Clinical Psychology & Psychotherapy

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Page 1 of 41 Clinical Psychology & Psychotherapy

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Abstract
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7 Two studies of a mindfulness training programme are presented. Study 1
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9 reports on a pilot investigation of the impact on wellbeing of the Breathworks
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12 mindfulness-based pain management programme. Significant positive change
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14 was found on self-report measures of depression, outlook, catastrophising,
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and pain self-efficacy in the Intervention Group, but not the Comparison
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19 Group. Particularly large effects were found for pain acceptance. These
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21 results support the short-term efficacy of the Breathworks programme and

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24 reinforce the importance of acceptance for positive outcome with chronic pain
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26 patients. Study 2 investigated alterations in mindfulness following participation
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28 in the Breathworks programme. Subjective and non-subjective measures of
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31 mindfulness were used. Scores on the Mindful Attention Awareness Scale
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33 (MAAS) were significantly higher at Time 2 in the Intervention Group, but not
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35 in the Comparison Group. There was no change on a measure of sustained
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38 attention. Results from an Implicit Association Test (IAT) provided some

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40 support for an increased awareness of positive stimuli, following the
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intervention. These results are discussed with reference to the mechanisms of
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45 mindfulness.
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KEY PRACTITIONER MESSAGE:
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52  Evidence supporting the efficacy of Breathworks for wellbeing
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 MAAS scores improved following mindfulness training
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57  Mindfulness may increase awareness of pleasant affect
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59  No change found on a measure of attention
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 Clinical Psychology & Psychotherapy Page 2 of 41

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During the past twenty years, the literature describing psychological
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6 approaches to chronic pain has been dominated by coping approaches
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8 (Geisser et al., 1999) advocating control of unpleasant thoughts and feelings
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(e.g. cognitive behaviour therapy). More recently, a “third wave” (e.g. Hayes,
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13 2004) of psychological therapies has moved towards acceptance based
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15 approaches which encourage the individual to relinquish the psychological
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18 and emotional struggle with pain, and live a productive, valued life, in its
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20 presence.
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22 Within acceptance based approaches, mindfulness is promoted as a
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25 key component of therapy (e.g. Acceptance and Commitment Therapy: ACT;

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27 Hayes et al., 1999). Mindfulness describes an open and receptive, non-
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judgemental attention to, and awareness of, moment-by-moment experience
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32 (Kabat-Zinn, 1990). Despite ongoing debate within Western academic
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34 literature about the fundamental nature of mindfulness (e.g. Brown et al.,
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37 2008), there is evidence to suggest that the occurrence of mindful states is
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39 related to psychological benefits. For example, recent regression studies
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have demonstrated negative associations between self-reported mindfulness

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44 and indices of pain, distress and disability in cancer and chronic pain patients
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46 (Brown & Ryan, 2003; Carlson & Brown, 2005; McCracken et al., 2007).
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48 Mindfulness is believed to be an inherent capacity of all humans but
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51 the extent to which this capacity is utilised may show great variation between,
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53 and within individuals (Brown & Ryan, 2003). In line with the premise that
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mindfulness can be cultivated, several ancient Buddhist meditation techniques
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58 are designed specifically to facilitate the development of mindfulness (Hahn,
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60 1976). However, only in the past 20 years have techniques for enhancing

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Page 3 of 41 Clinical Psychology & Psychotherapy

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mindfulness been increasingly incorporated into western therapeutic
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6 approaches, including treatments for people with chronic pain.
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8 Of the growing number of therapeutic training programs available,
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Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1982, 1990) is the
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13 most well known and widely researched. Typically, participants attend
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15 between eight and 10 weekly sessions during which they are taught
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18 mindfulness meditation techniques and yoga.
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20 Since the preliminary investigations during the 1980’s (Kabat-Zinn,
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22 1982; Kabat-Zinn et al., 1985; Kabat-Zinn et al., 1987), numerous publications
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25 have provided evidence supporting the efficacy of MBSR for the treatment of
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27 chronic pain (Kaplan et al., 1993; Randolf et al., 1999; Grossman et al., 2007;
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Morone et al., 2008). Outcome measures have included physical symptoms,
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32 mood and functional ability, with maintenance of benefits shown up to three
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34 (Grossman et al., 2007) and four years, post-intervention (Kabat-Zinn et al.,
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37 1987). Two recent review papers reported uncontrolled effect sizes (d)
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39 between .25 and .7 for MBSR studies involving pain patients (Baer, 2003;
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Grossman et al., 2004).

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44 Methodological issues
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46 Although such outcomes are promising, methodological shortcomings
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48 have been identified (e.g. Baer, 2003). For example, until recently, the lack of
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51 valid and reliable measurement tools meant that mindfulness itself was rarely
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53 measured (e.g. Bishop et al., 2004). This problem has interacted with the
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absence of a consensus operational definition of mindfulness: Awareness,
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58 attention and acceptance feature in the majority of definitions, to a greater or
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 Clinical Psychology & Psychotherapy Page 4 of 41

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lesser extent, but the centrality of these components remains contested
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6 (Bishop et al., 2004; Brown & Ryan, 2004; Dimidjian & Linehan, 2003).
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8 The recent proliferation of mindfulness questionnaires reflects a
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concerted effort to address these issues (see Baer et al., 2006). However, this
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13 emphasis on self-report may be ill-advised due to the susceptibility of such
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15 methods to subjective bias such as demand characteristics, placebo effects
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18 and inaccuracy due to post-hoc reprocessing of information (Redelmeier &
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20 Kahneman, 1996).
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22 More specifically, there are particular problems with the subjective
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25 measurement of mindfulness. Accurate self-report is dependent upon

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27 awareness of the attribute considered (Hofman et al., 2005). However,
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awareness itself is a core component of mindfulness, therefore, mindfulness
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32 questionnaires actually test participants’ “awareness of awareness”. This can
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34 confound subjective assessments. For example, less mindful individuals may
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37 overestimate levels of mindfulness due to a lack of awareness of mindful and
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39 mindless states. By contrast, individuals that are more mindful will be, by
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definition, more aware, and therefore more accurate in their estimates.

