Cultivating Mindfulness: Effects on Well-Being
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Cultivating Mindfulness: Effects on Well-Being
m
Shauna L. Shapiro
Santa Clara University
m
Doug Oman
University of California, Berkeley
m
Carl E. Thoresen
Stanford University
m
Thomas G. Plante and Tim Flinders
Santa Clara University
There has been great interest in determining if mindfulness can
be cultivated and if this cultivation leads to well-being. The
current study offers preliminary evidence that at least one
aspect of mindfulness, measured by the Mindful Attention
and Awareness Scale (MAAS; K. W. Brown & R. M. Ryan, 2003),
can be cultivated and does mediate positive outcomes.
Further, adherence to the practices taught during the meditation-
based interventions predicted positive outcomes. College under-
graduates were randomly allocated between training in two
distinct meditation-based interventions, Mindfulness Based Stress
Reduction (MBSR; J. Kabat-Zinn, 1990; n 5 15) and E. Easwaran’s
(1978/1991) Eight Point Program (EPP; n 5 14), or a waitlist control
(n 5 15). Pretest, posttest, and 8-week follow-up data were
gathered on self-report outcome measures. Compared to controls,
participants in both treatment groups (n 5 29) demonstrated
increases in mindfulness at 8-week follow-up. Further, increases in
We gratefully acknowledge support for this work from Metanexus Institute (grant: ‘‘Learning from
Spiritual Examples: Measures & Intervention’’), John Templeton Foundation, Academic Council of
Learned Societies, Contemplative Mind in Society, Fetzer Institute, Santa Clara University Internal
Grants for Research, and the Spirituality and Health Institute, Santa Clara University. We also thank
Kirk W. Brown for his insightful editorial feedback regarding the MAAS, as well as Hooria Bittlingmayer,
Sara Tsuboi, and Anthony Vigliotta for their valuable assistance.
Correspondence concerning this article should be addressed to: Shauna Shapiro, Santa Clara University,
Santa Clara, CA 95053; e-mail: slshapiro@scu.edu
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(7), 840--862 (2008) & 2008 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20491Cultivating Mindfulness 841
mindfulness mediated reductions in perceived stress and
rumination. These results suggest that distinct meditation-based
practices can increase mindfulness as measured by the MAAS,
which may partly mediate benefits. Implications and future
directions are discussed. & 2008 Wiley Periodicals, Inc. J Clin Psychol
64: 840--862, 2008.
Keywords: mindfulness; mediation; college mental health; meditation;
attention
The faculty of voluntarily bringing back a wandering attention, over and
over again, is the very root of judgment, character, and will y An
education which should improve this faculty would be the education par
excellence.’’ (James, 1890/1923, p. 424, italics in original)
Since at least the time of William James (epigraph), psychologists have been
interested in the power and benefits of training attention. Recently, one attention-
related construct, mindfulness, has galvanized considerable theoretical and empirical
interest (Brown, Ryan, & Cresswell, 2007). Twenty-five years of clinical research
have documented the efficacy of Mindfulness-Based Stress Reduction (MBSR), a
widely known program based explicitly on cultivating mindfulness. Evidence
indicates that MBSR is effective for reducing distress and enhancing well-being in
individuals with a variety of medical and psychiatric conditions (see reviews by Baer,
2003; Bishop, 2002; Grossman, Niemann, Schmidt, & Walach, 2004). The
cultivation of mindfulness, defined as intentional and nonjudgmental awareness of
moment-to-moment experience, has long been an essential feature of MBSR and
other interventions such as Mindfulness-Based Cognitive Therapy (MBCT; Segal,
Williams, & Teasdale, 2002); however, the mediators and mechanisms of action
underlying these interventions have yet to be clearly determined empirically.
Also unclear is whether gains in mindfulness or similar attention-related
constructs might mediate benefits from other empirically studied forms of
meditation, such as Transcendental Meditation, Benson’s method of meditation,
or Passage Meditation (Alexander, Robinson, Orme-Johnson, & Schneider, 1994;
Benson & Stark, 1997; Flinders, Oman, & Flinders, 2007). Such interventions, as
well as many other Eastern and Western methods of meditation and contemplative
practice, also involve an ‘‘effort to retrain attention’’ (Goleman, 1988, p. 169).
To address these questions, the current study examined mediators and effects from
two multimodal, spiritually based interventions: An explicitly mindfulness-based
program, MBSR (Kabat-Zinn, 1990), and a concentration-based meditation
program called the Eight Point Program (EPP; Easwaran, 1978/1991). As described
more fully later, the EPP program focuses on Passage Meditation, and involves
choosing a meaningful passage to recite during meditation practice. Like the MBSR,
the EPP is nonsectarian and can be used within any major religious tradition or
outside of all traditions. Each of the two interventions was based on teaching a form
of sitting meditation, and was implemented in 8 weekly small-group meetings of
90 min each. Both programs have been successfully taught in multiple healthcare and
academic settings, have generated wide international and multicultural interest, and
are supported by substantial published documentation of their beneficial health
effects. Here, findings on effects and mediators are reported from a randomized,
controlled trial with college undergraduates.
Journal of Clinical Psychology DOI: 10.1002/jclp842 Journal of Clinical Psychology, July 2008
The Mindfulness Construct
Mindfulness is complex and multifaceted, with a rich and evolving history. The
term mindfulness has entered English as a translation of certain usages of traditional
Eastern words that include smrti (Sanskrit), sati (Pali), and dran-pa (Tibetan). In
Buddhist tradition, the term is often associated with specific methods of meditation
(Thera, 1962) as well as with the qualities of recollection, care, and circumspection
(Payutto, 1988). In contemporary Western psychology, mindfulness is often defined
as the awareness that arises through intentionally attending to one’s moment-to-
moment experience in a nonjudgmental and accepting way (Kabat-Zinn, 2003;
Shapiro, Carlson, Astin, & Freedman, 2006). Theravadin scholar Bodhi (2000)
referred to mindfulness as bare attention; however, he also noted that ‘‘bare attention
is never completely bare’’ (Bodhi, 2006). The context and intention one brings to
practice and how one practices are very important (Bodhi, 2006). What bare
attention refers to is that we have removed our conditioned ‘‘emotional reactions,
evaluations, judgments, and conceptual overlays y ’’ (Bodhi, 2006).
