Meditation Awareness Training (MAT)

Meditation Awareness Training (MAT) for Psychological Well-Being in a SubClinical Sample of University Students: A Controlled Pilot Study William Van Gordon, Edo Shonin, Alex Sumich, Eva C. Sundin & Mark D. Griffiths Mindfulness ISSN 1868-8527 Volume 5 Number 4 Mindfulness (2014) 5:381-391 DOI 10.1007/s12671-012-0191-5

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Author's personal copy Mindfulness (2014) 5:381–391 DOI 10.1007/s12671-012-0191-5

ORIGINAL PAPER

Meditation Awareness Training (MAT) for Psychological Well-Being in a Sub-Clinical Sample of University Students: A Controlled Pilot Study William Van Gordon & Edo Shonin & Alex Sumich & Eva C. Sundin & Mark D. Griffiths

Published online: 7 February 2013 # Springer Science+Business Media New York 2013

Abstract Mindfulness has been practiced in the Eastern world for over twenty-five centuries but has only recently become popular in the West. Today, interventions such as “Mindfulness-Based Cognitive Therapy” are used within the Western health setting and have proven to be successful techniques for reducing psychological distress. However, a limitation of such interventions is that they tend to apply the practices of mindfulness in an “out of context” manner. To overcome this, a newly formed Meditation Awareness Training (MAT) program focusses on the establishment of solid meditative foundations and integrates various support practices that are traditionally assumed to effectuate a more sustainable quality of well-being. The aim of this pilot study was to assess the feasibility and effectiveness of MAT for improving psychological well-being in a sub-clinical sample of higher education students with issues of stress, anxiety, and low mood. Utilizing a controlled design, participants of the study (n=14) undertook an 8-week MAT program and comparisons were made with a control group (n=11) on measures of self-assessed psychological well-being (emotional distress, positive affect, and negative affect) and dispositional mindfulness. Participants who received MAT showed significant improvements in psychological well-being and dispositional mindfulness over controls. MAT may increase emotion regulation ability in higher education students with issues of stress, anxiety, and low mood. Individuals receiving training in mindfulness meditation may benefit by engendering a broader, more ethically informed, and compassionate intention for their mindfulness practice. W. Van Gordon : E. Shonin (*) : A. Sumich : E. C. Sundin : M. D. Griffiths Division of Psychology, Nottingham Trent University, Burton Street, Nottingham, UK e-mail: [email protected]

Keywords Meditation . Meditation awareness training . Mindfulness . Stress . Anxiety

Introduction Meditation has been practiced for thousands of years and by many of the world’s religions. However, relative to the more tenet-driven religions of the West, meditation represents a trait component of Eastern systems of philosophical practice (Bowker 2006). Meditation is a spiritual and introspective practice involving elements of both concentration and analysis as part of a process of becoming aware of and of training the mind (Dalai Lama 2001). Recent decades have observed a marked increase of research into the applications for meditation as a mainstream medical or psychotherapeutic intervention (Shapiro and Walsh 2009; Thompson and Waltz 2007). A Mental Health Foundation (2010) survey found that 86 % of British adults (n=2,007) acknowledged that they would be “much happier and healthier if they knew how to slow down and live in the moment” (p.12) and that 51 % of adults would be interested in attending meditation classes to help them deal with stress and take better care of their health. There are numerous forms of meditation many of which have demonstrable efficacy for the treatment of at least one condition of psychological or somatic illness (e.g. Chiesa and Serretti 2011; Edenfield and Saeed 2012; Arias et al. 2006). However, the forms most commonly utilized within Western healthcare settings are principally Buddhist or Buddhist-derived techniques. Such techniques include approaches known as mindfulness meditation as well as methods such as samatha (concentrative or tranquil abiding meditation), vipasyana (insight meditation), zen, and yogic meditation (Arias et al. 2006). Of the various modes of meditation, mindfulness meditation represents a particularly accessible form and as such

