The Effects of “The Work” Meditation (Byron Katie) on Psychological Symptoms and Quality of Life—A Pilot Clinical Study

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The Effects of “The Work” Meditation (Byron Katie) on Psychological Symptoms and Quality of Life - A Pilot Clinical Study Eric Smernoff PhD, Inbal Mitnik MA, Ken Kolodner ScD, Shahar Lev-ari PhD

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Cite this article as: Eric Smernoff PhD, Inbal Mitnik MA, Ken Kolodner ScD, Shahar Lev-ari PhD, The Effects of “The Work” Meditation (Byron Katie) on Psychological Symptoms and Quality of Life - A Pilot Clinical Study, Explore, http://dx.doi.org/ 10.1016/j.explore.2014.10.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

THE EFFECTS OF “THE WORK” MEDITATION (BYRON KATIE) ON PSYCHOLOGICAL SYMPTOMS AND QUALITY OF LIFE - A PILOT CLINICAL STUDY

Eric Smernoff, PhD1; Inbal Mitnik, MA1; Ken Kolodner, ScD2; Shahar Lev-ari, PhD1#

1

Center of Complementary and Integrative Medicine, Institute of Oncology at Tel-

Aviv Sourasky Medical Center and affiliated to the Sackler Faculty of Medicine at Tel-Aviv University, both in Tel-Aviv, Israel. 2

The Department of Psychiatry and Behavioral Sciences, The Johns Hopkins

School of Medicine, Baltimore, MD, USA.

#

Corresponding Author: Shahar Lev-Ari, PhD, Director, Center of Complementary and Integrative Medicine Institute of Oncology, Tel Aviv Sourasky Medical Center 6 Weizmann St. Tel Aviv 64239 Israel. Telephone: +972-3-6973630; Fax: 972-3-6974337; E-mail: [email protected]

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ABSTRACT Objectives: "The Work" is a meditative technique that enables the identification and investigation of thoughts that cause an individual stress and suffering. Its core is comprised of four questions and turnarounds that enable the participant to experience a different interpretation of reality. We assessed the effect of ―The Work‖ meditation on quality of life and psychological symptoms in a non-clinical sample. Design: This study was designed as a single group pilot clinical trial (open label). Participants (n = 197) enrolled in a 9-day training course (‗The School for the Work‘) and completed a set of self-administered measures on three occasions: before the course (n= 197), after the course (n = 164) and 6 months after course completion (n = 102). Outcome measures: Beck-Depression Inventory-II (BDI–II), Subjective Happiness Scale (SHS), Quality of Life Inventory (QOLI), Quick Inventory of Depressive Symptomology-Self Report (QIDS-SR16), Outcome Questionnaire (OQ-45.2), StateTrait Anger Expression Inventory-2 (STAXI-2) and State Trait Anxiety Inventory (STAI). Results: A mixed models analysis revealed significant positive changes between baseline compared to the end of the intervention and 6-month follow-up in all measures: BDI–II ( t=10.24, P < .0001), SHS ( t= -9.07, P < .0001), QOLI ( t= -5.69, P <.0001), QIDS-SR16 ( t= 9.35, P < .0001), OQ®-45.2 ( t=11.74, P < .0001), STAXI-2 (State) ( t=3.69, P =0.0003), STAXI-2 (Trait) ( t=7.8, P < .0001), STAI (State) ( t=11.46, P < 0.0001), (STAI) (Trait) ( t=10.75, P <.0001). Conclusions: The promising results of this pilot study warrant randomized clinical trials to validate "The Work" meditation technique as an effective intervention for improvement in psychological state and quality of life in the general population.

