SIX YEARS AGO, the cover of TIME magazine declared the coming of “The Mindful Revolution.” While that headline might seem a bit hyperbolic, it’s undeniable that mindfulness has gone mainstream in America. Magazines, retreats, and classes devoted to mindfulness and meditation have multiplied, and adherents include CEOs and celebrities as well as everyday people. A survey by the National Institutes of Health’s National Center for Complementary and Integrative Health revealed that between 2012 and 2017, the use of meditation by adults in the U.S. more than tripled, from 4.1 percent to 14.2 percent. But caveat emptor: the popularity of mindfulness has outpaced the research that shows what really works, and why.
Researchers at Brown have set out to change that. As an “early adopter” of contemplative studies (an initiative that dates back to 2005) and with longstanding strengths in neuroscience and psychiatry, Brown University provides fertile ground for the methodical and intentionally interdisciplinary study of mindfulness.
“I saw these pieces of the puzzle all around the University,” says Eric Loucks, Ph.D., an associate professor of epidemiology, behavioral and social sciences, and medicine, “and I could see that if we put them together they would make a beautiful picture and benefit a lot of people.”
In 2017, those pieces came together as the Mindfulness Center at Brown. Given its commitment to addressing health challenges and training tomorrow’s leaders, the School of Public Health was the Center’s natural home within the university. In fact, the Center is a key component of one of the main themes of the School’s 2019 Strategic Plan, “Mental Health, Resilience, and Mindfulness.”
“Mindfulness is awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally.”Jon Kabat-Zinn, Ph.D.
Launched on the heels of a $4.7 million grant to study the mechanisms of mindfulness from the National Institutes of Health, the Center’s mission from the start has been to conduct rigorous research on mindfulness-based interventions, or MBIs. By disseminating its findings, the Center wants to empower the medical community as well as insurers and, importantly, the public, by informing them about what interventions are effective and for whom.
The Center also aims to educate, offering academic courses for undergraduate and graduate students at Brown, a Mindfulness-Based Stress Reduction teacher-training program, and evidence-based mindfulness programs for the public, such as Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy. It also serves as the home of the Global Mindfulness Collaborative, through which many of the world’s leading mindfulness-based institutions share their teaching and research methods.
A modern practice based on ancient Buddhist philosophy and traditions, “mindfulness is awareness that arises through paying attention, on purpose, in the present moment, non-judgmentally,” according to Jon Kabat-Zinn, Ph.D., who introduced it into American culture. In the 1970s, Kabat-Zinn, an MIT-trained molecular biologist and student of Zen Buddhism and meditation, developed the now-famous Mindfulness-Based Stress Reduction program and, in 1979, founded the Mindfulness-Based Stress Reduction Clinic at the University of Massachusetts Medical School. In the 40 years since, the eight-week course has been taught to more than 20,000 people in 30 different countries, and MBSR has been widely used to treat chronic pain, anxiety, depression, and other afflictions.
In October 2019, UMass Memorial Health Care and the Mindfulness Center at Brown entered into a collaboration whereby Brown took the lead in providing training to the community of MBSR teachers-in-training affiliated with the health care system. According to Loucks, this new partnership creates unique research education synergies. “We’re doing research on programs like MBSR and MBCT to increase the evidence base,” he says. “Now, as we get new ideas, we can float them by some of the best mindfulness teachers in the country, and in turn they give us feedback on how those ideas work.”
Healthier hearts and minds
Loucks studies cardiovascular health, an interest he traces back to his youth in British Columbia. By 18, he was a highly ranked triathlete. “I really got to know my body because I had to monitor it during those two-and-a-half-hour races,” he says. Later, with a degree in cardiovascular physiology under his belt, he was working toward a doctorate in pharmacology and therapeutics when he asked himself, What does the world need? “The world definitely needed help with cardiovascular disease,” he says. “It was and is the number-one cause of death. I really wanted to do something about it.”
