The All-Party Parliamentary Group on Mindfulness, in their report, 'Mindful Nation UK' write: 'it is hoped that mindfulness will become as popular for improving mental health as jogging (only popularised in the 1970s) has become for improving physical health.' (1)

In 2015, the National Institute for Health and Care Excellence included mindfulness in guidelines for treating depression:

'Mindfulness-based cognitive therapy may be used for people who are currently well but have experienced three or more previous episodes of depression… It enables people to learn to recognise early warning signs in terms of negative bodily sensations, thoughts, and feelings, and to develop constructive responses that prevent relapse.' (2)

Religious groups have responded variously, but generally favourably. The Association of Christian Counsellors supports 'National Mindfulness Day for Christians'. (3) The website christianmindfulness.co.uk sells audio meditations whose 'aim is to facilitate growth in body, soul and spirit.' (4)

Mindfulness courses are widely available. One local advert includes the following phrases:

• Do you spend a lot of time ruminating about the past, or ...future?
• Mindfulness means paying attention to the present, on purpose, and without judgement.
• Regular practice can allow you to... step out of automatic pilot, improve positivity, and increase focus and concentration.
• An evidence-based course. (5)

There have been some critical voices. The Christian apologist Joe Boot is concerned that mindfulness sees 'the cure for our anxiety' in the 'cessation of the self' rather than in 'facing ourselves and our sins...and being reconciled to God'. (6)

Professor Thomas Joiner wrote an article in The Washington Post entitled, 'Mindfulness would be good for you. If it weren't so selfish.' (7)

What is mindfulness?

A principal founder of mindfulness, Jon Kabat-Zinn, defines mindfulness as 'paying attention in a particular way: on purpose, in the present moment, and non-judgmentally'. (8)

The key concept is that of 'awareness' (paying attention). A distinction is made between the mind in 'doing mode' in which our minds are busy problem solving, and often 'ruminating' unhelpfully; and 'being mode' where we step back and 'intentionally' experience and observe our thoughts and sensations as if from outside, in a gentle, accepting, self-compassionate and non-judgemental spirit.

As a practical activity, exercises can involve focusing on 'the breath' or on bodily sensations either in particular parts of the body, or by a 'body scan', and then also by observing our thoughts in a detached way without evaluating them.

These techniques are originally derived from Buddhist meditation, which sees desire as the root of suffering. Desires can be overcome by techniques including; 'right awareness', 'detachment', and 'concentrating the mind on single objects'. (9)

A considerable difficulty in analysing mindfulness is that it comes in many forms. Beyond academic discussion, popular mindfulness is taught and practised with no regulation or specific guidance.

The evidence for mindfulness

There are great challenges in demonstrating the effectiveness of any mental health therapy, and this is particularly so with talking therapies, relaxation techniques and meditation. The complexity of the interventions, differences between therapists, the diversity of problems being treated, the variety of possible end points to measure and the virtual impossibility of 'double-blinding' make it very difficult to carry out well-designed controlled trials. Nevertheless, there is a rapidly expanding body of literature on mindfulness. There were eleven academic articles on mindfulness in 1980-1989; 28 in 1990-1999; 513 in 2000-2009 and already 3,733 this decade at the time of publication. (10)

While many studies seem to show a clear effect of mindfulness, the meta-analyses of studies which have had control groups are more cautious about their findings. Though mindfulness practitioners often improve relative to control conditions, the improvement could be ascribed to features it has in common with other relaxation and meditation techniques, and may not be specific to mindfulness itself. (11) In the limitations of one recent study, the authors acknowledge that such studies are 'in their infancy'. (12) Thomas Joiner notes, 'when many of the supposed effects of mindfulness fade in the hands of highly credentialed teams publishing well-designed studies in the best journals, we should be skeptical of the benefits promulgated by people and in outlets that are not as scientifically rigorous.' (13)

A further paper points out that there has been very little research into possible harmful effects of mindfulness, despite there being a growing number of case reports associated with meditative practice. (14) For people who are already isolated and lonely, or those prone to psychotic hallucinations, or paranoia, it is quite plausible that being asked to sit in quiet and observe thoughts may have harmful effects. (15) Recently one of the biggest studies of its kind suggested that 'Mindfulness makes criminals worse.' (16,17)

Do we need evidence?

