Effects of Mindfulness on Psychological Health: A Review of Empirical Studies
Tue, 07 Jan 2020 09:42
Clin Psychol Rev . Author manuscript; available in PMC 2013 Jun 11.
Published in final edited form as:
Shian-Ling KengaDepartment of Psychology and Neuroscience, Duke University, Durham, NC 27708
Moria J. SmoskibDepartment of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710
Clive J. RobinsaDepartment of Psychology and Neuroscience, Duke University, Durham, NC 27708
bDepartment of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710
aDepartment of Psychology and Neuroscience, Duke University, Durham, NC 27708
bDepartment of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710
Correspondence concerning this paper should be addressed to Shian-Ling Keng, Box 3026, Duke University Medical Center, Durham, NC 27710.
ude.ekud@81kls, Phone: (1) 919-309-6226, Fax: (1) 919-684-6770
The publisher's final edited version of this article is available at
Clin Psychol RevSee other articles in PMC that
cite the published article.
AbstractWithin the past few decades, there has been a surge of interest in the investigation of mindfulness as a psychological construct and as a form of clinical intervention. This article reviews the empirical literature on the effects of mindfulness on psychological health. We begin with a discussion of the construct of mindfulness, differences between Buddhist and Western psychological conceptualizations of mindfulness, and how mindfulness has been integrated into Western medicine and psychology, before reviewing three areas of empirical research: cross-sectional, correlational research on the associations between mindfulness and various indicators of psychological health; intervention research on the effects of mindfulness-oriented interventions on psychological health; and laboratory-based, experimental research on the immediate effects of mindfulness inductions on emotional and behavioral functioning. We conclude that mindfulness brings about various positive psychological effects, including increased subjective well-being, reduced psychological symptoms and emotional reactivity, and improved behavioral regulation. The review ends with a discussion on mechanisms of change of mindfulness interventions and suggested directions for future research.
Keywords: Mindfulness, Mindfulness-oriented Interventions, Mindfulness Meditation, Psychological Health, Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive Therapy, Dialectical Behavior Therapy, Acceptance and Commitment Therapy
Mindfulness is the miracle by which we master and restore ourselves. Consider, for example: a magician who cuts his body into many parts and places each part in a different region'--hands in the south, arms in the east, legs in the north, and then by some miraculous power lets forth a cry which reassembles whole every part of his body. Mindfulness is like that'--it is the miracle which can call back in a flash our dispersed mind and restore it to wholeness so that we can live each minute of life.
Hanh (1976, p. 14)
Mindfulness has been theoretically and empirically associated with psychological well-being. The elements of mindfulness, namely awareness and nonjudgmental acceptance of one's moment-to-moment experience, are regarded as potentially effective antidotes against common forms of psychological distress'--rumination, anxiety, worry, fear, anger, and so on'--many of which involve the maladaptive tendencies to avoid, suppress, or over-engage with one's distressing thoughts and emotions (Hayes & Feldman, 2004; Kabat-Zinn, 1990). Though promoted for centuries as a part of Buddhist and other spiritual traditions, the application of mindfulness to psychological health in Western medical and mental health contexts is a more recent phenomenon, largely beginning in the 1970s (e.g., Kabat-Zinn, 1982). Along with this development, there has been much theoretical and empirical work illustrating the impact of mindfulness on psychological health. The goal of this paper is to offer a comprehensive narrative review of the effects of mindfulness on psychological health. We begin with an overview of the construct of mindfulness, differences between Buddhist and Western psychological conceptualizations of mindfulness, and how mindfulness has been integrated into Western medicine and psychology. We then review evidence from three areas of research that shed light on the relationship between mindfulness and psychological health: 1. correlational, cross-sectional research that examines the relations between individual differences in trait or dispositional mindfulness and other mental-health related traits, 2. intervention research that examines the effects of mindfulness-oriented interventions on psychological functioning, and 3. laboratory-based research that examines, experimentally, the effects of brief mindfulness inductions on emotional and behavioral processes indicative of psychological health. We conclude with an examination of mechanisms of effects of mindfulness interventions and suggestions for future research directions.
The word mindfulness may be used to describe a psychological trait, a practice of cultivating mindfulness (e.g., mindfulness meditation), a mode or state of awareness, or a psychological process (Germer, Siegel, & Fulton, 2005). To minimize possible confusion, we clarify which meaning is intended in each context we describe (Chambers, Gullone, & Allen, 2009). One of the most commonly cited definitions of mindfulness is the awareness that arises through ''paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally'' (Kabat-Zinn, 1994, p. 4). Descriptions of mindfulness provided by most other researchers are similar. Baer (2003), for example, defines mindfulness as ''the nonjudgmental observation of the ongoing stream of internal and external stimuli as they arise'' (p. 125). Though some researchers focus almost exclusively on the attentional aspects of mindfulness (e.g., Brown & Ryan, 2003), most follow the model of Bishop et al. (2004), which proposed that mindfulness encompasses two components: self-regulation of attention, and adoption of a particular orientation towards one's experiences. Self-regulation of attention refers to non-elaborative observation and awareness of sensations, thoughts, or feelings from moment to moment. It requires both the ability to anchor one's attention on what is occurring, and the ability to intentionally switch attention from one aspect of the experience to another. Orientation to experience concerns the kind of attitude that one holds towards one's experience, specifically an attitude of curiosity, openness, and acceptance. It is worth noting that ''acceptance'' in the context of mindfulness should not be equated with passivity or resignation (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008). Rather, acceptance in this context refers to the ability to experience events fully, without resorting to either extreme of excessive preoccupation with, or suppression of, the experience. To sum up, current conceptualizations of mindfulness in clinical psychology point to two primary, essential elements of mindfulness: awareness of one's moment-to-moment experience nonjudgmentally and with acceptance.
As alluded to earlier, mindfulness finds its roots in ancient spiritual traditions, and is most systematically articulated and emphasized in Buddhism, a spiritual tradition that is at least 2550 years old. As the idea and practice of mindfulness has been introduced into Western psychology and medicine, it is not surprising that differences emerge with regard to how mindfulness is conceptualized within Buddhist and Western perspectives. Several researchers (e.g., Chambers, Gullone, & Allen, 2009; Rosch, 2007) have argued that in order to more fully appreciate the potential contribution of mindfulness in psychological health it is important to gain an understanding of these differences, and specifically, from a Western perspective, how mindfulness is conceptualized in Buddhism. Given the diversity of traditions and teachings within Buddhism, an in-depth exploration of this topic is beyond the scope of this review (for a more extensive discussion of this topic, see Rosch, 2007). We offer a preliminary overview of differences in conceptualization of mindfulness in Western usage versus early Buddhist teachings, specifically, those of Theravada Buddhism.
Arguably, Buddhist and Western conceptualizations of mindfulness differ in at least three levels: contextual, process, and content. At the contextual level, mindfulness in the Buddhist tradition is viewed as one factor of an interconnected system of practices that are necessary for attaining liberation from suffering, the ultimate state or end goal prescribed to spiritual practitioners in the tradition. Thus, it needs to be cultivated alongside with other spiritual practices, such as following an ethical lifestyle, in order for one to move toward the goal of liberation. Western conceptualization of mindfulness, on the other hand, is generally independent of any specific circumscribed philosophy, ethical code, or system of practices. At the process level, mindfulness, in the context of Buddhism, is to be practiced against the psychological backdrop of reflecting on and contemplating key aspects of the Buddha's teachings, such as impermanence, non-self, and suffering. As an example, in the Satipatthana Sutta (The Foundation of Mindfulness Discourse), one of the key Buddhist discourses on mindfulness, the Buddha recommended that one maintains mindfulness of one's bodily functions, sensations and feelings, consciousness, and content of consciousness while observing clearly the impermanent nature of these objects. Western practice generally places less emphasis on non-self and impermanence than traditional Buddhist teachings. Finally, at the content level and in relation to the above point, in early Buddhist teachings, mindfulness refers rather specifically to an introspective awareness with regard to one's physical and psychological processes and experiences. This is contrast to certain Western conceptualizations of mindfulness, which view mindfulness as a form of awareness that encompasses all forms of objects in one's internal and external experience, including features of external sensory objects like sights and smells. This is not to say that external sensory objects do not ultimately form part of one's internal experience; rather, in Buddhist teachings, mindfulness more fundamentally has to do with observing one's perception of and reactions toward sensory objects than focusing on features of the sensory objects themselves.
The integration of mindfulness into Western medicine and psychology can be traced back to the growth of Zen Buddhism in America in the 1950s and 1960s, partly through early writings such as Zen in the Art of Archery (Herrigel, 1953), The World of Zen: An East-West Anthology (Ross, 1960), and The Method of Zen (Herrigel, Hull, & Tausend, 1960). Beginning the 1960s, interest in the use of meditative techniques in psychotherapy began to grow among clinicians, especially psychoanalysts (e.g., see Boss, 1965; Fingarette, 1963; Suzuki, Fromm, & De Martino, 1960; Watts, 1961). Through the 1960s and the 1970s, there was growing interest within experimental psychology in examining various means of heightening awareness and broadening the boundaries of consciousness, including meditation. Early electroencephalogram (EEG) studies on meditation found that individuals who meditated showed persistent alpha activity with restful reductions in metabolic rate (Anand, Chhina, & Singh, 1961; Bagchi & Wenger, 1957; Wallace, 1970), as well as increases in theta waves, which reflect lower states of arousal associated with sleep (Kasamatsu & Hirai, 1966). Beginning in the early 1970s, there was a surge of interest in and research on transcendental meditation, a form of concentrative meditation technique popularized by Maharishi Mahesh Yogi (Wallace, 1970). The practice of transcendental meditation was found to be associated with reductions in indicators of physiological arousal such as oxygen consumption, carbon dioxide elimination, and respiratory rate (Benson, Rosner, Marzetta, & Klemchuk, 1974; Wallace, 1970; Wallace, Benson, & Wilson, 1971).
Despite the fact that research on mindfulness meditation had already begun in the 1960s, it was not until the late 1970s that mindfulness meditation began to be studied as an intervention to enhance psychological well-being. Application of mindfulness meditation as a form of behavioral intervention for clinical problems began with the work of Jon Kabat-Zinn, which explored the use of mindfulness meditation in treating patients with chronic pain (Kabat-Zinn, 1982), now known popularly as Mindfulness-Based Stress Reduction. Since the establishment of MBSR, several other interventions have also been developed using mindfulness-related principles and practices, including Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002), Dialectical Behavior Therapy (DBT; Linehan, 1993a) and Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999). In this review, both meditation-oriented interventions (i.e., MBSR and MBCT), as well as interventions that teach mindfulness using less meditation-oriented techniques (i.e., DBT and ACT), are considered as a family of ''mindfulness-oriented interventions'', and thus are of empirical interest.
Correlational Research on Mindfulness and Psychological HealthRelationship between Trait Mindfulness and Psychological HealthMany studies of mindfulness to date have reported on correlations between self-reported mindfulness and psychological health. Such correlations have been reported for samples of undergraduate students (e.g., Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006; Brown & Ryan, 2003), community adults (e.g., Brown & Ryan, 2003; Chadwick et al., 2008) and clinical populations (e.g., Baer, Smith, & Allen, 2004; Chadwick et al., 2008; Walach, Buchheld, Buttenmuller, Kleinknecht, & Schmidt, 2006). Before going over these findings, it may be helpful to review questionnaires that have been developed to measure mindfulness. Questionnaires that assess mindfulness as a general, trait-like tendency to be mindful in daily life include: Freiburg Mindfulness Inventory (Buchheld, Grossman, & Walach, 2001), Kentucky Inventory of Mindfulness Skills (KIMS; Baer et al., 2004), Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003), Five-Facet Mindfulness Questionnaire (Baer et al., 2006), Cognitive Affective Mindfulness Scale-Revised (Feldman, Hayes, Kumar, Greeson, & Laurenceau, 2007), Toronto Mindfulness Scale-Trait Version (Davis, Lau, & Cairns, 2009), Philadelphia Mindfulness Scale (Cardaciotto et al., 2008), and Southampton Mindfulness Questionnaire (Chadwick et al., 2008). Some of these questionnaires measure mindfulness as a single-factor construct. For example, the MAAS (Brown & Ryan, 2003) assesses mindfulness as the general tendency to be attentive to and aware of experiences in daily life, and has a single factor structure of open/ receptive awareness and attention. Other questionnaires measure mindfulness as a multi-faceted construct. For example, the KIMS (Baer et al., 2004) contains subscales that correspond to four mindfulness skills conceptualized in DBT's framework: observing one's moment-to-moment experience, describing one's experiences with words, acting or participating with awareness, and nonjudgmental acceptance of one's experiences. In addition to trait measures of mindfulness, state measures of mindfulness have been developed to measure momentary mindful states. These measures include the Toronto Mindfulness Scale (Lau et al., 2006) and Brown and Ryan (2003)'s state version of the MAAS.
