Mechanisms of Mindfulness

Transcription

1 Mechanisms of Mindfulness Bachelor thesis, Clinical Health Psychology Department of Clinical Health Psychology Tilburg University Naam : Carmen Romijn ANR : Supervisor: Dr. Ivan Nyklíček Date:

2 Contents Abstract The concepts of Mindfulness and well-being Mindfulness Compassion in Buddhism Mindfulness in Western society Well-Being Effects of mindfulness on well-being Method Proposed mechanisms mediating the relationship of mindfulness and well-being Relaxation Meta-Cognitive insight Contact with reality Exposure The cognitive domain Perseverative thinking Experiential avoidance Cognitive reappraisal Flexible self-regulation Values clarification Compassion and empathy Conclusions and discussion Conclusions Limitations and recommendations References

3 Abstract Although the amount of literature on mindfulness is vastly growing, relatively little has been written about the mechanisms underlying the relationship between mindfulness and well-being. This paper aims to review the mechanisms that have been proposed in literature to be mediating the relationship between mindfulness and well-being. Research on the relationship between mindfulness and well-being is relatively new, and few seem to make comparisons of current psychological literature on mindfulness with mindfulness in Buddhist tradition. This paper explores the proposed mechanisms underlying the relationship between mindfulness and well-being by an investigation of how these mechanisms relate to mindfulness and well-being, in both Western and Buddhist traditions, by discussing theory and empirical evidence. It was concluded that the mechanisms relaxation, meta-cognitive insight, perseverative thinking, contact with reality, compassion and empathy, exposure and cognitive reappraisal all seem to be related to mindfulness, although some seem more directly related than others. It was also concluded that empirical research is too diverse in design and interventions to draw firm conclusions from them. Further research into the different contextualization of mindfulness in Buddhist and Western tradition might provide us with more information on the mechanisms underlying the relationship between mindfulness and well-being, which might in turn make mindfulness more efficient in the clinical setting. 3

4 Introduction Although the amount of literature on mindfulness is vastly growing, relatively little has been written about the mechanisms underlying the relationship between mindfulness and wellbeing. Both theoretical frameworks as well as randomized empirical research seem sparse. This is remarkable when looking at the popularity of mindfulness amongst lay public and the many claims made by practitioners about the wholesomeness of mindfulness. And although the efficacy of several mindfulness-based interventions on well-being seems to have been demonstrated, insufficient light has been shed on the constructs possibly mediating this relationship. An identification of such mediating constructs would stimulate research on mindfulness and well-being and would perhaps maximize the efficient usage of mindfulness in the professional setting. 1. The concepts of Mindfulness and well-being 1.1 Mindfulness To be able to define the concept of mindfulness, it is necessary to see how it is embedded in Buddhist literature. The concept of mindfulness originates from the realization of the four noble truths by Siddhartha Gautama, a spiritual teacher. The four noble truths mark the beginning of Buddhist teachings and the spread of Buddhism throughout Asia (Anderson, 2004), and contain the central principles of Buddhism which have been adopted by all Buddhist schools that have emerged ever since. The four noble truths explain the fact of suffering, the opposite of well-being, and propose the means to end this suffering, which is the ultimate goal of Buddhism. The first noble truth, Duhkha, explains the concept of suffering. It encompasses all kinds of suffering, both physical and mental. Once this is understood, the second noble truth, samudaya, teaches us where this suffering comes from, which is from desire and attachment. For example, the attachment to ideas and principles 4

5 might be the cause of suffering for a person. The third noble truth, nirodha, follows naturally from the second one and simply says that if one wants to end suffering, one needs to stop desiring. Finally, the fourth noble truth, marga, shows us the means to end this suffering, with the eightfold path. This path contains eight parts: right view, right intention, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration. These behavioral components are inseparable and interwoven with each other. They are not sequential, as the four noble truths are. For example, when practicing right mindfulness, one cannot do it without also practicing the seven other parts of the eightfold path. True mindfulness is described as a diligent awareness with a presence of mind and aware of the activities of the body, mind, ideas and sensations (Rahula, 1985). Thus, according to Buddhist tradition, the concept of mindfulness is interwoven with firstly having a right view. Right view can be seen as seeing the true nature of things, free of interpretations and labels (Rahula, 1985). Secondly, it is connected with having the right intention. To have the right intention means that one must have the right thoughts, because thoughts precede actions. These right intentions consist amongst others of the intention of good will, harmlessness and the intention of renunciation, which encompasses the will to detach yourself, and is opposite to desire ( Dhammapada, Muller). The third part of the eightfold path, right speech, is about realizing that through speech, like for example gossip and unfounded critique, we can hurt others. When we perform right speech, we try to speak truthfully and positively (Nhat Hanh, 1993). Fourthly, mindfulness is interwoven with right action, which constitutes of acting kindly and honestly, with respect to others belongings and sexual desires. The fifth of the eightfold path, is called right livelihood and it means that one should earn one's living in a legal, peaceful and righteous way. Sixthly, right effort is described as having a positive mental energy and will to achieve a good and wholesome state of mind, and to get rid of unwholesome thoughts (Rahula, 1985). This seems to incorporate a 5

