As a Mind & Life Fellow who received the Francisco J. Varela Research Grant in 2007 and the Mind & Life 1440 grant in 2013, Dr. Eric Garland has gone on to become the developer of an innovative, multimodal mindfulness-based intervention founded on insights derived from cognitive, affective and neurobiological science, called Mindfulness-Oriented Recovery Enhancement (MORE). He has received more than $20 million in research grants from a variety of prestigious entities including the National Institutes of Health and the Department of Defense to conduct translational research on biopsychosocial mechanisms implicated in stress and health, including randomized controlled trials of MORE as a treatment for prescription opioid misuse and chronic pain conditions.
How did you first become interested in studying mindfulness?
I began my personal practice of mindfulness when I was in college pursuing my bachelor’s degree in psychology. At that time, I was very interested in comparative religion, philosophy of mind, as well as anthropology. Along with my personal meditative experiences, I also sought out spiritual systems and philosophies for understanding reality, like Buddhism, Advaita Vedanta, Taoism and various shamanistic approaches. These learning experiences taught me that it was possible to tap into deep experiential insights about the philosophical concepts of the Absolute and the Relative by training the mind in a different way of seeing.
In the beginning, mindfulness was mostly a personal pursuit. To be honest I didn’t know that there was a scientific study of mindfulness for quite some time. In my early career I was working as a therapist and I had begun to use meditative techniques with my clients to help them deal with addiction, anxiety, depression and chronic pain. This was at a time when a few folks out there were practicing a combination of psychotherapy and meditation, but it wasn’t nearly as prevalent as it is now. There were no real formalized mindfulness-based therapy approaches available (other than MBSR and MBCT, which were not as widely disseminated at that time). So I began to experiment with how to integrate meditation into my practice as a clinician. It wasn’t until later when I decided to pursue my doctorate that I discovered there was a whole emerging research world focused on mindfulness. By serendipity I was plugged into an NIH-funded research study of mindfulness as a treatment for irritable bowel syndrome run by Susan Gaylord at UNC’s Program of Integrative Medicine. She kindly took me under her wing and trained me to be a mindfulness researcher. She taught me the tools of the trade. Ten years later here I am.
When did you first become involved with the Mind & Life Institute and how did that inform your direction as a researcher?
I first became connected in Mind & Life Institute in 2007 when I was a doctoral student at University of North Carolina–Chapel Hill and I applied to be a fellow of the Mind & Life Summer Research Institute. I was lucky enough to be selected to be a summer research fellow. To be honest, it was a life changing experience for me. I was surrounded by a group of peers who were all interested in a similar research field that I didn’t even know was a legitimate scientific pursuit! There was a panel of faculty who were some of the most esteemed researchers in the world coming from a wide range of disciplines and they were all devoting their careers to the development of contemplative science.
Long before my involvement in the Mind and Life Institute, I had been introduced to the second-order cybernetics of Francisco Varela, who was the progenitor of the Mind and Life Institute. His work, and earlier foundational work in cybernetics and systems theory by Gregory Bateson, had radically shaped my way of thinking. So it was very exciting to tap into a whole organization whose intention was to carry on the work of Varela. It was really catalytic for me in many ways. I received a Francisco J. Varela Research Grant the next year. It was a $15,000 grant and His Holiness the Dalai Lama’s signature was on the grant letter. How amazing is that?!? That grant funded my dissertation, which was the first study of Mindfulness-Oriented Recovery Enhancement (MORE). I’ve since pursued research on MORE for the past eight years and that line of investigation has blossomed into nearly $20 million dollars in federal research grants and more than 100 scientific publications. So I’m really indebted to Mind and Life and grateful to have made so many good friends and colleagues along the way.
Do you maintain a personal practice? If so, how has that informed your career focus?
I’ve been practicing mindfulness meditation for 22 years. I do maintain a personal practice, and also continue to use mindfulness to treat patients in clinical settings. I’ve done mindfulness-based therapy with hundreds and hundreds of patients — at this point I’ve lost count. Both my personal and clinical practice of mindfulness have been extremely productive in helping me to develop new models of mindfulness, understanding the therapeutic mechanisms involved, and ultimately discovering how these models and mechanisms may help to alleviate suffering.
