Lao 2016

Consciousness and Cognition 45 (2016) 109–123
Contents lists available at ScienceDirect
Consciousness and Cognition

journal homepage: www.elsevier.com/locate/concog
Review article
Cognitive effects of MBSR/MBCT: A systematic review

of neuropsychological outcomes
So-An Lao ⇑, David Kissane, Graham Meadows
School of Clinical Sciences at Monash Health, Monash University, Department of Medicine, Nursing and Health Sciences, Melbourne, Australia
a r t i c l e i n f o a b s t r a c t
Article history: Mindfulness is theorised to improve attention regulation and other cognitive processes.
Received 23 June 2015 This systematic review examines whether 8-week standardised and manualised mindful-
Revised 5 July 2016 ness training programs such as Mindfulness Based Cognitive Therapy (MBCT) and
Accepted 22 August 2016
Mindfulness Based Stress Reduction (MBSR) enhances attention, memory and executive
function abilities measured by objective neuropsychological tests. Seven databases were
searched resulting in 18 studies meeting inclusion criteria for review. Overall studies did
Keywords:
not support attention or executive function improvements. We found preliminary evidence
Mindfulness based cognitive therapy
(MBCT)
for improvements in working memory and autobiographical memory as well as cognitive
Mindfulness based stress reduction (MBSR) flexibility and meta-awareness. Short-term mindfulness meditation training did not
Attention enhance theorised attentional pathways. Results call into question the theoretical under-
Memory pinnings of mindfulness, further highlighting the need for a comprehensive theoretical
Executive function framework.
Awareness Ó 2016 Elsevier Inc. All rights reserved.
Meta-awareness
Cognitive function
Cognitive ability
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
1.1. Cognitive processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2.1. Eligibility criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
2.2. Information source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
2.3. Study selection, data extraction and synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
2.4. MBSR/MBCT intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
3. Results. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.1. Search results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.2. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.3. Effects of MBSR/MBCT on attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.3.1. Alerting/sustained attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.3.2. Orienting/selective attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
3.3.3. Executive attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
⇑ Corresponding author at: Monash Medical Centre, Level 3, P Block, 246 Clayton Road, Victoria 3186, Australia.
E-mail addresses: So-an.Lao@monash.edu (S.-A. Lao), David.Kissane@monash.edu (D. Kissane), Graham.Meadows@monash.edu (G. Meadows).
http://dx.doi.org/10.1016/j.concog.2016.08.017
1053-8100/Ó 2016 Elsevier Inc. All rights reserved.
110 S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123
3.4. Effects of MBSR/MBCT on memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

