Journal of Consulting and Clinical Psychology

2006, Vol. 74, No. 4, 714 719

Copyright 2006 by the American Psychological Association

0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.4.714

Passage Meditation Reduces Perceived Stress in Health Professionals:

A Randomized, Controlled Trial
Doug Oman

John Hedberg

Public Health Institute and University of California, Berkeley

University of Colorado Health Sciences Center

Carl E. Thoresen
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Stanford University
The authors evaluated an 8-week, 2-hr per week training for physicians, nurses, chaplains, and other
health professionals using nonsectarian, spiritually based self-management tools based on passage
meditation (E. Easwaran, 1978/1991). Participants were randomized to intervention (n 27) or waiting
list (n 31). Pretest, posttest, and 8- and 19-week follow-up data were gathered on 8 measures, including
perceived stress, burnout, mental health, and psychological well-being. Aggregated across examinations,
beneficial treatment effects were observed on stress ( p .0013) and mental health ( p .03). Treatment
effects on stress were mediated by adherence to practices ( p .05). Stress reductions remained large at
19 weeks (84% of the pretest standard deviation, p .006). Evidence suggests this program reduces
stress and may enhance mental health.
Keywords: meditation, spirituality, social cognitive theory, stress, mental health

research on meditation has suffered from nonrandomized designs

or other methodological shortcomings (Bishop, 2002).
One form of meditation, the Eight-Point Program (EPP), summarized in Figure 1, possesses both important similarities to and
key differences from other well-known methods of meditation
(Easwaran, 1978/1991). Like several other empirically researched
meditation programs, the EPPsometimes called passage meditationis nonsectarian and may be practiced within any major
religious tradition or outside of all traditions. As with almost all
forms of meditation (as well as contemplative prayer), this program may be seen as in essence, the effort to retrain attention
(Goleman, 1988, p. 169). As with well-documented work by
Kabat-Zinn (2003) and others, the EPP uses a variety of related
methods to integrate meditative states of mind, experienced during
formal sitting practice, into the remainder of daily living.
Compared with most other methods of meditation, however, the
EPP (explained more fully below) may be especially useful in
helping health care or other practitioners draw on the psychosocial
resources found in various spiritual and religious wisdom traditions (see Miller & Thoresen, 2003, regarding definitions of religion as more institutional, and spirituality as more personally
oriented to core issues of meaning and purpose). From 1994 to
1998, the proportion of U.S. adults feeling a need to experience
spiritual growth rose from 54% to 82% (Myers, 2000). Interest in
spirituality and religion is substantial among many health professionals (e.g., Curlin, Lantos, Roach, Sellergren, & Chin, 2005) and
has been increasingly linked empirically to better health outcomes.
This evidence supports studying the relevance of spiritual resources to both clinical and public health practice (Miller &
Thoresen, 2003).
Resources from spiritual and religious wisdom traditions provided by the EPP may complement or enhance meditation through
several mechanisms. The EPP uses a spiritually based focus for

Sustained stress experiences have been empirically linked with

major chronic health conditions such as hypertension and coronary
heart disease (McEwen, 1998). Among health care professionals,
stress has been linked to problems ranging from depression, decreased job satisfaction, and disrupted personal relationships to
reduced concentration, impaired decision making, and poorer relationships with patients (see Shapiro, Astin, Bishop, & Cordova,
2005). In recent decades, meditation has drawn increasing attention as a modality for reducing stress in clinical and general
populations. A critical review of scientific evidence by a National
Institutes of Health expert panel reported that persuasive evidence now exists that meditation interventions are associated with
better health outcomes among clinical populations (Seeman, Dubin, & Seeman, 2003). Critics have argued, however, that much

