Journal of Psychiatric and Mental Health Nursing, 2016, , –

Mindfulness interventions for psychosis: a systematic

review of the literature
J. AUST1 RNMH, BSc (Hons), PGCE, MA (O xon) & T. BRADSHAW2 RGN RNMH DPNS (PSI)
BSc (Hons), MPhil, PhD
1
Cognitive Behavioural Therapist, Early Intervention Team, Oldham, Pennine Care NHS Trust, and 2Reader,
School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK

Keywords: acceptance, compassion, Accessible summary

mindfulness, psychosis, schizophrenia
What is known on the subject?
Correspondence:
T. Bradshaw
• Psychosis and the more specific diagnosis of schizophrenia constitute a major
psychiatric disorder which impacts heavily on the self-esteem, functioning and
University of Manchester
quality of life of those affected.
•
Room 6.319
A number of mindfulness therapies have been developed in recent years, showing
Jean McFarlane Building
Oxford Road
promising results when used with people with the disorder.
Manchester M13 9PL What this paper adds to existing knowledge?
UK
E-mail: t.bradshaw@manchester.ac.uk
• This review of the literature included only randomized controlled trials (RCTs),
rather than other typically less robust methods of research (e.g. case studies, non-
Accepted for publication: 14 October controlled studies).
2016 What are the implications for practice?
doi: 10.1111/jpm.12357 • We concluded that mindfulness therapies can be safely used with people with
psychosis and that they provide a number of therapeutic benefits compared with
routine care and, in some cases, other interventions.
• Larger, methodologically improved trials are now recommended to evaluate the
benefits of mindfulness therapies further.

Abstract

Introduction: A growing number of mindfulness interventions are being used with

individuals with psychosis. These therapies employ elements of acceptance and com-
passion in addition to mindfulness. A number of randomized controlled trials
(RCTs) of these interventions have emerged in recent years, but no review of these
latest trials exists. Question: ‘For individuals with psychosis, are mindfulness inter-
ventions more effective than treatment as usual or an alternative intervention, in
improving patient-related outcomes as demonstrated in RCTs?’ Method: We under-
took a systematic review of randomized controlled studies of mindfulness interven-
tions for psychosis and schizophrenia (MIps). Studies were identified by searching
the databases Medline, Embase, PsycINFO, Cochrane Central Register of Controlled
Trials, and Allied and Complementary Medicine. Findings: The review identified 11
RCTs investigating eight mindfulness interventions. Significant improvements were
reported on a number of measures, although gains were mostly smaller in trials
employing well-designed controls and where assessors were blind to treatment allo-
cation. There was considerable heterogeneity amongst trials in the diversity of treat-
ments reviewed and the range of outcomes assessed. Implications for Practice: The
findings suggest MIps are feasible for individuals with psychosis and provide a num-
ber of significant benefits over routine care and, in some cases, other interventions.

© 2016 John Wiley & Sons Ltd 1

J. Aust & T. Bradshaw
Introduction
Rationale
Psychosis and the more specific diagnosis of schizophre-
nia constitute a major psychiatric disorder, in which an
individual’s perceptions, thoughts, behaviour and mood
undergo significant change (NICE, 2014). Despite the
efficacy of pharmacological treatments, around a third
(36%) of people with schizophrenia have a poor
response to antipsychotic medication (Liu-Seifert et al.
2005), whilst depression and anxiety symptoms are fre-
quent in those with schizophrenia and related psychotic
disorders (Lewandowski et al. 2006). When medication
is combined with psychosocial interventions, such as
family interventions and cognitive behavioural therapy
(CBT), outcomes are shown to improve (Lewis et al.
2005). Since the 1990s, a ‘third-wave’ of cognitive beha-
vioural interventions (Hayes et al. 2004) has emerged.
These therapies incorporate elements of mindfulness,
acceptance and compassion into a cognitive behavioural
framework (e.g. Linehan 1993, Segal et al. 2002, Gilbert
2009). Whilst diverse in their techniques, these mindful-
ness interventions (MIs) share a common goal, namely
the regulation of negative emotions by increasing an
individual’s willingness to embrace present-moment
experience (Khoury et al. 2013).
Mindfulness-Based Cognitive Therapy (MBCT; Segal
et al. 2002) is now recommended by the National Insti-
tute for Health and Clinical Excellence for relapse pre-
vention in depression (NICE 2010). Amongst other
authors, Chadwick et al. (1996) have highlighted the
benefits of developing mindfulness qualities to alleviate
distress associated with psychosis. Such observations,
alongside a growing interest in mindfulness for various
psychopathologies, have led to a range of mindfulness
interventions for psychosis (MIps) being developed. In
some of these, mindfulness meditation is the primary
focus (e.g. Chadwick et al. 2005), with formats sharing
many features of MBCT and MBSR (mindfulness-based
stress reduction; Kabat-Zinn 1990). In others, mindful-
ness meditation is part of a wider intervention, in which
aspects like ‘acceptance’ (e.g. acceptance and commit-
ment therapy; ACT, Hayes et al. 1999) and ‘compas-
sion’ (e.g. compassion-focussed therapy; Gilbert 2001)
are emphasized.
It has been argued this diversity of intervention focus
reflects the variety of operational definitions of mindful-
ness which exist (Khoury et al. 2013). Definitions
include the following: the purposeful cultivation of
attention (Kabat-Zinn 1990); the decentering from inter-
nal experience (Segal et al. 2002); the endeavour of
2 © 2016 John Wiley & Sons Ltd
connecting to each object in one’s awareness with open-
ness and curiosity (Bishop et al. 2004); and the accep-
tance of reality without attempts to avoid, escape or
change it (Hayes et al. 1999). A number of authors also
suggest the constructs of self-compassion and mindful-
ness are highly correlated (e.g. Baer & Krietemeyer
2006, Birnie et al. 2010). Neff (2003) asserts mindful-
ness is a prerequisite for self-compassion, whilst Kuyken
et al. (2010) argue that much of the success of mindful-
ness-based interventions can be attributed to the cultiva-
tion of self-compassion. Accordingly, H€ olzel et al.
(2011) suggest it is difficult to tease apart these con-
structs (Table 1).
The suitability of applying mindfulness-based
approaches with psychosis has been questioned, following
incidences of meditation-induced psychosis, although a
variety of methodological limitations have been noted in
the majority of studies reporting such cases (Shonin et al.
2014). By contrast, a review by Davis & Kurzban (2012)
concluded that mindfulness interventions may be ‘uniquely
suited’ to alleviating distress related to symptoms and
internalized stigma in individuals with severe mental illness
including psychosis, for whom social rejection and inter-
personal stress are common.
A meta-analysis by Khoury et al. (2013), which
reviewed 13 studies including 468 patients with various
psychotic disorders, found a moderate effect for mindful-
ness interventions in pre–post studies, and small-to-mod-
erate effects when studies included a comparison group
(e.g. waitlist, TAU). Results for MIps included moderate
improvements in negative and affective symptoms, func-
tioning and quality of life.
Since the time of these reviews, a number of random-
ized clinical trials of MIps have emerged, giving grounds
for renewed evaluation of this group of interventions.
Such a review might establish whether a sufficient body
of evidence has emerged to demonstrate a clear treat-
ment effect for MIps. The findings from the review may
be useful to service users experiencing psychosis and to
mental health professionals tasked with reducing the fre-
quency of relapse for these individuals, whilst helping
them to improve cognitive, social and occupational func-
tioning. Pitt et al. (2007) note the importance of offering
a choice of psychological and social treatments to such
individuals, for whom recovery is an idiosyncratic pro-
cess. Whilst definitions of recovery vary, Liberman
(2008) suggests it encompasses a broad set of outcomes,
involving both remission of symptoms and functional
elements, including engagement in productive activity
(work, education, etc.) and recreational activities, inde-
pendent management of daily needs, and satisfying social
relationships.
 Mindfulness for psychosis: systematic review

