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Mindful : April 2018
abating. “That’s targeting,” Brewer says, “a step way beyond first-generation chemotherapy, which throws a grenade in there hoping that the widespread destruction will kill the cancer before it kills the patient. By understanding the mechanism that underlies the problem, you can treat the problem in a targeted way.” How does this relate to mindfulness research? “ We need to find the mechanisms, the pathways that mindfulness targets. In my lab, we have been working with reward-based learning for some time—what is formally known as operant conditioning—and focusing on very measurable, observable behaviors, particularly smoking and overeating. If someone binge eats, we can trace back and map how they got there, and we find that they sought and received a particu- lar reward. However fleeting it might be, they report feeling a bit better or numbed out for a while. What took them there in the first place? A trigger, usually stress. It’s been amply demon- strated that if you stress people out and put a bunch of food in front of them, they will do the obvious to relieve their stress.” Brewer points out that “reward-based learning ” that leads to habit formation is a well-accepted mechanism in mainstream medical contexts. What he and his researchers need to do is to show, with specific interven- tions, that they can interrupt that pathway and achieve an observable result. (See pages 60-63 for a diagram outlining how mindfulness may work as an intervention that can alter habits by influencing the reward-based learning cycle.) They also need to compare their results to a control, a group that ideally takes another kind of training aimed at the same result. In the case of smoking, they compare their mindfulness intervention to a program from the American Lung Association. For overeating, they intend to compare their inter vention to a well-documented calorie-counting method. Results are already promising. For example, in a pilot study of obese women, led by Ashley Mason, PhD, the team found that mindful- ness training delivered through a smartphone was able to target and affect the reward-based learning pathway, leading to a 40% reduction in craving-related eating. Brewer and his lab are also working on the “mindfulness definition” challenge. “It seems like at this stage of development in the field,” he says, “we are going to need more granular definitions, more specificity. There are too many definitions of mindfulness floating around and it gets very conceptual very fast as you try to describe concrete experience in abstract terms. Drawn from user-centered research, we are working with the phrasing unforced freedom of choice emerging from embodied awareness as a measurable metric for mindfulness train- ing as related to behavior change. It’s a little technical sounding, but we’re basically saying that someone learns how a habit forms from paying attention to the results of their actions, which leads to a wisdom base that guides future behavior. When triggers for habitual behavior arise, drawing not from concept, but from their own previous experience, they see the possibil- ity of making their own choice about whether to continue the habit loop or to interrupt it and go to a fresh place. It brings together mindfulness, equanimity, and reward-based learning.” Brewer has very consciously begun with habits where you can observe the behavior. As an evidence base develops, he believes it will become easier to venture into areas, such as anxiety, that cannot be observed in the same concrete way as smoking or overeating. “As we demonstrate changes in habits that stick over the long term and lead to obvious health improvements, we will not have to make big speeches about how great mindfulness is. The evidence will be there for doctors and patients to see. They can make their own choice.” Mindful asked health reporter Peter Jaret to investigate a few other areas in the health-care landscape where mindfulness may make a dif- ference. In the following pages, he presents the results of his reporting. The key to wider acceptance in the mainstream medical world is evidence that the methods work, but the nature of that evidence is critical. You can’t just put 25 people in a room once a week for eight weeks, teach them to meditate, and simply ask them how they feel at the end. April 2018 mindful 51