Eric L. Garland, Ph.D., LCSW, is a clinical researcher and practicing, licensed psychotherapist. He serves as an Associate Professor at the University of Utah College of Social Work and Associate Director of Integrative Medicine in Supportive Oncology at the Hunstman Cancer Institute. He developed a multimodal mindfulness-based intervention called Mindfulness-Oriented Recovery Enhancement (MORE).
How did you first become interested in studying mindfulness?
I had a personal practice of mindfulness when I was in college pursing my bachelor’s degree in psychology. At that time, I was very interested in comparative religion, philosophies of mind, as well as anthropology. Along with my personal meditative experiences, I also had exposure to alternative systems and philosophies for understanding the world, like Buddhism, Advaita Vedanta, Taoism, and various shamanistic cultures. These learning experiences gave me a true passion for the idea that a person could access absolute and relative truths by training his or her mind to engage in a different way of seeing and experiencing the world.
In the beginning, mindfulness was mostly a personal pursuit. To be honest I didn’t know that there was a scientific study of mindfulness for quite some time. In my early career I was working as a therapist and I had begun to use meditative techniques with my clients to help them deal with addiction, anxiety, and depression. This was at a time when a few folks out there were practicing a combination of psychotherapy and meditation, but it wasn’t nearly as prevalent as it is now. There were no real formalized mindfulness-based therapy approaches. So I began to experiment how to integrate meditation into my practice as a clinician. It wasn’t until later when I decided to pursue my doctorate that I discovered there was a whole emerging research world focused on mindfulness. By serendipity I was plugged into an NIH-funded research study of mindfulness as a treatment for irritable bowel syndrome that was being run by Susan Gaylord at UNC’s Program of Integrative Medicine. She kindly took me under her wing and trained me to be a mindfulness researcher. She taught me the tools of the trade. Ten years later here I am.
Do you maintain a personal practice? If so, how has that informed your career focus?
I do maintain a personal practice, and also continue to use mindfulness to treat patients in clinical settings. Both my personal and clinical practice of mindfulness have been extremely productive in helping me in develop new models of mindfulness, understanding the therapeutic mechanisms involved, and ultimately discovering how this may be helpful to other people.
“A lot of my hypotheses, which I have then gone on to test in my research and found support for in my data, emerged from my own mindfulness experience or my experience sharing mindfulness and mediation techniques with patients.”
A lot of my research has been focused on teaching mindfulness to patients with little to no experience with mindfulness meditation practices. I think the experience of prolonged contemplative practice over the years can reveal deeper states of consciousness that a novice is unlikely to experience in the context of a standard 8-week therapeutic mindfulness intervention. I think it’s essential that a scientist who is pursuing this field has a personal mindfulness practice, and ideally also experience teaching mindfulness to others. A lot of my hypotheses, which I have then gone on to test in my research and found support for in my data, emerged from my own mindfulness experience or my experience sharing mindfulness and mediation techniques with patients. There are parts of my own personal practice that I have yet to study because there are related to the deeper layers of mindfulness and contemplative practice that may not be appropriate for research.
Do you think we have the tools and the technology to study those deeper states?
No, in fact I’m starting several new big studies where we want to start looking at the experience that is referred to as ‘non-dual awareness‘ in the context of clinical trials. We’re having a hard time finding any adequate measures, even self-report measures, of that phenomenon, let alone a task that might probe that state. So I don’t think we have yet developed the right tools and technologies to capture the deeper states of consciousness associated with mindfulness practice.
As a field it makes sense why we haven’t pursued that too heavily; we’ve been putting most of our energy into establishing the scientific legitimacy of the field. We’ve been trying to import methods from neuroscience and psychology into the field. This was a necessary stage in the development of contemplative science. Probably over the next coming decade we’ll start seeing measurement approaches that can tap constructs that haven’t been really formally considered in these other fields.
When did you first become involved with the Mind & Life Institute and how did that inform your direction as a researcher?
I first became connected in Mind & Life Institute in 2007 when I was a doctoral student at University of North Carolina- Chapel Hill and I applied to be a part of the Mind & Life Summer Research Institute. I was selected to be a summer research fellow. To be honest, it was a life changing experience for me. I was surrounded by a group of peers who all had an interest in a similar phenomenon in a field that I didn’t even know was a legitimate science. There was a panel of faculty who were some of the most esteemed researchers in the world across a wide range of disciplines and they were all devoting their career to the pursuit of contemplative science.
