1. What Is Mindfulness?
Mindfulness, originating from the Buddhist religion, is a form of awareness attained through regular self-
practice (Miller, Fletcher, & Zinn, 1995). Traditionally, mindfulness is practiced through meditation for a
number of years in aim of achieving a higher mental well-being (Chiesa, Anselmi, & Serretti, 2014).
Although in western medicine the objective of mindfulness may not be spiritual, the construct of
mindfulness in the scientific literature is consistent with Buddhist practices (Bishop, 2002).
Mindfulness in western culture can be defined as “dispassionate, non-evaluative and sustained moment-
to-moment awareness of perceptible mental states and processes (Grossman, Niemann, Schmidt &
Walach, 2004). Essentially, it is a mental state in which you are living in the present,or the “now”, as
opposed to being preoccupied with thoughts dealing with past or future. Many people struggle focusing
on the present, and are constantly being interrupted with thoughts irrelevant to the current moment.
Mindfulness is a way to calm the mind and become aware of ones present thoughts and feelings
(Grossman et al, 2004). Mindfulness advises we acknowledge what we are doing in the present, and as a
result, we will gain a better appreciation for the moment thus enjoying it more.
Specific elements of mindfulness are “self-regulation of attention”, usually focusing attention on the
present, and “adoption of a particular attitude toward one’s experiences”,usually marked by acceptance
and openness (Chiesa et al, 2014). It is also notable that mindfulness is non-deliberative, but rather a form
of “naturalistic observation”. Essentially, this means an individual practicing mindfulness is to observe
the thoughts that arise during practice without evaluating them (Grossman et al, 2004).
What is Mindfulness-Based Stress Reduction?
Mindfulness based stress reduction (MBSR) was created by Jon Kabat-Zinn in 1979 at the Center for
Mindfulness at the University of Massachusetts (Evans et al, 2011). It is a practice that utilizes the
fundamental principles of mindfulness. Although there are a variety of mindfulness interventions, MBSR
is the most widespread (Chiesa et al, 2014). It strives to teach patients how to tackle the stress of daily life
through mindful awareness (Grossman,et al 2004). Usually based on an 8-week program, it uses
relaxation and meditation techniques that can be translated into coping mechanisms to deal with stressful
situations (Grossman, et al, 2004). The primary goals being to have patients develop mindfulness
(Bishop, 2002).
Although MBSR programs may vary depending on the institution delivering them, there is a universal
framework proposed by Kabat-Zinn generally used by those offering the program (Nyklíêek, 2008). A
MBSR program is a structured 8 – 10 week group program. Groups usually consist of 10-40 participants,
depending on resources available and demand for the program (Grossman et al, 2004). The sessions are
usually held weekly, for a duration of 2.5 hours. Each session will explore a variety of different
mindfulness exercises at the discretion of the health-care provider. The list of mindfulness exercises that
can be included in a MBSR program is extensive, but all share the common goal of increased
mindfulness. The following are exercises often used in MBSR based off Kabat-Zinn’s program.
Sitting Meditation:In sitting meditation, the participant must focus their attention on
breathing while sitting; either on a chair or crossed-legged on the floor. Any thoughts
drifting into consciousness must be acknowledged, and let go. This pattern is repeated to
ensure participants are learning to appreciate each breath.
Mindful Breathing: Mindful breathing teaches participants awareness and guides them
in focusing on the present moment. Individuals emphasize each breath, gradually
expanding awareness to the whole body.
Progressive Muscle Exercise: In this exercise,participants are asked to first, tense
specific muscles, followed by complete relaxation of them. This exercise aims to
decrease stress tension in participants.

2. Mindful Eating-Raisin Exercise: In this exercise, participants are given a raisin (or
something similar) and asked to observe it slowly, with all their senses. Gradually they
bite into the raisin and swallow it. They then reflect on this experience.
Guided Imagery: Despite it’s title, guided imagery is an exercise involving all the
senses aiming to direct the imagination. It influences the psychological and physiologic
states of participants.
Body Scan: In body scan participants learn to be curious and accepting of their
body. By paying attention to each body part separately, participants learn to compassion
for themselves and their body.