Table 1
Existing mindfulness interventions
Intervention
Mindfulness-based stress reduction (MBSR)
Mindfulness-based cognitive therapy (MBCT)
Acceptance and commitment therapy (ACT)
Compassion-focussed therapy (CFT)
Outline
• An 8-week group-based programme (Kabat-Zinn 1990) originally developed to
manage stress related to chronic pain.
• Incorporates a number of techniques to build present-moment awareness.
• Participants are guided to carefully attend each sensory aspect of (e.g.) eating as
opposed to eating on ‘autopilot’.
• Structured exercises include mindfulness of breath and body scan meditation,
which help participants develop nonjudgmental awareness of thoughts, emotions
and sensations.
• An 8-week group-based therapy (Segal et al. 2002) adapted from MBSR, and
used for depression and prevention of depressive relapse.
• Incorporates many features of MBSR: sitting meditation, body scan, mindful
eating, yoga and mindful walking.
• Focus is on changing a person’s relationship to their thoughts, rather than
changing thought content as in traditional CBT.
• 1:1 therapy developed by Hayes et al. (1999).
•
Participants are helped to acknowledge distressing internal experiences
nonjudgmentally, as opposed to struggling with or avoiding them, whilst at the
same time identifying and pursuing valued life goals.
• Processes include the following: acceptance of private events,
cognitive diffusion, mindfulness and developing patterns of committed action.
• Group-based therapy (Gilbert 2009) developed for people with chronic and
complex mental health problems linked to shame and self-criticism.
• Based on a model of affect regulation derived from neuroscience and
evolutionary psychology.
• Uses compassionate mind training to help people develop experiences of inner
warmth, safeness and soothing via compassion for self and others.
• Integrates elements of mindfulness, attention regulation, compassionate imagery
and reframing.

intervention, which contains an explicit component of

Objectives
The aim of this paper was to provide a systematic review of
the effectiveness of mindfulness treatments for individuals
with psychosis, and to update the existing evidence base for
MIps. The review sought to answer the question: ‘For indi-
viduals with psychosis, are mindfulness interventions more
effective than treatment as usual or an alternative interven-
tion, in improving patient-related outcomes as demonstrated
in RCTs?’ A further objective of the review was to assess
and evaluate the moderators of the effectiveness of MIps.
Methods
formal mindfulness training.
• Trials in which a minimum of 50% of patients had a
diagnosis of schizophrenia or any related psychotic dis-
order, as defined in the ICD-10, i.e. schizoaffective dis-
order, schizophreniform disorder, delusional disorder
and other nonaffective psychoses.
• Participants were aged 16 years or over
• Studies of outpatients and/or inpatients.
• Therapist-led or self-help mindfulness interventions.
• Randomized study designs containing an active control
intervention (e.g. befriending) and/or treatment-as-
usual comparison.

Protocol and registration Exclusion criteria

No registered protocol exists for the present review. The
review was conducted according to PRISMA guidelines
(Preferred Reporting Items for Systematic reviews and
Meta-Analyses; Moher et al. 2009).
Eligibility criteria
Inclusion criteria
• Randomized controlled trials of any mindfulness-
based, acceptance-based or compassion-based
• Over 50% of the trial sample constitutes other psy-
chotic disorders not indicated above, e.g. bipolar disor-
der, unipolar psychotic depression.
• Other mind–body interventions (e.g. yoga, qi-gong).
• Metacognitive therapy or other ‘third-wave’ cognitive
therapy not containing an explicit component of for-
mal mindfulness training.
• Participants with subclinical symptoms of psychosis.
• Trials reporting no measures of symptoms or other
patient-related psychosocial outcomes.

© 2016 John Wiley & Sons Ltd 3

J. Aust & T. Bradshaw
In view of the early state of the literature in this
field, any study examining the controlled effects of a
mindfulness intervention for schizophrenia or any
related psychotic disorder was deemed eligible for
review. The review sought to include samples whereby a
minimum of 50% of participants had a diagnosis of
schizophrenia or related psychotic condition as defined
in the International Classification of Diseases, 10th
Revision (ICD-10) (World Health Organization 1992).
A range of mindfulness interventions were considered,
including those which incorporate elements of accep-
tance or compassion in addition to mindfulness. This
was in contrast to Shonin et al. (2014), whose review
excluded studies of certain interventions (e.g. ACT), on
the basis that they ‘integrate mindfulness meditation as
an adjunct to more traditional dialogue-based therapeu-
tic techniques’ (p.124). The present review sought to
include all existing randomized controlled trials (RCTs)
of MIps, in contrast to all three aforementioned reviews
which included other types of study design in their anal-
ysis. In the light of the early state of the literature, it
was decided that studies investigating any patient-related
outcome be considered for review. Studies were
excluded if 50% or more of the sample constituted
other psychotic disorders (e.g. bipolar disorder and
unipolar psychotic depression). Studies were also
excluded if they reported no measures of symptoms or
other psychosocial outcomes.
Information sources
Studies were identified by searching the databases Med-
line, Embase, PsycINFO, Cochrane Central Register of
Controlled Trials, and Allied and Complementary Medi-
cine (AMED), from the earliest available date until the 29
January 2016.
Search
The aim of the search strategy (Table 2) was to identify
all randomized controlled trials of any mindfulness-based,
acceptance-based or compassion-based intervention used
for the treatment of schizophrenia, or any related psy-
chotic disorder, and incorporating an explicit component
of formal mindfulness training.
Study selection
Assessment of eligibility was conducted primarily by
the first author with assistance from the second
author (TB) where there was uncertainty about a
study’s suitability.
4 © 2016 John Wiley & Sons Ltd
Table 2
Search strategy
#1 schizo*
#2 psychosis
#3 psychotic
#4 #1 OR #2 OR #3
#5 mindful*
#6 acceptance*
#7 compassion*
#8 meditation
#9 #4 AND #5
#10 #4 AND #6
#11 #4 AND #7
#12 #4 AND #8$
#13 #9 OR #10 OR #11 OR #12
Data collection process
Data extraction was conducted by the first author (JA)
using a battery of data extraction forms also developed by
the first author. The forms were pilot tested on two ran-
domly selected studies and refined before data collection
was repeated on all 11 selected trials.
Data items
Data items extracted from each trial included: (1) trial
characteristics (e.g. year of publication, therapist experi-
ence, length of follow-up); (2) intervention characteristics
(e.g. intervention protocol, treatment setting, target popu-
lation, number of participants, duration of treatment,
level of attendance, hours of home practice); (3) control
group characteristics (e.g. description of treatment, num-
ber of participants); and (4) characteristics of the partici-
pants (e.g. gender ratio, mean age, ethnicity, diagnosis,
duration of illness, attrition rate).
Risk of bias in individual studies
To minimize data selection bias, it was decided that data
pertaining to any patient-related outcome be included in the
review. The following primary outcomes were therefore
considered: positive and negative symptoms of psychosis,
hospital readmission data, affective symptoms, functioning
and quality of life. Measures of mindfulness, acceptance
and compassion were included as secondary outcomes, with
a view to assessing the moderators of the effects of MIps.
Methodological quality was assessed by the first author
(JA) using the Clinical Trials Assessment Measure
(CTAM, Tarrier & Wykes 2004), which scores trials of
psychological interventions in relation to: recruitment,
randomization, sample size, outcome measures, indepen-
dence of raters, rater blinding, data analysis, and experi-
mental and control conditions. The CTAM provides an
overall score on a 0–100 scale, with higher scores

