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Mindfulness Based Stress Reduction: An Overview

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 Edited by
Mental Health Deepi Hooda
Risks and Resources NovRattan Sharma
Publish by Global Vision Publishing House

Mindfulness Based Stress Reduction

(MBSR) Program: An Overview
Dharmender Kumar Nehra, NovRattan Sharma,
Pradeep Kumar and Sheetal Nehra

You cannot control what happens to you, but you can control
your attitude toward what happens to you. —Brian Tracy
In Modern everyday life, human beings are constantly dealing with
various stresses. It may be because of hectic lifestyle and intense
work pressure, under which we live today. In addition, personal
ambitions, social pressure, and individual orientation to sedentary
mental work, with many other possible reasons, make everyone go
through persistent stresses. Although the acuity of the stress response
and its behavioral manifestations have been shown to vary greatly
between individuals (Tyrka et al. 2006), it becomes a potential
problem when it is persists or is intense. It threatens the homeostasis,
which in turn is balanced through physical and psychological
mechanism. Constantly stressful situation may disrupt the balance
of health and the body’s ability to maintain wellness and lead to
poor health. It is generally accepted that debilitating stress affects
mental and physical well-being detrimentally (Evans, Huckelebridge,
Clow, 2000). Because of its epidemiological transition stress is
getting widespread attention in the scientific literature, as potential
risk factors for many diseases. An enlarging body of evidence
suggests that stress is an underlying risk factor for many health
conditions (Mooy, Vries, Grootenhuis et al., 2000), including physical
as well as mental illnesses (Koenen, Lyons, Goldberg, et al., 2003).

Dharmender Kumar Nehra, Clinical Psychologist, State Institute of Mental

Health (SIMH) PGIMS Bt. B.D. Sharma, University of Health Sciences,
Rohatk , Haryana dknehra@yahoo.com
Nov Ratten Sharma, Professor, Department of Psychology, M. D. University,
Rohtak sharmanr5@gmail.com
Sheetal Nehra, Deaprtment of Psychology, M.D. University, Rohatk
198 Mental Health: Risks and Resources

There is now mounting evidence that Psychological Risk Factors

are associated with not only with incidence (Ferketich, et al., 2000)
but also with progression (Lett et al., 2004) of medical condition.
In short, psychological factors and medical conditions have a
reciprocal relationship. This interplay is even more intimate and
intricate in cases of chronic medical illnesses, where emergence of
illnesses leads to disturbances in mental health. Human beings are
complex systems and illness can be caused by a multitude of
factors and a complex interaction between these factors. Therefore,
it is difficult to ignore psychological interventions for people who
suffer from psychological disorders, medical condition, or both.
Furthermore, understanding both individual mental and physical
responses to distress or illness is critical to developing and planning
for interventions across the biological, psychological, spiritual and
sociocultural levels. Evidence-based interventions at multiple levels
strengthen clinical care and facilitate resilience and recovery. So,
Health Professionals attempt to move away from a simple linear
model of health and looks at the combination of factors involved in
illness such as biological, psychological and social. Through the
years, traditional psychology has focused on ways to help in making
ill people better by findings clinically valid and empirically supported
methods to help fix things that are wrong with them (Kauffman,
2006). While there is no magic formula that will work in all situations,
one of the proved way to relieve distress or suffering is cognitive
behavior therapy (CBT) and other is Mindful Meditation. Although
both approaches aim at relieving distress but there are some basic
differences between the notions of these approaches, these are as
follows: In CBT, emphasis is placed on positive, negative, or faulty
thoughts and focuses more on changing the content of thoughts
(Segal, Teasdale, Williams, 2004) whereas in mindfulness based
interventions, the emphasis is on identifying thoughts as just
“thoughts,” whether they are positive or negative. Unlike standard
CBT, in mindfulness-based interventions the main goal is not to
change the content of the patient’s system of cognitions but rather
to change his or her way of relating to it. During mindfulness
training, patients are helped to shift from a focus on the past and/or
Mindfulness Based Stress Reduction (MBSR) Program... 199

the future (conditioned by memories and rumination) to a focus on

the present moment, developing a process of de-centering and dis-
identification from personal experience (Segal, Williams, Teasdale,
2002).
In CBT, therapists encourages their patients to adopt the
empirical problem solving approach of scientists, and the therapist
serves as a role model for their patients by instilling self-efficacy,
enthusiasm and hopefulness about the challenging work of changing
maladaptive cognitions (Knapp & Beck, 2008) by systematic
desensitization through the induction of symptoms/thoughts during
the intervention. On contrary, mindfulness interventions focus on
the meditation practice itself; rather than on specific symptoms.
Although not intentionally evoked, when a stressful sensation or
thought arises, either during formal meditation or in the course of
daily routine, patients are encouraged to see it as opportunities to
engage in mindful coping strategies, to observe the thoughts,
emotions and sensations as they arise and disappear, and to act
instead of reacting according to habitual and thoroughly ingrained
cognitive and behavioral patterns. So, Mindful meditation makes the
patient aware about the effects of mindless constant activity
(‘automatic pilot’) on their body, emotions, thoughts, and how they
react to events.
In addition it teaches people to observe negative thoughts
without changing their content, thus, relating towards them in a
new way. Through engaging in this approach, clients begin to
disengage from dysfunctional cognitive routines that often serve as
a gateway to relapsing back into depression and other problems
(Segal, Teasdale, Williams, 2004). From the above mentioned
comparison it is clear that Mindful meditation is rooted in the core
notion that all psychological sufferings result from judgment whereby
experiences are divided into good and bad, which should be either
strived for or avoided, inevitably leading to some level of frustration,
distress, anxiety, and depression (Nyklíèek & Kuijpers, 2008).
Although “Mindfulness” is deceptively simple, yet it is a powerful
form of meditation training and this approach has been used
successfully with different clinical population.
200 Mental Health: Risks and Resources

MINDFULNESS AND ITS ROOTS

The word “Mindfulness” is an English translation of Vipassana,
which is a combination of two words Vi (in a special way) and
Passanna (to see, to observe) which implies observing in a special
way. Mindfulness is a form of self-awareness training adapted from
Buddhist mindfulness meditation. It refers to non-judgmental
awareness of moment-to-moment experience. Through mindfulness
practice, a person intentionally pays full attention to whatever is
occurring in the present moment without judging it. In addition to
Vipassana, Mindfulness meditation, also known as insight meditation,
is not new but is an age-old form of meditation practices that
derives from Theravada Buddhism (Gunaratana, 2002). It has been
prevalent in India since ancient times as it was discovered by
Gautama, the Buddha, more than 2,500 years ago at the time of His
Supreme Enlightenment at Bodh Gaya (Ahir, 1999).
Historically, mindfulness has been called “the heart” of Buddhist
meditation (Thera, 1962), which the Buddha taught to his followers.
Among his earliest teachings, he detailed the meditation instructions
for mindfulness practice: the Anapanasati Sutra (Rosenberg, 1998)
and the Satipatthana Sutra (Smith, 1999). The approach is rooted in
the core Buddhist notion that all psychological sufferings are the
result of the judgmental mind, dividing experiences into good and
bad, which should be either strived for or avoided, inevitably leading
to some level of frustration, distress, anxiety, and depression
(Nyklíèek & Kuijpers, 2008). Mindfulness is a skill, and like learning
a musical instrument, is developed through repeated daily practice.
An intended result of mindfulness practice is the development of a
mental orientation of mindfulness toward daily events providing
enhanced mental/emotional flexibility and clarity to deepening one’s
enjoyment of life and making one more skillful in facing life’s
challenges (Davis, Fleming, Bonus, Baker, 2007).
By incorporating the basic factors of mindfulness i.e. non-
reactivity, observing, awareness and non-judging (Bear, Smith,
Hopkins et al., 2006), one’s inner world can begin to change
regardless of the external circumstances (Fries, 2009). An intended
Mindfulness Based Stress Reduction (MBSR) Program... 201

result of mindfulness practice is that a mental orientation of

mindfulness will develop toward daily events providing enhanced
mental/emotional flexibility and clarity to deepening one’s enjoyment
of life and making one more adept in facing life’s challenges (Davis,
Fleming, Bonus, Baker, 2007). Mindfulness practice cultivates
concentration, insight as well as physiologic relaxation. Therefore,
mindfulness training may allow for reductions in stress even when
changes in the organizational environment are impossible or are not
practical (Hayes et al, 2006). Mindfulness based interventions have
substantiated its efficacy in helping patients with different kind of
physical and psychiatric problems.
Over the years, mindfulness has been accepted and successfully
incorporated into many therapeutic interventions in both the medical
and psychological fields. Grossman, Niemann, Schmidt, and Walach,
(2004) cited the assumptions underlying this concept and approach
as follows:
(1) Humans are ordinarily largely unaware of their moment-
to-moment experience, often operating in an ‘‘automatic
pilot’’ mode.
(2) They are capable of developing the ability to sustain attention
to mental content.
(3) Development of this ability is gradual, progressive and
requires regular practice.
(4) Moment-to moment awareness of experience will provide
a richer and more vital sense of life, inasmuch as experience
becomes more vivid and active mindful participation
replaces unconscious reactiveness.
(5) Such persistent, non-evaluative observation of mental
content will gradually give rise to greater veridicality of
perceptions.
(6) As more accurate perception of one’s own mental
responses to external and internal stimuli is achieved,
additional information is gathered that will enhance effective
action in the world, and lead to a greater sense of control
202 Mental Health: Risks and Resources

