mindfulness psychology

8/17/2019 Mindfulness Psychology

1/22

Mindfulness Training as a Clinical Intervention: A

Conceptual and Empirical Review

Ruth A. Baer, University of Kentucky

Interventions based on training in mindfulness skills are

becoming increasingly popular. Mindfulness involves in

tentionally bringing one!s attention to t"e internal and e#ternal

e#periences occurring in t"e present moment$ and is often

taug"t t"roug" a variety of meditation e#ercises. T"is review

summari%es conceptual approac"es to mindfulness and

empirical researc" on t"e utility of mindfulnessbased

interventions. Metaanalytic tec"ni&ues were incorporated to

facilitate &uantification of findings and comparison across

studies. Alt"oug" t"e current empirical literature includes

many met"odological flaws$ findings suggest t"at

mindfulnessbased interventions may be "elpful in t"e

treatment of several disorders. Met"odologically sound

investigations are recommended in order to clarify t"e utility of

t"ese interventions.

Key words: mindfulness$ meditation$ metaanalysis$

treatment outcome. [Clin Psychol Sci Prac 10: 125–143, 2003]

Mindfulness is a way of paying attention that originated in

Eastern meditation practices. t has !een descri!ed as "!ringing

one#s complete attention to the present e$peri%ence on a

moment%to%moment !asis& 'Marlatt ( Kris%teller, )***, p. +-

and as "paying attention in a particular way on purpose, in the

present moment, and non/udg%mentally& 'Ka!at%0inn, )**1, p.

1-. 2he a!ility to direct one#s attention in this way can !e

developed through the practice of meditation, which is de3ned

as the intentional self%regulation of attention from moment tomoment

4end correspondence to Ruth A. Baer, 5epartment of

6sychol%ogy, ))7 Kastle 8all, University of Kentucky,

9e$ington, K: 1;7;+%;;11. E%mail r!aer


2/22

mental health treatment pro%grams usually teach these skills

independently of the reli%gious and cultural traditions of their

origins 'Ka!at%0inn, )*@9inehan, )**!-. n the current

empirical literature, clinical interventions !ased on training in

mindfulness skills are descri!ed with increasing freuency, and

their popu%larity appears to !e growing rapidly. According to

4almon, 4antorelli, and Ka!at%0inn

')**-, over 1; hospitals and clinics

in the United 4tates and a!road were

off ering stress reduction programs

!ased on mindfulness training as of

5C );.);*FclipsyF!pg;)7

'(() AMERICA* +,-C/0/1ICA0 A,,/CIATI/* 23' 3'4


3/22

)**?. Mindfulness training is also a central component of

dialectical !ehavior therapy '9inehan, )**a, )**!-, an

increasingly popular approach to the treatment of !order%line

personality disorder. 2he empirical literature on the eff ects of

mindfulness training contains many method%ological

weaknesses, !ut it suggests that mindfulness inter%ventions may

lead to reductions in a variety of pro!lematic conditions,

including pain, stress, an$iety, depressive re%lapse, and

disordered eating 'e.g., Ka!at%0inn, )*@Ka!at%0inn et al.,

)**@ Kristeller ( 8allett, )***@ 4hapiro, 4chwart>, ( Bonner,

)**@ 2easdale et al., ;;;-.

2his review summari>es the recent literature on mind%fulness

training as a clinical intervention. Girst, current methods for

teaching mindfulness skills are descri!ed. He$t, conceptual

approaches that articulate how mindful%ness skills may !e

helpful in treating clinical conditions are summari>ed. Ginally, the

empirical literature on the eff ects of mindfulness training is

reviewed.2his review does not address transcendental meditation '2M-

and other concentration%!ased approaches, which have !een

reviewed elsewhere '5elmonte, )*7@ 4mith, )*?7-.

Ioncentration%!ased approaches train participants to restrict the

focus of attention to a single stimulus, such as a word 'e.g., a

mantra-, sound, o!/ect, or sensation. Dhen attention wanders, it

is redirected to the o!/ect of meditation. Ho attention is paid to

the nature of the dis%traction. Mindfulness meditation, in

contrast, involves o!%servation of constantly changing internal

and e$ternal stimuli as they arise.

2his review also does not address 9anger#s ')**, )**?-

cognitive model of mindfulness, which includes alertness todistinctions, conte$t, and multiple perspectives, open%ness to

novelty, and orientation in the present '4tern!erg, ;;;-.

Mindfulness interventions studied !y 9anger and colleagues 'e.g.,

9anger, )**@ 9anger ( Moldoveanu, ;;;- often include teaching

participants to consider in%formation or situations from multiple

perspectives or within new conte$ts in order to increase learning or

cre%ativity. Although this concept of mindfulness shares with

meditative approaches an emphasis on Je$i!le awareness in the

present, several important diff erences can !e noted. 9anger#s

')**- mindfulness interventions usually involve working with

material e$ternal to the participants, such as information to !e

learned or manipulated, and often in%clude active, goal%orientedcognitive tasks, such as solving pro!lems. n contrast, the

meditation%!ased approaches

descri!ed in this review often are directed toward the in%ner

e$periences of the individual 'e.g., thoughts, emo%tions- and

emphasi>e a less goal%directed, non/udgmental o!servation.

9anger ')**- has cautioned against drawing unwarranted

parallels !etween the two forms of mindful%ness, noting that theyare derived from very diff erent his%torical and cultural

!ackgrounds.

I*TER5E*TI/*, 6A,E2 /* MI*2780*E,, TRAI*I*1

Mindfulness6ased ,tress Reduction

2he most freuently cited method of mindfulness training is the

mindfulness%!ased stress reduction 'MB4R- pro%gram, formerly

known as the stress reduction and rela$%ation program '4R%R6@

Ka!at%0inn, )*, )**;-. t was developed in a !ehavioral

medicine setting for populations with a wide range of chronic

pain and stress%related disor%ders. 2he program is conducted as

an % to );%week course for groups of up to ; participants who

meet weekly for .7 hr for instruction and practice in

mindfulness med%itation skills, together with discussion of stress,

coping, and homework assignments. An all%day '?%hr-

intensive mindfulness session usually is held around the si$th

week. 4everal mindfulness meditation skills are taught. Gor e$%

ample, the !ody scan is a 17%min e$ercise in which atten%tion is

directed seuentially to numerous areas of the !ody while the

participant is lying down with eyes closed. 4en%sations in each

area are carefully o!served. n sitting med%itation, participants

are instructed to sit in a rela$ed and wakeful posture with eyes

closed and to direct attention to the sensations of !reathing.

8atha yoga postures are used to teach mindfulness of !odily

sensations during gentle movements and stretching.

6articipants also practice mind%fulness during ordinary activities

like walking, standing, and eating.

6articipants in MB4R are instructed to practice these skills

outside group meetings for at least 17 min per day, si$ days per

week. Audiotapes are used early in treatment, !ut participants

are encouraged to practice without tapes after a few weeks. Gor

all mindfulness e$ercises, participants are instructed to focus

attention on the target of o!servation 'e.g., !reathing or walking-

and to !e aware of it in each moment. Dhen emotions,

sensations, or cognitions arise, they are o!served

non/udgmentally. Dhen the participant notices that the mind haswandered into thoughts, mem%ories, or fantasies, the nature or

content of them is !rieJy noted, if possi!le, and then attention is

returned to the

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3'


4/22

present moment. 2hus, participants are instructed to no%tice

their thoughts and feelings !ut not to !ecome a!sor!ed in their

content 'Ka!at%0inn, )*-. Even /udgmental thoughts 'e.g.,

"this is a foolish waste of time&- are to !e o!served

non/udgmentally. Upon noticing such a thought, the participantmight la!el it as a /udgmental thought, or simply as "thinking,&

and then return attention to the pres%ent moment. An important

conseuence of mindfulness practice is the reali>ation that most

sensations, thoughts, and emotions Juctuate, or are transient,

passing !y "like waves in the sea& '9inehan, )**!, p. ?-.

Mindfulness6ased Cognitive T"erapy

2easdale, 4egal, and Dilliams ')**7- proposed that the skills of

attentional control taught in mindfulness medita%tion could !e

helpful in preventing relapse of ma/or de%pressive episodes.

2heir information%processing theory of depressive relapse

suggests that individuals who have e$%perienced ma/or

depressive episodes are vulnera!le to re%currences whenever

mild dysphoric states are encountered, !ecause these states

may reactivate the depressive thinking patterns present during

the previous episode, or episodes, thus precipitating a new

episode. Mindfulness%!ased cog%nitive therapy 'MBI2- is a

manuali>ed '4egal, Dilliams, ( 2easdale, ;;- %week group

intervention !ased largely on Ka!at%0inn#s ')**;- MB4R

program. t incorporates ele%ments of cognitive therapy that

facilitate a detached or de%centered view of one#s thoughts,

including statements such as "thoughts are not facts& and " am

not my thoughts.& 2his decentered approach also is applied to

emotions and !odily sensations. MBI2 is designed to prevent

depressive relapse !y teaching formerly depressed individuals

to o!%serve their thoughts and feelings non/udgmentally, and to

view them simply as mental events that come and go, rather

than as aspects of themselves, or as necessarily accu%rate

reJections of reality. 2his attitude toward depression%related

cognitions is !elieved to prevent the escalation of negative

thoughts into ruminative patterns '2easdale et al., )**7-.

I*TER5E*TI/*, I*C/R+/RATI*1

MI*2780*E,, TRAI*I*1

2ialectical 6e"avior T"erapy

5ialectical !ehavior therapy '5B2- is a multifaceted ap%proach

to the treatment of !orderline personality disorder '9inehan,

)**a, )**!-. t is !ased on a dialectical world%

view, which postulates that reality consists of opposing forces.

2he synthesis of these forces leads to a new reality, which in

turn consists of opposing forces, in a continual process of

change. n 5B2, the most central dialectic is the relationship

!etween acceptance and change. Ilients are encouraged toaccept themselves, their histories, and their current situations

e$actly as they are, while working in%tensively to change their

!ehaviors and environments in order to !uild a !etter life. 2he

synthesis of this apparent contradiction is a central goal of 5B2.