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Key words: ―The Work‖, meditation, psychological symptoms, quality of life

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INTRODUCTION Mental disorders, in particular depression and anxiety, are associated with impairment in physical, social and role functioning, as well as in health-related quality of life. They are also associated with increased prevalence of chronic diseases and increased mortality and morbidity, such as in coronary heart diseases [1-3]. Mental disorders account for 13% of the global disease burden and their economic effect is significant [4]. A survey held in the US between 2001-2003 revealed that mental disorders are highly prevalent in the general population [5]. It found that anxiety disorders were the most common and that mood disorders were the next most common but had the highest proportion of serious cases [5]. There are various kinds of interventions aimed at improving mental state and quality of life, such as medication, psychotherapy, physical activity, and others [1, 6]. The past few decades have witnessed a growing interest in the therapeutic efficacy of mind-body interventions . These interventions are defined by the "National Center for Complementary and Alternative Medicine" as a variety of techniques aimed to strengthen the awareness of and affect bodily functions and symptoms. The common tools for treatment include meditation, prayer, yoga, guided imagination and art therapy [7]. The practice of meditation has become increasingly popular and has gained acceptance among clinicians, researchers and the public. Reports in the scientific literature demonstrated the effects of meditation practices on mental health (emotional distress, depression, anxiety, etc.) [8,9], as well as on medical conditions (cardiovascular and metabolic disorders, pain syndromes, etc.) [10,11]. Meditation was the first mind-body intervention to be widely adopted by mainstream healthcare and incorporated into therapeutic programs in the United States and other countries [12]. Despite a lack of consensus regarding its definition, most researchers agree that

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meditation is a form of mental training, striving to reach a state of ―detached observation" in terms of full awareness of the current moment without cognitive involvement [12].

"The Work" meditation technique was developed by Byron Katie in 1986. It is based on identifying and investigating the thoughts that cause stress and suffering. The basic assumption is that when we believe our thoughts, we suffer and when we do not believe, we do not suffer. This technique does not require any intellectual, religious or spiritual preparation, but rather a will to deepen the level of selfawareness. The first part of the technique is to identify stressful thoughts in a systematic and comprehensive way and write down the thoughts about various situations that are perceived as stressful. The second part is a meditative investigation of the stressful thoughts by a series of four questions and turnarounds, which enable the participant to experience a different interpretation of the perceived reality [13,14]. The technique incorporates ―Deliberative thinking‖, which occurs when one is consciously and intentionally thinking about something, and ―Witnessing awareness‖, which occurs when one observes what arises in his awareness without trying to control or think about it [15,16]. Like other psychological models, such as Cognitive Behavioral Therapy (CBT), "The Work" technique assumes that feelings (such as sadness, anger, and pain) emerge from an attachment to a stressful thought, which leads to behavior. This means that thought precedes feelings and behavior, and should be focused on as the primal cause of stress and suffering. However, unlike cognitive restructuring that encourages an individual to use deliberative thinking to answer questions, "The Work" uses it only for asking questions and "relies on one‘s witnessing awareness to listen for a response to arise naturally from within" [15]. The activated internal mental process of "The Work" is qualitatively different from 5

classical CBT as the inner wisdom associated with a meditative state of mind is addressed rather than the rationality [15a]. This process produces an essentially different experience as its discoveries feel as an emotional insight [15a]. This may address the problem frequently encountered in CBT where a client might report that he knows that the negative thought is not true, but he nevertheless feels that it is [13,14]. Additional differences from CBT relate to "The Work" inquiry format of the four questions and turnarounds, which encourages an emotional perspective and limits the cognition‘s influence and credibility (e.g. Yes/No questions) [15b]. It is estimated that ―The Work‖ has been practiced by hundreds of thousands of people in more than 30 countries [13]. Several clinical trials have been initiated to assess the effect of ―The Work‖ intervention on psychological and physical symptoms and quality of life of breast cancer survivors (observational study NCT01244087) [17] and of BRCA1/ BRCA2 mutation carriers (randomized clinical trial NCT01367639) [18]. The current study is a preliminary investigation of the effectiveness of ―The Work‖ in a non-clinical sample of individuals who enrolled in the technique's workshop. It assesses the effectiveness of the technique on participants‘ psychological symptoms and quality of life using well-established standardized assessments.

