Being mindful about mindfulness.

288 www.thelancet.com/psychiatry Vol 2 April 2015 The results of more than three decades of research have shown the many positive eff ects that mindfulness can have on health, improving quality of life both in the general population and in clinical populations. A mindful outlook helps people to avoid automatic behaviours that rely on pre-existing or underlying assumptions and evaluations that might not be applicable to the current situation. Despite a resurgence of interest in mindfulness as shown in academic publications (fi gure), and in the published work directed at the general public, this method continues to be much misunderstood. Our view is that a broad array of clinical applications exists for an increased understanding of the diff erent approaches to mindfulness, and we focus here on the details of two well known and diff erent conceptual frameworks. There are two major theoretical frameworks defi ning mindfulness, one developed by Ellen Langer in the mid1970s and the other by Jon Kabat-Zinn in the late 1970s. Ellen Langer’s concept of mindfulness is characterised by the process of actively making new distinctions about a situation and its environment, rather than relying on automatic categorisations from the past. This process of paying attention to novelty and to the context of the current situation can lead an individual to approach the scenario from many possible perspectives, reframing events in more than one way. Processing information within this framework might result in positive healthrelated outcomes. For example, being mindful about ageing enables us to understand that our preconceived notions about the apparently inevitable course of ageing is a function of our mindset, a refl ection of the view that growing older automatically coincides with a substantial reduction in the pleasures associated with youth. If, instead, we free ourselves of the conventional limitations imposed on ageing, we might add years to our lives or at least add more life to our years. Mindfulness is the reverse of mindlessness, in which a person takes a perspective about an event or a situation and relies on automatic or repetitive thought processes, judgments and behaviour. When mindless, people rely on previously established distinctions and categories, which in turn can lead to maladaptive behaviours. Examples of mindlessness include preju dice, stereotypes, and automatic behaviours (eg, driving somewhere and not remembering how we got there). In Jon Kabat-Zinn’s theory, mindfulness focuses on paying attention in a purposeful manner, in the present moment, and non-judgmentally: without moral and emotional assessments, as if no bad or good exists. In this approach, mindfulness is promoted by meditation, particularly a westernised version of Buddhist Vipassana meditation. The community of clinical psychologists in Europe and the USA tends to rely on the Kabat-Zinn construct as illustrated in two well known mindfulnessbased interventions: mindfulness-based stress reduction, and mindfulness-based cognitive therapy. In our view, it is inconsistent with mindfulness as a way of life to defi ne it as equating to or necessitating meditation; such an approach might be deemed mindless in its requirement to follow a particular process to achieve mindfulness. The concept of mindfulness, regardless of one’s theoretical approach, refers more to a psychological construct and is not rooted in any particular mechanism or set of exercises to achieve. In this sense, we see the function that meditation has in the construct of mindfulness as analogous to the role an antidepressant drug has in relation to depression, as a mechanism infl uencing a psychological variable. Moreover, just as an antidepressant drug is not the only way to reduce depressive symptoms, meditation is not the only method to establish a state of mindfulness. We fully agree that meditation training can be powerful in the improvement of psychological well being and quality of life, as articulated in the increased focus of academic studies. However, less than 10% of the general population of the USA engages in a regular practice of meditation. Although many people might not be aware of meditation’s benefi ts, clinical experience suggests Being mindful about mindfulness