Interpersonal Mindfulness Training for Well-Being: A Pilot Study With Psychology Graduate Students
by Jeanette Sawyer Cohen & Lisa J. Miller - 2009
Background/Context: Although mindfulness originated in Eastern meditation traditions, notably Buddhism, researchers, clinicians, and, more recently, educators suggest that the cultivation of mindfulness may be beneficial to Westerners uninterested in adopting Buddhist or other Eastern spiritual traditions. Mindfulness is understood as sets of skills that can be developed with practice and taught independently of spiritual origins as a way of being or relating to present-moment experience.
Purpose/Objective/Research Question/Focus of Study: This pilot study adds to this literature on mindfulness training for nascent mental health professionals, who may be at risk for occupational stress and burnout. This study aims to (1) expand on preliminary research supporting the helpfulness of mindfulness interventions for graduate students in psychology and (2) investigate the feasibility and helpfulness of a novel adaptation of mindfulness-based stress reduction (MBSR) that emphasizes relational awareness.
Population/Participants/Subjects: This sample consisted of clinicians-in-training (N = 21) within a graduate department of counseling and clinical psychology at an urban university. All students were in their first or second year of graduate school; 20 participants were enrolled in a psychology masterï¿½s program, and 1 participant was a doctoral student in clinical psychology.
Intervention/Program/Practice: The authors investigated a novel 6-week interpersonal mindfulness training (IMT) program modeled after the manualized MBSR intervention, with an added emphasis placed on relational awareness. IMT aims to reduce perceived stress and enhance interpersonal well-being and, as such, may be particularly well-suited for psychotherapy trainees. IMT was integrated into a semester-long graduate course in psychology.
Research Design: A pre-post design was used to examine outcomes associated with participation in IMT.
Findings/Results: Results suggest that IMT with psychology graduate students is a feasible intervention that positively affects mindfulness, perceived stress, social connectedness, emotional intelligence, and anxiety. Of special interest are changes in interpersonal well-being that suggest potential benefits for future mental health professionals.
Conclusions/Recommendations: High attendance rate and positive program evaluations suggest that IMT can be successfully taught within a graduate psychology curriculum. We suggest that mindfulness training may be a useful complement to the standard training of future clinicians.
Although mindfulness originated in Eastern meditation traditions, notably Buddhism, researchers and clinicians in recent decades suggest that the cultivation of mindfulness may be beneficial to Westerners uninterested in adopting Buddhist or other Eastern spiritual traditions (Baer, Smith, & Allen, 2004). Mindfulness can be understood as sets of skills that can be developed with practice and taught independently of spiritual origins and as a way of being or relating to present-moment experience (Bishop et al., 2004). Bishop et al. defined mindfulness as a mode or process of regulating attention in order to bring a quality of nonelaborative awareness to current experience within an orientation of curiosity, experiential openness, and acceptance (p. 234).
Mindfulness-based clinical interventions use meditative practices to enhance present-moment awareness of conscious thoughts, feelings, and body sensations and to recognize and relate to these mental events as such, rather than as necessarily accurate reflections of reality (Lee, Semple, Rosa, & Miller, 2008). Mindfulness-based and mindfulness-oriented psychotherapies are now used to treat a range of psychiatric illnesses. Mindfulness-based stress reduction (MBSR; Kabat-Zinn et al., 1992), initially developed for pain management, is a well-established program commonly used for the management of stress and anxiety disorders.
Preliminary support suggests that mindfulness training positively influences interpersonal outcomes in nonclinical adult samples (e.g., Carson, Carson, Gil, & Baucom, 2004), including health care professionals (e.g., Shapiro, Astin, Bishop, & Cardova, 2005). In a study of graduate counseling psychology students, Shapiro, Brown, and Biegel (2007) found that participation in a MBSR program was associated with improvements in mental health outcomes, including decreased stress and increased self-compassion. In an earlier study, Shapiro and colleagues showed that medical students who participated in a meditation-based stress reduction intervention aimed at enhancing the doctorpatient relationship through the cultivation of empathy reported increased empathy and decreased anxiety and depression compared with controls (Shapiro, Schwartz, & Bonner, 1998). The current study adds to this literature on mindfulness training for psychologists in training, who may be at risk for occupational stress (Skovholt & Ronnestad, 2003) and burnout (Spickard, Gabbe, & Christensen, 2002).