5B2 includes a wide range of cognitive and !ehavioral

treatment procedures, most of which are designed to change

thoughts, emotions, or !ehaviors. Mindfulness skills are taught

in 5B2 within the conte$t of synthesi>ing acceptance and

change. Although the skills taught are sim%ilar to those targeted

in MB4R, including non/udgmental o!servation of thoughts,

emotions, sensations, and envi%ronmental stimuli, the concepts

are organi>ed somewhat diff erently. Gor e$ample, 9inehan

')**a, )**!- descri!es three mindfulness "what& skills

'o!serve, descri!e, par%ticipate- and three mindfulness "how&

skills 'non/udg%mentally, one%mindfully, eff ectively-. 5B2 clients

learn mindfulness skills in a year%long weekly skills group, which

also covers interpersonal eff ectiveness, emotion regulation, and

distress tolerance skills. Ilients work with their indi%vidual

therapists on applying skills learned in group to their daily lives.

9inehan ')**1- notes that some severely impaired in%

dividuals may !e una!le or unwilling to meditate as e$tensively

as Ka!at%0inn#s ')**;- MB4R program rec%ommends. 2hus,

5B2 does not prescri!e a speci3c fre%uency or duration of

mindfulness practice. nstead, goals for mindfulness practice are

esta!lished !y individual clients and their therapists. 5B2 off

ersnumerous mind%fulness e$ercises from which clients may

choose 'some adapted from 8anh, )*?+-. n one e$ample,

clients imag%ine that the mind is a conveyor !elt. 2houghts,

feelings, and sensations that come down the !elt are o!served,

la%!eled, and categori>ed. n another e$ercise, clients imag%ine

that the mind is the sky, and that thoughts, feelings, and

sensations are clouds that they watch passing !y. 4everal

variations on o!serving the !reath are taught, including following

the !reath in and out, counting !reaths, coordi%nating !reathing

with footsteps while walking, and fol%lowing the !reath while

listening to music. 4ome e$ercises encourage mindful

awareness during everyday activities,

MI*2780*E,, TRAI*I*1 9 6AER 3';


5/22

such as making tea, washing dishes or clothes,

cleaning house, or taking a !ath.

Acceptance and Commitment T"erapy

Acceptance and commitment therapy 'AI2@ 8ayes, 4trosahl, (Dilson, )***- is theoretically !ased in con%temporary !ehavior

analysis '8ayes ( Dilson, )**-. Al%though AI2 does not

descri!e its treatment methods in terms of mindfulness or

meditation, it is included here !e%cause several of its strategies

are consistent with the mind%fulness approaches descri!ed.

Ilients in AI2 are taught to recogni>e an o!serving self who is

capa!le of watching his or her own !odily sensations, thoughts,

and emotions. 2hey are encouraged to see these phenomena

as separate from the person having them. Gor e$ample, they are

taught to say, "#m having the thought that #m a !ad person,&

rather than "#m a !ad person& 'Kohlen!erg, 8ayes, ( 2sai,

)**, p. 7-. 2hey also are encouraged to e$peri%ence

thoughts and emotions as they arise, without /udging,

evaluating, or attempting to change or avoid them. 8ayes ')*?-

descri!es an e$ercise in which the client imagines that his or her

thoughts are written on signs carried !y parading soldiers. 2he

client#s task is to o!serve the parade of thoughts without

!ecoming a!sor!ed in any of them. AI2 e$plicitly teaches

clients to a!andon attempts to con%trol thoughts and feelings,

!ut instead to o!serve them non%/udgmentally and accept them

as they are, while changing their !ehaviors in constructive ways

to improve their lives '8ayes, )**1-.

Relapse +revention

Relapse prevention 'R6@ Marlatt ( =ordon, )*7- is a cognitive%

!ehavioral treatment package designed to fore%stall relapses in

individuals treated for su!stance a!use. Mindfulness skills are

included as a techniue for coping with urges to engage in

su!stance use. Marlatt ')**1- notes that mindfulness involves

acceptance of the constantly changing e$periences of the present

moment, whereas ad%diction is an ina!ility to accept the present

moment and a persistent seeking of the ne$t "high& associated with

the addiction. 2he metaphor of "urge sur3ng& encourages clients to

imagine that urges are ocean waves that grow gradually until they

crest and su!side. 2he client "rides& the waves without giving in to

the urges, thus learning that urges will pass. 8owever, the client also

learns that new urges will appear and that these urges cannot easily

!e

eliminated. nstead, urges must !e accepted as normal re%

sponses to appetitive cues. Mindfulness skills ena!le the client

to o!serve the urges as they appear, accept them non%

/udgmentally, and cope with them in adaptive ways.

C/*CE+T8A0 A++R/ACE,: /< MI*2780*E,, ,=I00, MA-

E0+

2he authors of these treatment strategies have suggested

several mechanisms that may e$plain how mindfulness skills

can lead to symptom reduction and !ehavior change.

E#posure

2he 3rst pu!lished study of the eff ects of MB4R 'Ka!at%

0inn, )*- descri!ed its application in patients with chronic

pain. MB4R is !ased, in part, on traditional med%itation

practices, which often include e$tended periods of

motionless sitting. Although a rela$ed posture typically isadopted, prolonged motionlessness can lead to pain in

muscles and /oints. Mindfulness meditation instructors of%ten

encourage students not to shift position to relieve the pain,

!ut instead to focus careful attention directly on the pain

sensations, and to assume a non/udgmental attitude toward

these sensations, as well as toward the various cog%nitions

'"this is un!eara!le&- emotions 'an$iety, anger-, and urges

'to shift position- that often accompany pain sensations. 2he

a!ility to o!serve pain sensations non%/udgmentally is

!elieved to reduce the distress associated with pain.

Ka!at%0inn ')*- suggests that application of this strategy !y

chronic pain patients might serve several func%tions. Gor e$ample,

prolonged e$posure to the sensations of chronic pain, in the

a!sence of catastrophic conse%uences, might lead to

desensiti>ation, with a reduction over time in the emotional

responses elicited !y the pain sensations. 2hus, the practice of

mindfulness skills could lead to the a!ility to e$perience pain

sensations without e$cessive emotional reactivity. Even if pain

sensations were not reduced, suff ering and distress might !e

alleviated.

Ka!at%0inn et al. ')**- descri!e a similar mechanism for the

potential eff ects of mindfulness training on an$i%ety and panic.

4ustained, non/udgmental o!servation of an$iety%related

sensations, without attempts to escape or avoid them, may lead

to reductions in the emotional reac%tivity typically elicited !yan$iety symptoms. 2his approach is similar to the interoceptive

e$posure strategy descri!ed !y Barlow and Iraske ';;;-, who

instruct clients to in%

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3'>


6/22

duce symptoms of panic through e$ercises such as hyper%

ventilation and aero!ic activity, and to practice tolerating

these sensations until they su!side. n contrast, however,

mindfulness training does not include the deli!erate in%

duction of panic symptoms. nstead, participants are in%structed to o!serve these sensations non/udgmentally when

they naturally arise.

9inehan ')**a, )**!- descri!es individuals with !or%

derline personality disorder as emotion pho!ic. 2hat is, they are

often afraid of e$periencing strong negative aff ec%tive states.

2his fear is understanda!le, !ecause their neg%ative aff ective

states typically are very intense. 8owever, their attempts to

avoid these states often have maladaptive conseuences.

9inehan ')**a, )**!- suggests that pro%longed o!servation of

current thoughts and emotions, without trying to avoid or escape

them, can !e seen as an e$ample of e$posure, which should

encourage the e$tinc%tion of fear responses and avoidance

!ehaviors previously elicited !y these stimuli. 2hus, the practiceof mindfulness skills may improve patients# a!ility to tolerate

negative emotional states and a!ility to cope with them

eff ectively.

Cognitive C"ange

4everal authors have noted that the practice of mindfulness may

lead to changes in thought patterns, or in attitudes a!out one#s

thoughts. Gor e$ample, Ka!at%0inn ')*, )**;- suggests that

non/udgmental o!servation of pain and an$iety%related thoughts

may lead to the understanding that they are "/ust thoughts,&

rather than reJections of truth or reality, and do not necessitate

escape or avoidance !ehavior. 4imilarly, 9inehan ')**a,

)**!- notes that o!%serving one#s thoughts and feelings and

applying descrip%tive la!els to them encourages the

understanding that they are not always accurate reJections of

reality. Gor e$ample, feeling afraid does not necessarily mean

that danger is im%minent, and thinking " am a failure& does not

make it true. Kristeller and 8allett ')***-, in a study of MB4R in

patients with !inge eating disorder, cite 8eatherton and

Baumeister#s ')**)- theory of !inge eating as an escape from

self%awareness and suggest that mindfulness training might

develop non/udgmental acceptance of the aversive cognitions

that !inge%eaters are thought to !e avoiding, such as

unfavora!le comparisons of self to others and per%ceivedina!ility to meet others# demands.

2easdale ')***- and 2easdale et al. ')**7-, in their

discussion of MBI2, suggest that the non/udgmental,

decentered view of one#s thoughts encouraged !y mind%fulness

training may interfere with ruminative patterns !elieved to !e

characteristic of depressive episodes 'Holen%8oeksema, )**)-.

2hat is, mindfulness training may en%a!le formerly depressed

individuals to notice depressogenic thoughts and to redirectattention to other aspects of the present moment, such as

!reathing, walking, or environ%mental sounds, thus avoiding

rumination. 2easdale has descri!ed this perspective on one#s

thoughts as "meta%cognitive insight.& 2easdale et al. ')**7- also

note that a practical advantage of mindfulness skills in

encouraging cognitive change is that they can !e practiced at

any time, including during periods of remission, when depresso%

genic thinking may !e occurring too rarely to permit reg%ular

practice of traditional cognitive therapy e$ercises, such as

identi3cation and disputing of cognitive distortions. 2hat is, a

mindful perspective a!out one#s thoughts can !e applied to all

thoughts.

,elfManagement

4everal authors have noted that improved self%o!servation resulting

from mindfulness training may promote use of a range of coping

skills. Gor e$ample, Ka!at%0inn ')*- suggests that increased

awareness of pain sensations and stress responses as they occur

may ena!le individuals to en%gage in a variety of coping responses,

including skills not included in their treatment program. Kristeller and

8allett ')***- suggest that the self%o!servation skills developed

through mindfulness training might lead to improved recognition of

satiety cues in !inge eaters, as well as in%creased a!ility to o!serve

urges to !inge without yielding to them. Marlatt ')**1- suggests asimilar eff ect in patients recovering from addictions. 2easdale et al.

