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Relationships between mindfulness practice and levels of mindfulness,

medical and psychological symptoms and well-being in a mindfulness-based
stress reduction program

Article  in  Journal of Behavioral Medicine · March 2008

DOI: 10.1007/s10865-007-9130-7 · Source: PubMed

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J Behav Med (2008) 31:23–33
DOI 10.1007/s10865-007-9130-7

Relationships between mindfulness practice and levels

of mindfulness, medical and psychological symptoms
and well-being in a mindfulness-based stress reduction program
James Carmody Æ Ruth A. Baer

Accepted: August 17, 2007 / Published online: 25 September 2007

! Springer Science+Business Media, LLC 2007

Abstract Relationships were investigated between home Keywords Mindfulness ! Mindfulness based stress
practice of mindfulness meditation exercises and levels of reduction ! Meditation ! Medical symptoms ! Psychological
mindfulness, medical and psychological symptoms, per- symptoms ! Wellbeing ! Stress
ceived stress, and psychological well-being in a sample of
174 adults in a clinical Mindfulness-Based Stress Reduc-
tion (MBSR) program. This is an 8- session group program An increasing body of research supports physical and
for individuals dealing with stress-related problems, illness, mental health benefits of participation in mindfulness
anxiety, and chronic pain. Participants completed measures training. Recent reviews of the empirical literature (Baer
of mindfulness, perceived stress, symptoms, and well- 2003; Grossman et al. 2004; Salmon et al. 2004; Hayes
being at pre- and post-MBSR, and monitored their home et al. 2006) suggest that several interventions that incor-
practice time throughout the intervention. Results showed porate mindfulness, including mindfulness-based stress
increases in mindfulness and well-being, and decreases in reduction (MBSR) (Kabat-Zinn 1982; Kabat-Zinn 1990),
stress and symptoms, from pre- to post-MBSR. Time spent mindfulness-based cognitive therapy (MBCT) (Segal et al.
engaging in home practice of formal meditation exercises 2002), dialectical behavior therapy (DBT) (Linehan 1993)
(body scan, yoga, sitting meditation) was significantly and acceptance and commitment therapy (ACT) (Hayes
related to extent of improvement in most facets of mind- et al. 1999); lead to clinically significant improvements in
fulness and several measures of symptoms and well-being. psychological functioning in a wide range of populations.
Increases in mindfulness were found to mediate the rela- As evidence for the efficacy of these interventions con-
tionships between formal mindfulness practice and tinues to grow, the importance of investigating the mech-
improvements in psychological functioning, suggesting anisms of action by which mindfulness training exerts
that the practice of mindfulness meditation leads to salutogenic effects is increasingly recognized (Dimidjian
increases in mindfulness, which in turn leads to symptom and Linehan 2003; Baer et al. 2006; Hayes et al. 2006;
reduction and improved well-being Shapiro et al. 2006). Examination of this question requires
methods to assess levels of mindfulness to determine
whether individuals engaged in the practice of mindfulness
are in fact becoming more mindful over time, and if so,
whether these increases are responsible for the positive
outcomes observed.
J. Carmody (&)
The recent literature includes several newly developed
Division of Preventive and Behavioral Medicine, University
of Massachusetts Medical School, Shaw Building, self-report measures of a general tendency to be mindful in
Room 214, 55 Lake Ave North, Worcester, MA 01655, USA daily life (Baer et al. 2004); (Buchheld et al. 2001; Brown
e-mail: [email protected] and Ryan 2003; Feldman et al. In press). These measures
have been shown to be significantly correlated with each
R. A. Baer
Department of Psychology, University of Kentucky, Lexington, other and to have promising psychometric properties (Baer
KY, USA et al. 2006). However, differences in their content and

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24 J Behav Med (2008) 31:23–33

