Mindfulness-based interventions (MBIs) constitute a rapidly growing subset of psychological treatments, with mounting evidence for their efficacy across a range of treatment targets. As the field moves from studies of efficacy toward larger effectiveness trials, implementation and dissemination considerations have emerged as a leading priority in MBI research (Dimidjian and Segal 2015). Despite their chronicled association with religious traditions, rigorous examinations of religious identity, associations, and content in mindfulness have been sparse in psychological research (Lindahl 2015; Segall 2012; Sharf 2015). Although these two matters—implementation and dissemination of MBIs on one hand and MBIs’ religious associations on the other—have hitherto been pursued in separate bodies of research, we posit that they are importantly linked and address them together because religious associations may significantly impact their implementation and dissemination.

Over the past four decades, empirical support has grown for mindfulness as a treatment for various psychological problems, including depression, anxiety, and borderline personality disorder (Davies 2011; Linehan et al. 1999), preventing relapse of psychological disorders in early remission (Baer 2003), improving coping outcomes in patients with cancer (Ledesma and Kumano 2009) and other chronic medical conditions (Bohlmeijer et al. 2010), improving cognitive abilities in adults (Chiesa et al. 2011), and reducing stress in healthy people (Keng et al. 2011). Despite a large and promising body of efficacy research, MBIs face a set of challenges that may impact their ultimate dissemination and implementation among populations that stand to benefit from them. Our aim is to address the relevance of religion and spirituality to these challenges, and in doing so, to identify potential implementation solutions. Empirical research will help to guide implementation decisions and practice standards. Our aim is to provide a theoretical framework that can help orient and guide the development of a research program by integrating multidisciplinary perspectives and findings about these challenges. This article draws on bodies of literature that illuminate issues of religion and spirituality in MBIs and extends this literature to address implementation, dissemination, and research priorities.

We begin by examining the role of religious connotations in MBIs as a dissemination and implementation concern that stems, in part, from the history and nature of the interventions themselves. We review recent literature that discusses the nature and importance of the religious associations of MBIs and examine the relevance of these considerations to the acceptability and utilization of these interventions. We then examine the relevance of religion and spirituality to foundational dissemination priorities in clinical intervention science: cultural competence and the optimization of interventions for diverse populations. We present a review of the literature addressing religion as a likely determinant of disseminability for MBIs and conclude by proposing research and intervention strategies that may facilitate implementation across religiously diverse populations.

There is not yet scholarly consensus on a single definition of “mindfulness” or on what categorically constitutes a “mindfulness-based intervention” (as contrasted with other psychological interventions that may increase mindfulness or involve similar techniques). This is partly due to ongoing debates about how closely the construct’s psychological definition should reflect its Buddhist antecedents (Davidson and Kaszniak 2015; Lutz et al. 2015). Definitions of mindfulness commonly employed in scientific literature emphasize awareness of one’s present moment experience while having an attitude of non-judgmental acceptance toward these experiences (e.g., Bishop et al. 2004; Kabat-Zinn 1994; Shapiro et al. 2006). Rather than focusing on a “necessary and sufficient” definition of mindfulness, the present discussion centers on interventions that explicitly describe themselves as mindfulness or mindfulness based. This broad construal is in response, on one hand, to explicit calls from the field to examine concerns relevant to the effectiveness, implementation, and dissemination of these interventions (Davidson and Kaszniak 2015; Dimidjian and Segal 2015). On the other hand, it is in recognition that the linguistic field of mindfulness in intervention contexts has far exceeded the narrow list of interventions that researchers have reliably considered MBIs. Such interventions include (a) entire therapeutic modalities centered on mindfulness as a treatment mechanism (e.g., Mindfulness-Based Cognitive Therapy (MBCT); Teasdale et al. 2000), (b) specific techniques typically labeled as mindfulness such as mindful breath awareness (Daubenmier et al. 2013) and mindful eating (O’Reilly et al. 2014), and (c) “third-wave” behavioral psychotherapies that incorporate mindfulness principles and techniques among other therapeutic strategies (e.g., ACT DBT). Finally, participant perceptions of the mindfulness component in different intervention contexts might not overlap with the meticulous operationalizations that scholars use in their research. For these reasons, this review is broadly inclusive of interventions that claim mindfulness as a focus, mechanism, or principle. Although the present analysis cannot claim to be exhaustive of all such interventions, it is organized around principles that apply to religion and spirituality as dissemination concerns for MBIs.

Importantly, there are a number of interventions not typically referred to as mindfulness based that have a close taxonomic resemblance to MBIs and which share a space in the cultural imagination that borders on spirituality. This includes interventions that employ techniques (e.g., pranayama, yoga, transcendental meditation, compassion meditation) that are similar to techniques that are typical of MBIs, as well as psychosocial interventions that, while not called mindfulness based, have been found to have equivalent effects on self-reported mindfulness (e.g., progressive muscle relaxation; Agee et al. 2009). Although these interventions are not central to our review, some may be illustrative of the cultural considerations relevant to MBI dissemination. Although our focus is primarily on interventions that employ mindfulness, the present discussion may be relevant to other interventions that similarly evoke religious and spiritual diversity or ambiguity.

Religion as a Dissemination and Implementation Consideration in MBI Research

Do MBIs Have Religious Associations, and Why Does It Matter?