Interpersonal mindfulness training (IMT) was developed in line with the notion that mindfulness encompasses an awareness of all aspects of experience, including both self and other, of internal and external. This novel mindfulness-based intervention aims to reduce perceived stress and enhance interpersonal well-being and, as such, may be particularly well-suited for psychotherapy trainees.
This study aims to (1) expand on preliminary research supporting the feasibility and helpfulness of mindfulness interventions for graduate students in psychology and (2) investigate the feasibility and helpfulness of a novel adaptation of MBSR that stresses relational awareness.
The study was conducted in two waves. Wave 1 consisted of 12 psychology students enrolled in a graduate-level psychology course offered at an urban university. Wave 2 consisted of 16 graduate students enrolled in the same course the following year. Students in both classes were invited to choose the 6-week mindfulness training as one way to fulfill course requirements. All provided informed consent. There were no exclusion criteria.
Analyses revealed no significant differences between Waves 1 (N = 12) and 2 (N = 16); consequently, these two waves were combined. All 28 students provided informed consent and completed pretest measures, and 21 completed postintervention measures. Data for the 21 participants who completed assessment measures at both assessment points were retained for analyses. Those who completed the postintervention measures did not differ on any of the demographic or psychological variables at pretest (F = 1.32, p = .312). All subjects attended at least five of six sessions and were considered completers.
Demographics. The mean age of the 21 retained participants was 26 years, with a median of 24 years and a range of 2246 years. For unknown reasons, demographic data for one subject was not completed. All students were in their first or second year of graduate school; 20 participants were enrolled in a psychology masters program, and 1 participant was a doctoral student in clinical psychology. All participants were English speaking, and 20 were female. Racial composition of those with demographic data (N = 20) was as follows: 66.7% White-non-Latino (n = 14); 4.8% African American (n = 1); 4.8% Asian (n = 1); 4.8% mixed: Indian/Caucasian (n = 1); 4.8% mixed: White/Latino (n = 1); 4.8% other: Spanish/Mexican (n = 1); and 4.8% other: Indian American (n = 1). Religious affiliation varied.
Meditation experience. A total of 20 of 21 subjects responded to a preintervention question asking how often each subject engaged in meditation. Of these 20 respondents, 55% (n = 11) answered not at all or less than monthly; 35% (n = 7) answered monthly or once/week; and 9.6% (n = 2) answered several times/week or daily.
STUDY DESIGN AND PROCEDURES
The pilot study used a pretest-posttest design. During the initial meeting, participants provided informed consent and completed a demographic questionnaire and a packet of measures, including those described in the next section. The assessments at Time 1 provided baseline measures for all participants (also referred to as pretest). After attending three mindfulness classes, participants completed the same packet of questionnaires. These midtreatment data have not been analyzed and are not included in the present study. After the final (sixth) class session, participants were again given the same measures packet and asked to complete it within 1 week. Time 3 assessments served as the posttreatment measure.
INTERPERSONAL MINDFULNESS TRAINING
The group leader in the study (JSC) was an experienced meditation teacher and practitioner with advanced training in mindfulness and related techniques. The IMT was modeled after the manualized MBSR treatment program (Kabat-Zinn, 1982) and, like MBSR, consisted of mindfulness practices that promote an open and allowing stance intended to cultivate greater awareness of current experience. Each mindfulness session lasted 90 minutes. The intervention was primarily experiential and included sitting meditations that increased in length over the course of the training. Meditations began with verbal guidance from the instructor and ended in silence; participants were asked to notice all aspects of experience, including any thoughts, sounds, sensations, and feelings.
Like MBSR, IMT emphasizes mindfulness in daily life. Students completed weekly homework assignments based on their experience of mindfulness inside and outside of class. Each class began with a group review of mindfulness within the past week, including informal practice and journal assignment topics (e.g., my relationship with distraction; integrating mindfulness into my life; my body awareness).
Each session included mindfulness exercises intended to promote awareness of the present moment. These differed from the standard MSBR exercises (e.g., the body scan and hatha yoga; see Kabat-Zinn, 1982) in that an emphasis was placed not only on personal experiences but also on awareness of the self in relation to others. For example, dyads performed a mindful mirror exercise in which partners take turns leading and following the spontaneous movements of the other; this was done before and after a meditation and was followed by a discussion of how participants experienced the activity differently after meditating (e.g., reports of increased feelings of connection with the other). In another exercise, listening in the middle, one participant sat between two others who were instructed to talk to the person in the middle about anything for 30 seconds. Afterward, participants shared their experiences of trying to listen to simultaneous stimuli and to the different ways they dealt with the conflicting demands for attention (e.g., alternating between the two speakers, listening to the more interesting speaker, or creating a story that combined aspects of both narratives). Other exercises involved the whole group, such as creative movement with an emphasis of body awareness, and guided movement exercises in which participants were asked to describe their experience after they moved in different styles and tempos.