Recently, efforts have been made to more precisely elaborate mindfulness
practice by positing three fundamental components: (a) intention, (b) attention,
and (c) attitude (Shapiro et al., 2006). Intention, in this definition, involves knowing
why one is paying attention. It involves motivation; a conscious direction
and purpose. Attention involves the direct, moment-to-moment knowing of
what is happening as it is actually happening. The mind is trained to focus, aim,
and sustain attention. Attitude describes how one pays attention, refer to the
accepting, caring, and discerning qualities of mindfulness. As Kabat-Zinn
noted, mindfulness can be spoken of as ‘‘affectionate attention’’ (as cited in Cullen,
2006, p. 26).
The documented benefits of MBSR and MBCT are often attributed to the
cultivation of mindfulness, consistent with these programs’ explicit guiding theories
(Baer, 2003; Brown & Ryan, 2003; Shapiro, Astin, Bishop & Cordova, 2005). That
is, it is often hypothesized that: (a) these programs increase mindfulness, and (b) this
increase in mindfulness is a primary mediator of positive outcomes. Empirical tests
have been made possible by the recent development of measures of the mindfulness
construct (e.g., Baer, Smith, & Allen, 2004; Brown & Ryan, 2003; Walach, Buchheld,
Buttenmüller, Kleinknecht, & Schmidt, 2006). Empirically, mindfulness also appears
to be multidimensional: Baer, Smith, Hopkins, Krietemeyer, and Toney (2006)
found evidence that existing mindfulness scales measure at least four distinct, but
interrelated, constructs. Although optimal measurement strategies are not yet
determined, these scales have enabled initial and suggestive empirical tests of
hypotheses.
For the first hypothesis, that interventions can foster mindfulness, four
pioneering, nonrandomized studies have reported that mindfulness-based
interventions can indeed increase measured levels of one or more dimensions
of mindfulness. These studies found that participation in an MBSR intervention
was associated with significantly increased mindfulness in nurses (Cohen-Katz,
Wiley, Capuano, Baker, & Shapiro, 2005), outpatients in a medical center (Lau et al.,
2006), counseling psychology students (Shapiro, Brown, & Biegel, 2007), and
individuals with stress-related problems, illness, chronic pain, and anxiety
(Carmody & Baer, 2007). Additional research has correlated increased scores on
standardized measures of mindfulness with increasing mindfulness meditation
experience (Lau et al., 2006).
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 843
Not as much has been done to test the second hypothesis: that increases in
mindfulness lead to enhanced outcomes. The study by Shapiro and colleagues (2007)
lended preliminary supporting evidence, finding that increases in mindfulness
cultivated through MBSR mediated mental health outcomes in counseling
psychology students. Carmody and Baer (2007) reported similar results, finding
that improvements in psychological functioning were mediated by increases in
mindfulness in individuals with stress-related disorders. Further, Brown and
colleagues (Brown & Ryan, 2003; Carlson & Brown, 2005) found that trait measures
of mindfulness are correlated with a variety of cognitive and affective indicators of
mental health, including lower levels of emotional disturbance (e.g., depressive
symptoms, anxiety, and stress) and higher levels of well-being (e.g., vitality, positive
affect, satisfaction with life).
To date, empirical intervention studies of mindfulness have focused on MBSR and
other programs that aim explicitly to cultivate mindfulness; however, mindfulness is
a natural human capacity (Kabat-Zinn, 2003) as well as a skill that can potentially be
cultivated through many diverse paths (Bishop et al., 2004). As preliminary research
continues to implicate mindfulness as a potential mediator of positive outcomes, it
becomes increasingly important to explore diverse ways of cultivating mindfulness
and to clarify how mindfulness may mediate other effective attention-related
interventions.
Cultivating Mindfulness
Can the cultivation of mindfulness arise from distinct meditation-based
interventions? And can such gains in mindfulness lead to improved well-being?
The present study helps address these critical areas by (a) using an experimental
design to determine whether two distinct interventions could foster mindfulness
measured by the Mindful Attention and Awareness Scale (MAAS; Brown & Ryan,
2003) and by (b) determining whether increases in mindfulness mediated observed
benefits among well-being outcomes. More specifically, our second objective
examined whether mindfulness mediated previously documented treatment
effects in perceived stress, rumination, and forgiveness among college students
(Details are reported in a randomized study by Oman, Shapiro, Thoresen, Plante, &
Flinders, 2008.1)
We examined two distinct meditation-based interventions: one based on Kabat-
Zinn’s (1990) MBSR and the other based on Easwaran’s (1978/1991) EPP. Each
program has been associated with well-being benefits reported in randomized,
controlled studies in healthy adult populations (e.g., Oman, Hedberg, & Thoresen,
2006; Shapiro et al., 2005). Both programs were hypothesized to produce increases in
mindfulness, in part because both include training in silent sitting meditation, a
practice that may foster mindfulness (Goleman, 1988). Both also teach ‘‘informal’’
skills for effectively regulating attention throughout the day, and for integrating
mindfulness or other beneficial states of mind, experienced during sitting practice,
into the remainder of daily living. Similarly, both programs encourage cultivating
attitudes that support meditative/mindful attention (e.g., patience, kindness), and
both offer motivational support by exposing participants to inspiring poetry or
readings that reflect meditative/mindful perspectives.
1
Oman et al. (2007) reported outcome variables of the current study; however, the article did not examine
the mechanisms involved in the interventions nor conduct any mediational analyses.
Journal of Clinical Psychology DOI: 10.1002/jclp844 Journal of Clinical Psychology, July 2008
The two programs also contain notable differences, discussed later, that suggest
possible diverse pathways of cultivating mindfulness (Leary, Adams, & Tate, 2006),
reflecting in a small way the historical and cross-cultural variation in forms of
meditation and contemplative practice (Goleman, 1988).
Method
Recruitment, Randomization, and Schedule of Assessments
Participants were undergraduates enrolled at a Jesuit university in California. After
obtaining approval from the Institutional Review Boards of the overall administering
organization and the University, recruitment (targeted primarily at first-, second-, and
third-year undergraduate students for purposes of follow-up) was conducted
through flyers, e-mail, classroom presentations, and special recruitment sessions in
the Fall 2004 term. Approximately 75 eligible students expressed interest by directly
contacting the recruitment manager, who answered questions and disseminated
consent forms. A total of 54 completed consent forms were returned. In early
January 2005, these 54 participants were e-mailed instructions for the online pretest,
which 47 completed. Of the 47, no one was excluded from the study; thus, sample
size was determined by those participants who returned the online pretest. Using
simple randomization with S-Plus Version 3.3 computer software, these 47
participants were randomly allocated between the MBSR (n 5 16) and EPP
(n 5 16) training groups and a waitlist control group (n 5 15).