MBIs have, to differing degrees, drawn on contemplative techniques with roots in religions from around the world, and often upon Buddhist meditative practices. The word mindfulness is itself a translation of the Sanskrit word smrti, closely related to “recollection,” which coheres with Buddhist teachings about meditation as a practice situated within Buddhist teleology and epistemology. The history of cultural transformations that have led to mindfulness-based interventions in a clinical milieu is beyond the scope of this paper, but readers are referred to excellent work on this subject (Michaelson 2013; Sharf 2015; Williams and Kabat-Zinn 2013). Instead, our inquiry is concerned with the persistent ambivalence about religious associations of MBIs among interventionists, scholars, and—likely—the target recipients of MBIs, that has arisen out of this history, and with the ways in which this ambiguity may impact implementation and dissemination of MBIs.

One of the difficulties in evaluating the extent to which MBIs are demarcated as religious or spiritual, vs. secular, is the inconsistency with which intervention designers make such claims about the same interventions. Brown (2016) has termed this “code switching,” with multiple instances of interventions such as MBSR being presented as either secular, or as grounded in Buddhist principles, depending largely on the intended audience. Rather than attempting to resolve this inconsistency by means of some external taxonomic structure where some MBIs are placed in a secular “bin” and others in a religious/spiritual one, it is pragmatic to recognize that the status of MBIs vis-à-vis religion/spirituality is likely to be unstable in the public imagination, with important implications for dissemination and implementation. Succinctly expressed by Harrington and Dunne (2015, pp. 630), “Because of the peculiar circumstances behind its historical emergence, therapeutic mindfulness today sits on an unstable knife edge between spirituality and secularism, therapeutics, and popular culture.”

Perhaps because of their religious associations or antecedents, a typical departure point for scholarly work about MBIs’ religious associations is the pragmatically motivated secularization of MBIs (e.g., Hayes and Shenk 2004). There is a compelling argument that, if MBIs rely on biopsychological principles that are relevant to people across cultures, a religion-neutral (or “secular”) MBI can and should be implemented for the broadest possible impact. There is evidence from adjacent disciplines that not all patients, participants, and clients would find an overtly Buddhist practice—especially in its traditional form—palatable (Hathaway and Tan 2009; Knabb 2010). It is also good practice in intervention science to emphasize active ingredients of any intervention and to discard inert components (Kazdin 2002). Consequently, in order to construct religion-neutral versions of meditative practices originating in Buddhism for mainstream implementation, the developers of many MBIs have set aside concepts such as reincarnation, the eightfold path, the four noble truths, and “dharma” or Buddhist teachings about the world and one’s purpose in it (Baer 2003; Hayes 2002). Similar attempts have been made at secularizing practices with Hindu and Taoist antecedents (for a review concerning yoga, see: Cook-Cottone et al. 2019; see also for Tai Chi: Burschka et al. 2014). This process yielded a set of mindfulness techniques, not unlike the techniques of cognitive-behavioral therapy or biofeedback, whose cultural—and religious—components are minimized in order to eschew conflict. These techniques are regarded as secular, or at least neutral, to religion. Ideally, a Christian and a Confucian should be able to benefit in equal measure from a mindfulness-based intervention technique, much as they would with aspirin, whose pharmacological virtues are unhampered by matters of belief.

However, the building blocks of MBIs—which originated in one sociocultural context and are now being disseminated in a different one—are informed by constellations of dynamic psychosocial and cultural processes. These processes required adjustment and curating of MBIs in order to apply them as secular practices. A number of MBIs that designate themselves as secular have been developed and empirically tested (e.g., Grégoire and Lachance 2015; Mendelson et al. 2010). Nevertheless, some scholars have come to question the aptness of secularizing mindfulness—and whether secular interventions are in fact neutral. This debate primarily unfolds in the domain of ethics: do MBIs participate in cultural misappropriation (Carrette and King 2005)? Do MBIs lead to ethical problems when deracinated from their religious foundations (Sharf 2015)? Does elimination of traditional ethics teachings detract from the effectiveness of MBIs (Monteiro et al. 2015)? Conversely, is it fair to indoctrinate people with “stealth” Buddhism, which may be inextricable from MBIs (Brown 2016)? Finally, are Buddhist teachings being cynically implemented in a broader framework of unjust economic and political structures, such that suffering is increased rather than decreased (Gonzalez 2012)?

Some have argued for a deliberate pragmatic turn in response to these ethical questions, while nevertheless stipulating that any religious beliefs, or no religious beliefs, can be engaged with an appropriately secularized MBI (Hayes and Shenk 2004). Compson (2017) provides a cogent expression of this argument. She accedes that given their religious antecedents, the transformation of meditative practices into MBIs contributes to dilemmas of cultural identity and ethics. However, she suggests that these can be resolved through a pragmatic consideration: can mindfulness reduce suffering? Provided that MBIs work, clarifying the explicit and implicit religious or secular commitments of MBIs may be mere academic hair splitting. This influential view accompanies much of MBI research. We offer three considerations in our examination of this position.

First, different worldviews (including “religious” or secular worldviews) may differentially determine what it means for an intervention to work. The conceptions and interpretations of, and responses to suffering are often culture-bound (Sullivan et al. 2018). The prior contexts of mindfulness have at times assumed very different ends from those of contemporary “post-secular” societies. Harrington and Dunne (2015, pp. 621) note that “Mindfulness was never supposed to be about weight loss, better sex, helping children perform better in school, helping employees be more productive in the workplace, or even improving the functioning of anxious, depressed people.” Historically, it is not clear that Buddhists have sought a late-modern, Western model of mental health (Sharf 2015). Few contemporary Western clinicians would recommend that their clients cultivate despair at their faults and failings (Santideva 2008), give up their families to pursue a monastic life (Ashvaghosha 2008), or court an attitude of terror toward appearances (Buddhaghosa 2003), each of which can be found among the teachings attributed to the Buddha or influential Buddhist teachers, who cultivated mindfulness within their pedagogic repertoire. Thus, measurable reductions in anxiety or depression demonstrate that the intervention has “worked” only in a particular cultural context.

