what do we really know about mindfulnessbased stress reduction

8/10/2019 What Do We Really Know About Mindfulnessbased Stress Reduction

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What Do We Really Know About Mindfulness-Based Stress Reduction?SCOTT R. BISHOP, PHD

Objective:Mindfulness-Based Stress Reduction (MBSR) is a clinical program, developed to facilitate adaptation tomedical illness, which provides systematic training in mindfulness meditation as a self-regulatory approach tostress reduction and emotion management. There has been widespread and growing use of this approach withinmedical settings in the last 20 years, and many claims have been made regarding its efficacy. This article willprovide a critical evaluation of the available state of knowledge regarding MBSR and suggestions for future research.Methods: A review of the current literature available within the medical and social sciences was undertaken to

provide an evaluation regarding what we know about the construct of mindfulness, the effectiveness of MBSR, andmechanisms of action. Results: There has been a paucity of research and what has been published has been rife withmethodological problems. At present, we know very little about the effectiveness of this approach. However, thereis some evidence that suggests that it may hold some promise. Conclusions: The available evidence does not supporta strong endorsement of this approach at present. However, serious investigation is warranted and stronglyrecommended.Key words: Mindfulness-Based Stress Reduction, adaptation, chronic illness, psychiatric illness,review.

BAI Beck Anxiety Inventory; BDI Beck DepressionInventory; BES Binge Eating Scale; CSQ CopingStrategies Questionnaire; FIQ Fibromyalgia Atti-

tudes Questionnaire; FFS Fear Survey Schedule;HRSD Hamilton Rating Scale: Depression; MBSR Mindfulness-Based Stress Reduction; MIA MobilityInventory for Agoraphobia; POMS Profile of MoodStates; SCID Structured Clinical Interview for DSM-IV; SCL-90-R Symptom Checklist; SCL-90-R GSI Symptom Checklist Global of Severity Index; SOSI Symptoms of Stress Inventory.

MindfulnessBased Stress Reduction (MBSR) is aclinical program originally developed to facilitate ad-aptation to medical illness that provides systematictraining in mindfulness meditation as a self-regulationapproach to stress reduction and emotion manage-ment. Interest in MBSR has grown exponentially sinceits introduction approximately 20 years ago (1). Thereare an estimated 240 MBSR programs in North Amer-ica and Europe with new programs being establishedeach year (2). With the introduction of a residentialprofessional training program in MBSR now offered bythe Center for Mindfulness in Medicine, Health Careand Society at the University of Massachusetts Medi-cal Center (3), the use of this approach will likely

become even more widespread.

The primary goal of MBSR is to provide patientswith training in meditation techniques to foster the

quality of mindfulness. Mindfulness has beenbroadly conceptualized as a state in which one ishighly aware and focused on the reality of the presentmoment, accepting and acknowledging it, without get-

ting caught up in thoughts that are about the situationor in emotional reactions to the situation (1, 4). MBSRaims to teach people to approach stressful situationsmindfully so they may respond to the situation in-stead of automatically reacting to it.

MBSR is now being used widely to teach patients toself-manage the stress and emotional distress com-monly associated with a range of chronic illnesses andas a psychosocial treatment approach to some psychi-atric disorders (2, 4). However, the popularity of thisapproach has grown in the absence of rigorous scien-tific evaluation. Although there is some preliminaryevidence that suggests that MBSR may hold promise asan effective approach with applications in psychoso-matic medicine and general psychiatry, there is a lotthat we do not know about this treatment modality.This article will provide a comprehensive critical eval-uation of MBSR as a relatively new treatmentapproach.

DESCRIPTION OF THE INTERVENTION

The primary focus of MBSR is on training partici-pants in various meditation techniques that ostensibly

result in the development of mindfulness. Althoughthese various mindfulness training techniques differsomewhat in terms of procedures, they share the samegoal of teaching participants to become more aware ofthoughts and feelings and to change their relationshipto them. The meditation techniques are used to de-velop a perspective on thoughts and feelings so thatthey are recognized as mental events rather than asaspects of the self or as necessarily accurate reflectionsof reality (1, 5). With repeated practice, mindfulnessallows the participant to develop the ability to calmly

From Princess Margaret Hospital and the Department of Psychia-try, University of Toronto, Ontario, Canada.

Address reprint requests to: Princess Margaret Hospital, 610 Uni-versity Avenue, Toronto, Ontario, Canada, M5G 2M9. Email:[email protected]

Received for publication November 10, 2000; revision receivedApril 24, 2001.

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step back from thoughts and feelings during stressfulsituations, rather than engaging in anxious worry orother negative-thinking patterns that might otherwiseescalate a cycle of stress reactivity and contribute toheightened emotional distress.

