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Varying Treatment Duration in a Mindfulness
Meditation Stress Reduction Program
For Chronic Pain Patients

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David Sagula

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VARYING TREATMENT DURATION IN A MINDFULNESS MEDITATION
STRESS REDUCTION PROGRAM FOR CHRONIC PAIN PATIENTS
BY

David Sagula

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements

for the degree of

DOCTOR OF PHILOSOPHY

Department of Counseling Educational Psychology
and Special Education

1 999

ABSTRACT

Varying Duration In a Mindfulness Meditation Stress Reduction Program
for Chronic Pain Patients

By

David Sagula

An 8-week mindfulness meditation program requiring participants to practice 45
minutes per day has been demonstrated to be helpful for chronic pain sufferers. However,
many people find 45 minutes too much of a time commitment. The current study
involved 71 people seeking treatment for chronic pain, 53 were randomly assigned to a
20 or 45 minute per day mindfulness group, the balance comprised a comparison group.
Participants completed depression, anxiety, and grieving measures, and an open-ended
questionnaire. At post-test both treatment groups were lower on depression than the
comparison group. No differences were found between treatment groups on the
quantitative measures. When the treatment groups were combined they were found to
have lower depression, state anxiety and have progress further on initial phases of
grieving than the comparison group. Differences on the qualitative measure and drop-out
rates favored longer meditations. Drop-outs were characterized as having higher state
anxiety and being in the initial phases of grieving. Implications for screening instruments

and future research incorporating qualitative data are discussed.

ACKNOWLEDGMENTS

The completion of this dissertation would not have been possible without the
patient support and guidance of many people. My adviser and dissertation committee
chair, Dr. Ken Rice demonstrated patience and challenge to help make this document one
of the best works I have completed. I especially thank the members fi‘om my dissertation
committee for their time, assistance, and creativity: Drs. Nancy Crewe, John Schneider,
and Robbie Steward. I would like to extend a warm thanks to Dr. Ken Frank for his
statistical support. This project would not have been possible without the support and
guidance from the psychologists and staff at the Sparrow Regional Pain Clinic,
especially, Drs. John Jerome, Camala Riessinger, and Mary Stelrna. I would also like to
thank Dr. Fred Lopez for his guidance on this project and throughout my doctoral
graduate career, especially for his insistence that I let my heart guide my research
interests. I would like to thank Jon Kabat-Zinn for his research in this area, and the
support and encouragement that be extended to me. I would also like to thank all the
participants, those who completed the study and those who dropped out, for putting trust
in me that through this work I might be able to teach them an ancient practice that might
help them live with a little less suffering.

My graduate career would never have occurred, nor would I have been able to
complete it without the loving support of my family, F rank and Gloria Sagula; Karen,
David, Steven, and Eric Miller; Brian and Leean Sagula; and Diane Sagula. I also want
to thank my friends who were with me all, or part of the way throughout my doctoral
graduate work, especially: Amanda Baden, Jennie Leskala, Anne Mauricio, Ali Merzada,

Ellen Berger, David Derr, Barbara Gonnley, Sigrid Dixon, Carol Misseldine, Todd

iii

Walter, Suzanne Davino, Lucinda Sarter, Dollie Leveque, Carol Vega and all those too
numerous to mention. Finally, I would like to extend thanks to The Apple Farm
Community, The St. Gregorie Community,. Thomas Keating, Jake Foglio, and Audry
Cleary for their support, and wisdom that has guided me to a relationship with life that is

more vast than anything I could ever have imagined.

iv

TABLE OF CONTENTS

LIST OF TABLES ........................................................................ vii
LIST OF FIGURES ....................................................................... viii
Introduction ................................................................................. 1
Review of the Literature ................................................................... 8
Mindfulness Meditation .......................................................... 9
Pain and Mindfulness ............................................................. 10
The Practice of Mindfulness ...................................................... 11
Psychological Underpinnings of Mindfulness ................................. 12
Mindfulness and Grieving ......................................................... 15
Psychological Effects of Meditation ............................................. 17
Mindfirlness Meditation and Anxiety and Depression ........................ 20
Mindfulness and Chronic Pain ................................................... 23
Frequency and Duration of Practice ............................................. 25
Summary ............................................................................. 33
Hypothesis ........................................................................... 36
Methodology ................................................................................. 37
Participants .......................................................................... 37
The 8 Week Mindfulness Meditation Program ................................. 38
Instruments .......................................................................... 40
The Beck Depression Inventory .................................................. 40
The State-Trait Anxiety Inventory for Adults ................................... 42
The Response to Loss Scale ....................................................... 43
Statistical Analysis .................................................................. 45
Results ......................................................................................... 46
Introduction ......................................................................... 47
Quantitative Results ................................................................ 47
Completors vs. Drop-outs ......................................................... 53
Qualitative Data .................................................................... 54
Exploratory Analysis ............................................................... 57
Discussion ..................................................................................... 63
Hypotheses ........................................................................... 66
Qualitative Data ..................................................................... 73
Drop-out Rates ....................................................................... 75
Interaction Effects ................................................................... 76
Limitations and Future Research .................................................. 78
Conclusion ............................................................................ 81
Appendix A ........................................................................ 86
Appendix B ........................................................................ 9O

LIST OF TABLES

Table 1. Means, Standard Deviations, Ranges, and Reliabilities for

Quantitative Inventories ................................................ 48
Table 2. Means and Standard Deviations by Group and Inventory ................ 49
Table 3. Frequency Response to Open-Ended Questionnaire ....................... 55
Table 4. Group by Gender Interaction for Beck Depression Inventory ........... 59
Table 5. Skewness and Kurtosis ......................................................... 115
Table 6. Homogeneity of Variances: Levine’s Test ................................... 116
Table 7. Homogeneity of Regression .................................................... 117

vii

LIST OF FIGURES

Figure 1. Pain intensity by group interaction for Cope/Awareness ..................... 62

viii

Introduction

One in five adults in the state of Michigan have chronic pain, with one in ten of
these admitting to contemplating suicide (Anstett, 1997). The experience of intense and
prolonged physical pain is not just a physical problem demanding attention from only the
current bio-medical model. The psychological and social effects of chronic pain on a
person are extremely taxing. Intense physical and emotional pain can often lead to
substance abuse, difficulty in relationships, and depression (Anstett, 1997). Often there
are difficulties sleeping because of the intensity of the pain. Fatigue from sleep
difficulties coupled with the chronic pain also often affects work performance. In
addition, because the disability may not be visible, many people in the person's life may
question whether the person truly is in pain or just malingering. Anstett (1997) found
that over half of chronic pain sufferers are not sure if their employers believe them about
their pain.

Current medical treatment falls short of what patients need. Seven out of ten
people who suffer from chronic pain say that the care they receive does not relieve, or
only partially relieves, the pain (Anstett, 1997). Many physicians do not know how to
treat chronic pain (Anstett, 1997). Improving the life experience of people suffering fiom
chronic pain is a current dilemma for physicians (Cassel, 1982). Current treatments

include analgesics, narcotics, nerve blocks, and surgery, however, these often fall short of

providing reliable relief (Kabat-Zinn, 1985). Pain, difficulty working, difficulty in
relationships, sleep disturbances, substance abuse, and trust issues within family, friend
and work relationships all combine to propel the chronic pain sufferer into a
psychological downward spiral. No longer is the pain just physical, but it can become
life consuming. Considerable grieving can occur when hobbies, physical activities,
relationships, and careers are lost. However, without proper insight, the effect of grieving
may be repressed or expressed as anger with little resolution.

Currently, little can be done for most chronic pain sufferers. However,
psychological treatments are being developed to assist the intense discomfort. Recently,
Kabat-Zinn (1990) has developed a program using mindfulness meditation to assist
people with chronic illnesses to better cope with their situations. Mindfulness is a non-
judgmental awareness of one's present moment experience. It is similar to cognitive
approaches (Beck & Weishaer, 1989) to therapy in that one becomes aware of self-
dialogue that can be debilitating. For example, chronic pain sufferers employing

cognitive or mindfulness strategies may become more aware of self-defeating thoughts

such as, "this pain is killing me, this is the worst it has ever been, it is never going to
go away," "I'd be better off dead." However, mindfulness differs from cognitive
approaches in that it does not attempt to replace maladaptive cognitions with adaptive
ones. Rather, mindfulness involves disengaging from forming any types of thoughts,

positive or negative, and focuses the awareness into the observation of thoughts and

feelings. From this perspective, the relationships between thoughts and feelings can be

seen more objectively. A person suffering from chronic pain can begin to experience
how their judgments or self-dialogue about the pain often make the entire experience
more agonizing. Experiencing pain mindfully enables one to eliminate the psychological
agony of the physical pain. When one uses mindfulness with their pain, they no longer
fight or resist the pain. Instead, they non-judgmentally experience it as part of their
present moment experience. Generally, this does not take away from the extreme
physical discomfort of the pain, but it does provide more energy to deal with it because
they are no longer fighting or resisting the pain. This makes the life of someone with
chronic pain much less stressful.

The technique of mindfirlness meditation (Kabat-Zinn, 1990) consists of: (a)
bringing awareness to the primary object of attention (e.g., breath, body sensation), (b)
maintaining awareness from moment to moment, (c) when it is noticed that the awareness
has drifted from the primary object of attention, it is brought back to this object, (d) if the
pain gets very intense or a strong emotion is being experienced, this is made the object of
attention, when it subsides the person returns the awareness to the object of attention, and
(e) observe the process of thinking without getting caught up in the content of the
thoughts. When practicing mindfulness, all thoughts and feelings have equal value, that
is, they are all part of the experience in the current moment of life, and therefore they are
not pursued nor rejected. In the beginning stages the practice appears to be similar to an
exercise in concentration. When the mind goes into its habitual thinking patterns, one

lets go of judgmental self-dialogue and continually returns to the primary object of

attention. However, with continued practice, concentration improves and the mind
becomes slightly calmer. With increased development in concentration, one may begin
to expand the field of awareness and non-judgmentally experience the thoughts and
feelings, including pain, that arise in the present moment experience.

Kabat-Zinn's (1990) mindfulness meditation program is 8 weeks long and requires
participants to attend weekly meetings and practice at home for 45 minutes per day.
During the weekly meetings, mindfulness meditation instructions are given and practiced.

In addition, personal questions and problems in the person's practice are explored.

The research supporting the mindfulness program for reductions in anxiety has
been quite strong. Kabat-Zinn et a1. (1992) found significant reductions in depression
and anxiety for people with anxiety disorders who completed the program. In addition,
those who reported panic attacks prior to the program reported a significant reduction in
panic attacks after its completion. The results were maintained at a three month and three
year follow-up (Miller, Fletcher, & Kabat-Zinn, 1995). In addition, the number and
severity of panic attacks was significantly lower at three year follow-up when compared
to pretreatment levels. Investigating the degree the participants were maintaining the
meditation practice, 10 of the 18 original participants maintained a formal mindfulness
practice by meditating at least three times per week for at least 15 minutes per sitting.

In an effort to investigate the effectiveness of a mindfirlness meditation based
stress reduction program in a bilingual inner-city health care setting, Roth and Creaser

(1997) compared pre- and post-test data on 79 patients who completed the eight week

program over a two year period. The results indicated significant reductions in anxiety
and significant increases in self-esteem. This study indicated that mindfulness meditation
can be effectively integrated into a bilingual innercity population.

These studies indicate that not only was meditation effective in reducing anxiety
and depression on psychological inventories, but that participants rated the meditation
practice as important to them. In addition, the results were maintained over an extended
period of time. Moreover, participants continued with their meditation practice three
years after the conclusion of the program. This is a good indication that participants were
experiencing benefits from this practice.

Kabat-Zinn (1982) has extended this research with mindfulness to include people
with chronic pain. The results indicated that 65% of the patients reported a reduction of
at least 33% on a pain rating index and 50% showed at least a 50% reduction. There was
also a significant reduction in the number of reported medical symptoms and total mood
disturbance.

In a related study, Kabat-Zinn, Lipworth, and Burney (1984) compared
mindfulness meditation with traditional treatment protocols. Comparisons of pre- and
post-test measures for participants in the treatment group indicated significant reductions
in anxiety and depression as well as reductions in present moment pain, negative body
image, inhibition of activity by pain, and pain-related drug utilization. In addition,
treatment group participants activity levels and self-esteem increased. The results of the

chronic pain patients receiving traditional treatments demonstrated no significant

improvement on any of the indices measured. It is important to point out that participants
were not randomly assigned to treatment or control groups. In a 15 month follow-up,
improvements on all measures except present moment pain were maintained. More than
half of the participants reported that they still were meditating regularly.

Kabat-Zinn, Lipworth, Burney and Sellers (1987) extended the Kabat-Zinn et a1.
(1984) study over a four year period. By the end of the fourth year, 225 chronic pain
patients who completed the mindfulness meditation program were included in the study.
The results indicated that there was no reduction in mean post-intervention levels on all
but one of the measures of reported pain and medical symptoms from the Kabat-Zinn et
a1. (1987) study. Thirty to 55% of the participants rated their pain as greatly improved
since taking the meditation program.

From these results it seems apparent that the mindfulness meditation program
outlined by Kabat-Zinn (1990) is an effective treatment for anxiety and depression and
can be effectively utilized by chronic pain patients. However, one major difficulty in
implementing this program into a health care setting is the commitment required by
participants. The Kabat-Zinn (1990) program requires that participants practice 45
minutes per day. Many people are not able to make this significant time commitment,
and therefore are not able to participate in the program. Other studies employing
meditation have found significant reductions in anxiety and depression when participants
meditate 20 minutes per day (Carrington, et a1. (1980). This opens the question of how

significant is 45 minutes per day to the outcomes that have been found. If a person

practices a shorter duration, e. g.,20 minutes per day, what benefits, if any, would they
forfeit. Therefore, the purpose of this study will be to determine the effect of varying the
treatment duration in an 8 week mindfulness meditation program on measures of

depression, anxiety, and grieving.

Chapter II

Review of the Literature

Pain has been defined as "a sensation in which a person experiences discomfort,
distress, or suffering due to provocation of sensory nerves. . .." (Thomas, 1981, p. 1026).
However, when pain is pathological and chronic, with no benefit to the person, the result
is severe emotional, physical, and economic stresses to the person and his or her family.
People suffering with chronic pain often are confionted with questions from themselves
and others that add to the stress of the disease (Stanton & Dutes, 1996). Questions often
confronted by those diagnosed with chronic pain include: "is the pain real or
imagined?,""docs a cure exist?,” or will one ever exist?,” "what will happen next?"
People who once were productive, contributing to their community, and providing for
their families often are quickly stripped of these opportunities. People in this situation
have difficulty in close personal relationships because others may find it difficult being
with someone who is often experiencing extreme and chronic pain. Those who have
underlying genetic and environmental predispositions to personality disorders may incur
even greater losses when diagnosed with chronic pain (W eisberg & Keefe, 1997).

Weisberg and Keefe (1997) propose that the diathesis-stress model may be
applicable to those suffering from chronic pain and exhibiting personality disorders,
because coping methods that may have been adaptive or marginally adaptive prior to the

onset of chronic pain become ineffectual or maladaptive after the disability and result in a

personality disorder. Weisberg and Keefe (1997) estimate that as many as halfof those
suffering from chronic pain may have diagnosable personality disorders. With such
intense suffering, the need for research and interventions that might help those with
chronic pain manage their daily stressors is readily apparent. Kabat-Zinn (1982) has
developed a Stress Reduction and Relaxation Program (SR&RP) that employs a self-
regulatory technique called mindfulness to aid those suffering fi'om chronic pain.
Mindfulness Meditation

Defining meditation is not an easy task. Shapiro (1984) has commented on the
difficulty of attempting to capture into a single definition the variety of approaches or
techniques ( i.e., Zen, Yoga, Sufi Dancing, Contemplative Prayer, Vipassana, Tai Chi,
etc.,) that could be considered meditation . Often times, meditation practices are divided
into two categories, concentrative techniques or mindfulness (Delmonte, 1989;
Urbanowski & Miller, 1997). In addition, it is not unusual for a practitioner to switch, or
combine the two types of techniques. Shapiro (1984) defines the concentrative
techniques as "a family of techniques which have in common a conscious attempt to
focus attention in a nonanalytical way and an attempt not to dwell on discursive,
ruminating thought" (p. 6).

Mindfulness can be defined as a non-judgmental awareness of one's present
moment experience. There is not necessarily an attempt to focus the attention on any one
object, as in the concentrative techniques. To experience this type of awareness, the

focus of attention must shift from the continual stream of judgmental self-talk to the

unfolding present moment experience while remaining reflexive. "In this way,
relationships among one's behavior, physiological functioning, and cognition can become
apparent. We can therefore, envisage most forms of meditation as beginning with simple
concentration and ending in mindfulness meditation... " (Delomonte, 1989, p. 45).
From this perspective the present moment is able to be experienced without heavy
prejudices. Kabat-Zinn (1990) has described this present moment awareness as
consisting of an attitude with the qualities of non-judgment, patience, non-striving, trust,
letting go, non-attachment, and beginner's mind.
Pain and Mindfulness

From a mindfulness perspective pain is viewed as a sensation occurring in the
present moment. In and of itself, the present moment is not judged as good or bad, rather
the feelings and thoughts within it simply exists, and therefore, are simply experienced.
If a response can be made to relieve the pain then this response is made, if not, the
sensations of pain are experienced without engagement of a judgmental self-dialogue
about the nature, severity, or duration of the pain. When one realizes they are engaged in
judgmental self-dialogue, this is acknowledged, and the awareness is brought back to the
present moment experience. Returning and staying in the present moment is often aided
by focusing part of the awareness on some type of body sensation. Often the breath or
some area of the body is chosen, other times, the sensations of pain themselves may be
the object of the awareness. In approaching pain in this manner much of the self-created

suffering (e.g., this pain is never going to end, this is the worst it has ever been, etc.) that

10

accompanies pain is often eliminated (Kabat-Zinn et al., 1992). When practicing
mindfulness with pain, the pain is relaxed into, rather than tensed around and fought. In
this way considerably less time is spent in a "fight or flight" mode avoiding many of the
physiological and psychological debilitating effects of stress.

