Mindfulness as Relational: Participants’ Experience of Mindfulness-based Programs Are Critical to Fidelity Assessments

Abstract

Mindfulness outcome research has been criticized for issues in research design, precision of outcome measures, and reporting overoptimistically their power to effect change. Although mindfulness programs are a complex interaction of teachers, teachings, and participants, it is of some concern that current assessments of program fidelity focus primarily on teacher skills and program content delivery. Although ensuring that teachers are trained to criteria and adhere to program elements, the participants’ engagement, a critical parameter contributing to outcomes of mindfulness programs, has been neglected. Furthermore, the assessment measures are primarily actuarial even when assessing experiential or difficult-to-define aspects of teacher–participant interactions. The inclusion of the participants’ experience of the program as a component of fidelity assessments creates several opportunities to deepen our understanding of how mindfulness impacts the lives of practitioners. By investigating the teacher–participant relationship, determining how participants process the core elements, and exploring the implementation of the practices in their lives, a more nuanced understanding of the capacity of mindfulness-based programs to effect positive change may be possible.

Recent discussions about mindfulness-based programs (MBPs) have addressed the implications of its widespread use for psychological treatment and cautioned against an overly optimistic presentation of outcomes.¹ Furthermore, the emerging research on harmful effects of mindfulness practices suggests diligence in ensuring MBPs are reliable and safe.² However, because MBPs have been conceived and designed as a synergistic relationship among teacher, curriculum, and participants, assessing program efficacy and reliability is complex. One approach to determining reliability and safety is the assessment of treatment integrity or fidelity, markers of consistent and accurate curriculum delivery and of research rigor and outcome reliability.³ Specifically, the teacher–participant relationship and the participants’ experiences (PEs) are aspects related to the outcomes of MBPs that would benefit from further examination. The relationality of these 2 aspects of MBPs to fidelity will be explored through 2 available treatment fidelity checklists.

Although several measures are available, Kechter et al.⁴ noted that treatment fidelity is not routinely reported in investigations, with only 25 studies (12%) of MBP-controlled trails reporting treatment fidelity. This scarcity of fidelity information impacts assessing the contribution of program-unique components to outcomes. More importantly, the complex interactions among teacher, curriculum, and participants have not been fully explored which can impede program development and competency training. It may also be a missed opportunity to examine the relational aspects of program efficacy and appropriate use for marginalized and vulnerable populations. Fidelity assessments, therefore, contribute to clarifying broader ethical concerns of MBPs by integrating the thin layer (X happened) of program components with a thicker analysis⁵ (why and how X happened) of the relational components.

Reperceiving Fidelity Through a Relational Lens

McCown⁶ describes the ethical space of mindfulness as relational. This description supports exploring the participants’ understanding of the teaching points and how they perceive its traction in their life, in conjunction with teacher skills and curriculum adherence. Furthermore, the investigation of PEs offers an opportunity to address the ethical implementation of MBPs by highlighting processes that are inadvertently harmful. For example, fidelity of MBPs adhering to curriculum elements—without simultaneous awareness of PEs—may overlook distress caused to a participant. For a trauma survivor, the body scan (lying down with eyes closed and bringing attention to body sites) may elicit or intensify the feelings of vulnerability. Accessing these perspectives of PEs in fidelity measures can provide useful information for safe delivery of and participants’ engagement with an MBP.

Understandably, studying PEs adds a dimension of complexity to fidelity measures because relational nuances, lost when assessed quantitatively, require qualitative measures. However, the study of MBP integrity would be incomplete without including the participants’ relationship to the teacher and curriculum. To address this need for relational assessments, the components of current fidelity measures can be reperceived as interactive, particularly by bringing the participants’ understanding of and engagement with the curriculum to the foreground.

Two fidelity assessment checklists address teacher skills and relational aspects of teacher–participant interaction in research trials: the Template for Intervention Description and Replication (TIDieR)⁷ and the Treatment Fidelity Tool for mindfulness based interventions (TFTMBI).⁴ The TIDieR checklist evaluates consistency and adherence in research studies. Organized into 12 categories, it is comprised of general information about the study (1,2), materials and procedures used (3,4), teacher training criteria (5), logistics of delivery (6–8), adaptations (9,10), and fidelity plans (11,12). Of relevance to the relational aspects of MBPs are the assessments of teacher skills (5) and adaptations for participants’ needs (9,10).

The TFTMBI⁴ is comprised of 5 dimensions: design of the program, training of the facilitator, delivery components of the curriculum, relevant to the relational aspect of MBPs, the receipt of program elements (participants’ understanding of the curriculum components), and enactment (evidence of participants’ incorporation of the program elements into their real-life settings). The following discussion focuses on the overlapping categories of the 2 checklists: the participants’ receipt and enactment of the program elements as representative of the relational aspects of MBPs and adaptations to participants’ needs as reflections of the teacher–participant relationship.