A description of sitting meditation will illustrate thebasic mindfulness training technique. The participant

maintains an upright sitting posture, either in a chairor cross-legged on the floor, and attempts to sustainattention to the breath. Whenever attention wanders toinevitable thoughts and emotions as they arise, theparticipant simply acknowledges and accepts eachthought and feeling, then lets go of them as attention isdirected back to the breath. This process is repeatedeach time that attention wanders to thoughts and feel-ings. As sitting meditation is practiced, there is anemphasis on simply observing and accepting eachthought or feeling without making judgments about it,elaborating on its implications, additional meanings,

or need for action (1, 5). Thus, sitting meditation aimsto teach participants to passively observe thoughts andfeelings simply as mental events with no inherentvalue of their own. Other techniques (eg, body scan,yoga) are taught after the same basic procedure, al-though with a different object of focus to sustainattention.

MBSR typically consists of 8 to 10 weekly groupsessions, with one session being a full dayretreat.(3)The format is largely skill-based and psychoeduca-tional. There is considerable in-session experience anddiscussion of the various mindfulness-training tech-

niques. Patients are educated about the psychophysi-ology of stress and emotions and provided with waysof approaching specific situations using the mindful-ness skills. There is a program of homework exercisesthat largely involves practice of the mindfulness tech-niques, both formally as a daily meditation practice,and informally as participants bring mindfulness tothoughts, emotions, and behaviors in their daily lives,particularly during times of stress. Participants areprovided with audiocassettes that guide them throughthe mindfulness meditation exercises.

REVIEW OF OUTCOME STUDIES

There has been a paucity of controlled studies inclinical populations (6 9) and only a few uncontrolledstudies (10 16). Beyond obvious limitations of uncon-trolled designs, the research has suffered from meth-odological problems that seriously limits the kinds ofconclusions that can be drawn. These include inappro-priate or inadequate use of statistics, the use of unvali-dated measures, failure to control for concurrent treat-ments that might effect the outcome variables, and

arbitrary determination of clinical response. All of thepublished studies to date relevant to the self-manage-ment of stress and mood symptoms associated withchronic illness, with comments regarding strengthsand limitations, are described in detail in the Appen-dix. Because major depression and anxiety disorderscommonly are associated with chronic illness and of-

ten warrant specific treatment as part of the overallpsychosocial management of an illness, these studiesare presented as well. The order of the review beginswith controlled studies, followed by uncontrolledstudies. A summary of these studies highlighting themain findings and the conclusions that can be drawnfollows.

Controlled Studies

Two studies in nonclinical samples have shownthat MBSR may be effective in mitigating stress, anxi-

ety, and dysphoria in the general population (8, 9). Thestrength of these studies is in the use of randomizationto groups, and in the case of Shapiro et al. (9), matchedrandomization for important potential confoundingvariables (eg, ethnicity). Also, the decision to attemptreplication by having the control group participate inan MBSR program after the end of the randomizedcontrolled trial in the latter study provides an addi-tional test of efficacy. These studies are limited how-ever in the use of an inactive control group. Sincenonspecific factors, such as therapists attention, so-cial support, and positive expectancy can improve out-

come (1719) it is difficult to attribute the changes tothe specifics of MBSR. A better design would includean additional active control group (ie, with therapeuticattention, social support, and positive expectancy) in athree-arm trial. Any differences in postinterventionscores in favor of MBSR can then be attributed to thespecifics of the interventions. These studies also havequestionable generalizability to clinical populations.

Only two randomized, controlled trials have beenreported in clinical populations. Speca et al. (6) pro-vide the only rigorous test of MBSR in a medical pop-ulationa mixed sample of cancer patients. The re-

sults are impressive with 65% and 35% reductions intotal mood disturbance and stress symptoms, respec-tively. Also, time spent practicing meditation corre-lated with reductions in mood disturbance. This pro-vides compelling evidence that the techniques had atherapeutic effect. However, it is not possible to ruleout social desirability effects that may have been op-erative in patientsreports of mood and stress changesor their reports of treatment compliance. A measure ofsocial desirability should be included in future con-trolled trials as a control variable. Also, posttreatment

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follow-up is needed to fully evaluate the long benefitsof this approach.

Teasdale et al. (7) provide the only other random-ized controlled trial of an MBSR-based treatment in aclinical sample; recently recovered depressed patients.This rigorously designed study yielded impressive re-sults. MBSR combined with cognitive therapy resulted

in half the rate of relapse of depression over a 60-weekperiod for individuals who had three or more previousepisodes. If replicated, this combined approach wouldrepresent an important prophylactic treatment of re-current depression. Unfortunately, because a com-

bined treatment modality was used, it is not possibleto make strong statements regarding the effectivenessof MBSR per se for the prevention of depressive re-lapse. Furthermore, its application for the treatment ofmajor depression is yet unknown.