')**7- note that mindfulness training encourages awareness of all

cognitive and emotional events as they occur, including those that

may !e early signs of potential depressive relapse. 2hus,

mindfulness training may promote recognition of early signs of a

pro!lem, at a time when application of previously learned skills will

!e most likely to !e eff ective in prevent%ing the pro!lem. 9inehan

')**!- suggests that non/udg%mental o!servation and description

permits recognition of the conseuences of !ehaviors 'e.g., irritating

one#s !oss with freuent lateness- in place of glo!al /udgments

a!out the self 'e.g., " am a !ad employee&-. 2his recognition may

lead to more eff ective !ehavior change, including re%duction of

impulsive, maladaptive !ehaviors. 9inehan

MI*2780*E,, TRAI*I*1 9 6AER 3'?


7/22

')**!- also suggests that learning to focus "one%

mindfully& on the present moment develops control of at%

tention, a useful skill for individuals who have difficulty

completing important tasks !ecause they are distracted

!y worries, memories, or negative moods.

Rela#ation

2he relationship !etween meditation and rela$ation is somewhat

comple$. 4everal authors '=olden!erg et al., )**1@ Ka!at%0inn

et al., )**@ Kaplan, =olden!erg, ( =alvin%Hadeau, )**- have

suggested that mindfulness%!ased stress reduction may !e

applica!le to stress%related medical disorders, including

psoriasis and 3!romyalgia. 2hese authors note that meditation

often induces rela$%ation, which may contri!ute to the

management of these disorders. 2he induction of rela$ation

through various meditation strategies has !een well documented

'Benson, )*?7@ Crme%Lohnson, )*1@ Dallace, Benson, (

Dilson, )*1-. 8owever, the purpose of mindfulness training is

not to induce rela$ation, !ut instead to teach non/udg%mental

o!servation of current conditions, which might include

autonomic arousal, racing thoughts, muscle ten%sion, and other

phenomena incompati!le with rela$ation. n addition, evidence

suggests that rela$ation eff ects are not uniue to meditation, !ut

are common to many re%la$ation strategies '4hapiro, )*-.

2hus, although practice of mindfulness e$ercises may lead to

rela$ation, this out%come may not !e a primary reason for

engaging in mind%fulness skills.

Acceptance

2he relationship !etween acceptance and change is a cen%tral

concept in current discussions of psychotherapy '8ayes, Laco!sen,

Gollette, ( 5ougher, )**1-. 8ayes ')**1- sug%gests that acceptance

involves "e$periencing events fully and without defense, as they are&

'p. ;-, and notes that empirically oriented clinicians may have

overemphasi>ed the importance of changing all unpleasant

symptoms, without recogni>ing the importance of acceptance. Gor

e$ample, an individual who e$periences panic attacks may engage

in numerous maladaptive !ehaviors in an attempt to prevent future

attacks, including drug and alcohol a!use, avoidance of important

activities, and e$cessive an$ious vigilance toward !odily states. f

the individual could ac%cept that panic attacks may occasionally

occur and that they are time%limited and not dangerous, panic

attacks would !ecome unpleasant !ut !rief e$periences to !e tol%

erated, rather than fearsome and dangerous

e$periences to !e avoided, even at the cost of

signi3cant maladaptive !e%havior. All of the treatment programs reviewed here include ac%

ceptance of pain, thoughts, feelings, urges, or other !od%ily,cognitive, and emotional phenomena, without trying to change,

escape, or avoid them. Ka!at%0inn ')**;- de%scri!es

acceptance as one of several foundations of mind%fulness

practice. 5B2 provides e$plicit training in several mindfulness

techniues designed to promote acceptance of reality. 2hus, it

appears that mindfulness training may pro%vide a method for

teaching acceptance skills.

Relations"ip 6etween Mindfulness Training and

Cognitive6e"avioral Approac"es

2his discussion suggests that mindfulness training is con%sistent

with cognitive%!ehavioral treatment procedures in several ways.2raining in self%directed attention can result in sustained

e$posure to sensations, thoughts, and emo%tions, resulting in

desensiti>ation of conditioned responses and reduction of

avoidance !ehavior. Iognitive change appears to result from

viewing one#s thoughts as temporary phenomena without

inherent worth or meaning, rather than as necessarily accurate

reJections of reality, health, ad/ustment, or worthiness. 6ractice

of meditation also may lead to rela$ation and improved self%

management.

8owever, mindfulness training diff ers from traditional cognitive%

!ehavioral treatment in important ways. Gor e$%ample, mindfulness

training does not include the evalua%tion of thoughts as rational or distorted, or systematic attempts to change thoughts /udged to !e

irrational. n%stead, participants are taught to o!serve their thoughts,

to note their impermanence, and to refrain from evaluating them.

Another important diff erence is that traditional cognitive%!ehavioral

procedures usually have a clear goal, such as to change a !ehavior

or thinking pattern. n con%trast, mindfulness meditation is practiced

with a seemingly parado$ical attitude of nonstriving. 2hat is,

although a task is prescri!ed 'e.g., sit still, close your eyes, and pay

atten%tion-, no speci3c goal is adopted. 6articipants are not to strive

to rela$, reduce their pain, or change their thoughts or emotions,

although they may have sought treatment for these purposes. 2hey

are simply to o!serve whatever is happening in each moment

without /udging it. Ginally, mindfulness researchers have suggested

that eff ective teach%ing of mindfulness skills !y mental health

professionals re%uires that they engage in their own regular

mindfulness

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3)(


8/22

practice '4egal et al., ;;-. 6rofessionals using more

tra%ditional cognitive%!ehavioral strategies generally

are not e$pected to engage in regular practice of the

skills they are teaching.

Although the practice of mindfulness generallyinvolves acceptance of current reality, rather than

systematic at%tempts to change reality, individuals who

practice these skills may e$perience reductions in a

variety of symptoms. 2he empirical literature

addressing this issue is reviewed ne$t.

EM+IRICA0 RE,EARC /* MI*2780*E,,6A,E2

I*TER5E*TI/*,

2he empirical literature investigating the eff ects of mind%fulness%

!ased interventions is reviewed here. Meta%analytic procedures

were incorporated to facilitate uanti3cation of 3ndings and

comparisons across studies. 2o locate relevant studies, acomputer search 'using 6sycnfo and Medline data!ases- was

conducted of articles and chapters including the terms

mindfulness or meditation. Reference lists of all articles were

searched for additional articles. 4tudies were included if they

were pu!lished in English and compared a group of participants

trained in mindfulness with a group not trained, or a group who

provided data !efore and af%ter mindfulness training.

Unpu!lished dissertations and conference papers were

e$cluded, as were studies address%ing nonmindfulness forms of

meditation, such as transcen%dental meditation '2M-. 4tudies of

mindfulness as de3ned !y 9anger ')**, )**?- also were

e$cluded, for reasons descri!ed earlier. 2wenty%one studiesmeeting these cri%teria were found.

Gor each study, several demographic and methodolog%ical

varia!les were coded, including num!er, type, and

characteristics of participants, research design, the nature of the

mindfulness intervention, type of comparison group, whether

participants were randomly assigned to interven%tion or

comparison groups, the dependent varia!les re%ported, and

follow%up intervals and data.

Eff ect si>es 'Iohen#s d - were calculated for all studies that

provided sufficient data. Iohen#s d e$presses eff ect si>e in

standard deviation units@ thus, an eff ect si>e of ).; on a given

dependent measure indicates that the treatment group scored

one standard deviation !etter, on average, than the comparisongroup on that measure. Gor studies using !etween%groups

designs, eff ect si>es were calculated with the following formula

d 'M t M

c-FSD

p, in which M

t the mean of the treatment group

on a speci3c mea%

sure, M c the mean of the comparison group on that mea%sure,

and SDp the pooled standard deviation of the two groups. f

means or standard deviations were not provided, eff ect si>es

were calculated from the signi3cance level ' p-. Gor studies

using within%groups designs, eff ect si>es were calculated from t

or F ') df -, or from the signi3cance level when t or F were not

reported. Ialculations of eff ect si>es relied on methods

descri!ed !y Rosenthal ')*1-.

/verview of Treatment 0iterature

4tudies e$amining the eff ects of mindfulness%!ased inter%

ventions are summari>ed in 2a!le ). 2he studies are grouped !y

participant population, !eginning with stud%ies of chronic pain

patients. He$t are studies of patients with other A$is disorders

'an$iety, eating, and ma/or de%pressive disorders-, followed !y

studies of patients with other medical pro!lems '3!romyalgia,

psoriasis, and can%cer-. He$t are studies with mi$ed populations,

including psychotherapy and medical patients. 2he last group in%cludes studies of nonclinical populations 'students and other

volunteers-. Dithin each group studies are listed in order of

pu!lication date.

4ample si>es in these studies have ranged from )+ to

)1. Mean age of participants has ranged from 7;

years, with a mean of 17 years. =ender ratio of the

samples has ranged from ; to 1+N male. Education and

raceFethnicity were rarely reported.

Hine studies used pre%post designs with no control group.

Hine used !etween%groups designs with 2reatment As Usual

'2AU- or waiting%list control groups. Most stud%ies used the );

week MB4R group intervention 'Ka!at%0inn,)*, )**;-, or a

variation of this intervention tailored to the population under

study. 2wo studies '2eas%dale et al., ;;;@ Dilliams, 2easdale,

4egal, ( 4ouls!y, ;;;- e$amined MBI2. 5ependent varia!les

have in%cluded a variety of self%report measures of pain, other

med%ical symptoms, an$iety, depression, eating !ehaviors, and

general psychological functioning, as well as o!/ective measures

such as analysis of urine chemistry.

