Mindfull Study 2007

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A Randomized Controlled Trial of Mindfulness Meditation Versus Relaxation Training:Effects on Distress, Positive States of M ind, Rum ination, and DistractionShamini Jain, M.S.

SDSUIUCSD Joint Doctoral Program, Clinical PsychologyShauna L. Shapiro, Ph.D.

Department of Psychology, Santa Clara UniversitySummer Swanick, B.S.

Department of Psychology, University of ArizonaScott C. Roesch, Ph.D.

Department of Psychology, San Diego State UniversityPaul J. M ills, Ph.D.

Department of Psychiatry, University of California San DiegoIris Bell, M.D. Ph.D. and Gary E .R. Schwartz, Ph.D

Department of Psychology, University of Arizona

ABSTRACTBackground: Although mindfulness meditation interven-

tions have recently shown benefits for reducing stress in variouspopulations, little is known about their relative efficacy com-pared with relaxation interventions. Purpose: This randomizedcontrolled trial examines the effects of a 1-month mindfulnessmeditation versus somatic relaxation training as compared to acontrol group in 83 students (M age = 25; 16 men and 67women) reporting distress. Method: Psychological distress,positive states of mind, distractive and ruminative thoughts andbehaviors, and spiritual experience were measured, while con-trolling for social desirability. Results Hierarchical linearmodeling reveals that both meditation and relaxation groups ex-perienced significant decreases in distress as well as increasesin positive mood states over time, compared with the controlgroup (p < .05 in all cases). There were no significant differ-ences between meditation and relaxation on distress and posi-tive mood states over time. Effect sizes for distress were large forboth meditation and relaxation (Cohen's d = 1.36 and .91, re-spectively ), whe reas the m editation group showed a larger effe ctsize for positive states of mind than relaxation (Cohen's d =. 71and .25, respectively). The meditation group also demonstratedsignificant pre post decreases in both distractive and rumina-tive thoughts/behaviors compared with the control group (p .5 in all cases).Mediation Analyses

Rumination AnalysisWe first determined whether conditions were sufficient totest for rumination as a possible mediator of group status (medi-tation vs. control) on distress scores. In Step 1, change scores forGSI were entered as the dependent variable, with group status as

the predictor variable and pretest M-C scores entered ascovariates. Group status significantly predicted changes in GSI(standardized = -.337, p = .011), accounting for 17.9 of thevariance (R 2= . 179). In Step 2, we examine whether changes inrumination were related to changes in GSI scores, using pretestM-C scores as a covariates. Change scores for the GS I were sig-nificantly predicted by change scores of rumination (standard-ized (3 = . 363, p = .005, RZ = .20). Next, in Step 3, we examinewhether group status predicted changes in rumination using pre-test M-C scores as a covariate. Rumination change scores weresignificantly predicted by group status (standardized (3 = -. 396,p = .004, R 2= .16).R esults of these three steps suggest that sufficient condi-tions were met to test for mediation. Thus, in step 4, we examinewhether changes in GSI for group were potentially mediated bychanges in rumination. GSI change scores were entered as thedependent variable. Rumination change scores and group status


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18ain et al.nnals o Behavioral Med icinea = - .337 p=.01Goup assignmenthange in GSI distress0 =.-227 p = .099)

(b) Group assignment - - - - - - - - - - - - - - -Change in GSI distress

P.396(P=.004)7aPChanges in Rumination

FIGURE 1 D epictions of (a) the direct relation between group status(meditation vs. control) and changes in GSI distress scores, and (b) themediation model for changes in rumination on the relation betweengroup status (meditation vs. control) and changes in G SI distressscores. Standardized beta estimates are depicted, with p values in pa-rentheses. Although group status initially predicted differences in GSIchange scores, this relation was no longer significant when changes inrumination are entered into the model. Regression analyses are ad-justed for social desirability (M-C) scores.

were entered as predictor variables, and pretest M-C scores wereentered as a covariate. Results indicate that changes in GSI dis-tress scores were partially mediated by changes in rumination:Group status was no longer a significant predictor of GSIchange scores (standardized R = . 227, p = .099), whereaschanges in rumination remained significant (standardized (3 =.278, p = .04). The entire mediation model accounted for 24.4%of the variance in GSI change scores (R 2 = .24 4). This model isdepicted in Figure 1.