The realization of how quickly the mind slips into judgmental self dialog
becomes readily apparent when one attempts to live mindfully. Moreover, if an attempt
is made to be mindfirl during emotion laden events (e.g., pain), one has even more
difficulty because the mind shifts more quickly and strongly into habitual cognitive
generalizations regarding the current experience. Therefore, integrating mindfulness into
daily life, requires time to practice it with as few distractions as possible. In this way,
one is experienced with this approach and can integrate it when feeling emotional or
physical pain.

The Practice of Mindfulness

The technique of mindfulness meditation (Kabat-Zinn, 1990) consists of: (a)
bringing awareness to the primary object of attention (e. g., breath, body sensation), (b)
maintaining awareness of the primary object of attention from moment to moment, (c)
when it is noticed that the awareness has drifted finm the primary object of attention, it is
brought back to this object, (d) if the pain gets very intense or a strong emotion is being
experienced this is made the object of attention, when it subsides return to the primary
object of attention, and (e) observe the process of thinking without getting caught up in

the content of the thoughts. When practicing mindfulness, all thoughts and feelings have

11

equal value, that is, they are all part of the experience in the current moment of life, and
therefore they are not pursued nor rejected. In the beginning stages of meditation,
generally, a concentrative form of mindfulness is practiced by keeping the awareness
closely focused on the primary obj ect (e. g., breath). However, with increased
development in concentration, the field of awareness can be expanded to incorporate
more of the current experience. Using an analogy comparing the awareness to a zoom
lens might be helpful. In the beginning stages of meditation the awareness "zooms" in on
the primary object of attention, however, after concentration is developed the awareness
can be broadened like a wide angle lens.

Psychological Underpinnings of Mindfulness

 

Mindfulness has surprisingly strong historical roots within psychology, albeit, not
under the heading of mindfulness, but through the awarenesses and attention that
mindfulness fosters. Hothersall (1995) estimates that about 10 percent of Wundt's
research in Leipzig concerned attention. Wundt defined attention as "the state which
accompanies the clear grasp of any psychical context and is characterized by a special
feeling" (Hothersall, 1995; p. 129). Those who were trained at Leipzig under Wundt
were trained in what Wundt called "introspection.” Once sufficiently trained in
introspection, experimenters could distinguish between sensations and ideas in the field
of attention and those in the focus of attention. Because Wundt trained the first American
psychologists, it is not surprising to find that they also had interests in what today is

termed mindfulness. Titchener felt so strongly about introspection that he defined it as

12

the central method of psychology (Hothersall, 1995).

William James also commented on the value of a technique like mindfulness
meditation. According to James (1950, p. 424), "The faculty of voluntarily bringing
back a wandering attention over and over again is the very root of judgment, character,
and will. No one is compos sui if he has it not. An education which should improve this
faculty would be the education par excellence"(p.424).

Current psychotherapy theories are also consistent with some aspects of
mindfulness meditation. The cognitive perspective (Beck & Weishaar, 1989) illuminates
some of the therapeutic value of this practice. Kabat-Zinn (1992) has commented on the
similarity of cognitive-behavioral approaches and mindfulness meditation in that they
”share an emphasis on noting sensations and thoughts without viewing them as
catastrophic and the use of stress-inducing situations as cues to engage in new
behaviors”(p. 941). The emphasis of personal responsibility for practicing meditation
shares similarities with homework often given in cognitive and cognitive-behavioral
treatments. However, mindfulness meditation differs in several important ways.

In mindfulness meditation, thoughts are not judged as positive, negative, or
inaccurate as in cognitive approaches. "Rather, the emphasis is on identifying thoughts as
'just' thoughts and acknowledging the potential inaccuracy and limits of all thought, not
just thoughts that produce anxiety" (Kabat-Zinn, 1992, p. 941). Another difference is
meditation is practiced as a daily discipline irrespective of the state of anxiety currently

being experienced. Mindfulness is not a coping skill used just when one feels anxiety or

13

depression, rather it is an attitude that is established through a formal practice period so
that the entire scope of all experiences in one's life may be entered into mindfully.

From a psychoanalytic/psychodynamic perspective, Freud (1930) was not kind to
meditative experiences. When a fiiend described the feelings that often accompany
meditation to Freud he labeled them as "oceanic.” Although Freud admitted to never
experiencing this feeling himself he disnrissed it as a feeling of infantile helplessness
which he connected to religious feeling. Other psychoanalysts have remained consistent
with Freud's initial judgment and often view meditation as a form of regression
(Delmonte, 1990). Delmonte (1987) has commented that although there is a regression, it
is in service of personal growth. During mindfulness meditation, the continual self-
dialogue is nonjudgrnentally observed, as it is in free association by the analyst (Speeth
(1982). Therefore, defenses such as intellectualization and rationalization are inhibited.
Consequently, this nonjudgrnental awareness allows unconscious repressed material into
consciousness where it can be experienced and integrated into the personality. This
aspect of meditation, often termed "unstressing," is one of the primary features of
meditation that separates it from relaxation. In relaxation, the goal is to create the
relaxation response (Benson, Beary, & Carol 1974) and the corresponding peaceful,
pleasant feelings. In mindfulness meditation, the goal is to experience the present
moment as it is without judging the contents based on prior expectations of what one
wants to experience (Kabat-Zinn, 1990). Although this present moment attitude is often

pleasant and relaxing, at times it can be very stressful because previously repressed

14

material is now allowed to move from the unconscious to conscious without cognitive
manipulations. Relaxation involves following a procedure that changes the internal
feeling state to one that is specifically “relaxing” or not engaging the fight or flight
response. Mindfulness is a change in attitude, that may or may not, be relaxing.
Therefore, rather than creating peaceful feelings as in relaxation, the goal in mindfulness
meditation is to be at peace with what is happening in the present moment. Urbanowski
and Miller (1996) have commented on the potential volatility of these repressed emotions
and cautions that "the therapist must draw upon his or her in-depth experience with
meditation as well as the psychotherapeutic diagnostic formulation to skillfully decide
when, what meditative techniques, and what frequency of practice will be appropriate for
a particular client" (p. 34).

Mindfulness and Grieving

 

The grieving process is reengaged as one nonjudgmentally allows past loss issues
into consciousness. In this way, the grieving process can be intimately related to the
undertaking of a serious mindfulness meditation practice. Levine (1994) has commented
that, when a person begins a meditation practice, one of the first issues they will
experience is unresolved grief. Grieving can be defined as an emotional and
psychological reaction to a loss (Clayton, 1990). Recently, Schneider (1984) has
developed a model of grieving based on a review of the literature and his own clinical
experience working with loss. This model is comprehensive in that it includes four

phases (coping, awareness, healing, and growth) with each explored on five dimensions

15

(behavioral, cognitive, emotional, physical, and spiritual). The coping phase has two
forms: holding on (fight) or letting go (flight). Holding on is an attempt by the individual
to overcome the loss. For example a person holding on might attempt to keep busy
(behavioral), get aneg (emotional), and believe that the loss is reversible (spiritual).
Letting go involves responses that attempt to avoid the grief. For example by drinking
(behavioral), doomsday thinking (cognitive), and pessimism, (spiritual), a person may
attempt to avoid the grief. The next phase of grieving, awareness, is characterized by
beginning to more fully recognize what is lost.

Awareness begins when the cOping behaviors of holding on or letting go no
longer ward off the reality of the loss, or when one engages in a therapeutic endeavors
such as psychotherapy or mindfulness meditation that increase awareness. During this
phase there is exhaustion (physical), longing (emotional), and emptiness (spiritual). The
next phase of grieving involves perspective and integration, or what remains after the
loss. Perspective begins when the loss no longer feels like a crushing burden, yet the
grief is still clearly present. The person is able to relax (physical), experience pleasure
(emotional) and, find meaning (spiritual). Integration begins when the person can put
aside their preoccupation with the loss. Integration is recognized when there is a renewed
sense of passion (physical), new relationships (emotional), and forgiveness (spiritual).
The final stage of grieving is growth. This consists of reforrnulating and transforming the
loss. In reformulation the person is self-confident (cognitive), spontaneous (behavioral)

and more unconditionally loving (spiritual). Finally, in the transforming stage the five

16

dimensions merge or blur with less distinction. The person has a greater sense of
balance, wholeness, and wisdom. They also see the interconnectedness of people and
things more clearly. Therefore, when engaging in mindfulness meditation the purpose is
not to attempt to change feelings. Rather, the purpose is to become more aware of the
feelings that are there. Through this increased awareness, unresolved grief issues can be
integrated more completely into the personality.

Physiological effects of Meditation

 

The initial research with respect to the physiological changes brought about from
meditation were primarily focused on the Transcendental Meditation (TM) technique and
the physiological changes that this practice induced. These studies noted that TM
practitioners demonstrated reduced heart rates, decreased oxygen consumption, decreased
blood pressure, increased skin resistance, and increased alpha level brain activity
(Shapiro, 1980). This research with respect to changes in physiology and meditation has
now gone through two phases (Shapiro, 1984). The first phase consisted of a group of
studies that indicated that meditation may create unique physiological changes in the
body (Wallace, 1970; Wallace, Benson, & Wilson, 1971).

However, a second round of methodologically more sophisticated studies found
that the physiological changes accompanying meditation were not unique to meditation

(Benson, 1977; Cauthen & Prymak, 1977; Walrath & Hamilton, 1975). In reviews of the
literature, Shapiro (1984), Holmes (1984), and Delmonte (1984) all concluded that

meditation did not create unique physiological changes when compared to other self-

control (relaxation) techniques or just "resting.” However, J evning and O'Halloran (cited
in Shapiro & Walsh, 1984) claim that there may be unique effects brought about by
meditation which have not been reflected in the current literature due to a lack of
sophistication in research instruments. Some of these unique effects may be the
psychological healings that take place when a meditation practice is engaged. Healing
may result when one begins to experience insight into past traumatic experiences.
Therefore, to fully investigate the psychological efficacy of meditation more complex
outcomes than physiological measures should be examined.

Some of the strongest early work linking meditation and relaxation was done by
Benson (1974) who proposed a model entitled the "Relaxation Response" which states
that all relaxation techniques produce a single "relaxation response.” This response is
characterized by a decrease in sympathetic nervous system activity elicited by the "fight
or flight "response. He characterized the technique for eliciting the "Relaxation
Response," a highly concentrative format, as consisting of four elements: (a) a mental
device consisting of a word or phrase repeated, or a fixed gaze at an object (the purpose
of this is to shift from rational externally oriented thinking), (b) a passive attitude, (c)
relaxed muscles, and (d) a quiet environment.

Davidson and Schwartz (1976) have suggested that not only does relaxation
involve a general reduction in physiological activity, but also that a second pattern of
more specific changes are superimposed upon the "relaxation response" which are

dependent on the type of relaxation technique employed. More specifically, they propose

18

that anxiety can be broken down into two components: cognitive anxiety and somatic
anxiety. Moreover, they suggest that the optimal treatment for cognitive anxiety would
be a cognitive technique such as meditation, while somatically oriented approaches such
as physical exercise, or yoga would be optimal for somatic anxiety. In a study comparing
the effects of meditation versus exercise, Schwartz, Davidson and Goleman (1978) found
partial support for their theory in that those who exercised reported less somatic and more
cognitive anxiety, however, those who meditated experienced no significant differences
between the two modes of anxiety. Two limitations in this study were lack of
randomized assignment to treatment groups and no control group.

Support for Davidson and Shwartz's (1976) model has not been universal. In a
recent study investigating the relationship between cognitive and somatic anxiety, Kabat-
Zinn, Chapman, and Salmon (1997) compared anxiety type and relaxation technique
preference in 135 medical patients referred for a mindfulness based stress reduction
program. The program employed a body scan meditation, a sitting meditation, and Hatha
yoga. Of the 135 patients, 20 demonstrated high somatic/low cognitive anxiety, and 9
demonstrated high cognitive/low somatic anxiety. The results indicated that the high
cognitive/low somatic group demonstrated a significant preference for the most somatic
technique (hatha yoga) and disliked the most cognitive technique (seated meditation),
while the high somatic/low cognitive group preferred the most cognitive and disliked the
most somatic technique. The body scan was rated intermediate by both groups.

Therefore, an inverse relationship from what was predicted by Davidson and Shwartz's

19

(197 6) model was found.

Kabat-Zinn et a1. (1997) also found that the subjects who did not fit into the
high/low anxiety categories (i.e., those who had high or low levels of both cognitive or
somatic anxiety) also had preferences for relaxation techniques that did not fit Davidson
and Shwartz's (1976) theory, nor was their preference dependent on the overall level of
anxiety. Finally, the authors did find that regardless of the type of anxiety presented, the
mindfulness meditation program significantly reduced overall levels of anxiety.
Therefore, it appears that the dichotomy of cognitive vs. somatic anxiety may be more
complex than Davidson and Shwartz (1976) allow.

Mindfulness Meditation and Anxiety and Depression

In an effort to determine the effectiveness of an 8-week mindfulness meditation
program Kabat-Zinn et al. (1992) measured pre-test, post-test and 3 - month follow up
levels of anxiety and depression with 22 participants diagnosed with an anxiety disorder.
Thirteen patients reported at least one panic attack in the week preceding treatment. The
results indicated significant reductions in anxiety and depression between the pretest and
post-test measures. In addition, the post-levels of anxiety and depression were
maintained at 3 month follow-up. The number of panic attacks also decreased
significantly with only five of the original 13 participants who experienced panic attacks
in the week preceding treatment reporting a panic attack in the week preceding
posttreatment. At three month follow-up, three of the 13 original patients reported a

panic attack in the previous week. One of the limitations of this study was the size of the

20

sample and that it did not employ a control group.

Miller, Fletcher, and Kabat-Zinn (1995) found that the improvements
demonstrated on the posttreatrnent measures of anxiety and depression were maintained
in a three year follow-up study of the Kabat-Zinn et al. (1992). In addition, the number
and severity of panic attacks also were significantly lower at three year follow-up when
compared to pre-treatment levels. Investigating the degree the participants were
maintaining the meditation practice, 10 of the 18 original participants maintained a
formal mindfulness practice meditating at least three times per week for at least 15
nrinutes per sitting. In addition, 16 of the original 18 participants reported practicing an
informal technique of mindfulness, "Awareness of Breathing in Daily Life.” In addition,
participants rated the importance of the program in their life on a ten point scale, with 1
representing "of no importance" and 10 representing " very important.” Twelve rated the
program as a 7 or greater with five of these rating it a 10. Therefore, this study
demonstrated long-tenn effectiveness, both objectively and subjectively, of a mindfulness
meditation program. In an effort to investigate the effectiveness of a mindfulness
meditation based stress reduction program in a bilingual inner-city health care setting,
Roth and Creaser (1997) compared pre and post-intervention data on 79 patients who
completed the eight week program over a two year period. Participants completed an
anxiety inventory, a measure of self-esteem, and the SCL—90-R (Derogotis, 1977) ), a 90
item inventory which includes subscales for depression, anxiety and phobic anxiety, and

overall general functioning (GSI). The results indicated significant reductions on the

21

SCL-90-R, and the anxiety inventory while demonstrating significant increases on
measures of self-esteem. This study indicated that mindfulness meditation can be
effectively integrated into a bi-lingual inner-city population. Some of the changes that
the authors recommended integrating with a minority population include: holding the
program at a agency or health center that is utilized and treated by the population in
question, offering transportation, child care, reminder phone calls, and having an
instructor fluent in the languages of the population being instructed. Similarly, meditation
tapes for home practice should be made available in the participants native language. In
addition, tape players may need to be supplied for participants to use at home if
necessary. A major limitation of this study is that it did not employ a control group.
Therefore, it is not clear if the outcomes are the result of the 8 week mindfirlness
intervention or 8 weeks of other unknown factors.

These studies indicate that not only was meditation effective in reducing anxiety
and depression on psychological inventories, but that participants rated the meditation
practice as important to them. In addition, the results were maintained over an extended
period of time. Moreover, the majority of participants continued with their meditation
practice three years after the conclusion of the program. This is a good indication that
they were experiencing some type of benefit fi'om this practice. In order to determine
potential benefits of using mindfulness meditation in helping people suffering with

chronic pain, studies that focused on this population will now be reviewed.

22

Mindfulness and Chronic Pain

Kabat-Zinn (1982) investigated the effectiveness of a 10 week mindfulness
meditation program in the treatment of chronic pain in an effort to employ the
nonjudgrnental awareness of mindfulness meditation with a population who experiences
extreme physical discomfort. Fifty-one participants who were referred to the program
took part in the study. The classes of pain reported consisted of low back, upper back and
shoulder pain, cervical pain, and headaches. The average number of years participants
reported with their pain problem was 8.4. Pre and post measures consisted of pain
indices, a medical symptom check list, and a measure of overall mood disturbance. The
results indicated that 65% of the patients reported a reduction of at least 33% on a pain
rating index and 50% showed at least a 50% reduction. There was also a significant
reduction in the number of reported medical symptoms and total mood disturbance. Two
of the limitations of this study include the lack of a control group, and the reliance on
self-reported data.

In a follow-up study Kabat-Zinn, Lipworth, and Burney (1984) included a
comparison group. Pain patients participating in a 10 week mindfulness meditation
program were compared with a group of pain patients following traditional treatment
protocols (nerve blocks, physical therapy, analgesics, antidepressants). The results
indicated significant reductions in anxiety and depression as well as reductions in present
moment pain, negative body image, and inhibition of activity by pain for the treatment

group. In addition, pain-related drug utilization decreased and activity levels and self-

23

esteem increased for the treatment group. The results of the chronic pain patients
receiving traditional treatments demonstrated no significant improvement on any of the
indices measured. It is important to point out that participants were not randomly
assigned to treatment or control groups. In the 15 month follow-up, improvements on all
measures except present moment pain were maintained. With respect to continued
practice of meditation, 53% reported that they were still meditating regularly, 29% were
meditating sporadically, and 13 % reported not meditating at all. Five percent did not
respond to the question. Gender comparisons indicated that twice as many women than
men took the program. With respect to symptomatology, men had "consistently" higher
levels of psychological disturbance, however, there where no differences on the outcome
measures.