3.4.1. Memory specificity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
3.4.2. Working memory capacity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
3.4.3. Short-term memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
3.4.4. Effects of MBSR/MBCT on executive function inhibition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
3.4.5. Other cognitive outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
3.4.6. Awareness and meta-awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4.1. Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
4.2. Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
4.3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
1. Introduction
Mindfulness has grown exponentially in the last 15 years as a topic of scientific research and clinical practise. Research
has found mindfulness to be associated with many health and well-being indicators. Health benefits include decreased levels
of stress and anxiety, improved emotional, mental and physiological regulation and promotion of brain plasticity (Arch &
Craske, 2006; Grossman, Niemann, Schmidt, & Walach, 2004; Hoge, Bui, Metcalf, Pollack, & Simon, 2012; Holzel et al.,
2011; Keng, Smoski, & Robins, 2011; Mankus, Aldao, Kerns, Wright Mayville, & Mennin, 2013; Marchand, 2012). As such,
interest in mindfulness is beginning to spread beyond clinical settings into education, sports and businesses. As more and
more people practise mindfulness, it becomes important to better understand how mindfulness actually works.
Jon Kabat-Zinn, the founder of Mindfulness Based Stress Reduction (MBSR), defines mindfulness as ‘‘the awareness that
emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment
by moment” (2003). An operational definition proposes that mindfulness is comprised of the two components: attention reg-
ulation and orientation to experience characterised by an open and non-judgemental attitude (Bishop et al., 2004). Meditation
is the method most commonly used to train mindfulness. Lutz, Slagter, Dunne, and Davidson (2008) propose that meditation
styles or meditation traditions can be categorised as either focused meditation (FM) or open monitoring (OM) but see Nash
and Newberg (2013) for an alternative categorisation. FM involves using an object as a focal point for attention and returning
attention back to the object when the mind wanders away. This type of training is thought to be correlated with improve-
ments in sustained (concentration) and selective attention assessable by performance on neuropsychological tests such as
the attentional network task (ANT, Fan, McCandliss, Sommer, Raz, & Posner, 2002) and the continuous performance task
(CPT, Shalev, Ben-Simon, Mevorach, Cohen, & Tsal, 2011). OM does not have an explicit object of focus, instead it involves
noticing all experiences that arise. This type of meditation is thought to train a non-reactive awareness and develop an
awareness of automatic emotional and thought processes. Commonly, FM is introduced before OM, as OM is considered
more difficult without first stabilising attention through FM practise (Wallace, 2006).
The aim of this paper was to examine the evidence for cognitive effects from mindfulness training, specifically the effects
promoted through clinical mindfulness programs such as MBCT and MBSR. If mindfulness exerts its salutary effects through
cognitive processes, such as attention and awareness, then studies investigating this relationship are crucial to understand-
ing how mindfulness works. Knowing how mindfulness works will enable clinicians to confidently select, adapt and modify
treatment programs to different patient groups. Additionally, mindfulness has been predominantly assessed by self-report
measures. Concerns have been raised regarding the validity of subjective measures of this psychological construct (Belzer
et al., 2013; Grossman, 2011). Establishing cognitive correlates of mindfulness may offer an objective performance-based
measure of mindfulness – an area identified as important for the future development of mindfulness in research and science
(Garland & Gaylord, 2009; Sauer et al., 2013).
A previous review which investigated whether mindfulness training improved cognitive abilities found that mindfulness
did significantly improve the attentional sub-processes of selective, sustained and executive attention (Chiesa, Calati, &
Serretti, 2011). Working memory capacity and some executive functions, such as verbal fluency and inhibition of
pre-potent responses, were also shown to be enhanced. Furthermore, particular cognitive changes were associated with
the type of meditation engaged. For example, FM promoted selective and executive attention while OM developed sustained
attention, however, sustained attention was previously thought to be an effect of FM (Bishop et al.). Chiesa et al.’s review
covered different forms of meditation, ranging from mantra and visualisation to Buddhist based Zen, Shamatha-Vipassana
and secularised forms such as ACT, MBCT and MBSR. Programs also varied in duration and intensity from a brief 20 min
induction (Wenk-Sormaz, 2005) to 3-month intensive meditation retreats requiring 10–12 h of daily practise (Slagter
et al., 2007). There are marked differences in conceptualisation, goals, and techniques taught within different meditation
styles and both meditation style and amount of experience are likely associated with different cognitive outcomes
(Chiesa & Malinowski, 2011). Thus, comparisons of cognitive outcomes from mindfulness training ought to be conducted
on standardised forms of mindfulness. MBSR and MBCT are both standardised and manualised forms of mindfulness
intervention. A review of the available literature on such standardised interventions may be useful.
S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123 111
MBSR is the prototypical mindfulness intervention originally conceived for treatment of stress and anxiety (Kabat-Zinn,
Lipworth, & Burney, 1985; Kabat-Zinn et al., 1992). MBCT was modelled after MBSR and combines cognitive behavioural
therapy (CBT) with mindfulness for the treatment of recurrent depression (Teasdale, Segal, & Williams, 1995). Both are
8-week group programs designed to teach mindfulness skills through formal sitting meditation and other mindfulness
exercises. It is assumed that mindfulness skills help the patient to become aware of their habitual cognitive patterns and exit
those that perpetuate negative symptoms. However, MBSR/MBCT differs from CBT; the focus of mindfulness is not to change
thought content but to become aware of the thought process itself. MBSR/MBCT differs from other psychotherapies such as
ACT and DBT, where mindfulness is not a core skill and formal meditation is not taught. MBSR/MBCT also differs from
Buddhist based practices in its clinical orientation and secular nature.
Since Chiesa et al. (2011) included many other mindfulness protocols along with some MBSR and MBCT studies, it is not
clear what cognitive effects were specific to MBSR/MBCT treatment. In this review we selected prospective studies where
MBSR/MBCT intervention was delivered and outcomes of treatment were measured post-intervention. Some studies
overlapped with those in Chiesa et al.’s review but a significant number were new studies. We hope this approach reveals
more consistent findings than Chiesa et al.’s review and elucidate what cognitive effects result from MBCT/MBSR treatment.
We chose MBSR/MBCT interventions because the mindfulness training is standardised within these programs. Furthermore,
these interventions are growing in popularity and are an ecological representation of how people are likely to experience
mindfulness within a clinical setting.
1.1. Cognitive processes
The cognitive processes examined in mindfulness research include attention, executive functions and memory. We briefly
describe theorised models for these processes to provide a framework from which to interpret findings. However, the follow-
ing outline of visual attention, executive function and working memory are hypothesised subprocesses and should not be
taken as reflective of conceptual or neural underpinnings. The visual attentional system is thought to be comprised of the
subsystems: (1) alerting, (2) orienting and (3) executive attention (Posner & Petersen, 1990). Alerting refers to a basic awak-
eness or arousal to stimuli, and orienting (also referred to as selective attention) functions to prioritise target events by
selecting from the array of incoming sensory information. The role of executive attention is goal monitoring, conflict detec-
tion and resolution. The Attentional Network Test (ANT, Fan et al., 2002) was designed to assess all three subcomponents.
Executive attention itself is subserved by three subsystems of the executive network which include (1) mental set shifting;
(2) updating and monitoring; and (3) inhibition (Miyake et al., 2000). The subsystems of the executive network handle
higher order cognitive processes involved in activities such as planning, prioritising and problem solving. Mental set shifting
involves switching from one task set to another, while updating requires monitoring of incoming information and updating
old, no longer relevant, information held in working memory with newer information relevant to the current task. Inhibition
is described as the ability to deliberately inhibit prepotent automatic responses, of which the Stroop colour-word task is a
prototypical measure (Stroop, 1935). We only further discuss working memory because it is most closely aligned with
mindfulness. Mindfulness requires the regulation of attention toward present moment experiences, working memory is
responsible for storage of information that is relevant to the immediate experience and is also closely connected with
attention and awareness. Working memory is thought to be comprised of an auditory and a visual/spatial store governed
by an executive control allocating attention (Baddeley & Hitch, 1974). Baddeley (1992) has claimed that consciousness or
awareness operates through working memory while others have argued that working memory depends upon awareness
(Baars, 1997; Crick & Koch, 1990), either way the relationship is an intimate one. Complex span tasks are used to measure
working memory capacity. Simple span tasks require a straightforward recall of items presented, while complex span tasks
require not only the recall of items, but also involve conducting another task designed to interfere with the process of
storage. Thus, working memory measures not only the ability to store, but also the ability to resist distraction, which is a
central tenet of mindfulness.
While the above frameworks treat processes of attention, working memory and executive function as unitary it is
apparent from the brief descriptions that processes do overlap and interact within a dynamic cognitive system. Executive
functions support attention and working memory while working memory also draws upon attention. These classifications
of cognitive subsystems are heuristic and interpretation of outcomes should be considered in light of this.
2. Methods
2.1. Eligibility criteria
Controlled experimental studies were of adult populations (18 and above) delivering MBCT/MBSR intervention (or equiv-
alent), which have at least one outcome measure that is an objective neuropsychological measure of cognition. The studies
were drawn from English language peer reviewed journal articles published between January 2000 and February 2015.
Mindfulness research only began to grow exponentially in early 2000. A search of a popular database (Scopus) using the
search terms ‘‘mindfulness” and ‘‘cognition” returned only 1 result prior to 2000.
Since the focus of this review was cognitive change (not related to developmental growth) from mindfulness training
measured on neuropsychological performance tests, qualitative studies, studies of dispositional mindfulness and studies that
included non-adult populations were excluded from review.
2.2. Information source
This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses
(PRISMA, Moher, Liberati, Tetzlaff, & Altman, 2009) guidelines. Databases searched were CINAHL, Cochrane Library, Embase,
Informit, Medline, PsychINFO and Scopus. Search terms used: [mindfulness OR meditati⁄ OR MBCT OR MBSR AND attention
OR memory OR cogniti⁄ OR executive].
2.3. Study selection, data extraction and synthesis
Studies meeting inclusion criteria were retained for further analyses, the selection process is illustrated in Fig. 1. Where
studies stated mindfulness interventions were adapted or based on MBSR/MBCT, the intervention was assessed for equiva-
lence based on fidelity of mindfulness exercises to the original MBSR and MBCT program (Kabat-Zinn, 2005; Segal, Williams,
& Teasdale, 2013). Four standard sessions is considered by developers of MBCT to be an effective treatment duration
(Teasdale et al., 2000) so 8 h of in-class instruction was a minimum requirement. Authors were contacted for further clar-
ification when MBCT/MBSR fidelity was unclear based on the descriptions given. If MBCT/MBSR equivalency could not be
established, the study was excluded from further analyses. Data for study design, population, intervention, measures and
outcome were extracted from included studies and summarised in Table 1. Studies were grouped under cognitive outcome
measures of attention, memory and executive function. Studies with outcome measures that did not fit any of the aforemen-
tioned categories were grouped under a blanket category of ‘other cognitive measures’. Meta-analysis was not conducted
due to heterogeneity of included studies (Davies & Crombie, 1998). However, for descriptive purposes, effect sizes and their
confidence intervals were plotted when possible (Fig. 2). Effect sizes were calculated from omnibus significance tests (f-test)
of group differences across time or from contrasts (t-test) between mindfulness and control groups at post-test. Effects sizes,
Electronic Database Search

