reactivity, and (d) cognitive vitality. In the future, it is anticipated that mindfulness re- search will increasingly incorporate the neurobiological assessment domain, along with ubiquitous self-report measures currently utilized.
against perceived resources. In an empirically documented paper, Garland, Gaylord, and Park (2009) propose that mindfulness enhances the secondary appraisal process by fostering an openly receptive stance toward challenging circumstances.
An updated version of the transactional model that integrates elements of Lazarus and Folkman (1984), Kabat-Zinn (1990), and Garland, Gaylord, and Park (2009) has been developed by the present authors and is currently undergoing empirical testing (Figure 6.1). It illustrates how stress reactivity and coping patterns can be infl uenced by mindfulness, using constructs that lend themselves well to empirical testing. From this perspective, mindfulness functions by fostering heightened awareness of, and skillful responses to, potential stressors that otherwise elicit nonconscious, habitual reactions having adverse long-term consequences for health.
Event
M I N D F U L N E S S
(distorted perception/threatening)-- Appraisal --(clear perception/non-threatening)
(reacting: avoidant, passive)--- Coping ---(responding: focused, active)
(judged as negative)--- Event Outcome ---(positive, or not judged)
(distress, depression)--- Emotional Outcome ---(positive emotion)
(poor QOL, morbidity)--- Health Outcome ---(good QOL, good heath)
Physiological Outcomes Health
Behavior Autonomic
Response HPA Response
Sleep
Immunity Sympathetic activation
Hypo- or hyper-reactivity, poor circadian
coordination Disruption, poor efficiency,
non-restorative Inflammation, altered cell trafficking and cytotoxicity
Parasympathetic activation
Poor diet, little exercise, substance
use, poor health-care
utilization
Healthy diet, regular exercise,
low substance use, good health-care
utilization Rhythm coordination
with environment, sleep/wake cycle Rhythmic, efficient,
restorative Coordinated cellular and humoral immutity
Figure 6.1 Stress-Reducing Aspects of MBSR: Adaptation of the Transactional Model of Stress and Coping (Lazarus & Folkman, 1984)
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Referring to this fi gure, we hypothesize that mindfulness practice will promote movement from left to right on key components of the model; for example, from pas- sive, avoidant, or reactive coping methods to active, focused, responsive management of diffi cult events. Th e model further proposes that the impact of mindfulness is espe- cially relevant in present-moment circumstances that may have implications for future health-related outcomes. Th e capacity for accurate perception and appraisal, along with skillful responses to challenging circumstances of daily life, should reduce the incidence of habitual stress reactivity.
Although not depicted in the fi gure, we suggest that there are both direct and indi- rect eff ects of mindfulness on appraisal, coping, positive and negative mood, as well as on physiological stress responses. For example, simply focusing on the breath may result in a slower breathing rate and concomitant state of hypo-arousal (Salmon et al., 2004).
In support of this, we recently observed reduced sympathetic activation during medita- tion (body scan) sessions, as well as over the course of MBSR training, among a cohort of fi bromyalgia patients (Lush, Salmon, Floyd, Studts, Weissbecker, & Sephton, 2009).
Activation-reducing qualities of both basic meditation techniques and Yoga have also been documented (Raub, 2002; Kristeller, 2007). Th us, formal mindfulness practices, done slowly and deliberately, may reduce physiological activation patterns associated with sympathetic nervous and/or HPA axis arousal.
Although both of these models off er promising directions for clinical research on MBSR, the task of identifying mechanisms that account for its impact is hampered by the rich, multicomponent nature of the program. So far, no studies have “deconstructed”
the program in an attempt to isolate specifi c mechanisms of change. As an alternative to this approach, research eff orts are beginning to focus on variables that permit assessment of dose/response eff ects, such as length of class sessions (Carmody & Baer, 2009) and individual meditation practice time (Carmody & Baer, 2008). Th ese studies reported that formal meditation practice time correlated signifi cantly with symptom improve- ment, and that home practice increased self-reported mindfulness, which mediated improved well-being and reduced depressive symptoms. Consistent with these results, a recent randomized study of “compassion” meditation by Pace, et al. (2009) reported that home practice time was associated with reduced distress and lower infl ammatory response to laboratory stress. Although not all studies report reliable dose-response eff ects (Carlson, et al., 2003; Davidson, et al., 2003), evidence is beginning to accumulate suggesting that formal mindfulness practice is in fact a key aspect of the program’s eff ectiveness, at least for some participants.
Recent research has focused on specifi c facets of mindfulness that, over time, will further contribute to an understanding of mechanisms that account for its eff ects. For example, Kabat-Zinn (1982) fi rst proposed that mindfulness may reduce distress by fostering a capacity to diff erentiate organic and cognitive/interpretive aspects of pain, and to become less attached to the latter as a means of reducing suff ering. Although the original focus of this principle was chronic pain, it has been widely applied to other dis- tressing conditions, including depression (Segal, Williams, & Teasdale, 2002). A recent
study of depressed individuals showed increased self-reported mindfulness after MBCT, which was associated with lower cognitive reactivity (activation of negative thinking pat- terns) in response to sad mood (Raes, Dewulf, Van Herringen, & Williams, 2009).