Doug Oman, Public Health Institute, Oakland, California, and Division

of Community Health and Human Development, School of Public Health,
University of California, Berkeley; John Hedberg, Department of Medicine, University of Colorado Health Sciences Center; Carl E. Thoresen,
School of Education and Departments of Psychology and Psychiatry,
Stanford University.
Additional materials are on the Web at http://dx.doi.org/10.1037/0022006X.74.4.714.supp
We acknowledge grant support from Fetzer Institute of Kalamazoo,
Michigan, and U.S. National Heart, Lung, and Blood Institute Grant T32
HL07365-21. We also acknowledge the assistance of Exempla Healthcare
of Colorado and of coinstructors Don Etter, Sandy Fasso, Anne Hedberg,
Debra Parsons, Pat Sabadell, Maura Sullivan, and Sharon Yablon. We also
thank our colleague Alex H. S. Harris for useful recommendations.
Correspondence concerning this article should be addressed to
Doug Oman, School of Public Health, 140 Warren Hall #7360, University of California, Berkeley, Berkeley, CA 94720-7360. E-mail:
dougoman@post.harvard.edu
714

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

PASSAGE MEDITATION REDUCES STRESS

Figure 1. Brief description of the Eight-Point Program of Easwaran

(1978/1991; full text is available on the Web at http://www.easwaran.org).
Adapted from the writings of Eknath Easwaran, founder of the Blue
Mountain Center of Meditation, reprinted by permission of Nilgiri Press,
P.O. Box 256, Tomales, CA 94971, www.easwaran.org.

meditation that may enhance motivation to persist in meditating:

Practitioners slowly mentally recite a memorized inspirational
passage that they have selected, usually from a major spiritual
tradition (see Figure 1). Atheistic or agnostic practitioners may
avoid deistic or theistic references by selecting Buddhist, Taoist, or
other passages that emphasize qualities such as compassion and
equanimity (Easwaran, 1978/1991). Compared with a secular focus, a spiritual focus for meditation has been found more effective
in reducing anxiety and improving mood and pain tolerance
(Wachholtz & Pargament, 2005). More generally, passage meditation can help practitioners assimilate the spiritual attitudes, appraisals, strivings, and coping strategies exemplified in the passage
(Pargament, 1997). This process is termed spiritual modeling
(Bandura, 2003; Oman & Thoresen, 2003). The EPP integrates
passage meditation with several ancillary practices that facilitate
psychological processes underlying spiritual modeling. Previous
randomized research links an abbreviated version of the EPP to
improved health-related outcomes that include reduced stress, improved health behaviors, enhanced well-being, and psychosocial
adjustment to HIV (see Oman, Hedberg, Downs, & Parsons,
2003).
We report the first randomized controlled study, with follow-up
spanning over 4 months, of the effects of EPP training in altering
stress, mental health, and well-being outcomes among health professionals. We hypothesized improvements in all outcomes. We
also report tests of whether treatment effects were moderated by
covariates or mediated by adherence. Elsewhere, we report qualitative evidence that nurses found the EPP beneficial in their work
(Richards, Oman, Hedberg, Thoresen, & Bowden, 2006).

715

professional education credits were offered. After completing all assessments, participants received stipends of $100. This project was approved
by the Institutional Review Boards of the host hospital and of the Public
Health Institute of Oakland, California.
Prospective participants were instructed to attend one of three registration sessions in September 2002, in which they gave consent, completed a
pretest assessment (Exam 1), and were then informed of their randomized
group assignment. One or 2 weeks later, those in the treatment condition
began the 8-week training. Additional assessments occurred after the last
training session (Exam 2), 8 weeks later (Exam 3), and 19 weeks later
(Exam 4). Dropouts (n 3) were more likely to be other or no
denomination than Protestant or Roman Catholic ( p .05). Neither
treatment condition nor dropout was significantly associated with covariables or pretest values of any of the eight outcome variables ( p .05).
Participant flow is summarized in Figure 2. Selected characteristics of the
58 final participants included in the intent-to-treat analyses are displayed in
Table 1. Further details on theoretical and empirical background, participant characteristics, recruitment, and randomization are available on the
Web at http://dx.doi.org/10.1037/0022-006X.74.4.714.supp.
Eight major stress and well-being outcome variables were measured at
each examination: Perceived stress was measured with a well-known
14-item measure from S. Cohen and Williamson (1988); mental health
(five items) and vitality (four items) with subscales from the Medical
Outcomes Study (Ware, Kosinski, & Gandek, 2002); three dimensions of
burnout by psychometrically sound subscales of the Maslach Burnout
Inventory (Maslach, Jackson, & Leiter, 1996); and life satisfaction with a
commonly used five-item scale from Diener, Emmons, Larsen, and Griffin
(1985). Job satisfaction was measured with responses to a single item:
Considering all aspects of my job, I would say that I am very satisfied
with my job. Responses were coded on a 7-point scale from 1 (strongly
disagree) to 7 (strongly agree).
At Exam 1, we assessed covariables presented in Table 1, as well as total
years of patient contact and tendencies toward socially desirable responding, using a 13-item version of the MarloweCrowne scale (Reynolds,

