B (3:54)

You've conducted a Delphi study or you're conducting the study and actually I wondered whether you wouldn't mind just giving us a little primer on a Delphi study

C (4:06)

means first of all, yes, absolutely. Okay, so Delphi studies, they've been around since about the 50s and they're named after the Oracle at Delphi. And the reason for that is, you know, the Oracle would give pronouncements and then they would get interpreted by a group of experts, group of forecasters at the Oracle. And it's based on this idea that any one judgment by a group judgment will be more accurate on average than any one judgment. And it's really a way of capturing the differences in agreement within any given group. So you can actually use it with any kind of stakeholder group, I suppose, but it's often used with experts and it's used a lot in medical and nursing fields to come up with diagnostic criteria for new conditions, for example. And so it's very helpful when you have basically a low information environment. You're trying to, you know that there's a lot of knowledge out there, but what's actually in the empirical record is quite low. So it's trying to go out to communities that have a lot of this expert knowledge and to survey that in some way, but in a way that's reflexive and that involves them. So Delphi studies have multiple rounds and you start off in kind of a expansion phase where you capture everything that's out there and then you move over subsequent rounds towards describing any consensus or agreement that exists and you reflect back to the participants between that. So they're constantly looking at sort of what you're doing, refining it so it can be as representative as possible of what their views are.

B (5:53)

Yeah, wow, brilliant, brilliant summary. That's really, that's really helpful. What was the design of your Delphi study then?

C (6:01)

So. Oh, I should, I should first say that we did this Delphi study with meditation teachers and the reason why we did that Is we know that teachers have a lot of knowledge about what happens over time with meditation practitioners. You know, this is what they're working with day in, day out for many people. And so we know that they have a lot of this information. And as a scientific community, we don't have that much of it. So that's why we were specifically looking to work with meditation teachers. And our design was it's three rounds and we're currently designing our third round. But in our first round we wanted to capture all the different changes that can happen with continued meditation practice. So we worked with an advisory group of senior teachers and also quite a big research team to try to come up with an open ended survey that would ask about this. So we asked about changes during meditation, changes related to meditation, but not during meditation. And we asked about a number of different domains, so phenomenological changes, more sort of general changes, changes to mental and physical health. And basically this was designed to try not to prompt people too much, but to encourage them to think of all the different things that they notice in their students or clients with continued practice. And we also ended up including some interviews in that round as well. And then we took all that away. We did some interim analysis, so that was a thematic analysis and coded all of that and came up with a list of changes that all of the meditation teachers and therapists brought up. And then we reflected the ones that had reasonable agreement back to them and sort of told them this is about, on average, how many people mention this. Is this meaningful? So is this meaningful to. To whether or not a meditator is going well, whether or not they're not going well? Is it present but not meaningful to you or is it not present at all? So that's what we did in the second round. And with the thematic analysis of the first round, we also developed a model based on. We noticed a lot of relating of changes together. We didn't necessarily ask people to do that, but when they were discussing describing these changes, there were different relationships and patterns that they were describing. So we generated a thematic thematic model to describe that. And we also presented that in round two and asked them if they broadly agreed with it or not or if they had any comments. So there's space for comments everywhere here because it's all about being reflexive and consultative. Yeah, yeah.

B (8:56)

I love your clarity and your enthusiasm about Delphi study. That's really, really, really great.

C (9:03)

It's been my bread and butter for the last couple of years, I bet.

B (9:07)

Yeah. Yeah. Wonderful. Well, you, you mentioned there you know, sort of meaningful changes that the teachers maybe notice. And I think there was like 81 meaningful changes that, that seemed to the teachers kind of notice in their students over time. What were some of the, the results there? Perhaps the, the striking or even surprising things.