Gor each study eff ect si>es were calculated separately for each

dependent measure completed at the conclusion of treatment and atall reported follow%up intervals. 6ost%treatment eff ect si>es then

were averaged across dependent measures within studies, yieldinga single posttreatment eff ect si>e for each study. 4imilarly, eff ect

si>es for all de%pendent measures completed at all follow%up

intervals were averaged, yielding a single follow%up eff ect si>e for each

MI*2780*E,, TRAI*I*1 9 6AER 3)3


9/22

C0I*ICA0+, -C/0/1 -:,CIE*CEA*2+RACTICE9 53(*'$,8MME

R'(()

cal studies of effects of mindfulness%!ased interventions

Type Mean @ Researc" Treatment Control Rand @ 2ependent

,tudy * +articipant Age Male 2esign 1roup 1roup Assn Att 5ariables

Ka!at%0inn 7) Ihronic 1+ 7 6re%post MB4R Hone Ho ) 6ain Rtg nde$

')*- pain patients Body 6arts 6A

nterfere rtg

M4I9

6CM4 total

4I9%*;%R =4Ka!at%0inn *; Ihronic 11 6re%post MB4R Hone Ho )7 4ame as a!ove

et al. ')*7- pain patientsa

6art )

Ka!at%0inn 1 Ihronic 1 1 Between group MB4R 2AU Ho O 4ame as a!ove

et al. ')*7- pain patients!

'n )- 'n )-

6art Ka!at%0inn ;)1 Ihronic O ) 4eries of follow%ups MB4R Hone Ho O 6ain Rtg nde$

et al. ')*?- pain patientsc

.71 months Body 6arts 6A

post%MB4R M4I9

4I9%*;%R =4Randolph ? Ihronic 7; ) 6re%post MB4R Hone Ho O 6ain rtgs

et al. ')***- pain patients B4%=4

6CM4 total

6ain !eliefsKa!at%0inn An$iety 6re%post MB4R Hone Ho 8amilton An$

et al. ')**- patients 8anilton 5ep

B5@ BA@ G44

Mo!ility nv

Miller et al. ) An$iety O O %year follow%up MB4R Hone Ho O 8amilton An$

')**7- patients 'patients from 8amilton 5ep

from Ka!at% Ka!at%0inn et al., B5@ BA@ G44

0inn et al., )**- Mo!ility nv

)**-Kristeller ( ) Binge eating 1+ ; 6re%post Pariant of Hone Ho )1 Binge fre

8allett ')***- disorder MB4R Binge Eat 4c

B5@ BA

Eating rtgs2easdale ) Remitted 11 1 Between group MBI2 2AU :es )? M55 relapse

et al. ';;;- M55 after 'n +- 'n +*-

medicn t$

Dilliams 1) Remitted 1 ? Between group MBI2 2AU :es O Auto!iog

et al. ';;;- M55 after 'n )- 'n ;- Memory test

medicn t$d

Kaplan 7* Gi!ro%myalgia 1+ ); 6re%post Pariant of Hone Ho PA4#s pain, sleep, e

et al. ')**- patients MB4R M4I9

4I9%*;%R =4

Ioping 4trat Q

Gi!ro mpact Q


10/22

3

)

'


11/22

MI*2780*E,,TRAI*I*1

9 6AER

)) Gi!ro%myalgia 1+ ? Between group MB4R Dait list Ho * Pas#s pain, sleep, etc. ;.1 O

et al. ')**1- patients 'n ?*- 'n )-@ Gi!ro mpact Q

declined 4I9%*;%R =4

MB4R

'n 1-Ka!at%0inn ? 6soriasis 1 1+ Between group Mindfulness 2AU :es O 5ays to clearing

et al. ')**- patients tapes during of psoriasis

receiving light t$

light therapy

4peca et al. *; Iancer 7) )* Between group Pariant of Dait list :es ) 6CM4

';;;- patients MB4R 4C4Iarlson et al. 71 Iancer

f 7) )* +%month follow% Pariant of Hone Ho O 6CM4

';;;- patients up in 4peca et al. MB4R 4C4

';;;-

Kut> et al. ; 9ong%term O 6re%post MB4R Hone Ho O 4I9%*;%R

')*7- dynamic 6CM4

therapy clients nterfere rtg

2hera rtgsRoth ( Ireasor + Cutpatients 1 )+ 6re%post MB4R Hone HC 1; 4I9%*;%R

')**?- inner city BA

9atinoF9atina M4I9

Mi$ed d$ 4elf%esteemRei!el et al. )) Medical 1? * 6re%post MB4R Hone Ho )) 4G%+

';;)- patients, M4I9

Mi$ed d$ 4I9%*;%R =4Massion et al. )+ 8ealthy 1 ; Between group Regular Hon% Ho O Melatonin meta!olit

')**7- women mediators mediators in urine Astin ')**?- )* Iollege O 7 Between group MB4R Dait list :es )1 4I9%*;%R =4

students 'n )- 'n ?- Iontrol nv

H46R24hapiro et al. ? 6remed and O 11 Between group MB4R Dait list :es 4I9%*;%R =4

')**- med students 4I9%*;%R 5ep

42A

Empathy rtg

H46R2

Dilliams ?7 Iommunity 1 Between group MB4R Dait list :es )7 54

et al. ';;)- volunteers and info 4I9%*;%R =4

M4I9

Notes. rand assn random assignment@ att attrition from treatment group@ post posttreatment@ foll follow%up@ M55 ma/or depressive disorder@

medicn medication@ t$ treatment@ d$ diagnosis@ MB4R Mindfulness%Based 4tress Reduction@ MBI2 Mindfulness%Based Iognitive 2herapy@2AU 2reatment As Usual@ rtg rating@ 6A pro!lem assessment@ M4I9 Medical 4ymptom Ihecklist@ 6CM4 6rofile of Mood 4tates@ 4I9%*;%R 4ymptom Ihecklist%*; Revised@ =4 =eneral 4everity nde$@ An$ an$iety@ 5ep depression@ B5 Beck 5epression nventory@ BA Beck An$ietynven%tory@ G44 Gear 4urvey 4chedule@ nv inventory@ Auto!iog auto!iographical@ PA4 visual analog scale@ 4trat strategies@ Q uestionnaire@fi!ro fi!romyalgia@ 4C4 4ymptoms of 4tress nventory@ 4G%+ 4hort Gorm +@ H46R2 nde$ of Iore 4piritual E$periences@ 42A 4tate%2rait

An$iety nventory@ 54 5aily 4tress nventory@ H4 no significant difference !etween posttest and follow%up.ancludes 7) patients from Ka!at%0inn

')*-.!ncludes ) patients from 6art ) of this study.

cncludes patients from

Ka!at%0inn ')*- andKa!at%0inn et al. ')*7-.d 4u!set of patients in

2easdale et al. ';;;-.ensufficient data to calculate.

f 4u!set of patients in 4peca et al. ';;;-.


12/22

3

)

)


13/22

study that reported follow%up data. Mean posttreatmentand follow%up eff ect si>es are presented in the 3naltwo columns of 2a!le ).

Ho studies of 5B2, AI2, or R6 were included, !e%cause

none were found that e$amined the mindfulness component

independently of the !ehavior change strate%gies alsoincluded in these treatment approaches. 2hus, although

empirical studies support the efficacy of these treatments

'Iurry, Marlatt, =ordon, ( Baer, )*@ to, 5onovan, ( 8all,

)*@Koons et al., ;;)@9inehan, Arm%strong, 4uare>,

Allmon, ( 8eard, )**)@9inehan, 8eard, ( Armstrong, )**@

9inehan, 2utek, 8eard, ( Armstrong, )**1@4trosahl, 8ayes,

Bergan, ( Romano, )**@0ettle ( Raines, )**-, the relative

contri!ution of mindfulness training to these treatment

eff ects has not !een investi%gated. n contrast, studies of

MBI2 were included, !e%cause mindfulness training

appears to !e the central focus of this approach, although

some cognitive techniues have !een incorporated.

1eneral 7indings

Chronic Pain. Gour studies have e$amined the eff ects of MB4R

on patients with chronic pain. 2he 3rst study 'Ka!at%0inn, )*-

descri!es pre%post data for 7) patients. 2he second study

'Ka!at%0inn, 9ipworth, ( Burney, )*7-, has two parts. 6art )

presents pre%post data for a sample of *; patients, including the

7) patients from Ka!at%0inn ')*-. n 6art , ) of these *;

patients are compared to ) other pain patients who had

received 2AU in the pain clinic !ut had not participated in MB4R.

6arts ) and of this study are entered separately in 2a!le ).

2he third study 'Ka!at%0inn, 9ipworth, Burney, ( 4ellers, )*?-

is an e$tensive series of follow%up evaluations of chronic painpatients who had completed MB4R over the preceding several

years, including patients in the previous two studies. 2hus, the

3rst four entries in 2a!le ) are de%rived from three pu!lished

articles with overlapping par%ticipant samples. Ginally, Randolph,

Ialdera, 2acone, and =reak ')***- investigated the eff ects of

MB4R in an in%dependent sample of ? chronic pain patients.

n general, 3ndings for chronic pain patients show sta%

tistically signi3cant improvements in ratings of pain, other

medical symptoms, and general psychological symptoms.

Many of these changes were maintained at follow%up eval%

uations. Most of these comparisons used pre%post designs

with no control group.

Axis I Disorders. Ka!at%0inn et al. ')**- e$amined a sample of

patients with generali>ed an$iety and panic disorders, and

found signi3cant improvements in several measures of an$iety

and depression, !oth at posttreatment and at %month follow%up.

A no%treatment control group was not included. Miller, Gletcher,and Ka!at%0inn ')**7- reported a %year follow%up of the same

participants and found that treatment gains had !een

maintained.

Kristeller and 8allett ')***- e$amined the eff ects of

MB4R on !inge eating disorder. n a pre%post design with

no control group, ) female patients showed statistically

signi3cant improvements in several measures of eating

and mood.2easdale et al. ';;;- e$amined the eff ects of MBI2 on

rates of depressive relapse in a large sample of patients whose

ma/or depressive disorder 'M55- had remitted af%ter treatment

with medication. All participants had dis%continued their

medications at least ) weeks !efore the study !egan. 6atients

were randomly assigned to either MBI2 '%week manuali>ed

group treatment- or 2AU and then followed for ) year. Gor

patients with three or more previous depressive episodes,

results showed much lower relapse rates for MBI2 patients

'?N of patients relapsed- than for the 2AU group '++N of

patients relapsed- during the )%year follow%up period. 8owever,

relapse rates for the MBI2 and 2AU groups did not diff er for

patients with only one or two previous episodes.

Using a su!set of the participants from 2easdale et al.

';;;-, L. M. =. Dilliams et al. ';;;- found that those who had

completed MBI2 produced fewer general and more speci3c

memories when asked to recall events from their pasts inresponse to cue words. 2he authors speculate that mindfulness

training may modify the overgeneral auto!iographical memory

!elieved to !e characteristic of individuals with depression

'Kuyken ( Brewin, )**7-.

