Sunday Times 2
Can mindfulness be measured?
The interest in mindfulness has grown exponentially in recent decades. Much research has been done in using mindfulness in therapies for psychological disorders. Mindfulness has also extended into other fields such as education, sports, law, and business as a means of improving achievements.
Mindfulness is a construct explained in the Buddhist exposition of the mind. In modern psychotherapy, it was first used for stress management in 1979 by Kabat-Zinn, Professor Emeritus of medicine at Massachusetts University. The success of the programme led to the use of mindfulness as an intervention for psychological disorders. Research showed that mindfulness practice when integrated with other therapies such as the cognitive behaviour therapy was more effective than when either was used alone. Since then, a large number of mindfulness-based therapies have been developed, tested, and used for a wide range of psychological disorders. Examples include interventions for relapse prevention in depression, substance abuse, eating disorders, obsessive compulsory disorder, and borderline personality disorder.
Over the past forty years, research has focused on three specific areas. The first is defining and measuring mindfulness. The second is developing mindfulness-based therapies and measuring their efficacy. The third area of research focus is understanding the pathways through which mindfulness practice leads to positive psychological outcomes. Still much remains to be understood in these areas. This article focuses on the work that has been done so far on defining and measuring mindfulness. It is necessary to be able to measure mindfulness to assess whether a therapy improves mindfulness and consequently the psychological well-being.
Defining mindfulness
To measure mindfulness, it must first be defined. What is not defined cannot be measured. The mindfulness is a complex mental construct expounded in Buddhism within an Eastern culture. Defining it, while retaining its original meaning and being culturally aligned to modern society and amenable to current scientific investigative methods has proved to be challenging. Bhikkhu Gunaratana in his Book Mindfulness in Plain English explains that, being a pre-symbolic process, mindfulness is extremely hard to define in words. Mindfulness is a subtle process that occurs for a fleeting moment when a person first becomes aware of something before conceptualising or identifying the thing. Much work has been done to define mindfulness both conceptually and operationally.
The first landmark definition for use in modern psychotherapy was developed by Kabat-Zinn, Professor Emeritus of Medicine at the Massachsetts University. His definition was ‘Mindfulness is awareness that emerges through paying attention in a particular way: on purpose, in the present moment, and non-judgmentally’. About a dozen other conceptual definitions followed. Characteristics common to the definitions are awareness of and attention to the present moment with acceptance and without judging. A theory-based, construct-valid, and consensually agreed definition is yet to be evolved. Recent articles point out that finding and operationalising such a definition may require inputs from both those with an understanding of the Buddhist concept and those with an understanding of its psychological implications.
In the Buddhist discourses, mindfulness is explained in various ways. It is a latent or hidden factor, as statisticians would call it. It does not lend itself to direct physical measurement. Yet, scientists have explored options for capturing the level of mindfulness in an individual. The measurement is based on a conceptual definition, which is then translated into an operational definition. A conceptual definition provides a description as a concept. An operational definition provides measurable aspects so that the construct can be measured. Being a latent or hidden construct, it cannot be measured directly. However, the factors it influences can be measured.
Neuroimaging techniques
Scientists are working on several approaches to measuring mindfulness. One approach uses neuroimaging techniques. They measure the activities of parts of the brain that change with mind’s activities. Changing brain activity is captured by scanning using advanced technologies such as PET scans and functional magnetic resonance imaging (fMRI). These are sophisticated procedures which require advanced technology. Neuroimaging also requires highly trained people and is costly. \
A second approach to measuring mindfulness is to use self-report questionnaires. Over a dozen such questionnaires have been developed. One of the earliest developed questionnaires is Mindfulness Attention Awareness Scale (MAAS). Other questionnaires include Freiberg Mindfulness Inventory, the Kentucky Inventory of Mindfulness Skills, the Toronto Mindfulness Scale and the Philadelphia Mindfulness Scale. The Five-Facet Mindfulness Questionnaire developed by Baer and colleagues in 2006 is considered the most comprehensive. The five facets are observing, describing, non-reactivity to inner experiences, non-judging, and acting with awareness. These questionnaires consist of a collection of questions or items. Each item is designed to capture an aspect of mindfulness through a day-to-day experience.
The items are rated on a five-point scale. An example of an item in the Five Facet Mindfulness Questionnaire within the Observing Facet is as follows. When I’m walking, I deliberately notice the sensations of my body moving. An example from the Describing Facet is I am good at finding words to describe my feelings. An example from the Non-Judging Facet is I criticise myself for having irrational or inappropriate emotions. An example of Non-Reactivity to Inner Experience is I perceive my feelings and emotions without having to react to them. An example of a question for the Acting with Awareness is I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise distracted. The person answers these questions by indicating to what extent it is true of him or her on a scale of 1 (never or rarely true) to 5 (very often or always true). The Five Facet Questionnaire consists of 39 items. The items are scored within the five facets and then aggregated to give the total score. The higher the score, the higher the level of mindfulness is.
