ORIGINAL ARTICLE

Change in Stress Levels Following

Mindfulness-based Stress Reduction in a
Therapeutic Community
*Marianne T. Marcus, EdD, RN, FAAN, †P. Michele Fine, MEd, BBA,
‡F. Gerard Moeller, MD, *Myrna M. Khan, PhD, MBA, *Kathleen Pitts, MSN,
§Paul R. Swank, PhD, and *Patricia Liehr, PhD, RN

Abstract
Objectives: This pilot was designed to study identified changes in the psychologic and physiological stress
response of individuals who participated in a Mindfulness-Based Stress Reduction intervention while in
treatment of substance abuse in a therapeutic community.
Methods: Twenty-one participants in a residential therapeutic community received the intervention, which
consisted of training in 5 mindfulness practices. Stress response was assessed by measuring awakening
salivary cortisol and the Perceived Stress Scale (PSS) pre- and post-intervention.
Results: Awakening salivary cortisol levels were significantly lower (P < 0.0001) following the intervention.
Although there was a decrease in self reported stress between the baseline measurement and the
post-intervention measurement, the change in the PSS was not statistically significant (P = 0.65).
Conclusions: These results suggest that a Mindfulness-Based Stress Reduction intervention may influence the
physiological response to stress for individuals in a therapeutic community. The results also support the use
of salivary cortisol as an indicator of the stress response in this setting. Future studies are needed to
determine the value of this intervention as an adjunct to therapeutic community treatment.
Key Words: therapeutic community treatment, Mindfulness-Based Stress Reduction, meditation, salivary
cortisol.
Addict Disord Their Treatment 2003;2:63–68. Copyright © 2003 Lippincott Williams & Wilkins, Inc.

Introduction aim of TCs is to bring about this change by developing a

Therapeutic communities (TCs) provide a unique ap-
proach to treatment of substance use disorders. From the
TC perspective, drug use is a disorder of the whole person,
affecting social, cognitive, and behavioral functions. The
community is the “primary therapist” providing a highly
structured social learning environment to encourage posi-
tive changes in behavior, attitudes, and self-image, hence, a
“global change in the individual.”1–3 Studies have shown
that individuals who completed TC treatment had lower
levels of substance use, criminal behavior, unemployment,
and depression than they had prior to treatment.4–8 The
From *The University of Texas Health Science Center at Houston,
School of Nursing, †Mindful Living, Houston, Texas, ‡The University of
Texas Health Science Center at Houston, Department of Psychiatry and
Behavioral Sciences, and §The University of Texas Health Science Center
at Houston, Medical School.
Address reprint requests to Marianne T. Marcus, EdD, RN, FAAN, The
University of Texas Health Science Center at Houston, School of Nursing,
1100 Holcombe Blvd., Room 5.516, Houston, TX 77030. E-mail:
Marianne.T.Marcus@uth.tmc.edu.
positive work ethic, personal accountability, economic
self-reliance, acceptance of family responsibility, commu-
nity involvement, and concern for others.2,9 In addition to
the intense environment of behavior modification, the TC
approach involves encounter groups, occupational train-
ing, and the use of recovering addicts as co-therapists.10
Passage through the TC recovery program occurs in stages:
induction or orientation; primary treatment or “first
phase,” and “reentry” or return to the community. A point
system is used to designate accomplishments necessary to
move through the stages to reentry and graduation. The
dropout rate in TCs is significant, often as high as 50%.11
Attrition is highest within the first 30 to 60 days after
admission.11,12
For individuals whose lives were characterized by impul-
siveness and lack of self control, TC treatment is restrictive
and implicitly stressful. Research has shown that stress is
associated with initial acquisition of substance use behav-
iors as well as with relapse or return to use following
abstinence.13–20 According to a review by Sarnyai,21 stud-
ies of the relationship between the stress response and