N = 10, 962
Duplicates and articles excluded at

title and abstract level
N = 10,891
Articles retained for full text

screening
N = 71
Articles excluded N = 53
Reasons for exclusion:
Non MBSR/MBCT
intervention n = 18
Cross-sectional study n = 11
Mindfulness induction study
n=9
Trait mindfulness n = 1
Non-adult population n = 2
Articles included Non-cognitive outcome
N = 18 measure n = 3
No control arm n = 3
Unable to obtain study n = 1
Unable to establish
intervention equivalence to
MBI n = 5
Fig. 1. Flow chart of study selection process.

Table 1
MBSR/MBCT controlled and randomised controlled studies with objective measures of cognition.
Publication Type Population Age Treatment (n) Control (n) Measures T1-T2 ET-T2 Outcome
mean/range (mths) (mths)
Williams et al. RCT Recurrent 44 MBCT (21) TAU (20) AMT 6 4 Significant reduction in overgeneral memory in
(2000) depression MBCT group
Teasdale et al. RCT Recurrent 41 MBCT + TAU (39) TAU (48) MACAM NA 3.7 Meta-awareness was significantly greater
(2002) depression following MBCT compared to TAU
Anderson et al. RCT Healthy MT: 37 MBSR (39) Waitlist (33) VCPT 2–3 1 No significant group differences found on any
(2007) Control: 42 ST attentional measures
Stroop
ODT
Jha et al. (2007) CT Healthy MT: 24 MBSR (17) Retreat (17) ANT 2 0.3 At time 1: Intensive retreat group showed
Retreat: 35 No treatment (17) significantly better conflict monitoring
Control: 22 compared to MBSR + Controls. No significant
difference between groups in any other
S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123

attentional subcomponents
At time 2: MBSR group demonstrated
improved orienting compared to controls
Heeren et al. CT Healthy 54 MBCT (18) No treatment (18) AMT NA 1.7 Mindfulness increased cognitive flexibility,
(2009) HT specific memory and the capacity to inhibit
TMT prepotent responses. It decreased overgeneral
GSP autobiographical memory retrieval. Cognitive
VFT flexibility, and not inhibition, was a significant
mediator of overgeneral memories
Hargus et al. RCT Depressed 18–65 MBCT + TAU (14) TAU waitlist (13) RSS NA NA MBCT group showed significant memory
(2010) patients MACAM specificity and higher levels of meta-awareness
compared to TAU group
Jha et al. (2010) CT Predeployment MB: 30 MBSR (29) Military control (17) Ospan 2 0.2 In the mindfulness group, greater practise time
military personnel Military: 25 Civilian control (12) corresponded to higher WMC, while low
Civilian: 34 practise group showed significant degradation
of WMC. Ospan scores remained stable in
civilians, but degraded over time in military
control group
Oken et al. RCT Dementia 45–85 MBCT (10) Education (11) WLLT 3 0.7 Significant group differences in Stroop
(2010) caregivers Respite waitlist (10) Stroop interference and ANT alerting scores. While
ANT MBCT group showed the fastest RT on Stroop
task, it was the education group, which
displayed largest magnitude in RT
improvement from T1 to T2. MBCT group
showed higher alerting scores at T2 compared
to both control groups
van den Hurk et al. RCT Recurrent 49 MBCT (34) Waitlist (37) ANT 3 ET No improvements in specific components of
(2012) depression attentional processing following MBCT
De Raedt et al. CT Recurrent 45 MBCT (45) No treatment (26) NAP 2 ET At time 1: MBCT group displayed significant
(2012) depression attentional bias for negative and inhibition of
positive information compared to controls
At time 2: The significant baseline effects in
MBCT group disappeared indicating a more
open attention for all emotional experience.
The decrease in facilitation of negative
information was significant
113
(continued on next page)
114
Table 1 (continued)
Publication Type Population Age Treatment (n) Control (n) Measures T1-T2 ET-T2 Outcome
mean/range (mths) (mths)
Jensen et al. RCT Healthy 20–36 MBSR (16) NMSR (15) DART NA NA MBSR group improved significantly more than
(2012) No treatment (16) STAN other groups on selective attention. Only MBSR
Stroop improved visual perception and working
d2 memory capacity. Incentivised group improved
CombiTVA significantly on vigilance tasks
Greenberg et al. RCT Healthy MT: 37 MBCT (27) Waitlist (26) WJT NA ET Mindfulness group had significantly lower
(2012) Control: 31 rigidity scores than the waiting list group
Greenberg et al. RCT Healthy 26 MBCT (32) Waitlist (33) VBP NA ET Mindfulness improved the specific executive
(2013) component of backward inhibition but not
competitor rule suppression
Jermann et al. RCT Recurrent 76 MBCT (36) Depressed (20) PMT 3 0.5 No significant difference between MBCT and
(2013) depression No treatment (20) AMT TAU group in shifting or autobiographical
memory task
S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123

Moynihan et al. RCT Older adults MT: 72 MBSR (105) Waitlist (103) TMT NA ET Significantly better executive control
(2013) Control: 74 demonstrated by MBSR compared to waitlist
control
Vega et al. (2014) CT Therapists MT: 30 MBSR (58) Waitlist (43) CPT 2 ET No significant difference was found in
Control: 28 Stroop sustained attention task. MBSR group were
faster and made less error on the Stroop task
compared to controls
Schoenberg et al. RCT ADHD adults 18–65 MBCT (24) Waitlist (20) CPT 3 NA A significant main effect of condition, MBCT
(2013) showed improved task accuracy and a slowing
of reaction time to false alarms from pre-post
testing, but there were no significant
group/time/interaction effects
MacCoon et al. RCT Healthy 19–59 MBSR (29) HEP (25) CPT NA NA No sustained attention differences between
(2014) MBSR versus active control
Type: CT = Controlled trial; RCT = Randomised controlled trial.