A program director may choose to include all or only some of these components, depending on the
participants needs. Regardless of which exercises are included, all have the objective of cultivating open-
minded and non-judgmental awareness (Nyklíêek, 2008). It should be noted MBSR is based on the
assumption people are generally in “automatic pilot mood”, distracted by thoughts not based on the
present moment (Grossman et al, 2004).
There is an increasing demand for mindfulness interventions in a variety of health care settings; this
consequently increases the amount of programs offered (Nyklíêek, 2008). Over the last 20 years, there has
been a significant increase in the amount of available programs. Over 250 program are available in North
America alone (Minor et al, 2006). At the university of Massachusetts,a professional training program in
MBSR is offered, making MBSR even more ubiquitous (Bisoph, 2002). Recently, there has also been an
increase in availability of publications regarding MBSR (Chiesa et al, 2014). The increase in prevalence
of the programs indicates a positive patient experience.
The interventions may be used to treat a variety of patients with differing needs. It may be used to treat
those suffering from depression, anxiety, bipolar disorder, cancer,fibromyalgia, chronic clinical ailments,
disability, extraordinary stress,or those who are generally healthy but are seeking out solutions to deal
with daily stress. No matter the symptoms or disorder being treated,the goal of mindfulness based stress
reductions is to alleviate the overall stress level of the patient (Nyklíêek, 2008). By training an individual
to practice non-reactive, present moment awareness,a greater appreciation for one’s life can be developed
(Miller et al, 1995). This in turn decreases stress levels,resulting in a better quality of life. MBSR will
prevent the individual from engaging in negative thought patterns (Bishop, 2002).
MBSR programs have been proven to provide a clinically effective treatment for a variety of patients
across healthcare settings (Miller, 1995). Furthermore, many studies have reported a positive clinical
outcome from MBSR training (Chiesa et al, 2014). For example, MBSR has decreased stress and
decreased automatic negative thoughts in patients dealing with a variety of psychological disorders
(Chiesa et al, 2014). There have been many research studies which established MBSR is effective in
managing chronic pain, and in improving symptoms of depression and anxiety (Hazlett-Stevens, 2012).
Clinical benefits are also associated with changes in brain function, an important finding as it
demonstrates physical improvement in patients (Chiesa et al, 2004). Published articles state MBSR
exercises are effective in increasing an individual’s sense of spirituality, self-compassion and positive
state of mind (Chiesa et al, 2014). In a study by Nyklíêek and Kuijpers, participants showed a change in
their ability to accept without judgment, which lead to an improvement in quality of life over time (2008).
When compared with treatment-as-usualcontrolled groups, those receiving MBSR have shown improved
mental health in randomized controlled trials (Hazlett-Stevens, 2012). Asides from MBSR’s benefit to the
patient, it is also a cost-effective treatment option (Miller, 1995). Therefore,there are multiple advantages
both for the patient, and the healthcare team offering the program.
Why MBSR… for anxiety, depression and chronic pain
Mindfulness-Based Stress Reduction (MBSR) has proven to be a valuable intervention for
various aspects of health and well-being. It can be implemented a variety of ways, but consistently
provides significant improvements in quality of life. MBSR has provided convincing results in relation to
reductions in symptoms of anxiety, depression and chronic pain. This literature review will provide

3. details about best practice of MBSR relating to these conditions and validate it as an appropriate
intervention.
Lang (2013) acknowledged mindfulness and MBSR as a favoured choice among professionals in
approaching anxiety and depression interventions, highlighting two mindfulness components that are
exceptionally valuable in this area. First, the development of attentional control relates to the mindfulness
aspect of living in the present moment (Lang, 2013). Neuroimagery and attentional processing data
performed after meditation revealed an increase in the capacity to sustain and direct attention (Lang,
2013). Mood and anxiety disorders are partially attention disorders as patients customarily focus their
attention on thoughts relating to their mood (Lang, 2013). They have the tendency to fixate and then
dwell on anxious and depressive thoughts or information, unable to withdraw from this negativity (Lang,
2013). Ramel et al. published studies demonstrating how decreased rumination is one way that
mindfulness boosts mood as people develop the ability to consciously manage their attention without
harmful deliberation (as cited in Lang, 2013, p. 410). It may be difficult for some to detect the anxiety-
provoking thoughts, but research by Feldman et al. displayed that mindfulness led to greater detection of
ruminative thoughts when compared to other interventions (as cited in Lang, 2013, p. 411). Therefore,
this first component grants them control of their thoughts and releases them from the control of their
mood, which ultimately improves their state of mind.
