The Impact of Mindfulness Meditation Programs on Performance-Related Outcomes: Implications for the U.S. Army

Meditation is the act of focusing one's attention and awareness on a particular subject or experience (Walsh and Shapiro, 2006). Mindfulness meditation is a specific form of meditation practice that involves paying attention, on purpose, to the present moment without judgment (Kabat-Zinn, 2012). Regular mindfulness practice is intended to help reduce attachment to thoughts and emotions that cause distress, foster compassion and well-being, and promote individual agency in decisionmaking (Ludwig and Kabat-Zinn, 2008). Numerous mindfulness-based programs have been developed and studied, but most research has focused on two types of programs: mindfulness-based stress reduction and mindfulness-based cognitive therapy. Among those in the U.S. military, there has been growing interest in the potential benefits of mindfulness meditation, such as promoting attention and concentration, emotion regulation, impulse control, decisionmaking, morale, productivity, and other outcomes associated with better readiness and resilience of individual service members and units.

Mindfulness meditation programs may have a role in supporting service member readiness. Readiness, “the ability of military forces to fight and meet the demands of assigned missions,” is vital to the success of the U.S. armed forces (U.S. Department of Defense, 2017, p. GL-10). Readiness is shaped by team cohesion and individual soldier training, discipline, and fitness (U.S. Army, 2019b). Resilience typically refers to the ability to grow and adapt over time in response to challenges (U.S. Army, 2019a). This ability is shaped by a variety of factors, including individual- and unit-level characteristics. Individual readiness is associated with soldier discipline, training, and preparedness, but individual resilience seems to be associated with personality traits, such as emotional stability, sociability, and conscientiousness (Friborg et al., 2005).

Although studies have suggested that mindfulness-based interventions might be effective in enhancing military readiness and resilience, this has not been rigorously evaluated. This study fills that gap by presenting results from a systematic review of the research on mindfulness meditation as it pertains to outcomes of interest to the U.S. military in general and the U.S. Army specifically. At the Army's request, we conducted a systematic review and meta-analyses of published literature on mindfulness programs, with a focus on outcomes relevant to soldier readiness and resilience in nonclinical adults. We supplemented our systematic review by examining how mindfulness meditation could support stress management and exploring characteristics of selected mindfulness programs. The goal was to develop recommendations for mindfulness meditation programs for soldiers, should the Army choose to implement such programs in the future.

Methods

Any systematic literature review must be guided by one or more research questions. In collaboration with the Army, we developed a single overriding question that captured 13 outcomes that are potentially relevant to soldiers’ readiness and performance and that are priorities for the Army. We also generated two subquestions that focused on whether the effects of mindfulness programs differ between military and civilian populations (1a) and by program components (1b).

• Key Question 1: What is the effect of mindfulness programs on attention/concentration; decisionmaking; emotion regulation; impulse control/impulsivity; and work-related outcomes pertaining to absenteeism, accidents, communication skills, interpersonal conflict, morale, productivity, social support, teamwork, and turnover among nonclinical adults (both civilian and military populations)?
  • Key Question 1a: Do the effects of mindfulness programs differ for military versus civilian populations?
  • Key Question 1b: Do the effects of mindfulness programs differ by program characteristics, such as the type of mindfulness practice (e.g., mindfulness-based stress reduction), exposure (e.g., length or intensity of the program), or delivery format (e.g., in person, online, mobile app)?

We screened 5,900 unique publications and ultimately identified 104 articles, representing 106 studies, that met the inclusion and exclusion criteria for our systematic review. We followed guidelines for conducting high-quality systematic reviews. We assessed the quality of each study, the quality of the body of evidence for each outcome, and potential publication bias. Whenever possible, we grouped similar studies based on characteristics that might affect the estimated effectiveness of mindfulness, including the type of comparison group used in the study and whether the intervention was a mindfulness program or an analogue. When sufficient studies were available for a given outcome, we conducted a meta-analysis to pool results and generate an estimated effect size. Guided by content-area experts and previous meta-analyses, we classified the attention and emotion regulation outcomes into multiple suboutcomes and did separate meta-analyses on each suboutcome.¹

The quality of the existing literature limited our ability to draw strong conclusions about the effect of mindfulness programs for our target outcomes. Most studies in the systematic review were of poor overall quality with small numbers of participants, and most outcomes of interest to the Army were reported by only a small number of studies. Few of the studies focused on military populations, and although we included only studies of military-age populations, program effects—and, thus, best practices—might differ between civilian and military populations. Most studies assessed outcomes immediately after the intervention, and few studies included longer-term follow-up assessments. This limited our ability to identify the potential sustained effects of mindfulness programs.

The Army also aims to support the resilience of soldiers’ family members, so we supplemented our systematic review with a brief review of recent (published between 2015 and May 2021) systematic reviews examining the effects of mindfulness meditation on three high-priority outcomes that are relevant to both soldiers and their adult family members: stress, parenting, and relationship problems.