A lot of my research has been focused on teaching mindfulness to patients with little to no experience with mindfulness meditation practices. I think the experience of prolonged contemplative practice over the years can reveal deeper states of consciousness that a novice is unlikely to experience in the context of a standard eight-week therapeutic mindfulness intervention. I think it’s essential that scientists who are pursuing this field of study have a personal mindfulness practice, and ideally also have experience teaching mindfulness to others. A lot of my hypotheses which I have gone on to test in my research and found support for in my data, emerged from my own experiences during mindfulness meditation or my experiences of sharing mindfulness and meditation techniques with patients. There are parts of my own personal practice that I have yet to study because they are related to the deeper layers of mindfulness and contemplative practice that may not be readily accessible to science.
Do you think we have the tools and the technology to study those deeper states?
No, in fact I’m starting several new big studies where we want to start looking at the experience referred to as ‘non-dual awareness’ in the context of clinical trials. In reviewing tapes of therapeutic mindfulness sessions in these studies, we are finding that occasionally participants with very little mindfulness training report having “tastes” of non-dual states. We’re having a hard time finding any adequate measures, even self-report measures, of that phenomenon, let alone a task that might probe that state. So I don’t think we have yet developed the right tools and technologies to capture the deeper states of consciousness associated with mindfulness practice.
As a field, it makes sense why we haven’t pursued this too heavily; we’ve been putting most of our energy into establishing the scientific legitimacy of the field. We’ve been trying to import methods from neuroscience and psychology into the field. This was a necessary stage in the development of contemplative science. Probably over the next coming decade we’ll start seeing measurement approaches that can tap constructs that haven’t been really formally considered in these other fields.
What is Mindfulness-Oriented Recovery Enhancement (MORE)?
MORE is an integrative therapeutic approach that combines mindfulness training with reappraisal skills and techniques to promote savoring. In that sense, MORE combines multiple traditions; it unites a traditional mindfulness meditation-based intervention approach with techniques drawn from “third wave” cognitive-behavioral therapy (and even existential therapy), along with a positive psychology emphasis that acknowledges the importance of enhancing positive emotion through savoring. MORE was designed to ameliorate addictive behavior, stress and (physical and emotional) pain.
What are the biobehavioral mechanisms of MORE?
I’ve done a number of randomized controlled trials of MORE and the therapy seems to have a wide range of effects on both transdiagnostic mechanisms and addiction-specific mechanisms. Generally speaking, MORE seems to help people with addiction, stress and chronic pain conditions by enhancing self-control over automatic habits of fixating attention on negative or threat-related information, as well as enhancing attentional control over fixation on drug-related cues and cravings. The data is showing that MORE helps people become better able to disengage their attention from and become less fixated on stress and drug-related stimuli. At the same time, the data shows that MORE improves self-regulation of autonomic nervous system responses during attention to emotional information. In my studies, following the MORE intervention, participants show reduced attentional biases and heightened heart rate variability responses when confronted with stressors or drug-related cues and triggers. These psychophysiological markers seem to indicate that through MORE patients become better able to flexibly engage and disengage their attention from these stimuli — and thereby become better able to regulate their emotional reactions.
The data also indicates that MORE increases sensitization to natural reward. What I mean is that over time people who participate in MORE show heightened physiological responses to healthy pleasures, and report being able to extract more joy out of healthy objects and events in their lives through the use of mindfulness as a tool to enhance savoring. Across several published and soon-to-be-published studies, we are discovering that increasing sensitivity to natural reward through savoring may lead to decreased craving for drugs — a completely novel and radically important finding for the field of addiction science.
I also have data from several studies showing that mindfulness appears to relieve chronic pain symptoms by increasing interoceptive awareness. In other words, mindfulness seems to be decreasing chronic pain symptoms by enabling people to pay attention to the sensory qualities of their pain rather than being fixated on the emotional aspects of pain. So in MORE, we teach patients to focus mindful awareness on pain. Rather than distract themselves from pain, we encourage patients to disengage from their emotional reactions to pain and then to explore pain by breaking down the experience into its subcomponent sensations. So rather than think of low back pain as a terrible, anguishing experience, we train patients to focus on the sensation of heat, tightness and tingling in the back. In doing so they may find spaces inside of the pain sensation that don’t hurt at all or they might even find some pleasurable or neutral sensations in the body proximal to the pain.