(Amawattana, Mandel, Ekstrand, 1994; Brown, 1999;

Bruckstein, 1999).
In addition, Fries (2009) wrote three critical principles or beliefs
that act as a foundation for the development of mindfulness and
psychological well-being. (1) One must come to the realization that
“life is not fair”. (2) One must face reality and deal with the truth,
as it presents itself, in any situation. (3) One is always free to
choose one’s attitude no matter what the situation is. Mindfulness
meditation elicits more positive emotions, (Siegel, 2007), and
optimism has been found positively correlated with physical health,
effective coping strategies, successful recovery from diseases, and
longevity (Scheier & Carver, 1985, 2001). Alidina (2010) has
mentioned ten ways in which mindfulness helps: (1) Training the
Brain (2) Improving Relationships (3) Boosting Creativity (4)
Reducing Depression (5) Reducing Chronic Pain (6) Giving Deeper
Meaning to Life (7) Reducing Stress (8) Combating Anxiety (9)
Regulating Eating Habits (10) Increasing Your Happiness. A number
of different mindfulness-based training programs including
Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and
Commitment Therapy (ACT), Dialectical Behavior Therapy (DBT),
and Mindfulness-Based Eating Awareness Training (MB-EAT) can
effectively treat different health conditions. In addition, one of the
effective and widespread approaches where mindfulness is a key
component is called Mindfulness-Based Stress Reduction (MBSR).

MINDFULNESS BASED STRESS REDUCTION

What is Mindfulness Based Stress Reduction (MBSR)?
Mindfulness-based stress reduction (formerly known as the
stress reduction and relaxation program) is a standardized meditation
program developed by Jon Kabat- Zinn in 1979, by integrating
Buddhist mindfulness meditation with contemporary clinical and
psychological practice (Kabat-Zinn, 1990; Kabat-Zinn, 2003). It
was originally developed to relieve suffering among patient with
chronic pain and to facilitate adaptation to medical illness and provides
systematic training in mindfulness meditation as a self-regulation
approach to stress reduction and emotion management (Kabat-Zinn,
Mindfulness Based Stress Reduction (MBSR) Program... 203

1982). Presently, MBSR as an intensive structured training in

mindfulness meditation has proved its efficacy in different population
in different parts of the world. It is important to remember that
although MBSR has been borrowed from the instructions of Buddhist
tradition, it does not seek to be “Buddhist” or to convert anyone to
that tradition, therefore this program should be viewed as non-
religious and non-esoteric. It is firmly rooted in principles of mind–
body medicine, and offers itself to anyone who wishes to learn to
enhance his or her own health (Kabat-Zinn, 1990). Kabat-Zinn,
(2003a) described the two basic intentions behind the founding of
MBSR i.e. (1) the program was intended to become an effective
vehicle for relief of suffering, (2) MBSR was developed as a model
approach that could be adapted in a variety of health care concerns
in hospital and centers.
Interest in MBSR has grown exponentially since its introduction
and it has gradually gained recognition as an important means of
teaching people how to live their lives fully even if they are patients
with chronic illness (Speca, Carlson, Goodey, Angen, 2000).
Although, MBSR intervention is usually directed towards people
with chronic physical and mental illnesses, but the aim of the
intervention is not to replace medical treatment but to be used as a
vital complement to it (Kabat-Zinn, 1990), to improve patients’
quality of life and to reduce psychological distress, which in theory
would ultimately improve clinical outcomes. In addition, it has been
tried out on various nonclinical populations such as students,
therapists, prison inmates and impoverished inner city dwellers
(Grossman, Niemann, Schmidt, Walach, 2004). Recent years have
witnessed an increasing trend to use MBSR program in different
settings. There is no doubt in the fact that more and more people
are relying on MBSR as till 1998 an estimated 240 MBSR programs
were established in North America and Europe. In a nutshell, it
seems that this is the time when MBSR is considered to be an asset
and new programs are being established each year (Kabat-Zinn,
1998).
In the past few decades, rigorous scientific studies have
demonstrated that meditation have a positive influence on individual’s
204 Mental Health: Risks and Resources

health, both mental and physical. The health promotion effects of

MBSR appear to complement conventional biomedical treatment in
a comprehensive, patient-centered approach for the healing and the
alleviation of human suffering (Reibel, Greeson, Brainard, &
Rosenzweig, 2001). MBSR, a popular form of mindfulness based
intervention, is now widely used with a range of mental health
problems and can be adapted to various age groups including adult
population as well as with children (Wall, 2005). The empirical
basis of MBSR has been demonstrated through a number of studies
that have resulted in a growing conviction amongst clinicians that
MBSR is efficacious in diverse samples of patients and general
population regarding a variety of psychological states, including
reduction in mood disturbances (Brown, Ryan, 2003), general distress
(Speca, Carlson, Goodey, Angen, 2000) worry, rumination, and
anxiety (Jain, Shapiro, Swanick, et al., 2007), pain (Kabat-Zinn,
1982), and improves sleep quality (Carlson, Garland, 2005), sense
of well-being (Beddoe, Murphy, 2004) quality of life (Roth, Robbins,
2004).
Mindfulness-Based Stress Reduction (MBSR) has gradually
gained recognition as an important means of teaching people how
to live their lives fully even when suffering from chronic illness
(Speca, Carlson, Goodey, Angen, 2000). The core of MBSR involves
training in mindfulness meditation, a practice of self-regulating
attention that lowers reactivity to stress triggers (Kabat- Zinn, 1990).
Mindful meditation also decreases physical symptoms of distress
by balancing sympathetic and parasympathetic responses (Kabat-
Zinn, 2003b). Regular practice of mindfulness leads one to taking
care of health and emotional needs that ultimately lead to positive
emotions and happiness. The fact is that the meditator can take
better care of one-self (physically and emotionally) and choose to
feel calm even when things are not wonderful. Regular mindful
practice decreases the risk of developing distress that leads a person
to take responsibility of his health and he begins to have a yearning
to lead a healthy lifestyle and increases the chances of survival. In
addition, the MBSR program emphasizes the importance of bringing
mindfulness to everyday life. It invites attention to routine activities
Mindfulness Based Stress Reduction (MBSR) Program... 205

such as brushing one’s teeth, feeding the cat, and taking out the
garbage; to walk mindfully when walking; to use sensations in
one’s body as a way to stay aware and present in each moment;
and to support mindfulness of any experience by “breathing with” it
(Williams, Teasdale, Segal, & Kabat-Zinn, 2007). In short it can be
said that the MBSR model, with its focus on physical as well as
psychological conditions, offers an expanded dimension to the role
of meditation practices in clinical as well as everyday settings.

