness…is about coming home to the present moment, [to the] experience of life as we perceive it now, because that’s all there is (Participant 8)

Some practitioners provided a simplified characterisation,

…mindfulness to me is focusing specifically on the breath (Participant 12)

An Acupuncturist/qigong teacher defined mindfulness as

…that ability…to stand back…and…just see what’s going on and what you’re doing…and just being aware in that moment of what you’re doing… (Participant 13)

Characterisations of mindfulness also extended to physiological meanings, such as

…systems of the body (Participant 9)

This was exemplified by a physiotherapist, who characterised mindfulness in terms of the nervous system,

…understanding the difference between the sympathetic and the parasympathetic nervous system. And that when you’re in chronic pain, chronic stress, that you often get stuck in the sympathetic nervous system (Participant 9)

A traditional Chinese massage therapist/Wing Chun Kung Fu teacher characterised mindfulness in terms of a harmony between certain elements of one’s experiences,

…an internal awareness and communication with the…mental, physical, and emotional/spiritual…trying to synchronize a harmony between all of those and develop a communication, that’s as mindful as one can be (Participant 11)

Another participant, a physiotherapist, reported her practice of clinical hypnosis as aligning with mindfulness-based practice but acknowledged that others may not agree,

…the purist would say there’s a difference between mindfulness and clinical hypnosis, but I don’t know that there is…it’s by definition…focusing your attention on something. So, there are so many overlaps with mindfulness and clinical hypnosis and we…are… …asking our patients to put their rational mind… or the conscious mind to the side, and we’re trying to just let that subconscious or unconscious mind…step up to the fore. it’s that little voice that is talking to [you] all the time and helping you make decisions about the right thing to do, or, it’s like asking that part of your mind to just step forward and consider making some changes.

Interestingly, both allied health and medical practitioners reported very different perspectives to Buddhist teachers regarding the term “non-judgemental”, as used within the JKZ definition of mindfulness. The primary differences seemed to be whether this reflects the traditional Buddhist perspective, and whether being non-judgemental is at all possible during a mindfulness state. Both allied health and medical practitioners commonly reported that the term “non-judgemental” is a Buddhist concept, and that it is desirable in the process of reducing suffering. For example, a psychiatrist suggested that,

As soon as we have an experience, we immediately judge it, like it, dislike it, want more of it, want less of it…which the Buddha said was the cause of suffering…the idea is that you’re being non-judgmentally accepting of whatever’s happening in the present moment, … to give yourself time to settle and then take skilful action (Participant 7)

An allied health practitioner reported similar sentiments,

…be non-judgmental…helps us to be more aware of how we are judgmental…to be able to choose more wisely as to how we respond to stuff, rather than it just being based on our judgments (Participant 15)

In contrast, Buddhist teachers disagreed with the above view, and commonly reported that the term “non-judgemental” is not a term related to mindfulness practice within the context of Buddhism,

…non-judgmental awareness…in terms of what the Buddhist tradition defines as mindfulness…it’s actually completely incorrect…] it is judgment from go to woe. Are you sitting down? Are you standing up? …Are you breathing in or breathing out? That’s a judgment…To describe what you’re thinking about…that’s a judgment…So I think that [the JKZ] definition has bedevilled the work of mindfulness ever since (Participant 2)

Another viewpoint of Buddhist teachers suggested that many practices in MBSR and MBCT are similar to types of Buddhist meditation, but that these actually fall within the category of “Shamantha”, or “calm and concentration” meditation, and not in the category of mindfulness. Participant 3, a Buddhist teacher, outlined how these different streams of practice fit within the overall scope of Buddhist practice,

…there’s four…different strands of [Buddhist] teaching…you’ve got…ethics, calm and concentration, mindfulness that leads into insight, and…integration, which is the tantra stream…they’re the four streams. …and the mindfulness stream…links into insight (Participant 3)

Other Buddhist teachers explained that “Shamantha”, or “calm and concentration” meditation, aims to calm and focus the mind, to guide the meditator into deepening states of meditative absorption. According to these Buddhist teachers, this category of meditation can lead to non-judgemental awareness, or equanimity, but it does not qualify strictly as mindfulness within the Buddhist context,

