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Mindfulness Based Stress Reduction

Updated: Nov 17, 2020

A REVIEW AND CRITIQUE OF MBSR ON STRESS AND ANXIETY SYMPTOMS

Mindfulness based stress reduction (MBSR) was developed in 1979 by Jon Kabat-Zinn a professor of medicine at the University of Massachusetts Medical Centre. MBSR is based on the Buddhist philosophy and practice of mindfulness; a way of living that encompasses an awareness of internal and external events from moment to moment. (Kabat-Zinn, 1990) Kabat-Zinn, a student of Buddhism and yoga, assimilated the helpful fundamentals of Buddhist teachings without the religious doctrine with western medicine to support patients recovering from illness and injury. MBSR was developed as a part of a new medical model ‘behavioural medicine’, which recognises that thoughts and emotions have an effect on the body. The quality of those thoughts and emotions can positively or negatively influence recovery (Kabat-Zinn, 1990). MBSR was originally named the Stress Reduction and Relaxation Program (SR&RP) it was offered for those suffering illness or injury as a way to enhance or complement their treatment. (Kabat-Zinn,1990) The MBSR course runs for eight weeks with a 2-½ hour class per week, a full day at week six and students are required to listen to the course CD’s for 45 minutes per day. The classes involve formal meditative practices (yoga, body scanning, and sitting meditation) and informal home practice, which is the application of mindfulness to daily life (Shapiro et. al. 1998). The training teaches the student to cultivate a metacognitive mindset, of being aware of their body, thoughts, emotions and thoughtfully choosing to observe them with curious non-judgment rather than responding to them automatically (Kabat-Zinn 1990). The intention is to bring acceptance, compassion and non-judgment to every thought and experience (Shapiro et. al. 1998). The practice of MBSR is purported to increase coping skills to manage stressful situations, illness and injury, to cultivate self-compassion and reduce overall stress, anxiety and depressive symptoms.

There is considerable empirical evidence to suggest that MBSR is an effective clinical tool for stress reduction. This paper will review and critique some of the research conducted on the effectiveness of MBSR to determine whether it could be a valid clinical application to reduce stress and anxiety symptoms. This paper will also determine if there are specific populations it will work on and specific situations or diagnoses that it would be appropriate for and discuss some of the methodological limitations in the research.

Six studies were reviewed that included five individual research studies and one review paper. They were sourced via Google scholar using the search terms- ‘Mindfulness-based stress reduction’, ‘Mindfulness-Based Stress Reduction meta –analysis’, and ‘effectiveness of Mindfulness-Based Stress Reduction for stress and anxiety’. All except one of the studies (Baer et al. 2007) included, contain randomized controlled trials to provide a strong empirical evaluation.According to Fjorback (2011) the sample sizes need to be 33+ participants for the power to detect an effect, so only studies with 33 + participants were included. The studies reviewed here have all used the Five Factor Mindfulness Questionnaire (FFMQ, Baer et. al, 2007) to measure mindfulness, again to give a clear empirical evaluation of mindfulness and its effects on stress and anxiety symptoms.

Baer et. al (2007) wanted to test whether increased mindfulness mediates the correlation between increased wellbeing and mindfulness practice.174 participants were recruited from a list of students enrolled in the MBSR program at the University of Massachusetts Medical School, the participants paid to do the course. The participants completed a battery of tests to measure psychological wellbeing and symptoms of stress before and after the MBSR training. The hypothesis was supported that with increased wellbeing and meditation practice there was an increase in mindfulness scores, suggesting that practicing meditation increased mindfulness and reduces stress. The results also report that a significant correlation between the symptoms of stress and the wellbeing measures was only partially mediated by meditation practice, Baer et.al (2007) suggest that the other mediators could be the group social support received in the MBSR program or that the commitment to taking the MBSR could generalize to other areas of personal care taking such as exercising regularly or taking medications and consequently, increasing overall wellbeing (Baer et.al, 2007) The yoga component of MBSR showed significant increases in mindfulness, (particularly on the non-judgment scale) wellbeing and reduced stress symptoms. Baer et.al (2007) suggest that the body scanning may have prepared the participants for being mindful and that the act of stretching eased the process and the effects of yoga on stress reduction should be investigated further. The results of this study could not be generalized as the participants paid to do the course, which implies that they were self -motivated to complete it and there was no control group to compare the differences to.