C (9:29)

Absolutely. So I think what was most striking to me is how many different changes had this sort of agreement that they, that they occur. If you think about it, there's so many things that people are looking out for and find meaningful. And that really struck me that there was I, I. Where I think when I spoke to you, we were a little earlier in data analysis. So it's actually 97. 97, yes, actually 97 different changes that our teachers that were meaningful to their assessment of whether people are going well or not going well. And sometimes it's both. We didn't restrict people so it could be meaningfully a meaningful sign of things going well or not going well. And so the big thing that struck me was how many there were. We had, I believe it's 38 that all our teachers said are present. So everybody said I see this and there's 26 that 90% of people are saying yes, this is meaningful to me. So that's what really struck me. And some of them are things that you would expect and some of the things that motivate a lot of people when they start meditation practice like increasing emotional awareness and openness and self compassion as well. But there are also some things that are a bit surprising. So a lot of people say that they see worsening or poor relationships in their students. Yeah. And they also see that for some people, they think that meditation can, you know, lead to them neglecting responsibilities, maybe relationships as well and also self recrimination. So there can be instances of people, you know, maybe increasing some rumination and feeling badly about things that they weren't thinking about beforehand. So those were some, it was most striking to me how common those were. Were mentioned.

B (11:31)

Yeah, yeah. These were mindfulness teachers from certain traditions, weren't they? There were four different traditions there or approaches.

C (11:41)

So what we were. The teachers who we were recruiting were secular mindfulness teachers. So teachers in mbsr, MBCT and also micbt, but also from spiritual traditions, Buddhist traditions that informed mindfulness. So Theravada and Mahayana Buddhist teachers were included as well. Yeah, I suppose different patterns in there.

B (12:07)

Ah, ah, okay. Yeah. Because the thought that was, or the question that was coming to mind given, you know, I suppose my interest and the interest of the channel was you said there that self compassion was a, was One of the ones that pretty much all of the meditation teachers observed as a change. And I wondered what. Do you have any thoughts there? Do you have any kind of hypotheses about how mindfulness and mindfulness as a practice also leads to increases in self compassion?

C (12:42)

Yes, I think one of the things that people talked about a lot is sort of increasing reflection and introspection as well. And I think, you know, reflecting and turning maybe those skills that you develop in mindfulness practice to yourself with of the attitudes that are also developed, like openness that I mentioned before. I think that self compassion can be something arising from that, but also that what they're saying is, you know, I've seen self compassion in my students, and when I see it, it's a meaningful sign that things are going well. So it might not be that it's present for absolutely everyone, but when they see it, yes, it's meaningful and it's positive. And, you know, especially within the spiritual traditions and also those a little bit more. With a bit more of a clinical focus, I think that makes a lot of. A lot of sense to me that these are not isolated practices. And that's one of the great things about working with teachers is they're not just thinking about, you know, they're acquiring of certain skills or just the decrease in their stress. They're thinking a bit holistically about that person's development with meditation practice.

B (14:00)

Yeah, mindfulness certainly comes along with care and discernment, I suppose, as they say, as well, as you mentioned, openness. And I was thinking too, acceptance and self acceptance, I guess, is part of it there. And so self compassion starts to just bubble up a little bit in the context of those practices. I mean, the flip side is interesting as well, that sometimes relationships might be affected in the person's life. And is that a result of more introspection, more attention on the self in a way that is also tricky to navigate for relationships?

C (14:42)

I think there can be sort of a positive interpretation of it in that relationship. When people are becoming more aware, sometimes they become aware of, you know, perhaps unhealthy relationship dynamics where they were perhaps being too accommodating and that was sort of helping their relationship, but not necessarily serving them. And you do get people talking about people being a bit better with their boundaries, and that can have consequences for both relationships. And also people talked about, you know, changing occupation and that kind of things as well. So noticing environments that are detrimental and sort of resisting those a bit more. But there is also this other side where people can get really deep with meditation, get really, you know, really evangelistic about it, really excited about it, and just want to be practicing all the time and just want that to be the focus and, you know, trying to detach potentially from other things which might not always be appreciated by other people in their life, shall we say. But I think something I should mention is that. So the teachers that we were looking at, they had minimum, at least three years teaching experience and the average was about 12 and with some people was 43. Right. So there might be times where this might be something that happens at a particular time, but might not be sort of endpoint of someone's practice as well. So people might be going through periods where they just want to meditate all the time and they're not washing the dishes, but that's not necessarily how it's going to continue to be as well.