[MBSR] to me…is straight calm and concentration…and that’s fine, not a problem. But it’s just not mindfulness…that’s actually slightly different…So calm and concentration is the basic skills of calming the mind. Then mindfulness is a very specific subset…it’s about tracking the four levels [of mindfulness]…if you want non-judgmental, that’s equanimity…no problem…there is definitely a case for being non-judgmental, but [it’s] just not in that definition [of mindfulness within Buddhism] (Participant 2)

Participant 4, another Buddhist teacher, further clarified that “Shamantha”, or “calm and concentration” meditation, is a foundational skill upon which the practice of mindfulness is built,

…where you’re looking into the nature of the mind…once you’re established in…a calm and concentrated or tranquil abiding, and you’re not getting distracted…then you choose to stay in a calm state and then you do various insight practices to look at the nature of the mind

Transformation of Mindfulness

Many participants reported different interpretations regarding how mindfulness has transformed over time.

Participants discussed the term “mindfulness” within the context of Buddhism and Yoga when referring to changes in the use of the term mindfulness over time. For example, participant 4, a Buddhist practitioner, reported never hearing the term “mindfulness” within a Buddhist context until the late 1970s;

…the term mindfulness certainly wasn’t…in the air in the early seventies when…everybody was…learning transcendental meditation or…Zen…so when the word came…mindfulness…I remember a period of practice say[ing], okay, I’m gonna practice mindfulness…be mindful (Participant 4)

Similarly, participant 16 explained that the term mindfulness was not used in her post-graduate training in Yoga in her home country of India. Although she could understand where the term fit within the system of Yoga, she did not use the term until after migrating to Australia.

…when I did my master’s, I never used the word mindfulness. Nobody used the word mindfulness throughout the practice…in the recent times, lots of mindfulness …I can connect…what mindfulness means…but this term has originated from somewhere, I don’t know…it’s around everywhere. (Participant 16)

Participant 7, a psychiatrist, had a different perspective on the transformation of mindfulness. She reported the development of MBCT as an evolution of MBSR.

MBCT was…a modification of MBSR…the three people that developed MBCT … spent a lot of time training and learning from Jon Kabat-Zinn. And then they developed MBCT, which was a modification of MBSR, using the research on what causes…relapses of depression, realizing it was a tendency to ruminate, to think negatively, to be so critical…and to be mindless, to be on automatic pilot and not actually be present in here and now. So they were looking at modifying CBT, which was a treatment of the time…to try and address some of those to try and get better relapse prevention rates. (Participant 7)

There was a common belief among participants, across a variety of backgrounds, that there has been a “cheapening” of mindfulness as it transformed from its origins in eastern philosophy to allied health and medical practice, particularly in relation to how the word mindfulness has come to be used. Other participants suggested that mindfulness began to lose rigor and be “trivialized or superficial[ised]” following the development of MBCT once the term mindfulness had gained popularity,

…mindfulness really captured the public imagination and…has become widely applied…but also somewhat trivialized or superficial…[people are] very cloudy about what they mean by mindfulness…people started calling their meditation mindfulness meditation, whereas it might not have been mindfulness (Participant 7)

This sentiment was echoed by a Buddhist teacher who suggested that “…we’re verging on…diluting its value as a word by applying it to everything” (Participant 4). A yoga teacher similarly stated that “…it’s like everybody’s using the term yoga, but the essence or the goal of the yoga is…completely missing” (Participant 16).

Participant 5 shared a similar view on the evolution of Tai Chi, with its shift away from a martial arts application, towards a more health focused approach. She suggested that if Tai Chi is practiced within a martial arts context, the benefits to mindfulness may reach a deeper level,

I respect [the] martial arts side and I really think…today because everybody focus[es] on…health…some of the really important skill[s] get diluted…the authenticity has been challenged…it’s just lacking…It’s more dynamic but gives people…another layer [of] depth that I like to see my students do (Participant 5)

Multiplicity in Use

Captured within the theme of Multiplicity in use, were three subthemes: therapeutic choice, application to clinical practice, and adaptations of mindfulness. Therapeutic choice referred to both indications for use (ie instances where mindfulness is used, desired, and/or expected to have benefits) and contraindications to use (ie instances where mindfulness is not desirable). Application to clinical practice related to the different ways participants engaged in mindfulness practices across various disciplines. Adaptations of mindfulness related to participants perspectives that mindfulness has become cheapened and less rigorous along with its drastic rise in popularity.