Loucks began to study the biological mechanisms of how social factors such as poverty, abuse, or neglect affect health—especially cardiovascular health. At the same time, he maintained the serious mindfulness practice he’d begun at the age of 23. Then, a decade ago, the two came together.
In 2011, he and his colleagues added a mindfulness questionnaire to an NIH study they were working on, and were the first to discover that participants with the lowest levels of mindfulness—in other words, who were less aware of their thoughts and feelings—had more belly fat and worse regulation of their blood glucose, and were more likely to smoke and less likely to exercise than those who were naturally mindful.
As an MBSR-certified instructor himself, Loucks decided to tailor a mindfulness program for people with hypertension, focusing each session on a behavior that leads to high blood pressure. The results of the year-long study, published in 2019 and recently featured in The New York Times, showed that people who went through the customized program, dubbed Mindfulness-Based Blood Pressure Reduction, or MB-BP, significantly lowered their blood pressure readings. A follow-up study is currently under way, this time with a randomly assigned control group whose members will receive physician consultations and an at-home blood-pressure monitor rather than MB-BP. The addition of a control group will make it possible to determine whether it is in fact the mindfulness training that produces the improved health outcomes. The results are expected in August.
At the same time, Loucks and colleagues are working on the second phase of the five-year, $4.7 million NIH grant related to mindfulness and healthy habits. In the first phase, Willoughby Britton, Ph.D., assistant professor of psychiatry and human behavior and of behavioral and social sciences, Jared Lindahl, Ph.D., visiting assistant professor of religious studies, and Loucks scrutinized the data from studies involving thousands of participants to determine whether MBIs can be used to help patients stick to health-promoting lifestyle changes recommended by their doctors—and if so, what the “active ingredients” in mindfulness are that helped them do that. Evidence suggested that self-compassion and negative self-related rumination are two potentially important mechanisms.
In the second phase, Loucks and teams at Brown, Harvard University, and the University of Massachusetts are using their findings to customize two randomized controlled trials—the gold standard of clinical trials—that will look at the effect of MBIs on key health indicators such as blood pressure, mood, and medication adherence, all of which have significant effects on mental and physical health outcomes.
Loucks also heads the Mindfulness and Cardiovascular Lab, and is working with the lab’s coordinators, William Nardi ScM’19 and Frances Saadeh ’06 MPH’11, to create an MBSR-based program for “emerging adults”—also known as college students. This population, Loucks points out, is at a particularly unstable time of life. Mindfulness Based-College, or MB-College, is a nine-week course that focuses on age-relevant health issues such as diet, physical activity, and sleep and involves peer-to-peer interactions. They recently completed the first randomized controlled trial at Brown, and the results are promising. The study revealed that as the semester progressed, stressors increased but students’ depression levels remained stable; even better, loneliness levels dropped sharply over time because, Loucks says, “students were connecting with each other and having meaningful conversations” as part of the program. The contemplative practices baked into MB-College teach students “how they can be right here, right now for this life.” A second MB-College trial is now under way at Rhode Island College, a commuter college with a more socioeconomically diverse population and many first-generation college students.
Loucks recently received a grant to establish a network of researchers focused on using mindfulness to reverse the effects of early life adversity—what he calls “healing the past in the present moment”—and hopes to begin another, analyzing MBSR and its effects on pain, anxiety, and depression.
One size does not fit all
Taking mindfulness beyond the Ivy League aligns well with the School’s commitment to working with historically vulnerable populations, as expressed in the Strategic Plan, Advancing Well-Being for All. Critics have long pointed out that practitioners tend to be white and privileged. Yet mindfulness is a practice that has a lot to offer socioeconomically disadvantaged people with little access to such programs. Creating that access is exactly what health psychologist Jeffrey Proulx, Ph.D., assistant professor of behavioral and social sciences (research) and of psychiatry and human behavior (research), aims to do.
