Mindfulness-based stress reduction (MBSR) was created in 1979 as a way to integrate contemporary psychological practice with Buddhist mindfulness meditation (Chiesa & Serretti, 2009). As the name implies, it was initially developed to assist people to deal with stress (Chiesa & Serretti, 2009), however, over time it’s breadth of use has grown to include a multitude of illnesses including anxiety, depression, insomnia, and chronic pain (Carmody & Baer, 2008). More recently MBSR has become a popular form of intervention (Khoury et al., 2013), and many studies support its effectiveness (Carmody & Baer, 2008; Hou et al., 2013; Koszycki, Benger, Shlik, & Bradwejn, 2007; Vøllestad, Sivertsen, & Nielsen, 2011). And yet, when compared to other well-known treatment methods such as Cognitive Behaviour Therapy (CBT), it performs well but is not always more effective (Koszycki et al., 2007). There is still much discussion about the lack of strong evidence for this treatment method (Chiesa & Serretti, 2009), the possibility of better efficacy predictors, different moderators, long and short term benefits, and the impact of therapists in the process (Khoury et al., 2013). The purpose of this essay is to evaluate the evidence that MBSR provides improved mental health outcomes.
MBSR is a standardised 8-10-week program, with group sizes varying from 10 to 40 participants (Grossman, Niemann, Schmidt, & Walach, 2004). It is not necessary for group members to have the same disorders, groups may include participants with a mix of disorders or participants may all have the same disorder (Grossman et al., 2004). Each program includes a weekly class of approximately 2.5 hours, an additional day or half day session, and daily homework assignments of yoga, meditation or developing mindfulness in everyday life (Vøllestad et al., 2011). MBSR generally uses three main techniques: body scan, involving attention of the whole body from the head to the feet with an attentive awareness on each area as it comes into focus; sitting meditation, which involves mindful awareness of the breath and other sensations that arise; and yoga practices, which include breathing exercises, stretches and specific postures designed to relax the body (Chiesa & Serretti, 2009). Mindfulness itself can be defined as “paying attention, in a particular way: on purpose, in the present moment, with acceptance” (Kabat-Zinn, 1994, p. 4). The program offers a way to develop a better awareness of moment-to-moment experience and observable mental processes and assumes that greater awareness will allow for more realistic perception, a reduction in negative affect, and an improvement in vitality and coping .
MBSR was originally developed to deal with stress and teaches participants to observe thoughts and situations without judgement (Chiesa & Serretti, 2009). Although certain levels of stress can result in improved performance, ongoing stress can lead to rumination that is unproductive, uses energy and undermines resilience (Chiesa & Serretti, 2009). Additionally, continuous stress and a person’s reactive relationship to stressors often results in anxiety disorders (Vøllestad et al., 2011). The Vøllestad et al. (2011) study of 76 self-referred patients suffering from a range of diagnosed anxiety disorders in Norway found that mindfulness training had sustained beneficial effects on anxiety disorders and their symptoms compared to the control group. Additionally, the Frank, Reibel, Broderick, Cantrell, and Metz (2013) study of 36 high school educators in the United States of America (USA) that investigated the effectiveness of MBSR on educator stress and wellbeing demonstrated significant improvements in self-efficacy. Results showed that those who had participated in the MBSR program had significant gains in self-regulation, self-compassion, and mindfulness-related skills (observation, non-judgment, and non-reacting). Both studies indicate that MBSR has positive outcomes for both healthy subjects and patients with diagnosed disorders.