Some people with chronic pain may develop beliefs or schemas about what their pain feels like now and what it will be like in the future, and then they start to feel their assumptions, beliefs and thoughts about their body more than the actual physiological condition of the body — which is in fact always changing. So this is one way how pain can get “stuck” in the brain. By tuning interoceptive awareness into the pain experience, mindfulness seems to undo this process to alleviate pain. In some chronic pain cases, there are no easily defined physiological generators of pain, and no ongoing tissue damage — so there is no nociceptive activity happening. Yet, over time, the patient may come to perceive uncomfortable sensations in the body that might actually be harmless or innocuous as being threatening and dangerous. In MORE we try to reverse this process.
MORE has been used to treat chronic health, mental health and addiction- related issues. How can mindfulness be one therapeutic tool to address all of these conditions?
We need to take a transdiagnostic approach to understand how to alleviate human suffering. Across various forms of suffering, there are some crosscutting mechanisms or processes that create suffering regardless of the diagnosis. Let’s take one process: stress reactivity or sensitization to threat. We see sensitization to threat in anxiety, trauma, depression and chronic pain — in the latter case the threat might be perceived from sensations in the body. Prolonged use of addictive drugs or repeated exposure to stress and trauma can dysregulate stress systems in the brain and can increase sensitivity to stress, making it more likely that non-threatening or innocuous stimuli will be perceived as threatening and overwhelming. This mechanism of stress sensitization is a transdiagnostic mechanism that cuts across disorders and is common to many conditions that cause people suffering. It’s an important transdiagnostic mechanism to be targeted by interventions.
Another transdiagnostic process that I’m particularly interested in is reward insensitivity. This phenomenon is also found in depression, PTSD, chronic pain and addiction. Individuals suffering from these problems may become less able to experience natural pleasure from healthy and pleasant events, people and experiences in everyday life. When individuals become less able to extract the sense of joy from everyday life, this reward deficit may lead them to seek a sense of well-being through self-destructive coping behaviors, such as overindulging in food, alcohol, drugs, gambling, etc. Reward insensitivity is another important transdiagnostic mechanism to be targeted by mindfulness. Mindfulness is likely very useful for targeting multiple transdiagnostic mechanisms because the literature indicates that mindfulness has broad-spectrum effects.
Do you see mindfulness-based interventions as a primary therapy or as an adjunctive therapy?
In the case of chronic pain and prescription opioid misuse, what society is faced with is a large number of patients who are currently prescribed opioids for pain. Up until this point in history, the health care system has provided opioids as the primary medical intervention for chronic pain. Yet opioids carry a number of health risks, including overdose, misuse and the development of opioid use disorders. In contrast, patients who have had Mindfulness-Oriented Recovery Enhancement incorporated into their overall health-care plan have shown improvements in pain and stress, and reductions in opioid misuse and opioid use disorders.
In the future, it’s possible that policy changes focused on reducing opioid misuse will vastly alter the primary treatment of chronic pain. Rather than only being prescribed medication, people with chronic pain might also be prescribed meditation — that is a future that I can envision.
We’re not quite there yet. In my utopian vision of the future, when a patient presents to a doctor with an acute pain condition, the doctor would prescribe the patient a limited amount of medicine, but would also incorporate a mindfulness-based intervention as well as an exercise and nutrition program into the patient’s treatment plan. An integrative medicine approach would be built into the front end of the treatment plan. This could prevent a lot of problems and suffering down the line. Such an integrative approach might even prevent acute pain from becoming chronic pain.
Your studies incorporate cognitive, affective and social neuroscience. Given your background in social work, this might surprise people. Do you feel that the questions you study require an interdisciplinary approach or is this unique to your approach as a clinical scientist?