indicating increased methodological rigour. This measure
has been shown to have good interrater reliability, ade-
quate internal consistency and excellent concurrent valid-
ity with other established rating scales designed to assess
the quality of clinical trials (Wykes et al. 2008).
Summary measures
In this study, difference of means was the principle
method adopted to report effect size change in assessed
outcomes. The use of odds ratios was also considered for
summarizing data on hospital readmission.
Synthesis of results
Although a meta-analysis of data was considered, any
decision to combine findings in this way would depend on
the heterogeneity amongst the studies selected for review.
In the case where the review’s authors deemed heterogene-
ity amongst studies to be high, a narrative synthesis of
data would be favoured.
Risk of bias across studies
The narrated findings of individual researchers were com-
pared with corresponding ‘raw’ data to assess the validity
of narrative findings and highlight any inconsistencies or
omissions in the reporting of results. Although Higgins
et al. (2011) recommend assessing the completeness of
reporting for each identified outcome, no such formal
investigation of reporting bias was undertaken here. Nei-
ther was a formal assessment of publication bias under-
taken.
Additional analyses
In keeping with the objectives of the review, the use of meta-
regression meta-analyses was considered for assessing the
relationship between the pooled effect size of the selected
MIps and the following moderators: (1) effect size of mind-
fulness outcomes, (2) effect size of acceptance outcomes and
(3) effect size of compassion outcomes. As with the decision
of whether to proceed with meta-analysis, the suitability of
conducting meta-regression would depend on there being
sufficient homogeneity across the studies included for review.
Results
Study selection
The search (Fig. 1) identified 13 studies following exclu-
sions. The primary author of two papers (Chien & Lee
© 2016 John Wiley & Sons Ltd
Mindfulness for psychosis: systematic review
2013, Chien & Thompson 2014) was contacted and con-
firmed that both papers report data from the same trial.
Similarly, Bach et al. (2012) present 1-year follow-up data
from an earlier RCT (Bach & Hayes 2002). The search
therefore identified 13 eligible studies reporting data from
11 trials.
Study characteristics
A summary of the selected RCTs is shown in Table 3.
Three trials were conducted in the USA (Bach & Hayes
2002/Bach et al. 2012, Gaudiano & Herbert 2006, Davis
et al. 2015), three in the UK (Chadwick et al. 2009,
White et al. 2011, Braehler et al. 2013), two in Spain
(Langer et al. 2012, Lopez-Navarro et al. 2015), and one
in China (Chien & Thompson 2014), Germany (Moritz
et al. 2015) and Australia (Shawyer et al. 2012), respec-
tively. Two trials were conducted in inpatient settings
(Bach & Hayes 2002/Bach et al. 2012, Gaudiano & Her-
bert 2006). Langer et al. (2012) and Shawyer et al.
(2012) did not report this aspect of participants’ status.
The other seven trials recruited participants from various
outpatient services.
Risk of bias within studies
Methodological quality varied considerably amongst the
trials with CTAM total scores ranging between 43 (lowest
quality) and 95 points (highest quality). Table 6 shows an
itemized CTAM score chart, illustrating areas of method-
ological strength and weakness within each trial. Samples
were mostly small, with only three trials achieving the
CTAM recommended minimum of 27 participants per
treatment arm. Although all trials reported randomizing
participants, three trials did not describe the process of
randomization employed. Furthermore, blinding of asses-
sors to treatment allocation was reported by only seven of
the 11 trials. The potential for effect sizes to be inflated in
nonblind trials has been highlighted by Wykes et al.
(2008). A description of methods used to maintain blind-
ing was provided by only five trials, with verification of
blinding conducted by Shawyer et al. (2012) alone.
Around half (5/11) of trials compared MIp to TAU (or
waitlist) alone, whilst five of the other six trials used con-
trols incorporating another psychological intervention or
placebo treatment in addition to TAU. Employing
enhanced comparison treatments is recommended by
Wykes et al. (2008) to control for the nonspecific effects
of a psychological therapy. The quality of these enhanced
comparison conditions varied however, in that some
(Gaudiano & Herbert 2006, Chien & Thompson 2014),
controlled successfully for the extra time and attention
5
J. Aust & T. Bradshaw

Records idenfied by database searches (n = 3828)

Records aer duplicates removed (n = 2805)

Excluded (n = 2550):
Not pertaining to a mindfulness intervenon (n = 2532)
Mind–body intervenon, e.g. yoga, qi gong (n = 18)

Studies selected for further screening (n = 255)

Full-text arcles assessed for
eligibility (n = 23)
Excluded (n = 232):
Not pertaining to psychosis/psychoc disorder (n = 49)
Child and adolescent psychiatry (n = 3)
Dual diagnosis – psychosis and gambling (n = 1)
Intervenon for carers (n = 1)
Reviews/meta-analyses (n = 35)
Non–randomized, uncontrolled trial (n = 16)
Psychometric study (n = 5)
Case studies (n = 21)
Grounded theory (n = 2)
Themac analysis (n = 4)
Interpretave phenomenological analysis (n = 2)
Survey (n = 2)
Correlaonal/mediaon study (n = 12)
Commentary/opinion (n = 19)
Conceptual (n = 12)
Exploratory/developmental design (n = 6)
Preview of future study (n = 4)
Study protocol (n = 1)
Book (n = 10)
Book reviews (n = 4)
Book chapter – conceptual (n = 13)
Book chapter – case study (n = 1)
Book chapter – commentary (n = 6)
Book chapter – review (n = 3)