Other Medical Disorders. 2wo studies have investigated eff ects

of MB4R on 3!romyalgia. Both reported improve%ments in a

variety of symptoms. n a study of psoriasis pa%tients, Ka!at%

0inn et al. ')**- found that patients who listened to

mindfulness audiotapes during individual light%therapy sessions

showed uicker clearing of their skin 'Mdn +7 days- than did

patients who received light ther%apy alone 'Mdn *? days-.

4peca, Iarlson, =oodey, and Angen ';;;- e$amined the

eff ects of MB4R in a group of cancer patients and reported

signi3cant reductions in

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3)


14/22

mood distur!ance and stress levels. Iarlson, Ursuliak,

=oodey, Angen, and 4peca ';;)- reported that these

changes were maintained at +%month follow%up.

Mixed Clinical Populations. Kut> et al. ')*7- studied asample of long%term psychodynamic therapy patients with

diagnoses including an$iety and o!sessive neuroses, and

narcissistic and !orderline personality disorders. 2hey

completed a );%week MB4R program while continuing with

their individual psychotherapy and showed statisti%cally

signi3cant improvements in a variety of self% and therapist%

rated symptoms. Roth and Ireasor ')**?- stud%ied

outpatients from a low%income, primarily 9atino pop%ulation

attending an inner city health clinic and showed statistically

signi3cant improvements on several measures of medical

and psychological functioning. Rei!el, =reeson, Brainard,

and Rosen>weig ';;)- studied medical patients with a

variety of medical and psychiatric diagnoses and found

signi3cant improvements in medical and psycho%logical

symptoms. Hone of these studies used control groups.

Nonclinical Populations. Massion, 2eas, 8e!ert, Dert%heimer,

and Ka!at%0inn ')**7- analy>ed urine levels of a melatonin

meta!olite in two groups of women. 9evels were signi3cantly

higher in women previously trained in MB4R who continued to

meditate regularly than in wo%men who had never !een trained

and did not meditate. 2he authors cite previous 3ndings

suggesting that mela%tonin level may !e related to immune

function 'Bartsch et al., )**@=uerrero ( Reiter, )**-, andsuggest that mind%fulness meditation may inJuence health

status through its eff ects on melatonin. Astin ')**?- and 4hapiro

et al. ')**- studied student populations who completed group

MB4R, reporting signi3cant eff ects on psychological symptoms,

empathy ratings, and spiritual e$periences. Both of these

studies used waiting%list control groups. Dilliams, Kolar, Reger,

and 6earson ';;)- studied community volunteers who

completed MB4R to reduce their stress levels, re%porting

signi3cant improvements in medical and psycho%logical

symptoms.

Mean Effect ,i%e at +osttreatment

6osttreatment eff ect si>es ranged from ;.)7 to ).+7. An overallmean of these eff ect si>es, collapsed across studies, wascalculated. n order to include only independent mean

eff ect si>es in this calculation, the eff ect si>es o!tained from

Ka!at%0inn ')*- and 6arts ) and of Ka!at%0inn et al. ')*7-

3rst were averaged, !ecause these comparisons have

overlapping participant samples. 4imilarly, the mean eff ect si>es

o!tained for 2easdale et al. ';;;- and L. M. =. Dilliams et al.

';;;- were averaged, !ecause these two studies also haveoverlapping participant samples. After these preliminary

calculations, )7 independent posttreat%ment mean eff ect si>es,

each from a separate sample, were availa!le for analysis. 2heir

mean was ;.?1 'SD ;.*-. Dhen each of these )7 eff ect si>es

was weighted !y sample si>e, overall mean eff ect si>e was

;.7*.

Mean Effect ,i%e at 7ollow8p

Gollow%up data were reported less often. Eff ect si>es atfollow%up ranged from ;.; to ).7. Before an overall meanof these eff ect si>es was calculated, mean eff ect si>eso!tained from studies with overlapping participant sampleswere averaged. 2he overall mean of these independentfollow%up eff ect si>es was ;.7* 'SD ;.1)-.

Iohen ')*??- has descri!ed eff ect si>es of d ;., d ;.7,

and d ;. as small, medium, and large, respectively. 2hus, on

the average, the literature reviewed here suggests that

mindfulness%!ased interventions have yielded at least medium%

si>ed eff ects, with some eff ect si>es falling within the large

range. Many of the eff ect si>es calculated for these studies are

pro!a!ly conservative, !ecause several studies did not present

means, standard deviations, or t values, making it necessary to

calculate d from the p value. n many cases e$act p values were

not reported. nstead, for e$%ample, a p value !etween .;) and .

;7 might have !een re%ported as .;7, which was then used to

compute d. 9arger ps yield smaller d s. n addition, when

3ndings were re%ported only as nonsigni3cant, eff ect si>es of

>ero were recorded. f means, SDs, o r t values had !een

reported in these cases, the calculated eff ect si>e might have

!een larger than >ero.

Relations"ips 6etween Mean Effect ,i%e at +osttreatment

and ,tudy C"aracteristics

Relationships !etween mean eff ect si>es at posttreatment andselected methodological varia!les can !e seen in 2a!le . 'Gollow%up eff ect si>es are not included in this ta!le.- 2he small num!er of studies availa!le and the noninde%pendence of some of the eff ectsi>es make statistical analy%ses of these diff erences impractical.2hus, these 3ndings

MI*2780*E,, TRAI*I*1 9 6AER 3)4


15/22

Table '. Mean effect si>e at posttreatment and methodological varia!les

5ariable N Mean d SD

Research design6re%post ;.?) ;.11Between group ); ;.+* ;.1

Random assignment

'!etween group-:es ? ;.?7 ;.1Ho ;.77 ;.

2ype of control groupDait list 7 ;.?1 ;.112AU 1 ;.77 ;.;

6articipant populationIhronic pain 1 ;.B? ;.1Cther A$is

a1 ;.*+ ;.1?

Medical!

1 ;.77 ;.;*Honclinical

c1 ;.*A ;.11

5ependent measure6ain )? ;.B) ;.;Cther medical 'self%rated-

d)) ;.11 ;.+

An$iety ;.?; ;.1)5epression 7 ;.,+ ;.;4tress ;.+B ;.;=lo!al psychological

e) ;.+1 ;.1

C!/ective medicalf

;.,; ;.7

Method of Ialculating d Using M s and SDs, or t ); ;.,? ;.1;

Using p ;.1, ;.

ancludes an$iety, depression, and !inge eating.

!ncludes fi!romyalgia, psoriasis, and cancer.

cncludes

students and nonclinical volunteers.dncludes fatigue and sleep ratings, and medical symptom checklist.

encludes 6CM4 total mood distur!ance, 4I9%*;%R =4.

f ncludes urine and skin analysis.

should !e interpreted cautiously, as diff erences may not !e

signi3cant. Mean eff ect si>es were similar for studies using pre%

post and !etween%groups designs. Mean eff ect si>e was

somewhat larger when participants had !een randomly as%

signed to groups. 4tudies using waiting%list control groupsyielded slightly larger eff ect si>es than those using 2AU. Dhen

organi>ed !y type of participant, mean eff ect si>es appear

somewhat larger for comparisons using nonclinical populationsor patients with selected A$is pro!lems than for those with

chronic pain or medical pro!lems. Dhen organi>ed !y the type

of dependent varia!le, mean eff ect si>es ranged from ;.) for

pain measures to ;.+ for mea%sures of depression.

Ginally, eff

ect si>es derived from means and SDs or t val%ueswere somewhat larger, on average ';.?- than those derived from p

values ';.1-. 2his 3nding illustrates the im%portance of including

means, standard deviations, and t values in future research. =iven

the small num!er of avail%a!le studies, e$amination of interactions

!etween method of calculating d and other methodological varia!les

is not feasi!le. 8owever, !ecause none of the chronic pain stud%

ies reported means, SDs, or t values, eff ect si>es for thesestudies were calculated from p values. t is possi!le that meaneff ect si>e for chronic pain patients might have !een larger if these studies had provided additional data.

Clinical ,ignificance of 7indings

2he clinical signi3cance of the changes reported in these

studies is difficult to assess. 4everal studies reported only

raw scores on dependent measures, whereas others re%

ported percentage change in scores or the statistical signi%

3cance of the change in scores. n these cases the severity

of participants# pro!lems !efore treatment, or their pro$%imity

to the normal range of functioning afterwards, can%not readily

!e determined.

n order to assess the clinical signi3cance of some of the

3ndings reviewed here, reported raw scores for more freuently

used dependent measures were converted to 2%score euivalents or

ranges of functioning, with use of the instruments# pu!lished

manuals or pro3le sheets. Gor e$ample, several studies reported

pre% and posttreatment raw scores for the =lo!al 4everity nde$

'=4- of the 4ymptom Ihecklist *;%Revised '4I9%*;%R- '5erogatis,

)*-. 2hese scores were converted to 2 scores '2%score

euivalents for males and females were averaged- and then

averaged across studies. 2his procedure yielded a mean pretest 2

score for the =4 of +?, with a mean posttest 2 score of +;. Because

2 scores have a mean of 7; and a SD of );, this 3nding suggests

that patients scored nearly SDs a!ove the mean !efore treatment

and ) SD a!ove the mean after treatment. 4everal studies using the

=4 could not !e included in this procedure !ecause they did not

report scores, instead reporting only percentage decrease in scores,or the statistical signi3cance of the change in scores.

4imilar procedures were followed for the Beck 5epres%sion

nventory 'B5- and the Beck An$iety nventory 'BA- with use of

ranges of functioning descri!ed in the manuals 'Beck ( 4teer,

)*?, )**-. Cn the B5 raw scores of ;* are considered

asymptomatic, whereas scores of );) indicate mild to

moderate depression. Gor two studies reporting B5 scores, the

mean pretreatment score was )+. 'mild%moderate-, and the

mean posttreatment score was .+1 'asymptomatic-. Gor two

studies reporting BA scores, the mean pretreatment score was

;.1 'mod%erate- and the mean posttreatment score was ?.*1

'minimal to mild-.2hese indications of clinical signi3cance must !e con%sidered

tentative, !ecause they are !ased on very few stud%

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3)


16/22

ies, some of which used uncontrolled pre%post designs.

