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Mindfulness-based stress reduction (MBSR) enhances distress tolerance and resilience through changes in mindfulness
Mental Health & Prevention 4 (2016) 36–41
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Mental Health & Prevention journal homepage: www.elsevier.com/locate/mhp
Mindfulness-based stress reduction (MBSR) enhances distress tolerance and resilience through changes in mindfulness Karin Nila a,b, Daniel V. Holt b, Beate Ditzen a, Corina Aguilar-Raab a,n a b
Institute of Medical Psychology, University Hospital Heidelberg, Germany Institute of Psychology, Heidelberg University, Heidelberg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 9 November 2015 Accepted 19 January 2016 Available online 26 January 2016
Distress tolerance (DT) is associated with psychological health and has been shown to be predicted by mindfulness. Resilience, another protective capacity in the face of stress, is related to positive psychological outcomes, such as preventing development of PTSD. The current longitudinal online-study investigated whether Mindfulness-Based Stress Reduction (MBSR) can lead to an increase in DT and resilience, and whether these effects are mediated by facets of mindfulness. Forty nine participants were assessed, N¼ 20 of these were studied before and after MBSR training, and compared to a matched control group of N¼ 29. Changes in mindfulness were assessed using the Comprehensive Inventory of Mindfulness Experience (CHIME). In line with hypotheses, MBSR enhanced self-reported mindfulness, DT, and resilience. Results are consistent with assuming a mediation of these effects by the acceptance, decentering, and relativity facets of mindfulness.. Results indicate that MBSR might not only ameliorate existing psychopathologies, but may also serve as a preventative method to allow a more adaptive response to future stress. & 2016 Elsevier GmbH. All rights reserved.
Keywords: MBSR Mindfulness Distress tolerance Resilience Controlled longitudinal design Prevention Protective factors Mediator analysis
1. Introduction Mindfulness, a concept originally rooted in Buddhist tradition (Kabat-Zinn, 1990), refers to being aware of all internal and external experiences-may they be pleasant or unpleasant-and doing so in a non-judgmental, accepting, and self-empathetic manner (Bishop et al., 2004; Brown, Ryan & Creswell, 2007). Dispositional mindfulness has been shown to be associated with a variety of positive mental health outcomes, such as more benign stress appraisal (Weinstein, Brown, & Ryan, 2009), and better emotion regulation (Goodall, Trejnowska, & Darling, 2012). Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990), a manualized eight week long group program that aims to develop and increase mindfulness, has shown promising results in improving mental and physical health in clinical and non-clinical populations for a variety of symptoms and disorders (e.g., Eberth & Sedlmeier, 2012; Keng, Smoski, & Robins, 2011; Vollestad, Nielsen, & Nielsen, 2012). Yet, findings concerning the effect of MBSR on increasing selfreported mindfulness are heterogeneous, with some studies finding medium to large effects (d¼ .7–.89; Carmody & Baer, 2008; n Correspondence to: Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg, Bergheimer Straße 20, 69115 Heidelberg, Germany. E-mail address: [email protected] (C. Aguilar-Raab).
http://dx.doi.org/10.1016/j.mhp.2016.01.001 2212-6570/& 2016 Elsevier GmbH. All rights reserved.
Robins, Keng, Ekblad, & Brantley, 2011), while others find no effects or have mixed findings (e.g. Visted, Vollestad, Nielsen, & Nielsen, 2014). This disparity may partly be explained by the still diverging definitions of mindfulness (Bishop et al., 2004; Grossman, 2008), and the use of measures that vary conceptually between mindfulness as a one factor model versus a multi-facet construct (Chiesa, 2013). With regard to mental health issues, increasing emphasis has been placed on protective capacities that foster well-being in the face of stress, such as distress tolerance (DT) and resilience. DT is defined as the ability to withstand and tolerate aversive psychological states (Nock & Mendes, 2008; Simons & Gaher, 2005). It has been shown to protect against many psychopathologies, such as posttraumatic stress disorder (Fetzner, Peluso, & Asmundson, 2014), borderline personality (Bornovalova, Matusiewicz, & Rojas, 2011), and early drop-out of substance use treatments (Daughters et al., 2005). Recent data suggest that mindfulness can improve DT. Liu, Wang, Chang, Chen and Si (2013) found that compared to participants listening to gentle music, participants receiving a 15 min mindfulness instruction had significantly lower pain ratings and immersion distress, when placing their hands into ice-cold water. Further, Sauer and Baer (2012) found that participants with borderline personality disorder showed increased persistence on a behavioral DT task after eight minutes of mindful self-focusing, compared to those ruminatively self-focusing. In a recent study,
K. Nila et al. / Mental Health & Prevention 4 (2016) 36–41
Feldman, Dunn, Stemke, Bell and Greeson (2014) found that DT, operationalized as the ability to persist on a frustrating mirror tracing task, was predicted by mindfulness. Conceptually related to DT is the construct of resilience (Leyro, Zvolensky, & Bernstein, 2010), which can be defined as the ability to bounce back and recover quickly from stress (Smith et al., 2008). Resilience is associated to better adjustment after trauma (Mealer et al., 2012), positive affect, and less prevalence of anxiety, depression and negative affect (see Hu, Zhang, & Wang, 2015 for an overview). Intriguingly, while the effects of mindfulness as a psychological treatment option have received tremendous interest, data on mindfulness and resilience are relatively scarce. Orzech, Shapiro, Brown and McKay (2009) showed that one month of intensive mindfulness training led to increases in self-compassion, which can be indicative of resilience. No studies to date have, however, directly explored the effect of an extended mindfulness based intervention such as MBSR on DT and resilience. The fact that DT and resilience have shown to be protective capacities that are related to better mental health outcomes in the future, has particular significance for a preventative approach to mental health. Enhancing such capacities through MBSR could equip individuals with abilities that protectively strengthening psychological health, and hence reduce risk of developing psychopathologies in the future. This could extend the indication for MBSR over and above alleviating acute distress, to preventative applications. The present pilot study therefore aimed to investigate whether MBSR could enhance DT and resilience, and hence build capacities that allow for a more adaptive response to future stress. In order to improve our understanding by which processes MBSR actually works, a further explorative aim of the present study was to investigate which aspects of mindfulness mediate potential improvements in DT and resilience. We hypothesized that compared to a control group (CG), (1) MBSR would enhance mindfulness, (2) MBSR would enhance DT and resilience, and (3) that outcomes may be mediated by particular mindfulness facets.
