It’s the end of a long day. Your pain is higher than usual, your fatigue is heavier, and the 20-minute meditation you’d planned to do feels out of reach. Then, your phone buzzes with a message: “I know it’s been a hard day. You might try a three-minute breath practice before you go to bed.” That’s the kind of responsive support clinical psychologist and 2024 Mind & Life Varela grantee Erin Mistretta imagines: “a mindfulness teacher in your pocket” for people living with multiple sclerosis (MS), a degenerative neurological condition.
Keeping up a practice is hard for almost anyone. In two of the most common mindfulness programs, people with chronic pain practiced at home for just under 40 percent of the recommended time, according to a 2023 systematic review. For Mistretta, an acting assistant professor in the Department of Rehabilitation Medicine at the University of Washington (UW), the struggle to keep practicing became hard to ignore once she began working with patients. Early in her training, the mindfulness spaces she moved through were full of committed practitioners with the time and resources to show up. Then came her clinical psychology residency. “There were just a lot of things getting in the way of practicing on a regular basis,” she says. Her patients’ lives were far more complex than any single focus of therapy, and building any new habit was hard.
When she turned to the research literature, she noticed a pattern. In one review of self-help mindfulness programs, roughly half of participants didn’t practice as often as directed. And while real-time digital tools have helped people stick with other health behaviors, Mistretta notes they had rarely been applied to mindfulness. “It’s almost like we weren’t treating adherence to mindfulness practice like we do with other health behaviors,” she says. With her Varela grant, she set out to change that, starting by asking people with MS what gets in their way.
Listening First
Mistretta’s path to contemplative research began as an undergraduate in California. A collegiate athlete, she was sidelined by an injury that left her asking, who am I? At the same time, a professor in her personality psychology class assigned Jack Kornfield’s The Wise Heart, and a class visit to Spirit Rock, a meditation center in Northern California that Kornfield helped found, introduced Mistretta to meditation. A small undergraduate research study followed, and she has stayed in the contemplative space ever since. “I feel like it asks the most important questions of human flourishing,” she says. Her own experience of losing her identity as an athlete sparked a lasting interest in how people cope when illness or injury changes their sense of who they are, which eventually led her to focus on chronic conditions and chronic pain.
Nearly one million people in the United States live with MS, and its symptoms, from fatigue and memory difficulties to painful spasms, can vary from person to person and from day to day. Chronic pain is a significant problem for many people with MS—studies have found rates of pain ranging from 44 to 80 percent, depending on the sample. Mindfulness interventions such as Mindfulness-Based Cognitive Therapy (MBCT) are effective treatments for people with MS, but consistent home practice—a key factor in whether these programs work—can be especially challenging for people living with MS.
Through the Varela study, Mistretta set out to understand why, in participants’ own words. Her team interviewed 17 people with MS who had taken part in the team’s earlier mindfulness programs for pain at the UW Medicine’s Multiple Sclerosis Rehabilitation and Wellness Research Center—many of them more than five years before.
The study drew on human-centered design, an approach that engages people who will eventually use a tool into its design from the start. In one-on-one interviews over Zoom, participants described how often and how they practiced, what got in the way or helped during and after their program, and what they would want from a smartphone tool: details like how often messages should arrive, when, and whether by app or text. The team also explored how mindfulness shaped participants’ adjustment to living with MS. The goal was a set of “guiding principles” for an app Mistretta hoped to build.
Some barriers echoed what many people face when trying to practice: busyness, motivation, or feeling they simply weren’t ready. Other barriers were unique to MS. Intense fatigue made it hard to stay alert. Memory difficulties made it hard to even remember to practice. Painful spasms could arise in the middle of a sitting practice. And skepticism surfaced early: if my pain comes from my MS, participants wondered, how is mindfulness going to help?
Participants also told the team what would help: reminders for both formal and informal practice, social support, and education early on to address that skepticism. The team asked each person what they would say to someone with MS who is just starting a practice, creating what Mistretta calls a “bank of supportive messages” from people with lived experience to encourage future participants. One message has stayed with her: “Mindfulness involves stepping back from pain. It doesn’t have to mean stepping back from your life.”
“Mindfulness involves stepping back from pain.
It doesn’t have to mean stepping back from your life.”
That distinction matters, Mistretta says, because people with MS “already have to give up so much, related to disability and how their life looks day-to-day.” Mindfulness can initially be perceived as resignation. “That’s not what acceptance is, of course, but that’s an initial feeling,” she says. Instead, the participant’s message reframes practice as a way to take something off your plate.