Method
The intervention was hosted at a large hospital in Colorado. Enrollment
was open to health professionals with current patient contact. Participants
(N 61) were recruited through in-service talks, flyers, and word of mouth
at two local hospitals. Promotional talks and materials emphasized potential gains in stress management and professional effectiveness. Continuing

Figure 2. Flow of participant progress through study phases. EPP

Eight-Point Program.

OMAN, HEDBERG, AND THORESEN

716

Table 1
Selected Participant Characteristics by Treatment Status
No. (%)a

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Characteristic
Gender
Women
Men
Age, years
2639
4049
5059
6070
Occupation
Nurse
Physician
Other
Education, years
Less than 16
1618
19 or more
Marital status
Married now
Separated/divorced
Widowed/never married
Previous meditation
Yes
No

No. (%)a

All

Tx

Cx

50 (86)
8 (14)

23 (87)
4 (13)

27 (85)
4 (15)

7 (12)
20 (34)
22 (38)
9 (16)

2 (7)
10 (37)
10 (37)
5 (19)

5 (16)
10 (32)
12 (39)
4 (13)

37 (64)
7 (12)
14 (24)

20 (74)
2 (7)
5 (19)

17 (55)
5 (16)
9 (29)

13 (22)
32 (55)
13 (22)

8 (30)
13 (48)
6 (22)

5 (16)
19 (61)
7 (23)

36 (62)
14 (24)
8 (14)

15 (56)
9 (33)
3 (11)

21 (68)
5 (16)
5 (16)

24 (41)
34 (59)

10 (37)
17 (63)

14 (45)
17 (55)

Characteristic
Spiritual identity
Spiritual and religious
Spiritual, not religious
Not spiritual
Extent spiritual
Very
Moderate
Slightly/not at all
Extent religious
Very/moderate
Slightly
Not at all
Religious attendance
Weekly or more
Less than weekly
Never
Religious denomination
Protestant
Roman Catholic
Other
None
All (Total)

All

Tx

Cx

26 (45)
29 (50)
3 (5)

11 (41)
15 (56)
1 (4)

15 (48)
14 (45)
2 (6)

14 (24)
31 (53)
13 (22)

5 (19)
16 (59)
6 (22)

9 (29)
15 (48)
7 (23)

25 (43)
25 (43)
8 (14)

10 (37)
13 (48)
4 (15)

15 (48)
12 (39)
4 (13)

19 (33)
37 (64)
2 (3)

8 (30)
19 (70)
0 (0)

11 (35)
18 (58)
2 (6)

22 (38)
17 (29)
7 (12)
12 (21)

9 (33)
9 (33)
4 (15)
5 (19)

13 (42)
8 (26)
3 (10)
7 (23)

58

27

31

Note. Tx treatment group; Cx control group.

Treatment status was not associated with any participant characteristic ( ps .30).