Uncontrolled Studies

The remaining studies are seriously limited by thereliance on uncontrolled repeated measures designs.Although the rigor of this design can be greatly im-proved with the inclusion of a nontreatment compar-ison group to control for regression toward the mean,only one study uses this approach (10). Unfortunately,that study did not match participants on potentiallyimportant variables that might have otherwise differ-entiated the groups in a way that would affect out-come. Although the available evidence does not cur-rently support a strong endorsement of this

intervention in any of the following clinical popula-tions, some general statements can be made about theavailable evidence regarding the suggested efficacy ofMBSR that awaits rigorous testing via randomized con-trolled trials.

In chronic pain, there is preliminary evidence thatMBSR may assist patients with psychosocial adapta-tion as evidenced by reductions on self-report mea-sures of emotional distress, psychiatric symptoms, andfunctional disability (10). More importantly, thesegains may remain for up to 4 years posttreatment (11).However, the impact of MBSR on psychosocial adap-

tation to pain may be more robust than lasting impacton pain symptoms. Although MBSR resulted in somemitigation of pain, it returned to preintervention levelswithin 6 months after treatment. It is possible thatcontinued regular practice of mindfulness mediationmay prove to be an effective long-term strategy for painmanagement but this remains an empirical question. Itis important to note that the majority of the patientswho participated in the MBSR program had a longhistory of medical treatment with little or no improve-ment in either their pain status or emotional-behav-

ioral status. Despite the methodological limitations ofthe studies, the fact that these treatment resistantpatients improved at all is indeed impressive.

In terms of fibromyalgia, the one study published(12) has serious methodological limitations includinglack of a comparison group, failure to report descrip-tive and inferential statistics, and arbitrary determina-

tion of clinical response. In terms of the latter, patientswere identified as responsive to treatment if theyshowed at least a 25% improvement on at least half ofthe measures. There may be significant difficultieswith giving each of the measures equal weights indefining clinical significance. Furthermore, using ar-

bitrary criteria regarding clinical response is unneces-sary. Clinical improvement can be determined objec-tively by using established cut-off scores on themeasures included in the study. Also, the investigatorscombine illness symptoms with markers of adaptationwhen defining clinical response. Since psychosocial

interventions frequently facilitate adaptation withoutimpact on illness severity, it is important to considerthese separately. While methodological limitationspreclude strong statements regarding efficacy, it doesseem that MBSR may have been associated with asignificant reduction (39%) in severity of psychiatricsymptoms.

In generalized anxiety and panic disorder, MBSRwas associated with significant reductions in the se-verity of symptoms from pretreatment to posttreatmentwith mean reductions to the nonclinical or subclinicalrange on all clinician-ratings and self-report measures

(13). The study used rigorous assessment procedures,including structured clinical interviewing (DSM-III-Rcriteria) to select eligible patients and established psy-chometric instruments. Unfortunately, half of patients(55%) were also being treated pharmacologically dur-ing the MBSR program. It is unclear if the interventionhad any significant therapeutic effect beyond medica-tion. It seems that patients maintained their gains at a3-year follow-up, but half of the participants had re-ceived additional treatment for their anxiety disordersince ending the MBSR program (14).

One study has examined the efficacy of MBSR in

binge eating disorder (15). The investigators excludedparticipants who were concurrently involved in aweight-loss program or psychotherapy, which obvi-ously increases confidence in attributing change insymptoms to the MBSR. However, the lack of a com-parison group is a major limitation. Although prelim-inary, the results suggest that MBSR may be a promis-ing approach to both binge eating symptoms and theanxiety and depression that is frequently associatedwith binge eating disorder.

Although suffering similar methodological limita-

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tions as the other clinical investigations, the study byRoth (16) is important in that it examines the efficacyof MBSR in a sample of patients within a low socio-economic cohort and includes two samples from dif-ferent ethnic backgrounds (ie, English-speaking Amer-icans and Spanish-speaking Latin Americans).Unfortunately, differences between groups in terms of

treatment response were not examined statistically.Observation of completion rates for the program sug-gested that they were much lower than previouslyreported (53% of the English patients and 64% of theLatin American patients). Despite limits, this studyhighlights the importance of examining level of ac-ceptability and compliance of this intervention ap-proach in different populations.

In summary, there is some preliminary evidencethat MBSR may be effective in various medical andpsychiatric populations. The evidence is stronger inthe efficacy of MBSR as a general stress reduction

approach in nonclinical populations than clinical pop-ulations. Although replication is needed, MBSR seemsto hold promise as a highly effective psychosocialapproach for the management of stress and mood dis-turbance in cancer. The evidence in other medical andpsychiatric conditions is less compelling although pre-liminary evidence supports the argument that MBSRshould be evaluated via randomized controlled trials.