Distraction AnalysisWe performed similar analyses to determine whether suffi-cient conditions existed to test distraction as a mediator of groupstatus on GS I scores. Step I was identical to the step reportedpreviously for the rumination me diation analysis, with groupstatus significantly predicting G SI scores (standardized (3 =

.337, p = .0 11). Step 2 reveals that changes in GSI scores aresignificantly predicted by changes in distraction scores (stan-dardized 0 = .295, p = .023, R 2 = .16 ). Step 3 reveals significantdifferences between the meditation and control group m eans ondistraction change scores (standardized 3 = .315, p = .02 3, R 2 .09). Finally, in Step 4 we determine whether change s in GSImight be mediated by changes in distraction. Change scores forthe GSI are entered as the dependent variable, group status andchange scores for distraction are entered as predictor variables,and pretest M-C scores are entered as a covariate. Results revealthat group status remained a significant predictor of GSI ch angescores (standardized (3 = .269, p = .048), whereas distractionchange scores did not predict G SI change scores (standardized (3= .215, p = .115, R 2= .2 2). Thus, our data suggest that reductionsin distress for the meditation group are partially mediated by re-ductions in rumination but not distraction.

Effect SizesUsing Cohen's (39) guidelines for interpreting effect sizes,reductions in distress (GSI scores) were large for the relaxationgroup (d =.91) and for the MM group (d = 1.36). The GSI effect

size for the control group was small (d = . 27). T hus, effect sizesfor distress were comparable for both intervention groups, withthe MM effect size being somewhat larger. Effect sizes for posi-tive states of mind (PSO M) were above medium for the MMgroup (d = .71) and sm all for the relaxation group (d = .25),whereas the effect size for the control group was virtually zero(d = .03). Thus, the mindfulness group showed considerablylarger effects in increasing positive states of mind as comparedto the relaxation group.Although significant differences for reductions in rum ina-tion and distraction were only found for the MM versus controlgroups, effect sizes were also calculated for relaxation and con-trol group means. Effect sizes for rumination were small to me-dium for the relaxation group (d = . 30) and medium for the me-diation group (d = . 57). The control group, by contrast, showed asmall to medium effect size (d = .33) for rumination in the op-posite direction (rumination increased over time). Effect sizesfor distraction were small for the m editation group (d = .25),who show ed decreases in distraction over time. Interestingly,scores in distraction increased for both the relaxation (d = .19)and control (d = .41) groups. Thus the MM group was uniquein reducing as oppo sed to increasing distraction during the inter-vention period. Finally, effect sizes for INSPIRITR outcomeswere negligible for each group (d = . 02, .06, and .07 for thecontrol, meditation, and relaxation groups, respectively).

DISCUSSIONThis study directly compared two brief (1-month) stress-reduction interventions, each w ith considerably different ap-proaches, for the reduc tion of stress in a student populationstudying health and medicine. Results of this matched random-ized study indicated that, compared with a control group, partic-ipants in the MM and SR groups were successful in alleviatingoverall psychological distress as indexed by the G SI scores ofthe BS I and in increasing positive states of mind as measured bythe PSO M. Effect sizes on distress were large and comparable

for the meditation and relaxation groups (respective Cohen's dswere 1.36 and .91), whereas the me ditation group's effect sizefor positive states of mind was considerably larger than that ofrelaxation (respective Cohen's ds were .71 and .25).N ormative GSI scores for healthy men are reported as .25,and for women as .35 (27 ). Comparison of these normativescores with our data indicates that all students were experi-encing significant amounts of psychological distress pre-intervention (mean preintervention GSI = .66) but that only themeditation group fell to below-norm levels of distress (post-intervention GSI means for the control, relaxation, and medita-tion were .46, .35, and .22 , respectively). The result of loweredpsychological distress for students who underwent the interven-tions, thus, appears to have clinical as well as statistical signifi-cance, especially for students participating in the mindfulnessintervention.


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Volume 33 Number 1 2007indfulness Meditation V ersus Relaxation Training9Effects of MM on improving positive states of mind havebeen reported previously (17) and are replicated here. Althoughone may speculate that the relatively larger increase in PSO Mfor the meditation group versus the relaxation group may be re-lated to the greater practice of cultivating present-momentawareness (and thus being more aware of positive states as theyoccur), the significant increase in PSO M for the relaxationgroup also indicates that increases in positive states of mind arenot necessarily specific to mindfulness practice but may also bedue to more general relax ation effects. Importantly, positive af-fect measures such as the PSOM have been shown to be in-versely related to stress and anxiety (41), and there is mountingevidence that positive affect independently serves as a b ufferagainst deleterious physiological consequences of stress(41,42). Future research would benefit from examining whethermindfulness interventions may reduce physiological conse-quences of stress by enhancing positive affect and well-being.This research could be conducted, for example, via paradigmsthat examine potential immune and affect changes in a chroni-cally stressed population (such as Alzheimer caregivers) in re-sponse to m indfulness training or through ex amining responseto specific laboratory stressor settings (e.g., examining imm uneor cardiovascular responses to an emotionally salient laboratorystressor) before and after mindfulness training. Finally, resultsof this study also suggested a trend for practice effects on posi-tive states of mind for both the relaxation and meditation groups,such that increased practice of either relaxation or meditationtechniques were associated with increases in positive states ofmind. It will be important for future research to e lucidate whichelements of the practices lend themselves to improvem ents inpositive states of mind, as well as optimal dose response interms of practice and outcomes.MM was unique from relaxation in its ability to reduce ru-mination and distraction as compared with the control group.Further, results from this study sugg est that the reductions indistress for the meditation group may be mediated by redu ctionsin rumination. Findings support previous research that MM andrelaxation interventions can alleviate psychological distress inclinical and nonclinical populations (5,9,10,14 ,16,43 ) and lendsupport to the theory that MM interventions may prevent de-pressive relapse by reducing tendencies to lock in to a rumina-tive cognitive cycle (44,45). However, because we did not haveweek ly data on the rumination measures, we were only ableto assess mediation using prepost data, and, thus, thedirectionality of our meditation model requires further valida-tion with longitudinal designs. Further, our assessment of rumi-nation was based on the D ER , which assesses rumination specif-ically in response to depressed mood . Thus, further studiesexamining MM 's potential effects on rumination as a mo reglobal response style or in response to anxiety, anger, or othernegative emotional states are warranted.It is also worth noting that postintervention data were col-lected Ito 2 week s after completion of the last intervention classand just before the final exam period. T his indicates that the de-creases in psychological distress for both groups, and decreasesin distracting and ruminating thoughts and behaviors for the

