10 Misconceptions on Mindfulness for Mental Health - Part 1

By Dr. Phang Cheng Kar (M.D.) & Dr. Song Beng Kah (Ph.D.)

In the past few years, we have seen a big leap in popularity of mindfulness practice in Malaysia. We appreciate the effort made by various organizations in promoting mental health through mindfulness training workshops or classes. In the midst of mindfulness popularity, there are however some mindfulness related misconceptions, which need to be clarified for the benefits of people who are interested in this method. With a threefold increase in the prevalence of mental health problem among Malaysian adults (from 10.7% in 1996 to 29.2% in 2015), it is timely for the public to have a better understanding of mindfulness. We hope this article can help to curb the problem of “McMindfulness”, a term borrowed from the popular fast food chain and coined for referring to the easily available but diluted and distorted form of mindfulness.

With a threefold increase in the prevalence of mental health problem among Malaysian adults (from 10.7% in 1996 to 29.2% in 2015), it is timely for the public to have a better understanding of mindfulness.

Definition of mindfulness by Dr. Jon Kabat-Zinn.

What is the most popular secular definition of mindfulness? According to Dr. Jon Kabat-Zinn, the famous American mindfulness teacher who created the popular Mindfulness-Based Stress Reduction (MBSR), “mindfulness” refers to the awareness that emerges through paying attention in a particular way; on purpose, in the present moment, and non-judgmentally. Being mindful also means the process of paying attention to the unfolding of the inner (e.g. thought and feeling) and outer (e.g. sound and sight) experiences from moment to moment, in the “particular ways” defined by Kabat-Zinn. If understood and practiced correctly, the definition is useful for reducing stress, anxiety, depression, and increasing well-being. Otherwise, it is not helpful and can even be harmful. We will now share with you some of the common misconceptions of mindfulness.   

1. Mindfulness is religious.

No, it is not religious; it is secular and scientific. Are you sure? Yes, mindfulness is not always religious. The concept of mindfulness originates from various spiritual traditions in particular Buddhism. But, modern mindfulness-based therapy is delivered in a secular way without religious doctrines, rites, or rituals. The Malaysian mindfulness-based program MINDFULGym, with grants and support from the Ministry of Health and Universiti Putra Malaysia (UPM), has successfully been introduced to hundreds of people from the multi-ethnic background, regardless of their religion or belief. Whether associated with a secular or religious context, mindfulness practice does not necessarily involve “meditation” or meditate with the legs crossed and eyes closed. More importantly, mindfulness is merely a training of mind based on sound science and credible clinical studies around the world. In 2013, in a review of 209 scientific studies by Khoury and colleagues in the journal Clinical Psychology Review, it was concluded that mindfulness-based therapy is an effective treatment for reducing stress, anxiety, and depression.

2. Mindfulness practice is difficult and time-consuming.

No, it might not always be difficult and time-consuming; it can be simple and practical. As in playing any sports, mindfulness practice (can be seen as a form of mind sport) is of various levels of difficulty. Not all of us can play badminton as good as world champion Datuk Lee Chong Wei. But that does not mean we cannot enjoy and gain benefits from playing badminton. The same goes for mindfulness training. For beginners, it is good enough if we can try to take a few slow, deep, and mindful breaths intermittently throughout the day to refresh ourselves and make peace with the present moment. To be mindful is easy; remembering to be mindful is difficult. Using a phone app with the soothing sound of a bell as a reminder to take mindful breaths periodically is useful for many people. Advanced mindfulness training is, of course, more challenging. But that is fine as mindfulness cultivation is a life-long journey. We progress step-by-step and learn from the journey, every step, every moment – take your time – enjoy the present moment.

