Cost Effectiveness of Mindfulness Based Stress Reduction | Hacker News Reader

Cost Effectiveness of Mindfulness Based Stress Reduction

acesounderglass.com

134 pointsluu61 comments

My sister is a mental health professional and she has recommended meditation and headspace (an app) to me a year ago. I've found it to be a great help and to the exercises to have a measurable impact on my life.

It provides techniques (reflection, visualization, noting etc) that offer tools to deal with day to day stress related information.

There are a lot of studies about meditation's effectiveness:

https://www.ncbi.nlm.nih.gov/pubmed/29110263 https://www.ncbi.nlm.nih.gov/pubmed/29126747

I'm always surprised that when people discuss it with me they're surprised I do it. Somehow it has a reputation for pseudoscience but there are easily a hundred articles supporting the benefits.

I think it has a reputation as a pseudo science because it's derived from religious practice. While religious practice isn't always bunk (as is the case here) assuming that religious practices are bunk is a pretty damn effective heuristic.

> [A]ssuming that religious practices are bunk is a pretty damn effective heuristic.

Maybe, but if I take your statement seriously, I would surmise that it's only an effective heuristic because being excessively distrusting/cynical has less downside in cases where the practice is actually sound.

That aside, you have to work a little bit harder to discern religious practices that are rooted in activities that are observably and directly beneficial to individuals and society (meditation, compassion), and activities that are either antiquated (not eating shellfish/pork) or were created to perpetuate the religion or its leaders (tithing).

> That aside, you have to work a little bit harder to discern religious practices that are rooted in activities that are observably and directly beneficial to individuals and society (meditation, compassion)

Leaving meditation out of this, I think the religious practices you're implying were basic human moral practices adopted _by_ religion, not the other way around.

In our Western post-Enlightenment society, most of the beneficial aspects of Christian practice were adopted into secular practice. Consider: charity for the needy, monogamous marriage, burial of the dead, a 7th day of rest.

We haven't adopted as many practices from other religions. We eventually (1800s) adopted regular washing from Islam, but adoption was slowed by its taint of foreignness, much to the chagrin of millions of people who died of disease. The stretching aspects of yoga became mainstream within the last 50 years. Meditation and yoga breathing are still exotic. Perhaps some day they won't be, and our descendants will wonder how people from our era stayed sane without daily meditation.

The https://en.wikipedia.org/wiki/Art_of_Living_Foundation teaches meditation and yoga breathing worldwide, including regular classes in the Bay Area, if you want to try it yourself.

Another example: if you don't want worms or salmonella, don't eat poorly cooked white meat. No doubt the meat was considered cursed after people consistently fell ill after eating it.

When it comes to eastern practices (yoga, meditation and so forth) my bullshit barometer is calibrated much, much higher. I'm far more likely to approach their practices with an open mind. Take spirit guides as an example; while I certainly don't agree that there are spirit guides, it is a religious explanation for the subconscious - your autopilot that guides you through small decisions every day. I can't see why you wouldn't try to wield it to your advantage (obviously with the appropriate care that eastern religions have unwittingly formulated).

Even the core of Christianity can be helpful. Life is far less stressful if you are generous in the most insignificant ways. Simple acts like letting traffic enter in front of you, over time, drastically erodes the stress that you feel in those situations.

From my perspective, religious texts have at least a few pragmatic observations - even if they lack scientific explanations.

> Even the core of Christianity can be helpful. Life is far less stressful if you are generous in the most insignificant ways. Simple acts like letting traffic enter in front of you, over time, drastically erodes the stress that you feel in those situations.

I believe James May (of Top Gear fame) specifically calls this "Christian driving". It's amazing how much more relaxed you are after a drive, if you simply stop thinking of traffic as a race or a competition. You're not going to change your arrival time by any significant amount anyway, so you might as well just relax.

In traffic, the only winning move is to not play.

> thinking of traffic as a race or a competition

People behaving like traffic is a race still raises my blood pressure. At the end of the day I still need to get into the toll lane, but I can't because there's 20 cars trying to get back into traffic at 75mph and I'm far too damned courteous to butt in at 60mph. It's far more of a blessing than a curse (I'm getting far more out of my habits), but the downsides do certainly exist.