Vollestad et. al (2011) conducted a randomised controlled trial to find if MBSR was an effective treatment for a variety of anxiety disorders and if mindfulness was a mediator on the effects (if any) on depression, worry and anxiety. There were 106 participants recruited via an advertisement in a newspaper and allocated randomly to a wait-list control group or the treatment group. The participants completed seven questionnaires including the FFMQ and kept a logbook of their daily mindfulness practices. The results showed that MBSR had a significant effect on the symptoms of anxiety with effect sizes ranging from (0.53 to 0.97) across the various tests, compared to the control group and remained stable at a six month follow up. The results indicated that all measures improved post MBSR except for ‘sleep disturbance’.Vollestad et al (2011) found that compared to the control group, the treatment group had significantly higher scores of trait mindfulness. However, they suggest that mindfulness can only partially explain the effects of reduced anxiety, as mindfulness could not be validated to precede the effects due to the FFMQ scores significantly changed only four weeks into the MBSR training. They state that a limitation to their research was lack of an active control group and a lack of diagnostic interview post MBSR training to fully gauge the clinical significance of the results. Vollestad et al (2011) suggest that MBSR has potential for being a viable treatment option for a broad range of anxiety disorders, and particularly for the cost effectiveness of group treatment.

Robins et.al (2012) conducted a randomized controlled trial (Wait list control) on the effects of MBSR on emotional experience and regulation on a non-clinical sample. The 41 participants were recruited via fliers at a university and were tested pre and post MBSR training on 14 measures including the FFMQ, The results indicate that the treatment group experienced increases in self-compassion, mindfulness and emotional regulation plus decreases in anger, worry, fear of emotions and absent-mindedness. They did not find reductions in fear of anxiety or fear of anger, the researchers are unclear as to why fear of emotions was reduced but fear of anxiety and anger were not. However, they did find decreases in aggressive anger suppression and anger suppression, Robins et. al (2012) suggest that the participants may have learnt to respond to the thoughts and feelings of anger and accept and observe it rather than react to it and express it (Robins et al. 2012). The results also showed that there was no significant difference in rumination between the control and treatment groups, however, both groups reported decreases in rumination at follow up, Robins et. al (2012) suggest that it may take longer to develop the skills to manage rumination, however it does not explain why the control groups rumination also decreased. Geers and Rose (2011) suggest that if the treatment is of the participants choice, the expectancy effect is enhanced and may have produced the reduction in rumination in the control group. Robins et. al (2012) state that social desirability did not mediate this effect, which indicates that the MBSR results are genuine. The changes were upheld at a two- month follow up. Overall, Robins et. al (2012) suggest that the MBSR has potential for clinical use for emotion regulation processes and therefore effective for stress reduction.

Jazaieri et. al (2012) conducted a study to determine if MBSR and Aerobic Exercise (AE) were effective treatment for patients diagnosed with Social Anxiety Disorder (SAD) The study was conducted with a non- treatment control group of 56 SAD diagnosed participants. The results indicate that there were clinically significant results for twenty-five percent of the MBSR group, which was lower than other studies ranging from 31%-75% (Heimborg et al. 1990 and Borge et.al 2008) It is unknown what aspect of MBSR worked for the twenty-five percent and what didn’t, further research is required to explore the potential mediators of that effect. The results were maintained at a 3 -month follow up. The treatment is conducted in group settings and for patients with SAD that could be challenging, being a social disorder. Rodenbaugh et. al (2004) suggest that the exposure to others experiencing similar problems and the exposure component of traditional therapy is what makes it work. The research is further evidenced by Goldin and Gross’ (2010) study that found MBSR was effective in reducing emotional reactivity in SAD patients via neuroimaging techniques. Reducing emotional reactivity is central to reducing stress in SAD patients as it helps to break the cycle of habitual responding to social threat and negative self -beliefs. (Goldin and Gross, 2010)

Fjorback et. al (2011) conducted a review of randomized controlled studies on MBSR and Mindfulness Based Cognitive Therapy (MBCT) (This review will focus only on the MBSR aspects of Fjorback et.al’s [2011] review) The review found that psychological distress and/or perceived stress were significantly reduced, compared to control groups in seven studies (See appendix 1) and did not in one study (Mularski et. al, 2009) which was a study using chronically ill participants, MBSR may not be suitable for some serious medical conditions. Anxiety was reduced in six studies (See appendix 2). However, it was not reduced in two studies that contained active control groups. (Moritz et al. 2006; Koszycki et. al 2007) Moritz et al. (2006) was a study comparing a home based spirituality course compared to MBSR and Koszycki et. al (2007) research measured the MBSR against Cognitive Behavioural Therapy (CBT), suggesting that MBSR was not as clinically effective as CBT. Fjorback et. al (2011) conclude that both clinical and non -clinical populations can benefit from MBSR as an effective instrument for improving mental health.