METHODS Participants The sample included individuals self-enrolled in a 9-day workshop entitled "The School for The Work" at Los Angeles, CA, USA in November, 2008. All the participants signed an informed consent form prior to enrolment in the research study. Due to the sample's characteristics, minimal exclusion criteria of ability to read 6

English at a ninth grade level or higher (as judged by successful completion of a battery of self-reported measures) and willing to sign an informed consent were employed. Data collection Each participant was assigned a number that was used on all test materials in order to ensure confidentiality. All the subjects filled in seven self-administered questionnaires on three occasions: at the beginning of the training course (T1), at the completion of the training course (T2) and six months after completing the training course (T3). The forms were returned by mail at T3. The research staff was available at all times to answer questions. Questionnaires were scored according to the standard procedures of each instrument‘s instruction manual. Intervention method The participants attended a 9-day workshop guided by Byron Katie, and assisted by a staff of facilitators who were trained in the authorized certification program at ―The institute of the Work‖ (ITW), an international learning center [13] based in the USA. All sessions followed the guidelines of the training manual that was developed in order to maintain consistency in the program. This manual is based on the instructions of ―Judge-your-neighbor‖ worksheet (JYN, Appendix 1) and the inquiry technique detailed in "Loving what is" [14]. The subjects received a training manual to serve as a guideline for performing the various forms of the inquiry practice. During the sessions, the participants were encouraged to explore their stressful thoughts using ―The Work‖ technique, which is based on identifying and investigating the thoughts that cause distress and suffering. This process is divided into two parts. The first part is to identify the stressful thoughts in a systematic and comprehensive

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way and to write down the thoughts about various situations perceived by the person as being stressful. JYN worksheet is the main tool for systematically identifying stressful thoughts in ―The Work‖ technique. The participant is instructed to "think of a reoccurring stressful situation, a situation that is reliably stressful even though it may have only happened once and reoccurs only in your mind. Before answering each of the questions below, allow yourselves to mentally revisit the time and place of the stressful occurrence". The participant then writes down all the thoughts and beliefs regarding the stressful situation as he/she perceives them according to the worksheet format [13,14]. In the second part, the participant, with or without the help of a facilitator, (a person with experience in ―The Work‖ technique) chooses the most stressful thought and investigates it by four questions and turnarounds. Examples of stressful thoughts are "My husband doesn‘t listen to me", "My boss should appreciate me", "My body is too fat". The participant then examines the selected thoughts by the asking the following questions: 1) Is it true? 2) Can I absolutely know that it is true? 3) How do I react when I believe that thought? 4) Who would I be without the thought? This part is meditative and the participant is guided to search the true and genuine answers to the four questions with no fixed agenda. Unlike deliberate thinking in which a person consciously and deliberately thinks about something and experiences it as if he/she "created" the thought, the participant is guided to be aware of the thoughts that come into his/her mind without trying to control or direct them. He perceives himself/herself as a "witness‖, apart from these thoughts. Encouraging this kind of meditative ability is a central part of ―The Work‖ technique [13-15].

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The next stage is the implementation of the ―turnarounds‖, in which the participant experiences a different interpretation of the reality as he/she perceives it. If the original thought was: "My husband doesn't listen to me", a possible turnaround can be: "I don't listen to my husband‖ (turnaround to the other), ―I don't listen to myself‖ (Turnaround to myself), ―My husband does listen to me‖ (turnaround to the opposite). The participant is asked to find three genuine examples in which the turnaround is as true as the original thought. By doing so, the participant can understand and experience that he/she does not have to automatically believe the thoughts that cause stress and frustration, but can choose to replace them by other thoughts and different interpretations of reality. By doing so, situations perceived as stressful (such as a visit to the doctor) can become less threatening [13,14]. Measures Beck Depression Inventory—II (BDI–II): measures the level of depressive symptoms reported by respondents, with higher numbers indicating higher levels of depression: a score of 0-13 indicates minimal level of depression, 14-19 mild depression, 20-28 moderate depression, and 29-63 severe depression [19]. Quick Inventory of Depressive Symptomology-Self Report (QIDS-SR16): measures self-reported depressive symptoms. Higher numbers indicate higher levels of depression [20,21]. State-Trait Anger Expression Inventory (STAXI) (State): assesses the intensity of anger as an emotional state at a particular ―snapshot‖ in time. Higher scores indicate higher levels of anger. The mean score is 18.75 for normal adults and 23.38 for the psychiatric population. The STAXI-2 (Trait) measures the respondent‘s more enduring disposition to experience anger as a personality trait. Higher scores indicate