Addictive Disorders & Their Treatment Vol 2, No 3, 2003 63–68 63

64
drugs of abuse have yielded 3 main findings: (1) activation
of the hypothalamic-pituitary-adrenocorticol (HPA) stress
axis occurs with acute administration of drugs of abuse22;
(2) drug withdrawal syndrome resembles the physiological
stress response with changes in corticotropin-releasing fac-
tor (CRF), the stress neuropeptide23; and (3) stress is
linked to increased drug-taking and relapse in humans.13
While the exact mechanisms of the stress response in drug
use remain to be explicated, individuals in recovery can
benefit from the acquisition of stress management
skills.17,19,24–26 Successful outcomes for TC treatment are
highly correlated with time in treatment.2,12,27 Interven-
tions to reduce the stress associated with the strict behav-
ioral expectations of the TC might assist clients to remain
engaged in treatment long enough for the full benefit of
the modality to take effect and reduce the likelihood of
future relapse.
A number of studies conducted over the last 20 years
document the promise of a Mindfulness-Based Stress Re-
duction (MBSR) program28 in reducing stress in a variety
of clinical and non-clinical populations.29 MBSR is a spe-
cific meditation program founded in 1979 by Jon
Kabat-Zinn at the University of Massachusetts.30 The
8-week program is designed to help participants foster the
skill of bringing non-judgmental attention to their
present-moment experience. No physiological measures of
the stress response were used in the 13 MBSR studies
published between 1985 and 2000.29 None of the studies
were conducted with clients in recovery from substance use
disorders. Our prior study demonstrates the effects of
MBSR in (1) reducing psychologic problems and psycho-
pathology, and (2) increasing positive coping styles, in per-
sons recovering from addictive disorders in a TC.31 We are
interested in the psycho-physiological stress response of
these clients to a program of MBSR.
Cortisol has been used as a physiological measure of the
stress response in humans. Salivary cortisol, a noninvasive
technique, has been used in studies of stress in a wide
variety of circumstances.32–44 Repeated early morning sali-
vary cortisol determinations can be a stable and reliable
biologic marker of the stress response.35,45 Salivary cortisol
measurement is ideally suited to the structured environ-
ment of the residential TC where hours of awakening are
prescribed. Moreover, salivary cortisol is superior to serum
cortisol in a population where venipuncture could trigger
stimuli associated with drug use. The purpose of this pilot
study is to determine changes in salivary cortisol levels
and subjective self-report of stress following an MBSR
intervention among individuals in recovery in a residen-
tial TC.
Methods
This repeated measures pilot study was designed to as-
sess changes in stress over time for people in a TC
who participated in an 8-week mindfulness meditation
stress-reduction intervention. Stress was measured with
Marcus et al
salivary cortisol and subjective self-report at baseline and 8
weeks after participation in the MBSR intervention. The
Perceived Stress Scale (PSS) was used as the self-report
stress measure. This study was approved by the Committee
for the Protection of Human Subjects at the University of
Texas Health Science Center.
The sample for this study was recruited from Cenikor, a
TC in Houston, Texas, which is a member of the Thera-
peutic Communities of America and operates by their stan-
dards. The average monthly census at this facility, 1 of 4 in
the Cenikor network, is 150 participants who are in vary-
ing stages of recovery. The usual course of recovery at
Cenikor is 30 months. Subjects who had been in residence
more than 30 days were recruited for the study to avoid the
first-month period of highest attrition. Staff members in-
vited the participation of TC residents. Those residents
who expressed an interest in participation were then ap-
proached by the principal investigator, who has had a long
time relationship with Cenikor.46 Interested persons were
gathered in one room, where the investigators summarized
study components and answered questions. After answer-
ing residents’ questions, individual consent forms were
signed and a data collection and intervention schedule was
formulated.
Mindfulness Meditation Intervention
The MBSR intervention was conducted with a group of
21 subjects each Saturday morning for a total of 8 ses-
sions. Three subjects left Cenikor during the 8 weeks,
thereby dropping out of the study. During each session,
subjects spent 2 1⁄2 hours in class, learning 5 mindfulness
practices: a guided meditation focusing on bodily sensa-
tions and the breath, sitting mindfulness meditation,
mindful Hatha yoga, walking meditation, and eating medi-
tation. Each session included discussion of mindfulness
and its application to everyday life, and study participants