OPERATIONAL DEFINITIONS, VALIDATION,AND MEASUREMENT

MBSR was adapted from traditional mindfulnessmeditation practices originating in Theravada and Ma-hayana Buddhism in India approximately 2500 yearsago (20). The construct of mindfulness, therefore,has its roots in Buddhism. The Abhibdhamma (21)represents a compilation of the Buddhist psychologyand philosophy and includes detailed descriptions ofstates of consciousness said to be attainable throughmeditative techniques. In the fifth century, the portionof the Abhibdhamma that deals with meditation wassummarized in a collection known as the Visuddhim-agga, or the path of purification. (22) Within these

texts are descriptions of the qualities of mindfulnessthat are said to be attained through vipassana, or mind-fulness meditation practice. For the most part, modernWestern descriptions of the construct in the scientificliterature have been consistent with the traditionalBuddhist conceptualizations of mindfulness.

Unfortunately, the defining criteria for mindfulnesshave not been elaborated substantially beyond nonspe-cific descriptions of the construct. For example, mind-fulness has been described as a state in which one isfully present in the moment, focused on the reality of

the situation,whileacknowledging and accepting itfor what it is(1, 4, 5). There have been no attempts tooperationalize these qualities. However, each of thethree dimensions emphasized in the literature seemsto involve an aspect of attention regulation.

First, this seems to involve maintaining ones atten-tion to a single point of awareness whereas disengag-

ing from thoughts or feelings about the object beingobserved or from irrelevant discursive thoughts. Thisability is hypothesized to develop during meditationas the individual sustains attention to the breath toanchorit to the present moment and repeatedly dis-engages attention from thoughts and emotions as theyinevitably arise. This is said to allow the individual to

be fully present in the moment. At a behaviorallevel, maintaining awareness to an object or situationover time would involve sustained attention (23, 24).To disengage from mental activity that might arise andfocus back on the object or situation being observed

would involve attention-switching (25).Secondly, toobserve the reality of the present mo-

ment the practitioner attends to the objective quali-ties of experience or a situation without immediatelyresorting to an active process of making judgmentsabout it, elaborating on its implications, further mean-ings, or need for action. This is referred to as bareattention. (1) During meditation, thoughts and emo-tions that spontaneously come into conscious aware-ness are observed as they are, although the practitionerattempts to inhibit the regular tendency to judge, in-terpret, or otherwise elaborate on them. This inhibi-

tion of elaborative secondary processing would requirethe ability to control attention to terminate thinkingabout, or otherwise elaborating on, the primary mentalevent so that it can be simply observed (26, 27).

Third, the practitioner is said to remain open toexperience as all available information is intentionallyobserved without attachment to any particular point ofview or outcome. This is thought to allow the person toacknowledge and accept the situation for what it is.In meditation, thoughts and emotions that inevitablyarise are simply accepted and observed; there are noattempts to change or escape from anything, nor are

there attempts to hold on to or prolong anything. In-stead, the practitioner remains open to observing thepresence of each thought and emotion that arises, aswell as its dissolution. In terms of implicated psycho-logical processes, this seems to involve reliance less onpreconceived ideas, beliefs, and biases and more onpaying attention to all available information (28).

Mindfulness seems to reflect a kind of meta-cogni-tive ability (29) in which the participant has the ca-pacity to observe his or her own mental processes.This process ofstepping backand observing the flow

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of consciousness is thought to result in the recognitionthat each thought and feeling reflects a mental eventwith no more inherent value or importance other thanwhat the practitioner affords them. There seems to bea shift in perspective from automatically accepting thevalidity or relevance of each thought, to the suspen-sion of commitment to any one thought or perspective.

Thoughts are therefore treated as potentialities pend-ing further evidence. Similarly, affect states are notinherentlypleasant or unpleasant but are merelyobserved as mental events. This would be expected toimprove affect tolerance and decreased reactivity inthe presence of emotional states. Situations are ap-proached with the same objective awareness; they con-sist of the unfolding of events with no inherent valueother than what one affords them.

The shift in perspective on ones own experienceseems to be further facilitated by a set of attitudes thatare emphasized during MBSR. These attitudes involve

a way of attending to experience and are practicedduring the various mindfulness meditation techniquesand applied more generally to real-life situations (2, 4).Two of the more salient and related attitudes includenonstriving, which has been described as a kind ofsurrendering to the moment, acknowledging and fac-ing ones experience instead of fighting it or trying tomake it something else, and acceptance of the situ-ation. Also, the importance of dealing with the imme-diacy of the current situation, rather than possiblefutures or the past, is emphasized. The voluntary de-ployment of attention, in combination with these atti-

tudes, is thought to result in a heightened state ofawareness in which one is conscious of a particularsituation and ones cognitive, emotional, and somaticexperience in that situation in a way that fosters agreater sense of equanimity. Thus, in addition to atten-tion regulation skills, mindfulness can be conceptual-ized in terms of a core set of attitudes and a generalapproach-orientation to experience.