B (16:33)

Yeah, in fact, that's a really interesting point, that these are signs of progress, but they're not signs of the eventual sort of final outcome or something like that. And so people may move through. In fact, you looked at that in a sense, that the teachers broadly agreed on sort of a pathway from practice to wellbeing and through cultivating certain relational qualities and processing certain challenges that arise. Yeah.

A (17:04)

Tell us a bit more about that

B (17:06)

pathway or the model that you, you've came up with.

C (17:09)

Absolutely. So we kept the language deliberate about, you know, endpoints or goals or anything like that deliberately quite vague because we know people are bringing different traditional outlooks on that and whether or not it's even appropriate to use that kind of goal orientated language. So that's why we had this going well, not going well. And that was informed by our advisory group. But nevertheless, when we looked at the responses that we got, there were these kinds of patterns, or I think the phrase that we were using was sort of pathways or possible journeys or common journeys that kept coming up. And that was part of the thematic analysis. You know, that was something that was coming through very strongly. And the first main part of it was that without practice you can't be going. So asking about going well, not going well, without practice, you're not going. So one of the main things they talked about is people doing practice, people being disengaged with practice. And it makes sense that as a meditation teacher, if people are disengaged from their practice, you don't see that as going as going well. Right. But that also once people are doing practice, they're building attentional skills. So they kind of have this initial building of attentional skills and that allows sort of space for introspection. And it can also have challenging things that come up. Whether that's like the pain of sitting when you haven't done it before or things that are, might be a bit more dramatic, but that you can have this sort of introspection and also challenges that come up. And if you're able to meet those challenges with space and helpful attitudes that you may also be cultivating, that can lead to really positive well being outcomes that are related towards, you know, personal things, even health things, relationships. But on the flip side that you can also have some of these experiences responded to in unhelpful ways and that, you know, it's possible to have even functional, functional impairment in relation to some meditation experiences as well. So this was sort of what people were talking about. They were talking about moving from practice, developing some skills. And then when you meet challenges, those

B (19:34)

being opportunities for growth, it's almost, I mean, it's a really useful thing for all of us to remember that there will be challenges actually, that that's part of the journey and so on. And some of those challenges are within the, within the sitting, within the meditation practice itself. And then others might be outside of that, I guess, or things that start to develop in their lives generally.

C (20:05)

Yes, absolutely. So when I'm talking about challenges there, I suppose I'm talking about challenges that can arise within practice, challenges that can arise because of practice. But also, I mean, that's just part of life that you're going to come into contact with, with challenging experiences, challenging periods. And that if you're, if you have some of these skills that you've cultivated, even that can be an opportunity for growth with it personally. But within your practice as well, what

B (20:34)

was the relationship between practice and challenges? Were there often were the challenges a source of, you know, kind of just blocks to continuing the practice? Is that, is that part of that model?

C (20:49)

So interesting, Stan, because it was, you know, something that was emphasized a lot is that no one journey is the same. And so yes there are, you know, when someone's taught over many years, many people, there are things that they may notice as more common, but it's not prescriptive, it's not saying, you know, this is where you're going to go. So some people were saying that, you know, you can't actually put progress without challenges. That if you don't have some, you know, if you don't move towards challenge and you're just sort of sitting in this, you know, closing your eyes, feeling calm, sitting there for a while and then, you know, that's it. And if all of your meditation practice is always like that, you might. You might be calmed by it, but you're not necessarily going to go towards this teacher, what this teacher thinks would be more helpful for you. But then there are other. And there are some challenges that people talk about basically being universal, like the physical adjustments to different sitting types and all that kind of stuff. But then there are other teachers who are like, no, you don't have to go through, you know, you don't have to struggle on the path. That that's something that can happen, but it's not necessary for progress. So it's. It's quite varied. But what I would say is that most teachers say they see it. You know, they may not say that it's necessary for progress, but that it does happen. And they do. They do see people encounter challenges in their practice.

A (22:26)

I was sort of intrigued.

B (22:27)

There was fair agreement across teachers and

A (22:33)

you did allude to this a moment

B (22:34)

ago, that, you know, what.

A (22:35)

What does that tell us about how

B (22:37)

different traditions maybe do conceptualise progress differently and what. What progress might mean?

