Ellett, L. (2023). Mindfulness for psychosis: Current evidence, unanswered questions and future directions. Psychology and Psychotherapy: Theory, Research and Practice. https://doi.org/10.1111/papt.12480
Key Points
- Research on mindfulness-based interventions for psychosis has proliferated over the past 15 years. Meta-analyses of these studies have found a range of small to large effect sizes for reductions in symptoms like hallucinations and delusions, indicating potential benefits.
- Four key issues discussed in the field are: (a) Safety – is mindfulness safe, or could it exacerbate symptoms for some people? (b) Home practice – is practicing mindfulness at home essential for good outcomes? (c) Metacognitive insights – does developing metacognitive awareness explain benefits beyond mindfulness practice? (d) Implementation – do positive effects found in research translate successfully into real clinical practice settings?
- Overall, mindfulness is emerging as a promising and likely effective adjunct treatment for psychosis, both for reducing symptoms as well as increasing metacognitive awareness and self-compassion. However, further research is still needed on optimizing protocols, identifying mechanisms of change, assessing feasibility in routine care, and evaluating longer-term outcomes.
Rationale
Mindfulness interventions aim to teach non-judgmental acceptance and observation of moment-to-moment experiences, including difficult emotions, sensations, and beliefs.
For psychosis, mindfulness may reduce distress and disturbance associated with hallucinations and delusions by enhancing metacognitive awareness and decreasing maladaptive emotional and behavioral reactions.
For example, by noticing psychotic thoughts as “just thoughts,” the person relates to them differently and no longer sees them as absolutely real or requiring behavioral responding.
Reviews indicate mindfulness holds promise for symptom improvement, supporting continued research on change mechanisms and the feasibility of large-scale implementation.
Method
This review paper identified ten published meta-analyses examining mindfulness interventions for psychosis, spanning from 2013 to early 2023.
To systematically search for these meta-analyses evaluating mindfulness for psychosis, the key terms “mindfulness,” “psychosis,” and “meta-analysis” were used.
Databases searched were not reported. The meta-analyses included 3 to 26 studies investigating group- and individual-based mindfulness protocols tailored for psychosis, often integrated with cognitive-behavioral therapy (CBT).
Primary outcomes summarized were overall psychotic symptom severity and negative symptoms. No formal risk of bias assessment was undertaken for the included reviews.
Sample
While details of individual study samples were not reported here, the collected study samples across meta-analyses included clinical adult populations with confirmed psychotic disorder diagnoses such as schizophrenia or schizoaffective disorder.
No information was provided regarding the demographic composition of samples across studies.
Statistical Analysis
Key statistical results extracted from the identified meta-analyses were effect sizes gauging the magnitude of pre-post changes or differences between mindfulness groups versus control conditions on psychotic symptom severity.
Effect sizes reported predominantly included Hedges g, a variation of the more well-known Cohen’s d, corrected for small sample biases.
Larger g values indicate larger effects, with benchmarks of 0.2 = small, 0.5 = medium, 0.8 = large effects.
Results
Reported meta-analytic effect sizes for symptomatic improvements ranged substantially from 0.46 to 0.86 across reviews.
Two meta-analyses found large effect sizes of 0.67 to 0.86, while other reviews converged on more modest small-medium effects of 0.46 to 0.57.
Though not completely consistent, results overall indicate promise and preliminary support for mindfulness to lessen the severity of persistent psychosis symptoms.
Insight
This review offers an insightful, updated overview of the cumulative evidence regarding mindfulness as a supplementary treatment specifically for psychotic conditions.
By collating findings only from meta-analyses, results distill the key effects found across the exponentially growing body of research in this area.
The paper also helpfully discusses critical future research directions focused on mechanisms of therapeutic change, safety, the feasibility of dissemination into routine care, and real-world clinical effectiveness.
Strengths
- Systematically searched for and identified meta-analytic reviews to best summarize collective evidence
- Findings are highly relevant as synthesized papers only through early 2023
- Quantified study results using effect sizes to allow comparison of effects across meta-analyses
- Outlined important next research steps targeting mechanisms and implementation
Limitations
- Did not report assessing risk of bias in the reviewed meta-analyses
- Provided minimal details about some included reviews
- Did not conduct any novel quantitative syntheses across existing effect sizes
- Lacked information on study samples and mindfulness protocols used
Implications
The reported small-large effect sizes indicate the potential for clinically meaningful reductions in persistent symptoms when mindfulness approaches are applied in research contexts among people with enduring psychotic disorders.
Effects may be enhanced by identifying active ingredients accounting for change, such as metacognitive awareness, along with optimizing home practice.
Support for feasibility and effectiveness in community practice remains preliminary, but findings signify promise for wider implementation under pragmatic conditions if tailored appropriately to overcome barriers.
Conclusions
In conjunction with prior treatments, mindfulness training allows individuals with psychosis to relate to their symptoms in more accepting yet detached ways, reducing associated distress and dysfunction.
Current research provides initial evidence for mindfulness as likely safe and useful for lessening psychosis severity.
Open questions remain regarding what specific mechanisms explain benefits, how protocols could be optimized, and whether favorable outcomes endure over extended periods or translate successfully into large-scale practice across broader clinical settings.
Carefully designed implementation research focusing on these issues should be a priority next steps for the field.
References
Primary reference
Ellett, L. (2023). Mindfulness for psychosis: Current evidence, unanswered questions and future directions. Psychology and Psychotherapy: Theory, Research and Practice. https://doi.org/10.1111/papt.12480
Other references
Chadwick, P. (2014). Mindfulness for psychosis. The British Journal of Psychiatry, 204(5), 333-334. https://doi.org/10.1192/bjp.bp.113.136044
Chien, W. T., & Thompson, D. R. (2014). Effects of a mindfulness-based psychoeducation programme for Chinese patients with schizophrenia: 2-year follow-up. The British Journal of Psychiatry, 205(1), 52–59. https://doi.org/10.1192/bjp.bp.113.134635
Learning check
- What do you see as potential benefits or risks of incorporating mindfulness practices into treatment for people with psychotic disorders? How might these differ from effects for other mental health conditions?
- In your opinion, what core components of mindfulness interventions do you think drive improvements in symptoms like hallucinations or delusions? What mechanisms might explain the impacts on these kinds of experiences?
- How could mindfulness protocols be feasibly and successfully adapted for implementation in real-world public mental health settings? What barriers or practical challenges might come up?
- Do you foresee any ethical issues arising from offering mindfulness-based approaches to people with severe, persistent mental illness? If so, what safeguards could be put in place to avoid potential harms?
- From a clinical perspective, what patient characteristics or symptom profiles would make someone more or less suitable for adjunct mindfulness treatment? When might integrative mindfulness be contraindicated?