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44 Consequently, subjective measurements may underestimate any actual
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46 differences in mindfulness and thus undersell the impact of mindfulness
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48 training.
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51 There is, therefore, a need to develop non-subjective (i.e. implicit
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53 and/or objective) tests of mindfulness (particularly the awareness component)
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to validate subjective measures and evaluate mindfulness training (Bishop et
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58 al., 2004; Schmertz et al., 2009). Accordingly, a number of recently published
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Page 5 of 41 Clinical Psychology & Psychotherapy

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papers have included experimental measures to test the impact of
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6 mindfulness training on facets of mindfulness with non-clinical samples.
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8 Thus far, these investigations have primarily focused on the attention
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component, with mixed results. Some studies report enhanced attention
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13 control or regulation (Chambers et al., 2008; Jha et al., 2007; Tang et al.,
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15 2007; Wenk-Sormaz, 2005) and others report no improvements (Anderson et
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18 al., 2007; Ortner et al., 2007). The only study with a clinical sample (McMillan
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20 et al., 2002) found no improvement in attention following MBSR intervention
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22 for individuals with a traumatic brain injury. However, neurological damage
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25 may have caused irrevocable disruption to the attentional networks of these

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27 patients (Anderson et al., 2007),
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Interestingly, although Anderson et al. (2007) found no advantage for
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32 MBSR upon attentional control, they did report changes on an object
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34 recognition measure i.e. a test of non-directed attention, which the authors
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37 equate to present-moment awareness. Moreover, Ortner et al. (2007) found
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39 that mindfulness training produced a reduction in interference by unpleasant
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stimuli on an attention task, in the absence of improved attentional control.

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44 They suggest that mindfulness may enable more rapid disengagement from
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46 emotionally provocative stimuli. This conclusion is consistent with the
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48 hypothesis that mindfulness leads to a broadening of awareness away from a
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51 narrow focus on emotionally salient stimuli, such as pain and perceived threat
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53 (Bradley et al., 2003) towards inclusion of more positive aspects of experience
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(e.g. Melbourne Academic Mindfulness interest Group, 2006). The suggestive
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58 results related to awareness warrant further investigation.
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60 Implicit Measurement of Awareness

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 Clinical Psychology & Psychotherapy Page 6 of 41

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Brown and Ryan (2003) used an implicit test of mindfulness to validate
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6 the Mindful Attention Awareness Scale (MAAS). Based on the premise that
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8 affect can operate outside awareness (Shevrin, 2000; Westen, 1998) they
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investigated the extent to which the MAAS mediated emotional awareness, as
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13 measured by the relationship between implicitly measured affect and self-
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15 report. They used the Implicit Association Test (IAT; Greenwald, et al., 1998)
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18 which is believed to measure automatic associations between categories.
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20 Brown and Ryan (2003) reported a non-significant correlation between implicit
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22 and explicit affect but the relation was mediated by the MAAS for high
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25 scorers. That is, for those with higher MAAS scores there was greater
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27 emotional awareness, supporting the validity of the MAAS with more mindful
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individuals. Of note, the questions on the MAAS are indirect, i.e. they
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32 measure less mindlessness (as opposed to more mindfulness), which may
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34 reduce the confounding problem described above (e.g. Brown & Ryan, 2003;
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37 McCraken et al., 2007).
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39 This effective utilisation of the IAT for measuring affect awareness
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prompted its inclusion in Study 2. The primary assumption of the IAT is that
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44 strongly associated attribute-concept pairs are easier (and thus quicker) to
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46 classify together than more weakly associated pairs (Farnham et al., 1999).
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48 Therefore, faster pairings of self-related words and pleasant affect words
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51 would indicate a more positive self-concept. Research demonstrates a highly
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53 consistent bias for pairing self and positive words quicker than self and
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negative words, known as an IAT effect (Farnham et al., 1999). The larger the
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58 IAT effect, the more positive the self-concept. An individual who is aware of
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Page 7 of 41 Clinical Psychology & Psychotherapy

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IAT effect and self-reported affect. That is, large IAT effects would accompany
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6 higher subjectively reported positive affect.
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8 However, the relationship between explicit measures and IAT results is
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not straightforward (Hoffman et al., 2005). For example, according to a recent
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13 meta-analysis by Hoffman and colleagues (2005), concordance rates are
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15 reduced when personal pronouns (e.g. as me, they, us) are used as target
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18 words. Brown and Ryan (2003) used personal pronouns and constructed a
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20 composite score of explicit affect by subtracting scores from trials involving
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22 unpleasant affect words from scores on trials involving pleasant affect words.
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25 However, there is a substantive body of research that contends that positive

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27 and negative affect are qualitatively distinct phenomena and may not
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represent end points on a single continuum (e.g. Berscheid, 1983; Diener &
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32 Emmons, 1985; Taylor, 1991). Thus, simply subtracting one score from the
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34 other may preclude the identification of post-mindfulness training alterations
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37 that specifically pertain to either positive or negative affect. Given that
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39 mindfulness may differentially enhance awareness of positive aspects of
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experience over more salient negative features (see Ortner et al., 2007)
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44 awareness of positive and negative traits may require separate analyses. In
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46 response to these issues, additional analyses were performed with the IAT
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48 data in Study 2.
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51 The work presented below attempts to build upon these experimental
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53 tests of the individual components of mindfulness and inform our
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understanding of the processes underlying the effectiveness of mindfulness.
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58 However, before investigating these processes it is first necessary to establish
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60 the effectiveness of the mindfulness training programme itself. With these

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 Clinical Psychology & Psychotherapy Page 8 of 41

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goals in mind, we present two studies; Study 1 evaluates the clinical utility of
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6 the mindfulness programme and Study 2 provides subjective and objective
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8 tests of attention and awareness before and after mindfulness training.
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Study 1
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13 Aims and Hypotheses
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15 This study involved a pilot investigation of the effects of the
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18 Breathworks mindfulness-based pain management programme on wellbeing.
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20 Breathworks teaches mindfulness embedded within the Buddhist foundation
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22 of “loving kindness” (see Salzberg, 2002). This is distinct from many Western
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25 mindfulness programmes and is sensitive to the growing concerns about

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27 removing mindfulness from the original ethical framework in which it was
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developed (e.g. Grossman, 2008; Rosch, 2008).
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32 Wellbeing was assessed using questionnaires measuring physical and
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34 psychological functioning, pain-related catastrophising, pain self-efficacy and
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37 pain acceptance, all of which are believed to impact on role adjustment and
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39 disability (e.g. Adams & Williams, 2003; Cohen et. al., 2000; Flor & Turk,
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1988; Turk & Rudy, 1986; Keefe et al., 1997; Nicholas et al., 1992;
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44 McCracken & Eccleston, 2006). Positive change was predicted across time in
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46 the Intervention Group on all measures.
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48 Method
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51 Ethical Approval
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53 Both studies were approved by the Wiltshire Research Ethics
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Committee.
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58 Recruitment
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Page 9 of 41 Clinical Psychology & Psychotherapy

