Maintaining Mindfulness practice after 8-week course, a

preliminary survey
By Ramon Torres
Final project to De-Mystifiying Mindfulness Course, Universiteit Leiden at Coursera

1. Introduction

One of my motivations to do this Course was my desire to improve and sustain my mindfulness
practice. I meet meditation for first time twelve years ago, and since then I have had ups and
lows in my practice. In one hand, I feel mindfulness practice of great value to my body and
mind, but in other hand I find hard to sit on cushion and meditate.

Reaching the end of this course several questions arisen in my mind: Why its so hard for me to
maintain a daily meditation practice? Am I the only one who struggle to maintain my practice
or it is a common problem? What are the most important things to consider or to focus on if
you want to sustain your meditation practice? Is this a problem of will? Maybe Motivation?
Environmental factors? Peers support? . After a 8 week course like MBSR or MBCT, or maybe
after a course like this, what percentage of attendants will continue their mindfulness
practice?.

I consider all these questions very important issues related to Mindfulness, and I have taken
them as a starting point in this project. I will try to shed light and find some answers, if
possible.

The objective, third person part of this project comprises all knowledge and researches
about mindfulness practice sustainment, and more generally speaking, well-being habits
creation and adherence.

In the subjective, first-persons part of the project, I have conducted a survey to attendants
to a MBSR course held two months ago, asking them about their current practice and what
aspect they consider more important to sustain the practice.

2. Findings about establishment and maintaining Mindfulness practice

Many studies report significant improvements in both mental and physical well-being after a 8
week course like MBSR or MBTC, like improvements in anxiety, depression, immune system
and inflammation, and aging, among others [AMRA,2017] but little attention has been paying
on the factors that contribute to sustain and maintain a Mindfulness practice after these
courses.

In a dissertation, [Masheder, 2013] the author studies what factors motivate and support an 8-
week mindfulness course participants to establish and maintain a mindfulness practice. The
author conducted semi-structured interviews with nine course participants at three stages in
their practice (halfway through the course, at the end and two or three months later) and
consult different studies in the area of healthcare treatment adherence and Buddhist
literature.

The author found two categories of factors, internal and external.

Internal factors are:

Self-efficacy. This factor is defined by Bandura as belief in ones capabilities to

organize and execute the course of action required to produce given attainments.
Self-efficacy appears in different health behaviors change models (Health Belief
Model, Protection Motivation Theory) and social cognitive theories as a key factor
to maintain a health behavior, and the author empathizes its crucial importance in
establishing and maintaining meditation practice.

Planning. It refers to setting behavioral goals (like I will meditate every day for 10
minutes) adding some flexibility in its accomplishment. Here, implementation
intentions can help to achieve behavioral goals through creating habits, as we see
later. The author recommends set specific plans to participants with low levels of
motivation or self-efficacy.

Protection motivation and self-care. Protection Motivation Theory determines that

peoples fear of disease would motivate them to take specific actions to reduce the
state of fear and it appears in several Healthy Behaviors models. In Mindfulness
practice seems that a more positive approach focusing on positive reasons to
engaging in practice is more appropriated. The author recommends emphasizing
the self-care aspect of Mindfulness can reduce the feeling that practice is a chore,
and therefore easier to maintain.

Belief about the efficacy of Mindfulness. The beliefs about the efficacy of the
practice or remedy proposed appear in several models of behavior change as well
(Health Belief Model, Theory of Reasoned Action and Protection Motivation
Theory). In the case of mindfulness practice the author states that belief is only
necessary for a short time until the benefits can be directly experienced.

External factors are:

Social factors and supportive environment. These factors also are mentioned in
several models (Theory of Reasoned Action and Theory of Interpersonal Behavior).
Here the author includes factors like a peer group and support it gives. Once
finished 8-week course, participants need to find other forms of social support.
People can find in their partners, family and colleagues this kind of support. When
the partner or family does not support the practice, the participant may meet
resistance that affect largely to the sustainment of Mindfulness. Other
environmental factors are physical space to be in silent and undistracted, and
prompts or reminders like smartphone apps. The author concludes that these
factors are helpful though not enough by themselves.
 Relationship with the teacher and behavioral contracting. Again, in several models
the relationship with the Health Care Provider is a factor that determines the level
of adherence. Another factor to improve adherence is behavioral contracting, that
work better when it is communicated or made public. For the author, relationship
with teacher is a big influence on the establishment of the practice. Also, some
form of informal contracting may help.