2. Method 2.1. Sample and procedure Data were collected online following Internet testing guidelines by Reips (2002) to increase data quality. MBSR participants were recruited through contacting MBSR trainers and the German, Austrian and Swiss MBSR associations. MBSR participants filled in questionnaires online before and after their MBSR course. CG assessment was the same, with 8 weeks in-between online questionnaire completions. Main research questions were masked to both groups. Data sets from T1 and T2 were matched anonymously. Participants were not compensated for participation. Two hundred and 35 participants filled in the online questionnaires at T1, and N ¼86 at T2. Of those, N ¼ 46 MBSR and N ¼84 CG participants completed them at T1, N ¼ 22 MBSR and N ¼ 36 CG participants at T2. After applying exclusion criteria, the remaining MBSR sample consisted of N ¼20 participants (Mage ¼44.5 years, SD ¼7.72), and the CG of N ¼29 participants (Mage ¼44.34 years, SD ¼12.99). Exclusion criteria were aversive opinion about mindfulness practice and no intention to treat in the CG, mood and performance altering medication onset, start of psychotherapy, and an exam period during the course of the experimental period. MBSR participants received a standard, typically 8 week long MBSR group program, conducted by certified teachers. The CG was a non-clinical sample without intervention (69% female, 55% reporting a university degree as highest education), with similar
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demographic characteristics as the non-clinical MBSR group (85% female, 70% reporting a university degree as highest education). A brief psychological symptoms assessment revealed no difference between MBSR and CG participants. 2.2. Measures The Comprehensive Inventory of Mindfulness Experience (CHIME; Bergomi, Tschacher & Kupper, 2014) consists of 37 items. It contains aspects already included by existing measures of mindfulness and extends those to a final of eight facets: (1) awareness towards inner experiences (Inner Awareness), (2) awareness towards outer experiences (Outer Awareness), (3) Acting with Awareness, being present (awareness), (4) accepting, non-judgmental and compassionate orientation (acceptance), (5) non-reactive and decentered orientation (decentering), (6) openness to experience (openness), (7) relativity of thoughts (relativity), and (8) insightful understanding (understanding). in prior studies, the CHIME has shown incremental validity over and above the widely used Five Facet Mindfulness Questionnaire (FFMQ, Baer et al., 2008) with good change sensitivity, internal consistency, and good test-retest reliability (Bergomi et al., 2014) in all subscales In the current study Cronbach’s Alpha was α ¼.90. The Distress Tolerance Scale (DTS; Simons & Gaher, 2005) consists of 15 items with higher scores representing better DT. There are four subscales: (1) ability to tolerate emotional distress, (2) appraisal of distress, (3) absorption by negative emotions, and (4) regulation to alleviate distress. The scale has demonstrated high internal consistency and good test-retest reliability (Simons & Gaher, 2005). For the present study, the original English scale was translated by an English-German translator, and was subsequently retranslated by an English-German bilingual researcher. Afterwards, the original and translated scales were re-examined by both, and semantic coherence and conceptual equivalence were checked. In the current study, Cronbach’s Alpha was α ¼ .93. The Brief Resilience Scale (BRS; Smith et al., 2008) measures the ability to bounce back from stress. It consists of 6 items. The BRS has demonstrated good internal consistency and good test-retest reliability (Smith et al., 2008; Windle, Bennett, & Noyes, 2011). The same translation procedure was applied as described above. In this study, the scale was internally consistent with Cronbach’s Alpha coefficient of ¼.84. 2.3. Statistical analysis We computed change scores, by deducting T1 scores from T2 scores. Negative change scores thus represent lower scores at T2. Independent t-tests were utilized to examine differences in the main outcome measures between MBSR and CG. For effect sizes, Hedges’s g was calculated (Cumming, 2012; Lakens, 2013), which is a more conservative unbiased version of Cohen’s d, correcting for differences in small and dissimilar samples sizes. To examine mediations of CHIME subscales, between MBSR and changes in outcomes, bootstrapping analyzes were run in SPSS, using the PROCESS macro developed by Hayes (2013). Bootstrapping makes no assumptions about the normality distribution of study variables, nor about the relationship between predictor and outcomes (Hayes, 2013). Simulations have shown that bootstrapping as a mediation modeling method has highest power and best Type I error control among the existing mediation approaches, and can be used with more confidence also for smaller sample sizes (Hayes, 2013; Shrout & Bolger, 2002).