6 certain goal-directedness and a judgmental attitude, which contradicts what critics call modern approaches to mindfulness, where a non-judgmental attitude plays a central role (Baer, 2003). However, Rapgay and Bystrisky (2009) state that this approach is not enough to reduce maladaptive thoughts and behaviours, and that the classical approach to mindfulness contains mechanisms by which one can identify maladaptive experiences in order to replace them with adaptive ones. This process of focusing on a wholesome state of mind and letting go of unwholesome thoughts is described in the Pali Cannon, allegedly the oldest remaining Buddhist scripture. Right concentration in the context of the eightfold path, means a mental state where one concentrates in a wholesome state of mind. The meditations used to cultivate right concentration can involve contemplation on unattractive objects or thoughts, like a human body in decay, with the purpose of cultivating concentration in a wholesome state of mind by reflecting upon one s own death and with it the realization of the transient qualities of life and the importance of detaching oneself from desire in order to end suffering. The four noble truths and with it, the eightfold path, in which mindfulness is included, is at the center of Buddhism, and must be seen as a way of life (Rahula, 1985). It has been incorporated in most of the Buddhist schools that were founded since this first teaching. Another teaching that is central to all Buddhist schools, is the teaching of conditioned arising, or co-dependent origination, which is the realization that all things are interdependent of each other and are interwoven in a complex web of cause and effect, stimulating the insight that all are equal, and in this way encouraging the development of compassion and empathy. The concept of co-dependent origination is in accordance with the four noble truths and the incorporated eightfold path, which in turn includes mindfulness, because it emphasizes the inevitability of cause and effect. For example, if one lives with desire and tries to hold on to things whilst wishing they are permanent, then suffering will occur as an 6

7 effect of this desire. This principle of conditioned arising is fundamental to all Buddhist schools, and has strong connections to the concept of mindfulness. However, there are also some differences in viewpoints between schools in how this eightfold path should be practiced. A third teaching that is central to Buddhism is that, to end suffering, one must develop wisdom (paññā) and compassion (karuṇā) equally. Compassion stands for qualities on the emotional side, like love and kindness, and wisdom stands for the intellectual side, or the qualities of the mind (Rahula, 1985) Compassion in Buddhism Although Buddhist schools put forward compassion as a vital ingredient that needs to be cultivated in the path to end suffering, some nuances are made in the Zen tradition. The Vietnamese Zen monk Thich Nhat Hanh (2008) seems to explain that compassion follows from having the right view. He explains that only when we are able to look upon both positive and negative aspects of life without labeling them, we can see the causes of suffering. In this moment we begin to grasp compassion, he says. He also emphasizes that compassion needs to be developed and he cites the Lotus Sutra describing Avalokiteshvara who practices 'looking with the eyes of compassion and listening deeply to the cries of the world (Nhat Hanh, 2008). We might conclude that the feeling of compassion is a central concept in Buddhism and that together with wisdom it is being placed parallel to the eightfold path. To promote well-being, the qualities of wisdom and compassion must be developed equally (Rahula, 1985). The essential means considered by all Buddhist schools to achieve a state of ideal mental health is through meditation, which is a mental culture that aims to clean the mind of 7

8 disturbances by cultivating, amongst others, concentration and mindfulness, leading finally to seeing the nature of things as they really are (Rahula, 1985) Mindfulness in Western society There has been a diverse conceptualization of mindfulness in Western literature, and it is being practiced in significantly different ways in different mindfulness-based intervention strategies (Linehan, 2002). Most conceptualizations stem from one of the earliest definitions of mindfulness in psychology by Jon Kabat-Zinn, who conceptualized mindfulness as paying attention in a particular way, on purpose, in the present moment, and nonjudgmentally (as cited in Shapiro, Carlson, Astin & Freedman, 2006). Building on this definition, in order to concretize it and stimulate further research, Shapiro et al. (2006) have broken down the construct into three components that altogether constitute mindfulness, which they define as Intention, Attention and Attitude. In other words; Mindfulness should be done on purpose, while paying attention to the moment-to-moment content of consciousness, and at the same time having an open, curious and kind attitude (Shapiro et al., 2006). However, questions have been raised about the validity and necessity of breaking up mindfulness in separate components (Nyklíček, 2011), and the describing of the concept in terms of behaviors instead of a quality of awareness (Chambers, Gullone & Allen, 2009). It s clear that a definition of mindfulness has not been agreed upon, yet, there have been many implementations of mindfulness. The differences in conceptualization and operationalization might account for the differences in how mindfulness has been integrated in clinical practice (Chiesa & Malinowski, 2011). Based on our previous discussions of mindfulness in both the eastern and western context, we will define the concept of mindfulness as diligent awareness of the activities of the body, mind, ideas and sensations, nonjudgmentally. It is similar to the definition of 8