After randomization yet prior to the first group meetings, 5 participants
were allowed to change between the two intervention groups due to scheduling
conflicts. Three participants switched from the earlier scheduled EPP group
to the MBSR group which met 2 hr later, and 2 participants switched from the
MBSR group to the EPP group. In addition, after attending one EPP session, 1
participant withdrew from the intervention due to the death of a parent. Two
participants in the MBSR intervention never attended any meetings;1 participant
explained that he had overextended himself whereas the other provided no
explanation (see Figure 1).
During the Winter 2005 term, 29 participants completed either MBSR (n 5 15) or
EPP (n 5 14) training. Of these participants, 83% attended all (n 5 11) or all but one
(n 5 13) of the eight training meetings, 3 participants missed 2 meetings, and 1 from
each group, due to sickness, missed three or four meetings. Eight weeks after the
conclusion of MBSR and EPP training (early March 2005), a link for the online
posttest assessment (Exam 2) was e-mailed to participants in the treatment (n 5 29)
and control groups (n 5 15). Exam 2 was completed by 43 of 44 participants (98%); 1
participant from the EPP group did not return the assessment, and no reason was
given. After 8 more weeks, a link for the online follow-up assessment (Exam 3) was
e-mailed and also was completed by 43 of 44 participants (98%). Again, 1 student
(though not the same student) from the EPP group did not return the assessment,
and no reason was given. Participants were mailed $10 checks after the pretest, $20
after the posttest, and $30 after the follow-up assessment.
Participants
The final 44 participants included in the intent-to-treat analysis were primarily 18
years old (59%; range 18–24), first-year (66%), female (80%), White (73%), had
never meditated (68%), and were Roman Catholic (48%) or had no religious
Journal of Clinical Psychology DOI: 10.1002/jclpJournal of Clinical Psychology
Cultivating Mindfulness
DOI: 10.1002/jclp
Figure 1. Flowchart of participant enrollment, allocation, follow-up, and analysis.
845846 Journal of Clinical Psychology, July 2008
affiliation (41%) (for further details on participant recruitment and characteristics,
see Oman et al., 2008). Neither treatment nor dropout condition was significantly
associated with covariables or pretest values of mindfulness or any of the three well-
being outcomes (p4.10).
Intervention
Training for both the MBSR and the EPP groups took place in 8 weekly meetings of
90 min each in a quiet, spacious activity room in on-campus student housing. Each
training involved instruction in a form of sitting meditation, informal corollary
practices, and cultivation of attitudinal and motivational supports. Every weekly
meeting of each group included practice of formal sitting meditation as well as
informal discussion and didactic instruction. The instructor for the MBSR
intervention followed a manual for MBSR, has a Ph.D. in clinical psychology,
and had over 10 years of experience leading MBSR interventions. The two
instructors who co-led the EPP intervention, one with a Ph.D. in counseling
psychology, also used a structured session protocol, and had each taught EPP
interventions for over 10 years.
MBSR instruction corresponded closely to the MBSR training developed by
Kabat-Zinn (1982). Participants received training in the following meditative
practices: (a) ‘‘Mindful Sitting Meditation,’’ which involves awareness of body
sensations, thoughts, and emotions while continually returning the focus of attention
to the breath; (b) ‘‘Body Scan,’’ a progressive movement of attention through the
body from toes to head observing any sensations in the different regions of the body;
(c) ‘‘Mindful Movement,’’ which consists of stretches and postures designed to
enhance greater awareness of and to balance and strengthen the musculoskeletal
system; (d) ‘‘3-Minute Breathing Space’’ (Segal et al., 2002); and (e) ‘‘Lovingkindness
meditation,’’ designed to help develop greater compassion for self, others, and
humanity-at-large. Inherent to all these practices is an emphasis on mindfulness,
continually bringing attention to the present moment. In addition to the formal
meditation practices, didactic presentation and dialogue emphasized how to bring
mindfulness into daily life. Topics included mindful eating, mindfulness in
relationships, mindfulness at work and school, and a mindful approach to pain,
suffering, and stress. The program differed from the traditional MBSR program in
two important ways: (a) Sessions were 90 min instead of 120 to 150 min, and (b) no
day-long retreat was included.
EPP instruction emphasized core EPP practices as described elsewhere, including
Passage Meditation, focused attention, slowing down, and mantram repetition (see
Easwaran, 1978/1991, which was used as a source book in the intervention; see also
Flinders et al., 2007; Oman et al., 2006). Point 1, Passage Meditation, the foundation
of the EPP, is a concentrative method of sitting meditation (Goleman, 1988). In
Passage Meditation, the focus is neither on the breath (as in MBSR) nor on a single
spiritual phrase (as in Benson’s method or Transcendental Meditation) but on a
memorized inspirational passage. During the period of sitting meditation, one slowly
recites mentally a memorized passage from a scripture or a major spiritual figure.
Practitioners individually choose their own passages for meditation. Recommended
passages include the 23rd Psalm, the Buddha’s Discourse on Good Will (from the
Sutta Nipata), Rumi’s Garden Beyond Paradise, the Prayer of Saint Francis, the
Beatitudes of the Sermon on the Mount, or many others (see Easwaran, 1982/2003,
which was used in the intervention as a second source book). Any inspirational
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 847
passage used for meditation is recommended to be ‘‘positive, practical, inspiring, and
universal’’ (Easwaran, 1978/1991, p. 234). In its focus on an inspiring text, Passage
Meditation is similar to the well-known Christian practice of lectio divina (Casey,
1996).
Point 2 of the EPP involves frequent repetition throughout the day of a mantram,
sometimes called a holy name such as Om mani padme hum (Buddhist), Jesus
(Christian), or others from all major traditions (Bormann & Oman, 2007; Easwaran,
1978/1991). A mantram is used to stabilize attention throughout the day. Points 3
(slowing down) and 4 (focused attention), also practiced throughout the day, involve
cultivating mental habits and states that are similar to mindfulness. In the EPP,
slowing down involves moving with care and deliberation through the day,
permitting us to ‘‘be aware of others y and pay attention to what is happening’’
(Easwaran, 1978/1991, p. 90). It does not necessarily mean going slowly on a
physical level but requires setting priorities and limiting activities so as not to live
with a constant sense of time urgency. One-pointed attention (ekāgratā in Sanskrit,
ekaggatā in Pali) involves doing only one thing at a time and giving it full attention.
The practitioner will ‘‘refrain from doing more than one thing at a time y When
you study, give yourself completely to your books. When you go to a movie,
concentrate completely on that’’ (Easwaran, pp. 127, 134). The remaining points
were presented more briefly; Point 5: training the senses, Point 6: putting others first,
Point 7: spiritual fellowship, and Point 8: inspirational reading.