Kabat-Zinn, Lipworth, Burney and Sellers (1987) extended the Kabat-Zinn et al.
(1984) study over a four year period. By the end of the fourth year, 225 chronic pain
patients who completed the mindfulness meditation program were included in the study.
The post treatment follow-up times ranged from 2.5 - 48 months. The results indicated
that there was no deterioration in mean post-intervention levels on all but one of the
measures of reported pain and medical symptoms. Thirty to 55% of the participants rated
their pain as greatly improved and 60 to 72 % reported at least moderate improvement in
their pain since taking the meditation program. With respect to adherence to the
meditation practice, 30 % reported being regular meditators (at least 3 times per week),

20% reported being sporadic meditators and 20% were marginal meditators (once per

24

week). The authors concluded that the mindfirlness meditation program can have long-
term benefit for chronic pain patients.

From these results it is apparent that the mindfulness meditation program outlined
by Kabat-Zinn (1990) is an effective treatment in helping chronic pain patients cape with
many of the stressors brought about by their condition. However, one major difficulty in
implementing this program into a health care setting is the comnritrnent required by
participants. The Kabat-Zinn (1990) program requires that participants practice 45
minutes per day as well as attend weekly meetings. This is more than twice as long as
most other meditation techniques (Benson, 1974). Many people are not able to make this
significant time commitment, and therefore are not able to participate in the program.
This opens the question of how significant is 45 nrinutes per day to the outcomes that
have been found. Kabat-Zinn (1997) has commented that the importance of the 45
minutes is to allow participants ample time to develop "tolerance to aversive states." By
practicing longer, participants will get a "more mature understanding of pain. " Moreover,

practicing for 45 minutes will enable participants to move beyond experiencing just the
"relaxation response" (Benson, 1974) and practice mindfulness with "aversive states
beyond relaxation." Studies that investigate the relationship between the length of time
meditating and outcome will now be reviewed.
Frequency and Duration of Practice

Carrington et al. (1980) investigated the effect of meditation in a working

population of 154 telephone company employees self-selected for a meditation-relaxation

25

 

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training program. The participants received a brief description of three meditation
techniques and selected which one they would prefer, although, they were informed that
their actual group would be selected by chance. The participants completed a personality
inventory and a symptom inventory prior to assignment in one of the three treatment
groups or control group. The three treatment groups consisted of two concentrative
meditative techniques and a progressive muscle relaxation group. Participants learned the
techniques in their homes through instructional tapes and written material, and were
instructed to practice 15 to 20 minutes twice per day.

Participants were divided into three groups to assess the results of the effect of
frequency of practice: (I) frequent practicers (practiced an average of 5.6 — 7.5 times per
week), (2) occasional practicers, and (3) stopped practicers. The results indicated that
there were no significant differences between frequent and occasional practicers on
degree of symptom improvement. Therefore, frequent and occasional practicers were
collapsed into one group, as were controls and those who stopped practicing. The results
indicated that, after 22 weeks, participants who practiced the two meditation techniques
were significantly lower than the progressive muscle relaxation group and the control
group on measures of depression and anxiety. Although there were no significant
differences in symptom reduction between those who practiced more than those who
practiced occasionally, a chi square analysis indicated that frequent practitioners reported
that they experienced more beneficial effects, were more satisfied, had improved social

relationships, and that the practice was more valuable to them than those who practiced

26

occasionally. Therefore, although frequency did not affect self-report measures of
symptom reduction, it appeared to be related to perceived benefits, and related to the
degree of enthusiasm demonstrated to the technique. It is interesting to note that, when
comparing the amount actually practiced, progressive muscle relaxation was practiced the
least. In addition, there were no significant associations between demographic factors and
frequency of practice.

Although frequency of practice did not predict symptom improvement, the
researchers point out that it still maybe an important factor. For example, there may be
individual differences that require some participants to practice more to achieve the same
benefit as those who practice occasionally. In addition, this study only lasted 5.5 months.

Therefore, because many consider meditation a life long practice (Kabat-Zinn, 1994),
these results give no indication of the effects of frequent meditation over long periods of
time. This is especially noteworthy because most participants reported using the
technique for strategic purposes, or as needed, and not for general well being. Finally,
the researchers point out that it is not known whether "frequency of practice was a cause
or an effect of the perceived benefits of the techniques"(p. 229). They suggest that "to
investigate this question it would be necessary to design a study in which frequency of
practice was systematically varied" @229).

Smith, Compton and West (1995) included frequency of practice as one of the
variables in a study of the effects of adding meditation to Fordyce's (1977) Personal

Happiness Enhancement Program (PHEP). With a population of 36 undergraduate

27

volunteers, they found that adding meditation to the PHEP program demonstrated
significant reductions on the Beck Depression Inventory (Beck, 1987) and the State-Trait
Anxiety Inventory (Spielberger et al., 1970) over both the PHEP group alone and the
control group. The groups met for twelve 90 nrinute sessions over a period of 6 weeks.
The researchers split the group into two subgroups: one for those who practiced three or
more times per week and the other for those who practiced less than three times per week.
This division was made based on previous research by Delmonte (1984) which stated
that practicing under three times per week results in little benefit. The results indicated
no difference on any of the measures between the low meditation group and the PHEP
only group. Therefore, these two groups were combined and compared to the high
meditation subgroup. The results of this analysis indicated significant differences
between the high meditation subgroup and both the control group and the combined low
meditation subgroup and the PHEP only group. With the exception of state anxiety,
significant differences on all dependent measures were found between the combined low
meditation group and PHEP only group and the control group. Therefore, including
meditation in the PHEP may improve its effectiveness. However, consistent with
Delomonte's findings (1984), the current results suggest that meditation must be practiced
at least three times per week.

Astin (1997) investigated frequency of practice as one of the variables in his study
of a 8 week mindfulness meditation program with 28 undergraduate student volunteers.

Participants were randomly assigned to a control or treatment group. Participants met

28

once a week throughout the program and were instructed to practice 45 minutes per day 5
times a week. The pre and post measures was the SCL -90-R (Derogatis, 1977).
Participants completed inventories examining both sense of control and spiritual
experiences, in addition to maintaining daily diaries to monitor fiequency of practice. A
final review of meditation logs indicated participants practiced meditation an average of
30 minutes per day 3.5 days per week. The results indicated that there was no
relationship between the amount practiced and degree change on the SCL-90-R GSI.
Comparing those who completed the eight week meditation course with controls
indicated significant reductions on the overall SCL - 90-R, GS], and on the subscales of
depression, anxiety, obsessive-compulsive disorder, somatization, interpersonal
sensitivity, psychoticism and paranoid ideation. In addition, those who completed the
program demonstrated a significantly greater change on the two subscales of the sense of
control inventory consisting of acceptance and a measure of self as source of control.
Those in the treatment group also demonstrated significantly higher scores on a measure
of spiritual experiences compared to controls.

Peters, Benson, and Douglas (1977) included frequency of practice as one of the
variables they investigated in studying the effect of a daily meditation practice with a
working population. The volunteers for the study were divided into three groups: (a) a
meditation group, (b) a group that was instructed to sit quietly, and (c) a group receiving
no instructions. An effort was made to match the meditation group and relaxation group

for expectation effects. The results indicated that the meditation group demonstrated

29

significant improvements compared to the control group on four of the five measures
used: a symptom index, illness index, performance index, and sociability satisfaction
index. There were no significant differences on a happiness-unhappiness index. The
resting group was not significantly different from the meditation group or the control
group. There were no significant correlations between practice rate and change on any of
the five indices. However, there were some within group variations between amount of
practice and change on the symptoms index. In the meditation group those who practiced
six to eight times per week demonstrated the largest decreases on the symptoms index,
however no additional benefits were demonstrated for more practice than this. On the
performance index, those who practiced at least three to five times per week
demonstrated as much change as those who practiced more, while on the sociability-
satisfaction index, "substantial" changes were associated with nine or more practice
periods per week. The other indexes showed no relationship with practice rate as was the
case for all five measures in the resting group.

Beauchamp—Turner and Levinson (1992) investigated the effects of frequency in
the practice of meditation on stress, illness, depression, anxiety, hostility and affect. One
hundred and thirty four participants were surveyed on three assessment inventories to
determine stress levels, health status, and fiequency of meditation. Frequency of practice
was divided into two categories, those who reported practicing frequently and those who
"never,” "rarely,” or "occasionally" practiced. The results indicated that those who

practice frequently reported significantly fewer stressors and illness symptoms. More

30

specifically, frequent meditators reported lower levels of anxiety, hostility, depression,
and dysphoria, as well as, high levels of positive affect and sensation seeking. However,
frequent meditation was not related to a reduction in the correlation between stress and
illness, but it was related to a correlation between stress and dysphoria and illness and
dysphoria. A significant limitation of this study was that it employed survey data, and
that the type of meditation participants were practicing was not identified, nor was the
length of time participants had been meditating prior to the study controlled.

Zuroff and Schwartz (1978) randomly assigned 60 volunteer participants to
receive training in TM, a muscle relaxation training program, or a no treatment control.
Training in TM consisted of two group lectures of one hour, one hour of individual
instruction on the technique, and three additional one hour group meetings. The training
in the muscle relaxation group was designed to duplicate the TM group design as much as
possible. The results indicated no relationship between frequency of practice and
reductions in anxiety. However, the treatment group did demonstrate significant
reductions on state anxiety compared to the muscle relaxation group and the control
group. With respect to a behavioral measure of anxiety, locus of control and drug use,
there were no treatment effects. The authors concluded that TM may reduce trait anxiety
but was of little value in affecting general personality changes.

Dehnonte (1981) investigated frequency of practice as it relates to expectation and
meditation. Ninety four prospective meditators volunteered for the study and completed

questionnaires on their perceived-self and their expectations of TM: before receiving

31

instructions on TM, after instructions, and 7 months later on follow-up. The results
indicated that those who took up meditation were older, had initially a more negatively
perceived self and had higher expectations of meditation. At post-test a positive
perceived self and higher expectations at all three testing periods were positively related
to frequency of practice. In addition, at the 7 month follow-up, frequency of practice
itself was related to improved perceived self and increased expectation scores. In
addition, the expectations of those who were older were more resistant to change by the
introductory talk on TM. The author concludes that those who took up meditation report
significantly more problems, whereas those who meditate most frequently have the
fewest problems.

Deberry, Davis, and Reinhard (1989) compared a meditation-relaxation program
with a cognitive/behavioral program and a control group on measures of anxiety and
depression in a geriatric population. Fourteen male and 18 female volunteers ranging in
age from 65 to 75 years were randomly assigned to a meditation-relaxation program, a
cognitive/behavioral treatment, or a control group. Participants completed depression and
anxiety measures and then were given a tape with instructions based on their respective
program and instructed to listen to the tape once per night. The groups also met twice per
week. Ten weeks after the distribution of the tapes the participants were again given the
depression and anxiety inventories. The results indicated a main effect for treatment and
time. There were no significant gender differences. Post hoc analysis revealed a

significant reduction in state anxiety for only the meditation-relaxation group. There

32

were no significant treatment effects for trait anxiety or depression. However, there were
significant reductions on depression, and state and trait anxiety on all measures with
respect to practice time. The authors recommended meditation-relaxation as a "safe,
quick method for reducing state anxiety, or as a ancillary treatment within more
traditional models of psychotherapy" (p. 245). One of the limitations of the study was the
time limited nature of the cognitive-behavioral treatment. The experimenters felt that
"the nature of the time limited involvement clearly evoked a resistance in treatment"
(p.244). The authors recommended that future research should be focused on
determining what the ideal treatment durations are to achieve clinical or experimental
results.
Summgy

Combining the results of the above studies does not illuminate the importance of
meditating 45 minutes per day because no study compared amount of time practiced each
day. All of the studies that used a technique other than mindfulness meditation assigned
meditation periods between 15 - 20 minutes in duration. With respect to number of
sessions per week, Carrington et al. (1980) and Smith et al. (1995) found no difference
between fiequent and occasional practicers. However, Carrington et al. (1980) found that
frequent practitioners reported significantly more satisfaction with their meditation
practice than occasional meditators. Debeny et a1. (1989) and Peters et al. (1977) did
find differences with respect to amount practiced and outcome, with less than three times

per week producing little change. Delmonte (1981) not only noted a relationship between

33

frequency of practice and outcome, but also in the demographics between those who
took up the practice, and those who meditate most frequently. Therefore, there does seem
to be some link between amount practiced and outcome. It is important to point out that
all of the studies did find significant positive differences both quantitatively and
qualitatively on symptom measures between treatment groups and control groups and/or
between pre and post measures. However, currently, no study has investigated the effect
of meditating for a longer or shorter duration. For example, Kabat-Zinn's (1990)
program has proven very effective in clinical settings especially for chronic pain
sufferers. However, all mindfulness research using an 8 week model has followed his
format of 45 minutes per day. Due to a number of factors, many people cannot comrrrit to
45 rrrinutes per day, and therefore, are not able to take this program. Therefore, this
study will investigate the differences between a 45 minute and a 20 rrrinute mindfirlness
meditation group following a format similar to the Kabat-Zinn (1990) and a comparison
group. The outcomes that will be of interest in the study include, depression, anxiety and
grieving.

Grieving is a variable that has not currently been investigated in a study
employing meditation. It is important to include it here because the first 20 nrinutes of
meditation the practitioner may be simply utilizing the "relaxation response.” More
specifically, when one begins a meditation period, the initial stages of the practice
involve physiological changes which include reduced heart rates, decreased oxygen

consumption, decreased blood pressure, increased skin resistance, and increased alpha

34

level brain activity (Shapiro, 1980). These changes often leave the meditator refreshed
and rejuvenated, which is one of the strong benefits of a relaxation practice. However,
the purpose of mindfulness is not relaxation, but rather a change in attitude consisting of
a nonjudgrnental acceptance of the present moment experience. This acceptance is easy
when one is feeling relaxed and refreshed, however, it is quite difficult when the
experience is painful. Therefore, if people meditate longer than 20 minutes, they will
have more practice at learning how to nonj udgrnentally experience unpleasant feelings.
Those who only practice 20 minutes will often only experience the pleasant feelings of
relaxation and rejuvenation and not learn how to mindfully experience unpleasant
feelings. Because unresolved grief issues often surface when a meditation practice is
undertaken (Levine, 1994), those who have more practice time beyond relaxation may
resolve more of their loss issues.

In Schneider's (1994) model of grieving, the first stage begins with awareness of
the loss. When practicing meditation, the present moment experience is not cognitively
defended against. Therefore, awareness of unresolved issues increases. After awareness
of what is lost is complete, a deeper perspective and integration of the issue can take
place and a determination of what is left after the loss occurs. This is the second stage of
the model. The final stage involves reformulation and transformation, or what is now
possible. Therefore, those who meditate longer will not only be able to cope with chronic
pain better because of more practice time employing mindfulness with aversive states, but

they will also have a greater opportunity to realize closure on unresolved loss issues.

35

Hmothesis
It is apparent that the mindfulness meditation program proposed by Kabat-Zinn

(1990) is effective in helping people with chronic pain cope better with their situation.
However, what is not known is how important meditating for 45 minutes per day is as
opposed to a shorter duration. Because this program requires participants to practice for
45 minutes per day, some potential participants may choose not to take the program
because sitting in silence with awareness focused inwards for 45 nrinutes may appear too
overwhelming. In addition, some people may not have enough free time in their daily
schedule to add a new activity requiring 45minutes per day. Therefore, the purpose of this
study was to investigate differences between meditating for different lengths of time.

The null hypothesis for this study is there will be no difference between the comparison
group and participants assigned to an 8 week, 45 rrrinute per day mindfulness meditation
program, and an 8 week, 20 minute per day mindfulness meditation program on measures

of depression, anxiety, and grieving.

36

CHAPTER III

Methodology

The present study investigated the effect of varying treatment duration in a
mindfulness meditation stress reduction program with 51 people with chronic pain in a
between groups quasi-experimental design. This sample size was determined from effect
size derived in previous research (Kabat-Zinn, 1992), and through a power analysis
(Cohen, 1992) using a power of 0.8 and alpha level of 0. 10. The participants were
randomly assigned to one of two treatment groups: a 45 or a 20 minute per day
mindfirlness meditation group. Volunteers were assigned to a control group. Both
treatment groups and the control group completed pre and post measures of depression,
state and trait anxiety, and grieving. The treatment consisted of an 8-week mindfulness
meditation program. For the purposes of this study, depression was assessed using the
Beck Depression Inventory short form (Beck & Beck, 1972, Appendix A), while anxiety
was measured using the State-Trait Anxiety Inventory (Spielberger, 1983, Appendix B),
and grieving was measured using the Response to Loss Scale split-half form (Schneider,
Deutsch, 1994, Appendix C).

Participants
Participants for this study were recruited fiorn those seeking psychological

assistance in coping with their chronic pain condition at a pain clinic. Recruitment took

37

place through psychologists at the clinic informing their clients of the program, as well as
through brief presentations given during group psychoeducational and psychotherapy
programs at the pain clinic. Twenty four participants were recruited for the treatment
groups. These participants were randomly assigned to either a 45 or a 20 minute per day
mindfulness meditation group. In an effort to control for between group differences with
respect to the time of day the group met, equal numbers of both treatment groups met in
the afternoon and in the evening. Eighteen people seeking or receiving medical
assistance, or who were on a waiting list for psychological assistance in response to their
chronic pain condition were recruited to serve as a comparison group. All participants
completed a demographic data sheet (see Appendix D).
The 8 week mindfulness program

The primary objective of the mindfulness program (Appendix E) was to teach
participants how to change their attitude toward their pain and their life in general. This
change was brought about by developing an attitude that is based on living in the present
moment in a nonjudgrnental manner enabling insight into the nature and relationships
between thoughts, and sensations (e.g., pain) to develop. In order to develop this insight,
the focus of attention must shift from the continual stream of judgmental self-talk. This
shift enables the field of awareness to expand allowing the current flow of feelings and
thoughts to be observed and experienced in a nonjudgrnental manner. From this
perspective the present moment is able to be experienced without prejudice.

