Clinical Handbook of Mindfulness (29 page)

due to a reduction in levels of rumination. As the authors point out, they

only assessed rumination pre- and post-intervention, and therefore they were

unable to test whether changes in rumination occurred prior to changes in

distress. Thus, further research is necessary to determine if rumination is

a true mediator. A prior study by
Ramel, Goldin, Carmona, and McQuaid

(2004)
also presented data supportive of the hypothesis that mindfulness has its effect at least partially through a reduction in rumination. They examined previously depressed individuals before and after undergoing MBSR

92

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

(Kabat-Zinn, 1982)
and found that MBSR led to decreases in rumination and that these decreases in rumination accounted for reductions in depressive

and anxious symptoms. Additionally, compared to a control group, Cham-

bers, Lo, and Allen (in press) found that a group of non-clinical novice medi-

tators reported significant improvements in a number of variables including

rumination.

In the area of anxiety, there is some support in favor of continuing to exam-

ine rumination as a mechanism of change. Patients with social anxiety disor-

der who took part in MAGT demonstrated significant reductions in levels

of rumination from baseline to mid-treatment, post-treatment, and follow-up

(Kocovski et al., 2007).
However, the intervention consisted of elements in addition to mindfulness training; there was no control group, and a mediation

model was not tested. As an aside, these variables were investigated in a stu-

dent sample cross-sectionally, and there was support for a mediation model,

such that rumination partially mediated the relationship between social anxi-

ety and mindfulness
(Kocovski, Vorstenbosch, & Rogojanski, 2007).
Additionally, self-focused attention was also examined with this student sample and

also found to partially mediate the relationship between social anxiety and

mindfulness. In both cases, lower levels of mindfulness were associated with

increased levels of the mediator (rumination, self-focused attention), which

were in turn associated with increased levels of social anxiety. These results

need to be replicated in a clinical sample that has undergone a mindfulness

intervention.

Attentional Control

Mindfulness training inherently requires that individuals alter their attention

to be more present-moment focused. Chambers and colleagues (in press)

specifically investigated how a 10-day mindfulness meditation retreat affected

sustained attention in non-clinical, novice meditators. Participants exhibited

decreased reaction times when they performed an attention task after attend-

ing the meditation retreat compared to their baseline times. This decrease

was not found in the control group of participants who did not undergo

mindfulness training. Furthermore, decreases in reaction times were sig-

nificantly correlated with decreases in depression scores, indicating that

improvements in cognitive functioning may be associated with improved

mood. Mindfulness training, however, did not lead to improved performance

on an attention-switching task, and mediation models were not tested. Jha,

Krompinger, and Baime
(2007)
also investigated the effect of mindfulness training on attention. They compared meditators who were attending a

retreat, participants in an MBSR course with no previous meditation expe-

rience, and a control group. At baseline, participants with past mindful-

ness training (i.e., those in the retreat group) demonstrated better conflict-

monitoring performance compared to the other two groups. At the second

assessment point, participants who had completed MBSR improved in their

ability to orient their attention compared to the other two groups, while

those who attended the retreat improved on exogenous alerting compared

to the other two groups. Therefore, various subcomponents of attention may

be affected differentially depending on the type of meditation and perhaps

the length of meditation experience.

Chapter 5 Mindfulness and Psychopathology

93

Increased
Acceptance

Mindfulness treatments strongly emphasize acceptance of symptoms rather

than avoidance or suppression of symptoms
(Baer, 2003;
Brown & Ryan,

2003; Hayes et al., 1999).
For example, ACT
(Hayes et al., 1999)
is strongly rooted in the belief that with increased acceptance, one can experience

greater psychological health. There are studies showing that mindfulness-

and acceptance-based therapies are in fact leading to increased acceptance.

For example,
Roemer and Orsillo (2007)
administered the Acceptance and

Action Questionnaire (AAQ) pre- and post-intervention as one measure of a

proposed mechanism of change for their acceptance-based behavior ther-

apy for generalized anxiety disorder and found lower levels of experien-

tial avoidance (i.e., higher levels of acceptance) for patients following treat-

ment. When looking at pain tolerance tasks, there are a number of studies to

support that using acceptance strategies leads to increased pain tolerance

(Hayes, Bissett et al., 1999)
and greater willingness to persist at the task

(Gutierrez, Luciano, & Fink, 2004)
compared to more control-based strategies.
Levitt, Brown, Orsillo, and Barlow (2004)
randomly assigned individuals with panic disorder to a short acceptance, suppression, or distraction intervention. Individuals were then exposed to air enriched with carbon dioxide.

It was found that those who received the acceptance intervention were more

willing to take part in the task and reported lower levels of anxiety compared

with those who received the suppression or distraction intervention. Overall,

it appears that levels of acceptance are increasing following treatment, and

there are laboratory studies that have manipulated acceptance and found less

distress and greater willingness in the acceptance condition.