structure suggest some disagreement between researchers meditation practices (sitting meditation, body scan, mind-
about how mindfulness should be defined and operation- ful yoga), and the integration of this capacity into everyday
alized. In particular, the number of components or facets of life as a coping resource for dealing with intensive physical
mindfulness varies widely across instruments. In a recent symptoms and difficult emotions (Kabat-Zinn 1994). Par-
study of facets of mindfulness, Baer et al. (2006) con- ticipants attend eight weekly 2 1/2 h sessions, plus an all-
ducted exploratory factor analysis of the combined item day session on a weekend day during the sixth week. These
pool from all available mindfulness questionnaires and sessions include training in formal mindfulness practices as
found that a five-factor structure appeared to capture sev- well as group interaction. Class discussion centers around
eral distinct but related underlying dimensions. Items with the challenges and achievements participants are experi-
the highest loadings on each of the five factors (and low encing using mindfulness in the face of stressful situations
loadings on all other factors) were combined to form the occurring in their everyday lives. In the body scan, par-
Five Facet Mindfulness Questionnaire (FFMQ) (Baer et al. ticipants focus attention sequentially on parts of the body,
2006), which assesses five elements of mindfulness. These non-judgmentally noticing whatever sensations may be
include observing (attending to or noticing internal and present in each area. Mindful hatha yoga postures also are
external stimuli, such as sensations, emotions, cognitions, practiced to develop awareness during gentle movements
sights, sounds, and smells), describing (noting or mentally and stretching. In sitting meditation, participants use
labeling these stimuli with words), acting with awareness awareness of the sensations of breathing as a baseline
(attending to one’s current actions, as opposed to behaving attentional focus, while noticing any other sensations in the
automatically or absent-mindedly), non-judging of inner body, sounds in the environment, and/or cognitions and
experience (refraining from evaluation of one’s sensations, feeling states that also present themselves to attention. In
cognitions, and emotions) and non-reactivity to inner addition, participants are encouraged to engage in informal
experience (allowing thoughts and feelings to come and go, mindfulness practice by doing everyday activities (such as
without attention getting caught up in them). Examples of eating, walking, washing the dishes, etc) with full aware-
items for each factor can be seen in Table 1. ness of the associated movements, sensations, cognitions
These five facets of mindfulness have shown good and feelings that may be present. Participants are given two
internal consistency and correlations in the expected CD’s containing instructions to guide their formal medi-
directions with many variables predicted to be related to tation practices (body scan, yoga, and sitting meditation)
mindfulness, such as experiential avoidance, thought sup- and encouraged to practice at home by listening to the CD
pression, openness to experience, and emotional intelli- for 45 min each day throughout the seven weeks of the
gence (Baer et al. 2006). Significant relationships with program (Kabat-Zinn 1990).
meditation experience in long-term meditation practitio- The importance of regular out-of-class practice in
ners also have been documented (Baer et al. 2007), but establishing the capacity for mindfulness in everyday life,
changes in these facets of mindfulness over the course of a and hence its purported benefits, is also clearly stated in
mindfulness-based program in a clinical setting have not other mindfulness-based programs. The manual for MBCT
been investigated. One purpose of the current study recommends 45 min of daily practice in order to obtain the
therefore, was to examine whether participation in MBSR benefits of participation (Segal et al. 2002) and a recent
is associated with changes in levels of mindfulness, as ACT manual (Hayes and Smith 2005) suggests practicing
measured by the FFMQ. for 15–30 min per day. In DBT, the importance of regular
The foundation and methodology of MBSR has been practice is emphasized, but specific practice goals are
described in detail elsewhere (Kabat-Zinn 1982; Kabat- determined by clients and their therapists. While this
Zinn 1990). Briefly, it is a group program that focuses on expectation of daily practice is well established in the
the cultivation of mindfulness through instruction in formal Buddhist meditation traditions upon which these programs

Table 1 Example items for mindfulness facets

Facet Example item

Observing I notice the smells and aromas of things.

Nonreactivity to inner experience I perceive my feelings and emotions without having to react to them.
Describing I’m good at finding words to describe my feelings.
Nonjudging of inner experience I think some of my emotions are bad or inappropriate and I shouldn’t feel them. (R)
Acting with awareness I find myself doing things without paying attention. (R)
Note: R = reverse-scored item (higher scores represent higher levels of mindfulness)

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J Behav Med (2008) 31:23–33 25