Participants in the mindfulness program attended 8 weekly 90 minute training

38

sessions (appendix E), and agreed to practice mindfulness meditation once per day for 45
or 20 minutes depending on their group assignment. Participants were given a
meditation log (Appendix F) to record the actual time they spent meditating each day.
The group size was between seven and ten participants per group. The program was led
by the principle investigator. Much of the emphasis of this program was on self-
responsibility (Kabat-Zinn, 1982). It was emphasized that participants must use and
develop their own internal resources for self-healing. The long-term perspective of using
mindfulness meditation in the healing process is also emphasized. The initial 8-week
program is viewed as only a first step towards gaining greater insight into their own
nature and the nature of the healing process.
The practice of mindfulness meditation in this program consisted of three

different techniques: (a) the body scan, (b) mindfulness on the breath, and (c) hatha yoga.

The body scan technique involved slowly sweeping the awareness throughout the body
and observing the different sensations with a non-judgmental awareness. Mindfulness on
the breath consisted of observing the respiration as well as the continual flow of thoughts
and feelings as they appeared and faded in awareness. Hatha yoga postures were used to
"reverse disuse atrophy of the musculoskeletal system while developing mindfulness
during movement" (Kabat-Zinn, 1982, p.36).

The general outline for the mindfulness program consisted of initially practicing

the body scan, followed by yoga and mindfulness of the breath meditation. During the

eight week sessions, instructions on the various meditation techniques were given as well

39

as didactic information on the psychology and physiology of stress and coping covered.
The background of the instructor of the mindfirlness training groups in this study was a
doctoral candidate in counseling psychology, and attended a training program led by
Kabat-Zinn in Mindfulness-Based Stress Reduction in Mind-Body Medicine during the
study. As recommended by Kabat-Zinn (Kabat-Zinn Personal Communication, July
1997) the instructor of the mindfulness groups in the this study had a daily mindfulness
meditation practice.
Instruments

The Beck Depression Inventory short form (Beck & Beck, 1972; BDI, Appendix
A) was used as a measure of depression. Due to the large number of inventories the
participants were completing in this study the short form of the BDI was chosen over the
standard form in an effort to keep response fatigue to a minimum. The BDI short form,
which uses 13 of the 21 items from the standard form BDI (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961), is self-report measure of the presence and intensity of
depressive symptomatology. For each item, the respondent is asked to choose which of
four statements describes the way he or she has been feeling in the past week, including
today. The items inquire about feelings of sadness, hopelessness, self-esteem, suicidal
ideation, interest, decision-making ability, occupational functioning, fatigue, and appetite.
Each participant's depression score on the short form is obtained by summing all of the
numbers associated with each statement that the subject endorsed. These scores range

flour 0 to 39. The BDI short form takes about 5 minutes to complete, with high scores

indicating increased depressive symptomatology. The estimated degree of depression
according to the BDI short form is: 04 none or minimal depression, 5-7 mild depression,
8-15 moderate depression, and greater than 16 severe depression (Beck & Beck, 1972).

Knight (1984) found the BDI short form to give an internal consistency reliability
of 0.81, and F oelker, Shewchuk, and Niederehe (1987) found an internal consistency of
.74 and .80 for two different samples. Scogin, Beutler, Corbishley, and Haman (1988)
concluded their study investigating the psychometeric properties of BDI short form with
older adults stating that it was adequately reliable to suggest its use as a research and
clinical tool.

With respect to validity of the BDI short form Doetch, Alger, Glasser and
Levenstein (1994) found that it correlated so well with the longer Geriatric Depression
Scale that they recommended it be substituted for it. Leahy (1992) conducted a principal-
component factor analysis with the BDI short form which indicated a two-factor model
for depression associated with bereavement. The first factor was affective and behavioral
components of depression and the second was cognitive. The BDI short form was also
found to correlate better with clinician’s ratings of depression than the BDI standard form
(Beck & Beck, 1972).

A combined approach of correlational analysis and clinician rating scores
determined which questions should be dropped from the BDI standard form to create the
BDI short form. The BDI short form was found to correlate 0.96 with the standard form

(Beck & Beck, 1972). The standard form of the BDI is a widely used 21-item self-report

41

measure of the presence and intensity of depressive symptomatology. Split-half reliability
estimates for the BDI (Beck, et al., 1961) have ranged from .53 to .93, while test-retest
reliability using normal undergraduates was reported to be .74 after 3 months and .75
after 1 month (Gallager, Nies, & Thompson, 1982). The items on the test are relatively
transparent, giving the BDI high face validity. Beck et al. (cited in Kolenc, Hartley, &
Murdock, 1990) reported validity estimates greater than .60 for relationships with clinical
assessments and at least .60 with other self-report measures of depression such as the
Minnesota Multiphasic Personality Inventory (MMPI) Depression scale and the Multiple
Affect Adjective checklist depression scale. Beck et al. (1988) also found acceptable
discriminant validity when reviewing numerous studies; the BDI consistently
differentiated normal and psychiatric samples.

State-Trait Anxiety Inventory for Adults (Spielberger, 1983, Appendix B) was
used to measure anxiety. It is comprised of two, 20 item self-report measures. One
measure is for state anxiety, and the other is for trait anxiety. The questions for both
scales are answered on a 4-point likert scale. Questions pertaining to state anxiety ask
how the person is feeling "right now, in this moment,” whereas those on the trait anxiety
scale ask how the person "generally" feels. Examples of questions on the state anxiety
scale include: "I feel calm,” "I feel nervous,” "I feel frightened.” Examples of questions
on the trait anxiety inventory include: "I feel pleasant,” "I feel inadequate,” "I am a steady
person.” Approximately half of the questions on the state and trait anxiety inventories are

reversed scored (i.e., on half of the items a high score represents high anxiety, on the

42

other half a high score represents low anxiety).

With respect to the reliability of the measure, the alpha coefficients ranged from
0.83 to 0.92 on the State Anxiety Inventory and 0.86 to 0.92 on the Trait Anxiety
Inventory (Spielberger, Gorsuch, & Lushene, 1970). With respect to validity, the Trait
Anxiety Inventory correlated 0.75 with the IPAT Anxiety Scale (Cattell & Scheier, 1963)
and 0.80 Taylor Manifest Anxiety Scale (Taylor, 1953). The validity of the State Anxiety
Inventory was deterrrrined by correlating it with the Mooney Problem Checklist (Mooney
& Gordon, 1950). The results indicated strong positive correlations for the aggression,
impulsivity and social recognition subscales. The STAI takes about 10 minutes to
complete with high scores indicating a more anxious symptomatology.

The Response to Loss Scale (RTL; gut-half) (Schneider, Deutsch, 1994,
Appendix C) is an inventory that describes how a person is reacting to a loss. It was used
in this study to measure how participants responded to the grieving process of a recent
self-identified loss. The split-half version contains 262 questions answered on a 5 point
likert scale. Seven subscales correspond to the different stages of grieving according to
Schneider's (1984) model. Each of these, with the exception of Transformation, are
measured on dimensions of: Behavioral, Cognitive, Emotional, Physical, and Spiritual
characteristics. The seven subscales with corresponding Cronbach alpha's are: (a)
Holding on (0.93), which is an attempt by the individual to overcome the loss by keeping
busy (behavioral), being angry (emotional), and believing that it is reversible (spiritual);

(b) Letting go (0.94), which involves responses that attempt to avoid the grief by drinking

43

(behavioral), doomsday thinking (cognitive), and pessimism, (spiritual), (c) Awareness
(0.97), which involves exhaustion (physical), longing (emotional), and emptiness
(spiritual), (d) Perspective (0.93) begins when the loss no longer feels like a crushing
burden, yet the grief is still clearly present, the person is able to relax (physical),
experience pleasure (emotional), and find meaning (spiritual); (e) Integration (0.95) is
recognized when there is a renewed sense of passion (physical), new relationships
(emotional), and forgiveness (spiritual), (f) Refonnulation (0.97), begins when the person
is self-confident (cognitive), spontaneous (behavioral) and more unconditionally loving
(spiritual), (g) Transformation (0.88) which involves a merge or blur of the five
dimensions with less distinction begins when the person has a greater sense of balance
wholeness and wisdom, and can see the interconnectedness of people and things more
clearly.

The reliabilities given are for the RTL long version which contains 520
questions. The items for the short version of the RTL were selected by taking the items
with the highest reliabilities from the long version. Reliabilities for the short version are
all approximately 0.90 (Schneider, personal communication, November 26, 1997).

In an attempt to determine the validity of the RTL, Picone and Hoogterp (1992)
correlated the RTL with the Beck Depression Inventory (Beck et al., 1961). The results
indicated strong positive correlations in the early stages of grieving and strong negative
correlations in the final stages of grieving. The construct validity of the awareness scale

of the RTL was demonstrated by McGovern (1983) who found that scores on the BDI

decreased as scores on the Awareness scale of the RTL increased. The RTL takes fiom
45 to 90 nrinutes to complete, with higher scores indicating greater intensity of grieving.

Statistical Analysis

 

The results from the pre-test measure of the BDI short fonrr, The State-Trait
Anxiety Scale, and the Response to Loss Scale split-half form were incorporated into an
Analysis of Variance (ANOVA) to determine initial group differences. An ANCOVA
was conducted with the group assignment (45 rrrinutes, 20 minutes, or control) serving as
the independent variable, and the post-treatment results fiom the BDI short form, the
State-Trait Anxiety Scale, and the Response to Loss Scale split-half form serving as the
dependent variables, while controlling for pre-treatment levels. Follow-up tests on
demographic variables were investigated (e.g., gender, pain intensity, SES). The criterion

for rejection of the null hypothesis was 0.10.

45

Chapter IV

Results

Introduction

This study investigated the effect of varying treatment duration in a mindfirlness
meditation program with chronic pain patients on levels of depression, anxiety, and
grieving. In this chapter a preliminary analysis of the data will be presented followed by a
restatement of eaCh hypothesis along with the results of the statistical analysis conducted
for each hypothesis. An exploratory analyses will also be conducted investigating the
relationship between actual meditation time and levels of depression, anxiety, and
grieving; and a complex comparison combining treatment groups and investigating
differences between receiving treatment and no treatment.

Seventy-one people seeking treatment for chronic pain participated in the study.
F itty-three participants volunteered to be in a treatment group and were randomly
assigned to either a 20 or 45 minute per day mindfulness meditation group. Eighteen
participants comprised a comparison group which received no treatment and only agreed
to complete the questionnaires. Thirty-nine of the original 53 participants in the
treatment groups completed the 8 week program. There were 40 women and 17 men who
completed the study. Forty three of the participants identified themselves as White,
European American, one as Black - African American, one as Chicana, one as Italian, one

as multicultural, one as Native American, and one as half American Indian and half

46

European American. The balance of participants did not identify their racial/ethnic

background.

Quantitative Results

 

This study employed three different quantitative measures, the Beck Depression
Inventory- Short Form (BDI), the State-Trait Anxiety Inventory, and the Responses to
Loss Scale split-half form (RTL). The overall measurement psychometrics for
participants who completed the program fiom all groups are reported in Table l.

The BDI is a 13 item measure with a range from 0 to 39. The STAI is a 20 item
measure with a range from 20 to 80. Consistent with previous research (Schneider &
Deutsch, 1997) the RTL was divided into two factors, Cope/Awareness (151 items) and
growth (99 items), each with a range from 0 to 1. The Cope/Awareness factor was made
up of the holding on, letting go and awareness subscales; and the Growth factor consisted
of the perspective, integration, and reformulation subscales of the RTL. The higher the
number, the greater the intensity of grieving.

An initial Analysis of Variance (ANOVA) was performed on each of the pre-
treatment measures to determine pre-treatment between group differences (the
assumptions for all statistical analyses can be found in Appendix G). This analysis
revealed no significant pre-treatment differences on any of the measures: BDI, F(2,56) =
.85,p < .43; State Anxiety, F(2,56) = 1.08, p < .346; Trait Anxiety, §(2,56) =.676, p <
.512; Cope/Awareness, F (2,39) =.43, p < .65; Growth, F(2,39) = .41, p < .66. However,

because the effect sizes between the groups were moderately large for some of the groups

47

(e.g., the effect size between the 20 minute group and the 45 minute group on the BDI
and the State Anxiety Inventory was d = 0.45), the post-treatment measures were
Table 1.

Means, Ranng and Reliabilities for Quantitative Inventories for Completers

 

 

Inventory N Mean SD Poss. Poss. Actual Actual Alpha
Min. Max. Min. Max.
Beck Depression
Inventory
Pre—Test 57 8.94 7.40 0 39 0 38 0.92
Post-Test 57 5.57 5.48 0 39 0 31 0.88
State Anxiety
Inventory
Pre-Test 57 45.59 11.92 20 80 20 73 0.93
Post-Test 57 38.22 10.84 20 8O 20 68 0.92
Trait Anxiety
Inventory
Pre-Test 57 47.24 11.90 20 80 22 69 0.93
Post-Test 57 41.26 10.15 20 80 22 65 0.92
Cope/Awareness
Pre-Test 40 0.38 0.14 0 1 0.13 0.75 0.97
Post-Test 40 0.29 0.10 0 1 0.11 0.54 0.93
Growth Pre-Test 40 0.58 0.16 0 1 0.24 0.91 0.96

Growth Post-Test 40 0.61 0.16 0 1 0.28 0.92 0.94

48

Table 2.

Means and Standard Deviations by Group and Inventory

 

 

Inventory Group N Pre-Test Mean Post-Test Mean
(SD) (SD)
Beck Depression 20 17 7.23 3.11
Inventory (5.41) (2.97)
45 22 10.36 5.77
(6.98) (4.15)
Compar. 18 8.83 7.66
(9.33) (7 .66)
State Anxiety 20 17 42.05 35.17
Inventory (1 1.04) (8.45)
45 22 47.36 47.31
(11.51) (11.06)
Compar. 18 46.77 42.22
(12.82) (11.90)
Trait Anxiety 20 17 45.05 38.52
Inventory (9.92) (8.00)
45 22 46.91 41.40
(13.94) (11.51)
Compar. 18 49.72 43.66
(11.08) (10.10)

49

 

 

Inventory Group N Pre-Test Mean Post-Test Mean
(SD) 48D)
Response to Loss 20 12 0.34 0.25
Scale
Cope/ Awareness (0.12) (0.08)
Factor
45 15 0.37 0.28
(0.11) (0.09)
Compar. 13 0.39 0.34
(0.17) (0.10)
Growth Factor 20 12 0.54 0.60
(0.16) (0.17)
45 15 0.57 0.59
(0.17) (0.12)
Compar. 13 0.60 0.63
(0.18) (0.19)

 

analyzed using an Analysis of Covariance (ANCOVA) controlling for pre-treatment
levels. The means, standard deviations, and ranges for the pre-treatment and post-

treatrnent measures across groups are listed in Table 2 .

would be a significant difference demonstrating a decrease in depression from the 45

minute treatment group to the 20 minute treatment group to the comparison group. The

50

The alternative hypothesis for this study with respect to depression was that there

results indicated that this hypothesis was partially supported. There was a significant
difference for depression, _F_‘ (2, 56) = 8.34, p <.001. Post hoc ANCOVAs revealed a
significant mean difference in the hypothesized, direction between the 20 minute group
and the comparison group, F(1,34) = 13.44, p < .001, and between the 45 nrinute group
and the comparison group, _F_‘(1,39) = 10.51, p < .003. However

there was not a significant difference between the two treatment groups, F0 ,3 8) = 2.46,
p <. 125.

The alternative hypothesis for this study with respect to state and trait anxiety was
that there would be a significant difference demonstrating a decrease in state and trait
anxiety from the 45 minute treatrrrent group to the 20 rrrinute treatment group to the
comparison group. Investigating the results with respect to state anxiety revealed that the
difference was not significant, however, it did approach statistical significance, F_(2,56) =
1.95, p < .15. The difference with respect to trait anxiety was not significant, F (2,56) =
0.49, R < .614.

Consistent with previous analyses (Schneider & Deutsch, 1997), the RTL was
divided into two factors, Cope/Awareness and growth. The first factor, Cope/Awareness,
incorporates questions that consider the initial phases of grieving, and consists of
questions focused at developing greater awareness of what is lost. Higher scores on this
factor reflect a higher intensity in the beginning phases of the grieving process. The
second factor, growth, involves questions that consider what is left after the loss and what

is now possible. Higher scores on this factor indicate that the loss has been more deeply

51

integrated. Analysis of the raw data indicated that a number of participants completed the
262 item questionnaire leaving many items either blank, or with a "0" response indicating
that the item in question "isn't true about my current response to this loss.” If over half of
the items were left blank, or with a zero response, the questionnaire was considered
invalid for the purposes of this analysis. Seventeen questionnaires were determined
invalid using this procedure. Some possible reasons for incomplete questionnaires (or
with excessive "0" responses) might include a participant selecting a loss that was not
very significant to them, or the possibility of response fatigue because this was the last
questionnaire in the packet and is quite lengthy (262 items).

The alternative hypothesis for this study with respect to the Cope/Awareness
factor was that there would be a significant difference demonstrating a decrease on the
Cope/Awareness factor from the 45 nrinute treatment group to the 20 minute treatment
group to the comparison group. The results of the analysis with respect to the first factor,
Cope/Awareness, indicated a significant difference in the hypothesized direction, F(2,39)
= 3.3, p < .05. Post hoc analysis revealed significant differences in the hypothesized
direction between the 20 minute group and the comparison group, 130,24) = 5.49, p < .02,

while the difference between the 45 minute group and the comparison group approached
significance, F (1,27) = 3.47, p < .07. However, there was no significant difference
between the two treatment groups, F (1,26) = 0.51, p < .48. These results indicate that,
controlling for pretreatment differences, the intensity of the initial stages of grieving at

post-treatment was less for the 20 minute treatment group compared to the comparison

52

group.