C (22:45)

Yeah, so that's. In round two, when we showed all the changes to teachers, there was a fair agreement across them. And basically that reflects our criteria for including them in the second round, which was that they needed to be mentioned by a reasonable proportion of at least one tradition. So not of everybody, but at least one tradition. And we did that because we're really interested at looking at the sort of within sample agreement, but also the differences between traditions. And we want to preserve that and report on it when we get to that stage. And as I said, there are some changes that we have very, very high agreement across tradition on, but then there are some that, you know, they're very particular and, you know, you're not getting very high agreement for a particular tradition or, you know, it might be one tradition's change. Well, you know, something that they notice a lot that other people don't. So I think that is one of the main things driving that. The other is, I think I've alluded to the differences in experience that our teachers had. So there are vastly different timescales that people are working with. And even the very experienced teachers who are MBSR and just teach in eight weeks, if they don't teach beyond that, there might be things that they don't see because they don't see people post that sort of. There might be things that happen in the long term that they don't necessarily see. And Also that with some of our teachers that there is a, and it's important to mention this, a resistance to this whole way of talking about change or development and practice. Practice. And it's important to preserve that, especially for some of the Zen teachers, for some people that they really engage with the very willing, very happily with the way we were asking. But for some teachers, they were like, this is not how I think about it at all. And that it's really important to preserve those perspectives.

B (24:50)

Moving through, can you just elaborate a bit there? What were the sorts of things that perhaps some people were balking at in the questions or how you conceptualized the questions?

C (25:02)

I guess so it was mostly about generalization. So when we were asking about, you know, what are all the different things that you see, that's not so quite so objectionable. But when we're asking about, you know, is this specific change meaningful? One of the things you run into a lot is it depends, you know, it depends on the person, it depends on the context. And that's not the case for some traditions. Some traditions, like if I see this, it's a great sign. If I see self compassion, fantastic. But for other things, for other teachers, no, it's very, very context dependent. And all of their work is happening in this one on one environment where everything is dependent on contextual factors. And so that's, you know, that's how they're making those judgments about meaning. And so asking them about it through a survey is not conducive to the way that they work.

B (26:04)

You were looking at changes when practice is going well and not going so well. Was it that sort of language?

C (26:12)

Yes.

B (26:12)

Yeah, because that was one of the things I wondered about myself was is there such a thing as a meditation practice not going well? I mean, I guess there is if it stops. But, but that in some ways the challenges, the distractions, the, the frustrations and hindrances and so on, they're all almost part of the practice. That, that's the. And so, yeah, I wondered about just that distinction. What are your thoughts there?

C (26:43)

We did have a lot more changes that were agreed to be meaningful when things are going well than were not going well. Like sort of about six times the amount. So, you know, that might reflect what you're saying. But I think also maybe that for a lot of teachers, they do have in their practice history people who they can think of where things have gone really seriously wrong. So I think, you know, you might say, okay, maybe this is not going poorly in their meditation practice and it's not Something that's an impediment to their practice. But if it's, you know, something that's serious enough that they stop, as you said, but also where they experience, you know, real functional impairment in their day to day life. Because, you know, a lot of people aren't these, these practices that a lot of the times were restricted to monastic practitioners are now out in the general public. And things where, you know, you might get a depersonalization experience that really impedes your ability to go to work or cook your kids dinner. You know, that is something that I think most teachers are happy to say is, Is the meditation not serving them or not going well?

B (28:05)

Yeah, no, that really makes a lot of sense. I guess there are helpful or healthy or kind of difficulties. And then there are things that are more concerning. I guess there is a. Increasing research highlighting adverse and really destabilizing effects of meditation in some cases. How does some of your work sit alongside that more recent research on meditation experiences and perhaps even harmful or certainly unhelpful experiences like that?

