Western science doesn’t take indepth look at meditation

The Western scientific and health community of scientists and clinicians has generated in excess of 3,000 peer-reviewed articles on or referring to meditation (as featured in the major bibliographic databases such as MEDLINE and PsycINFO).

The maximum yearly output was in 2000–2001 when 12 RCTs were reported in MEDLINE. In the same time period 106 RCTs for fluoxetine, as an example of a mainstream medication, and 98 RCTs for acupuncture, as an example of a complementary medicine, were published.

The rate of publication of RCTs on meditation is poor in comparison to other therapeutic modalities in either the mental health or complementary and alternative medicine genres. Thus although meditation is often a topic of superficial discussion amongst scientists and clinicians, it is rarely the subject of in-depth scientific examination.

Dr Ramesh Manocha.

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Mental Silence

First - there is insufficient evidence to support the idea that meditation, as conceived and tested by scientific researchers in the West, is any more effective than simple relaxation or rest.

Second - the use of high face-validity control groups is critical in meditation research because of the need to exclude the important confounding effects of non-specific factors that relate to plausibility of the intervention (such as placebo, expectancy, or therapeutic contact).

Third - there is at the moment no systematic comparison of different conceptualizations of meditation. Only Carrington has compared two kinds of meditation in the context of work stress and found that there were no major differences between the two36. It should be noted however that the different meditations in her trial both belong in the same “relaxation meditation” category.

These observations could lead to three possible conclusions:
1. Meditation is in fact no more effective than other approaches to rest and relaxation. Yet that meditative traditions have existed for thousands of years and at least in India, are widely perceived to have specific and unique features. In other words history and culture do not agree with the idea that meditation is simply a method of mundane relaxation. While this “test of history” does not provide proof of efficacy, it does encourage the undertaking of a thorough examination of the phenomenon before it is discarded as mere folklore and superstition.

2. The measures which have so far been used to assess the effects of meditation are not sensitive to the specific effects of meditation. The wide variety of outcome measures used means that if the specific effects of meditation are not detectable, then the effects are either too small or too esoteric for mundane study.

Yet classical descriptions of meditation suggest that despite the metaphysical basis of meditation, its effects do manifest themselves in mundane dimensions such as health and behaviour, implying that at least some of the many measures available to researchers should be able to detect a differential effect.

Again, while this might be satisfactorily applied to the genre as a whole, there appear to be isolated exceptions which suggests that certain as yet undetermined categories may be able to generate specific effects. Yet our analysis of the aggregated data has not yet yielded a pattern with sufficient clarity to identify the features of that category.

3. The methods that have been labelled as “meditation” in the trials do not consistently reflect the true nature of meditation. This is the most interesting and important issue and therefore merits considerable discussion. The functional and conceptual definition determines the nature of the intervention, which in turn influences the choice of the control method that ought to be used and therefore the validity and generality of the findings.

Yet defining meditation has proven to be a difficult challenge for modern researchers. While early empirical reports seemed to show that measurable distinctions between meditation and rest or simple relaxation existed, rigorous trials did not support these perceptions74. As a result, much of the research work on meditation has been based on the assumption that meditation techniques are much the same despite minor external and superficial differences.

Indeed Western researchers have proposed that most meditative processes are physiologically similar to simple rest and relaxation75 and the high quality physiological trial data seems to support this76. These perceptions have thus given rise to an assumption of “psycho-physiological uniformity”.

This last idea, it is contended, is the key to the problem because in fact, both Western meditation enthusiasts and Western scientists, despite their opposing views, have failed to apprehend a key factor that underlies the ancient tradition of meditation: The idea that meditation necessarily involves the experience of mental silence.

Dr Ramesh Manocha.

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Effects of meditation on anxiety and stress

The effects of meditation on anxiety and stress are comparable to effect sizes described in conventional meta-analyses of psychotherapy field studies73.

For example Andrews’ review of psychotherapy for neurotic patients reported a mean effect size of 0.74 for verbal psychotherapy and 0.97 for behavioural psychotherapy vis-a-vis a mean effect size of 0.55 for placebo56.

It should be noted however that the meditation studies focused on participants with non-pathological anxiety states, raising the possibility that the potential impact of meditation may be limited by a “ceiling effect” due the recruited sample’s relatively mild symotomatology and hence minimal scope for clinical improvement.

Dr Ramesh Manocha.

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Meditation: a lifestyle not a treatment

Unlike modern Western therapeutic thinking however, meditation was not originally designed to be used as a course of treatment so much as to be part of an ongoing lifestyle thus implying that the benefits of meditation are likely to persist in the follow-up phase only so long as the person chooses to meditate regularly.

Meditation instructional programs are usually relatively intense and it is therefore worthwhile determining whether changes brought on by the instructional program can be maintained when participants are left to continue unsupervised with whatever skills they have acquired in the more formal phase of their training. Given that consistent evidence for a specific effect is lacking even within the intervention phase of the studies, it is even more unlikely that evidence for an effect will be detectable in the follow-up phases.

Like any other evaluation of therapeutics, the detectable effect of the intervention will be determined by the degree to which the participant complies with the treatment. This is particularly important in meditation research because meditation requires considerable active involvement and commitment. There are several ways to assess compliance, including attendance rates at supervised treatment sessions, home-practice diaries and subjective experience reports.

Dr Ramesh Manocha.

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Sham meditation procedures

Sham meditation procedures necessarily involve deception of participants and the ethicality of this in clinical trials is open to dispute. Further, this kind of strategy can be logistically challenging and there is always a risk that the deception might be uncovered, thereby immediately invalidating the entire study.