It's not at all consistent, but my behavior is sometimes viral. I'll see the vehicle behind me keeping a generous following distance, or letting someone in. Almost every time that I've tried to resolve a traffic jam in Seattle, the person behind me has caught on - they will keep their distance and keep rolling in order to compensate for the tailgating person in front of me.

> competition

My favorite competition is to improve the commute of those behind me. There's always the guy who cuts in front of me, forcing me to stop, but there's also always the guy behind me who has caught on. Getting everyone home quickly is a far more interesting, and far less pointless, than the game of trying to beat everyone else home.

I do my best to keep a decent following distance, and try to match the average speed of traffic in rush hour. Sure, some people will merge in front of me, but there's usually enough buffer space that I don't have to adjust my speed by a lot. And when traffic inevitably clumps up, I slack off the speed a little instead of having to brake. I've notice that some people are perfectly happy to stay behind me and match my speed, to avoid stop-and-go.

I also try to position myself to make my merging intentions clear. I try to find a reasonable space to match speed and merge in, instead of trying to force myself in front. If traffic is completely blocked up, I will drive closer to the car in front if it's necessary to encourage a proper zipper merge. I sometimes see people getting really pissed off at that, usually the people who seem to be glued to the rear bumper of the car in front of them.

The basic rule I adhere to is that whoever's front bumper is the furthest forward gets to merge in front. It should be so self-evident and obvious, put people just don't want to let other people "win".

> People behaving like traffic is a race still raises my blood pressure.

The same tricks from mindfulness and meditation can aid here: don't judge, have compassion, focus on breathing, acceptance (of thoughts and feelings including negative ones such as anger) and relaxation shall follow.

My favorite competition in traffic is to have the least amount of anger (or other negative emotions). If someone else is angry, don't let them influence you; stay calm and rational instead.

I also find a good way to reduce stress is making sure you don't resort to last minute stuff like having to rely on a green light, not taking into account regular traffic jams, having tight appointments or an overburdened agenda, or arriving at the train station 30 seconds before the train departs. Instead, one's schedule should take into account minor delays. If there's a massive traffic accident you might get delayed but that is both rare and reasonable. If everyone would follow this advice, we'd all have a much more pleasant traffic experience.

> Meditation and yoga breathing are still exotic. Perhaps some day they won't be, and our descendants will wonder how people from our era stayed sane without daily meditation.

Yes! Energy can be experienced very simply after perhaps just 30 minutes of practice (for some - everyone's different). An excellent, clear introduction is "Energy Work" by Robert Bruce. Read with an open mind and practice.

Just because you haven't experienced something, don't discount it.

The dangerous aspect of religion for me is blind faith. If you view religious claims as hypotheses that can be personally verified, you become a scientist.

Yoga is such a scientific system. Kriya yoga is a good place to start, although at some level all of Patanjali's 8 limbs can increase the chance of experiencing the ultimate goal - enlightenment. Today, most people think yoga = stretching. That's just the preparation.

Another problem is that it's difficult to measure to the standards that we would like. You can't blind, so it's difficult to separate the placebo effect. Results take time to manifest, so you have long-running studies with problems with drop-out and survivorship bias.

I'm wondering, isn't it the same as placebo effect? In that it's not a change that occurs from taking a medication. It's a change that is the result of mental state change. Both can produce a physical change, as studies have shown (no link, sorry). But one is entirely the result of mental processes, though those mental processes were not induced by a placebo pill. So it's basically the same as the placebo effect, isn't it?

What would you consider a placebo for meditation?

a "placebo" generally refers to an inactive control arm of a study of a drug. For studying something like meditation, you would use a different kind of control arm. The most common example is "treatment as usual". So half of ppl get meditation therapy for a given condition (say, depression), half get "treatment as usual" (pills and Or therapy). This has lots of problems as "treatment as usual" varies a lot from patient to patient, doctor to doctor

A better control is basically taking every aspect of mindfulness based therapy except for the mindfulness (i.e. You educate the patient about the condition, have a group therapy session with a healthcare provider, have at-home therapy assignments, etc). You standardize this "active control" and compare how patients do with this intervention compared to the mindfulness based intervention. This isolates the effect of mindfulness vs other potential confounding effects, and also should reduce physician to physician variability

In the one large study of mindfulness interventions using this active control, there was no measurable benefit to the mindfulness arm

I want to reply here as well:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964149/

The study you mentioned shows that mindfulness is overall as effective as the (best?) known other treatment options. If you take this literally you are right, there is no "benefit" in choosing mindfulness based therapy over the other options. It is "only" on par with the other known treatment options.