Basic Principles and Components of MBSR

MBSR has proved to be enormously empowering for patients
with chronic diseases and debilitating conditions, as well as for
psychological problems such as anxiety and panic (Williams, Teasdale,
Segal, & Kabat-Zinn, 2007). Cohen-Katz et al, (2005) have described
the procedure of MBSR program briefly in following lines “The
MBSR is taught as an 8-week program that meets approximately
2.5 hours a week and includes a 6-hour daylong retreat between the
6th and 7th weeks. Participants are asked to practice the mindfulness
techniques 6 days a week as “homework” and given audiotapes to
facilitate this. Group sessions include a combination of formal didactic
instruction on topics such as communication skills, stress reactivity,
and self-compassion and experiential exercises to help participants
integrate these concepts.
The program is described in detail in Kabat-Zinn’s textbook
“Full Catastrophe Living: Using the Wisdom of Your Body and Mind
to Face Stress, Pain and Illness.” (Cohen-Katz et al, 2005).
Participants commit themselves to spend at least 45 minutes daily,
six days a week, conducting MBSR exercises during the training
period. MBSR is a structured group program though there are
examples where it was administered in individual settings (Weiss,
Nordlie, Siegel, 2005; Nehra, Sharma et al., 2012). MBSR utilizes
stress-reduction skills including sitting meditation, hatha yoga, and
a somatically focused technique called the body scan (Kabat-Zinn,
1982). Kabat-Zinn explains that the purpose of the 8-week program
is to teach participants how to ‘pay attention in a particular way: on
purpose, in the present moment, and non-judgmentally’. By learning
206 Mental Health: Risks and Resources

to cultivate present-moment awareness, practitioners are described

as becoming more mindful of their thoughts, emotions, sensations
and overall sense of self. The approach assumes that greater
awareness will provide more veridical perception, reduce negative
affect and improve vitality and coping (Grossman, Niemann, Schmidt,
Walach, 2004).
The MBSR program recommends using meditation, yoga,
relaxation training as well as strategies to incorporate these practices
into everyday life. A range of other mindfulness meditation techniques
are taught: awareness of breathing, mindful walking, mindful eating,
and mindful communication. In all of these practices, the participant
is trained to pay full attention to present-moment experience,
choosing to respond skillfully rather than react automatically to
external events, thoughts, emotions, or sensations as they arise.
1 Body scan: MBSR’s most innovative technique is the body
scan, which teaches patients to “re-establish contact with
the body” through a “thorough and minute focus on the
body” in a guided meditation in which patients lie supine
and are verbally taken on a tour of the body, focusing
awareness sequentially on individual parts of the body.
Patients become aware of where pain and stress are carried,
where pain is centered—and where it doesn’t exist at all—
as well as gaining a sense of how the body changes over
time between scans (Kabat-Zinn, 1990). Body-Scan
Meditation is the first formal mindfulness practice that
patients engage in for a sustained period of time. It involves
lying on your back and moving your mind through the
different regions of your body. Transformation and change
occur by learning to be open and accepting whatever is
present—good, bad, or neutral; to be intentional in the
way one pays attention; to skillfully relate to difficulties,
distractions, and the wanderings of the mind, and to be
more compassionate and befriending of whatever arises
(Nehra, Nehra, Dogra, 2012).
Mindfulness Based Stress Reduction (MBSR) Program... 207

2 Sitting meditation: Sitting meditation is called the heart

of the formal meditation practice. Usually practice of the
sitting meditation is done either on a chair or on the floor.
In this technique, participants are instructed to sit in a
relaxed, upright posture and to direct their full attention to
the sensations of breathing. They are instructed to return
their attention to the breath whenever it wanders (Jha,
Krompinger, Baime, 2007). Further, participants are
encouraged to observe their thoughts and emotions but to
let them pass without judging them or becoming immersed
in them (Praissman, 2008). This allows both positive and
negative thoughts and emotions to pass quickly and can
cultivate a greater awareness of the ways thoughts, feelings,
and behaviors that affect emotional, mental, and physical
health. This may also help reduce distractive or ruminative
thoughts and assist practitioners in better noticing,
understanding, and integrating their own perception of self
and the environment (Jain, Shapiro, Swanick et al., 2007).
After a period of systematic practice, participants begin to
observe the impermanence of all thoughts. People start to
notice that they can witness their own thoughts objectively
without having to act on them. This is particularly helpful
in working with impulse control when a craving arises. It
is also possible to realize that the part observing is not in
pain, confused, or damaged. This silent witnessing allows
participants to see unanticipated possibilities in managing
adversity. Transformation and change occur by learning to
anchor awareness in the present moment and to live life in
a curious interested way, instead of the usual ‘‘I like’’ or
‘‘I don’t like’’ mode.
3. Mindful Hatha Yoga: Mindful hatha Yoga is the third
major formal meditation technique along with body scan
and sitting meditation. These exercises are the central part
of the MBSR intervention. Gentle, often modified yoga
stretches are practiced for approximately 30 minutes in
each 90-minute session, with a focus on body awareness
208 Mental Health: Risks and Resources

rather than form. The Hatha Yoga exercises are performed

in a slow and mindful manner, keeping the mind focused
on the parts of the body that are engaged in a particular
exercise, and allowing the muscles that are not engaged to
rest and relax (Vallejo & Amaro, 2009). The aim of the
exercise is to notice the changing sensations, not necessarily
to do the exercise perfectly. This attentive movement allows
a discovery of the body’s ability to gradually surpass initial
limits of stamina and flexibility (Vallejo & Amaro, 2009). It
makes the body feel good; improves balance, flexibility of
the joints and muscles; and relaxes stiff, tight muscles.
Yoga also relieves stress, makes one more “mindful” and
aware, helps improve concentration, and helps one feel
more tranquil and calm.
In addition to the above mentioned formal techniques, there
are some informal techniques (Mindful Walking; Mindful Eating
etc.) that are also taught to the participants. The purpose is to make
the participants to learn mindfulness skills that they will then put
into practice in everyday life. So it can be said that MBSR is based
on self-awareness notion and skills that are brought about by breath
concentration in order to recover all living activities (Jam, Imani,
Foroughi, Alinaghi, Koochak, Mohraz, 2010), which have
demonstrated its applications to daily life (Biegel, Brown, Shapiro,
Schubert, 2009). Together, this package of mindfulness practices
(formal and informal) aims to enhance the ability to observe the
immediate content of experience, specifically, the transient nature
of thoughts, emotion, memories, mental images, and physical
sensation (Goldin & Gross, 2010).

Essential Pillars of MBSR

MBSR is a standardized meditation program but simply
following the set of instructions mechanically is not enough to
cultivate the healing power of mindfulness. The attitude with which
one undertakes the mindfulness practice is important (Nehra, Nehra,
Dogra, 2012); Kabat-Zinn (1990) advocates seven attitudinal
foundations of mindfulness practice that are considered as pillars of
mindfulness.
Mindfulness Based Stress Reduction (MBSR) Program... 209

1 Non-Judging: Almost everything one sees is labeled and

categorized by the mind as “good”/ “bad”/ “neutral”. The
habit of mental categorization and judgment posits acts to
restrain individuals’ growth via mechanical thoughts and
behavior that suspend the process of learning. Non-judging
means to be an impartial witness to one’s own experience
and, in the process, to notice the never-ending stream of
evaluating and reacting to experiences that one engages in
(Knowles, 2008). During meditation, people become aware
of the fact that they are continuously immersed in an
uninterrupted flow of thoughts that come regardless of
their will to have them or not, one after the other, in very
rapid succession. Through mindfulness practice, a person
intentionally pays full attention to whatever is occurring in
the present moment without judging it. This means not
making a positive or negative evaluation of what is
happening, just simply observing it, all that is needed is to
watch what is happening…including how one habitually
judges & reacts to his/her own experience. It requires that
one becomes aware of the stream of judging and reacting
to inner and outer experiences and step back from it.
2 Patience: One of mind’s favorite activities is to wander
into the past and into the future and lose itself in thinking.
Patience is the knowledge that things unfold in their own
time. Practicing mindfulness gives one the chance to give
time and space to one’s own unfolding. From this peace,
one becomes more able to re-evaluate one’s relationship
with the disturbance.
3 Beginner’s Mind: Too often one lets one’s thinking and
beliefs about what he/she “knows” prevent him/her from
seeing things as they really are. Practicing mindfulness
means to take the chance to see everything as if it was for
the first time and not allow one’s illusion of knowing
prevent one from being present to one’s experiences.
Because no moment is the same as any other moment,
beginner’s mind helps one to stay alert to the unique
possibilities that each moment presents.
210 Mental Health: Risks and Resources

