This document summarizes research on the expected outcomes of Mindfulness Based Stress Reduction (MBSR) training. It finds that while MBSR is generally linked to positive changes like reduced depression, anxiety, and increased empathy, there is limited neurological evidence to explain these outcomes. The document reviews studies on modified MBSR programs and their efficacy, as well as subjective outcomes like improved sleep quality and increased ability to accept pain. Overall, the research suggests MBSR shows promise but more long-term studies are needed to understand its full structural and functional impacts.
Enhancing Awareness of Yoga in Health Professions Education Students through ...Yogacharya AB Bhavanani
Yogachemmal G Dayanidy's presentation during the Fourth National Conference – Authentic Learning Innovations for 21st Century Medicos – organised by medical education unit of the Mahatma Gandhi Medical College and Research Institute, a constituent college of Sri Balaji Vidyapeeth, in Puducherry on 30 June 2018.
Integrative Nursing: Effects on a training reflexology programNeus Esmel-Esmel
Reflexology, as a modality of Integrative Medicine, recognizes the importance of the person from a comprehensive and non-invasive care, enhancing the search for a physical, emotional and spiritual balance.
The aim of this study was to evaluate the effects of a training program that introduces reflexology as an integrative modality in nursing degree education.
Descriptive observational stud, in which 85 students participated. The students responded the SF12v2 health questionnaire and the TMMS24 emotional intelligence questionnaire pre-post the teaching program. The perceived effects during and among sessions were also collected. Their personal experience was collected as well through their own stories.
Conclusions. Reflexology promotes physical and emotional well-being, facilitating an integrative understanding of the body and health. It is necessary to include them in the health science teaching programs.
Regular practice of yoga promotes strength, endurance, flexibility and facilitates characteristics of friendliness, compassion & self-control. So this study was conducted to find out the effect of yoga on anxiety. This study was conducted on 200 anxiety cases having age range of 18 to 55 years. Hamilton anxiety scale was used to measure the anxiety. These cases were divide into two group randomly i.e. study group and control group. Study group was given certain set of yogic exercise. Both the groups were followed and results were compared where independent variables yoga and dependent variable Anxiety was used. Chi-square, independent t test, was used for data analysis. It was observed that Anxiety was significantly decreased after the yogic intervention (P=0.042S). So it can be concluded that yoga can reduce perceived stress improve well-being even more significantly so its recommend to do yoga regularly.
Efficacy of classification-based_cft_in_nsclbpMeziat
Artigo (6) importante para a preparação para o curso de dor lombar crônica. "Eficácia da Terapia Cognitiva Funcional em pacientes com dor lombar crônica inespecífica: ensaio clínico randomizado controlado."
EFFECTIVENESS OF ADJUVANT YOGA THERAPY IN DIABETIC LUNG: A RANDOMIZED CONTROL...Yogacharya AB Bhavanani
EFFECTIVENESS OF ADJUVANT YOGA THERAPY IN DIABETIC LUNG: A RANDOMIZED CONTROL TRIAL
Balaji Rajasekaran1, Ananda Balayogi Bhavanani2, Meena Ramanathan3
1 Assistant Professor, Centre for Yogic sciences, Aarupadai Veedu Medical Colleges, Vinayaka Missions Research Foundation, Pondicherry
2 & 3 Director and Deputy Director, Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Pondicherry.
E-mail of presenter: balaji.rajasekaran@avmc.edu.in
Abstract:
Context: Recent studies provide ample evidence of the benefits of yoga in various chronic disorders. Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia and Sandler coined the term “Diabetic Lung" for the abnormal pulmonary function detected in diabetic patients due underlying pulmonary dysfunction. Yoga therapy may help in achieving better pulmonary function along with enhanced glycaemic control and overall health benefits.
Aim: To study the effect of adjuvant yoga therapy in diabetic lung through spirometry.
Settings and Design: Randomized control trial done as interdisciplinary collaborative work between Yoga Therapy, Pulmonary Medicine and Endocrinology departments of MGMC & RI, Sri Balaji Vidyapeeth Puducherry.