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K. Nila et al. / Mental Health & Prevention 4 (2016) 36–41
Table 1 Correlations between study variables and CHIME subscales at T1 (N ¼49). Variable 1 2 3 4 5 6 7 8 9 10 11
DTS BRS CHIME overall Inner Awareness Outer Awareness Acting with Awareness Acceptance Decentering Openness Relativity Understanding
1
2
3
4
5
6
7
8
9
10
11
– .43n .40nn .07 .14 .37nn .52nn .30n .24 .19 .09
– .38nn .001 .13 .33n .45nn .46nn .15 .13 .16
– .63nn .56nn .44nn .78nn .79nn .50nn .62nn .64nn
– .44n .26 .26 .28 .43nn .20 .37nn
– .08 .35n .24 .33n .24 .15
– .24 .40nn .18 .02 .07
– .70nn .34n .43nn .38nn
– .20 .47nn .54nn
– .04 .09
– .59nn
–
Notes: DTS ¼ Distress Tolerance Scale. BRS¼ Brief Resilience Scale. CHIME¼ Comprehensive Inventory of Mindfulness Experience. CHIME subscales: Inner Awareness ¼ awareness towards internal experiences. Outer Awareness¼awareness towards external experiences. Acceptance ¼ accepting, non-judgemental and compassionate orientation. Decentering¼ non-reactive and decentered orientation. Openness ¼ openness to experience. Relativity¼ relativity of thoughts. Understanding ¼ insightful understanding. n
pr .05. p r.001.
nn
Awareness, p o.001, g ¼1.25, Acting with Awareness, p¼ .028, g¼ 0.65, acceptance, p o.001. g ¼1.47, decentering, p o.001, g ¼1.96, openness, p¼ .001, g ¼0.98, relativity, p¼ .004, g ¼0.86, understanding, p o.001, g ¼1.15). To examine mediations of the different CHIME subscales between intervention and changes in resilience and DT, exploratory mediation analyzes following Hayes (2013) were run in SPSS. All statistically significant mediations of mindfulness facets are depicted in Fig. 1. The relationship between MBSR and DT change was statistically mediated by changes in overall mindfulness (overall CHIME score; ab ¼.531, with 95% CI ¼ .246–.936), changes on the CHIME subscale 4 “acceptance” (ab ¼.367, with 95% CI ¼.089–.724) and subscale 7 “relativity” (ab ¼.216, with 95% CI ¼.072–.458). The relationship between MBSR and resilience was statistically mediated by changes in overall mindfulness (overall CHIME score; ab¼ .474, with 95% CI ¼.185–.869), changes on the CHIME subscales 5 “decentering” (ab¼ .410, with 95% CI ¼.179–.729) and subscale 7 “relativity” (ab ¼.206 with 95% CI ¼.055 to.440). For all other mediation models, the CI included zero (thus suggesting no meaningful mediation effect).
3. Results 3.1. Descriptives and preliminary group comparisons Average time between the completion of T1 and T2 were 9.87 (SD ¼ 1.92) weeks for MBSR participants, and 8.70 (SD ¼1.24) weeks for the CG. In the MBSR group 85% reported intrinsic motivation for participation. Twenty percent reported having practiced MBSR exercises daily, 15% 5–6 times a week, 55% 3–4 times a week, and 10% 1–2 times a week. Group comparisons revealed no effects of more (5–7 times a week) or less (1–4 times a week) regular MBSR practice; prior mediation and relaxation routines; more or less time between questionnaire completions; completion of questionnaires before or after the first MBSR session. At T1, compared to the CG, MBSR participants had significantly lower mindfulness scores (MMBSR ¼3.32, SD ¼0.45, Mcontrol ¼3.93, SD ¼.45, t(47) ¼ 4.65, p4 .001, g ¼ 1.33). 3.2. Main results Correlations of all variables are shown in Table 1, means and standard deviations are provided in Table 2. In contrast to the CG, MBSR participants showed significant increases from T1 to T2 in overall mindfulness (t(19) ¼ 6.36, p o.001, gav ¼1.46), DT (t (19) ¼ 3.60, p¼ .002, gav ¼0.64), and resilience (t(19) ¼ 2.83, p ¼.011, gav ¼ 0.59). The same pattern was evident when directly comparing the change scores of the MBSR group to the CG for overall mindfulness (t(28.24)¼6.35, po .001, g ¼1.99), DT (t(47) ¼ 2.58, p ¼.013, g ¼0.74) and resilience (t(47) ¼2.95, p ¼.005, g ¼0.84). The mindfulness change in the MBSR group was reflected in all CHIME subscales (Inner Awareness, p ¼.012, g ¼0.81, Outer
4. Discussion The current study investigated whether MBSR enhances DT and resilience. Both are preventative capacities associated with a variety of positive mental health outcomes. We found that MBSR indeed enhanced DT and resilience. These findings are in line with previous studies, showing associations between mindfulness, DT and resilience (Feldman, Dunn, Stemke, Bell & Greeson, 2014; Orzech, Shapiro, Brown & McKay, 2009). The present longitudinal
Table 2 Means and standard deviations of study variables in MBSR and control group for T1 and T2; Independent t-tests on changes with effect sizes. Measure
CHIME DTS BRS
MBSR-Group (N ¼20)
Control Group (N ¼ 29)
T1
T2
T1
T2
Independent t-test on change scores
M (SD)
M (SD)
M (SD)
M (SD)
t (df)
p
g
3.32 (.45) 2.56 (.90) 2.73 (.60)
3.96 (.41) 3.14 (.85) 3.13 (.72)
3.93 (.45) 2.98 (.68) 3.09 (.82)
3.86 (.43) 3.06 (.71) 3.06 (.70)
6.35 (28.24) 2.58 (47) 2.95 (47)
o .001 .013 .005
1.99 0.74 0.84
Notes: M ¼ Mean. SD ¼Standard deviation. CHIME ¼ Comprehensive Inventory of Mindfulness Experience. DTS ¼Distress Tolerance Scale. BRS ¼Brief Resilience Scale. df ¼degrees of freedom. g ¼ Hedges’ g.