Studies included in synthesis
(n = 13) (= 11 RCTs)
Excluded (n = 10):
Not a mindfulness intervenon (n = 3)
Not pertaining to psychosis (n = 1)
Pertains to major depressive disorder with psychosis (n = 1)
Pre–post, uncontrolled trial (n = 2)
Non–randomized, mixed between–within subjects design (n = 1)
Insufficient data (n = 2)

Figure 1
Flow chart of the study selection process (adaptation of format from Moher et al. 2009).

afforded to participants receiving mindfulness interven-
tion, whilst others (Davis et al. 2015, Lopez-Navarro
et al. 2015) did not.
Two samples were made up entirely of volunteers
(Chien & Thompson 2014, Moritz et al. 2015). Ganguli
et al. (1998) note that volunteer participants may differ
significantly from nonvolunteer participants. Two trials
recruited mixed samples of volunteers and clinician-
referred clients (Chadwick et al. 2009, Davis et al. 2015),
whilst samples in six of the other seven trials comprised
clinician-referred participants entirely.
Ten of the 11 trials employed standardized measures
(see Table 3) to assess their primary and secondary out-
comes. Only Bach & Hayes (2002)/Bach et al. (2012)
included no published psychometric outcome measures,
although the study’s primary focus, hospital readmission
data, was a notably objective measure of outcome. Posi-
tive symptoms were the most commonly assessed outcome
(eight studies), followed by insight (five studies), then
functioning and mindfulness (four studies). The most com-
monly cited primary outcome was data on hospital read-
mission (two studies). In five trials however, no primary
outcome was identified. Although a number of secondary
outcomes featured in multiple studies, considerable
heterogeneity was evident amongst the primary outcomes
assessed. Gøtzsche et al. (1996) caution against emphasiz-
ing findings based on secondary, or ‘surrogate’, outcomes
as this can lead to an over- or underestimation of an inter-
vention’s effects.
Formal treatment fidelity assessments were conducted
by only two trials (Shawyer et al. 2012, Davis et al.
2015), whilst in two trials (Gaudiano & Herbert 2006,
White et al. 2011) adherence to treatment protocols was
assessed via a process of supervision. Six trials made no
reference to treatment fidelity.
In accordance with the recommendations of Streiner &
Geddes (2001), two trials used intention-to-treat (ITT)
analysis exclusively (Chien & Thompson 2014,

6 © 2016 John Wiley & Sons Ltd

 Mindfulness for psychosis: systematic review

Table 3
Characteristics of included studies
Sample
Study size Study aim Outcome measures
Bach & Hayes (2002) 80 To examine the impact of a brief version of acceptance and Rehospitalization rate;
Bach et al. (2012) commitment therapy (ACT) on inpatients. To measure self-ratings of psychotic
changes in symptom reporting and rehospitalization rates. symptoms
Braehler et al. (2013) 40 Feasibility study assessing the safety, acceptability, potential NRSS, CGI-I, BDI-II, PANAS, PBIQ-R
benefits and change processes of compassion-focussed
therapy (CFT) with people recovering from psychosis.
Chadwick et al. (2009) 21 To assess the feasibility of randomized evaluation of group CORE, SMQ, PSYRATS, SMVQ,
mindfulness therapy for psychosis, to replicate gains from BAVQ-r
an uncontrolled study, and assess for changes in
mindfulness.
Chien & Thompson (2014) 107 To examine the effects of a mindfulness-based BPRS, SLOF, SSQ-6; ITAQ;
psychoeducation programme (MBPP) for people with Rehospitalization data
schizophrenia in China.
Davis et al. (2015) 34 To examine the feasibility and acceptability of Mindfulness WBI; CSQ-8; hours worked
Intervention for Rehabilitation and Recovery in
Schizophrenia (MIRRORS) and its impact on work function
in people with the diagnosis.
Gaudiano & Herbert (2006) 40 To assess the effects of ACT on inpatients with psychosis. To BPRS; CGI; SDS; self-ratings of
examine change in rehospitalization rates, and change in psychotic symptoms;
symptom reporting using standardized measures. Rehospitalization data
Langer et al. (2012) 23 To analyse the feasibility and effectiveness of a mindfulness CGI-SCH; AAQ II; SMQ
group for people with psychosis.
Lopez-Navarro et al. (2015) 44 To examine the effectiveness of a group mindfulness-based WHOQOL-BREF; PANSS; MAAS
intervention for improving measures of quality of life in
patients with severe mental illness.
Moritz et al. (2015) 90 To assess whether an online, self-help mindfulness therapy POD (Paranoia Checklist;
was more effective than online, self-help progressive OCI-R; CES-D)
muscle relaxation in people with psychosis.
Shawyer et al. (2012) 43 To evaluate whether acceptance-based cognitive behavioural PANSS; mGAF; PSYRATS; QoLESQ;
therapy (ABCBT) was more effective than befriending at CSQ; VAAS; BAVQ-R;
reducing the negative impact of command hallucinations. Insight Scale.
White et al. (2011) 27 To determine the feasibility of conducting a blind HADS; PANSS; AAQ-II; KIMS
randomized controlled trial of ACT for emotional
dysfunction (e.g. depression and anxiety) following
psychosis.
Key: AAQ-II, Acceptance and Action Questionnaire-II; BAVQ-r, Beliefs about Voices Questionnaire-revised; BPRS, Brief Psychiatric Rating Scale; BDI-II, Beck
Depression Inventory-II; CAPE, Community Assessment of Psychotic Experiences Scale; CAS, Change Assessment Scale; CES-D, Center for Epidemiologic
Studies-Depression scale; CGI, Clinical Global Impressions scale; CGI-I, Clinical Global Impression-Improvement scale; CGI – SCH, Clinical Global Impression-
Schizophrenia scale; CORE, Clinical Outcomes in Routine Evaluation; CSQ, Client Satisfaction Questionnaire; CSQ-8, Client Satisfaction Questionnaire;
FORSE, Fear of Recurrence Scale; HADS, Hospital Anxiety and Depression Scale; ITAQ, Insight and Treatment Attitudes Questionnaire; KIMS, Kentucky
Inventory of Mindfulness Skills; MAAS, Mindfulness Attention Awareness Scale; mGAF, modified Global Assessment of Functioning scale,; DSM-IV version;
NRSS, Narrative Recovery Style Scale; OCI-R, Obsessive-Compulsive Inventory-Revised; PANAS, The Positive and Negative Affect Scale; PANSS, Positive and
Negative Syndrome Scale; PBIQ-R, Personal Beliefs about Illness Questionnaire-Revised; POD, Paranoia-Obsession-Depression scale; PSYRATS, Psychiatric
Symptom Rating Scale; QoLESQ, Quality of Life Enjoyment and Satisfaction Questionnaire; SDS, Sheehan Disability Scale; SHER, Single Hallucination Epi-
sode Record; SLOF, Specific Level of Functioning Scale; SMQ, Southampton Mindfulness Questionnaire; SMVQ, Southampton Mindfulness Voices Ques-
tionnaire; SSQ-6, Social Support Questionnaire (6-item); WBI, Work Behaviour Inventory; WHOQOL-BREF, World Health Organization Quality of Life-BREF;
VAAS, Voices Acceptance and Action Scale.