Both programs are integrated and incorporate multiple practices that perform
many analogous functions; however, these functions are sometimes accomplished in
different ways. For example, taxonomists of methods of meditation for retraining
attention have long distinguished between those that employ ‘‘(a) concentration, in
which mind focuses on a fixed mental object [and] (b) mindfulness, in which mind
observes itself’’ (Goleman, 1988, p. 105). Whereas the MBSR program uses sitting
meditation that emphasizes mindfulness, the EPP program uses a concentrative
method (Flinders et al., 2007). Whereas the MBSR program has a strong mindful-
movement component, the EPP program teaches the mantram and other practices
that can be combined with everyday movements, such as walking, to foster
integration of body and mind. Whereas a wider attentional field is cultivated in
MBSR’s sitting meditation and informal practices, the EPP program encourages
wider attention through ‘‘slowing down.’’ Whereas MBSR explicitly encourages
cultivation of loving kindness, the EPP encourages cultivation of similar practices
through ‘‘putting others first’’ as well as meditating on passages that endorse
kindness and compassion. Whereas MBSR fosters inspiration for continued practice
with poetry drawn ad hoc from a wide range of secular and spiritual sources (e.g.,
Shapiro, 2001), the EPP places greater emphasis on sources from spiritual wisdom
traditions.
Yet, both MBSR and EPP can be practiced within any major religious tradition,
or outside of all traditions (Atheist and agnostic practitioners of the EPP commonly
use Buddhist and Taoist passages that do not contain theistic references.) Both
MBSR and EPP incorporate numerous practices that are widespread in spiritual
wisdom traditions (see Wallace, 2006, regarding the importance of concentration in
Buddhism). Emerging evidence has demonstrated similar patterns of impact on
several measures related to beliefs about spiritual realities, and spiritual methods of
coping with stress (Oman et al., 2007). To the extent that both MBSR and EPP
cultivate similar states of consciousness, they might be regarded as examples of
equifinality, the notion that ‘‘the same final state may be reached from different
Journal of Clinical Psychology DOI: 10.1002/jclp848 Journal of Clinical Psychology, July 2008
initial conditions and in different ways’’ (von Bertalanffy, 1968, p. 40), a concept of
increasing interest in psychology (e.g., Curtis & Cicchetti, 2003). Simply put,
equifinality conveys that there may be many paths to the same goal. And yet, given
the complex, multimodal nature of both interventions studied, it is hard to determine
the relative contribution to the observed well-being effects. The intention of this
study is to begin to tease out these mediating mechanisms, focusing specifically on
mindful attention and awareness.
Measures
Outcome measures. Mindfulness was assessed at three examinations (pretest,
posttest, and 8-week follow-up) by the MAAS (Brown & Ryan, 2003). The MAAS is
a 15-item trait measure of one’s tendency to attend to present-moment experiences in
everyday activities. The MAAS uses a Likert scale ranging from 0 (almost always) to
6 (almost never) to assess such items as ‘‘I find myself listening to someone with one
ear, doing something else at the same time’’ and ‘‘I tend to walk quickly to get where
I’m going without paying attention to what I experience along the way.’’ The MAAS
has demonstrated reliable internal consistency (coefficient a 5 .82). The authors also
showed that scores were significantly higher for practitioners of mindfulness
meditation than those for control groups of nonmeditators.
Measures of major stress and well-being outcome variables have been described
elsewhere (Oman et al., 2008). Each was assessed at the three examinations (pretest,
posttest, and 8-week follow-up): Perceived stress was measured with a 10-item
version of the well-known Perceived Stress Scale developed by Cohen and
Williamson (1988). Rumination was measured with a 12-item subscale of the
Rumination and Reflection Questionnaire (a 5 .90) (Trapnell & Campbell, 1999).
Forgiveness of others was measured with a six-item subscale of the Heartland
Forgiveness Scale (test-retest rs and as 4.70 in student samples) (Thompson &
Snyder, 2003).
Adherence to practices during intervention. Meditation practice was measured by
self-report diaries that recorded daily practice. The MBSR group was instructed in
four types of practice: (a) formal sitting practice, (b) mindful movement, (c) body
scan meditation, and (d) informal practices. At each subsequent meeting (Weeks
2–8), MBSR participants reported the number of minutes that they had engaged in
each practice during each day of the previous week, and that number was averaged
(mean of 49 daily counts from 7 weeks’ reports). EPP participants were instructed in
formal sitting meditation at Meeting 1, mantram repetition at Meeting 4, and
spiritual reading at Meeting 6. Means were calculated from their reported number of
minutes engaged in sitting meditation (49 daily counts from 7 weeks’ reports) and
reading (2 weeks’ daily counts). Also calculated was the mean number of occasions
during the day in which participants repeated the mantram (4 weeks’ daily counts), a
measure used in previous studies of mantram repetition as a mediator of benefits
(Bormann & Oman, 2007). For inclusion in regression models, each diary variable
was set to a participant’s cumulative measured training adherence to practices taught
in the interventions at each exam. That is, the diary variable was set to the mean
recorded value at posttreatment assessments (Exams 2 and 3), and set to zero at
baseline (Exam 1) and in the control group.
The waitlist control group was told that the meditation-based course (i.e.,
intervention) would be offered again the following Winter quarter if they wanted to
enroll at that time.
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 849
Adherence to practices after intervention. For EPP group participants at Exams 2
and 3, adherence to the practices was measured by one question for each of the eight
practices, and an additional question regarding each participant’s adherence to the
program’s ‘‘practices as a whole.’’ Previous research has shown that these measures
may mediate EPP effects (Oman et al., 2006). These nine questions were introduced
by asking:
In the past two weeks, how consistently do you feel that you have done the
Eight Point Program practices? For each of the practices individually, on a
scale of 1 to 5, please indicate how consistently you feel you have done the
practices.
To facilitate consistency with diary adherence measures (in which 0 designates
total lack of practice), 1 was deducted from each numeric value prior to analysis,
yielding transformed response categories of 0 (not at all), 1 (a little bit), 2 (somewhat),
3 (quite a bit), and 4 (consistently). Since participants untrained in specific program
practices would have been unable to use them, adherence measures were set to 0 (not
at all) for waitlist participants at all exams and for the EPP group at pretest. Because
of logistical considerations, no posttraining adherence measures were assessed for
the MBSR group.
Covariables. Participants’ tendencies toward socially desirable responding were
assessed at baseline with a short (13-item) version of the Marlow-Crown Scale
(Reynolds, 1982).
Study Questions and Hypotheses
Our primary hypothesis was that measured levels of mindfulness (MAAS) would
increase in both treatment groups compared to the controls (Hypothesis 1).