Second, it is not known whether MBIs are actually perceived to be as secular as their promoters suggest. In other words, if an intervention is presented as secular, does this mean that it is received as secular? There is little empirical research to suggest that this is the case. On the contrary, our preliminary findings from a sample of 1587 participants (Palitsky et al. in preparation) indicate that over 25% of respondents believe, prima facie, that mindfulness contains a religious component, and over half believe that it might.

Third, there is not adequate data demonstrating that framing MBIs in a secular fashion increases or maximizes their effectiveness. Even if MBIs work in general, it is not known if the various religious and secular re-framings of MBIs affect how well they work, and for whom. And when they do not work, the extent to which religious framing was a relevant moderator is undetermined. The conventions and statistical procedures commonly followed in mindfulness research have not been helpful in this regard. Only a minority of published mindfulness studies report on religion variables (Brener et al. n.d.), although there have been some calls for inclusion of such measures (Hulett and Armer 2016); when religion is measured, it is often treated as a demographic “control variable,” in lieu of close consideration of its moderating effects.

Insofar as interventionists have attempted to address the religious associations of MBIs, their efforts have typically concentrated on determining an appropriate stance toward religion during the intervention design process. We term this phenomenon “religious pre-positioning” because the MBI’s religious positions are resolved by the interventionists before it is placed before the target population. As previously suggested, this is not only an ethical concern—or even primarily an ethical concern—but also numbers among likely implementation and dissemination obstacles.

Dissemination and Implementation Priorities in MBI Research

Intervention research reflects a range of priorities and challenges that differ depending on the status of a given research program. The NIH 6-stage model has helped to organize research priorities across psychological science (Onken et al. 2014). This model indicates distinct priorities for research at different stages of a continuum, from basic research (Stage 0) through implementation and dissemination (stage V). From the six-stage model perspective, there is evidence for the utility of the basic mechanisms of mindfulness (stage 0), and a number of efficacious MBIs have been designed (stage I) and subsequently tested in controlled research clinic environments (stage II). These steps establish a foundation of efficacy within MBI research. In contrast with the robust research in stages 0–II, however, there has been comparatively little progress in later stages concerned with the effectiveness, implementation, or dissemination of MBIs. One review of the MBI literature found that 99 percent of all MBI research falls under stage 0–II research, with less than 1% of all MBI research falling under stages II–-V combined (Dimidjian and Segal 2015). Although MBIs yield impressive outcomes in well-controlled studies, comparatively little is known about their effectiveness outside of the lab, in community settings where most mental health interventions take place.

Thus, as evidence for the utility of MBIs grows, an expansion of priorities from efficacy to effectiveness is appropriate. This entails an explicit focus on intervention and participant characteristics that moderate the positive outcomes associated with MBIs (Davidson and Kaszniak 2015; Dimidjian and Segal 2015; Lutz et al. 2015). Religious and spiritual attributes are an important target in this work for three reasons. First, a degree of interpretation has been inevitable in turning practices derived from religious traditions into interventions appropriate for secularized contexts, and the impact of the resulting presence, or absence, of religious elements remains unclear (Lindahl 2015; Monteiro et al. 2015). Second, and relatedly, participants bring their own religious commitments into the intervention setting, and this can impact their experience of these interventions (Crescentini et al. 2014; Luu et al. 2009; Walker et al. 2011).

Third, religion is a key cultural foundation, and therefore represents an important dissemination consideration from the perspective of cultural competence (Milstein et al. 2017; Whaley and Davis 2007). All psychological interventions make cultural assumptions (DelVecchio Good and Hannah 2015). This may affect the dissemination of interventions because, on one hand, a patient’s acceptance of a therapy’s premises is often designated as a treatment mechanism in and of itself (e.g., accepting the CBT model of antecedent-cognition-behavior) (Goodman 2016; Wampold 2015). On the other hand, cultural differences may prompt a rejection of these very premises, which may impede the intervention’s effectiveness (Flowers 1987; Ibrahim 1985). This is especially the case when cultural differences touch upon religious worldviews, as has been found in atheists’ responses to Alcoholics Anonymous (Ellison and George 1994; Tonigan et al. 2002), and in dissemination challenges for CBT among Native American populations (Renfrey 1992). Thus, in dissemination to a population with diverse religious commitments, appropriate religious framing in any intervention becomes a matter of cultural competence.

Religion and Cultural Competence in Dissemination of MBIs

Religious and spiritual competence is an important feature of cultural competence in clinical domains (Vieten et al. 2013). Whaley and Davis (2007) argue that cultural competence is essential for the dissemination of empirically supported therapies, defining cultural competence as:

… a set of problem-solving skills that includes (a) the ability to recognize and understand the dynamic interplay between the heritage and adaptation dimensions of culture in shaping human behavior; (b) the ability to use the knowledge acquired about an individual’s heritage and adaptational challenges to maximize the effectiveness of assessment, diagnosis, and treatment; and (c) internalization (i.e., incorporation into one’s clinical problem-solving repertoire) of this process of recognition, acquisition, and use of cultural dynamics so that it can be routinely applied to diverse groups. (Whaley and Davis 2007, pp. 565)

In the context of MBIs and religion, cultural competence accordingly means recognizing that individuals’ religious priorities (a) reflect their embeddedness in a culture and community and represent adaptive potential; (b) should inform interventions that stand to interact with these priorities; and that (c) approaches for effectively working with participants’ diverse religious commitments should be incorporated into the MBI interventionist’s repertoire.

