Mindfulness Interventions Delivered by Technology Without Facilitator Involvement: What Research Exists and What Are the Clinical Outcomes?

There is now a great deal of evidence supporting mindfulness-based interventions in reducing clinical features of depression, anxiety, stress and psychological components of pain alongside increases in well-being (Bohlmeijer et al. 2010; Chiesa and Serretti 2009; Chiesa and Serretti 2011; Grossman et al. 2004; Ledesma and Kumano 2009; Marchand 2012; Piet and Hougaard 2011). The two most popular programmes are mindfulness-based stress reduction (MBSR; Kabat-Zinn 1982) and mindfulness-based cognitive therapy (MBCT; Segal et al. 2002). Meta-analyses show moderate within-group effect sizes on clinical features associated with common psychological disorders (ES ≈ .5; e.g. Chiesa and Serretti 2011; Fjorback et al. 2011; Khoury et al. 2013).

The quality of the training provided by mindfulness teachers is considered crucial to the overall success of a mindfulness training programme (Crane et al. 2010). Up until recently, the majority of mindfulness teachers were, as Crane et al. (2012) describe it, first- or second-generation teachers who were either taught by Jon Kabat-Zinn or his colleagues, or learning from those who had. This is changing now and increasing numbers of mindfulness trainers are teaching with limited experience. In order to provide some benchmark for programmes, the UK Network of Mindfulness-Based Teacher Trainers (2011) provide an outline of the core experience and competencies which are considered an essential basis for teaching mindfulness. This includes teachers having a sustained and consistent personal mindfulness practice. Given the growing popularity of mindfulness-based approaches along with the extensive commitment and experience required to teach it, there is currently a tension between limited supply and increasing demand. There are concerns that in the rush to meet demand, it is possible that the integrity and authenticity of the work may be diminished if delivered by inexperienced teachers (Crane et al. 2012).

There is unlikely to be one single way to address this issue; however, one approach might be the delivery of well-designed mindfulness training online, using web-based programmes, mobile apps and other technological platforms. Internet-based interventions are by no means new (e.g. Barak et al. 2008; Taylor and Luce 2003); some are even well-established. Computerised cognitive behavioural therapy (cCBT), for example, is supported in the UK for use with mild to moderate depression and anxiety by the National Institute for Health and Clinical Excellence (National Institute of Clinical Excellence 2006). During cCBT, patients login to a secure website at specific time points in order to access and read content online. Content is generally arranged in a series of eight lessons or modules and can take the form of a website or even a smart-phone application (Andersson and Titov, 2014). Overall, there is evidence supporting use of such interventions for major depression, panic disorder, social phobia or generalised anxiety disorder, with a moderate mean within-group effect size of .88. (Andrews et al. 2010). However, there are a number of issues with these interventions. Drop-out rates can be high (range 3–34 %) and, as a recent meta-analysis suggested, effects may not be sustained into follow-up (So et al. 2013). Additional therapist support appears to be more effective than those without (ES = 1 vs .2; Spek et al. 2007) and reduce attrition rates (So et al. 2013), so there is some loss of effectiveness when direct contact with a therapist is lost.

By removing face-to-face contact with an experienced mindfulness teacher, interventions have the potential to be more cost-effective, accessible, and flexible. This needs to be balanced against the potential reduction in quality and ultimately effectiveness. Extensive research is therefore needed before such interventions can be supported for use in a clinical environment. It is clear that these interventions could be popular with participants. Commercial mindfulness training from websites and mobile apps (e.g. Headspace and Buddify) along with books with audio files is increasingly popular, and there is a growing public interest in mindfulness training online and using smart phones. Most of these products do not have any facilitator involvement beyond their initial design and many are similar to the interventions included in this review. This may offer cost-effective interventions with a huge potential for scalability after initial design.

This review explores the current research into mindfulness training interventions delivered on technological platforms that do not have direct facilitator involvement. We take a first look at whether such programmes are beneficial for participants and lead to changes to clinical outcomes such as stress, anxiety and depression which are consistent with the broader literature on mindfulness interventions.

