1 Cultivating Mindfulness: Effects on Well-Being m Shauna L. Shapiro Santa Clara University m Doug Oman University of California, Berkeley m Carl E. Thoresen Stanford University m Thomas G. Plante and Tim Flinders Santa Clara University There has been great interest in determining if mindfulness can be cultivated and if this cultivation leads to well-being. The current study offers preliminary evidence that at least one aspect of mindfulness, measured by the Mindful Attention and Awareness Scale (MAAS; K. W. Brown & R. M. Ryan, 2003), can be cultivated and does mediate positive outcomes. Further, adherence to the practices taught during the meditationbased interventions predicted positive outcomes. College undergraduates were randomly allocated between training in two distinct meditation-based interventions, Mindfulness Based Stress Reduction (MBSR; J. Kabat-Zinn, 1990; n 5 15) and E. Easwaran s (1978/1991) Eight Point Program (EPP; n 5 14), or a waitlist control (n 5 15). Pretest, posttest, and 8-week follow-up data were gathered on self-report outcome measures. Compared to controls, participants in both treatment groups (n 5 29) demonstrated increases in mindfulness at 8-week follow-up. Further, increases in We gratefully acknowledge support for this work from Metanexus Institute (grant: Learning from Spiritual Examples: Measures & Intervention ), John Templeton Foundation, Academic Council of Learned Societies, Contemplative Mind in Society, Fetzer Institute, Santa Clara University Internal Grants for Research, and the Spirituality and Health Institute, Santa Clara University. We also thank Kirk W. Brown for his insightful editorial feedback regarding the MAAS, as well as Hooria Bittlingmayer, Sara Tsuboi, and Anthony Vigliotta for their valuable assistance. Correspondence concerning this article should be addressed to: Shauna Shapiro, Santa Clara University, Santa Clara, CA 95053; JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 64(7), (2008) Published online in Wiley InterScience (www.interscience.wiley.com). & 2008 Wiley Periodicals, Inc
2 Cultivating Mindfulness 841 mindfulness mediated reductions in perceived stress and rumination. These results suggest that distinct meditation-based practices can increase mindfulness as measured by the MAAS, which may partly mediate benefits. Implications and future directions are discussed. & 2008 Wiley Periodicals, Inc. J Clin Psychol 64: , Keywords: mindfulness; mediation; college mental health; meditation; attention The faculty of voluntarily bringing back a wandering attention, over and over again, is the very root of judgment, character, and will y An education which should improve this faculty would be the education par excellence. (James, 1890/1923, p. 424, italics in original) Since at least the time of William James (epigraph), psychologists have been interested in the power and benefits of training attention. Recently, one attentionrelated construct, mindfulness, has galvanized considerable theoretical and empirical interest (Brown, Ryan, & Cresswell, 2007). Twenty-five years of clinical research have documented the efficacy of Mindfulness-Based Stress Reduction (MBSR), a widely known program based explicitly on cultivating mindfulness. Evidence indicates that MBSR is effective for reducing distress and enhancing well-being in individuals with a variety of medical and psychiatric conditions (see reviews by Baer, 2003; Bishop, 2002; Grossman, Niemann, Schmidt, & Walach, 2004). The cultivation of mindfulness, defined as intentional and nonjudgmental awareness of moment-to-moment experience, has long been an essential feature of MBSR and other interventions such as Mindfulness-Based Cognitive Therapy (MBCT; Segal, Williams, & Teasdale, 2002); however, the mediators and mechanisms of action underlying these interventions have yet to be clearly determined empirically. Also unclear is whether gains in mindfulness or similar attention-related constructs might mediate benefits from other empirically studied forms of meditation, such as Transcendental Meditation, Benson s method of meditation, or Passage Meditation (Alexander, Robinson, Orme-Johnson, & Schneider, 1994; Benson & Stark, 1997; Flinders, Oman, & Flinders, 2007). Such interventions, as well as many other Eastern and Western methods of meditation and contemplative practice, also involve an effort to retrain attention (Goleman, 1988, p. 169). To address these questions, the current study examined mediators and effects from two multimodal, spiritually based interventions: An explicitly mindfulness-based program, MBSR (Kabat-Zinn, 1990), and a concentration-based meditation program called the Eight Point Program (EPP; Easwaran, 1978/1991). As described more fully later, the EPP program focuses on Passage Meditation, and involves choosing a meaningful passage to recite during meditation practice. Like the MBSR, the EPP is nonsectarian and can be used within any major religious tradition or outside of all traditions. Each of the two interventions was based on teaching a form of sitting meditation, and was implemented in 8 weekly small-group meetings of 90 min each. Both programs have been successfully taught in multiple healthcare and academic settings, have generated wide international and multicultural interest, and are supported by substantial published documentation of their beneficial health effects. Here, findings on effects and mediators are reported from a randomized, controlled trial with college undergraduates.
3 842, July 2008 The Mindfulness Construct Mindfulness is complex and multifaceted, with a rich and evolving history. The term mindfulness has entered English as a translation of certain usages of traditional Eastern words that include smrti (Sanskrit), sati (Pali), and dran-pa (Tibetan). In Buddhist tradition, the term is often associated with specific methods of meditation (Thera, 1962) as well as with the qualities of recollection, care, and circumspection (Payutto, 1988). In contemporary Western psychology, mindfulness is often defined as the awareness that arises through intentionally attending to one s moment-tomoment experience in a nonjudgmental and accepting way (Kabat-Zinn, 2003; Shapiro, Carlson, Astin, & Freedman, 2006). Theravadin scholar Bodhi (2000) referred to mindfulness as bare attention; however, he also noted that bare attention is never completely bare (Bodhi, 2006). The context and intention one brings to practice and how one practices are very important (Bodhi, 2006). What bare attention refers to is that we have removed our conditioned emotional reactions, evaluations, judgments, and conceptual overlays y (Bodhi, 2006). Recently, efforts have been made to more precisely elaborate mindfulness practice by positing three fundamental components: (a) intention, (b) attention, and (c) attitude (Shapiro et al., 2006). Intention, in this definition, involves knowing why one is paying attention. It involves motivation; a conscious direction and purpose. Attention involves the direct, moment-to-moment knowing of what is happening as it is actually happening. The mind is trained to focus, aim, and sustain attention. Attitude describes how one pays attention, refer to the accepting, caring, and discerning qualities of mindfulness. As Kabat-Zinn noted, mindfulness can be spoken of as affectionate attention (as cited in Cullen, 2006, p. 26). The documented benefits of MBSR and MBCT are often attributed to the cultivation of mindfulness, consistent with these programs explicit guiding theories (Baer, 2003; Brown & Ryan, 2003; Shapiro, Astin, Bishop & Cordova, 2005). That is, it is often hypothesized that: (a) these programs increase mindfulness, and (b) this increase in mindfulness is a primary mediator of positive outcomes. Empirical tests have been made possible by the recent development of measures of the mindfulness construct (e.g., Baer, Smith, & Allen, 2004; Brown & Ryan, 2003; Walach, Buchheld, Buttenmu ller, Kleinknecht, & Schmidt, 2006). Empirically, mindfulness also appears to be multidimensional: Baer, Smith, Hopkins, Krietemeyer, and Toney (2006) found evidence that existing mindfulness scales measure at least four distinct, but interrelated, constructs. Although optimal measurement strategies are not yet determined, these scales have enabled initial and suggestive empirical tests of hypotheses. For the first hypothesis, that interventions can foster mindfulness, four pioneering, nonrandomized studies have reported that mindfulness-based interventions can indeed increase measured levels of one or more dimensions of mindfulness. These studies found that participation in an MBSR intervention was associated with significantly increased mindfulness in nurses (Cohen-Katz, Wiley, Capuano, Baker, & Shapiro, 2005), outpatients in a medical center (Lau et al., 2006), counseling psychology students (Shapiro, Brown, & Biegel, 2007), and individuals with stress-related problems, illness, chronic pain, and anxiety (Carmody & Baer, 2007). Additional research has correlated increased scores on standardized measures of mindfulness with increasing mindfulness meditation experience (Lau et al., 2006).