Considering the influential role of religion in Americans’ lives, and of the provenance of MBIs in non-European religious traditions, religion is an important cultural attribute of both the intervention, and of its intended recipients, which may help or hinder its uptake. It is therefore a likely determinant of the effectiveness and disseminability of MBIs. A careful examination of how MBIs’ perceived religious associations might bear upon their dissemination and implementation would be of benefit to researchers and participants aiming to carry these interventions into the community.

Religious and Secular Presentation in MBIs

The importance of religion and spirituality for many of the people who seek clinical support has contributed to the adaptation of multiple interventions for religious populations. Some treatments, such as Alcoholics Anonymous (AA) and other Twelve-Step programs, have contained spiritual language and concerns from their inceptions. Others, such as CBT with religious content, have involved augmenting non-religious interventions with religious content. Propst et al. (1992) found in their classic paper that for religious participants, CBT with religious content was not inferior, and often superior, to CBT without religious content. More recent research has identified adherence to be somewhat higher among religious participants enrolled in religious CBT, and with slightly better outcomes for these participants (Koenig et al. 2015). Similarly, AA has performed disappointingly in meta-analytic reviews (Ferri et al. 2006; Kownacki and Shadish 1999). However, closer analyses indicate that religiously motivated individuals experience greater improvement in AA, at least partly due to religion or spirituality influencing treatment adherence (Dermatis and Galanter 2016; Kelly et al. 2011). A full review of religiously adapted treatments falls beyond the scope of this paper (see, Hook et al. 2010). However, there is promising meta-analytic evidence supporting religious accommodations in psychotherapy for religious populations, with non-inferiority or superiority in clinical and spiritual outcomes (Worthington et al. 2011).

A handful of religiously framed MBIs have also been developed to accommodate religious populations. Hathaway and Tan (2009), Knabb (2010), and Trammel (2015, 2018) have formulated MBIs based on Christian practices. Thomas, Furber, and Grey (2018) have made useful suggestions for adjusting MBSR for Muslim populations, in light of evidence that Muslim women found aspects of standard MBSR to be culturally unsatisfying (Thomas et al. 2016). These interventions involve modifying, orienting, and describing MBIs as explicitly religious or spiritual, and emphasizing their relevance to the religious perspectives of a target population (e.g., Christians). Some of these modifications may shift the intervention to the point where it no longer meets the strictest mindfulness practice criteria, but this question may be deferred to mechanisms-oriented inquiries. From the standpoint of religion as a dissemination priority, these attempts at diverse religious framings are highly relevant. Certain mainstream MBIs also make clear associations with specific religious traditions, such as Buddhism (e.g., MBCT; Segal et al. 2001), although the significance of these associations often remains unstated. In addition, some approaches strive for religious inclusivity through an argument for equifinality—that multiple paths can lead to a single destination. For example, even certain non-MBI research that included religious components, such as Easwaran’s Eight-Point Program, has been shown to contribute to increases in self-reported mindfulness, a putative mechanism of action in many MBIs (Shapiro et al. 2008). Religiously oriented MBIs thus make substantive contributions to the interventionist’s armamentarium. However, two questions remain unanswered, the first of which has already been introduced: do MBIs with religious or spiritual components increase or diminish the benefit of the intervention, and for whom? Second, is the interventionist’s own determination (rather than determination by the recipient of the intervention) of the religious or spiritual content—or lack thereof—in an MBI an expedient way to optimize efficacy and effectiveness?

There have been several notable attempts by Pargament and colleagues to examine MBIs, as well as other meditation protocols, in secular and spiritual framings side by side. Feuille and Pargament (2015) compared the efficacy of three protocols in a population of college students: “standardized” mindfulness, “spiritualized” mindfulness, and relaxation. Standardized and spiritualized mindfulness both outperformed the relaxation protocols in this research. Prior research (Wachholtz and Pargament 2005, 2008) fielded a similar protocol comparing secularized and spiritualized meditation, with the spiritualized condition surpassing the “secularized” condition on the primary outcomes of reported pain after a cold-pressor task. However, the MBI comparison of Feuille and Pargament (2015) yielded no observed differences between the two interventions. This has led some to conclude that there is no difference in benefit between religiously oriented and secular mindfulness techniques (Creswell 2017). However, the latter study also found that the spiritually framed intervention corresponded with higher scores on indices of mindfulness. It may be inaccurate, then, to assume that there is no difference in benefit between the two framings, especially considering that the index of the putative mechanism—mindfulness—differed between the two conditions. An important detail of all three studies is that their populations were predominantly Christian, which may have contributed to greater amenability toward the “spiritual” mindfulness intervention. As previously stated, such population attributes may play an important role in determining the responses to an MBI, vis-à-vis its religious associations.

An MBI’s difference from or similarity to participants’ religious beliefs may not be a unilateral determinant of their openness to it. In the context of globalization and dynamic cultural exchange, the tendency for people to accept or reject cultural elements that they appraise to be incongruous with their own background has been studied as “culture mixing.” Culture mixing is subject to several determining factors relevant for the current discussion. Research on culture mixing may help to clarify conditions that lead participants to accept or reject MBIs.

MBIs in the Context of Culture Mixing

MBIs developed for US and European settings typically derive from Asian religious and cultural traditions. As such, they represent an example of culture mixing, which occurs when previously distinct elements of diverse cultures are mixed in the context of globalization (Chiu and Kwan 2016; see also: Morris et al. 2011; Torelli et al. 2011). These admixtures can prompt different responses, often depending on the identity of the respondent and features of the novel product.