Treatment/control: n = sample size; MBCT = Mindfulness based cognitive therapy; MBSR = Mindfulness based stress reduction; TAU = Treatment as usual; HEP = Health enhancement program.
Age: MT = Mindfulness treatment group.
Measures: AMT = Autobiographical memory task; ANT = Attention network test; CombiTVA = Combination theory of visual attention paradigm; CPT = Continuous performance task; d2 = d2 test of attention;
DART = Dual attention to response task; GSP = Go stop paradigm; HT = Hayling task; MACAM = Measure of awareness and coping in autobiographical memory; NAP = Negative affective priming task; ODT = Object
detection task; OSPAN = Operation span; PMT = Plus minus task; RSS = Relapse signature specificity measure; STAN = Spatial and temporal attention network; ST = Switching task; TMT = Trail making test;
VBP = Vertical boxes paradigm; VFT = Verbal fluency task; VCPT = Vigil continuous performance task; WJT = Water-jug task; WLLT = Word list learning task.
T1–T2: T1 = Testing session 1; T2 = Testing session 2; ET = End of treatment; NA = Information not available/reported.
Outcomes: RT = Reaction time.
Fig. 2. Study effect sizes and their confidence intervals for cognitive processes.
using Cohen’s d, were calculated for both significant and non-significant outcomes that were in the predicted direction and
interpretable. Effect sizes were not calculated for analysis that only reported within group changes. The 95% confidence
interval of effect sizes were computed using an online calculator (Wilson, 2001) based on the standard error of the mean
and a critical value (1.96) from the z-distribution, formulas can be found in Rosnow and Rosenthal (2009).
2.4. MBSR/MBCT intervention
The standardised and manualised MBSR/MBCT program, which most studies adhered to, requires patients to attend
weekly group sessions for 8 weeks, usually in groups of up to 12 for MBCT and up to 30 for MBSR. The total group session
time for MBSR is 26 h (2.5 h weekly sessions and one full day class) and for MBCT typically 16 h (2 h weekly sessions, which
may or may not include full day class). Mindfulness exercises include formal sitting meditation, the body scan, yoga, walking
meditation and mindfulness in everyday life. For formal sitting meditation, patients sit in a chair or a cushion on the floor;
maintain a straight back posture and eyes can either be open or closed. Attention is directed to the inhalation and exhalation
of the breath, if attention wanders off, it is brought gently back to the breath. Other objects of focus for sitting meditation
may include sounds and images in the immediate environment and one’s own thoughts and emotions. In the body scan,
patients lie on their back and their attention is guided (by audio recording) sequentially through different parts of the body,
usually beginning with the toes, moving up the leg, down the other leg, torso, arms, neck and head. Patients are instructed to
notice the quality of sensations at each location with openness and nonjudgment. The body scan trains several mindfulness
skills, including awareness of body sensations, deliberate and flexible direction of attention and the acceptance of observed
experiences while yoga stretches and walking meditation train mindfulness of movement. MBCT teaches an additional
exercise called the three-minute breathing space, which is a brief meditation that patients can use at any time to help them
handle difficult situations that may arise in daily life. It consists of three steps: the first involves focusing awareness on the
range of internal experiences; second step focuses attention on the breath; and the third step is to expand awareness to the
whole body. Apart from the three-minute breathing space, other mindfulness exercises in MBCT follow closely the MBSR
program. Participants are required to practise the exercises learnt in class for up to 45 min each day. FM is the main
meditation technique taught during MBCT and MBSR. The 8-week program is designed to foster mindfulness skills; there
are also psychoeducation components where MBSR provides information specific to stress, anxiety and pain while MBCT
focuses on depression and relapse prevention.
3. Results
3.1. Search results
An initial search of databases resulted in 10,962 articles. Screening at title and abstract level and removal of duplicates
resulted in the exclusion of 10,891 articles. This left 71 for full text screening, which further excluded 53, mainly due to
studies not employing a MBSR or MBCT intervention or equivalent (18) or were cross-sectional studies (11). Refer to
Fig. 1 for full list of reasons for excluded studies. Following, a total of 18 studies were included in this systematic review.
3.2. Study characteristics
Studies included participants from both healthy (11 studies) and patient populations (7 studies). Five out of seven patient
groups were depression relapse patients, the other two patient groups consisted of patients with active depression or ADHD.
Healthy participants included a group of therapists training in MBSR (Vega et al., 2014), a group of older adults aged 65-years
and above (Moynihan et al., 2013) and individuals under highly stressful situations, such as predeployment military person-
nel (Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010) and dementia caregivers (Oken et al., 2010).
Eleven studies delivered MBCT as the treatment intervention and 7 studies used MBSR. While the standard MBCT/MBSR
protocol was observed five studies modified the program and/or session length or adapted psychoeducation material to suit
the treatment population. For example, MBCT weekly session time and program length were both shortened to 1.5 instead of
2 h and 7 instead of 8 weeks respectively to accommodate the time constraints of dementia caregivers and to better align to
the program run in the active control arm (Oken et al., 2010). Studies were judged to be following program guidelines if
modifications did not state changes to mindfulness components or caused total group session time to drop below 50% of that
outlined in the program manual: that is a minimum of at least 8 h of MBCT and 10 h for MBSR, not including the full day
class.
All 18 studies were controlled trials, of which, 13 were randomised controlled trials. Control groups consisted of
treatment as usual (TAU, 4 studies), waiting list (8 studies), no treatment (5 studies) or an education program that was
comparable to intervention but without the meditation component (3 studies). Several studies employed more than one
control (4 studies), for instance one study compared MBSR to a no treatment group and a group that received intensive
training in a retreat environment (Jha, Krompinger, & Baime, 2007); another study compared predeployment military
personnel who received MBSR to a no treatment military cohort as well as civilians (Jha et al., 2010). Average time taken
from pre to post-test ranged from immediately following intervention completion to 4 months later. Studies utilised a wide
range of neuropsychological instruments to measure attention, memory and executive functions.
3.3. Effects of MBSR/MBCT on attention
3.3.1. Alerting/sustained attention

Eight studies investigated alerting or sustained attention, but only one found a significant difference between groups on
this subcomponent of attention following intervention (Oken et al., 2010). Studies included both RCTs and CTs and covered
diverse population groups, including depression relapse patients, ADHD adults, healthy participants, dementia caregivers
and therapists. Study sample sizes ranged from small (28) to large (101). The majority delivered an MBSR intervention
(5 out of 8 studies), which may be a reflection of MBSR being the preferred intervention for healthy participants and MBCT
for patient groups. Oken et al.’s (2010) small (n = 28) study was the only one to find a significant outcome for improvement
in alerting in a group of dementia caregivers. While overall, studies did not support improvement of alerting ability from
MBSR/MBCT training the treatment groups did display significant improvements from pre to post test. Effect sizes were
small, d = 0.04–0.25 with confidence intervals that included zero, representing no significant effect. This suggests a trend
toward improvement in alerting form mindfulness but the effect was not large enough to achieve statistical or practical
significance.
3.3.2. Orienting/selective attention

