By Stephany Tlalka
Be prepared to be bored.
This is the gist of one of the notifications you receive before you try the body scan meditation from Mindful Mood Balance, a web-based program currently being piloted in a version for therapists. The app allows users to take Mindfulness-Based Cognitive Therapy (MBCT) at a distance using their phone, tablet, or computer.
Once you complete the 30-minute exercise, you navigate to a video featuring a group of people who've also just tried it. A few admit the experience was not incredibly riveting at times.
It's something you don't often hear from a mindfulness app: You might not enjoy this.
It smacks up against the wonder-drug version of mindfulness we're so often sold.
In a time when there are so many brain-training apps drumming up excitement for their products through marketing, others have taken to the lab--how else, they argue, can you try to make good on promises of cognitive gains?
That's their benchmark, and it's a new one. But more app developers may want to follow suit, especially after what happened to the brain-training game Lumosity: In January, the company was fined $2 million for deceptive advertising. Lumosity claimed that its products would improve cognitive performance on a daily basis and protect against cognitive decline, but fell short on providing the appropriate research to back up its extensive marketing campaigns. For instance, Lumosity took out targeted Google ads called Adwords with keywords like "memory loss," "dementia," and "Alzheimer's."
"Lumosity preyed on consumers' fears about age-related cognitive decline, suggesting their games could stave off memory loss, dementia, and even Alzheimer's disease," said Jessica Rich, the director of the FTC's Bureau of Consumer Protection, in a statement. "But Lumosity simply did not have the science to back up its ads."
When apps target vulnerable populations
Visit the app store, and you're greeted with hundreds of mindfulness apps, a few dozen of them claiming to benefit your brain in some manner. Some of the most popular ones make health claims with no research to back up their programs--they rely on the science of mindfulness in general to prove the worthiness of their product. It seems enough to simply provide a link to the most recent mindfulness study taking place, or a comprehensive four-year meta-analysis on mindfulness and X, and then mention how their app relates--as if some sort of osmosis was taking place between the research study, in no way connected to the company itself, and the app.
We spoke with two mindfulness researchers who have also developed their own apps on the importance of research-backed mindfulness apps in order to pinpoint exactly what went wrong with Lumosity and have them share lessons for the burgeoning industry of apps that train your brain.
Zindel Segal developed the Mindful Mood Balance (MMB) app mentioned earlier. He's Director of Clinical Training in the Graduate Department of Clinical Psychological Science at the University of Toronto Scarborough, and he's one of the developers and founders of MBCT. Working with individuals recovering from depression, Segal is particularly concerned when apps with unfounded health claims target vulnerable populations--in Lumosity's case, the elderly.
"The problem is there's very little evidence that progress on these Lumosity games has any impact on memory and cognitive functioning in the real world when you're engaged in other tasks like adding up a bill at a restaurant or if you have a very busy day and you're in a rush," says Segal, "and that's really the point of contention here."
The company was fined in part due to unfounded claims that its games "reduce or delay cognitive impairment associated with age or other serious health conditions," according to the FTC ruling.
The Lumosity program consists of 40 games designed to train specific areas of the brain. At the time of the FTC fine, the company advertised that if users trained for 10-15 minutes three to four times a week, they would see benefits. In one game aimed at training attention called Train of Thought, users have to match trains to appropriate-colored stations by modifying the tracks. At the highest level, 67 trains come pouring out of a mountain. In Tidal Treasures, a memory-testing game, users have to click beach objects that wash up on shore that they haven't selected before.
While people might become skilled at these games, it's not clear that cognitive gains translate into everyday activities. That was the impetus for 70 researchers to speak out against brain-training games like Lumosity in 2014 when they signed a letter of consensus with the Stanford Center on Longevity.
Since Segal's work and app involves mood disorders, he has one app on his radar right now: Headspace--in particular, their Depression Pack. Last year, the company launched a 30-day pack of mindfulness practices tailored to working with emotions related to depressive symptoms.
"I've listened to some of the guided meditations from the depression pack--they're pretty much straightforward mindfulness meditation: watching thoughts, working with thoughts," says Segal. "Those practices take a while to build up to for people with depression who don't really take this material in the same way that people that haven't had a history of rumination or critical self-judgment."
