García‑Campayo et al. Trials (2023) 24:125 Trials https://doi.org/10.1186/s13063-023-07151-0 STUDY PROTOCOL Open Access Effectiveness of four deconstructive meditative practices on well‑being and self‑deconstruction: study protocol for an exploratory randomized controlled trial Javier García‑Campayo1,2, Rinchen Hijar‑Aguinaga2, Yolanda López‑Del‑Hoyo1,3,4*, Rosa Magallón‑Botaya1,5,6, Selene Fernández‑Martínez1, Alberto Barceló‑Soler1,7, Joaquim Soler‑Ribaudi8,9,10 and Jesus Montero‑Marin11,12,13 Abstract Introduction The efficacy of interventions based on mindfulness and compassion has been demonstrated in both clinical and general population, and in different social contexts. These interventions include so-called attentional and constructive meditation practices, respectively. However, there is a third group, known as deconstructive meditation practices, which has not been scientifically studied. Deconstructive practices aim to undo maladaptive cognitive pat‑ terns and generate knowledge about internal models of oneself, others and the world. Although there are theoretical and philosophical studies on the origin of addiction to the self or on the mechanisms of action associated with the deconstruction of the self, there are no randomized controlled trials evaluating these techniques in either a healthy population or clinical samples. This study aims to evaluate the effect of three deconstructive techniques by compar‑ ing them to mindfulness in the general population. Methods and analysis A randomized controlled clinical trial will be conducted with about 240 participants allo‑ cated to four groups: (a) mindful breathing, (b) prostrations, according to Tibetan Buddhist tradition; (c) the Koan Mu, according to Zen Buddhist tradition; and (d) the mirror exercise, according to Toltec tradition. The primary outcome will be the qualities of the non-dual experience and spiritual awakening, measured by the Nondual Embodiment Thematic Inventory, assessed at pre- and post-treatment and at 3- and 6-month follow-ups. Other outcomes will be mindfulness, happiness, compassion, affectivity and altered state of consciousness. Quantitative data will be com‑ pared using mixed-effects linear regression models, and qualitative data will be analysed through thematic analysis and using the constant comparative method from grounded theory. Ethics and dissemination Approval was obtained from the Research Ethics Committee of Aragon, Spain. The results will be submitted to peer-reviewed specialized journals, and brief reports will be sent to participants on request. Trial registration ClinicalTrials.gov NCT05317754. Registered on August 2,2022. Keywords Deconstructive meditation practices, Mindfulness, Randomized controlled trial, Wellbeing, Self- deconstruction, General population *Correspondence: Yolanda López‑Del‑Hoyo ylopez.iacs@gmail.com Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://​creat​iveco​mmons.​org/​licen​ses/​by/4.​0/. The Creative Commons Public Domain Dedication waiver (http://​creat​iveco​ mmons.​org/​publi​cdoma​in/​zero/1.​0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. García‑Campayo et al. Trials (2023) 24:125 Page 2 of 15 Background In contrast with the great amount of scientific research According to Kabat-Zinn [1], “mindfulness is the prac- on attentional and constructive meditations, decon- tice of purposely bringing one’s attention to experiences structive meditation types have received little attention occurring in the present moment without judgment”, a from neuroscientists [12]. This is surprising, given that skill that can be developed through attentional medita- deconstruction of the self forms the core of meditative tion. Since he started to teach mindfulness in 1979 at a practices in a number of major Eastern contemplative hospital associated with the University of Massachusetts, traditions, such as Buddhism, Vedanta Advaita and Tao- mindfulness has demonstrated efficacy for increasing ism [13]. In fact, there is a trend away from the stringent psychological and physical well-being in healthy adults in frame of mindfulness and meditation to a wider concept general [2], and in specific environments such as clinical of contemplative sciences [14], in which deconstruction settings [3], the workplace [4] and schools [5, 6]. of the ego would be one of the most important goals. In the early years of the twenty-first century, another Moreover, evolutionary social psychology has also kind of meditative technique, known as compassion, shown concern for the fact that human beings have an emerged in the West. Goetz et al. [7] defined compassion evolved capacity for self-awareness, along with a propen- as the feeling that arises when witnessing another’s suf- sity to focus primarily on their own welfare. Although fering and motivates a subsequent desire to help. System- this focus has clear adaptive functions, such as physi- atic reviews and meta-analyses indicate that compassion cal preservation and self-regulation, this pervasive egoic has an important role to play in the treatment of disor- mindset, in an increasingly crowded and interdependent ders such as depression and anxiety and the improve- world, is associated with high personal and societal costs. ment of well-being in healthy individuals [8–10]. This is the basis of rising interest in hypo-egoic phenom- The large number of meditation types and the great ena in psychology [15]. differences that set them apart led authors such as Dahl Despite the publication of a number of theoretical and et al. [11] to develop a now widely used classification, philosophical papers on the origin of ego addiction [16] based on cognitive neuroscience and clinical psychology, and the mechanisms of action associated with decon- which comprises three groups of meditation types: struction of the ego [17, 18], no randomized controlled trials have been conducted to assess these techniques (a) Attentional meditations. These types train a variety either in a healthy population or in clinical samples. of processes related to the regulation of attention, This is the first exploratory randomized controlled trial with mindfulness being the best-known type in this to evaluate the effect of several different deconstruc- group. The authors propose that a shared character- tive meditation techniques on healthy individuals. Our istic of all these meditation practices is the system- hypothesis is that all four interventions would be effec- atic training of the capacity to intentionally initiate, tive for decreasing the ego perspective in the general direct and/or sustain these attentional processes population, and more specifically, that the three specific while strengthening the ability to be aware of the deconstructive interventions would be more effective processes of thinking, feeling and perceiving. than the control attentional mindfulness technique. (b) Constructive meditation. These types include a variety of meditation practices that strengthen psychological patterns that foster well-being. In Methods contrast to attentional practices, which often focus Study design on simply monitoring cognitive and affective pat- Participants will be randomly allocated to a four-armed terns, constructive meditation involves systemati- randomized controlled clinical trial with four condi- cally altering the content of thoughts and emotions. tions: (a) standard mindfulness alone, using the mind- Compassion would be the most widely studied ful breathing technique mindfulness of breathing, which technique within this group. will be considered the control condition; (b) prostrations, (c) Deconstructive meditation. These types aim to according to Tibetan Buddhist tradition; (c) the Koan undo maladaptive cognitive patterns by exploring Mu, according to Zen Buddhist tradition; and (d) the mir- the dynamics of perception, emotion and cognition, ror exercise, according to Toltec tradition. They will be and by generating insights into one’s internal mod- assessed at pre- and post-treatment and 3- and 6-month els of the self, others and the world. The authors follow-ups. This study will conform to the Consolidated suggest that a central mechanism in this kind of Standards of Reporting Trials (CONSORT) statement meditation is self-inquiry, which is the process of (http://​www.