Therapeutic Choice

Participants reported many different indications for the use of mindfulness, which appeared to align with the participant’s primary discipline backgrounds. The primary indications of use included pain, depression, anxiety, and spiritual growth.

A Buddhist teacher outlined several reasons why someone might pursue the practice of mindfulness. It was suggested that these desired outcomes may be best sought from mindfulness practitioners of differing backgrounds,

…there are three reasons why you learn to meditate first…to manage the mind…second…is for personal development…for therapeutic reasons. So, you become fully self-actualized…that you become a mature, wholesome, healthy ego…the third reason to meditate is for spiritual reasons where…the goal [is] self-transcendence or self-realization (Participant 4)

Two different acupuncturist/Qigong teachers reported similar, but also different indications. One stated that the

…one thing I see…all the time is stress (Participant 12)

The other practitioner indicated that

…people come to the class for different reasons…to learn some gentle movement…[to help with] knee replacements… to strengthen [the] legs. …[for]anxiety…to calm their minds…[to] scan [their] body and see if there’s any…tension (Participant 13)

A physiotherapist reported being “particularly interested in working with…complex pain…[using] MBSR” (Participant 15), while a practitioner of Tuina Massage and Wing Chun Kung Fu reported using mindfulness exercise for a variety of physical issues,

…pain complaints…rolled shoulders and anterior backs…those postures…can all be rectified with just the basics of the CST [Chu Shong Tin Wing Chun] postural stance (Participant 11)

Regarding situations where mindfulness is contraindicated, all 16 participants agreed that there are situations where mindfulness is not indicated, … anything that’s powerful will have side effects or problems” (Participant 7), although some relayed this information in differing terms. Commonly reported contraindications were schizophrenia, acute post-traumatic stress syndrome (PTSD), and suicidal tendencies. For example, a psychologist explained that someone experiencing acute PTSD would likely encounter difficulties practicing mindfulness safely,

…[in] acute phase of PTSD, I wouldn’t do it because that’s too much sitting with the unpleasant…and…it’s just not the appropriate time or…treatment (Participant 10)

A Buddhist teacher reported that with

…severe depression, schizophrenia or bipolar…you’d want to go fairly gently…I can see that it could be an incredible benefit, but I guess that I would be cautious…I think everyone can benefit from it, but…there’s an assumption that people will be disciplined about it. (Participant 3)

An acupuncturist/Qigong teacher also reported avoiding mindfulness in cases of suicidal thoughts or self-harming,

…there’s a lot of suicidal kids out there…self-harming…I would not be going down the mindfulness road…it’s way…beyond [them]…They’ve already got psychologists and psychiatrists. …when I’m with them, I totally focus on just body work (Participant 13)

A physiotherapist reported drawing upon the advice of a multi-modality team, which included psychotherapists, to determine whether mindfulness would be right for a client that exhibits common contraindicated conditions,

…I like to understand more about what support services they’ve got outside of this…So asking them what other support networks they’ve got…if they have got a mental health practitioner, I’ll…collaborate with them. Do you think this is appropriate…for your client (Participant 15)

All participants reported a strong belief about the safety of mindfulness practices, if properly practiced, and where indicated. Several participants reported minimal to no adverse reactions in their experience of providing mindfulness, although some argued that it was important for a practitioner to recognise situations where mindfulness would be contraindicated for a client,

…I’ve only ever had one person that after the first session I contacted her and said, I don’t think this is…the right pathway for you (Participant 15)

It was also suggested that there was a fine line between actual contraindications and when the practice of mindfulness becomes difficult. Participant 15 outlined the importance of understanding this sensitive aspect as at times, mindfulness causes people to address difficult thought patterns and behaviours and that level of practice is often not a contraindication,

…midway through an MBSR course, week four or five is challenging for a lot of people…when you actually start noticing your patterns…you recognize…that tendency to wanna judge yourself…you’re turning towards the difficulty and the challenging work. So, it’s not a cruise through the park… But…that’s actually where people really get their benefits from. So is that an adverse reaction? I think often it’s not, if it’s managed properly. What’s actually so liberating with doing the course is going through that little bit (Participant 15)