Where there are specific claims of effectiveness in the promotion of mindfulness, we should require evidence. Indeed, advertising regulators could potentially investigate unsubstantiated claims.

However, in primary care, the reality is that advice often takes the form of suggestions of possible courses of action that may or may not help depending on the particular situation and personal factors of the patient. Richard Smith, editor of the BMJ until 2004, argues that proponents of evidence-based medicine have always recognised 'that evidence alone cannot make decisions and that values are just as important.' (18)

Patient narratives do not necessarily lend themselves to giving definitive evidence-based advice. Asking questions, and probing to help people find their own solutions to personal problems may be more appropriate. (19) Sometimes common sense suggestions may emerge for consideration. 'Have you considered taking a break?', 'do you think you are sleeping enough?', 'are you over-thinking this?', 'what worries you about it?', 'might it help to take your mind off it?', 'have you tried using relaxation techniques?' To this we could add, 'some people find that focusing their mind on their breathing is a good way of stopping ruminating thoughts', 'have you tried observing your thoughts in a non-judgemental way?', or 'do you think that your mobile phone distracts you from being fully aware of the present moment when you are spending time with your family?'

We needn't make any claims of effectiveness, but in the complexity of an individual's experience, an idea may be potentially useful. This is no panacea - but some mindfulness techniques or attitudes may help from time to time.

We need each other to help us see simple truths about ourselves. It may be that there are deep denial mechanisms, or an unwillingness to give up certain idols that lie behind our inaction. However, it may be that we are too busy, or distressed, or feeling too guilty to realise that going for a walk for ten minutes a day might, for example, 'lift our horizons', give us 'a breath of fresh air', 'stretch our legs', make us more 'aware of our surroundings' or appreciate the singing of the birds.

Interestingly, this point was made 700 years ago by the Augustinian mystic, Walton Hilton:

'You should recognise that in the matter of meditation there is no universal rule which can be established for everyone to keep in every situation. These things are by nature a gift of our Lord and are directed to the various dispositions of his chosen souls according to their particular state and condition. And according to each person's growth in virtue and spiritual estate, he increases opportunities of meditation for their spiritual knowledge and for their love of himself.' (20)

Life is infinitely variable and complex. Trying to understand each other, and sharing practical wisdom are a core part of how we carry each other's burdens. (21) Mindfulness may have helped us be aware of some of the pressures of the modern world we live in, and of the human tendency to distract ourselves to the point of harming our mental health whilst offering some sensible tips on how we might be ableto stop ruminating and be more intentionally aware of what we are doing.

The appeal of mindfulness

The proliferation of smartphones, tablets and social media provides the immediate context for the appeal of mindfulness in a modern world which was already fast paced and full of distractions. One study showed that a third of British adults check their phones after going to bed. (22)

Not that stress is a new problem. In the 17th century Pascal argued that we live paradoxical lives, where though we claim we are aiming to rest, in fact we fill ourselves with busyness in order to avoid self-reflection:

'You would only have to take away all their cares, and then they would see themselves and think about what they are, where they come from, and where they are going. That is why men cannot be too much occupied and distracted.' (23)

Emphasising awareness of ourselves and our experiences, rather than being caught up in the endless demands placed upon us, has an obvious attraction. Stress is frequently identified as being a core human problem which mindfulness addresses.