Proulx, who joined the Center in fall 2019, studies the relationship between psychological stress and physical health—in particular, how stress exacerbates diabetes, and how stress reduction might improve the health of Native Americans who have the disease. American Indians and Native Alaskans are more likely to have diabetes than any other racial group in the United States, and kidney failure from diabetes is highest among Native Americans. Proulx chose this disease as his target not only because of the potential for significantly improved health outcomes through stress reduction, but also because he knew there would be buy-in among Native communities precisely because of its prevalence.
According to Proulx, a member of the Mohawk Nation and a longtime mindfulness practitioner, it’s essential to understand how daily stress, historical stress, cultural trauma, and poor health behaviors are connected in Native communities. “One of the main causes of stress and trauma in Native communities is the loss of culture, the loss of land, the loss of family, all the things that are tied to that,” he says. In addition to this intergenerational trauma, Native Americans have, like other minority groups, a longstanding distrust of the medical establishment. (Think Tuskegee syphilis study.) Proulx wants to “indigenize” mindfulness by integrating traditional practices, many of which are inherently mindful, into mainstream MBIs. Swapping out potentially meaningless or offensive components of standard MBSR with more Native-friendly ones, he says, will make it more likely that such programs will be adopted.
Proulx is using a prestigious K99/R00 career development award from the NIH’s National Center for Complementary and Integrative Health to develop programs for two tribes in Oregon and California. He has already delivered standard MBSR to those communities and received feedback on what works for them and what doesn’t. In January 2020, he and 10 members of the tribes spent three days at the Mindfulness Center breaking down standard MBSR, studying how Loucks adapted each module of it to create MB-BP, and then proposing substitutions drawn from Native culture to create their own version. Instead of inviting a participant to “take a cleansing breath,” Proulx says, one tribe member suggested “smoke yourself,” referring to a purifying gesture one makes before entering a sweat lodge; another adaptation might entail replacing “mindful movement” with a traditional Indian dance. In March and April, Proulx traveled to the West Coast to test the adapted interventions with the tribes.
Proulx, who is also working with a Cherokee community in North Carolina and the Narragansett Tribe in Rhode Island, makes the point that while Native Americans need different interventions from those developed by and for white culture, Native culture is not monolithic; variations across Native communities call for variations within “indigenized” MBSR programs. Eventually, Proulx hopes to launch several longitudinal
studies across the U.S. to account for this diversity and to develop a variety of adaptations.
Years ago, while doing research on Native American mental health, Proulx would ask health centers if they offered traditional healing. Almost everyone said no: insurance companies wouldn’t cover it because no empirical best-practices model for such traditions existed. He made it his goal then to produce that model. “Eventually we’re going to have evidence that Native traditions are in fact better for Native people, because I’m creating that data set,” he says. “This is my way of keeping that promise from a long time ago.”
Lost in Thought
Another way the Center is working to bring evidence-based MBIs to the public is through a decidedly nontraditional but accessible—and affordable—channel: smartphone apps that help the user change his or her unhealthy behavior.
According to Judson Brewer, M.D., Ph.D., associate professor of behavioral and social sciences and of psychiatry and human behavior, breaking bad habits requires understanding both the psychological model of reward-based learning and the underlying neural pathways that lead people to get “caught up” in their craving. In his 2017 book, The Craving Mind, he describes the former as a “habit loop,” the trigger-behavior-reward cycle that thousands of years ago helped keep humans alive: “See food. Eat food. Feel good. Repeat.” That loop has been “hijacked by modern culture,” he writes, so that “with the same brain mechanisms, we have gone from learning to survive to literally killing ourselves with these habits.” Think cigarettes. Think sugar. Think Facebook.
Brewer, an addiction psychiatrist and neuroscientist who led UMass’s mindfulness center and is now director of research and innovation at Brown’s, wants to teach us how to use mindfulness to break out of that loop. To do so, he points to a part of the brain called the posterior cingulate cortex, or PCC, which is associated with daydreaming, ruminating—and, importantly, craving. The trick, he says, is not to try to eliminate the craving, but rather to change how we relate to it. That’s where mindfulness comes in: it hacks the reward system by “driving a wedge of awareness” between the craving and our reaction to it. The “clear seeing and nonreactivity” of the practice makes it possible to take an all-important pause and consider whether that cigarette or candy bar really will make us happy (and understand it probably won’t). That pause in turn enables us to “ride out” the desire without acting on it. If not fed, he explains, craving is “like a fire that burns itself out.”