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appears to be the method of choice for clinical interventions (Baer 2003). Group-based interventions using mindfulness meditation generally comprise an 8-week secular format of which the two most established techniques are “MindfulnessBased Stress Reduction” (MBSR; Kabat-Zinn 1990) and Mindfulness-Based Cognitive Therapy (MBCT; Segal et al. 2002). MBCT is advocated by the National Institute for Health and Clinical Excellence (NICE) for the treatment of recurrent depression in adults (NICE 2009). MBCT is also included in the practice guidelines of the American Psychiatric Association (APA) for the treatment of major depression (APA 2010). Examples of more recently formulated mindfulness-based interventions (MBIs) include techniques known as “Mindfulness-Based Relapse Prevention” (Bowen et al. 2009) for the treatment of substance-use disorders and “Mindfulness-Based Childbirth and Parenting” (Duncan and Bardacke 2010). Mindfulness is also integrated into a number of “third wave” one-to-one cognitive behavioural therapeutic modes such as Dialectic Behaviour Therapy (Linehan 1993) and Acceptance and Commitment Therapy (Hayes et al. 1999). MBIs can be delivered in group format making them particularly cost-effective treatment options (Allen et al. 2009). Versatility is a further strength of MBIs which have evinced efficacy for treating a broad spectrum of medical illnesses ranging from depression, anxiety, stress, substanceuse disorders, and sleep disorder, to epilepsy, asthma, and cancer. The strongest meta-analytical effect sizes (e.g. Hedges’ g>0.85) are typically reported for the treatment of mood and anxiety disorders (Vollestad et al. 2011). Effect sizes fall into the moderate range (e.g. d≈0.5) for the treatment of somatic illness (Baer 2003; Grossman et al. 2004). Whilst there is a growing body of evidence that attests to the effectiveness of MBIs, a number of factors limit the overall validity of empirical findings. These factors include (for example): (a) an over-reliance in MBI studies on selfreport measures rather than clinical diagnostic interviews, (b) poorly designed control interventions that do not account for non-specific factors such as therpeutic alliance, psychoeducation, and group engagement, (c) fidelity of implementation not controlled for (i.e. the extent to which facilitators adhere to the delivery plan), (d) absence of (or poorly executed) intent-to-treat analysis, (e) variations in the experience and competance of program facilitators, (f) adherance to practice data not elicited, and (g) variances in the way different MBIs define and operationalize mindfulness (e.g. the extent of deviation from the Buddhist contextualization of mindfulness). Mindfulness-Based Interventions: Concerns and Design Issues A growing concern regarding MBIs is that they lack foundational congruence and apply the practice of mindfulness

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in an “out of context” manner (e.g. Howells et al. 2010; Singh et al. 2008; Rosch 2007; McWilliams 2011; Shonin et al. 2012a). This critique arises because in its traditional Buddhist setting, rather than a standalone technique, mindfulness is practiced only as part of a composite and interdependent array of spiritually inclined perspectives and trainings. According to the Buddhist perspective, the development of mindfulness arises as a result of its “cross-fertilization” with wisdom, ethical discipline, and meditative elements (known as the three trainings). These three elements provide a stable platform and context for the successful and sustainable cultivation of “right mindfulness” (Shonin et al. 2012a). The psychological literature is far from unified in terms of an accepted understanding and definition of mindfulness (Kang and Whittingham 2010). Consequently, the role and importance of the context of mindfulness practice has been largely overlooked throughout successive Westernized models of mindfulness. However, Dorjee’s (2010) fivedimensional model of mindfulness reflects an example of a more recent and encompassing schema in which the importance of the context of practice is stressed. Dorjee’s model encompasses the elements of: (a) intention and context, (b) bare attention, (c) attention control, (d) wholesome emotions, and (e) ethical discernment. Indeed, Dorjee contends that there are important differences between the context of mindfulness as practiced within Buddhism and MBIs that relate to a different degree of emphasis on shorter-term symptom relief compared with liberation in the more spiritual sense. A further reason for concern in respect of the utilization of mindfulness in MBIs relates to inconsistency in the use or misuse of other related Buddhist terms and concepts. For example, within the psychological and healthcare literature, mindfulness meditation is generally viewed as being synonymous with a technique known as insight meditation (also known as vipasyana meditation). Although (for whatever reason) a small number of Buddhist approaches appear to share or have possibly influenced the formation of this view, the more traditional perspective is that vipasyana refers to a subtle form of meditative analysis that can permit a “penetration” into the “empty” nature of self and reality (Dalai Lama and Berzin 1997). Confusion in this respect is probably the reason why the vital role of insight meditation (in relation to its more traditional depiction) has been largely overlooked in the design of MBIs and in the psychological literature more generally. A further concern relates to the competency, supervision, and general experience levels of MBI facilitators and clinicians. Whilst there are efforts underway to establish competency, assessment, and practice guidelines for MBI facilitators (see Crane et al. 2011), teachers of mindfulness are not currently regulated by a national accrediting special-purpose body. In fact, mindfulness instructors can deliver MBIs with