Implementing Mindfulness Meditation Programs in the Army

If Army leaders opt to expand the implementation of mindfulness programs, they must consider best practices in order to help ensure the programs’ success. Mindfulness meditation programs vary considerably in their characteristics, such as length and timing, individual or group format, and whether they include virtual delivery. This variability makes it challenging for the Army to know which program (or programs) to implement and how. Unfortunately, the existing literature does not provide clear guidance on best practices for implementing mindfulness meditation programs. To fill this gap, we supplemented our systematic review by exploring the characteristics of four mindfulness programs: mindfulness-based stress reduction, mindfulness-based cognitive therapy, mindfulness-based mind fitness training, and mindfulness-based attention training; the latter two were developed specifically for service members. We used descriptions from the program developers to compare key characteristics of these programs that the Army might consider when implementing its own mindfulness meditation programs for soldiers. It will be important for the Army to consider factors that make service members and military settings unique, and the success of mindfulness meditation programs could hinge on, for example, when they are delivered (e.g., while soldiers are on duty versus off duty) and the degree of commander involvement.

Key Findings

We found beneficial effects of mindfulness programs for some aspects of attention and emotion regulation, along with impulsivity and work-related morale and social support, but no apparent benefit for productivity. The strength of the evidence was generally low, and the strength of the best evidence was only moderate. We identified too few studies to conduct meta-analyses for decisionmaking, work-related communication skills, and work-related teamwork, and there were no studies on work-related absenteeism, accidents, interpersonal conflict, or turnover. Table 1 summarizes the high-level findings from our systematic review.

Outcome	Effect of Mindfulness Programs	Strength of the Evidence	Number of Studies
Attention
Executive attention accuracy (resolving conflicts or solving problems)	Potential small beneficial effect	Moderate	23 studies
Self-perception of attention and reaction time	No effect	Very low to moderate*	4–25 studies (per suboutcome)
Decisionmaking	Unknown	Very low	Too few studies to conduct pooled analyses
Emotion regulation
Reappraisal, suppression, and emotional interference	Potential small to medium beneficial effect	Low	Fewer than 5 studies (per suboutcome)
General emotion regulation and change in negative mood	No effect	Very low to low*	Fewer than 5 studies (per suboutcome)
Impulsivity	Potential small beneficial effect	Moderate	Fewer than 5 studies
Work-related outcomes
Absenteeism, accidents, interpersonal conflict, and turnover	Unknown	Very low	No studies
Communication skills and teamwork	Unknown	Very low	Too few studies to conduct pooled analyses
Morale	Potential small beneficial effect	Moderate	Fewer than 5 studies
Productivity	No effect	Low	Fewer than 5 studies
Social support	Potential medium beneficial effect	Low	Fewer than 5 studies

NOTE: Shaded rows indicate outcomes for which there was evidence of a potential effect of mindfulness programs, although, in many cases, the strength of evidence was low.

* These ranges reflect grades for different suboutcomes. Each individual suboutcome had a grade of very low, low, or moderate.

Mindfulness May Improve Some Aspects of Attention and Emotion Regulation, Impulsivity, and Work-Related Morale and Social Support

Our analyses indicated that mindfulness may improve accuracy on attention tests that involve resolving conflicts or solving problems (executive attention) but not reaction time or self-perception of attention. Regarding emotion regulation, we found that mindfulness may increase the use of a specific adaptive emotion regulation strategy (reappraisal), decrease the use of a specific maladaptive emotion regulation strategy (suppression), and reduce the extent to which negative emotions slow down reaction time on attention tests (emotional interference). Our analyses did not suggest that mindfulness improves general emotion regulation ability or that it decreases negative mood intensity. Our analyses suggested that mindfulness may have a small beneficial effect on impulsivity, and the strength of evidence for this finding was moderate. Furthermore, our analyses showed a small beneficial effect of mindfulness on morale, and our confidence in this conclusion was also moderate. For social support, our analyses showed a medium beneficial effect, but the strength of this evidence was low.

The Available Evidence Does Not Suggest That Mindfulness Improves Other Outcomes of Interest to the Army

Across the 13 target outcomes in our systematic review, there was inadequate evidence to suggest that mindfulness had an effect on eight of the outcomes; however, future research could strengthen the evidence for these outcomes. Our analyses indicated that mindfulness programs did not have a significant impact on productivity. For three outcomes (decisionmaking, communication skills, and teamwork), we identified relevant studies but were not able to conduct pooled analyses. Finally, we did not find any relevant studies for four target outcomes (absenteeism, accidents, interpersonal conflict, and turnover).