The second component is a nonjudgmental stance toward internal experiences, which will reduce
unnecessary reactions. It is important for patients to recognize that thoughts do not naturally reflect the
truth as mindfulness allows them to see how numerous thoughts come and go (Lang, 2013). Anxiety often
creates a feeling of fear when internal sensations related to the anxiety response arise which increases
anxiety and these sensations (Lang, 2013). Dwelling on these anxious symptoms validates the fear and
promotes avoidance coping (Lang, 2013). This vicious cycle can be stopped if they nonjudgmentally
notice these sensations and acknowledge them as non-threatening (Lang, 2013). Accepting negative
thoughts in this way will also break the cycle for those suffering with depression, as it will prevent
additional depressive thoughts or self-loathing. The impact of mindfulness on the reduction of
psychological distress, particularly regarding anxiety and depression, is maximized when the relevant
aspects of mindfulness are used.
The term, reperceiving is used to encompass the two previously mentioned components, which
should mediate other changes of mindfulness (Carmody, Baer,Lykins, & Olendzki, 2009). Carmody et al.
(2009) argued that, “if the model is valid, then changes in mindfulness should predict changes in self-
regulation, values clarification, cognitive and behavioral flexibility, and exposure” (p. 615). Various
literary reviews (R. A. Baer,2003; Grossman, Niemann, Schmidt, & Walach, 2004; Salmon et al., 2004)
demonstrated that psychological distress and medical symptoms were reduced after participating in a
MBSR program (Carmody et al., 2009). A study by Carmody and Baer revealed self-reported increases in
daily mindfulness after MBSR participation, which also improved physiological functioning and reduced
stress (as cited in Carmody et al., 2009, p. 614). There is interplay between aspects of mindfulness that
improve well-being and quality of life.
The study performed by Carmody et al. (2009) included participants with anxiety, chronic pain
and employment- and illness-related stress,among other problems. The table below exhibited expected
pre- to post-MBSR changes and the t tests declared the scores to be statistically significant (Carmody et
al., 2009). The Brief Symptom Inventory (BSI) measured symptoms of anxiety and depression while the
Medical Symptom Checklist (MSCL) measured chronic pain, which along with stress were all
significantly reduced. Scales of the Five-Facet Mindfulness Questionnaire (FFMQ) and the Experience
Questionnaire (EQ) measured mindfulness and reperceiving respectively, which both significantly
increased (Carmody et al., 2009). The high correlations between FFMQ and EQ demonstrated the
connection between reperceiving and mindfulness (Carmody et al., 2009). The study’s main limitation
was the reliance on measures that were self-reported,as participants may have felt inclined to offer
positive changes for research purposes (Carmody et al., 2009). However,FFMQ was chosen because of
its reliability and validity, which should offset response biases. Also, self-report measures rarely have

4. problematic responses and they provide many benefits such as feasibility, cost-effectiveness and their
direct approach with participants offers personal experience and perspective (Nunes et al., 2009). The
study’s limitations did not hinder the positive impact of mindfulness on mental health and chronic pain.
Harnett et al. (2010) offered the short-term impact of a MBSR program on depression
and life satisfaction using self-report measures. There was a focus on the importance of mindfulness as a
skill that comes with practice (Harnett et al., 2010). The results of their study proved an, “increase in
mindfulness was a necessary component in achieving clinically significant reduction in psychological
distress” (Harnett et al., 2010, p. 186). Harnett et al. (2010) used the Depression, Anxiety, and Stress
Scale (DASS) to measure psychological distress and the Mindful Attention Awareness Scale (MAAS) to
measure mindfulness. DASS scores had a clinically significant decrease with a correlating increase in
mindfulness in all but one participant for both measures (Harnett et al., 2010). The study displayed the
benefits of mindfulness in reducing anxiety, depression and stress while also improving life satisfaction.