4 Cultivating Mindfulness 843 Not as much has been done to test the second hypothesis: that increases in mindfulness lead to enhanced outcomes. The study by Shapiro and colleagues (2007) lended preliminary supporting evidence, finding that increases in mindfulness cultivated through MBSR mediated mental health outcomes in counseling psychology students. Carmody and Baer (2007) reported similar results, finding that improvements in psychological functioning were mediated by increases in mindfulness in individuals with stress-related disorders. Further, Brown and colleagues (Brown & Ryan, 2003; Carlson & Brown, 2005) found that trait measures of mindfulness are correlated with a variety of cognitive and affective indicators of mental health, including lower levels of emotional disturbance (e.g., depressive symptoms, anxiety, and stress) and higher levels of well-being (e.g., vitality, positive affect, satisfaction with life). To date, empirical intervention studies of mindfulness have focused on MBSR and other programs that aim explicitly to cultivate mindfulness; however, mindfulness is a natural human capacity (Kabat-Zinn, 2003) as well as a skill that can potentially be cultivated through many diverse paths (Bishop et al., 2004). As preliminary research continues to implicate mindfulness as a potential mediator of positive outcomes, it becomes increasingly important to explore diverse ways of cultivating mindfulness and to clarify how mindfulness may mediate other effective attention-related interventions. Cultivating Mindfulness Can the cultivation of mindfulness arise from distinct meditation-based interventions? And can such gains in mindfulness lead to improved well-being? The present study helps address these critical areas by (a) using an experimental design to determine whether two distinct interventions could foster mindfulness measured by the Mindful Attention and Awareness Scale (MAAS; Brown & Ryan, 2003) and by (b) determining whether increases in mindfulness mediated observed benefits among well-being outcomes. More specifically, our second objective examined whether mindfulness mediated previously documented treatment effects in perceived stress, rumination, and forgiveness among college students (Details are reported in a randomized study by Oman, Shapiro, Thoresen, Plante, & Flinders, ) We examined two distinct meditation-based interventions: one based on Kabat- Zinn s (1990) MBSR and the other based on Easwaran s (1978/1991) EPP. Each program has been associated with well-being benefits reported in randomized, controlled studies in healthy adult populations (e.g., Oman, Hedberg, & Thoresen, 2006; Shapiro et al., 2005). Both programs were hypothesized to produce increases in mindfulness, in part because both include training in silent sitting meditation, a practice that may foster mindfulness (Goleman, 1988). Both also teach informal skills for effectively regulating attention throughout the day, and for integrating mindfulness or other beneficial states of mind, experienced during sitting practice, into the remainder of daily living. Similarly, both programs encourage cultivating attitudes that support meditative/mindful attention (e.g., patience, kindness), and both offer motivational support by exposing participants to inspiring poetry or readings that reflect meditative/mindful perspectives. 1 Oman et al. (2007) reported outcome variables of the current study; however, the article did not examine the mechanisms involved in the interventions nor conduct any mediational analyses.
5 844, July 2008 The two programs also contain notable differences, discussed later, that suggest possible diverse pathways of cultivating mindfulness (Leary, Adams, & Tate, 2006), reflecting in a small way the historical and cross-cultural variation in forms of meditation and contemplative practice (Goleman, 1988). Method Recruitment, Randomization, and Schedule of Assessments Participants were undergraduates enrolled at a Jesuit university in California. After obtaining approval from the Institutional Review Boards of the overall administering organization and the University, recruitment (targeted primarily at first-, second-, and third-year undergraduate students for purposes of follow-up) was conducted through flyers, , classroom presentations, and special recruitment sessions in the Fall 2004 term. Approximately 75 eligible students expressed interest by directly contacting the recruitment manager, who answered questions and disseminated consent forms. A total of 54 completed consent forms were returned. In early January 2005, these 54 participants were ed instructions for the online pretest, which 47 completed. Of the 47, no one was excluded from the study; thus, sample size was determined by those participants who returned the online pretest. Using simple randomization with S-Plus Version 3.3 computer software, these 47 participants were randomly allocated between the MBSR (n 5 16) and EPP (n 5 16) training groups and a waitlist control group (n 5 15). After randomization yet prior to the first group meetings, 5 participants were allowed to change between the two intervention groups due to scheduling conflicts. Three participants switched from the earlier scheduled EPP group to the MBSR group which met 2 hr later, and 2 participants switched from the MBSR group to the EPP group. In addition, after attending one EPP session, 1 participant withdrew from the intervention due to the death of a parent. Two participants in the MBSR intervention never attended any meetings;1 participant explained that he had overextended himself whereas the other provided no explanation (see Figure 1). During the Winter 2005 term, 29 participants completed either MBSR (n 5 15) or EPP (n 5 14) training. Of these participants, 83% attended all (n 5 11) or all but one (n 5 13) of the eight training meetings, 3 participants missed 2 meetings, and 1 from each group, due to sickness, missed three or four meetings. Eight weeks after the conclusion of MBSR and EPP training (early March 2005), a link for the online posttest assessment (Exam 2) was ed to participants in the treatment (n 5 29) and control groups (n 5 15). Exam 2 was completed by 43 of 44 participants (98%); 1 participant from the EPP group did not return the assessment, and no reason was given. After 8 more weeks, a link for the online follow-up assessment (Exam 3) was ed and also was completed by 43 of 44 participants (98%). Again, 1 student (though not the same student) from the EPP group did not return the assessment, and no reason was given. Participants were mailed $10 checks after the pretest, $20 after the posttest, and $30 after the follow-up assessment. Participants The final 44 participants included in the intent-to-treat analysis were primarily 18 years old (59%; range 18 24), first-year (66%), female (80%), White (73%), had never meditated (68%), and were Roman Catholic (48%) or had no religious