Mindful Attention Awareness Scale. The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) was used to measure mindfulness. This 15-item unidimensional scale assesses attention and awareness in daily life. Respondents rate how often they have been preoccupied or not paying attention to the present moment, on a scale ranging from 1 (almost always) to 6 (almost never). Sample items include: I find it difficult to stay focused on whats happening in the present; I drive places on automatic pilot and then wonder why I went there; and I find myself preoccupied with the future or the past. This indirect measure of mindfulness was chosen because mindlessness is more commonly accessible to most individuals than is mindfulness (Brown & Ryan). The maximum possible score on the MAAS is 90 points. Higher scores reflect higher levels of mindfulness. MAAS scores were expected to increase from pre- to postintervention, reflecting increased mindfulness.
Perceived Stress Scale. The Perceived Stress Scale (PSS; S. Cohen, Kamarck, & Mermelstein, 1983) was used as a measure of subjective distress. The PSS measures the degree to which an individual appraises life situations as stressful (S. Cohen & Williamson, 1988). Shapiro et al. (2005) found a significant decrease in PSS scores following a MBSR intervention for health care professionals. It was hypothesized that PSS scores would decrease from pre- to postintervention, indicating lower levels of perceived stress.
Meaning in Life Questionnaire. The Meaning in Life Questionnaire (MLQ; Steger, Frazier, Oishi, & Kaler, 2006) is a 10-item measure of meaning in life, understood as a positive marker of well-being (Ryff, 1989). The MLQ consists of two subscales: Presence of Meaning and Search for Meaning. The former (e.g., My life has a clear sense of purpose) measures the subjective sense that ones life is meaningful, whereas the latter (e.g., I am looking for something that makes my life feel meaningful) measures the orientation and drive toward finding such meaning.
Satisfaction With Life Scale. The Satisfaction With Life Scale (SWLS; Pavot & Diener, 1993) is a widely used and well-validated five-item measure of ones satisfaction with ones life. Mindfulness is associated with the promotion of positive qualities (Kabat-Zinn, 2000), including quality of life and subjective well-being (Baer, 2003). Brown and Ryan (2003) found that the MAAS was related to a modified SWLS (Pavot, Diener, & Suh, 1998).
Social Connectedness ScaleRevised. The Social Connectedness ScaleRevised (SCSR; Lee, Draper, & Lee, 2001) is a 20-item measure of social connectedness, a construct derived from Kohuts (1984) self-psychology theory that represents a type of belongingness related to ones view of oneself in relation to others (e.g., I am able to connect with other people; Even around people I know, I dont feel that I really belong). An increase in social connectedness from pre- to postintervention was anticipated.
Self-Report of Emotional Intelligence. The Self-Report of Emotional Intelligence (SREIT; Schutte et al., 1998) is a 33-item self-report measure of emotional intelligence (EI). Sample items include, I know why my emotions change and I can tell how other people are feeling by listening to the tone of their voice. Baer et al. (2004) found a positive correlation between EI and mindfulness, as did Brown and Ryan (2003). An increase in SREIT scores was anticipated.
Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI; Beck, 1990) is a 21-item measure of both physiological and cognitive aspects of anxiety or panic-related symptoms that are shared minimally with those of depression. For each of the 21 items, respondents indicate how much they have been bothered by each symptom during the past week, on a scale ranging from 1 (not at all) to 4 (severelyI could barely stand it). This measure was included to screen for symptoms of anxiety. Data from any participant reporting clinical levels of anxiety would be considered for separate analysis. Clinical levels of anxiety were not anticipated in this sample.
Center for Epidemiological StudiesDepression. Depressive symptoms were assessed using the 20-item Center for Epidemiological StudiesDepression (CESD; Radloff, 1977), which measures symptoms experienced in the past week. This measure was included to screen for depressive symptoms. Data from any participant reporting clinical levels of depression would be considered for separate analysis. Clinical levels of depression were not anticipated in this sample.