Harnett et al. (2010) proposed their study as a pilot to provide the foundation to build and
implement future programs. As it was intended to show the short-term benefits, which it was successfulin
doing, the results did not supply insight on the lasting effects of MBSR (Harnett et al., 2010). Therefore,
they mentioned the need for follow-up research to determine sustained benefits, especially the impact of a
long-term consistent mindful practice (Harnett et al., 2010). Another limitation mentioned is the absence
of a daily mindfulness log, which would have demonstrated the benefits of regular practice (Harnett et al.,
2010). The MAAS scores may have instead shown more of the understanding of mindfulness as a
construct (Harnett et al., 2010). The study successfully provided a basis for future programs to further
increase mindfulness and reduce harmful symptoms in MBSR setting.
A study by Goldin and Gross (2010) demonstrated the impact of MBSR with clinical, behavioural
and neural methods. Goldin and Gross (2010) also highlighted the importance of attentional control and
decreased rumination for anxiety, specifically social anxiety disorder (SAD). They did include
participants with generalized anxiety disorder and depressive disorder in their study as well (Goldin &
Gross, 2010). A study performed by Koszycki, Benger,Shlik, & Bradwejn found an eight-week MBSR
program to produce lower anxiety scores than a twelve-week cognitive-behavioural group therapy
(CGBT) when reported both by patients and clinicians (as cited in Goldin and Gross, 2010, p. 84). Goldin
and Gross (2010) explained that a MBSR study by Golden et al., “for adults with generalized SAD
showed reduced anxiety, negative self-view, and conceptual–linguistic self-referential processing along
with increased self-esteem and positive self-view” (p. 84). The study by Goldin and Gross (2010) focused
on regulation of negative self-beliefs such as being ashamed of one’s shyness or thinking others
continually judge them. The trial involved reacting to those self-critical beliefs and implementing
attention regulation, which was breath-focused or distraction-focused (Goldin & Gross, 2010). Only
breath-focused attention regulation produced a reduction in negative emotion (Goldin & Gross, 2010).
This MBSR program witnessed increased self-esteem and a reduction in anxiety, depression and
rumination, which were presented in the table below (Goldin & Gross, 2010).
This was a particularly reputable study for a number of reasons. First, it exceeded
previous articles mentioned by including self-report measures along with neuroimaging data (Goldin &
Gross, 2010). Lang (2013) mentioned that neuroimaging is lacking in relation to research on MBSR
interventions as most imaging has solely involved long term practitioners of mindfulness. Goldin and
Gross (2010) used neuroimaging in their MBSR study to support their results. Anxious participants
experienced a significant decrease of emotion-related limbic activity of the right amygdala and an
increase in attention-related brain areas (Goldin & Gross, 2010). Secondly, unlike the 2010 Harnett et al.
study, participants were required to complete weekly hours of individual practice and fill out daily logs
that recorded formal and informal practice (Goldin & Gross, 2010). A limitation of the study was the lack
of a control group and the strict focus on breath-focused attention without investigating other important

5. MBSR activities such as body scan (Goldin & Gross, 2010). However,it provided insight on MBSR
advantages that other studies have not.
The study performed by Nyklicek and Kuijpers (2008) randomly assigned participants
into the intervention or control group (Nyklicek & Kuijpers, 2008). Those in the control group were put
on a wait list to take part in the MBSR program after the intervention group (Nyklicek & Kuijpers, 2008).
The other studies mentioned earlier in this review did not use a control group. Nyklicek and Kuijpers
(2008) analyzed various research studies and came across limitations such as no control group (Kabat-
Zinn, 1982; Chang et al., 2004; Reibel, Greeson, Brainard, & Rosenzweig, 2001), benefits reported from
assorted patient samples and the variety of states and symptoms addressed such as psychological distress
(Astin, 1997; Speca,Carlson, Goodey, & Angen, 2000; Carlson, Speca,Patel, & Goodey, 2003; Shapiro,
Astin, Bishop, & Cordova, 2005), and pain (Kabat-Zinn, 1997; Kabat-Zinn, Lipworth, & Burney, 1985;
Astin et al., 2003). However,MBSR has produced positive results with a diversity of groups (Nyklicek &
Kuijpers, 2008). The main goal of research by Nyklicek and Kuijpers (2008) was to discover if these
results were due to genuine changes in mindfulness skills.