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control-group design is the first to show however, that MBSR can actually enhance these capacities. Increasing DT and resilience through MBSR could reduce vulnerability to developing psychopathologies and stress-related symptoms, particularly for individuals with increased exposure to adverse events. Using MBSR as a mean to prevent pathologies could have further implications in relation to reducing mental health costs, or work absence due to mental health issues. It would be particularly interesting to follow up on our data, and study these effects in individuals at higher risk for life events, for whom adaptive stress responses might be especially important. We further found, in line with other research (e.g. Robins, Keng, Ekblad, & Brantley, 2011; Carmody & Baer, 2008) that MBSR led to a significant increase in self-reported mindfulness. In contrast, Visted, Vollestad, Nielsen, and Nielsen (2014) reported in their review and meta-analysis that half of their assessed mindfulness based interventions, including MBSR, did not show significant increases in self-reported mindfulness, and that there was no advantage with mindfulness-based interventions in enhancing mindfulness, compared to active control groups. Underlining this issue, MacCoon et al. (2012) found that improvements in mental health variables after MBSR did not differ from improvements in an active control group. However, MBSR participants were significantly more able to alter the unpleasantness of pain, induced by a thermal pain task. Thus, firstly, for some outcomes MBSR’s effects might not differ from that of an active control group, whereas other outcomes can be specifically related to the mindfulness aspect of interventions. In order to assess how much variance in outcomes is attributable specifically to the mindfulness aspect of MBSR, studies need to consistently compare effects to those of an active control group, with a comparable structure and equal group and therapist contact, but without teaching mindfulness techniques (MacCoon et al., 2012). Secondly, the discrepancy in findings about increases in mindfulness through MBSR highlights the difficulties around the conceptualisations of mindfulness. The diversity of theoretical models and measures complicates the meaningfulness of outcome comparisons (for a discussion see Brown, Ryan & Creswell, 2007). Clearly, there is a need for further theoretical clarification of the concept and its measurement. At least we can conclude that MBSR did affect all facets of mindfulness included in the CHIME, which justifies taking all of them into account in order to enable a more comprehensive assessment of mindfulness. The relatively large effect size in our study might partly be attributable to having used a new measure, allowing for the most differentiated assessment of mindfulness so far. Responding to the criticism of different understanding of mindfulness questionnaire items, depending on previous meditation experience (e.g. Keng, Smoski, & Robins, 2011), the CHIME explicitly aimed to formulate items intelligible also to the non-meditating population, which
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might have explained additional variance in mindfulness. Importantly and shedding more light on to the processes by which MBSR works, changes in DT and resilience are consistent with assuming a mediation by changes in mindfulness facets. An enhanced non-judgemental and accepting attitude (subscale 4: “accepting and non-judgemental orientation”) may be responsible for an increase in DT. Accordingly, accepting distressing experiences in a non-judgemental way, can make them to become more tolerable. Further, increases in non-identification and in a nonreactivity (subscale 5: “decentering and nonreactivity”) can be considered as responsible for increases in resilience. Hence, a reduced reactivity to, and identification with distressing experiences is related to a quicker recovery from them. Additionally, being aware of the relativity of one's thoughts also seems to be crucial for a more adaptive coping responses to stress and strains. This mindfulness facet (subscale 7: “relativity of thoughts”) statistically mediated the relationship between MBSR and both DT, and resilience. Becoming more aware of the transience of one’s experiences and perceptions might reduce negative evaluations of aversive experiences and consequently reduce their negative impact. Further, the fact that each outcome was also mediated by another unshared mediator indicates that particular mindfulness facets are central to specific outcomes. Further theoretical unraveling of the relationship between mindfulness facets and outcomes will help to gradually determine more precisely how mindfulness-based interventions can be best used or adapted for specific purposes. Final noteworthy findings are that MBSR participants had significantly lower mindfulness scores compared to the CG at T1. This might be explained by the fact that MBSR participants are likely to be under some sort of strain, and therefore participate in a stress reduction treatment. Future studies need to investigate whether this lowered mindfulness level is caused by, or rather is the consequence of an elevated stress level in MBSR participants. Contrary to previous studies (e.g. Carmody & Baer, 2008), we did not find a difference in outcomes between participants with more or less regular home practice of MBSR exercises. However, we did not control for quality of intervention, trainers’ experience, or trainers’ mindfulness, which might have influenced outcomes (Grepmair et al., 2007). 4.1. Limitations and future research Our sample had a high educational level, limiting the generalizability of findings. Further, self-report based data is always biased, assuming a high self-reflective ability. As research has pointed out discrepancies between self-report and behavioral measures of DT (McHugh et al., 2011), future studies need to assess whether findings can be replicated with improvements on behavioral tasks of DT. Also, there is a lack of a uniform definition of resilience. The measure we used defines resilience as the ability to
Fig. 1. Mediations of changes in mindfulness facets (CHIME subscales) between Intervention (MBSR vs. control group) and changes in distress tolerance and resilience. Intervention was coded 0¼ Control, 1¼ MBSR. CHIME subscales: Acceptance ¼acceptance, non-judgemental and compassionate orientation. Relativity¼ relativity of thoughts. Decentering ¼ non-reactive and decentered orientation. *po .05. **po .001.
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bounce back in the face of stress. Other widely used resilience scales are based on different conceptualizations of resilience, such as self-compassion (Windle, Bennett, & Noyes, 2011). Inferences from self-reported resilience and DT to real life capacities need to be made with reservations. More, we did not use randomized controlled allocation to groups, nor did we use a wait-list CG, which reduces comparability of groups at T1, although we did control for hypothetical willingness to participate in MBSR. Despite many advantages, there are disadvantages with online studies, such as unstandardized conditions and no control over unplanned interruptions (Callaghan, Graff, & Davies, 2013). Furthermore, although the results of the mediation analysis are theoretically plausible, they should be viewed as preliminary and require further validation. The method was applied exploratively to a range of possible mediators and statistical mediation does not allow strong conclusions about causality. Finally, although we controlled for social desirability, demand characteristics and expectations for improvement might have influenced results. 4.2. Conclusion DT and resilience are protective psychological capacities that are associated with more adaptive stress responses. We showed that both can be enhanced by MBSR. This might extend the application of MBSR from alleviating negative states to preventing psychopathologies, and promoting as well as maintaining mental health. Particular facets of mindfulness may be responsible for mediating the outcomes. Further investigation of the construct of mindfulness is needed in order to clarify more precisely its relation to psychological outcomes.