6 Cultivating Mindfulness 845 Figure 1. Flowchart of participant enrollment, allocation, follow-up, and analysis.
7 846, July 2008 affiliation (41%) (for further details on participant recruitment and characteristics, see Oman et al., 2008). Neither treatment nor dropout condition was significantly associated with covariables or pretest values of mindfulness or any of the three wellbeing outcomes (p4.10). Intervention Training for both the MBSR and the EPP groups took place in 8 weekly meetings of 90 min each in a quiet, spacious activity room in on-campus student housing. Each training involved instruction in a form of sitting meditation, informal corollary practices, and cultivation of attitudinal and motivational supports. Every weekly meeting of each group included practice of formal sitting meditation as well as informal discussion and didactic instruction. The instructor for the MBSR intervention followed a manual for MBSR, has a Ph.D. in clinical psychology, and had over 10 years of experience leading MBSR interventions. The two instructors who co-led the EPP intervention, one with a Ph.D. in counseling psychology, also used a structured session protocol, and had each taught EPP interventions for over 10 years. MBSR instruction corresponded closely to the MBSR training developed by Kabat-Zinn (1982). Participants received training in the following meditative practices: (a) Mindful Sitting Meditation, which involves awareness of body sensations, thoughts, and emotions while continually returning the focus of attention to the breath; (b) Body Scan, a progressive movement of attention through the body from toes to head observing any sensations in the different regions of the body; (c) Mindful Movement, which consists of stretches and postures designed to enhance greater awareness of and to balance and strengthen the musculoskeletal system; (d) 3-Minute Breathing Space (Segal et al., 2002); and (e) Lovingkindness meditation, designed to help develop greater compassion for self, others, and humanity-at-large. Inherent to all these practices is an emphasis on mindfulness, continually bringing attention to the present moment. In addition to the formal meditation practices, didactic presentation and dialogue emphasized how to bring mindfulness into daily life. Topics included mindful eating, mindfulness in relationships, mindfulness at work and school, and a mindful approach to pain, suffering, and stress. The program differed from the traditional MBSR program in two important ways: (a) Sessions were 90 min instead of 120 to 150 min, and (b) no day-long retreat was included. EPP instruction emphasized core EPP practices as described elsewhere, including Passage Meditation, focused attention, slowing down, and mantram repetition (see Easwaran, 1978/1991, which was used as a source book in the intervention; see also Flinders et al., 2007; Oman et al., 2006). Point 1, Passage Meditation, the foundation of the EPP, is a concentrative method of sitting meditation (Goleman, 1988). In Passage Meditation, the focus is neither on the breath (as in MBSR) nor on a single spiritual phrase (as in Benson s method or Transcendental Meditation) but on a memorized inspirational passage. During the period of sitting meditation, one slowly recites mentally a memorized passage from a scripture or a major spiritual figure. Practitioners individually choose their own passages for meditation. Recommended passages include the 23rd Psalm, the Buddha s Discourse on Good Will (from the Sutta Nipata), Rumi s Garden Beyond Paradise, the Prayer of Saint Francis, the Beatitudes of the Sermon on the Mount, or many others (see Easwaran, 1982/2003, which was used in the intervention as a second source book). Any inspirational
8 Cultivating Mindfulness 847 passage used for meditation is recommended to be positive, practical, inspiring, and universal (Easwaran, 1978/1991, p. 234). In its focus on an inspiring text, Passage Meditation is similar to the well-known Christian practice of lectio divina (Casey, 1996). Point 2 of the EPP involves frequent repetition throughout the day of a mantram, sometimes called a holy name such as Om mani padme hum (Buddhist), Jesus (Christian), or others from all major traditions (Bormann & Oman, 2007; Easwaran, 1978/1991). A mantram is used to stabilize attention throughout the day. Points 3 (slowing down) and 4 (focused attention), also practiced throughout the day, involve cultivating mental habits and states that are similar to mindfulness. In the EPP, slowing down involves moving with care and deliberation through the day, permitting us to be aware of others y and pay attention to what is happening (Easwaran, 1978/1991, p. 90). It does not necessarily mean going slowly on a physical level but requires setting priorities and limiting activities so as not to live with a constant sense of time urgency. One-pointed attention (ekāgratā in Sanskrit, ekaggatā in Pali) involves doing only one thing at a time and giving it full attention. The practitioner will refrain from doing more than one thing at a time y When you study, give yourself completely to your books. When you go to a movie, concentrate completely on that (Easwaran, pp. 127, 134). The remaining points were presented more briefly; Point 5: training the senses, Point 6: putting others first, Point 7: spiritual fellowship, and Point 8: inspirational reading. Both programs are integrated and incorporate multiple practices that perform many analogous functions; however, these functions are sometimes accomplished in different ways. For example, taxonomists of methods of meditation for retraining attention have long distinguished between those that employ (a) concentration, in which mind focuses on a fixed mental object [and] (b) mindfulness, in which mind observes itself (Goleman, 1988, p. 105). Whereas the MBSR program uses sitting meditation that emphasizes mindfulness, the EPP program uses a concentrative method (Flinders et al., 2007). Whereas the MBSR program has a strong mindfulmovement component, the EPP program teaches the mantram and other practices that can be combined with everyday movements, such as walking, to foster integration of body and mind. Whereas a wider attentional field is cultivated in MBSR s sitting meditation and informal practices, the EPP program encourages wider attention through slowing down. Whereas MBSR explicitly encourages cultivation of loving kindness, the EPP encourages cultivation of similar practices through putting others first as well as meditating on passages that endorse kindness and compassion. Whereas MBSR fosters inspiration for continued practice with poetry drawn ad hoc from a wide range of secular and spiritual sources (e.g., Shapiro, 2001), the EPP places greater emphasis on sources from spiritual wisdom traditions. Yet, both MBSR and EPP can be practiced within any major religious tradition, or outside of all traditions (Atheist and agnostic practitioners of the EPP commonly use Buddhist and Taoist passages that do not contain theistic references.) Both MBSR and EPP incorporate numerous practices that are widespread in spiritual wisdom traditions (see Wallace, 2006, regarding the importance of concentration in Buddhism). Emerging evidence has demonstrated similar patterns of impact on several measures related to beliefs about spiritual realities, and spiritual methods of coping with stress (Oman et al., 2007). To the extent that both MBSR and EPP cultivate similar states of consciousness, they might be regarded as examples of equifinality, the notion that the same final state may be reached from different