Mindfulness evidently impacts other capabilities as well, including processing ongo- ing events as if they are occurring for the fi rst time (i.e., “beginner’s mind” ), rather than relying on previously conditioned, habitual reactions. A focus on the present moment rather than on rule-governed behavior (Hayes et al., 1999) can potentially “de-automate”
such reaction patterns (Kabat-Zinn, 1990), and thereby increase response fl exibility.
Th is characteristic is consistent with Langer’s research-based view of mindfulness as the capability to treat present circumstances as new and unique experiences that facilitate generating multiple alternative response options (Langer & Moldoveanu, 2000). Con- sistent with this perspective, a recent study by Levesque and Brown (2007) using the Mindfulness Acceptance and Awareness Scale (MAAS; Brown & Ryan, 2003), found that dispositional mindfulness moderates the negative impact of implicit (i.e., noncon- scious, habitual) motivation on day-to-day behavioral autonomy.
Two recent laboratory studies examined this aspect of cognitive fl exibility using the Stroop Test, an attention- and memory-intensive cognitive interference task in which subjects read color names printed in diff erent colors (McLeod, 1991; Golden &
Freshwater, 2003). Wenk-Sormaz (2005) compared a brief Zen-based breathing medita- tion session with a concentration task of comparable length in a randomized control study. Participants in the former condition demonstrated signifi cantly reduced interfer- ence on the Stroop Test, indicating increased present-moment regulation of normally automated cognitive processes. A follow-up study revealed that a second group of meditation practitioners signifi cantly increased the number of atypical responses on a category production task, further evidence of reduced automatic responding. Moore and Malinowski (2009) compared performance of mindfulness meditation practitio- ners and non-practitioners on the Stroop Test and reported similar results. Th ose in the meditation group scored signifi cantly higher on the Kentucky Inventory of Mindful- ness Skills (KIMS) and showed greater cognitive fl exibility than nonpractitioners.
Overall, cognitive mechanisms appear to account for a signifi cant proportion of ben- efi cial eff ects attributed to mindfulness. Of these, decentering appears to be paramount, but as suggested above, information-processing aspects of cognition may be operative as well. Such mechanisms presumably underlie the benefi cial eff ects of mindfulness on a range of clinically relevant variables documented in recent research, including self- focused attention and ruminative tendencies (Watkins & Teasdale, 2004), experiential avoidance (Arch and Craske, 2006; Hayes, 2004; Roemer & Orsillo, 2009), and per- ceived control (Astin, 1997; Kabat-Zinn, 1982).
FUTURE DIRECTIONS
Several years ago, Dimidjian and Linehan (2003) articulated a systematic agenda for research on clinical mindfulness practice. Among the many questions for research they
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raised in this discussion, two in particular stand out, as relevant today as they were then: First, what is mindfulness? And second, how does mindfulness work? Concerning the nature of mindfulness, our current understanding of the concept is based largely on questionnaire measures intended to identify key characteristics and derive a widely agreed-upon operational defi nition, in keeping with traditional Western scientifi c prac- tice. But as noted by Grossman (2008) and others, mindfulness is an elusive construct, one that is historically unfamiliar to Westerners. Rational science can only go so far in defi ning mindfulness—a state of being that is widely acknowledged to be largely preconceptual in nature. As recently noted by Shapiro (2009, p. 555), “. . . we must fi nd ways of translating its nonconceptual, nondual, and paradoxical nature into a language that clinicians, scientists, and scholars can understand and agree on.” Current reliance on verbally mediated self-assessment questionnaires limits sampling of mindfulness correlates to a single domain, and, according to Grossman, raises signifi cant concerns about validity as well. We concur with his view that MBSR research should expand the range of outcome domains. Th is could include, for example, qualitative, interview- based assessments of novice and experienced practitioners. Detailed phenomenological investigations of the elusive “present moment” could be incorporated into mindfulness research, perhaps using the intriguing microanalytic interviewing technique developed by Stern (2004), in which a very brief (approximately fi ve-second) “slice of life” is sub- jected to detailed exploration. Th e capacity of MBSR to systematically alter a range of physiological responses should be thoroughly investigated. Immune function, sleep pat- terns, and autonomic reactivity are examples of assessment domains that are practical to monitor. Current use of imaging technologies like fMRI to study cognitive and even social correlates of mindfulness is of course an especially promising avenue for research (Siegel, 2007; Stein et al., 2008).
Th e second question posed by Dimidjian and Linehan (2003) concerned the mechanism(s) by which mindfulness interventions operate. We have summarized con- temporary responses to this question, and updated the original transactional model on which MBSR was based in this chapter. It is our hope that the current formulation will provide a useful framework for subsequent research. Nonetheless, it is important to remember that trying to uncover “mechanisms” is a characteristically Western approach to discovery that implies the existence of structures or processes that are amenable to empirical discernment and verifi cation. Inherent limitations in this approach may delay true understanding of how mindfulness “works.” Nevertheless, there are clear indica- tions that we are further along in this process than was the case when Dimidjian and Linehan fi rst proposed their research agenda.