Two focus groups captured first-person accounts of insomnia patients’ experiences learning mindfulness techniques, applying their newly acquired meditation practices and knowledge to improve sleep, and describing personal benefits to sleep and other aspects of their lives. Participants told of falling asleep faster (sleep latency), returning to sleep sooner after night-time awakenings (reduced wake time after sleep onset) and awakening more refreshed. They did not report sleeping longer, but emphasized that being less stressed about their insomnia and better able to cope with occasional episodes of sleeplessness was a major benefit. They also mentioned benefits beyond sleep, including feeling more flexible and having fewer aches and pains, and being more calm and emotionally stable and as result, better able to relate to others and problem-solve at home and at work. The analysis revealed the process of gaining mindfulness skills to be quite challenging and the explanations for the sleep benefits obtained exposed the tightly woven interplay between motivation to make changes and the cognitive and physiologic impacts of those changes. These focus group findings complement and extend our previously published RCT findings of improvement on standardized scales of sleep quality, insomnia symptoms and dysfunctional sleep beliefs, and positive changes in objective and subjectively recorded sleep-wake parameters [19]. This evidence of mindfulness meditation’s benefit to chronic insomnia is important given insomnia’s negative health consequences [1, 8] and huge monetary burden on society [4, 5].
Overall, findings conformed to established models of health behavior change, and lend support to posited mechanisms of mindfulness for insomnia, including reduced arousal, rumination, worry and bed-time verbal over-regulation [10, 11]. Findings were also congruent with the conceptual frameworks and hypothesized mechanisms responsible for the health benefits of mindfulness considered by Brown, Ryan and Creswell [13] and Shapiro et al. [36]: focused attention/awareness, exposure/acceptance, diminished emotional reactivity/increased emotional, cognitive and behavioral flexibility, insight/values clarification and enhanced self-regulation and self-management. There is as yet no consensus or proven mechanisms, but emerging evidence from experimental, clinical and imaging studies to support mechanisms of mindfulness have been recently reviewed by Hölzel et al. [37].
Participants were in the ‘action stage’ of readiness to make health behavior changes [38], as evidenced by enrolling in an insomnia treatment trial, and completing a 4-step screening process. Participants described how the MBSR program affected their sleep routine using words and examples congruent with established theories of health behavior change and the concepts of motivation, self-efficacy, outcome expectancies and social learning as articulated by Bandura [39]. Participants reported greater awareness of their own sleep-related behaviors, becoming more conscious and intentional about sleep behavior, and making some changes to their sleep routine a “priority.” These attitudes and actions are consistent with Brown and Ryan’s explanation of how mindfulness could build capacity to self-regulate behavior and motivate healthy coping in order to attain positive health outcomes [40]. Brown and Ryan noted that mindfulness enables recognition of automatic thoughts and behavior patterns, and is therefore a first step to disengaging from unhealthy habits. Similar to Fredrickson’s broaden and build theory [41], Brown and Ryan note that by being open, curious and attentive, mindful individuals can more effectively gather and interpret factual information to guide their health behaviors.
As participants started to experience improved sleep quality and positive impacts on their daily lives, they realized a strong connection between practice of mindfulness techniques and effects on emotional regulation. Consistent with the mechanisms proposed by Lundh and by Bootzin [10, 11], participants regularly practicing mindful meditation techniques such as sitting meditation, the body scan or yoga reported being able to relax and to maintain feelings of calmness throughout the day, to avoid getting “worked up” or “stressed out” in responding to difficult people or problematic events, and to eliminate the “chatter” or mind-racing that previously impeded falling asleep at night. The inverse was also true: participants noted positive outcomes faded when mindfulness techniques were no longer practiced. These observations are consistent with experimental and physiologic evidence cited by Hölzel et al. [37] supporting emotional regulation as one of the main mechanisms responsible for the health benefits of mindfulness, and also congruent with Benson’s relaxation response [42].