Long before my involvement in the Mind and Life Institute, I had been introduced to the work of Francisco Varela, who was the progenitor of the Mind and Life Institute. It was very exciting to tap into a whole organization whose intention was to carry on the work of Varela. It was really catalytic for me in many ways. I received a Francisco J. Varela Research Award the next year. It was a $15,000 award and His Holiness the Dalai Lama’s signature was on the award letter. That award funded my dissertation, which was the first study of Mindfulness-Oriented Recovery Enhancement (MORE). I’ve since pursued research on MORE for the past eight years and that line of research has blossomed into multiple multi-million dollar federal grants and a number of studies came out of that. So I’m really indebted to Mind and Life and grateful to have made so many friends and colleagues along the way.
What is Mindfulness-Oriented Recovery Enhancement (MORE)?
MORE is an integrative therapeutic approach that combines mindfulness training with reappraisal skills and techniques to promote savoring. In that sense, MORE combines multiple traditions; it unites a traditional mindfulness-based intervention approach with some techniques drawn from cognitive-behavioral therapy, and even existential therapy, along with a positive psychology approach that acknowledges the importance of enhancing positive emotion. MORE was designed to ameliorate addictive behavior, stress, and (physical and emotional) pain.
What are the biobehavioral mechanisms of MORE?
I’ve done a number of studies on MORE and the therapy seems to have a wide range of effects on both transdiagnostic mechanisms and addiction-specific mechanisms. Generally speaking, MORE seems to help people enhance their attentional control over automatic habits of fixating attention on negative or threat-related information. The data is showing that participants in MORE become better able to disengage and become less fixated on stressful information and consequently gain greater autonomic nervous system regulation in the face of negative emotional information. In other words, if a person is confronted with stressful stimuli or drug-related stimuli, they evidence heightened heart rate variability responses when they are paying attention to these stimuli. This physiological marker seems to indicate that through MORE patients become more flexibly able to engage and disengage their attention from these stimuli – and thereby are better able to regulate their reactions.
“Across several published and unpublished studies, we are discovering that increasing sensitivity to natural reward through MORE may lead to decreased craving for drugs – a completely novel and radically important finding for the field of addiction science.”
The data also seems to suggest that MORE increases sensitization to natural reward. What I mean is that over time people who participate in MORE seem to extract more pleasure out of healthy objects and events in their lives through the use of mindfulness as a tool to enhance savoring. Across several published and unpublished studies, we are discovering that increasing sensitivity to natural reward through MORE may lead to decreased craving for drugs – a completely novel and radically important finding for the field of addiction science.
I also have data from several studies showing that mindfulness appears to relieve chronic pain symptoms by increasing interoceptive awareness. In other words, mindfulness seems to be decreasing chronic pain symptoms by enabling people to pay attention to the sensory qualities of their pain rather than being fixated on the emotional aspects of pain. So in MORE for the treatment of pain, we teach patients to focus their awareness on pain. Rather than distract themselves from pain, we encourage patients to explore pain and to break down the experience of pain into its parts. So rather than think of low back pain as a terrible anguishing experience, we train patients to focus on the sensation of heat, tightness, and tingling in the back. In doing so they may find spaces inside of the pain sensation that don’t hurt at all or they might even find some pleasurable sensation in the body proximal to the pain.
Some people with chronic pain may develop beliefs or schemas about how their pain is and how their body feels, and then they start to feel their assumptions, beliefs, and thoughts about the state of their body more than the actual physiological condition of the body – which is in fact always changing. By tuning interoceptive awareness into the pain experience, mindfulness seems to undo this process to alleviate pain. In many of chronic pain cases, there are no easily defined physiological generators of pain, and no ongoing tissue damage. Yet, over time, the patient may come to perceive uncomfortable sensations in the body that might actually be harmless or innocuous as being threatening and dangerous. In MORE we try to reverse this process.
MORE has been used to treat chronic health, mental health, and addiction related issues. How can mindfulness be one therapeutic tool to address all of these conditions?
We need to take a transdiagnostic approach to understand how to alleviate human suffering. Across various forms of suffering, there are some crosscutting mechanisms for processes that create suffering regardless of diagnosis. Let’s take one process: stress reactivity or sensitization to threat. We see sensitization to threat in anxiety, trauma, depression, and chronic pain – in which the threat might be from sensations in the body. Prolonged use of addictive drugs or repeated exposure to stress and trauma can dysregulate stress systems in the brain and can increase sensitivity to stress. This mechanism of stress sensitization is a transdiagnostic mechanism that cuts across disorders and is common to many conditions that cause people suffering.