4 Trust: Anybody who is imitating somebody else, no matter

who it is, is heading in the wrong direction. Having trust
in yourself, your intuition, and your abilities is the hallmarks
of mindfulness practice. Trust means that one learns how
to honor his/her own feelings rather than to distrust or
suppress them. With this attitude, comes the knowledge of
practicing progress toward one’s desired goals, as opposed
to rigidity or perfection.
5 Non-Striving: “Almost everything one does, is done for a
purpose, to get something or somewhere.” Actually this
attitude can be a real obstacle in meditation. Although
meditation takes a lot of work and energy, ultimately it is
about non-doing. Mindfulness practice is a chance to try a
profoundly different approach. It has no goal other than
meditation itself. Non-Striving is the state of not doing
anything, just simply accepting that things are happening
in the moment just as they are supposed to.
6 Acceptance: In the course of our daily lives we often
waste a lot of energy denying and resisting what is already
a fact. This actually prevents positive change from
occurring. Acceptance means completely accepting the
thoughts, feelings, sensations, and beliefs that you have,
and understanding that they are simply those things only.
Acceptance is not a passive response to the conditions
you encounter but a willingness to see things as they
actually are, in that moment, not as you wish or expect
them to be. Acceptance does not imply that you like the
way things are. In Mindfulness practice acceptance is
cultivated by taking each moment and each aspect of our
experience just as they come, focusing on the present and
being receptive to the flow of all that comes to us and
passes on. Doing that uses up one’s energy in the struggle
instead of using it for healing and change.
7 Letting Go: When we pay attention to our inner
experience, we discover that there are certain thoughts,
feelings and situations that the mind seems to want to hold
Mindfulness Based Stress Reduction (MBSR) Program... 211

on to. In mindfulness practice we just keep on

acknowledging whatever arises, then letting it pass on
when it will, making space for the next moment and the
next experience. Letting go occurs when you neither try
to hold on to nor to reject your experience. Let a thought
or feeling come in and pass without connecting it to
anything, observing them exactly as they are and allowing
them to come and go. Alidina (2010) also has cited Kindness
and curiosity as another vital attitudinal foundation of
mindfulness.
8 Kindness: Kindness is one of the most important of all
attitudes one can bring to mindfulness practice. Mindfulness
teaches and utilizes non-judgmental observing of the arising
and emergence of thoughts and feelings and also focuses
on (re)directing attention, with a focus on trying to generate
feelings of warmth, gentleness and kindness (Gilbert, 2000;
Gilbert & Irons, 2005). Kindness involves understanding
one’s difficulties and being kind and warm in the face of
failure or setbacks rather than harshly judgmental and self-
critical (Gilbert & Tirch, 2009). By bringing a sense of
friendliness or kindness to experience, the experience,
whether it’s pleasant, unpleasant or neutral, transforms
(Alidina, 2010).
9 Curiosity: Curiosity is the basis of all true learning (Alidina,
2010). Segal et al. (2002) note that “. . .in mindfulness
practice, the focus of a person’s attention is opened to
admit whatever enters experience, while at the same time,
a stance of kindly curiosity allows the person to investigate
whatever appears, without falling prey to automatic
judgments or reactivity”. Applying curiosity to oneself
requires courage, because seeing the world as it is means
not seeing the world as one would like it to be. This
tolerance of internal or external stimuli is described in
many eastern languages as a general curiosity or openness,
an ‘‘affectionate, compassionate quality within the
attending, a sense of openhearted, friendly presence and
212 Mental Health: Risks and Resources

interest’’ (Kabat-Zinn, 2003). In this way a curious person

is fully connected with one’s senses (Alidina, 2010) and to
be connected with senses (present moments) are the basis
of cultivating mindfulness.
Mindfulness Skills as Mechanisms of Change
Mindfulness has its modern origins in the late 1970’s with the
work of Jon Kabat-Zinn, who introduced MBSR to the psychological
field. By the late 1990s, over 240 hospitals in the United States and
Europe offered MBSR programs (Salmon, Santorelli, & Kabat-Zinn,
1998). Such a great emergence of MBSR within a comparative
short span of time is very promising. Despite great interest in the
application of MBSR in mentally and physically ill patients, less
attention has focused on the actual mechanism underlying the
helpfulness of MBSR. However, in an attempt to understand how
mindfulness meditation might be therapeutic; several explanations
have been proposed to explain the processes by which mindfulness-
based interventions leads positive physical, psychological, and
emotional effects. Some of the possible mechanisms which are
proposed in world literature are metacognitive awareness (Teasdale,
Moore et al. 2002), decentering (Fresco, Segal et al. 2007), re-
perceiving (Shapiro, Carlson et al. 2006), and decreased rumination
(Deyo et al. 2009).
More recently Garland et al. (2009) have proposed “mindful
coping model” that depicted how mindfulness creates positive result.
The model suggests that to re-construe an appraisal of a given
event as positive, one must first disengage and withdraw from the
initial, negative appraisal into a transitory metacognitive state that
attenuates semantic evaluations associated with the event (Garland,
Gaylord, Fredrickson, 2011). In addition, Baer in 2003 and Ludwig
& Kabat-Zinn in 2008 did superb reviews of the literature on the
use of mindfulness as a clinical intervention and a description of the
applications of mindfulness to mental health problems that is as
follows:
Baer (2003) has reviewed several mechanisms that may explain
how mindfulness skills can lead to stress reduction, behavior and
cognitive change.
Mindfulness Based Stress Reduction (MBSR) Program... 213

1 Exposure: Through mindfulness practice, a person

intentionally pays full attention to whatever is occurring in
the present moment without judging it. So, MBSR teaches
patients to change their relationship with thoughts and
feelings by developing an objective, compassionate, and
inquisitive approach to thoughts and feelings. This shift in
perspective can lead to enhancement of self-regulation,
cognitive and emotional flexibility, and decreased experiential
avoidance (Ong, Shapiro, Manber, 2008). Kabat-Zinn, et
al. (1992) describes mechanism for the potential effects of
mindfulness training on anxiety and panic. Sustained,
nonjudgmental observation of anxiety-related sensations,
without attempts to escape or avoid them, may lead to re-
educations in the emotional reactivity typically elicited by
anxiety symptoms. Participants are instructed to observe
these sensations non-judgmentally when they naturally arise.
Thus, the practice of mindfulness skills may improve
patients’ ability to tolerate negative emotional states and to
cope with them effectively.
2 Cognitive Change: Mindfulness actually may lead to
changes in thought patterns and the attitude of one’s
thoughts: cognitive change. Kabat-Zinn (1990) suggests
that this occurs through the practice of nonjudgmental
thinking as well as the understanding that thoughts are not
necessarily the reality or the truth.
3 Self-Management: Mindfulness practice, sitting and
attending to one’s thought is in itself a self-management
intervention. Again, the first stage in change is self-
awareness of a problem or pattern. By sitting and using
focused awareness on what’s happening at the moment
the urges emerge; the triggers and stressors may also
come into awareness and facilitate more active problem
solving (Hooker & Fodor, 2008). Further, Mindfulness
increases awareness which allows individuals to respond
to the situation at hand, instead of automatically reacting
to it on the basis of past experiences (Proulx, 2003).
214 Mental Health: Risks and Resources

4 Relaxation: Meditation often induces relaxation, which

may contribute to the management of stress related medical
disorders (Kabat-Zinn & Chapman-Waldrop, 1988). Here,
it is very important to understand that relaxation associated
with mindfulness meditation is contrasted with behavioural
relaxation techniques in that the goal of mindfulness
meditation is not to induce relaxation of the body but
rather to cultivate awareness and stay present with whatever
thoughts or body sensation arise in the moment (Kabat-
Zinn 1990). Moreover, a randomized controlled trial showed
that while both mindfulness practice and relaxation training
reduced distress and produced positive mood states, only
mindfulness practice led to significant decreases in
ruminative thoughts which partially mediated its therapeutic
effect on distress (Jain, Shapiro, Swanick, et al., 2007).
5 Acceptance: Acceptance, the tendency to tolerate, or even
approach, unwanted internal experiences rather than avoid
them. It involves “experiencing events fully and without
defense as they are” which include acceptance of pain,
thoughts, feelings, urges, or other bodily, cognitive, and
emotional phenomena, without trying to change, escape,
or avoid them (Hayes, 1994). This can help an individual
to accept reality and the present situation without reacting
impulsively and engaging in maladaptive behaviors, in an
attempt to alter the situation such as taking alcohol at
times of anxiety arousing situations. In working with medical
and clinical populations, mindfulness training includes an
acceptance of pain, worries, thoughts, and emotions without
trying to escape, avoid, or change them. By being willing
to stay with the pain and negative emotions, researchers
suggest, individuals may benefit through a greater sense of
self-acceptance (Baer, 2003).
In addition to above mentioned mechanisms researchers have
also suggested alterations in biological pathways affecting health,
such as the autonomic nervous system, neuroendocrine function,
and the immune system (Ludwig & Kabat-Zinn, 2008). Alidina
Mindfulness Based Stress Reduction (MBSR) Program... 215