MBSR has been found to provide other mental health benefits such as the enhancement of spirituality, a reduction in rumination, an increase in empathy, increases in self-control and better sleep (Chiesa & Serretti, 2009). The Shapiro (1998) study of 78 medical students from a university in the USA found that MBSR reduced anxiety and depressive symptoms and hence reduced overall stress levels. The study found that anxiety was negatively correlated to the participant’s level of spirituality, and indicated that the individual’s perception of stress was the connecting factor. Spirituality seems to be a buffer to the negative effects of life stressors, and it has been shown that spirituality can enhance both physical and psychological well-being (Shapiro, 1998). In relation to rumination, long-term mindfulness training seems to reduce activity in the areas of the brain associated with self-focused processing and allows for a increased acceptance of emotional states leading to reduced rumination about self and emotions (Chiesa, Serretti, & Jakobsen, 2013). MBSR has been found to significantly increase empathy and self-compassion levels (Shapiro, 1998). Empathy has been defined as the capacity to understand and to be sensitive to what another person is feeling, and assists in the development of healthy relationships and moderating the effects of stress (Chiesa & Serretti, 2009). Mindfulness training also assists in emotional regulation, recruiting the prefrontal cortex regions to modulate limbic activity to improve self-control (Chiesa et al., 2013). During this process executive attention, cognitive monitoring, and sensory awareness are enhanced (Chiesa & Serretti, 2011). And finally, the relaxed awareness and attitude of letting go predominant in mindfulness training seems to assist in reducing insomnia and ensuring better sleeping patterns (Vøllestad et al., 2011). Overall, improved mental health outcomes are achieved through enhanced emotional processing, better coping, improved self-efficacy and improved quality of life .
It is useful to consider MBSR in comparison to CBT, a more traditional psychological intervention. The Koszycki et al. (2007) study of 53 patients with social anxiety disorder (SAD) in Canada compared participants of an 8-week course of MBSR to a 12-week course of cognitive behaviour group therapy (CBGT). Both interventions showed similar improvements in mood, functionality, and quality of life. However, MBSR did not do as well as CBGT in reducing SAD symptoms. It is possible that the different timeframes of the treatment programs may have influenced the final result. In the Arch and Ayers (2013) study of 71 patients with an anxiety disorder in the USA, participants were also randomly grouped into either an MBSR group or a CBT group and were assessed at baseline, post-treatment, and at a 3-month follow-up. These results showed that CBT outperformed MBSR with participants that had no to mild symptoms of depression and, at post-treatment only, among those with very high levels of anxiety. At follow-up, MBSR outperformed CBT among participants with moderate to severe depressive symptoms and among those with an average level of anxiety. From a broader perspective, the Khoury et al. (2013) meta-analysis review indicated that overall MBSR was not more effective than CBT. However, the same analysis showed that MBSR was more effective when treating psychological disorders than physical or medical conditions, and it showed strong effects when treating anxiety and depression and indicated that improvements were maintained at follow-up. Overall it is not clear which program is more effective, CBT or MBSR, and results indicate that there may be some difference in the short and long term effectiveness of MBSR that warrants further investigation.
Many of the studies reviewed had limitations that impacted on their results. Little is known about the stability of treatment gains and what exactly accounts for the efficacy of MBSR (Khoury et al., 2013). Moderator variables could include treatment duration, homework practice, course attendance, and the clinical and mindfulness training and experience of the therapists delivering MBSR (Khoury et al., 2013). However, Carmody and Baer (2008) indicate that strong predictors of efficacy could be attendance in class and the length of at-home meditation practice as they measure motivation and whether or not the participants find the process useful. Other moderators suggested in the literature include meditation depth and group cohesion (Imel, Baldwin, Bonus, & Maccoon, 2008). Additionally, it has been mentioned that self-report measures could be biased by social desirability impacting the results of many studies (Chiesa & Serretti, 2009). With so many factors influencing MBSR, it is no wonder that it is difficult to conclusively determine it’s effectiveness.
In conclusion, MBSR shows significant benefits in relation to anxiety and stress for both healthy people and those suffering from a diagnosed mental illness. MBSR provides a range of benefits that can improve mental health including a reduction of certain disorders (e.g. anxiety) and their symptoms, reduced stress levels, greater well-being, improved self-efficacy, enhancement of spirituality, reduced rumination, increased empathy, increased self-control and better sleep. In comparison to CBT, MBSR fares well, but the results are inconclusive as to which treatment therapy is better, and results appear to be impacted by the length of treatment and when effectiveness is measured. Additionally, the difficulties in measuring the effectiveness of MBSR have to do with a large number of moderator influences that impact the program and a lack of understanding of what exactly account for it’s effectiveness. However, overall it appears that it is an effective treatment for a variety of psychological problems and offers improvements to mental health.
This article was written by Sarah O'Flaherty while completing her Graduate Diploma in Psychological Science.
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