Mistretta was also moved to hear from participants who, more than five years after their program, were still practicing—by her estimate, around 70 percent—and who described leaning on their practice through hard circumstances beyond pain, like a COVID illness or the death of a close family member.
From Seed Grant to Federal Funding
Research that is, in Mistretta’s words, “niche upon niche upon niche” can be hard to fund. Many small, one-off awards, she notes, aren’t enough to move the needle toward a larger federal grant. “I am so grateful that Mind & Life supports these ideas and saw the value in this work,” she says.
Mistretta’s path to the grant began at the Mind & Life Summer Research Institute, which she attended in 2022. Alumni of the program are eligible for Varela grants, which support researchers early in their careers. That same year, she presented a poster on her dissertation research on self-compassion at the inaugural conference of the International Society for Contemplative Research in San Diego.
From the start, she saw the Varela project as a stepping stone. As her study got underway, she resubmitted a proposal for an early career development award from the National Institutes of Health (NIH), a common step since applications often go through more than one round. “What’s great about this is I didn’t even have the data [from my Varela grant] yet,” she says. Her progress on the 2024 Varela grant showed reviewers that she could successfully recruit people with MS and that she was asking questions that would directly shape the app she hoped to build. Reviewers took note of the Mind & Life grant and could see the leap from a small interview study to a five-year project. “I think that was critical,” she says, it showed she could lead this research as an independent scientist.
In spring 2026, Mistretta began a five-year NIH K23 Career Development Award, Optimizing Mindfulness Practice for Pain in People with Multiple Sclerosis. The work will expand from 17 interviews to studies with 80 and then 50 participants, along with training that builds toward a future R01, the National Institutes of Health’s main grant for scientists leading their own research programs.
A Mindfulness Teacher in Your Pocket
The new project builds toward a just-in-time adaptive intervention, or JITAI: a tool that uses information from a participant to offer support right when they need it most, like that end-of-day suggestion to try a three-minute breathing practice. The idea is to accommodate each person’s day and counter the thoughts that, as Mistretta puts it, get in everyone’s way: “I’m not doing it right…I’m not a meditator,” or, “I’m just not gonna do it because I can’t do it for 20 minutes.”
That information comes from ecological momentary assessment (EMA)—brief check-ins that arrive as a push notification on your phone, asking questions like where your pain and fatigue are today. Rather than wearable sensors, which some researchers use to detect stress and prompt practice, Mistretta’s approach relies on these quick self-reports. For people with MS, real-time check-ins are essential, because the condition is characterized by variability.
What Mistretta learned through the Varela interviews shaped the new study directly. Her team felt confident including MS-specific symptoms as potential daily barriers, and added measures of how helpful people find the practices and how busy they are. Where the Varela study relied on participants’ recollections from years earlier, the new study asks about barriers and facilitators day by day, as people are learning mindfulness.
The work unfolds in three steps. First, 80 people with MS will complete daily check-ins during an eight-week MBCT for pain program, capturing what helps or hinders practice from one day to the next. Next, using those findings and design feedback from people with MS, the team will build the JITAI and its personalized “nudges” to practice. Finally, in a micro-randomized trial with 50 participants, the app will sometimes send a message encouraging practice and sometimes not, so the team can see which messages actually lead people to practice more at the next check-in.
Along the way, the award provides mentored training in these research designs, in developing JITAIs, and in grant writing, preparing Mistretta to lead this line of research independently.
By the end of five years, Mistretta hopes to have an app optimized for people with MS: one that asks the fewest questions possible, “because that itself can be burdensome,” as she puts it, and keeps only the pieces that increase practice. On hard days, even a modified practice counts. “We know reps count in terms of behavior change,” she says, “so how can I get you to practice, even in a modified way, given what you’re going through today?”
“We know reps count in terms of behavior change, so how can I get you to practice, even in a modified way, given what you’re going through today?”
Beyond Multiple Sclerosis
Mistretta hopes the work encourages more researchers to think about mindfulness as a health behavior and to bring behavior change principles into building mindfulness as a habit. Because people with MS experience many symptoms that others share, she sees potential for people with other chronic pain conditions, as well as for mindfulness programs addressing depression or increasing physical activity.
For Mistretta, the work comes back to uncertainty. “I feel like this practice is a path to greater ability to cope with uncertainty,” she says. Many of the people she works with live with uncertainty every day. “To give them a tool to help them through that…That’s incredibly meaningful.” What began as 17 conversations, made possible by a Mind & Life Varela grant, is now a five-year federally-funded effort to help people with MS turn mindfulness into a lasting habit, one practice at a time.