At a conceptual level, mindfulness seems to share anumber of features with other psychological con-structs. Mindfulness seems to be related to absorption,an individuals proclivity toward complete attentional

involvement in ones perceptual, imaginative, and ide-ational experience (30). Both share a number of similarfeatures including an attentional focus on current ex-perience and awareness of available stimuli. Unlikeabsorption, however, mindfulness does not involve acomplete immersion in experience. In mindfulness,the person remains able to observe experience in adetached way, as if somewhat removed from the expe-rience (5). Mindfulness may also be related to thepersonality trait of openness (31, 32). Both constructsinvolve a reflective and contemplative approach to

situations, open-mindedness, and a tendency towardcurious introspection (5, 32). However, unlike open-ness to experience mindfulness does not involve aneffort to seek out novel experience or engage in activeimagination. Instead, mindfulness involves directingattention to whatever happens to be within currentexperience. Mindfulness can also be differentiated

from other attentional states such as dissociation,which involves an altered state of awareness that istypically characterized by restricted attention (33). Un-like dissociative states, mindfulness involves an effortto direct attention to all available information.

There is currently no evidence that can be cited insupport of the validity of the construct of mindfulness.However, operationalizing the construct does allow forinvestigators to test the validity. For example, convinc-ing evidence in support of construct validity would beobtained if experience with mindfulness meditationwere to produce enhanced performance on cognitive

tasks that require sustained attention and attention-switching, termination of elaborative processing, andawareness of stimuli. There are a number of standard-ized attention vigilance (that require sustained atten-tion) and attention-switching tasks can be adaptedfrom cognitive neuroscience (25, 34). Similarly, theability to inhibit elaborative processing can be mea-sured with such attention control tasks as the stopsignal paradigm,which measures the speed that onecan disengage from a cognitive operation (26). Atti-tudes and beliefs thought to be associated with mind-fulness can be readily measured with self-report ques-

tionnaires. Convergent validity can be established byexamining whether scores on the mindfulness mea-sure correlate positively with measures of absorptionand openness to experience. Discriminate validity can

be established by examining whether scores on themindfulness measure correlate with measures of dis-sociation and social desirability; they should not cor-related if these constructs are orthogonal. Since mind-fulness is theoretically predicted to mitigate stress andmood symptoms, criterion-related validation can beestablished by testing whether an increase in mindful-ness corresponds with decreased scores on measures

of stress and mood symptoms.

MECHANISMS OF ACTION AND CLINICALISSUES

Questions concerning the operational definitionsand validation of the construct of mindfulness arehighly relevant to identifying the mechanism of actionof this approach. MBSR was developed to assist indi-viduals in mastering meditation techniques and to be-come skillful in producing a state of mindfulness (1),




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the hypothesized primary active component (3, 4).There is no evidence, however, that MBSR actuallyenhances ones ability to produce a state of mindful-ness. In addition to the substantive significance of thisgap in our knowledge, it also raises practical consid-erations. MBSR is a demanding clinical program, re-quiring participants to practice meditation for a mini-

mum eight-week course of daily 45-minute sessions,ostensibly to develop the skill of cultivating mindful-ness (3). MBSR may merely produce nonspecific ben-efits, such as increased self-efficacy or social support,common mediators of many group interventions (3537). If MBSR does not induce mindfulness, or mind-fulness is not the primary therapeutic component,then it becomes difficult to justify such a demandingprogram. Even if mindfulness meditation proves to bea major therapeutic component, it may have nothing todo with mindfulness; it may simply produce deeprelaxation (38, 39). Research needs to clarify whether

mindfulness meditation produces some kind of alteredawareness such asmindfulnessor whether it simplyreflects another relaxation technique. The next logicalstep for the field is thus to investigate the meditatingrole of mindfulness. However, mindfulness mustfirst be conceptually defined, an appropriate measure-ment procedure must then be developed, and its con-struct validity tested.

It is also important to evaluate the efficacy of thisapproach against other treatments developed oradapted to facilitate adjustment to illness. For exam-ple, cognitive therapy has been demonstrated as an

effective treatment for many chronic illnesses, and it isgenerally accepted as the psychosocial treatment ofchoice for major depressive and anxiety disorders (35,40 42). If MBSR were to be adopted as a psychosocialapproach, than it would be important that the efficacyof this approach meets or exceeds that of other vali-dated treatments. Furthermore, it cannot be assumedthat because MBSR is effective for the management ofstress and emotional distress associated with one typeof chronic illness (eg, cancer) that it will be effectivefor other illnesses (eg, chronic pain).

There are also important questions concerning who

might benefit from MBSR. Preexisting personalitytraits may influence recruitment and compliance. Thisissue is particularly relevant to this approach consid-ering the demands and somewhat unusual nature ofthe program. Also, pretreatment personality traits ordifferences in attention control skills may also influ-ence the ability to use meditation to develop mindful-ness and mitigate stress and mood symptoms (43).Indeed, it is entirely possible that the efficacy of thisapproach has more to do with the kinds of people whogravitate to the program than the approach itself. This

needs to be investigated. Pretreatment levels of emo-tional distress and/or severity of psychiatric symptomsmay influence efficacy as well. For example, severestress or mood symptoms may impede the develop-ment or use of mindfulness to mitigate distress reac-tions. Also, there needs to be some clarification regard-ing what types of mood states or psychopathology is

responsive to this approach. These questions have im-portant implications for the identification of potentialpatients who would be expected to benefit from thisapproach.

