Mindfulness-based stress reduction: What processes are at work?

Summary

Mindfulness-Based Stress Reduction (MBSR) is a program that has been shown to be beneficial for clinical and non-clinical populations. While much attention has been paid to participants’ outcomes, little work has been published concerning processes underlying improvements. Herein, women who had finished medical treatment for breast cancer completed questionnaires pre- and post-MBSR and were interviewed using focus group methodology such that quantitative and qualitative data were combined to explore potential mechanisms underlying changes. It was found that the Mindfulness Attention Awareness Scale was a useful process measure to assess changes in mindfulness and that the Coping with Health Injuries and Problems questionnaire was useful in documenting changes in palliative (self-care) coping over the course of the 8 week program. Moreover, the Sense of Coherence questionnaire suggested that the women viewed life as more meaningful and manageable following MSBR. Our findings fit with Shapiro et al.'s theory that, over time, participants in an MBSR program “reperceive” what they encounter in their daily experiences.

Introduction

Mindfulness-Based Stress Reduction (MBSR), a clinical program developed over 25 years ago has gradually gained recognition as an important means of teaching people how to live their lives fully whether they are patients with chronic illness,¹ health professionals,² community members dealing with the stressors inherent in life,[3], [4] students,[5], [6] prisoners, or priests. Interest in MBSR has grown in the clinical and the research communities.⁷ The literature is replete with articles documenting outcomes from observational studies, randomized clinical trials, as well as theoretical discussions pertaining to the construct “mindfulness”, its impact on mental and physical health, as well as its measurement.⁸

Given that several review articles have been published with regard to the benefits associated with MBSR[9], [10], [11] as well as potential mechanisms for change,[10], [12] herein the focus extends beyond outcomes in an attempt to comprehend what arises in between pre- and post-program assessments.

Relatively little attention has been paid to process variables related to MBSR.¹³ That is, what changes during participation in the program? Do individuals become more mindful? Do they modify how they cope with stressors? Is their world view altered (e.g., Do they see life as more manageable)? Clearly, because the development of measures of mindfulness has lagged behind efficacy studies⁸ this remains to be established, as does the relationship between such changes and outcomes.¹¹ Moreover, while some researchers have documented practice (usually in terms of frequency and/or duration[11], [14]), the study of adherence to practice of various forms of meditation taught in MBSR is generally cursory.¹⁵ Furthermore, it is unknown if it is the quantity or quality of meditation practice that is instrumental in effecting changes.¹⁶ Importantly, it is likely that if and how one integrates mindfulness into daily life (i.e., “informal practice”) is critical to healing. This latter point is relevant to the choice of instruments used to measure mindfulness in that a tool that captures both “on and off the cushion” mindfulness is needed.

Researchers have reported data pertaining to adherence as it relates to the program's core practices (body scan, yoga, sitting meditation).¹⁷ Some are based on retrospective reports that participants provide upon completion of the MBSR program using the University of Massachusetts Stress Reduction clinic follow-up questionnaire; others request that participants keep a diary of their practice.¹⁸ Thus far, this has been the main process variable addressed. Occasionally it has been related to outcomes; for example, Astin⁵ did not find a correlation between the reduction in psychological distress and time spent meditating in undergraduate students; but the average time of practice was only 30 min per day, 3.5 days per week which was considerably less than what was “prescribed” (45 min per day, 6 times per week). Speca et al.¹ employed the variable “number of sessions attended” and found that it was the best predictor of improvements in stress-related symptoms (accounting for 13.2% of the variance) in cancer patients.

As for measurement of “mindfulness”, there has been progress with regard to new approaches. Baer et al.¹⁹ developed the Kentucky Inventory for Mindfulness Skills; Brown and Ryan⁸ developed the Mindfulness Attention Awareness Scale (MAAS); Lau et al.²⁰ developed the Toronto Mindfulness Scale; Buchheld et al.²¹ developed the Freiburg Mindfulness Inventory; and Feldman et al. ²² have developed the Cognitive Affective Mindfulness Scale. Each tool has its strengths and limitations. For example, the Toronto Mindfulness Scale cannot be used outside mindfulness training and the Freiburg Mindfulness Inventory is designed for experienced meditators and those attending meditation retreats. The research team in Calgary, Canada, in collaboration with Brown and Ryan,⁸ used the MAAS with 41 early-stage breast (n=32) and prostrate cancer (n=9) patients who participated in a MBSR program.

It was hypothesized that changes in MAAS-measured mindfulness would predict pre- to post-MBSR changes in emotional distress and stress. The results showed that even though the MAAS scores did not change significantly from pre- to post-MBSR, increases in mindfulness predicted a decrease in psychological distress and a decline in stress and stress-related symptoms. This instrument thus shows promise with regard to use as a process measure.