1982). For treatment group participants at Exams 2, 3, and 4, adherence

was measured by one question for each of the eight practices, coded on a
5-point scale from 1 (not at all) to 5 (consistently). Factor analyses revealed
one dominant factor with loadings that were approximately equal for each
of the 8 points. Total adherence was therefore computed as the unweighted
average of the 8 point-specific adherence measures (adherence measures
were set to 1, i.e., not at all, for wait-listed participants at all exams and for
the treatment group at pretest).
We implemented the full EPP emphasizing issues relevant to health care
professionals with patient contact in hospital settings. Treatment group
participants (n 27) met together weekly in one large group. Part of each
weeks activities took place in facilitated subgroups of 6 to 8 persons. The
main course instructor was an internal medicine physician with host
hospital staff privileges and several years personal experience using the
EPP. Subgroups were facilitated by seven co-instructors who had received
several hours of formal EPP training and personally used the EPP. Participant training occurred weekly for 2 hr over 8 weeks and included time for
presentation, discussion, a break, and a group meditation. A treatment
manual is available for research purposes on request from the corresponding author (Doug Oman).
Effects of treatment condition on the eight outcome variables were
assessed in eight separate hierarchical linear regression (HLM) models that
adjusted for preexisting individual differences in outcome level (with a
Level 2 random effect) and allowed for correlated errors within individuals
across time (a generalization of an autoregressive model; Raudenbush &
Bryk, 2002). To explore whether the treatment effect might change or
decay over time, initial regression models permitted the treatment effect to
vary between Exams 2, 3, and 4 (time-varying treatment effect). Subsequently, models assumed the treatment effect was constant across these
three examinations (time-constant treatment effect). For outcomes that
departed significantly ( p .10) from a Gaussian (normal) distribution in
ShapiroWilk tests, HLM analyses were supplemented with nonparametric
Wilcoxon tests for group differences in change from Exam 1 to Exams 2,

3, 4, and the median of Exams 2 4. Moderation by pretest covariates was

explored through their inclusion as Level 2 predictors in time-constant
HLM models, testing for statistical interaction with treatment. Mediation
by adherence was tested by procedures from Baron and Kenny (1986), as
described later.

Results
No adverse effects from the EPP training were observed. Table
2 presents estimates and confidence intervals for changes on
outcome measures since pretest. Perceived stress showed strong
and significant reductions relative to pretest at all subsequent
examinations. At Exam 2 (posttest), stress in the treatment group
versus the control group was already reduced by more than 60% of
a pretest standard deviation ( p .05, d 0.63; J. Cohen, 1988).
The stress reduction was even larger at Exam 3 (d 1.00, p
.001) and at Exam 4 (d 0.84, p .01). After a highly
conservative Bonferroni adjustment for the presence of 24
outcome-focused hypothesis tests in Table 2, Exam 3 stress reduction remained statistically significant ( p .05), clearly rejecting
the global null hypothesis of no real treatment effects on any
outcome.
Other than stress, all outcomes except depersonalization and life
satisfaction demonstrated one or more changes in the hypothesized
direction ( p .20). These changes were most common at Exam 3
(8-week follow-up), in which all outcomes except mental health
were more favorable than at Exam 2.
Despite consistently stronger effects at Exam 3, tests for heterogeneity of treatment effect between Exams 2, 3, and 4 failed for
all outcomes to reject the null hypothesis of a time constant

PASSAGE MEDITATION REDUCES STRESS

717

Table 2
Examination 1 Pretest Values and Observed Treatment Effects at Examinations 2, 3, and 4 (n 58)
Treatment effects
Exam 1
pretest values

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Hypothesized change direction and variable

Tx change Cx change

SD

Exam

95% CI

p (2-tailed)

Stress

26.14

6.57

Mental health

64.76

15.72

Vitality

54.74

20.66

Emotional exhaustion

21.40

10.76

6.88

5.34

Personal accomplishment

37.62

6.34

Life satisfaction

24.29

5.99

Job satisfaction

5.28

1.59

Adherence

1.00

0.00

2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24
2
3
4
24

4.14
6.57
5.55
5.23
5.31
5.10
4.06
4.82
0.15
5.42
1.39
2.23
0.45
3.51
0.10
1.00
0.67
0.44
0.52
0.60
1.52
1.90
1.19
1.51
0.58
1.68
0.80
0.93
0.03
0.39
0.06
0.08
2.39
2.15
2.07
2.20