MBSR was found to decrease anger expression, rumination, absent-mindedness, anxiety, worry, depression and psychological distress and increase self-compassion, mindfulness and emotional regulation in clinical and non-clinical samples. The effects

were maintained at follow up, ranging from two to six months suggesting that MBSR could be a cost effective way to treat patients with anxiety and stress that has persistent utility. A longer range follow up would be useful to determine the persistence of the effects over time.

The generalizability of the current research is minimal as the majority of the reported participants were middle- aged, self –selected, educated, Caucasian females, some of whom paid to participate in the MBSR training. These demographics do not necessarily generalize to other populations, further testing is required on more diverse populations to be able to generalize further. Another limitation is that post MBSR clinical interviews were not conducted which could provide further evidence of clinical significance of changes in stress and anxiety status.

MBSR could be a viable alternative for anxiety patients or stressed people that do not respond to traditional treatments, that choose not to take medication or that don’t want the stigma of being in therapy (Jazaieri et. al 2012) and particularly for those that seek that style of treatment. Most of the papers reviewed stated that compliance with the treatment was strong with most reporting an 80% compliance rate on average, so self- selection appears to be conducive to the success of the reported reductions in stress and anxiety symptoms.

Overall, MBSR shows some promising clinical effectiveness in self-referred populations.

REFERENCES

Baer, R. Smith, G., Hopkins, J., Krietemeyer, J., Toney, L. (2006) Using self-report assessment methods to explore facets of mindfulness. Assessment 13:1

Goldin, P., Gross, J. (2010) Effects of Mindfulness-Based Stress Reduction (MBSR) on Emotion Regulation in Social Anxiety Disorder. Emotion 10:1. pp.83-91

Geers, A Rose, J (2011) Treatment Choice and Placebo Expectation Effects Social and Personality Psychology Compass 5:10

Jazaieri, H., Goldin, P.,Werner, K., Ziv, M., James J. (2012) A Randomized Trial of MBSR Versus Aerobic Exercise for Social Anxiety Disorder. Journal of Clinical Psychology, Vol. 68(7). pp. 715-731

Kabat-Zinn, J (1990) Full Catastrophe Living, How to cope with stress, pain, and illness using mindfulness meditation. Paitkus Publishers London.

Koszycki D, Benger M, Shlik J, Bradwejn J. (2007) Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour and Research Therapy 45. pp.2518–2526.

Moritz S, Quan H, Rickhi B (2006) A home study-based spirituality education program decreases emotional distress and increases quality of life–a randomized, controlled trial. Alternative Therapies in Health and Medicine 12. pp.26–35.

Mularski, R., Munjas, B., Lorenz, K. (2009) Randomised controlled trial trial of Mindfulness-based Therapy for dyspnea in chronic obstructive lung disease. Journal Alternative and Complementary Medicine 15. pp.1083-1090

Robins, C., Keng, S., Ekbald, G., Brantley, J. (2012) Effects of Mindfulness-Based Stress Reduction on emotional experience and expression: A randomized controlled trial. Journal of Clinical Psychology 68(1), pp. 117-131

Rodenbaugh, T., Haloway, R., Heimberg, R. (2004) The treatment of Social Anxiety Disorder. Clinical Psychology Review, 24. pp. 883-908

Shapiro, S., Schwartz, G. Bonner, G. (1998) Effects of Mindfulness –Based Stress reduction on Medical and Premedical Students. Journal of Behavioural Medicine 21:6

Vollestad, J., Siversten, B., Nielsen, G. (2011) Mindfulness-Based Stress Reduction for patients with anxiety disorders: Evaluation in a randomized controlled trial. Behaviour Research and Therapy 49. pp.281-288

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