Nyklicek and Kuijpers (2008) focused on perceived stress,vital exhaustion, negative
affect and reversed positive affect score as measures of psychological distress, which decreased for both
groups. However,the intervention group had a greater reduction in distress, increase in quality of life and
increase of mindfulness (Nyklicek & Kuijpers, 2008).
“Increase in general mindfulness, as measured by MAAS, correlated significantly with
decreases in perceived stress (r = 0.28, p = 0.033), vital exhaustion (r = 0.57, p <
0.001), and negative affect (r = 0.30, p = 0.022), as well as with increases in physical,
psychological, and overall quality of life (0.39<0.45, p<0.004). Accept Without
Judgment correlated significantly only with increases in environmental, physical,
psychological, and overall quality of life” (Nyklicek & Kuijpers, 2008, p. 337).
Nyklicek and Kuijpers (2008) replicated preceding MBSR findings decreasing psychological distress
(Astin, 1997; Speca et al., 2000; Shapiro et al., 2005) and increasing quality of life (Carlson et al., 2003;
Brown & Ryan, 2003; Roth & Robbins, 2004). They also extended effects to other measures such as vital
exhaustion, mood and quality of life (Nyklicek & Kuijpers, 2008). In addition, this was the first study to
demonstrate a mediation effect by mindfulness in a controlled study (Nyklicek & Kuijpers, 2008). The
study presented a strong case for the importance of MBSR on psychological distress.
A limitation of the study by Nyklicek and Kuijpers (2008) was the inability to observe
effects beyond immediate window post-intervention. Participants were asked at each session about daily
or home practice relating to previous week instructions (Nyklicek & Kuijpers, 2008). However,the
relation between home practice, attendance and outcome was examined to deliver inconclusive results
because of the small sample size, low initial levels of distress and ceiling effects (Nyklicek & Kuijpers,
2008). The study highlighted the need for additional research to better understand the benefits and
importance of home practice during MBSR programs.
The studies and research mentioned so far have focused on short-term impacts, but
referred to the need for insight on long-term effects. Miller, Fletcher and Kabat-Zinn (1995) performed an
eight-week group MBSR program that displayed clinically and statistically significant enhancements in
symptoms of anxiety and depression. In a three-year follow up study with 82% of the original
participants, there was maintenance of benefits from the first study and ongoing compliance with
mindfulness practice (Miller et al., 1995). This validated the time-limited group MBSR program of
having long-term benefits for those with anxiety and depression (Miller et al., 1995). Research by Plews-
Ogan, Owens,Goodman, Wolfe and Schorling (2005) also discussed the sustainability of benefits of
MBSR. The study exposed the impact of MBSR to be more durable than other de-stress programs like
massage therapy because participants learn a life skill (Plews-Ogan et al., 2005). The positive effect on
mental health appeared persistent after program completion and beneficial effects only grow (Plews-Ogan
et al., 2005). MBSR has proven to be a sustainable intervention for anxiety, depression and chronic pain.

6. Mindfulness and MBSR can have a significant impact on chronic pain via direct pain
reduction and improved quality of life. Other articles mentioned in this review have demonstrated the
benefits of MBSR for chronic pain, but there was an emphasis on psychological distress. Depression and
chronic pain are often comorbidities and psychosocial factors frequently influence chronic pain (Miller et
al., 2005). The goal of the study by Plews-Ogan et al. (2005) was to measure participation in a
randomized MBSR program of chronic pain patients with low socioeconomic status and participation
barriers. Regardless of the obstacles, 76% of patients completed the program, as they recognized the
importance of the program for their health (Plews-Ogan et al., 2005). Participants in the Miller et al.
(1995) study built the capacity to better handle stress,pain and chronic illness by using self-observation
and self-regulation. There is a meaningful relationship between MBSR,mental health and chronic pain
reduction.