The alternative hypothesis for this study with respect to Growth factor was that
there would be a significant difference demonstrating an increase in the Growth factor
from the 45 minute treatment group to the 20 minute treatment group to the comparison
group. The results of the analysis of the Growth factor on the RTL demonstrated no
significant differences between groups, F(2,39) = 0.347, p_< .709.
Completors vs. Drop-outs

Drop-outs were defined as those who completed the initial questionnaire and who
attended at least one session, but then failed to complete the program or any other
questionnaires. Most of the participants who dropped out of the program elected to do so
by the third session, with no one dropping-out after the fourth session. Therefore, if a
participant completed more than half of the program that person finished the study.
Investigating which group the drop-outs attended revealed that ten were from the 20
minute treatment group and four were from the 45 rrrinute treatment group. A Chi Square
analysis revealed significant between group drop-out differences X2(l, N=14) = 2.57, p <
.10. Analysis of Variances (AN OVA) of the pre-treatment data were conducted to
determine if there were any differences between those who completed the program and
those who dropped-out. In this analysis the two treatment groups where combined. The
results of these analyses revealed significant differences on State Anxiety, F( 1,52) = 2.83,
p < .09, and the on the Cope/Awareness factor, F(1,35) = 3.04, p < .09. In order to

investigate this difference on the Cope/Awareness factor more closely, AN OVAs were

53

performed on its three Cope/Awareness factor subscales of holding on, letting go, and
awareness. This analysis revealed significant differences on the first two stages, holding
on, 5(1 ,47) = 4.99, p < .03, and letting go, F(1,47) = 3.41, p < .07, but not on the third
stage, awareness, F (1,46) = 1.02, p < .31. Therefore, those who dropped out of the
program were significantly higher on the first two stages of the Cope/Awareness factor
but not on the third.

Qualitative Data

 

The participants in the treatment groups completed an open-ended questionnaire
containing three questions (Appendix H). The questions along with the response
frequencies are given in Table 3. The first question asked what changes the participant
has noticed, since starting the treatment, in their ability to cope with pain and cope with
their life in general. The second question asked if they noticed any differences in their
meditation practice when they meditate more as opposed to meditate less. The third
question asked if they noticed any differences in their daily life when they meditate more
as opposed to meditate less. The data from these questionnaires were coded by the
investigator. For example, responses that stated that the treatment allowed one to be less
judgmental, or that it increased awareness, were grouped under the heading of increased
mindfulness. The data were coded by grouping similar statements for the same question.
The coding was done while blind with respect to which treatment group a particular

response was from. It is important to note that the investigator who coded the data also

54

Table 3.

Response Frequencies to Open-Ended Questionnaire.

 

 

 

 

Group
Question Response 20 nrin 45min
Coping with pain
increased mindfulness 8 16
(47%) (73%)
less reaction to pain 4 3
(23%) (14%)
less actual pain 3 4
(18%) (18%)
increased peace/less stress 1 3
(6%) (14%)
no difference 1 1
(6%) (4%)
coping with life in general
increased mindfulness 2 4
(12%) (18%)
less reactivity 6 5
(35%) (23%)
increased peace/less stress 1 6
(6%) (27%)
improved self-esteem 3 2
(18%) (9%)
improved ability to 2 0
forgive (12%) 0%)
improve ability to sleep 0 2
(0%) (9%)

55

 

Group

 

Question Response 20 min 45min
differences in meditation
practice with respect to time
longer meditations better 5 7
(30%) (32%)
shorter meditations better 1 2
(6%) (9%)
less pain with longer 0 2
(0%) (9%)
differences in life in general
with respect to time
longer meditations better 5 8
(30%) (3 6%)
no difference 1 1
(6%) (4%)

 

instructed the participants in mindfulness, and therefore may have inherent biases with

respect to concluding “increased awareness,” or “more mindfulness.” It is also important

to note that there were five more participants in the 45 nrinute group than in the 20

minute group, and that response frequencies were very low, therefore, these data should

56

not be emphasized in determining group differences.
In general, the qualitative data did not demonstrate a clear difference between the

20 and 45 minute groups. A noteworthy exception is in the categories of mindfulness and
increased peace/less stress. When participants were responding to both coping with pain,
and with their life in general, at least double the number of responses indicating increased
mindfirlness and increased peace/less stress came fi'om participants in the 45 minute
group. Similarly, although the number of respondents mentioning improved sleep and
less pain with more meditation was very low (N=2), both were fiom the 45 nrinute group.
With respect to more or less meditation being better, the 45 minute group favored longer
meditations when responding with respect to their meditation practice, whereas twice as
many participants in the 45 minute group noted improvements in their life in general
when they meditated longer rather than less. In addition, both groups indicated that they
preferred longer meditation times.

Exploratory Analyses

In an effort to determine how much participants actually meditated, the meditation

logs for each group were averaged. The participants in the 20 minute group averaged 971
total minutes or 19.8 minutes per day, while those in the 45 minute group averaged 1608
total minutes or 32.8 nrinutes per day. To determine if total meditation time was related
to any of the outcome variables, a partial correlation analysis was performed between
actual meditation time and all of the outcome variables controlling for pretreatment

variables. This analysis revealed no significant correlations between actual meditation

57

time and the BDI ( r = .27, p = .13), State Anxiety Inventory (r = .02, p = .91), Trait
Anxiety Inventory ( r = .16, p = .37), Cope/Awareness factor (r =-.05, p = .82), and the
Growth factor ( r = .03, p = .89).

In order to investigate the differences between receiving treatment and no
treatment, a complex comparison was constructed by collapsing the 20 and 45 minute
groups, and an AN COVA was conducted investigating differences between the treatment
group and the comparison group while controlling for pre-treatment differences. The
results of these analyses revealed significantly lower mean differences favoring the
combined treatment group on the BDI, _F( 1,56) = 16.08, p < .001, State Anxiety
Inventory, _F_‘(1,56) = 3.94, p < .052, and the Cope/Awareness factor of the RTL, E(l,39) =
6.18, p < .018. Nonsigrrificant differences were found between the treatment group and
the comparison group on the Trait Anxiety inventory, F(1,56) = .39, p < .53, and the
Growth factor of the RTL, {(1,39) = .06, p < .8.

In order to determine generalizability of the results, and if other variables might
have interacted with the above results, exploratory analyses were completed with respect
to gender, pain intensity and SES. An exploratory analysis of the influence of gender
revealed a significant interaction between group and gender for depression when pre-
treatment depression levels were controlled for, §(1,56) = 2.59, p < .085. However, there
were no significant interactions between group and gender for any of the other measures.

Investigating mean values of the group by gender interaction for depression (see Table

4), suggests that the treatment was more effective in lowering depression in women as

58

compared to men. It is important to interpret this interaction cautiously because some of

the cell sizes are very small. For example, in the 20 rrrinute group there were only 4

males.

Table 4.

goup by Gender Interaction for Beck Depression Inventory.

 

 

 

Group
E Gender 45 20 Comparison
Male 6.33 3.75 7.71
(5.39, 6) (2.87, 4) (10.42, 7)
Female 5.56 2.92 7.63
(3.78, 16) (3.09, 13) (5.89, 11)

 

Note. Values are the mean post-treatment Beck Depression Inventory scores for each

cell

(Numbers in parenthesize denote standard deviation and cell size)

An exploratory analysis of the interaction between pain intensity and group on the

59

 

outcome variables, controlling for pre-treatment levels, revealed a significant interaction
between group and pain intensity on the Cope/Awareness scale of the RTL, _F_(1,31) =
1 .88, p<.07. The regression lines for this interaction are demonstrated in Figure 1.
There where no other interactions between group and pain intensity on any of the other
outcome variables.

Because it might be hypothesized that participants in higher SES groups may be
more educated and grasp the conceptualizations of mindfulness more quickly, a follow-up
analysis of the influence of SES on outcome also was investigated. SES was determined
through prestige status ratings (Stevens & Hoisington, 1987). Ratings ranged from 15.60

(News Vendor) to 81.09 (Physician). Because the data from these ratings were not
linearly distributed (i.e., they were skewed from the lower end of the distribution,
indicating that most of the participants were from a lower SES group) the ratings were
divided into 3 equally sized groups based on the frequency distribution of scores. The
results of separate AN COVAs revealed no significant interaction between group and SES
on any of the measures (BDI, F [2,42] = .25, _p < .251, State Anxiety Inventory, _F_[2,42] =
.81, p < .45, Trait Anxiety Inventory, 212,42] = .96, p < .39, Cope/Awareness factor,
F[2,30] = 2.38, p < .113, Growth factor, fl2,50] = .47, p < .63).
During the second half of the data collection, it was determined that it would be
helpfirl to know how many participants in the comparison group would be interested in
(axing a mindfulness meditation program, and if they were interested, what length of

intervention they would prefer ( 20 or 45 rrrinutes per day). Of the 11 participants who

 

responded to this question, 10 indicated that they would not be interested in taking a
mindfulness meditation course; the one participant who was interested preferred a 45

minute group.

61

ssauar saw/odes

 

GROUP

0 Comp

 

20m

n45!“

 

 

 

 

Pain Intensity

Figure 1. Pain intensity by group interaction for CopelAwareness

62

Chapter V

Discussion

Chronic pain is a severely difficult disorder, striking one in five people in
Michigan (Anstett,1997). This experience of intense prolonged pain has more than just
physical ramifications, rather it affects a person on all dimensions of their life. The added
psychological stress of managing the physical pain, coupled with the severe losses that
often include careers, relationships, and hobbies, can make this an overwhelming
experience. Therefore, interventions that help people better cope with chronic pain are
desperately needed.

Recently, a number of studies have been published citing the effectiveness of
mindfulness meditation in helping people cope more effectively with a variety of
stressors. More specifically, Kabat-Zinn et al. ( 1985, 1992) have demonstrated
significant reductions in depression and anxiety with participants diagnosed with anxiety
disorders and with chronic pain using a mindfulness meditation program. One of the
major requirements in Kabat-Zinn's mindfulness meditation program is a commitment for
participants to practice 45 minutes per day. For two primary reasons this commitment
may be too demanding for some people. From a pragmatic perspective, many people do
not have 45 minutes available to them to commit to the practice. With dual income
families becoming the norm in the current culture, along with other commitments, adding

an extra demand of meditating for 45 minutes may steer people away from a program that

63

could potentially help them. From a psychological perspective, attempting to sit quietly
for 45 minutes may be rather difficult. For people who are very active or who may be
suffering from a recent loss, depression, or anxiety, sitting still with the awareness
focused inwards for 45 minutes may initially appear too overwhehning, and detract them
from participation in the program.

The purpose of this study was to investigate the effect of varying the treatment
duration in a mindfulness meditation program with chronic pain patients. Participants
were randomly assigned to one of two treatment groups. In one group, participants were
assigned to meditate 20 minutes per day, while in the other participants were assigned to
meditate 45 minutes per day. There was also a comparison group composed of
volunteers seeking treatment for chronic pain who agreed to complete the questionnaires
at the pre- and post-treatment intervals (8 weeks), but who did not receive any treatment.
The treatment consisted of attending eight weekly sessions and agreeing to practice
mindfulness meditation for the assigned amount each day (20 or 45 minutes). The
weekly sessions consisted of instruction and practice in mindfulness meditation along
with a group discussion on integrating the practice into coping with pain and with daily
stressors. Participants were also requested to keep a daily log of their actual meditation
times. The questionnaires consisted of a depression measure (BDI-Short Form), a
measure of state and trait anxiety (STAI), and a measure of stages and intensity of
grieving (RTL).

Seventy-one people seeking treatment for chronic pain participated in the study.

64

Fifty-three comprised the treatment group and 18 the comparison group. Fourteen people
dropped out of the study, with all of them doing so by the fourth session. Consequently,
if a person attended more than half of the weekly meetings, they finished the program.
Therefore, people appeared to realize relatively quickly if mindfulness meditation was
worthwhile for them. Analysis of the data on the pretest measures investigating
differences between those who dropped out of the program as compared to those who
completed it indicated that drop-outs demonstrated significantly more state anxiety, and
more intensity in the beginning stages of the grieving process.

It is interesting to note that drop-outs did not differ significantly from those
completing the program on depression, but they did differ on the initial phases of
grieving, and on state anxiety. This finding may support Levine’s (1994 ) theory
regarding initial experiences in meditation. Levine (1994) argued that the initial personal
issues that present when one undertakes a mindfulness meditation program are those
related to grief. Because drop-outs did not report a significant difference in depression
from completors, there appears to be a distinction between the experience of the initial
phases of grieving and depression that may influence one's ability to complete an 8 week
mindfulness meditation program. Therefore, it might be too difficult for many people to
sit still with increased awareness of their internal experience while in the initial phases of
grieving. This nright also be reflected by the significant difference in state anxiety
between dropouts and completors. Schneider (1994) has theorized that in the initial phase

of grieving the response is to limit the awareness of the loss through fighting the loss and

65

keeping very busy (holding-on), or by minimizing the significance of the attachment to
the lost object, person, or the feelings that accompany the loss (letting-go).

One recommendation that might be suggested from these results is that a
screening assessment be developed using the questions from the RTL corresponding to
the first stage of grieving, holding on and letting go. Potential participants who score
high on this assessment might be advised to seek an alternative form of treatment before
attempting an 8 week mindfulness meditation group.

Analyzing the pre-treatment data on all measures indicated no significant between
group differences. However, the pre-treatment effect sizes between groups of differences
were moderately large. For example, the effect size between the 20 minute group and the
45 minute group on the BDI and the State Anxiety Inventory was (I = 0.45. Therefore, to
account for these moderate, albeit, non-significant differences the post-treatment data
were analyzed controlling for pre-treatment differences.

Hymtheses

The alternative hypothesis for this study was that there would be a significant
difference between the comparison group and the treatment groups, and that there would
be a significant difference between the 20 minute treatment group and the 45 minute
treatment group on measures of depression, anxiety, and grieving. More specifically, it
was hypothesized that longer meditation periods would result in a healthier outcome
reflected in lower depression, anxiety, and intensity in the initial phases of grieving

(coping), and increased intensity in the final stages of grieving (growth). The

66

results indicated that this hypothesis was partially supported. There were significant
differences for depression and the Cope/Awareness factor of grieving. Post hoc analysis
of the BDI revealed significant differences between the 20 minute treatment group and
the comparison group, and between the 45 minute treatment group and the comparison
group. These differences were in the hypothesized direction.

The significant differences between the treatment groups and the comparison
group on the BDI indicates that, for people seeking treatrrrent for chronic pain,
participation in an 8 week mindfulness meditation program that incorporates a daily
meditation of at least 20 rrrinutes may result in significantly lower levels of depression.
This finding is consistent with Kabat-Zinn et al. (1985) who found reductions in
depression for those who participated in a mindfulness meditation program compared to a
comparison group seeking other traditional treatments for chronic pain. However, there
was not a significant difference between the two treatment groups. This indicates that
with respect to depression, longer meditation time may not make much difference. There
might be a plateau that is reached so that practicing some minimal amount, at least 20
minutes per day in the present study, leads to new awarenesses that reduce depression, yet
practicing for longer periods does not result in additional significant decreases. In other
words, longer meditations may not give added benefit with respect to depression over an
8 week period. However, it is important to note that the 8 week mindfulness meditation
program is just an introduction to the technique, and that increased benefits of longer

meditation periods resulting in greater drops in depression may appear over months or

67

years of practice.

As suggested by the correlation of depression and time it is also possible that
longer sittings may allow more troubling emotions into awareness, and therefore inhibit
some of the lowering of depression. Carrington (as cited in Mead, 1993) has commented
that, for some people, meditating longer than 15 minutes of Clinically Standardized
Meditation (CSM) may lead to adverse side affects, and therefore, it is preferable to “err
on the side of under meditation rather than risk any build up of stress in the meditator”
(Carrington, 1978, p. 108). Although, CSM is a more concentrative form of meditation
than mindfulness meditation in that it employs a mantra, it does share many of the same
characteristics. Carrington (1993) also recommends beginning with shorter meditations
starting as low as 10 nrinutes per day. However, inspecting the raw data in the present
study with respect to high scores on the BDI indicated that there were no increases in
depression over the course of treatment. More specifically, higher depression levels
dropped, while some very low depression levels slightly increased (e.g., below 2 on pre-
treatment to 4 at post-treatment on the BDI). These lower scores increasing from pre-
treatment to post-treatment might be due to becoming more mindful of issues that were
previously held just outside of awareness, and therefore might be considered positively.
It is also possible that these slight increases reflect error variance.

The hypotheses with respect to State and Trait Anxiety were not supported. The
results of the State and Trait Anxiety Inventories did not demonstrate a significant

difference between the three groups. However, when the treatment groups were

68

combined and compared to the comparison group, there was a significant difference
between those who meditated and those who did not on State Anxiety. This finding is
supported by Kabat-Zinn et al. (1985) who found lower levels of anxiety in chronic pain
patients who participated in a mindfulness meditation program requiring 45 rrrinutes per
day when compared to those in a comparison group who did not meditate at all. One
possible explanation for not finding a difference between the treatment groups is that
initial levels of anxiety for the participants in this study might have been too low, and
therefore created a floor effect.

Investigating the between group differences on trait anxiety indicated that there
were no significant differences between any of the groups. It is difficult to compare these
results with previous research comparing treatment to non-treatment groups of chronic
pain patients because only one other study reviewed employed the STAI. For example
Kabat-Zinn et al. (1985) determined anxiety levels with the SCL 90 which asks
participants to complete the inventory according to how they felt over the past week. The
Trait Anxiety Inventory instructs participants to complete the measure reflecting how
they "generally feel" while the State Anxiety Inventory instructs participants to complete
it reflecting how they are feeling "right now, that is, in this moment.” Therefore,
apparent inconsistencies of these results with previous research may be partially due to
measuring different aspects of anxiety.