Rewards. In classical behavior modification approaches, rewards and punishments

are used to help a person develop a habit. According to the author, in Mindfulness
practice, external rewards may be inappropriate, but internal or intrinsic rewards
help us to maintain a health behavior. The author considers the beneficial effects
of practice as internal rewards. She advice to remind benefits of practice when
motivation to follow is low.

The study also describes possible changes in mindfulness practice over time, finding cycles of
more al less formal practice, and yet mindfulness is never really lost, because always we have
the opportunity to come back to present moment. Despite of this, the author did not found
significant changes on their practice. Those who did not established a regular practice during
course, did not establish one after, and vice versa.

As conclusion, the author points out that self-efficacy, perceived benefits and wanting to care
for oneself are the vital factors to sustain mindfulness practice. They acts in a cause-effect
chain: first, self-efficacy is necessary to establish a practice. As soon as participants experiment
benefits, they obtain enough intrinsic rewards, therefore they sustain mindfulness practice.
Belief of benefits can act as a starter motor, but it is not enough to sustain a practice over
time. The rest of factors are all useful but not enough by themselves.

In another study [Langdon, 2011] the authors used the grounded theory to explore the factors
which help or hinder people in maintaining formal mindfulness practice after a MBCT
participation. The grounded theory is a research method that helps you to enable a theory
about some issue exanimating emerging patterns in data. In such study, the raw data was
obtained through semi-structured interviews. The authors found five high-order categories:

Participants described mindfulness as a journey, and that having established a

practice during MBCT, they then moved into a Virtuous practice cycle,
supported by factors such as integrating mindfulness in everyday life (informal
practices).

Due to various challenges and obstacles, participants described a reduction in

regular practice: slipping out of the cycle.

Factors such as finding resolve and overcoming obstacles helped participants

with getting back to the cycle of regular practice.

Participant recognized positive belief about mindfulness and the influence

of significant others to play important roles in their ongoing mindfulness
 practice.

The group as a support to practice and its harder to practice without group
support sub-themes appears, so the authors considers that ongoing group
practice is a key aspect to support practice.

In another study [Field, 2015] the author uses again grounded theory to explore what
participants of MBSR course learned from taking the course and particularly whether they
reported their intentions to practice as having shifted once they learned MBSR. In this study,
three categories arisen:

Doing: practicing to achieve. This reflects an intention to practice to attain

specific results (goal-striving). Five sub-themes has been identified here:
obtain benefits (practicing mindfulness would be beneficial), escape (escape
from stressors), learn the right way (refers to learn specific way of practicing
meditation correctly) and attain goal (obtain specific state or goal as reducing
blood pressure or stress).

Being: practicing to become mindful. Three sub-themes has been identified

here: establishing a daily practice (refers how integrate mindfulness practice
into daily life), cultivating compassion (change self-criticism into self-
compassion) and developing curiosity in everyday activities.

Shifting Awareness: From Doing to Being. Here participants described an

evolution going from initially striving-goals approach to a deeper commitment
to be mindful in life and therefore no longer engaging in practice solely in
order to achieve something. There are three sub-themes identified: awareness
of choice (when participants recognized that they had a choice in how they
could respond to stressors and to be more mindful), awareness of change
(refers to change on perspective, or change in our response, from being
competitive to being collaborative, or from being self-critical to being self-
compassionate) and redefining mindfulness (refers to revising initial concept
of mindfulness or meditation).

The author concludes that intention to practice mindfulness is an important mechanism in

developing the practice after the course ends. It is expected that the more shifting from doing
to being the participant makes, the more sustained the practice becomes after the course.

In another study [Mejia, 2013] the author uses a ground theory framework to examine the
subjective experiences of mindfulness conducting semi-structure interviews with 10 individuals
who practice mindfulness on a regular basis, with different expertise (range from 10 months to
25 years) and backgrounds (students, psychologists, MBSR trainer and Zen master, among
others).