Trait mindfulness has been associated with higher levels of life satisfaction (Brown & Ryan, 2003), agreeableness (Thompson & Waltz, 2007), conscientiousness (Giluk, 2009; Thompson & Waltz, 2007), vitality (Brown & Ryan, 2003), self esteem (Brown & Ryan, 2003; Rasmussen & Pidgeon, 2010), empathy (Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008), sense of autonomy (Brown & Ryan, 2003), competence (Brown & Ryan, 2003), optimism (Brown & Ryan, 2003), and pleasant affect (Brown & Ryan, 2003). Studies have also demonstrated significant negative correlations between mindfulness and depression (Brown & Ryan, 2003; Cash & Whittingham, 2010), neuroticism (Dekeyser et al., 2008; Giluk, 2009), absent-mindedness (Herndon, 2008), dissociation (Baer et al., 2006; Walach et al., 2006), rumination (Raes & Williams, 2010), cognitive reactivity (Raes, Dewulf, Van Heeringen, & Williams, 2009), social anxiety (Brown & Ryan, 2003; Dekeyser et al., 2008; Rasmussen & Pidgeon, 2010), difficulties in emotion regulation (Baer et al., 2006), experiential avoidance (Baer et al., 2004), alexithymia (Baer et al., 2004), intensity of delusional experience in the context of psychosis (Chadwick et al., 2008), and general psychological symptoms (Baer et al., 2006). Research also has begun to explore the association between mindfulness and cognitive processes that may have important implications for psychological health. For example, Frewen, Evans, Maraj, Dozois, and Partridge (2008) found that, among undergraduate students, mindfulness was related both to a lower frequency of negative automatic thoughts and to an enhanced ability to let go of those thoughts. Two other studies have also demonstrated an association between mindfulness and enhanced performance on tasks assessing sustained attention (Schmertz, Anderson, & Robins, 2009) and persistence (Evans, Baer, & Segerstrom, 2009).
Mindfulness has been shown to be related not only to self-report measures of psychological health, but also to differences in brain activity observed using functional neuroimaging methods. Creswell, Way, Eisenberger, and Lieberman (2007) found that trait mindfulness was associated with reduced bilateral amygdala activation and greater widespread prefrontal cortical activation during an affect labeling task. There was also a strong inverse association between prefrontal cortex and right amygdala responses among those who scored high on mindfulness, but not among those who scored low on mindfulness, which suggests that individuals who are mindful may be better able to regulate emotional responses via prefrontal cortical inhibition of the amygdala. Trait mindfulness also was negatively correlated with resting activity in the amygdala and in medial prefrontal and parietal brain areas that are associated with self-referential processing, whereas levels of depressive symptoms were positively correlated with resting activity in these areas (Way, Creswell, Eisenberger, & Lieberman, 2010). These findings are consistent with the association of mindfulness with greater self-reported ability to let go of negative thoughts about the self (e.g., Frewen et al., 2008).
Relationship between Mindfulness Meditation and Psychological HealthResearch also has examined the relationship between mindfulness meditation practices and psychological well-being. Lykins and Baer (2009) compared meditators and non-meditators on several indices of psychological well-being. Meditators reported significantly higher levels of mindfulness, self-compassion and overall sense of well-being, and significantly lower levels of psychological symptoms, rumination, thought suppression, fear of emotion, and difficulties with emotion regulation, compared to non-meditators, and changes in these variables were linearly associated with extent of meditation practice. In addition, the data were consistent with a model in which trait mindfulness mediates the relationship between extent of meditation practice and several outcome variables, including fear of emotion, rumination, and behavioral self-regulation. In two other studies, facets of trait mindfulness were found to mediate the relationship between meditation experience and psychological well-being in combined samples of meditators and non-meditators (Baer et al., 2008; Josefsson, Larsman, Broberg, & Lundh, 2011). In addition to correlations with self-report measures, research has examined behavioral and neurobiological correlates of mindfulness meditation. Ortner, Kilner and Zelazo (2007) used an emotional interference task in which participants categorized tones presented 1 or 4 seconds following the onset of affective or neutral pictures. Levels of emotional interference were indexed by differences in reaction times to tones for affective pictures versus neutral pictures. A participant's mindfulness meditation experience was significantly associated with reduced interference both from unpleasant pictures (for 1 and 4 second delays) as well as pleasant pictures (for 4 second delay only), as well as higher levels of self-reported mindfulness and psychological well-being. These findings suggest that mindfulness meditation practice may enhance psychological well-being by increasing mindfulness and attenuating reactivity to emotional stimuli by facilitating disengagement of attention from stimuli. There is also emerging evidence from studies comparing meditators and non-meditators on a variety of performance-based measures that suggest that regular meditation practice is associated with enhanced cognitive flexibility and attentional functioning (Hodgins & Adair, 2010; Moore & Malinowski, 2009), outcomes that may have important implications for psychological well-being. Research has also identified potential neurobiological correlates of mindfulness meditation by comparing brain structure and activity in adept mindfulness meditation practitioners to those of non-practitioners. These studies found that extensive mindfulness meditation experience is associated with increased thickness in brain regions implicated in attention, interoception, and sensory processing, including the prefrontal cortex and right anterior insula (Lazar et al., 2005); increased activation in brain areas involved in processing of distracting events and emotions, which include the rostral anterior cingulate cortex and dorsomedial prefrontal cortex, respectively (H¶lzel et al., 2007); and greater gray matter concentration in brain areas that have been found to be active during meditation, including the right anterior insula, left inferior temporal gyrus, and right hippocampus (H¶lzel et al., 2008). These findings are consistent with the premise that systematic training in mindfulness meditation induces changes in attention, awareness, and emotion, which can be assessed and identified at subjective, behavioral, and neurobiological levels (cf. Treadway & Lazar, 2009).
Overall, evidence from correlational research suggests that mindfulness is positively associated with a variety of indicators of psychological health, such as higher levels of positive affect, life satisfaction, vitality, and adaptive emotion regulation, and lower levels of negative affect and psychopathological symptoms. There is also burgeoning evidence from neurobiological and laboratory behavioral research that indicates the potential roles of trait mindfulness and mindfulness meditation practices in reducing reactivity to emotional stimuli and enhancing psychological well-being. Given the correlational nature of these data, experimental studies are needed to clarify the directional links between mindfulness and psychological well-being. Does training in mindfulness practices result in improvements in psychological well-being? Does psychological well-being facilitate greater mindfulness and/or inclination towards engagement in mindfulness practice? The next section reviews empirical evidence from studies of the effects of mindfulness-oriented interventions on psychological health.
Controlled Studies of Mindfulness-Oriented InterventionsSeveral mindfulness-oriented interventions have been developed and received much research attention within the past two decades, including MBSR, MBCT, DBT and ACT. Some research on these interventions has been uncontrolled and some has focused primarily on physical health outcomes. In this section, we limit our review to published, peer-reviewed randomized controlled trials (RCTs) that assessed psychological health outcomes in adult populations. Some other promising interventions have also incorporated mindfulness techniques, including mindfulness-based relapse prevention (Witkiewitz, Marlatt, & Walker, 2005) and exposure-based cognitive therapy for depression (Hayes, Beevers, Feldman, Laurenceau, & Perlman, 2005), but no RCTs of those interventions have yet been published.
Mindfulness-Based Stress Reduction (MBSR): Description of Intervention and Review of Controlled StudiesMBSR is a group-based intervention program originally designed as an adjunct treatment for patients with chronic pain (Kabat-Zinn, 1982; 1990). The program offers intensive training in mindfulness meditation to help individuals relate to their physical and psychological conditions in more accepting and nonjudgmental ways. The program consists of an eight-to-ten week course, in which a group of up to thirty participants meet for two to two and a half hours per week for mindfulness meditation instruction and training (Kabat-Zinn, 1990). In addition to in-class mindfulness exercises, participants are encouraged to engage in home mindfulness practices and attend an all-day intensive mindfulness meditation retreat. The premise of MBSR is that with repeated training in mindfulness meditation, individuals will eventually learn to be less reactive and judgmental toward their experiences, and more able to recognize, and break free from, habitual and maladaptive patterns of thinking and behavior.
A number of RCTs of MBSR have been conducted among clinical and non-clinical populations, mostly using a waiting-list control design. Early studies were reviewed by Baer (2003) and Grossman, Niemann, Schmidt, and Walach (2004), but several important studies have since been published. Table 1 summarizes RCTs that have examined the impact of MBSR on psychological functioning. Overall, these studies found that MBSR reduces self-reported levels of anxiety (Shapiro, Schwartz, & Bonner, 1998; Anderson, Lau, Segal, & Bishop, 2007), depression (Anderson et al., 2007; Grossman et al., 2010; Koszycki, Benger, Shlik, & Bradwejn, 2007; Sephton et al., 2007; Shapiro et al., 1998; Speca, Carlson, Goodey, & Angen, 2000), anger (Anderson et al., 2007), rumination (Anderson et al. 2007; Jain et al., 2007), general psychological distress, including perceived stress (Astin, 1997; Br¤nstr¶m, Kvillemo, Brandberg, & Moskowitz, 2010; NyklÄek, & Kuipers, 2008; Oman, Shapiro, Thoresen, Plante, & Flinders, 2008; Shapiro, Astin, Bishop, & Cordova, 2005; Speca et al., 2000; Williams, Kolar, Reger, & Pearson, 2001), cognitive disorganization (Speca et al., 2000), post-traumatic avoidance symptoms (Br¤nstr¶m et al., 2010), and medical symptoms (Williams et al., 2001). It has been found to improve positive affect (Anderson et al., 2007; Br¤nstr¶m et al., 2010), NyklÄek, & Kuijpers, 2008), sense of spirituality (Astin, 1997; Shapiro et al., 1998), empathy (Shapiro et al., 1998), sense of cohesion (Weissbecker et al., 2002), mindfulness (Anderson et al., 2007; Shapiro, Oman, Thoresen, Plante, & Flinders, 2008; NyklÄek, & Kuijpers, 2008), forgiveness (Oman et al., 2008), self compassion (Shapiro et al., 2005), satisfaction with life, and quality of life (Grossman et al., 2010; Koszycki et al., 2007; NyklÄek, & Kuijpers,2008; Shapiro et al., 2005) among both clinical and non-clinical populations.
Table 1Randomized controlled trials of MBSR
StudyNType ParticipantMean Age% MaleNo. of Treatment SessionsControl Group(s)Main OutcomeAstin, 199728College undergradsNR58 2-hr sessionsNI (14)MBSR > NI: reductions in psychological symptoms, increases in domain-specific sense of control & spiritual experiencesShapiro et al., 199878Medical & premedical studentsNR447 2.5-hr sessionsWL (41)MBSR > WL: reductions in state and trait anxiety, overall distress, & depression, increases in empathy & spiritual experiencesSpeca et al., 200090Cancer patients51197 1.5-hr sessionsWL (37)MBSR > WL: reductions in mood disturbance & symptoms of stressWilliams et al., 2001103Community adults43288 2.5-hr sessions, 1 8-hr sessionReceived educational materials and referral to community resources (44)MBSR > Control Group: reductions in daily hassles, distress, & medical symptomsWeissbecker et al., 200291Fibromyalgia patients4808 2.5-hr sessionsWL (40)MBSR > WL: increase in disposition to experience life as manageable and meaningfulDavidson et al., 200341Corporate employees36298 2.5-hr sessions, 1 7-hr sessionWL (16)MBSR > WL: increased left-sided anterior activation & antibody titer responses to influenza vaccine, reduction in anxietyShapiro et al., 200538Health care professionalsNRNR8 2-hr sessionsWL (20)MBSR > WL: reductions in perceived stress & burnout, increases in self compassion & satisfaction with lifeKoszycki et al., 200753Generalized social anxiety disorder patientsNRNR8 2.5-hr sessions, 1 7.5-hr sessionCBGT (27)MBSR = CBGT: improvements in mood, functionality, & quality of life; MBSR < CGBT: reductions in social anxiety & response and remission ratesSephton et al., 200791Fibromyalgia patients4808 2.5-hr sessions, 1 day-long sessionWL (40)MBSR > WL: reductions in depressive symptomsFarb et al., 200736Community adults44258 2-hr sessionsWL (16)MBSR > WL: reduced activation of mPFC; increased activation of lPFC & several viscerosomatic areas when engaging in mindfulness exercisesJain et al., 200781Students25194 1.5 hr-sessionsSR (24), NI (30)MBSR (a shortened program) = SR > NI: reductions in distress & increase in positive mood states; MBSR > NI: reductions in rumination & distractionAnderson et al., 200772Community adultsNRNR8 2-hr sessionsWL (33)MBSR = WL: performance on attentional tasks; Tx > WL: increases in mindfulness & positive affect; reductions in depression, anxiety symptoms, & general and anger-related ruminationOman et al., 200844College undergrads18208 1.5-hr sessionsEPP (14), WL (15)MBSR = EPP > WL: reductions in perceived stress & rumination, increase in forgivenessNyklÄek, & Kuijpers, 200860Community adults with symptoms of stress44338 2.5-hr sessions, 1 6-hr sessionWL (30)MBSR > WL: reductions in perceived stress & vital exhaustion, increases in positive affect & mindfulnessShapiro et al., 2008*44College undergrads18208 1.5-hr sessionsEPP (14), WL (15)MBSR = EPP > WL: increase in mindfulnessBranstrom, Kvillemo, Brandberg, & Moskowitz, 201071Cancer patients5218 2-hr sessionsWL (39)MBSR > WL: reductions in perceived stress & posttraumatic avoidance symptoms, increase in positive states of mindFarb et al., 201036Community adults44258 2-hr sessionsWL (16)MBSR > WL: reduced activation in medial and lateral brain regions, reduced deactivation in insula and other visceral and somasensory areasGrossman et al., 2010150Patients with multiple sclerosis47218 2.5-hr sessions, 1 7-hr sessionUC (74)MBSR > UC: increases in health-related quality of life, reductions in fatigue & depressionParticipation in MBSR has also been associated with brain changes reflective of positive emotional states and adaptive self representation and emotion regulatory processes, such as increases in left frontal activation, which is indicative of dispositional and state positive affect (Davidson et al., 2003), increased activation in brain regions implicated in experiential, present-focused mode of self reference (Farb et al., 2007), and reduced activation in brain regions implicated in conceptual processing, cognitive elaboration, and reappraisal (Farb et al., 2010; Ochsner & Gross, 2008).