It is therefore a fully valid and effective choice for treatment.

i guess an analogy that could be appropriate here is to imagine there is a study that compares two interventions for treating cancer: chemotherapy as one intervention, and chemotherapy plus playing video games for several hours as another intervention. Let's say that both interventions provide the same benefit in terms of killing the tumor, helping patients live longer. Does this suggest that playing video games for several hours is an effective treatment for cancer?

The control in that study was specifically designed to "unpack" mbct into its components, and then test mindfulness + other components vs just the other components. When they did that, both arms looked equal

I meditate regularly and don't doubt it helps me, and I think if people actually committed to studying mindfulness rigorously they'd find great things, but it's a shame that most mindfulness research isn't that robust or rigorous

>assuming that religious practices are bunk is a pretty damn effective heuristic.

Only if naively only count goals as stated by the religion itself, and only first order effects.

(E.g. if one examines whether there's really a heaven people go to, as opposed to examining whether the thought of such a place existing providing great psychological and personal benefit to the believer -- among tons of other similar things, I'm not even touching upon the impact on society, ethics, etc).

I'm not religious, but I know many many people who practice religion because it helps them in very real ways. From having a community to providing meaning to taking comfort in rituals to praying as a form of meditation, there are many religious practices that are psychologically and emotionally healthy. Religion has played such a huge role in human history not just bc some power hungry priests brainwashed people, but because it actually helps people

i fully support mindfulness and meditation as tools with real potential benefit, but the literature on clinical effectiveness leaves a lot to be desired. see a good overview of this issue here by one of the leaders in mindfulness research: https://www.ncbi.nlm.nih.gov/pubmed/26436311

overall, the body of literature on therapeutic benefits of mindfulness to date does not refute the hypothesis that mindfulness is "pseudoscience" (though it doesn't confirm this hypothesis either). there has been a surge in publications related to therapeutic applications of mindfulness in recent years, and nearly all of them are small, single-center, uncontrolled studies. as far as i know, there has only been one large, well designed randomized controlled clinical study of mindfulness based interventions (don't recall the paper, but it is in the grossman et al 2003 meta analysis), but that study did not include a positive control. a more recent study (similar in size and design, but including a positive control), failed to show a therapeutic benefit for mindfulness based intervention vs the control (study is jmg williams et al 2014 in journal of consulting and clinical psychiatry). so there are two high quality studies on clinical benefits of mindfulness interventions, one is positive and one is not

with respect to the less well designed (and more numerous) recently published clinical studies of mindfulness, the results are almost always positive. with small poorly controlled studies, this is always a red flag. one of the markers of "science" vs "pseudoscience" is the definition of the limitations of an intervention. if something seems too good to be true, it probably is

dont mean to rant or be a wet blanket. i personally believe mindfulness has great clinical potential, but to convince the medical community (and payers) of this, the field needs to focus on quality vs quantity of evidence

I just looked up the study with positive control you mentioned. Are you deliberately portraying the study in a false light?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3964149/

The study literally says: "MBCT provided significant protection against relapse for participants with increased vulnerability due to history of childhood trauma, but showed no significant advantage in comparison to an active control treatment and usual care over the whole group of patients with recurrent depression."

Which means: in some cases MBCT is SIGNIFICANTLY BETTER than the compared treatments and overall it is AS GOOD AS the compared treatments (i.e. cognitive psychological education (CPE) and treatment as usual (TAU)).

Now, looking back at your post, you said "failed to show a therapeutic benefit" which is strange, because the mentioned study shows that the therapeutic benefit is about the same and sometimes it is even better compared to CPE and TAU. So why would you say that MBCT does not show therapeutic benefit if it has the same results as the other (best?) known treatment methods?

PS: I would really like to turn your biased question around: Do you know of any treatment method which is better than MBCT?

It showed a slight benefit in a small particular subgroup for one of the things they checked (only those with above median severity benefited a bit more).