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On registration, students attending the Breathworks Pain Management
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6 Programme provided written consent to participate in research. They
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8 continued to receive medical Treatment As Usual (TAU) throughout the
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duration of the study. Comparison Group participants were recruited from an
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13 out-patient pain clinic in the South West of England and all continued to
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15 receive unstructured pain-control TAU including medication, hydrotherapy,
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18 epidural and monthly peer support. See Figure 1 for details on participant flow
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20 through the study.
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22 Design
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25 A 2 × 2 mixed factors design was employed. The between participants

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27 factor was Group (Intervention Group or Comparison Group) and the within
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participants factor was the Time at which participants were tested; either Pre-
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32 intervention (Time 1) or Post-intervention (Time 2). The dependent measures
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34 were the scores on the well-being measures.
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37 Participants
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39 In total, 33 Intervention Group participants contributed pre- and post-
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intervention questionnaire data. However, Breathworks periodically modified

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44 the self-report battery accounting for the variability in participant numbers for
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46 each measure (see Table 1). The Comparison Group consisted of twenty
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48 participants who contributed pre- and post-intervention wellbeing
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51 questionnaires.
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53 The majority of participants in both the Intervention and Comparison
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Group were white British (95% and 89% respectively) and female (93% and
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58 55% respectively). The mean age was 46.7 years (SD = 11.5) in the
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60 Intervention Group and 48.4 years (SD = 12.3) in the Comparison Group. The

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 Clinical Psychology & Psychotherapy Page 10 of 41

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main causes of pain within the Intervention and Comparison Group were
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6 lower back pain (24% and 45% respectively), arthritis (26% and 20%), sciatic
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8 injury (18% and 10%) and fibromyalgia (18% and 10%). All participants had
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been experiencing pain between one and 15 years, with no significant
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13 differences between groups (Intervention Group: M = 5.64, SD = 2.4;
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15 Comparison Group: M = 7.1, SD = 3.6; p >.05). None of the participants
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18 reported changes to their medication regime over the duration of the study.
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20 Intervention
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22 Breathworks has been in existence since 2001 and there are currently
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25 12 branches throughout the UK. Information about Breathworks is available

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27 from local NHS services including GP surgeries and pain clinics. Self-referrals
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are taken from people with any chronic pain condition. Other than living with
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32 chronic pain, the only prerequisite of the course is full engagement, including
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34 commitment to attend the group meetings and additional daily practice of
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37 between 30 and 45 minutes.
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39 Participants attended weekly group meetings (each lasting 2.5 hours)
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in which they were guided through a progressive experiential exploration of

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44 mindfulness. Topics included breath-awareness, body-scan, mindful
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46 movement, kindly awareness and mindfulness in daily life. These techniques
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48 are fully described in Burch (2008) so brief details only will be provided here.
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51 Breath awareness begins with an inquiry into the full-body experience
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53 of breathing. A four-stage mindfulness of breathing meditation is subsequently
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introduced, which allows the mind to become focused on increasingly subtler
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Page 11 of 41 Clinical Psychology & Psychotherapy

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The body scan practice involves systematically moving awareness
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6 through each part of the body and noticing the presence of sensation in a
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8 detailed and precise way. This enables contact with the actual sensations of
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the body (as opposed to thoughts, ideas or fears about these sensations).
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13 Mindful movement involves bringing awareness to physical activity,
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15 thus allowing movement of the body within the limits of its physical capability.
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18 This is taught by means of a comprehensive sequence of movements based
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20 on yoga and Pilates.
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22 “Kindly awareness” is a meditation practice concerned with the
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25 development of loving kindness. In the practice there are five stages in which
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27 the individual brings a kindly attitude and intention to: 1) themselves; 2) a
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friend; 3) someone in the periphery of the person’s life; 4) someone with
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32 whom there is a difficult relationship; 5) all living things. Throughout each
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34 stage, awareness is brought to bear on shared experience and
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37 connectedness.
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39 Mindfulness in daily life involves bringing awareness to ordinary,
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everyday life, including eating, sleeping and habitual behaviour. Attention is

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44 brought to the patterns of “boom and bust”, i.e. over-activity followed by a
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46 period of recovery and under-activity. These habits are addressed by means
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48 of a systematic, mindful approach to pacing.
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51 Participants were encouraged to develop a daily meditation practice
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53 with audio-recordings for guidance. All participants attended between six and
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ten sessions. Course facilitators were experienced mindfulness practitioners,
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 Clinical Psychology & Psychotherapy Page 12 of 41

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Measures were administered before and after the programme for the
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6 Intervention Group (i.e. between 7 and 11 weeks apart, M = 10.39, SD =
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8 1.09), and at matched intervals for the Comparison Group (M = 10.30, SD =
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1.30).
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13 Wellbeing Measures
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15 The Depression, Anxiety and Positive Outlook Scale (DAPOS; Pincus
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18 et al., 2004) was developed from factor analyses of the Beck Depression
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20 Inventory (BDI; Beck et al., 1961) and the Hospital Anxiety and Depression
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22 Scale (HADS; Zigmond & Snaith, 1983) in order to create a new questionnaire
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25 that captured the strengths, while avoiding the pitfalls of each. The 11-item,
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27 three-factor questionnaire (Depression, Anxiety and Positive Outlook) has
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demonstrated good validity and reliability (Pincus et al., 2004).
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32 The Chronic Pain Acceptance Questionnaire (CPAQ; McCracken et al.,
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34 2004) is a 20-item, two factor (Activity Engagement and Pain Willingness)
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37 questionnaire, adapted through the process of factor analysis from the
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39 original, longer version (Geiser, 1992 - unpublished). The CPAQ has
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demonstrated good internal consistency (between .78-.82), reliability, factor

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44 stability and construct validity (McCracken et al., 2004).
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46 The Pain Self−Efficacy Questionnaire (PSEQ; Nicholas, 1989)
47
48 assesses an individual’s confidence in his/her ability to perform specific
49
50
51 behaviours while experiencing pain. Stability of the factor structure, internal
52
53 consistency, construct validity and test reliability over time have been
54
55
56
demonstrated (see Nicholas, 2007 for review).
57
58 The Pain Catastrophising Scale (PCS; Sullivan et al., 1995) is a 13-
59
60 item Likert-style scale. Good internal consistency and stability of the three