C (28:40)

Absolutely. So our advisory group especially were really keen to look at this side of what can happen and highlight that a lot of teachers work with this and are and are aware of it. Right. And I think the most important thing that we heard time and time again is, you know, while destabilizing events are possible, it's not the same for if something being unpleasant versus it being, you know, very problematic. So there are lots of things that can happen that are, that are unpleasant, like a little bit of sitting pain or, you know, more extreme kind of experiencing fear in practice that may be unpleasant, even highly unpleasant at the time. That can be a sign of things not going well, but also can be a kind of normal part of practice. That all depends on how the meditator is able to appraise it and deal with it. Not to say that it's. That it's on the meditator, but if it's something that they react to in a kind of generative way, then it's highly possible for an unpleasant experience to be not destabilizing. However, I would say that the other thing that comes through is that meditation is powerful. So it's a, it's a powerful practice. And that anything that's powerful, that has, you know, powerful positive possibilities can also have powerful destabilizing possibilities. And that, you know, teachers are very aware of that. But I'm not sure. And research is starting to be. But I'm not sure practitioners necessarily always are. So I think that's very Important. And it's very important to emphasize that because a lot of people go in not expecting it. But you know, more and more we're finding that it's not really even right to call these unusual experiences because they can actually be quite common. You know, you can call them intense experiences if you like. And that, that is, you know, something that many, many teachers see in many, many practitioners. Yeah.

B (30:52)

Yes. Even in self compassion practices there'll often be emotional backdraft where really difficult we turn towards ourselves with kindness and all of a sudden we're in contact with our own suffering and very difficult, intense, painful emotions start to come up.

A (31:13)

And I was reading about

B (31:17)

whether preparation or psycho education or those sorts of things are useful in the lead up to beginning a mindfulness practice or whether that also then just primes people to expect to have difficult challenges arising and so on. Whether are there things that came from your study or from your general reading on the topic that in terms of how do we help to manage those more destabilizing or really adverse experiences?

C (31:53)

I think from a personal perspective, I think that especially if you're offering it in a clinical setting, informed consent is really important. So I think, you know, acknowledging that there are some concerns about possibly priming people, I think that, you know, people are now they're getting recommended meditation by their teachers, by their GPs, by their universities, by their workplaces. And I think many people regard it as relatively mild and benign. And so to me, I think that communicating before you direct people to meditate that some of these things are possible is very important. Just from an informed consent perspective, we don't, I think, really know about whether or not this can prime people in that way. And we'll talk a little bit more about this in a minute. But my organization, the Contemplative Study center, is launching a big longitudinal cohort study. And this is one of the things that using longitudinal methods actually allows us to look at is, is there anything that predicts these experiences that we can see? And you know, it's understandable to have concerns about, about priming people. But on the other hand, it might be that having foreknowledge of this allows people to understand their experience when they have it. And if people, you know, don't get quite so freaked out, for example, about seeing lights, maybe they think, oh yes, okay, I've heard that other people can experience this and you know, they might appraise that as sort of a normal part of practice as opposed to something very frightening. So I think all those things are sort of yet to be determined. And for me, the ethical perspective of, you know, moving, moving with that informed consent is at the moment the primary importance.

B (33:56)

Yes, there's sort of the informed consent at the front end and then there's the inquiry, I suppose, at the other end, where people are able to reflect on and express and explore what the experience was really like and the good bits or the not so good bits and have a safe place and a person who they're able to do all of that with. Regarding clinicians, I suppose, and there is a lot of, like you said, mindfulness is a practice that's in many places in the community, I suppose, in schools and workplaces and also amongst therapists and in a therapeutic context. What would you say we need to be more aware of? I suppose, you know, given the results of the Delphi study so far, when we're bringing mindfulness into and meditation practice into our therapy work.

C (34:48)

Into the therapy work is interesting. I think where I get very concerned is people who are less informed than clinicians, you know, offering it in schools where it's just the teacher who may not know about it. I think in clinicians, I mean, part of the whole Delphi project is acknowledging that clinicians already know a lot about, you know, what's possible. But just being aware that people can have very, very intense experiences and that that's not necessarily a problem, but it can be. And that if somebody has a, you know, something they find deeply destabilizing, I think sometimes there can be a notion that you can just sort of practice through it. And I don't think that's the case for some people. I think for some people, and that's something that I. Is sort of a research interest of mine is, you know, whether or not this is sort of universally applicable, but, or whether for some people practice is fantastic and for other people it might be something that either they're not ready for or it might not be what suits them.

B (36:00)

Okay, cool.

A (36:02)

Well, I did want to ask you

B (36:03)

about your longitudinal study and sort of tracking meditation practitioners over time. Tell us a bit about what you're looking at there.