Repeated-measures analysis of variance (ANOVA) was used to examine whether there were significant changes in levels of mindfulness, well-being, and distress from pretest to posttest. The magnitude of intervention effect was calculated using J. Cohens (1977) standard interpretation of d = 0.2 as a small effect size, d = 0.5 as medium, and d = 0.8 as large (see Table 1 for means and effect sizes).
Table 1. Pretest and Posttest Means and Effect Sizes
***p < .005. **p < .01. *p < .05. ^p < .01.
Mindful awareness. As shown in Figure 1, a significant increase in mindfulness as measured by MAAS scores was found (F =10.037, p =.005).
WELL-BEING AND INTERPERSONAL WELL-BEING
Perceived stress. As shown in Figure 1, there was a significant decrease in perceived stress from pretest to posttest (F = 14.957, p = .001).
Satisfaction with life and social connectedness. Following anecdotal reports of an enhanced sense of connection to others following participation in IMT, these two measures were added to the test battery in the second wave of data collection. Preliminary analyses of second-wave data revealed no significant differences on any measures or demographic variables between those who completed postintervention questionnaires (n = 12) and those who did not (n = 4; F = .430, p = .851). The 12 participants with complete data were retained for these analyses. As shown in Figure 1, a repeated-measures ANOVA found a trend for increased satisfaction with life (F = 4.928, p = .051) and a significant increase in social connectedness from pretest to posttest (F = 16.018, p = .002). See Figure 2 for social connectedness means and effect size.
Emotional intelligence. As shown in Figure 2, there was a significant increase in EI as measured by SREIT scores from pretest to posttest (F = 6.396, p = .020).
Meaning in life. There was no significant change in presence of meaning in life from pretest to posttest (F = .363, p = .553), as shown in Figure 1. There was a trend toward decreased searching for meaning in life (F = 3.708, p = .069).
Anxiety and depression. None of the subjects reported clinical levels of anxiety at pretest or posttest. As shown in Figure 1, there was a significant reduction in anxiety as measured by the BAI (F = 5.733, p = .027). None of the subjects reported clinical levels of depression at pretest or posttest. There was no significant change in CES-D scores (F = .533, p = .474).
Figure 1. Mindfulness, well-being, and clinical symptoms
***p < .005. **p < .01. *p < .05. ^p < .01.
Figure 2. Interpersonal well-being
FEASIBILITY OF INTERVENTION
Program evaluations were positive for the current intervention, and all participants indicated that they would recommend this course to others. A participant who wrote in an early homework entry, The idea of my being more aware of my surroundings and body states having an effect on my general state of being seemed so counterintuitive to someone like myself who normally relies on logic and empiricism to back ideas concluded at the end of the training, Not only do I have a powerful skill set that I can use to both relax and alternatively reinvigorate myself, but Ive also figuratively given myself permission to let go of that chip on my shoulder that refused to believe something so simple could be so effective.
HELPFULNESS OF INTERVENTION
Increased mindfulness. Results from this study indicate that the IMT shows promise as an intervention designed to increase mindfulness.
Decreased anxiety. Results suggest that participation in IMT is associated with significant decreases in anxiety within a sample that evidenced nonclinical levels of anxiety at baseline.
Enhanced well-being. Consistent with earlier research suggesting a relationship between mindfulness and well-being (i.e., Brown & Ryan, 2000), results from this pilot study imply that relationally oriented mindfulness training is associated with significant decreases in perceived stress and are suggestive of a trend toward increased life satisfaction. There was also a trend toward decreased searching for meaning in life (e.g., I am looking for something that makes my life feel meaningful; I am always looking to find my lifes purpose), perhaps due to greater acceptance of life as it is. Frankl (1965) suggested that the search for meaning in life may be distressing, as supported by correlations between searching for meaning subscale scores and negative affect, depression, and neuroticism (Steger et al., 2006).
Interpersonal well-being. IMT with healthy adults appears to positively affect ones sense of social connectedness, understood as a relational schema or cognitive structure representing regularities in patterns of interpersonal relatedness (Baldwin, 1992, p. 461). Interventions that increase social connectedness may positively alter relational schemata, which may influence interpersonal behaviors and decrease psychological distress (Lee et al., 2001). Support for the notion that mindfulness leads to increased relationship satisfaction comes from a study of nondistressed couples using a randomized wait-list control in which a mindfulness-based relationship enhancement (MBRE) intervention brought about significant improvements in day-to-day relationship happiness and relationship stress, as well as in stress coping efficacy and overall stress (Carson et al., 2004).