Many studies have proven MBSR to be effective in the treatment and care of chronic
pain. A study by Pradhan et al. (2007) randomly assigned rheumatoid arthritis patients into a MBSR or
control group. There was no effect on the disease,but there was a 35% reduction in psychological distress
that was maintained and increased at a 4-month follow-up (Pradham et al., 2007). There is a focus on
psychological distress because mindfulness complements disease management by strengthening well-
being (Pradham et al., 2007). It will indirectly impact the disease as it reduces stress-related progression
and improves pain management (Pradham et al, 2007). A MBSR program for older adults with chronic
lower back pain (CLBP) used indirect and direct pain reduction methods (Morone, Lynch, Greco, Tindle,
& Weiner, 2008). They included distraction, behavior change with body awareness,coping mechanisms
and mediation to directly reduce pain (Morone et al., 2008). The program resulted in improved sleep,
well-being, attention skills and mood which has positive short-term impacts for chronic pain (Morone et
al., 2008). In the long-term, there was improved quality of life and overall the study portrayed
mindfulness as a valuable non-pharmacologic treatment of chronic pain (Morone et al., 2008).
Overall, MBSR has proven to be a strong intervention for psychological distress and
chronic pain. Lang (2013) explained that, “mindfulness can be life-altering, having a dramatic impact
across multiple domains of one’s life” (p. 411). This is portrayed well in MBSR relating to anxiety,
depression and chronic pain as it promotes resilience. There is a powerful connection between these
conditions and stress. Despite,limitations such as self-report measures lack of control groups and short-
term observation, the mentioned studies demonstrated the general positive impact and extensive benefits
that result from MBSR for anxiety, depression and chronic pain.

7. REFERENCES
Lang, A. J. (2013). What mindfulness brings to psychotherapy for anxiety and depression. Depression
and anxiety, 30(5),409-412.
Harnett,P. H.,Whittingham, K., Puhakka, E., Hodges, J., Spry, C.,& Dob, R. (2010). The short-term
impact of a brief group-based mindfulness therapy program on depression and life satisfaction.
Mindfulness,1(3),183-188.
Nunes, V.,Neilson, J., O’Flynn, N., Calvert, N., Kuntze, S., Smithson, H.,Benson, J.,Blair, J., Bowser,
A., Clyne, W., Crome, P.,Haddad, P.,Hemingway, S., Horne, R.,Johnson, S., Kelly, S., Packham,B.,
Patel, M., & Steel, J. (2009). Medicinesadherence: involving patientsin decisions about prescribed
medicines and supporting adherence. London: National Collaborating Centre for Primary Care and Royal
College of General Practitioners.
Goldin, P. R.,& Gross, J. J. (2010). Effects of mindfulness-based stress reduction (MBSR) on emotion
regulation in social anxiety disorder. Emotion, 10(1),83-91.
Nyklicek, I., & Kuijpers, K. F. (2008). Effects of mindfulness-based stress reduction intervention on
psychological well-being and quality of life: is increased mindfulness indeed the mechanism? Annuals of
Behavioral Medicine, 35(3),331-340.
Miller, J. J., Fletcher, K., & Kabat-Zinn, J. (1995). Three-year follow-up and clinical implications of a
mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General
Hospital Psychiatry, 17(3),192-200.
Plews-Ogan,M., Owens,J. E., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: a pilot
study evaluating mindfulness-based stress reduction and massage for the management of chronic pain.
Journal of General Internal Medicine,20(12),1136-1138.
Pradhan,E. K.,Baumgarten, M., Langenberg, P.,Handwerger,B., Gilpin, A. K., Magyari, T., Hochberg,
M. C., & Berman, B. M. (2007). Effect of mindfulness-based stress reduction in rheumatoid arthritis
patients. Arthritis and Rheumatism, 57(7),1134-1142.
Morone, N. E., Lynch, C. S., Greco, C. M., Tindle, H. A.,& Weiner, D. K. (2008). “I felt like a new
person.” The effects of mindfulness meditation on older adults with chronic pain: qualitative narrative
analysis of diary entries. The Journal of Pain, 9(9),841-848.
Carmody, J., Baer,R. A., Lykins, E. L., & Olendzi, N. (2009). An empirical study of the mechanisms of
mindfulness in a mindfulness-based stress reduction program. Journal of Clinical Psychology,65(6),613-
626.