​conso​rt-​state​ment.​org) [19] for reporting investigating the dynamics and nature of conscious trials and the Standard Protocol Items: Recommenda- experience. tions for Intervention Trials (SPIRIT) guidelines [20] for García‑Campayo et al. Trials (2023) 24:125 Page 3 of 15 clinical trial protocols. The study’s trial registration num- consistent or not with mood and suicide risk; and (c) tak- ber is ClinicalTrials.gov NCT05317754. ing any psychiatric medication. Study population, recruitment and eligibility criteria Sample size This randomized controlled clinical trial will be con- The sample size estimation was based on testing whether ducted within the Master’s in Mindfulness programme the trend in the pre-to-post change would be different and supervised by the Chair of Contemplative Sciences between the intervention groups. Firstly, we assumed of the University of Zaragoza. Participants will be healthy that mindfulness practice would be able to present small adults recruited online from the general population of pre-post effects on deconstruction of the ego, according Spain and Spanish-speaking countries. to the previous studies on this subject [21]. For this rea- The participants will be recruited through several dif- son, we assumed a common mean (SD) at baseline of 65 ferent social media (e.g. Twitter, Facebook and LinkedIn) in the Nondual Embodiment Thematic Inventory [22], and university newsletters (specifically, as part of the and a mean at post-test of 69 and 75 in the mindfulness university’s Master’s in Mindfulness programme). When group and the other deconstructive practices, respec- participants contact the research team, the study will be tively. This assumes a pre-post standardized difference in explained by one of the researchers, and if they agree to the mindfulness group of d = 0.3, a pre-post standardized participate, an informed consent form containing the difference in any of the other deconstructive practices of main aim of the study, the name of the study leader and d = 0.8, and a post-test standardized difference between contact details will be provided. In order to prevent a the mindfulness group and any of the other arms of high dropout rate, the research team will emphasize that d = 0.5, which corresponds to the average effect in some once the study is completed, participants will be able to exploratory studies conducted by our group [23] and is access the other study interventions, as well as being able aligned with the 0.5 standard deviation criterion consid- to request a report with the results of the study. ered clinically relevant [22]. Using a 1:1:1:1 ratio, assum- Participants will subsequently undergo a clinical inter- ing a 5% significance level and a statistical power of 80%, view and fill out the paper-and-pencil screening survey and applying the Hotelling-Lawley Trace approach for describing their sociodemographic and clinical char- the general linear model, which supports the inclusion of acteristics. This first data collection and screening step baseline covariates and coincides with the Wald test for will be performed by specially trained psychologists for the general linear mixed model [24], we will need a total the purpose of assessing whether participants meet the of 240 participants, and thus 60 subjects in each group. eligibility criteria for inclusion in the study. When a par- ticipant is found to meet the inclusion criteria, an inde- Randomization and blinding pendent researcher will implement randomization by Participants who meet the inclusion criteria for the telephone to avoid predictability Flowcharts giving an study will receive a code from the screening assessors in overview of the study design and the study timeline are order to preserve their confidentiality. An independent summarized in Figs. 1 and 2, respectively. researcher unaware of the study characteristics will per- Inclusion criteria will be as follows: (a) older than form the randomization process. In order to randomly 18 years of age; (b) no psychiatric diagnosis (self- allocate the participants to one of the four previously reported); (c) more than 1 year’s experience of daily described conditions, a computer-generated random meditation practice, (d) having a computer and Internet number sequence (https://​www.​rando​mizer.​org) will connection at home; (e) being able to read and under- be used by means of a simple allocation strategy. After stand the Spanish language; and (f ) willingness to partici- the participants are informed of the study characteris- pate in the study and sign the written informed consent tics, they will agree to participate before random alloca- form. Exclusion criteria include the following: (a) any tion and without knowing the condition to which they diagnosis of a disease that may affect the central nerv- will be allocated. The researcher who administers base- ous system (pathological condition affecting the brain, line assessments will be blind to the participants’ prac- traumatic brain injury, dementia) or other psychiatric tice group. This researcher will be different from the diagnoses or acute psychiatric illnesses (severe range of one—also blinded—who administers the other measures depression, substance dependence or abuse, history of throughout the study. Participants will complete all the schizophrenia or other psychotic disorders, eating dis- measures online. Participants will not be blind to the orders), except for anxiety disorder; (b) any medical, intervention condition for practical reasons, but they will infectious or degenerative disease that may affect mood; be blind at the time of the first assessment (pre-interven- presence of delusional ideas; and hallucinations tion). The person responsible for carrying out the data García‑Campayo et al. Trials (2023) 24:125 Page 4 of 15 Fig. 1 Study flowchart analysis will not know the type of intervention that each Interventions participant has carried out. Four different meditative interventions will be assessed: (a) mindful breathing, which will be considered the control condition; (b) prostrations, according to Data management Tibetan Buddhist tradition, (c) The Koan Mu, according A psychologist from the research team will manage and to Zen Buddhist tradition, and (d) the mirror exercise, monitor the data. All study information will be kept in according to Toltec tradition. All participants in the secure drawers with limited access. Electronic data files four arms will receive these general instructions: will be password protected. Participant codes and per- sonal information will be stored in a separate password- - Formal practice should take 30–60 min/day. It can protected file. The data will be stored for 5 years after be divided into as many as 4 sessions/day at times the end of the study, and only the study investigators led of participants’ choosing, but the recommended by the principal investigator will have access to the final times are after waking up in the morning and data set. Results of the study will be presented through before going to bed at night. peer-reviewed publications and conferences. In addition, - There is no limit to the number of times informal participants who request it will receive a report with the practice can be performed during the day. final results. García‑Campayo et al. Trials (2023) 24:125 Page 5 of 15 Fig. 2 Schedule of enrolment, interventions and assessments - Use of a diary is