(2010) claimed that mindfulness meditation does change the brain,

and the more one practises, the greater the positive change within
his brain. Neuroimaging studies have identified specific brain
structures active during meditation. Their findings show increased
regional blood flow to the anterior cingulate cortex and dorsolateral
prefrontal cortex during meditation (Cahn & Polich, 2006).
Concerning meditation onset, some functional magnetic resonance
imaging (fMRI) studies have employed short periods of meditation
(\1 min) that displayed increased activity of different frontal cortical
areas including lateral prefrontal cortex (Farb et al. 2007), and
increased involvement in viscerosomatic areas, including insula,
secondary somatosensory and inferior parietal regions.
Imaging studies have also shown increased gray matter,
particularly in the prefrontal cortex, the right anterior insula, and the
putamen, areas associated with attention, interoception, and sensory
processing, with differences correlating with meditation experience,
suggesting neural plasticity with meditation (Lazar, Kerr, Wasserman,
et al., 2005; Pagnoni & Cekic, 2007). One recent study (Ho¨lzel et
al., 2007) found an increased size of the right anterior insula in a
meditation group compared to controls. They also both revealed
increases in structures of the left temporal cortex although not in
the same exact structures. Goldin and Gross (2010) examined MBSR-
related changes in the brain–behavior indices of emotional reactivity
and regulation of negative self-beliefs in patients with social anxiety
disorder. Sixteen patients underwent functional MRI while reacting
to negative self-beliefs and while regulating negative emotions using
2 types of attention deployment emotion regulation— breath-focused
attention and distraction-focused attention. Post-MBSR, 14 patients
completed neuroimaging assessments. Compared with baseline,
MBSR completers showed improvement in anxiety and depression
symptoms and self-esteem. Meditators also showed a more robust
and effective immune response to an influenza vaccine administered
at the end of the training period (Easterlin & Carden˜a, 1998).
Groundbreaking research during the last decades by researchers
such as Professor Richard Davidson has provided us with a better
216 Mental Health: Risks and Resources

understanding of neurobiological mechanisms of meditation. On the

basis of an extensive corpus of both animal and human data, Davidson
and colleagues recently suggested (Davidson, Jackson, Kalin, 2000)
that prefrontal activation asymmetries are plastic and could be shaped
by training. The findings from their study are the first to suggest
that meditation can produce increases in relative left-sided anterior
activation that are associated with reductions in anxiety and negative
affect and increases in positive affect (Davidson, Kabat-Zinn,
Schumacher, et al., 2003). So it can be said that the literature on
neurobiological mechanism of MBSR is now beginning to emerge
and biological methods are expected to answer other related important
questions in the near future. Even in this age of advancements in
neuroscience research, for a better understanding of many disorders,
MBSR still has much to contribute to the overall understanding of
mechanism of treatment of different disorders.

Empirical Evidences of MBSR’s Outcome

Occurrence of chronic illnesses poses a major life stress that
requires considerable physical, emotional, and psychological
accommodation and coping. Although initially developed for stress
management, it has evolved to encompass the treatment of a variety
of health related disorders. It employs mindfulness meditation to
alleviate suffering associated with physical, psychosomatic and
psychiatric disorders. Over 200 medical centers across the world
offer MBSR as an alternative treatment option to patients (Niazi &
Niazi, 2011). The reviews generally suggest that MBSR may be
beneficial to reduce stress, anxiety, and depression. MBSR helps
the patients in adapting to the daily treatment needs and managing
the psychosocial issues associated with chronic illness that is
challenging and stressful for patients.
Participants in a large number of studies have been found to
experience improvements in stress reduction (Astin, 1997); chronic
pain (Kabat-Zinn, 1982); anxiety disorders (Miller, Fletcher, & Kabat-
Zinn, 1995); worry, rumination, and anxiety (Jain, Shapiro, Swanick,
et al., 2007); relapsing depression (Teasdale, Segal, & Williams,
1995); eating disorders (Kristeller & Hallett, 1999); smoking (Davis,
 Mindfulness Based Stress Reduction (MBSR) Program... 217

Fleming, Bonus, & Baker (2007); and attention-deficit hyperactivity

disorder (Zylowska, Ackerman et al., 2008); sleep complaints
(Shapiro, Bootzin et al., 2003); cancer (Speca, Carlson, Goodey, &
Angen, 2000); diabetes mellitus (van Son, Nyklíèek, Pop, Pouwer,
2011); hypertension (Schneider, Staggers, Alexander, 1995); human
immunodeficiency virus (HIV) infected adults (Creswell, Myers,
Cole, 2009); coronary heart disease (Nehra, Sharma et al., 2012);
fibromyalgia (Weissbecker et al., 2002); chronic low back pain
(Morone, Greco, Weiner, 2008); rheumatoid arthritis (Zautra et al.,
2008), and psoriasis (Kabat-Zinn et al., 1998) after MBSR training.
A sample of 136 heterogeneous patients with a variety of
medical diagnoses, including chronic pain, hypertension, cancer,
sleep disorder, anxiety, panic and depression, were enrolled in 12
different 8-week MBSR groups (Reibel, Greeson, Brainard,
Rosenzweig, 2001). Kabat-Zinn (1982) reported on the outcomes
of MBSR in a sample of 51 individuals afflicted with chronic pain.
Dominant pain categories were back, neck, shoulder and headache.
³ Sixty-five percent of the participants showed a reduction of ³ 33%
in pain ratings and 50% showed a reduction of 50%. In addition,
76% of participants reported a reduction in mood disturbance of
33 and 62% of participants reported a reduction of 50%.
Results indicated that participants benefited in reports of health-
related quality of life and physical and psychological symptoms. In
recent study from India (Nehra, Sharma et al., 2012), it was found
that Depression, Anxiety and Perceived Stress are preponderant in
patients suffering from Coronary Heart Disease patients’ pre
intervention level and reduced significantly post intervention level.
These changes were present only in the experimental group whereas
control group showed no significant changes.
The results clearly show that MBSR is effectively reduced
depression, anxiety, perceived stress in CHD patients. From several
studies around the world, a long list of physical and mental disorders
that can be well managed with MBSR and a large number of MBSR
induced benefits have been recognized, and new disorders and
benefits are periodically added to the list as the comprehension of
218 Mental Health: Risks and Resources

the MBSR process grows (Nehra, Nehra, Dogra, 2012). In view of

above mentioned revolutionary research findings it can be advocated
that MBSR may help a broad range of individuals to cope with their
clinical problems (Physical and Psychiatric). This intervention is
can be an effective component with traditional management in
improving emotional well-being in patients with chronic illnesses.
The latest scientific researches on mindfulness training are promising
but warrant additional study in a larger comparative trial.

Evaluating the Need For MBSR in Indian Setting

The numbers of patients with chronic diseases are increasing
(Rosamond, Flegal, Furie et al., 2008) and psychosocial factors are
now recognized as playing a significant and independent role in the
development of physical disorders and its complications. Although,
these psychosocial factors appear to be outside the immediate realm
of medicine, they have a profound impact on the patient’s quality of
life, symptoms severity, disability level (Saravay, 1996), and survival
(Krumholz. Butler, Miller et al., 1998). Co-existence of physical and
psychiatric disorders makes the situation more dreadful. As a result,
there has been a great deal of interest in potential treatments of
these factors in chronic disease patients, with the hope that
successful mental health treatment may also have a positive effect
on physical health outcomes. It is plausible that when one develops
chronic and life threatening illness, like CHD, they usually experience
negative emotions. The experience of physical disease seems to
contribute to risk for numerous psychiatric problems, especially
depression, anxiety, and cognitive disorders (Shapiro, Astin, 2005).
In addition, patient also experiences increasing concerns about
survival, well-being, effects on social roles/relationships/loved ones
and concerns about dependency, autonomy along with inciting fears
about vitality, sexuality, and mortality. So the recovery from emotional
challenge and increased tolerance of negative affect are both hallmarks
of holistic (mental and physical) health. MBSR has emerged as a
ray of hope to help patients to recover from bad conditions as it has
been found efficacious in both kinds of the conditions.
Mindfulness Based Stress Reduction (MBSR) Program... 219