Chiu and Kwan (2016) have organized reactions to culture mixing along a spectrum ranging from “exclusionary” to “integrative,” depending on which elements of culture are altered, fused, or juxtaposed. When cultural elements perceived to be sacred are mixed—for instance, building a mosque near Ground Zero in Manhattan or a McDonalds at the Great Wall of China—people typically respond in an exclusionary fashion by resisting mixing and prioritizing their own cultural norms. When “material” elements of culture—recognized for utility rather than sacred significance—are mixed, the response can often be integrative and accepting, as with “fusion” food dishes like curry burgers or French-Thai cuisine.

If MBIs are indeed a form of culture mixing, their association with religious values and beliefs may lead those with strong religious commitments to see them as encroaching on sacred elements of their culture. Meanwhile, those inclined to see MBIs as “material” may welcome such interventions as forms of creative mixing. Notably, when individuals see themselves as members of threatened cultural groups they are likelier to perceive culture-mixing as infringing on sacred values, and to react in an exclusionary fashion (Roos et al. 2015). Religious groups with more fundamentalist religious perspectives are in turn more likely to perceive their core values to be threatened or victimized by globalizing forces (Boyd 2010; Mashuri et al. 2015) and may therefore be likelier to respond to mindfulness in an exclusionary way.

Even well tested and empirically supported interventions can fail when clients are unmotivated or offended by the treatment (Roth and Fonagy 2005). This problem is exacerbated with relatively novel, yet involved, interventions such as MBIs, which depend a great deal on participant willingness. Prior research indicates that meditation practice time and overall engagement with the intervention may critically moderate the effects of MBIs (Pace et al. 2013). Thus, when considering the daily commitment that many MBIs require, the potential obstacles to maximally effective interventions multiply further.

Religious influences on implementation and dissemination of MBIs transpire at the intersection of cultural, individual, and intervention attributes. Therefore, the interactions of these characteristics represent important dissemination concerns. Investigating and addressing these interactions can help interventionists respond to cultural concerns without over-generalizing and allows for the advancement of recommendations to improve research and implementation.

Recommendations for Research and Implementation of MBIs

We have hitherto presented a rationale for addressing religiosity in MBI research, and in the implementation of these interventions. We now offer tentative recommendations for addressing religiosity in future MBI research and practice. Especially in the domain of practice, these recommendations are predominantly guided by theory rather than direct empirical findings. In the absence of such findings, recommendations must be delineated, tested, and revised. These recommendations themselves should be the subject of research and corresponding adjustment in light of further data.

Participant and Intervention Characteristics: Recommendations for Research

As is observed in most, if not all, clinical interventions (Kazdin 2007), attributes of participants and attributes of interventions are likely to moderate target populations’ responses to MBIs. Religious and spiritual attributes are particularly valuable targets for future research. These include participants’ individual characteristics (e.g., flexibility of religious beliefs, religious fundamentalism, and intrinsic religiosity). They also include intervention-level characteristics such as the description and framing of the intervention, as well as intervention content.

Participant Characteristics

Extant research in the psychology of religion may help identify relevant participant characteristics. This research comprises a diverse, expanding field; a thorough accounting of the assessment of religion and concomitant methodological implications is beyond the scope of this review, but for further reading, readers are directed to other literature (Baumsteiger and Chenneville 2015; Hill and Pargament 2008; Hill et al. 2000; Koenig 2012). Nevertheless, key constructs and measures from the field can inform considerations for addressing individual-level characteristics pertinent to the dissemination of MBIs. These can be organized along the following lines: historical/affiliative attributes, private/psychological attributes, and public/behavioral attributes. These attributes represent a guiding heuristic rather than an ontological distinction; for further discussion, see Palitsky et al. (2019).

Historical/Affiliative Attributes

Denominational differences among participants may predict different responses to an MBI. However, little is known about the extent to which denomination may be a predictor. Affiliation with covenantal religious traditions such as the Church of Latter Day Saints, Mennonite, or Hassidic Judaism (Bromley and Busching 1988) may predict more exclusionary responses. Groups who adhere to more fundamentalist values may perceive themselves to be culturally threatened and may be likelier to experience culture-mixing as an infringement on sacred values (Mashuri et al. 2015; Roos et al. 2015). Novel content may be likelier to interact with sacred values for those who belong to such groups. For example, there is evidence that conservative Protestants view moral arguments described as “scientific” with some skepticism and reservation (Evans 2013), which may contribute to rejection of secularized interventions. In the context of psychotherapy, Christian clients who score more highly in religious commitment tend to prefer Christian therapists, and tend to rate those therapists more highly, than those who score lower on these measures (Walker et al. 2011). Certain atheists may likewise be disposed to reject religious or spiritual content (McAnulla 2014; Ribberink et al. 2017). Cohen et al. (2014) have found evidence that Protestants, as a broad denominational group, may assign greater moral consequences to mental states than do Catholic and Jewish participants. A plausible explanation for these differences concerns the history of Protestantism, which placed greater epistemological and salvific priority on internal experiences of believers during and after the Protestant Reformation (Asad 1993; Cohen and Hill 2007). Mental experiences, an ostensive focus of MBIs, may tread close to domains perceived by such participants to be sacred. Mental experiences may also be likelier to provoke moral responses when sinful, unwanted, or shame-inducing thought content arises. Adopting a “non-judgmental” attitude toward these may run counter to other religious injunctions, and provoke rejection. Importantly, one’s affiliation with a denomination contains an element of historicity, both developmental and cultural. For example, those who have disaffiliated with covenantal religious groups may exhibit complicated relationships to elements of these religions due to their past personal history (Bromley 1991). Experiences of abuse in a faith community may cause starker responses, which have been termed “spiritual trauma” by some (Doyle 2009). Finally, when it comes to individual differences, it is likely that variation of key variables within religious denominations is at least as important as variation between these denominations (Idler et al. 2009; Minkov and Hofstede 2014; Olson and Perl 2002), indicating some caution in generalizing based on denomination alone.