Consistent with previous research (Schneider & Deutsch, 1997), the RTL was

69

divided into two factors. The first factor, Cope/Awareness, incorporated the first 3 stages
of Schneider's (1994) model of grieving, holding on, letting go, and awareness. The RTL
asks participants to select a recent loss and complete the questionnaire in response to this
loss. Examples of questions that make-up the first factor, Cope/Awareness, consist of,
"since the time of the loss: ‘I keep active’, ‘I avoid being alone’, ‘the tears are hard to
stop’, ‘I lose track of what is going on’.”

The second factor, growth is made up of the fourth, fifth, and sixth stages of
Schneider's (1994) model of grieving, perspective, integration, and self-empowennent.
Examples of questions from this factor consist of, "since this loss happened: ‘being by
myself has been healing’, ‘I've already passed the lowest point’, ‘I've changed in ways
that would not have happened otherwise’, ‘I am more open to possibilities.”’ Participants
were instructed to complete the RTL at post-test using the same loss they selected at pre-
test so that a measure of how they progressed through the stages of grieving may be
obtained.

The hypothesis with respect to grieving was partially supported. There was a
significant difference in the hypothesized direction for the Cope/Awareness factor, but
there was not a significant difference for the Growth factor. Analysis revealed a
significant difference between the 20 nrinute group and the comparison group. This
suggests that those who participated in the 20 minute treatment progressed through the
initial phases of grieving more than the comparison group. The difference between the

45 minute group and the comparison group approached significance. There were no

70

statistically significant differences between the 20 and 45 minute groups. When the two
treatment groups were combined there was a difference in the hypothesized direction for
the Cope/Awareness factor but not for the Growth factor. One possible reason for not
finding a difference between treatment groups on both the Cope/Awareness and Growth
factor and between the combined treatment group and the comparison group on the
Growth factor might be similar for the reason cited for not finding a difference between
treatment groups for depression. That is, longer meditation times may allow more
unresolved grief into awareness which will take longer to resolve.

The decrease of intensity in initial phases of grieving for the participants in the
combined treatment group as compared to those in the comparison group appears to
support Levine’s (1994) theory that the first issue that presents when a meditation
practice is undertaken is grieving. Mindfulness may enable the loss issue to be more
fully grieved because it fosters a non-judgmental attitude of emotional and cognitive
material, thereby reducing defenses such as intellectualization, rationalization, and
denial. This result may be related to the finding in the present study that drop-outs
demonstrated significantly more intensity in the beginning stages of the grieving process
and in state anxiety. A possible explanation for this is that drop-outs may not have been
ready to increase their awareness of a loss they were grieving. Schneider (1994) has
commented that in the first stages of grieving, defensive attempts are made to minimize
awareness of the loss in an effort to lessen its emotional impact. Because mindfulness

increases awareness, a person who may already be emotionally overwhelmed, may,

71

consequently discontinued their participation in the program. Therefore, beginning a
mindfulness meditation practice during the very early phases of grieving may increase
anxiety above an already elevated level and is not recommended. However, the current
study did find that once the loss begins to be integrated, rather than defended against, a
mindfulness meditation practice may be helpful in progressing through grieving more
quickly. Future research might explore using the RTL as a screening instrument for
mindfulness programs. Participants who demonstrate high scores on the holding on and
letting go sub-scales should be recommended to seek alternative treatments, such as
individual therapy, group therapy, or a support group focused on their loss issue(s) prior
to undertaking a mindfulness meditation program.

Another possible explanation for the decrease in the initial stages of grieving
while not also realizing a significant increase in the Growth aspects of grieving may be
that moving from the initial stage of grieving, (determining what is lost) to the Growth
stage (determining what is left) may not be a clear stage-wise progression. This is
consistent with Schneider's (1994) theory which states that although the stages are
organized in a linear fashion, “people do not go through a linear progression of grief
stages... we go through the grief process many times, often cycling through the same loss
several times as we get new information or a new perspective”(p. 66). The increased
awareness fostered through mindfulness meditation may offer this “new information or

new perspective” which may instigate a recycling of the initial stages of the grieving

72

process, and therefore minimize progression into the growth stages of grieving. The
significant drop of intensity in the Cope/Awareness stage of grieving for those in the
treatment groups may reflect this recycling. However, Schneider (1994) does propose
that “in the larger picture there is a progression toward integration and growth”(p. 66).
Schneider (1994) also comments that entering into the full awareness of what is lost, the
first stages of grieving, are “the most painful, lonely, helpless, and hopeless times we will
ever face” (p. 158), and therefore the most difficult. Thus, it may take considerable time
to move through the initial stages of grieving, and once this happens there may not be an
immediate increase in the growth phase. Future research might profit fiom conducting a
follow-up study after several months or years to determine if mindfulness may indeed
accelerate the growth aspects of grieving. Another possible influence for the non-
significant change in the Growth factor might be due to participants entering the study
with already elevated levels on the Growth factor due to them being in treatment for
chronic pain. Participants for this study were recruited fiom a multidisciplinary pain
clinic. Therefore, they may already have elevated levels on the Growth factor due to this
treatment, leaving little room for change in the eight week time span of the present study.
For example, the pre-treatment intensities were all above 0.54, 0.15 points higher than
any of the Cope/Awareness factor's intensities.
Qualitative Data

The qualitative data were collected fiom an open-ended questionnaire containing

three questions (Appendix G). The responses were coded into different categories by the

73

investigator who also taught the mindfulness meditation classes, consequently there may
be some biases in the manner the data were grouped. It is also important to note that the
small number of responses in each category (see Table 3), and the differing numbers of
people in the groups minimize the confidence of conclusions drawn from this data. Initial
examination indicated no clear differences between the two groups. However, it is
interesting to note that when asked how the meditation program assisted in coping with
both pain and life in general, the 45 nrinute group had more than double the responses to
categories that related to increased mindfulness and more peace/less stress. In addition,
although only two people indicated that their mindfulness practice helped them get to
sleep more quickly, they were both from the 45 minute group. Both treatment groups
indicated that they preferred longer meditation times, a finding supported by Kabat-Zinn's
(1997) theory. This theory differentiates between two purposes of meditation. One
popular and effective use of meditation is as a relaxation exercise, the second is using
meditation as a means to gain deeper insight into the nature of thoughts and feelings and
the relationship between the two (i.e., increased mindfulness). For example, if meditation
is practiced for a shorter period of time, a reversal of the stress response might occur and
a pleasant relaxation may be experienced (the “relaxation response”). However, if
meditation is continued beyond achieving relaxation, there is an opportunity to observe
more clearly cognitive and affective pattenrs, rather than react in a habitual or addictive
manner to given cognitive or affective stimuli. In addition, the longer meditation period

gives more time to calm cognitive processes which will often carry over into daily life.

74

Therefore, longer meditation periods may increase the effectiveness of responding
mindfully to stressfirl situations with respect to pain and daily life.
Drop-out Rates

Investigating the between group differences between drop-outs indicated that
significantly more participants dropped out of the 20 minute group compared to the 45
minute group. A possible explanation for this finding might be that the longer meditation
time gives more favorable results (not noticeable on the measures used in this study), and
therefore has fewer dropouts. Another possible explanation is that the longer meditation
time leads to a quicker realization of the benefit of the practice, and therefore fewer
dropouts, but these results may plateau midway through the program allowing those in
the shorter meditation group time to “catch up” during the later stages of the program.
Another possible explanation is that there are benefits to meditating longer that the
outcome measures used in this study did not represent. It is possible that longer practice
times improved such characteristics as mindfulness, peace and sleep, and lowered stress
as indicated by the qualitative data. It is important to interpret this finding cautiously
because the number of dropouts was small (N=14).

In an attempt to determine if the amount of overall time influenced any of the
outcome variables, the relationship between the total meditation time over the course of
the program calculated from the participants’ meditation logs and the outcome variables
were explored. There was no relationship between total amount meditated over the

course of the program and any of the outcome variables. Combining these results with

75

the complex comparison analysis indicates that with respect to the quantitative data what
appears most important is that a person meditate at least 20 minutes per day. Longer
meditations may be more beneficial as reflected in the qualitative data, and the dropout
rates, but these results may be too subtle to be indicated on the qualitative measures.
Interaction Effects

The influence of gender and SES on the outcome variables was analyzed to
determine if these variables might have interacted with the treatment. The results
indicated that women appeared to have greater drops in depression over the course of
treatment as compared to men. However, these results should be interpreted cautiously
because there were only 10 men compared to 29 women in the treatment groups. This
enrollment gender difference is not unique to this study. Kabat-Zinn et al. (1984) also
had an enrollment gender difference with twice as many women than men enrolling in a
mindfulness meditation program. These results might indicate that women prefer, and
improve more with a more passive or receptive form of treatment such as mindfulness
meditation than men with respect to depression. Nolen-Hoeksema (1987) found that men
tend to lessen their depressive symptomatology by distracting behaviors, but women are
more likely to amplify their depressed mood by ruminating behavior. In addition, Butler
and Nolen-Hoeksema (1994) found that when rumination style was controlled for gender
was not a predictor of depression. Therefore, rumination and not gender appears to be
what might differentiate depressive symptomatology in men and women. The

attractiveness and efl‘ectiveness of mindfulness meditation for women might be in that it

76

 

inhibits a ruminative coping style. For example, whenever a participant becomes aware
that they are ruminating they are instructed to change the focus of their attention to the
breath or a body part. Nolen-Hoeksema (1998) concluded that those who use a
ruminative style of responding to their initial symptoms of depression will have longer
and more severe episodes of depressed mood than those who have more active or less
ruminative styles.

Another possible explanation for these gender differences is in different styles of
relating. Sethi and Nolen-Hoeksema (1997) found that women tend to be more relation
focused than men. Therefore they might find it more difficult than men to take time out
for themselves. They rrright judge taking this time as being self-fish and experience
feelings of guilt. By taking this course they were instructed to take up to 45 minutes per
day for self-nurturence. Being part of a research study might have enabled them to
overcome possible feelings of guilt and take care of some of their own needs.

There was also a significant interaction between pain intensity and the initial
stages of grieving. This demonstrated that for people who have higher pain intensities
longer meditation times might be more beneficial in moving through the initial stages of
grieving than shorter meditation times. A possible explanation for this might be that the
longer meditation time might be needed to offer more of an opportunity to develop
insight into beliefs and reactions to pain due to higher pain intensities. Schneider has
stated that one begins to work through the initial phases of grieving when awareness of

the lost issue is increased. It is possible that prior to learning mindfulness participants

77

with higher pain intensities used distraction techniques more than participants with lower
pain intensities to deal with uncomfortable emotional and physical experiences.
Participants with greater pain nright use more distraction from all feelings and sensations,
including feelings related to unresolved loss issues. Therefore, longer meditation times
might be recommended for those with higher pain intensities due to a possible inclination
to use more awareness limiting techniques such as distraction. Those with lower pain
intensities might not realize the same benefits with more practice due to a possible
plateau being reached in the initial phases of working through unresolved grief issues.

Because it is conceivable that education, income, or occupational prestige might
influence the results an investigation of the relationship between group assignment and
SES on the outcome variables was conducted. The results indicated no significant
interactions. Therefore, education, occupation, or status does not appear to influence the
outcomes fi‘om learning and practicing mindfulness meditation.
Limitations and Future Research

One of the limitations of this study was the small sample size. It is possible that a
larger sample size might have been more representative of this population. This is
especially noteworthy with respect to the representation of minorities in this study.
Because some minorities are subject to increased stress due to being in the minority
(Jackson & Sears, 1992), mindfulness meditation programs incorporating representatives
from a broad array of minority groups is essential. Ifthe power of mindfulness

meditation is going to be utilized to make significant changes in the quality of a culture,

78

programs are going to have to incorporate more minority groups. Future research could
follow Roth and Creaser’s (1997) lead and offer programs in minority neighborhoods that
are modified to fit the specific needs of that culture (e.g., child care, bilingual
instructional tapes and instructors, tape player loans). The low representation of
minorities in this study is probably due to the type and location of pain clinic where this
study took place. Because participants were recruited for this study through
psychologists at this clinic, the sample population reflected that of the clinic.

Another limitation of this study was the complete reliance on self-report data.

The participants might have given a response in a biased manner due to their feelings
towards the researcher or research in general. For example, if a participant was
attempting to be a “good research participant” or desires to “look good” they might have
answered the questions in a more positive manner. Conversely, a participant might have
answered the questions in a negatively biased manner if they did not like the researcher or
research in general, or as a “cry for help.” Using data collection methods other than self-
report might help eliminate these biases.

Another limitation of this study is the use of a comparison group rather than a
randomly selected control group consisting of people who would be interested in taking a
mindfulness meditation program. Although the comparison group used in this study
consisted of people seeking treatment for chronic pain, they did not necessary express an

interest in taking a mindfulness meditation program. Of the 11 members of the

comparison group questioned, only one expressed interest in participating in an 8 week

79

meditation course. Consequently, this is a difference between treatment and comparison
groups and limits the internal validity of the study.

Another limitation of this study was the depth of the qualitative data. Although
the data fi'om the questionnaire did seem to support differences in the hypothesized
direction, the nature and size of the data collected severely limited any conclusions that
could be drawn from the participants’ responses. A recommendation for future research
that investigates varying meditation periods is a more extensive use of qualitative data.
This could also validate the categories developed from this study. It seems apparent that
if there are differences on the outcome variables used in this study with respect to varying
treatment duration, they are difficult to discern on paper and pencil inventories.
However, if an interview format of data collection were used that allowed for follow-up
questions, the potential for discerning differences between shorter and longer meditation
times might be increased.

Future research might follow-up on the results with respect to meditation and
grieving. More specifically, studies could modify the Response to Loss scale to serve as
a screening assessment for mindfulness meditation programs. Prospective participants
who score high in the first stage of grieving might be referred for an alternative form of
treatment prior to participation in this type of program. In addition, firture research could
employ 6 month or year long follow-up studies to investigate the aspects of grieving

more completely than accomplished in the present study.

80

Conclusion

The purpose of this study was to determine what the differences were when the
length of meditation is varied in a population of chronic pain patients. The results of this
study indicated that there might be an advantage to longer meditation times with respect
to increasing mindfulness, and peace, lowering stress, and completing a mindfulness
program. In addition, women may prefer meditation, and benefit from it more with
respect to depression than men. No advantage was found between the treatment groups
with respect to depression, anxiety, or the factors associated with grieving. These results
are not consistent with Smith et al. (1995) who did find a difference on symptom
measures between those who meditated frequently as compared to occasional meditators.
However, frequent meditation in that study was defined as more than three times per
week. One possible reason for not finding significant differences on these measures was
that the measures employed were not sensitive enough to tap the differences between the
two treatment groups. Indeed, although the number of responses on the qualitative data
were small, there did appear to be more indication of mindfulness being helpful in coping
with pain and life in general from those in the longer meditation group. There was also a
slight indication of increased ease in sleeping by those in the 45 minute group, and that
both groups preferred longer meditations.

Another possible reason for not finding differences between treatment groups is
that increased meditation time, above a threshold level (e.g., 20 minutes per day) does not

make a significant difference on depression anxiety and grieving. Carrington et al.

81

(1980), did not find a difference between fiequent and occasional meditators on symptom
improvement. However Carrington et al. (1980) did find a difference between frequent
and occasional meditators on statements by participants indicating improved social
relationships, more satisfaction from the practice, and that the practice was more valuable
them. Therefore, the results of the present study are very consistent with Carrington et al.
(1980), in that the present study also did not demonstrate a difference between length of
meditation time and symptom improvement, but there was a difference with respect to
participants statements indicating increased mindfulness, peace, less stress, and higher
completion rates by those in the longer meditation group. The higher completion rate in
the 45 minute group could reflect, as in Carrington et al. (1980), that these participants
found the practice more satisfying and valuable. Moreover, both groups in the present
study indicated that they preferred longer meditations.

A major result of this study, and consistent with Kabat-Zinn et al. (1985), was
that for people suffering from chronic pain, a mindfulness meditation program
incorporating a daily meditation period of at least 20 minutes can be effective in helping
to reduce depression, and state anxiety, and in accelerating the initial stages of grieving
for people with chronic pain.

Currently, more than 100 mindfulness meditation programs are being offered in
the United States (Roth & Creaser, 1997) that follow the format offered by Kabat-Zinn
(1990). Much of the enthusiasm for this program has been generated through the research

of Kabat-Zinn and/or the Stress Reduction Clinic, at the University of Massachusetts.

82

Therefore, the need to duplicate and extend these findings by other researchers and clinics
is needed. The current study accomplished this by supporting and extending previous
research by demonstrating significant reductions in depression, state anxiety, and the
initial phases of grieving for participants seeking treatment for chronic pain who took part
in the 8 week mindfulness meditation program when compared to a comparison group.
The comments made by participants indicated that the mindfulness meditation practice
enabled them to feel “more peace of mind” and not feel as “hopeless,” or “judgmen ” as
well as “develop an awareness that I have periods without pain.” With respect to longer
meditations being more beneficial, the results of the current study indicated that those in
the longer meditation group had less tendency to drop-out from the program than those in
the shorter meditation group. In addition, the comments from participants seem to
indicate that participants fiom both groups preferred longer meditations, and that those in
the longer meditation group indicated more mindfirlness, peace, and less stress. With
respect to gender differences, women may prefer mindfulness meditation, and improve on
depression more than men. Another interesting finding from this study is the relationship
between grieving and meditation. More specifically, that in the initial stages of grieving,
the increased awareness fostered by meditation may be too overwhelming, and therefore
not recommended. However, after the initial stages of grieving have been completed,
meditation appears to accelerate the grieving process. Consequently, the measure used in
this study to quantify stages of grieving (the RTL) might be modified to serve as a

screening assessment for future studies and meditation programs.