Lopez-Navarro et al. 2015), whilst three trials reported
both ITT and completer-only results. Gaudiano & Her-
bert (2006) and Moritz et al. (2015) reported their ITT
analyses essentially confirmed per protocol results. In
Bach & Hayes (2002)/Bach et al. (2012), there was
marked contrast between the hospital readmission hazard
rate increase (for TAU group) for completers (254%)
compared to the ITT sample (97%). Data in five of the
other six trials were analysed on a per-protocol basis,
although in three of these (Shawyer et al. 2012, Braehler
et al. 2013, Davis et al. 2015), dropout rates were below
the 15% upper limit suggested by Tarrier & Wykes
(2004).
Results of individual studies
In two of the 11 trials, all participants had a diagnosis of
schizophrenia (Chadwick et al. 2009, Chien & Thompson
2014), whilst in seven of the other trials the majority of
participants had schizophrenia. Other diagnoses in these

© 2016 John Wiley & Sons Ltd 7

J. Aust & T. Bradshaw
seven trials included the following: schizoaffective disor-
der or mood disorder and comorbid psychosis (Shawyer
et al. 2012). The majority of participants in Gaudiano &
Herbert (2006) had a psychotic disorder (58%) whilst the
remainder were diagnosed with affective mood disorder
with psychosis (42%). Precise diagnostic figures were not
reported in Langer et al. (2012) although inclusion criteria
stipulated: ‘diagnosis of schizophrenia, schizophreniform
disorder, schizoaffective disorder or delusional disorder’.
Amongst the trials reporting data about length of ill-
ness, mean durations ranged from 2.6 years (Chien &
Thompson 2014) to 21.5 years (Davis et al. 2015, estima-
tion based on mean age at first hospital admission).
Besides Chien & Thompson (2014), the next lowest mean
illness duration (10.4 years) was reported in Braehler
et al. (2013). Samples therefore comprised individuals
with largely chronic, established psychotic conditions.
Samples tended towards male predominance, with nine
RCTs reporting lower representation by female partici-
pants. In three trials, over 75% of participants were male
(White et al. 2011, Davis et al. 2015, Lopez-Navarro
et al. 2015). Gender ratios for the other eight trials ranged
from 42.2% male (Moritz et al. 2015) to 64% male (Gau-
diano & Herbert 2006). This over-representation by
males is in line with the findings of Ochoa et al. (2012).
There was considerable variation between trials in par-
ticipants’ ethnicity. In White et al. (2011), 26 of 27 partic-
ipants were white British. Similarly, the entire Braehler
et al. (2013) sample was white British. Gaudiano & Her-
bert (2006) however reported a predominantly African
American (88%) sample, whilst in Davis et al. (2015)
approximately two-thirds of participants were African
American. The other US-based sample was predominantly
non-Hispanic Caucasian (80%, Bach & Hayes 2002/Bach
et al. 2012), whilst the entire sample in Chien & Thomp-
son (2014) were Chinese outpatients. Five studies did not
provide details about ethnic status.
Eight distinct mindfulness treatments were identified
for review. These were as follows: Acceptance and Com-
mitment Therapy (ACT; Hayes et al. 1999); Acceptance-
Based Cognitive Behavioural Therapy (ABCBT; Shawyer
et al. 2012); Compassion-Focussed Therapy (CFT; Braeh-
ler et al. 2013); Mindfulness-Based Cognitive Therapy
(MBCT; Segal et al. 2002); Mindfulness-Based Psychoedu-
cation Programme (MBPP; Chien & Lee 2013); MIR-
RORS (Mindfulness Intervention for Rehabilitation and
Recovery in Schizophrenia; Davis et al. 2015); Person-
Based Cognitive Therapy (PBCT; Chadwick et al. 2000;
Chadwick 2006); and self-help, Internet-based, mindful-
ness intervention (Moritz et al. 2015, ).
Table 4 shows the therapies grouped according to
treatment emphasis (i.e. mindfulness, acceptance or
8 © 2016 John Wiley & Sons Ltd
compassion). The table highlights the contrast in formats
of the interventions reviewed (individual or group). This
requires consideration when comparing any reported
effects between the MIps, in view of the greater resources
involved in delivering psychological interventions on a
one-to-one basis (Morrison 2001).
Table 5 shows the effect sizes yielded by the respective
mindfulness intervention in each trial. Amongst eight
studies reporting data on positive symptoms, three
described significant improvements for MIp on this out-
come. In Chien & Thompson (2014), scores on the Brief
Psychiatric Rating Scale (Overall & Gorham 1962)
increased significantly more for the mindfulness-based
psychoeducation group (MBPP) compared to both con-
ventional psychoeducation (CPEP) and TAU. Gaudiano &
Herbert (2006) reported significantly greater improvement
for ACT participants in distress related to hallucinations
compared to ‘enhanced treatment as usual’ in their non-
blind trial. By contrast, White et al. (2011) reported no
significant improvement in positive symptoms when com-
paring ACT against TAU in a trial where raters were blind
to the treatment allocation of participants. Shawyer et al.
(2012) reported significant improvement in positive symp-
toms, though both for participants receiving the accep-
tance-based treatment for command hallucinations
(ABCBT) and for those in the Befriending group. Chad-
wick et al. (2009) recorded a small effect on positive
symptoms for group-based mindfulness therapy (PBCT)
compared to waitlist, whilst Bach & Hayes 2002/Bach
et al. (2012; ACT) and Lopez-Navarro et al. (2015; mind-
fulness group) observed no treatment effect on positive
symptoms. In Moritz et al. (2015), no differences in para-
noia were detected over time or between groups for the
self-help mindfulness and progressive muscle relaxation
conditions.
From three trials reporting data on hospital readmis-
sions, two reported significant benefits for MIp compared
to control on this outcome. Chien & Thompson (2014)
reported significant reductions in the duration of hospital
readmissions for MBPP. Bach & Hayes (2002; Bach et al.
2012) identified a 254% increased risk of readmission for
TAU participants compared to those receiving ACT. In
Gaudiano & Herbert (2006), although enhanced control
(ETAU) participants were 1.62 times more likely to be
readmitted than those receiving ACT, this difference was
not clinically significant.
Of the three studies reporting data on negative symp-
toms, two described significant benefits for MBTp com-
pared to control. White et al. (2011) reported significant
changes in PANSS negative scores (Positive and Negative
Syndrome Scale; Kay et al. 1987) for ACT compared with
TAU. In Shawyer et al. (2012), there were significant
 Mindfulness for psychosis: systematic review