Private Psychological Attributes

Researchers have employed a large collection of self-report scales to assess motivation, beliefs, and attitudes associated with religiosity. Among these, several variables are likely to bear upon the uptake of MBIs, with corresponding measures that can be used in future research. These represent a non-exhaustive list of likely candidates to guide further research.

In light of Chiu, et al.’s work on culture mixing (Chiu and Kwan 2016; Torelli et al. 2011), an important participant characteristic to investigate is the propensity to respond negatively to religious content perceived to be different from one’s own. Openness to such content corresponds with amenability toward change in one’s own beliefs about oneself, one’s purpose, and questions of meaning in life. This characteristic is may be probed by means of Existential Quest (9 items; Van Pachterbeke et al. 2012) or Xenosophia (a 5-item subscale within the Religious Schema Scale; Streib et al. 2010), both of which can be applied to non-religious and religious individuals. Existential Quest assesses the extent to which a person believes their own existential outlook to be continuously developing, and the extent to which such development is a motivating force in a person’s life; Xenosophia corresponds with an appreciation of religious and spiritual content from faith traditions distinct from one’s own. These traits may be associated with less interference when participants are exposed to religious framings in MBIs that are inconsistent with their own views about religion.

Conversely, religious fundamentalism may predict rejection of content perceived to be different from one’s faith tradition. The meaning of the construct of religious fundamentalism has broadened over time (Almond et al. 2003). Following Altemeyer and Hunsberger (1992), it is operationalized here as a belief in a singular set of core teachings about a religious truth, which is opposed by malevolent forces, which must be followed in a traditional fashion, and which impart a special relationship with a deity or transcendent reality. Those with more fundamentalist perspectives may identify spiritually derived, or explicitly secular, practices as conflicting with values they deem sacred, contributing to the rejection of novel content (Torelli et al. 2011). Religious groups with fundamentalist perspectives may also perceive themselves to be threatened by external cultural forces (Boyd 2010), which may similarly contribute to exclusionary responses.

Fundamentalism should be considered distinct from traits such as intrinsic religiosity (Allport and Ross 1967), which indicates a view of one’s religion as an end in itself, rather than a means to an end. Higher intrinsic religiosity should correspond with more favorable responses to MBIs with religious content, but in the absence of fundamentalist views may not spur the same degree of rejection of perspectives deemed distinct from one’s own. Individuals high in intrinsic religiosity (8 items; Hoge 1972) may have an easier time integrating interventions with religious associations with the rest of their lives, in light of their religious outlook. Intrinsic religiosity may potentially apply to those who see themselves as spiritual but not religious, and represents another way in which religiosity may heterogeneously determine responses to MBIs among different populations.

Public/Behavioral Attributes

Perhaps the most predictive variables in the study of religion pertain to behaviors rather than beliefs. For example, religious attendance frequently out-performs “interior” religion variables as a predictor of health (Idler et al. 2009). Such activities are often bundled with social interaction, provision of support, and—relevantly to MBIs—a shared mindset and set of motivations (Ellison and George 1994). Interaction with those in one’s religious community outside of services (Item 7 of the Social Network Index; Cohen et al. 1997) may also be an important factor because it may speak to shared values as well. Prayer is another behavior that can convey different attitudes toward religious content (Krause and Hayward 2013). Frequency, type, and context of prayer may bear on individuals’ response to MBIs—not only due to aspects of participants’ beliefs, but also because people who pray regularly may perceive mindfulness as overlapping with, supporting, or competing for, their time for and ways of observance.

Intervention-Level Characteristics

Intervention-level characteristics include the ways in which interventions are described and framed, as well as the explicit religious or spiritual content of these interventions. Interventions may be described from the outset as scientific, secular, “Christian,” “Buddhist,” spiritual, or as incorporating any other religious or spiritual perspective. Alternately, such descriptions may be glossed over or avoided altogether. Interventionists may find themselves making such descriptive statements about interventions intentionally, as a matter of routine, or in ad hoc modulations of an intervention to the intended audience. Besides the overt description of interventions, the content of interventions may also vary, as in Feuille and Pargament’s (2015) research or within explicitly religious MBIs (Hathaway and Tan 2009).

Differences in description and content may interact with individual-level religious characteristics to affect responses to a given MBI. For example, fundamentalism may not predict resistance to MBIs in its own right. If an intervention is framed in a way that is consistent with participants’ views, greater fundamentalism may correspond with greater adherence. Then again, the same intervention may be rejected by certain atheists on the grounds of its religious language.

We therefore suggest that the effects of an intervention’s religious framing be regarded as interactive with participant characteristics. Worthington (1988, pp. 170) postulated that when religion is salient for psychotherapy clients, certain factors might influence to the degree to which they experience conflict with external, religion-relevant values. These comprise “(a) contextual pressures, (b) presentational styles of the interactants, (c) emotional state of the interactants, and (d) previously established communication patterns of the interactants.” Each of these factors constitutes a research domain unto itself (Adelson and Owen 2012; Beutler 1997; Poznanski and McLennan 1999), and a detailed account would exceed the scope of our recommendations. However, these factors make the values, attitudes, and styles of interventionists relevant among intervention characteristics.