9 Rahula (1985), which is based on the Buddhist tradition, and bears resemblance to the more recent definition of Shapiro et al. (2006), of which we have excluded the element of mindfulness needing to be carried out on purpose. In this respect we agree with Nyklíček (2011), that there seems to be no reason for incorporating an element which emphasizes that mindfulness should be practiced on purpose, because one might also experience mindfulness when not practiced on purpose. It is important to note that, following our previous discussions, there seems to be a difference between the two traditions, that is, the Buddhist and the more modern Western tradition which has derived the conceptualization of mindfulness from the Buddhist tradition. It seems that mindfulness, when being research in the Western tradition, is measured as a state of consciousness that leads to well-being. In the Buddhist context, mindfulness is defined as a state as well, but one that leads to well-being in combination with certain other concepts and guidelines. This difference in contextualization might lead to different measures in well-being. We will bear this in mind when examining the possible mechanisms underlying the relationship between mindfulness and well-being. 1.2 Well-Being Kahneman, Diener & Schwartz (2003) suggest that the relative dominance in theoretical development of firstly behaviorism and secondly cognitive psychology, might have left little attention for the positive aspects that are part of well-being. Under the influence of positive psychology, which has the goal, as summed up in 1998 by amongst others Mihaly Csikszentmihalyi, to make normal life more fulfilling and is put forward in order to complement general psychology, the measurement of well-being has developed from a different perspective which has given rise to the concept of subjective well-being (SWB). Aiming to extend the idea of mental health beyond the absence of symptoms of depression 9

10 and distress, SWB includes the presence of happiness and life satisfaction as measures for well-being (Diener, Oishi & Lucas, 2003). The Personal Well-being Index (PWI) was designed to measure SWB, and includes measurements of personal satisfaction on the following domains: (1) Standard of living; (2) Personal health; (3) Achievements in life; (4) Personal relationships; (5) Personal safety; (6) Community and connectedness; (7) Future security, and (8) religion and spirituality. The exact relationship between SWB and mental disorders is unclear. There is research that supports the proposition that the loss of SWB indicates clinical depression (Gargiulo & Stokes, 2008), and that certain subjective well-being affect states increase vulnerability to depression and anxiety (Burns, Anstey & Windsor, 2011). It cannot be concluded from this research however that all instances of depression and anxiety are due to low SWB. Intuitively, the concept of SWB seems to bear great resemblance to the concept of Quality of Life (QoL). Research however on this relationship is sparse and diverse. For example, Camfield and Skevington (2008) suggest that SWB and subjective QoL are virtually synonymous with each other, and Cummins (2010) suggests that health related QoL (HRQoL) is less flexible in measuring life quality than SWB. Although interesting, further elaboration on the relationship between SWB and QoL is beyond the scope of this paper. At the first glance, SWB seems to be able to take more broad measurements of wellbeing. However, it has received some criticism because it does not measure having goals and challenges in life, which has been pointed out as being an important part of psychological human life in all cultures and may be seen as self-actualization (Vitterso, 2003). Considering our discussion of mindfulness as a broad concept that is applicable to mental development in general, as we will further elaborate on in the course of this paper, we will define well-being as comprising the following three constructs; (1) mental health; (2) 10

11 subjective well-being, and (3) self-actualization. With this definition, we extend the concept of mental health beyond the absence of symptoms of depression and distress. 1.3 Effects of mindfulness on well-being The efficacy of mindfulness-based therapies has not yet been widely researched, but outcomes seem to demonstrate a positive effect of mindfulness on well-being. A recent meta-analytic review on the effects of mindfulness-based therapy (MBT) on anxiety and depression by Hofmann, Sawyer, Witt, and Oh (2010), reveals moderate effects of MBT in people with conditions including cancer, anxiety disorder, depression, and other psychiatric or medical conditions for improving anxiety (Hedges s g = 0.63) and mood symptoms (Hedges s g = 0.59). In patients with anxiety and mood disorders, the effect was large: (Hedges s g) 0.97 and Chiesa and Serretti (2009) have reviewed the research on the effects of the MBRS program on stress management in healthy people, and found that ruminative thinking was lowered significantly in participants in the MBRS program, however, no specific active ingredient in the MBRS program was appointed as being responsible for this reduction. Also, empathy and self-compassion were reported to be significantly higher to those following an MBRS program as opposed to those in waiting list groups. Mindfulness is also being connected with emotion regulation (ER), which may be linked with psychological dysfunction (Chambers et al., 2009). In addition, mindfulness was associated with changes in spirituality by Birnie, Speca and Carlson (2010), showing a medium effect size of 0.47 (Cohen s d). Several weaknesses arise when examining the research on the effectiveness of mindfulness. These weaknesses consist of, amongst others, methodological differences, 11