Table 4
Interventions grouped according to treatment emphasis
MIp emphasis Intervention n RCT Individual (I) or group-based (Gp)
Mindfulness MBCT 1 Langer et al. (2012) Gp
MBPP 1 Chien & Thompson (2014) Gp
MIRRORS 1 Davis et al. (2015) Gp
PBCT 2 Chadwick et al. (2009) Gp
Lopez-Navarro et al. (2015) Gp
Self-help Internet-based 1 Moritz et al. (2015) I
mindfulness intervention
Acceptance ACT 3 Bach & Hayes (2002); Bach et al. (2012) I
Gaudiano & Herbert (2006) I
White et al. (2011) I
ABCBT 1 Shawyer et al. (2012) I
Compassion CFT 1 Braehler et al. (2013) Gp
ABCBT, acceptance-based cognitive behavioural therapy; ACT, Acceptance and Commitment Therapy; CFT, Compassion-Focussed Therapy; MBCT, Mindful-
ness-Based Cognitive Therapy; MBPP, Mindfulness-Based Psychoeducation Programme; MIp, mindfulness intervention; MIRRORS, Mindfulness Intervention
for Rehabilitation and Recovery in Schizophrenia; PBCT, Person-Based Cognitive Therapy.

(small) improvements in PANSS negative scores for
ABCBT though not Befriending. Lopez-Navarro et al.
(2015) described a nonsignificant statistical trend towards
improvement in PANSS negative scores for MBI compared
to IRT.
From four studies assessing change in insight, two
reported significant results for MIp on this measure. In
Chien & Thompson (2014), the MBPP group recorded
significantly greater improvement in insight compared
with CPEP and TAU. Bach & Hayes (2002/Bach et al.
2012) reported significant reductions in believability of
symptoms for ACT compared to TAU, although caution
should be exercised interpreting these findings, in view of
the nonstandardized measures used to assess symptoms in
the trial. In Chadwick et al. (2009), a small improvement
in insight was observed for mindfulness group partici-
pants. Shawyer et al. (2012) reported improved insight for
ABCBT, although this was not maintained at follow-up.
Amongst the three trials reporting data on depression,
White et al. (2011) detected a trend approaching signifi-
cance for differences between ACT and TAU on change in
depression scores, whilst Moritz et al. (2015) observed a
medium-to-large effect on depressive symptoms both for
self-help mindfulness and Progressive Muscle Relaxation
(PMR). White et al. (2011) however observed no signifi-
cant change in anxiety scores between ACT and TAU par-
ticipants.
From four trials reporting measures of functioning, two
described significant improvements for MIp. In Shawyer
et al. (2012), ABCBT participants showed significant
within-group improvements in modified GAF scores (Glo-
bal Assessment of Functioning, Hall 1995), whilst in
Chien & Thompson (2014) the MBPP group improved
significantly more than CPEP and TAU on various aspects
of functioning. In Chadwick et al. (2009), moderate
improvements in functioning were reported for
mindfulness-group participants compared to waitlist. In
Davis et al. (2015) MIRRORS participants worked a sig-
nificantly greater number of hours and performed signifi-
cantly better at work by 4 months postintervention
compared with those in Intensive Support.
Two of the three studies assessing changes in global
symptoms reported significant results for MIp compared
to control. Braehler et al. (2013) reported a significant
improvement in global symptoms for CFT compared with
TAU, whilst in Gaudiano & Herbert (2006) a marginally
significant difference in global symptoms was reported for
ACT compared with ETAU at post-treatment. In Langer
et al. (2012), changes in global symptoms for MBCT were
reportedly in the right direction compared to waitlist, but
did not reach significance.
High levels of client satisfaction were reported by MIR-
RORS participants in Davis et al. (2015), whilst in Shaw-
yer et al. (2012), client satisfaction scores were high for
both experimental and control participants. Only Moritz
et al. (2015) employed a measure of obsessive–compulsive
disorder (OCD). Results showed moderate reductions in
OCD scores for both self-help mindfulness and PMR.
Two trials employed measures of quality of life. Lopez-
Navarro et al. (2015) reported significant differences
between the pre- and postmeasures of psychological qual-
ity of life for MBI but not IRT, whilst Shawyer et al.
(2012) reported improvements in quality-of-life scores for
both ABCBT and Befriending, although none reached sig-
nificance.
Amongst four studies measuring change in mindfulness,
three reported moderate-to-large improvements on this
outcome. White et al. (2011) reported significant increases
in mindfulness skills for ACT over TAU, whilst in Langer
et al. (2012), MBCT participants showed significant
improvements in mindful response to distressing thoughts
compared to waitlist. Chadwick et al. (2009) reported

© 2016 John Wiley & Sons Ltd 9

 10
Table 5
Effect sizes of mindfulness interventions on reported outcomes
Positive Rehosp. Accep/ Client Glob. ES* report
J. Aust & T. Bradshaw

Study MIp symptoms Neg. syms Dep. Anx. Aff. Func. data QOL Mindful. avoid Comp. Ins. satis. OCD Work syms. method

Bach & Hayes (2002) ACT No ES 1.97 (OR) No ES OR

Bach et al. (2012)
Gaudiano & ACT 0.60 (d) No ES 1.62 (OR) No ES d/OR
Herbert (2006)
White et al. (2011) ACT 0.05 0.47 0.43 0.03 0.50 0.13 d
Shawyer ABCBT 0.19 0.25 -0.15 0.43 0.35 0.39 0.37 d
et al. (2012)
Davis et al. (2015) MIRRORS 0.04 0.76 –hrs d
0.82 -perf
Langer et al. (2012) MBCT 1.306 0.010 1.167 d
(within)
Chadwick PBCT 0.26 –PSY-H 0.56 0.86 –SMQ 0.29 d
et al. (2009) 0.12 –PSY-D 0.47 -SMVQ
Lopez-Navarro PBCT 0.006 0.096 0.285 0.038 ɳ²
et al. (2015)
Chien & MBPP 0.16 0.19 0.09 –Num 0.28 0.05 ɳ²p
Thompson (2014) 0.16 -Dur
Moritz et al. (2015) Self-help 0.002 <.001 .004 ɳ²p
Mindfulness
Braehler CFT No ES No ES 0.41 0.59 No ES No ES r
et al. (2013) (within)
*The method used to report effect sizes (ES) varied between trials. Effect sizes refer to between-group effects, unless labelled ‘within’ (= within-group effects).
Key: ABCBT, acceptance-based cognitive behavioural therapy; Accep./avoid, acceptance/avoidance; ACT, Acceptance and Commitment Therapy; Aff., affect; Anx., anxiety; CFT, Compassion-Focussed Ther-
apy; Comp., compassion; Dep., depression; Dur, Duration of admissions; Func., functioning; Glob. syms., global symptoms; hrs, hours worked; Ins., insight; MBCT, Mindfulness-Based Cognitive Therapy;
MBPP, Mindfulness-Based Psychoeducation Programme; Mindful., mindfulness; MIp, mindfulness intervention; MIRRORS, Mindfulness Intervention for Rehabilitation and Recovery in Schizophrenia; Neg.
syms, negative symptoms; No ES, No effect size reported; Num, number of admissions; OCD, obsessive–compulsive disorder; perf, work performance; PBCT, Person-Based Cognitive Therapy; PSY-D, PSYRATS
delusions; PSY-H, PSYRATS hallucinations; QOL, quality of life; Rehosp., hospital readmission; satis., satisfaction; SMQ, Southampton Mindfulness Questionnaire; SMVQ, Southampton Mindfulness Voices
Questionnaire.