Three studies had outcome measures for orienting/selective attention (Jensen, Vangkilde, Frokjaer, & Hasselbalch, 2012;
Jha et al., 2007; van den Hurk et al., 2012). Jensen et al. found that the MBSR group improved significantly on selective atten-
tion measured by the d2 paper and pencil letter cancellation task compared to both active and incentivised control groups.
However, there was no significant difference between groups on another attentional selectivity measure, the CombiTVA
(Bundesen, 1990), a computer based task where target letters were required to be identified amongst distractors and perfect
selection should be unaffected by number of distractors presented. The other two studies administered the ANT, but only Jha
et al., found a significant difference in orienting ability with the MBSR group performing better than controls. Interestingly,
the control and retreat group (comprised of experienced meditators whom took part in a month long intensive mindfulness
retreat) did not differ in their orienting scores. The authors hypothesised that retreat practise might have fostered the devel-
opment of receptive attention, evidenced by a significant reduction in alerting reaction time in the no cue condition of the
ANT. Furthermore this was correlated with meditation experience, whereby more meditation experience corresponded with
faster reaction times. The authors interpreted this to mean that the retreat participants’ attention was in a more readied state
to detect targets when no information was given, a characteristic of receptive attention. Effects sizes for orienting were
small, d = 0.12 (van den Hurk et al., 2012) and d = 0.19 (Jha et al., 2007) and their 95% confidence intervals included zero,
meaning there were no significant effects. Sample sizes of the three studies were comparable but the two studies that found
statistically significant outcomes for orienting were from healthy population samples, while van den Hurk et al.’s was a
depression relapse patient group with a higher mean age. Cognitive performance is affected by both age and depression,
particularly in sustained and selective attention tasks (Farrin, Hull, Unwin, Wykes, & David, 2003; Gualtieri, Johnson, &
Benedict, 2006). The older the adult and the more severe the depression the greater the cognitive deficit (Chao & Knight,
1997; Farrin et al., 2003). Overall the evidence for improvement in selective attention was divided.
3.3.3. Executive attention

Executive attention was measured by the efficiency of conflict resolution in the ANT by comparing the reaction time and
error rate scores in congruent versus incongruent conditions. Results from three studies (Jha et al., 2007; Oken et al., 2010;
van den Hurk et al., 2012) did not support improvements in executive attention. Studies included both healthy and patient
population groups, two studies were RCTs and post-testing occurred immediately (van den Hurk et al.) following course
completion and up to 3 weeks later (Oken et al.). While Oken’s study suffers from a small sample size, van den Hurk’s
and Jha et al.’s studies consisted of 71 and 51 participants respectively. The effect size for executive attention was small,
d = 0.13 and 0.19 and confidence intervals for effect sizes included zero. There was no evidence to support executive
attention being improved by mindfulness training.
3.4. Effects of MBSR/MBCT on memory
3.4.1. Memory specificity

Four studies used autobiographical memory measures to assess participants’ recall of self-relevant past events. Responses
to memory prompts were rated as either overgeneral/categorical (repeated past events) or specific (past personal events that
have a particular time and place). Depressed individuals tend to recall overgeneralised autobiographical memories, which
reinforce depressive rumination (van Vreeswijk & de Wilde, 2004). Mindfulness might impact on autobiographical memory
by training participants to be attentive to specific aspects of their experiences, facilitating more accurate encoding and retrie-
val, thus improving specific memory. Three studies found significant improvements following mindfulness intervention
(Hargus, Crane, Barnhofer, & Williams, 2010; Heeren, Van Broeck, & Philippot, 2009; Jermann et al., 2013; Williams,
Teasdale, Segal, & Soulsby, 2000). The one study (Jermann et al., 2013) that did not find any difference in memory specificity
was similar in design to one that did (Williams et al., 2000). Both studies were RCTs, which delivered MBCT to depression
relapse patients with at least 2 previous episodes and assessed outcomes using AMT. Sample size was larger in Jermann
et al.’s study (76) compared to William et al.’s (41). However, Jermann’s control groups comprised of a never depressed
and a currently depressed group whereas Williams et al.’s control and intervention group were more comparable; both were
remitted depression patients. While Jermann et al.’s study had a larger sample size, we consider William et al.’s study more
robust given they compared differences of intervention effects within the same population. The effect size was medium
(d = 0.70) for William et al.’s study and small (d = 0.11) for Jermann et al.’s study. One study used the Relapse Signature
Specificity (RSS) measure to assess autobiographical memory (Hargus et al., 2010). This study examined a group of currently
depressed suicidal patients and also found significant memory specificity improvements following intervention. Although
this study suffered from a small sample size (27) the effect size was d = 0.99, a large effect on memory. Overall, evidence
supports MBCT/MBSR treatment improving memory specificity.
3.4.2. Working memory capacity

Only two studies investigated working memory (Jensen et al., 2012; Jha et al., 2010). Jha and colleagues examined male
predeployment military cohorts who were divided into groups that received mindfulness treatment and no treatment con-
trols; there was also a civilian control arm. Mindfulness protected against working memory deterioration in the high practise
group, but did not do so in the low practise group. Working memory was also found to be degraded in the military controls,
but remained stable for the civilian group. Jensen and colleagues investigated a healthy population of students randomly
assigned to MBSR or an active control arm of non-mindfulness stress reduction (NMSR). NMSR was designed to structurally
resemble MBSR in all aspects but without meditation practices and training in a nonjudgmental attitude. For example the
bodyscan was also practised in NMSR but instructions were to feel and relax muscles rather than to become aware and
accept bodily sensations experienced. This study was intriguing in that the aim was to find out what elements of cognitive
functioning attributed to mindfulness training were actually confounded by attentional effort. The study found that visual
working memory capacity was improved and was specific to mindfulness training. Jensen et al.’s study used the CombiATV,
which yields several attentional outcome measures of which visual working memory is one, measured in number of letters
reported. Two studies, using different measures of working memory, found evidence for MBSR effects on working memory in
both a highly stressed and healthy population group. Both studies support mindfulness effects upon working memory
capacity.
3.4.3. Short-term memory