One Tai Chi teacher also highlighted that in movement-based mindfulness practices, certain injuries may make practice less beneficial or dangerous,

People don’t look at Tai chi as…difficult or physical. It’s a moderate intensity cardiovascular exercise, but also resistance on the legs can be demanding…for people who have total knee replacement, for example…I would advise to…have [a] break and sit and then come back and do it again, that’s absolutely fine (Participant 5)

Several Buddhist teachers emphasised the importance of understanding the scope of mindfulness practice, and how it relates to the overall goals of the client. One Buddhist practitioner highlighted that, in a Buddhist context, mindfulness often focuses on spiritual growth, that is, to increase the likelihood of experiencing certain spiritual insights, such as the “dissolution of self”, or “transcending the ego”. The practitioner also explained that if not done appropriately, mindfulness can lead to concerning outcomes such as psychosis, and so self-dissolution is often not a desirable outcome for those that are not expecting that level of depth,

…[for] some people who have the strong experience of not being their ego…it’s a psychotic state, so…you need to have a healthy ego before you can…transcend [it]…If you [are] doing it for spiritual reasons, then that’s your goal. A lot of people think they’re doing meditation for spiritual reasons when they’re not. They…wanna become…a fully fulfilled ego…[for their] relationships to be all positive…[or to] make money…which is a very worthy goal. I’m not degrading it…but it’s not transcending the ego…[for] most people who come to it, it is just for…body mind health…when we’re looking at the spiritual reasons, it’s a form of mindfulness to see the illusion of the mind (Participant 4)

Another Buddhist teacher echoed these sentiments, adding that mindfulness practitioners that are not trained to teach Buddhism specifically should not be referring to Buddhism when providing mindfulness. Difference were highlighted in the aims and outcomes of Buddhist and non-Buddhist mindfulness practice in terms of whether the aim is building a healthy ego or transcending the ego,

I see a bit of a problem….in the mindfulness world, some of the proponents of it are looking for status and cred[ibility] from the Buddhist tradition…So…if you really are from the wisdom side…we’re heading into the no-self territory…you can’t plug that on someone who’s looking for a therapeutic intervention…there’s…confusion [in] wanting to have the cake and eat it too. Mindfulness…in inverted commas…is a great therapeutic intervention…fine…we’ll keep it to that in everyday level but it is also this wonderful Buddhist [practice]…if you really are claiming the Buddhist thing, the therapy side is…of no relevance…If you’re really going to…come at it…with the Buddhist backing and…pantheon behind you, take out the therapeutic side, that’s not what Buddhism is for…[and] there’s a danger if it’s not done with awareness (Participant 2)

These Buddhist teachers also emphasised that practicing mindfulness for health reasons (ie developing a well-functioning mind and ego) is an important part of the practice, and accordingly can be utilised to support both health and spiritual growth,

Those…reasons [to use mindfulness] aren’t mutually exclusive. In fact, they build on each other. The fundamental one is having a healthy mind and body. And mindfulness is useful in that because…you train yourself to realize when you’re out of balance and you do something to bring yourself back into balance… but there is a danger that…[to] approach… mindfulness from the health model…is just for that - for health, it’s not for spiritual development….It’s for…mental and bodily health….personal development…strengthening a healthy ego. (Participant 4)

Participant 2, a Buddhist teacher, suggested that approaching mindfulness with the goals of spiritual insight (which he referred to as the “wisdom side” of mindfulness) may be indicated provided that the practitioner is skilled in these areas of spiritual growth, and that the client is properly informed,

…if…the teacher and client…both know what they’re doing…[it’s] fine to cross that boundary…but if the client doesn’t…I think it’s cruel and unfair for a teacher to lob that on [someone] if they’re coming for a therapeutic intervention (Participant 2)

Application to Clinical Practice

Participants used diverse mindfulness practices, which varied within and across disciplines. Each participant also reported implementing mindfulness in different ways, from regular classes to one-on-one sessions (usually performed within a clinical setting), to more structured group-based programs delivered over a specific period of time.