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subscales (Rumination, Magnification and Helplessness) has been reported
4
5
6 (Sullivan et al., 1995; Osman et al., 1997) and replicated with a clinical pain
7
8 sample (Osman et al., 2000).
9
10
11
SF-36 Health Survey (Ware, 1993) is a widely-used measure of
12
13 generic physical and psychological health status and functioning. Good
14
15 psychometric properties have been reported for the two main subscales and
16
17
18 the total score (e.g. Brazier et al.,1992; Jenkinson et al., 1993). To assess
19
20 overall functional disability, the total score was used.
Fo

21
22 Pain scale: Following the guidance of Jenson and Karoly (1992), a 10-
23
24
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25 point rating scale measured the intensity of average pain. The validity of
26
27 numerical scales is evidenced by significant positive correlations with other
28
29
ee

30
measures of pain (e.g. Jensen et al., 1986; 1989).
31
32 Missing Values
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33
34 Missing values were rare, accounting for less than 2% of all data
35
36
37 values and no specific patterns were evident to suggest non-random errors.
ev

38
39 As is customary in the field, missing values were replaced with the individual’s
40
41
iew

mean subscale score (e.g. Gibbons et al., 2004).

42
43
44 Analytic Strategy
45
46 All data sets were initially examined for distribution normality and
47
48 outliers. Parametric tests were used to analyse the wellbeing measures. In
49
50
51 accordance with Huberty and Morris (1989), multiple univariate analyses
52
53 (ANOVAs) were applied to wellbeing questionnaire subscales in preference to
54
55
56
multivariate analyses (MANOVA). This was due to the exploratory nature of
57
58 the research and reflected the research aims of identifying group differences
59
60 on outcome variables rather than identifying outcome variable subsets or

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underlying constructs associated with the results. To protect against type I
4
5
6 error, the p value for statistical significance was set at .01 for all wellbeing
7
8 measures.
9
10
11
Results
12
13 Means and standard deviations for each of the wellbeing
14
15 questionnaires are given in Table 1. A 2 (Group: Intervention versus
16
17
18 Comparison) × 2 (Time: 1 versus 2) ANOVA with repeated measures on the
19
20 second factor was conducted upon the scores for each of the questionnaire
Fo

21
22 scales and subscales. Results are reported in Table 2, including the F value
23
24
and effect size (partial Eta squared: 2p). At Time 1, there were no significant
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25
26
27 differences between the Intervention and Comparison Group on any of the
28
29
ee

30
indices.
31
32 Inspection of the means in Table 1 indicates that positive change
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33
34 occurred on all wellbeing measures in the Intervention Group. In addition,
35
36
37 statistically significant interactions (p<.01) between Group and Time were
ev

38
39 found on the Depression and Positive Outlook subscales of the DAPOS, the
40
41
iew

Activity Engagement subscale and total score of the CPAQ, and the
42
43
44 Magnification subscale of the PCS. Analysis of the simple effects indicated
45
46 that these interactions were due to positive change across time in the
47
48 Intervention Group but not the Comparison Group.
49
50
51 Interactions on the Willingness subscale of the CPAQ, the PSEQ and
52
53 the PCS Rumination and Helplessness subscales were marginally significant
54
55
56
(.01 < p < .07). Planned comparisons indicated that changes in scores from
57
58 Time 1 to Time 2 occurred in the Intervention Group but not the Comparison
59
60 Group.

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Medium to large effect sizes (.08 < 2p < .42) were found for all
4
5
6 significant results, with a particularly large effect associated with the change in
7
8 CPAQ total score in the Intervention Group.
9
10
11
The changes across time on the Anxiety subscale of the DAPOS and
12
13 the Pain Intensity scale were non-significant. There was a main effect of time
14
15 on the SF-36 due to changes in both groups.
16
17
18 Discussion
19
20 This is the first quantitative evaluation of the Breathworks pain
Fo

21
22 management programme, and evidence regarding the immediate effects on
23
24
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25 subjective wellbeing is provided. In line with the hypotheses, significant

26
27 interactions were found between Group and Time on measures of depression,
28
29
ee

30
positive outlook, pain acceptance and pain catastrophising. These interactions
31
32 reflected greater changes over time within the Intervention Group than in the
rR

33
34 Comparison Group. Marginally significant interactions (.01< p <.07) were
35
36
37 found on indices of willingness, pain self-efficacy, rumination and
ev

38
39 helplessness. Once again, improvements over time were greater for the
40
41
iew

Intervention Group than for the Comparison group. Moreover, effect sizes
42
43
44 were medium to large on all significant indices.
45
46 These findings are consistent with the growing body of literature on the
47
48 efficacy of mindfulness-based interventions for chronic pain and, given the
49
50
51 importance of wellbeing factors in the functional adjustment of patients
52
53 (Adams & Williams, 2003; Cohen et. al., 2000; Flor & Turk, 1988; Turk &
54
55
56
Rudy, 1986; Keefe et al., 1997; Nicholas et al., 1992; McCracken & Eccleston,
57
58 2006), these outcomes are greatly encouraging.
59
60

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 Clinical Psychology & Psychotherapy Page 16 of 41

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As predicted, scores for the SF-36 increased over time in the
4
5
6 Intervention Group. However, there was a similar improvement over time in
7
8 the control group precluding further conclusions on functional outcome. The
9
10
11
null result on the DAPOS Anxiety subscale is difficult to explain. However,
12
13 relative to other mindfulness-based interventions, the Breathworks course
14
15 involves less direct exposure work, the process through which anxiety may be
16
17
18 optimally reduced (e.g. Kabat-Zinn, 1982; 1992).
19
20 There was no change across time on the Pain Intensity scale, which is
Fo

21
22 surprising given the multifaceted nature of pain and the interactions between
23
24
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25 cognitive and emotional factors and the subjective experience of pain (i.e.
26
27 Gate Control Theory: Melzack & Casey, 1968; Melzack & Wall, 1965).
28
29
ee

30
However, this finding most likely reflects the acceptance ethos of the
31
32 Breathworks programme and the absence of direct attempts to reduce pain.
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33
34 Improved wellbeing without pain reduction reinforces the importance of pain
35
36
37 acceptance for clinical outcome. This is reinforced by the relatively large effect
ev

38
39 size found on the total score of the CPAQ (2p = .42). This result is not
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surprising given that acceptance is frequently proposed as a key mechanism