Up to this stage in my career, I’ve employed methods from cognitive and affective neuroscience, particularly psychophysiology. I incorporate paradigms like the dot-probe task and emotional go/nogo task to assess cognition-emotion interactions, and collect autonomic nervous system measures and EEG during task performance. I’m essentially self-taught; I taught myself psychophysiology in an independent study under the guidance of one of my mentors, Barbara Fredrickson, Ph.D., while I was a doctoral student at UNC. In terms of doing more complex neuroscience, like the use of fMRI or molecular neuroimaging using PET, we do need interdisciplinary partners. In that regard, I have great neuroscience collaborators like Brett Froeliger, Ph.D., from the Medical University of South Carolina.
I just received a new grant from the National Center for Complementary and Integrative Health to use molecular neuroimaging to investigate the effects of MORE on neurotransmitter function with my Co-PI Jon-Kar Zubieta, MD, PhD, Chair of Psychiatry at the University of Utah, who is a pioneer of the use of PET to examine endogenous opioid function in the brain during the experience of pain.
What is Mindfulness to Meaning Theory?
Essentially, Mindfulness to Meaning Theory is an account of how the acute state of mindfulness that is generated when a person sits down on “the cushion” to meditate can impact one’s sense of meaning in the face of adversity. It aims to answer the question: How does the acute, ostensibly non-judgmental, non-discursive state of mindfulness positively influence the discursive, language-based narrative of our autobiographical sense of meaning in everyday life? This whole idea emerged out of the clinical observation that patients seem to benefit from mindfulness meditation by not only decreasing physiological stress arousal, but also by experiencing more complex cognitively-oriented and meaning-based benefits, such as a greater capacity to reframe the stressors and adversities in their lives. Many patients participating in mindfulness-based interventions report that mindfulness helps them to see these adversities as learning opportunities to grow stronger as a person, to gain a sense of meaning or purpose, and to become more compassionate human beings. They reported that the formal practice of mindfulness meditation was benefiting them in broader, more abstract ways than mere stress reduction. This makes sense, because if people were only benefiting from the ten minutes that they were on the cushion focusing on their breathing, mindfulness wouldn’t be a very meaningful pursuit.
The reason why we practice mindfulness is because it has a broader impact on our lives and our sense of self. Mindfulness seems to have an impact on our life story, the way we define ourselves, and the way we understand the opportunities and the challenges that we face in life. There was no scientific model to really explain that process in a fine-grained way. I think the reason for that oversight is that the field has invested a lot into answering the questions of what ‘mindfulness’ is, what is happening when someone sits down and practices mindfulness meditation, and what is happening in the brain. These are fundamental questions. However, there has been less attention paid to how the acute state of mindfulness blossoms into these more longitudinal and broader impacts on a person’s life, their life story and their self-concept. These abstract concepts are harder to define and measure. For a variety of reasons, there’s been less attention paid to them.
The definition of mindfulness that was put forth by Jon-Kabat Zinn has directed the type of questions that contemplative scientists have been asking. And while this was a seminal contribution to the field, this definition has left a vacuum; for example, in defining mindfulness as “non-judgmental awareness,” we haven’t thoroughly explored the question of how the acute state of mindfulness produced by mindfulness meditation affects our judgments when we get off the meditation cushion and go about our everyday lives. There are people who will tell you that mindfulness doesn’t affect judgment because it’s a non-judgmental process. But I’m pretty sure as a mammal with a prefrontal cortex and a limbic system that it’s impossible to shut off judgment completely — at least for any length of time. And would we want to do that anyway? There are a lot of positive, healthy judgments made in life; we use our judgments to navigate the world, to build relationships and to define our sense of ethics and values. And if you go back and look at the traditional Buddhist systems from which many mindfulness practices are derived, these traditional systems don’t seem to abstain from judgment. To the contrary, within the Noble Eightfold Path, for example, there is ‘right action,’ ‘right speech,’ ‘right intention’ and so forth. ‘Right’ implies wrong. There’s a judgment or evaluation there. What is correct? What is wholesome? From a Buddhist perspective, this evaluative process might be called discernment. But from a social psychological perspective, we would call these sorts of evaluations “cognitive appraisals.”
