Cognitive Processes Mediate the Relation Between Mindfulness

and Social Anxiety Within a Clinical Sample

Stefan K. Schmertz, Akihiko Masuda, and Page L. Anderson

Georgia State University
Objectives: The researchers investigated the relation between mindfulness and social anxiety
symptoms, and examined whether this relation is mediated by cognitive appraisals commonly asso-
ciated with social anxiety. Participants: Ninety-eight individuals diagnosed with social phobia.
Design: Using a cross-sectional design, ordinary least squares regression and bootstrapping media-
tion analyses were used to test the study hypotheses. Results: Mindfulness was negatively related
to symptoms of social anxiety. This relation was partially mediated by cognitive appraisals about the
likelihood and cost of a negative social outcome. Conclusion: Further research using a longitudinal
design and other measures of mindfulness is needed to replicate these ndings and further explicate
the mechanism by which mindfulness might be associated with negative cognitive appraisals.
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2012
Wiley Periodicals, Inc. J. Clin. Psychol 68:362371, 2012.
Keywords: social phobia; mindfulness; cognitive appraisal; outcome cost; outcome probability; psy-
chopathology; mediation
There has been a growing interest in mindfulness and its relation to psychopathology and well-
being. Empirical ndings consistently show a negative relation between self-report mindfulness
and depression, negative affect, and anxiety among college-student samples (Baer, Smith, &
Allen, 2004; Lau et al., 2006; Brown & Ryan, 2003; Feldman, Hayes, Kumar, Greeson, &
Laurenceau, 2007). Furthermore, clinical samples score lower on mindfulness than nonclinical
samples (Baer et al., 2004; Feldman et al., 2007; Roemer et al., 2009), and studies have found
a negative linear relation between mindfulness and symptoms of pathology in some clinical
samples of adults (Smalley et al., 2009; Wupperman, Neumann, Whitman, & Axelrod, 2009).
Mindfulness interventions are nowreceiving broad attention in outpatient settings (Kabat-Zinn,
2003), and meta-analysis reveals that mindfulness interventions have demonstrated promise in
the treatment of chronic pain, stress, anxiety, depressive relapse, and disordered eating (Baer,
2003).
Recently, interest has arisen in using mindfulness interventions to treat social phobia. This is
largely based on the documented role of maladaptive attentional processes in the maintenance
of social anxiety (e.g., attention toward internal cues of negative thinking and self-imagery;
Bogels, Sijbers, &Voncken, 2006; Hope, Gansler, &Heimberg, 1989). In contrast to the habitual,
self-focused, judgmental attentiontypically associatedwithsocial apprehension, increasedmind-
fulness might help one to refocus attention to the social task at hand. Several studies suggest that
individuals with social anxiety report reductions in symptomatology after mindfulness-based
interventions (Bogels, Sijbers, & Vocncken, 2006; Goldin, Ramel, & Gross, 2009; Kocovski,
Fleming, & Rector, 2009; Koszycki, Benger, Shlik, & Bradwejn, 2007). However, no published
study to date has examined the relation between mindfulness and symptom severity within a
sample diagnosed with social phobia, nor has there been a study on the potential mediators of
this relation.

The work performed for this study was conducted at Georgia State University.
This work was supported by NIMH R42 MH 60506-02, awarded to the last author.
Correspondence concerning this article should be addressed to: Page Anderson, Department of Psychology,
Georgia State University, 140 Decatur Street, Atlanta, GA 30302; e-mail: panderson@gsu.edu
JOURNAL OF CLINICAL PSYCHOLOGY, Vol. 68(3), 362371 (2012)
C
2012 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20861
Mindfulness and Cognitive Processes 363
Part of the difculty in examining how mindfulness relates to psychopathology is that the
conceptualization of mindfulness varies among researchers and practitioners (Hayes & Wilson,
2003). However, the notion that mindfulness involves enhanced attention to and awareness of
the present moment is a commonality across a variety of denitions (e.g., Kabat-Zinn, 2003;
Shapiro, Carlson, Astin, & Freedman, 2006). The enhanced awareness of the present moment
cultivated in mindfulness is thought to be in contrast to automatic or habitual cognitive processes
that are more prone to rumination, preoccupation with the past, and anxiety about the future
(Brown & Ryan, 2003). Habitual cognitive processes also gure in models of social anxiety
(Clark & Wells, 1995; Rapee & Heimberg, 1997). Cognitive theories highlight the importance
of two types of threat appraisal in the maintenance of anxiety disorders: overestimating the
likelihood that something bad will happen as a result of an encounter with the feared stimulus
(probability bias) or overestimating the negative consequence of the encounter (cost bias; Foa &
Kozak, 1986). There is good empirical evidence that such biases contribute to the maintenance
of the disorder and serve as a mechanism for change as a result of treatment (Foa, Franklin,
Perry, & Herbert, 1996; Smits, Roseneld, McDonald, & Telch, 2006). Therefore, it is possible
that mindfulness (or lack thereof) might be related to symptoms of social anxiety via its impact
on cognitive appraisals, such as probability and cost biases.