DISCUSSION

Group-based psychosocial interventions that facili-tate adaptation and adjustment to chronic illness are

both effective and time-efficient and cost-efficient.Consistent with the recognized goal to improve thequality of life of patients with chronic medical disor-

ders, the integration of group-based psychosocial in-terventions into standard care is strongly recom-mended. A psychosocial treatment approach that caneffectively assist patients to self-manage their stressand emotional distress, and/or treat mood and anxietydisorders commonly associated with chronic illness,would be highly valued in most treatment settings.

Although MBSR has been presented as such an ap-proach, there is insufficient evidence based on rigor-ous scientific methods to strongly recommend it at thistime. However, there is some preliminary evidencethat suggests that this approach should be evaluated.

Certainly, with the current and growing popularity,both among the increasing number of health profes-sionals who are using this approach and health con-sumers who are demanding it, this is enough of areason alone to subject it to scientific scrutiny. In anera of increased accountability to demonstrate that ourpsychosocial interventions are indeed safe and effec-tive, the issue regarding the paucity of empirical studyis not a minor one.

Although preliminary evidence is promising, con-trolled studies are clearly needed. Although the effi-cacy of MBSR to self-manage stress and mood symp-

toms associated with cancer seems particularlypromising, it would be difficult based on a single ran-domized controlled trial to strongly recommend it atthis time. The study is significant however as it repre-sents the first rigorous test of the efficacy of this ap-proach to foster adaptation to a medical illness. Rep-lication is clearly needed to firmly establish itsefficacy in this population. Clinicians are cautionedfurther against generalizing the efficacy of this ap-proach based on this study to other chronic illnesses.The efficacy of MBSR should be investigated in each

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illness that it was adapted for until it has been shownthat the treatment effects can generalize across ill-nesses. Finally, clinicians are cautioned against at-tempting to use this approach as a cure all for anyproblematic mood-state or psychiatric disorder thatpresents with chronic illness. Substantial clarificationregarding the specific markers of psychosocial distress

or psychopathology associated with chronic illnessthat are amenable to this approach is needed.

The next logical step within future randomized con-trolled trials is to investigate questions concerning themeditating role of mindfulness. However, mindful-ness needs to be operationalized and its constructvalidity tested, and a method of assessment needs to bedeveloped, before researchers are able to investigate itsmediating role. The current paper has presented anoperational definition of the construct in a manner thatoutlines specific testable hypotheses for its validation.This should allow for the development of a method of

measurement that can be included in future controlledstudies. A systematic investigation of questions re-garding the therapeutic mechanisms of MBSR raised inthis paper would then be possible.

It is time to subject this approach to serious scien-tific inquiry. MBSR seems to hold promise as a poten-tially effective treatment option that may assist somepatients to self-manage stress and mood symptoms inthe face of their illness. Scientist-practitioners who seevalue in the approach are urged to adopt rigorousmethods of investigation so that its efficacy, indica-tions, and limits of application within psychosomatic

medicine can be clearly established. In the same vein,skeptics are cautioned that absence of evidence doesnot necessarily indicate absence of efficacy. It is hopedthat this review will foster cautious optimism aboutthe potential of this approach and direct investigatorstoward addressing relevant research questions thatwill result in an empirical base that can guide clinicalpractice.

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S. R. BISHOP



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APPENDIX

Review:Mindfulness-BasedStressReduction

Study

Condition

Participants

Design

Measures

Results

Comments

Controlledstudies

Specaetal.(6)

(2000)

Cancer

90outpatients

Randomizedw

ait-list

controltrial;7-

weekMBSR

program

ProfileofMoodStates

SymptomsofStress

Inventory

PosttestPOMS;lowertotalmood

distu

rbance,anxiety,

depression,anger,and

confusionandhighervigor

scoresforthetreatmentgroup.

PosttestSOSI;feweroverall

symptomsofstress.Also

presentschangescoresfrom

pretreatmenttoposttreatment

whichshowedevengreater

diffe

rencesinfavorofthe

treatmentgroup.

Standardizedmeasuresanddesign

astrength.Also,examined

relationbetweencompliance

(attendanc

eandtimespent

meditating)andoutcome;

allowsfor

someinferences

regarding

mediatingroleofthe

mindfulne

sstechniques.

Changescorescanbeassociated

withdecreasedreliability.

Bestpredictorofimprovementin

totalmooddisturbancewas

aver

agetimespentmeditating;

best

predictorofstress

redu

ctionwasnumberof

sessionsattended.

Effectsofsocialdesirabilityasa

potentialfactorthatmightbias

self-reportdatanotcontrolled.

Long-termbenefitneedstobe

investigatedviafollow-up.