For what is worth, the fact that any treatment has roughly the same effects (with some being slightly more or less effective in some subgroups in smallish samples) shows that the effects of all those treatments are likely placebo, or at minimum that there is nothing special about meditation (e.g. you can get the same benefit from talking to someone/listen to an audiobook or whatever).

the full context of the quote you used from my comment is that mbct "failed to show a significant benefit vs the control". Your shortened quotation misses that very important context. The control exists to account for all the other confounding factors, besides mindfulness, involved in mbct. When you control for those, and mindfulness is the only variable that differs between active arm and control arm, there is no significant benefit to mindfulness. So one can reasonably conclude that other things like being in a therapy group, learning about depression, etc were driving the benefit, not mindfulness

Regarding the subgroup finding: as far as I know, the study was not designed or powered to rigorously measure the impact of the interventions on this subgroup. If they did another good study looking just at this subgroup and the results were positive, that's a different thing. The first thing investigators do when a study fails the primary endpoint is mine for subsets of the data that show a positive result. That doesn't make the result meaningless, but should invite skepticism

Reproducibility is a huge problem in scientific research. These are not determinate systems, and a huge number of things can bias a result, intentionally or otherwise. Scientific publications, even in good journals, need to be viewed with an appropriate amount of skepticism

According to NICE, one of the leading agencies on cost effectiveness and clinical guidelines, MBCT is only recommended for prevention of relapse in patients who have had three or more episodes of depression. CBT and augmenting antidepressants work just as well. Funny thing about depression studies is most interventions, pill or psychotherapy (or even placebo sometimes) tend to have similar levels of effect

> Somehow it has a reputation for pseudoscience

I can only speak from personal experience, but my company tried a big mindfulness push a couple of years ago. Maybe we just had a bad instructor, but everything was just wishy-washy and felt like a giant waste of time, full of tautologies and wrapping perfectly ordinary common sense (you're more relaxed when you allow yourself to relax, WELL DUH!) up in some sort of vague mysticism.

I am perfectly capable of relaxing and unburdening my mind, but it just ain't happening during a normal workday with deadlines and badly defined business processes.

If you just let me be and let me listen to some music without being disturbed, I'll be perfectly calm and relaxed, no mysticism needed.

> If you just let me be and let me listen to some music without being disturbed, I'll be perfectly calm and relaxed, no mysticism needed.

Meditation is more than just relaxation. It's about a state of mind. About being in the present moment, letting go, looking inward and reflecting about oneself. I don't think you do any of those things when just relaxing while listening to music.

Also,

> I am perfectly capable of relaxing and unburdening my mind, but it just ain't happening during a normal workday with deadlines and badly defined business processes.

That means you are not perfectly capable of relaxing your mind.

> Meditation is more than just relaxation. It's about a state of mind. About being in the present moment, letting go, looking inward and reflecting about oneself. I don't think you do any of those things when just relaxing while listening to music.

Well, it's obviously that you don't know me. I am in fact in the moment and I do in fact let go and reflect when I listen to music. Or when I go for a walk or any of a multitude of other non-stressful activities that let me ignore the annoyances of daily life and other people, for a little while.

> That means you are not perfectly capable of relaxing your mind.

Like I said, it's obvious that you don't know me at all.

If you really get the same benefits from listening to music as somebody who does correct mindfulness meditation, then good for you.

It's most likely not true though.

The idea of the parent is that you should be able to relax despite the "annoyances of daily life and other people" -- in other words, in any environment.

Else, baring some physiological/psychological condition, everybody can relax when in a relaxed environment...

Maybe we have different definitions of "relaxing".

Maybe not all of them are valid when discussing "Mindfulness Based Stress Reduction".

I don't understand why this is being downvoted. Kamac's comment comes across as patronizing.

Phrases like "state of mind", "letting go" and "looking inward" don't actually mean a whole lot. Even "meditation" can be ambiguous. Unclear terminology is IMO always a symptom of snake-oil mumbo jumbo.

Funny that the SV tech elite seems to just suck that quackery up and plays along.

It's a topic that's difficult to put into words, true. I don't agree that "letting go" or "looking inward" are meaningless. In fact, letting go has a very literal meaning. You're supposed to not think about something on purpose, and when thoughts come, you don't follow them.