necessary to record the time and their choosing, but this information must always be duration of all formal and informal practices. recorded in their diary. - The intervention will have a duration of 60 days. During this period, participants are to take part Specific instructions for every intervention: only in the intervention to which they have been randomized and no other. After this period of time (1) Mindful breathing (I): paying attention to your and during the follow-up, participants will be able breathing to practise any kind of meditation and at times of García‑Campayo et al. Trials (2023) 24:125 Page 6 of 15 • Step 1. Assume a comfortable sitting posture, allow- You can feel the connection with your inhaling and ing the body slowly settle into position. You can take exhaling, instant by instant, perceiving your how one or two deep breaths to draw your attention to you are anchored by your breathing and the feel- your body. Then very gradually begin to notice your ing of balance. Slowly, when you feel ready, you can bodily sensations at that time (for example, your bring the practice to an end. body making contact with the floor, mat or chair; the temperature of your skin; general sensations), until Mindful breathing (II): paying attention to your body you come to include all the sensations of your entire (Between steps 5 and 6) body in general. After 10–15 min of mindful breathing, as previ- • Step 2. Very slowly start to become aware of your ously described, allow your awareness to expand to all breathing. You can focus your attention on the move- the sensations of your whole body. Gradually change ments of your chest or abdomen as you breathe in the focus of your attention by moving away from your and out, or on the sensations of the air entering and breathing and becoming aware of the sensation of your exiting your nostrils as you breathe. It is important whole body and of how your sensations are continu- to follow the natural flow of your breathing, without ously changing. You could feel your breathing through- trying to change it, simply observing and being aware out your body, as if it were breathing. of it, accepting what is happening in the present. Besides your whole body and the sensations of • Step 3. Your mind will eventually begin to wander. breathing, you can include the sensations of the parts of It is quite normal for your attention to be repeatedly your body in contact with the floor, chair, clothes or any distracted from your breathing and bodily sensations. other object. This is not a problem. When you become aware of a If your mind wanders, which is its usual behaviour, certain distraction arising in your mind—whether in be happy that you have become aware of this, observe the form of a sensation, thought, feeling or sudden where your mind has gone, and draw it back kindly to impulse—simply be aware that the mind is wander- the sensation of your whole body. ing, and allow the distractions to pass kindly, without If you experience unpleasant or painful sensations, fol- becoming upset with yourself or judging them, and low the instructions previously given in steps 4 and 5. then redirect your attention to your breathing and When you are ready, you can bring the session to a your whole body. close as described in step 6. • Step 4. You may experience intense sensations, such Mindful breathing (iii): paying attention to sounds, as pain in a part of your body, and you will find that thoughts and emotions your attention is repeatedly drawn away by such sen- (Between steps 5 and 6) sations from your chosen anchor (breathing or body). • Sounds. Turn your attention to sounds. Get a feel- You may want to take advantage of this moment to ing for where they come from, what their character- deliberately decide to change your posture or to keep istics are, how they appear and disappear, where in it and change the focus of your attention to those the space around you the come from (above, below, more intense sensations. If you choose this option, besides, in front or behind you). you can explore the sensations in more detail: How do you feel those sensations? Where? Do they change You need not follow the sounds; they happen without intensity or location over time? The aim is not to you having to seek them out. Do not think about them or think about these things but what you feel. You can label them; only experience them as simple auditory sen- use your breathing to direct your attention to the sations (i.e. pay attention to their tone, pitch, volume and area, by “breathing it”, as you would when practising duration). Even if you hear words in your own language, body scan meditation. do not think about their meaning; listen to them as if they • Step 5. Whenever your attention is drawn away by were in a different language. Be aware of the more and the intensity of the physical sensations or when your less intense sounds, and of the space between sounds and attention is distracted, you can reconnect with the pre- of silence. sent by directing your awareness to the movement of If your attention wanders, acknowledge kindly where it your breathing or the sensations of your whole body. has gone and bring it back to the sounds. This will hap- Your awareness can then be expanded to take in all the pen repeatedly. sensations coming from all parts of your body. Attention to sounds is a very powerful practice for • Step 6. Before the session ends, turn your atten- expanding your awareness. You can continue with tion back to the sensations of abdominal breathing. mindful breathing and move on to mindfulness of García‑Campayo et al. Trials (2023) 24:125 Page 7 of 15 thoughts and sensations, or this can be a separate prac- According to Patrul Rinpoche, as explained in his tice on its own. best-known book Words of My Perfect Teacher, prostra- • Thoughts and emotions. Just as you have focused tions are the antidote to pride, and it is important to your attention on sounds, which are phenomena combine the body, words and mind when performing beyond your control and appearing in your mind them [26]. Therefore, the goals of this practice are to autonomously, the thoughts that occur during med- dissolve pride, purify the physical, verbal and mental itation (unlike when you think voluntarily) are also dimensions, and unify and integrate these three spheres beyond your control; they simply appear. Observe of the person. the process of how they appear, how they remain in Performing prostrations: your mental space, and how they disappear in a few The practice begins with visualization. In this con- seconds, without you having to do anything. You text, we have reduced it to the essentials in order to can even perceive the side of your mind in which facilitate the practice. Visualize Shakyamuni Buddha in they appear: from above, below, on the right or on front of you, feeling that he is truly present. Visualize the left. Do not try to stop them from appearing, all beings beside you, feeling that they are not essen- speed up the process or wish them to disappear. Let tially different from you and that they are prostrated them follow their natural process, as you did with together with you. You should visualize the images the sounds. with the consistency of a rainbow or hologram, not as solid entities. This should not diminish the feeling of Some people find it useful to imagine their mental space their presence. as a cinema screen and observe how thoughts appear on In the physical aspect, you start by cupping your it, using the same process previously described. Another hands to form the shape of a closed lotus flower that popular metaphor is to imagine your mind as the endless is about to open, leaving an empty space between blue sky and thoughts as clouds that appear in it. them. The palms should not be pressed together with- out leaving a space, nor should they only