Another transdiagnostic process that I’m interested in is reward insensitivity. This phenomenon is also found in depression, PTSD, chronic pain, and addiction. Individuals suffering from these problems can become less able to experience natural pleasure from healthy and pleasant events, people, and experiences in everyday life. Because individuals may have this lessened ability to extract the sense of joy from everyday life, this deficit may lead them to seek a sense of well-being through self-destructive coping behaviors, such as overindulging in food, alcohol, drugs, gambling, cutting, etc. Reward insensitivity is another important transdiagnostic mechanism to be targeted by mindfulness. Mindfulness is likely very useful for targeting multiple transdiagnostic mechanisms because it seems to have broad-spectrum effects.
Do you see mindfulness-based interventions as a primary therapy or as an adjunctive therapy?
In the case of chronic pain and opioid misuse, what society is faced with is a large number of patients are currently take opioids for pain- that is the medical intervention that they were given by the health care system. Patients who have had Mindfulness-Oriented Recovery Enhancement incorporated into their overall health care plan may experience improvements with pain and stress, and also reduce their misuse of opioids and possibly their dependence on opioids.
“Rather than being prescribed medication, people with chronic pain will be prescribed meditation – that is a future that I can envision.”
In the future, it’s possible that policy changes focused on reducing opioid misuse will vastly alter the treatment of chronic pain. Rather than being prescribed medication, people with chronic pain will be prescribed meditation – that is a future that I can envision.
We’re not quite there yet. Ideally, the doctor would prescribe a person with acute pain a limited amount of opioids, but also incorporate a mindfulness-based intervention as well as an exercise and nutrition program into the patient’s treatment plan. An integrative medicine approach would be built into the front end of the treatment plan. This could prevent a lot of problems and suffering down the line.
Your studies incorporate cognitive, affective, and social neuroscience. Given your background in social work, this might surprise people. Do you feel that the questions you study require an interdisciplinary approach or is this unique to your approach as a clinical scientist?
Up to this stage in my career, I’ve employed methods from cognitive and affective neuroscience, particularly psychophysiology. I incorporate tasks like the dot-probe task to measure attention biases to emotional information. I’m essentially self-taught; I taught myself psychophysiology in an independent study led by Barbara Fredrickson, Ph.D., while I was a doctoral student at UNC. In terms of doing more complex neuroscience, like the use of fMRI, or molecular neuroimaging using PET, we do need interdisciplinary partners. Going forward, I will definitely be collaborating with others.
I just received a new grant from the National Center for Complementary and Integrative Health that will be using molecular neuroimaging of MORE to look at its effects of neurotransmitter function with my Co-PI Jon-Kar Zubieta, MD, PhD, Chair of Psychiatry at the University of Utah, who is a pioneer of the use of PET to look at endogenous opioid function in the brain during the experience of pain.
What is Mindfulness to Meaning Theory?
Essentially, Mindfulness to Meaning Theory attempts to explain how the acute state of mindfulness that is generated when a person sits down on “the cushion” to meditate might impact one’s sense of meaning in the face of adversity. It aims to answer the question: How does the acute, ostensibly non-judgmental, non-discursive state of mindfulness have positive influences on the discursive, language-based narrative, our autobiographical sense of meaning in everyday life? This whole idea emerged out of the observation that patients benefit from doing mindfulness meditation by not only increasing clarity, and decreasing stress, but also experiencing more complex cognitive and meaning-based benefits, such as a greater ability to reframe the stressors and adversities in their lives. Many patients participating in mindfulness-based interventions come to see these adversities as learning opportunities to grow stronger as a person and to become more compassionate. Their formal practice of mindfulness meditation was benefiting them in broader, more abstract ways than mere stress reduction. This makes sense, because if people were only benefiting from the ten minutes that they were on the cushion focusing on their breathing, mindfulness wouldn’t be a very meaningful pursuit.
The reason why we practice mindfulness is because it has a broader impact on our lives and our sense of self. Mindfulness seems to have an impact on our life story, the way we define ourselves, and the way we understand the opportunities and the challenges that we face in life. There was no scientific model to really explain that process in a fine-grained way. I think the reason for that oversight is that the field has invested a lot into answering the questions of what ‘mindfulness’ is, what is happening when someone sits down and practices mindfulness meditation, and what is happening in the brain. There has been less attention paid to how the acute state of mindfulness blossoms into these more longitudinal and broader impacts on a person’s life, and life story, and self-concept. These abstract concepts are harder to define and measure. For a variety of reasons, there’s been less attention paid to them.
“This whole idea emerged out of the observation that patients benefit from doing mindfulness meditation by not only increasing clarity and decreasing stress, but also experiencing more complex cognitive and meaning-based benefits, such as a greater ability to reframe the stressors and adversities in their lives.”
