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Recent evidence highlights the value of monitoring practice quality during mindfulness training

Is it helpful to monitor the quality of one's mindfulness practice ... and, if so, what should one be monitoring?  I've raised this question with experienced mindfulness teachers before and been answered with the concern that monitoring practice quality might increase an "achievement orientation" state of mind that could actually interfere with the "non-judging" benefits of the practice itself.  Well here's a perfectly reasonable scientific question: does monitoring the quality of one's mindfulness practice help, hinder or have no effect on how beneficial the practice is?  Del Re & colleagues have just published an interesting paper looking at this question - see "Monitoring mindfulness practice quality: An important consideration in mindfulness practice".  The abstract reads:  "Mindfulness-Based Stress Reduction (MBSR) is an experientially based group intervention empirically supported to reduce psychological symptomology. Although MBSR has shown to be an effective intervention, little is known about which facets of the intervention are important in producing positive outcomes. This study tested several aspects of mindfulness practice (total practice duration, practice frequency and practice quality) with the primary focus being on validating (i.e., predictive and convergent validity) a new measure of mindfulness practice quality (PQ-M). The PQ-M fit a two-factor solution via a Maximum Likelihood Exploratory Factor Analysis (n=99). Using longitudinal multilevel modeling on a smaller subsample (n=19), preliminary support was found for changes in practice quality over the course of the MBSR intervention. Further, change in practice quality was associated with improvements in psychological symptoms. While this study was exploratory, these findings suggest that practice quality is a relevant factor to promote positive outcomes and may guide mindfulness instructors in providing highly tailored interventions."

Great to see researchers looking seriously at these kinds of important questions.  In this example, considerable care was taken to develop a meaningful measure - "The Practice Quality - Mindfulness (PQ-M) Scale".  Participants were asked to answer six questions each time they completed a mindfulness practice.  The instructions read "With respect to today's session, please place a vertical mark on the line below each question to indicate the approximate percentage of time that your experience reflected each statement below."   The lines below each question were each marked from 0 to 100%.  Three questions assessed Attention - "During practice, I attempted to return to my present-moment experience, whether unpleasant, or neutral", "During practice I attempted to return to each experience, no matter how difficult, with a sense that 'it's OK to experience this'" & "During practice I attempted to feel each experience as bare sensations in the body (tension in throat, movement in belly, etc)".  And three questions assessed Receptivity (these questions were reverse scored) - "During practice, I was struggling against having certain experiences (e.g. unpleasant thoughts, emotions, and/or bodily sensations)", "During practice I was actively avoiding or 'pushing away' certain experiences" & "During practice I was actively trying to fix or change certain experiences, in order to get to a 'better place'".  As one would hope, participants improved their practice quality over the eight weeks of a Mindfulness-Based Stress Reduction course (MBSR) and, crucially, improvements in quality were associated with improvements in psychological benefits. 

When discussing the clinical implications of their findings, the authors write: "This study contributes to the mindfulness intervention literature by validating a measure of mindfulness practice quality and testing practice-related factors that are associated with outcomes of health and well-being. This is the first study we are aware of to assess quality of mindfulness practice. Preliminary findings indicated the PQ-M to be a valid and reliable measure. Specifically, change in practice quality over the course of the MBSR intervention was associated with outcome, controlling for baseline symptoms. Results from this study indicated that the PQ-M is minimally burdensome on participant's time (1-2 minutes completion time) and has potential as a tracking tool for assessing changes in mindfulness practice quality. In particular, results are in accord with findings in the field of learning theory (Ericsson et al., 1993) and suggest higher practice quality during the MBSR intervention may lead to greater reductions in psychological symptoms by the end of the intervention.  These results may be of use to mindfulness practitioners and teachers of mindfulness interventions.  For example, the measure has potential to be used during the mindfulness intervention to track participants' practice quality, and perhaps identify those at risk of poorer outcomes. As an add-on to well-introduced feedback systems (e.g., Lambert & Shimokawa, 2011), mindfulness instructors can use this ongoing feedback to begin integrating corrective directions for remediation during the intervention.  That is, MBSR instructors could administer the measure after in-session mindfulness practices to enable them to identify participants who are reporting lower practice quality and provide additional instruction. Further, completing the PQ-M is one way in which participants can track their own practice habits, allowing a clear reminder as to the specific qualities of attention and receptivity emphasized in MBSR. These self-monitoring activities may both bolster participants' commitment to practice and provide direction for improving practice quality over time. This topic warrants further exploration in future studies."

Fascinating.  So it looks like improvement in practice quality matters if one is going to benefit as much as possible from mindfulness training.  As a meditator with over forty years' experience, I am also very aware of how my mindfulness quality can become fairly threadbare at times even after decades of practice.  Quite possibly occasional monitoring of quality would benefit a wide cross section of inexperienced & experienced meditation practitioners.  But what should we be monitoring?  These researchers have emphasised Attention and Receptivity.  They also comment on the possible value of "the addition of a third factor related to the degree of sleepiness or ‘‘haziness'' during practice" saying "Alertness is theorized to be an important element of practice (e.g., if a practitioner is sleeping throughout practice, how much mindfulness can actually be developed?)" 

I would make two additional suggestions.  Willem Kuyken & colleagues in their paper "How does mindfulness-based cognitive therapy work?" note "MBCT's effects were mediated by enhancement of mindfulness and self-compassion across treatment. MBCT also changed the nature of the relationship between post-treatment cognitive reactivity and outcome. Greater reactivity predicted worse outcome for mADM participants but this relationship was not evident in the MBCT group. MBCT's treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment."  Should we be monitoring self-compassion during practice as well?

The second suggestion is to look again at the rather avoided question of how mindfulness training relates to relaxation teaching.  It is after all applied relaxation rather than mindfulness that is one of the two psychological approaches recommended by NICE for generalized anxiety.  People going through mindfulness training frequently mention increased relaxation & calmness as benefits coming from this approach.  My experience is that mindfulness teachers are sometimes rather coy about whether trainees should or should not encourage their practice to promote states of calmness.  If relaxation is seen as a "not-doing" or an "un-doing" ... noticing where in my body I'm holding onto muscle tension and realising that I don't have to continue to do this to myself ... then it could be interesting and potentially helpful to monitor relaxation level before & after practice as well.

But the overall message is clear.  Monitoring quality of mindfulness practice looks as though it may well be worth incorporating into both initial and refresher aspects of mindfulness training.

A mindfulness teacher colleague & friend (Ratnadevi) has put together a weekly practice monitoring chart incorporating the six questions described here on quality of Attention and Receptivity. Click to download either a Word doc or a PDF version of this practice record.

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