42
43
44 of action in mindfulness (e.g. Brown & Ryan, 2003; Bishop et al., 2004).
45
46 Study 2
47
48 Aims and hypotheses
49
50
51 The aim of Study 2 was to investigate the impact of the Breathworks
52
53 programme on mindfulness itself, with specific focus on two core components
54
55
56
- attention and awareness (Brown & Ryan, 2003). Given the potential biases
57
58 inherent in self-report, and the need to assess the individual components of
59
60 mindfulness separately (e.g. Brown et al., 2008; Leary & Tate, 2008), multiple

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Page 17 of 41 Clinical Psychology & Psychotherapy

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methods of measurement were employed. This is the first study involving a
4
5
6 chronic pain sample in which core components of mindfulness have been
7
8 experimentally assessed, in addition to self-report.
9
10
11
Post-intervention changes reflecting improved mindfulness were
12
13 expected in the Intervention Group but not in the Comparison Group on all
14
15 measures, across time. Furthermore, given that mindfulness may free up
16
17
18 resources for processing positive aspects of experience (e.g. Ortner et al.,
19
20 2007) a greater improvement was anticipated in awareness of pleasant stimuli
Fo

21
22 rather than unpleasant stimuli.
23
24
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25 Method
26
27 Recruitment
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29
ee

30
Recruitment methods were identical to Study 1.
31
32 Participants
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34 Of the 33 Breathworks students who participated in Study 1, a
35
36
37 subgroup of 12 volunteered to complete additional mindfulness measures.
ev

38
39 This subgroup was comparable to the group as a whole, in terms of
40
41
iew

demographic variables, pain indices and outcome wellbeing measures.

42
43
44 Comparison Group participants for both studies were the same.
45
46 However, due to illness, Study 2 data were unobtainable from two individuals
47
48 at Time 2, leaving 18 complete data sets.
49
50
51 Design
52
53 The same 2 × 2 mixed factors design from Study 1 was used. The
54
55
56
score on the MAAS was one dependent measure. Performance on the
57
58 Continuous Performance Task was measured using the proportion of hits and
59
60 the proportion of false alarms and standard measures of sensitivity (d’) and

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 Clinical Psychology & Psychotherapy Page 18 of 41

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bias (C) were computed. Explicit affect was measured using the subjective
4
5
6 ratings of affect and implicit affect was assessed using the IAT effect (see
7
8 below for further details).
9
10
11
Procedure
12
13 The time of day at which mindfulness tests were administered was
14
15 approximately equivalent (within one hour) on both testing occasions to
16
17
18 minimise the impact of medication and diurnal fluctuation in pain intensity
19
20 (Folkard et al., 1976; Jamison & Brown, 1991). Mindfulness measures were
Fo

21
22 completed in a quiet room, with the researcher present, who read aloud
23
24
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25 standardised instructions. Completion of the measures took approximately 30

26
27 minutes, with breaks as required.
28
29
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Measures
30
31
32 The Mindful Attention Awareness Scale (MAAS, Brown & Ryan, 2003),
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33
34 is a 15-item, single factor, indirect self-report measure of emotional
35
36
37 awareness and attention. Good psychometric properties reported in the
ev

38
39 original paper (Brown & Ryan, 2003) have been replicated with chronic pain
40
41
iew

patients (McCracken & Thompson, 2009), cancer patients (Carlson & Brown,
42
43
44 2005) and student samples (MacKillop & Anderson, 2007), and incremental
45
46 validity has been demonstrated (Zvolensky et al., 2006). Moreover, MAAS
47
48 scores were recently shown to correlate negatively with attention lapses as
49
50
51 measured by a Continuous Performance Task (Schmertz et al., 2009).
52
53 A Continuous Performance Task (CPT) was created to measure
54
55
56
sustained and focused attention. The standard CPT was modified for use with
57
58 adults to include a measure of response inhibition (Epstein et al., 1998). Four
59
60 hundred stimuli (in the form of uppercase letters) were flashed on to the

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Page 19 of 41 Clinical Psychology & Psychotherapy

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centre of a computer screen at the rate of one per 130 milliseconds, with 600
4
5
6 milliseconds between letters (Klee & Garfinkel, 1983). Participants were
7
8 required to press the space bar immediately following presentation of any
9
10
11
letter except an X and inhibit responding on presentation of an X. The letter X
12
13 constituted 10% of stimulus presentations.
14
15 A computerised Implicit Association Test (IAT) was constructed to
16
17
18 measure automatic associations between self and affective states. The
19
20 content and format of the IAT were identical to that used by Brown and Ryan
Fo

21
22 (2003) and the reader is referred to that paper for further details. The IAT
23
24
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25 required participants to decide whether a target word (presented in the centre

26
27 of the screen) belonged to the category named in the top left-hand corner of
28
29
ee

30
the screen or the category named in the top right-hand corner of the screen.
31
32 Participants indicated their choice by pressing a button on the left or right side
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33
34 of the keyboard, respectively. Categories were presented in concept pairs,
35
36
37 with one category presented on each side of the screen. Four categories,
ev

38
39 consisting of two concept pairs were used. One concept pair related to the
40
41
iew

self and was labelled “Me” and “Not Me”. The target words for this pair were:
42
43
44 me, my, mine, I, participant’s name (“Me” category); they, them, their, other
45
46 (“Not Me” category). The other concept pair related to affect and was labelled
47
48 “Pleasant” and “Unpleasant”, for which the target words were: happy,
49
50
51 enjoying, pleased, joyful (“Pleasant”); angry, depressed, frustrated, unhappy
52
53 (“Unpleasant”).
54
55
56
Initially, two practice blocks involved categorising the target word when
57
58 only the relevant concept pair was shown (simple blocks). For example, for
59
60 the target word “angry” the categories “Pleasant” and “Unpleasant” were

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 Clinical Psychology & Psychotherapy Page 20 of 41

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shown. The “Me/Not Me” categories were presented first (block 1) followed by
4
5
6 the “Pleasant/Unpleasant” categories (block 2). This was followed by another
7
8 practice (block 3) but this time with all four categories shown, with one
9
10
11
category from each concept pair on the left and the other on the right. So, for
12
13 example, the categories “Me” and “Pleasant” were shown on the left of the
14
15 screen and the categories “Not Me” and “Unpleasant” were shown on the
16
17
18 right. Data were collected from block 4 which was identical to block 3. Block 5
19
20 was a simple practice block in which the “Me” and “Not Me” categories
Fo