Treatment effect sizes on well-being outcomes were only moderate in size
(0.34rCohen’s dr0.45; Oman et al., 2008). Comparatively limited statistical power
was therefore available to examine mediation by most adherence variables, which
were available only for one treatment group (MBSR or EPP, but not both).
However, a key requirement, necessary but not sufficient for formal mediation, is that
the outcome is predicted by the potential mediator (Baron & Kenny, 1986). We
therefore sought insight about potential mediators by exploratory analyses of how
each adherence measure predicted, in an expected favorable direction, treatment
effects on mindfulness (MAAS) and well-being outcomes (Exploratory Question 1).
To compensate for the small sample size and correspondingly low statistical power,
we used one-tailed tests of statistical significance in models that included only the
relevant treatment group. Multivariate models were then employed to probe the
mutual independence of significant predictors, especially independence from MAAS
(Exploratory Question 2).
Three secondary hypotheses concerned potential mediating factors that were
measured for both MBSR and EPP groups, thereby allowing the analysis of pooled
data using formal statistical criteria for mediation (Baron & Kenny, 1986). The first
of these additional hypotheses was based on the centrality of sitting practice in most
systems of meditation (Goleman, 1988). We hypothesized that diary measures of
sitting practice would mediate gains in mindfulness (MAAS) (Hypothesis 2).
The other two secondary hypotheses concerned mediation of beneficial treatment
effects on well-being, reported earlier (Oman et al., 2008). This earlier study
compared the 29 treated participants (the MBSR and EPP groups combined) versus
Journal of Clinical Psychology DOI: 10.1002/jclp850 Journal of Clinical Psychology, July 2008
the 15 controls, and found (a) decreases in perceived stress (po.05), (b) decreases in
rumination (po.10), and (c) increases in forgiveness (po.05). In the present study,
our Hypotheses 3a, 3b and 3c, respectively, stated that increases in mindfulness
(MAAS) would formally mediate these changes, with statistical significance at a level
equivalent to or exceeding the original treatment effect (i.e., pso.05, .10, and .05,
respectively). Our Hypotheses 4a, 4b, and 4c (respectively) were that diary measures
of sitting practice, which were available for both MBSR and EPP groups, also would
formally mediate these changes.
Statistical Analyses
Major analyses in this study used hierarchical linear models (HLMs; Raudenbush &
Bryk, 2002). HLMs are increasingly a tool of choice for analyzing longitudinal data,
and are sometimes known, especially among physical scientists, as linear mixed
models (Singer, 1998). Compared to more conventional methods such as ANOVA,
HLM allows improved handling of unbalanced designs and missing data, and more
flexible analyses of data gathered at multiple time points.
We implemented HLM models that adjusted for preexisting individual differences
in levels of outcome variables (using what Raudenbush & Bryk, 2002, called a ‘‘Level
2’’ random effect). We followed the same general approach as that used in previous
analyses of these data (Oman et al., 2007; Oman et al., 2008). More specifically,
bivariate analyses of the predictiveness of a potential mediating variable A within a
treatment group k (without reference to changes in the control group) used the
following model:
YkðiÞ;t ¼ c0 þ bðAÞ AkðiÞ;t þ Tt þ RkðiÞ þ ekðiÞ;t
In this formula, Y kðiÞ;t represents the outcome for the ith individual within treatment
condition k at exam t (t 5 1, 2, or 3). The value of the mediating variable for
individual i at exam t is represented by AkðiÞ;t , which Raudenbush and Bryk (2002)
called a ‘‘Level 1’’ predictor. The mediating variable’s effect on the outcome is
conceived as constant over time, and is represented by the estimated coefficient b(A).
Adjustment for temporal trends that affect all participants equally, such as possible
effects from the treatment received by group k (not mediated by variable A), or from
chronological trends unrelated to the intervention, is included as a fixed effect, Tt.
Other model terms represent additional adjustments and an error term. Adjustment
for preexisting individual differences in outcome level is represented by RkðiÞ , a
random effect. Residual error, the discrepancy between the observed and expected
outcome of individual kðiÞ at exam t, is represented by the random effect ekðiÞ;t ,
assumed to be independent and normally distributed with a mean of zero and a
variance of s2. The global intercept is represented by c0.
When this model was used to analyze predictors within the MBSR and EPP
treatment groups pooled together, an additional fixed effect, Gk, was included to
adjust for baseline group differences (even though these baseline differences were
never statistically significant). Multivariate models of the independent predictiveness
of several potential mediators included additional terms of the form bðBÞ BkðiÞ;t or
bðCÞ CkðiÞ;t .
A similar model was used to determine treatment effects on mindfulness
(MAAS) by comparing changes in treatment groups versus changes in the
control group. In these analyses, the mediating variable, prior reception of
treatment, was represented as a 0/1 indicator variable for whether each individual
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 851
had received treatment:
YkðiÞ;t ¼ c0 þ b2 I ð2Þ k þ b3 I ð3Þ k þ RkðiÞ þ Gk þ Tt þ ekðiÞ;t
Terms for Y, c, R, G, T, and e were as defined earlier (Y represents MAAS scores).
I ð2Þ k is an indicator set to 1 for either treatment group (MBSR or EPP) at Exam 2,
and 0 otherwise. That is, I ð2Þ k represents whether an individual at Exam 2 has
received treatment. Similarly, I ð3Þ k represents whether an individual at Exam 3 has
received treatment. The treatment effect at Exam 2 is represented by b2, and at Exam
3 is represented by b3. Some analyses allowed differences in treatment effect between
MBSR and EPP. In these analyses, we substituted bðEPPÞ 2 and bðMBSRÞ 2 for b2,
bðMBSRÞ 2 I ðMBSR;2Þ k and I ðEPP;2Þ k for I ð2Þ k , with similar substations for b3 and I ð3Þ k .
Finally, our formal tests for mediation of well-being outcomes (stress, rumination,
and forgiveness) used a ‘‘time-constant’’ version of this model that assumed equal
treatment effects at Exam 2 and Exam 3 (e.g., that b2 5 b3). Time-constant models
provide additional statistical power, and are justified by the observed absence of
statistically significant differences between treatment effects at Exam 2 and Exam 3.
In employing time-constant models, we followed the initial analyses, published
elsewhere, that established beneficial treatment effects (Oman et al., 2008).
Shapiro–Wilk tests confirmed that all four outcome measures were approximately
normally distributed (MAAS, stress, rumination, and forgiveness). All regression
analyses were implemented using SAS PROC MIXED (Singer, 1998).