A Thick Understanding of Receipt and Enactment

Assessing PEs is likely a robust litmus test of the teacher’s ability to convey the subtle, experiential elements of an MBP. Skillful teaching respects the participant’s desire to end their emotional discomfort while compassionately exploring distress tolerance. In fact, Crane and Hecht³ note that a teacher who embodies the skills of curiosity and compassion is likely to foster a safe environment for the participant to explore their discomfort collaboratively.

Furthermore, Doyle et al.⁸ reported that relationships between facilitation quality and participant responsiveness were mediated by the perceived usefulness and understanding of the material. Facilitation quality was directly related to the length of time participants engaged in the practices and also to their reduction in stress. Interestingly, completion of learning objectives, but not completion of facilitation activities, was positively related to understanding the material and engaging in the practices. These outcomes suggest that teachers’ relational skills and flexibility foster receipt and enactment. The interactive nature of program adherence, teacher skills, and PEs highlighted by these results also raises curiosity about the range of flexibility (adaptations) that promotes positive outcomes.

Skillful Adaptation as an Ethical Stance

Recently, Monteiro et al.⁹ proposed that MBPs cultivate a moral arc of wisdom and compassion for the participants’ relationships with self, others, and the world. Insofar as this arc also reflects the intersectionality of cultural, social, age, and gender factors, adaptations of program elements are necessary, and the PE of the relevance of the material become important considerations. Adaptations may be a priori to meet age, gender, social, cultural, spiritual, and racial demographics or to ensure appropriate care for specific psychological vulnerabilities. Spontaneous adaptations rely significantly on teachers’ flexibility and occur as group or individual needs shift in situ (e.g., anxiety reactions during in-session practices). These latter changes present challenges to assessing adherence however may be ethically unavoidable. Finally, teachers’ flexibility and responsiveness to their inner experience while responding to participant and group needs can range from skillful to reactive, adding a dimension of complexity to assessing adherence.

For example, body scans can evoke unforeseen emotional reactions. Planned and spontaneous adaptations would invite participants to choose physical positions that feel safe or teachers may rephrase trigger words. Responsive adaptations arise from teachers’ capacity to attune moment by moment to participants’ vulnerabilities, and so tailor the teaching process to make it accessible.

Exploring planned and unplanned adaptations can contribute to understanding the interactions of the teacher–participant relationship and the PEs of the adapted content. Responsive adaptations are particularly informative; they highlight teachers’ flexibility skills and further emphasize the need to conceptualize adherence as a relational process.

Recommendations

Assessing fidelity is a challenge yet necessary for reliability and the safe, effective delivery of MBPs. Three recommendations are presented that reperceive fidelity as relational. First, the dimensions of teacher, curriculum, and PEs serve as organizing categories. Assessment of the relationship between teacher effectiveness and PE addresses receipt and enactment, an interaction that is direct and subtle.³ Because teachers’ skills and flexibility are connected to enactment,⁸ participants can perceive “not doing” a home practice as “failing.” The skill of the teacher is to turn this experience into an opportunity for nonjudgmental inquiry.

Differentiating between teacher “competence-expertise” assessed by trainers and “competence-perceived” assessed by the participant also may parse out the interactions. Program evaluations can ask participants to note their “take-away points” about mindfulness (receipt) and their experience of the teacher’s ability to communicate the core elements of the curriculum (teacher competence perceived).

Second, measures that examine participants’ enactment of the practices that include any subsequent relationships to behavioral or attitudinal changes provide important information. Monteiro et al.¹⁰ reported that engaging in behavioral commitments as well as not engaging in them generated useful insights. Participants tend to present with rigid self-expectations and experience incongruities between their values and actions as a negative characteristic. As flexible attitudes toward enactment developed, the tolerance and acceptance needed regarding perceived “success” or “failure” shifted. That is, exploring insights that occur as a result of not engaging in practices can contribute to clarifying the relationship between PEs and engagement. Furthermore, assessing intervention effects on incongruence between ideal and lived experiences can clarify values embedded in PEs and their influence on practice engagement.

Third, adapting MBPs to meet participants’ needs is an important step toward offering programs that are safe, compassionate, and therefore broadly accessible. Current insights acquired from understanding the negative impact of elements of MBPs either for individual or diverse groups can be integrated into new training protocols that prevent harm. In addition to postprogram evaluations that capture respectful interactions, participants can be invited to describe how the program aligned with their cultural, faith, and ethnic values. Finally, adaptations of MBPs may require collaborative processes with diverse demographics to ensure appropriate care.

Change never occurs in a vacuum. Revisioning fidelity as an interactive process that continuously generates connections is an opportunity to understand deeply the effectiveness of MBPs. It is also an ethic of care,⁹ ensuring broad accessibility to all persons regardless of age, culture, race, faith, gender, or psychological needs.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Lynette M Monteiro https://orcid.org/0000-0002-2538-4835