The self in crisis

In his analysis of our modern secular selves, philosopher Charles Taylor observes that we have protected or 'buffered' ourselves from the threats of disease and disaster which made life so fragile in the past. (24) People's vulnerability led them to conclude that our internal and external worlds were so enmeshed that the boundary between them was porous, and mysterious spiritual forces controlled our destinies. Today however, we feel we have a measure of control of our external environments, which enables us to be 'autonomous' or 'free' in our decisions - 'the buffered self'. (25)

Internal threats, however, remain and perhaps have increased in our modern existential crises. We are free, but to do what? Other people, even our own selves, do not do as we wish. We have become wealthy, healthy and increasingly anxious.

Mindfulness is attractive because it raises awareness of our internal struggles, and suggests we can detach ourselves from desires which disturb us, and non-judgementally accept ourselves as we are. As a secular form of a non-theistic religion (Buddhism), we would not expect to find mention of God here.

The secular solution to conflicting opinions in social relations is individualism, freedom and tolerance. Criticising the thoughts, beliefs and practices of others is inadmissible, except where the liberties of others are infringed. Non-judgemental acceptance of our inner worlds seems a logical extension of this 'tolerance' principle. Personal freedom is bolstered by denying the power our 'inner critic' and self-doubt have to restrict our happiness. The secular self seems caught between maintaining the illusion that 'all is well' in our inner worlds, and despairing that despite our ability to control external realities, our selves remain in turmoil

Christianity and Mindfulness

Christian meditation

'Blessed is the one... whose delight is in the law of the Lord, and who meditates on his law day and night.' (26)

The Bible, and particularly the Psalms, frequently commend meditation on God, his laws, and his works.

J I Packer warns of the danger of knowing about God, without a personal knowledge or experience of God. When we study scripture, we are capable of becoming proud because of our knowledge, and of being superior and patronising to those who know less. He asks,

'How can we turn our knowledge about God into knowledge of God? The rule for this is demanding, but simple. It is that we turn each truth that we learn about God into matter for meditation before God, leading to prayer and praise to God.' (27)

Meditation in this sense involves a type of awareness which is intentional - listening to God's word, and reflecting on its application in our lives. It is not in this sense silent, since we want to hear God speaking to us.

The Psalmist writes: 'My God, whom I praise, do not remain silent.' (28)

Solitary meditation has limits for Christians. Dietrich Bonhoeffer observes:

'Our righteousness is an "alien righteousness" a righteousness that comes from outside of us (extra nos)... God has put this Word into the mouth of men that it may be communicated to other men... A Christian needs another Christian... when he becomes uncertain and discouraged...The Christ in his own heart is weaker than the Christ in the word of his brother; his own heart is uncertain, his brother's is sure.' (29)

Distractions and desires

Christianity, like mindfulness, identifies distracting and unsatisfying desires. The writer of Ecclesiastes observes, 'All things are wearisome, more than one can say. The eye never has enough of seeing, nor the ear its fill of hearing.' (30)

Whereas Buddhism seeks to extinguish desires as the cause of suffering, Augustine says, 'Our heart is restless until it rests in you'. (31)

The problem is not our desire itself, but the object of our desires. Paul writes, 'They exchanged the truth of God for a lie, and worshipped and served created things, rather than the Creator.' (32)

We have become attached to things. Tozer writes: 'Men now have no peace within their hearts, for God is crowned there no longer, but there in the moral dusk, stubborn and aggressive usurpers fight among themselves for first place on the throne.' (33)

We are therefore filled with inner turmoil from which we seek escape. Christians have often meditatively sung from the Psalms, 'Be still and know that I am God'. (34) The implied interpretation is that we can come to know God better in quietness. However, if this is seen not as a piece of advice, but as a rebuke and a command, then it has a different feel. Jesus commanded the storm, 'Quiet, Be still' and the demon possessing a man to 'Be quiet'. (35)

The rest we seek is not the quiet life. Passivity can be a tool of the devil, who sees a clean room as a place to live. (36) Our desires cannot be eliminated, instead they need to be satisfied.

'Truly my Soul finds rest in God'. (37)

Christian awareness

Awareness is a biblical virtue. 'Consider how the wild flowers grow...' says Jesus. (38) Paul asks,'What do you have that you have not received?' (39) The glories of the world point beyond themselves to the glory of their creator, causing us to reflect on our place in it all.