Results
Intervention Effects on Mindfulness and Diary Adherence
Table 1 shows the measured values of mindfulness (MAAS) and diary adherence
measures. Figure 2 graphically displays the values of the MAAS measure across
time, and displays effect sizes and levels of statistical significance. Mean MAAS was
not significantly different between MBSR and the EPP at any exam (p4.40). In
HLM analyses that pooled MBSR and EPP participants into a single treatment
group, a clear treatment effect on MAAS emerged at Exam 3. More specifically,
significant gains since baseline in comparison to controls were demonstrated at
Exam 3 (M 5 13.43, p 5 .004, two-tailed, Cohen’s d 5 1.00), but not at Exam 2
(M 5 3.76, p 5 .41). These results were not substantially altered by adjusting for
socially desirable responding. Exam 3 gains were significantly larger than Exam 2
gains for the EPP and for both groups combined (p 5 .04), indicating a problematic
fit for the time-constant treatment effect model, and the desirability of reporting
separate effect sizes on MAAS for Exams 2 and 3. Still, HLM time-constant models
that pooled across Exams 2 and 3 yielded an estimated average gain of 8.80 (p 5 .04,
Cohen’s d 5 0.64), offering clear support for Hypothesis 1.
Predictiveness of Potential Mediating Factors
Table 2 addresses Exploratory Question 1, showing bivariate analyses of how
mindfulness (MAAS) and diary adherence predicted outcomes. This table displays
regression coefficients from HLMs that include all three assessments (baseline
through 8-week follow-up), and data from one or both treatment groups (MBSR
and/or EPP), but do not include data from the waitlist control group. As noted
earlier, baseline (Exam 1) values of adherence were imputed as 0. Each model adjusts
for average group change between exams (adjusts for mean change in the treatment
Journal of Clinical Psychology DOI: 10.1002/jclp852 Journal of Clinical Psychology, July 2008
Table 1
Potential Mediating Factors by Group
Mediator M SD
Combined group predictors (MBSR & EPP, n 5 29)
Mindfulness (MAAS)
Exam 1 (pretest) 54.00 (13.26)
Exam 2 (posttest) 59.86a (12.69)
Exam 3 (follow-up) 62.18b (14.61)
Diary adherence (during training)
Sitting 7.75 (3.80)
MBSR group predictors (n 5 15)
Mindfulness (MAAS)
Exam 1 (pretest) 53.33 (13.05)
Exam 2 (posttest) 60.40a (12.60)
Exam 3 (follow-up) 60.60 (17.07)
Diary adherence (during training)
Sitting 6.18 (4.31)
Scan 7.53 (4.05)
Movement 4.46 (2.61)
Informal 6.05 (5.82)
EPP group predictors (n 5 14)
Mindfulness (MAAS)
Exam 1 (pretest) 54.71 (13.94)
Exam 2 (posttest) 59.23 (13.27)
Exam 3 (follow-up) 64.00bc (11.55)
Diary adherence (during training)
Sitting 9.42 (2.29)
Mantram (occasions) 3.19 (1.26)
Reading 5.58 (4.15)
Note. Diary adherence values represent daily averages (means) that a participant recorded during the
intervention period, measured as number of occasions (mantram repetition) or number of minutes (all
others).
a
Exam 1 to 2; bExam 1 to 3; or cExam 2 to 3 changes were statistically significant in paired t tests, po.05,
two-tailed.
group). Each regression coefficient and its p value therefore represent how strongly a
potential mediator is associated with larger beneficial changes in an outcome. As
noted in the Method section, these analyses correspond closely to a primary
criterion required for statistical mediation of changes in a treatment group (Baron
& Kenny, 1986): that the mediator predicts the outcome, after adjusting for
treatment.
Table 2 shows that mindfulness (MAAS) demonstrated remarkably similar
predictiveness of stress reductions in the MBSR and EPP groups, where the
regression coefficient [b] was 0.22 (po.01) in each group separately. MAAS also
significantly predicted reductions in rumination in the MBSR group (b 5 0.33,
po.01) and in both groups together (b 5 0.19, po.05). However, compared to the
MBSR group, the mindfulness (MAAS) coefficient for the EPP group was
marginally significantly different (po.10, two-tailed), and did not predict EPP
group changes in rumination (b 5 .04, p4.10) or changes in forgiveness in either
treatment or both together (p4.10). Finally, sitting meditation predicted gains in
forgiveness among the EPP group (b 5 0.86, po.05), but not in the MBSR group
(b 5 0.50).
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 853
Figure 2. Trends in mindfulness (MAAS) over time and effect sizes, by group.
Table 2
Bivariate Regression Coefficients for Predictiveness of Mindfulness (MAAS) and Diary
Adherence, by Outcome and Treatment Group
Outcome
Potential
mediator MAAS Stress Rumination Forgiveness
Combined group predictors (MBSR & EPP, n 5 29)
Mindfulness (MAAS) – 0.23 0.19 b 0.05 (n.s.)
Diary adherencea
Sitting n.s. 0.18 (n.s.)c
MBSR group predictors (n 5 15)
Mindfulness (MAAS) – 0.22 0.33 b 0.09y
a
Diary adherence (min)
Sitting n.s.
Scan
Movement 0.54y
Informal 0.38
EPP group predictors (n 5 14)
Mindfulness (MAAS) – 0.22 0.04 (n.s.)b 0.06 (n.s.)
Diary adherencea
Sitting (min) 0.80y 0.86 c
Mantram (occasions) 2.07 1.01y
Reading (min) 0.57
Note. All models include only observations from individuals in the subgroup and represent the regression
coefficient for the predictor, adjusted for examination (and for MBSR vs. EPP when subgroup contains
both). Blank cells or those designated ‘‘n.s.’’ are nonsignificant (p4.10).
a
Diary measures assessed during treatment.
b
Effects of mindfulness on rumination different between MBSR and EPP (po.10).
c
Effects of sitting on forgiveness different between MBSR and EPP (po.01).
y
po.10; po.05; po.01 in directional (one-tailed) t tests.
Journal of Clinical Psychology DOI: 10.1002/jclp854 Journal of Clinical Psychology, July 2008
Table 3
Means and Bivariate Predictiveness of EPP Post-Training Adherence Measures, by Exam
Exam 2 Exam 3 Predictiveness, by Outcome
EPP Adherence M SD M SD MAAS Stress Rum. Forg.