The facilitator or provider of the MBI may be an important intervention-level characteristic that is not be part of the initial intervention design, but which may be considered a “therapist effect” (Crits-Christoph et al. 1991). For example, although many psychotherapists report themselves to be spiritual, they have also been observed to score substantively lower on indices of religiosity than the US population (Rosmarin et al. 2013). In many cases, a mismatch in values between participant and interventionist is inevitable, although not necessarily problematic (Pecnik and Epperson 1985). In a systematic review, although mismatch between therapist and client R/S attributes did not appear to have clear influence on outcomes, both therapist and client religious attributes were associated with willingness to integrate religion or spirituality into treatment, as well as attitudes toward values that contrasted with their religious outlooks (Cummings et al. 2014). Beyond affiliative attributes, measurement of therapist factors is important and can take many forms. Research and practice is likely to benefit from detailed coding (Decker et al. 2014), and there exist promising self-report measures of facilitators’ attitudes that may affect interactions in an MBI (e.g., Cultural Humility: Hook et al. 2013).

Critically, whether or not MBIs take a position on religiosity is itself an intervention-level characteristic. Although religious “pre-positioning” is a typical (if inconsistent) characteristic of many MBIs, religious pluralism presents an alternate way of navigating the religious associations of MBIs that may be more appropriate.

Recommendations for Religion-Informed Dissemination of MBIs: A Case for Pluralism

Pluralism as a Pathway Toward Improved MBIs

Wang et al. (2003) found that in the USA, more of the people who sought treatment for mental disorders initially turned to clergy (25%) than to physicians or psychiatrists (16.7%). This disparity indicates that religious concerns are important to many of the people who may become the recipients of MBIs in a clinical setting. It is therefore worth asking how interventions can address the diversity of religious orientations in collaboration with, rather than despite, people’s religious commitments.

Deciding a priori whether an MBI should be secular or religious might present a barrier to the implementation and dissemination of these interventions. As noted earlier, there is preliminary empirical evidence that mindfulness is publicly perceived (even if erroneously) to have a religious or spiritual component (Palitsky et al. in preparation), and also that engagement in an MBI is an important determinant of its impact (Pace et al. 2013). Religion is a key cultural foundation and, perhaps especially in light of the chronicled association between MBIs and South and East Asian religious traditions, represents a fundamental cultural competence consideration in the implementation of MBIs. An approach consistent with religious pluralism, aligned with principles introduced by Eck (2003), offers potential for an effective approach to handling issues of religious diversity that impact the disseminability of MBIs.

According to these principles, pluralism is an engagement with diversity that seeks understanding across differences, fostering an encounter of commitments—closely held religious perspectives—based on dialogue. Pluralism may be distinguished from religious diversity or relativism: diversity or relativism indicate the coexistence of different religious perspectives, but pluralism seeks the encounter of religious commitments, “… opening up those commitments to the give-and-take of mutual discovery, understanding, and, indeed, transformation” (Eck 2003, pp. 168). This approach is paralleled in many ways by a description of religious pluralism in clinical settings presented by Zinnbauer and Pargament (2000, pp. 168), which similarly states “within a cross-cultural framework, the pluralist can respect the religious views of the client while bringing his or her own religious views into the treatment.” In following Eck, however, our stance on pluralism for MBIs is distinct in two ways. First, it is not centered on the clinical relationship in light of the wide variety of settings for MBIs. Correspondingly, to bring pre-existing “religious views into the treatment” involves the examination of intervention-level characteristics as described earlier. Second, our approach eschews an equifinal perspective on spirituality because the assumption of equivalent ends to different paths may elide real differences in favor of superficial agreement.

In the context of MBIs, pluralism suggests an inclusive approach to addressing religious obstacles to implementation. Rather than resolving religious differences through eliminating religious elements (a potential consequence of labeling an MBI as secular), opportunities are created for meaningful responses to sources of religious and ideological impasse. By addressing religious differences directly, a pluralistic approach can maintain the autonomy of individuals’ sacred values, while offering ways to integrate aspects of mindfulness that have some material utility. Such an approach may also facilitate increased participation in MBIs, as it invites engagement (rather than withdrawal) in response to perceived discrepancies between individual beliefs and the content of the intervention.

Recommendations: Pluralism in Practice

In light of the reviewed theory and research, implementation and dissemination of MBIs may be improved by including components that address the potential for religious differences directly and non-coercively. The following recommendations are intended to serve this function. These recommendations should, themselves, be tested and improved upon with the advent of empirical evidence.

  1. 1.

    Provide participants with opportunities to examine their own ethical and faith commitments

    Participants should be given the opportunity to explore their individual religious or ethical commitments within the context and structure of MBIs. Such a discussion is universally applicable, even to participants who do not profess religious beliefs. Atheism, agnosticism, humanism and identifying as “spiritual but not religious” each represent a unique stance on religion and typically contain some form of guiding ethical principles.

    Such opportunities need not be time or resource-intensive. MBI instructors might introduce a brief segment into the general course of the instruction, concordant with the duration of the intervention itself (e.g., an 8-week intervention may include 30 min, while a 1-h intervention might allot 5 min). Such a segment can introduce the consideration of ethical and faith commitments (whether secular or religious) and how these may interact with the intervention, in the form of a guided dialogue, a worksheet, or a brief inviting statement. The optimal structure of such materials is likely to vary considerably depending on the MBI but would pose a non-obstructive addition to MBI curricula. Instructors should not provide ready-made resolutions to practitioners’ quandaries; rather, instructors should be able to supply information to clarify any misunderstandings (e.g., mindfulness is not a process of “emptying” one’s mind). This means that in manualized, regimented interventions like MBCT and MBSR, opportunities to explore how these interventions fit with religious commitments (or lack thereof) must be carved out.

    These activities and ones described below should be optional. Facilitators of MBIs are encouraged to take into account the existence of diverse pressures that may discourage participants from reporting or discussing their religious identity, commitments, or struggles. In a homogeneous religious community, for example, it may be inopportune for participants to publicly disclose aberrant religious perspectives. Participants’ statements about their religiosity should be treated with appropriate confidentiality and responsibility.