Teasdaleetal.(7)

(2000)

Majordepressive

disorde

r;

recurre

nt

145recently

recovered

depressed

patients

Randomized

controlledtrial

assessedat52

weeksfollowingan

eight-weekprogram

Blindassessmentwith

theStructured

ClinicalInterview

forDSM-IV(SCID)

HamiltonRating

Scale:Depression

(HRSD)

BeckDepression

Inventory(BDI)

Forpatientswiththreeormore

prev

iousepisodes,the

treatmenthalvedtherateof

relapseofdepression.For

patientswithonlytwoprevious

episodes,nodecreasein

relapse.

CombinedM

BSRwithcognitive

therapy;h

owmuchis

mindfulne

sstrainingvs

cognitivetherapy?

Verywell-designedstudywith

highlevel

ofrigor.

Relevantonlytothepreventionof

relapse;canthisbegeneralized

tothetrea

tmentofdepression?

Astin(8)(1997)

Non-clinical

sample

28university

undergraduates

Randomizedw

ait-list

controlledtrial;

eight-weekMBSR

versuscontrol

SCL-90-R

ShapiroControl

Inventory

MBSR

groupdemonstrated

statisticallysignificantlower

postinterventionscoresonthe

GSI

ontheSCL-90-R(65%

aver

agereduction),aswellas

subs

calescoresfordepression,

anxiety,obsessive-compulsive

symptoms,interpersonal

sens

itivity,psychoticism,and

para

noidideationthan

participantsinthecontrol.Also

dem

onstratedstatistically

significantgreateradaptive

changesinoverallsenseof

control,senseofselfassource

ofcontrol,greatercapacityto

acce

ptoryieldcontrolin

uncontrollablesituations,and

satis

factionwithlevelof

control.

Randomizationtogroups,

standardiz

edmeasures

strengths.

Questionablegeneralizabilityto

clinicalpopulations.




10/14

APPENDIX

(Continued)

Study

Condition

Participants

Design

Measures

Results

Comments

Shapiroetal.(9)

(1998)

Nonclinical

sample

70premedicaland

130medical

students

Randomized

controlledtrial;

eight-weekMBSR

versuswaiting-list

control

SCL-90-R

State-TraitAnxiety

Inventory

EmpathyConstruct

RatingScale

MBSR

groupdemonstrated

statisticallysignificantlower

postinterventionscoresonthe

SCL-90-RGSIanddepression

subs

caleandstateanxiety

scoresthanparticipantsinthe

control.Alsodemonstrated

statisticallysignificantlygreater

scoresontheempathyscale.

Participants

werematchedwithin

randomizationforgender,

ethnicity,

andmedicalschool

status(pre

medicalvs.medical

student).S

tudywasdesignedto

coincidewithstudentsexams

(highstres

speriod).

Controlgroup

participated

ina

secondMBSR

groupinarepeated

measuresdesign

aftertheinitialtrial

Contro

lparticipantsreported

statisticallysignificant

redu

ctionsinGSIand

depressionsubscalescoreson

theSCL-90-Randlowerstate

anxietyandgreaterempathy

follo

wingtheMBSRprogram.

Attemptatreplicationisstrength;

lackofco

mparisontocontrol

forregressiontowardthemean

isalimit.

Samemetho

dologicallimitations

notedforAstin(8).

Uncontrolled

studies

Kabat-Zinnetal.(10)

(1985;Study1)

Chronic

pain;

mostly

muscle

-

skeletal

90outpatients

mostlyreferred

fromapain

clinic.Most

patientshad

longhistoryof

medical

treatmentwith

littlechangein

painor

psychosocial

status.

Pre/postrepea

ted

measures;

participated

inten-

weekMBSR

program

SCL-90-R

McGillPain

Questionnaire

ProfileofMoodStates

Questionnaire

regardingfunctional

impact

Therewasa58%statistically

significantreductioninpain

intensitywith72%ofthe

participantsreportingatleasta

33.3

%reductioninpainand

61%

reportingatleasta50%

redu

ction.Intermsof

func

tionalimpairment,there

was

a30%statistically

significantreductioninthe

mea

n.OnthePOMS,there

was

a55%statistically

significantreductioninthe

mea

nfortotalmood

distu

rbance.Themeanforthe

SCL-90-RGSIwasreducedby

35%

with59%ofpatients

repo

rtingatleasta33.3%

redu

ctionand39%reportingat

leasta50%reduction.

Standardizedmeasuresused

exceptfor

disabilitymeasure,

whichhasnoreliabilityor

validitydata.

Nocomparisontocontrolfor

regression

towardthemean.

Statisticsare

appropriatebutnot

adequatelyreported;onlythe

meansandprobabilityof

significanceareprovided.

Withoutp

rovidingthevariance

aroundthemeansand

inferentialstatistics(t-values,

degreesoffreedom)itisdifficult

fortherea

dertogainafull

understandingofthedata.