21
22 swapped screen sides with each other. Block 6 was a combined practice
23
24
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25 block involving all four categories but this time with a different combination on
26
27 each side of the screen. So, this time, the categories “Me” and “Unpleasant”
28
29
ee

30
appeared on the left and “Not Me” and “Pleasant” appeared on the right. Data
31
32 were collected from block 7 which was identical to block 6.
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33
34 The ordering was counterbalanced so that half the participants began
35
36
37 with the “Me/Pleasant” and “Not Me/Unpleasant” combinations and the other
ev

38
39 half began with the “Me/Unpleasant” and “Not Me/Pleasant” combinations,
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iew

with the same order presented at time 1 and time 2. Each target stimulus was
42
43
44 presented twice within each block. Reaction times and errors were recorded.
45
46 Again, following Brown and Ryan (2003), awareness of affect was
47
48 tested by assessing the correlation between the IAT effect and a
49
50
51 corresponding explicit measure. The explicit measure contained the same
52
53 affect words as the IAT and required participants to respond on a 7-point
54
55
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Likert-type scale (1 = not at all; 7 = extremely) to the question: “At the present
57
58 time, to what degree are you experiencing the following emotion?”
59
60 Analytic strategy

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Page 21 of 41 Clinical Psychology & Psychotherapy

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All data sets were initially examined for distribution normality and
4
5
6 outliers. MAAS results were analysed in the same way as the wellbeing
7
8 measures in Study 1. Non-parametric tests were applied to the non-subjective
9
10
11
mindfulness data due to distribution instability.
12
13 Results
14
15 Table 3 provides means and standard deviations for all three
16
17
18 mindfulness measures, and z scores for the IAT and explicit affect measure.
19
20 There were no significant differences between the groups at Time 1 on any of
Fo

21
22 the measures.
23
24
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25 Using the Wilcoxon Signed Ranks Test, MAAS scores showed a

26
27 significant increase across time in the Intervention Group (z = -2.80; p < .005)
28
29
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but not the Comparison Group (z = -1.18; p > .05).

30
31
32 The most complete measure of performance on the CPT was the
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34 statistic d prime (d’). Essentially d’ reflects the proportion of non-X trials on
35
36
37 which the space bar was depressed (correct hits) minus the proportion of X
ev

38
39 trials on which the space bar was depressed (false hits). Inspection of the
40
41
iew

means in Table 3 shows that there was no meaningful improvement in

42
43
44 performance across time. Similarly, there were no differences over time in
45
46 either group for Hits, False Alarms or for a measure of response bias (C). Nor
47
48 was there a significant difference between Intervention and Control Group at
49
50
51 either Time 1 or Time 2.
52
53 The IAT effect was calculated following the procedures outlined in
54
55
56
Greenwald et al. (1998). This meant that six participants from the Comparison
57
58 Group were excluded because they made incorrect classifications on more
59
60

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 Clinical Psychology & Psychotherapy Page 22 of 41

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than 20% of items, leaving 12 participants in each group. There were no
4
5
6 differences between these two groups on demographic and pain indices.
7
8 In line with previous research, there was a significant IAT effect in both
9
10
11
groups at both time points. Thus, participants responded significantly more
12
13 quickly on the consistent pairings (i.e. “Me”/”Pleasant” and “Not
14
15 Me”/”Unpleasant”), than on the inconsistent pairings (i.e. “Me”/”Unpleasant”
16
17
18 and “Not Me”/”Pleasant”). There were no differences in IAT effect from Time 1
19
20 to Time 2 (Intervention, z = -.68, Comparison, z = -.31). That is, implicit affect
Fo

21
22 did not change over time. This was as predicted – mindfulness training was
23
24
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25 not designed to improve implicit self-concept rather it was designed to

26
27 improve awareness, assessed here as the concordance between implicit and
28
29
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30
explicit measures of affect.
31
32 The explicit measure of current affect found that participants
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33
34 predominantly reported pleasant rather than unpleasant affect. In the
35
36
37 Intervention Group the difference between pleasant and unpleasant explicit
ev

38
39 affect was non-significant at Time 1 but was significant at Time 2. There were
40
41
iew

no significant differences between pleasant and unpleasant explicit affect in

42
43
44 the Comparison group. This pattern is consistent with the changes over time
45
46 on the subjective wellbeing measures reported above.
47
48 The Spearman Rank Correlation Coefficient was calculated to assess
49
50
51 the degree of association between the IAT effect and the explicit measure of
52
53 affect. The correlation between the overall IAT effect (i.e. including all items)
54
55
56
and the explicit measure was non-significant at Time 1 and Time 2 in both
57
58 groups (-.378 < rss (10) < -.203).
59
60

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Page 23 of 41 Clinical Psychology & Psychotherapy

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The IAT effect was also calculated separately using the responses to
4
5
6 the five pleasant traits and the five negative traits (excluding trials on which
7
8 personal pronouns acted as target words). Within the Intervention Group data
9
10
11
at Time 1 there was a non-significant trend towards a negative correlation
12
13 between explicit and implicit scores, for the pleasant traits (rs (9) = -.47). This
14
15 trend was reversed at Time 2 and there was a non-significant positive
16
17
18 correlation (rs (10) = .37). This is in contrast to the Comparison Group data, in
19
20 which there was no correlation at either time point (Time 1, rs (10) = -.028;
Fo

21
22 Time 2, rs (10) = -.007). One outlying value (> 2 SD from mean) was removed
23
24
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25 from the Intervention Group Time 1 data.

26
27 No patterns were present in the negative trait data in either group
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29
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[Intervention: Time 1 rs (10) = .17; Time 2 rs (10) = -.14; Comparison: Time 1 rs

30
31
32 (10) = .15; Time 2 rs (10) = .26].
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34 Discussion
35
36
37 Self-reported mindfulness, as measured by the MAAS, improved
ev

38
39 following the Breathworks course. This suggests that people perceived
40
41
iew

themselves to be more mindful following mindfulness training.

42
43
44 In line with Brown and Ryan (2003), no correlation was found between
45
46 implicit and explicit affect when all target words were included in the IAT data
47
48 analysis. However, following the removal of pronoun target words the
49
50
51 correlations between implicit and explicit affect were re-calculated for pleasant
52
53 and unpleasant affect separately. Within the Intervention Group, this
54
55
56
correlation was negative for pleasant words at Time 1 and positive for
57
58 pleasant words at Time 2. The trend was not significant but was not observed
59
60 for the unpleasant affect words nor for any words in the Comparison Group.