be joined at • Attention without an object. To finish it, you might the fingertips.2 Place your cupped hands on your head want to let go of the object on which you were focus- first, then at your throat and, finally, at your heart to ing your attention (breathing, sounds, thoughts) and purify the corruptions of the body (e.g. the actions allow your field of awareness expand to include eve- of killing, stealing or harmful sexual conduct), the rything that appears in your mind and body. Simply words (e.g. lying, causing arguments, harmful words try to relax your awareness, without anchoring it. Do or deceitfulness) and the mind (e.g. envy or covetous- not latch on to anything or want anything; simply ness, wishing harm on others). Next, touch the floor observe what is happening with equanimity. When with five points of the body: the forehead, both palms you are ready, you can bring the session to a close (as of the hands and both knees.2 Once you have finished described in step 6). stretching out your body fully on the floor, you can raise your cupped hands over your head. Afterwards, As an informal practice, focus your attention on your when you stand up again, you straighten your body breathing whenever you can during the day. completely, cupping your hands again. Continue to perform prostrations in this way. (2) Postrations With regard to the words, each lineage recites their own verses, which in this case have been adapted to a The term “prostration” is generally used to describe an simplified formula: “All beings and I prostrate ourselves act of homage and respect. In Tibetan Buddhism, which before Buddha, who has transcended suffering. May is the most widespread form of Vajrayana Buddhism, the all beings be able to transcend suffering.” This is recited tantric path begins with special, or extraordinary, pre- while performing each prostration. liminary actions. These special preliminary actions are As the practice progresses, you can visualize how rays divided into five parts. The first of these is the Refuge of light emanate from Buddha to tough your forehead, practice, which is typically accompanied by prostrations. throat and heart, purifying your body, words and mind. As explained by Kalu Rinpoche in his book Foundations Quality is more important than quantity, the main of Tibetan Buddhism, prostrations are the physical ele- indicators of which are the level of integration between ment of the physical, verbal and mental aspects involved the physical, verbal and mental actions and the feeling of in the Refuge [25]. This practice includes a visualization presence in the visualization. (mental activity), a recital (speech activity) and a gesture/ As informal practice, you can repeat the verse in your movement (bodily activity). mind and perform the visualization whenever you can. García‑Campayo et al. Trials (2023) 24:125 Page 8 of 15 (3) Koan Mu The practice consists of sitting in front of a mirror, putting on a mask and telling the story of your life while Koan is a Japanese word for dialogue or question. It wearing the mask. You have to explain your problems and can be considered the hallmark practice of the schools concerns aloud, as if we were telling it to a psychothera- of Zen Buddhism, mainly of Rinzai Zen. In this medi- pist. You have to speak about your problems and worries tation, the student observes or concentrates on a sin- until you feel free from your present life. You should ded- gle word or phrase for days or weeks. There are several icate between 30 and 45 min to the exercise every day, books with collections of koans in the Zen tradition, whenever you can. and a type of progression has been described and The result of the practice tends to be that by the 15th used by meditation masters. One of the most famous day, you discover that you no longer believe the story ones that has been used by hundreds of masters for of your life and that it does not even matter to you. By centuries with beginners is “Mu” or “Does a dog have changing masks, you learn to laugh at your own life. It Buddha-nature?”. reaches the point where you have nothing more to say, The koan is explained to the students in this way (Japa- and you stand in front of the mirror changing masks. nese version): Nothing in your life makes you feel bad. Dreams tend to A monk asked Joshu: “Does a dog have Buddha-nature change to greater lucidity. or not?” Joshu replied, “Mu” (Mu is a Japanese word that As informal practice, you should observe yourself can be translated as “No”). in front of a mirror whenever you can. Masks are not The practice as proposed to the participants will be required for the informal practice. based on the instructions given by Zen Master David Loy at a retreat, as follows: Assume your usual meditation posture. After taking Measurements several conscious breaths, gradually make contact with Evaluations will be performed at screening, pre-inter- “Mu”, while maintaining unforced breathing. When you vention, post-intervention and 3 and 6-month follow-up. breathe in, only observe the mind, without generating any- All variables and assessment periods of the study can be thing within. When you breathe out, mentally pronounce found in Table 1. “Muuuu” with a deep and low-pitched sound, in tune to the rhythm of your breathing. Forget all notions of obtain- ing an answer, much less something a rational one. And Sociodemographic data and meditation experience breathe out again producing mentally the sound “Muuuu”. Participants will be asked about their gender, age (in Do not look for anything; eliminate any hopes or expecta- years), nationality, current city of residence, marital tions; there is nothing to gain or win. Do not expect any- status (single, married, cohabiting couple, separated/ thing in the future; focus on what you are doing just now. divorced, widowed or other), education (undergradu- Take this to your everyday life, not only during formal ate/bachelor’s degree/diploma, master’s degree, doc- meditation but in informal practice as well: while you are torate and others) and for information regarding their walking, eating, showering or in any other activity. experience with meditation, such as whether they have had meditation experience in general (“yes” or “no”), (4) The mirror exercise the mean in minutes for each time that they practised formal meditation, length of meditation experience (i.e. According to the Toltec tradition, when we dream, we less than 1 year, between 1 and 3 years, between 4 and are the same figure that we are in our waking reality. This 6 years, between 7 and 9 years, or more than 10 years), single figure makes us repeat ourselves both when we are the time (in months) that they may have interrupted their awake and in our dreams. One of the first tasks is to break formal practice during their lives, and the percentage of the relationship between our face, i.e. our ego, and our past. their time dedicated to each type of formal meditation The way in which we do this is to wear a mask in front of (concentrative or focused attention, open monitoring, a mirror. In the Toltec tradition, this practice is called “the compassion/loving-kindness, values, deconstructive/ venerable quetzal”. The quetzal is one of the sacred birds of non-duality and informal practice). A brief explanation Mexico. When it flies, it loses its green colour and takes on of each type of meditation practice will be provided. In iridescent colours. The practice aims to make us lose our addition, an open field is included so that participants ego and our past in order to become beings of light. Two can indicate other meditative techniques that they prac- different masks are used. The mask can be changed two or tice and have not been explicitly collected. The medita- three times each session, so you we will need at least two tion information provided and collected will