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as little as 1 year’s mindfulness experience following completion of a single 8-week course (MHF 2010). This is in contrast to the Buddhist perspective where traditionally, the meditation teacher will have invariably received transmissions directly from an accomplished meditation master and will have undergone prolonged periods (normally decades) of focussed meditation training (Shonin et al. 2012a). Provenance and Aims of the Current Study Pressures arising from adjusting to a new social environment, achieving academically, finding life partners, and securing employment make university students a particularly at-risk group for stress, loneliness, and anxiety (Ross et al. 1999). Stress and depression amongst students are deemed to be principal factors that can lead to academic non-completion (Hess and Copeland 2001). However, there is a limited amount of research assessing the benefits to psychological well-being of meditation in student populations. Nevertheless, students more accustomed to Buddhist principles have been shown to conceptualize mindfulness in different ways compared with students from non-Buddhist backgrounds (Christopher et al. 2009). Although such findings have important implications in terms of the crosscultural validity of existent measures of mindfulness, it is currently unclear whether Westernized versus Buddhist approaches to meditation and mindfulness involve different mediating mechanisms. Indeed hitherto, there has not existed a secularized, group-based, and psychotherapeutically orientated mindfulness-based intervention that adopts a more “traditionally aligned” and comprehensive theoretical basis. Consequently, it has not been possible to determine whether an intervention placing a greater focus upon the cultivation of solid meditative foundations as opposed to being limited to mindfulness (which according to the traditional Buddhist perspective is only one key aspect of meditative practice) would not only be of benefit but also be a welcomed alternative for service-users. Thus, the aim of this pilot study was to assess the benefits and feasibility of a newly designed, 8-week long program called “Meditation Awareness Training” (MAT) to psychological well-being in higher education students. A subclinical population was the subject of the current pilot study, with a longer-term objective of evaluating the effectiveness of MAT within clinical populations.

Method A controlled small-sample design was employed as this study represented the first empirical testing of the proposed intervention. Qualitative data were also collected and

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findings of the qualitative analysis are reported elsewhere (see Shonin et al. 2012b). Participants and Recruitment A convenience sample was drawn from an undergraduate and postgraduate student population from a university in the East Midlands (UK). Recruitment was by way of electronic flyers designed to appeal to as broad a profile of students as possible. Aside from contact, dates, and venue details, information on the e-flyers was kept to a minimum and included the following statements: (a) that the research involved an 8-week meditation and mindfulness training program, (b) that no prior meditation experience was required, (c) that the research was being conducted to assess the benefits to well-being of meditation and mindfulness, and (d) that the research was being conducted with the backing of the university’s Student Support Services. Most participants (68 %) enrolled on the program for the primary purpose of improving their low mood and/or reducing their levels of stress and anxiety. However, a small number of participants (32 %) enrolled for the primary purpose of learning to meditate. Participation was completely voluntary and individuals were not otherwise rewarded for their involvement (although all participants received a course completion certificate). The sample comprised students with a diverse range of higher education levels (i.e. first-year undergraduate to final-year doctoral students). Thus, to control for an effect of education, a simple matching procedure was undertaken in order to match the intervention group (n=14) and control group (n=11) as closely as possible on “years of education”. Based on visual inspection, manual adjustments were then made in iterative fashion until the most homogeneous match (i.e. factoring in age, sex, and ethnicity) between allocation conditions was established. Random assignment was not appropriate due to a need to manually assign a small number of participants to the control group for consent-based reasons (e.g. a small number of participants did not consent to their one-to-one support sessions being audio recorded— transcripts of the recorded one-to-one sessions were required for the qualitative arm of the study). In order to minimize selection bias, group allocation occurred after participant screening but before the baseline assessment of participant psychological well-being. The intervention group undertook MAT over an 8-week course and was compared against non-participating controls on measures of psychological well-being at both baseline and completion phase. Participant recruitment as well as the administration and scoring of psychometric tests were conducted by an independent analyst. As an ethical consideration, control group participants were prioritized for acceptance onto a later MAT program. Ethical approval was given by the researchers’ University Ethics Committee.