Three databases (Ovid Medline, PsychINFO and Embase) were searched for relevant keywords, titles, medical subject headings (MeSH) and abstracts. Each database was searched up to the 6 July 2014. Two search strings were developed: (1) ‘mindfulness’ and (2) ‘technology’. Inclusion criteria were as follows: (1) the study intervention must teach formal mindfulness techniques (for example sitting and moving meditation as compared to informal mindfulness exercises such as being mindful of day to day activities), (2) the mindfulness training must be taught via technology only, (3) the study must include clinical outcomes, (4) the intervention must not include direct facilitation, (5) the paper must be available in full, and (6) it must be written in English. The titles and abstracts of identified studies were screened by two screeners (JF and JB). Disagreements were discussed. Data was extracted from the remaining papers using an electronic data extraction sheet. Any missing or unclear data was marked as such.

A PRISMA flow diagram for this review demonstrates the process (see Fig. 1; Moher et al. 2009). Two thousand eighty-nine papers were initially identified after duplicates and non-English papers were removed. One thousand four hundred eighty-two papers were excluded after a title search, clearly on a different subject. A further 532 papers were excluded following abstract reading, clearly on a different subject. Sixty-five papers were then excluded after a full text review. Of these, 24 were not technology-delivered, 22 were not published research, 14 were not interventions and four were not mindfulness interventions. Nine studies remained. One paper that was in press was subsequently added (Dimidjian et al. 2014). This led to a total of 10 studies being included.

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Although research is in its infancy, this review lends some initial support to mindfulness interventions using technological platforms to deliver mindfulness training without direct facilitator input. Reduction in clinical features of anxiety, depression and stress was found in a number of studies. Anxiety and depression effects were comparable in size to NICE recommended cCBT (Andrews et al. 2010) along with face-to-face mindfulness interventions (within group ES ≈ .5; e.g. Chiesa and Serretti 2011; Fjorback et al. 2011; Khoury et al. 2013). Effects appear to last into follow-up, even increased further in one study at 1-month post-intervention. Despite encouraging findings, firm conclusions about effectiveness cannot be made yet.

Criticisms of cCBT that dropout rates can be high and effects may not be sustained (So et al. 2013) support the need for research into other interventions like those reviewed which may produce longer lasting effects and lower attrition rates. The mindfulness interventions included had a wide range in dropout rates (7.7-52.3 %) so cannot currently be favourably compared to cCBT in terms of attrition. However, there is initial support for the longevity of stress, anxiety and depression reduction effects. Not only were continued effects seen in the majority of studies which measured this but also one study even found further effects after 1 month. Notably, this study was subject to multiple biases in its design, using fast completers only in analysis. Longevity of effects may be due to the nature of mindfulness interventions which teach the use of continued formal and informal practice n a way that CBT does not.

Participation, engagement and attrition are all likely to play an important role in outcomes and mediate effects. A dose-response relationship may even exist although the evidence so far is not strong enough to support this. One finding by Krusche et al. (2012) that longer course completion times correlated with weaker effects on outcome measures supports this. Specifically, the contribution of informal but not formal practice lies in opposition to a previous study by Carmody and Baer (2008) who found no significant relationship between informal practice and outcomes in their review of face-to-face interventions.

Participant and intervention characteristics are likely to both contribute to effects. Whether participant characteristics led to greater effects in certain interventions is largely unclear although one study found that participants with higher levels of initial distress had lower attrition rates (Glück and Maercker 2011). Participants that urgently require help may be more likely to actively engage with practice and gain greater effects. Unfortunately, none of the studies investigated why people left studies. Course length and time commitment, encouraged daily practice, meditations taught (e.g. body scans, mindfulness of breathing and mindful movement) and types of resources (e.g. text, audio, videos and workbooks) all varied between studies and there is no clear link between these and outcomes. Despite the lack of clear support for one particular model though, shared characteristics, especially between the more successful interventions, do suggest a template on which future interventions should be based. The qualitative study found that participants liked many of the elements shared between interventions, particularly the web-based, modular e-learning format that used different types of content such as text, audio and videos. Animations were less popular.

Whilst these programmes do not include direct facilitator contact with participants, it is important to recognise the role of those who designed the programme and prepared the course materials. Experience of those who designed the course was not mentioned in most papers but this is also likely to play an important role. Given that quality of the training is thought to be crucial to the effectiveness of face-to-face mindfulness training (Crane et al. 2010), it stands to reason that those involved in an online programme are just as, if not more, important as the trainer in a face-to-face mindfulness intervention. Programme developers are doing two things, developing a targeted teaching programme for a given population and then deciding the best way to communicate and deliver that using technology. Recently, the UK Network of Mindfulness-Based Teacher Trainers (2011) developed good practice guidelines for those delivering mindfulness training face-to-face. It seems important that the conversation now extends to the development and delivery of mindfulness programmes online, learning programmes, and fully online training programmes.