C (36:13)

Yeah, so, you know, we've done this work with meditation teachers, which is fantastic and very exciting and I'm looking forward to getting into the third round where we're going to ask about timing. But the meditation practitioners internal experience is not accessible to teachers. Right. And they're also talking about, in the Delphi study, they're talking about their, their full professional history. At the same time, they're talking about everybody. They've seen rather than exactly what happens when. And again, what I was just saying about potential predictors of change. So the well good method for looking at that is longitudinal cohort studies. So we're launching a longitudinal cohort study to basically track beginner meditators over two years to see what happens to their well being and also what happens to their practice. So who keeps practicing and why? And why do people stop? And also, you know, look at the changes in their well being and a whole, a whole raft of other measures as well.

B (37:24)

Yeah, you've got a bigger survey at the beginning and then one year and then two years I think. And then you've got, is it a weekly kind of brief survey that they will also be completing and then there's a little audio diary that they might

A (37:44)

provide as well as some daily prompts.

B (37:46)

So it's, it's comprehensive. Have I got most of it right there?

C (37:49)

Yes, yeah, absolutely. So it's a bit of a complex protocol but essentially we have, we're looking at our primary outcomes which is well being. We have these like larger yearly time point surveys. But for the, for the practitioners, probably the element of the study that will be most, that they'll be interacting with most is that we have these weekly voice diaries. So they're going to ask a little bit of questions about how much they've been practicing and it's very important to do that regularly because people aren't incredibly accurate in recalling how much they've been practicing. So we have that and then we have this weekly voice diary where we ask them to talk about their practice this week or if they didn't practice that week, to just talk about their week. And that means that we're going to collect this really rich qualitative information where people are reflecting on their practice. If they have an intense experience, maybe they're reflecting on that and, and reflecting on their week generally as well. And so this is going to give us a lot of opportunities to, you know, we have all our standardized measures but look at people talking about their practice in their own words, which I think, you know, preserving individuals perspectives through research isn't always something that we get the opportunity to do. So it's very exciting when we are able to do this. Yeah. And we have collaborators at Emory University who are enabling us to do that. It's all with an app, through a phone and.

B (39:18)

Yeah, no, very fancy. What sort of hypotheses do you have? Have you sort of established a sense of what you expect to see or that sort of thing?

C (39:30)

So it's observational. So we have a lot of exploratory things, but we are predicting that at the moment, the more practice people do, the better it'll be for their quality of life. So that is our primary hypothesis. But we also have a lot of exploratory things that we're looking at to do with. We're also investigating cost effectiveness as well. So. And we, and we are predicting that it will be cost effective, but we will, we will see for their mental health.

B (39:59)

Yeah, practice seems like it's kind of at the heart of it a bit, doesn't it? I mean, whether you playing golf or learning guitar or doing meditation, it's kind of practice makes. Well, practice.

A (40:13)

I was going to say practice makes

B (40:14)

perfect, but that doesn't sound very mindfulness. Ish. But anyway, yeah, that's good.

C (40:19)

Practice makes progress. Maybe.

A (40:21)

I don't know, it just makes progress.

B (40:23)

It might even be the. On the thumbnail for this episode. Nice one. Well, I will include the link to the longitudinal study because I think you

A (40:35)

are recruiting as we speak.

B (40:37)

And. And people from Australia and UK and usa, I think were the main three that I noticed on the, on the website.

C (40:45)

Australia, New Zealand, the US and the uk. Pardon me.

B (40:48)

Yes.

C (40:49)

People who've been. Yes, I don't want to leave out New Zealand, but it's people who've been practicing for. Regularly for at least a month, but not more than four months because we are trying to capture these. The sort of beginner area so we can follow them. Yeah.

B (41:04)

All right. Well, Dr. Lillian Ward, thank you for this work you're doing. It's very interesting and revealing and the idea of, you know, how we might progress over time and the sort of the, the various ups and downs and

A (41:17)

all the rest of it that might

B (41:18)

happen is all very interesting stuff. But also, thank you for speaking with me on Compassion in a T shirt.

C (41:24)

Thank you very much for having me.