7.82, 0.45
10.49, 2.65
9.51, 1.59
8.39, 2.08
2.54, 13.14
2.77, 12.96
3.80, 11.93
1.56, 11.20
9.57, 9.27
4.02, 14.86
8.05, 10.83
5.46, 9.91
4.16, 3.26
7.69, 0.66
4.43, 4.23
4.33, 2.33
1.06, 2.40
1.60, 2.49
1.67, 2.71
0.99, 1.20
0.62, 3.67
0.48, 4.28
1.25, 3.63
0.38, 3.40
1.88, 3.05
0.97, 4.32
1.87, 3.48
1.18, 3.05
0.61, 0.55
0.26, 1.05
0.62, 0.74
0.44, 0.60
2.19, 2.59
1.91, 2.40
1.81, 2.34
2.01, 2.40

.03a
.0012a
.006a
.0013a
.11b
.16b
.31b
.03b
.49b
.18b
.57b
.25b
.81a
.099a
.96a
.55a
.67b
.99b
.90b
.97b
.30b
.19b
.16b
.18b
.64a
.21a
.56a
.38a
.92b
.199b
.49b
.50b
.0001a
.0001a
.0001a
.0001a

Depersonalization

Note. Exam 2 4 refers to combined analyses of Exams 2, 3, and 4. Tx treatment group; Cx control group; CI confidence interval; Exam 1
pretest; Exam 2 posttest; Exam 3 8-week follow-up; Exam 4 19-week follow-up.
a
t tests for group differences in mean change from hierarchical linear models. b Wilcoxon nonparametric tests of change scores for variables that were
nonnormally distributed ( p .10) on ShapiroWilk tests of Exam 1 distributions.

treatment effect ( ps .10). In Table 2, rows for Exam 2 4 show

estimates that modeled treatment effects as constant from Exams 2
to 4. Significant effects were found for perceived stress (5.23,
d 0.80, p .0013) and mental health (4.82, d 0.31, p
.05, nonparametric).

Moderation of Effects by Covariates

Tests of statistical interaction in time-constant models indicated
that socially desirable responding at pretest moderated the effects
of the intervention on mental health ( p .05) and stress ( p .10),
with greater socially desirable responding corresponding to
smaller stress reductions and smaller gains in mental health. These
associations are the opposite of what would be expected if reported
changes were due to socially desirable responding. We also found
that treatment effects for stress and mental health were signifi-

cantly larger ( p .01) among the 44 participants who were

moderately or less spiritual than among the 14 very spiritual
participants, findings not substantively altered by adjusting for
socially desirable responding or for pretest outcome levels. No
other spiritual covariate significantly moderated treatment effects
on these outcomes, nor did demographic variables show moderation more commonly than expected by chance.

Adherence to Treatment as a Mediating Factor

Total self-rated adherence by the treatment group declined gradually from a mean of 3.4 (SD 0.5) at Exam 2 to a mean of 3.1
(SD 0.7) at Exam 4. On the response scale, these values
represent more than somewhat but less than quite a bit of adherence to EPP practices. To test whether treatment effects on perceived stress were mediated by adherence, we used procedures

OMAN, HEDBERG, AND THORESEN

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718

described by Baron and Kenny (1986). The adherence measure

was incorporated as a Level 1 predictor into HLM regressions
(time-constant model), and all mediation criteria were supported
( p .05). More specifically, Baron and Kennys (1986) first
criterion was supported because experience of treatment (the independent variable) was demonstrated to affect the outcome (see
Table 2, rows for perceived stress). Second, treatment was demonstrated to affect the proposed mediator (see Table 2, rows for
adherence). Third, in additional HLM regressions, adherence was
demonstrated to predict the outcome after adjusting for treatment
( p .011). Fourth, also in these additional analyses, the treatment
effect was smaller in magnitude after adjustment by the mediator
(1.58 vs. 5.23). Finally, the null hypothesis of no indirect (mediated) effect was rejected in the Sobel test ( p .011). Thus, all
Baron and Kenny (1986) statistical criteria were supported for
adherence as a mediator of reductions in perceived stress.