Other Psychological Mechanisms: Values Clarification, Exposure,

Decreased Anxiety and Increased Emotional Stability, and Increased

Psychological Flexibility

There are a number of other possible mechanisms of change that have little, if

any, empirical support at this time. One such possible mechanism of action of

mindfulness training is the ability to carefully make decisions that are reflec-

tive of one’s true values
(Shapiro et al., 2006).
Often when individuals operate on automatic pilot, they make quick decisions that may not be in line

with their needs and/or values. Through mindfulness training, one can adopt

a more objective perspective and make choices that are more congruent

with one’s values. In support of this potential mechanism of change, Brown

and Ryan
(2003)
found that individuals who scored higher on a measure of state mindfulness also reported engaging in more valued behaviors and interests. Second, mindfulness may promote exposure. Exposure has been out-

lined as a key component in mindfulness training
(Baer, 2003;
Kabat-Zinn,

1982).
By having individuals focus their awareness on emotional symptoms in a nonjudgmental manner, mindfulness can help to prevent avoidance or

escape. When individuals fully experience their feared emotional symptoms,

they can properly observe the consequences of their emotional symptoms

and formulate more effective coping strategies. In this way, mindfulness may

play a role in the extinction of the fear response
(Baer, 2003).
Third, in conjunction with biological differences between meditators and non-meditators,

Travis and Arenander (2006)
found that those with meditation experience

94

Nancy L. Kocovski, Zindel V. Segal, and Susan R. Battista

also had significantly lower levels of both state and trait anxiety compared

to those without meditation experience. Experienced meditators were also

more emotionally stable than non-meditators. A final mechanism of action

may be that mindfulness promotes the adoption of an overall more flexible

cognitive, emotional, and behavioral style
(Shapiro et al., 2006),
or increased overall psychological flexibility (Hayes et al., 1999).

Mechanisms of Change: Considerations and Limitations

There are several limitations and considerations in this area of research. It

is important that a distinction be made between mindfulness and relaxation

techniques, and only some studies have sought to do this (e.g.,
Jain et al.,

2007).
Further, clear definitions and descriptions of the particular mindfulness interventions used are essential in examining mechanisms of change

(Dimidjian & Linehan, 2003).
There are many different forms of meditation, and the actual results that are found may depend on the technique that is

used
(Hankey, 2006).
Therefore, it would be beneficial to examine the specific components of meditation and how they lead to various outcomes.

Additionally, mindfulness techniques are often not studied independent of

the other components involved in the treatment, which does not allow for

conclusions to be drawn about what is specifically helpful about mindfulness

(Dimidjian & Linehan, 2003).
It is important to keep in mind that while some of the research in this area does test for mechanisms of action, most research

studies show that mindfulness interventions lead to a decrease or increase

in a variable, but have not tested that variable as a mediator of change. Even

research that does test for mechanisms of change is often not meeting the

criteria for a stringent test, namely, showing that there is a change in the

mediator prior to a change in the outcome variable
(Kraemer et al., 2001).

As noted by
Teasdale et al. (2003),
mindfulness may target processes that affect many disorders (sixth consideration). Rather than taking this to mean

that mindfulness can be applied indiscriminately as a treatment for many

disorders, there is still room for specificity; the exact nature of each compo-

nent will likely differ depending on the disorder. For example, rumination is

common in both depressed and socially anxious patients. However, the con-

tent of the rumination can be different (e.g., dwelling on depressive symp-

toms versus dwelling on social inadequacies) and the consequences may also

be different (e.g., relapse versus avoidance or increased anxiety). Therefore,

knowing that rumination may be reduced via mindfulness interventions can

be a starting place. However, the exact problem formulation can still vary

across disorders that might have rumination as a process to be targeted.

Beyond Mechanisms of Change

In addition to understanding the mechanisms of change of mindfulness inter-

ventions for specific disorders, other factors require attention. Personality

factors may also play a role in understanding which patients might benefit

from a mindfulness treatment approach. For example, in our social anxi-

ety work, our first MAGT patients had already received CBT and were still

experiencing clinically significant symptoms and were interested in further

Chapter 5 Mindfulness and Psychopathology

95

treatment. They made significant gains with our mindfulness and accep-

tance approach; these particular patients may have been better suited for

this approach. In contrast, other clients have not been interested in listen-

ing to mindfulness CDs or tapes outside of the group sessions and are not

particularly open to this type of intervention. There is a paucity of research

examining personality as a predictor of treatment outcome for mindfulness

interventions and, as such, it is an important direction for future research.

Conclusion

Mindfulness is an old technique that has recently gained considerable atten-

tion within psychological research, and there has been a promising level of

empirical support. However, as we have argued, it is important to be cautious

in its application and not to expect it to be a cure-all intervention on its own.

We advocate for the following basic steps for clinicians considering the use

of mindfulness in their practice: (1) careful consideration of the population

being served, and the current understanding with respect to etiology and

maintenance of the particular condition being treated, (2) determination of

how mindfulness might be helpful with this population, making reference to

the mechanisms of change research, (3) evaluation of whether mindfulness

training can be integrated with other empirically supported interventions,

and (4) inclusion of a rationale to patients for the mindfulness components.

The recent research empirically evaluating mindfulness interventions and

the early research on the identification of mediators of change are excit-

ing. Certainly, there is a need for the continued empirical evaluation of the

integration of mindfulness components with other interventions. Addition-

ally, as reviewed above, much of the research on mediators has only pro-