The benefits of practicing mindfulness in a group setting, as opposed to one-on-one teaching, was discussed by several participants. According to one psychiatrist,

…There’s something very powerful about the group effect and…it’s not just the camaraderie of being in a group, there’s something about learning from other participants that can be a lot more powerful than if you’re with a therapist who says, do this, try that… (Participant 7)

The same sentiment was echoed by a physiotherapist,

there’s something quite powerful…in sharing not only that journey, but also seeing other people’s…wins and losses…sharing that and holding that space with each other…makes it all that more powerful (Participant 9)

Several participants (namely medical and allied health professionals) seemed to favour contemporary western approaches to mindfulness because of their standardised structure.

the eight-week [MBCT] course was really carefully constructed, so it certainly has a kind of an arc to it, and it leads people through a process that is very structured and clear that also builds a certain momentum (Participant 7)

Notwithstanding, there were some participants who believed that programs such as MBSR should be able to adjust to the specific needs of a group,

…the…magic of MBSR comes in how you…bring those topics to that particular group…we follow the same sequence of practices…The valuable part…is how we relate and respond to those participants and what’s coming up for them through the course, tying into those themes (Participant 15)

Participants reported using different styles of mindfulness in their practice, including mixed practices. For example, a Buddhist teacher reported separating a mindfulness class into a breathing meditation (aimed at relaxing and focusing the mind), followed by a more formal meditation where clients were guided through various philosophical topics related to Buddhism,

We go through the basics of…mindfulness of breathing meditation for the first 30 minutes. We have a break, and then we resume with…a guided meditation…the guided meditations are based on a specific topic of the Buddhist teachings…but they’re very broad…they range from things like developing self-compassion, developing gratitude, all the ethical, hallmarks of Buddhism are brought into this meditation practice (Participant 1)

Similarly, a Yoga teacher indicated that they add practices such as creating sound and focusing on breathing to compliment movement-based mindfulness practices,

I have divided my classes in two sessions. The first half is…the warmup and the physical postures…the second half is…breath work, resonance, sound, and relaxation…sound is very important…one of the yoga practices in which we create the sound…‘n’ or the humming bee sound…creates an immense sound resonance. There’s a resonance in your mind as well, which helps your mind to calm down…and it’s the state of awareness as well as relaxation simultaneously (Participant 16)

A Wing Chun Kung Fu teacher also outlined how they often combined a “stance” exercise in the form of body scanning, and a visualisation technique to help form an “internal structure”, in order to foster a greater sense of physical relaxation,

[It’s]…about a mind and body connection…that’s obtained through stance…and stance training is the baseline of [this] method of training, but it’s not just standing there…drawing a mindful line between your [perineum]…and your [crown]…just in front of the spine…to have a line of mental focus from the bottom…to the top…then once you’ve gotten to the top…a release…just drops all of your external…fascial tissue and…lets that sit on that structure of awareness…and you…just start to become…internally glowy…And so…through the process of…mindfully relaxing the body and replacing that tension with a more efficient structure…you see that remedial effect…on physical pain…[and] emotional anxiety…as well (Participant 11)

This same participant also reported using mindfulness differently within a one-on-one clinical setting as a massage therapist. The participant explained that bringing the clients own awareness to their area of pain “empowers” them to manage their pain,

…pain can sometimes blind our awareness of what’s going on…there’s a really nice diffusing of stress and anxiety just by walking them through the [pain]…and letting them feel it…and if we apply force here, you can see how that pain refers and they can start to actually [become] aware of it. So, the anxiety calms down just by empowering them with understanding (Participant 11)

Another practitioner working in the area of pain, a physiotherapist, outlined how they used multiple mindfulness practices to prepare clients for subsequent therapies, such as clinical hypnosis,

…I use it [clinical hypnosis] as a relaxation option… to reduce a lot of the anxiety and stress around the pain …patients will lie down…[or] sit in a chair…close their eyes and start [focusing] on their breathing, calming their body, [through] progressive muscular relaxation…once they’re very relaxed and comfortable, I ask them to put their focus on…not…what they may be feeling at the time, but what they would like to feel instead.and work on building that up in their mind… (Participant 6)

Adaptations to Mindfulness

There were criticisms of the ways in which some people practiced and provided mindfulness. There was a sense that mindfulness was becoming “less rigorous” or “watered down” over time, which was a view shared by participants across various backgrounds,