Materials and Methods: 72 patients of diabetic lung as confirmed by spirometry (<70% of expected) were randomized and divided equally into control group who received only standard medical treatment and yoga group who received yoga training thrice weekly for 4 months along with that. Yoga therapy protocol included yogic counseling, preparatory practices, Asanas or static postures, Pranayama or breathing techniques and relaxation techniques. Hathenas of the Gitananda Yoga tradition were the main practices used. Spirometry was done at the end of the study period. Data was analyzed by Student’s paired and unpaired ’t’ test as it passed normality.
Results: There was a statistically significant (p < 0.05) reduction in weight, BMI along with a significant (p < 0.01) improvement in pulmonary function (FEV1, FVC) in yoga group as compared to control group where parameters worsened over study period.
Conclusion: It is concluded from the present RCT that yoga has a definite role as an adjuvant therapy as it enhances standard medical care and hence is even more significant in routine clinical management of diabetes, improving physical condition and pulmonary function.
Key words: diabetic lung, PFT, hathenas, yoga therapy
Find out the benefits of yoga and mindfulness meditation and the university studies demonstrating a range of mental and emotional benefits for individuals and the workplace.
Learn how mindfulness-based stress reduction (MBSR) can help relax your body, calm your mind and spirit, and reduce overall stress. Our meditation techniques are ideal for women and men coping with chronic anxiety, illness, and pain.
Enhancing Awareness of Yoga in Health Professions Education Students through ...Yogacharya AB Bhavanani
Yogachemmal G Dayanidy's presentation during the Fourth National Conference – Authentic Learning Innovations for 21st Century Medicos – organised by medical education unit of the Mahatma Gandhi Medical College and Research Institute, a constituent college of Sri Balaji Vidyapeeth, in Puducherry on 30 June 2018.
Integrative Nursing: Effects on a training reflexology programNeus Esmel-Esmel
Reflexology, as a modality of Integrative Medicine, recognizes the importance of the person from a comprehensive and non-invasive care, enhancing the search for a physical, emotional and spiritual balance.
The aim of this study was to evaluate the effects of a training program that introduces reflexology as an integrative modality in nursing degree education.
Descriptive observational stud, in which 85 students participated. The students responded the SF12v2 health questionnaire and the TMMS24 emotional intelligence questionnaire pre-post the teaching program. The perceived effects during and among sessions were also collected. Their personal experience was collected as well through their own stories.
Conclusions. Reflexology promotes physical and emotional well-being, facilitating an integrative understanding of the body and health. It is necessary to include them in the health science teaching programs.
Regular practice of yoga promotes strength, endurance, flexibility and facilitates characteristics of friendliness, compassion & self-control. So this study was conducted to find out the effect of yoga on anxiety. This study was conducted on 200 anxiety cases having age range of 18 to 55 years. Hamilton anxiety scale was used to measure the anxiety. These cases were divide into two group randomly i.e. study group and control group. Study group was given certain set of yogic exercise. Both the groups were followed and results were compared where independent variables yoga and dependent variable Anxiety was used. Chi-square, independent t test, was used for data analysis. It was observed that Anxiety was significantly decreased after the yogic intervention (P=0.042S). So it can be concluded that yoga can reduce perceived stress improve well-being even more significantly so its recommend to do yoga regularly.
Efficacy of classification-based_cft_in_nsclbpMeziat
Artigo (6) importante para a preparação para o curso de dor lombar crônica. "Eficácia da Terapia Cognitiva Funcional em pacientes com dor lombar crônica inespecífica: ensaio clínico randomizado controlado."
EFFECTIVENESS OF ADJUVANT YOGA THERAPY IN DIABETIC LUNG: A RANDOMIZED CONTROL...Yogacharya AB Bhavanani
EFFECTIVENESS OF ADJUVANT YOGA THERAPY IN DIABETIC LUNG: A RANDOMIZED CONTROL TRIAL
Balaji Rajasekaran1, Ananda Balayogi Bhavanani2, Meena Ramanathan3
1 Assistant Professor, Centre for Yogic sciences, Aarupadai Veedu Medical Colleges, Vinayaka Missions Research Foundation, Pondicherry
2 & 3 Director and Deputy Director, Centre for Yoga Therapy, Education and Research, Sri Balaji Vidyapeeth, Pondicherry.