Inclusion/Exclusion Criteria Inclusion criteria were: (a) undertaking undergraduate or postgraduate level study at the time of recruitment, (b) aged between 18 and 65 years, and (c) English speaking. Exclusion criteria were: (a) current participation in a program of structured psychotherapy or counselling, (b) previously received formal meditation training, (c) diagnosed with a psychological disorder within 12 months prior to recruitment (based on self-reports), and (d) current use of prescription psychopharmacology (based on self-reports). Program Description of Meditation Awareness Training Prior to commencing the intervention, all participants were asked to confirm they understood and agreed to the level of time and commitment required by the program. Unlike the current battery of MBIs, MAT employs a comprehensive approach to meditation whereby mindfulness practice is an integral part but does not form the exclusive focus of the program. MAT is a group-based secularized program and whilst firmly grounded in Buddhist principles, the intervention makes no explicit reference to Buddhist terms. Consistent with a traditional approach to meditation, insight meditation techniques are integrated in order to encourage a gradual familiarization with (and ideally a preliminary realization of) concepts such as impermanence and emptiness. MAT integrates elements designed to foster (for example) improved selfcontrol and ethical awareness, patience, generosity, and compassion. MAT differs from existent MBIs such as MBSR and MBCT in a number of ways (Table 1) and is structured as follows: 1. Session format: Sessions (each of 2 h duration) begin with an interactive seminar and conclude with a guided meditation and/or guided mindfulness exercise. 2. Weekly session overview: In sequential order, the weekly sessions are themed as follows: (a) introducing meditation and mindfulness, (b) introducing impermanence and emptiness, (c) cultivating joy and equanimity, (d) generosity towards self and others, (e) ethical awareness and patience, (f) revisiting impermanence and emptiness, (g) loving-kindness and compassion, and (h) letting go (including course review). 3. Attendance: Attendance at at-least seven of the eight weekly sessions is a prerequisite for course completion. A certificate is awarded upon completion. 4. Self-practice: Participants are encouraged and asked to introduce mindfulness and meditation into their normal daily routine. A CD consisting of guided meditations and a course booklet is provided as a support resource. Participants are asked to adhere to a particular set of guided meditations per each week of the program.

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However, they are not assigned a minimum length of daily practice. Rather, participants are encouraged to adopt a dynamic meditation routine and are guided on an individual basis to find the optimum frequency and duration of meditation sessions. In this manner, participants are dissuaded from drawing divisions between meditation during formal sitting settings and meditation during everyday activities. The purpose of this is to reduce the likelihood of dependency on the need for formal meditation sessions. 5. One-to-one support sessions: During weeks three and seven of the program, each participant is invited to attend a one-to-one support session (duration approximately 50 min) with the program facilitators. The support sessions provide an opportunity to discuss individual progress or problems with the training. Consistent with a traditional approach to meditation (known as “Dharma sharing”), the participant is not prescribed a fixed set of “answers” to their particular issues with the training. Rather, the role of the facilitator is more one of aiding a process of “guided discovery”. The objective is to give rise to a co-produced form of understanding or wisdom that can be shared by facilitator and participant alike. The one-to-one dialogues are not explicitly designed as psychotherapy sessions and are orientated more towards the understanding and application of meditative principles in everyday situations. Nevertheless, the sessions inevitably exert a form of therapeutic effect and inherently integrate many of the conditions considered to be important for maintaining a fertile “therapeutic environment” (e.g. conditions of active listening, unconditional positive regard, accurate empathy, genuineness, and congruence; Wells 1997). 6. Facilitator aptitude: MAT is administered by facilitators with a minimum of three years supervised meditation experience. Facilitators are required to have completed foundation, intermediate, and facilitator level MAT training courses (each of 8-week duration). In order to maximize the fidelity of implementation, each MAT program is conducted within a framework of supervised delivery. Outcome Measures From the conventional perspective, psychological wellbeing refers to the more humanistic notion of goal achievement in which dimensions such as purpose in life, personal growth, and environmental mastery are deemed to be important (Ryff 1989). However, for the purposes of this study, psychological well-being was considered as that which incorporates the mood-related concepts of positive and negative affect (Keyes et al. 2002) as well as the more clinically familiar conditions of depression, anxiety, and stress.