S. R. BISHOP



11/14


12/14


13/14

APPENDIX

(Continued)

Study

Condition

Participants

Design

Measures

Results

Comments

Kristelleretal.(15)

(1999)

BingeEating

Disorder

21womennot

currently

receiving

treatmentfor

bingeeating

disorder

Pre/postrepea

ted

measures;six-week

MBSRprogram

BingeEatingScale

BeckInventories

(anxietyand

depression)

Telephone

assessmentsof

bingeeating

episodes.

Statisticallysignificantreductions

inbingeeatingfromfourto

1.5perweek;reductionsin

BES

scores(50%reductionin

themean);reductionsin

anxietyanddepression.

UsesofDSM

-IVcriteriaforbinge

eatingdisorderandtelephone

assessmen

tstocomplimentself-

reportmeasuresofbingeeating

arestrengths.

Lackofcom

parisontocontrolfor

regression

tothemean;rater

biasinknowingthat

participan

tswereinatreatment.

Roth(16)(1997)

Mixedmedica

l

conditions;

mostly

chronic

pain,

anxiety

,

depression,

diabete

s,

andhypertension

Outpatientsatan

innercityclinic;

21English-

speakingand51

Spanish-

speaking(Latin

American)

Pre/postrepea

ted

measures

SCL-90-RforEnglish

patients

BeckAnxiety

Inventoryof

Spanishpatients

CoopersmithSelf-

EsteemInventory

RosenbergSelf-Esteem

Inventory

MedicalSymptom

Check-List

Inthe

Englishsample,therewas

asta

tisticallysignificantchange

inSCL-90-RGSIscoreswitha

50%

meanreductionfrom

preinterventionto

postintervention.Therewas

also

astatisticallysignificant

increaseinself-esteemonone

ofth

emeasures.IntheSpanish

sample,therewasastatistically

significantchangeinBAI

scoreswithamean70%

decreaseinanxiety.Therewas

also

astatisticallysignificant

increaseinself-esteemonboth

mea

sures.Bothgroupsalso

repo

rtedstatisticallysignificant

changeinthefrequencyof

self-reportedmedical

symptomswitha47%

redu

ctionfortheEnglish

patientsand41%reductionfor

theSpanishpatients.

Inclusionof

twodifferentcultural

samplesisstrength.

Nocomparisontocontrolfor

regression

tothemean;statistics

werenotadequatelyreported;

investordidnotcomparetwo

samples.




14/14

ERRATUM

Dr. Lipsitt reports that two errors appeared in his article: Lipsitt DR. Consultation-Liaison Psychiatry andPsychosomatic Medicine: The Company They Keep. Psychosom Med 2001;63:896 909. The first sentenceof the abstract should read:

Objective:The objectives of this review are 1) to briefly describe the parallel historical developments ofconsultation-liaison (C-L) psychiatry and psychosomatic medicine; 2) to analyze the extent to which the

literature of C-L psychiatry and psychosomatic medicine relate to each other, given that both fields haveevolved simultaneously in the history of psychiatry; and 3) to propose possible explanations for observedpublication patterns in selected C-L resources and the journal Psychosomatic Medicine.

Also, the footnote on page 900 should read:1Numbers of C-L psychiatrists in the American Psychosomatic Society have significantly decreased since

the 1986 survey (D. Drossman, personal communication, March 2001).

ANNOUNCEMENT

Academy of Psychosomatic Medicine 49th Annual Meeting

Consultation-Liaison Psychiatry: Humane and Scientificwill be the topic of the annual meeting, whichwill be held November 21 to 24, 2002 at the Loews Ventana Canyon Resort, Tucson, Arizona.

Physical illness intensifies and changes the profound challenges all of us experience about meaning andvalue in our lives. As psychiatrists of the medically ill, we share the opportunity to confront basic questionsabout living and dying well. We know that emotional distress and psychiatric illness arise in response tothis confrontation, and, as well, shape the experience of our patients in dealing with illness and the

problems of recovery, disability, and death. The scientific revolution in psychiatrythe renaissance of abiomedical model emphasizing molecular genetics, neurobiology, and psychopharmacologyprovides uswith new models of understanding and intervention which complement, but may also exist in dynamictension with, old paradigms in psychiatry that emphasize a complex and humane psychological under-standing of the plight of our patients. The 2002 Annual Meeting of the Academy of Psychosomatic Medicinewill focus on the progress we have made toward integration of new scientific understanding and evidenced-

based interventions with the humane care of our patients. We hope that this meeting will allow us to reviewthese many developments and to unify the humane and scientific aspects of our work. Accordingly, weencourage submission of workshops and symposia that bring together multiple viewpoints, as well aspapers on specific issues of interest to consultation-liaison psychiatry. Abstracts Due: April 6, 2002.

Preliminary program and registration materials available August, 2002. For further information or toreceive an abstract submission form contact: Executive Director, A.P.M., 5824 N. Magnolia, Chicago, IL

60660.


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