were asked to describe their experiences during the previ-
ous week. In addition to attending class, each subject was
asked to practice mindfulness activities independently from
45 to 60 minutes, at least 6 days/week. This practice was
supported with audiotapes and workbooks, prepared by
the mindfulness-trained psychotherapist who conducted
the intervention. No record was kept of subjects’ indepen-
dent practice of mindfulness; however, class discussions
indicated that some participants did engage in the practice
while others were less involved.
Salivary Cortisol
Salivary samples were obtained at 0, 30, 45, and 60 min-
utes after awakening on the first morning pre-intervention.
This procedure was repeated post-intervention. Samples
were obtained using the Salivette sampling device (Sarstedt
Inc.). Subjects were instructed not to brush their teeth, eat,
or smoke prior to collection of saliva samples to avoid the
confounding effects of these activities.47 Saliva collection
Change in Stress Levels Following Mindfulness-Based Stress Reduction
using the Salivette sampling device was carried out accord-
ing to the following instructions: “Remove the cotton wool
swab from the suspended insert of the Salivette and chew
for 30 to 45 seconds. Afterward, replace the cotton wool
swab in the suspended insert and firmly close the Salivette
using the stopper.” This methodology normally results in a
saliva yield of approximately 0.7 mL. Recovery of saliva
from the cotton wool swab was carried out by centrifuga-
tion of the Salivette at 1,000 × g for 2 minutes. The
centrifugation procedure forces any mucous material or
solid substances into the conical base of the Salivette tube.
These methods have been used previously to collect salivary
cortisol and examine the effect of stress on cortisol lev-
els.48,49 Samples were transferred on dry ice to the Neu-
robehavioral Research Laboratory, where they were stored
at −80°C until assay. Cortisol assays were performed using
Cortisol 125I RIA kits (ICN Diagnostics Inc.) as described
below:
3 × 25 µL of standards (0, 0.125, 0.375, 1.25, 3.75, 12.5
µg/dl) and 3 × 200 µL of each of the salivary samples was
added separately into cortisol-antibody coated tubes supplied
in the RIA kit. To the standards, 200 µL of phosphate buff-
ered saline (pH 7.5) was added and 25 µL of zero standard was
added to the sample tubes, to equilibrate volumes in all tubes.
To each tube 1.0 mL of labeled [125I]-cortisol was added and
vortexed. All tubes were then incubated at 37°C for 45 min-
utes. At the end of the incubation, contents in the tubes were
decanted to separate antibody-bound tracer (on tube wall)
from free tracer in solution.
Bound [125I]-cortisol in the tubes was counted in a
Gamma counter and unknown concentrations of the
samples were determined by plotting a standard curve us-
ing the known standard concentrations. The intra- and
inter-assay variabilities were 7.0% and 7.9%, respectively.
Perceived Stress Scale (PSS)
The Perceived Stress Scale (PSS) measures the degree to
which situations in one’s life are appraised as stressful. The
PSS is a 10-item measure,50 which asks subjects to rate the
extent to which they have felt their life to be stressful (ie,
unpredictable, uncontrollable, overloading) during the last
week (0 ⳱ never; 4 ⳱ very often). The PSS has acceptable
internal consistency reliability (alpha ⳱ 0.78) and has
demonstrated moderate correlations with other measures
of appraised stress.51
Analysis
Descriptive statistics were used to evaluate characteristics of
this therapeutic community sample. The Paired t test was
used to determine change in self-reported stress scores. A
mixed model repeated measures analysis of variance
(ANOVA) was used to examine changes in salivary cortisol
over time. There was insufficient saliva in 4 of the samples.
The total cortisol concentration over 45 minutes (4
samples, 15 minutes apart) in 12 subjects having complete
65
data at baseline and at the end of the intervention was
calculated as area under the curve (AUC) using the trap-
ezoid method.52
Results
Most of the participants in the study were male, the ma-
jority were white, and under 30% had attended college
(Table 1). The average age was 33.4 years, with a range
from 21 to 51.
Although there was a decrease in self reported stress
(PSS) over time [average PSS was 18.6 (4.0) at baseline and
17.8 (±7.0) following the intervention], the change was
not statistically significant (P ⳱ 0.65, effect size measured
by Cohen’s d ⳱ 0.44 relative to the pretest standard de-
viation). See Table 2.
Factors in the mixed models analysis of the repeated
observations for cortisol were day of testing (pre versus
post) and time (0, 30, 45, and 60 minutes after awaken-
ing). The model random parameters were the pooled vari-
ances for each day and the covariance between days plus
the correlation between assessments within the same day,
that is, a first order autoregressive model within each day.