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Table 1 Distinguishing features of MAT compared with existent MBIs Key features

MAT

Typical MBIs (e.g. MBSR)

Average/typical duration Group-based Secularized Average total intervention hours per participant (excluding at home practice) Average facilitator hours per participanta Follow up/booster session

8 weeks Yes Yes Approx. 18 (8×2 h weekly sessions, 2×50 min one-to-one sessions) 3.6 h Yes—option to progress to further 8-week course (Intermediate level) No No Yes Yes (in weeks 3 and 7 of the program— each of 50 min duration) Yes

8 weeks Yes Yes Approx. 31 (8×3 h weekly sessions, 1×7 h 1-day silent retreat) 3.1 h Yes—often a monthly follow-up session for a fixed period e.g. 6 months Yes Yes Yes Not a formal requirementb

Yes

No

Yes

Not explicitly taughtc

3-years supervised meditation experience, completion of MAT at foundation, intermediate, and advanced levels (each of 8-week duration)

12 months experience and completion of an 8-week course (however, see Crane et al. 2011)

Yoga exercises One-day retreat component Guided meditation CD and other support materials Formal structured one-to-one support sessions with program facilitators Meditations on joy, loving-kindness, compassion, and equanimity Vipasyana/insight meditation (as per its traditional utilization) Teachings on ethical awareness, generosity, patience, compassion, etc. Min. competency of facilitators

a

Not explicitly taughtc

Calculation of average facilitator hours per participant is based on delivery of the intervention by one facilitator to 10 participants

b

Although structured one-to-one sessions are not a formal component of MBIs, in certain MBIs such as MBSR participants may request to meet with the facilitators outside of the weekly group sessions c

With the exception of loving-kindness meditation which sometimes forms part of MBSR, in general these practices are not explicitly taught in MBIs but may be touched upon depending upon facilitator preference

Depression, Anxiety and Stress Scale The 21-item depression, anxiety and stress scale (DASS) is a short-form adaptation of Lovibond and Lovibond’s (1995) 42-item full-form version that measures emotional distress based on subscales of depression, anxiety, and stress. This self-report measure is suitable for sub-clinical populations and takes approximately ten minutes to complete with each subscale featuring seven items. The scale is scored on a four-point Likert scale (from: 0=“Did not apply to me at all”, to 3=“Applied to me very much or most of the time”) and features items such as “I found it hard to wind down” and “I felt that life was meaningless”. DASS-21 is completed in respect of the foregoing 7-day period. In the current study, scores for each of the depression, anxiety, and stress sub-scales were totalled together to provide an overall measure of psychological distress. Cronbach’s alpha measures of internal consistency are .88 for the depression scale, .82 for the anxiety scale, .90 for the stress scale, and a value of .93 for the overall scale (Henry and Crawford 2005). The scale shows adequate levels of test-retest reliability in student populations (Mahmoud et al. 2010). The 21-item (as opposed to the longer 42-item version) was

chosen because factor analysis yields a superior latent structure for the short-form measure as items which result in lower discriminant validity (due to double or inadequate loading) have been removed (Henry and Crawford 2005). A good balance between sensitivity and specificity has likewise been demonstrated (Gloster et al. 2008). Positive and Negative Affect Scale The positive and negative affect scale (PANAS; Watson et al. 1988) is a self-report scale that measures predisposition to negative and positive mood states. The scale features twenty items consisting of ten positive affect (PA) adjectives and ten negative affect (NA) adjectives. Adjectives such as “interested” and “hostile” are scored on a five-point Likert scale (varying from “very slightly or not at all” to “extremely”) that records the extent to which the participant experienced such feelings “in general”. Item scores (ranging from 1 to 5) are added to give two separate scores (for total NA and total PA) and scores range from 10 to 50 with higher scores representing greater degrees of affect. Factor analysis has confirmed the independence of the scales as assessing two global dimensions of affect (r=−0.09; Watson et al.