12 short-term measurements and differences in operationalization of the relationship between mindfulness and well-being. Although several effects of mindfulness on well-begin have been demonstrated, it remains unclear what the mechanisms are that mediate this relationship. The aim of this essay is to examine the mechanisms underlying the relationship between mindfulness and well-being by answering the following questions: (1) Which mechanisms are being described in literature that mediate the relationship between mindfulness and wellbeing?, (2) how do these mechanisms relate to mindfulness, both from a Western as from a Buddhist perspective?, (3) how can the influence of the proposed mechanisms on well-being be explained?, (4) what empirical evidence supports the effects of mindfulness on well-being regarding these mechanisms? The essay will end with a conclusion, a discussion and recommendations for future research and clinical implementation on the relationship between mindfulness and well-being. 2. Method Studies were identified by searching PsycINFO and Sciencedirect, through an internet connection with Tilburg University Library. Searches were conducted for studies published between januari 1, 2000 and april, 2011, using the search term mindfulness combined with the term mechanism, which yielded 168 results. A search was conducted using the search term mindfulness combined with the term review and mechanisms, which yielded 43 results. Additional searches were conducted using the term mindfulness with the terms relaxation, exposure, avoidance, reappraisal, values clarification, spirituality, compassion and empathy, which yielded 95, 62, 95, 8, 2, 118, 108 and 64 results respectively. From these, studies were selected which discussed the possible mechanisms of the relationship between mindfulness and well-being, as opposed to mere effects of mindfulness on well-being. 12

13 Experimental studies, if applicable, were selected on the basis of the presence of continuous measures. 3. Proposed mechanisms mediating the relationship of mindfulness and well-being 3.1 Relaxation Relaxation is usually defined as an absence or decline of arousal, which promotes well-being. Theories about the role of relaxation in mindfulness meditation are various. Although Chambers et al. (2009) identifies relaxation as a process mediating the relationship between mindfulness and well-being, unlike Baer (2003), who stress that relaxation could be an effect of practicing mindfulness, but one should see this as a sideeffect. Baer (2003) clarifies this by saying that the sole focus of mindfulness is nonjudgmental observation, and not relaxation (Baer, 2003). She suggests that is not the goal of mindfulness to push away negative thought or feelings and replace them by a feeling of relaxation, which would be a denial of these feelings, but rather observing these feelings nonjudgmentally. The previous conclusions might have been reason for Shapiro et al. (2006) to exclude relaxation from the underlying mechanisms they propose for mindfulness and wellbeing. There are reasons though for other scholars to identify relaxation as an active ingredient in the relationship between mindfulness and well-being. The decision of Chamber et al. (2009) to put forward relaxation as a mechanism, is backed up by Buddhist literature in which relaxation is associated with mindfulness. Both the Dalai Lama (Dalai Lama & Cutler, 1998) and Sogyal Rinpoche (2002), speak about relaxation in this context. Sogyal Rinpoche (2002) explains that meditation is nothing more than bringing home the mind to its natural state, and to relax the exhausted mind of its busy thought patterns by letting go of them. He speaks about relaxation of the mind as one of the three pillars of mediation. Although the goal is to put the mind at rest, this is usually not 13

14 instantly achieved when practicing meditation. The Dalai Lama points out that it takes practice and that from the moment one starts meditating, a lot of lessons are learned, and rest is gradually achieved (Dalai Lama & Cutler, 1998). Possibly, Baer (2003) and Shapiro et al. (2006) give a rather hedonistic interpretation of relaxation, and have therefore excluded it from mindfulness so conspicuously. Relaxation however, in relation to mindfulness practice, should be interpreted as relaxation of the mind, and as a direct result of mindfulness practice, as is proposed by Nyklíček (2011). Well-performed research and empirical evidence for the mediating role of relaxation in the relationship between mindfulness and well-being is sparse. Agee, Danoff-Burg and Grant (2009), however compared a five-week mindfulness meditation (MM) intervention to a training in progressive muscle relaxation (PMR) (n=43). Well-being was measured with the Brief Symptom Inventory (BSI) and mindfulness was measured with the Mindful Attention Awareness Scale (MAAS), both pre- and post treatment. The effect size analyses indicated a medium-sized effect of 0.63 (Cohen s d) for the MM intervention on reductions in the BSI general severity index (Agee et al., 2009). Also, Agee et al. (2009) found that MM participants attained moderate levels of relaxation. Exact measures of this relationship however, are not mentioned in this study (Tabel 1). 3.2 Meta-Cognitive insight Another mechanism that is, amongst others, proposed by Chambers et al. (2009) is metacognitive insight, which we can define as insight into our own thinking processes. Bishop et al. (2004), in their attempt to operationalize meta-cognitive insight as intrinsic to mindfulness, speak about meta-cognitive insight as insight into the nature of one s mind, which they further explain as the ability to simply look at the processes of the mind, like thoughts and feelings, and realize that they are fleeting processes (Bishop et al., 14

15 2004). Apart from this explanation of the construct, further elaboration on the construct in literature is limited, and it is not being included in empirical research on the relationship between mindfulness and well-being. Although often overlooked in western literature, meta-cognitive insight is frequently described in Buddhist literature, and it takes a central place. Its definition is closely connected to the part of the eightfold path named right view, which is described as seeing the true nature of things, free of interpretations and labels, which clearly incorporates simply looking at the processes of the mind. Also, in the context of the eightfold path, true mindfulness is described as a diligent awareness with a presence of mind and aware of the activities of the body, mind, ideas and sensations, which clearly embodies the act of viewing thoughtprocesses. That being so, we can say that meta-cognitive insight might indeed be a mechanism by which mindfulness influences well-being. The influence of meta-cognitive insight on well-being might be explained in various ways. Shapiro et al. (2006) explain that this viewing of the mind may facilitate cognitive, emotional and behavioral flexibility, while by perceiving these processes as just processes, we might become less automatic in our responses because we understand that they are the mere product of an (over)engaged mind, and we can choose the responses which are right for us (Shapiro et al., 2006). In conclusion, we can say that meta-cognitive insight might have a positive effect on well-being. 3.3 Contact with reality A construct named contact with reality has been hypothesized by Nyklίček (2011), who explains that as a consequence of being mindful and thus being open for what happens in the present moment nonjudgmentally, a certain intimacy with what we perceive arises. As the mind opens up to its natural state (Sogyal Rinpoche, 2002), with less and less of its ever- 15