Oken et al. (2010) was the only study that examined short-term memory, in older dementia caregivers aged 45–85 years.
The group were randomised to a shortened MBCT program (10.5 h instead of the standard 16 h of class time), an active
control arm receiving education on self-care, or a respite care waitlist control arm. There were no significant differences
found between the groups on short-term memory as measured by the Word List Learning Task (WLLT), a subscale of the
Alzheimer’s Disease Assessment Scale (Rosen, Mohs, & Davis, 1984). More studies are required to draw conclusions regarding
the effects of mindfulness training on short-term memory.
3.4.4. Effects of MBSR/MBCT on executive function inhibition

There were seven studies that measured inhibition (Anderson, Lau, Segal, & Bishop, 2007; De Raedt et al., 2012;
Greenberg, Reiner, & Meiran, 2013; Heeren et al., 2009; Jensen et al., 2012; Oken et al., 2010; Vega et al., 2014). Of these
studies, three did not find significant gains for inhibition from mindfulness intervention. Heeren and colleagues employed
two measures of inhibition: the Hayling task and the GoStop paradigm. The former measures capacity to inhibit prepotent
verbal responses and the latter assesses ability to inhibit motor behaviour. While the mindfulness group performed signif-
icantly better on the Hayling task, there was no significant difference on the GoStop task. While both tasks used an inhibition
measure, the response modality was different, one required verbal and the other motor inhibition. Mindfulness appeared to
influence inhibition related to verbal rather than motor responding. Three of four studies, which used the Stroop paradigm,
found no significant performance differences between mindfulness groups and controls (Anderson et al., 2007; Oken et al.,
2010; Vega et al., 2014). Vega et al. found significant decreases in error rate at follow-up in the MBSR group, however, this
was offset by longer reaction times, indicating a speed-accuracy trade-off. Mindfulness training appeared to change
test-taking strategy through slower, more accurate responding rather than promoting changes in executive function per
se. Jensen et al., also found that the mindfulness group made fewer errors on incongruent blocks on the Stroop compared
to controls, however, the incentivised control group, who were paid according to performance, also committed fewer errors.
The authors proposed that Stroop performance was confounded by effort on both incongruent error rate and task speed,
concluding that MBSR did not produce unique effects on this measure. Taken together, the effects of mindfulness on the
executive function of inhibition were mixed, positive outcomes were confounded by modality of response, participant
test-taking strategy and motivation.
3.4.4.1. Mental set shifting. A total of 4 studies investigated mental set shifting or switching abilities (Anderson et al., 2007;
Heeren et al., 2009; Jermann et al., 2013; Moynihan et al., 2013). Only Moynihan et al. found significant improvements in the
mindfulness group following intervention using the Trail Making Task (TMT). Heeren et al. also administered the TMT, but
found no difference on this performance measure between their intervention and control groups. Heeren et al.’s study
sample was smaller (36 participants) and younger (mean age 54) compared to Moynihan et al.’s better-powered study
(201 participants) conducted on older adults (mean age 70). The effect size of Moynihan et al.’s study was small, d = 0.17
and 95% confidence interval included zero indicating no significant effect. There was insufficient information provided to
calculate an effect size for Heeren et al.’s study. Given only one study found a statistically significant albeit not a practical
significant effect, there was limited evidence that mindfulness training improved mental set-shifting abilities.
3.4.5. Other cognitive outcomes

3.4.5.1. Cognitive flexibility. Two studies investigated whether MBCT improved cognitive flexibility (Greenberg, Reiner, &
Mairan, 2012; Heeren et al., 2009). Heeren et al. used the Verbal Fluency Task (VFT), while Greenberg employed the Water
Jug Task (WJT). The VFT requires participants to generate as many words related to a given category in a limited time, while
the WJT assesses cognitive flexibility by whether participants could switch to simple ways of solving a water jug problem
after experiences of solving the problem in more complex ways. Both studies recruited healthy participants and found that
mindfulness promoted less rigid responding to the given tasks in the intervention group. Furthermore, a medium effect size
was found for the WJT (d = 0.69) and large effects sizes for the three subscales of the VFT (from d = 1.31–2.18). While these
findings lend preliminary support to cognitive flexibility improvements from mindfulness training, more studies are
required to draw firm conclusions.
3.4.6. Awareness and meta-awareness