draw, there is limited empirical evidence for the effects of Methods

home practice in clinical populations.
In a sample of women with binge eating disorder who Participants
completed a 6 week mindfulness-based treatment, Kris-
teller and Hallett (1999) found that time spent in the practice Study participants were drawn from individuals enrolled in
of eating-related mindfulness exercises was significantly the University of Massachusetts Medical School MBSR
correlated with degree of improvement in binge eating. program in Worcester MA during 2006. While detailed
Practice of ‘‘mini-meditations,’’ in which participants stop data were not available on participants’ diagnoses, the
for a few moments at key times during daily activities to MBSR groups included adults with a wide range of prob-
practice nonjudgmental awareness of thoughts and feelings, lems including illness-related stress, chronic pain, anxiety,
was significantly related to improvements in depressive and personal and employment-related stress. Each class
symptoms. In a subsequent study with a similar population, included approximately 20–25 participants; about half
time spent engaging in eating-related mindfulness exercises were referred by their health-care practitioner and others
was significantly related to improvements in eating control were self-referred. Participation in the program is on a self-
(Kristeller et al. under review). In a study of MBSR with pay basis. Self-report data for program evaluation and
cancer outpatients, Speca et al. (2000) reported that home participant information are routinely collected before the
practice of meditation was significantly related to first class, and again at the end of each 8-week group. All
improvements in mood. In contrast, Astin (1997) found that participants are asked on the intake questionnaire whether
practice time and symptom improvement were not signifi- their response information can be used for research pur-
cantly correlated in a sample of college students completing poses, on condition that they are not identified as individ-
MBSR. Similarly, Davidson (2003) found no relationship uals. The current study includes data from the 96% of the
between reported practice time during an MBSR course and participants who consented to the use of their data for
degree of change in either biological or self-report measures research purposes.
in a worksite sample of healthy employees. Since most A total of 206 individuals in nine MBSR groups who
participants in mindfulness-based programs are likely to consented to the use of their data completed the pre-
have many competing time demands, the disclosure of the intervention measures. Of these, 10 (5%) attended three or
expectation of lengthy out-of-class practice may act as a fewer sessions and provided no assessment data at post-
barrier to participation for some. For these reasons, and also intervention. Of the remaining 196, 22 attended four or
to further understanding of mechanisms of action, it is more sessions but failed to provide post-intervention
important to clarify and confirm the role of home practice in assessment data. Thus, data at both pre- and post-MBSR
obtaining the program’s potential benefits. were available for 174 participants (85% of those who
In light of the above, the purpose of the present study consented to participate). Of these, 168 (97%) attended
was to investigate three related questions: (1) Whether six or more of the eight weekly sessions, whereas five
participation in MBSR was associated with increases in participants attended five sessions or fewer. Attendance
mindfulness as measured by the FFMQ; (2) if such data for one participant were unavailable. The all-day
increases were observed, whether the amount of out- session in week six was attended by 150 (86%) of these
of-class practice of mindfulness was related to improve- participants.
ment in mindfulness scores; and (3) if support for this The mean age of the 174 participants was 47.05 years
relationship was found, whether the increases in levels of (SD = 10.26, range 19–68) and 63% were female. Most
mindfulness mediate the relationship between mindfulness were married (65%) or cohabitating (9%), whereas 12%
practice and any observed improvements in psychological were single, 9% were separated, divorced, or widowed, and
functioning and reported medical symptoms. Our outcome 5% did not answer this question. Most participants reported
variables included measures of medical and psychological white collar and professional occupations. Current or pre-
symptoms shown in previous research to be associated with vious participation in psychotherapy was reported by 63%
significant improvements in MBSR participants (see sec- of the sample.
tion on measures below). In addition, because meditation Differences between the participants who failed to
traditions consistently suggest that the practice of mind- provide post-treatment data (N = 32) and the rest of the
fulness cultivates positive qualities such as wisdom, com- sample (N = 174) were examined using one-way analysis
passion, insight, and equanimity (Shapiro et al. 2002), we of variance and chi-square analyses. No significant differ-
included a measure of psychological well-being (Ryff ences were found for demographic variables (age, gender,
1989) that assesses aspects of psychological health inde- marital status, participation in psychotherapy) or for any of
pendent of symptom levels. This measure has not been the dependent variables as measured at pre-treatment
included in previous studies of MBSR. (medical and psychological symptoms, perceived stress,

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26 J Behav Med (2008) 31:23–33