Conflict of interest The authors declare that they have no conflict of interest.
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Mental Health & Prevention journal homepage: www.elsevier.com/locate/mhp
Mindfulness-based stress reduction (MBSR) enhances distress tolerance and resilience through changes in mindfulness Karin Nila a,b, Daniel V. Holt b, Beate Ditzen a, Corina Aguilar-Raab a,n a b
Institute of Medical Psychology, University Hospital Heidelberg, Germany Institute of Psychology, Heidelberg University, Heidelberg, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 9 November 2015 Accepted 19 January 2016 Available online 26 January 2016
Distress tolerance (DT) is associated with psychological health and has been shown to be predicted by mindfulness. Resilience, another protective capacity in the face of stress, is related to positive psychological outcomes, such as preventing development of PTSD. The current longitudinal online-study investigated whether Mindfulness-Based Stress Reduction (MBSR) can lead to an increase in DT and resilience, and whether these effects are mediated by facets of mindfulness. Forty nine participants were assessed, N¼ 20 of these were studied before and after MBSR training, and compared to a matched control group of N¼ 29. Changes in mindfulness were assessed using the Comprehensive Inventory of Mindfulness Experience (CHIME). In line with hypotheses, MBSR enhanced self-reported mindfulness, DT, and resilience. Results are consistent with assuming a mediation of these effects by the acceptance, decentering, and relativity facets of mindfulness.. Results indicate that MBSR might not only ameliorate existing psychopathologies, but may also serve as a preventative method to allow a more adaptive response to future stress. & 2016 Elsevier GmbH. All rights reserved.
Keywords: MBSR Mindfulness Distress tolerance Resilience Controlled longitudinal design Prevention Protective factors Mediator analysis
1. Introduction Mindfulness, a concept originally rooted in Buddhist tradition (Kabat-Zinn, 1990), refers to being aware of all internal and external experiences-may they be pleasant or unpleasant-and doing so in a non-judgmental, accepting, and self-empathetic manner (Bishop et al., 2004; Brown, Ryan & Creswell, 2007). Dispositional mindfulness has been shown to be associated with a variety of positive mental health outcomes, such as more benign stress appraisal (Weinstein, Brown, & Ryan, 2009), and better emotion regulation (Goodall, Trejnowska, & Darling, 2012). Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990), a manualized eight week long group program that aims to develop and increase mindfulness, has shown promising results in improving mental and physical health in clinical and non-clinical populations for a variety of symptoms and disorders (e.g., Eberth & Sedlmeier, 2012; Keng, Smoski, & Robins, 2011; Vollestad, Nielsen, & Nielsen, 2012). Yet, findings concerning the effect of MBSR on increasing selfreported mindfulness are heterogeneous, with some studies finding medium to large effects (d¼ .7–.89; Carmody & Baer, 2008; n Correspondence to: Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg, Bergheimer Straße 20, 69115 Heidelberg, Germany. E-mail address: [email protected] (C. Aguilar-Raab).
http://dx.doi.org/10.1016/j.mhp.2016.01.001 2212-6570/& 2016 Elsevier GmbH. All rights reserved.
Robins, Keng, Ekblad, & Brantley, 2011), while others find no effects or have mixed findings (e.g. Visted, Vollestad, Nielsen, & Nielsen, 2014). This disparity may partly be explained by the still diverging definitions of mindfulness (Bishop et al., 2004; Grossman, 2008), and the use of measures that vary conceptually between mindfulness as a one factor model versus a multi-facet construct (Chiesa, 2013). With regard to mental health issues, increasing emphasis has been placed on protective capacities that foster well-being in the face of stress, such as distress tolerance (DT) and resilience. DT is defined as the ability to withstand and tolerate aversive psychological states (Nock & Mendes, 2008; Simons & Gaher, 2005). It has been shown to protect against many psychopathologies, such as posttraumatic stress disorder (Fetzner, Peluso, & Asmundson, 2014), borderline personality (Bornovalova, Matusiewicz, & Rojas, 2011), and early drop-out of substance use treatments (Daughters et al., 2005). Recent data suggest that mindfulness can improve DT. Liu, Wang, Chang, Chen and Si (2013) found that compared to participants listening to gentle music, participants receiving a 15 min mindfulness instruction had significantly lower pain ratings and immersion distress, when placing their hands into ice-cold water. Further, Sauer and Baer (2012) found that participants with borderline personality disorder showed increased persistence on a behavioral DT task after eight minutes of mindful self-focusing, compared to those ruminatively self-focusing. In a recent study,
K. Nila et al. / Mental Health & Prevention 4 (2016) 36–41
Feldman, Dunn, Stemke, Bell and Greeson (2014) found that DT, operationalized as the ability to persist on a frustrating mirror tracing task, was predicted by mindfulness. Conceptually related to DT is the construct of resilience (Leyro, Zvolensky, & Bernstein, 2010), which can be defined as the ability to bounce back and recover quickly from stress (Smith et al., 2008). Resilience is associated to better adjustment after trauma (Mealer et al., 2012), positive affect, and less prevalence of anxiety, depression and negative affect (see Hu, Zhang, & Wang, 2015 for an overview). Intriguingly, while the effects of mindfulness as a psychological treatment option have received tremendous interest, data on mindfulness and resilience are relatively scarce. Orzech, Shapiro, Brown and McKay (2009) showed that one month of intensive mindfulness training led to increases in self-compassion, which can be indicative of resilience. No studies to date have, however, directly explored the effect of an extended mindfulness based intervention such as MBSR on DT and resilience. The fact that DT and resilience have shown to be protective capacities that are related to better mental health outcomes in the future, has particular significance for a preventative approach to mental health. Enhancing such capacities through MBSR could equip individuals with abilities that protectively strengthening psychological health, and hence reduce risk of developing psychopathologies in the future. This could extend the indication for MBSR over and above alleviating acute distress, to preventative applications. The present pilot study therefore aimed to investigate whether MBSR could enhance DT and resilience, and hence build capacities that allow for a more adaptive response to future stress. In order to improve our understanding by which processes MBSR actually works, a further explorative aim of the present study was to investigate which aspects of mindfulness mediate potential improvements in DT and resilience. We hypothesized that compared to a control group (CG), (1) MBSR would enhance mindfulness, (2) MBSR would enhance DT and resilience, and (3) that outcomes may be mediated by particular mindfulness facets.