3. Mindfulness is just paying attention to the present moment.

Not fully correct. It is not just paying attention to the present moment; it is relating to the present moment with kindness and appreciation. People who are clinically depressed often pay attention to their faults and blame themselves. Those with poor self-esteem habitually pay attention to and amplify their weakness. Is that paying attention in a mindful way? No. Mindfulness is paying attention in a particular way; non-judgmental, with kindness, compassion, appreciation, gentleness, goodwill, warmth. It is not just attention; it is ‘kindful’ attention to the present moment - ourselves, others, and the world. Relating to our present moment experience with kindness, appreciation, and gratefulness is an effective way of increasing mental wellbeing. Here is a question to test your understanding of mindfulness. Does aiming to shoot and kill a bird involves mindful attention?

Mindfulness is paying attention in a particular way; non-judgmental, with kindness, compassion, appreciation, gentleness, goodwill, warmth. It is not just attention; it is ‘kindful’ attention to the present moment - ourselves, others, and the world.

To be continued - Part 2

10 Misconceptions on Mindfulness for Mental Health - Part 2

4. Mindfulness is blindly focusing on everything in the here-and-now.

No, it is not blindly focusing on everything in the here-and-now; it must be supported by an understanding of how the mind works. For people with anxiety disorders (e.g. illness anxiety disorder), the mind easily focuses on unpleasant bodily sensations (e.g. chest tightness, breathlessness, rapid beating of the heart). And they often mistook them to mean that they are suffering from a serious sickness (e.g. heart attack). To avoid the sickness, they automatically pay more attention to detect any alarming sensations. Naturally, they become aware of more sensations and worry more. Mindful attention training must be supported by understanding. It is not just “noting, noting, noting” the sensations blindly. To emphasize that, in the MINDFULGym program, mindfulness is defined as, “….attention to the present moment with kindness, beginner’s mind, and wisdom.” We need understanding or wisdom to guide us on where and how to pay attention; purposeful attention, as Kabat-Zinn defines it. In the context of anxiety disorders, we need to understand that the brain is abnormal and tends to find faults and catastrophize whatever we pay attention to. In mindfulness training for coping with anxiety, we learn to calm the mind (e.g. using mindful breathing) so that we react less negatively to stimulus.We also learn to pay attention to the positive aspects of life, e.g. our strength, blessings, good deeds, and success.


5. Mindfulness is simply bare awareness; you are not supposed to think or do anything.

No, it is not simply bare awareness of the present moment; it is also remembering the good advice related to mindfulness for good mental health. In the contemporary world, mindfulness is usually conceptualized as a form of awareness or attention training. However, in the traditional Pāli (a classical and literary Indian language), the word associated with mindfulness is “Sati.” Besides awareness of the present moment, “Sati” also carries the meaning of recollection or memory of advice given by the instructor in mindfulness training. In the context of mental health, it is remembering (thinking) and practicing (doing) all the mindfulness related principles that are conducive to psychological wellbeing, e.g. minimize multitasking, let go of the past, focus on what you can do now, do not always take thoughts too seriously as they may not be facts, embrace impermanence, accept imperfection, and pay attention to the good things in life. Just like a newbie in sports remembers advice from the coach in training, a mindful student remembers advice from the teacher in mindfulness training. In the MINDFULGym program, gentle reminders on mindfulness practice are periodically sent through the WhatsApp group to consolidate the understanding and practice of mindfulness.

6. Mindfulness is making the mind blank.

No, it is not making the mind blank; it is learning how to shift attention away from unhelpful thoughts, understand our thoughts and not to be carried away by them. Mindfulness is not going into a trance, half-conscious, or passive state. On the contrary, mindfulness training helps us to be more conscious of our experience. For people with mental health problems, having a method to free the mind from negative thoughts and feelings seem great. Yes, mindfulness training may help with that. But it is not done by forcefully purge or cleanse the unwanted thoughts. In fact, studies have shown that when we desperately try to suppress unwanted inner experience, they grow. When people tell us not to think too much, we often think more. “Whatever we resist, persists,’ says Carl Jung. In mindfulness training, instead of battling thoughts directly, we learn to calm the mind by shifting its attention from thoughts to body sensation (e.g. through the body scan practice). When the mind is calm, then we can investigate our thoughts (e.g. I’m useless) with understanding and guidance from a therapist. Once there was a patient with Generalized Anxiety Disorder who came to the clinic for mindfulness-based therapy after failing to gain benefits from cognitive therapy. He shared with the therapist something insightful, “When I do mindful breathing, I’m calm. I don’t have to challenge my thoughts. With a calm mind, thoughts just disappear or don’t have the power to influence me. Once mindful, I can also pray more wholeheartedly and that’s very important to me.” 