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 Clinical Psychology & Psychotherapy Page 24 of 41

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This finding is consistent with the hypothesis that mindfulness enables greater
4
5
6 awareness of a wider range of experience, as opposed to a narrowed focus
7
8 on the most emotionally salient aspects of the perceptual field, such as pain
9
10
11
and negative mood (Melbourne Academic Mindfulness interest Group, 2006).
12
13 Further support for this idea was that implicit pleasant affect was significantly
14
15 greater than implicit unpleasant affect pre- and post-intervention (the IAT
16
17
18 effect), whereas the difference on the explicit measure was significant post-
19
20 intervention only. There is, therefore, some evidence that awareness of
Fo

21
22 inherently positive implicit affect improved following mindfulness training.
23
24
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25 Interestingly, the technique of mood monitoring in cognitive behavioural

26
27 therapy is concerned with similar processes.
28
29
ee

30
There were no changes on any of the indices of the CPT, despite the
31
32 inclusion of an inhibition component within the measure. A number of possible
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33
34 explanations are considered. First, lack of power in the analyses could be
35
36
37 responsible, although this seems unlikely given the essentially equivalent
ev

38
39 performance of both groups across time. Second, perceptual CPTs may lack
40
41
iew

sufficient sensitivity to detect changes, given the dominance of apperception

42
43
44 (i.e. perception of internal phenomena) within the Breathworks teachings. As
45
46 such, tests of somatosensory attention deserve future consideration. Lastly,
47
48 there may be no effect of mindfulness on basic attention abilities, as Anderson
49
50
51 and colleagues (2007) have recently concluded. Instead, as discussed above,
52
53 mindfulness may have a specific impact on particular facets of attention such
54
55
56
as the processing of salient emotional stimuli (Ortner et al., 2007).
57
58 Summary and conclusions
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Page 25 of 41 Clinical Psychology & Psychotherapy

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Two aims were addressed in this study: Firstly, to provide pilot data on
4
5
6 the effectiveness of the Breathworks mindfulness training programme on
7
8 indices of wellbeing, and secondly to investigate the impact of the course on
9
10
11
multiple measures of mindfulness.
12
13 Preliminary evidence has been provided for the immediate efficacy of
14
15 the Breathworks course on important indices related to the impact of chronic
16
17
18 pain. Particularly large effects were found for pain-acceptance in the absence
19
20 of reduced pain intensity, and a trend towards increased awareness of
Fo

21
22 pleasant affect was identified in the data. These findings provide further
23
24
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25 support for the role of acceptance and awareness in mindfulness. However, in

26
27 order to assess the extent to which mindfulness mediates beneficial
28
29
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30
outcomes, and the mechanisms by which it does so, large scale regression
31
32 studies are required.
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33
34 The measurement of mindfulness is in its infancy. This is the first study
35
36
37 to use both subjective and objective methodology to evaluate a mindfulness-
ev

38
39 based intervention with a clinical pain population. Improved MAAS scores
40
41
iew

post-intervention reinforces the validity of this questionnaire. The objective

42
43
44 measures provided complementary methodology through which the
45
46 processes underlying mindfulness could be investigated. Null findings on the
47
48 attention measure add to continued speculation about the role of basic
49
50
51 attentional function within mindfulness. The suggestive result with the IAT
52
53 demonstrated the potential value of this approach and provides scope for
54
55
56
further investigation.
57
58 Limitations
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60

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 Clinical Psychology & Psychotherapy Page 26 of 41

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A number of limitations of this study should be noted. Small sample
4
5
6 sizes threaten the validity of results, and effect sizes should be interpreted
7
8 with caution. Nonetheless, reliable differences have been found on many of
9
10
11
the key measures and these findings, alongside the trends found within the
12
13 mindfulness measures, could provide helpful stimuli for future research.
14
15 Clinical outcome studies can be criticised for the self-selection of
16
17
18 participants. However, there is no evidence that Breathworks participants
19
20 were particularly susceptible to mindfulness training given the equivalence of
Fo

21
22 Intervention and Comparison Group MAAS scores at Time 1. Moreover,
23
24
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25 people attending the Breathworks course are frequently doing so as a last

26
27 resort, having unsuccessfully attempted many other medical and
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29
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30
psychological interventions. At the outset, participants often report scepticism
31
32 about the utility of mindfulness training. Thus, placebo effects are likely to be
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33
34 minimal. Notwithstanding these observations, the implementation of an RCT
35
36
37 represents a fundamental next step.
ev

38
39 The absence of objective functional outcome measures reduces the
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41
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impact of the results. The importance of “doing differently” to enable

42
43
44 meaningful change, is being increasingly emphasised (e.g. Hayes et al.,
45
46 1999) and future research should endeavour to include non-subjective
47
48 behavioural indices of change.
49
50
51 Inclusion of a comparison group enabled assessment of the effects of
52
53 random fluctuation, the passage of time and practice effects. Although the
54
55
56
samples were drawn from distinct populations, the absence of between group
57
58 differences on all measures at Time 1 supports the validity of comparisons
59
60 across groups.

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Page 27 of 41 Clinical Psychology & Psychotherapy

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This study provided evidence regarding the immediate effects of the
4
5
6 Breathworks programme but long-term consequences are, as yet, unknown.
7
8 Research from other longitudinal studies shows that meditation practice and
9
10
11
associated benefits, are maintained between 3-months and 4-years post-
12
13 intervention (Grossman et al., 2007; Kabat-Zinn et al., 1987; Morone et al.,
14
15 2008) and are related to functional outcomes such as return to work (Cohen
16
17
18 et. al.,2000; Adams & Williams, 2003). Subsequent research is required to
19
20 assess the longevity of the benefits reported here.
Fo

21
22 Acknowledgement
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24
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25 Most importantly we thank all the participants who gave their time so
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27 generously. Thank you to Gary Hennessy and Mike Osborn for their
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enthusiasm and support throughout the duration of this research. Thanks also
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32 to Jeremy Gauntlett-Gilbert and Reg Morris for helpful comments on previous
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34 drafts of the manuscript.
35
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37 References
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Figure 1: Participant flow