Two of the categories that this study identifies are conditions and strategies of practice of
mindfulness. Conditions refer to the situation in which the practice takes place, with three sub-
categories: formal practices, informal practices and coping with a struggle. Formal practice
time ranges from 20 to 60 minutes of practice each day. All of the participants had a dedicated
space for practice, and all but one attended a center to formally practice. Informal practice
means for participants to infuse mindfulness throughout the day, especially when they are in a
difficult or distressing situation.

In the strategies category, this study finds two themes: philosophy of practice and elements
needed to practice. In discussing central aspects of their practice, all participants agree on the
importance of practicing on a regular basis and finding a guide to further develop their
practice. Additionally, participants shared the natural consequences of engaging in a regular
practice of mindfulness, which include: a shift in perspective about self, others and life and a
deeper understanding of the practice. These experiences also serve as reinforcement to
continue to practice.

Finally, in another study [Morgan, 2014] the author examines the relationship between three
types of mindfulness practice (formal, informal and mindfulness of breath on daily life) and
longer-term outcomes in worry and anxiety in participant of Acceptance Based Behavior
Therapy treatment for Generalized Anxiety Disorder. A 9-months follow up showed the
importance of informal practice to sustain the benefits obtained.

3. The Survey

In order to study quantify the sustainability of mindfulness practice after an 8-week course and
find factors that contribute more, a survey was prepared and launched. The questions that this
survey seeks to answer are the following:

- Which percentage of participants sustains mindfulness practice several months after

finishing course?
- What kind of practices (formal, informal, intensive) are more used?
- Which factors are most important to sustain mindfulness practice?

In order to identify different kinds of practice, the following definitions are proposed:

Formal practice is a deliberate, planned, and structured time set aside to practice mindfulness
on a regular basis. Informal practice involved actively infusing mindfulness throughout the day,
usually depending of situations or events happened. Intensive practice involves attending
meditation retreats or doing more 8-week courses.

3.1. Method

Survey consists of 8 questions to be filled in two minutes time. There are two parts. In the
first part, the survey explores formal practice (how many days are done and how long it
takes each time), informal practice (how frequent it is and how long it takes in an average)
and intensive practice (intention to perform or have performed such practice).

In the second part, survey explores which factors contributed more to the sustainability of
practice. A likert scale type ranging from 1 (unimportant) to 5 (very important) has been
disposed to quantify the effect of different factors. An open question was added to explore
additional factors. Another question is done to detect if respondents have experience in
meditation practice before course. Finally, impact of mindfulness is measured using a likert
scale type, ranging from 1(no or little impact of mindfulness in respondent) to 5 (extreme
impact of mindfulness in respondents life).

Universe of study is constituted by a total of 20 attendants to a MBSR course held in

October to November, 2016. All of them are psychologist. All but one are women. The
survey has been created using Google Forms and was sent by email on February, 15th, this
year 2017. Three days was left to collect responses.

3.2. Results

Survey was completed by 13 participants (65% of population). 69,2% of total respondents

was not engaged in any kind of meditation practice before MBSR, and 30,8% was
practicing some kind of meditation practice regularly.

Formal practice has been sustained by 692% of respondents two months after finishing
MBSR. Respondents who maintain practice do it an average of 4,2 days a week, and spend
27,9 minutes each time.

30,8% of respondents does at least one kind of informal practice every day, and 23,1%
does different kind of informal practices every day. 615% does informal practices one or
several times each week, and one respondent (8%) does not practice informal practice. An
average of 4,29 minutes is spend in each informal practice, with values ranging from 1 to
10 minutes.

16,7% of the total of respondents who maintain mindfulness practice has been doing
intensive practice or plan to do for sure and 66,7% might do this year.

92% of total respondents do some kind of mindfulness practice two months after
MBSR course.

Regarding to factors that contribute to maintaining of practice, they are divided in two
groups, using classification of mentioned study [Masheder, 2013]:

- External factors:
1. To do practice at specific place (Supportive environment)
2. To have reminders to do the practice (Supportive environment)
3. To have a peer group of practice (Social factor)
4. To have and use audio recordings (Relationship with teacher)
5. To have had pleasant experiences doing practice (Reward)
6. To use mindfulness as a useful therapeutic technique in my job (Reward)

- Internal factors:
7. Commitment with oneself to do practice (Self-efficacy)
8. Consider benefits of practice to diminish unwanted symptoms or help in
life situations (Protection motivation)
9. To do practice at specific time (Planning)
10. To Keep a record of practice (Planning)
 11. To Think of mindfulness as a self-care practice (Self-care)
12. To Read books or papers about mindfulness (Belief about efficacy of
Mindfulness)

The first three factors are internal ones: the most important factor reported is Self-care
(3,85), following of commitment with oneself (Self-efficacy) with 3,77, and third
protection motivation (3,62). The first external factor mentioned is to do practice in
specific place (3,54), an aspect of supportive environment.