For someone recovering from depression, Segal says it's not a good idea to jump into mindfulness meditation with just simple guided instruction--even if, as in Headspace's case, that instruction is based on over ten years experience at monasteries all around the world. Instead, the programs need to be tailored to their needs: As they learn the practices, they need to also be learning about how their disorder will crop up during the meditation experience.
"It's especially hard for people with depression to dis-identify from their own thinking--disorders like depression and anxiety have powerful messages that their thoughts carry vital information," says Segal. "These practices need to be customized in a way that allows them to build skills gradually and sequentially while also providing them with information about how the disorder might camouflage itself in terms of thinking patterns."
Thoughts of unworthiness and hopelessness, for instance, aren't part of the reality that the individual has to face head on, but surface due to the disorder. Once that's established, "maybe they can start to approach some of these thoughts a little bit more lightly," says Segal.
Additionally, Segal says there's a rebound effect of trying the practices and quickly giving up. Compassion practices, for example, are difficult when you don't feel you deserve to be kind to yourself or pay attention to your experience because you're struggling with feelings of inadequacy.
"Unless you have a program that's engineered to recognize these needs early on, then you're going to be doing this population a disservice," says Segal.
Headspace employs an in-house chief medical officer, David Cox, MD, who co-authored a pamphlet on the "Quantifiable Positive Outcomes of Mindfulness Training" with Andy Puddicombe. But it's difficult to determine how much research went into Headspace to bring it to market in 2012. The app, now downloaded by six million users according to the company, consists of ten minutes of meditation for ten days--those first ten days are free. From there, for $10.83 a month, you have access to meditation "packs" bundled into themes like "Balance," "Anxiety," and "Self-Esteem."
Headspace lists research collaborators on its website, including Stanford Health Care. Headspace will also be involved in an upcoming clinical trial in conjunction with Barts Health NHS Trust: "Mindfulness Meditation Using a Smart-phone Application for Women With Chronic Pelvic Pain." So the app will be used within a study of the efficacy of delivering mindfulness by smartphone, but the program's efficacy itself is not studied.
A visit to the Depression Pack introductory page and video with Andy Puddicombe yields no mention of research. When contacted for comment about the research that went into launching Headspace and the Depression Pack in particular, the company passed on an interview.
It's not as if Headspace is buying up Adwords for depression and blanket-marketing their pack on depression--but there are parallels with Lumosity: touting the benefits of a product for dissolving depression before the product itself has been tested with identified groups in pilot studies.
For Segal's app, the major difference is in the research. Segal is currently collecting data in an NIH-funded study with 460 patients at Kaiser Permanente in Colorado, which is forthcoming. The results of this study will determine whether Mindful Mood Balance will make it to market.
"If those results come out and show really there's no difference between people who do Mindful Mood Balance and those who don't, it's going to make life difficult for us," says Segal.
Building apps around data, not hype
"Some have argued that Lumosity was the warning shot over the bow of the industry that put everybody on notice," says Judson Brewer, addiction psychiatrist and Director of Research at the Center for Mindfulness at the University of Massachusetts Medical School. Brewer has developed two apps: a smoking cessation app called Craving to Quit and a mindful eating app called Eat Right: Now!
To bring both apps to market took clinical trials and studies--not standard at this juncture for mindfulness apps or any apps that are marketing themselves as therapeutic.
"We've seen companies make all sorts of claims--I won't name any in particular but they have to do with apps and mindfulness training and subscription services to their apps--and they say 'based in science' and to my knowledge there's at least one company that hasn't published any data on their apps but they're citing scientific research about mindfulness in general," says Brewer.
When asked about the possibility of creating his app without research, Brewer replied: "Oh God, the app would have been a bunch of garbage. . . . I wouldn't have known where to begin."
In Brewer's own experience, it's the data that determines the app's structure--not the great app idea, or even the creator's own meditation expertise. When he was developing Craving to Quit, he thought, "Oh, I meditate, so therefore meditation must be the groundwork, the most basic piece." What he found was that the informal meditation practices, the little bits of mindfulness parsed out during the day, were the biggest driver for people to use the app, so they developed the program around that.
"We had to follow the data because my predictions were wrong," says Brewer.