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4 Comparison Group Intervention Group
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Presentation to local pain Breathworks facilitators distribute
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support group. Information information packs to group members.
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packs distributed.
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10 Volunteers opt-in to Study 1 and Study 2 by Volunteers opt-in to
11 returning consent forms. Volunteers contacted by Study 1 by completing
st
12 telephone to arrange 1 meeting. consent forms.
13 n=20 n=13 n=20
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15 Experimenter ensures understanding of demands of participation. Consent re-
16 obtained. Participant completes Study 1 questionnaires.
17 Time 1
18 n=20 n=13
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n=20
20 Participant completes Study 2 tasks.
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n=20 n=13
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23 Comparison Group Intervention Group
24 Treatment as usual. Breathworks programme completed.
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n=18 n=12 n=20
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28 Participant completes Study 1 questionnaires.
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30 n=18 n=12 Time 2

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Participant completes Study 2 tasks.
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Table 1: Self-report wellbeing measures: means and standard deviations.
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7 Intervention Control
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9 Time 1 Time 2 Time 1 Time 2
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11 DAPOS N 21 21 20 20
12 Depression Mean 12.52 10.10 11.55 11.70
13 SD 3.57 3.35 4.74 4.03
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15 Anxiety Mean 7.43 6.71 6.20 6.25
16 SD 2.79 2.69 3.12 3.14
17
18 Positive Outlook Mean 9.48 10.71 10.50 9.85
19 SD 1.44 2.53 2.98 2.94
20
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21 CPAQ N 24 24 20 20
22 Activities engagement Mean 35.08 42.67 35.25 35.65
23 SD 10.51 10.81 9.99 9.21
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25 Willingness Mean 20.75 26.17 23.80 24.90

26 SD 7.36 7.21 5.78 8.54
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28 Total Pain Acceptance Mean 55.83 68.83 59.05 60.55
29 SD 13.75 14.76 7.79 10.68
ee

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31 PSEQ N 33 33 20 20
32 Mean 31.58 36.42 31.70 31.45
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33 SD 12.11 12.25 8.86 11.63

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35 PCS N 30 30 20 20
36 Magnification Mean 4.94 3.48 4.20 5.25
37 SD 2.59 2.49 2.01 3.32
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39 Rumination Mean 8.29 5.68 7.90 7.55
40 SD 4.82 3.68 4.53 4.43
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42 Helplessness Mean 10.26 6.32 10.40 9.20

43 SD 6.11 4.22 6.07 5.43
44
SF-36 N 32 32 20 20
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Total Mean 43.60 48.69 35.68 41.40
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SD 17.20 16.46 10.50 14.45
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Pain intensity N 32 32 20 20
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Mean 5.62 4.99 6.60 6.20
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SD 2.07 1.84 1.94 2.25
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Table 2: Self-report wellbeing measures: 2*2 ANOVA results.
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7 Note: Time = main effect of time; Group x Time = Interaction; Intervention Group - Time =
8 simple effect of Time within the Intervention Group.
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10 Note: * = p <.01;  p = partial Eta squared: A small effect is 0.01 to 0.06, a medium effect is
11 0.06 to 0.14, and a large effect is 0.14 and higher.
12
13
14 Measure F df MSE 2p
15 DAPOS
16 Depression Time 4.20* 1,39 6.33 .10
17 Group x Time 5.21* 1,39 6.33 .12
18 Intervention Group - Time 9.78* 1,39 6.33 .20
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20 Anxiety Time .71 1,39 2.26 .02
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21 Group x Time .94 1,39 2.99 .02

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23 Positive Outlook Time .98 1,39 1.79 .03
24 Group x Time 10.15* 1,39 1.79 .21
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25 Intervention Group - Time 8.94* 1,39 1.79 .19

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27 CPAQ
28 Activities Time 9.71* 1,42 35.79 .19
29 engagement Group x Time 7.86* 1,42 35.79 .16
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30 Intervention Group - Time 19.28* 1,42 35.79 .32

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32 Willingness Time 9.59* 1,42 24.16 .19
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33 Group x Time 4.21 1,42 24.16 .09

34 Intervention Group - Time 14.57* 1,42 24.16 .26
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36 Total Pain Acceptance Time 17.08* 1,42 67.16 .29
37 Group x Time 10.74* 1,42 67.16 .20
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38 Intervention Group - Time 30.20* 1,42 67.16 .42

39
40 PSEQ Time 3.03 1,51 43.43 .06
41 Group x Time 3.73 1,51 43.43 .07
iew

42 Intervention Group - Time 8.93* 1,51 43.43 .15

43
44 PCS
45 Magnification Time .31 1,48 3.34 .02
Group x Time 11.63* 1,48 3.34 .19
46
Intervention Group - Time 9.98* 1,48 3.34 .17
47
48
Rumination Time 7.01 1,49 30.47 .13
49
Group x Time 4.09 1,49 30.47 .08
50
Intervention Group - Time 13.90* 1,49 30.47 .22
51
52
Helplessness Time 12.32* 1,49 13.01 .20
53
Group x Time 3.30 1,49 13.01 .06
54
Intervention Group - Time 18.45* 1,49 13.01 .28
55
56 SF-36 Time 7.35* 1,50 99.99 .13
57 Group x Time 3.77 1,50 99.99 .07
58
59 Pain intensity Time 3.80 1,50 17.62 .07
60 Group x Time .16 1,50 17.62 .00

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Page 41 of 41 Clinical Psychology & Psychotherapy

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Table 3: Means, standard deviations and z scores for the mindfulness
4
5 measures.
6
7 Note:* = p < .05; ** = p < .01; z = Wilcoxon Signed Ranks Test statistic of difference between
8 pleasant and unpleasant scores
9
10 Intervention Comparison
11 Time 1 Time 2 Time 1 Time 2
12 MAAS N 12 12 18 18
13 Mean 3.35 4.09 3.55 3.72
14 SD .66 .62 .94 1.06
15
16 CPT N 12 12 18 18
17 d’ Mean 2.61 2.63 2.02 2.18
18 SD .62 .99 1.11 1.40
19
20 IAT effect N 12 12 12 12
Fo

21 Mean 329.47 379.90 419.49 456.17

22 SD 218.04 170.73 316.66 265.01
23 Z -3.06** -3.06** -3.06** -3.06**
24
rP

25 Explicit affect N 12 12 12 12
26 (pleasant – unpleasant) Mean .74 2.13 1.73 2.01
27 SD 1.90 1.24 1.71 2.84
28 Z -1.16 -3.06** -2.59** -1.96*
29
ee

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rR

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37
ev

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41
iew

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45
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