Mindfulness-Based Cognitive Therapy (MBCT): Description of Intervention and Review of Controlled StudiesMBCT is an eight-week, manualized group intervention program adapted from the MBSR model (Segal et al., 2002). Developed as an approach to prevent relapse in remitted depression, MBCT combines mindfulness training and elements of cognitive therapy (CT) with the goal of targeting vulnerability processes that have been implicated in the maintenance of depressive episodes. Like CT, MBCT aims to help participants view thoughts as mental events rather than as facts, recognize the role of negative automatic thoughts in maintaining depressive symptoms, and disengage the occurrence of negative thoughts from their negative psychological effects (Barnhofer, Crane, & Didonna, 2009). However, unlike the traditional CT approach that places considerable emphasis on evaluating and changing the validity of the content of thoughts and developing alternative thoughts, MBCT aims primarily to change one's awareness of and relationship to thoughts and emotions (Teasdale et al., 2000). The theoretical rationale on which MBCT is based (Teasdale, Segal, & Williams, 1995) is that the negative thoughts that accompany depression become associated with the depressed state, and that, as the number of depressive episodes increases, negative automatic thoughts become more easily reactivated by feelings of dysphoria, even when these do not occur in the context of a full-blown depressive episode. The negative thoughts, in turn, increase depressed mood and other symptoms of depression, leading to an increased risk for relapse to a major depressive episode. MBCT specifically targets loosening the association between negative automatic thinking and dysphoria. Because these associations are theorized to be stronger among those with a greater number of previous episodes, they may be expected to show the greatest benefit of the intervention.
Several RCTs, summarized in Table 2 , have evaluated the effects of MBCT on relapse prevention and other depression-related outcomes (for recent reviews, see Chiesa & Serreti, 2010; Coelho, Canter, & Ernst, 2007). Consistent with the theoretical model, initial studies found that MBCT reduced relapse rates among patients with three or more episodes of depression, but not among those with two or fewer past episodes (Ma & Teasdale, 2004; Teasdale et al., 2000). Subsequent studies of MBCT and depression relapse selected only patients with three or more episodes and have replicated the effect of MBCT on reduced relapse rates (Goldfrin & Heeringen, 2010; Kuyken et al., 2008) or prolonged time to relapse (Bondolfi et al., 2010). Furthermore, MBCT also has been found to improve a range of symptomatic and psychosocial outcomes among remitted depressed patients, such as residual depressive symptoms and quality of life (Goldfrin & Heeringen, 2010; Kuyken et al., 2008). There is also preliminary evidence that MBCT is more effective than treatment as usual (TAU) in reducing depressive symptoms among currently depressed patients (Barnhofer et al., 2009; Hepburn et al., 2009). Lastly, MBCT has been adapted for treatment of bipolar disorder (Williams et al., 2008), social phobia (Piet, Hougaard, Hecksher, & Rosenberg, 2010), and depressive symptoms among individuals with epilepsy (Thompson et al., 2010). The results of these studies are promising and in need of further replication.
Table 2Randomized controlled trials of MBCT
StudyNType ParticipantMean Age% MaleNo. of Treatment SessionsControl Group(s)Main OutcomeTeasdale et al., 2000145Patients in remission from depression43248 2-hr sessionsTAU (69)MBCT > TAU: reduction in rate of depressive relapse/recurrence for patients with 3 or more previous relapses, but not patients with 2 or fewer episodesWilliams et al., 2000*45Patients in remission from depression44518 2-hr sessionsTAU (20)MBCT > TAU: reduction in generality of autobiographical memoryTeasdale et al., 2002*100Patients in remission from depression44228 2-hr sessionsTAU (48)MBCT > TAU: increase in metacognitive awarenessMa & Teasdale, 200475Patients in remission from depression45248 2-hr sessionsTAU (38)MBCT > TAU: reduction in rate of depressive relapse/recurrence for patients with 3 or more previous relapses, but not patients with 2 or fewer episodesCrane et al., 200868Patients in remission from depression and with a history of suicidal ideation or behaviorNRNR8 2-hr sessions, 1 all-day sessionWL (35)MBCT + TAU > TAU: less increase in actual-ideal self discrepancyKuyken et al., 2008123Patients in remission from depression and with a history of 3 or more depressive episodes49248 2-hr sessionsm-ADM (62)MBCT = m-ADM: rate of depressive relapse/recurrence; MBCT > m-ADM: reductions in residual depressive symptoms & psychiatric comorbidity, increase in quality of lifeBarnhofer et al., 200931Patients with recurrent depression and a history of suicidal ideation42258 2-hr sessionsTAU (15)MBCT > TAU: reductions in depressive symptoms & number of patients meeting full criteria for depression at post-treatmentHepburn et al., 200968Patients in remission from depression and with a history of suicidal ideation44NR8 2-hr sessions, 1 6-hr sessionTAU (35)MBCT > TAU: reductions in depressive symptoms & thought suppressionHargus et al., 201027Depressed patients with a history of suicidal ideation or behavior42338 2-hr sessionsTAU (13)MBCT + TAU > TAU: reduced depression severity, increased meta-awareness of & specificity of memory related to previous suicidal crisisWilliams et al., 200868Patients with unipolar and bipolar disordersNRNR8 2-hr sessions, 1 all-day sessionWL (35)MBCT > WL: reduced depressive symptoms in both subsamples & less increase in anxiety among bipolar patientsBondolfi et al., 201060Patients in remission from depression and with a history of 3 or more depressive episodes47288 2-hr sessionsTAU (29)MBCT + TAU > TAU: prolonged time to relapse; Tx = TAU: rate of depressive relapse/recurrenceGodfrin & Heeringen, 2010106Recovered depressed patients with a history of 3 or more depressive episodes46198 2.75-hr sessionsTAU (54)MBCT + TAU > TAU: reduced rate of depressive relapse/recurrence, depressive mood & quality of lifePiet et al., 201026Patients with social phobia22308 2-hr sessionsGCBT (12)MBCT = GCBT: reductions in symptoms of social phobiaThompson et al., 201053Patients with epilepsy and depressive symptoms36198 1-hr sessionsTAU (27)MBCT > WL: reduction in depressive symptomsDialectical Behavior Therapy (DBT): Description of Intervention and Review of Controlled StudiesDBT (Linehan, 1993a) was first developed as a treatment for chronic suicidal and other self-injurious behaviors, which are often present in patients with severe borderline personality disorder (BPD). It conceptualizes the dysfunctional behaviors of individuals with BPD as a consequence of an underlying dysfunction of the emotion regulation system, which involves intense emotional reactivity and an inability to modulate emotions. DBT integrates elements of traditional CBT with Zen philosophy and practice, and has a simultaneous focus on acceptance and behavior change strategies to help patients improve their emotion regulation abilities (Linehan, 1993a; Robins, 2002). There are four modes of treatment in DBT: individual therapy, group skills training, telephone consultation between therapist and patient, and consultation team meetings for therapists. Mindfulness skills are taught in the context of the skills-training group as a way of helping patients increase self acceptance, and as an exposure strategy aiming to reduce avoidance of difficult emotion and fear responses (Linehan, 1993b). These skills consist of a set of mindfulness ''what'' skills (observe, describe, and participate) and a set of mindfulness ''how'' skills (nonjudgmentally, one-mindfully, and effectively). Specific exercises that are used to foster mindfulness include visualizing thoughts, feelings, and sensations as if they are clouds passing by in the sky, observing breath by counting or coordinating with footsteps, and bringing mindful awareness into daily activities. Mindfulness skills are also integrated within the other three skills modules, which focus on distress tolerance, emotion regulation, and interpersonal effectiveness.
To date, 11 randomized trials of DBT, or adaptations of it, have been conducted (Lynch, Trost, Salsman, & Linehan, 2007; Robins & Chapman, 2004). These studies are summarized in Table 3 . Standard outpatient DBT has been found to be more effective than TAU or another active treatment in reducing frequency and severity of parasuicidal and self harm behavior among individuals with BPD, especially those with a history of parasuicidal behavior; reducing number of inpatient psychiatric days, emergency visits, and hospitalizations (Koons et al., 2001; Linehan, Amstrong, Suarez, Allmon, & Heard, 1991; Linehan et al., 2006; Verheul et al., 2003); and in reducing substance use among individuals with co-morbid BDP and substance use disorders (Linehan et al., 1999; Linehan et al., 2002). Among studies that included follow-up assessments, the effects of DBT were found to last for up to one year on the following outcome measures: number of parasuicidal behaviors, global functioning, social adjustment, and use of crisis services (Linehan et al., 1991; Linehan et al., 2006; Linehan et al., 1999; Linehan, Heard, & Armstrong, 1993; Linehan, Tutek, Heard, & Armstrong, 1994). Finally, modifications of DBT have been found to be effective in binge eating disorder (Telch, Agras, and Linehan, 2001), bulimia (Safer, Telch, & Agras, 2001), and chronic depression in the elderly (Lynch, Morse, Mendelson & Robins, 2003).
Table 3Randomized controlled trials of DBT
StudyNType ParticipantMean Age% MaleNo. of Treatment SessionsControl Group(s)Main OutcomeLinehan et al., 199146Chronically parasuicidal patients with BPDNR01 yearTAU (22)DBT > TAU: reductions in number of & medical severity of parasuicide behavior & number of psychiatric inpatient days, treatment retention; DBT = TAU: depression, hopelessness, suicidal ideation, & reasons for livingLinehan et al., 1993*39Chronically parasuicidal patients with BPDNR01 yearTAU (20)DBT > TAU: increases in global functioning & social adjustment, reductions in parasuicide behavior & number of psychiatric inpatient daysLinehan et al., 1994*26Chronically parasuicidal patients with BPD2701 yearTAU (13)DBT > TAU: reductions in anger, increases in global social adjustment & global functioningLinehan et al., 199928Patients with comorbid BPD and substance dependence3001 yearTAU (16)DBT > TAU: reductions in drug use, increased global & social adjustment, & treatment retentionTurner, 2000**24Patients with BPD22211 yearCCT (12)DBT > CCT: reductions in parasuicide behavior, suicidal ideation, depression, impulsivity, anger, & number of psychiatric inpatient days, & increase in global functioningKoons et al., 200128Patients with BPD3506 monthsTAU (14)DBT > TAU: reductions in suicidal ideation, depression, hopelessness, dissociation, & anger expressionTelch et al., 2001**44Patients with BED50020 weeksWL (22)DBT > WL: reductions in number of binge episodes & days; DBT = WL: improvements in mood & affect regulationSafer et al., 2001**31Individuals with at least one binge/purge episode per week34020 weeksWL (16)DBT > WL: reductions in number of binge episodes & days; DBT = WL: improvements in mood & affect regulationLinehan et al., 200223Patients with comorbid BPD and substance dependenceNR01 yearCVT+12S (12)DBT = CVT+12S: drug use; DBT > CVT+12S: maintenance of reduction of drug use throughout treatment; DBT < CVT+12S: treatment retentionVerheul et al., 200358Patients with BPD3501 yearTAU (31)DBT > TAU: reductions in self-mutilating & self harm behaviors, treatment retentionLynch et al., 2003**34Depressed patients661528 weeksMED (17) (Note: In this study, MED was compared against MED+DBT)DBT > MED: reduction in depression, improvements in dependency & adaptive coping, number of patients in remission at post-treatmentLinehan et al., 2006101Patients with BPD3001 yearCTBE (49)DBT > CTBE: reductions in suicide risk, medical risk of suicide attempts & self injurious behavior, psychiatric hospitalizations & emergency visits, treatment retentionLynch et al., 2007**35Patients with co-morbid depression and personality disorder613424 weeksMED (14) (Note: In this study, MED was compared against MED+DBT)DBT > MED: reductions in interpersonal sensitivity & interpersonal aggressionAcceptance and Commitment Therapy (ACT): Description of Intervention and Review of Controlled StudiesACT (Hayes et al., 1999) was developed based on the premise that psychological distress is often associated with attempts to control or avoid negative thoughts and emotions, which often paradoxically increase the frequency, intensity, or salience of these internal events, and result in further distress and inability to engage in behaviors that would lead to valued long-term goals. Thus, the central aim of ACT is to create greater psychological flexibility by teaching skills that increase an individual's willingness to come into fuller contact with their experiences, recognize their values, and commit to behaviors that are consistent with those values. There are six core treatment processes that are highlighted in ACT: acceptance, defusion, contact with the present moment, self as context, values, and committed action (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Mindfulness is taught in the context of the first four processes, where a variety of exercises are used to enhance awareness of an observing self and foster the deliteralization of thoughts and beliefs. Although ACT does not incorporate mindfulness meditation exercises, its focus on helping patients cultivate present-centered awareness and acceptance is consistent with that of other mindfulness-based approaches (Baer, 2003). ACT has been delivered in both individual and group settings, with durations varying from one day (e.g., Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007) to 16 weeks (e.g., Hayes et al., 2004).
A number of studies, summarized in Table 4 , have been conducted to evaluate the efficacy of ACT in treating a range of mental health outcomes, including those associated with depression, anxiety, impulse control disorders, schizophrenia, substance abuse and addiction, and workplace stress (Hayes et al., 2006; Powers, Zum Vorde Sive Vording, & Emmelkamp, 2009). Specifically, ACT has been found to be more effective than TAU in improving affective symptoms, social functioning, and symptom reporting, and lowering rehospitalization rates and symptom believability among psychiatric inpatients with psychotic symptoms (Bach & Hayes, 2002; Gaudiano & Herbert, 2006). Among populations with depressive and anxiety symptoms, ACT was generally found to be superior to no intervention, and as effective as another established treatment in reducing levels of depression, anxiety, and poor mental health outcomes (Bond & Bunce, 2000; Forman, Herbert, Moitra, Yeomans, & Geller, 2007; Lappalainen et al., 2007; Zettle, 2003; Zettle & Hayes, 1986; Zettle & Rains, 1989). In addition, ACT has been shown to be effective at reducing substance use and dependence among nicotine-dependent (Gifford et al., 2004) and polysubstance-abusing individuals (Hayes et al., 2004). Finally, there is preliminary evidence indicating the effectiveness of ACT in treating trichotillomania (Woods, Wetterneck, & Flessner, 2006).