83

Mindfulness meditation appears to have many benefits, some of which were
demonstrated in this study. In addition, longer meditation periods may be more
beneficial, however, further research, utilizing multiple assessments including qualitative

approaches, are needed to clarify these benefits.

 

Appendix A

85

INSTRUCTIONS: This is a questionnaire. On the questionnaire are
groups of statements. Please read the entire group of statements in each
category. Then pick out the one statement in that group which best
describes the way you feel today, that is, right now! Circle the number
beside the statement you have chosen. If several statements in the group
seem to apply equally well, circle each one.

BE SURE TO READ ALL THE STATEMENTS IN EACH GROUP
BEFORE MAKING YOUR CHOICE.

A.

3 I am so sad or unhappy that I can't stand it.

2 I am blue or sad all the time and I can't snap out of it.
1 I feel sad or blue.

0 I do not feel sad.

B.

3 I feel that the future is hopeless and that things cannot improve.
2 I feel I have nothing to look forward to.

1 I feel discouraged about the future.

0 I am not particularly pessimistic or discouraged about the future.

C.

3 I feel I am a complete failure as a person (parent, husband, wife).
2 As I look back on my life, all I can see is a lot of failures.

1 I feel I have failed more than the average person.

0 I do not feel like a failure.

D.

3 I am dissatisfied with everything.

2 I don't get satisfaction out of anything anymore.
1 I don't enjoy things the way I used to.

0 I am not particularly dissatisfied.

86

 

E.

3 I feel as though I am very bad or worthless.

2 I feel quite guilty.

1 I feel bad or unworthy a good part of the time.
0 I don't feel particularly guilty

F.

3 I hate myself.

2 I am disgusted with myself.

1 I am disappointed in myself.

0 I don't feel disappointed in myself.

G.

3 I would kill myself if I had the chance.

2 I have definite plans about committing suicide.
1 I feel I would be better off dead.

0 I don't have any thoughts of harming myself.

H.

3 I have lost all of my interest in other people and don't care about them at
all.

2 I have lost most of my interest in other people and have little feeling for
them.

1 I am less interested in other people than I used to be.

0 I have not lost interest in other people.

I.

3 I can't make any decisions at all anymore.
2 I have great difficulty in making decisions.
1 I try to put off making decisions.

0 I make decisions about as well as ever.

87

 

J.

3 I feel that I am ugly or repulsive-looking.

2 I feel that there are permanent changes in my appearance and they make
me look unattractive.

1 I am worried that I am looking old or unattractive.

0 I don't feel that I look any worse than I used to.

K.

3 I can't do any work at all.

2 I have to push myself very hard to do anything.

1 It takes extra effort to get started at doing something.
0 I can work about as well as before.

L.

3 I get too tired to do anything.

2 I get tired from doing anything.

1 I get tired more easily than I used to.
0 I don't get any more tired than usual.

M.

3 I have no appetite at all anymore.

2 My appetite is much worse now.

1 My appetite is not as good as it used to be.
0 My appetite is no worse than usual.

88

Appendix B

89

 

SELF-EVALUATION QUESTIONNAIRE STAI Form v.1
Please provide the following information:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name Date 5
Age Gender (Circle) M F T___
DIRECTIONS: 0 ’3‘
A number of statements which peeple have used to describe themselves are given below, ,1, J, 6‘ '9).
Read each statement and then circle the appfllpfillfi "W10 ""0 right 91 the statement 0) 04?, {7,} 470
to indicate how you feel right now. that is. at this moment. There are no nght or wrong ‘1) ’12 {1. 0'9
answers. Do not spend too much time on any one statement but give the answer Which 1? ) .150 "PO
seems to dascnba your present feelings best.
I. I feel calm l 2 3 4
2. i feel secure 1 2 3 4
3. 1 am tense 1 2 3 4
4. i feel strained l 2 3 4
5. i feel at case 1 2 3 4
6. i feel upset I 2 3 4
7. 1 am presently worrying over possible misfortunes 1 2 3 4
8. i feel satisfied 1 2 3 4
9. i feel frightened l 2 3 4
10. i feel comfortable 1 2 3 4
n. r feel self-confident ' r 2 3 4
12. i feel nervous I 2 3 4
I3. I am jittery , 1 2 3 4
l4. I feel indecisive 1 2 3 4
15. lam relaxed I 2 3 4
16. I feel content 1 2 3 4
l7. lam worried I 2 3 4
18. i feel confused I 2 3 4
19. I feel steady l 2 3 4
20. i feel pleasant I 2 3 4

 

 

c Copyright 1968,1977 by Consulting Psychomglsts Press. InC- All rights reserved. STAIP-AD Test Form Y

90

' SELF-EVALUATION QUESTIONNAIRE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STAI Form Y-2
Name Date
niaecnons 1( 7Q,
A number of statements which people “"3 ”“6.“ “”6”” themselves are 9”” below. 991' dbl; of)
Read each statement and then circle the appropriate number to the right of the statement to ’4. 6)) O 1(
indicate how you generally feel. There are no nsht 0' wrong answers. Do not spend too 0’3“ 4, 4%} 7
much time on any one statement but give the answer Wh'd‘ seems 10 describe how you .9 (if ’5‘»
generally feel.
21. i feel pleasant l 2 3 4
22. I feel nervous and restless ..... l 2 3 4
23. i feel satisfied with myself-"- I 2 3 4
24. I wish 1 could be as happy as Others 5w“ ‘° '3‘ r 2 3 4
25. I feel like a failure 1 2 3 4
26. i feel rested l 2 3 4
27. I am “calm, cool, and collected" 1 2 3 4
28. I feel that difficulties are piling UP 50 that I cannot overcome them - 1 2 3 4
29. I worry too much over something that really doesn’t maner- l 2 3 4
30. 1 am happy 1 2 3 4
31. l have disturbing thoughts.-- 1 2 3 4
32. 1 lack self-confidence--- 1 2 3 4
33. i feel secure 1 2 3 4
34. I make decisions easily--- 1 2 3 4
35. i feel inadequate l 2 3 4
36. 1 am content 1 2 3 4
37. Some unimportant thought runs through my mind ”‘9 bothers me 1 2 3 4
38. 1 take disappointments so keenly that 1 can't put them our of my mind 1 2 3 4
39. 1 am a steady person 1 2 3 4
40. 1 get in a state of tension or turmoil as 1 think over my recent concerns and interests ...... .. 1 2 3 4

O Cepyright 1968,1977 by Consulting 1’511‘30010913ts P793?» '"C- A" rights reserved.

.91

ST Alp-AD Test Form Y

Appendix C

92

”'“wmme-M ”Warpath“
1:...offhethtflsismlgflly aeration-
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nusisanmuuoryofwayspgplerespmdmlmaofintheirnmmofthe
M reflect norm-Irma- fnflmammlgh. nurse, of
”gnawemmmmmwtommfigm

m bnng' rnenrorleeorfeelingswhich painful“ ],y m
citinfisnislrtlii’sayrrrvr:rrtor‘jlrpYouuserustrequrrrrrih’t‘q'rloas.“ onmaynot

cancethisinventorynks only aredomg' new,
0“ W389-

.nnfightbehelpfnltodiscnsa reactiorrswithaomaomYonareinvited
toreeordyourthonglrtsabouttaking‘ lnverdorydfheudofyourmsheats.

OWhanpoasiblarespondtoorllyornpardcnlarlessm-dnngeinyourlife.
TheLi WW maylravealreruiyhalpedyoutoselecr masts-scent
md/orfimoatsignififlntlose. Pie-embinthembookletwldgrufouitisthat
OWhurrtfsnotposaibletefocnsonadnglelmfieaseindimanthalo-es
whichwereinvolvedinyonrresponse.

oAsyonreadeachqneeflmaskyoursalfifthastatunamlstrneahout
mmmrintheputfewdaysosm Yoncanindiusethadegreatowm
youareiuvingtheaerespmaeaerdingtodrefdlowmgsdrm

o-fihim’tmaboesuymmtotflsm
I-Waythisismaboatmymmthhlm
z-mafthsthncthfsismaboatmymtetflslm
sawtofthetnnaddsismaboatuymwtfislm

anaisdfim'tdyisaeaaboatuymmtetflslm

mnamhmaboutymbntismtammtotflslmlm
itblank.

Plenarudanqueaflmmtfyonleavesomaoflhamblnk. Younay
findithelpfoltotakeoneormorebreahwhilayonareflmngmm.

° Itdoeenotneedtobefilledonttnomday,bntwlthinafewdays. If
glmyonareanuidednghflommyporflfiningontthmim
mommmvmmmwmfimnsmwwm

93

wrongs ‘1?) L055 (er/mo

Name or code: Date:
Age: __ Sex: Male: __ Female: ._
LivingCondition: Alone: _ With partner: __ With parentts)_

With children: __ With family (partner 8: children): _ Others: __

 

 

_w-myownlife-threateningillmaeoreonditicn
_OI-deathofapartner/spouse
_02a-deathofachild

_Oasdeathofayendchild
_04adeathofaparent

_OS-death ofagrandparurt

_06-deathofafriend

_073deathofabrotherorsister

_(B :- loae of job (e.g., being fired. quitting, retirement)
_09-loeeofpartner/spouseotherthanbydeath

_10- lossofhealth

_13- loaeoffseedom(e.g.,arreet.imprisorunart)

_14-loaeofparentsodrerthanthroughdeath

_IS-loasofchildrenothertlunthroughdeath
_16-lossofsdfduemmmaflcexpuiams)(eg.duemaoddmtcfimhulcmvicdm,murder,war
natural disaster. rape. nicest. exterrded litigation) '
_17 - Multiple losses. Please indicate which losses apply:

WW
_Within thepastthreemontb
_Fourtosixmarthsago

_Sevenrnontlutoayeasago
_Morethanayearbutlenthantwoyears
_‘l‘wotofouryearsago
_MoretlunfouryeambutluthanMyeassago
_Morethantenyearsago

WW
_Sudden _Vlolent _Prernedltated_,Aocidental _Unknown
-Suicide _Hornicide

_Iwitnessedthernurdertsflsuicide
_lviewedthebodfilee)
_ I saw photos of the bodyfiee)
_lbrewtheperpetratorprlortothetimeof themusderts)
_Sorneonewaschargedwiththemmder
If yes,howlargdldthelegalprooeaalast?
Hmv long ago was it completed?
_Someonewaaconvictedofthermn'der
..J receivedtherapyafterthemurddsVsuidde
Ifyes,howsoonafter?___
For how long? .
Whatwastheeffeetofthiathenpy?

 

 

Markymrramonthemsheetprovidedwtthmisqueedormaire.
lumofspeeialnou:
Com

94

Quflsdusofthslsss,
lesepadlvsaldbuly.
Llano-magma.
lTsldngcassofothsudfluctsmsfiumthhflqaboutmyloss.
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Slfllryl'mdsnoughlcanbmuckwhatllod.
armbokhgforwhomdsthislo.
7.1mmvsdwithmyffi-dsandfamly' to deith |
tlhavdlgivuupthsdhahndhflbthngd’mtomylo‘ my 0..
9.llookjutssgood-lalwaysdid.
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finathsfinsoffihlmlhanw
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lllhytofigusoutlnwltmldlnvebssndifi-ul.
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ulfldoo'tmonm‘vhstluwl'nf
ltlfl'm goodmlganobodyllovswmsvsrdls. 0'8““-
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ltEverydoudluasilvsr

l9.Peoplsgslthssqsctthqd-Ininthism

W
21.1dlslmdsusthsdsvil'awm
alflangoodmughupdsdmglxmmlostwllmbadc
nlthinklm (cation.

saladbsl-s Minimum
nMyfsslhpasssounpsdldablslmlflmcmy.
Elisslguiltyjuthhkhgabod
nMyfsslhgsssssoMInssl‘mahldl'nlod‘cowol.
altrytoholdhackthstssn.
almahidtothhk “alumnus.
aNoMbmmxobmdnyisslhgsabouttlhlm
nl‘vsincsnsdnyexsldss.
3£Sssgsts uhhflthslon.
33.ch lhlmamdm
36,1havetnuhls
aldoo'tsdssmdi.
alandssplngla.
lsthsfiusissuflslu,

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W
albsllsvssonsthlnggoodwlllm
42.11311qu
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Allan‘slwfllnotbstdsdbsyalluyapadtytosulms.
BJlelt-ssllydatnwhdlhave.

 
  

 
     
   

     

95

“tibia“
“‘“m‘fihmw
0.1m to («this
ammmumm P‘Y

alasddtslllnganyons human/arm
arms-panama “mm“
aldon'tsssmchofmyoldfiids.

nl'vsbssncanlsl. -

alavudgstfinginvolvedinanythhg.

“loudngatofagetmylm
amwmmmmmmdmm
SJhavsksptssuatwhstnally happsosd.
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Stl'vshadnussuwlthms
Southboftflslusflhu

   

Lida-us l‘n
am mama/m
fiNommldqwhdwfllhsppsnwfl

“Emiflmddwwhyfllnppdltwoddn'tchangem

filt'sesslsnvhul ssh!
aumm:mum

6V.l'wujsctsdothu’ldsssabodfluloa.
63.1 Ms‘ddnk-dhsnuyJa-memm
$.Doo'tnckthsbotYou'llh‘gstnothd.

Alu I

     

m
nWhatthssysdou'tsnthlI-tbQ1m.
nfiioyyundfmw.Whomfioutm?
anyou'utoohqpynauflqbadlsboulltohappn
75. ltlsthsnsilthstdandsoottlutgslslunsudthshldsst.
flawless
77.lfsslanfussllaodW
Alkytnttoldauytflqsflsctns.
79.1fssldstadlsdanlaspasatsfiunothus.
W

nflllduysdfilgstsoudisppylm'tst-lllt.
algatipsdwlfltnysdflocthswaylhvsbshvsd.
B. lamxevoltsdbythswaypsoplshsvsmdsd.
uldm'lmlohsm
87.1311dest
lllhavefsltslcktomystanch.

”Jamaal. '

W

96

 

6
Doubtful.“ “mutt
luwflbguqmbm

3..“ ”nihilism“
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aldmbtthuqthlngwuyoosmglvs lib
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air-magnum my. my W

 

mwabmmm
mlmmbmmbdowlhqflf.
no. lhavsvuy Mata sq.
“Idols-dilutlllnplufloydbshs.
lozl'vsootbsuwhmuyusm.
mllacklonaflsdhndw
man-tum

hthstinsslnstflslou,

WW
mtmwmmmbumu

112.l “32:,“qu

113.113 s-Ilto mull:
nub-Immune. 9 Mn""""““
mTh-s'smwsylaahllymwu
ntlanmandwulsmla'ap-tduyms.
mltflnkfioutwhst'sddginnylls.

m‘l'hst-nuh-dtoshp.

119.llngforwhfl(whulll‘vslod.

mini-Minn".
$112:an dusts-oomph.

muyhodytsfihnvy.
Inl'vshsllmuutodosuythhg.
mimm

midgh.
mlwahupfsdhng-Ilaclly,uifl'dbsatsassanm
mxmqmmw
muydmmdmdnylon.

mllsckasullla.

97

“this lockup-d,
MWMWmm’mmmu‘m
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mMyatomachnsllydmnl.
139.1havsadnsandpsluwhlchmmdmylou.
lmlwouldrathsrdlstlnngoonexpdsodqtlu .
llLNoamountolmyauldssu-tqlsosit.
lfl'l'hsfuhussssn-snpty.
lflmlvahsmstlnlifishssbsso
lulqosstloothsudstundthscodlnssdtobellsveln. .
lfilmotaflhnslfisthssqiswayubdoss.
1&Myflhwmmbstohflyflssfunpahndm
lfllwilllossthhgsndpsoplslnpostaottom
luPutsoflnsusM.

10.1mmtthsmmmpmlm

l. Alli-u Huuu- .- ‘I'H o ~'«

5.. .
Mllunlonmydds live.
mmmw-wmmmup.
filhibdhflmpmlmmonhm
BLBsiqbyuysdflnshsso
gltahsloqwalh-fljudm .
.Acfivlflssllksgsflhgampdflhgcufieusm,
157.7dklngawdflngaboutltglv-mnllsfndnl.
ulmldtfllptunodthswqthsywfll.
m.thMl'vslualot,hulhav-nlostw
lbLPmmtns-paflilsaslthooghtlmforwhsthw
Mlhmahsdyp‘dtblow-tpu.
muyfusfioutdyhgasslu.
Mlmaflstouplumyfsdhpfioutthloa.
lflMqussflflcflhnshy-pdsshtfl-ydoo'thstulmg.
muyguilllul‘ld.
WJ'mootsosad.

168. dhgut “Th-laud.

W
171.1'hsachss-Idpahlussdtohavswlthtflslo-lmslsnud.
Uzlsqoybdogtouclndndhsldonu
mnmluuybdotflqatlmitusdh.
fltlmlmvthhpcnsllandtue
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gwmmmap 9"
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98

lathefoundwayabgstbackmyhugfity.
luldmldapssd-mchooothsu.
mmwmxmnymmmmn
187.1'vaflnisbdthhpnlahdlomylo-ascnnplstdyaslm
mrmtahnatspstofugivsthossinvolved.
189.1ammflngtuflhxflonformymntubnuomtotflsloss.

luminythooghbmmdshnhslpsdmsm.
mmwmmmdmummirsmlm
muyllfishumstoit.
mmwanmmmm

”shutout! waystootps. W

196. MWthlslo-lnwaysflmhaling.
197.1'vslstgodthaguilt.

lgl'nlatgooflhsaqsr. '

l .lannhsusoatoflhs {nan .
Mldoo'tpdimybodybqudwllm uybody
”Links.

mlalsapwall.

mlaatslfllly.
mlmhmflywmw
mllmowmyllfislsinporm

“this“
“MyaanplayMndefuL
lizl‘ver-tossdornginsdpartofwhatlhsdlost.
mlfsslthsplmdwhatlwhollost.