…mindfulness-based interventions, I guess are what a lot of psychologists not trained in MBCT are using cuz it’s sort of become a little bit…you know, let’s just use it a bit everywhere (Participant 10)

A similar view was shared by a Yoga teacher, who believed that Yoga was becoming “cheapened” by its widespread popularity, indicating that there has been a movement away from the meditative and spiritual foci of yoga, towards a more physical based practice that focuses on stretching and strengthening,

…Less deep and…more movements…and recently, more of [a] fashion statement…because whatever is being taken from yoga, be it the physical postures or the mindfulness…it’s more like business…like a marketing strategy (Participant 16)

Many participants echoed the belief that “marketing strategies” and “business type mindfulness” are having a negative effect on the rigor of mindfulness.

…the dangers of the whole Mac mindfulness movement…is confusion and people not really understanding what are the consequences of mindfulness… And…that they are likely…to be confronted with those sort of traumas (Participant 4)

It might have been…a concentration practice or a mantra practice. Or a movement practice. But everybody would put the word “mindfulness” in front of things because it was a very good marketing ploy…And that also happened in the research world where people were saying, all right, we’ve taught…a bunch of university students, some mindfulness meditation, and now we’re going to see what’s happening to the thinking five minutes later. And it’s like…well that’s not quite how mindfulness works (Participant 7)

Many of the criticisms about mindfulness were aimed at people with less to no experience or training in providing mindfulness. There were also concerns about the growing popularity of MBI and how this popularity has led to these practices being used in ways that may not be indicated by the literature.

…you don’t…know…how people train…are they getting their training through…the evidence-based pathways or are they sort of reading a book and delivering it, or have they…done a two week course and then they’re delivering it?.so that probably makes a difference…you don’t wanna judge others training…but it should be a requirement…of teachers to have their own practice…if I didn’t experientially know it myself, and I was just telling people, right, go and meditate 40 minutes a day, and this is gonna help you with depression and anxiety…I would be absolutely not telling the truth (Participant 10)

An interesting finding was the belief that mindfulness could be implemented in various ways, including through the use of “colouring in books”,

… for me…yoga is mindfulness. Other people it might be tinkering with a car, or it might be knitting or colouring in. (Participant 14)

On the other hand, two participants, a psychiatrist and a physiotherapist, indicated that such adaptations of mindfulness could be harmful,

I say, never get mindfulness colouring in books…people just scatter a bit of what they think is mindfulness over everything and think it’s some kind of sophisticated relaxation exercise, which it’s not…you often don’t feel relaxed at the end…of a mindfulness meditation. (Participant 7)

it can be a bit harmful…because…[mindfulness is] not about distraction….it’s about engaging and…I think…distracting from what’s happening in the body…and [although]…you’re in that moment of colouring in…you are also distracted…And I think when it comes to chronic pain, we have to be careful when we are working with mindfulness, sort of that we’re not just building in distraction…you don’t ever learn how to work with the difficult. (Participant 15)

Discussion

This research, for the first time, has explored the theoretical underpinnings, beliefs, aims and practices of mindfulness amongst diverse self-nominated mindfulness practitioners. While there were some shared perspectives among practitioners (eg contraindications, precautions in use), there was considerable heterogeneity regarding how mindfulness was understood and practised. Similar findings have been previously reported in other studies.^17,19,44,45 This research adds to these findings by identifying several important differences within and between disciplines, as well as across clinical settings. These differences to individual practitioner’s approaches to mindfulness were influenced by a range of factors including their personal background (such as training and philosophical underpinnings) and the clinical or professional purpose for using the mindfulness practice.