16 distracting ruminative activities, we are more and more in touch with things as they are in the current moment. Contrary to the distance to the thought processes in the own mind which is created by meta-cognitive insight, Nyklίček (2011) propose intimacy with the self and its surroundings as the effect of mindfulness. Intuitively, this effect seems logical, while when thoughts are silent and the brain subdues its mental activities, the perception of all that is left grows stronger. It should be noted that intimacy, quoted in the Oxford English Dictionary as a connectedness with the inmost nature or fundamental character of a thing should not be attributed an emotional aspect of closeness in this case, rather, it should be interpreted as a measure of closeness to what is perceived. The concept of contact with reality has, to our knowledge, not been researched empirically. Also, the construct as such is not mentioned as a separate construct in Buddhist literature, but seems to correlate with having the right view, described as seeing the true nature of things, free of interpretations and labels. Also, we expect a relationship with metacognitive insight, because the viewing of the processes of our mind as just processes, directs our attention to what is left, that is the whole reality, as proposed by Nyklίček (2011). A part of the difference between the two concepts is that contact puts emphasis on both the internal and external world, whereas meta-cognitive insight focuses on internal processes belonging to our mind. The question is however, whether such a distinction between an internal and external world is relevant to the concept of mindfulness as described in Buddhist literature. As we ve seen before, a notion central to Buddhism is conditioned arising, which entails the realization that all things are closely interwoven with each other in a vast web of cause and effect. One of its consequences is, as we ve explained previously, that we perceive all living and non-living things as interrelated with each other, and in some way dependent on each other. This realization places the self in a different perspective, causes our internal and 16

17 external world to become one and the same, and implicates an experience of closeness to reality. It might be that with the addition of this concept to western mindfulness theories, the construct of contact with reality will become more clear in this context Exposure Exposure might be correlated to closeness to reality, as suggested by Nyklίček (2011). However, exposure entails only negative feelings and thoughts, while closeness to reality entails both the positive and negative. Exposure can be seen as a psychological intervention, where the person is being exposed to her negative thoughts and feelings, mostly in a gradual way, and guiding him/her through the process of systematic desensitization. Shapiro et al. (2006) suggest that desensitization of internal stimuli, i.e. anxious thoughts, can be a mechanism through which mindfulness, which involves disidentification from these thoughts and merely viewing them as they are, operates. This disidentification gives the opportunity to explore these feelings and, in a way, get used to these feelings so that they are less disturbing (Shapiro et al., 2006). Traenor (2011), confirms in his literature review that research on extinction has indicated several ways in which mindfulness may facilitate the process of extinction. This proposed mechanism underlying the relationship between mindfulness and wellbeing has not yet been empirically researched, and therefore there is no evidence to support the theory. In Buddhist tradition, the concept is not mentioned as such, which does not rule out the possibility of exposure being a mechanism to the relationship. A correlation with mindfulness seems plausible from the perspective of the exposure intervention theory. To what extent such an approach to dealing with negative emotions like anxiety is compatible with Buddhist theory however, is not researched. The variety explained by the mechanism of 17

18 exposure in the relationship of mindfulness and well-being, might be relatively small as compared to the proposed mechanism of contact with reality, which encompasses the totality of reality as it, both positive and negative. 3.4 The cognitive domain Perseverative thinking Perseverative thinking can be defined as the involuntary repetition of thoughts. It is also being called worry, or rumination, because they are frequently negative, and they are thought to be at the core of some mental disorders as mentioned in the DSM-IV, like for example depression and generalized anxiety disorder (GAD). Recently, a proposal has been made by Andrews et al (2010), to re-label GAD as generalized worry disorder, as worry is the central feature of GAD, and would make diagnosis more accurate and efficient, they argue (Andrews et al., 2010). Rumination, or worry, has been mentioned in the context of the relationship between mindfulness and well-being, by several scholars (Borders, Earleywine, & Jajodia, 2010 Chambers et al., 200 Hofmann et al., 2010 Nyklíček, 2011; Shapiro et al., 2006), for apparent reasons. It is often theorized that through mindfulness, thoughts are merely looked upon as transient processes of the mind, and that as a result, one disidentifies with the thoughts, which are in this case worries, and creates the possibility to become more flexible with them and let them go. Research on the relationship between ruminative thinking and mindfulness is diverse. In 2010, Mathew, Whitford, Kenny, and Denson (2010) conducted a clinical audit (n=39) on the long-term effects of mindfulness-based cognitive therapy as a relapse prevention treatment for major depressive disorder. The long-terms effects of MBCT were measured on three aspects: (1) Rumination, which was measured with the Ruminative Responses Scale 18