In traditional Buddhism there is a huge focus on wholesome qualities. And defining a quality as wholesome implies that there are unwholesome qualities. Implicit in these traditions was the need to make right judgments and discriminations to identify a wholesome way to live in the world — a noble path that leads to fundamental insights about the nature of self and reality. These insights were held to be important keys to enlightenment, and mindfulness was traditionally used as a tool to help sharpen and clarify insight. Given that history, I developed that Mindfulness to Meaning Theory to help explain how the acute state of mindfulness can help a person to make adaptive evaluations and appraisals of the self and the world to ultimately strengthen the sense of meaningfulness in life.
What is the newest development in the science of mindfulness that excites you?
I’m really excited about some recent clinical trial results from Philippe Goldin and James Gross that show that mindfulness training increases reappraisal and that cognitive-behavioral therapy (CBT) increases mindfulness. We like to think of these interventions as being distinct with distinct therapeutic mechanisms. But in fact, in a well-controlled study of patients with social anxiety, Goldin and Gross found that mindfulness helped people reappraise or change the way they think about their life situation — which provides some of the strongest evidence for the Mindfulness to Meaning Theory yet. Furthermore, they found that CBT helped people become more mindful. From a transdiagnostic and transtherapeutic perspective, these different treatment approaches can promote mental well-being through common pathways.
In terms of technologies and methodologies, I think that the use of molecular neuroimaging to study the effects of meditation practice on neurotransmitter function is an exciting new development. There’s almost been no work in that area.
Lastly, for a long time I have been fascinated by studies of the effects of mindfulness meditation on gene expression. There is a body of work showing that changes in gene expression can drive changes in protein synthesis. Several studies have now provided evidence that mindfulness training is associated with changes in downstream markers of gene expression. These findings underscore a potential pathway by which psychological interventions might change the basic functions of the body. This gene expression research provides a means of testing some of the most time-honored theories of the mind-body relationship.
If you were to win a Nobel Prize, what would it be for and why?
If I were to win the Nobel, it would be on this simple yet powerful idea: If addiction involves a process by which the individual becomes increasingly insensitive to natural pleasure which drives them to take higher and higher doses of the drug just to feel okay, then if we can teach people to extract a healthy sense of reward out of everyday life, might it reverse addiction and reduce dependence on drugs?
We’re pretty clear now in terms of the neurobiological mechanisms by which this reward dysregulation occurs in the mesocorticolimbic dopamine system. We believe this mechanism is partially located in the striatal regions of the brain, which in addiction become hypersensitized to drug-related cues and insensitive to naturally rewarding pleasures. So if we show that mindfulness can promote savoring of natural rewards, and if savoring is associated with reduced craving and addiction, I would hypothesize that we would should see this shift localized in the ventral striatum, and more broadly across the mesocorticolimbic dopamine and endogenous opioid systems of the brain. I call this the restructuring reward hypothesis: I think that mindfulness can be used to restructure reward learning from valuation of drug rewards to valuation of natural rewards. By using mindfulness to train people to savor what is good, beautiful, and meaningful in life we may increase sensitivity to natural rewards and thereby decrease sensitization to drug-related cues and craving.
Do you have any advice for aspiring scientists hoping to pursue a career in science?
Science can be a rough game. One should not enter into this field without recognizing that. Yet, the scientific profession is joyous because it provides the opportunity to live the life of the mind. My advice to aspiring scientists is this: Don’t pursue merely what interests you. Instead, you should ask yourself, “What are the most pressing questions from a societal perspective? What are the needs of society right now?” Based on what society needs, and based on your theoretical and empirical assessment of those problems, you can work to use science to generate solutions to those problems. If an aspiring scientist directs his or her scientific career along those lines, then he or she will have more of an impact on the world, and will also have an easier time obtaining funding and a faculty position. The other important reason to pursue science is for pure discovery. But funding in science is so tight right now that grant money is going to support the most pragmatic applications and questions rather than the grand metatheoretical questions. I think it is much harder to pursue a scientific career for the purpose of pure discovery – though it is certainly a worthy endeavor. But I think a fruitful and meaningful path may open up out of asking yourself, “What are the needs of society and how can science be applied to address those questions?”
Eric Garland, PhD, LCSW, is Presidential Scholar, Associate Dean for Research, and Associate Professor in the University of Utah College of Social Work, Associate Director of Integrative Medicine in Supportive Oncology and Survivorship at the Huntsman Cancer Institute.