Table 4Randomized controlled trials of ACT
StudyNType ParticipantMean Age% MaleNo. of Treatment SessionsControl Group(s)Main OutcomeZettle & Hayes, 198618Depressed patientsNR012 weeksCT (12)ACT > CT: reductions in depression & believability of thoughts; Tx = CT; frequency of automatic thoughtsZettle & Rains, 198931Depressed patients41012 weeksCCT (10) PCT (10)ACT = CCT = PCT: reduction in depression; ACT < CCT & PCT: reduction in dysfunctional attitudesBond & Bunce, 200090Volunteers of a media organization36503 9-hr sessionsIPP (30) WL (30)ACT = IPP > WL: reduction in depression & increase in propensity to innovateBach & Hayes, 200280Psychiatric inpatients with psychotic symptoms39644 45-50-min sessionsTAU (40)ACT > TAU: improvement in symptom reporting, reductions in symptom believability & rates of hospitalizationZettle, 200324College students31176 weeksSD (12)ACT = SD: reductions in math & test anxiety; ACT < SD: reduction in trait anxietyGifford et al., 200476Nicotine-dependent smokers43417 weeksNRT (43)ACT = NRT: average number of cigarettes smoked & quit ratesHayes et al., 2004124Polysubstance-abusing Opiate Addicts424916 weeksMM (38) ITSF (44)ACT = ITSF > MM: reductions in opiate & drug use (at follow up); ACT = ITSF = MM: reduction in distress & improvement in adjustmentWoods et al., 200625Patients with trichotillomania35812 weeksWL (13)ACT > WL: reductions in hair pulling severity, impairment, & amount of hair pulledGaudiano & Herbert, 200640Psychiatric inpatients with psychotic symptoms40643 sessions (average)ETAU (21)ACT > ETAU: reductions in affective symptoms, social impairment, & hallucination-associated distressLappalainen et al., 200728Outpatients (mixed symptoms/ diagnoses)421110 sessionsCBT (14)ACT > CBT: reduced depression, improved social functioningForman et al., 200799Outpatients (mixed symptoms/ diagnoses)282015-16 sessions (average)CT (44)ACT = CT: reductions in depression & anxiety, improvements in quality of life, life satisfaction, & general functioningA growing research body supports the efficacy of all four major forms of mindfulness-oriented interventions, but several important research questions need to be addressed in future studies. Because these interventions all involve multiple components, future research should examine how individual treatment components, especially the mindfulness training component, contribute to overall treatment effects. Also, these interventions differ in how they teach mindful awareness, and future research could compare the efficacy of different mindfulness teaching approaches in fostering greater mindful awareness in daily life. For example, both MBSR and MBCT place considerable emphasis on engaging participants in formal meditative practices. DBT and ACT, on the other hand, incorporate a range of informal mindfulness exercises in their treatment approach. Research attention should also be devoted to possible moderators of treatment effects, such as pre-existing differences in coping style and types of cognitive processes maintaining a particular psychological problem. Finally, research needs to examine whether there is a dose-response relationship between amount of intervention exposure and amount of psychological benefits. Although MBSR in its standard form involves eight weekly 2-2.5 hour classes and an all-day retreat, it has been delivered in abbreviated forms to fit the needs of specific populations. Carmody and Baer (2009) examined class contact hours and effect sizes of psychological outcomes reported in published trials of MBSR, and did not find a systematic relationship between the two variables. Another review (Vettese, Toneatto, Stea, Nguyen, & Wang, 2009) found no consistent relationship between amount of home mindfulness meditation practice and treatment outcomes. Taken together, these reviews do not support a dose-response relationship between level of treatment exposure and reported psychological benefits. Other factors, such as level of expertise of an instructor, may account for the psychological improvements observed following MBSR or other mindfulness-based interventions, and should be systematically measured in future studies.
Laboratory Research on Immediate Effects of Mindfulness InterventionsIn addition to correlational and clinical intervention research on mindfulness, a third line of empirical research has examined the immediate effects of brief mindfulness interventions in controlled laboratory settings on a variety of emotion-related processes, including recovery from dysphoric mood, emotional reactivity to aversive or emotionally provocative stimuli, and willingness to return to or persist on an unpleasant task. Such laboratory studies have the advantage of more easily isolating mindfulness practice from other elements typically present in clinical intervention packages, thus allowing greater control over independent variables and stronger conclusions about causal effects.
Several studies have examined the immediate effects of mindfulness interventions on coping with dysphoric mood. Instructions to practice mindfulness of thoughts and feelings following negative mood induction were found to be more effective than rumination or no instruction in alleviating negative mood states in healthy university students (Broderick, 2005), previously depressed individuals (Singer & Dobson, 2007), and currently depressed individuals (Huffziger & Kuehner, 2009), but not in one study of university students (Kuehner, Huffziger, & Liebsch, 2009). As the latter authors noted, these differential findings may result in part from differences in methods used to induce mindfulness across studies (use of mindful self-focus statements on cards in Kuehner et al., 2009 versus audiotaped guided meditation instructions in Broderick, 2005), and/or differences in clinical status of study samples (e.g., beneficial effects of mindfulness may be more noticeable among clinical populations than among healthy subjects). It is unsurprising that mindfulness instructions would be more helpful in recovery from sad mood than rumination, which has been shown to be maladaptive (Nolen-Hoeksema & Morrow, 1991). Mindfulness also has been compared with other potentially adaptive mood-regulation strategies. Evidence is mixed with regard to the relative effects of mindfulness and distraction. Whereas two studies (Huffziger & Kuehner, 2009; Singer & Dobson, 2007) found that mindfulness and distraction had equivalent effects on recovery from dysphoric mood, one study (Broderick, 2005) found that mindfulness was more effective than distraction and another study (Kuehner et al., 2009) found that distraction was more effective than mindfulness. Further studies are needed to clarify the relative effects of mindfulness and distraction on mood regulation, and whether those effects may be moderated by situational or personality factors. No published studies to date have compared the effects on recovery from dysphoric mood of mindfulness and cognitive reappraisal of distressing stimuli or situations.
Studies have also examined effects of mindfulness instructions on emotional responses to aversive or emotionally provocative stimuli. In a study by Arch and Craske (2006), university students viewed a series of affectively-valenced pictures and rated their emotional responses to them, both before and after one of three sets of recorded instructions to which they were randomly assigned: focused breathing, unfocused attention, or worry. Whereas the other two groups showed a decrease in positive emotional response to neutral slides from pre-induction to post-induction, those assigned to the focused breathing condition maintained consistently positive responses to neutral slides. They also reported lower negative affect than the worry group in response to post-induction negative-valence slides and greater willingness to view negative slides than those in the unfocused attention condition, as indicated by viewing a greater number of additional optional negative slides. Findings of this study were extended by a recent study by Erisman and Roemer (2010), which found that a brief mindfulness intervention, relative to a control condition, resulted in reduced emotion regulation difficulties and negative affect in response to an affectively-mixed film clip. Campbell-Sills, Barlow, Brown, and Hofmann (2006) randomly assigned patients with mood and anxiety disorders to instructions to either accept or suppress their emotions while viewing an emotionally provocative film. The two groups reported similar levels of subjective distress while watching the film but, relative to those in the suppression condition, the acceptance group displayed lower heart rate while viewing the film and reported less negative emotion during the post-film recovery period. The findings of these studies suggest that training in two key elements of mindfulness practice (focused awareness and acceptance) may reduce emotional reactivity to negative stimuli and increase willingness to remain in contact with them. There is preliminary work investigating the effects of brief mindfulness instructions on substance-related urges and substance use behavior. Bowen and Marlatt (2009) presented college smokers either brief mindfulness instructions or no instructions before and after exposure to a cue designed to elicit urges to smoke. Although there was no immediate effect on urge to smoke, mindfulness instructions resulted in significant decreases in smoking behavior during the next 7 days. As the authors noted, mindfulness training may alter responses to urges, rather than reducing urges. These findings were extended in another study that compared the effectiveness of using suppression versus a mindfulness-based strategy in coping with cigarette craving among a community sample of smokers (Rogojanski, Vettese, & Antony, 2011). The study found that whereas both strategies reduced self-reported amount of smoking and increased self-efficacy associated with coping with cigarette craving, only those in the mindfulness condition reported significant decreases in negative affect and depressive symptoms and marginal decreases in nicotine dependence.
Research has also examined the efficacy of mindfulness as an emotion regulation strategy in response to a biological challenge, specifically to inhalations of carbon dioxide-enriched air (CO2 challenge), a procedure that has frequently been used to create a laboratory analog of panic attacks (Sanderson, Rapee, & Barlow, 1988). In a study by Feldner, Zvolensky, Eifert, and Spira (2003), individuals who scored either high or low on a measure of emotional avoidance were instructed either to mindfully observe and accept or to try to suppress feelings during CO2 challenge. High emotional avoidance participants reported higher anxiety than low emotional avoidance participants in the suppression condition, but not in the observation condition. Levitt, Brown, Orsillo, and Barlow (2004) randomized patients with panic disorder to one of three experimental conditions: a 10-minute audiotape describing a rationale for either suppressing or accepting one's emotions, or a neutral narrative, and then exposed them to CO2 challenge. The acceptance group reported significantly lower levels of anxiety during the biological challenge than the other two groups and greater willingness to participate in a second challenge. One coping strategy commonly taught to patients with anxiety disorders, particularly panic disorder, is breathing retraining, in which patients are taught to take deeper, slower breaths. Eifert and Heffner (2003) compared the effects of brief acceptance training, breathing retraining, and no training on responses to CO2 challenge in undergraduates who scored high on a measure of anxiety sensitivity. Acceptance instructions led to less intense fear, fewer catastrophic thoughts, and lower behavioral avoidance (indicated both by latency between trials and reported willingness to return for another experimental session) than breathing retraining instructions or no instructions. Collectively, these studies suggest that mindful observation and acceptance of emotional responses may be an effective strategy for reducing subjective anxiety and behavioral avoidance in the face of physiological arousal, among highly anxiety sensitive or emotionally avoidant individuals and patients with panic disorder.
Laboratory studies of mindfulness have helped provide further insight into the functions of mindfulness and the potential processes through which mindfulness lead to positive psychological effects. The majority of the findings suggest that brief mindfulness training, whether in the form of a short, guided meditation practice or in the form of instructions to adopt an accepting attitude toward internal experiences, can have an immediate positive effect on recovery from dysphoric mood and level of emotional reactivity to aversive stimuli, consistent with the positive psychological effects reported in research on mindfulness-oriented intervention programs. The laboratory studies also suggest that it does not take extensive prior training in mindfulness to experience some immediate benefits of mindfulness training.
From a methodological standpoint, it is important that future studies more closely examine the extent to which a state of mindfulness is actually manipulated by the study instructions. Whereas most studies did include post-experimental manipulation checks on adherence to the training instructions, they did not explicitly assess the extent to which participants were able to be mindfully aware of their emotions or thoughts during or after exposure to a mood induction or a laboratory stressor. Research also could examine which training approaches or instructions (e.g. mindful breathing or mindfulness of emotions) are most effective at helping individuals regulate emotions in response to a stressor; whether there are key moderator variables such as pre-existing differences in dispositional mindfulness or coping styles; and whether effects differ by type of stressors or across different emotions. Research is also needed to compare the effects and mechanisms of mindfulness instructions with those of other documented emotion regulation strategies, such as cognitive reappraisal and distraction.
Mechanisms of Effects of Mindfulness InterventionsThe studies reviewed so far indicate that measures of mindful awareness are related to various indices of psychological health and that mindfulness interventions have a positive impact on psychological health. The next natural question, then, is how this impact comes about. Several psychological processes, some of which may overlap, have been proposed as potential mediators of the beneficial effects of mindfulness interventions, including increases in mindful awareness, reperceiving (also known as decentering, metacognitive awareness, or defusion), exposure, acceptance, attentional control, memory, values clarification, and behavioral self-regulation.
Mindfulness training would be expected to increase scores on measures of mindfulness, and changes in mindfulness would be expected, in turn, to predict clinical outcomes. Research has found that mindfulness training leads to increases in self-reported trait mindfulness, assessed by the MAAS (Anderson et al., 2007; Brown & Ryan, 2003; Carmody, Reed, Kristeller and Merriam, 2008; Michalak, Heidenreich, Meibert, & Schulte, 2008; Shapiro, Brown & Biegel, 2007), the CAMS-R (Greeson et al., in press) and the FFMQ (Carmody & Baer, 2008; Robins, Keng, Ekblad, & Brantley, 2010; Shapiro et al., 2008), as well as TMS-assessed state mindfulness (Carmody et al., 2008; Lau et al., 2006). Intervention-associated increases in trait mindfulness, assessed by the MAAS, the KIMS, the CAMS-R, and/or the FFMQ, have been shown to predict increases in sense of spirituality (Carmody et al., 2008; Greeson et al., in press), self-compassion (Shapiro et al., 2007), and positive states of mind (Br¤nstr¶m et al., 2010), and decreases in rumination (Shapiro et al., 2007), trait anxiety (Shapiro et al., 2007), risk of depressive relapse (Michalak et al., 2008), posttraumatic avoidance symptoms (Br¤nstr¶m et al., 2010), perceived stress (Br¤nstr¶m et al., 2010; Shapiro et al., 2007), and overall psychological distress (Carmody et al., 2008). A number of studies have also demonstrated that increases in trait mindfulness (again, assessed by the MAAS, the KIMS, and/or the FFMQ) statistically mediated the effects of mindfulness interventions on perceived stress (NyklÄek, & Kuipers, 2008; Shapiro et al., 2008), rumination (Shapiro et al., 2008), cognitive reactivity (Raes et al., 2009), quality of life (NyklÄek, & Kuipers, 2008), depressive symptoms (Kuyken et al., 2010; Shahar, Britton, Sbarra, Figueredo, & Bootzin, 2010), and behavioral regulation (Keng, Smoski, Robins, Ekblad, & Brantley, 2010). Lastly, one study (Carmody & Baer, 2008) demonstrated that changes in FFMQ-assessed mindfulness at least partially mediated the relationships between amount of formal mindfulness practice and changes in psychological well being, perceived stress, and psychological symptoms.