well-being, mindfulness). Thus, the 174 participants of the seven weeks of the MBSR program. Participants
included in analyses described later appear to be repre- were asked to record the number of minutes of home
sentative of the slightly larger group that consented to practice they did each day in each of the formal meditation
participate. practices taught in the program (body scan, mindful yoga,
sitting meditation) as well as the minutes of informal
Procedures (becoming mindful in everyday activities) practice.
Psychological symptoms were assessed with the Brief
Prospective MBSR participants attend an orientation/ Symptom Inventory (BSI) (Derogatis 1992) which includes
information session during the three weeks prior to the 53 items and provides nine sub-scale scores measuring a
beginning of each 8-week group. In these sessions the goals range of psychological symptoms and somatic complaints.
and format of the program are explained and any questions A global severity index (GSI) also can be calculated.
they may have about their participation are answered. Pre- Studies of MBSR show significant reductions in GSI,
program questionnaires (described below) were completed anxiety and depression associated with participation in the
immediately prior to these orientation sessions. Post-pro- program (Shapiro et al. 1998; Williams et al. 2001; Ma-
gram instruments were completed during the final MBSR jumdar et al. 2002).
session. Home practice data were derived from a mind- Medical symptoms were assessed using the Medical
fulness practice log in which participants recorded the Symptom Checklist (MSCL) (Kabat-Zinn 1982). This is a
number of minutes of formal and informal mindfulness list of 115 common medical symptoms and respondents
practice they did each day. Participants placed their com- are asked to check those they have experienced as both-
pleted logs in the slot of a closed purpose-built box that ersome in the past month. The score is the total number
was in the classroom each week. The study assistant col- of symptoms checked. While the reliability and validity of
lected the logs from the box following each session. the MSCL have not been evaluated, several studies of
Respondents were assured that their responses would not MBSR have shown significant reductions in the MSCL
be seen by the instructor. Logs were color-coded by week. associated with participation in the program (Kabat-Zinn
Participants who forgot to bring their log to class were et al. 1985; Kabat-Zinn 1987; Kabat-Zinn and Chapman-
asked to fill out a retrospective plain white log for that Waldrop 1988; Kabat-Zinn et al. 1992; Williams et al.
week. 2001).
Perceived stress was assessed using the Perceived
Measures Stress Scale (PSS) (Cohen et al. 1983; Cohen and
Williamson 1988), a widely-used and well-validated
Demographic characteristics were assessed at pre-inter- 10-item scale that measures the degree to which situa-
vention only. Participants reported their age, gender, mar- tions in one’s life over the past month are appraised as
ital status, occupation, any history of substance abuse, and unpredictable, uncontrollable and overwhelming. It pos-
past or current participation in psychotherapy. its that people appraise potentially threatening or chal-
Variables assessed at both pre- and post-MBSR lenging events in relation to their available coping
included mindfulness, medical and psychological symp- resources. A higher score indicates a greater degree of
toms, perceived stress, and psychological well-being. perceived stress. Participation in MBSR has been asso-
Home mindfulness practice was assessed throughout the ciated with significant declines in PSS scores (Carmody
intervention. et al. 2006).
Mindfulness was assessed using the FFMQ (Baer et al. Psychological Well-Being was assessed using the Scales
2006). This instrument was derived from a factor analysis of Psychological Well-Being (Ryff and Keyes 1995) which
of questionnaires measuring a trait-like general tendency to conceptualize psychological well-being (PWB) as has
be mindful in daily life. It consists of 39 items assessing having six elements: self-acceptance (positive attitude
five facets of mindfulness: observing, describing, acting toward one’s self, life, and past, including good and bad
with awareness, non-judging of inner experience, and non- qualities), positive relations with others (warm, satisfying,
reactivity to inner experience. Items are rated on a Likert trusting relationships), autonomy (independence, ability to
scale ranging from 1 (never or very rarely true) to 5 (very resist social pressures and follow own standards), envi-
often or always true). The FFMQ has been shown to have ronmental mastery (competence in managing life’s
good internal consistency and significant relationships in demands), purpose in life (goals and direction, sense of
the predicted directions with a variety of constructs related meaning), and personal growth (view of self as growing
to mindfulness (Baer et al. 2006). and developing, openness to new experiences). The PWB
Home mindfulness practice was assessed using a folder scales measure these six elements and are available in
of seven color-coded homework logs––one color for each several lengths. The 54-item version, with nine items per

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J Behav Med (2008) 31:23–33 27

scale, was used in the present study. This version has been effect size. Medical and psychological symptoms and
shown to have good psychometric properties (Sewell et al. perceived stress levels all decreased significantly, with
2004). We used a total score derived by summing the moderate to large effect sizes.
elements of well-being.
Home mindfulness practice

Results Of the 174 participants who provided both pre- and post-
MBSR assessment data, 121 (69.5%) provided some or all
Changes in mindfulness facets, well-being, perceived of their home practice data. Only these 121 participants are
stress and symptoms included in the following analyses of practice time. For
these 121 participants, the mean number of practice logs
Changes in all variables from pre- to post-MBSR provided was 6.16 out of a possible seven (SD = 1.34), and
(N = 174) can be seen in Table 2. Paired sample t-tests 91% provided five or more of the seven logs. For missing
showed that all variables changed significantly and in the logs, values of zero were entered. Thus, practice times may
expected direction. Pre-post effect sizes (Cohen’s d) were be under-estimates, as participants may have engaged in
calculated using the formula suggested by Rosenthal mindfulness practice on days for which they completed no
(1984) for matched-pairs data (d = t/"df). Scores on all logs.
mindfulness facets increased significantly pre- to post- For each of the formal practices, a mean of 97.7% of
program. Effect sizes were large for observing and non- reported practice times fell between 0 and 45 min. Nearly
reactivity to inner experience and moderate for describing, all of the remaining practice times fell between 46 and
acting with awareness, and non-judging. Psychological 90 min. A few individuals occasionally reported practicing
well-being subscales also increased significantly in asso- one particular exercise on one specific day for
ciation with program participation, and showed a large 100–300 min. These latter reports, although extreme,