2. Method 2.1. Sample and procedure Data were collected online following Internet testing guidelines by Reips (2002) to increase data quality. MBSR participants were recruited through contacting MBSR trainers and the German, Austrian and Swiss MBSR associations. MBSR participants filled in questionnaires online before and after their MBSR course. CG assessment was the same, with 8 weeks in-between online questionnaire completions. Main research questions were masked to both groups. Data sets from T1 and T2 were matched anonymously. Participants were not compensated for participation. Two hundred and 35 participants filled in the online questionnaires at T1, and N ¼86 at T2. Of those, N ¼ 46 MBSR and N ¼84 CG participants completed them at T1, N ¼ 22 MBSR and N ¼ 36 CG participants at T2. After applying exclusion criteria, the remaining MBSR sample consisted of N ¼20 participants (Mage ¼44.5 years, SD ¼7.72), and the CG of N ¼29 participants (Mage ¼44.34 years, SD ¼12.99). Exclusion criteria were aversive opinion about mindfulness practice and no intention to treat in the CG, mood and performance altering medication onset, start of psychotherapy, and an exam period during the course of the experimental period. MBSR participants received a standard, typically 8 week long MBSR group program, conducted by certified teachers. The CG was a non-clinical sample without intervention (69% female, 55% reporting a university degree as highest education), with similar
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demographic characteristics as the non-clinical MBSR group (85% female, 70% reporting a university degree as highest education). A brief psychological symptoms assessment revealed no difference between MBSR and CG participants. 2.2. Measures The Comprehensive Inventory of Mindfulness Experience (CHIME; Bergomi, Tschacher & Kupper, 2014) consists of 37 items. It contains aspects already included by existing measures of mindfulness and extends those to a final of eight facets: (1) awareness towards inner experiences (Inner Awareness), (2) awareness towards outer experiences (Outer Awareness), (3) Acting with Awareness, being present (awareness), (4) accepting, non-judgmental and compassionate orientation (acceptance), (5) non-reactive and decentered orientation (decentering), (6) openness to experience (openness), (7) relativity of thoughts (relativity), and (8) insightful understanding (understanding). in prior studies, the CHIME has shown incremental validity over and above the widely used Five Facet Mindfulness Questionnaire (FFMQ, Baer et al., 2008) with good change sensitivity, internal consistency, and good test-retest reliability (Bergomi et al., 2014) in all subscales In the current study Cronbach’s Alpha was α ¼.90. The Distress Tolerance Scale (DTS; Simons & Gaher, 2005) consists of 15 items with higher scores representing better DT. There are four subscales: (1) ability to tolerate emotional distress, (2) appraisal of distress, (3) absorption by negative emotions, and (4) regulation to alleviate distress. The scale has demonstrated high internal consistency and good test-retest reliability (Simons & Gaher, 2005). For the present study, the original English scale was translated by an English-German translator, and was subsequently retranslated by an English-German bilingual researcher. Afterwards, the original and translated scales were re-examined by both, and semantic coherence and conceptual equivalence were checked. In the current study, Cronbach’s Alpha was α ¼ .93. The Brief Resilience Scale (BRS; Smith et al., 2008) measures the ability to bounce back from stress. It consists of 6 items. The BRS has demonstrated good internal consistency and good test-retest reliability (Smith et al., 2008; Windle, Bennett, & Noyes, 2011). The same translation procedure was applied as described above. In this study, the scale was internally consistent with Cronbach’s Alpha coefficient of ¼.84. 2.3. Statistical analysis We computed change scores, by deducting T1 scores from T2 scores. Negative change scores thus represent lower scores at T2. Independent t-tests were utilized to examine differences in the main outcome measures between MBSR and CG. For effect sizes, Hedges’s g was calculated (Cumming, 2012; Lakens, 2013), which is a more conservative unbiased version of Cohen’s d, correcting for differences in small and dissimilar samples sizes. To examine mediations of CHIME subscales, between MBSR and changes in outcomes, bootstrapping analyzes were run in SPSS, using the PROCESS macro developed by Hayes (2013). Bootstrapping makes no assumptions about the normality distribution of study variables, nor about the relationship between predictor and outcomes (Hayes, 2013). Simulations have shown that bootstrapping as a mediation modeling method has highest power and best Type I error control among the existing mediation approaches, and can be used with more confidence also for smaller sample sizes (Hayes, 2013; Shrout & Bolger, 2002).
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Table 1 Correlations between study variables and CHIME subscales at T1 (N ¼49). Variable 1 2 3 4 5 6 7 8 9 10 11
DTS BRS CHIME overall Inner Awareness Outer Awareness Acting with Awareness Acceptance Decentering Openness Relativity Understanding
1
2
3
4
5
6
7
8
9
10
11
– .43n .40nn .07 .14 .37nn .52nn .30n .24 .19 .09
– .38nn .001 .13 .33n .45nn .46nn .15 .13 .16
– .63nn .56nn .44nn .78nn .79nn .50nn .62nn .64nn
– .44n .26 .26 .28 .43nn .20 .37nn
– .08 .35n .24 .33n .24 .15
– .24 .40nn .18 .02 .07
– .70nn .34n .43nn .38nn
– .20 .47nn .54nn
– .04 .09
– .59nn
–
Notes: DTS ¼ Distress Tolerance Scale. BRS¼ Brief Resilience Scale. CHIME¼ Comprehensive Inventory of Mindfulness Experience. CHIME subscales: Inner Awareness ¼ awareness towards internal experiences. Outer Awareness¼awareness towards external experiences. Acceptance ¼ accepting, non-judgemental and compassionate orientation. Decentering¼ non-reactive and decentered orientation. Openness ¼ openness to experience. Relativity¼ relativity of thoughts. Understanding ¼ insightful understanding. n
pr .05. p r.001.