Participants also gained new perspectives, letting go of the success or failure dichotomy of sleep or no sleep, perceiving and experiencing the value of being in the present with attitudes of awareness and acceptance. This led to enhanced self-efficacy, confidence and trust that one can cope with insomnia when it occurs. Experience provided a foundation for re-focusing outcome expectations beyond sleep to a more holistic view of benefits from stress reduction. This was especially important to busy parents, as they became to be more accepting of their situation and able to demonstrate self-compassion.
Our findings support and extend the sleep findings revealed by Morone et al. [23]’s content analysis of daily mindfulness practice logs written by 27 elderly patients during a clinical trial of MBSR for chronic low back pain. These investigators identified improved sleep as a major theme. Mindfulness may have had both direct effects on sleep and indirect effects through pain relief in these patients. Pain and poor sleep are frequently co-morbid; reduced pain and enhanced ability to cope with pain were also major themes in this study. Support for our findings of sleep benefit from “clearing the mind” can be found in verbatims reported in a recently published phenomenology study of the lived experience of MBSR training in 8 women with breast cancer conducted by Weitz et al. [22].
It is interesting to note that Morone et al. [23] termed sleep promotion a negative short-term side effect, because it interfered with maintaining awareness during meditation practice. Although participants in our study mentioned episodes of unintentionally falling asleep during guided meditations in class and during home practice, their reports were touched with irony and humor, and none ascribed a negative valence to this experience. Falling asleep during the body scan is a common occurrence, very familiar to MBSR teachers and described in Full Catastrophe Living [12].
Our findings strongly support adding sleep hygiene information to MBSR in order to optimize treatment impacts for patients with chronic insomnia. Because sleep hygiene education is the standard of care when prescribing sedative hypnotics, our trial protocol required both the MBSR and the pharmacotherapy treatment arms receive 10 minutes of in-person education and a sleep hygiene booklet from study staff (not the MBSR teacher) at the start of the trial. Focus group participants specifically mentioned taking actions to comply with the booklet’s recommendations for adopting a sleep-healthy bedtime routine and using the tips for responding mindfully to sleep problems described by Kabat-Zinn [12]. Having this information readily available was instrumental to those highly motivated to cure their insomnia. Although improved sleep outcomes after MBSR without added sleep hygiene has been reported [17, 18], our focus group findings suggest adding sleep hygiene information may increase treatment effect sizes. It is noteworthy that others have begun to develop a program to integrate mindfulness training with CBT-I, the current gold standard non-pharmacological treatment for chronic insomnia, considering reduced arousal and rumination, and enhanced emotion regulation specific benefits of mindfulness training likely to make CBT-I more potent [43].
Shared experiences and support were also linked to the positive impacts of MBSR in our study. Similar findings have been noted in previous qualitative research about mindfulness training [20, 21, 44]. In Mackenzie et al. [21]’s analysis of interviews and a focus group with 9 cancer patients who were long-time attendees of a MBSR drop-in group, patients described the sense of validation and empowerment that arises from learning MBSR in a room full of people who were also cancer survivors, words echoed by our insomnia patients.
Our findings suggest that social learning is a key element responsible for the effectiveness of MBSR. Participants commented that being part of a group allowed for both observation and discussion. These interactions promoted connections between techniques and beneficial outcomes, and as a result increased motivation, self-efficacy and outcome expectations. Positive comments about the power of learning MBSR within a group were also elicited in focus groups with 8 breast cancer survivors by Dobkin [20]. Overall, these findings emphasize the importance of considering social learning and group effects when evaluating the mechanisms responsible for the treatment impact of the MBSR program.
Our findings about the challenges and successes of adopting a regular mindfulness meditation practice are congruent with the work of Kerr et al. [26] and Carroll et al. [24]. Kerr et al. conducted a longitudinal analysis of home practice diaries completed by 6 healthy women during their MBSR class. They found that each diary showed a trajectory of struggle to build a meditation practice, and levels of success varied. Carroll et al. identified the qualities of MBSR training useful to patients from a content analysis of stories written by patients who learned MBSR practices during a residential treatment program for substance abuse. These qualities were: the diversity of techniques/tools taught, the wide range of situations and settings where the tools can be employed, and the durability of the skills learned. These three factors, termed utility, portability and sustainability, were evident in the reports of our insomnia patients, who spoke of the flexibility of MBSR and told of using mindful approaches in communications and problem-solving at home and at work, and expressed gratitude for having acquired mindfulness skills for lifelong use.