9 848, July 2008 initial conditions and in different ways (von Bertalanffy, 1968, p. 40), a concept of increasing interest in psychology (e.g., Curtis & Cicchetti, 2003). Simply put, equifinality conveys that there may be many paths to the same goal. And yet, given the complex, multimodal nature of both interventions studied, it is hard to determine the relative contribution to the observed well-being effects. The intention of this study is to begin to tease out these mediating mechanisms, focusing specifically on mindful attention and awareness. Measures Outcome measures. Mindfulness was assessed at three examinations (pretest, posttest, and 8-week follow-up) by the MAAS (Brown & Ryan, 2003). The MAAS is a 15-item trait measure of one s tendency to attend to present-moment experiences in everyday activities. The MAAS uses a Likert scale ranging from 0 (almost always) to 6(almost never) to assess such items as I find myself listening to someone with one ear, doing something else at the same time and I tend to walk quickly to get where I m going without paying attention to what I experience along the way. The MAAS has demonstrated reliable internal consistency (coefficient a 5.82). The authors also showed that scores were significantly higher for practitioners of mindfulness meditation than those for control groups of nonmeditators. Measures of major stress and well-being outcome variables have been described elsewhere (Oman et al., 2008). Each was assessed at the three examinations (pretest, posttest, and 8-week follow-up): Perceived stress was measured with a 10-item version of the well-known Perceived Stress Scale developed by Cohen and Williamson (1988). Rumination was measured with a 12-item subscale of the Rumination and Reflection Questionnaire (a 5.90) (Trapnell & Campbell, 1999). Forgiveness of others was measured with a six-item subscale of the Heartland Forgiveness Scale (test-retest rs andas 4.70 in student samples) (Thompson & Snyder, 2003). Adherence to practices during intervention. Meditation practice was measured by self-report diaries that recorded daily practice. The MBSR group was instructed in four types of practice: (a) formal sitting practice, (b) mindful movement, (c) body scan meditation, and (d) informal practices. At each subsequent meeting (Weeks 2 8), MBSR participants reported the number of minutes that they had engaged in each practice during each day of the previous week, and that number was averaged (mean of 49 daily counts from 7 weeks reports). EPP participants were instructed in formal sitting meditation at Meeting 1, mantram repetition at Meeting 4, and spiritual reading at Meeting 6. Means were calculated from their reported number of minutes engaged in sitting meditation (49 daily counts from 7 weeks reports) and reading (2 weeks daily counts). Also calculated was the mean number of occasions during the day in which participants repeated the mantram (4 weeks daily counts), a measure used in previous studies of mantram repetition as a mediator of benefits (Bormann & Oman, 2007). For inclusion in regression models, each diary variable was set to a participant s cumulative measured training adherence to practices taught in the interventions at each exam. That is, the diary variable was set to the mean recorded value at posttreatment assessments (Exams 2 and 3), and set to zero at baseline (Exam 1) and in the control group. The waitlist control group was told that the meditation-based course (i.e., intervention) would be offered again the following Winter quarter if they wanted to enroll at that time.
10 Cultivating Mindfulness 849 Adherence to practices after intervention. For EPP group participants at Exams 2 and 3, adherence to the practices was measured by one question for each of the eight practices, and an additional question regarding each participant s adherence to the program s practices as a whole. Previous research has shown that these measures may mediate EPP effects (Oman et al., 2006). These nine questions were introduced by asking: In the past two weeks, how consistently do you feel that you have done the Eight Point Program practices? For each of the practices individually, on a scale of 1 to 5, please indicate how consistently you feel you have done the practices. To facilitate consistency with diary adherence measures (in which 0 designates total lack of practice), 1 was deducted from each numeric value prior to analysis, yielding transformed response categories of 0 (not at all), 1 (a little bit), 2 (somewhat), 3(quite a bit), and 4 (consistently). Since participants untrained in specific program practices would have been unable to use them, adherence measures were set to 0 (not at all) for waitlist participants at all exams and for the EPP group at pretest. Because of logistical considerations, no posttraining adherence measures were assessed for the MBSR group. Covariables. Participants tendencies toward socially desirable responding were assessed at baseline with a short (13-item) version of the Marlow-Crown Scale (Reynolds, 1982). Study Questions and Hypotheses Our primary hypothesis was that measured levels of mindfulness (MAAS) would increase in both treatment groups compared to the controls (Hypothesis 1). Treatment effect sizes on well-being outcomes were only moderate in size (0.34rCohen s dr0.45; Oman et al., 2008). Comparatively limited statistical power was therefore available to examine mediation by most adherence variables, which were available only for one treatment group (MBSR or EPP, but not both). However, a key requirement, necessary but not sufficient for formal mediation, is that the outcome is predicted by the potential mediator (Baron & Kenny, 1986). We therefore sought insight about potential mediators by exploratory analyses of how each adherence measure predicted, in an expected favorable direction, treatment effects on mindfulness (MAAS) and well-being outcomes (Exploratory Question 1). To compensate for the small sample size and correspondingly low statistical power, we used one-tailed tests of statistical significance in models that included only the relevant treatment group. Multivariate models were then employed to probe the mutual independence of significant predictors, especially independence from MAAS (Exploratory Question 2). Three secondary hypotheses concerned potential mediating factors that were measured for both MBSR and EPP groups, thereby allowing the analysis of pooled data using formal statistical criteria for mediation (Baron & Kenny, 1986). The first of these additional hypotheses was based on the centrality of sitting practice in most systems of meditation (Goleman, 1988). We hypothesized that diary measures of sitting practice would mediate gains in mindfulness (MAAS) (Hypothesis 2). The other two secondary hypotheses concerned mediation of beneficial treatment effects on well-being, reported earlier (Oman et al., 2008). This earlier study compared the 29 treated participants (the MBSR and EPP groups combined) versus
11 850, July 2008 the 15 controls, and found (a) decreases in perceived stress (po.05), (b) decreases in rumination (po.10), and (c) increases in forgiveness (po.05). In the present study, our Hypotheses 3a, 3b and 3c, respectively, stated that increases in mindfulness (MAAS) would formally mediate these changes, with statistical significance at a level equivalent to or exceeding the original treatment effect (i.e., pso.05,.10, and.05, respectively). Our Hypotheses 4a, 4b, and 4c (respectively) were that diary measures of sitting practice, which were available for both MBSR and EPP groups, also would formally mediate these changes. Statistical Analyses Major analyses in this study used hierarchical linear models (HLMs; Raudenbush & Bryk, 2002). HLMs are increasingly a tool of choice for analyzing longitudinal data, and are sometimes known, especially among physical scientists, as linear mixed models (Singer, 1998). Compared to more conventional methods such as ANOVA, HLM allows improved handling of unbalanced designs and missing data, and more flexible analyses of data gathered at multiple time points. We implemented HLM models that adjusted for preexisting individual differences in levels of outcome variables (using what Raudenbush & Bryk, 2002, called a