nn
Awareness, p o.001, g ¼1.25, Acting with Awareness, p¼ .028, g¼ 0.65, acceptance, p o.001. g ¼1.47, decentering, p o.001, g ¼1.96, openness, p¼ .001, g ¼0.98, relativity, p¼ .004, g ¼0.86, understanding, p o.001, g ¼1.15). To examine mediations of the different CHIME subscales between intervention and changes in resilience and DT, exploratory mediation analyzes following Hayes (2013) were run in SPSS. All statistically significant mediations of mindfulness facets are depicted in Fig. 1. The relationship between MBSR and DT change was statistically mediated by changes in overall mindfulness (overall CHIME score; ab ¼.531, with 95% CI ¼ .246–.936), changes on the CHIME subscale 4 “acceptance” (ab ¼.367, with 95% CI ¼.089–.724) and subscale 7 “relativity” (ab ¼.216, with 95% CI ¼.072–.458). The relationship between MBSR and resilience was statistically mediated by changes in overall mindfulness (overall CHIME score; ab¼ .474, with 95% CI ¼.185–.869), changes on the CHIME subscales 5 “decentering” (ab¼ .410, with 95% CI ¼.179–.729) and subscale 7 “relativity” (ab ¼.206 with 95% CI ¼.055 to.440). For all other mediation models, the CI included zero (thus suggesting no meaningful mediation effect).
3. Results 3.1. Descriptives and preliminary group comparisons Average time between the completion of T1 and T2 were 9.87 (SD ¼ 1.92) weeks for MBSR participants, and 8.70 (SD ¼1.24) weeks for the CG. In the MBSR group 85% reported intrinsic motivation for participation. Twenty percent reported having practiced MBSR exercises daily, 15% 5–6 times a week, 55% 3–4 times a week, and 10% 1–2 times a week. Group comparisons revealed no effects of more (5–7 times a week) or less (1–4 times a week) regular MBSR practice; prior mediation and relaxation routines; more or less time between questionnaire completions; completion of questionnaires before or after the first MBSR session. At T1, compared to the CG, MBSR participants had significantly lower mindfulness scores (MMBSR ¼3.32, SD ¼0.45, Mcontrol ¼3.93, SD ¼.45, t(47) ¼ 4.65, p4 .001, g ¼ 1.33). 3.2. Main results Correlations of all variables are shown in Table 1, means and standard deviations are provided in Table 2. In contrast to the CG, MBSR participants showed significant increases from T1 to T2 in overall mindfulness (t(19) ¼ 6.36, p o.001, gav ¼1.46), DT (t (19) ¼ 3.60, p¼ .002, gav ¼0.64), and resilience (t(19) ¼ 2.83, p ¼.011, gav ¼ 0.59). The same pattern was evident when directly comparing the change scores of the MBSR group to the CG for overall mindfulness (t(28.24)¼6.35, po .001, g ¼1.99), DT (t(47) ¼ 2.58, p ¼.013, g ¼0.74) and resilience (t(47) ¼2.95, p ¼.005, g ¼0.84). The mindfulness change in the MBSR group was reflected in all CHIME subscales (Inner Awareness, p ¼.012, g ¼0.81, Outer
4. Discussion The current study investigated whether MBSR enhances DT and resilience. Both are preventative capacities associated with a variety of positive mental health outcomes. We found that MBSR indeed enhanced DT and resilience. These findings are in line with previous studies, showing associations between mindfulness, DT and resilience (Feldman, Dunn, Stemke, Bell & Greeson, 2014; Orzech, Shapiro, Brown & McKay, 2009). The present longitudinal
Table 2 Means and standard deviations of study variables in MBSR and control group for T1 and T2; Independent t-tests on changes with effect sizes. Measure
CHIME DTS BRS
MBSR-Group (N ¼20)
Control Group (N ¼ 29)
T1
T2
T1
T2
Independent t-test on change scores
M (SD)
M (SD)
M (SD)
M (SD)
t (df)
p
g
3.32 (.45) 2.56 (.90) 2.73 (.60)
3.96 (.41) 3.14 (.85) 3.13 (.72)
3.93 (.45) 2.98 (.68) 3.09 (.82)
3.86 (.43) 3.06 (.71) 3.06 (.70)
6.35 (28.24) 2.58 (47) 2.95 (47)
o .001 .013 .005
1.99 0.74 0.84
Notes: M ¼ Mean. SD ¼Standard deviation. CHIME ¼ Comprehensive Inventory of Mindfulness Experience. DTS ¼Distress Tolerance Scale. BRS ¼Brief Resilience Scale. df ¼degrees of freedom. g ¼ Hedges’ g.