Effect size method* Small Medium Large

Odds Ratio (OR) – – –

Cohen’s d (d) 0.2 0.5 0.8
ɳ² 0.02 0.13 0.26
Partial ɳ² (ɳ²p) 0.01 0.06 0.14
Pearson’s r (r) 0.1 0.3 0.5

© 2016 John Wiley & Sons Ltd


moderate improvements in mindfulness scores for the
experimental treatment group compared to waitlist. No
significant effects on mindfulness were registered in
Lopez-Navarro et al. (2015) for the mindfulness group
compared to enhanced control.
From four studies employing measures of acceptance/
avoidance, two described small-to-moderate effects for
MIp. Shawyer et al. (2012) reported small improvements
in ABCBT participants’ acceptance of general auditory
hallucinations, whilst in Braehler et al. (2013) CFT partic-
ipants showed moderate (within-group) reductions in
avoidance. In Langer et al. (2012), the postintervention
score for acceptance/avoidance was in the right direction
for MBCT though did not reach significance. White et al.
(2011) also detected no significant differences between
ACT and TAU in change scores on a measure of accep-
tance/avoidance. Lastly, in the only trial to employ a mea-
sure of compassion, Braehler et al. (2013) found end-of-
treatment compassion scores were significantly greater for
CFT participants than TAU.
Synthesis of results
Meta-analysis of the data was not feasible because of
heterogeneity in the designs, interventions and outcome
measures used by the studies. In view of this, a narrative
synthesis of data was conducted in line with the recom-
mendations of Popay et al. (2006). The same authors sug-
gest that even in reviews focussing on effectiveness, meta-
analysis of data may often be an inappropriate approach
to synthesizing findings, and therefore, narrative synthesis
need not be considered a ‘second best’ option.
In the present review, synthesis began with the first
author (JA) creating textual descriptions of studies, and
tabulating data (e.g. effect sizes, CTAM scores) to develop
a ‘preliminary synthesis’ (see: Popay et al. 2006, pg 13),
before moving on to explore relationships both within
and between studies in order to identify factors which
might explain differences in the direction and size of
effects in the selected trials. As part of this second phase
of synthesis, interventions were grouped according to
treatment emphasis (i.e. mindfulness, acceptance or com-
passion) with the aim of considering relationships between
the results of therapies of the same kind (Table 5). To
ensure the synthesis was robust, any general conclusions
were made with reference to the methodological quality
of the selected studies (Table 6), in accordance with
Popay et al. (2006).
The two US-based trials of ACT offer preliminary evi-
dence for its feasibility as a concise treatment for inpa-
tients with psychosis, in preventing future hospital
readmissions, reducing distress associated with
© 2016 John Wiley & Sons Ltd
Mindfulness for psychosis: systematic review
hallucinations and improving global symptoms. Notwith-
standing its large sample, the Bach & Hayes (2002)/Bach
et al. (2012) trial featured several methodological weak-
nesses. Furthermore, when comparing ACT to an
enhanced control Gaudiano & Herbert (2006) failed to
replicate the significant reductions in hospital readmission
rates in the earlier US study. Despite other methodological
improvements, Gaudiano & Herbert (2006) contained
key limitations, and the reported improvements in positive
symptoms and global symptoms should therefore be trea-
ted with caution. Preliminary support also exists for ACT
improving depressive and negative symptoms in UK-based
individuals with psychosis, although confidence in findings
is compromised by the small sample (n = 27) and absence
of an enhanced control treatment in White et al. (2011).
There is limited evidence that ABCBT yields superior
outcomes to social support (befriending), although results
from one trial indicate with reasonable confidence that
offering either treatment to persons with problematic psy-
chosis is beneficial compared to routine care. Benefits of
either treatment include the following: significant
improvement in negative symptoms and measures of func-
tioning, and nonsignificant improvement in insight and
command hallucinations.
There is reasonable evidence that a combination of
mindfulness group therapy and integrated rehabilitation
treatment (IRT) is superior to IRT alone in improving psy-
chological health-related quality of life and negative symp-
toms in outpatients with psychosis. Other findings for
group mindfulness therapy for psychosis are based on
small-scale feasibility trials involving waitlist controls and
either an absence, or inadequate reporting, of rater blind-
ing. Potential benefits include the following: improved
clinical functioning, and enhanced mindful response to
stressful thoughts. Findings from a feasibility trial suggest
MIRRORS was acceptable to the outpatient veterans who
participated, although important methodological limita-
tions in the same trial suggest caution in interpreting the
reported gains in work-related behaviour.
There is reasonable evidence from one large trial that
Internet-based, self-help mindfulness therapy effects mod-
erate reductions in depressive symptoms and OCD symp-
toms in outpatients with psychosis, but also that self-help
PMR yields comparable effects. Another large trial (Chien
& Thompson 2014) provides considerable support that
MBPP is superior to both CPEP and TAU in improving
psychiatric symptoms, psychosocial functioning, insight
and duration of hospital readmissions in Chinese people
with schizophrenia. However, the gains reported by the
more recently diagnosed, volunteer-based sample in this
study may not generalize to less motivated individuals
with longer durations of illness. Similarly, the all-Chinese
11
 12
Table 6
J. Aust & T. Bradshaw