An important finding from this study was the variability in the understanding and use of mindfulness in clinical and professional settings. This finding corroborates the conclusions of a recent review undertaken by the research team, which noted that there was considerable heterogeneity in how mindfulness was used in the management of chronic musculoskeletal pain.¹⁷ Other systematic reviews have similarly commented on the diverse ways in which mindfulness is used for managing health conditions, including rheumatoid arthritis, bipolar disorder, and cancer.^46–48

How health care interventions are variably interpreted and applied at the frontline of care is not unique to mindfulness, with similar observations reported in studies of acupuncture, dry needling, and rehabilitation.^49–51 However, understanding variations in practice is important as findings from an umbrella review suggest that even small variations to mindfulness practice, such as duration of the intervention, may impact the effectiveness of mindfulness.¹⁰ These variations in practice can be attributed in part, to the lack of consensus on what constitutes mindfulness, of which there is both varied interpretations and outright disagreements.¹²

There are several other possible explanations for the diverse understanding and use of mindfulness. The ideological perspectives of practitioners for instance, may shape how mindfulness is applied and/or adapted to clinical practice, particularly if mindfulness is considered to be either a “judgemental” or “non-judgemental” practice. According to the Buddhist dictionary, the term mindfulness, translated from the Sanskrit word “Sati”, refers to the practice of contemplation of the body, the feelings, the mind, and the mind-objects.⁵² This contemplation involves finding the sense of self in any of these elements (mind, body, feelings), which essentially involves judging between self and non-self.^53,54 This is in contrast to the definition of mindfulness coined by Jon Kabat-Zinn in 1979, which states that Mindfulness is “the awareness that arises from paying attention, on purpose, in the present moment, non-judgementally”.³ These two ideological perspectives seem to be at the heart of how practitioners understand and use mindfulness. On the one hand, there is a judgmental and analytical perspective (drawn from the Buddhist approach), and on the other, there is a non-judgemental and observational perspective (such as MBSR).

Mindfulness approaches that are often indicated for the management of conditions such as pain, anxiety or depression (eg MBSR and MBCT), typically require users to purposefully pay attention to (aka observe) the present moment without making judgement (non-judgemental). By doing so, users can develop an ever-present awareness that forms a foundation for the development of healthy behaviours, psychological and emotional resilience, and overall wellbeing.³ A notable implication of present moment awareness is that it gives the user greater agency over catastrophizing and ruminating behaviours, which are known to exacerbate symptoms such as pain,⁵⁵ depression,⁵⁶ anxiety.⁵⁷ Several participants in this study believed that this agency is achieved by cultivating mindfulness within a state of non-judgemental awareness.

The Buddhist approach to mindfulness on the other hand, involves analysing and judging (judgemental) one’s subjective experience of four different levels of mindfulness, which are the body, emotions, mind, and mind contents.⁵² Although various Buddhist schools often differ in perspective and doctrine, generally, the overall goal of Buddhism is the cessation of Dukka, which is often translated as suffering or dissatisfaction.^52,53,58 Buddhists believe that this suffering is caused, in large part, by a disconnect between the reality of what is happening now, and what a person desires to be happening now.^53,58,59 This state of dissatisfaction and craving is thought be caused by a fundamental misinterpretation about the nature of how we, and all phenomena exist.^53,54 And so, the aim of mindfulness within Buddhism appears to be to analyse the nature of all phenomena including self and others, to raise the chances of having an experience of one’s selfless nature, and to maintain a level of awareness that helps to manage the habits related to dissatisfaction as it relates to the concept of Dukka. The anticipated outcome of this practice is an awakening to the true nature of the way things exist instead of being mentally lost in a fictional fantasy about the way we would like things to be.⁵³

Another possible explanation for the variable understanding and use of mindfulness among practitioners is the differences in training. Buddhist-trained practitioners in our study, while still maintaining individual perspectives and practices, tended to draw their beliefs of mindfulness from their traditional texts, such as the Mahasatipatthana Sutta.⁶⁰ This text gives instructions for mindfulness practice and points repeatedly to the importance of making certain judgements (eg “…While breathing in long”, he knows “I am breathing in long”, or, while breathing out long, he knows “I am breathing out long”).⁶⁰ This type of instruction, which is consistent throughout the entire text, was interpreted by several of the Buddhist-trained participants as describing a discrimination between different sensations and was believed to be essentially judgemental. This difference of characterisation as “judgemental” vs “non-judgemental” may have occurred when MBSR was introduced in the late 1970s. In developing MBSR, JKZ may have attempted to make meditation more palatable for Western communities.⁶¹ Although it is thought that MBSR was developed from Buddhist practices, JKZ has been challenged for removing mindfulness from the overall framework of the Buddhist pantheon while promoting some of its benefits.^61,62