Level 2 random effect). We followed the same general approach as that used in previous analyses of these data (Oman et al., 2007; Oman et al., 2008). More specifically, bivariate analyses of the predictiveness of a potential mediating variable A within a treatment group k (without reference to changes in the control group) used the following model: Y kðiþ;t ¼ c 0 þ b ðaþ Ak ðiþ;t þ T t þ R kðiþ þ e kðiþ;t In this formula, Y kðiþ;t represents the outcome for the ith individual within treatment condition k at exam t (t 5 1, 2, or 3). The value of the mediating variable for individual i at exam t is represented by A kðiþ;t, which Raudenbush and Bryk (2002) called a Level 1 predictor. The mediating variable s effect on the outcome is conceived as constant over time, and is represented by the estimated coefficient b (A). Adjustment for temporal trends that affect all participants equally, such as possible effects from the treatment received by group k (not mediated by variable A), or from chronological trends unrelated to the intervention, is included as a fixed effect, T t. Other model terms represent additional adjustments and an error term. Adjustment for preexisting individual differences in outcome level is represented by R kðiþ, a random effect. Residual error, the discrepancy between the observed and expected outcome of individual k ðiþ at exam t, is represented by the random effect e kðiþ;t, assumed to be independent and normally distributed with a mean of zero and a variance of s 2. The global intercept is represented by c 0. When this model was used to analyze predictors within the MBSR and EPP treatment groups pooled together, an additional fixed effect, G k, was included to adjust for baseline group differences (even though these baseline differences were never statistically significant). Multivariate models of the independent predictiveness of several potential mediators included additional terms of the form b ðbþ B kðiþ;t or b ðcþ C kðiþ;t. A similar model was used to determine treatment effects on mindfulness (MAAS) by comparing changes in treatment groups versus changes in the control group. In these analyses, the mediating variable, prior reception of treatment, was represented as a 0/1 indicator variable for whether each individual
12 Cultivating Mindfulness 851 had received treatment: Y kðiþ;t ¼ c 0 þ b 2 I ð2þ k þ b 3 I ð3þ k þ R kðiþ þ G k þ T t þ e kðiþ;t Terms for Y, c, R, G, T, and e were as defined earlier (Y represents MAAS scores). I ð2þ k is an indicator set to 1 for either treatment group (MBSR or EPP) at Exam 2, and 0 otherwise. That is, I ð2þ k represents whether an individual at Exam 2 has received treatment. Similarly, I ð3þ k represents whether an individual at Exam 3 has received treatment. The treatment effect at Exam 2 is represented by b 2, and at Exam 3 is represented by b 3. Some analyses allowed differences in treatment effect between MBSR and EPP. In these analyses, we substituted b ðeppþ 2 and b ðmbsrþ 2 for b 2, b ðmbsrþ 2 I ðmbsr;2þ k and I ðepp;2þ k for I ð2þ k, with similar substations for b 3 and I ð3þ k. Finally, our formal tests for mediation of well-being outcomes (stress, rumination, and forgiveness) used a time-constant version of this model that assumed equal treatment effects at Exam 2 and Exam 3 (e.g., that b 2 5 b 3 ). Time-constant models provide additional statistical power, and are justified by the observed absence of statistically significant differences between treatment effects at Exam 2 and Exam 3. In employing time-constant models, we followed the initial analyses, published elsewhere, that established beneficial treatment effects (Oman et al., 2008). Shapiro Wilk tests confirmed that all four outcome measures were approximately normally distributed (MAAS, stress, rumination, and forgiveness). All regression analyses were implemented using SAS PROC MIXED (Singer, 1998). Results Intervention Effects on Mindfulness and Diary Adherence Table 1 shows the measured values of mindfulness (MAAS) and diary adherence measures. Figure 2 graphically displays the values of the MAAS measure across time, and displays effect sizes and levels of statistical significance. Mean MAAS was not significantly different between MBSR and the EPP at any exam (p4.40). In HLM analyses that pooled MBSR and EPP participants into a single treatment group, a clear treatment effect on MAAS emerged at Exam 3. More specifically, significant gains since baseline in comparison to controls were demonstrated at Exam 3 (M , p 5.004, two-tailed, Cohen s d ), but not at Exam 2 (M , p 5.41). These results were not substantially altered by adjusting for socially desirable responding. Exam 3 gains were significantly larger than Exam 2 gains for the EPP and for both groups combined (p 5.04), indicating a problematic fit for the time-constant treatment effect model, and the desirability of reporting separate effect sizes on MAAS for Exams 2 and 3. Still, HLM time-constant models that pooled across Exams 2 and 3 yielded an estimated average gain of 8.80 (p 5.04, Cohen s d ), offering clear support for Hypothesis 1. Predictiveness of Potential Mediating Factors Table 2 addresses Exploratory Question 1, showing bivariate analyses of how mindfulness (MAAS) and diary adherence predicted outcomes. This table displays regression coefficients from HLMs that include all three assessments (baseline through 8-week follow-up), and data from one or both treatment groups (MBSR and/or EPP), but do not include data from the waitlist control group. As noted earlier, baseline (Exam 1) values of adherence were imputed as 0. Each model adjusts for average group change between exams (adjusts for mean change in the treatment
13 852, July 2008 Table 1 Potential Mediating Factors by Group Mediator M SD Combined group predictors (MBSR & EPP, n 5 29) Mindfulness (MAAS) Exam 1 (pretest) (13.26) Exam 2 (posttest) a (12.69) Exam 3 (follow-up) b (14.61) Diary adherence (during training) Sitting 7.75 (3.80) MBSR group predictors (n 5 15) Mindfulness (MAAS) Exam 1 (pretest) (13.05) Exam 2 (posttest) a (12.60) Exam 3 (follow-up) (17.07) Diary adherence (during training) Sitting 6.18 (4.31) Scan 7.53 (4.05) Movement 4.46 (2.61) Informal 6.05 (5.82) EPP group predictors (n 5 14) Mindfulness (MAAS) Exam 1 (pretest) (13.94) Exam 2 (posttest) (13.27) Exam 3 (follow-up) bc (11.55) Diary adherence (during training) Sitting 9.42 (2.29) Mantram (occasions) 3.19 (1.26) Reading 5.58 (4.15) Note. Diary adherence values represent daily averages (means) that a participant recorded during the intervention period, measured as number of occasions (mantram repetition) or number of minutes (all others). a Exam 1 to 2; b Exam 1 to 3; or c Exam 2 to 3 changes were statistically significant in paired t tests, po.05, two-tailed. group). Each regression coefficient and its p value therefore represent how strongly a potential mediator is associated with larger beneficial changes in an outcome. As noted in the Method section, these analyses correspond closely to a primary criterion required for statistical mediation of changes in a treatment group (Baron & Kenny, 1986): that the mediator predicts the outcome, after adjusting for treatment. Table 2 shows that mindfulness (MAAS) demonstrated remarkably similar predictiveness of stress reductions in the MBSR and EPP groups, where the regression coefficient [b] was 0.22 (po.01) in each group separately. MAAS also significantly predicted reductions in rumination in the MBSR group (b , po.01) and in both groups together (b , po.05). However, compared to the MBSR group, the mindfulness (MAAS) coefficient for the EPP group was marginally significantly different (po.10, two-tailed), and did not predict EPP group changes in rumination (b 5.04, p4.10) or changes in forgiveness in either treatment or both together (p4.10). Finally, sitting meditation predicted gains in forgiveness among the EPP group (b , po.05), but not in the MBSR group (b ).