Table 2 Means and SD’s, paired sample t-tests, and pre-post effect sizes for all variables
Variable Pre-MBSR Post-MBSR t d
M SD M SD

Mindfulness facets
Observe 23.79 5.84 28.28 4.72 –11.94** .91
Describe 26.90 6.42 28.92 6.02 –6.12** .47
Act with awareness 23.72 5.76 26.49 5.13 –7.60** .58
Nonjudge 26.34 7.01 30.78 5.86 –8.70** .68
Nonreact 17.97 4.98 22.19 4.13 –11.09** .86
Psychological well-being 227.62 37.41 246.55 37.95 –9.77** .77
Perceived stress 22.13 6.19 15.78 6.33 13.14** 1.02
Symptom measures
MSCL 21.63 12.09 13.66 9.77 11.83** .90
BSI-global severity 0.77 0.47 0.53 0.40 8.38** .65
Somatization 0.55 0.57 0.42 0.48 3.54* .27
Obsessive-compulsive 1.34 0.82 0.96 0.68 7.61** .58
Interpersonal sensitivity 0.92 0.85 0.62 0.64 5.86** .45
Depression 0.81 0.70 0.57 0.65 5.64** .44
Anxiety 1.04 0.74 0.65 0.53 7.84** .61
Hostility 0.75 0.65 0.46 0.46 6.84** .53
Phobic anxiety 0.32 0.51 0.17 0.38 3.83** .30
Paranoia 0.55 0.61 0.41 0.46 4.15** .32
Psychoticism 0.54 0.54 0.37 0.45 4.99** .39
Note. MSCL = Medical Symptom Checklist, BSI = Brief Symptom Inventory
* p < .01, ** p < .001

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28 J Behav Med (2008) 31:23–33

represented less than .05% of all reported practice times. day. Informal practice (becoming mindful in everyday
To normalize the distribution of practice times and reduce activities) was reported on a mean of just under 20 days,
the potential influence of outliers on the analyses that fol- for an average of 11–15 min per day.
low, reported daily practice times for each exercise were
coded on a 0–10 scale, in which 0 = no practice, Relationships between home mindfulness practice
1 = 1–5 min of practice, 2 = 6–10 min, 3 = 11–15 min, and other variables
and so on, with 10 = greater than 45 min of practice.
Participants were encouraged to engage in out-of-class We examined whether time reported spent in mindfulness
practice 6 days per week and homework practice logs were practice was related to the extent of change in mindfulness,
requested at sessions two through eight (seven weeks) well-being, and medical and psychological symptoms. For
yielding a maximum total number of 42 expected practice these analyses, daily homework practice times (coded on
days. While the sequence of introduction of the formal the 0–10 scale described above) for each exercise were
mindfulness techniques could vary in individual classes at summed, yielding a total reported practice time for each
the discretion of the instructor, generally during the first exercise over the course of the 7-week program.
two weeks participants were asked to practice the body scan Table 4 shows correlations between total practice time
6 days per week. Mindful yoga was introduced in the third and pre-post changes in all dependent variables. Because of
session and participants were asked to practice the body the large number of correlations presented, only those with
scan and yoga on alternate days during the following two p values less than .01 are considered significant. These
weeks. While short sitting meditation periods were intro- findings suggest that practice time for formal meditation
duced during the first four sessions and participants were (body scan, yoga, sitting) is associated with many changes
encouraged to practice this at home, the 45-min recording in the beneficial direction. Practice of the body scan was
of guided sitting meditation was not introduced until the significantly related to increases in the mindfulness facets
fifth session. At that time, participants were instructed to of observing and non-reactivity to inner experience,
practice the sitting meditation on alternate days, with their increases in psychological well-being, and decreases in
choice of either the body scan or the yoga on the inter- interpersonal sensitivity and anxiety. Yoga practice was
vening days. After that, they were given considerable significantly associated with changes in four of five
flexibility to choose which exercise(s) to practice each day. mindfulness facets (all but describing), well-being, per-
Table 3 shows the mean number of days on which ceived stress levels, and several types of psychological
participants reported practicing each exercise, together symptoms. A similar pattern was seen for total formal
with the mean duration (in min) of practice on each of practice time (body scan, sitting, and yoga combined).
those days, and the total number of hours of practice over Practice of sitting meditation was significantly associated
the course of the program. On the average, participants with changes in two mindfulness facets (acting with
reported practicing the body scan on 19.6 days, for awareness and non-reactivity), psychological well-being,
31–35 min each day that they practiced it. Participants and symptoms of psychoticism (social alienation and
practiced yoga on nearly 17 days, for 16–20 min per day. concerns about the health of one’s mind). In contrast,
Sitting meditation was reported on roughly 20 days, for reported informal mindfulness practice (doing routine
16–20 min per day. Many participants reported engaging in activities mindfully) showed no significant relationships
more than one formal practice on a single day. The average with changes in any of the dependent variables. In addition,
number of days on which any formal practice occurred changes in the describing facet of mindfulness were not
(body scan, sitting, and/or yoga) was 33.55, or 80% of the related to practice times for any of the mindfulness exer-
42 assigned days of practice. The average total practice cises. No significant correlations were found between
time for all formal practices combined was 31–35 min per practice time and change in medical symptoms.