In addition to endorsing increased social connectedness, study participants qualitatively described an enhanced sense of connectedness. In a journal assignment wherein students were asked to answer, in their own words, What will I take away from this class? one student wrote, There is a huge difference between being mindful and self-absorbed; actually, there is probably very little common ground, as mindfulness leads to a feeling [italics added] of connection. Another participant wrote, Mindfulness, to me, means being grounded, having a sense [italics added] of connectedness. The study authors are not aware of any quantitative measures of this felt sense of connection, which may represent Siegels (2007) proposed relational sense, or
our relationship, our connection, with some being. When we attune with another person . . . we can become aware of this resonant state that is created within the relating. The eighth sense is how we are aware of feeling felt by another and enables us to feel part of the larger whole. . . . This intentional attunement may be at the heart of resonating relationships of all sorts. (p. 123)
The significant increase in SREIT scores from pretest to posttest suggests that participation in the present mindfulness training is associated with increased EI. Higher levels of EI are associated with less alexithymia, greater clarity of feeling, more mood repair, greater optimism and less pessimism, less depression, and less impulsivity (Schutte et al., 1998). We have categorized EI as an indicator of interpersonal well-being because of the social nature of this construct; EI has been referred to as emotional-social intelligence (Bar-On, 2000). Approximately half of the SREITs items refer to interpersonal aspects of EI (e.g., I can tell how other people are feeling by listening to the tone of their voice; I am aware of the nonverbal messages I send to others) that may influence social relationships such as the therapistpatient relationship.
IMPLICATIONS FOR GRADUATE PSYCHOLOGY TRAINING
Mindfulness in psychology education. This mindfulness training was integrated into a semester-long graduate course in psychology. Increasingly, educational institutes are introducing mindfulness education (see Garrison Institute, 2005). The high attendance rate and positive program evaluations suggest that experiential IMT can be successfully taught within a graduate psychology curriculum.
This study adds to findings that MBSR for health care professionals is associated with decreased perceived stress (Shapiro et al., 2005). This intervention was implemented with graduate students in the fields of clinical and counseling psychology, all of whom are training to work in mental health care, and many currently conduct psychotherapy. Because nascent therapists and helping professionals may be at an increased risk of occupational stress (Skovholt & Ronnestad, 2003), which in turn may lead to increased burnout (e.g., Spickard et al., 2002), programs aimed at teaching stress management to these trainees may bolster students psychological resilience and may reduce burnout. Our findings are consistent with a previous study of graduate counseling psychology students, in which Shapiro and colleagues (Shapiro et al., 2007) found that participation in a MBSR program was associated with improvements in mental health outcomes. We agree with these authors in suggesting that mindfulness training may be a useful complement to the standard training of future therapists.
Care for the caregivers. The current study reports increased interpersonal well-being following participation in IMT, adding to findings that mindfulness is associated with enhanced relationship satisfaction (Carson et al., 2004) and empathy (see Dekeyser, Raes, Leijssen, Leysen, & Dewulf, 2008). Sawyer Cohen and Semple (in press) argue that these findings are relevant for parenting interventions and that research is needed on potential benefits of mindful parenting interventions. Just as interest in mindful parenting has increased, so too has interest in understanding the role of mindfulness within the therapeutic relationship. Mindfulness training for psychotherapists, who also rely on empathic interactions, may have important implications for the quality of the therapeutic alliance and/or therapeutic outcomes.
A chief limitation of this exploratory study is the lack of a control-group comparison, without which it is not possible to attribute changes from pretest to posttest to the effects of the mindful awareness intervention. Likewise, without another group intervention available for comparison, it is not possible to examine possible nonspecific factors of the mindful awareness training (e.g., group membership) that may have influenced outcomes such as social connectedness. Another significant limitation is the small sample size and lack of statistical power to examine whether increased mindfulness per se moderated the relationship between participation in the intervention and changes in outcome variables. A larger sample size is needed to test the reliability of the current results. This study relied solely on self-report data, and future research ought to incorporate reports from other informants, ideally those blind to the treatment conditions.
Despite the growing empirical support for mindfulness-based interventions for symptom reduction, research on relationally oriented interventions designed to improve interpersonal outcomes is scant. Findings from this pilot study of interpersonal mindfulness training indicate that this relationally oriented mindfulness training is feasible and helpful for clinicians-in-training. More broadly, these findings add to the growing body of literature examining interpersonal mindfulness, with relevance beyond the therapeutic relationship.
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