Theoretical support for this can be found in the mindfulness literature that suggests that
increased mindfulness might reduce ruminative tendencies (Bishop et al., 2004). It is thought
that directing ones attention to present experience inherently engages attentional resources that
would otherwise be used to ruminate (Brown & Ryan, 2003). This might allow one to disengage
from common ruminative patterns that comprise appraisals about the likelihood and cost of
negative social interactions. Indeed, mindfulness is negatively related to rumination, concern for
social impression, and anxiety in social situations (Brown & Ryan). Furthermore, results from
mindfulness interventions show that reduction in rumination is related to reduction in distress
(Jain, Shapiro, & Swanick, 2007; Ramel, Goldin, Carmona, & McQuaid, 2004).
The hypotheses of the current study are that self-report mindfulness will be negatively related
to levels of social anxiety and that cognitive appraisals about the likelihood and cost of a negative
social outcome will mediate this relation. These hypotheses are tested within a clinical sample
with a primary diagnosis of social phobia using a cross sectional design.
Method
Participants
Participants (N = 98) completed the procedures of this study as part of participation in a ran-
domized controlled trial comparing virtual reality exposure therapy (VRE; Anderson, Zimand,
Hodges, & Rothbaum, 2005), exposure group therapy (EGT; Hofmann, 2004), and a wait-list
control group. For the larger study, participants self-referred in response to advertising and pub-
licity efforts, or they were referred by professionals in the greater Atlanta area. Inclusion criteria
included literacy in English, as well as a primary diagnosis of social phobia with a predominant
fear of public speaking as determined by the Structured Clinical Interview for the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (SCID-IV; First, Gibbon, Spitzer,
& Williams, 2002). Exclusion criteria included history of seizure disorder, mania, schizophrenia,
or other psychoses, as well as prominent suicidal ideation or current alcohol or drug abuse
or dependence. Meditation experience or past exposure to mindfulness was not an inclusion
criterion. Thus, mindfulness assessed in the current study is conceptualized as trait mindfulness
(Brown & Ryan, 2003), rather than mindfulness developed through instruction or meditative
practice. All participants meeting inclusion criteria and completing the pretreatment assessment
(N = 98) were included in the current study.
The sample was predominantly female (60%), with a mean age of 39.09 (standard deviation
[SD] = 11.27; range = 1969). Most participants self-identied as either Caucasian (47%) or
African American (36%). Four self-identied as Hispanic, two as Asian American, two as Asian,
one as African, one as Ethiopian, and two as biracial. Sixty-six percent of the sample reported
completing college. Forty-ve percent of the sample met criteria for the generalized subtype
364 Journal of Clinical Psychology, March 2012
of social phobia. The mean number of the Diagnostic and Statistical Manual, Fourth Edition
(DSM-IV) diagnoses was 1.38 (SD = .77; range = 15).
Measures
The Brief Fear of Negative Evaluation Brief Form (BFNE; Leary, 1983). This
is a 12-item self-report questionnaire that measures fear of negative evaluation by others. It is
derived from Watson and Friends (1969) original measure of this construct, with which it is
highly correlated (r = .96; Leary). Items are rated on a 5-point scale, and scores range from 12
to 60, with higher scores representing increased evaluative concerns. Results from two recent
studies using clinical samples of socially anxious adults indicate that the BFNE shows excellent
psychometric properties, including test-retest reliability (r = .94), internal consistency ( = .89
.97), convergent validity, and discriminant validity (Collins, Westra, Dozois, & Stewert, 2005;
Weeks et al., 2005).