7. Mindfulness means “non-judgmental” – do not judge!

No, it is not “non-judgmental” (avoid making judgments); it is having an open mind and making wise judgments. When Kabat-Zinn says, ‘…paying attention in a particular way on purpose, in the present moment, and non-judgmentally,”  he does not mean that we should avoid making judgments in life. He means we should try to be patient, gentle, accepting, and not beat ourselves up when facing challenges in mindfulness practice and life. Related to that, it also means we should be aware of fixated judgments or assumptions that stress us out, e.g. “People cannot be trusted,” “I’m useless,” “I’m a troublemaker,” “Nobody likes me,” “Everything has to be perfect.” People go to counselors to have a better understanding of their problems. Counselors need to make professional judgments to support clients, and clients need to make discerning judgments on how to solve their problems. In mindfulness training, we do not avoid making judgments. We learn to cultivate curiosity, open-mindedness, or beginner’s mind in approaching problems in life. Then we can make wise decisions and generate creative solutions for the challenges in life. Interestingly, in 2010, there was a Mindful Lawyer Conference at the University of California at Berkeley School of Law. Mindfulness practice involves non-judgmental awareness. But at the heart of judicial decision-making is judgment. Here is another question to test your understanding. How can a mindful judge make judgments “non-judgmentally”?

When Kabat-Zinn says, ‘…paying attention in a particular way on purpose, in the present moment, and non-judgmentally,”  he does not mean that we should avoid making judgments in life.

To be continued - Part 3

10 Misconceptions on Mindfulness for Mental Health - Part 3

8. Mindfulness practice is stress-free and relaxing. 

No, the practice is not always stress-free and relaxing; it sometimes involves experiencing more stress for a meaningful purpose. The mindfulness-based approach is one of the useful ways for relaxing the mind and body. However, the process of mindfulness training may not always be relaxing. At times, practicing mindfulness can bring up old painful memories that create a lot of stress, that some may not be well prepared to confront alone. It is not uncommon for people to have the wrong attitude in mindfulness practice, like the unrealistic expectation (using mindfulness) to be totally free from stress or compulsively trying to control things in life. The unhelpful attitude naturally generates more stress. That is why, it is often emphasized in mindfulness training, “Mindfulness is not a technique to get rid of stress; it’s an approach to help us to understand and make peace with stress.” In fact, in certain situations, like exposure therapy to manage social anxiety, one needs to experience more stress (supported by mindfulness-based approach) for a long-term happiness. That is stressful, right?  But it is a good stress; the type of stress that eventually leads to less stress. For people with severe mental health disorders (schizophrenia, bipolar disorders, depression with psychosis), using mindfulness as self-help is usually not helpful; it often generates more stress and confusion. A better option is to seek help from mental health professionals (e.g. psychiatrist) to stabilize the disorder. Once emotionally stabilized, guided mindfulness practice (preferably by a psychotherapist trained in mindfulness-based therapies) is a useful option. 


9. Mindfulness is the best treatment for clinical depression.

No, it is not the best treatment for clinical depression; it is one of the treatment options for recurrent depression. As mindfulness becomes popular, we often see such headlines in the media: “Mindfulness can control depression as well as drugs, study shows,” “Mindfulness holds promise for treating depression,” “Curing depression with mindfulness meditation.” These headlines are often misinterpreted to mean that mindfulness is the best treatment for depression. That is a fact, right? Well, not really. It is true that mindfulness-based therapy in the form of Mindfulness-Based Cognitive Therapy (MBCT) is being professionally recommended as one of the treatment options for people with three or more episodes of recurrent depression (Kuyken et al., 2016). However, it does not mean that MBCT is the best treatment for people with clinical depression. The best treatment of depression depends on many factors, e.g. types and severity of depression, patients’ preference for treatment options, and experience of the therapists. Proper psychological assessment is necessary before we can decide on the best-individualized treatment plan. Medications supported by psychotherapy may be necessary for certain types of severe depression. Even if one is keen and suitable to use mindfulness to complement depression treatment, it is better to be guided by someone who understands depression well and is trained in both mindfulness and psychotherapy. For example, a professional counselor or clinical psychologist who has received training in MBCT, instead of a corporate mindfulness trainer or mindfulness meditation teacher without understanding on clinical depression.