John Calvin writes, 'Our wisdom, if it is to be thought genuine, consists almost entirely of two parts: the knowledge of God and of ourselves.' (40)

Mindfulness rightly invites us to be aware rather than distracted, but its secular form does not point us to God. Christian awareness is evaluative, however, and not non-judgemental. Of the flowers, Jesus says, '...not even Solomon in all his splendour was dressed like one of these', and Paul implies that we owe gratitude for everything we have received to God alone.

Our inner critic

Mindfulness identifies the distress caused by our 'inner critic', recommending a 'non-judgemental, compassionate, and gentle' attitude towards ourselves. The Bible might seem to agree; 'The Lord is compassionate and gracious, slow to anger, abounding in love'. (41)

However, Christianity also insists we listen to our consciences. Paul argues that although people 'suppress the truth by their wickedness... God's invisible qualities... are clearly seen, being understood from what has been made, so that people are without excuse.' John writes, 'If we claim to be without sin, we deceive ourselves, and the truth is not in us.' (42)

Jesus is the light of the world, shining his light into our darkness, and revealing our sin. Tozer writes of 'the veil' separating us from God:

'It is the veil of our fleshly fallen nature living on, unjudged within us, uncrucified and unrepudiated.' (43)

Removing the veil is painful, 'To rip through the dear and tender stuff of which life is made can never be anything but painful. Yet that is what the cross did to Jesus and it is what the cross would do to every man to set him free. Let us beware of tinkering with our inner life in hope ourselves to rend the veil.' (44)

Pascal shows why it is that this painful process does not lead to despair for the follower of Christ, 'The man who knows God but does not know his own misery, becomes proud. The man who knows his own misery but does not know God, ends in despair. The knowledge of Jesus Christ constitutes the middle course because in him we find both God and our own misery. Jesus Christ is therefore a God whom we approach without pride, and before whom we humble ourselves without despair.' (45)

Rather than 'buffering' ourselves with self-acceptance, Christianity offers us the opportunity to repent, turn from our sins and be forgiven - but not without great cost. 'For the accuser... who accuses them before our God day and night, has been hurled down. They triumphed over him by the blood of the Lamb.' (46)

Stress and self-sacrifice

Mindfulness is promoted as a weapon against the evil of stress in our modern lives. But our avowed opposition to all things stressful, in principle, means that we fail to see that stress may not be such a bad thing after all. Of course there are different degrees of stress and anxiety, and sometimes these can become paralysing and pathological. However, for much of the time, and for most people, stress and pressure are what enable us to achieve things in life. Deadlines, exams, problems that need solving, challenges - all these are what make humans dynamic. It has been said that human life is like the elastic band in a toy propeller aeroplane - it is the tension that makes it go.

Far from being called to the 'stress free' life (as if such a thing were attainable), Christians are called to be self-sacrificial after the model of Christ. (47)

Conclusion

Mindfulness offers to buffer us from the existential angst, self-doubt and alienation we experience in our busy modern lives. Its non-judgmental stance appeals to our culture of tolerant individualism. In our post-modern age of pick and mix spirituality, mindfulness, as a secularised form of a non-theistic belief system could be mistaken by some as a spiritual tool, which can be placed alongside Christian belief, with similar insights and benefits.

They both identify problems in our inner worlds, recommend increasing our awareness of inner realities, see that we are full of desires for things that will ultimately not satisfy us, identify attachment as a problem and are compassionate, non-judgemental and accepting of who we are. However, for each element of mindfulness that Christian belief holds in common, it remains radically different, and in each case the difference is God. We should not be surprised to find that non-judgementalism fails to address the deep problem of human sin and selfishness - for that we need the gospel.

The lack of robust evidence for the effectiveness of mindfulness, accumulating criticisms, 48 and evidence of possible harms should make us doubly cautious.

James May is a General Practitioner in London.