Last year, Brewer published the results of a randomized controlled trial that showed that his mindfulness-based smoking cessation app, Craving to Quit, was significantly more effective at helping participants reduce their cigarette consumption than an app provided by the National Cancer Institute, which uses inspirational messages and distractions. The PCCs of those who reduced their cigarette consumption the most were also the least reactive to smoking-related images, an effect that was specific to the group that received mindfulness training.
The trick is not to try to eliminate the craving, but rather to change how we relate to it.Judson Brewer, M.D., Ph.D., Associate Professor of Behavioral and Social Sciences and of Psychiatry and Human Behavior
It’s precisely by leaning into the desire for a cigarette, Brewer says—or even smoking a cigarette mindfully—that one can become disenchanted with smoking.
“Reward value doesn’t change when someone is sitting and meditating,” he explains. “Reward value changes when you actually pay attention when you smoke the cigarette.”
This isn’t Brewer’s only foray into digital therapeutics. He has created two other apps to help people overcome emotional eating (Eat Right Now) and anxiety (Unwinding Anxiety). In a recent study on physician burnout and anxiety, the latter app was found to reduce anxiety (by 57 percent), depersonalization, and emotional exhaustion among stressed-out doctors. Brewer and his colleagues have applied for funding for new studies, including one on anxiety in children of people with Alzheimer’s and another that will use the anxiety and smoking cessation apps sequentially to help people with HIV quit smoking.
Brewer, who has meditated since day one of his M.D.-Ph.D. program, says that while the science is fascinating and the results promising, it’s real people who make the work matter to him—like the patients with opioid use disorder whom he treats in Butler Hospital’s clinic. “Everything my lab does is geared pragmatically. Every one of my postdocs and students has to answer the ‘So what? question, which asks, Is this relevant to helping people?”
Brewer adds, “My patients are suffering. What I love about the Center is that we’re all oriented toward helping people reduce their suffering.”
Loucks stresses that the Center does not evangelize about the practice. With new mindfulness-based courses, programs, and apps coming on the market every day, he says, it’s more important than ever to root the practice squarely in a scientifically rigorous evidence base. Indeed, Britton and Lindahl, who co-direct the Clinical and Affective Neuroscience Laboratory at Brown, have received international attention for their research investigating the adverse effects of mindfulness meditation, and Loucks considers their work to be as important as research that proves its benefits. He is encouraging a review of the Center’s studies to determine prevalence of harm, and is himself leading adverse-events monitoring on the MB-BP trial, advised by Britton and Lindahl. Loucks says the Center is committed to publishing all results, not just the positive ones: “We want to know the truth.”
A first in the nation, the Brown University School of Public Health will launch a new mindfulness concentration in its Master of Public Health (MPH) program. Students will learn from a vibrant core of interdisciplinary faculty focused on the full spectrum of mindfulness ranging from theory to measurement to treatment delivery to teacher training.
In addition to the standard MPH program, students in the Mindfulness concentration will also:
- Differentiate the relative impacts of mindfulness on physical health and mental health.
- Critically analyze the major types of mindfulness interventions that are available in public health and educational settings, including their strengths and limitations.
- Evaluate the relative merits and limitations of self-report and objective tools for measuring mindfulness.
- Gain knowledge in the evaluations of mindfulness research studies.
- Develop a testable theoretical framework for how mindfulness interventions influence health outcome through the examination of clinical trials.
- Apply research methods in cognitive neuroscience to public health issues.
The program is a rigorous blend of core classes, electives, and a thesis. Beyond the strengths of the School of Public Health, active collaborations extend to the Brown University affiliated hospitals, state government, local government, community organizations and industry, setting the stage for interdisciplinary discoveries across fields.