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more proclivities for anger. The mean score is 18.14 for normal adults and 19.96 for psychiatric population [22]. State-Trait Anxiety Inventory Form (STAI): measures anxiety in adults. It differentiates between State Anxiety and long-standing qualities of Trait Anxiety. Higher scores indicate higher levels of anxiety for both measures. The mean score is 37.2 for the normal adult population for State Anxiety and 36.79 for Trait Anxiety [23]. The Quality of Life Inventory (QOLI): measures the overall positive mental health and satisfaction with life. Higher numbers indicate a better quality of life. An average score on this measure ranges from 1.6 to 3.5, and a clinically significant change is denoted by a score that is either 2 standard deviations higher than a dysfunctional clinical mean or 1 standard deviation higher than a functional nonclinical mean [24,25]. Subjective Happiness Scale (SHS): a self-report measurement of happiness. Higher scores indicate higher levels of happiness: the highest possible score is 7 and an average score is 4.5-5.5 [26]. Outcome Questionnaire OQ-45.2: a 45-item self-report instrument, encompassing multidimensional measures of key functional and symptomatic areas. The broad areas assessed are: symptom distress, interpersonal relations, and social role (dissatisfaction and distress in tasks related to work, family roles, and leisure life). This questionnaire was designed for repeated measurements of clients‘ progress through therapy and has demonstrated sensitivity to change following behavioral treatments. Higher scores indicate higher levels of distress. A score over 63 indicates levels of distress higher than normal. A 14-point change in either direction is significant [27].

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Data analysis Analysis was carried out by an independent statistician using the SAS analysis Version 9.2. A total of 463 surveys were entered into a database, and composite scores were formed for all of the measures of well-being/outcome measures. To assess possible bias in the results due to missing data, we compared those who were assessed at the end of the intervention and were followed at 6 months postintervention to those who were missing at both follow-up time points. We used t-tests to compare continuous measures (all outcome measures and age) for those who had at least one follow-up measure (n=168) to those with no follow-up data (n=29). No differences were observed for any variable. We used chi-squares to compare categorical demographic variables (gender, and collapsed versions of marital status and occupation). Again, no differences were observed. These data are not presented. To assess changes in outcomes from baseline to follow-up, we used mixed models (SAS PROC MIXED). A ―time‖ effect was used to model statistical differences between the baseline (T1) and follow-up periods (T2 and T3) and to contrast the two follow-up periods. No statistical changes were observed from T2 (immediate post-intervention) to T3 (6 month follow-up) for all measures. The time effect was completely limited to T1 vs. the two follow-up periods. Thus, we also compared time 2 and time 3 as a single ―phase‖ and compared this phase to the baseline for all measures. Finally, we again used mixed models with ―change scores‖ (time 1 minus time 2; time 1 minus time 3). All methods yielded uniform results. To ensure the appropriateness of our analysis, we plotted distributions for all measures and changed scores. For most variables, scale values and change scores generally approximated a normal distribution with skewness and kurtosis below 1. For the values that were not normal, transformations succeeded in normalizing the data.

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Results did not differ on transformed and un-transformed data. Thus, we only present the results on the original (untransformed) data.

RESULTS All 197 participants who were initially recruited to this study completed the initial surveys (T1), 164 completed the surveys immediately after the intervention (T2), and 102 completed the surveys at the 6-month follow-up after the intervention (T3). Table 1 provides the demographic characteristics of the participants. One hundred and sixty eight subjects completed one of the two follow-ups. 68% were females (mean age 48.27 ± 9.05 years) and 31% were males (mean age 46.83 ± 12.28 years). Most of the participants were married, employed full time and had a college degree. Mixed models revealed a significant positive change in all measures when comparing the baseline to T2 and T3 (Table 2). There were no differences in any measures from T2 to T3. To simplify our analysis, we also performed our analysis on change scores using a phase average of T2 and T3 (as described in the data analysis section.) The results were consistent when using change scores (T1 minus T2, T1 minus T3) or actual values. Depression levels decreased significantly from the "mildly depressed" category at T1 to "no depression" at T2 and T3. Anxiety levels improved significantly after the intervention and the values were below the norm for adult population. The follow-up analysis of the 3 measures revealed a persistent post-intervention change. Both Anger State and Anger Trait scores decreased significantly after the intervention and this effect persisted six months after the intervention. These levels fell below the normal range. Quality of Life improved significantly as demonstrated