MM gro up were present even in times of high stress and consid-erably after commencement of the intervention itself.N o significant differences were found between the threegroups in spiritual awareness as indexed by the INSPIR IT R, afinding that is in contrast to previous studies (9). This lack o freplication was not expected and may be due to brevity of the in-tervention (Shapiro, Schwartz & Bonner's [9] intervention con-sisted of 7 weeks as opposed to the 4 weeks in this intervention).The necessitated short duration of the intervention may be seenas a limitation of the study. Other potential limitations includethe possibilities of bias due to a self-selected sam ple and inabil-ity to separate potential nonspecific effects of both interventions(e.g., social support effects due to group form at for both inter-ventions).The reductions in rumination and distraction found for themeditation group might be ex plained by the changes in attentionprocesses that are hypothesized to occur as a result of mindful-ness practice. MM attempts to cultivate nonjudgmental, mo-ment-to-moment awareness to inner as well as outer stimuli.The development of this skill would result in the ability to shiftand redirect attention to the present moment rather than think ingabout past or future experience or otherwise distracting oneselffrom the present moment. O ur findings thus suggest that a po-tential unique mechanism of action for mindfulness trainingmay be its ability to decrease both rumination and distraction,perhaps thereby decreasing psychological distress. MM's abil-ity to decrease ruminative thoughts and thus decrease psycho-logical distress has been sugg ested previously (44,45 ), with atleast one other study with previously depressed patients sup-porting such a contention (22).Further, results from this comparative study indicate that re-ductions in rumination ma y be unique to mindfulness trainingand not simply a consequence of relaxation effects and thatthese reductions in rumination may provide a pathway in re-ducing distress. Our findings have co nsiderable implications,providing an initial step toward understanding possible mech-anisms by which MM may decrease anxiety and depres-sion. However, given that our findings may have limitedgeneralizability, future research should confirm whether theseresults are consistent for populations w ith clinical levels of de-pression or anxiety, as well as examine potential mediating ef-fects of decreased rumination in preventing onset of depressiveepisodes and anxiety disorders in other distressed populations.Interestingly, this study also indicates that participation inthe MM intervention reduced distractive thoughts and behav-iors. Although this finding is understandable given the pres-ent-moment attention practice encouraged in MM, it is yet un-clear what the clinical implications would be should thesedecreases in both rumination and distraction persist in the MMpractitioner over time. Some researchers and theorists assert thatdistraction is a positive coping sk ill for depressive disorders(19,31). O thers suggest that distraction's effects on reducing de-pression may depend on a person's belief and concentrative abil-ity to distract oneself from a negative mood state (46) or on se-verity of depression (47,4 8). If our results are replicated insubsequent mindfulness intervention studies, future studies


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20ain et al nnals o Behavioral Med icinemight compare the effects of mindfulness training with tech-niques that promote distractive coping in distressed populationsto determine whether reduced or increased distractive coping ismore beneficial in relation to reducing distress.

In summary, results from this study indicate that both MMand SR are effective in reducing negative psychological statesand enhancing positive states of mind for students experiencingsignificant distress, although MM appears unique in reducingrumination and distraction compared with relaxation. Compari-sons of effect sizes indicate that mindfulness and relaxation aresimilar with respect to reducing distress; however, mindfulnessappears more effective in enhancing positive states of mind. Inaddition, this study suggests that MM may be unique in its abil-ity to reduce ruminative and distractive responses to depressedmood and that the reductions in rumination during mindfulnesstraining may mediate reductions in distress. Future researchshould confirm and extend these preliminary results.

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Mindfull Study 2007