The Five Facet Mindfulness Questionnaire has been tested and shown to have good psychometric properties. It has been translated into other languages such as French, Japanese, Danish. These translated versions are shown to have good psychometric properties indicating they are valid measures of mindfulness. It is now being tested in Sri Lanka. However, there are many issues to consider. I would list a few of them here from my understanding.
The first issue is whether the definition is comprehensive enough to capture the key aspects of mindfulness. The current definition captures the overall qualities of attention and awareness of mindfulness. However, there appears to be other aspects of mindfulness in the Buddha’s exposition of the mind. One very important aspect is the wholesome quality of mindfulness. Sati is a wholesome mental factor, which occurs in the wholesome thoughts. At present, mindfulness is taken as the ability to stay focused on the present moment. The wholesome nature of mindfulness is not considered.
Recollection is another characteristic of mindfulness. Dhammasa-ga-ippkara-a states that mindfulness arises when there is the following: recalling, repeatedly recalling (anussati), recalling by bringing to the front (paissati), recalling with remembrance (sati saranata), bearing (dharanatha), immersing in the object (apila panata), and un-perishing sati (asammussanata). Rhys Davids translates this description of sati in Dhammasa-ga-ippkara-a as “Sati is collecting, calling back to mind, bearing in mind. Sati is not merely memory but a lucid retention of both the past and the present. It is compared to an inward mentor, or adviser, discriminating between good and bad, and prompting choice. Not floating on the surface like empty pumpkins or pots on the water”. Sumangalavilasini, defines mindfulness as “sarana tthena sati” or sati is memory or the process of recalling to mind what has been committed in the past (pahana). It is necessary to examine the role of recalling as a characteristic of mindfulness.
The third key aspect of mindfulness is that it is what must be established. What must be established is the four foundations of mindfulness. Establishment of sati on the four foundations of mindfulness is the highest form of meditation (bhavana). Meditation is that which develops, proliferates and perfects wholesome consciousness. Development of sati in this manner is what leads to the attainment of the ultimate and complete freedom from all mental defilements – the state of enlightenment (nibbana). Current definition of mindfulness does not pay explicit attention to this feature of mindfulness.
Functions
The purpose of mindfulness must be considered in defining and using it. Mindfulness serves several functions. Dhammasa-ga-ippkara-a describes mindfulness as a faculty (sati indriya), a power (sati bala), and a Noble Eightfold Path Factor (samma sati). It is also one of the seven factors that must be developed to attain freedom from all suffering (sati sambojja-ga). Bhikkhu Analayo (2003) says that whether as a faculty, as an awakening factor or as a factor of the Noble Eightfold Path, a characteristic quality of mindfulness is the “presence” (upa-hana). It is, therefore, important to pay attention to these qualities of mindfulness as its multiple functions. Attention and awareness of the present moment is such that they serve these purposes.
The current definition of mindfulness, therefore excludes some key characteristics of mindfulness. Central to these qualities is the wholesome nature of mindfulness. It is the correct or wholesome mindfulness (samma diti) that occurs in wholesome consciousness. Developing mindfulness is for the explicit purpose of discriminating between wholesome and unwholesome and keeping the mind focussed on wholesome objects. This continued effort to stay focussed on wholesome objects is to be carried out as a path factor, which together with other path factors leads to the eradication of defilements from the mind.
The focus on mindfulness is a welcome and hugely progressive step in psychotherapy. However, mindfulness is only partly understood. It needs to be understood fully and a more comprehensive definition needs to evolve. It can then be measured more accurately. Measurements that are more accurate will also help researchers measure the effectiveness of mindfulness-based therapies. Most important, understanding the construct of mindfulness more clearly is necessary to understand how mindfulness reduces psychological disorders.
It must, however be remembered that mindfulness alone cannot provide relief from psychological disorders. Unless a person is established in ethical behaviour, mindfulness cannot be developed. Therefore, psychotherapies must aim not only at developing mindfulness but also at developing wholesome behaviour. These are some random thoughts. Buddhist scholars, psychiatrists, and psychologists in Sri Lanka now have a great opportunity to collaborate with Western scientists to integrate the Buddhist principles of the mind into psychotherapies. One can raise questions such as why mindfulness needs to be measured. Or can or should it ever be measured. Exploring these issues in an unbiased manner serves a major purpose. It helps the application of the Budha’s exposition of the mind in psychotherapies and thereby making great strides in developing therapies for mental disorders.
(The writer holds a PhD in Buddhist studies from the University of Kelaniya and an MSc in applied psychology from the Coventry University, UK and a MA from the Georgetown University, USA. She also has a BSc Hons degree from the University of Colombo. She is a retired Regional Advisor on Monitoring and Evaluation for UNICEF South Asia. )