be based on masks. We use our intuition to make the change. author recommendations and previous studies [11, 27]. García‑Campayo et al. Trials (2023) 24:125 Page 9 of 15 Table 1 Study outcomes Instrument Assessment area Time to assessment Sociodemographic Gender, age, marital status, education, occupation, Screening economic level NETI Deconstruction of self Baseline, post-treatment and follow-up sessions NADA Nondual Awareness Baseline, post-treatment and follow-up sessions FFMQ Facets and factors of mindfulness Baseline, post-treatment and follow-up sessions PHI Well-being Baseline, post-treatment and follow-up sessions SOCS-O and SOCS-S Compassion Baseline, post-treatment and follow-up sessions PANAS Positive and negative affect Baseline, post-treatment and follow-up sessions OAV Altered states of consciousness Baseline, post-treatment and follow-up sessions NETI Nondual Embodiment Thematic Inventory, NADA The Nondual Awareness Dimensional Assessment, FFMQ Five Facet Mindfulness Questionnaire, PHI Pemberton Happiness Index, SOCS-0 and SOCS-S Sussex-Oxford Compassion Scales, PANAS Positive and Negative Affect Schedule, OAV Altered State of Consciousness Rating Scale Main outcome The Five Facet Mindfulness Questionnaire (FFMQ) With The Nondual Embodiment Thematic Inventory (NETI 39 items (range 39–195 points) and five subscales: will be the primary outcome at post-intervention). This observing (e.g. “I am aware of the bodily sensations when is a 20-item questionnaire designed to evaluate quali- O take a bath”), describing (e.g. “I find it hard to express ties of non-dual experience and spiritual awakening. what I feel”), acting with awareness (e.g. “I am easily dis- The NETI assesses a number of facets, including fre- tracted”), non-judging of inner experience (e.g. “I am quency of non-dual experiences, which refer to self- aware that some of my thoughts are not normal, and I transcendent states that have also been referred to as know that I shouldn’t feel that way”) and non-reactivity peak experiences (e.g. “Understanding that there is ulti- to inner experience (e.g. I think before reacting under mately no separation between what I call my “self ” and stressful situations”). The items are rated on a Likert-type the whole of existence”) [28]. The items are rated on a scale ranging between 1 and 5 points (from 1 = “never or 5-point scale with a score of 1 indicating “never” and 5 very rarely true” to 5 = very often or always true”), and indicating “All of the time”. A total score, ranging from higher total values indicate better full mindfulness. The 20 to 100, is calculated by totalling the scores from all validated Spanish version of the questionnaire that has the items, with higher scores indicating higher levels demonstrated appropriated psychometric properties will of non-dual awareness. The scale has shown good psy- be used (Cronbach’s alpha > 0.80) [31, 32]. chometric properties in its original validation, with an internal consistency of Cronbach’s alpha = 0.91 [28, 29]. Sussex‑Oxford Compassion Scales (SOCS) The Sussex- Oxford Compassion for Others Scale (SOCS-O) and Sussex-Oxford Compassion for the Self Scale (SOCS-S) Secondary outcomes are two 20-item self-report scales measuring compas- sion. These are based on the theoretically and empirically The Nondual Awareness Dimensional Assessment supported definition of compassion as comprising five (NADA) This scale was developed to measure experien- dimensions: (a) recognizing suffering (e.g., “I recognize tial effects of nondual awareness, such as bliss and self- when other people are feeling distressed without them transcendence. To study the trait, there is the NADA-T having to tell me”), (b) understanding the universality version with 13 items (e.g. “I have experienced all notion of suffering (e.g. “I understand that everyone experience of self and identity dissolve away”), which are rated on suffering at some point in their lives”), (c) feeling for the a 5-point Likert-type scale ranging from “never or very person suffering (e.g. When someone is going through rarely” to “very often or always”. On the other hand, to a difficult time, I feel kindly towards them”), (d) tolerat- assess the state, the NADA-S version composed of 3 ing uncomfortable feelings (e.g. “When someone else items and scored on a 10-point Likert scale (1 = Not at all, is upset, I try to stay open to their feelings rather than 10 = Very Much) will be used. Their psychometric prop- avoid them”) and (e) motivation to act/acting to allevi- erties are adequate (NADA-T: Cronbach’s alpha > 0.9; ate suffering (e.g. When others are struggling, I try to do NADA-S: Cronbach’s alpha between 0.67 and 0.88) [30]. things that would be helpful”). The items are rated on a García‑Campayo et al. Trials (2023) 24:125 Page 10 of 15 Likert-type scale ranging between 1 (“not at all true”) and effects of meditation. Their psychometric properties are 5 (“always true”) points. Their psychometric properties adequate (Cronbach’s alpha > 0.80) [30, 37]. are adequate (SOCS-O: Cronbach’s alpha between 0.76 and 0.97; SOCS-S: Cronbach’s alpha between 0.74 and Diary for recording activity During the intervention and 0.97) [33]. follow-up periods, participants will be asked to record information on the formal practice (number of ses- The Pemberton Happiness Index (PHI) The PHI is used sions, total duration, time of day) and on informal prac- to assess remembered well-being (general, hedonic, tice (duration, time of day) for inclusion as a moderator eudaimonic and social well-being) through 11 items variable. rated on a Likert scale ranging from 0 (strongly disagree) to 10 (strongly agree). In addition, experienced well- Interconnection graph After each meditation, the par- being (positive and negative emotional events that may ticipants will record the degree of connection they feel have happened the day before) is also measured through with the “community”, “humanity” and the “planet/world” 10 items answered dichotomously (“yes” or “no”). The using a pictorial scale. Each item will be evaluated from remembered well-being score is calculated with the mean seven pairs of superimposed circles representing differ- score of the 11 items and varies from 0 to 10. The items ent levels of interconnection, with one circle representing for experienced well-being are transformed into a sin- the participant and the other circle representing one of gle score from 0 (zero positive experiences and 5 nega- the three items mentioned. The participant must high- tive experiences) to 10 (5 positive experiences and no light which pair of circles, respectively, represents their negative experiences). To calculate the overall PHI index, feeling of connection with each item. which included remembered and experienced well-being, individuals’ scores of the 11 items related to remembered well-being plus the sum of scores on the experienced Statistical analysis well-being were summed; the total sum is then divided Descriptive data will be visually compared in terms of by 12, so the resulting PHI total mean score also ranges sociodemographic data, meditation experience and psy- from 0 to 10. The Spanish validated version will be used chological variables across the arms at baseline to ensure in this study (Cronbach’s alpha > 0.80) [34]. balance among groups. They will be summarized using means (SDs) for continuous variables, and frequencies Positive and Negative Affect Schedule (PANAS) (percentages) for categorical variables. All analyses will [35] This questionnaire comprises 20 items and two follow a pre-specified plan. Outcomes will be compared independent dimensions: positive affect (e.g. “interested”) between groups using the intention-to-treat principle. and negative effect (e.g. “irritable”), with answers ranging Missing outcome data (assumed to be missing at ran- in a Liker-type scale