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in the overall positive mental health scores both at T2 and T3. Happiness levels increased significantly after the intervention, reaching the higher end of the average range. In the Outcome Questionnaire (OQ 45.2), there was a significant positive change in self-esteem, relationships with others and efficiency in carrying out life tasks at T2 and T3. Compliance - Of the original 197 people whose data were collected for baseline measurement (T1), 164 people also filled out the questionnaires at the completion of the program (T2), and 102 filled them out 6 months post intervention (follow-up phase, T2). This represents dropout rates of

5% for the intervention

phase and additional 37.8% for the follow-up phase. The sampling failures at followup (T3) may be partially the result the high processing time of the questionnaire. Another factor leading to high dropout could have been caused by fact that the third measurement was conducted via a postal survey; thus, high postage costs could have been a deterrent. The attendance and dropout rates of the current study are similar to those reported in previous studies regarding non-pharmacological group interventions for cancer patients such as psycho-social groups, support groups, physical activity, yoga and meditation (10-50%) [27a, 27b].

DISCUSSION This pilot study assessed the effectiveness of "The Work" intervention in a non-clinical sample and its preliminary results indicated a significant improvement in psychological state and quality of life after the intervention, as measured by a range of well-established psychometric assessment tools. This effect lasted 6 months after the intervention. The selected sample represents a non-clinical cohort with depression scores within the normal range according to Beck's depression scale [19]. Likewise,

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the state-trait anger scores [22] and the subjective happiness scale [26] were not significantly different from the published norms. The Quality of Life scales further confirmed that this cohort was mentally healthy and relatively satisfied with their lives [30]. Levels of Trait Anxiety, which were higher than the normal population [23], decreased significantly after the intervention and this effect persisted for six months after it. Trait anxiety had previously been considered a stable personality trait [23,29,30], but recent studies have shown that it may be reduced by various interventions, including mind-body interventions [31-33]. Konefal and Duncan [34] demonstrated significant reductions in trait anxiety after a 21-day training course in Neuro- Linguistic-Programming. These reductions were correlated with significant increases in internal locus of control scores. The current study did not measure locus of control; however, this concept can be demonstrated in a key tenet of "The Work", according to which individuals take responsibility for their own life by the active process of meditatively questioning stressful thoughts [34]. Scores of subjective happiness increased significantly after the intervention and this increase persisted 6 months, indicating that the change remained stable over time. These findings are similar to other studies that found a positive effect of meditation on the subjective happiness of participants [35,36]. A study by Davidson et al. demonstrated that meditation was associated with greater activation of the left prefrontal cortex, which is an area of the brain associated with positive emotional experience [37]. Schiffrin & Nelson examined the relationship between happiness and perceived stress and revealed an inverse relationship between the two measures: individuals with higher levels of perceived stress reported being less happy than those

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with lower levels [38]. Reduction of perceived stress has been found to be correlated to the practice of meditation in several studies [39,40], There are several limitations to this non-randomized pilot study on a convenience sample. First, selection bias may limit the possibility of generalizing the results to other populations and may overestimate the benefits of the intervention. In addition, the current sample included a majority of high-educated individuals, which may further limit the generalization ability. Second, there was no control group nor was there any randomization. Third, the dropout rate of respondents by the final 6month follow-up reduced the available measures and could produce bias in the results. However, mixed models showed that there was no ―time effect‖ between the assessments at the end of the intervention compared to the 6-month follow-up. That is, there is no evidence of decay in the effects from the assessment at the end of the intervention to the 6-month follow-up. Further, no baseline differences for any variable were observed for those lost to follow-up (no follow-up assessments) compared to those with at least one follow-up assessment. As a final precaution to guard against bias, we also performed a sensitivity analysis where all subjects who were without a follow-up measurement were assigned a baseline value for one followup period. Following an intent-to-treat philosophy, this assumes no change for all those subjects who are without follow-up data. Repeating the mixed models analyses, the level of statistical significance was attenuated (as expected) but the results were still statistically significant for all outcomes. . Fourth, while the intervention mainly focuses on teaching and practicing "The Work" technique, the program includes several other activities and provides the opportunity to meet a range of people, forge friendships, hold informal discussions and take a break from daily routines. As such, we are limited in inferring the extent to which the process of "The Work" techniques

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was the mechanism of change as opposed to a combination of all these various elements. In conclusion, this pilot study presents preliminary findings on potentially beneficial effects in a non-clinical sample following "The Work" intervention. Randomized clinical studies with a control group are warranted in order to further examine the effectiveness of the intervention in the general population. Its effectiveness in a clinical population comprised of individuals experiencing more severe levels of distress, such as people with major depression, should also be investigated.