1988). Both subscales demonstrate adequate degrees of internal consistency using student samples (alpha > 0.84; Watson 2000). Mindful Attention and Awareness Scale The mindful attention and awareness scale (MAAS; Brown and Ryan 2003) was used to assess dispositional mindfulness. The MAAS is a 15-item scale with items such as “I find myself preoccupied with the future or the past” and “I find myself doing things without paying attention”. Scoring is frequency-based and follows a six-point Likert scale (ranging from “almost always” to “almost never”) with higher scores reflecting greater degrees of dispositional mindfulness. The scale demonstrates satisfactory levels of internal consistency (range of alpha coefficients .82 to .87 for student and adult populations respectively; Brown and Ryan 2003). The MAAS has likewise been shown to have good levels of concurrent validity with scales such as the Beck Depression Inventory and the State-Trait Anxiety Inventory (Brown and Ryan 2003). Statistical Analysis Visual inspection of frequency histograms suggested normal distribution thus repeated measures analysis of variance (ANOVA) was used to test for interactions between group (intervention, control) and time (baseline, follow-up) on four dependent variables (PA, NA, MAAS, and DASS). Significant multivariate effects were followed by univariate analysis of each dependent variable. Unless otherwise stated Wilks Lambda statistics are reported. Effect sizes are shown using Partial Eta Squared (ηp2) as well as Cohen’s d statistic. The latter was based on difference scores (baseline-followup) of each dependent variable, and showed the size of the between groups effect (absolute value) using an averaged standard deviation.

Results

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15.91, SD=3.53) whilst the control group comprised two more females than the intervention group (73 % females for controls vs. 56 % females for the intervention group). In the DASS manual (Lovibond and Lovibond 1995), the percentile cut-offs for symptom severity are as follows: 0– 78=Normal, 78–87=Mild, 87–95=Moderate, and > 95= Severe. The mean baseline score for the control group (of M=8.18—see Table 2) corresponded to the 57th percentile and was within normative range. However, the mean baseline score for the intervention group of M=15.36 corresponded to the 81st percentile and was within the mild (i.e. “sub-clinical”) range. Attrition and Attendance Of the 14 participants who commenced the intervention, 11 finished the program and completed post-intervention measures of self-assessed psychological well-being. Reasons for non-completion were “started employment” (two participants) and “not specified” (one participant). For the 11 participants who satisfied the minimum attendance criteria and completed at least seven of the eight weekly group sessions, the average number of group sessions attended was 7.45 (SD=0.52). The same 11 participants attended 100 % of the one-to-one sessions in weeks three and seven of program. All participants allocated to the control group (n=11) completed both baseline and end-point measures. The average age of the 3 participants (2 female, 1 male) who dropped-out was 26.33 years (SD=2.89). Multivariate comparison of baseline scores showed higher mean negative affect and lower MAAS scores in these three individuals compared to completers [NA: F(1,23)=9.54, p=.005, η2 =.29, Cohen’s d=1.01; MAAS F(1,23) = 5.18, p=.032, η2 =.18, Cohen’s d= 1.14], but no difference in any other outcome variable, age or education. Table 2 Baseline and end-point mean scores for intervention (n=11) and control (n=11) groups Measure

Group

Mean

SD

Mean

SD

Intervention Control Intervention Control

15.36 8.18 56.09 58

7.9 6.62 11.04 8.58

4.45 12.27 68.09 55.54

3.83 8.03 13.01 10.83

Intervention Control Intervention Control

32.64 35.45 19.55 15.64

8.02 5.16 4.78 2.94

37 34.27 13.55 17.73

8.04 4.47 3.96 6.21

Demographic and Base-line Characteristics DASS

Demographic characteristics were reasonably well matched across the two allocation groups. The mean age was 30.27 years (range 20–42 years; SD=8.57 years) for the intervention group and 27.64 years (range 20–41 years; SD=7.03 years) for controls. Both the intervention and control groups comprised an equal number (73 %) of participants from a White British ethnic background, with a reasonable match for other ethnic backgrounds. The average number of years in education was almost identical between groups (intervention: M=15.82, SD=2.89; controls: M=

MAAS PANAS Positive affect Negative affect

a

End-pointa

Baseline

End-point was within 1 week after the end of the intervention


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Analysis of Outcome Measures

Discussion

Table 2 and Fig. 1 show descriptive statistics for baseline and follow-up scores on each of the dependent variables. Multivariate analysis showed a significant effect of time [F(4,17)=3.79, p=.022, η2 =.47] and a group by time interaction [F(4,17)=10.59, p