Except for some Tai chi and Yoga instructors who had undertaken formal training, CAM practitioners were less likely to be formally trained in the provision of mindfulness relative to allied health, medical or Buddhist practitioners. The understanding and use of mindfulness among CAM practitioners relied upon a diverse range of practices and personal experiences, rather than a reliance on predesigned systems of practice such as MBSR. The practices used by CAM practitioners were broad in range and were often formed using a mixture of several techniques and practices that included mindful breathing techniques, Yoga practices, Qigong exercises, Tai Chi and Kung Fu practices, and body scanning techniques that were often integrated into the normal process of manual therapies such as massage and acupuncture. CAM practitioners appear more likely to make large adaptations to their mindfulness practice over time. The precise reasons for this are unclear but may in part relate to the same barriers that CAM practitioners experience when accessing and implementing research evidence into practice (eg Lack of resources, inadequate governance/leadership, lack of communication within and outside of CAM, and lack of research competency).^63,64

Research indicates that practitioners are increasingly customising their approach to certain interventions to better suit client needs; and in certain settings, modularity as a treatment model is gaining popularity.⁶⁵ This view is supported by findings from our research, with several practitioners indicating that they adapt their practices over time to better suit clients’ needs. While customising interventions to cater to the needs of clients is good practice, it may also inadvertently impact the effectiveness of the practice by reducing the fidelity of the intervention.

Limitations and Strengths

The limitations of this research are important to consider. Despite a comprehensive recruitment strategy, which covered a broad scope of disciplines, some disciplines were represented by only one participant (eg Tai chi), and some potentially important disciplines were not represented (eg there were no practitioners of Zen or Theravāda Buddhism). The inclusion of such practitioners may have introduced a contrasting narrative, particularly as JKZ had a background in Theravāda and Zen Buddhism prior to his creation of MBSR.⁹ Although not all participants of this study reported English as their first language, all interviews were conducted in English. Furthermore, all participants were currently living in Australia. There were also proportionally more female participants than male participants, which could have introduced a degree of gender bias. Self-nominating as a mindfulness practitioner may also have introduced self-selection bias.⁶⁶

This study had many strengths. This was the first study to explore mindfulness practitioners’ personal perspectives and practices related to mindfulness. To ensure transferability, this study provided diverse perspectives from a broad range of disciplines, including practitioners with medical, allied health, CAM, and traditional backgrounds. The study also maintained a high level of rigor by piloting the interview guide, triangulating interview data with field notes, performing the analysis with two independent coders, and reporting rich descriptions of the interviews to best represent the participant’s voice.

Implications for Practice and Future Research

Based on the findings from this research, we propose three key recommendations. First, given that the ideological perspectives and practical realities of practitioners seem to influence their understanding and use of mindfulness, it is likely that myriad adaptations of mindfulness practice exist. This has important implications for healthcare stakeholders, such as consumers, who may not be well informed about the practices they are engaged in, how best to undertake it and what outcomes they can expect. Second, while plurality of understanding and multiplicity in use of mindfulness may be the result of centuries of transformation, it also limits standardisation. While respecting different ideological perspectives, standardised protocols will assist in replication and uniformity of practice. Third, given the popularity of mindfulness it is likely there are other variations of mindfulness currently practiced in the community. As acknowledged in the limitations, despite extensive recruitment efforts, our research was not able to capture the perspectives of practitioners of all known forms of mindfulness. Future research could seek to explore these practitioners’ perspectives in order to further our understanding of how practitioners perceive and use mindfulness. This would contribute to an extended knowledge base about mindfulness, from which similarities and variations of how mindfulness is practiced could be further explored.

Conclusion

This qualitative research highlights and extends the breadth of the complexities when seeking to answer the question, “what constitutes mindfulness?”. The answer seems to be nuanced and influenced by a range of factors, including the ideological perspectives, training, and disciplinary background of practitioners. While the rich diversity and broad application of mindfulness practices may be a strength, it also may be a weakness as the value of mindfulness may be diluted by plurality of understanding and multiplicity in use. This requires careful and considered actions from mindfulness stakeholders. The findings also highlight the need for further development of standardised protocols where possible, and for further qualitative research, expanding on these findings by capturing the perspectives and practices used by a wider range of mindfulness practitioners.