* Financial Assistance – "The Work" Foundation, a non-profit 501 © organization, partially supported this study. "The Work" Foundation was not involved at any stage of data collection, interpretation of results or the writing of this paper.

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40. Danucalov MAD, Kozasa EH, Ribas KT, et al. Yoga and Compassion Meditation Program Reduces Stress in Familial Caregivers of Alzheimer's Disease Patients Evidence-Based. Complementary and Alternative Medicine 2013; Volume 2013: 8 pages.

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Table Legends

Table 1. Demographic Characteristics of the Participants Table 2. Comparison of Findings at the Three Time Points

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Appendix 1- "Judge-Your-Neighbor" worksheet

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Table 1. Demographic Characteristics of the Participants (n=197) No. (%1) or Mean (SD)

Characteristic Female

134 (68.37%)

Male

62 (31.63%)

Missing

1

Women

48.27 (9.05)

Men

46.83 (12.28)

Single

55 (32.16%)

Married

59 (34.50%)

Divorced

41 (23.98%)

Separated

13 (7.6%)

Widowed

3 (1.75%)

Missing

26

Full Time

73 (42.20%)

Part Time

12 (6.94%)

Self-Employed

68 (39.31%)

Unemployed

6 (3.47%)

Retired

14 (8.09%)

Missing

24

<12 y

1 (0.54%)

Good Enough Diploma*

0

High school

9 (4.86%)

13 to 15 Years

32 (17.30%)

Bachelor‘s degree

74 (40%)

Sex

Age (years)

Marital status

Employment status

Education level

25

No. (%1) or Mean (SD)

Characteristic Master's degree

47 (25.41%)

Doctorate degree

22 (11.89%)

Missing

12

*

Awarded to high school dropouts who passed an examination

1

Percentages are based on valid (non-missing) observations

Abbreviation: SD, Standard Deviation

26

Table 2. Comparison of Outcomes for the Baseline versus Post Intervention (n=197) Using Mixed Models Before

After

After 6

Intervention

Intervention

Months t value 1

Instrument (T1)

(T2)Mean

(T3)

Mean (SD)

(SD)

Mean (SD)

11.89 (10.42)

4.01 (5.16)

3.86 (5.29)

Beck Depression

P

< 10.24

Inventory (BDI)

.0001

Subjective Happiness

< 4.71 (1.37)

5.49 (1.18)

5.50 (1.21)

-9.07

Scale (SHS)

.0001

Quality of Life

< 1.95 (1.1.73)

2.89 (1.17)

2.67 (1.27)

-5.69

Inventory (QOLI)

.0001

Quick Inventory of Depressive

< 7.30 (4.76)

4.28 (2.90)

3.73 (2.66)

9.35

Symptomology-Self

.0001

Report (QIDS-SR) Outcome

41.52

41.47

(20.58)

(22.00)

16.40

16.36

(4.28)

(4.70)

61.17 (24.46) Questionnaire (OQ)

< 11.74 .0001

State Trait Anger Expression 18.48 (5.63) Inventory- State

3.69

(STAXI)

27

0.0003

Before

After

After 6

Intervention

Intervention

Months t value 1

Instrument (T1)

(T2)Mean

(T3)

Mean (SD)

(SD)

Mean (SD)

15.36

14.64

P

State Trait Anger Expression 18.13 (5.53) Inventory- Trait

< 7.80

(4.07)

(3.78)

27.69

31.23

.0001

(STAXI) State Trait Anxiety 40.29 (13.05) Scale- State (STAI) State Trait Anxiety

(8.53)

(11.28)

34.37

33.10

42.22 (11.67) Scale- Trait (STAI)

< 11.46 .0001 < 10.75

(10.88)

(10.60)

Abbreviation: SD, Standard Deviation 1

The t value represents a contrast using mixed models of the baseline versus the

pooled phase average of both follow-up time periods

28

.0001