The Wild West of apps
If you go into the Apple Store on your device, "type in 'depression,' it's hard to know if the apps that you get back are high-quality, if they work, if they are even safe to use," John Torous told Nature recently. He's a psychiatrist at Harvard Medical School in Boston, Massachusetts, who chairs the American Psychiatric Association's Smartphone App Evaluation Task Force. That same article mentions a 2013 review of depression-related apps: At the time, there were 1,500 in commercial app stores, but only 32 published research papers on the subject.
Segal is also concerned about how many mindfulness apps have been tested when he types "mindfulness" into the app store, and it churns out 150-200 results. But it was also part of his impetus for developing MMB: the difficulty in getting access to MBCT--a form of cost-effective treatment for recurrent depression that's been recommended by the National Institute for Clinical Excellence in the UK.
MBCT involves a process of inquiry: A patient becomes familiar with their thoughts, identifying negative patterns, ruminations, or cognitive distortions, and they learn how to redirect the thought process that's getting them into trouble. It's a skills-based approach that allows a person to get into the habit of seeing what's going on in their minds without immediately reacting to the content. It's a process of becoming familiar with these patterns--and this act of awareness is what helps loosen the grip of what some call negative thought loops and storylines that these patterns can trigger.
In the largest meta-analysis to date, which included data from nine clinical trials that compared MBCT to routine treatments for depression, including antidepressants, MBCT was found to reduce rates of relapse over sixty weeks follow-up.
"Many people, even if they want to, aren't going to find an MBCT group anywhere near where they live," says Segal. "The public health model would say it's better to give everyone a little bit of something than to reserve everything for just a few people, and that's where we are coming from."
In other words, while Segal says that the live MBCT group experience is not the same as the MMB experience, the app can address an important gap in health care. MMB is offered as a program for therapists to learn and then teach to their patients. While you do end up compressing the content of an eight-week mindfulness program into an app, it's better than therapists not having access to MBCT tools at all.
"You do have to dumb things down, but there's a trade-off that's really important to understand," says Segal. "The reason that we developed MMB in the first place was because there is this issue of barriers to care."
Brewer predicts that as more apps for behavioral treatments come to market--and as others surface that aren't clinical apps but use medical language in their marketing--organizations like the Substance Abuse and Mental Health Administration, which provides guidelines for evidence-based treatments and a national registry of programs, could inherit a role in this Wild West. In particular, by becoming the benchmark by which apps will be measured and determinations about the veracity of health claims will be made.
Ultimately, Brewer thinks companies can avoid Lumosity's fate by starting with data: Let the mechanism for improvement and the science behind what works determine the app, and don't get carried away with hype around meditation or how the brain can do amazing things if you train it.
"Where all the Mcmindfulness stuff will go away is when we can get more mechanistically based apps and brain-trainings and therapies," Brewer says.
Essentially, if you can't show that a certain dynamic is at play in your app and in the brains of the people using your app, such as improved cognitive gains or reduced cravings, it's going to become more difficult to simply say your app is "based in science" in the future. Lumosity is a lesson for the burgeoning field, and a warning to mindfulness apps that are eager to harness the hype and the excitement around the early science into mindfulness: It's not enough to hitch your wagon to current science and say that your app helps with "depression" or the latest health fad. It might not be so easy in the future for developers to craft their marketing materials around these keywords without having the research to back it up.
How to find the right mindfulness app for you
Here are three things to look for when considering an app for mindfulness:
- Get clear on its purpose: Is there a clear rationale for why this app would be helpful? If it is for stress, then how will it reduce stress? If it is for anxiety, then how will it help reduce anxiety?
- Show me the research: Ideally, any claims made about benefits should be backed up by research studies showing that practices included in the app are helpful for these conditions.
- Music doesn't help: Some features like music are popular for relaxation apps, but may not be particularly helpful for mindfulness apps where the goal is awareness. "The practice of mindfulness is about observing and experiencing states that arise in the mind as we find it," says Segal. "Elements such as music and waterfalls are designed to induce a state of relaxation, calm, or soothing that may or may not be in the mind of the practitioner. It might make it more difficult, rather than easier, to connect with what's happening in the present moment."