8owever, they suggest that mindfulness training, on aver%

age, may !ring participants with mild to moderate psy%

chological distress into or close to the normal range.

Attrition$ Ad"erence$ and Maintenance of Mindfulness +ractice

2hirteen studies reported !oth the num!er of individuals who

agreed to participate in mindfulness training and the num!er

who completed it. 6rogram completion usually was de3ned as

attendance at a minimum num!er of ses%sions, or was

unde3ned. 6ercentage of enrolled partici%pants who completed

treatment ranged from +; to *?, with a mean of 7N 'SD

.*)-. 2he lowest completion rate '+;N- was noted !y Roth (

Ireasor ')**?-, who stud%ied an inner city health clinic

population. 2he highest com%pletion rate '*?N- was reported !y

4hapiro et al. ')**-, whose participants were premedical and

medical students.2he most e$tensive analysis of program completion was

provided !y Ka!at%0inn and Ihapman%Daldrop ')*-, who

reported completion rates for the MB4R program 'at that time

known as the 4tress Reduction and Rela$ation 6rogram- at the

University of Massachusetts Medical Ien%ter. '2his study is not

included in 2a!le ), !ecause it did not e$amine treatment

eff ects.- 5uring the %year period e$amined ')*)*1-, ),)77

patients were referred to the program, mostly !y their

physicians. Cf these patients, ?7N completed an intake

interview, and *;N of those interviewed enrolled in the program.

Cf the ?1 patients who enrolled, ?+N completed the program,

whereas )7N dropped out after !eginning and *N never attended a ses%sion. Regression analyses showed that patients

with stress%related pro!lems 'hypertension, an$iety, sleep

disorders, etc.- were signi3cantly more likely to complete the

pro%gram than those with chronic pain complaints 'lower !ack,

headache, etc.-. Iompleters also had somewhat higher

pretreatment scores than noncompleters on the =4 and the

C!sessive%Iompulsive 'CI- scales of the 4I9%*;%R. Dithin the

chronic pain group, women were slightly more likely than men to

complete the program.

Cnly three studies reported the e$tent to which partic%ipants

completed their assigned home practice during the course of the

mindfulness intervention. Kristeller and 8al%lett ')***-, in asample of women with !inge eating disor%der, noted that

participants reported engaging in a mean of )7. hr of

meditation 'SD .)7- across the +%week in%tervention program.

Reported practice time was signi3%cantly correlated with

improvements in Binge Eating 4cale

scores 'r .++- and in B5 scores 'r .7*-. Astin ')**?-, in a

sample of college students, reported that participants practiced

meditation for an average of ; min per day, .7 days per week.

Reported practice time and improvement on the =4 of the 4I9%

*;%R were not signi3cantly corre%lated. Rei!el et al. ';;)-reported that *;N of their mi$ed sample of medical patients

practiced three times per week or more and 7?N practiced

nearly every day, most for )7 ; min each time.

Gour studies reported the e$tent to which participants

trained in mindfulness skills continued to practice these skills

after treatment had ended. n a series of follow%up studies of

former MB4R patients, Ka!at%0inn et al. ')*?- noted that

?7N of former patients reported that they still practiced

meditation 'averaged across follow%up intervals of +1

months-. Cf these patients, 1N meditated regu%larly '≥

three times weekly, ≥ )7 min each time-, whereas )*N

meditated sporadically 'one or two times weekly, ≥ )7 min

each time, or ≥ three times weekly, ≤ )7 min each time-,

and N were classi3ed as marginal meditators ' one time

weekly for any length of time, or three times weekly, )7

min each time-. 6ractice of yoga two or more times per week

was reported !y )N of respon%dents, and 1*N reported

using awareness of !reathing in daily life often.

Ka!at%0inn et al. ')**-, at %month follow%up of patients with

an$iety disorders, found that 1N reported practicing meditation or

yoga three or more times per week, for )717 min each time.

Mindfulness of !reathing in daily life was practiced !y *7N '??N

often and )N some-times-. Miller et al ')**7- contacted ) of these

patients for a %year follow%up evaluation and reported that ); '7+N-

still practiced meditation 1 regularly, sporadically, and marginally

'as de3ned a!ove-. 4i$teen of ) '*N- reported that they used

awareness of !reathing in daily life '1 often,

)) sometimes, and ) rarel -.

K. A. Dilliams et al. ';;)-, in a sample of community

volunteers self%identi3ed as "stressed out,& reported that

at %month follow%up )N of MB4R participants were

prac%ticing either meditation, yoga, or awareness of

!reathing in daily life.

+atients! Reactions to Treatment

n their follow%up study of former MB4R patients, Ka!at%0inn et

al ')*?- found that the ma/ority of those who considered

themselves improved since completing MB4R attri!uted 7;

);;N of their improvement to the M4BR

MI*2780*E,, TRAI*I*1 9 6AER 3);


17/22

program. 2he ma/ority gave ratings of ); on a );%point

rating of the importance of completing the program ') not

at all important! ); "er important -, and +N reported that

they "got something of lasting value& from the pro%gram.

Most commonly reported changes included a "new outlookon life& and improved a!ility to control, under%stand, and

cope with pain and stress.

Miller et al. ')**7-, in their %year follow%up of pa%tients

with an$iety disorders, asked participants to rate the

importance of the MB4R program on a )); scale ') no

importance! ); "er important -. 2he ma/ority gave ratings

of ? or higher, and *N reported that the program had

"lasting value& for them.

Astin ')**?- asked undergraduate participants to rate the

e$tent to which their mindfulness program had "last%ing value

and importance.& Cn a );%point scale, partici%pants gave a mean

rating of *.. Randolph et al. ')***- reported that *N of their patients with chronic pain re%ported !ene3ts of "lasting value&

and rated the program#s importance at . on a );%point scale.

Rei!el et al. ';;)- reported that their mi$ed sample of medical

patients rated their satisfaction with MB4R at 1.*; on a 7%point

scale.

Although these 3ndings suggest that participants in

mindfulness%!ased interventions rate these program highly, they

should !e interpreted cautiously. 2hey are derived only from

participants who completed their treatment pro%grams.

6articipants who dropped out might have given lower ratings.

Ka>din ')**1- notes that client satisfaction measures may not

correlate with measures of dysfunction, and Brock, =reen,Reich, and Evans ')**+- suggest that participants who have

invested su!stantial time and eff ort in a treatment program may

!e unwilling to evaluate it negatively. 8owever, Ka>din ')**1-

also notes that client satisfaction is an important consideration

when one is choosing among treatment alternatives, and these

results suggest that many clients 3nd mindfulness interventions

!ene3cial.

Met"odological Issues

As noted in 2a!le ), the pu!lished literature on the eff ects of

mindfulness training reports changes in the therapeutic direction

in several populations on a variety of dependent measures.

8owever, many studies have signi3cant method%ologicalweaknesses that make it difficult to draw strong conclusions

a!out the eff ects of mindfulness%!ased inter%ventions. 2hese

issues are summari>ed !elow.

Control #roups. 4everal of the studies reviewed e$am%ined

the eff ects of MB4R with pre%post design and no control

group. Although most of these studies reported statistically

signi3cant improvements in a wide range of dependent

varia!les, none controlled for passage of time, demand

characteristics, or place!o eff ects, or compared MB4R toother treatments.

4everal studies used !etween%groups designs with

waiting%list or 2AU control groups. 2he latter studies pro%vide

!etter controls for demand characteristics and place!o

eff ects, and permit comparisons with alternative treat%ments.

8owever, in the studies reviewed here, 2AU con%sisted of

medical approaches or unspeci3ed mental health

approaches. Gor e$ample, in Ka!at%0inn et al. ')*7, 6art -,

2AU included medical approaches to chronic pain, such as

nerve !locks, physical therapy, analgesics, and anti%

depressants. n Ka!at%0inn et al. ')**-, 2AU consisted of

phototherapy for psoriasis. Gor 2easdale et al. ';;;- and L.M. =. Dilliams et al. ';;;-, 2AU included depression%

related visits to a general practitioner, psychiatric treat%ment,

counseling, psychotherapy, and other mental health

contacts. 2hus, these studies do not allow comparison of

mindfulness training with other speci3c psychological ap%

proaches.

Sample Si$es. 4ome of the studies reviewed here report

small sample si>es. According to Iohen ')*??-, an ;N

chance of detecting a medium%to%large treatment eff ect 'd

;.?;- with a two%tailed t test at alpha .;7 reuires

participants per sample. Guture research should include

sample si>es adeuate to detect medium%to%large treatmenteff ects.

%"aluation of Inte&rit of 'reatment. Evaluation of the eff ects of

any treatment reuires that it !e adeuately ad%ministered

'Ka>din, )**1-. ntegrity of treatment imple%mentation can !e

enhanced through rigorous training and regular supervision of

therapists, with procedures such as direct o!servation, review of

audio% or videotapes of ses%sions, and feed!ack. 2he studies

reviewed here do not de%scri!e the procedures used to train

therapists or to evaluate their delivery of mindfulness treatment.

2easdale et al. ';;;- report that MBI2 sessions were video% or

audio%taped to allow monitoring of treatment integrity, !ut anal%

ysis of these tapes is not descri!ed. n several studies therapists

are descri!ed as "e$perienced,& !ut the term is

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3)>


18/22

not well de3ned. Many of the studies reviewed here were

conducted in the program developed !y the originator of MB4R

'Ka!at%0inn, )*, )**;-. 4imilarly, the MBI2 groups in

2easdale et al. ';;;- were led !y the developers of the

treatment. n these cases it seems likely that thera%pistsconducted the treatment competently. 8owever, !e%cause

mindfulness%!ased interventions are relatively new and may !e

less familiar than more esta!lished cognitive%!ehavioral

interventions, descriptions of the training and supervision of the

therapists conducting the mindfulness treatment might increase

con3dence in the 3ndings from future studies.

Clinical Si&nificance. 2he clinical signi3cance of the eff ects

of an intervention can !e evaluated in several ways ' La%

co!son ( Revensdorf, )*@ Laco!son ( 2rua$, )**)@

Ka>din, )**1-. Gor e$ample, after patients have completed

the e$perimental treatment, the e$tent to which they fallwithin the normal range on relevant dependent measures

can !e e$amined. Alternatively, their diagnostic status can

!e reevaluated to determine whether they continue to meet

criteria for the disorder for which they sought treat%ment. 2he

studies reviewed here do not e$plicitly address the clinical

signi3cance of their 3ndings in either of these ways.

ncreased attention to the issue of clinical signi3%cance

would contri!ute su!stantially to the utility of future studies.