The fact that some techniques elicit detectable effects when compared to sham procedures while others do not implies that some meditation techniques may not have specific effects whereas others may well have such effects. This logically suggests the possibility that the genre is not homogenous and that the use of meditation versus sham studies offers a method by which specifically effective techniques may be separated from those that are not.

Dr Ramesh Manocha.

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Ideal control method for meditation

It may not be practically possible to devise and implement an ideal control method for meditation trials, nevertheless it is important to select a strategy that approximates that ideal.

The bare minimum criteria for a control process in meditation research should therefore be:
• First, high face validity as a therapeutic/stress management intervention in its own right. It should actually appear to be a credible meditation technique if that is the expectation of participants.
• Second, a process that involves relaxation and reduction of somatic arousal since this is the nearest conventionally understood phenomenon that meditation resembles and from which it needs to be distinguished.

Given these considerations, two strategies with high face validity are worth discussing in further detail.

Sham meditation involves designing control strategies that overtly resemble the intervention, but which do not actually trigger the effects purported to be specifically associated with meditation.

Dr Ramesh Manocha.

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Control strategies in meditation

Examining the studies in the review ”Does Meditation Have a Specific Effect? A Systematic Experimental Evaluation of a  Mental silence Orientated Definition”, control methods were presumptively categorized according to their face-validity into low, moderate or high face validity categories.

The low face-validity controls used strategies that were:

  • Passive and unstructured: Participants were involved in minimal or no activity relating to the trial and had no interaction with researchers as a result of being allocated to the control group (e.g. waiting list, no treatment, self-directed reading, or referral to community resources). This kind of comparator controls for minor non-specific effects, such as regression to the mean, the natural history of disease states and environmental factors common to all participants. It does not however, control for any non-specific effects that may be elicited by behaviour therapies.

The moderate face-validity controls use strategies:

  • Passive and structured. These involved some sort of regular and structured interaction with personnel associated with the experiment (e.g. regular lectures, specific reading, structured educational sessions on unrelated topics, regular BP checks). This controls for the same confounders as Category 1 in addition to the effects of therapeutic contact and sense of active involvement.
  • That were active in nature and generated some expectation of benefit but did not have effects or credibility as either a method of relaxation or meditation e.g. support groups, education about health factors measured in the study, or lectures on stress and lifestyle management. This controls for the same as Categories 2 and 3 in addition to the effects of social support, improved lifestyle, etc. Social support has been repeatedly demonstrated to be effective in improving mood and quality of life and reducing the severity of disease symptoms. “Standard treatment” was included in this category.

High face-validity controls use strategies that were:

  • That were active in nature but not designed to generate significant expectation of therapeutic benefit (e.g. exercise). This controls for the same as Category 2 in addition to the effects of regular physical activity. Regular physical exercise has been shown to improve mood.
  • Active in nature, generated some expectation of benefit and elicited the simple physiological effects on rest but did not have specific credibility as a meditative method (e.g. PMR, other relaxation methods, hypnosis, biofeedback, psychotherapy).
  • The same as above but also had credibility as a meditative method (e.g. meditation techniques, strategies designed to convincingly mimic meditation) or constituted a legitimate form of psychotherapy (e.g. desensitization, CBT, counselling).

Dr Ramesh Manocha.

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Control methods in meditation

Control methods in meditation trials can be positioned on a spectrum based on their varying ability to elicit non-specific effects. At the low face validity end are those that are mostly passive and implausible (such as “waiting list”) and therefore unlikely to control for non-specific factors, while at the other extreme are those that are mostly active and, by virtue of their credibility and active content are high face validity and much more able effectively to elicit and therefore control for non-specific effects.

High face validity, active control strategies that elicit a respectable level of non-specific effect are however very resource intensive to devise and implement. Researchers with very limited resources therefore often opt for simpler, less demanding strategies with necessarily poorer control for non-specific effects.

Dr Ramesh Manocha.

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The influence of control strategies on meditation outcomes

It seems obvious that the non-specific effect of any intervention is closely related to its credibility and plausibility as a therapeutic intervention i.e. its “face validity”.

Now, some of the effects associated with meditation must be non-specific, i.e. comprising a mixture of placebo, therapeutic contact, spontaneous improvement, and so on, whereas some, hopefully, are specific to meditation alone. One might even propose that different meditation techniques have varying proportions of specific and non-specific effects. Within the context of an RCT (randomised control test), the control strategy should ideally:

  • elicit all the non-specific effects that meditation might have, but have none of meditation’s specific effects
  • not have any specific effects of its own.

By fulfilling these criteria the control strategy makes the RCT methodology sensitive to any specific effects of meditation that might be detectable.

Dr Ramesh Manocha.

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Designing randomized controlled trials for meditation

The design of RCTs ( randomized controlled trials) for meditation (or any behaviour-based therapy for that matter) involves a number of unique challenges compared with pharmacological trials.

While both categories of trial use an inactive placebo, the pharmaceutical trial uses an inert “sugar tablet” which appears similar to the medication being administered. The participant taking the “sugar tablet” is unable to ascertain whether or not they are taking the active or placebo treatment thus allowing the trial to control for confounding factors that may contribute to changes in the participants condition other than that caused by the treatment being studied.

The meditation trial however poses a unique challenge, since participants receiving the “inert” treatment must be involved in a placebo-like activity that nevertheless requires their active, conscious and conscientious involvement. They must also be sufficiently convinced of its authenticity to motivate them to participate at a level necessary to maintain the validity of the study.

Dr Ramesh Manocha.

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