14 Cultivating Mindfulness 853 Figure 2. Trends in mindfulness (MAAS) over time and effect sizes, by group. Table 2 Bivariate Regression Coefficients for Predictiveness of Mindfulness (MAAS) and Diary Adherence, by Outcome and Treatment Group Outcome Potential mediator MAAS Stress Rumination Forgiveness Combined group predictors (MBSR & EPP, n 5 29) Mindfulness (MAAS) b 0.05 (n.s.) Diary adherence a Sitting n.s (n.s.) c MBSR group predictors (n 5 15) Mindfulness (MAAS) b 0.09 y Diary adherence (min) a Sitting n.s. Scan Movement 0.54 y Informal 0.38 EPP group predictors (n 5 14) Mindfulness (MAAS) (n.s.) b 0.06 (n.s.) Diary adherence a Sitting (min) 0.80 y 0.86 c Mantram (occasions) y Reading (min) 0.57 Note. All models include only observations from individuals in the subgroup and represent the regression coefficient for the predictor, adjusted for examination (and for MBSR vs. EPP when subgroup contains both). Blank cells or those designated n.s. are nonsignificant (p4.10). a Diary measures assessed during treatment. b Effects of mindfulness on rumination different between MBSR and EPP (po.10). c Effects of sitting on forgiveness different between MBSR and EPP (po.01). y po.10; po.05; po.01 in directional (one-tailed) t tests.
15 854, July 2008 Table 3 Means and Bivariate Predictiveness of EPP Post-Training Adherence Measures, by Exam Exam 2 Exam 3 Predictiveness, by Outcome EPP Adherence M SD M SD MAAS Stress Rum. Forg. Overall a 2.31 (0.75) 1.85 (0.80) M (Pts. 1 8) 2.17 (0.65) 1.64 b (0.77) Point 1 (sitting) 2.15 (1.28) 1.08 b (0.95) y Point 2 (mantram) 3.23 (0.93) 2.00 b (1.22) Point 3 (slow down) 2.31 (1.11) 2.15 (1.14) y Point 4 (focus) 2.15 (1.07) 1.62 b (1.33) Point 5 (train senses) 2.00 (1.00) 1.23 b (1.36) Point 6 (others first) 2.62 (1.12) 2.38 (0.96) Point 7 (fellowship) 1.46 (0.97) 1.15 (1.21) 2.87 Point 8 (reading) 1.46 (0.88) 1.54 (1.13) Note. All predictiveness models include observations only from EPP participants and represent the regression coefficient for the adherence measure, adjusted for examination. Blank cells are nonsignificant (p4.10). Measures were gathered as part of Exam 2 or 3 and are coded 0 5 not at all, 15 a little, 2 5 somewhat, 3 5 quite a bit, or 4 5 consistently. a Overall EPP adherence assessed with a single item on adherence to practices as a whole. b po.05 (two-tailed) for change in mean between Exams 2 and 3. y po.10; po.05; po.01 in directional (one-tailed) t tests. In the MBSR group alone, two measures of diary adherence were predictive: Informal practices predicted less stress (po.05), and mindful movement marginally predicted forgiveness (po.10). Similarly, in the EPP group alone, diary records of mantram and sitting each predicted more forgiveness and less stress. Less stress also was predicted by EPP diary records of spiritual reading (po.05). Finally, Table 3 displays mean values and predictiveness for posttreatment measures of adherence to practices taught during the intervention, available only for the EPP group. Significant reductions of several adherence measures at Exam 3 compared to Exam 2 represent the common decline of amount of practice as time passes. Several measures, most notably mean adherence, predicted increased mindfulness (MAAS) as well as reduced stress and rumination. Mutual Independence of Mediators Whether significant potential mediators were independent of each other in predicting outcomes was explored in multivariate models that addressed Exploratory Question 2. Only mindfulness (MAAS) was significant among measures available for both treatments, so no multivariate models were relevant for a combined treatment analysis (MBSR 1 EPP). For measures available only in one treatment group, Table 4 shows results of all multivariate models involving mindfulness (MAAS) and an adherence measure, when both were at least marginally significantly predictive (po.10, one-tailed) in bivariate models reported in Table 2 or Table 3. Clearly, mindfulness (MAAS) was the stronger predictor in most cases, suggesting its importance as a mediating factor. However, for both MBSR and the EPP, some adherence measures predicted stress independently of mindfulness (po.05). For example, in the MBSR group, independently of MAAS, stress reductions were predicted by informal practices (p 5.048, b 5.31). Similarly in the EPP group, independently of MAAS, diary measures of sitting meditation and mantram repetition
16 Cultivating Mindfulness 855 Table 4 Multivariate Independent Predictiveness by Adherence and Mindfulness of Well-Being Outcomes Adherence MAAS Outcome Measure Coef. P (one-tailed) Coef. P (one-tailed) MBSR (n 5 15) Stress Informal (diary) Forgiveness Movement (diary) EPP (n 5 14) Stress Sitting (diary) Stress Mantram (diary) Stress Reading (diary) Stress M (Pts. 1 8) Stress Overall a Stress Point 1 (sitting) Stress Point 4 (focus) Stress Point 5 (train senses) Stress Point 6 (others first) Note. Coefficients and p values (one-tailed) from multivariate HLMs for the indicated outcome within the indicated treatment group. P values are regarded as statistically significant if po.05 (full significance) or po.10 (marginal significance). Models used data from all three exams and included the indicated adherence measure, the MAAS, and adjustments for time point and individual differences in the outcome measure. a Overall EPP adherence as assessed with a single item. each predicted stress reductions (p 5.04, bs and 1.72, respectively). Several EPP measures of posttreatment adherence to the practices also predicted stress reductions independently of MAAS. Note that when both were in the model, EPP Point 4 (focused attention) predicted stress reductions more strongly (p 5.046) than did MAAS (p 5.098). In sum, results of Exploratory Question 2 suggest that mindfulness (MAAS) was generally a stronger predictor than adherence to the practices, but some adherence measures retained independent predictiveness. Formal Tests of Mediation Formal tests for meditation of treatment effects included control group participants, used the model described in the Statistical Analysis section, and relied on criteria from Baron and Kenny (1986). Each variable that significantly predicted an outcome in bivariate pooled treatment group models (Table 2, top) also met other formal criteria for mediation. More specifically, sitting meditation did not predict changes in mindfulness (MAAS) in analyses that included controls and both treatment groups (p4.10), failing to support Hypothesis 2. Similarly, sitting meditation did not significantly predict any of the three well-being measures, failing to support Hypotheses 4a, 4b, and 4c. However, formal tests of mediation in pooled groups (n 5 44) confirmed that mindfulness (MAAS) mediated reductions in stress (po.05, one-tailed) and marginally in rumination (po.10, one-tailed), according to criteria of Baron and Kenny (1986). Criteria for mediation by MAAS of gains in forgiveness were not satisfied (p4.10, one-tailed). More specifically, in HLM models, treatment (experience of MBSR 1 EPP vs. control) predicted all well-being outcomes, as noted earlier (po.05 for stress and forgiveness, marginally po.10 for rumination;