Even if one is keen and suitable to use mindfulness to complement depression treatment, it is better to be guided by someone who understands depression well and is trained in both mindfulness and psychotherapy. 

10. Mindfulness is suitable and safe for everyone.

No, it may not be suitable and safe for everyone; it can have negative effects. Despite its effectiveness, mindfulness practice (especially intensive mindfulness meditation) may not be suitable for everyone. In an online survey of 342 meditation practitioners (Cebolla et al., 2017) in European countries and North America, 87 (25.4%) reported negative effects of meditation. The negative effects include boredom; more fear, anxiety, and depression; heighten awareness of their negative traits; greater self-criticism; the feeling of being alienated from society; and lack of life orientation. In another interview of 60 Western Buddhist meditation practitioners (sixty percent were meditation teachers), the similar distressing experience was reported (Lindahl et al., 2017). Although relatively rare, mindfulness practice can have negative side effects and are usually more common among people with who are emotionally vulnerable. Due to the intense emotional suffering, that is exactly the group of people who are attracted to mindfulness practice; high-risk group. In view of that, we strongly recommend that for people with mental illness, if they wish to learn mindfulness for better mental health, it should be guided by someone who understands mindfulness and mental illness well.

So, what else should we be mindful of in mindfulness for mental health?

The huge investment in mindfulness-based therapies will only see its worth when the general public adopts a correct mindset and right understanding of mindfulness. We welcome an open discussion with stakeholders, including patients with their family and healthcare providers on these emerging issues related to “mindfulness industry.” Keeping in mind that research and media publications might be biased and sensationalized, the discussion should be based on credible sources. It should be supported by robust scientific studies, clinical and teaching experience, and not in a way of picking up bits and pieces from the internet or social media. This can be achieved with the support of public education.


About the authors:

Dr. Phang Cheng Kar (M.D.) is a consultant psychiatrist and mindfulness-based therapist. He is the creator of the MINDFULGym program and president of the Malaysia Association for Mindfulness Practice & Research.

Dr. Song Beng Kah (Ph.D.) is a molecular geneticist by training. He is interested in mindfulness practice ever since his first meditation retreat during undergraduate years. With scientific skepticism and a belief that every problem has a solution, he tries to explore and learn more about ''mindfulness'' through writing.

References:

1. Khoury, B., T. Lecomte, G. Fortin, M. Masse, P. Therien, V. Bouchard, M. A. Chapleau, K. Paquin, and S. G. Hofmann. "Mindfulness-Based Therapy: A Comprehensive Meta-Analysis." Clinical Psychology Review. 2013; 33(6): 763-71.

2. Kuyken W, Warren FC, Taylor RS, Whalley B, Crane C, Bondolfi G, Hayes R, Huijbers M, Ma H, Schweizer S, Segal Z, Speckens A, Teasdale JD, Van Heeringen K, Williams M, Byford S, Byng R, Dalgleish T. Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials. JAMA Psychiatry. 2016; 73(6):565-74.

3. Lindahl JR, Fisher NE, Cooper DJ, Rosen RK, Britton WB. The varieties of contemplative experience: A mixed-methods study of meditation-related challenges in Western Buddhists. PLoS One. 2017 May 24;12(5):e0176239.

4. Cebolla A, Demarzo M, Martins P, Soler J, Garcia-Campayo J. Unwanted effects: Is there a negative side of meditation? A multicentre survey. PLoS One. 2017 Sep 5;12(9):e0183137.

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