19 (RSS), (2) depression, which was measured with the Beck s Depression Inventory II (BDI- II), and (3) mindfulness, which was measured with the Mindful Attention Awareness Scale (MAAS) (Brown & Ryan, 2003). The results revealed a strong negative correlation between rumination and mindful attention (p <.001), with total variance being explained of 51.84%. The total variance in well-being, as measured with the DBI, was explained by mindfulness for 45% (p <.05) (table 1). No correlational measures were given for the relationship between rumination and well-being controlled for mindfulness, with the result that mediation in the relationship between mindfulness and well-being by rumination was not demonstrated. Mathew et al. (2010) explain that MBCT targets meta-cognitions in its therapy, which are the ruminative thoughts about the depression. With mindfulness therapy, patients disidentify from these thoughts (Mathew et al., 2010). Although these results look promising, we must be cautious in interpreting them. The study was not randomized and consisted of a group of patients who were diagnosed for major depressive disorder. Another study by Borders et al. (2010), performed research a group of students on order to examine the relations between mindfulness, rumination, and aggression (n=464). Mindfulness was measured with the Mindful Attention Awareness Scale (MAAS) (Brown & Ryan, 2003), which measures trait mindfulness. To measure rumination and well-being, the Reflection Rumination Questionnaire (RRQ) and the Aggression Questionnaire (AQ) were used respectively. In their examination of the relationship between mindfulness and aggression, Borders et al. (2010) divided aggression into the four separate constructs of physical aggression, verbal aggression, hostility and anger, and tested these constructs separately for possible mediation by rumination. It was found that rumination did not play a mediating role in the relationship between mindfulness and physical aggression. A mediating role for rumination was however established for the constructs of verbal aggression, hostility and anger, of which the construct of anger will be discussed. 19

20 In the relationship between mindfulness and anger, total variance was explained for 5% (p <.01). Also, a correlation between mindfulness and rumination was established, resulting in total variance being explained of 23% (p <.001). The correlational measures of the relationship between rumination and anger controlled for mindfulness was significant and resulted in total variance being explained for 17% (p <.001), after which a mediating role for rumination in the relationship between mindfulness and anger was established (table 1). Jain et al. (2007), performed a controlled study (n = 81) in which participants received either a Mindfulness Meditation training (MM), or a Somatic Relaxation (SR) intervention. Rumination was measured with the Daily Emotion Report (DER), while well-being was measured with the Brief Symptom Inventory (BSI), which provides an overall measure of psychological distress, termed the GSI. Higher scores on the GSI reflect higher overall distress. In order to determine establish a possible mediation by rumination in the relationship between mindfulness and distress, Jain et al. (2007) found that being a member of the meditation group significantly predicted changes in GSI scores (standardized β =.337, p =.011). Change scores for the GSI were also significantly predicted by change scores of rumination (standardized β =.363, p =.005, R 2 =.20), and, rumination change scores were significantly predicted by group status (standardized β =.396,p =.004, R 2 =.16). Finally, when Jain et al. (2007) tested whether the relationship between mindfulness meditation and distress is mediated by rumination, it was found that group status was no longer a significant predictor of change scores in GSI (standardized β =.227, p =.099), whereas changes in rumination remained significant (standardized β =.278, p =.04), indicating a mediating role for rumination in this relationship. Similarly, Deyo, Wilson, Ong, and Koopman (2009), have conducted a study (n=22), where participants followed MBSR training and filled in the RRQ and the Kentucky Inventory of Mindfulness Skills (KIMS) questionnaires to measure rumination and 20

21 mindfulness respectively. Well-being was measured with the Schwartz Outcomes Scale (SOS-10), which included 10 statements designed to reflect optimal mental health. Scores on pretest and posttest measures showed large effect sizes for the KIMS scores (d = 1.17) and SOS-10 scores (d =.78), and a medium effect size for the RRQ scale (d =.50) (table 2). The correlation coefficient of 0.34 that was found between changes in mindfulness and changes in rumination however did not attain statistical significance (p=.068), and the conditions to measure mediation were not met (table 1). Yook et al. (2008) researched the effects of MBCT on insomnia symptoms in patients with anxiety disorder (n=19). Patients with anxiety disorder were assigned to an 8-week MBCT clinical trial. Well-being was operationalized in terms of sleep quality and measured with the Pittsburgh Sleep Quality Index (PSQI), as well as anxiety and depression, measured with the Hamilton Anxiety Rating Scale (HAM-A) and the Hamilton Depression Rating Scale (HAM-D) respectively. Anxiety symptoms as well as depressive symptoms were significantly decreased (Z = -3.73, p = 0.00 and Z = -3.06, p = 0.00 respectively), which indicates a relationship between mindfulness and well-being. Rumination was also significantly reduced (Z = -3.83, p = 0.00) after MBCT, indicating a relationship between mindfulness and the possible mediating condition rumination. No measures however were given for the relationship between rumination and well-being, controlled for mindfulness, and mediation was not tested (table 1 and 2). Burg and Michalak (2010) examined the relationships between mindfulness and rumination, repetitive negative thinking, and depressive symptoms (N = 42). A mindfulbreathing exercise (MBE) was implemented as a computer task. Mindfulness was measured with KIMS, Rumination with the Response Styles Questionnaire Rumination (RSQ- Rumination), and well-being with the CES-D. Correlational measures for mindfulness and well-being were found, and total variance was explained for 10% in this relationship 21