from 1 “very slightly or not at all” dom) will be imputed using multiple imputations based to 5 “extremely or very much”. Each scale has 10 items, on chained equations. The imputation model will include and the score range for each is from 10 to 50. The Spanish the outcomes at each time point, trial arm, the comple- version of the PANAS, adapted with adequate psycho- tion of the training and the extent to which meditation metrics and designed to assess affective states over the was practised, as well as other characteristics pre-spec- last week, will be used (Cronbach’s alpha between 0.87 ified for covariate adjustment, generating 20 imputed and 0.91) [36]. datasets. The primary analysis will be carried out for NETI total scores at post intervention. Outcomes at Altered state of consciousness rating scale (OAV) This is each time point will be compared using mixed-effects a 42-item scale grouped into 11 domains (i.e. experience linear regression models. The main comparisons will of unity, spiritual experience, blissful state, insightfulness, be adjusted for baseline scores, gender and age. Means disembodiment, impaired control and cognition, anxiety, (SDs) will be reported for each trial arm along with the complex imagery, elementary imagery, audio-visual syn- adjusted mean difference between arms, 95% confidence aesthesia and changed meaning of perceptions). Partici- interval (95% CI) and p-value for the adjusted mean dif- pants are asked to respond to the described experiences ference. Results from the complete-case analyses will be by placing marks on horizontal visual analogue scales also reported, as well as additional sensitivity analyses (VAS), which are anchored as no, not more than usual utilizing complier-average causal effect (CACE)/instru- on the left and as yes, very much more than usual on the mental variable methods to explore the causal effects of right. It assesses altered states of consciousness produced (a) participant engagement with the intervention and (b) by drugs such as ketamine, psilocybin or MDMA and the regular meditation practice. García‑Campayo et al. Trials (2023) 24:125 Page 11 of 15 An alpha level of 0.05 will be established using a two- single interviewer, who will indirectly raise the objec- tailed test. The probability values relative to the main tives of the study, questioning interviewees about top- analysis will be adjusted according to Benjamini-Hoch- ics in an open and progressive way. The interviewer will berg’s correction for multiple comparisons, but the sec- also explain the need to record the session (only audio) ondary analyses will not be corrected. and will take notes about non-verbal language ele- ments. The focus groups will be moderated by an inter- Qualitative analysis viewer, and another person from the research team may A qualitative study is proposed in the context of this RCT. be present as an observer. The role of the moderator Through in-depth interviews [38], an attempt will first be will be to indirectly explain the aims of the study, intro- made to understand the experiences of people practising duce the topics of interest, and direct group dynamics types of deconstructive meditation, the expectations and in order to encourage dialogue and participation. The difficulties with these practices, and the reasons why peo- function of the observer will be limited to collecting ple decided to end their practice. Focus groups [38] will field notes to provide additional information to the also be formed to explore dynamic interactions in light of verbal data, such as information related to non-verbal cultural characteristics and specific values that can be the language, responses to the moderator’s interventions basis for participants’ views and preferences. In this way, and contextual aspects. The indirect introduction of qualitative information will be obtained from a collective the objectives will enable us to analyse the participants’ and group perspective that only emerges from individual natural approach to the issues of interest. interviews with some difficulty [39]. This methodological We will seek to achieve optimum standardization in triangulation will increase the consistency and rigour of the sessions with a specification guide whose content the study by combining multiple techniques [40]. will be open and flexible (the topic list is included in Table 2), while allowing the inclusion of emergent Participants issues introduced by the participants [43]. Participants in the qualitative study will be recruited We will ensure the confidentiality and anonymous from the participants of the RCT. They will be selected nature of the study for potential participants. All the while considering the variables that maintain homoge- sessions will be audio taped with the consent of the neity and discursive heterogeneity regarding the aims participating subjects, and materials will be verbatim of the study, such as age, gender, previous meditative transcribed. Both interviews and focus groups will last experiences, time devoted to meditation or changes in around 60–90 min. The two researchers responsible for the measures assessed. Through purposive sampling, an the focus groups will meet after each session to clarify attempt will be made to capture rich and varied informa- and exchange views and field notes. This information tion in agreement with the goals of the study [41], thus will be analysed with data from the audio recordings optimizing the representation of participants’ opinions. and notes [43]. A preliminary analysis will allow us to progress though the interviews in an iterative manner until data satura- tion; in other words, until the new information becomes redundant and provides no new perspectives. We expect that this will occur after approximately 10 interviews in Table 2 Topic list each of the four groups of meditation assessed. After Areas Issues the interviews, four focus groups will be conducted, each consisting of between eight and twelve subjects. Characteristics of the practice Culture shock An attempt will be made to ensure adequate represen- Routine formal and informal practice tation of the stratification variables considered but with Enjoyment/boredom intergroup heterogeneity and intragroup homogeneity to Experiences Peak experiences allow the groups to be formed appropriately [39, 42]. The Lucid dreams information to establish stratifications will be collected Intrasession before beginning the individual/group interviews. Expectations Pre-practice Post-practice Data collection Information Need for a facilitator Topics to be addressed in both the individual and group More/less information interviews will be discussed by the team of researchers Results Description and will guide the interviewers/moderators in the same Altered states of consciousness Description direction. In-depth interviews will be carried out by a García‑Campayo et al. Trials (2023) 24:125 Page 12 of 15 Analysis strategy groups, and special attention will be given to “sensitive The body of text will consist of the verbatim transcrip- moments” in the interaction as indicators of important tions of the recordings, supplemented by notes from topics. The whole process will be triangulated between observations and comments by interviewers/moderators. the two researchers, and differences will be resolved The interviewers/moderators will verify the transcripts to through discussion. guarantee the accuracy of the data. Final validation will To manage the data, we will use the MAXQDA 2022 be performed by inviting the participants to read and dis- data analysis software package. The results of the the- cuss the transcribed content [44]. matic content analysis of the interviews and the interpre- The preliminary analysis will begin after the first inter- tation of the main explanatory axes in the focus groups views and progress