Liebowitz Social Anxiety Scale-Self Report (LSAS-SR; Fresco et al., 2001). This
widely used self-report measure is adapted from a clinician administered measure of social
anxiety (Liebowitz, 1987). The LSAS-SR contains 24 items that measure fear and avoidance
experienced in a variety of social and performance situations in the past week using a 4-point
rating scale, ranging from 0 (never) to 3 (usually 67%100% of the time). Scores range from
072, with higher scores indicating greater fear and avoidance. The self-report version shows
good psychometric properties and is comparable to the clinician-administered format (Baker,
Heinrichs, Kim, Hofmann, 2002; Fresco et al.; Mennin et al., 2002; Rytwinski et al., 2009).
Internal reliability estimates range from .88 to .95 (Oakman, Amerigen, Mancini, & Favolden,
2003).
Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The MAAS is
a 15-item, single factor, self-report measure assessing individual differences in the frequency of
mindful states over time. Participants rate the degree to which they function without awareness
in daily life (e.g., I rush through activities without being really attentive to them and I drive
places on automatic pilot and then wonder why I went there). Respondents indicate how often
they have the experiences referenced by each item using a 6-point Likert-type scale, anchored
from 1 (almost always) to 6 (almost never). Scores range from 16 (average item score), with
lower scores indicating greater mindlessness. Authors report internal consistency alphas ranging
from .82 to .87.
The Outcome Probability Questionnaire (OPQ) and Outcome Cost Questionnaire
(OCQ; Uren, Szabo, & Lovibond, 2004). The OPQ and OCQ were developed from a set of
items used by Butler and Mathews (1983) and Foa et al. (1996) to measure cognitive biases. The
questionnaire includes 12 items assessing feared outcomes related to social threat (e.g., You will
feel embarrassed by something you did). For the OPQ, participants are asked to rate how likely
it is that an outcome would happen in a public speaking situation and for the OCQ, participants
rate how bad or distressing the outcome would be if it happened. Items are scored on a 9-point
Likert scale, ranging from 0 (not at all likely/distressing) to 8 (extremely likely/distressing), with
summary scores ranging from 0 to 96. Internal consistency is excellent (OPQ; = .92 .94;
OCQ; = .89 .90). The authors report good convergent validity and that individuals with
social anxiety score higher on the OPQ and OCQ than nonanxious controls.
Procedure and Data Analysis
All study procedures took place in the Georgia State University psychology clinic in Atlanta,
Georgia. Eligibility for the study was determined through a two-part process, including a brief
telephone screening and an in-person diagnostic interview. Four doctoral candidates in clinical
psychology conducted all assessment procedures. Doctoral students were trained in diagnostic
interviewing by watching training tapes and by practice interviews, which were reviewed by a
Mindfulness and Cognitive Processes 365
Table 1
Correlations, Descriptive Statistics, and Internal Consistency of Study Variables (N = 98)
MAAS BFNE LSAS-SR OCQ OPQ
MAAS 1.00
BFNE .38
**
1.00
LSAS-SR .44
**
.32
**
1.00
OCQ .33
**
.50
**
.38
**
1.00
OPQ .47
**
.46
**
.45
**
.62
**
1.00
Mean 4.07 31.87 53.00 64.63 53.00
SD 1.00 7.48 19.46 18.12 19.10
Cronbachs alpha .91 .88 .93 .85 .87
Note. MAAS = Mindful Attention Awareness Scale; BFNE = Fear of Negative Evaluations Brief form;
LSAS-SR = Liebowitz Social Anxiety Scale; OCQ = Outcome Cost Questionnaire; OPQ = Outcome
Probability Questionnaire; SD = standard deviation.
*p < .05; **p < .01.
licensed clinical psychologist. Doctoral student assessors received weekly supervision, which
included review of videotapes.
During the phone screen, potential participants were asked a series of questions to rule out
obvious exclusion criteria (e.g., prior seizures). After the phone screen, interested and eligi-
ble individuals were scheduled for a face-to-face interview. After consent, the anxiety, mood,
and substance abuse modules of the SCID were administered to establish inclusion criteria
(e.g., diagnosis of social phobia that included a fear of public speaking) and rule out exclusion
criteria (e.g., current substance dependence). Inter-rater reliability for the primary diagnosis was
examined for 12 randomly selected participants and revealed 100% agreement. After the diag-
nostic interview, participants completed a self-report battery, including the previously described
measures.
Prior to any analyses, data were inspected for normalcy, excessive missing cases, and outliers,
dened as scores greater or less than three standard deviations from the mean (Field, 2005).