  2. 2.

    If uncertain, admit uncertainty

    For MBIs like ACT and MBSR that exhibit a range of positions with regard to their religious and spiritual affiliations, it may be best for instructors to respond to such questions about the religious stance of an MBI or the implications of its techniques with an admission of uncertainty. Instructors can also use such questions as opportunities to model an attitude of openness and curiosity about the potential relevance of religious and spiritual attributes to the participants’ experience. An apt response to the question “Is mindfulness meditation a spiritual practice?” might be, “This practice was adapted from the religious tradition of Buddhism, but the variation of the practice that we’re doing here is different from a more traditional practice in many ways. This mindfulness practice has been studied by scientists for its stress-reduction benefits, and it is unknown what role spirituality plays in these benefits or in how people experience these practices. Some of these practices will feel spiritual, and if they do, it is up to you whether or not to engage with these practices, and how you would engage with them. I’m curious, what prompted you to ask that question?”

    Questions about the religious or spiritual affiliations of MBIs may indicate participant ambivalence about this aspect of the intervention, and therefore present an opportunity for instructors to explore any areas of conflict. Such an approach is not dissimilar from motivational interviewing, an empirically supported therapy that enhances motivation for change by helping individuals identify and resolve sources of ambivalence. Motivational interviewing practitioners provide a framework for individuals to explore and resolve their own ambivalence (rather than prescribing a resolution), which reduces resistance and reactance (Hettema et al. 2005). Similarly, allowing uncertainties regarding the spiritual underpinnings of mindfulness into the process of learning MBIs, and empowering participants to consider the fit of the MBI with their own beliefs, can amplify the effectiveness of these interventions and reduce attrition.

    Relatedly, participants may have questions or concerns about religious matters that are more appropriate for religious professionals or paraprofessionals than they are for MBI facilitators. Facilitators should therefore not be expected to provide theological guidance and may find themselves practicing outside their area of competence if they attempt to do so. In such situations, facilitators are encouraged to help participants access resources within the appropriate religious traditions. Several models exist for collaborative partnerships between communities of faith and mental health professionals, such as the COPE model (Milstein et al. 2010), which encourage the cultivation of relationships with a diverse network of religious professionals. Ultimately, participants may wish to turn to MBIs that derive from their own tradition, or may prefer the guidance of their own religious community. Encouraging them to find such guidance helps to support participant autonomy.

  3. 3.

    Encourage participants to self-determine their level of intervention engagement

    If participants are concerned about MBIs interfering with their sacred values, they should be provided opportunities to discern for themselves the parts of the intervention that they are and are not willing to accept, with non-coercive assistance from the facilitator. Although beyond the scope of the present paper, such a process is amenable to manualization and may even implement or adapt established methods of inquiry, such as theological reflection (Graham et al. 2005). This applies to didactic components of the MBI—for example, instruction provided about the nature of the mind or rationale for practice—which may or may not readily integrate with participants’ belief systems. Although MBI techniques are often intertwined with the pedagogical material behind them, this need not always be the case. For example, a participant may engage in a body-scanning technique from an MBI, but incorporate an interpretation of the practice drawn from their own religious beliefs about the body. Broadly, interventionists should invite participants to engage in the practices in a manner that works for them, embracing components that they find beneficial and leaving behind anything unpalatable or incongruent with their own experiences.

Facilitators

Although these recommendations are primarily concerned with MBIs, their conception, and dissemination, it is important to recognize that facilitators play important roles in many MBIs. MBI instructors have differing degrees of training. Psychotherapists, layperson support providers, and bearers of specialized certifications like MBSR instructors bring diverse skillsets as facilitators. Our recommendations are intended as guideposts for adopting a pluralistic posture, which can be implemented by facilitators at any training level because they signal orientations and priorities in intervention provision rather than specific techniques. Importantly, these guidelines might best stand to inform the manuals and trainings that instructors rely on and may be implemented by any training model. The foundations of pluralism and the common tenets of most MBIs share a common thread: an emphasis on openness and curiosity toward the individual experiences of participants. These recommendations are intended to draw naturally from this shared thread without requiring any additional expertise. As suggested in recommendation 2, instructors may also find it helpful to build collaborations with professionals in religious communities in order to draw on the expertise of clergy in a continuum of care.

These suggestions for facilitators are aligned with work by Vieten et al. (2013), which proposes a set of spiritual and religious competencies for psychologists. This resource is recommended to facilitators, with one caveat: the relationships between facilitators and participants may differ in important ways from those between clinical psychologists and their clients. For example, Vieten et al. (2013) suggest that psychologists inquire bout their clients’ religious and spiritual backgrounds. This may be appropriate under some circumstances, but as stated in recommendation 1, facilitators should exercise discretion when making direct inquiries about participants’ religious and spiritual backgrounds in group settings.

Time is a precious resource in any intervention, and following these recommendations may add to the duration of some MBIs. However, this possible cost is recouped by potentials for reduced attrition, improved intervention experience, preserved participant autonomy, and the potential of this process to enhance buy-in for the intervention among stakeholders. Such gains and losses can be evaluated empirically with trial designs that address obstacles to adherence and include opportunities to evaluate these directly and indirectly, with intent-to-treat designs. For participants who withdraw from an intervention, the explicit affirmation of their core values may promote willingness to contribute data to ongoing research.

In summary, implementation and dissemination of MBIs may be improved by attending to how they interact with participants’ religious commitments. Pre-determining an MBI’s stance toward religion, or neglecting to address the matter of religion altogether, may be alienating for some. As an alternative, a pluralistic approach can center participants’ autonomy while enhancing intervention disseminability. MBIs that are responsive to religious diversity can advance culturally competent practices in the field.