22 (p <.05). Also, correlational measures were found for the relationship of mindfulness with rumination, resulting in total variance being explained for 7% (p <.05). No measures however were given for the relationship between rumination and well-being, controlled for mindfulness, and mediation was not tested (table 1 and 2). Rumination is mentioned frequently in Buddhist literature and it is seen as a product of the over-active mind. As we ve seen earlier in our discussion on the mechanism relaxation, Sogyal Rinpoche (2002) explains that meditation is nothing more than bringing home the mind to its natural state, and to relax the exhausted mind of its busy thought patterns by letting go of them. Buddhism seems to additionally suggest that through right effort, one should have a will to let go of unwholesome thoughts (Rahula, 1985), and that a certain path should be followed in order to identify maladaptive experiences in order to replace them with adaptive ones (Rapgay & Bystrisky, 2009). It is unclear however, if the addition of such a path to current implementations of mindfulness would cause a stronger mediation of rumination in the relationship between mindfulness and well-being Experiential avoidance Experiential avoidance can be defined as avoidance of internal experiences, such as emotions or thoughts. Experiential avoidance has been mentioned by several scholars as a psychological process underlying mindfulness (Hofmann et al., 2010 Nyklíček, 2011; Shapiro et al. 2006) and it is believed that this avoidance of internal emotion might contribute in maintaining mental disorders (Hofmann et al., 2010). It is hypothesizes that mindfulness can successfully counteract experiential avoidance, by seeing negative thoughts as fleeting processes of the mind, without relating to the content of them. In this way, the person experiences the thoughts and emotions he was avoiding, but then from a safe and distant place. An example of experiential avoidance is emotional avoidance in post-traumatic stress 22

23 disorder (PTSD). To put it simply: People who suffer PTSD don t like what they feel, and start avoiding this feeling. The avoidance in turn maintains the disorder. The relationship between experiential avoidance and mindfulness has been researched, and empirical evidence has been produced. Moore, Brody, and Dierberger (2010) conducted a randomized study amongst students (n=233), to explore whether narrative emotional disclosure improves mindfulness, decreases experiential avoidance, and improves mental health. Participants in the experimental group were asked to disclose their traumatic experiences in writing, whereas the control group was asked to perform neutral tasks. The participants were asked to perform their tasks on three consecutive days, while it was hypothesized that the narrative disclosure task may reduce experiential avoidance because writing repeated narratives involves the process of mindfulness. Mindfulness was measured with the KIMS, and experiential avoidance was measured with the Acceptance and Action Questionnaire (AAQ). Well-being was measured with the Center for Epidemiological Studies Depression Scale (CES-D). It was found that narrative disclosure did not improve well-being or experiential avoidance at a 1-month follow-up. The results did reveal a correlation of mindfulness and well-being, resulting in total variance explained of 2% (p <.02). Other conditions in order to establish mediation however were not met (Moore et al., 2010) (Tabel 1). Additionally, Thompson & Waltz (2010) conducted research on experiential avoidance as a mediating factor in the relationship between mindfulness and well-being (n= 378). Psychology students were administered self-report questionnaires. PTSD was measured with the Posttraumatic Stress Diagnostic Scale (PSD), Mindfulness with the Five Facet Mindfulness Questionnaire (FFMQ) and experiential avoidance was measured with four different questionnaires, of which we will discuss the White Bear Suppression Inventory (WBSI). The WBSI is a 15-item measure of thought suppression. The measurements of the 23

24 Pearson product-moment correlation coefficients of the sample revealed that the total variance was explained in the relationship between mindfulness and well-being, in this case PSTD symptoms, for 14% (p <.01). Similarly, in the relationship between mindfulness and experiential avoidance, as measured with the WBSI, the total variance was explained for 19% (p <.01). Thirdly, in the hierarchical regression analysis for PTSD avoidance symptoms, the correlation of the possible mechanism underlying the relationship of well-being and mindfulness, experiential avoidance, with well-being, controlled for mindfulness, revealed a total variance explained of 7% (p <.05). Mediation of the mechanism experiential avoidance however was not measured (table 1). From a Buddhist perspective, experiential avoidance can be viewed as another emotion or thought that s being produced by the thought-producing machine of the mind. By labeling this negative emotion, and following this thought of avoiding the emotion, one does not relax the mind, but it is again caught in the web of thoughts that the mind produces. In the example of people who are suffering from PTSD, a person, from a Buddhist perspective, is then caught up in the thought of not liking what they feel, and is being guided by this thought. This is quite opposite to mindfulness, in which all thoughts, including both the negative emotions and the avoiding thoughts, are being viewed as transient processes, resulting in being released from their burden. In conclusion, we can say that experiential avoidance is a psychological concept that has much in common with mindfulness, although the focus of mindfulness is not limited to thoughts that are about avoidance Cognitive reappraisal Cognitive appraisal can be defined as the personal interpretation of a situation. The perception of a situation can be the cause of a negative psychological reaction, rather than the situation itself. For example, a student who gets a series of bad grades can become depressed 24