A BFNE score of 11 that fell 3.17 standard deviations below the mean was removed from the
relevant analyses. Ordinary least squares regression analyses were used to examine the relation
between self-report mindfulness scores and levels of social anxiety. Mediation was tested using
the bootstrapping analysis described by Preacher and Hayes (2008). For each proposed mediator
(OPQ and OCQ), separate analyses were conducted to test whether they mediated the relation
between mindfulness (MAAS) and each measure of social anxiety (BFNE and LSAS-SR).
Results
Correlations, descriptive statistics, and internal consistencies for all measures are shown in
Table 1. As expected, the social anxiety measures were positively correlated with each other.
All study measures demonstrated adequate internal consistency. Demographic variables were
examined as possible covariates, but were not signicantly associated with levels of social anxiety
or mindfulness.
Hypothesis I
There was a signicant negative relation between mindfulness scores (MAAS) and social anx-
iety as measured by both the BFNE, b = .19, standard error [SE] = .05, t(97) = 4.01,
p < .001, R
2
= .14, and the LSAS-SR, b = .61, SE = .11, t(97) = 5.67, p < .001, R
2
= .20.
Hypothesis II
The Preacher and Hayes (2008) bootstrapping macro was used in conjunction with ordinary
least squares regression analyses to examine whether outcome probability and outcome cost
366 Journal of Clinical Psychology, March 2012
Figure 1. (top panel) The relation between mindfulness (MAAS) and social anxiety symptoms (BFNE
and LSAS-SR) mediated by the expectancy for a negative social interaction (OPQ). (bottom panel) The
relation between mindfulness (MAAS) and social anxiety symptoms (BFNE and LSAS-SR) mediated by
the expectancy for high social cost (OCQ). (both panels) A = relation between the independent variable
and mediator; B = the relation mediator and dependent variable; C = the direct effect of the independent
variable on the dependent variable; C

the indirect effect of the independent variable on the dependent

variable controlling for the mediator. *p < .05. **p < .01. ***p < .001.
expectancies mediated the relation between mindfulness and social anxiety symptoms. As with
other mediation analyses (i.e., Baron &Kenny, 1986), it is informative to examine the association
between variables in each pathway of the mediation model (e.g., between independent variable
and mediators and mediators and dependent variable). The total effects of the model are reported
above in the testing of hypothesis 1, in which mindfulness scores (MAAS) were signicantly re-
lated to each measure of social anxiety (BFNE and LSAS-SR). The least squares regression
analyses for the other pathways of the mediation model, including the indirect effect of mindful-
ness on social anxiety symptoms while controlling for outcome probability and outcome cost,
are presented in Figure 1.
On the recommendation of Preacher and Hayes (2008), 2,000 bootstrap samples were gen-
erated to obtain unbiased condence intervals of these indirect effects. Ninety-ve percent
condence intervals (CIs) for the indirect effects that do not overlap with zero indicate that the
Mindfulness and Cognitive Processes 367
indirect effects are different from zero at p < .05 (two-tailed). Results indicate that outcome
probability scores (OPQ) signicantly mediated the relation between mindfulness and both
BFNE scores, mean [M] = .09 (SE = .03), CI
95
= .15 to .04, and LSASSR scores, M=
.19 (standard error [SE] = .08), CI
95
= .34 to .02. Outcome cost (OCQ) also signicantly
mediated the relation between mindfulness and both measures of social anxiety, BFNE, M =
.07 (SE = .03), CI
95
= .13 to .03; LSASSR, M= .11 (SE = .05), CI
95
= .22 to .03.
Discussion
This is the rst study to show that mindfulness is related to symptom levels within a sample of
people with a diagnosis of social phobia, and to test a theoretically driven hypothesis of how
they might be related, via participants appraisals of the perceived probability and cost of a
negative social outcome. The results of the current study are consistent with cognitive theories
of social anxiety that emphasize that assumptions about the probability and cost of a negative
outcome are maintaining factors of the disorder.
These ndings also are consistent with studies showing positive benet from mindfulness-
based interventions for social phobia (Bogels et al., 2006; Goldin & Gross, 2010; Goldin et al.,
2009; Kocovski, Fleming, & Rector, 2009; Koszycki et al., 2007). Results from the current study
suggest that mindfulness might reduce symptoms in part via their relation to negative cognitive
appraisals. However, to truly answer this question requires a longitudinal and experimental de-
sign. The partial mediation observed in this study suggests that there might be other mechanisms
by which mindfulness is related to symptoms of social anxiety. For example, Bogels and Mansell
(2004) have emphasized the role of mindfulness in reducing self-focused attention, whereas oth-
ers have focused on the potential for mindfulness to attenuate attentional biases for social threat
(Chen, Ehlers, Clark, & Mansell, 2002; Mogg, Philppot, & Bradley, 2004). Recent research also
has highlighted the importance of the nonjudgmental, compassionate attention encouraged in
mindfulness as one of the strongest predictors of well-being (Baer, Smith, Hopkins, Kriete-
meyer, & Toney, 2006). Thus, future research should use other measures of mindfulness and
explore other theoretically driven hypotheses about the way they might be related. Furthermore,
it would be interesting to test whether cognitive behavioral therapy for social phobia augmented
with mindfulness interventions that specically target biased cognitive appraisals would result
in better treatment outcome than cognitive behavioral interventions alone.