C/*C08,I/*

n spite of signi3cant methodological Jaws, the current literature

suggests that mindfulness%!ased interventions may help to

alleviate a variety of mental health pro!lems and improve

psychological functioning. 2hese studies also suggest that many

patients who enroll in mindfulness%!ased programs will complete

them, in spite of high demands for homework practice, and that

a su!stantial su!set will con%tinue to practice mindfulness skills

long after the treatment program has ended. Mindfulness%!ased

interventions ap%pear to !e conceptually consistent with many

other em%pirically supported treatment approaches and may

provide a technology of acceptance to complement the

technology of change e$empli3ed !y most cognitive%!ehavioral

pro%cedures '9inehan, )**a-.

2hus, it appears that methodologically sound studies of mindfulness%!ased interventions would !e very informa%tive.

Randomi>ed clinical trials are needed to clarify

whether o!served eff ects are due to mindfulness training or to

confounding factors such as place!o eff ects or passage of time

'Iham!less ( 8ollon, )**-. Cutcome studies using waiting%list or

no%treatment controls might shed more light on the eff ects of

mindfulness training as a treatment pack%age, !ut more rigorous

tests would compare mindfulness%!ased interventions to esta!lished

treatments. 5ismantling studies of treatment packages that include

!oth mindfulness and !ehavior change strategies, such as 5B2,

AI2, and R6, could clarify the relative contri!utions of acceptance%

!ased and change%!ased strategies in these packages. Dhether the

eff ectiveness of esta!lished treatment pro%grams may !e increased

!y adding mindfulness training is also an important uestion.

Additional research could in%vestigate the eff ects of mindfulness

practice on a !roader range of outcomes, such as su!/ective well%

!eing and ual%ity of life, as well as symptom reduction. 2he

mechanisms through which mindfulness training may create clinical

change, such as e$posure, rela$ation, and cognitive change, also

should !e e$amined.

2he 5ivision ) 2ask Gorce on 6romotion and 5is%semination

of 6sychological 6rocedures ')**7- proposed de3nitions for

well%esta!lished and pro!a!ly efficacious treatments. Dell%

esta!lished treatments have !een shown to !e superior to a

place!o or alternative treatment, or euivalent to an already

esta!lished treatment, in group%design studies with adeuate

sample si>es and conducted !y diff erent investigators.

Alternatively, they have demon%strated efficacy in a large series

of single case designs that compare the intervention to another

treatment. n all cases, well%esta!lished treatments have !een

investigated for speci3c disorders, with use of treatment

manuals and well%speci3ed samples.

5esignation as "pro!a!ly efficacious& reuires two stud%ies

showing the treatment to !e more eff ective than a wait%ing%listcontrol group, or than another treatment '!ut conducted !y thesame investigator-, or two studies demon%strating eff ectivenessin heterogeneous client samples.

Give studies of MB4R using group designs with random

assignment are reviewed here 'Astin, )**?@ Ka!at%0inn et al.,

)**@ 4hapiro et al., )**@ 4peca et al., ;;;@ K. A. Dilliams et

al., ;;)-. All show MB4R to !e more eff ec%tive than a waiting%

list or 2AU control group. 4amples in%clude students 'two

studies-, psoriasis patients, cancer patients, and community

volunteers complaining of high stress levels. 2hus, MB4R may

meet criteria for the "pro!%

MI*2780*E,, TRAI*I*1 9 6AER 3)?


19/22

a!ly efficacious& designation in that it has !een shown to !emore eff ective than waiting%list or 2AU control groups inseveral studies using heterogeneous samples.

MBI2 may !e approaching the "pro!a!ly efficacious&

designation for the prevention of depressive relapse. 2eas%dale

et al. ';;;- is among the strongest of the studies re%viewedhere. t shows MBI2 to !e superior to 2AU in preventing

relapse, using a treatment manual '4egal et al., ;;- and a

large and clearly speci3ed sample of formerly depressed

patients. Additional studies conducted !y inde%pendent

investigators con3rming this 3nding, or showing MBI2 to !e

euivalent or superior to another treatment in preventing

depressive relapse, would ualify MBI2 for the "well

esta!lished& designation.

2wo issues may complicate the empirical validation of

mindfulness%!ased interventions. 2he empirical evalua%tion of

any intervention reuires clear operational de3ni%tions of

concepts and procedures, and the identi3cation of conceptually

sound mechanisms that may account for changes produced !y

the intervention. 2he preceding dis%cussion illustrates that

mindfulness%!ased interventions can !e rigorously

operationali>ed, conceptuali>ed, and empir%ically evaluated.

8owever, to do so risks overlooking important elements of the

long tradition from which mindfulness meditation originates. As

descri!ed !y Ka!at%0inn ';;;-, the practice of mindfulness

meditation is concerned with the cultivation of awareness,

insight, wis%dom, and compassion, concepts that may !e

appreciated and valued !y many people yet difficult to evaluate

empir%ically. 2hus, although methodologically rigorous investi%

gations of the eff ects of MB4R are !oth possi!le and necessary,

perhaps researchers should consider ways to in%corporate theseother concepts, in addition to more read%ily measured constructs

such as symptom reduction.

n addition, unlike many empirically supported treat%ments,

MB4R was not developed to treat any speci3c dis%order.

Although the initial pu!lications e$amined its eff ects in chronic

pain patients, it is generally taught in groups of people with a

wide range of complaints. As the term stress reduction implies, it

is designed to reduce suff ering and im%prove health and well%

!eing, and to !e !roadly applica!le to many pro!lems. 2hus,

evaluation of its eff ectiveness with speci3c disorders, although

necessary for empirical validation, may not !e entirely consistent

with current methods of application in many settings. Dhen

studies are conducted with mi$ed populations, thorough

diagnostic

assessment of participants would help clarify eff ectson speci3c conditions.

Although the empirical literature supporting its effi%cacy is

small, MB4R programs are widely availa!le. 4cheel ';;;- and

4wenson ';;;- have descri!ed a similar pro%liferation of 5B2

programs, of which mindfulness training is an importantcomponent. =iven the potential !ene3ts and increasing

popularity of mindfulness training, it seems critically important to

conduct methodologically sound empirical evaluations of the

eff ects of mindfulness inter%ventions for a range of pro!lems,

!oth in comparison to other well%esta!lished interventions and

as a component of treatment packages.

AC=*/anne 4egerstrom, and =reg

4mith for helpful comments on earlier drafts.

RE7ERE*CE, Astin, L. A. ')**?-. 4tress reduction through mindfulness medi%

tation. Pschotherap and Pschosomatics, ((, *?);+.

Barlow, 5. 8., ( Iraske, M. =. ';;;-. Master of our anxiet and

panic 'rd ed.-. Hew :ork 6sychological Iorporation.

Bartsch, 8., Bartsch, I., 4imon, D. E., Glehmig, B., Egels, .,( 9ippert, 2. 8. ')**-. Antitumor activity of the pinealgland Eff ect of unidenti3ed su!stances versus the eff ectof mela%tonin. Oncolo&, )*, ?;.

Beck, A. 2., ( 4teer, R. A. ')*?-. +ec Depression In"entor man-

ual. 4an Antonio, 2S 6sychological Iorporation.

Beck, A. 2., ( 4teer, R. A. ')**-. +ec Anxiet In"entor man-

ual. 4an Antonio, 2S 6sychological Iorporation.

Benson, 8. ')*?7-. 'he relaxation response. Hew :ork Morrow. Brock,

2. I., =reen, M. I., Reich, I. A., ( Evans, 9. M.')**+-. 2he Consumer eports study of psychotherapynvalid is

invalid. American Pscholo&ist, /, );.

Iarlson, 9. E., Ursuliak, 0., =oodey, E., Angen, M., ( 4peca, M.

';;)-. 2he eff ects of a mindfulness meditation%!ased stress

reduction program on mood and symptoms of stress in

cancer outpatients +%month follow%up. Supporti"e Care in

Cancer, *, ))).

Iham!less, 5. 9., ( 8ollon, 4. 5. ')**-. 5e3ning

empirically supported therapies. 0ournal of Consultin&

and Clinical Pschol-o&, ((, ?).Iohen, L. ')*??-. Statistical po1er analsis for the 2eha"ioral sciences

'nd ed.-. Hew :ork Academic 6ress.Iurry, 4. L., Marlatt, =. A., =ordon, L., ( Baer, L. 4. ')*-. A comparison

of alternative theoretical approaches to smoking cessation and

relapse. 3ealth Pscholo&, 4, 71777+.

C0I*ICA0 +,-C/0/1-: ,CIE*CE A*2 +RACTICE 9 53( *'$ ,8MMER '(() 3(


20/22

5elmonte, M. M. ')*7-. Meditation and an$iety reduction A

literature review. Clinical Pscholo& e"ie1, , *));.

5erogatis, 9. R. ')*-. SC5-*6-7 Administration, scorin&,

and procedures manual-II. 2owson, M5Ilinical

6sychometric Re%search.

=olden!erg, 5. 9., Kaplan, K. 8., Hadeau, M. =., Brodeur, I.,

4mith, 4., ( 4chmid, I. 8. ')**1-. A controlled study of a stress%

reduction, cognitive%!ehavioral treatment program in

3!romyalgia. 0ournal of Musculoseletal Pain, 8, 7++.

=oleman, 5. L., ( 4chwart>, =. E. ')*?+-. Meditation as an in%

tervention in stress reactivity. 0ournal of Consultin& and

Clinical Pscholo&, )), 17+1++.

=uerrero, L., ( Reiter, R. ')**-. A !rief survey of penial

gland immune system interrelationships. %ndocrinolo&

esearch, /9, *))).

8anh, 2. H. ')*?+-. 'he miracle of mindfulness. Boston

Beacon 6ress.

8ayes, 4. I. ')*?-. A conte$tual approach to therapeuticchange. n H. 4. Laco!son 'Ed.-, Pschotherapists in clinical

prac-tice7 Co&niti"e and 2eha"ioral perspecti"es 'pp. ?

?-. Hew :ork =uilford 6ress.