The less important factor ( 1,92) is to keep a record of practice (planning). The second less
important (2,00) is to have a support group (social factor).

4,50

4,00 3,77 3,85

3,54 3,62
3,50 3,31 3,23
3,15
3,00 2,85
2,38
2,50
2,08 2,00
1,92
2,00

1,50

1,00

0,50

0,00
1 2 3 4 5 6 7 8 9 10 11 12

The open question asking for other factors not mentioned was answered for three people.
The answers were consider mindfulness as a philosophy of life, to have free time and
To use an app with audio meditations, peer group contact and tracking capabilities.

Finally the impact of mindfulness practice has been rated. For 30,8% of respondents
mindfulness has been had a huge impact in personal and professional life.
3.3. Discussion

It is difficult to know the real percentage of attendants that continues with mindfulness
practice because, probably, there is a hint of bias in responses, although in the email was
pointed out that all attendants could fill the survey, including those who had little or none
interest on mindfulness. Nevertheless it is reasonable to think that most of respondents
are interested in mindfulness. In general sense percentage of attendants that continues
engaging in mindfulness is high; near 70% sustaining a formal practice of reasonable
length, and 92% sustain informal practice. Asking to the first question, the percentage of
participants that sustain a certain kind of practice is high, as well as the impact of
mindfulness on attendants (77% with a huge or significant impact).

When we consider what kind of practice is more used, we find that informal practices are
used by all respondents that continue practicing mindfulness. This is to be expected,
because informal practice has more chance to integrate as a habit. The fundamental
aspect of informal practice in my opinion is that you can do your informal practice at the
same time that you are doing something else. For example, you can practice walking
meditation when you are going to work, or you can do some mindfulness eating at lunch.
Although the time spent in practice can be something difficult to say [Mejia, 2013], I think
that it can be a good indicator to know the transition between Doing and Being [Field,
2015], because informal practice is closely related to trait mindfulness, as well as formal
practice is closely related to state mindfulness.

This study shows that all respondents who do formal practices, do informal ones, but there
are 3 respondents (23%) who do informal practices but they do not do formal practices.
This can be interpreted in the following way: informal practice acts as a bridge that helps
people to go from an incipient practice of mindfulness to a consolidated one. Some study
has emphasized the importance of informal practice to maintain the benefits of
mindfulness [Morgan, 2014].

With regard to intensive practice, one might think that its presence can identify a more
engagement with mindfulness, but in this study 834 % of respondents are open to engage
with intensive practice. This is a high percentage, near of 92% of people that do some kind
of mindfulness practice. This might point out that intensive practice of mindfulness is in
parallel to formal and informal practices, instead of to be something that people do only
when they do a well stablished formal and informal practices.

When we study factors that contribute to maintain mindfulness practice, we see that
internal factors are more important than external ones. First two factors, Self-care and
Self-efficacy, are in line with other study [Masheder, 2013] in which Self-efficacy and
benefits experimented are key components to maintain practice. Intrinsic rewards appears
with high rates also (3,31 and 3,23). Although the higher external factor considered has
 been the place. To have a fixed place, ready to use is a external cue that make easier the
creation and reinforcement of habit.

In this survey, peer group and positive beliefs about mindfulness does not appear as a key
factor as mentioned in other studies [Langdon, 2011],[Mejia, 2013].

The open question to identify other key factors different from the proposed ones shows
interesting things to consider. One of them, consider mindfulness as a philosophy of life
might indicate the need of a hidden information in the survey like the state in which
participant are in respect to understanding of mindfulness as appears in [Field, 2015]. I
mean, people that are in Being: practicing to become mindful would have different
factors to maintain practice than people that are in Doing: practicing to achieve. Also, an
additional question to know if respondent is Buddhist or not would help, because usually
they have different view of mindfulness that secular ones.