This study assessed individual differences in the frequency of mindful states over time or
what might be termed trait mindfulness, which is in contrast to state mindfulness, or
the ability for one to enter a mindful state. As state mindfulness might be more relevant to
mindfulness cultivated through mindfulness interventions, future work should measure the
impact of state mindfulness on cognitive appraisals and social anxiety symptoms. Measures of
state mindfulness such as the Toronto Mindfulness Scale (Lau et al., 2006) could be employed
in such research.
The present study is subject to several methodological and conceptual concerns. A primary
limitation of the current study is that it is cross sectional; thus, one cannot conclude that
mindfulness (or lack thereof) leads to biased cognitive appraisals or to social anxiety symptoms.
Longitudinal work tracking the change in cognitive processes over the course of an intervention
is needed. One possible source of bias in this study is that participants volunteered knowing that
their treatment was part of a research project. Therefore, these ndings might not generalize to
clinical populations, especially given the documented difculty in engaging people diagnosed
with social phobia in therapy. Another caveat is that trait mindfulness scores (MAAS) in this
sample (M= 4.07, SD = 1) are higher than those obtained in other clinical samples (M= 3.68,
SD = .66; Evans et al., 2008), and more similar to those reported from a student sample (M=
3.93, SD = .64; Brown & Ryan, 2003). It is thus unclear whether the relations observed in the
present study would generalize to samples with lower levels of mindfulness. It is also important
to note that although statistically signicant, the correlation between the MAAS and social
anxiety symptoms is modest (.14 and .20). Other measures of mindfulness might show stronger
(or weaker) relations with social anxiety symptoms.
368 Journal of Clinical Psychology, March 2012
Additionally, the measurement of mindfulness is a topic of much debate. Thus, our choice
of the MAAS, and more general issues related to self-report measures of mindfulness, deserves
some mention. On the positive side, the MAAS is widely used as a measure of mindfulness
(e.g., Shapiro, Brown, Thoresen, & Plante, 2011; Keng, Smoski, & Robbins, 2011), and the
empirical research shows that the MAAS has theoretically consistent relationships to neural ac-
tivity (Creswell, Way, Eisenberger, &Lieberman, 2007) and is a known mediator of outcome as a
result of mindfulness-based interventions (Nykl cek & Kuijpers, 2008). However, there are many
criticisms of the MAAS as a measure of mindfulness. The MAAS indirectly assesses mindfulness
by asking one to rate functioning without awareness in daily life, or mindlessness (Brown &
Ryan, 2003). Furthermore, the MAAS is a single-factor instrument that conceptualizes mind-
fulness as awareness of present experience in daily life (Brown & Ryan). Thus, it is a limited
measure of mindfulness. Indeed, other researchers have argued that mindfulness includes addi-
tional factors, such as nonjudgmental attention to the present moment (Baer et al., 2004; Baer
et al., 2006). Finally, important questions have been raised about the elds current ability to mea-
sure mindfulness by self-report. In its traditional form, mindfulness is learned through practice,
as an experiential exercise that transcends intellectualized rote learning of skills (Gunaratana,
2001). From this perspective, the ability of nonmeditators to report on levels of mindfulness is
drawn into question. Thus, the present research is limited by the lack of agreement regarding
self-report or behavioral measurement of this construct (Grossman, 2008).
Despite these limitations, the present study is the rst to show that mindfulness is related
to social anxiety symptoms within a clinical sample and to show that this relation is partially
mediated by participants cognitive appraisals. Another strength is that the sample in the current
study is relatively racially diverse, answering the call from many researchers for more clinical
research with diverse samples (Masuda, Anderson, & Sheehan, 2010; Iwamasa, Sorocco, &
Koonce, 2002). We believe the results of the present study should stimulate further research
on the nature of the relation between mindfulness and social anxiety. Research using a lon-
gitudinal design, other measures of mindfulness, and diverse clinical samples is particularly
needed.