Overalla 2.31 (0.75) 1.85 (0.80) 5.09 3.67
M (Pts. 1–8) 2.17 (0.65) 1.64b (0.77) 8.99 3.94 5.15
Point 1 (sitting) 2.15 (1.28) 1.08b (0.95) 2.06 0.92y
Point 2 (mantram) 3.23 (0.93) 2.00b (1.22)
Point 3 (slow down) 2.31 (1.11) 2.15 (1.14) 6.07 2.47y
Point 4 (focus) 2.15 (1.07) 1.62b (1.33) 6.23 2.05 2.98
Point 5 (train senses) 2.00 (1.00) 1.23b (1.36) 5.95 1.76 3.61
Point 6 (others first) 2.62 (1.12) 2.38 (0.96) 6.35 2.60
Point 7 (fellowship) 1.46 (0.97) 1.15 (1.21) 2.87
Point 8 (reading) 1.46 (0.88) 1.54 (1.13)
Note. All predictiveness models include observations only from EPP participants and represent the
regression coefficient for the adherence measure, adjusted for examination. Blank cells are nonsignificant
(p4.10). Measures were gathered as part of Exam 2 or 3 and are coded 0 5 not at all, 1 5 a little,
2 5 somewhat, 3 5 quite a bit, or 4 5 consistently.
a
Overall EPP adherence assessed with a single item on adherence to ‘‘practices as a whole.’’
b
po.05 (two-tailed) for change in mean between Exams 2 and 3.
y
po.10; po.05; po.01 in directional (one-tailed) t tests.
In the MBSR group alone, two measures of diary adherence were predictive:
Informal practices predicted less stress (po.05), and mindful movement marginally
predicted forgiveness (po.10). Similarly, in the EPP group alone, diary records of
mantram and sitting each predicted more forgiveness and less stress. Less stress also
was predicted by EPP diary records of spiritual reading (po.05).
Finally, Table 3 displays mean values and predictiveness for posttreatment
measures of adherence to practices taught during the intervention, available only for
the EPP group. Significant reductions of several adherence measures at Exam 3
compared to Exam 2 represent the common decline of amount of practice as time
passes. Several measures, most notably mean adherence, predicted increased
mindfulness (MAAS) as well as reduced stress and rumination.
Mutual Independence of Mediators
Whether significant potential mediators were independent of each other in predicting outcomes
was explored in multivariate models that addressed Exploratory Question 2. Only mindfulness
(MAAS) was significant among measures available for both treatments, so no multivariate
models were relevant for a combined treatment analysis (MBSR 1 EPP).
For measures available only in one treatment group, Table 4 shows results of all
multivariate models involving mindfulness (MAAS) and an adherence measure, when both
were at least marginally significantly predictive (po.10, one-tailed) in bivariate models
reported in Table 2 or Table 3. Clearly, mindfulness (MAAS) was the stronger predictor in
most cases, suggesting its importance as a mediating factor. However, for both MBSR and
the EPP, some adherence measures predicted stress independently of mindfulness (po.05).
For example, in the MBSR group, independently of MAAS, stress reductions were
predicted by informal practices (p 5 .048, b 5 .31). Similarly in the EPP group,
independently of MAAS, diary measures of sitting meditation and mantram repetition
Journal of Clinical Psychology DOI: 10.1002/jclpCultivating Mindfulness 855
Table 4
Multivariate Independent Predictiveness by Adherence and Mindfulness of Well-Being Outcomes
Adherence MAAS
Outcome Measure Coef. P (one-tailed) Coef. P (one-tailed)
MBSR (n 5 15)
Stress Informal (diary) 0.31 .048 0.20 .003
Forgiveness Movement (diary) 0.52 .107 0.09 .08
EPP (n 5 14)
Stress Sitting (diary) 0.92 .04 0.23 .002
Stress Mantram (diary) 1.72 .04 0.19 .007
Stress Reading (diary) 0.35 .13 0.19 .009
Stress M (Pts. 1–8) 2.68 .06 0.17 .02
Stress Overalla 2.90 .015 0.16 .02
Stress Point 1 (sitting) 1.66 .03 0.19 .009
Stress Point 4 (focus) 2.38 .046 0.18 .098
Stress Point 5 (train senses) 0.86 .21 0.20 .013
Stress Point 6 (others first) 1.63 .08 0.16 .03
Note. Coefficients and p values (one-tailed) from multivariate HLMs for the indicated outcome within the
indicated treatment group. P values are regarded as statistically significant if po.05 (full significance) or
po.10 (marginal significance). Models used data from all three exams and included the indicated
adherence measure, the MAAS, and adjustments for time point and individual differences in the outcome
measure.
a
Overall EPP adherence as assessed with a single item.
each predicted stress reductions (p 5 .04, bs 5 0.92 and 1.72, respectively). Several EPP
measures of posttreatment adherence to the practices also predicted stress reductions
independently of MAAS. Note that when both were in the model, EPP Point 4 (focused
attention) predicted stress reductions more strongly (p 5 .046) than did MAAS (p 5 .098).
In sum, results of Exploratory Question 2 suggest that mindfulness (MAAS) was
generally a stronger predictor than adherence to the practices, but some adherence
measures retained independent predictiveness.
Formal Tests of Mediation
Formal tests for meditation of treatment effects included control group participants,
used the model described in the Statistical Analysis section, and relied on criteria
from Baron and Kenny (1986). Each variable that significantly predicted an outcome
in bivariate pooled treatment group models (Table 2, top) also met other formal
criteria for mediation. More specifically, sitting meditation did not predict changes in
mindfulness (MAAS) in analyses that included controls and both treatment groups
(p4.10), failing to support Hypothesis 2. Similarly, sitting meditation did not
significantly predict any of the three well-being measures, failing to support
Hypotheses 4a, 4b, and 4c.
However, formal tests of mediation in pooled groups (n 5 44) confirmed that
mindfulness (MAAS) mediated reductions in stress (po.05, one-tailed) and
marginally in rumination (po.10, one-tailed), according to criteria of Baron and
Kenny (1986). Criteria for mediation by MAAS of gains in forgiveness were not
satisfied (p4.10, one-tailed). More specifically, in HLM models, treatment
(experience of MBSR 1 EPP vs. control) predicted all well-being outcomes, as
noted earlier (po.05 for stress and forgiveness, marginally po.10 for rumination;
Journal of Clinical Psychology DOI: 10.1002/jclp856 Journal of Clinical Psychology, July 2008
PERCEIVED STRESS RUMINATIO N
TOTAL EFFECTS
d = –.45* d = –.34†
Treatment Stress Treatment Rumination
(p=.04) (p=.09)
MEDIATION BY MINDFULNESS
Treatment Stress Treatment Rumination
d = –.25 d = –.16
( p=.18) ( p=.26)
d = +.64* r = –.32** d = +.64* r = –.27**
(p=.02) (p=.0001) (p=.02) (p=.0003)
Mindfulness Mindfulness
(MAAS) (MAAS)
Notes
Treatment coded as 1 (received MBSR or EPP, n=29) or 0 (Controls, n=15);
d indicates effect size standardized by baseline SD of outcome;
r indicates regression coefficient standardized by baseline SD of both predictor
and outcome (which is equivalent to the partial correlation coefficient);
†pCultivating Mindfulness 857
from both a program explicitly oriented toward that goal (MBSR) and another
meditation-based program that does not explicitly emphasize mindfulness (EPP).