25 and get the feeling that he is not intellectually capable of finishing the study, or he can interpret the situation differently and take it as a challenge to try harder, and get higher grades in the future. It is thought that mindfulness contributes to disidentifying from these interpretations, either positive or negative ones, by regarding the events and the feelings without labeling them. This causes the appraisal to lose its importance, as explained by Nyklίček (2011). Cognitive reappraisal, that is, changing the contents of a specific appraisal to a more beneficial one, is regarded as an emotion regulation (ER) strategy. ER refers to the process of adjusting emotional experiences. The inability to regulate emotions is associated with several mental disorders, like depression and anxiety (Chambers et al., 2009). ER strategies are often learned in cognitive-behavioral therapy (CBT), amongst which MBCT, DBT and ACT (Chambers et al., 2009). Chiesa and Serretti (2009) state that, although these therapies all explicitly incorporate mindfulness, and the subject of therapy learns to disidentify with thoughts in this way, the goal of these therapies seems to be, amongst other through using reappraisal as a strategy for ER, to eventually adjust cognitions and behaviors. Nyklίček (2011) suggests deappraisal as a more appropriate term than reappraisal in the context of mindfulness. Deappraisal is at the core of mindfulness in Buddhist literature, because it emphasizes disidentification with thoughts. In this process, one can experience the thought as less intrusive. Certain thought processes might eventually even no longer surface. Buddhist literature also seems to additionally suggest that, by following the eightfold path, one is stimulated not only to disidentify with them, but also recognize unwholesome thoughts and let go of them, which seems to implicate judgment of the thoughts. Right intention seems to even add a certain goal-directedness to this process. It is unclear however, if the addition of such a path to current implementations of mindfulness would cause mindfulness to be more strongly mediated by cognitive reappraisal in its relationship with well-being. 25

26 To our knowledge, there is no empirical research available that delivers statistics on the magnitude of the correlation between cognitive reappraisal and mindfulness. 3.5 Flexible self-regulation Self-regulation refers to one s capacity to alter one s own behaviors, and it increases flexible and adaptive behavior. The benefit of self-regulation is that it allows people to adjust their behavior to situations they encounter. Low self-regulation can have an effect on well-being in the form of e.g. addiction or anger control problems and it is thought of being correlated to self-awareness, while, to direct your behavior, one must at least be in some way aware of the thoughts and motivations behind these behaviors. Shapiro et al. (2006) explain that flexible self-regulation is a result of by being mindful, because we are not controlled by the content of our thoughts, which we see as mere processes. In this way, the emotion is less obtrusive and we can more flexibly choose the behavior or way of thinking that is most beneficial to ourselves or the situation (Shapiro, 2006). The Buddha emphasizes the middle way in his teachings, which refers to not behaving in extremes but in a modest way. The means to achieve this is by following the eightfold path (Rahula, 1985). Thus, from the Buddhist perspective, we can imagine that the disidentification with thoughts causes a detachment from the content of thoughts. Moreover, by emphasizing the intention of good will, harmlessness, the will to detach yourself versus having desire, the realization that through speech like for example gossip and unfounded critique we can hurt others, acting kindly and honestly, right livelihood, and a focus on wholesome thoughts, one seems to be encouraged to develop positive mental states. It is unclear however if the addition of these concepts would enhance flexible self-regulation, nor is there any clarity about the possibility that right mindfulness would automatically cause right view, right intention, right speech, right action, right livelihood, right effort and right 26

27 concentration through the mechanism of self-regulation, which the centrality of right mindfulness in Western tradition seems to suggest. Research is sparse on self-regulation in the relationship between mindfulness and well-being. Jimenez, Niles, and Park (2010) conducted a cross-sectional study (n=514) to investigate if affect regulation mediates the relationship of mindfulness with depressive symptoms, with self-report questionnaires. Self-regulation was operationalized as mood regulation expectancies, expressing expected ability to regulate negative mood, and measured with the Negative Mood Regulation expectancies scale (NMR-15). Well-being was measured with the CES-D, and mindfulness with the Freiburg Mindfulness Inventory (FMI-7). Total variance of 8% was explained in the relationship between mindfulness and well-being (p <.001). Also, a correlation between mindfulness and self-regulation was established, resulting in total variance being explained of 20% (p <.001). The correlational measures of the relationship between self-regulation and well-being controlled for mindfulness was significant and resulted in total variance being explained for 28% (p < 0,001). Finally, in testing a possible mediating role for self-regulation in the relationship between mindfulness and well-being, partial mediation was established (Jimenez et al., 2010) (Tabel 1). 3.6 Values clarification Values clarification has been mentioned, amongst others, by Shapiro et al. (2006) as a possible mechanism underlying the relationship between mindfulness and well-being. Shapiro et al. (2006) explain that through the process of mindfulness, we are able to reflect upon the values that we have adopted. By taking distance from them, we see that a lot of these thoughts are automatic, and consisting of values that we have adopted from our surroundings. 27