17 856, July 2008 PERCEIVED STRESS RUMINATIO N TOTAL EFFECTS Treatment d =.45* (p=.04) Stress Treatment d =.34 (p=.09) Rumination MEDIATION BY MINDFULNESS Treatment d =.25 (p=.18) Stress Treatment d =.16 (p=.26) Rumination d = +.64* (p=.02) r =.32** (p=.0001) d = +.64* (p=.02) r =.27** (p=.0003) Mindfulness (MAAS) Notes Treatment coded as 1 (received MBSR or EPP, n=29) or 0 (Controls, n=15); d indicates effect size standardized by baseline SD of outcome; r indicates regression coefficient standardized by baseline SD of both predictor and outcome (which is equivalent to the partial correlation coefficient); p<.10, *p<.05, **p<.001 for 1-tailed tests of statistical significance. Mindfulness (MAAS) Figure 3. Meditation by mindfulness of effects from treatment on stress and rumination. Oman et al., 2008). Second, treatment affected MAAS, the proposed mediator (p 5.02, one-tailed). Third, the mediator (MAAS) predicted changes in outcomes after adjusting for experience of treatment (met p 5.02 for stress and rumination, but failed for forgiveness, p 5.15, one-tailed). Fourth, Figure 2 shows that in each case that MAAS (the mediator) predicted the outcome, the adjusted treatment effect was smaller in magnitude. Finally, in each case that MAAS (the mediator) predicted an outcome (po.05 or po.10), the null hypothesis of no indirect (mediated) effect was rejected by the Sobel test at an equivalent level of significance (Null was rejected p for stress and p 5.09 for rumination.) Thus, Hypothesis 3c (mediation of forgiveness by MAAS) was not supported. Nevertheless, all of Baron and Kenny s (1986) criteria for statistical mediation by mindfulness (MAAS) were met for treatment effects on stress (significantly) and rumination (marginally), supporting Hypotheses 3a and 3b. These findings, expressed as causal path diagrams using standardized effect sizes, are graphically represented in Figure 3. Discussion The current study produced several important findings. The results support our primary hypothesis that training college undergraduates in both MBSR and the EPP can increase levels of mindful attention and awareness as compared to a waitlist control group. Main effects on MAAS averaged about 2 3 of an SD above the control group, and grew in magnitude in the 8 weeks following treatment. Moreover, increases in MAAS significantly mediated reductions in perceived stress and rumination. These results suggest that there are different ways to increase mindfulness and that it may be a significant mediating factor affecting positive outcomes. This study is one of the first to investigate impacts on mindful attention and awareness
18 Cultivating Mindfulness 857 from both a program explicitly oriented toward that goal (MBSR) and another meditation-based program that does not explicitly emphasize mindfulness (EPP). This also is one of the first studies to demonstrate that the cultivation of mindfulness mediates positive well-being outcomes using a controlled study design. Notably, treatment effects on the MAAS were larger at 8-week follow-up than at posttest, significantly so (po.05) for the EPP intervention. Such gains over time are unusual and contrast with the more common observation of temporal decay of many types of treatment effects. Growth over time is consistent, however, with viewing each program as transmitting tools that participants apply in their own daily living. As participants become more experienced and effective in engaging in the practices, their levels of mindfulness continue to increase. This supports the definition of mindfulness as a skill that can be developed over time with practice (Bishop et al., 2004; Shapiro et al., 2006). Larger gains at 8-week posttest also have been observed for the EPP for other outcomes (Oman et al., 2007) and in other populations (Oman et al., 2006). We also found that several measures of adherence to the practices taught during treatment predicted stress reductions independently of the MAAS. A possible explanation for why changes are not mediated by the MAAS alone is that this measure does not assess all facets of mindfulness. Theoretical conceptualizations of mindfulness, noted earlier, have suggested at least three components of mindfulness: intention, attention, and attitude (Shapiro et al., 2006). The MAAS captures only the attentional component and does not address intention or attitude (e.g., acceptance). It is likely that both the MBSR and EPP interventions may be cultivating other dimensions of mindfulness not captured by the MAAS but still significant in terms of improving well-being. For example, such considerations may explain why the MAAS measure did not mediate gains in forgiveness. Such gains may be mediated by other dimensions of mindfulness contained in the interventions, such as attitudinal qualities of acceptance, kindness, and openness (Shapiro et al., 2006). Another aspect of mindfulness, not captured by the MAAS, which potentially mediates positive outcome is the process of decentering (Fresco et al., 2007) or reperceiving (Shapiro et al., 2006). Decentering and reperceiving refer to a shift in perspective which allows one to disidentify from the contents of one s consciousness (i.e., one s thoughts, emotions) and view one s moment-by-moment experience with greater clarity and objectivity (Shapiro et al., 2006). Preliminary evidence supports the possibility that these processes mediate benefits from mindfulness practices (Fresco et al., 2007). Future research could include measures such as the Experiences Questionnaire (EQ) to examine this process (Fresco et al., 2007). Finally, note that for each treatment modality, stress reductions were predicted by diary measures of adhering to practices for regulating attention throughout the day (the MBSR informal practices and the EPP mantram ). This may indicate that the MAAS measure fails to fully capture participants varying efforts to integrate mindfulness-like states into day-to-day living. More broadly, the independent predictiveness of numerous dimensions of adherence to practice also may plausibly reflect intervention components that are not fully mediated by mindfulness. Rosch (2007) noted with regard to MBSR and other emerging mindfulness therapies that these therapies could as much be called wisdom-based as mindfulness-based. Mindfulness would seem to play two roles: as part of the therapy itself and as an umbrella justification ( empirical ) for the inclusion of other aspects of wisdom (p. 262).