In MBSR program, participant learns how to take care of

himself and discovers a deeper sense of ease and tranquillity of
mind as well as actively engage in own health and well-being. By
focusing on the present, rather than ruminating on the past or
worrying about the future, patients can more effectively deal with
life stressors that frequently lead to feelings of anxiety and depression
(Kabat-Zinn, 2003). Non-judgmental observation allows people to
experience phenomena with a novel openness that invites more
objective emotional and behavioural reactions (Brown et al., 2007).
One of the most valuable teachings and principles that mindfulness-
based programmes are based on (e.g., MBSR, Kabat-Zinn, 1990,
and MBCT, Segal, Williams & Teasdale, 2002) is the idea of not
being your own thoughts. It was found that the patients with
chronic illnesses, who had become disillusioned with the slow
progress or no program in their symptoms, were helped with MBSR
by decreasing distress and enhancing self-reported well-being. They
started believing that the problem is not to eliminate the distressing
thoughts that are generated, but rather to dis-identify themselves
from their thoughts. In this regard, Mindfulness based interventions
are believed to counter experiential avoidance strategies that maintain
and exacerbate emotional disorders, in part by teaching patients to
respond reflectively rather than reflexively to stressful situations
and negative emotions (Bishop, Lau, Shapiro, et al., 2004). There is
one point to remember that the aim of these psychological
interventions is not to replace medical treatment but to be used as
an essential complement to it, to improve patients’ quality of life
and to reduce psychological distress, which in theory would ultimately
improve clinical outcomes (Kabat-Zinn, 1990) and well-being (see
Grossman, Niemann, Schmidt, & Walach, 2004, for a metaanalysis).
MBSR is one of the most extensively researched psychological
approaches and is increasingly being recognized as the gold standard
for many psychological and physical disorders. Although early
implementations of MBSR were largely indicated for physical
disorders, more recent clinical and research efforts have begun to
apply MBSR for wider range of problems (psychiatric too) as well
220 Mental Health: Risks and Resources

as with healthy people, health professionals, student. So it is

appropriate to say that in future also MBSR will be regarded as the
most preferred psychological treatment for many disorders as well
a structured program to diminish distress and improve quality of
life (Nehra, Nehra, Dogra, 2012).

CONCLUSION
The relation between psychological factors and medical
conditions has been the subject of research since past few decades
and over that time the evidence of links between them has continued
to grow. Psychological factors co-occurring with medical problems
or vice versa are highly prevalent and associated with a wide range
of adverse outcomes. It seems particularly true in the case of
established chronic illnesses, where anxiety, depression and perceived
stress are predictive of adverse short-term and long-term outcomes.
These factors not only have a major impact on the quality of life of
patients but also negatively affect the long term outcome in these
patients. Since chronic illnesses (such as Coronary Heart Disease)
is a multifactorial process, intervention programs should be multi-
factorial based and involve psychological interventions along with
the routine medical care. Research had demonstrated that MBSR
alleviate suffering associated with medical and psychiatric conditions
and improve quality of life. MBSR has been proven effective in lists
of studies; it can be consider that MBSR is well positioned to
become a dominant approach. But this is only one side of the coin.
The other side of the coin shows that most of the efficacious
research has been done in Western setting and only few meta-
analyses have been done to this point. Despite strong evidence on
the efficacy of MBSR for psychiatric and physical disorders, notably
fewer studies has been conducted in Indian settings, and indicate a
strong need to conduct MBSR related studies in our setting also. In
spite of lacunae of related studies in our country, there are a growing
number of studies from different parts of world that indicate a
positive effect of mindfulness intervention on several different
disorders. Hence, it can be said with a great confidence that MBSR
is an important intervention step towards developing a comprehensive
Mindfulness Based Stress Reduction (MBSR) Program... 221

psychological management program for medical as well as psychiatric

patients.

REFERENCES
Ahir, D.C. (1999). Vipassana: A Universal Buddhist Meditation
Technique. Sri Satguru Publication. Delhi.
Alidina, S. (2010). Mindfulness for Dummies. England: John Wiley &
Sons
Amawattana, T., Mandel, J., Ekstrand, M. (1994). A pilot study of AIDS
education combined with Vipassana meditation among Thai
university students. International Conference on AIDS. 10, 344
(abstract no. PD0555).
Astin, J.A. (1997). Stress reduction through mindfulness meditation.
Effects on psychological symptomatology, sense of control, and
spiritual experiences. Psychotherapy & Psychosomatics, 66(2),
97–106.
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A
conceptual and empirical review. Clinical Psychology: Science and
Practice, 10, 125–143.
Baer, R.A., Smith, S.T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006).
Using Self-Report Assessment Methods to Explore Facets of
Mindfulness. Assessment. 13, 27-45.
Beddoe, A.E., & Murphy, S.O. (2004). Does mindfulness decrease stress
and foster empathy among nursing students? J Nurs Educ. 43,
305-312.
Biegel, G.M., Brown, K.W., Shapiro, S.L., Schubert, C.M. (2009).
Mindfulness-Based Stress Reduction for the Treatment of
Adolescent Psychiatric Outpatients: A Randomized Clinical Trial.
Journal of Consulting and Clinical Psychology, 77(5), 855–866.
Bishop, S.R., Lau, M., Shapiro, S., et al (2004) Mindfulness: a proposed
operational definition. Clinical Psychology: Science and Practice,
11, 230–241.
Brown, J.R. (1999). Psychospiritual openings of meditating pain patients:
a phenomenological study. Dissertation, Pacifica Graduate Institute,
USA.
222 Mental Health: Risks and Resources

Brown, K.W., Ryan, R.M. (2003). The benefits of being present:

mindfulness and its role in psychological well-being. J Pers Soc
Psychol, 84, 822-848.
Brown, K.W., Ryan, R.M., & Creswell, J.D. (2007). Mindfulness:
Theoretical foundations and evidence for its salutary effects.
Psychological Inquiry, 18, 211-237.
Bruckstein, D.C. (1999). Effects of acceptance-based and cognitive
behavioral interventions on chronic pain management. Dissertation,
Hofstra University, USA.
Cahn, B.R., & Polich, J. (2006). Meditation states and traits: EEG, ERP,
and neuroimaging studies. Psychological Bulletin, 132, 180–211.
Carlson, L.E., & Garland, S.N. (2005). Impact of mindfulness-based stress
reduction (MBSR) on sleep, mood, stress and fatigue symptoms in
cancer outpatients. International Journal of Behavioral Medicine.
12, 278–285.
Cohen-Katz, J., Wileys, S.D., Capuano, T., Bakers, D.M., Kimmel, S., &
Shapiro, S. (2005). The effects of mindfulness-based stress reduction
on nurse stress and burnout, Part II: A quantitative and qualitative
study. Holistic Nursing Practice, 19, 26-35.
Creswell, J.D., Myers, H.F., Cole, S.W. (2009). Mindfulness meditation
training effects on CD4+ T lymphocytes in HIV-1 infected adults: a
small randomized controlled trial. Brain Behav Immun, 23(2),
184-188.
Davidson, R.J., Jackson, D.C., Kalin, N.H. (2000). Emotion, plasticity,
context, and regulation: perspectives from affective neuroscience.
Psychol Bull; 126:890 –909.
Davidson, R.J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller,
D., Santorelli, S.F., Urbanowski, F., Harrington, A., Bonus, K.,
Sheridan, J.F. (2003). Alterations in brain and immune function
produced by mindfulness meditation. Psychosomatic Medicine, 65,
564–570.
Davis, J.M., Fleming, M.F., Bonus, K.A., & Baker, T.B. (2007). A pilot
study on mindfulness based stress reduction for smokers. BMC
Complementry and Alternative Medicine. 7 (2), 212-217.
Deyo, M., Wilson, K. A., Ong, J., & Koopman, C. (2009). Mindfulness
and rumination: Does mindfulness training lead to reductions in the
Mindfulness Based Stress Reduction (MBSR) Program... 223