Looking inward is basically not focusing on the outside world. You're not supposed to sit and stare at a chair, but focus on something that is "inward", which could be for example your presence or your breathing.

Unclear terminology sometimes comes from either not having a deep enough grasp of the topic at hand. Sometimes on the other hand, the thing you're trying to explain is just hard to put into words.

Meditation is pretty simple. It's just getting better at something you practice. Specifically controlling your attention and being aware of what you're thinking about.

No magic, pretty straightforward. But an enormous amount of suffering is caused by us thinking/worrying about bad shit.

Now if you are more aware of what you're thinking and can change what you're paying attention to you can make your mind spend a lot less time worrying about shit that makes you miserable.

That's my point. I don't need mindfulness to reflect on my thoughts.

But that literally is mindfulness. It is not a magic technique... Simply reflecting on your thoughts (and/or feelings) is basically the definition of mindfulness.

PS: It is sad that this marketing/self-help-book/guru/training etc. hype around "mindfulness" distorted the original simple meaning of the word mindfulness.

Probably. My experience was that they were trying to teach common sense, wrapped up in mysticism and marketing.

It's not common sense to most people, that's precisely why it gets recommended so much. It's very easy for you to say it is, perhaps because that's all you know. For some people you can get stuck in a sort of auto pilot, moving from acting on one thought to the next, instead of realizing they're just thoughts and you can let some go.

I'm also a bit skeptical that you actually are mindful of yourself. When you actually do it and realize how it works, it's pretty amazing. I certainly didn't think "well, that's just common sense". When you actually do it, start observing your thoughts and feelings as separate from you instead of consuming them and getting caught up in them, it does bring calm and a feeling of refreshment.

The best thing I use mindfulness for is stopping a destructive cyclical worry. As an example from the past, say I'm worried about a client not having paid his bill yet, I know they're having cash flow problems and I worry I exposed myself to too much risk. What can happen is that thought can spiral and keep popping into my head, intruding into my day. It might create a cascade of thoughts, what my bank balance is like, how might I get a partial payment, is it too early to phone, should I look for another client, what will I do with the existing work, should I have asked for better payments terms, etc., etc., etc. But the worst part is, I would have that exact same chain multiple times a day. It intruded over and over, until the client would pay (predictably) late again.

But none of that helped when it was firing, it's not even that late yet. It just made me stressed and stopped me from getting what I needed to get done that day, sometimes I couldn't just place it aside.

Using mindfulness, instead of consuming that thought and worrying about it, I can just look on it as a thought.

I used to suffer from a severe temperament, so I've had to learn how to control my thoughts and emotions, and how to not give a shit, figuratively speaking. I'm very good at clearing my head and only thinking about the things I care about. When I leave work, I leave work, both physically and mentally.

Maybe that is mindfulness, I don't know. It just feels very far removed from the mysticism and mumbo-jumbo I was confronted with, which honestly just added stress, rather than mitigating it.

the mysticism and marketing isn't part of the mindfulness itself, but it is part of the self-help and new-age religion industry which attaches itself to concepts like mindfulness and meditation.

It's a bit more than that. It's your thoughts now and your emotions now and your sensations now. Just generally reflecting on thoughts is vague, the point of mindfulness is not to reflect on past thoughts or future speculations.

This then gives you the power to manage them better in a few ways, including that thoughts are just thoughts and you don't have to act on them all, and actually be aware of how you're feeling and what actually caused that and how to manage that feeling if it's destructive.

As a counter-anecdote (don't mean that in a snarky way), I am absolutely terrible at reflecting on my thoughts, feelings and physical state without some form of mindfulness.

I also notice a marked decrease in anxiety or tiredness after meditating. While of course that could be a placebo effect, almost all other things I did to deal with anxiety (including CBT) didn't really do much, despite my belief that they would.

I've talked to a number of people who didn't really see the point of meditation, only to discover that what they were already naturally doing was essentially a similar thing. Or they just didn't feel the need.

Similarly, I've met people who can smoke cigarettes for months without getting addicted, people who can remain calm in incredibly stressful situations, people who just don't understand the concept of 'boredom', etc.

Perhaps you're just one of those people who don't need it, and I'm kinda jealous of you if that's the case!