through the interviews iteratively to will be presented alongside the empirical references in confirm or discount the topics found [45]. The transcrip- the text, selecting the most representative verbatim seg- tions and notes will be reread and analysed by two inde- ments for use as examples. The researchers will develop pendent social researchers who are experts in qualitative a list of concepts identified in the interviews and focus content analysis, using a vertical, interpretive, emergent groups and create conceptual diagrams that increase and non-frequency-based approach [46]. Through the- understanding and comparability. The final coding matic analysis, supported by the initial topic guide for framework will be discussed with the main researcher content specification as the first framework for approxi- and two participants from individual/group interviews, mation and using the constant comparative method from so that all stakeholders agree. grounded theory, key units of meaning will be identified that enable us to deconstruct every sentence [47]. The information contained in the generated text segments Patient and public involvement will be compared and grouped through open coding until Although importance is being given to engaging stake- a common conceptual denomination for all segments of holders in the choice of research questions, no members text that share the same thematic unit is reached [48]. of the public were directly involved in the development of Provisional interpretations will be made to highlight the the research questions, in this case because of the novelty characteristics and relationships of the emerging codes and incipient use of deconstructive meditative practices generated, which will form new categories as a result of on improving well-being in the general population. Nev- their gradual fusion [47–49]. These broader categories, ertheless, a group of participants will be contacted after defined in an exclusive manner based on agreement the trial and will be interviewed about the research ques- among the researchers, will make the conceptual struc- tions as well as the design and feasibility of interventions. ture denser until a parsimonious solution can be reached. This qualitative information will be used as an advisory Cases that cannot be classified will be actively sought out first experience of public involvement and its respon- during the analysis, and the emerging categories will be siveness in order to develop and refine future research redefined in response to these cases [50, 51]. related to the use of deconstructive meditative practices The information gathered from focus groups will be in the general and even clinical populations. analysed using the model of sociological analysis [52]. In this technique, the reading and organization of data are Discussion not based on fragmentation of the text but on the inter- This exploratory randomized controlled trial will allow us pretation of the different discursive positions among the to know more about the efficacy of several deconstruc- participants and the identification of the explanatory axes tive meditation techniques in order to improve the well- of their interventions. Themes and patterns will be iden- being of healthy people. Possible mechanisms of action tified and coded by two independent researchers, consid- and the relationship with time of formal and informal ering the context in which the interventions took place. practice may also be studied. Finally, the association of Each step towards configuring the potential explana- any of the practices with altered states of consciousness tory axes will require an iterative reading to validate and will be made clearer. The qualitative study will provide confirm the interpretation of new findings, ensuring the information on the barriers and facilitators for Western credibility of the process by reviewing the data again meditators to adapt ancient meditative practices that are from the beginning [53]. At first, the material from dif- deeply entwined in Eastern culture and religion. The field ferent groups will be analysed separately (intragroup of psychology could benefit from specific interventions analysis). However, it will subsequently be regrouped developed over generations to increase the mental health, and pooled in order to compare the relevant themes wellness and happiness of humanity, and to generate (intergroup analysis). The precision of the analysis will prosocial and interconnected attitudes and behaviours in be increased by highlighting the consistent results in all a frantic world. García‑Campayo et al. Trials (2023) 24:125 Page 13 of 15 The study has various strengths. Firstly, to the best of disorders. The data on mechanisms of action could allow our knowledge, this is the first RCT to assess different new interventions to be designed based on this knowl- types of deconstructive meditation applied to improving edge, and the results of the qualitative study could help to well-being, and the first qualitative study on the expecta- tailor interventions to the characteristics of the individ- tions of, effects on and barriers to participants. Secondly, ual. All this could increase the range and characteristics in spite of the exploratory character of the study, the of the psychological interventions available for thera- sample size is large enough to generate knowledge and pists, creating a new paradigm within third-generation hypotheses on the comparative efficacy of all the types psychotherapies. and on the differences in their mechanisms of action. The limitations are the potential non-representative- Trial status ness of the sample, the multiple comparisons between The protocol version number is 2.0 which was approved arms that would limit statistical power, and the relatively on 23 March 2022. Recruitment will commence in Sep- short follow-up, all of which are aspects related to the tember 2022 and is expected to be completed by Septem- exploratory nature of the study. ber 2023. Ethical aspects and dissemination Abbreviations This study will be conducted according to the interna- AUC​ Area-under-the-curve tional standards of the Declaration of Helsinki and sub- BDI-II Beck Depression Inventory II sequent amendments. This trial will be conducted in CBT Cognitive behavioural therapy CI Confidence interval compliance with the study protocol and with good clini- CSRI Client Service Receipt Inventory cal practice guidelines with the main aim of protecting EQ-5D EuroQoL-5D and preserving human rights [54]. Data security will be ETS Expectation for Treatment Scale FFMQ Five Facet Mindfulness Questionnaire guaranteed; the participants included in the study will be GP General practitioner protected by the Organic Law on Protection of Personal ICERs Cost-effectiveness ratios Data (15/1999 of December 13, LOPD) and all relevant ICURs Cost-utility ratios ITT Intention to treat EU legislation in this regard; and international privacy MBCT Mindfulness-based cognitive therapy agreements will be observed and respected. The Inter- MINI Mini International Neuropsychiatric Interview V-5.0.0 net platform will be accessed through a unique user- OTS Opinion of Treatment Scale PANAS Positive and Negative Affect Schedule name + password combination. Since the interventions PC Primary care to be applied in this study are low risk, the creation of PHI Pemberton Happiness Index a Data Monitoring Committee is not considered neces- PHQ Patient Health Questionnaire QALY Quality-adjusted life-year sary. This study has been approved by the Research Eth- REML Restricted maximum likelihood ics Committee of the regional authority (CEICA Aragon, RM Repeated measures Spain registry number PI22/110). An informed consent SF-12 Short Form Health Survey-12 TAU​ Treatment as usual form will be signed by participants before randomization. WHO World