ruminative thinking associated with depression? Explore, 5,

265–271.
Easterlin, B.L., & Carden˜a, E. (1998). Cognitive and emotional differences
between short- and long-term Vipassana meditators. Imagination,
Cognition, and Personality, 18, 69–81.
Evans, P., Huckelebridge, F., & Clow, A. (2000). Mind, Immunity and
Health: The Science of Psychoneuro-immunology. London: Free
Association Books.
Farb, N.A.S., Segal, Z.V., Mayberg, H., Bean, J., McKeon, D., Fatima, Z.,
Anderson, A.K. (2007). Attending to the present: mindfulness
meditation reveals distinct neural models of self-reference. Soc Cogn
Affect Neurosci, 2, 313–322.
Ferketich, A.K., Schwartzbaum, J.A., Frid, D.J., Moeschberger, M.L. (2000).
Depression as an antecedent to heart disease among women and
men in the NHANES I study. National health and nutrition
examination survey. Arch. Intern. Med., 160, 1261– 1268.
Fresco, D.M., Segal, Z.V., Buis, T., & Kennedy, S. (2007). Relationship of
past treatment decentering and cognitive reactivity to relapse in
major depression. Journal of Consulting and Clinical Psychology,
75, 447–455.
Fries, M. (2009). Mindfulness Based Stress Reduction for the Changing
Work Environment. Journal of Academic and Bussiness Ethics, 2.
Garland, E.L., Gaylord, S.A., Fredrickson, B.L. (2011). Positive Reappraisal
Mediates the Stress-Reductive Effects of Mindfulness: An Upward
Spiral Process. Mindfulness. 2, 59-67.
Garland, E.L., Gaylord, S., & Park, J. (2009). The role of mindfulness in
positive reappraisal. Explore (NY), 5(1), 37–44.
Gilbert, P. (2000). Social Mentalities: Internal ‘social’ conflicts and the
role of inner warmth and compassion in cognitive therapy. In P.
Gilbert, & K. G. Bailey (Eds.) Genes on the couch: Explorations in
evolutionary psychotherapy (p.118–150). Hove: Psychology Press.
Gilbert, P., & Irons, C. (2005). Focused therapies and compassionate
mind training for shame and self attacking. In P. Gilbert (Ed.),
Compassion: Conceptualisations, research and use in
psychotherapy (pp. 263–325). London: Routledge.
224 Mental Health: Risks and Resources

Gilbert, P. & Tirch, D. (2009). Emotional Memory, Mindfulness and

Compassion. In: Didonna, F., editor. Clinical handbook of
mindfulness. New York, NY: Springer.
Goldin, P.R. & Gross, J.J. (2010). Effects of Mindfulness-Based Stress
Reduction (MBSR) on Emotion Regulation in Social Anxiety
Disorder. Emotion; 10(1), 83–91.
Grossman, P., Niemann, L., Schmidt, S., Walach, H. (2004). Mindfulness-
based stress reduction and health benefits. A meta-analysis. Journal
of Psychosomatic Research, 57(1), 35-43.
Gunaratana, H. (2002). Mindfulness in plain English. Somerville, MA:
Wisdom Publications.
Hayes, S.C. (1994). Content, context, and the types of psychological
acceptance. In S. C. Hayes, N. S. Jacobson, V. M. Follette, & M. J.
Dougher (Eds.), Acceptance and change: Content and context in
psychotherapy. Reno, NV: Context Press.
Hayes, S.C., Bond, F.W., Barnes-Holmes, D. and Austin, J., editors (2006).
Acceptance and Mindfulness at Work: Applying Acceptance and
Commitment Therapy and Relational Frame Theory to
Organizational Behavior Management. New York, NY: Haworth.
Ho¨lzel, B.K., Ott, U., Gard, T., Hempel, H., Weygandt, M., Morgen, K.,
Vaitl, D. (2007). Investigation of mindfulness meditation practitioners
with voxel-based morphometry. Soc Cogn Affect Neurosci, 3, 55–61.
Hooker, K.E. & Fodor, I.E. (2008). Teaching Mindfulness to Children.
Gestalt Review, 12(1), 75-91.
Jain, S., Shapiro, S.L., Swanick, S., Roesch, S.C., Mills, P.J., Bell-Schwartz,
G.E. (2007). A randomized controlled trial of mindfulness meditation
versus relaxation training: effects on distress, positive states of
mind, rumination, and distraction. Ann Behav Med. 33, 11–21.
Jam, S., Imani, A.H., Foroughi, M., Alinaghi, S.A.S., Koochak, H.E.,
Mohraz, M. (2010). The Effects of Mindfulness-Based Stress
Reduction (MBSR) Program in Iranian HIV/AIDS Patients: A Pilot
Study. Acta Medica Iranica. 48(2), 101-106.
Jha, A., Krompinger, J., & Baime, M. (2007). Mindfulness training modifies
subsystems of attention. Cognitive, Affective and Behavioral
Neuroscience, 7, 109-19.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for
chronic pain patients based on the practice of mindfulness
Mindfulness Based Stress Reduction (MBSR) Program... 225

meditation: Theoretical considerations and preliminary results.

General Hospital Psychiatry, 4(1), 33–47.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of
your body and mind to face stress, pain, and illness. New York:
Delacorte.
Kabat-Zinn, J. (1998). Meditation. In: Holland JC, eitor. Psycho-oncology.
New York: Oxford University Press, 767–79.
Kabat-Zinn, J. (2003a). Mindfulness-based interventions in context: Past,
present, and future. Clinical Psychology: Science & Practice, 10(2),
144–156.
Kabat-Zinn, J. (2003b). Mindfulness-based stress reduction (MBSR).
Constructiv Hum Sci., 8, 73–107.
Kabat-Zinn, J., & Chapman-Waldrop, A. (1988). Compliance with an
outpatient stress reduction program: Rates and predictors of program
completion. Journal of Behavioral Medicine. 11, 333-352.
Kabat-Zinn, J., Massion, M.D., Kristeller, J., Peterson, L.G., Fletcher, K.E.,
Pbert, L., et al. (1992). Effectiveness of a meditation-based stress
reduction program in the treatment of anxiety disorders. American
Journal of Psychiatry, 149, 936–943.
Kabat-Zinn, J., Wheeler, E., Light, T., Skillings, A., Scharf, M. J., Cropley,
T. G., et al. (1998). Influence of a mindfulness meditation-based stress
reduction interventiononrates of skin clearing in patients with
moderate to severe psoriasis undergoing phototherapy (UVB) and
photochemotherapy (PUVA). Psychosomatic Medicine, 60(5),
625–632.
Kauffman, C. (2006). Positive psychology: The science at the heart of
coaching. In D. R. Stober & A. M. Grant (Eds.), Evidence based
coaching handbook: Putting best practices to work for your clients
(pp. 219-253). Hoboken, NJ: John Wiley.
Knapp, P., Beck, A.T. (2008). Cognitive therapy: foundations, conceptual
models, applications and research. Rev Bras Psiquiatr; 30 (Suppl
II): S54-64.
Knowles, P. (2008). What Is Trying to Happen Here? Using Mindfulness
to Enhance the Quality of Patient Encounters. The Permanente
Journal, 12 (2), 55-59.
Koenen, K.C., Lyons M.J., Goldberg J. et al. (2003). Co-twin control
study of relationships among combat exposure, combat-related
226 Mental Health: Risks and Resources

PTSD, and other mental disorders. J. Traumatic Stress, 16, 433–438.

Kristeller, J.L., & Hallett, C. (1999). An exploratory study of a meditation-
based intervention for binge eating disorder. Journal of Health
Psychology, 4(3), 357–363.
Krumholz, H.M., Butler, J., & Miller, J. (1998). Prognostic importance of
emotional support for elderly patients hospitalized with heart failure.
Circulation, 97, 958-964.
Lazar, S.W., Kerr, C.E., Wasserman, R.H., et al. (2005). Meditation
experience is associated with increased cortical thickness.
Neuroreport; 16(17), 1893–7.
Lett, H.S., Blumenthal, J.A., Babyak, M.A., Sherwood, A., Strauman, T.,
Robins, C., Newman, M.F. (2004). Depression as a risk factor for
coronary artery disease: evidence, mechanisms, and treatment.
Psychosom. Med., 66, 305–315.
Ludwig, D.S. & Kabat-Zinn, J. (2008). Mindfulness in Medicine. JAMA.
300(11), 1350-1352.
Miller, J.J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up
and clinical implications of a mindfulness meditation-based stress
reduction intervention in the treatment of anxiety disorders. General
Hospital Psychiatry, 17(3), 192–200.
Mooy, J.M., Vries, H., Grootenhuis, P.A., Bouter, L.M., Heine, R.J. (2000).
Major stressful life events in relation to prevalence of undetected
type 2 diabetes: the Hoorn Study. Diabetes Care; 23, 197-201.
Morone, N.E., Greco, C.M. & Weiner, D.K. (2008). Mindfulness meditation
for the treatment of chronic low back pain in older adults: A
randomized controlled pilot study. Pain, 134(3), 310–319.
Nehra, D.K., Nehra, S. & Dogra, R. (2012). Positive Psychological
Functioning with Mindfulness Based Stress Reduction (MBSR)
Program. In Yadava A, Hooda D, Sharma NR: Biopsychosocial Issues
in Positive Health. Global Vision Publishing House, Delhi.
Nehra, D.K., Sharma, N.R., Kumar, P. & Nehra, S. (2012). Efficacy of MBSR
program in treating Depression, Anxiety and Perceived Stress in
Coronary Heart Disease Patients. Indian Journal of Positive
Psychology, 3(1), 91-95.
Niazi, A.K., & Niazi, S.K. (2011). Mindfulness-based stress reduction: a
non-pharmacological approach for chronic illnesses. North American
Journal of Medical Sciences, 3(1), 20-23.
Mindfulness Based Stress Reduction (MBSR) Program... 227