Examination of the fixed effects of the model indicated a
significant change over time within each day, F(3,45) ⳱
39.90; P < 0.0001, but also a day and time interaction,
F(3,39) ⳱ 25.70; P < .0001, such that the increase in
cortisol on awakening post-intervention was less than the
increase prior to the intervention. At pretest, the increase in
level from 0 to 30 minutes was 0.32 compared with 0.05
post-intervention, a 1.43 standard deviation effect.
Another means of comparing cortisol levels over time is
to use area under the curve method. The mean and stan-
dard deviation for AUC changed from 1.246 ± 0.445 at
baseline to 0.958 ± 0.442 at the end of intervention. A paired
t test showed a significant difference between baseline and
Table 1. Descriptive statistics (n ⳱ 21)
Gender %
Male 85.7
Female 14.3
Ethnicity
African American 38.1
Latino 4.8
White 52.3
Other 4.8
Highest grade completed
Grade 1–12 71.4
College 13–16 23.8
College 17–20 4.8
Age 33.4 (±8.8)
Range 21–51
66
Table 2. Perceived stress scores
Perceived stress scores Mean
Pre- 18.6
Post- 17.8
Paired t-test, P ⳱ 0.6463
end of intervention AUC (t ⳱ 2.424, df ⳱ 11, P ⳱
0.0338, Cohen’s d ⳱0.65). (See Fig. 1).
Discussion
The primary aims of this pilot study were to identify
changes in physiological and psychologic stress in a group
of individuals who received an 8-week program of MBSR
as an adjunct to TC treatment of substance use disor-
ders. The results suggest that MBSR may influence the
physiological response to stress as indicated by a signifi-
cant difference in salivary cortisol levels from pre- to
post-intervention. While the scores on the measure of psy-
chologic stress, the PSS, moved in the right direction, the
results were not significant. The first consideration for lack
of significant findings on the PSS is the possibility of a type
II error. The small sample size may have resulted in “no
difference” findings. From another perspective, an expla-
nation for the discrepancy between physiological and psy-
chologic response to stress may be found in the nature of
the intervention itself. Mindfulness practice brings indi-
viduals into greater awareness of their thoughts and feel-
ings, and with this new awareness, subjects may make a
more realistic appraisal of their stress responses. So subjec-
tive stress did not decrease because subjects were learning
to be more aware of stress even though they were physi-
ologically less stressed.
Another view of these findings leads to questions about
the value of self-report instruments, which retrospectively
FIGURE 1. Salivary cortisol day by time.
Marcus et al
SD Median Range N
4.0 18.5 11–26 16
7.0 17.0 4–34 16
query feelings occurring in a previous time-frame. These
“remembered” assessments may not accurately reflect
“state” experiences such as stress, which are constantly
changing in the course of everyday living.53 At the very
least, a better assessment may have been achieved if the
10-item PSS was administered while salivary cortisol was
being collected, with instructions to the subjects to note
stress feelings at that time.
Finally, the pre- and post-intervention PSS scores
showed poor reliability. This low internal consistency
among the questions may also partly explain the small
differences between the pre- and post-scores.
A limitation of the study is the fact that there was no
control group, so the post-intervention reduction in stress
cannot be directly attributed to MBSR but may reflect
further adjustment to TC treatment. Despite this limita-
tion, and that of the small sample size inherent in a pilot
study, we believe the findings provide preliminary support
for a larger study. Future controlled studies should examine
the differences in stress responses of individuals who receive
TC treatment only and those who participate in TC treat-
ment combined with a program of MBSR. The PSS dem-
onstrated poor reliability in this population. We will review
the literature to identify a second measure of appraised
stress to use with the PSS in future studies.
Overall, the results support the use of salivary cortisol as
an indicator of the stress response in this setting. This
information will inform future studies. The study’s
strength is that it is the first of its kind to use salivary
cortisol determination to assess the stress response follow-
ing MBSR in a TC. Future studies are needed to determine
the value of this intervention as an adjunct to TC treat-
ment. Studies are planned to examine the effect of inte-
grating MBSR into the orientation phase of TC treatment
as one of the “rules and tools” of the program and of a
subsequent positive drug-free lifestyle. Stress is an inescap-
able part of life. The ability to self-regulate the physiologi-
cal and psychologic response to stress is key to health.54
MBSR has the potential to increase the cognitive and be-
havioral response repertoire to stress in this vulnerable
population.
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