One concern about technology delivered mindfulness programmes such as those reviewed is that the integrity and authenticity of the teachings will necessarily be compromised given the lack of face-to-face contact with a facilitator. This review found evidence that interventions can teach mindfulness and maintain faithfulness to accepted models. The qualitative study included (Boggs et al. 2014) went some way to show that it is at least possible for such interventions to teach the core elements of face-to-face courses. For example, participants here stated that they were better at coming out of ‘autopilot’ and ‘slowing down’ along with re-framing negative thoughts and identifying triggers for anxiety and depression. Quantitative support comes from all four studies that assessed mindfulness which reported increases in mindfulness. There at the very least exists a correlation between clinical effects and mindfulness levels.

It is vital that we learn how to make interventions more effective, and one way to do this may be by encouraging more practice. Practice times were short across the studies and no interventions encouraged or achieved levels of practice seen on a face-to-face MBSR/CT course (40 min a day). However, participants in the qualitative study have noted that the amount of time encouraged (30 min) is too much, especially at the start of the intervention (Boggs et al. 2014). This may explain some of the attrition. Notably, many studies found comparable rates to those found with face-to-face interventions (16.5 %; Khoury et al. 2013). Shortening practice times may achieve lower attrition rates and more participation and engagement, but they may also reduce the effectiveness of the intervention. One way forward might be to encourage multiple shorter sessions throughout the day building on the 3-min breathing space included in many programmes already. Another option may be to gradually increase time commitment as suggested by participants in Boggs et al. (2014).

Moving forward, research is likely to follow two distinct paths. The first of which is to build on the initial support for the effectiveness of technology-delivered mindfulness interventions without direct facilitator input. This should also include an understanding of mechanisms behind effective interventions. A standardised intervention format would allow for robust, large-scale quantitative evaluations and adaptations including novel approaches. Previous interventions and quantitative study suggest elements which should be used in the future including a modular course structure, use of different materials within the same course (e.g. text, audio, videos and printouts) and an e-learning environment. The importance of many key elements such as course length, practice time, materials used, techniques taught and course designer experience are still not well understood, and comparisons between otherwise standardised interventions would elucidate the impact of these elements. This approach also allows specific interventions focus on particular issues (e.g. addiction, depression and eating disorders). An approach incorporating standardisation and specific focus of interventions is similar to that seen in the face-to-face MBSR/MBCT community (e.g. Kristeller and Wolever 2011; Sibinga et al. 2011; Salmoirago-Blotcher et al. 2012; Reid 2013). High-quality supporting research is needed.

This review recommends a number of components to a standardised intervention model: courses should last at least 4 weeks; 30 min of practice for 6 days a week should be encouraged although variations on this should be explored; the use of a wide range of materials (e.g. audio, video and text), development find experienced mindfulness practitioners should develop courses; core mindfulness exercises should be taught (i.e. mindfulness of breathing and movement, body scans). This review also recommends a number of components to future research models: conducting intention-to-treat analyses, comparing interventions against appropriate control groups (e.g. cCBT or face-to-face mindfulness interventions), measuring mindfulness as a mediator, including follow-up measures up to at least 6 months, measuring individual practice levels and drop-out rates and including exploration of participants’ experiences, especially their understanding of mindfulness and why some participants drop out or do not fully engage. A limited number of well developed programmes must be comprehensively evaluated before widespread use.

The second research focus should be experimentation with novel approaches including integration of interventions with face-to-face programmes and varying degrees of instructor-led or group work through technology. The use of mobile technology may offer an innovative way to encourage practice. Many existing interventions already included reminder emails. Building on this, mobile technology could also be used to monitor and encourage home practice. Like web-based delivery, it is low cost and flexible. Use of new technologies such as mobile apps and even integration of technology into established programmes could create more effective interventions. Although some of the advantages of a self-contained intervention, such as low cost, scalability and accessibility, may be lost, technology may be a useful addition to existing face-to-face interventions within a blended learning environment. This would satisfy the need that some participants, but notably not all, have for facilitator and group interactions. Another approach may be to have groups that meet to share in online delivery of interventions designed by experienced teachers, perhaps even with live video links.