Mindfulness training also is thought to increase metacognitive awareness, which is the ability to reperceive or decenter from one's thoughts and emotions, and view them as passing mental events rather than to identify with them or believe thoughts to be accurate representations of reality (Hayes et al., 1999; Segal et al., 2002; Shapiro, Carlson, Astin, & Freeman, 2006). Increased metacognitive awareness has been hypothesized to lead to reductions in rumination (Teasdale, 1999), a process of repetitive negative thinking that has been considered a risk factor for a number of psychological disorders (Ehring & Watkins, 2008). Preliminary evidence suggests that mindfulness training leads to increases in metacognitive awareness (Hargus et al., 2010; Teasdale et al., 2002) and reductions in rumination (Jain et al., 2007; Ramel, Goldin, Carmona, & McQuaid, 2004), and that increased metacognitive awareness, or decentering, may in turn predict better clinical outcomes such as lower rates of depressive relapses (Fresco, Segal, Buis, & Kennedy, 2007).
Exposure is another process that several authors have suggested may occur during mindfulness practice (Baer, 2003; Kabat-Zinn, 1982; Linehan, 1993a). By intentionally attending to experiences in a nonjudgmental and open manner, an individual may undergo a process of desensitization through which distressing sensations, thoughts and emotions that otherwise would be avoided become less distressing. One study has shown that participation in MBSR is associated with significant pre- to post-intervention increases in exposure (Carmody, Baer, Lykins, & Olendzki, 2009). A closely-related process of change that has been highlighted in the literature is acceptance (Hayes, 1994). Several studies reported that increases in experiential acceptance mediated the effects of ACT on a range of psychological outcomes, including workplace stress (Bond & Bunce, 2000), smoking cessation (Gifford et al., 2004), and functioning difficulties (Forman et al., 2007).
Because mindfulness practices involve sustaining attention on the present-moment experience, as well as switching attention back to the present-moment experience whenever it wanders (Bishop et al., 2004), mindfulness training may improve the ability to control attention, which may, in turn, influence other beneficial psychological outcomes. Several aspects of attention, each related to different neurobiological substrates, may be distinguished (Posner & Petersen, 1990): orienting (the ability to direct attention towards a set of stimuli and sustain attention on it), alerting (the ability to remain vigilant or receptive towards a wide range of potential stimuli), and conflict monitoring (the ability to prioritize attention among competing cognitive demands/tasks). Using a variety of neuropsychological tasks, experimental studies have shown that mindfulness training is associated with improvements in orienting (Jha, Krompinger, & Baime, 2007) and conflict monitoring (Tang et al., 2007). Among experienced meditators, participation in an intensive mindfulness retreat has also been associated with improved alerting (Jha et al., 2007). In addition, mindfulness training has been associated with improvements in sustained attention among both novice meditators (Chambers, Lo, & Allen, 2008) and experienced meditators (Valentine & Sweet, 1999), with one study demonstrating an association between intervention-related improvements in sustained attention and reductions in depressive symptoms (Chambers et al., 2008). Overall, evidence suggests that mindfulness training may affect various subcomponents of attention, and that the specific subsystems affected may depend on the extent of previous meditation experience.
Another mechanism through which mindfulness training may influence psychological well-being is change in memory functioning. Two studies (Hargus et al., 2010; Williams et al., 2000) have shown that mindfulness training reduces overgeneral autobiographical memory, a construct that has been associated with increased severity of depression and suicidality (Kuyken & Brewin, 1995). Participation in mindfulness training has also been shown to buffer against decreases in working memory capacity (WMC) during high stress periods, with changes in WMC mediating the relationship between amount of mindfulness practice and reductions in negative affect (Jha, Stanley, Kiyonaga, Wong, & Gelfand, 2010). In addition, brief mindfulness training has been shown to reduce memory for negative stimuli (Alberts & Thewissen, in press), a mechanism that may partly underlie the beneficial effects of mindfulness-based interventions on emotion functioning.
Finally, values clarification and improved behavioral self-regulation may be two additional avenues through which mindfulness training improves psychological well-being (Gratz & Roemer, 2004; Shapiro et al., 2006). Staying present with thoughts and emotions in an objective, open and nonjudgmental manner may facilitate a greater sense of clarity with regard to one's values, and behaviors that are more consistent with those values. Higher levels of self-reported mindfulness are associated with self-reports of greater engagement in valued behaviors and interests (Brown & Ryan, 2003) and of ability to engage in goal-directed behavior when emotionally upset (Baer et al., 2006). In addition, mindfulness training has been found to lead to self-reported improved behavioral regulation in a nonclinical sample (Robins et al., 2010) and reduced self-discrepancy, which is associated with adaptive self-regulation, among recovered depressed patients with a history of depression and suicidality (Crane et al., 2008). In another study, values clarification was found to mediate partially the relationship between increased mindfulness/ reperceiving and decreased psychological distress in a sample of participants who underwent MBSR (Carmody et al., 2009).
Areas in Need of Further ResearchUnderstanding and Quantification of MindfulnessBecause mindfulness is a construct that originates in Buddhism, and has only a brief history in Western psychological science, it is unsurprising that there is considerable challenge in defining, operationalizing, and quantifying it (Grossman, 2008). Although a number of self-report inventories have been developed to assess mindfulness, they vary greatly in content and factor structure, reflecting a lack of agreement on the meaning and nature of mindfulness (Brown, Ryan, & Creswell, 2007). Whereas some researchers consider mindfulness to be a one-dimensional construct referring specifically to paying attention to the present-moment experience (e.g., Brown & Ryan, 2003; Carmody, 2009), others argue that qualities such as curiosity, acceptance, and compassion are inherent to mindfulness (Baer & Sauer, 2009; Feldman et al., 2007; Lau et al., 2006). Further collaborative inquiry is needed so that researchers can reach a general agreement on the nature and meaning of mindfulness, or at least clarify and specify which aspects of mindfulness are being addressed in a particular study.
Several issues pertaining to the assessment of mindfulness are also worth highlighting here. First, individual responses to questionnaire items may vary as a function of differential understanding of the questionnaire items (Grossman, 2008), which may depend on the extent of an individual's exposure to the idea or practice of mindfulness. One study demonstrated that the factor structure of the Freiburg Mindfulness Inventory changed within the same group of respondents from just before to just after attending meditation retreats of 3 to 10 days (Buchheld, Grossman, & Wallach, 2001). Further research is clearly needed to improve the construct validity of self-report mindfulness questionnaires, in part via reducing potential variability in item functioning across meditators and non-meditators. A second issue concerns limitations in the use of self-report measures of mindfulness, which rely on the assumption that mindfulness is assessable by declarative knowledge (Brown et al., 2007). It is not known how well self-reports of mindfulness correspond with actual experiences in daily life. To make the matter more complicated, there is an inherent paradox in using frequency of attention lapses as an index of mindfulness because the ability to detect such lapses is contingent upon one's overall level of mindfulness (Van Dam, Earlywine, & Borders, 2010; Van Dam, Earleywine, & Danoff-Burg, 2009). One way in which the validity of self-report questionnaires can be improved is by developing performance-based measures of mindfulness against which they can be calibrated, or which can be used in multi-method assessment of the construct (Garland & Gaylord, 2009).
Specificity of Effects of Mindfulness InterventionsLittle is yet known regarding for whom and under what conditions mindfulness training is most effective, but there is some preliminary evidence to suggest that its effectiveness may vary as a function of individual differences. Cordon, Brown, and Gibson (2009) found that participation in MBSR resulted in greater reduction in perceived stress for individuals with an insecure attachment style than for securely attached individuals. Another recent study (Shapiro, Brown, Thoresen, & Plante, 2011) showed that trait mindfulness moderated the effects of MBSR. Specifically, compared to controls, participants with higher levels of baseline trait mindfulness demonstrated greater improvements in mindfulness, subjective well-being, empathy, and hope, and larger decreases in perceived stress up to one year post-intervention. MBCT is effective for reducing depressive relapses among remitted depressed patients with a history of three or more depressive episodes, but not among patients with two previous episodes (e.g., Teasdale et al., 2000; Ma & Teasdale, 2004). In light of these considerations, several researchers have cautioned against the indiscriminate application of mindfulness as a general-purpose, ''cure-all'' therapeutic technique, and instead advocated for a problem formulation approach in the use of mindfulness techniques for treating psychological conditions (Kocovski, Segal, Battista, & Didonna, 2009; Teasdale, Segal, & Williams, 2003). In order to maximize the effectiveness and clinical utility of mindfulness interventions, sufficient attention needs to go into tailoring them to fit the needs of specific populations and psychological conditions. For example, treatment of disorders that primarily involve a deficit in attentional abilities, like attention deficit hyperactivity disorder (ADHD), may require that greater focus be placed on the attentional aspect of mindfulness training. On the other hand, treatment of disorders that tend to involve excessive shame and guilt, such as eating disorders, may benefit from greater treatment emphasis on the acceptance and self compassion aspects of mindfulness. Finally, given that mindfulness training has been increasingly integrated with a variety of psychotherapeutic techniques (e.g., Linehan, 1993a), it is important that future research examine how mindfulness works alongside these psychotherapeutic techniques.
Other Potential Applications of Mindfulness InterventionsMindfulness-oriented interventions have been shown to improve psychological health in nonclinical populations and effectively treat a range of psychological and psychosomatic conditions. There may be additional therapeutic applications of mindfulness training. Researchers have reported promising results in pilot trials of mindfulness interventions for attention deficit hyperactivity disorder (Zylowska et al., 2008), bipolar disorder (Miklowitz et al., 2009; Weber et al., 2010; Williams et al., 2008), panic disorder (Kim et al., 2010), generalized anxiety disorder (Evans et al., 2008; Craigie, Rees, Marsh, & Nathan, 2008; Roemer, Orsillo, & Salters-Pedneault, 2008), eating disorders (Baer, Fischer, & Huss, 2005; Kristeller & Hallett, 1999), psychosis (Chadwick, Taylor, & Abba, 2005), and alcohol and substance use problems (Bowen et al., 2006; Witkiewitz et al., 2005). While the data is overall preliminary and requires further validation, the results are promising. Researchers have also begun to investigate the application of mindfulness techniques within specific populations and settings, such as children (Bogels, Hoogstad, van Dun, de Schutter, & Restifo, 2008; Lee, Semple, Rosa, & Miller, 2008; Napoli, Krech, & Holley, 2005), adolescent psychiatric outpatients (Biegel, Brown, Shapiro, & Schubert, 2009), parents (Altmaier & Maloney, 2007; B¶gels et al., 2008; Singh et al., 2006), school teachers (Napoli, 2004), elderly and their caregivers (Epstein-Lubow, McBee, Darling, Armey, & Miller, in press; McBee, 2008; Smith, 2004), prison inmates (Bowen et al., 2006; Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007), and socio-economically disadvantaged individuals (Hick & Furlotte, 2010).
With regard to applications of mindfulness training that have received empirical support, research now needs to examine practical issues surrounding their implementation, delivery, and dissemination. Little is known about their cost effectiveness, nor about the amount and type(s) of training that is required for an individual to be a competent provider of mindfulness training (Allen, Blashki, & Gullone, 2006). Future research should examine these issues as they are critical to the successful implementation and dissemination of mindfulness-oriented interventions.
ConclusionBased on an examination of empirical literature across multiple methodologies, this review concludes that mindfulness and its cultivation facilitates adaptive psychological functioning. Despite existing methodological limitations within each body of literature, there is a clear convergence of findings from correlational studies, clinical intervention studies, and laboratory-based, experimental studies of mindfulness'--all of which suggest that mindfulness is positively associated with psychological health, and that training in mindfulness may bring about positive psychological effects. These effects ranged from increased subjective well-being, reduced psychological symptoms and emotional reactivity, to improved regulation of behavior. There is also an increasingly substantial research body pointing to a number of psychological processes that may serve as key mechanisms of effects of mindfulness interventions. As research on mindfulness is in its early stages of development, further collaborative research is needed to develop a more solid understanding concerning the nature of mindfulness, how mindfulness can best be measured, fostered, and cultivated, and the mechanisms and specificity of effects of mindfulness-oriented interventions. Future research should also continue to explore other potential applications of mindfulness, and examine practical issues concerning the delivery, implementation, and dissemination of mindfulness-oriented interventions. Given the advances that have been made thus far, it is likely that new paradigms for the understanding and application of mindfulness will continue to appear, which would move us further toward the goals of alleviating human psychological suffering and helping others live a life that is happier and more fulfilling.
AcknowledgmentsWe gratefully acknowledge M. Zachary Rosenthal, Mark Leary, Jeffrey Brantley, and Kathleen Sikkema for their helpful comments on an earlier version of this manuscript.