Itemized CTAM (Clinical Trials Assessment Measure) scores for the 11 RCTs
Bach &
Maximum Hayes (2002), Braehler Chadwick Chien & Gaudiano & Moritz Shawyer White
possible Bach et al. et al. Thompson Davis Herbert Langer Lopez-Navarro et al. et al. et al.
Item item score et al. (2012) (2013) (2009) (2014) et al. (2015) (2006) et al. (2012) et al. (2015) (2015) (2012) (2011)
Type of sample? 5 2 2 2 0 1 2 2 2 0 2 2
Sample size? 5 5 0 0 5 0 0 0 0 5 0 0
True random allocation? 10 0 10 10 10 0 10 0 10 10 10 10
Randomization described? 3 0 3 3 3 0 3 0 3 3 3 3
Randomization carried 3 0 3 3 3 0 3 0 3 3 3 3
out independently?
Assessments carried 10 10* 10 0 10 10 0 10 10 10 10 10
out by independent assessors?
Standardized assessments used? 6 6* 6 6 6 6 6 6 6 6 6 6
Assessments carried out 10 10* 10 0 10 0 0 10 10 10 10 10
blind to treatment allocation?
Methods of rater blinding 3 3* 3 0 0 0 0 0 3 3 3 3
adequately described?
Rater blinding verified? 3 3* 0 0 0 0 0 0 0 3 3 0
Control group incorporates TAU? 6 6 6 6 6 0 6 6 6 6 6 6
Control group controls for 10 0 0 0 10 10 10 0 0 10 10 0
non-specific effects of therapy?
Analysis is appropriate to 5 5 5 5 5 5 5 5 5 5 5 5
the study design and
outcome measure?
Analysis is intention-to-treat? 6 6 0 0 6 0 6 0 6 6 0 0
Adequate investigation 4 4 4 4 4 0 4 0 4 4 4 0
and handling of dropouts?
Was the experimental 3 3 3 3 3 3 3 3 3 3 3 3
treatment adequately
described?
Protocol or manual used? 3 3 3 3 3 3 3 3 3 3 3 3
Adherence to protocol 5 0 0 0 0 5 5 0 0 5 5 5
assessed?
Total score: (max = 100) 66* 68 45 84 43 66 45 74 95 86 69
*Scores pertain to the primary outcome (rehospitalization) in Bach & Hayes (2002); Bach et al. (2012) and not the secondary outcomes (symptom reporting, symptom believability).

© 2016 John Wiley & Sons Ltd


sample may not be representative of service users from
other cultures.
There is some evidence that CFT reduces depression
and fear of relapse and improves insight in people with
schizophrenia-spectrum disorders. There is also some sup-
port that CFT improves global symptoms, although repli-
cation of findings in a fully-powered trial, involving a
better designed control, would lend greater confidence to
existing preliminary findings.
Risk of bias across studies
As described above, no formal investigation of risk of bias
across studies was conducted in this review. No significant
inconsistencies were detected between raw data and nar-
rated findings of individual researchers. Notable omissions
from the findings however (see Table 5) were effect size
calculations for ‘functioning’ and ‘global symptoms’ in
Gaudiano & Herbert (2006) and for ‘frequency of symp-
toms’ and ‘believability of symptoms’ in Bach & Hayes
(2002/Bach et al. 2012). In the case of both studies how-
ever, these omissions represented secondary outcomes,
and effect sizes were reported for the primary outcomes in
both trials. In Braehler et al. (2013), no simple effect sizes
were provided for changes in depression, affect, insight or
global symptoms, although the trial’s authors did provide
scores of correlations between these variables and changes
in avoidance and compassion.
Additional analysis
In the light of heterogeneity in the designs, interventions
and outcome measures used by different studies, it was
not feasible to conduct meta-regression meta-analysis to
explore the relationships between the pooled effect sizes
of MIps and measures of mindfulness, acceptance and
compassion. Although meta-analysis of these moderators
was not feasible, at the individual study level Braehler
et al. (2013) reported a significant association between a
reduction in avoidance and a reduction in perceived ‘lack
of control over illness’ scores for participants assigned to
compassion-focussed therapy (CFT). For the CFT group
also, an increase in compassion was significantly associ-
ated with reduced depression, improved insight, and
reduced fear about relapse.
Discussion
Summary of evidence
The review’s findings suggest mindfulness interventions
are feasible for individuals with psychosis and provide a
© 2016 John Wiley & Sons Ltd
Mindfulness for psychosis: systematic review
number of significant benefits to routine care and, in some
cases, other psychological interventions. The scale and
quality of existing trials however vary considerably, and
the evidence is therefore stronger for some MIps (e.g.
MBPP) than for others (e.g. MIRRORS). Attrition was
low in the majority of trials, and this is an encouraging
finding for the acceptability of MIps, when considered this
population has historically been difficult to engage (Kil-
laspy et al. 2006). No ill effects were reported, suggesting
mindfulness interventions can be safely administered if
adapted to the needs of this client group. This review has
also highlighted again the variety of definitions of mind-
fulness which exist and the need for more agreement
regarding conceptualization before general conclusions
about its efficacy for psychosis can be made.
Limitations
Whilst meta-analysis can be a powerful tool for combin-
ing findings from individual studies (DerSimonian &
Laird 1986), meta-analysis of the data in this review was
not deemed feasible, because of heterogeneity in the
designs, interventions and outcome measures used by dif-
ferent studies. In the light of these variations, the decision
to conduct a narrative synthesis of data seemed appropri-
ate. The heterogeneity in therapies included the format of
interventions (group or individual). It may be that one-to-
one interventions yield larger effects than group-based
MIps simply because of their superior levels of therapist-
client contact and formulation-driven approach (see:
Chadwick et al. 2003). Other sources of heterogeneity
included the variety of trial locations and diverse ethnic
make-up of samples. Whilst there was some variation in
the diagnostic mix of samples, all met the eligibility crite-
ria for review in this regard. Treatment arm samples were
also largely well balanced.
The review was principally conducted by a single
author, rather than the minimum two researchers recom-
mended (Centre for Reviews and Dissemination 2009).
Whilst this risked introducing bias in study selection, the
review’s inclusion criteria and search strategy were expli-
cit and the search is therefore replicable. The potential
for bias and error during data extraction and scoring of
methodological quality cannot be dismissed. Although
all trials met RCT design criteria, a number were feasi-
bility or pilot studies with small samples. Employing a
measure of methodological quality however allowed for
consideration of trial quality during analysis. Whilst the
CTAM is a valid and reliable tool for assessing method-
ological quality, the review would have benefited from
an additional, specific measure of risk of bias (e.g. Hig-
gins et al. 2011).
13
J. Aust & T. Bradshaw

minimize bias. Greater verification of treatment fidelity

Conclusions
The findings in this review suggest there are good
grounds to make mindfulness approaches available to
people with psychosis alongside currently recommended
interventions (e.g. CBT, family interventions). These
mostly preliminary findings for MIps’ effects provide a
basis for further evaluative research, to offer service users
a broader choice of treatments adjunctive to pharma-
cotherapy. Future trials should employ consistently large
samples based on a priori power calculations, adopt rig-
orous randomization procedures and use comparison
treatments which successfully control for the nonspecific
effects of therapy. Trials should blind assessors as stan-
dard, and describe and verify blinding procedures to
would allow findings to be confidently attributed to the
therapy examined. Analysis of data should consistently
include all randomized participants (ITT), rather than
completer-only analyses. It is also suggested that future
research and practice of mindfulness approaches continue
to consider a range of outcomes besides reduction in posi-
tive symptoms. A similar shift to other markers of well-
being and recovery has been recommended for CBT
(Birchwood & Trower 2006).
Funding
The authors were given no financial support for the
research, authorship or publication of this review.

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