Nyklíèek, I. & Kuijpers, K.F. (2008). Effects of Mindfulness-Based Stress

Reduction Intervention on Psychological Well-being and Quality of
Life: Is Increased Mindfulness Indeed the Mechanism? Ann Behav
Med. June; 35(3), 331–340.
Ong, J.C., Shapiro, S.L., Manber, R. (2008). Combining Mindfulness
Meditation with Cognitive Behavior Therapy for Insomnia: A
Treatment-Development Study. Behavior Therapy. 39, 171-182.
Pagnoni, G., Cekic, M. (2007). Age effects on gray matter volume and
attentional performance in Zen meditation. Neurobiol Aging; 28,
1623–7.
Praissman, S. (2008). Mindfulness-based stress reduction: a literature
review and clinician’s guide. J Am Acad Nurse Pract 20, 212–216.
Proulx, K. (2003). Integrating mindfulness based stress reduction. Holistic
Nursing Practice. 17(4), 201-8.
Reibel, D., Greeson, J., Brainard, G., & Rosenzweig, S. (2001). Mindfulness
based stress reduction and health related quality of life in a
heterogeneous patient population. General Hospital Psychiatry, 23,
183–192.
Rosamond, W., Flegal, K., Furie, K., Go, A., Greenlund, K., Haase, N.
(2008). Heart disease and stroke statistics—2008 update: a report
from the American Heart Association Statistics Committee and Stroke
Statistics Subcommittee. Circulation. 117, 25-146.
Rosenberg, L. (1998). Breath by breath: The liberating practice of insight
liberation (with D. Guy). Boston, MA: Shambhala.
Roth, B., Robbins, D. (2004). Mindfulness-based stress reduction and
health-related quality of life: findings from a bilingual inner-city
patient population. Psychosom Med. 66, 113–123.
Salmon, P.G., Santorelli, S.F., & Kabat-Zinn, J. (1998). Intervention
elements promoting adherence to mindfulnessbased stress reduction
programs in the clinical behavioural medicine setting. In S.A.
Shumacher, E.B. Schron, J.K. Ockene, & W.L. McBee (Eds),
Handbook of health behaviour change (2nd ed., pp. 239–68).
NewYork: Springer.
Saravay, S.M. (1996). Psychiatric interventions in the medically ill.
Psychiatr Clin North Am. 19, 467-479.
Scheier, M.F. & Carver, C.S. (1985). Optimism, coping, and health:
Assessment and implications of generalized outcome expectancies.
Health Psychology, 4, 219-247.
228 Mental Health: Risks and Resources

Scheier, M.F. & Carver, C.S. (2001). Adapting to cancer: The importance
of hope and purpose. In A. Baum & B. L. Andersen (Eds.),
Psychosocial interventions for cancer (pp. 15-36). Washington, DC:
American Psychological Association.
Schneider, R.H., Staggers, F., Alexander, C.N. (1995) A Randomized
Controlled Trial of Stress Reduction for Hypertension in Older
African Americans. Hypertension; 26, 820.
Segal, Z.V., Teasdale, J.D., & Williams, J.M.G. (2004). Mindfulness-based
cognitive therapy. In S.C. Hayes, V.M. Follette, & M.M. Linehan
(Eds.), Mindfulness and Acceptance: Expanding the Cognitive-
Behavioral Tradition (pp. 45-65). New York: The Guilford Press.
Segal, Z.V., Williams, J.M., & Teasdale, J.D. (2002). Mindfulness-based
cognitive therapy for depression: A new approach to preventing
relapse. New York: The Guilford Press.
Shapiro, P.A. (2005). Textbook of Psychosomatic Medicine. The American
Psychiatric Publication inc, Washington, USA.
Shapiro, S.L., Astin, J.A., Bishop, S.R., Cordova, M. (2005). Mindfulness
based stress reduction for health care professionals: results from a
randomized trial. Int. J. Stress Management; 12(2), 164–76.
Shapiro, S. L., Bootzin, R. R., Figueredo, A. J., Lopez, A. M., & Schwartz,
G. E. (2003). The efficacy of mindfulness-based stress reduction in
the treatment of sleep disturbance in women with breast cancer: An
exploratory study. Journal of Psychosomatic Research, 54, 85–91.
Shapiro, S.L., Brown, K.W., Biegel, G.M. (2007). Teaching Self-Care to
Caregivers: Effects of Mindfulness-Based Stress Reduction on the
Mental Health of Therapists in Training. Training and Education
in Professional Psychology. 1(2), 105–115.
Shapiro, S.L., Carlson, L.E., Astin, J.A., & Freedman, B. (2006).
Mechanisms of mindfulness. Journal of Clinical Psychology, 62,
373–386.
Siegel, D.J. (2007). The mindful brain: Reflection and attunement in the
cultivation of well-being. New York, NY: W. W. Norton & Company.
Smith, J. (1999). Radiant mind: Essential Buddhist teachings and texts.
New York: Riverhead Books.
Speca, M., Carlson, L.E., Goodey, E., & Angen, M. (2000). A randomized,
wait-list controlled clinical trial: The effect of a mindfulness
Mindfulness Based Stress Reduction (MBSR) Program... 229

meditation-based stress reduction program on mood and symptoms

of stress in cancer outpatients. Psychosomatic Medicine, 62(5),
613–622.
Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., &
Segal, Z. V. (2002). Metacognitive awareness and prevention of
relapse in depression: Empirical evidence. Journal of Consulting
and Clinical Psychology, 70, 275–287.
Teasdale, J.D., Segal, Z., & Williams, J.M. (1995). How does cognitive
therapy prevent depressive relapse and why should attentional
control (mindfulness) training help? Behaviour Research & Therapy,
33(1), 25–39.
Thera, N. (1962). The heart of Buddhist meditation. New York: Weiser.
Tyrka, A.R., Mello, A.F., Mellow, M.F., Gagne, G.G., Grover, K.E., Anderson,
G.M., Price, L.H., Carpenter, L.L. (2006) Temperament and
hypothalamic-pituitary-adrenal axis function in healthy adults.
Psychoneuroendocrinology, 31, 1036 – 1045.
Vallejo, Z. & Amaro, H. (2009).Adaptation of Mindfulness-Based Stress
Reduction Program for Addiction Relapse Prevention. The
Humanistic Psychologist, 37, 192–206.
van Son, J., Nyklíèek, I., Pop, V.J.M., Pouwer, F. (2011) Testing the
effectiveness of a mindfulness-based intervention to reduce
emotional distress in outpatients with diabetes (DiaMind): design
of a randomized controlled trial. BMC Public Health, 11:131.
Wall, R.B. (2005). Tai Chi and Mindfulness-Based Stress Reducation in a
Boston Public Middle School. J Pediatr Health Care, 19, 230-237.
Weiss, M., Nordlie, J.W., & Siegel, E.P. (2005). Mindfulness-Based Stress
Reduction as an Adjunct to Outpatient Psychotherapy,
Psychotherapy and Psychosomatics, 74, 108-112.
Weissbecker, I., Salmon, P., Studts, J. L., Floyd, A. R., Dedert, E. A., &
Sephton, S. E. (2002). Mindfulness-based stress reduction and sense
of coherence among women with fibromyalgia. Journal of Clinical
Psychology in Medical Settings, 9(4), 297–307.
Zautra, A.J., Davis, M.C., Reich, J.W., Nicassario, P., Tennen, H., Finan,
P., Kratz, A., Parrish, B., Irwin, M.R. (2008). Comparison of cognitive
behavioral and mindfulness meditation interventions on adaptation
 230 Mental Health: Risks and Resources

to rheumatoid arthritis for patients with and without history of

recurrent depression. Journal of Consulting and Clinical
Psychology, 76, 408–421.
Zylowska, L., Ackerman, D.L., Yang, M.H., Futrell, J.L., Horton, N.L.,
Hale, T.S., Pataki, C., Smalley, S.L. (2008). Mindfulness meditation
training in adults and adolescents with ADHD: a feasibility study.
Journal of Attention Disorders, 11, 737–746.

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