Mindfulness Programs Reduce Stress and May Reduce Parental Stress, Which Could Benefit Army Families

Numerous systematic reviews suggest that mindfulness programs can be effective in reducing stress in nonclinical populations. Our supplementary review of recent systematic reviews indicated that mindfulness programs significantly decreased self-reported stress, were associated with some modest improvements in systolic blood pressure and heart rate, and may promote small to medium improvements on other select physiological measures of job stress (e.g., cortisol levels, heart rate variability) (Querstret et al., 2020; Pascoe et al., 2017; Heckenberg et al., 2018). Taken together, the studies provide robust support for the positive impact of mindfulness on general stress reduction. Studies of parenting stress suggest that mindfulness programs could benefit both parent and child outcomes. One systematic review of studies on mindful parenting programs indicated small to moderate improvements in parenting stress and symptoms associated with externalizing disorders in children (Townshend et al., 2016). Another identified a link between improvements in parental stress and child and youth outcomes, even when only the parents participated in a mindfulness program (Burgdorf, Szabó, and Abbott, 2019). However, none of these studies focused on military populations, and they often had small samples or were of low quality.

More Research Is Needed to Identify Best Practices for Implementing Mindfulness Programs in the Military

Although there is evidence to support the efficacy of mindfulness programs to reduce stress and anxiety (Chiesa, 2009; Khoury et al., 2015; Sharma and Rush, 2014; Fjorback et al., 2011), the Army will need to consider several factors before implementing such programs. However, the research literature on mindfulness programs in real-world military settings is scant, and clear guidance about best practices is not yet available. We identified three categories of program characteristics for the Army to consider: program goal, target audience, and program structure and design. Mindfulness-based mind fitness training and mindfulness-based attention training have been used with military populations, but research support for these programs is more limited than it is for mindfulness-based stress reduction. With further study, it is possible that these programs will provide greater clarity on best practices for mindfulness meditation program implementation in military contexts.

We identified possible considerations for implementing mindfulness programs targeting military populations. First, it may be important to consider scheduling constraints and other logistical challenges that service members face, particularly when selecting the program structure, duration, and modality. Second, it may be helpful to design programs with the hierarchical structure of the military in mind. Finally, it may be beneficial to consider the importance of the trainer. Lessons learned from resilience training programs suggest that military personnel might find programs delivered by a fellow service member more acceptable and relevant (Roski et al., 2019). However, more research is needed to establish standards for trainer competencies and determine how the quality of the trainer might affect outcomes for mindfulness program participants (Crane et al., 2012; Ruijgrok-Lupton, Crane, and Dorjee, 2018; Khoury et al., 2013).

Recommendations

After considering our findings, we identified two recommendations to inform the Army's decisionmaking process regarding mindfulness meditation programs for soldiers.

Recommendation 1. Conduct High-Quality Evaluations of Mindfulness Meditation with Soldiers

Our systematic review suggests that mindfulness meditation could have an impact on a variety of outcomes related to soldier performance, including aspects of attention, emotion regulation, impulsivity, and work-related morale and social support. But, because of the generally small effect sizes that we identified and the low levels of evidence for these effects, there is not strong support for implementing mindfulness meditation programs Army-wide at this time. However, we did identify robust evidence that such programs have a medium-sized effect on reducing stress among civilian populations. It is possible that the Army will choose to implement mindfulness programs to support stress management and that such programs could have additional benefits on other performance-related outcomes, such as morale, social support, and emotion regulation. Even small effects could be beneficial when implemented across a large proportion of the force.

However, we recommend that the Army conduct high-quality evaluations of mindfulness meditation before pursuing large-scale implementation. Such evaluations could help fill the evidence gap related to the impact of mindfulness meditation in military populations, identify best practices for implementation, and clarify the effects on individual and unit readiness and resilience. We identified seven studies that were funded by the U.S. Army or the Department of Defense and that met our inclusion criteria (all evaluating mindfulness-based mind fitness training or mindfulness-based attention training), and, for all seven, we identified major concerns with the quality of the design or implementation that could have biased the results. This study provides explicit recommendations for designing studies of the rigorous quality needed to ensure that programs are effective and feasible before attempting large-scale implementation.

Recommendation 2. Assess the Impact of Mindfulness Meditation on Military Families

Although we found robust evidence that mindfulness meditation reduces general stress and promising evidence that it could reduce parental stress, we did not identify any systematic reviews addressing relationship problems or other aspects of parenting. Further research is needed to rigorously assess the impact of mindfulness meditation on military families—with a focus on outcomes that are relevant to this population, such as relationship problems, parenting, and child outcomes. Additional studies or pilot evaluations of these interventions would provide additional guidance on whether they should be made more widely available. Decreasing stress and improving the well-being of military families is a high priority for the Army Resilience Directorate and the Department of Defense overall, and programs that enhance the well-being and resilience of families can have a significant impact on military readiness.