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control-group design is the first to show however, that MBSR can actually enhance these capacities. Increasing DT and resilience through MBSR could reduce vulnerability to developing psychopathologies and stress-related symptoms, particularly for individuals with increased exposure to adverse events. Using MBSR as a mean to prevent pathologies could have further implications in relation to reducing mental health costs, or work absence due to mental health issues. It would be particularly interesting to follow up on our data, and study these effects in individuals at higher risk for life events, for whom adaptive stress responses might be especially important. We further found, in line with other research (e.g. Robins, Keng, Ekblad, & Brantley, 2011; Carmody & Baer, 2008) that MBSR led to a significant increase in self-reported mindfulness. In contrast, Visted, Vollestad, Nielsen, and Nielsen (2014) reported in their review and meta-analysis that half of their assessed mindfulness based interventions, including MBSR, did not show significant increases in self-reported mindfulness, and that there was no advantage with mindfulness-based interventions in enhancing mindfulness, compared to active control groups. Underlining this issue, MacCoon et al. (2012) found that improvements in mental health variables after MBSR did not differ from improvements in an active control group. However, MBSR participants were significantly more able to alter the unpleasantness of pain, induced by a thermal pain task. Thus, firstly, for some outcomes MBSR’s effects might not differ from that of an active control group, whereas other outcomes can be specifically related to the mindfulness aspect of interventions. In order to assess how much variance in outcomes is attributable specifically to the mindfulness aspect of MBSR, studies need to consistently compare effects to those of an active control group, with a comparable structure and equal group and therapist contact, but without teaching mindfulness techniques (MacCoon et al., 2012). Secondly, the discrepancy in findings about increases in mindfulness through MBSR highlights the difficulties around the conceptualisations of mindfulness. The diversity of theoretical models and measures complicates the meaningfulness of outcome comparisons (for a discussion see Brown, Ryan & Creswell, 2007). Clearly, there is a need for further theoretical clarification of the concept and its measurement. At least we can conclude that MBSR did affect all facets of mindfulness included in the CHIME, which justifies taking all of them into account in order to enable a more comprehensive assessment of mindfulness. The relatively large effect size in our study might partly be attributable to having used a new measure, allowing for the most differentiated assessment of mindfulness so far. Responding to the criticism of different understanding of mindfulness questionnaire items, depending on previous meditation experience (e.g. Keng, Smoski, & Robins, 2011), the CHIME explicitly aimed to formulate items intelligible also to the non-meditating population, which
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might have explained additional variance in mindfulness. Importantly and shedding more light on to the processes by which MBSR works, changes in DT and resilience are consistent with assuming a mediation by changes in mindfulness facets. An enhanced non-judgemental and accepting attitude (subscale 4: “accepting and non-judgemental orientation”) may be responsible for an increase in DT. Accordingly, accepting distressing experiences in a non-judgemental way, can make them to become more tolerable. Further, increases in non-identification and in a nonreactivity (subscale 5: “decentering and nonreactivity”) can be considered as responsible for increases in resilience. Hence, a reduced reactivity to, and identification with distressing experiences is related to a quicker recovery from them. Additionally, being aware of the relativity of one's thoughts also seems to be crucial for a more adaptive coping responses to stress and strains. This mindfulness facet (subscale 7: “relativity of thoughts”) statistically mediated the relationship between MBSR and both DT, and resilience. Becoming more aware of the transience of one’s experiences and perceptions might reduce negative evaluations of aversive experiences and consequently reduce their negative impact. Further, the fact that each outcome was also mediated by another unshared mediator indicates that particular mindfulness facets are central to specific outcomes. Further theoretical unraveling of the relationship between mindfulness facets and outcomes will help to gradually determine more precisely how mindfulness-based interventions can be best used or adapted for specific purposes. Final noteworthy findings are that MBSR participants had significantly lower mindfulness scores compared to the CG at T1. This might be explained by the fact that MBSR participants are likely to be under some sort of strain, and therefore participate in a stress reduction treatment. Future studies need to investigate whether this lowered mindfulness level is caused by, or rather is the consequence of an elevated stress level in MBSR participants. Contrary to previous studies (e.g. Carmody & Baer, 2008), we did not find a difference in outcomes between participants with more or less regular home practice of MBSR exercises. However, we did not control for quality of intervention, trainers’ experience, or trainers’ mindfulness, which might have influenced outcomes (Grepmair et al., 2007). 4.1. Limitations and future research Our sample had a high educational level, limiting the generalizability of findings. Further, self-report based data is always biased, assuming a high self-reflective ability. As research has pointed out discrepancies between self-report and behavioral measures of DT (McHugh et al., 2011), future studies need to assess whether findings can be replicated with improvements on behavioral tasks of DT. Also, there is a lack of a uniform definition of resilience. The measure we used defines resilience as the ability to
Fig. 1. Mediations of changes in mindfulness facets (CHIME subscales) between Intervention (MBSR vs. control group) and changes in distress tolerance and resilience. Intervention was coded 0¼ Control, 1¼ MBSR. CHIME subscales: Acceptance ¼acceptance, non-judgemental and compassionate orientation. Relativity¼ relativity of thoughts. Decentering ¼ non-reactive and decentered orientation. *po .05. **po .001.
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bounce back in the face of stress. Other widely used resilience scales are based on different conceptualizations of resilience, such as self-compassion (Windle, Bennett, & Noyes, 2011). Inferences from self-reported resilience and DT to real life capacities need to be made with reservations. More, we did not use randomized controlled allocation to groups, nor did we use a wait-list CG, which reduces comparability of groups at T1, although we did control for hypothetical willingness to participate in MBSR. Despite many advantages, there are disadvantages with online studies, such as unstandardized conditions and no control over unplanned interruptions (Callaghan, Graff, & Davies, 2013). Furthermore, although the results of the mediation analysis are theoretically plausible, they should be viewed as preliminary and require further validation. The method was applied exploratively to a range of possible mediators and statistical mediation does not allow strong conclusions about causality. Finally, although we controlled for social desirability, demand characteristics and expectations for improvement might have influenced results. 4.2. Conclusion DT and resilience are protective psychological capacities that are associated with more adaptive stress responses. We showed that both can be enhanced by MBSR. This might extend the application of MBSR from alleviating negative states to preventing psychopathologies, and promoting as well as maintaining mental health. Particular facets of mindfulness may be responsible for mediating the outcomes. Further investigation of the construct of mindfulness is needed in order to clarify more precisely its relation to psychological outcomes.
Conflict of interest The authors declare that they have no conflict of interest.
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