Two studies examined whether MBCT improved meta-awareness (Hargus et al., 2010) and meta-cognitive awareness
(Teasdale et al., 2002). Both studies use these terms to refer to the relationship between self and mental content where
low meta-awareness is characterised by an inability to distinguish self from content. The Measure of Awareness and Coping
in the Autobiographical Memory (MACAM) was used to assess patient’s meta-awareness. A score is derived from rating
patient’s responses to imagined vignettes that are mildly depressive. High scores mean the patient is better able to distance
themselves from the scenarios presented and can discriminate their own thoughts and emotions. Both studies found that
MBCT significantly improved meta-awareness scores on the MACAM. Hargus et al.’s study had a small sample size (27) while
Teasdale’s was more robust (87); irrespective of sample size, both studies achieved medium effects sizes r = 0.4 and r = 0.29
respectively.
Two other studies, which did not explicitly set out to investigate awareness, however, concluded from their findings that
mindfulness improves general awareness (Anderson et al., 2007; De Raedt et al., 2012). Anderson and colleagues set out to
investigate the attention regulation component of their proposed operational definition of mindfulness (Bishop et al., 2004).
They found no significant difference between groups on any of the attentional measures employed. However, they found that
higher mindfulness scores were correlated with better object detection ability on an object detection task in the MBSR group
but not the controls. The task assumes that objects placed in inconsistent, and thus, unexpected scenes take longer to detect.
The MBSR group displayed less of this consistency effect, suggestive of an awareness grounded in the present moment and
less influenced by past experiences. Similarly, De Raedt and his colleagues found that following MBCT training, patients
showed less facilitation of negative information as well as less inhibition of positive information on the Negative Affective
Priming Task (NAP). Mindfulness appeared to promote a more balanced and unbiased processing of information. The above
four studies present preliminary evidence that both general awareness and meta-awareness were improved by mindfulness
training.
4. Discussion
The review set out to examine what cognitive abilities would be improved following standardised mindfulness interven-
tions MBSR and MBCT. Contrary to theoretical expectations that mindfulness training would improve sustained, selective
and executive attention, we found no evidence for this. Similarly, there was limited evidence for improvements in executive
functions. However, there was preliminary evidence for working memory capacity and autobiographical memory improve-
ments as well as affects on meta-awareness and cognitive flexibility.
While a previous review found preliminary evidence for attentional change (Chiesa et al., 2011) their positive findings
were mainly from cross-sectional studies comparing long term to novice meditators. Given that our review excluded
cross-sectional studies, which also removed effects from experienced meditators, we found no evidence for improvements
in attention. This finding lends further support to the proposition that attentional changes may require lengthier and/or
more intensive mindfulness training than that offered by MBCT/MBSR (Jha et al., 2007). Another more intriguing explanation
is that mindfulness perhaps fosters a different kind of attention. Mindfulness trains an internally directed attention and may
promote, for example, attention to mental representations. Attention to mental representations also aligns well with our
positive findings in working memory capacity and meta-awareness.
The majority of studies that investigated autobiographical memory found that mindfulness increased specific and/or
decreased overgeneral memories. This is in line with the rationale behind MBCT as a program designed to help patients focus
attention on details of present moment experiences and disengage from negative thought patterns perpetuated by automatic
and categorical thinking. Studies investigating working memory also found that mindfulness improved or was protective of
working memory deterioration, which was consistent with conclusions from a previous review (Chiesa et al., 2011). Given
more consistent positive outcomes related to memory domains, the lack of new studies directed toward investigating this
process is surprising. Future studies should examine memory, particularly working memory, to determine its relationship
to mindfulness.
Evidence for improvement in the executive functions was weak. The subcomponent of Inhibition, which a recent review
claimed to be consistently improved by mindfulness (Gallant, 2016), we found the outcome to be mixed, positive findings
were confounded by participant motivation and test-taking strategy. The role of motivation in test-taking can be quite sub-
stantial, increasing cognitive test scores by as much as one standard deviation (Duckworth, Quinn, Lynam, Loeber, &
Stouthamer-Loeber, 2011). Motivation can be triggered externally through monetary incentives but intrinsic motivation is
thought to be increased by events which satisfy an inherent need for competence and autonomy (Standage, Duda, &
Pensgaard, 2005). Mindfulness teaches participants to become competent in using skills learnt to handle difficult events
encountered both internally and externally, importantly, participants rely on their own abilities to handle these situations
developing both competence and autonomy. Improvements in inhibition and other cognitive abilities could be due to moti-
vation rather than mindfulness, or rather, mindfulness training may have increased motivation which in turn led to
improved cognitive performance. Jensen et al. (2012) controlled for motivation with an incentivised group paid according
to performance. They found that the incentivised group performed just as well if not better than the mindfulness group
on all cognitive measures. However, other studies have claimed that rewarding performance impairs inhibition performance
(Padmala & Pessoa, 2010). Inhibition is a complex function and no doubt the influence of motivation and mindfulness on this
executive function is equally as complex, requiring further investigation to elucidate. The bulk of evidence did not support
improvements for the subcomponent of mental set-shifting from mindfulness intervention and there were no studies that
utilised a specific measure tapping only the monitoring and updating component of executive function. Monitoring and
updating may be especially relevant to mindfulness since monitoring present moment experiences is a key skill taught. This
subcomponent of the executive network supports working memory and is indirectly measured through tests of working
memory capacity, it may be valuable to investigate this component independently in future studies.
While only a total of four studies investigated cognitive flexibility and meta-awareness, all four studies found positive
outcomes from mindfulness treatment. This is a promising direction for future studies to pursue. Cognitive flexibility and
meta-awareness are more global processes, possibly reflecting the interactions of many if not all cognitive domains men-
tioned earlier. It is likely that mindfulness may have influences at the global rather than domain specific level. Previous
researchers have observed that when investigating the two components of mindfulness it was not the attentional but the
awareness component which appeared to be changed through training (Anderson et al., 2007). Cognitive flexibility is typi-
cally assessed using creative (or insight) problem solving tasks, which depend on working memory to direct attention, resist
distraction and navigate through the problem space (Wiley & Jarosz, 2012). Working memory is closely related to awareness,
its subcomponents: input, rehearsal and recall are all reportable events. Reportable events also happens to be the standard
definition of awareness (Baars, 1998). We hypothesise that improvements in working memory capacity may drive changes in
global functioning. However, the precise relationship between working memory capacity, cognitive flexibility, awareness
and meta-awareness requires clarification and how these processes respond to mindfulness training warrants closer
investigation.
Standardised mindfulness interventions were chosen for this review in order to reduce heterogeneity of interventions
when examining cognitive changes derived from mindfulness practise. However, substantial heterogeneity still exists in
population and outcome measures, which we will discuss in turn. Included studies varied widely in age and included both
healthy and patient populations. Cognitive performance is impacted by both age and pathology. Aging is associated with
decline in working memory and attention (Daniels, Toth, & Jacoby, 2006). Pathology, such as depression, impairs executive
function, processing speed and tests demanding attentional effort while memory and reaction time appear to be unaffected
(Gualtieri et al., 2006). Mindfulness training for older adults and patient groups may not impact cognitive abilities to the
same extent or in the same way as it would younger and healthy participants. Gualtieri et al. (2006) found that with
treatment intervention cognitive impairment can be improved in depressed patients, but not normalised, while untreated
depression demonstrated global impairment rather than specific deficits. We hypothesise that mindfulness intervention
effects on aging and pathology might have greater protective rather than enhancement effects. That is, mindfulness may
prevent further cognitive decline instead of markedly improve functioning in these populations. There was evidence for this
in Jha et al.’s (2010) study where mindfulness practise protected against working memory decline in a highly stressed
military cohort. Therefore, non-significant findings in cognitive performance may not mean no effect of intervention in older
and patient groups, particularly when their performance has been compared to healthy samples.