References
Anderson, Zimand, E., Hodges, L.F., & Rothbaum. B.O. (2005). Congitive behavioral therapy for
public-speaking anxiety using virtual reality for exposure. Depression and Anxiety, 22, 156158.
doi:10.1002/da.20090
Baer, R.A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review.
Clinical Psychology: Science and Practice, 10, 125143. doi:10.1093/clipsy/bpg015
Baer, R.A., Smith, G.T., & Allen, K.B. (2004). Assessment of mindfulness by self-report. Assessment, 11,
191206. doi:10.1177/1073191104268029
Baer, R.A., Smith, G.T., Hopkins, H., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment
methods to explore facets of mindfulness. Assessment, 13, 2745. doi:10.1177/1073191105283504
Baker, S.L., Heinrichs, N., Kim, H.J., Hofmann, S.G. (2002). The Liebowitz Social Anxiety Scale as a self-
report instrument: A preliminary psychometric analysis. Behaviour Research & Therapy. 40, 701715.
doi:10.1016/S0005-7967(01)00060-2
Baron, R.M., & Kenny, J.A. (1986). The moderator-mediator variable distinction in social psychological
research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psy-
chology, 51, 11731182. doi:10.1037/0022-3514.51.6.1173
Bishop, S.R., Lau, M., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J., . . . Devins, G. (2004).
Mindfulness: A proposed operational denition. Clinical Psychology: Science and Practice, 11, 230241.
doi:10.1093/clpsy.bph077
Bogels, S.M., & Mansell, W. (2004). Attention processes in the maintenance and treatment of social pho-
bia: Hypervigilance, avoidance and self-focused attention. Clinical Psychology Review, 24, 827856.
doi:10.1016/j.cpr.2004.06.005
Bogels, S.M., Sijbers, G.F.V.M., & Vocncken, M. (2006). Mindfulness and task concentration train-
ing for social phobia: A pilot study. Journal of Cognitive Psychotherapy, 20, 3344. doi:10.1891/
jcop.20.1.33
Mindfulness and Cognitive Processes 369
Brown, K.W., & Ryan, R.M. (2003). The benets of being present: Mindfulness and its role in psychological
well-being. Journal of Personality and Social Psychology, 84, 822848. doi:10.1037/0022-3514.84.4.822
Butler, G., & Mathews, A. (1983). Cognitive processes in anxiety. Advances in Behavior Research and
Therapy, 24, 461470. doi:10.1016/0146-6402(83)90015-2
Chen, Y.P., Ehlers, A., Clark, D.M., & Mansell, W. (2002). Patients with generalized social phobia direct
their attention away from faces. Behaviour Research and Therapy, 40(6), 677687. doi:10.1016/S0005-
7967(01)00086-9
Clark, D.M., & Wells, A. (1995). A cognitive model of social phobia, In R.G. Heimberg, M.R. Liebowitz,
D.A. Hope, & F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 6993. New
York: Guilford Press.
Collins, K., Westra, H.A., Dozois, D.J.A., &Stewart, S.H. (2005). The validity of the brief formof the Fear of
Negative EvaluationScale. Journal of Anxiety Disorders, 19, 345359. doi:10.1016/j.janxdis.2004.02.003
Creswell, J.D., Way, B.M., Eisenberger, N.I., & Lieberman, M.D. (2007). Neural correlates
of dispositional mindfulness during affect labeling. Psychosomatic Medicine, 69, 560565.
doi:10.1097/PSY.0b013e3180f6171f
Evan, S., Ferrando, S., Findler, M., Stowell, C., Smart, C., &Haglin, D. (2008). Mindfulness-based cognitive
therapy for generalized anxiety disorder. Journal of Anxiety Disorders, 22, 716721.
Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J. (2007). Mindfulness and emotion regula-
tion: The development and initial validation of the Cognitive and Affective Mindfulness Scale-Revised
(CAMS-R). Journal of Behavioral Assessment, 29, 177190. doi:10.1007/s10862-006-9035-8
Field, A. (2005). Discovering statistics using SPSS (2
nd
Ed.). London: Sage.
First, M.B., Gibbon, M., Spitzer, R., & Williams, J.B.W. (2002). Structured Clinical Interview for DSM-IV
(SCID I/R). New York: Biometrics Research Department, New York State Psychiatric Institute.