References Alberts H, Thewissen R. The effect of a brief mindfulness intervention on memory for positively and negatively valenced stimuli. Mindfulness in press. [PMC free article] [PubMed] [Google Scholar] Allen NB, Blashki G, Gullone E. Mindfulness-based psychotherapies: A review of conceptual foundations, empirical evidence and practical considerations. Australian and New Zealand Journal of Psychiatry. 2006; 40 :285''294. [PubMed] [Google Scholar] Altmaier E, Maloney R. An initial evaluation of a mindful parenting program. Journal of Clinical Psychology. 2007; 63 :1231''1238. [PubMed] [Google Scholar] Anand BK, Chhina GS, Singh B. Some aspects of electroencephalographic studies in yogis. Electroencephalography and Clinical Neurophysiology. 1961; 13 :452''456. [Google Scholar] Anderson ND, Lau MA, Segal ZV, Bishop SR. Mindfulness-based stress reduction and attentional control. Clinical Psychology and Psychotherapy. 2007; 14 :449''463. [Google Scholar] Arch JJ, Craske MG. Mechanisms of mindfulness: Emotion regulation following a focused breathing induction. Behaviour Research and Therapy. 2006; 44 :1849''1858. [PubMed] [Google Scholar] Astin JA. Stress reduction through mindfulness meditation: Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy and Psychosomatics. 1997; 66 :97''106. [PubMed] [Google Scholar] Bach P, Hayes SC. The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2002; 70 :1129''1139. [PubMed] [Google Scholar] Baer RA. Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice. 2003; 10 :125''143. [Google Scholar] Baer RA, Fischer S, Huss DB. Mindfulness and acceptance in the treatment of disordered eating. Journal of Rational-Emotive & Cognitive-Behavior Therapy. 2005; 23 :281''300. [Google Scholar] Baer RA, Sauer S. Mindfulness and cognitive behavioral therapy: A commentary on Harrington and Pickles. Journal of Cognitive Psychotherapy: An International Quarterly. 2009; 23 :324''332. [Google Scholar] Baer RA, Smith GT, Allen KB. Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment. 2004; 11 :191''206. [PubMed] [Google Scholar] Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L. Using self-report assessment methods to explore facets of mindfulness. Assessment. 2006; 13 :27''45. [PubMed] [Google Scholar] Bagchi BK, Wenger MA. Electrophysiological correlates of some yogi exercises. Electroencephalography and Clinical Neurophysiology. 1957;(Suppl. 7):132''149. [Google Scholar] Barnhofer T, Crane C, Didonna F. Mindfulness-based cognitive therapy for depression and suicidality. In: Didonna F, editor. Clinical handbook of mindfulness. New York, NY: Springer; 2009. pp. 221''243. [Google Scholar] Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JMG. Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary study. Behaviour Research and Therapy. 2009; 47 :366''373. [PMC free article] [PubMed] [Google Scholar] Benson H, Rosner BA, Marzetta BR, Klemchuk HM. Decreased blood pressure in pharmacologically treated hypertensive patients who regularly elicited the relaxation response. Lancet. 1974:289''291. [PubMed] [Google Scholar] Biegel GM, Brown KW, Shapiro SL, Schubert CM. Mindfulness-based stress reduction for the treatment of adolescent psychiatric outpatients: A randomized clinical trial. Journal of Consulting and Clinical Psychology. 2009; 77 :855''866. [PubMed] [Google Scholar] Bishop SR, Lau M, Shapiro S, Carlson L, Anderson ND, Carmody J, Devins G. Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice. 2004; 11 :230''241. [Google Scholar] B¶gels S, Hoogstad B, van Dun L, de Schutter S, Restifo K. Mindfulness training for adolescents with externalizing disorders and their parents. Behavioural and Cognitive Psychotherapy. 2008; 36 :193''209. [Google Scholar] Bond F, Bunce D. Mediators of change in emotion-focused and problem-focused worksite stress management interventions. Journal of Occupational Health Psychology. 2000; 5 :156''163. [PubMed] [Google Scholar] Bowen S, Marlatt A. Surfing the urge: Brief mindfulness-based intervention for college student smokers. Psychology of Addictive Behavior. 2009; 23 :666''671. [PubMed] [Google Scholar] Bowen S, Witkiewitz K, Dillworth TM, Chawla N, Simpson TL, Ostafin BD, Marlatt A. Mindfulness meditation and substance use in an incarcerated population. Psychology of Addictive Behaviors. 2006; 20 :343''347. [PubMed] [Google Scholar] Br¤nstr¶m R, Kvillemo P, Brandberg Y, Moskowitz JT. Self-report mindfulness as a mediator of psychological well-being in a stress reduction intervention for cancer patients: A randomized study. Annals of Behavioral Medicine. 2010; 39 :151''161. [PubMed] [Google Scholar] Bondolfi G, Jermann F, Van der Linden M, Gex-Fabry M, Bizzini L, Rouget BW, Bertschy G. Depression relapse prophylaxis with Mindfulness-based cognitive therapy: Replication and extension in the Swiss health care system. Journal of Affective Disorders. 2010; 22 :224''231. [PMC free article] [PubMed] [Google Scholar] Boss M. A psychiatrist discovers India. London: Oswald Wolff; 1965. [Google Scholar] Broderick PC. Mindfulness and coping with dysphoric mood: Contrasts with rumination and distraction. Cognitive Therapy and Research. 2005; 29 :501''510. [Google Scholar] Brown KW, Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology. 2003; 84 :822''848. [PubMed] [Google Scholar] Brown KW, Ryan RM, Creswell JD. Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry. 2007; 18 :211''237. [Google Scholar] Buchheld N, Grossman P, Walach H. Measuring mindfulness in insight meditation (Vipassana) and meditation-based psychotherapy: The development of the Freiburg Mindfulness Inventory (FMI) Journal for Meditation and Meditation Research. 2001; 1 :11''34. [Google Scholar] Campbell-Sills L, Barlow DH, Brown TA, Hofmann SG. Effects of suppression and acceptance on emotional responses of individuals with anxiety and mood disorders. Behaviour Research and Therapy. 2006; 44 :1251''1263. [PubMed] [Google Scholar] Cardaciotto L, Herbert JD, Forman EM, Moitra E, Farrow V. The assessment of present-moment awareness and acceptance: The Philadelphia Mindfulness Scale. Assessment. 2008; 15 :204''223. [PubMed] [Google Scholar] Carmody J. Evolving conceptions of mindfulness in clinical settings. Journal of Cognitive Psychotherapy: An International Quarterly. 2009; 23 :270''280. [Google Scholar] Carmody J, Baer RA. Relationship between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal of Behavioral Medicine. 2008; 31 :23''33. [PubMed] [Google Scholar] Carmody J, Baer RA. How long does a mindfulness-based stress reduction program need to be? A review of class contact hours and effect sizes for psychological distress. Journal of Clinical Psychology. 2009; 65 :627''638. [PubMed] [Google Scholar] Carmody J, Baer RA, Lykins ELB, Olendzki N. An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program. Journal of Clinical Psychology. 2009; 65 :613''626. [PubMed] [Google Scholar] Carmody J, Reed G, Kristeller J, Merriam P. Mindfulness, spirituality, and health-related symptoms. Journal of Psychosomatic Research. 2008; 64 :393''403. [PubMed] [Google Scholar] Cash M, Whittingham K. What facets of mindfulness contribute to psychological well-being and depressive, anxious, and stress-related symptomatology? Mindfulness. 2010; 1 :177''182. [Google Scholar] Chadwick P, Hember M, Symes J, Peters E, Kuipers E, Dagnan D. Responding mindfully to unpleasant thoughts and images: Reliability and validity of the Southampton Mindfulness Questionnaire (SMQ) British Journal of Clinical Psychology. 2008; 47 :451''455. [PubMed] [Google Scholar] Chadwick P, Taylor KN, Abba N. Mindfulness groups for people with psychosis. Behavioural and Cognitive Psychotherapy. 2005; 33 :351''359. [Google Scholar] Chambers R, Gullone E, Allen NB. Mindful emotion regulation: An integrative review. Clinical Psychology Review. 2009; 29 :560''572. [PubMed] [Google Scholar] Chambers R, Lo BCY, Allen NB. The impact of intensive mindfulness training on attentional control, cognitive style, and affect. Cognitive Therapy and Research. 2008; 32 :303''322. [Google Scholar] Chiesa A, Serretti A. Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Research 2010 in press. [PubMed] [Google Scholar] Coelho HF, Canter PH, Ernst E. Mindfulness-based cognitive therapy: Evaluating current evidence and informing future research. Journal of Consulting and Clinical Psychology. 2007; 75 :1000''1005. [PubMed] [Google Scholar] Cordon SL, Brown KW, Gibson PR. The role of mindfulness-based stress reduction on perceived stress: Preliminary evidence for the moderating role of attachment style. Journal of Cognitive Psychotherapy: An International Quarterly. 2009; 23 :258''268. [Google Scholar] Crane C, Barnhofer T, Duggan D, Hepburn S, Fennell MV, Williams JMG. Mindfulness-based cognitive therapy and self-discrepancy in recovered depressed patients with a history of depression and suicidality. Cognitive Therapy & Research. 2008; 32 :775''787. [Google Scholar] Craigie MA, Rees CS, Marsh A, Nathan P. Mindfulness-based cognitive therapy for generalized anxiety disorder: A preliminary evaluation. Behavioural and Cognitive Psychotherapy. 2008; 36 :553''568. [Google Scholar] Creswell JD, Way BM, Eisenberger NI, Lieberman MD. Neural correlates of dispositional mindfulness during affect labeling. Psychosomatic Medicine. 2007; 69 :560''565. [PubMed] [Google Scholar] Davidson R. Well-being and affective style: neural substrates and biobehavioral correlates. Philosophical Transactions of the Royal Society. 2004; 359 :1395''1411. [PMC free article] [PubMed] [Google Scholar] Davidson RJ. Emotion and affective style: hemispheric substrates. Psychological Science. 1992; 3 :39''43. [Google Scholar] Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, Sheridan JF. Alterations in brain and immune function produced by mindfulness meditation. Psychosomatic Medicine. 2003; 65 :564''570. [PubMed] [Google Scholar] Davis KM, Lau MA, Cairns DR. Development and preliminary validation of a trait version of the Toronto Mindfulness Scale. Journal of Cognitive Psychotherapy: An International Qaurterly. 2009; 23 :185''197. [Google Scholar] Dekeyser M, Raes F, Leijssen M, Leysen S, Dewulf D. Mindfulness skills and interpersonal behaviour. Personality and Individual Differences. 2008; 44 :1235''1245. [Google Scholar] Ehring T, Watkins E. Repetitive negative thinking as a transdiagnostic process. International Journal of Cognitive Therapy. 2008; 1 :192''205. [Google Scholar] Eifert GH, Heffner M. The effects of acceptance versus control contexts on avoidance of panic-related symptoms. Journal of Behavior Therapy and Experimental Psychiatry. 2003; 34 :293''312. [PubMed] [Google Scholar] Epstein-Lubow G, McBee L, Darling E, Armey M, Miller I. A pilot investigation of mindfulness-based stress reduction for caregivers of frail elderly. Mindfulness in press. [Google Scholar] Erisman SM, Roemer L. A preliminary investigation of the effects of experimentally induced mindfulness on emotional responding to film clips. Emotion. 2010; 10 :72''82. [PMC free article] [PubMed] [Google Scholar] Evans DR, Baer RA, Segerstrom SC. The effects of mindfulness and self-consciousness on persistence. Personality and Individual Differences. 2009; 47 :379''382. [Google Scholar] Evans S, Ferrando S, Findler M, Stowell C, Smart C, Haglin D. Mindfulness-based cognitive therapy for generalized anxiety disorder. Journal of Anxiety Disorders. 2008; 22 :716''721. [PubMed] [Google Scholar] Farb NAS, Andersen AK, Mayberg H, Bean J, McKeon D, Segal ZV. Minding one's emotions: Mindfulness training alters the neural expression of sadness. Emotion. 2010; 10 :25''33. [PMC free article] [PubMed] [Google Scholar] Farb NAS, Segal ZV, Mayberg H, Bean J, McKeon D, Fatima Z, Anderson AK. Attending to the present: Mindfulness meditation reveals distinct neural modes of self-reference. Social Cognitive and Affective Neuroscience. 2007; 2 :313''322. [PMC free article] [PubMed] [Google Scholar] Feldman G, Hayes A, Kumar S, Greeson J, Laurenceau J. Mindfulness and emotion regulation: The development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R) Journal of Psychopathology and Behavioral Assessment. 2007; 29 :177''190. [Google Scholar] Feldner MT, Zvolensky MJ, Eifert GH, Spira AP. Emotional avoidance: An experimental test of individual differences and response suppression using biological challenge. Behaviour Research and Therapy. 2003; 41 :403''411. [PubMed] [Google Scholar] Fingarette H. The self in transformation: Psychoanalysis, philosophy, and the life of the spirit. New York: Basic Books; 1963. [Google Scholar] Forman EM, Herbert JD, Moitra E, Yeomans PD, Geller PA. A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification. 2007; 31 :772''799. [PubMed] [Google Scholar] Fresco D, Segal ZV, Buis T, Kennedy S. Relationship of posttreatment decentering and cognitive reactivity to relapse in major depression. Journal of Consulting and Clinical Psychology. 2007; 75 :447''455. [PubMed] [Google Scholar] Frewen PA, Evans EM, Maraj N, Dozois DJA, Partridge K. Letting go: Mindfulness and negative automatic thinking. Cognitive Therapy and Research. 2008; 32 :758''774. [Google Scholar] Garland E, Gaylord S. Envisioning a future contemplative science of mindfulness: Fruitful methods and new content for the next wave of research. Complementary Health Practice Review. 