209.lhavsfosgivso

ZlLlwouldnotwantmylo-msusdiflttnsaotglvhg all growth
mrmmwhwmmmmw‘w my hon-it.
mittalnsslcsefiatndthoaghttodowhulmsdtodo.
zltlsqoybshgaloos.

album-tom’s“.

mrmm-m.

217.1'msblstotalns gain.

21&Pmmosssdf-disdplinsd.
219.1doo'tplacellmiiainfxmtofmysdfunsdnyasldldbsionthbloss.

mllnvsflmfauyfandlyandfdudsandtimsform
mlcnaxpsnuysslflnmauyways.
mlcanappssdatsthspandoauandsssumg' Mania life.
mlfsdmsconfidsot. my
ml‘vegsown.

  

 

 

gmdispadnjugumumhhappmm.
mlfssldlaflmdtolnsspmgoiq.
229.1tmstmywaysdtlfinflng.

mJ'vsloandmwaystoaapI. my.
232..Ifssl loving and am my

mSadns-runhdsmhmvhnpmdislo-w-toms.
34.1mm“ my”.
35.11“»meme
mlqoymfihglovs.

237.le dqhnyssfl'

233.:me My.
239.Whatlsatlslhdthy. .
lesdmalovar.
uLIhavswhfllsns-inglolwlflinma.
mrvsls-nsdtotqsdmyaslf.
mlfsdlihawholspm
mrvswmusismstomsthnwlltmststhseys.
mMydrs-namhsaoss.

lelvsastnllyasloan. '
”.mhmumbmmw
mlhsvsfawsrundfllouoouylon.
249.1nsliulmdods‘mdlvothlqs.

W

ml'vsdnllqsdndahsds-admymstwu mm mg.
m. lwaotothrpsoplshuyfla. '0'! “
mlmtosluowflhothuwlnhavshsllfew

mJVhatlowni-I'tas

mmcydndlifshavstlusofhirthuddsflh.
mlmsumthn-supussdbywhullamvandssy.
81lfsslansctsdlothswuldndtom
mlwgslnuqllbmdlngsndlllsmstill ham
239.!ammdomflmitwhatwilllnppsnaasrldls.

260.1can'tllvewlthoutlovingmyssli. -
fitldlscovsssdmuutlalp-tsdm

mMyllislustln-ofloy.

100

 

Directions:

RTL Answer Sheet
Form 2, Odd, pg. 1

Fill in the answers on this answer sheet. using the following key.
0 I- this isn’t trueabout mycun'ent response to this loss.
1 - occasionally true about my current response to this loss.
2 - some of the time this is true about my current response to this loss.
3 -rnostofthetimethisistrueaboutmyatnenttesponsetothisloss
4-thisdefinitelyis truenboutmycun'entresponsetothisloss.

PLEASE RECORD YOU ANSWERS ON THESE ANSWER SHEETS

1- (0) (I) (I) (I) (I)
2. (0) (I) (I) (I) (I)
3- (0) (I) (I) (I) (I)
4- (0)(I) (I) (I) (I)
5- (0) (I) (I) (I) (I)
6~ (0) (I) (I) (I) (I)
7. (IMO (I) (I) (I)
3- (0) (I) (I) (I) (I)
9- (0) (I) (I) (I) (I)
10- (0) (I) (I) (I) (I)

11. (0) (I) (I) (I) (I)
12- (0) (I) (I) (I) (I)
13- (0) (I) (I) (I) (I)
14- (0) (I) (I) (I) (I)
15- (0) (I) (I) (I) (I)
16. (0) (I) (I) (I) (I)
17- (0) (I) (I) (I) (I)
13. (0) (I) (I) (I) (I)
19- (0) (I) (I) (I) (I)
20- (0) (I) (I) (I) (I)

21- (0) (I) (I) (I) (I)
22- (0) (I) (I) (I) (I)
23- (0) (I) (I) (I) (I)
24- (0) (I) (I) (I) (I)
25- (0) (I) (I) (I) (I)
2.5- (0) (I) (I) (I) (I)
27- (0) (I) (I) (I) (I)
23- (0) (I) (I) (I) (I)
29. (0) (I) (I) (I) (I)
30- (0) (I) (I) (I) (I)

31. (0) (I) (I) (I) (I)
32. (0) (I) (I) (I) (I)
33. (0) (I) (I) (I) (I)
34. (0) (I) (I) (I) (I)
35. (0) (I) (I) (I) (I)
36. (0) (I) (I) (I) (I)
37- (0) (I) (I) (I) (I)
38. (0) (I) (I) (I) (I)
39. (0) (I) (I) (I) (I)
40- (0) (I) (I) (I) (I)

41- (0) (I) (I) (I) (I)
42. (0) (I) (I) (I) (I)
43- (0) (I) (I) (I) (I)
44- (0) (I) (I) (I) (I)
45. (0) (I) (I) (I) (I)
46- (0) (I) (I) (I) (I)
47- (0) (I) (I) (I) (I)
48- (0) (I) (I) (I) (I)
49- (0) (I) (I) (I) (I)
50. (0) (I) (I) (I) (I)

51- (0) (I) (I) (I) (I)
52. (0) (I) (I) (I) (I)
53. (0) (I) (I) (I) (I)
54. (0) (I) (I) (I) (I)
55. (0) (I) (I) (I) (I)
55. (0) (I) (I) (I) (I)
57- (0) (I) (I) (I) (I)
58- (0) (I) (I) (I) (I)
59- (0) (I) (I) (I) (I)
60- (0) (I) (I) (I) (I)

61- (0) (I) (I) (I) (I)
62- (0) (I) (I) (I) (I)
63- (0) (I) (I) (I) (I)
64- (0) (I) (I) (I) (I)
65- (0) (I) (I) (I) (I)
66- (0) (I) (I) (I) (I)
67- (0) (I) (I) (I) (I)
534°) (I) (I) (I) (I)
69. (0) (I) (I) (I) (I)
70- (0) (I) (I) (I) (I)

71. (0) (I) (I) (I) (I)
72- (0) (I) (I) (I) (I)
73. (0) (I) (I) (I) (I)
74. (0) (I) (I) (I) (I)
75- (0) (I) (I) (I) (I)
76- (0) (I) (I) (I) (I)
77- (0) (I) (I) (I) (I)
78- (0) (I) (I) (I) (I)
79. (0) (I) (I) (I) (I)
30- (0) (I) (I) (I) (I)

31. (0) (I) (I) (I) (I)
82- (0) (I) (I) (I) (I)
83- (0) (I) (I) (I) (I)
84. (0) (I) (I) (I) (I)
85- (0) (I) (I) (I) (I)
86. (0) (I) (I) (I) (I)
87- (0) (I) (I) (I) (I)
83- (0) (I) (I) (I) (I)
89- (0) (I) (I) (I) (I)
90- (0) (I) (I) (I) (I)

@lNTEGRA lMallridIsreaaved

101

91. (o) (I) (2) (I) (I)
92. (o) (I) (2) (I) (I)
93. (o) (I) (2) (I) (I)
94. (o) (I) (2) (I) (I)
95. (o) (1) (2) (a) (I)
96. (o) (I) (2) (I) (I)
97. (o) (1) (2) (a) (I)
93. (o) (1) (2) (a) (I)
99. (o) (t) (2) (I) (I)
100. (o) (I) (2) (I) (I)

101- (0) (I) (I) (I) (I)
102. (0) (I) (I) (I) (I)
103. (0) (I) (I) (I) (I)
104- (0) (I) (I) (I) (I)
105- (0) (I) (I) (I) (I)
106- (0) (I) (I) (I) (I)
107- (0) (I) (I) (I) (I)
103- (0) (I) (I) (I) (I)
109. (0) (I) (I) (I) (I)
110. (0) (I) (I) (I) (I)

111- (0) (I) (I) (I) (I)
112- (0) (I) (I) (I) (I)
113. (0) (I) (I) (I) (I)
114- (0) (I) (I) (I) (I)
115. (0) (I) (I) (I) (I)
116. (0) (I) (I) (I) (I)
117. (0) (I) (I) (I) (I)
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102

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Appendix D

103

Research Number (do not put your name on this form)
(1) Age
(2) Gender: Male , Female

(3) Marital Status

 

(4) Please circle the number next to your Race/Ethnicity or please describe the specific group that you

identify with the most in the blank next to your ethnicity (for example Chinese American, German, Navajo,

Alaskan Aleut):
(1) Asian or Asian-American
(2) Black, African-American
(3) Hispanic, Latino, Mexican-American
(4) Pacific Islander
(5) Native American or American Indian
(6) White, European American
(7) Multicultural, Mixed Race
(8) Other, Please Specify

 

 

 

(5) What was you highest level of formal education you completed?

(1) less than high school

(2) high school degree (or GED)

(3) post high school (e.g., trade, technical, secretarial)
(4) some college (e.g., one year, associate's degree)
(5) completed college (e.g., bachelor's degree)

(6) some graduate or post-bachelor's training

(7) completed graduate or post-bachelor's training

Are there other important education experiences?

 

(6) What is your current occupation (please name job or describe what you do or did, even if you are laid
off disabled or retired?)

 

(7) What is your current employment status?

(1) I work full-time
(2) I work part-time (less than 30 hours per week)

(3) I do not work outside the home because I am employed full-time in home-making.
(4) I do not work because I was laid ofi‘ or unemployed.

(5) I do not work because I am disabled

(6) I do not work because I am retired

(7) other (please describe

 

104

 

(8) How would you rate your current stress level?
(circle an appropriate number on the scale)

not at all moderately extremely
stressed stressed stressed
l 2 3 4 5 6 7 8 9 10

(9) How well are you managing your current stress level?
(circle an appropriate number on the scale)

not at all moderately extremely

well well well
1 2 3 4 5 6 7 8 9 10

(10) Have you been currently experiencing chronic pain?
Yes No If so, please answer Questions 11 - 14. If not please skip to question 15.

(l 1) Where are you currently experiencing pain?

 

(12) How long have you been experiencing this pain?

(13) How intense does your pain get?
(circle an appropriate number on the scale)

mild moderately extremely
irritation intense intense
I 2 3 4 5 6 7 8 9 10

(14) How ofien does it get to the maximum intensity 7
(please specify, times/day or times/week).

 

(15) Have you or (do you) practice relaxation (do not include mindfulness meditation)?
yes , No

 

(16) If you have used (or currently use) relaxation how often did (do) you practice it (do not include
mindfulness meditation)? (please specify, times/day or times/week)?

Are you still practicing this amount?

 

(l 7) I consider myself a spiritual person
(circle an appropriate number)

3‘10“le strongly
agree agree neutral disagree disagree
1 2 3 4 5 6 7

105

(18) I consider myself a religious person
(circle an appropriate number)

strongly strongly
agree agree neutral disagree disagree
1 2 3 4 5 6 7

(19) Taking time out of my day for personal prayer is important to me
(circle an appropriate number)

 

strongly strongly
agree agree neutral disagree disagree

1 2 3 4 5 6 7
(20) How satisfied are your with the quality of your social relationships?
not at all moderately extremely
satisfied satisfied satisfied

1 2 3 4 5 6 7 8 9 10
(21) How satisfied are your with the quality of your relationships with your family?
not at all moderately extremely
satisfied satisfied satisfied

1 2 3 4 5 6 7 8 9 10
(22) Are you taking medication? (if not skip to 24)

If so, what types?

 

 

(23) Does the medication make you drowsy?

 

(24) Before taking this mindfulness meditation class how did you cope with pain?

 

(25) How motivated were you to take this program?

Not very moderately Very motivated
motivated motivated
l 2 3 4 5 6 7 8 9 10

(26) How confident were you that you would be able to learn and practice meditation successfully?

not at all moderately extremely
confident confident confidant
1 2 3 4 5 6 7 8 9 10

106

Appendix E

107

8 Week Mindfulness Program Outline

Required text: Full Catastrophe Living, Kabat-Zinn (1994).

 

Required tape: Side A: Body Scan followed by hatha yoga,
Side B: Mindfulness of Breathing followed by hatha yoga.

(Tape created for the study by principal investigator.)

Week 1:

 

Introductions, describe course outline, describe required text and tape, introduce
mindfulness, practice body scan technique.

Discussion on weeks practice, discussion on how to be mindful with thoughts and
feelings, practice body scan.
m

Field questions on weeks practice, discussion on how to use mindfulness with
pain and suffering, introduce and practice mindfulness of the breath technique.
was
Field questions on the week’s practice, describe fight or flight response, discussion on
how to use mindfulness to manage daily stressors, introduce hatha yoga, practice yoga

and mindfulness on the breath technique.

108

 

E92152;

Field questions on weeks practice, describe grieving process and how to use
mindfulness in grieving, practice mindfulness on the breath.
was

Field questions on weeks practice, discussion on meaningfulness and
meaninglessness of chronic pain and of life in general, practice mindfulness on the
breath.

Field questions on weeks practice, discussion on forgiveness and its relationship
to grieving, practice mindfulness on the breath.

Field questions on weeks practice, discussion on integrating mindfulness in
everyday life and how to support daily practice without weekly group, practice

mindfulness on the breath.

109

 

Appendix F

110

 

 

 

 

 

 

 

 

 

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Appendix G

112

Assumptions for the use of Analysis of Variance:
The following are the list of assumptions that must be met in order to use an analysis of
variance and/or analysis of co-variance. A statement regarding how each assumption was

handled will be given.

Independence: Each individuals scores on the pre-treatment and post-treatment measures
are independent of the scores of all other subjects. With respect to the relationship
between the treatment groups independence can be assumed due to random assignment.
However, it is possible to have a violation with respect to comparing treatment and non-
treatment because participants self-selected to the treatment, and the comparison group
was not necessarily made up of participants who would want to take a mindfulness
meditation program. Therefore, the comparison group may share some factor in

common that the treatment group does not and thus violate subject independence.

Normality: Normality was determined by comparing the values of skewness with the
standard error for skewness. According to Tabachnick and Fidell (1983) the standard
error of skewness can be calculated from

sss= (6/N) 1/2
where N is the number of cases.
To determine the probability that a data set is skewed a 2 value is calculated

2 = S-O/sss

113

 

Where S is value reported for skewness. Kurtosis is calculated in a similar manner using
the equations

ssk=(24/N)l/2

and

z = (k-0)/ssk
A 2 value in excess of + or — 2.58 leads to a rejection of the assumption of normality at
p<.01.

The values for skewness and kurtosis can be found in table 5

The normality assumption is violated for BDI pre and post. The positive
skewness indicates that the bulk of the scores are distributed at the lower end of
the scale. This is not surprising because the normal range for depression on the
BDI is at the lower end of the inventory's range. Therefore, when given to the
general population a floor effect is possible. With respect to violations to
normality, the AN COVA is robust provided the sample sizes are equal
(Shavelson 1981). Because the sample sizes in these analyses are similar the

violation of this assumption is not a problem.

114

Table 5.

Skewness and Kurtosis

 

 

Inventory Skewness Kurtosis
BDI pre 4.07 3.36

BDI post 6.64 11.70
State pre 0.40 0.05
State post 0.58 0.61
Trait pre 0.36 1.17

Trait post 0.41 1.20

Cope/ 1 .39 0.30
Aware.pre
Cope/ 0.69 ~0.55
Awarepost

erthpre 0.15 -0.70

Growthpst 0.18 - 0.74

Homogeneity of variances: Levine’s test was used to determine if the
error variances were equal across groups. The probability that the error variances
were not equal can be found in Table 6. From these results it is apparent that the
Growth factor of the RTL violates the assumption of homogeneity of variances.
However, with reSpect to violations to the homogeneity of variance, the
AN COVA is robust provided the sample sizes are equal (Shavelson 1981).
Because the sample sizes in these analyses are similar the violation of this

assumption is not a problem.

115

 

Table 6.
Homogeneity of Variances: Levine’s Test

 

Inventory Sign.

 

BDI 0.63
State 0.96
Anx.
Trait 0.46
Anx.
Cope/ 0.37
Aware.
erth 0.02
Factor

Linearity: Because the pre-test measures are all linear with the post-test

measures this assumption is met.

Homogeneity of regression slopes: The significance of the interaction of
the pretest measure and group is given in Table 7. From these results it is
apparent that the BDI violates the assumption of homogeneity of regression -
slopes. More specifically, this means that there is an interaction between the pre-
test measure and the group assignment. Investigating the data revealed that for
those in the treatment groups, high scores on the BDI pre-test resulted in greater
decreases than low scores on the BDI when compared to the comparison group.
This result is not surprising due to the floor effect of the BDI (see normality
assumption). Those on the low end of the scale do not have as much opportunity

to lower their score as those on the high end of the scale. With respect to

116

 

violations of this assumption, Maxwell and Delaney (1989) state that for
randomized designs the effect is a loss of power. However, because power relates
to the probability of rejection of the null hypothesis given it is false, and the
overall F test for the BDI was, F (2,56) = 8.34, p < .001 with an average effect
size between treatment and comparison groups of d=0.9, a slight loss in power
does not appear to be critical.

Table 7.

Homogeneity of Regression

 

Inventtfl Sign.
BDI 0.002

 

State Anx. 0.110
Trait Anx. 0.930
Cope/ 0.670

Awareness
Growth 0.85

 

Independence of covariate and treatments: Because the covariates were all
measured prior to treatment this assumption is valid.
Covariate measured without error: The reliability and validity of all the measures is
given in the methods section. All of the measures have demonstrated good reliability and

validity.

117

 

Appendix H

118

 

Research Number_________(do not put your name on this feral

(1) With respect to copind With Pain, and with your life in
general. what chanIO' h‘VG ’99 noticed Since startinl thil
mindfulness meditation presto-7

 

(2) What differences have you noticed in your meditation prgctic.
when you eeditate lenser (toquired aeount of tine or sore each
day) as opposed to when you eeditate less?

(3) What differences have you noticed in your 4.11, 11:. uhgn you
eeditate longer (requirOd llflunt 01 tile or sore each day) as
opposed to when you eeditate less?

119

Appendix I

120

 

 

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121

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Appendix J

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