Foa, E.B., Franklin, M.E., Perry, K.J., & Herbert, J.D. (1996). Cognitive biases in generalized social phobia.
Journal of Abnormal Psychology, 105, 433439. doi:10.1037/0021-843X.105.3.433
Foa, E.B., & Kozak, M.J. (1986). Emotional processing of fear: Exposure to corrective information. Psy-
chological Bulletin, 99, 2035. doi:10.1037/0033-2909.99.1.20
Fresco, D.M., Coles, M.E., Heimberg, R.G., Liebowitz, M.R., Hami, S., Stein, M.B. &Goetz, D. (2001). The
Liebowitz Social Anxiety Scale: Acomparison of the psychometric properties of self-report and clinician-
administered formats. Psychological Medicine, 31, 10251035. doi:10.1017/S0033291701004056
Goldin, P.R., & Gross, J.J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion
regulation in social anxiety disorder. Emotion, 10, 8391. doi:10.1037/a0018441
Goldin, P., Ramel, W., & Gross, J. (2009). Mindfulness meditation training and self-referential processing in
social anxiety disorder: Behavioral and neural effects. Journal of Cognitive Psychotherapy, 23, 242257.
doi:10.1891/0889-8391.23.3.242
Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological research. Journal of
Psychosomatic Research, 64, 405408. doi:10.1016/j.jpsychores.2008.02.001
Gunaratana, B.H. (2001). Eight mindful steps to happiness. Walking the Buddhas path. Somerville, MA:
Wisdom Publications.
Hayes, S.C., & Wilson, K.G. (2003). Mindfulness: Method and process. Clinical Psychology: Science and
Practice, 10, 161165. doi:10.1093/clipsy/bpg018
Hofmann, S.G. (2004). Cognitive mediation of treatment change in social phobia. Journal of Consulting
and Clinical Psychology, 72, 393399. doi:10.1037/0022-006X.72.3.392
Hope, D.A., Gansler, A.D., & Heimberg, R.G. (1989). Attentional focus and causal attributions in social
phobia: Implications from social psychology. Clinical Psychology Review, 9, 4960. doi:10.1016/0272-
7358(89)90046-9
Iwamasa, G., Sorocco, K., & Koonce, D. (2002). Ethnicity and clinical psychology. A content analysis of
the literature. Clinical Psychology Review, 22, 931944.
Jain, S., Shapiro, S.L., & Swanick, S. (2007). A randomized controlled trial of mindfulness mediation versus
relaxation training effects on distress, positive states of mind, rumination, and distraction. Annals of
Behavioral Medicine, 33, 1121.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and Future. Clinical
Psychology: Science and Practice, 10, 144156. doi:10.1093/clipsy/bpg016
Keng, S., Smoski, M.J., & Robins, C.J. (in press). Effects of mindfulness on psychological health: A review
of empirical studies. Clinical Psychology Review, 31, 10411056. doi:10.1016/j.cpr.2011.04.006
370 Journal of Clinical Psychology, March 2012
Kocovski, N.L., Fleming, J.E., & Rector, N.A. (2009). Mindfulness and acceptance based group ther-
apy for social anxiety disorder: an open trial. Cognitive and Behavioral Practice, 16, 276289.
doi:10.1016/j.cbpra.2008.12.004
Kocovski, N.L., Segal, Z.V., & Battista, S.R. (2009). Mindfulness and psychopathology: Problem formula-
tion. In Didonna, F. (Ed.), Clinical handbook of mindfulness (pp. 8598). New York: Springer Science
& Business Media.
Koszycki, D., Benger, M., Shlik, J., & Bradwejn, J. (2007). Randomized trial of a meditation based stress
reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behavior
Research and Therapy, 45, 25182526. doi:10.1016/j.brat.2007.04.011
Lau, M., Bishop, S.R., Segal, Z.V., Buis, T., Anderson, N.C., Carlson, L., . . . Devins, G. (2006). The
Toronto Mindfulness Scale: development and validation. Journal of Clinical Psychology, 62, 14451467.
doi:10.1002/jclp.20326
Leary, M.R. (1983). A brief version of the Fear of Negative Evaluation Scale. Personality and Social
Psychology Bulletin, 9, 371375. doi:10.1177/0146167283093007
Liebowitz, M.R. (1987). Social phobia. Modern Problems in Pharmacopsychiatry, 22, 141173.
Masuda, A., Anderson, P., & Sheehan, S. (2009). Mindfulness and mental health among African American
college students. Contemporary Health Practice Review, 14, 115127.