2009; 14 :3''9. [PMC free article] [PubMed] [Google Scholar] Gaudiano BA, Herbert JD. Acute treatment of inpatients with psychotic symptoms using acceptance and commitment therapy: Pilot results. Behaviour Research and Therapy. 2006; 44 :415''437. [PubMed] [Google Scholar] Germer CK, Siegel RD, Fulton PR. Mindfulness and psychotherapy. New York, NY US: Guilford Press; 2005. [Google Scholar] Gifford EV, Kohlenberg BS, Hayes SC, Antonuccio DO, Piasecki MM, Rasmussen-Hall ML, Palm KM. Acceptance-based treatment for smoking cessation. Behavior Therapy. 2004; 35 :689''705. [Google Scholar] Giluk TL. Mindfulness, big five personality, and affect: A meta-analysis. Personality and Individual Differences. 2009; 47 :805''811. [Google Scholar] Godfrin KA, van Heeringen C. The effects of mindfulness-based cognitive therapy on recurrence of depressive episodes, mental health and quality of life: a randomized controlled study. Behaviour Research and Therapy. 2010; 48 :738''746. [PubMed] [Google Scholar] Gratz KL, Roemer L. Multidimensional assessment of emotion regulation and dysregulation: Development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology and Behavioral Assessment. 2004; 26 :41''54. [Google Scholar] Greeson J, Webber D, Brantley J, Smoski M, Ekblad A, Suarez E, Wolever R. Changes in spirituality partly explain health-related quality of life outcomes after Mindfulness-Based Stress Reduction. Journal of Behavioral Medicine in press. [PMC free article] [PubMed] [Google Scholar] Gregg JA, Callaghan GM, Hayes SC, Glenn-Lawson JL. Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology. 2007; 75 :336''343. [PubMed] [Google Scholar] Grossman P. On measuring mindfulness in psychosomatic and psychological research. Journal of Psychosomatic Research. 2008; 64 :405''408. [PubMed] [Google Scholar] Grossman P, Niemann L, Schmidt S, Walach H. Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research. 2004; 57 :35''43. [PubMed] [Google Scholar] Grossman P, Kappos L, Gensicke H, D'Souza M, Mohr DC, Penner IK, Steiner C. MS quality of life, depression, and fatigue improve after mindfulness training: A randomized trial. Neurology. 2010; 75 :1141''1149. [PMC free article] [PubMed] [Google Scholar] Hanh TN. The miracle of mindfulness. Boston: Beacon Press; 1976. [Google Scholar] Hargus E, Crane C, Barnhofer T, Williams JMG. Effects of mindfulness on meta-awareness and specificity of describing prodromal symptoms in suicidal depression. Emotion. 2010; 1 :34''42. [PMC free article] [PubMed] [Google Scholar] Hayes AM, Beevers C, Feldman G, Laurenceau JP, Perlman C. Growth after depression: The roles of avoidance and cognitive/emotional processing in an integrative therapy for depression. International Journal of Behavioral Medicine. 2005; 12 :111''122. [PubMed] [Google Scholar] Hayes AM, Feldman G. Clarifying the construct of mindfulness in the context of emotion regulation and the process of change in therapy. Clinical Psychology: Science and Practice. 2004; 11 :255''262. [Google Scholar] Hayes S. Content, context, and the types of psychological acceptance. In: Hayes SC, Jacobson NS, Follette VM, Dougher MJ, editors. Acceptance and change: Content and context in psychotherapy. Reno, NV: Context Press; 1994. pp. 13''32. [Google Scholar] Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and commitment therapy: Model, processes, and outcomes. Behaviour Research and Therapy. 2006; 44 :1''25. [PubMed] [Google Scholar] Hayes SC, Strosahl KD, Wilson KG. Acceptance and commitment therapy. New York: Guilford Press; 1999. [Google Scholar] Hayes SC, Wilson KG, Gifford EV, Bissett R, Piasecki M, Batten SV, Gregg J. A preliminary trial of twelve-step facilitation and acceptance and commitment therapy with poly substance-abusing methadone-maintained opiate addicts. Behavior Therapy. 2004; 35 :667''688. [Google Scholar] Hepburn SR, Crane C, Barnhofer T, Duggan DS, Fennell MJV, Williams JGW. Mindfulness-based cognitive therapy may reduce thought suppression: Findings from a preliminary study. British Journal of Clinical Psychology. 2009; 48 :209''215. [PubMed] [Google Scholar] Herrigel E. Zen in the art of archery. New York: McGraw-Hill; 1953. [Google Scholar] Herrigel E, Hull RFC, Tausend H. The method of Zen. New York: Pantheon Books; 1960. [Google Scholar] Herndon F. Testing mindfulness with perceptual and cognitive factors: External vs. internal encoding, and the cognitive failures questionnaire. Personality and Individual Differences. 2008; 44 :32''41. [Google Scholar] Hick SF, Furlotte C. An exploratory study of radical mindfulness training with severely economically disadvantaged people: Findings of a Canadian study. Australian Social Work. 2010; 63 :281''298. [Google Scholar] Hodgins HS, Adair KC. Attentional processes and meditation. Consciousness and Cognition. 2010; 19 :872''878. [PubMed] [Google Scholar] H¶lzel BK, Ott U, Gard T, Hempel H, Weygandt M, Morgen K, et al. Investigation of mindfulness meditation practitioners with voxel-based morphometry. Social Cognitive and Affective Neuroscience. 2008; 3 :55''61. [PMC free article] [PubMed] [Google Scholar] H¶lzel BK, Ott U, Hempel H, Hackl A, Wolf K, Stark R, et al. Differential engagement of anterior cingulate and adjacent medial frontal cortex in adept meditators and non-meditators. Neuroscience Letters. 2007; 421 :16''21. [PubMed] [Google Scholar] Huffziger S, Kuehner C. Rumination, distraction, and mindful self-focus in depressed patients. Behaviour Research and Therapy. 2009; 47 :224''230. [PubMed] [Google Scholar] Jain S, Shapiro SL, Swanick S, Roesch SC, Mills PJ, Bell I, Schwartz GER. A randomized controlled trial of mindfulness meditation versus relaxation training: Effects on distress, positive states of mind, rumination, and distraction. Annals of Behavioral Medicine. 2007; 33 :11''21. [PubMed] [Google Scholar] Jha AP, Krompinger J, Baime MJ. Mindfulness training modifies subsystems of attention. Cognitive, Affective & Behavioral Neuroscience. 2007; 7 :109''119. [PubMed] [Google Scholar] Jha AP, Stanley EA, Kiyonaga A, Wong L, Gelfand L. Examining the protective effects of mindfulness training on working memory capacity and affective experience. Emotion. 2010; 10 :54''64. [PubMed] [Google Scholar] Josefsson T, Larsman P, Broberg A, Lundh LG. Self-reported mindfulness mediates the relation between meditation experience and psychological well-being. Mindfulness. 2011; 2 :49''58. [Google Scholar] Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: Theoretical considerations and preliminary results. General Hospital Psychiatry. 1982; 4 :33''47. [PubMed] [Google Scholar] Kabat-Zinn J. Full catastrophe living: How to cope with stress, pain and illness using mindfulness meditation. New York: NY: Bantam Dell; 1990. [Google Scholar] Kabat-Zinn J. Wherever you go there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion; 1994. [Google Scholar] Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice. 2003; 10 :144''156. [Google Scholar] Kasamatsu A, Hirai T. An electroencephalographic study on the Zen meditation (Zazen) Psychologia. 1966; 12 :205''225. [PubMed] [Google Scholar] Keng SL, Smoski MJ, Robins CJ, Ekblad A, Brantley J. Mechanisms of change in MBSR: Self compassion and mindful attention as mediators of intervention outcome; Poster presented at the annual meeting of the Association for Behavioral and Cognitive Therapies; San Francisco, CA. Nov 19, 2010. [Google Scholar] Kim B, Lee SH, Kim YW, Choi TK, Yook K, Suh SY, Yook KH. Effectiveness of a mindfulness-based cognitive therapy program as an adjunct to pharmacotherapy in patients with panic disorder. Journal of Anxiety Disorders. 2010; 24 :590''595. [PubMed] [Google Scholar] Kocovski NL, Segal ZV, Battista SR, Didonna F. Mindfulness and psychopathology: Problem formulation. In: Didonna F, editor. Clinical handbook of mindfulness. New York, NY: Springer; 2009. pp. 85''98. [Google Scholar] Koons CR, Robins CJ, Tweed JL, Lynch TR, Gonzalez AM, Morse JQ, Bastian LA. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy. 2001; 32 :371''390. [Google Scholar] Koszycki D, Benger D, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy. 2007; 45 :2518''2526. [PubMed] [Google Scholar] Kristeller JL, Hallett CB. An exploratory study of a meditation-based intervention for binge eating disorder. Journal of Health Psychology. 1999; 4 :357''363. [PubMed] [Google Scholar] Kuehner C, Huffziger S, Liebsch K. Rumination, distraction and mindful self focus: Effects on mood, dysfunctional attitudes and cortisol stress response. Psychological Medicine. 2009; 39 :219''228. [PubMed] [Google Scholar] Kuyken W, Brewin CR. Autobiographical memory functioning in depression and reports of early abuse. Journal of Abnormal Psychology. 1995; 104 :585''591. [PubMed] [Google Scholar] Kuyken W, Byford S, Taylor RS, Watkins E, Holden E, White K, Teasdale JD. Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology. 2008; 76 :966''978. [PubMed] [Google Scholar] Kuyken W, Watkins E, Holden E, White K, Taylor RS, Byford S, Dalgleish T. How does mindfulness-based cognitive therapy work? Behaviour Research and Therapy. 2010; 48 :1105''1112. [PubMed] [Google Scholar] Lappalainen R, Lehtonen T, Skarp E, Taubert E, Ojanen M, Hayes SC. The impact of CBT and ACT models using psychology trainee therapists: A preliminary controlled effectiveness trial. Behavior Modification. 2007; 31 :488''511. [PubMed] [Google Scholar] Lau MA, Bishop SR, Segal ZV, Buis T, Anderson ND, Carlson L, Carmody J. The Toronto Mindfulness Scale: Development and validation. Journal of Clinical Psychology. 2006; 62 :1445''1467. [PubMed] [Google Scholar] Lazar SW, Kerr CE, Wasserman RH, Gray JR, Greve DN, Treadway MT, Fischl B. Meditation experience is associated with increased cortical thickness. Neuroreport. 2005; 16 :1893''1897. [PMC free article] [PubMed] [Google Scholar] Lee J, Semple RJ, Rosa D, Miller L. Mindfulness-based cognitive therapy for children: Results of a pilot study. Journal of Cognitive Psychotherapy: An International Quarterly. 2008; 22 :15''28. [Google Scholar] Levitt JT, Brown TA, Orsillo SM, Barlow DH. The effects of acceptance versus suppression of emotion on subjective and psychophysiological response to carbon dioxide challenge in patients with panic disorder. Behavior Therapy. 2004; 35 :747''766. [Google Scholar] Linehan M. Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press; 1993a. [Google Scholar] Linehan M. Skills training manual for treating borderline personality disorder. New York: Guilford Press; 1993b. [Google Scholar] Linehan MM, Amstrong HE, Suarez A, Allmon DJ, Heard HL. Cognitive-behavioral treatment of chronically suicidal borderline patients. Archives of General Psychiatry. 1991; 48 :1060''1064. [PubMed] [Google Scholar] Linehan MM, Heard HL, Amstrong HE. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry. 1993; 50 :971''974. [PubMed] [Google Scholar] Linehan MM, Comtois KA, Murray AM, Brown MZ, Gallop RJ, Heard HL, Lindenboim N. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry. 2006; 63 :757''766. [PubMed] [Google Scholar] Linehan MM, Dimeff LA, Reynolds SK, Comtois KA, Welch SS, Heagerty P, Kivlahan DR. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder. Drug and Alcohol Dependence. 2002; 67 :13''26. [PubMed] [Google Scholar] Linehan MM, Schmidt H, III, Dimeff LA, Craft JC, Kanter J, Comtois KA. Dialectical behavior therapy for patients with borderline personality disorder and drug dependence. American Journal of Addiction. 1999; 8 :279''292. [PubMed] [Google Scholar] Linehan MM, Tutek D, Heard HL, Armstrong HE. Interpersonal outcome of cognitive-behavioral treatment for chronically suicidal borderline patients. American Journal of Psychiatry. 1994; 51 :1771''1776. [PubMed] [Google Scholar] Lykins E, Baer RA. Psychological functioning in a sample of long-term practitioners of mindfulness meditation. Journal of Cognitive Psychotherapy: An International Quarterly. 2009; 23 :226''241. [Google Scholar] Lynch TR, Morse JQ, Mendelson T, Robins CJ. Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry. 2003; 11 :33''45. [PubMed] [Google Scholar] Lynch TR, Trost WT, Salsman N, Linehan M. Dialectical behavior therapy for borderline personality disorder. Annual Review of Clinical Psychology. 2007; 3 :181''205. [PubMed] [Google Scholar] Ma SH, Teasdale JD. Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology. 2004; 72 :31''40. [PubMed] [Google Scholar] McBee L. Mindfulness-based elder care: A CAM model for frail elders and their caregivers. New York, NY: Springer; 2008. [Google Scholar] Michalak J, Heidenreich T, Meibert P, Schulte D. Mindfulness predicts relapse/recurrence in major depressive disorder after mindfulness-based cognitive therapy. Journal of Nervous and Mental Disease. 2008; 196 :630''633. [PubMed] [Google Scholar] Miklowitz D, Alatiq Y, Goodwin GM, Geddes JR, Fennell MJV, Dimidjian S, Williams JMG. A pilot study of mindfulness-based cognitive therapy for bipolar disorder. International Journal of Cognitive Therapy. 2009; 2 :373''382. [Google Scholar] Moore A, Malinowski P. Meditation, mindfulness and cognitive flexibility. Consciousness and Cognition. 2009; 18 :176''186. [PubMed] [Google Scholar] Napoli M. Mindfulness training for teachers: A pilot program. Complementary Health Practice Review. 2004; 9 :31''42. [Google Scholar] Napoli M, Krech PR, Holley LC. Mindfulness training for elementary school students: The attention academy. Journal of Applied School Psychology. 