The definition of mindfulness that was put forth by Jon-Kabat Zinn has directed the type of questions that contemplative scientists have been asking. And while a seminal contribution, this definition has left a vacuum; for example, in defining mindfulness as “non-judgmental awareness,” we haven’t asked the question of how mindfulness affects our judgments. There are people who will tell you that mindfulness doesn’t affect judgment because it’s a non-judgmental process. But I’m pretty sure as a mammal that it’s impossible to shut off judgment completely. Would we want to do that? There are a lot of positive judgments made in life; we use our judgments to navigate the world, to build relationships, and define our sense of ethics and values. And if you go back and look at the traditional Buddhist systems from which a lot of these mindfulness practices derive, they don’t seem to abstain from non-judgmental perspectives in the least. To the contrary, within the Noble Eightfold Path, for example, there is ‘right action,’ ‘right speech,’ ‘right intention,’ and so forth. ‘Right’ implies wrong. There’s a judgment there. What is correct, what is wholesome?
In these Buddhist systems there is a huge focus on wholesome qualities. And defining a quality as wholesome implies that there are unwholesome qualities. Implicit in these spiritual systems was a sense of making judgments and discriminations to identify what is a wholesome way to live in the world. Mindfulness was traditionally used as a tool to help gain insight into those positive judgments. Given that history, I developed that Mindfulness to Meaning Theory to help explain how the acute state of mindfulness can help an individual make helpful evaluations of their own sense of self and the world around them so as to experience their life as more meaningful.
What is the newest development in the science of mindfulness that excites you?
I’m really excited about the Mindfulness to Meaning Theory. Some recent clinical trial work by Philippe Goldin and James Gross shows that mindfulness training increases reappraisal and that cognitive-behavioral therapy (CBT) increases mindfulness. We like to think of these interventions as being distinct with distinct therapeutic mechanisms. But in fact, in these well-controlled studies in patients with social anxiety, Goldin and Gross found that mindfulness helped people change the way they think about their life situation – which provides some of the strongest evidence for the Mindfulness to Meaning Theory yet. Furthermore, CBT helped people become more mindful. From a transdiagnostic and transtherapeutic perspective, these different treatment approaches can promote mental well-being through common pathways.
In terms of technologies and methodologies, I think that the use of molecular neuroimaging to study the effects of meditation practice on neurotransmitter function is an exciting new development. There’s almost been no work in that area.
Lastly, for a long time I have been fascinated by studies of the effects of mindfulness meditation on gene expression. There is a body of work studying the changes in gene expression that drive changes in protein synthesis, which provide a pathway by which a psychological intervention might change the function of the body. This technological approach provides a means of testing some of the most time-honored theories of the mind-body relationship.
If you were to win a Nobel Prize, what would you want it to be for and why?
If I were to win the Nobel, it would be on this idea: If addiction involves a process by which the individual becomes increasingly insensitive to natural pleasure which drives them to take higher and higher doses of the drug just to feel okay, then if we can teach people to extract pleasure out of everyday life, might it reverse the addictive and interrupt dependence on drugs?
We’re pretty clear now in terms of the neurobiological mechanisms by which this reward dysregulation occurs in the mesocorticolimbic dopamine system. We believe this mechanism is partially located in brain in the ventral striatum, which in addiction becomes hypersensitized to drug-related cues and becomes insensitive to naturally rewarding pleasures. So clinically, if we can show that teaching mindfulness can promote savoring of the natural beauty of life, and that this savoring process seems to undo craving and addiction, I would hypothesize that we would see that same shift in the brain specifically reflected in the ventral striatum, and more broadly across the mesocortical dopamine and endogenous opioid systems. Through mindfulness training, as the brain becomes less sensitive to drug-related cues, it may become more sensitive to natural pleasures in life.
Do you have any advice for aspiring scientists hoping to pursue a career in science?
Science is a rough game. One should not enter into this field without recognizing that. Yet, the scientific profession is joyous because it provides the opportunity to live the life of the mind. My advice to aspiring scientists is often this: don’t pursue merely what interests you. Instead, you should ask yourself, “What are the pressing questions from a societal perspective? What are the needs of society right now?” Based on what society needs, and based on your assessment of those problems, you work to use science to generate solutions to those problems. If an aspiring scientist directs his or her scientific career along those lines, then he or she will have more of an impact on the world, and also have an easier time obtaining funding and a faculty position.
“Yet, the scientific profession is joyous because it provides the opportunity to live the life of the mind.”
The other important reason to pursue science is for pure discovery. From a practical perspective, I think it is very hard to build a career to do science for the purpose of pure discovery. Funding in science is so tight right now that funding is going for the most pragmatic applications and questions rather than the grand metatheoretical questions. I think it would be hard to pursue a scientific career in those domains – though it is certainly a worthy endeavor. But I think a fruitful and meaningful path may open up out of asking yourself “What are the needs of society and how can science be applied to address those questions?”
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