> If you just let me be and let me listen to some music without being disturbed, I'll be perfectly calm and relaxed, no mysticism needed.

Do you spontaneously laugh because you're filled with such joy in this state of "relaxation"? I've done that after a body scan and just mindful breathing.

The thing with relaxation is it's easy to think you are relaxed until you experience actual deep relaxation. Search on youtube for "Yoga nidra", lie down and just follow the instructions. Simple yet profound.

Yes, some of my favorite music will give me chills down my spine, make me smile (occasionally laugh), sing along and dance.

I also get a profound sense of relaxation after a hard hour of crossfit, an urge to just lean back, take a deep breath and not give a shit about anything. When I think back afterwards, during the exercise my mind is completely clear of all worries, only the movements matter.

Different strokes for different folks. Sounds good to me :-)

> The World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health.

> The disability-adjusted life year (DALY) is a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death

I knew the first, but thought that someone else might not. I didn't remember the second abbreviation offhand, and thought someone else might appreciate a short explanation too.

We should work on actually reducing stress instead of abusing mindfulness to handle stress better.

exactly.

and it's more like "handle" stress better

Absolutely agree, but there are many situations where stress is not able to be reduced easily (relationship problems/breakups or other family problems, anxiety issues, athletic events, work issues which come up even in relatively healthy work environments). Having coping strategies ready when things doesn't go as expected is important, and something I'm still working toward myself.

For me, mindfullness wasn't about "handling" stress. It made situations that were previously stressful into non-stressful situations.

That's not quite what mindfulness does in the long run. It actually reduces gray matter density in the amygdala, which is associated with immediate stress response. These changes are permanent. Therefore, it not only helps you "handle" stress, but also causes situations to "cause" less stress in the first place. Check out https://news.harvard.edu/gazette/story/2011/01/eight-weeks-t...

Also, you do not actually need to practice an hour a day to get the benefits. The above study has participants practicing on average 27 minutes per day.

Sorry, how does your comment relate to mine? Was this meant for somebody else?

I agree with you to a degree, but I think you might be missing a major benefit mindfulness meditation. In particular, mindfulness meditation helps you to reprogram the way you relate to experiences and thoughts in a way that, in my experience, does eliminate stress.

In other words, my relationship with experiences and thoughts can tend to be either more objective or more subjective (perhaps reactive is a better word). The more objectively I view things, the less those things elicit a stress response. Again, this is in my experience and might not be universally true.

Sure there are stimuli that, for most people, will always elicit a stressful response. I would guess (emphasis on the word guess) this comprises at most ~10% of a person’s thoughts and experiences which is likely much less than most people think.

Anyways, just my two cents.

You also realize when someone is trying to appeal to your insecurities to extract something from you. You start avoiding those situations and the kinds of stress that they embody.

You just named a very specific thing that I've been wondering how to fortify myself against. Thank you for the succinct endorsement, this is very helpful for me

Stress is your internal reaction to a situation. Meditation can give you the skills to modify your reactions. What is a stress-inducing situation to some becomes just a calmly observed event to the skilled meditator. So sure, work on removing or reducing the stress inducers. But meditation is a personal super power that does not depend on anything external.

>We should work on actually reducing stress instead of abusing mindfulness to handle stress better.

yep, and to achieve that the people causing us stress should use mindfulness to better handle their own stress and cause us less of it as a result.

Why not both?

Both/and in my opinion. I've had to work to reduce a lot of stressors in my own life, but I also had to learn to handle necessary levels and sources of stress. Humans need stress, just in the right quantity, and with the right activities to process it healthily.

It’s clear the management types who are pushing that agenda don’t really understand what they’re asking. I have a feeling it’s going to blow up in their faces when all of a sudden people don’t want to play their other mind games anymore.

I find that mindfulness both reduces my stress in the short term, and causes me to reflect and choose to eliminate stress-causes in my life in the long term. Both effects are positive.

Sometimes you need to become calmer first before you even understand what exactly is the source of your stress and/or are able to act on removing that source.

Besides of that, any kind of life consisting of anything else than lying in bed in a closed, dark, sound-protected room includes handling a kind of stress. And that is only if you consider hunger, thirst and the urge to pee and shit to be no stress.

Reply on news.ycombinator.com