Table 3 Homework practice during MBSR course for 121 participants providing homework data
Mindfulness exercise Total days practiced Minutes per day practiced Total hours practiced
Mean SD Mean Minimum Maximum

Body scan 19.61 9.32 31–35 6–10 >45 10.79

Movement (yoga) 16.92 11.14 16–20 1–5 41–45 5.08
Sitting meditation 19.70 10.98 16–20 1–5 41–45 5.91
Any formal practice 33.55 10.87 31–35 6–10 >45 18.45
Informal practice 19.94 13.69 11–15 1–5 >45 4.3

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J Behav Med (2008) 31:23–33 29

Table 4 Correlations between total practice time during MBSR course and pre-post changes in other variables for 121 participants providing
homework data
Body scan Movement (yoga) Sitting meditation Total formal practice Informal practice

Mindfulness facets
Observe .29* .24* .23 .33* .21
Describe .02 .02 .04 .03 .02
Act with awareness .09 .32* .26* .27* .14
Nonjudge .08 .26* .09 .18 .03
Nonreact .28* .32* .26* .36* .09
Psychological well-being .27* .42* .32* .42* .21
Medical symptoms .17 .19 .12 .21 .03
Perceived stress .16 .24* .23 .26* .15
Psychological symptoms
Somatization .14 .14 .12 .17 –.02
Obsessive-compulsive .10 .13 .03 .12 .06
Interpersonal sensitivity .24* .31* .19 .31* .08
Depression .05 .18 .15 .15 .01
Anxiety .26* .25* .19 .29* .09
Hostility .04 .06 –.02 .04 –.12
Phobic anxiety .15 .33* .16 .26* .21
Paranoia .06 .17 .11 .14 –.09
Psychoticism .22 .33* .27* .33* .10
Global severity .21 .32* .19 .30* .02
* p < .01

Although these findings suggested that greater practice methods described by MacKinnon et al. (2000). In each
time is associated with increases in mindfulness and well- case the independent variable (IV) was total formal prac-
being and decreases in stress and symptoms, it was tice time over the course of the program, created by sum-
important to consider whether pre-treatment levels of ming the practice times (coded 0–10 as described earlier)
mindfulness or psychological functioning were related to for body scan, sitting meditation, and yoga. Informal
participants’ likelihood of engaging in their assigned practice time was not included in this variable because it
homework exercises. Correlations were therefore com- was not significantly correlated with changes in other
puted between total formal practice time during the inter- variables. The proposed mediating variable was the degree
vention and pre-treatment scores on the mindfulness facets, of change in mindfulness from pre- to post-intervention
perceived stress, medical and psychological symptoms, and and was created by summing the pre-post change scores for
well-being. These correlations were non-significant, sug- the observing, acting with awareness, non-judging, and
gesting that participants’ pre-treatment levels of these non-reactivity facets. The describing facet was not
variables had no significant effect on the amount of included in this variable because it was not significantly
assigned home mindfulness practice they reported doing. correlated with practice time. The dependent variables
(DV) for the three mediation analyses were pre-post
Mediation analyses change scores for psychological symptoms (BSI-global
severity index), perceived stress (PSS total score), and
Because the findings suggested that engaging in formal psychological well-being (PWB total score), respectively.
mindfulness practices was associated with improvements in According to Baron and Kenny (1986), several condi-
both mindfulness and symptoms/well-being, our third goal tions must be met to show support for a mediational
was to test the hypothesis that increases in mindfulness hypothesis. The IV, mediator, and DV all must be signifi-
mediate the relationship between reported minutes spent in cantly inter-correlated. When the IV and the mediator are
practice and improved psychological functioning. To entered simultaneously into a model predicting the DV, the
examine this question we conducted three mediation relationships between the IV and DV must become non-
analyses using the methods based on linear regression significant, or must be significantly reduced. For the first
described by Baron and Kenny (1986), supplemented with mediation analysis, in which decrease in psychological