2005; 21 :99''125. [Google Scholar] Nolen-Hoeksema S, Morrow J. A prospective study of depression and posttraumatic stress symptoms after a natural disaster: The 1989 loma prieta earthquake. Journal of Personality and Social Psychology. 1991; 61 :115''121. [PubMed] [Google Scholar] Ochsner K, Gross J. Cognitive emotion regulation: Insights from social cognitive and affective neuroscience. Current Directions in Psychological Science. 2008; 17 :153''158. [PMC free article] [PubMed] [Google Scholar] Oman D, Shapiro SL, Thoresen CE, Plante TG, Flinders T. Meditation lowers stress and supports forgiveness among college students. Journal of American College Health. 2008; 56 :569''578. [PubMed] [Google Scholar] Ortner CNM, Kilner SJ, Zelazo PD. Mindfulness meditation and reduced emotional interference on a cognitive task. Motivation and Emotion. 2007; 31 :271''283. [Google Scholar] Piet J, Hougaard E, Hecksher MS, Rosenberg NK. A randomized pilot study of mindfulness-based cognitive therapy and group cognitive-behavioral therapy for young adults with social phobia. Scandinavian Journal of Psychology. 2010; 51 :403''410. [PubMed] [Google Scholar] Posner MI, Peterson SE. The attention system of the human brain. Annual Review of Neuroscience. 1990; 13 :25''42. [PubMed] [Google Scholar] Powers MB, Zum Vorde Sive Vording MB, Emmelkamp PMG. Acceptance and commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics. 2009; 78 :73''80. [PubMed] [Google Scholar] Raes F, Dewulf D, Van Heeringen C, Williams JMG. Mindfulness and reduced cognitive reactivity to sad mood: Evidence from a correlational study and a non-randomized waiting list controlled study. Behaviour Research and Therapy. 2009; 47 :623''627. [PubMed] [Google Scholar] Raes F, Williams MG. The relationship between mindfulness and uncontrollability of ruminative thinking. Mindfulness 2010 in press. [Google Scholar] Ramel W, Goldin PR, Carmona PE, McQuaid JR. The effects of mindfulness meditation on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research. 2004; 28 :433''455. [Google Scholar] Rasmussen MK, Pidgeon AM. The direct and indirect benefits of dispositional mindfulness on self-esteem and social anxiety. Anxiety, Stress & Coping 2010 in press. [PubMed] [Google Scholar] Robins CJ. Zen principles and mindfulness practice in dialectical behavior therapy. Cognitive and Behavioral Practice. 2002; 9 :50''57. [Google Scholar] Robins CJ, Chapman AL. Dialectical behavior therapy: Current status, recent developments, and future directions. Journal of Personality Disorders. 2004; 18 :73''79. [PubMed] [Google Scholar] Robins CJ, Keng SL, Ekblad AG, Brantley JG. Effects of mindfulness-based stress reduction on emotional experience and expression: A randomized controlled trial. Manuscript submitted for publication 2010 [PubMed] [Google Scholar] Roemer L, Orsillo SM, Salters-Pedneault K. Efficacy of an acceptance- based behavior therapy for generalized anxiety disorder: evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology. 2008; 76 :1083''1089. [PMC free article] [PubMed] [Google Scholar] Rogojanski J, Vettese L, Antony M. Coping with cigarette cravings: Comparison of suppression versus mindfulness-based strategies. Mindfulness. 2011; 2 :14''26. [Google Scholar] Rosch E. More than mindfulness: When you have a tiger by the tail, let it eat you. Psychological Inquiry. 2007; 18 :258''264. [Google Scholar] Ross NW. The world of Zen: An east-west anthology. New York: Random House; 1960. [Google Scholar] Safer DL, Telch CF, Agras WS. Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry. 2001; 158 :632''634. [PubMed] [Google Scholar] Samuelson M, Carmody J, Kabat-Zinn J, Bratt MA. Mindfulness-based stress reduction in Massachusetts correctional facilities. The Prison Journal. 2007; 87 :254''268. [Google Scholar] Sanderson WC, Rapee RM, Barlow DH. Panic induction via inhalation of 5.5% CO2 enriched air: A single subject analysis of psychological and physiological effects. Behaviour Research and Therapy. 1988; 26 :333''335. [PubMed] [Google Scholar] Schmertz SK, Anderson PL, Robins DL. The relation between self-report mindfulness and performance on tasks of sustained attention. Journal of Psychopathology and Behavioral Assessment. 2009; 31 :60''66. [Google Scholar] Segal ZV, Williams JMG, Teasdale JD. Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press; 2002. [Google Scholar] Sephton SE, Salmon P, Weissbecker I, Ulmer C, Floyd A, Hoover K, Studts JL. Mindfulness meditation alleviates depressive symptoms in women with fibromyalgia: Results of a randomized clinical trial. Arthritis & Rheumatism. 2007; 57 :77''85. [PubMed] [Google Scholar] Shahar B, Britton WB, Sbarra DA, Figueredo AJ, Bootzin RR. Mechanisms of change of mindfulness-based cognitive therapy for depression: Preliminary evidence from a randomized controlled trial. International Journal of Cognitive Therapy. 2010; 3 :402''418. [Google Scholar] Shapiro SL, Brown KW, Thoresen C, Plante TG. The moderation of mindfulness-based stress reduction effects by trait mindfulness: Results from a randomized controlled trial. Journal of Clinical Psychology. 2011; 67 :267''277. [PubMed] [Google Scholar] Shapiro SL, Schwartz G, Bonner G. Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine. 1998; 21 :581''599. [PubMed] [Google Scholar] Shapiro SL, Astin JA, Bishop SR, Cordova M. Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management. 2005; 12 :164''176. [Google Scholar] Shapiro SL, Brown KW, Biegel GM. Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology. 2007; 1 :105''115. [Google Scholar] Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. Journal of Clinical Psychology. 2006; 62 :373''386. [PubMed] [Google Scholar] Shapiro SL, Oman D, Thoresen CE, Plante TG, Flinders T. Cultivating mindfulness: Effects on well-being. Journal of Clinical Psychology. 2008; 64 :840''862. [PubMed] [Google Scholar] Singer AR, Dobson KS. An experimental investigation of the cognitive vulnerability to depression. Behaviour Research and Therapy. 2007; 45 :563''575. [PubMed] [Google Scholar] Singh NN, Lancioni GE, Winton ASW, Fisher BC, Wahler RG, McAleavey K, Saabawi M. Mindful parenting decreases aggression, noncompliance, and self-injury in children with autism. Journal of Emotional and Behavioral Disorders. 2006; 14 :169''177. [Google Scholar] Smith A. Clinical uses of mindfulness training for older people. Behavioural and Cognitive Psychotherapy. 2004; 32 :423''430. [Google Scholar] Speca M, Carlson LE, Goodey E, Angen M. A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients. Psychosomatic Medicine. 2000; 62 :613''622. [PubMed] [Google Scholar] Suzuki DT, Fromm E, De Martino R. Zen buddhism and psychoanalysis. New York: Harper & Row; 1960. [Google Scholar] Tang YY, Ma Y, Wang J, Fan Y, Feng Y, Lu S, Posner MI. Short-term meditation training improves attention and self-regulation. Proceedings of the National Academy of Sciences. 2007; 104 :17152''17156. [PMC free article] [PubMed] [Google Scholar] Teasdale JD. Emotional processing, three modes of mind and the prevention of relapse in depression. Behaviour Research and Therapy. 1999; 37 :53''77. [PubMed] [Google Scholar] Teasdale JD, Moore RG, Hayhurst H, Pope M, Williams S, Segal ZV. Metacognitive awareness and prevention of relapse in depression: Empirical evidence. Journal of Consulting and Clinical Psychology. 2002; 70 :275''287. [PubMed] [Google Scholar] Teasdale JD, Segal Z, Williams JM. How does cognitive therapy prevent depressive relapse and why should attentional control training help? Behaviour Research and Therapy. 1995; 33 :25''39. [PubMed] [Google Scholar] Teasdale JD, Segal ZV, Williams JMG. Mindfulness training and problem formulation. Clinical Psychology: Science and Practice. 2003; 10 :157''160. [Google Scholar] Teasdale JD, Segal ZV, Williams JMG, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology. 2000; 68 :615''623. [PubMed] [Google Scholar] Telch CF, Agras WS, Linehan MM. Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology. 2001; 69 :1061''1065. [PubMed] [Google Scholar] Thompson NJ, Walker ER, Obolensky N, Winning A, Barmon C, Dilorio C, Compton MT. Distance delivery of mindfulness-based cognitive therapy for depression: Project UPLIFT. Epilepsy & Behavior 2010 in press. [PubMed] [Google Scholar] Thompson BL, Waltz J. Everyday mindfulness and mindfulness meditation: Overlapping constructs or not? Personality and Individual Differences. 2007; 43 :1875''1885. [Google Scholar] Thompson BL, Waltz J. Everyday mindfulness and mindfulness meditation: Overlapping constructs or not? Personality and Individual Differences. 2007; 43 :1875''1885. [Google Scholar] Treadway MT, Lazar SW. The neurobiology of mindfulness. In: Didonna F, editor. Clinical handbook of mindfulness. New York, NY: Springer; 2009. pp. 45''58. [Google Scholar] Turner RM. Naturalistic evaluation of dialectical behavior therapy-oriented treatment for borderline personality disorder. Cognitive and Behavioral Practice. 2000; 7 :413''419. [Google Scholar] Van Dam NT, Earleywine M, Borders A. Measuring mindfulness? An item response theory analysis of the Mindful Attention Awareness Scale. Personality and Individual Differences. 2010; 49 :805''810. [Google Scholar] Van Dam NT, Earleywine M, Danoff-Burg S. Differential item function across meditators and non-meditators on the Five Facet Mindfulness Questionnaire. Personality and Individual Differences. 2009; 47 :516''521. [Google Scholar] Valentine ER, Sweet PLG. Meditation and attention: A comparison of the effects of concentrative and mindfulness meditation on sustained attention. Mental Health, Religion and Culture. 1999; 2 :59''70. [Google Scholar] Verheul R, van den Bosch LMC, Koeter MWJ, de Ridder MAJ, Stijnen T, van den Brink W. Dialectical behavior therapy for women with borderline personality disorder: 12-month randomized clinical trial in The Netherlands. British Journal of Psychiatry. 2003; 182 :135''140. [PubMed] [Google Scholar] Vettese L, Toneatto T, Stea JN, Nguyen L, Wang JJ. Do mindfulness meditation participants do their homework? And does it make a difference? A review of empirical evidence. Journal of Cognitive Psychotherapy: An International Quarterly. 2009; 23 :198''224. [Google Scholar] Walach H, Buchheld N, Buttenmuller V, Kleinknecht N, Schmidt S. Measuring mindfulness: The Freiburg Mindfulness Inventory (FMI) Personality and Individual Differences. 2006; 40 :1543''1555. [Google Scholar] Wallace RK. Physiological effects of Transcendental Meditation. Science. 1970; 167 :1751''1754. [PubMed] [Google Scholar] Wallace RK, Benson H, Wilson AF. A wakeful hypometabolic physiologic state. American Journal of Physiology. 1971; 221 :795''799. [PubMed] [Google Scholar] Watts AW. Psychotherapy east and west. New York: Pantheon Books; 1961. [Google Scholar] Way BM, Creswell JD, Eisenberger NI, Lieberman MD. Dispositional mindfulness and depressive symptomatology: Correlations with limbic and self-referential neural activity during rest. Emotion. 2010; 10 :12''24. [PMC free article] [PubMed] [Google Scholar] Weber B, Jermann F, Gex-Fabry M, Nallet A, Bondolfi G, Aubry JM. Mindfulness-based cognitive therapy for bipolar disorder: A feasibility trial. European Psychiatry. 2010; 25 :334''337. [PubMed] [Google Scholar] Weissbecker I, Salmon P, Studts JL, Floyd AR, Dedert EA, Sephton SE. Mindfulness-based stress reduction and sense of coherence among women with fibromyalgia. Journal of Clinical Psychology in Medical Settings. 2002; 9 :297''307. [Google Scholar] Williams JMG, Alatiq Y, Crane C, Barnhofer T, Fennell MJV, Duggan DS, Goodwin GM. Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: Preliminary evaluation of immediate effects on between-episode functioning. Journal of Affective Disorders. 2008; 107 :275''279. [PMC free article] [PubMed] [Google Scholar] Williams JMG, Teasdale JD, Segal ZV, Soulsby J. Mindfulness-based cognitive therapy reduces overgeneral autobiographical memory in formerly depressed patients. Journal of Abnormal Psychology. 2000; 109 :150''155. [PubMed] [Google Scholar] Williams KA, Kolar MM, Reger BE, Pearson JC. Evaluation of a wellness-based mindfulness stress reduction intervention: A controlled trial. American Journal of Health Promotion. 2001; 15 :422''432. [PubMed] [Google Scholar] Witkiewitz K, Marlatt A, Walker D. Mindfulness-based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy. 2005; 19 :211''228. [Google Scholar] Woods DW, Wetterneck CT, Flessner CA. A controlled evaluation of acceptance and commitment therapy plus habit reversal for trichotillomania. Behaviour Research and Therapy. 2006; 44 :639. [PubMed] [Google Scholar] Zettle RD. Acceptance and commitment therapy (ACT) vs. systematic desensitization in treatment of mathematics anxiety. Psychological Record. 2003; 53 :197''215. [Google Scholar] Zettle RD, Hayes SC. Dysfunctional control by client verbal behavior: The context of reason giving. Analysis of Verbal Behavior. 1986; 4 :30''38. [PMC free article] [PubMed] [Google Scholar] Zettle RD, Rains JC. Group cognitive and contextual therapies in treatment of depression. Journal of Clinical Psychology. 1989; 45 :438''445. [PubMed] [Google Scholar] Zylowska L, Ackerman DL, Yang MH, Futrell JL, Horton NI, Hale S, Smalley SL. Mindfulness meditation training in adults and adolescents with ADHD: A feasibility study. Journal of Attention Disorders. 2008; 11 :737''746. [PubMed] [Google Scholar]