Another open answer, to have free time, reflects the difficulty of integrating formal
practice in our daily routine. As has been stated earlier, informal practices should be a way
to go from inexistent formal practice to established one.

Another open answer is related with mobile app that facilitates to do the practice. In
reality, this factor is represented by Supportive environment and maybe social factor if the
app has the feature of contact to a peer group. Nevertheless, would be better to specify
one factor to consider technological gadgets like this.

Finally the survey reflects the impact of mindfulness in participants. It shows a high impact
of mindfulness, with 77% of respondents with significant or huge impact. Mindfulness is
important to mayority of people who continues practicing it. Again would be interesting to
compare this value with stage of respondent [Field, 2015].

4. Conclusions

Establishment and maintaining mindfulness practice is a complex one, more than I expected
before start this study. In one hand it has to be with creation of a habit, especially in formal
practice.

Mindfulness practice has some things in common with other healthy habits, like go to gym or
eat healthy food, and some differences. Some studies show that habit formation take times
that ranges from 18 days (simple habits) to 254 days (complex habits like go to gym) [Lally,
2010]. Mindfulness could be compared with other complex healthy habit like go to gym. This is
more true if you consider formal practice, but informal practice is easier to maintain.

One finding of this study is the crucial importance of informal practice to establish and
maintain a full range mindfulness practice. In such case, it is important to consider the creation
of little habits that improve and extend informal mindfulness practice.
Another finding is the importance to consider the intention that a participant puts in
mindfulness. People at Doing stage has different motivations and ways to establish practice
than people at Sifting from Doing to Being or Being: practicing to become mindful stages.

Mindfulness is a journey, with different stages of development. Belief on its efficacy probably
are crucial at start, but once the trip has started increasing importance of other factors
appears, like Self-efficacy and Self-care.

Little attention has been given to the study of establishment and maintaining mindfulness
practice, and this is an essential aspect for people that meet meditation or mindfulness. More
study should be done, and more explanation should be given in 8-week courses like MBSR or
MBTC, regarding of creation and maintaining mindfulness practice.

5. References

[AMRA,2017] American Research Mindfulness Association web, Reviews and Meta-Analysis

(https://goamra.org/resources/reviewsmeta-analysis/)

[Field, 2015] Field, J. (2015). From Goal-Striving to Right Intention: A Grounded Theory
Analysis of Interviews with Mindfulness-Based Stress Reduction Participants. Undergraduate
Review, 11, 58-65. Available at: http://vc.bridgew.edu/undergrad_rev/vol11/iss1/12

[Lally,2010 ] Phillippa Lally, Cornelia H. M. van Jaarsveld, Henry W. W. Potts, Jane WardleHow
are habits formed: Modelling habit formation in the real world, European Journal of Social
Psychology, October 2010.

[Langdon, 2011] Langdon, Jones, Hutton & Holttum. A grounded-theory study of mindfulness
practice following Mindfulness-based cognitive therapy. Mindfulness (2011) 2:270281 DOI
10.1007/s12671-011-0070-5

[Masheder, 2013] Masheder, J.J. What factors motivate and support an 8-week mindfulness
course participant to establish and maintain a mindfulness practice?. Master's Dissertation,
University of Exeter, December 2013.
Available at:
https://cedar.exeter.ac.uk/media/universityofexeter/schoolofpsychology/cedar/documents/T
hesis-JM.pdf

[Mejia, 2013] Mejia, A. Personal Conceptualization and Use of Mindfulness: Developing an

Emerging Model using a Grounded Theory Framework. Dissertation, Arizona State University,
December, 2013. Available at:
https://repository.asu.edu/attachments/126002/content/Mejia_asu_0010E_13566.pdf

[Morgan, 2014] Morgan, Lucas P K; Graham, Jessica R; Hayes-Skelton, Sarah A et al. (2014)
Relationships Between Amount of Post-Intervention of Mindfulness Practice and Follow-up
Outcome Variables in an Acceptance-Based Behavior Therapy for Generalized Anxiety
Disorder: The Importance of Informal Practice. J Contextual Behav Sci 3:173-176 Available at:
http://isiarticles.com/bundles/Article/pre/pdf/30191.pdf