Health Organization On the consent form, participants will be asked if they agree to use of their data should they choose to withdraw Acknowledgements We are grateful for the support received by Master of Mindfulness and Chair from the trial. Participants will also be asked for permis- of Contemplative Sciences, University of Zaragoza, Spain. JMM has a “Miguel sion for the research team to share relevant data with Servet” research contract from the ISCIII (CP21/00080). JMM is grateful to the people from the Universities taking part in the research CIBER of Epidemiology and Public Health (CIBERESP CB22/02/00052; ISCIII) for its support. or from regulatory authorities, where relevant. This trial does not involve collecting biological specimens for stor- Authors’ contributions age. The protocol will be available after its publication. All the authors participated in the design and planning of the intervention evaluated here. Specifically, AB-S and RH-A will adapt the web format for Anonymised participant-level datasets and procedures recruiting data, RH-A and SF-M will apply the intervention, JM-M will plan the will be available for replication studies on reasonable necessary statistical and qualitative analysis, and JS-R, JM-M, YLdH, RM-B and request. JG-C will coordinate the process. In addition, all the authors will read and cor‑ rect the draft versions and approve the final version. Clinical implications Funding This research is supported by DGA group (B17_20R) and the Network for Positive results of this RCT may have an important Prevention and Health Promotion in Primary Care (RD16/0007/0005) and impact on the development of new interventions, not the Research Network on Chronicity, Primary Care and Health Promotion only for the improvement of happiness and well-being (RICAPPS)—RD21/0016/0005 grant from the Carlos III Health Institute of the Spanish Ministry for Economy and Competitiveness, co-financed with in healthy populations but potentially also for the pre- European Union ERDF funds. The funding body did not play any role in vention and treatment of psychological and medical the design of the study, nor will it play any role in data collection, analysis, García‑Campayo et al. Trials (2023) 24:125 Page 14 of 15 interpretation of data or the writing of manuscripts. The funding body will 3. Goldberg SB, Tucker RP, Greene PA, Davidson RJ, Wampold BE, Kearney DJ, audit trial conduct. et al. Mindfulness-based interventions for psychiatric disorders: A system‑ atic review and meta-analysis. Clin Psychol Rev. 2018;59:52–60 Available Availability of data and materials from: https://​linki​nghub.​elsev​ier.​com/​retri​eve/​pii/​S0272​73581​73038​47. In accordance with the International Committee of Medical Journal Edi‑ 4. Vonderlin R, Biermann M, Bohus M, Lyssenko L. Mindfulness-Based Pro‑ tors (ICMJE), the data generated by this trial will be made available upon grams in the Workplace: a Meta-Analysis of Randomized Controlled Trials. reasonable request to researchers (i) who provide a methodologically sound Mindfulness (N Y). 2020;11(7):1579–98 Available from: http://​link.​sprin​ger.​ proposal and (ii) whose proposed use of the data has been approved by an com/​10.​1007/​s12671-​020-​01328-3. independent ethical review committee. The data sharing plan includes all 5. Dawson AF, Brown WW, Anderson J, Datta B, Donald JN, Hong K, et al. of the individual anonymized and completely de-identified participant data Mindfulness-Based Interventions for University Students: A Systematic collected during the trial, as well as other related documents such as the study Review and Meta-Analysis of Randomised Controlled Trials. Appl Psychol protocol, the statistical analysis plan and the data dictionary with descriptive Heal Well-Being. 2020;12(2):384–410. Available from: https://​doi.​org/​10.​ labels. Data will become available immediately following each publication 1111/​aphw.​12188. with no end date and for any analytical purpose that is related to achieve 6. Dunning DL, Griffiths K, Kuyken W, Crane C, Foulkes L, Parker J, et al. aims in the original approved proposal. The database will be encrypted and Research Review: The effects of mindfulness-based interventions on password protected. Passwords will be provided by the corresponding author cognition and mental health in children and adolescents – a meta- to interested researchers that meet the both previously described criteria. The analysis of randomized controlled trials. J Child Psychol Psychiatry. plan and all related documents will be downloadable at https://​doi.​org/​10.​ 2018;60(3):jcpp.12980 Available from: https://​pubmed.​ncbi.​nlm.​nih.​gov/​ 3886/​E1707​41V1. 30345​511/. Cited 22 Feb 2022. 7. Goetz JL, Keltner D, Simon-Thomas E. Compassion: An evolutionary analy‑ sis and empirical review. Psychol Bull. 2010;136(3):351–74. Available from: Declarations https://​doi.​org/​10.​1037/​a0018​807. 8. Galante J, Galante I, Bekkers M-J, Gallacher J. Effect of kindness-based Ethics approval and consent to participate meditation on health and well-being: A systematic review and meta- The study protocol has been approved by the Ethics Committee of Aragon analysis. J Consult Clin Psychol. 2014;82(6):1101–14. Available from: (Zaragoza, Spain) with reference number PI22/110, and follows the guidelines https://​doi.​org/​10.​1037/​a0037​249. of the Declaration of Helsinki and current Spanish and European Union legisla‑ 9. Leaviss J, Uttley L. Psychotherapeutic benefits of compassion-focused tion on privacy and data protection. The study participants will sign a written therapy: an early systematic review. Psychol Med. 2015;45(5):927–45 informed consent form before randomization. Participants will be provided Available from: https://​www.​cambr​idge.​org/​core/​produ​ct/​ident​ifier/​ with detailed information about the study and informed that they may leave S0033​29171​40021​41/​type/​journ​al_​artic​le. the study at any time. 10. Shonin E, Van Gordon W, Compare A, Zangeneh M, Griffiths MD. Buddhist-Derived Loving-Kindness and Compassion Meditation for Consent for publication the Treatment of Psychopathology: a Systematic Review. Mindful‑ Not applicable. ness (N Y). 2015;6(5):1161–80. 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Available from: https://​www.​cambr​idge.​org/​core/​journ​als/​psych​ologi​ 4 Primary Care Prevention and Health Promotion Research Network (RedIAPP), cal-​medic​ine/​artic​le/​abs/​medit​ation-​techn​iques-v-​relax​ation-​thera​pies-​ Saragossa, Spain. 5 University of Zaragoza, Saragossa, Spain. 6 Arrabal Primary when-​treat​ing-​anxie​ty-a-​metaa​nalyt​ic-​review/​6F167​C7F5B​2A00C​B2039​ Care Health Center, Aragon Health Service, Saragossa, Spain. 7 Navarra Medical C05E8​9F6E5​C2. Cited 8 Mar 2022. Research Institute (IdiSNA), Pamplona, Spain. 8 Department of Psychiatry, 13. García-Campayo J. Vacuidad y no-dualidad. Barcelona: Kairós; 2020. Hospital de La Santa Creu I Sant Pau, Barcelona, Spain. 9 Universitat Autònoma 14. Garcia-Campayo J, López del Hoyo Y, Navarro-Gil M. Contemplative sci‑ de Barcelona (UAB), Barcelona, Spain. 10 Centro de Investigación Biomédica ences: A future beyond mindfulness. 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Psychometric Evaluation of the Altered States of Consciousness Rating Scale (OAV). PLoS One. • gold Open Access which fosters wider collaboration and increased citations 2010;5(8):e12412. Available from: https://​doi.​org/​10.​1371/​journ​al.​pone.​ • maximum visibility for your research: over 100M website views per year 00124​12. Bell V, editor. 38. Valles MS. Técnicas cualitativas de investigación social. Madrid: Síntesis At BMC, research is always in progress. Sociología; 2003. 39. Callejo J. El grupo de discusión: introducción a una práctica de investi‑ Learn more biomedcentral.com/submissions gación. Barcelona: Ariel; 2001. p. 272.