Discussion
This randomized, controlled study of a comprehensive
meditation-based spiritual intervention found statistically significant effects on perceived stress, suggesting this programs possible
value for a variety of stress management and other health applications. Combined analyses of posttest and two follow-up examinations demonstrated statistically significant beneficial treatment
effects for perceived stress and mental health. These effects could
not be attributed to socially desirable responding. The large perceived stress reductions are clinically promising, as this measure
has been correlated with a wide range of health variables including
depression, health services utilization, and self-reported health and
symptoms (S. Cohen & Williamson, 1988).
This study provides at least five novel contributions to the
literature. First, we provide the first randomized evidence that the
EPP, a meditation-based intervention, was successfully used with
health professionals. Second, we are the first to study effects of
EPP training sustained over two follow-ups spanning almost 6
months. Third, compared with the only other randomized study of
meditation for health professionals (Shapiro, Astin, Bishop, &
Cordova, 2005), we attained a much higher treatment group retention rate (90% vs. 56%). Fourth, this is the first time that the EPP
has been examined with the well-established measures used here.
Finally, these findings provide an important foundation for further
research on how the EPP or similar nonsectarian spiritual practices
might foster health by drawing on spiritual and religious resources.
Caution, however, is recommended in interpreting these findings. The current study lacked an active comparison group that
could more firmly rule out competing explanations for reported
effects. We do not know if similar effects would have been found
if we had used an active control group that provided opportunities
to participate in other types of weekly activities on the topic of
stress management. Such a finding seems highly unlikely given
extensive experience in teaching the EPP, but it remains a possibility to control in future studies.
Evidence that EPP practice mediated treatment effects is consistent with findings from qualitative interviews and earlier quantitative studies (Oman, Hedberg, Downs, & Parsons, 2003; Richards, Oman, Hedberg, Thoresen, & Bowden, 2006). Such
evidence, however, fails to clearly demonstrate causality (reverse
causality is not ruled out) but remains suggestive at best.

Findings that stress and mental health benefits were larger for
participants who were only moderately or less spiritual, compared
with highly spiritual, are consistent with findings of moderation by
spirituality in a previous EPP study (Oman, Hedberg, Downs, &
Parsons, 2003). One explanation may be that participants with
lower initial spirituality have more to learn because they possess
less initial familiarity with spiritual self-management tools.

Generalizability
Results appear most likely to generalize to other populations
that are similarly self-selected, such as health professionals who
enroll in continuing professional education courses that use similar
promotional materials. Further research would be required to assess generalizability to non-self-selected groups, such as an entire
staff of a unit or a hospital. No evidence was found for moderation
by demographics, but smaller numbers of non-nurses and male,
non-middle-aged, and non-White participants suggest considerable
caution in generalizing to these groups.

Other Limitations
Another limitation was the studys relatively small sample size,
which provided statistical power above 90% only for testing larger
changes, that is, changes that approach or exceed 80% of the
pretest standard deviation (d 0.80; S. Cohen & Williamson,
1988). As a result, favorable changes ( p .20, 2-tailed) in several
outcomes are at best suggestive of possible benefits and may merit
further study. Clearly there is no basis for any firm conclusions.
Most importantly, the absence of a competing comparison group
treatment to control for generalized benefits of participating in a
group leaves open what specifically accounted for the observed
changes. The competency of the instructors was not formally
assessed. Possible prior participant adherence to EPP practices was
not assessed, nor whether waiting list group participants engaged
concurrently in other meditation or stress management programs
or increased their spiritual activities. We lacked adequate sample
size and detailed measures of prior experience with meditation to
more fully explore how they might moderate treatment effects. We
did not evaluate changes in spiritual strivings, religious coping, or
various other potential mediators of longer term effects. Finally,
we relied entirely on self-report measures that were more vulnerable to confounding with related constructs.

Strengths and Future Directions

Despite these drawbacks, this study has several strengths, including a randomized design, a very high retention rate, multiple
validated outcome measures, multiple follow-up assessments, and
a focus on a culturally adaptable intervention that has been translated into over 20 European and Asian languages. Current findings
suggest that the EPP holds promise among health professionals for
reducing stress and improving mental health. Future studies should
test replicability, generalizability to more diverse groups, sustainability over longer follow-up, and implications for physiological
stress and disease markers. Also needed are qualitative and structured interviews and the study of other potential moderating variables, such as personality style, that may influence who is most
motivated to learn and benefit.

PASSAGE MEDITATION REDUCES STRESS

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Received December 20, 2004

Revision received February 20, 2006
Accepted February 27, 2006