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30 J Behav Med (2008) 31:23–33

symptoms was the dependent variable, all conditions were A similar pattern was found for the second mediation
met. Meditation practice time was a significant predictor of analysis, in which decrease in perceived stress was the
decrease in psychological symptoms (R = .30, F = 11.39, dependent variable. (Fig. 1b). In this case, meditation
p < .01), and of increase in mindfulness (R = .42, practice time was a significant predictor of decrease in
F = 21.95, p < .001). Increase in mindfulness also was a perceived stress (R = .26, F = 8.30, p < .01) and of
significant predictor of decrease in symptoms (R = .49, increase in mindfulness (R = .42, F = 46.50, p < .001).
F = 46.50; p < .001). When formal practice time and Increase in mindfulness also was a significant predictor of
increase in mindfulness were entered simultaneously as decrease in perceived stress (R = .44, F = 34.74, p < .001).
predictors of decrease in symptoms, the regression coeffi- When formal practice time and increase in mindfulness
cient for practice time dropped to .10 (ns). According to the were entered simultaneously as predictors of decrease in
formula described by MacKinnon et al. (2000), the drop in perceived stress, the regression coefficient for practice time
the regression coefficient from .30 to .10 is significant dropped significantly (t = 2.77, p < .01) to .12 (ns), sug-
(t = 3.57, p < .01). This result is consistent with the gesting that the relationship between practice time and
hypothesis that the relationship between practice time and perceived stress also is completely mediated by the
psychological symptoms is completely mediated by development of mindfulness skills.
increases in mindfulness skills. This analysis can be seen in For increase in psychological well-being, only partial
Fig. 1a. mediation was shown (Fig. 1c). In this case, meditation
practice time was a significant predictor of well-being
(R = .42, F = 24.14, p < .001) and of increase in mind-
a Increase in
mindfulness
fulness (R = .42, F = 21.95, p < .001). Increase in mind-
.42* (FFMQ) .49* fulness also was a significant predictor of well-being
(R = .49, F = 45.95, p < .001). However, when practice
time and increase in mindfulness were entered simulta-
Total formal Decrease in
neously as predictors of well-being, the relationship
practice time psychological between practice time and well-being remained significant,
symptoms (BSI-
(.10) .30* GSI)
although the drop in the regression coefficient from .42 to
.25 was significant (t = 3.87, p < .01). This finding sug-
b Increase in
gests that, although increases in mindfulness are important
mindfulness in accounting for improvements in well-being, other vari-
.42* (FFMQ) .44*
ables not included in the model may also be important in
accounting for increased well-being.

Total formal Decrease in

practice time perceived stress
(PSS) Discussion
(.12) .26*

The first goal of this study was to investigate whether

c Increase in
mindfulness participation in MBSR would lead to changes in levels of
.42* (FFMQ) .49* mindfulness as measured by the FFMQ. If such changes
were observed, the second goal was to examine whether
extent of home practice of mindfulness meditation was
Total formal Increase in
related to changes in mindfulness as well as changes in
practice time psychological symptoms and well-being. Finally, if these relationships
well-being
(.25*) .42* (PWB) were found, the third goal was to explore whether increases
in mindfulness mediate the relationship between medita-
Fig. 1 Mediation of the relationship between formal meditation tion practice and improvements in functioning. Results
practice time and pre-post decrease in psychological symptoms as showed that levels of mindfulness increased significantly
measured by the BSI-GSI (a), pre-post decrease in perceived stress as
measured by the PSS (b), and pre-post increase in psychological well-
from pre- to post-MBSR, with effect sizes in the moderate
being as measured by the PWB total score (c). In each case, the to large range. Results also showed that the extent of home
mediating variable is the sum of pre-post change scores in the practice of formal meditation exercises (body scan, yoga,
observing, acting with awareness, nonjudging, and nonreactivity sitting) is significantly correlated with degree of change in
facets of mindfulness. All values are beta coefficients. Values in
parentheses show relationships between formal practice time and the
most facets of mindfulness (all but describing), and several
dependent variable, when the mediating variable is included in the measures of symptoms and well-being, although informal
model. *p < .01 mindfulness practice (doing routine activities mindfully)