8ayes, 4. I. ')**1-. Iontent, conte$t, and the types of psycho%

logical acceptance. n 4. I. 8ayes, H. 4. Laco!son, P. M.

Gol%lette, ( M. L. 5ougher 'Eds.-, Acceptance and chan&e7

Content and context in pschotherap 'pp. )-. Reno,

HP Ionte$t 6ress.

8ayes, 4. I., Laco!son, H. 4., Gollette, P. M., ( 5ougher, M. L.

'Eds.-. ')**1-. Acceptance and chan&e7 Content and context

in pschotherap. Reno, HP Ionte$t 6ress.

8ayes, 4. I., 4trosahl, K., ( Dilson, K. =. ')***-. Acceptance and

Commitment 'herap. Hew :ork =uilford 6ress.8ayes, 4. I., ( Dilson, K. =. ')**-. 4ome applied

implications of a contemporary analytic account of ver!al

events. +eha"ior Analst, /(, ;).8eatherton, 2. G., ( Baumeister, R. G. ')**)-. Binge eating as es%cape

from self%awareness. Pscholo&ical +ulletin, //6, +);.

to, L. R., 5onovan, 5. M., ( 8all, L. L. ')*-. Relapsepreven%tion in alcohol aftercareEff ects on drinkingoutcome, change process, and aftercare attendance.+ritish 0ournal of Addiction, 9:, )?))).

Laco!son, H. 4., ( Revensdorf, 5. ')*-. 4tatistics for

assessing the clinical signi3cance of psychotherapy

techniues ssues, pro!lems, and new developments.

+eha"ioral Assessment, /6, ))17.

Laco!son, H. 4., ( 2rua$, 6. ')**)-. Ilinical signi3cance A sta%

tistical approach to de3ning meaningful change in psycho%

therapy research. 0ournal of Consultin& and Clinical

Pscholo&, *, ))*.

Ka!at%0inn, L. ')*-. An outpatient program in !ehavioral med%icine for

chronic pain patients !ased on the practice of mind%

fulness meditation 2heoretical considerations and prelimi%nary

results. #eneral 3ospital Pschiatr, ), 1?.

Ka!at%0inn, L. ')**;-. Gull catastrophe livingUsing the

wisdom of your !ody and mind to face stress, pain, and

illness. Hew :ork 5elacorte.Ka!at%0inn, L. ')**1-. ;here"er ou &o, there ou are7 Mindfulness

meditation in e"erda life. Hew :ork 8yperion.

Ka!at%0inn, L. ';;;-. ndra#s net at work2he mainstreaming of 5harma

practice in society. n =. Datson ( 4. Batchelor 'Eds.-, 'he

pscholo& of a1aenin&7 +uddhism, science, and our da-to-da

li"es 'pp. 71*-. Hork Beach, ME Deiser.

Ka!at%0inn, L., ( Ihapman%Daldrop, A. ')*-. Iompliance with

an outpatient stress reduction program Rates and pre%

dictors of program completion. 0ournal of +eha"ioral

Medicine, //, 7.

Ka!at%0inn, L., 9ipworth, 9, ( Burney, R. ')*7-. 2he clinical use of

mindfulness meditation for the self%regulation of chronic pain.

0ournal of +eha"ioral Medicine, 9, )+)*;.Ka!at%0inn, L., 9ipworth, 9., Burney, R., ( 4ellers, D. ')*?-. Gour%

year follow%up of a meditation%!ased program for the self%

regulation of chronic pain2reatment outcomes and com%pliance.

Clinical 0ournal of Pain, 8, )7*)?.

Ka!at%0inn, L., Massion, M. 5., Kristeller, L., 6eterson, 9. =.,Gletcher, K. E., 6!ert, 9., et al. ')**-. Eff ectiveness of a

meditation%!ased stress reduction program in thetreatment of an$iety disorders. American 0ournal of Pschiatr, /)*, *+ *1.

Ka!at%0inn, L., Dheeler, E., 9ight, 2., 4killings, 0., 4charf, M. L.,

Iropley, 2. =., et al. ')**-. nJuence of a mindfulness

meditation!ased stress reduction intervention on rates of skin

clearing in patients with moderate to severe psoriasis undergoing

phototherapy 'UPB- and photochemotherapy '6UPA-.

Pschosomatic Medicine, 6, +7+.

Kaplan, K. 8., =olden!erg, 5. 9., ( =alvin, H. M. ')**-. 2he impact

of a meditation%!ased stress reduction program on

3!romyalgia. #eneral 3ospital Pschiatr, /, 1*. Ka>din,

A. E. ')**1-. Methodology, design, and evaluation in

psychotherapy research. n A. E. Bergin ( 4. 9. =ar3eld

'Eds.-, 3and2oo of pschotherap and 2eha"ior chan&e

'1th ed., pp. )*?)-. Hew :ork Diley.

Kohlen!erg, R. L., 8ayes, 4. I., ( 2sai, M. ')**-. Radical !e%

havioral psychotherapy 2wo contemporary e$amples. Clini-

cal Pscholo& e"ie1, /:, 7?*7*.

Koons, I. R., Ro!ins, I. R., 2weed, L. 9., 9ynch, 2. R., =on%>ale>,

A. M., Morse, L. Q., et al. ';;)-. Efficacy of dialecti%cal !ehavior

therapy in women veterans with !orderline personality disorder.

+eha"ior 'herap, :8, ?)*;.

Kristeller, L. 9., ( 8allett, I. B. ')***-. An e$ploratory study of a

meditation%!ased intervention for !inge eating disorder.

0ournal of 3ealth Pscholo&, ), 7?+.

MI*2780*E,, TRAI*I*1 9 6AER 33


21/22

Kut>, ., 9eserman, L., 5orrington, I., Morrison, I., Borysenko, L., (

Benson, 8. ')*7-. Meditation as an ad/unct to psycho%therapy.

Pschotherap and Pschosomatics, ):, ;*).

Kuyken, D., ( Brewin, I. R. ')**7-. Auto!iographical memory

functioning in depression and reports of early a!use. 0ournal

of A2normal Pscholo&, /6), 777*).

9anger, E. L. ')**-. Mindfulness. Reading, MAAddison Desley. 9anger,

E. L. ')**?-. 'he po1er of mindful learnin&. Reading, MA

Addison Desley.

9anger, E. L., ( Moldoveanu, M. ';;;-. 2he construct of

mind%fulness. 0ournal of Social Issues, (, )*.

9inehan, M. M. ')**a-. Co&niti"e-2eha"ioral treatment of

2orderline personalit disorder. Hew :ork =uilford 6ress.

9inehan, M. M. ')**!-. Sills trainin& manual for treatin& 2order-

line personalit disorder. Hew :ork =uilford 6ress.

9inehan, M. M. ')**1-. Acceptance and change2he central di%

alectic in psychotherapy. n 4. I. 8ayes, H. 4. Laco!son, P.

M. Gollette, ( M. L. 5ougher 'Eds.-, Acceptance and chan&e7Con-tent and context in pschotherap 'pp. ?+-. Reno,

HP Ion%te$t 6ress.

9inehan, M. M., Armstrong, 8. E., 4uare>, A., Allmon, 5., (

8eard, 8. 9. ')**)-. Iognitive%!ehavioral treatment of

chronically suicidal !orderline patients. Archi"es of

#eneral Pschiatr, )9, );+;);+1.

9inehan, M. M., 8eard, 8. 9., ( Armstrong, 8. E. ')**-.

Hat%uralistic follow%up of a !ehavioral treatment for

chronically parasuicidal !orderline patients. Archi"es of

#eneral Pschiatr, 6, )7?)7.

9inehan, M. M., 2utek, 5., 8eard, 8. 9., ( Armstrong, 8. E.

')**1-. nterpersonal outcome of cognitive%!ehavioral treat%

ment for chronically suicidal !orderline patients. American0ournal of Pschiatr, /, )??))??+.

Marlatt, =. A. ')**1-. Addiction, mindfulness, and acceptance. n 4. I.

8ayes, H. 4. Laco!son, P. M. Gollette, ( M. L. 5ougher 'Eds.-,

Acceptance and chan&e7 Content and context in pscho-therap 'pp.

)?7)*?-. Reno, HP Ionte$t 6ress.

Marlatt, =. A., ( =ordon, L. R. ')*7-. elapse pre"ention7

Main-tenance strate&ies in the treatment of addicti"e

2eha"iors. Hew :ork =uilford 6ress.

Marlatt, =. A., ( Kristeller, L. 9. ')***-. Mindfulness and

medi%tation. n D. R. Miller 'Ed.-, Inte&ratin& spiritualit

into treat-ment 'pp. +?1-. Dashington, 5I American

6sychological Association.

Massion, A. C., 2eas, L., 8e!ert, L. R., Dertheimer, M. 5., (Ka!at%0inn, L. ')**7-. Meditation, melatonin, and !reastF

prostate cancer 8ypothesis and preliminary data.

Medical 3potheses, )), *1+.

Miller, L. L., Gletcher, K., ( Ka!at%0inn, L. ')**7-. 2hree%year follow%

up and clinical implications of a mindfulness meditation%!ased

stress reduction intervention in the treat%

ment of an$iety disorders. #eneral 3ospital Pschiatr,

/4, )* ;;.

Holen%8oeksema, 4. ')**)-. Responses to depression and their eff ects on the duration of depressive episodes. 0ournal of A2-normal Pscholo&, /66, 7+*7.

Crme%Lohnson, 5. D. ')*1-. Autonomic sta!ility and tran%scendental meditation. n 5. 8. 4hapiro, Lr., ( R. H. Dalsh

'Eds.-, Meditation7 Classic and contemporar perspecti"es

'pp. 7); 7)-. Hew :ork Aldine.

Randolph, 6. 5., Ialdera, :. M., 2acone, A. M., ( =reak, M. 9. ')***-.

2he long%term com!ined eff ects of medical treat%ment and a

mindfulness%!ased !ehavioral program for the multidisciplinary

management of chronic pain in west 2e$as.

Pain Di&est, *, );)).

Rei!el, 5. K., =reeson, L. M., Brainard, =. I., ( Rosen>weig, 4.

';;)-. Mindfulness%!ased stress reduction and health%related

uality of life in a heterogeneous patient population. #eneral

3ospital Pschiat

mindfulness psychology

Documents