19 858, July 2008 Limitations A significant limitation of the study is generalizability. Most participants were female, White, and first-year students, so it is unclear whether results fully apply to males, non-whites, and older students. The present results appear most likely to generalize to other populations that are similarly self-selected, and may not apply to college students as a whole. Aside from constraints on generalizability, other limitations of this study include its relatively small sample size and correspondingly reduced statistical power for assessing precise changes over time, or differences in treatment effect that may be associated with covariates. Further, this study relied entirely upon paper-and-pencil self-reports and did not include physiological or behavioral measures of stress or well-being. Inherent in self-report data is the potential for demand characteristics to affect the data, especially when the intervention is fairly transparent in its emphasis on present-moment awareness, and the primary assessment measure also is transparent in its emphasis on the present moment. Thus, another limitation of the study is the inability to discern if results are true or if they represent demand characteristics. A final limitation, and perhaps the most salient, is the lack of a multidimensional measure that more adequately captures the meaning of mindfulness. There is considerable variation in the ascribed meaning and operationalization of mindfulness, not only between the classical (Buddhist) and clinical perspectives (Lutz, Dunne, & Davidson, 2007) but between different clinical mindfulness researchers (Brown et al., 2007). The MAAS was designed to assess mindfulness from a Buddhist perspective, focusing on attention and awareness. Future research could build on the current study by including a multidimensional measure of mindfulness, which captures its broader definition (e.g., attitudinal qualities of acceptance and discernment). Strengths and Future Directions Despite these limitations, this study had several strengths. A significant strength is the inclusion of a 2-month follow-up assessment, which found that mindfulness (MAAS) gains increased significantly in magnitude from posttest to follow-up. Our postrandomization dropout rate of 3 of 47 (6%) was lower than many, if not most, meditation intervention studies (see Oman et al., 2008). A final strength is that the present study measured adherence to the practices taught both during intervention (Table 2 diary measures) and postintervention (Table 3), both of which predicted more favorable outcomes. The current findings are consistent with preliminary research that mindfulness as measured by the MAAS can be cultivated and that it is beneficial for one s wellbeing. It is encouraging that two distinct interventions led to increases on the MAAS, suggesting mindfulness attention and awareness can be trained through a variety of different practices that differ in their focus of attention, vocabularies, backgrounds, and level of explicit emphasis on mindfulness. This raises many questions concerning what dimensions of mindfulness may be fostered by other preexisting popular practices or psychosocial interventions (e.g., Benson & Stark, 1997; Goleman, 1988). A salient direction for future work is to continue to dialogue about a unified definition of mindfulness and to develop measures that capture its rich, multidimensional nature. It will be helpful to refine current measures as well as develop new measures based on sound theory and empirical rigor. Further, clinical trials such
20 Cultivating Mindfulness 859 as the current one could include multiple measures of mindfulness (e.g., Baer et al., 2004; Walach et al., 2006), in an attempt to better capture all of its components. Further, in addition to including other mindfulness measures, research studies could include measures of focused attention or one-pointed attention (ekāgratā in Sanskrit, ekaggatā in Pali). One-pointed attention has many theoretical benefits, and is part of the theoretical background to the EPP and many other concentrative systems of meditation (Shah, Friedman, & Kruglanski, 2002). Goleman (1988) suggested that training attention is y the single invariant ingredient in the recipe for altering consciousness of every meditation system (p. 107). It will be interesting to determine to what extent the MAAS or other measures of mindfulness already measure one-pointed attention, or perhaps features of attention that characterize both mindfulness and one-pointedness. Mikulas (2007) observed that mindfulness and concentration are often confused and confounded y many mindfulness-based programs are actually cultivating both concentration and mindfulness, but all results are attributed to mindfulness (p. 20). This observation may be one of the significant problems facing the current field of mindfulness research. For example, mindfulness-based practices begin by focusing attention on the breath to cultivate a stable, calm, and concentrated base. Thus, brief mindfulness-based interventions such as MBSR include significant training in onepointed attention, in addition to an emphasis on objectless awareness (i.e., awareness observing itself). Mindfulness-based research focuses on mindfulness. However, the specific interventions may not be teaching one thing but several (e.g., concentration 1 mindfulness; or other wisdom practices; Rosch, 2007). According to Thanissaro Bhikkhu, mindfulness meditation and concentration practices are both part of a single whole, noting that concentration stabilizes and calms the mind so it can see things clearly and with discernment (1997, p. 1). Future research could begin to tease out the unique and possibly synergistic contributions these different components and practices may be making to observed treatment effects. Conclusion We evaluated effects on the MAAS and well-being of two distinct, meditation-based interventions for undergraduates. Results demonstrated significant increases in MAAS and well-being. Mediation analyses demonstrated that the MAAS partially predicted positive outcome, and that measures of adherence to practice also independently predicted some positive outcomes. Further research could continue to refine and explore the mechanisms, sustainability, and generalizability of such effects, and to creatively explore different ways of cultivating and measuring the multifaceted construct of mindfulness. References Alexander, C.N., Robinson, P., Orme-Johnson, D.W., & Schneider, R.H. (1994). The effects of transcendental meditation compared to other methods of relaxation and meditation in reducing risk factors, morbidity, and mortality. Homeostasis in Health & Disease, 35, Baer, R.A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science & Practice, 10, Baer, R.A., Smith, G.T., & Allen, K.B. (2004). Assessment of mindfulness by self-report: The Kentucky Inventory of Mindfulness Skills. Assessment, 11,
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