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J Behav Med (2008) 31:23–33 31

was unrelated to these outcomes. Finally, increases in BSI. Given that mindful yoga was practiced on fewer days
mindfulness were shown to completely mediate the rela- and for fewer total hours than the other formal practices,
tionships between meditation practice over the course of these results are striking and bear further investigation. As
the intervention and improvement in psychological symp- the body scan is assigned for daily practice during the first
toms and perceived stress, suggesting that the improve- two weeks and is also a somatically-oriented practice, it
ments in mindfulness that appear to result from regular may be that the time participants spent in practice of the
practice are related to the significant reductions in psy- body scan prepared them to be more mindful of their
chological distress and perceived stress that were observed. bodily sensations during the yoga, and hence obtained
Because perceived stress and symptom scores were sig- more benefit from the yoga practice than if they had come
nificantly inter-correlated at both pre- and post-interven- to it without prior mindfulness practice. It may also be
tion, it is not surprising that mediation analyses for these easier for participants to bring mindful attention to the
two variables showed similar findings. Psychological well- body while it is moving or stretching as the yoga requires,
being also was significantly intercorrelated with stress and than while it is still as in the body scan or sitting medita-
symptoms, yet only partial mediation was shown for this tion, and this feature may also facilitate the transfer of the
variable, suggesting that other variables not measured here resultant mindfulness into everyday life. The considerably
are important in accounting for the relationship between higher average number of reported minutes of body scan
formal practice time and increased well-being. practice than the average yoga and sitting practice may
These findings are important because they provide initial represent the initial novelty of practice in the early weeks
support for a central tenet of several mindfulness-based of participation in the program, which may have waned
treatment approaches: that the regular practice of medita- over subsequent weeks.
tion should cultivate mindfulness skills in everyday life, Another unexpected finding was the lack of significant
which in turn should lead to improved psychological relationships between informal practice (doing routine
functioning such as symptom reduction, reduced stress and activities mindfully) and extent of change in other vari-
enhanced well-being. While this expectation is well ables. Informal practice is often described as an important
established in the Buddhist meditation traditions upon method for generalizing mindfulness skills learned in for-
which these programs draw, there is limited empirical mal practices into daily life (Kabat-Zinn 1990). Since no
evidence for the claim in clinical settings (Ramel et al. audio recordings are provided to guide informal practice, it
2004; Toneatto and Nguyen 2007) and this is the first study is possible that participants in this study had difficulty in
to report these associations with a large sample in a clinical providing accurate estimates of the time they spent in
context. An alternative explanation––that more mindful informal practice. Better methods of monitoring this type
people are more likely to practice meditation––was not of practice may be helpful in future studies as well as a
supported by our findings, which showed non-significant more detailed investigation of the importance of ‘living
relationships between baseline levels of mindfulness and mindfully’ on health and well-being outcomes.
extent of home practice during the intervention. The find- Several symptom measures, including the Medical
ings also provide encouraging support for the validity and Symptom Checklist and several scales of the BSI, showed
utility of the FFMQ in measuring mindfulness. While significant improvements from pre- to post-MBSR that
significant improvements were noted in the describing were not correlated with the amount of home practice of
factor of the FFMQ, these changes were not significantly any of the mindfulness exercises. Home practice is not the
associated with reported practice. This may be because only mechanism by which improvements may be obtained
MBSR training does not emphasize verbal labeling of the in MBSR and it is possible that reductions in these
components of experience to the extent seen in some other symptoms can be attributed to other potentially important
mindfulness-based interventions, such as DBT and ACT, factors not measured here, such as social support from
which include exercises for labeling of emotions, cogni- other group members, caring attention from the group
tions, and sensations. leader, the effect of mindfulness together with the physical
An unexpected finding was the strong association exercise that comes from yoga, or improved ability to
between the mindful yoga form of practice and changes in relax. Further, a person who undertakes the commitment of
other variables, including increased mindfulness skills, a course such as MBSR may also be motivated to con-
reduced symptoms, and improved well-being. Practice time currently practice other mind-body techniques or to change
for mindful yoga was significantly correlated with more of or improve other health-related behaviors such as medi-
these variables than were practice times for the body scan cation and treatment compliance for existing medical or
or sitting meditation, and yoga was the only formal prac- psychological conditions. Future research should attempt to
tice significantly related to increases in the non-judging measure these variables, so that other potential mechanisms
facet of mindfulness and the global severity index of the of change can be studied.

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The following limitations of the study should be con- Acknowledgements The authors would like to acknowledge the
sidered. Most of the participants were well educated, had assistance of staff in the Center for Mindfulness for administrative
support and data entry.
the financial resources to pay for the treatment and had
agreed to take part in a meditation-based program. It cannot
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