Another source of substantial heterogeneity was the diverse range of neuropsychological tests employed by included
studies to measure cognitive performance. The ANT, CPT and Stroop were amongst the most frequently employed but studies
using these measures have also consistently found no effect from mindfulness training. Given the ANT is an assay of visual
attention, CPT of sustained attention (but also requiring inhibition of motor responding) and the Stroop measures inhibition.
If mindfulness promotes an internally directed attention then visual attention tasks such as the ANT may not probe these
changes, if sustained attention is improved but not motor inhibition then the CPT may mask these improvements, some
researchers have claimed that the Stroop task cannot measure the type of inhibition promoted by mindfulness. The Stroop
measures inhibition of currently competing stimuli whereas mindfulness promotes backward inhibition: the inhibition of
things that have been recently relevant, presumably to better focus on the present moment. Backward inhibition can only
be measured in paradigms that require switching between three or more task sets (Greenberg et al., 2013). Ideally, the
selection of neuropsychological instruments should be guided by theory but currently that theory is lacking and speculation
is rife. Another issue with experimental paradigms is that almost all paradigms used were reaction time based tasks. Several
studies have reported speed accuracy trade-offs (Schoenberg et al., 2013; Vega et al., 2014) where accuracy was achieved at
the expense of speed, or vice versa. Speed-accuracy trade-offs can occur on any test where the outcome measure is
reaction time based and they are also highly susceptible to motivation effects (Jensen et al., 2012). We recommend that
neuropsychological findings should not only report accuracy and speed outcomes but also standardly report reaction time
and error rate variability. Performance variability between early and later test sets is taken to reflect fatigue and resource
depletion. These measures are more likely to be related to skills trained in mindfulness instead of processing speed.
Alternatively, studies could use instruments that are not reaction time based.
4.1. Limitations
Relatively short 8-week interventions may only reveal short-term effects of mindfulness practise on the examined
cognitive processes. There may be additional differences and effects of the practise that develop later on, which this review
does not cover. While we have attempted to remove variability resulting from different mindfulness protocols by only exam-
ining MBSR/MBCT, variability may still arise when programs are modified for different patient groups. Program fidelity and
therapist competence may also be factors that contribute to variability across programs. Most studies mentioned therapist
mindfulness knowledge and experience, but only two studies conducted fidelity checks for therapist adherence to program
curriculum (Jermann et al., 2013; Moynihan et al., 2013). Other factors that may confound cognitive outcomes include
participant’s level of motivation, previous mindfulness training experience and amount of practise completed during and
following intervention. A number of studies did not exclude current meditation practise, nor addressed this factor at
analysis; therefore, there is a possibility of ceiling effects resulting from having already improved on functions being tested.
Variability in the timing of post-intervention observations could have allowed participants to continue to improve and
benefit from continued practise, or vice versa, skills may have degraded if they stopped practicing mindfulness following
intervention. The diverse neuropsychological outcome measures employed by studies also contributed to methodological
variation, compounded by differential analysis and interpretation of subscales. Lastly, there was also the possibility of
publication bias. Clinical trials are required to be registered and research outcomes made publicly available as per the guide-
lines of the Declaration of Helsinki (World Medical Association WMA, 2008). However, this practise is possibly taking effect
only in recent years and there is currently no requirement for registration of non-clinical trials. The presence of unpublished
studies of non-significant results is more than probable and even a small number of which could easily change some of the
conclusions drawn by this review. As more studies of standardised mindfulness interventions using common neuropsycho-
logical measures becomes available, a future review should conduct a meta-analysis of both published and unpublished
studies. Data from unpublished studies could be obtained through clinical trial registration platforms and include thesis
and dissertation studies that have not been published in peer-reviewed journals.
4.2. Implications
If theorised attentional changes do not occur during an 8-week mindfulness intervention, then there are both clinical and
theoretical implications. Brief mindfulness training for treatment of attention disorders may not be appropriate nor
efficacious. Further research is needed to confirm whether longer more intensive mindfulness training is required to change
basic attentional processes. Attention-centric models of mindfulness will need to be revised to account for other cognitive
functions, in particular, working memory capacity. The review raises further questions regarding the specificity of processes,
for instance, what type of attention, which type of inhibition and what kind of memory, are implicated in mindfulness?
Adopting a modular approach to the cognitive system ignores that processes interact and overlap within a dynamic system;
nor can this approach explain global processes, such as awareness and general cognitive flexibility, which may be supported
by many processes. Ideally, a model of mindfulness should be grounded in a cognitive architecture that integrates all the
processes discussed in an overarching framework. We propose that global workspace theory may offer such a framework
(Baars, 1988). It is an integrative cognitive model that importantly explains the function of awareness within cognition.
While only a small number of studies examined meta-awareness, cognitive flexibility and working memory, taken
together these findings offer preliminary support for the rationale behind MBSR/MBCT, which purport to teach patients to
become more aware of their negative thought patterns and switching to a way of responding to experiences that is more
equanimous. Assessments of autobiographical memory indicate that patients improved their awareness of mental content,
strengthened encoding of memory of specific events, and cognitive flexibility improvements afford a wider response option.
This may explain how mindfulness works to reduce rumination in depression relapse patients. However, mindfulness may
not be the only mediator of change, self-compassion is perhaps another (Kuyken et al., 2010). MBSR/MBCT programs involve
various components making it difficult to specify changes due to mindfulness alone. Dismantling studies are a way to
address this issue, they compare MBSR/MBCT to another intervention that resembles MBSR/MBCT but with intent to exclude
the active ingredient of mindfulness, usually this involves removing the meditation practices from the program. The study by
Jensen et al. for example compared MBSR to a non-mindfulness stress reduction program (NMSR) and found that only selec-
tive attention, perceptual threshold and working memory capacity improvements were specific to mindfulness, while most
other cognitive processes were not.
While the evidence for improvements in memory were not substantial, they were nevertheless positive, and studies are
already underway to investigate the potential of mindfulness in treatment of memory disorders caused by injury or a result
of normal aging (Azulay, Smart, Mott, & Cicerone, 2013; Gard, Holzel, & Lazar, 2014). The indicated improvements in working
memory may also mean MBSR/MBCT could be useful in treating psychosis, where working memory and other cognitive func-
tions are particularly impaired, studies are also currently being piloted in this area (Tabak & Granholm, 2014).
4.3. Conclusion
To summarise, this review did not find evidence for the improvement in attention and executive functions through
MBSR/MBCT training. There was preliminary evidence that working memory and autobiographical memory specificity, as
well as more global processes, such as cognitive flexibility and meta-awareness, were improved by MBSR/MBCT. However,
the small number of studies and various methodological challenges prevented firm conclusions to be drawn. These cognitive
processes and their interactions should be the focus of future studies guided by a cognitive framework that describes
mindfulness pathways.
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Consciousness and Cognition 45 (2016) 109–123

Contents lists available at ScienceDirect

Consciousness and Cognition

Cognitive effects of MBSR/MBCT: A systematic review

3.4. Effects of MBSR/MBCT on memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

1.1. Cognitive processes

2.1. Eligibility criteria

2.2. Information source

2.3. Study selection, data extraction and synthesis

Electronic Database Search

Duplicates and articles excluded at

Articles retained for full text

Fig. 1. Flow chart of study selection process.

S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123

S.-A. Lao et al. / Consciousness and Cognition 45 (2016) 109–123

Type: CT = Controlled trial; RCT = Randomised controlled trial.

2.4. MBSR/MBCT intervention

3.1. Search results

3.2. Study characteristics

3.3. Effects of MBSR/MBCT on attention

3.3.1. Alerting/sustained attention

3.3.2. Orienting/selective attention

3.3.3. Executive attention

3.4. Effects of MBSR/MBCT on memory

3.4.1. Memory specificity

3.4.2. Working memory capacity

3.4.3. Short-term memory

3.4.4. Effects of MBSR/MBCT on executive function inhibition

3.4.5. Other cognitive outcomes

3.4.6. Awareness and meta-awareness

Baars, B. J. (1988). A cognitive theory of consciousness. Cambridge: Cambridge University Press.

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