Mennin D.S., Fresco, D.M., Heimberg R.G., Schneier, F.R., Davies, S.O., Liebowitz, M.R. (2002). Screening
for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale. Journal of
Anxiety Disorders, 16, 661673. doi:10.1016/S0887-6185(02)00134-2
Nykl cek, I., & Kuijpers, K.F. (2008). Effects of mindfulness-based stress reduction intervention on psy-
chological well-being and quality of life: Is increased mindfulness indeed the mechanism? Annals of
Behavioral Medicine, 35, 331340.
Oakman, J., Van Ameringen, M., Mancini, C., & Farvolden, P. (2003). A conrmatory factor analysis of a
self-report version of the Liebowitz Social Anxiety Scale. Journal of Clinical Psychology, 59, 149161.
doi:10.1002/jclp.10124
Preacher, K.J., & Hayes, A.F. (2008). Asymptotic and resampling strategies for assessing and com-
paring indirect effects in multiple mediator models. Behavior Research Methods, 40, 879891.
doi:10.3758/BRM.40.3.879
Ramel, W., Goldin, P.R., Carmona, P.E., & McQuaid, J.R. (2004). The effects of mindfulness meditation
on cognitive processes and affect in patients with past depression. Cognitive Therapy and Research, 28,
433455.
Rapee, R.M., & Heimberg, R.G. (1997). A cognitive behavioral model of anxiety in social phobia. Behavior
Research and Therapy, 35, 741756. doi:10.1016/S0005-7967(97)00022-3
Roemer, L., Lee, J.K., Salters-Pedneault, K., Erisman, S.M., Orsillo, S.M., & Mennin, D.S. (2009). Mind-
fulness and emotion regulation difculties in generalized anxiety disorder: Preliminary evidence for
independent and overlapping contributions, Behavior Therapy, 40, 142154. doi:10.1016/j.beth.2008.
04.001
Rytwinski, N.K., Fresco, D.M., Heimberg, R.G., Coles, M.E., Liebowitz, M.R., Cissell, S., . . . Hofmann,
S.G. (2009). Screening for social anxiety disorder with the self-report version of the Liebowitz Social
Anxiety Scale. Depression & Anxiety, 26, 3438. doi:10.1002/da.20503
Shapiro, S.L., Brown, K.W., Thoreses, C., & Plante, T.G. (2011). The moderation of mindfulness based
stress reduction effects by trait mindfulness: Results from a randomized control trial. Journal of Clinical
Psychology, 67, 267277. doi:10.1002/jclp.20761
Shapiro, S.L., Carlson, L.E., Astin, J.A., & Freedman, B,(2006). Mechanisms of mindfulness. Journal of
Clinical Psychology, 62, 373386. doi:10.1002/jclp.20237
Smalley, S.L., Loo, S.K., Hale, T.S., Shrestha, A., McGough, J., Flook, L., et al. (2009). Mindful-
ness and attention decit hyperactivity disorder. Journal of Clinical Psychology, 65, 10871098.
doi:10.1002/jclp.20618
Smits, J., A., Roseneld, D., McDonald, R., & Telch, M.J. (2006). Cognitive mechanisms of social anxiety
reduction: Anexaminationof specicity andtemporality. Journal of Consulting andClinical Psychology,
74, 12031212. doi:10.1037/0022-006X.74.6.1203
Uren, T.H., Szabo, M., & Lovibond, P.F. (2004). Probability and cost estimates for social and phys-
ical outcomes in social phobia and panic disorder. Journal of Anxiety Disorders, 18, 481498.
doi:10.1016/S0887-6185(03)00028-8
Mindfulness and Cognitive Processes 371
Watson, D., & Friend, R. (1969). Measurement of social-evaluative anxiety. Journal of Consulting and
Clinical Psychology, 33, 448457. doi:10.1037/h0027806
Weeks, J.W., Heimberg, R.G., Fresco, D.M., Hart, T.A., Turk, C.L., Schneier, F.R., & Liebowitz, M.
R. (2005). Empirical evaluation and psychometric evaluation of the Brief Fear of Negative Evaluations
Scale in patients with social anxiety disorder. Psychological Assessment, 17, 179190. doi:10.1037/1040-
3590.17.2.179
Wupperman, P., Neumann, C.S., Whitman, J.B., & Axelrod, S.R. (2009). The role of mindfulness in
borderline personality disorder features. Journal of Nervous and Mental Disease, 197, 766771.
doi:10.1097/NMD.0b013e3181b97343