Strengths of the study
Focus groups generated first-hand accounts that provided a rich context for interpreting the results of a RCT of MBSR for chronic insomnia. This qualitative approach exposed factors which were not measured in the trial (e.g., use of sleep hygiene practices, amount of group support and social learning) as strongly linked to perceived sleep benefits. Modifications of the MBSR program that influence these factors are likely to impact the type and extent of sleep outcomes that can be achieved. This report provides information on the sleep impacts of MBSR in a group of patients who met rigorous diagnostic criteria for primary chronic insomnia. Although first-hand reports of the impact of mindfulness training on sleep have been reported in other populations, evidence of changes in this population strongly supports the clinical relevance of MBSR as a promising treatment for insomnia.
Several quality assurance steps were taken to ensure the legitimacy of results [30, 45]. An experienced focus group moderator led both focus groups, using the same questions as prompts. When body language communications, such as nodding heads or shaking heads occurred, the moderator made a verbal comment (e.g., “I see nodding heads, can someone tell me more.”) to ensure that the audio transcript would reflect these sentiments. Credibility was demonstrated when participants agreed that the summaries read aloud by the moderator’s assistants were accurate reflections of the discussion. To promote reliability and reproducibility, transcripts were coded multiple times by two reviewers and inconsistencies resolved iteratively through discussion between these reviewers and a third party.
The characteristics of focus group participants were similar to all participants who completed MBSR in the MVP trial. There were no significant differences between those who did (n = 9) and did not participate (n = 9) in focus groups based on age (means = 46 and 45 years), race (100% white), gender (67% and 89% female) marital status (67% and 57% married), employed at least part-time (67% and 89%), duration of insomnia (means = 7 and 10 years), and number of medications at enrollment (means = 3.7 and 2.6). With respect to education, 44% of both focus group participants and non-participants had completed a graduate degree, and only one person had not attended college. Average baseline scores on self-report sleep scales [46–48] for focus group participants and non-participants were nearly identical (Pittsburgh Sleep Quality Index - 11.4 and 11.6; Insomnia Severity Index – 16.6 and 16.3; Dysfunctional Beliefs and Attitudes about Sleep – 5.4 and 5.7, respectively).
Study limitations
Lack of gender and racial diversity are study limitations. Replication in a more diverse sample could yield additional findings. There is also the potential for selection bias; participants who had a poor experience with MBSR may have been less likely to attend a focus group. However, questionnaires completed by all subjects in the MBSR arm indicated high treatment satisfaction, so the risk of this type of bias is low. There is a risk that focus group participants over-reported benefits in an effort to please their MBSR teacher or to not disappoint the study investigators. To minimize this type of social desirability bias, the moderator and assistant moderators were not previously known to the participants. Directed content analysis may have set up expectations of what would emerge from discussion. This bias is acknowledged, as it stems directly from the purpose of the study (e.g., to learn how MBSR affected sleep), and was manifested through targeted questions posed by the moderator. These questions established boundaries for discussion and guided the initial coding scheme. However, the richness of the discussions which ensued revealed major themes which were not pre-determined, so we do not think this was problematic. However, it should be kept in mind that the subjects in this study completed a MBSR program within the context of a RCT for persons with chronic insomnia. Findings may not generalize to people taking MBSR on their own, to those taking MBSR without ancillary sleep hygiene information or to persons without insomnia. Finally, only two focus groups were held. Ideally, three or more focus groups should have been held to ensure data saturation. However, no new themes emerged in the analysis of the second focus group, which provides some confidence that data saturation was reached.