This also is one of the first studies to demonstrate that the cultivation of mindfulness
mediates positive well-being outcomes using a controlled study design.
Notably, treatment effects on the MAAS were larger at 8-week follow-up than at
posttest, significantly so (po.05) for the EPP intervention. Such gains over time are
unusual and contrast with the more common observation of temporal decay of many
types of treatment effects. Growth over time is consistent, however, with viewing
each program as transmitting tools that participants apply in their own daily living.
As participants become more experienced and effective in engaging in the practices,
their levels of mindfulness continue to increase. This supports the definition of
mindfulness as a skill that can be developed over time with practice (Bishop et al.,
2004; Shapiro et al., 2006). Larger gains at 8-week posttest also have been observed
for the EPP for other outcomes (Oman et al., 2007) and in other populations (Oman
et al., 2006).
We also found that several measures of adherence to the practices taught
during treatment predicted stress reductions independently of the MAAS. A possible
explanation for why changes are not mediated by the MAAS alone is that this
measure does not assess all facets of mindfulness. Theoretical conceptualizations
of mindfulness, noted earlier, have suggested at least three components of
mindfulness: intention, attention, and attitude (Shapiro et al., 2006). The MAAS
captures only the attentional component and does not address intention or attitude
(e.g., acceptance). It is likely that both the MBSR and EPP interventions may be
cultivating other dimensions of mindfulness not captured by the MAAS but
still significant in terms of improving well-being. For example, such considerations
may explain why the MAAS measure did not mediate gains in forgiveness.
Such gains may be mediated by other dimensions of mindfulness contained in the
interventions, such as attitudinal qualities of acceptance, kindness, and openness
(Shapiro et al., 2006).
Another aspect of mindfulness, not captured by the MAAS, which potentially
mediates positive outcome is the process of decentering (Fresco et al., 2007) or
reperceiving (Shapiro et al., 2006). Decentering and reperceiving refer to a shift in
perspective which allows one to disidentify from the contents of one’s consciousness
(i.e., one’s thoughts, emotions) and view one’s moment-by-moment experience with
greater clarity and objectivity (Shapiro et al., 2006). Preliminary evidence supports
the possibility that these processes mediate benefits from mindfulness practices
(Fresco et al., 2007). Future research could include measures such as the Experiences
Questionnaire (EQ) to examine this process (Fresco et al., 2007).
Finally, note that for each treatment modality, stress reductions were predicted by
diary measures of adhering to practices for regulating attention throughout the day
(the MBSR ‘‘informal’’ practices and the EPP ‘‘mantram’’). This may indicate that
the MAAS measure fails to fully capture participants’ varying efforts to integrate
mindfulness-like states into day-to-day living.
More broadly, the independent predictiveness of numerous dimensions of
adherence to practice also may plausibly reflect intervention components that are
not fully mediated by mindfulness. Rosch (2007) noted with regard to MBSR and
other emerging ‘‘mindfulness’’ therapies that ‘‘these therapies could as much be
called wisdom-based as mindfulness-based. Mindfulness would seem to play two
roles: as part of the therapy itself and as an umbrella justification (‘‘empirical’’) for
the inclusion of other aspects of wisdom’’ (p. 262).
Journal of Clinical Psychology DOI: 10.1002/jclp858 Journal of Clinical Psychology, July 2008
Limitations
A significant limitation of the study is generalizability. Most participants were
female, White, and first-year students, so it is unclear whether results fully apply to
males, non-Whites, and older students. The present results appear most likely to
generalize to other populations that are similarly self-selected, and may not apply to
college students as a whole. Aside from constraints on generalizability, other
limitations of this study include its relatively small sample size and correspondingly
reduced statistical power for assessing precise changes over time, or differences in
treatment effect that may be associated with covariates. Further, this study relied
entirely upon paper-and-pencil self-reports and did not include physiological or
behavioral measures of stress or well-being. Inherent in self-report data is the
potential for demand characteristics to affect the data, especially when the
intervention is fairly transparent in its emphasis on present-moment awareness,
and the primary assessment measure also is transparent in its emphasis on the
present moment. Thus, another limitation of the study is the inability to discern if
results are true or if they represent demand characteristics.
A final limitation, and perhaps the most salient, is the lack of a multidimensional
measure that more adequately captures the meaning of mindfulness. There is
considerable variation in the ascribed meaning and operationalization of mind-
fulness, not only between the ‘‘classical’’ (Buddhist) and clinical perspectives (Lutz,
Dunne, & Davidson, 2007) but between different clinical mindfulness researchers
(Brown et al., 2007). The MAAS was designed to assess mindfulness from a Buddhist
perspective, focusing on attention and awareness. Future research could build on the
current study by including a multidimensional measure of mindfulness, which
captures its broader definition (e.g., attitudinal qualities of acceptance and
discernment).
Strengths and Future Directions
Despite these limitations, this study had several strengths. A significant strength is
the inclusion of a 2-month follow-up assessment, which found that mindfulness
(MAAS) gains increased significantly in magnitude from posttest to follow-up. Our
postrandomization dropout rate of 3 of 47 (6%) was lower than many, if not most,
meditation intervention studies (see Oman et al., 2008). A final strength is that the
present study measured adherence to the practices taught both during intervention
(Table 2 diary measures) and postintervention (Table 3), both of which predicted
more favorable outcomes.
The current findings are consistent with preliminary research that mindfulness as
measured by the MAAS can be cultivated and that it is beneficial for one’s well-
being. It is encouraging that two distinct interventions led to increases on the
MAAS, suggesting mindfulness attention and awareness can be trained through a
variety of different practices that differ in their focus of attention, vocabularies,
backgrounds, and level of explicit emphasis on mindfulness. This raises many
questions concerning what dimensions of mindfulness may be fostered by other
preexisting popular practices or psychosocial interventions (e.g., Benson & Stark,
1997; Goleman, 1988).
A salient direction for future work is to continue to dialogue about a unified
definition of mindfulness and to develop measures that capture its rich, multi-
dimensional nature. It will be helpful to refine current measures as well as develop
new measures based on sound theory and empirical rigor. Further, clinical trials such
Journal of Clinical Psychology DOI: 10.1002/jclpYou can also read