E-mail of presenter: balaji.rajasekaran@avmc.edu.in
Abstract:
Context: Recent studies provide ample evidence of the benefits of yoga in various chronic disorders. Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia and Sandler coined the term “Diabetic Lung" for the abnormal pulmonary function detected in diabetic patients due underlying pulmonary dysfunction. Yoga therapy may help in achieving better pulmonary function along with enhanced glycaemic control and overall health benefits.
Aim: To study the effect of adjuvant yoga therapy in diabetic lung through spirometry.
Settings and Design: Randomized control trial done as interdisciplinary collaborative work between Yoga Therapy, Pulmonary Medicine and Endocrinology departments of MGMC & RI, Sri Balaji Vidyapeeth Puducherry.
Materials and Methods: 72 patients of diabetic lung as confirmed by spirometry (<70% of expected) were randomized and divided equally into control group who received only standard medical treatment and yoga group who received yoga training thrice weekly for 4 months along with that. Yoga therapy protocol included yogic counseling, preparatory practices, Asanas or static postures, Pranayama or breathing techniques and relaxation techniques. Hathenas of the Gitananda Yoga tradition were the main practices used. Spirometry was done at the end of the study period. Data was analyzed by Student’s paired and unpaired ’t’ test as it passed normality.
Results: There was a statistically significant (p < 0.05) reduction in weight, BMI along with a significant (p < 0.01) improvement in pulmonary function (FEV1, FVC) in yoga group as compared to control group where parameters worsened over study period.
Conclusion: It is concluded from the present RCT that yoga has a definite role as an adjuvant therapy as it enhances standard medical care and hence is even more significant in routine clinical management of diabetes, improving physical condition and pulmonary function.
Key words: diabetic lung, PFT, hathenas, yoga therapy
Find out the benefits of yoga and mindfulness meditation and the university studies demonstrating a range of mental and emotional benefits for individuals and the workplace.
Learn how mindfulness-based stress reduction (MBSR) can help relax your body, calm your mind and spirit, and reduce overall stress. Our meditation techniques are ideal for women and men coping with chronic anxiety, illness, and pain.
Mindfulness at Work: Navigating Multitasking With Focus & EaseShalini Bahl
This is a webinar I did for AllOne Health’s clients on mindfulness at work and how it enhances the ability to focus and well being. If you would like to see the full webinar please visit the website:
http://mindfuluniverse.com/video/mindfulness-at-work-new-approaches-to-maximize-focus If you would like the slides please let me know and I will be happy to email you a copy
1 Guided Imagery and Progressive Muscle Relaxation.docxkarisariddell
1
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
Hannah K. Greenbaum
George Washington University
PSYC 3170: Clinical Psychology
Dr. Tia M. Benedetto
October 1, 2019
2
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
A majority of Americans experience stress in their daily lives (American Psychological
Association, 2017). Thus, an important goal of psychological research is to evaluate techniques
that promote stress reduction and relaxation. Two techniques that have been associated with
reduced stress and increased relaxation in psychotherapy contexts are guided imagery and
progressive muscle relaxation (McGuigan & Lehrer, 2007). Guided imagery aids individuals in
connecting their internal and external experiences, allowing them, for example, to feel calmer
externally because they practice thinking about calming imagery. Progressive muscle relaxation
involves diaphragmatic breathing and the tensing and releasing of 16 major muscle groups;
together these behaviors lead individuals to a more relaxed state (Jacobson, 1938; Trakhtenberg,
2008). Guided imagery and progressive muscle relaxation are both cognitive behavioral
techniques (Yalom & Leszcz, 2005) in which individuals focus on the relationship among
thoughts, emotions, and behaviors (White, 2000).
Group psychotherapy effectively promotes positive treatment outcomes in patients in a
cost-effective way. Its efficacy is in part attributable to variables unique to the group experience
of therapy as compared with individual psychotherapy (Bottomley, 1996; Yalom & Leszcz,
2005). That is, the group format helps participants feel accepted and better understand their
common struggles; at the same time, interactions with group members provide social support and
models of positive behavior (Yalom & Leszcz, 2005). Thus, it is useful to examine how stress
reduction and relaxation can be enhanced in a group context.
The purpose of this literature review is to examine the research base on guided imagery
and progressive muscle relaxation in group psychotherapy contexts. I provide overviews of both
guided imagery and progressive muscle relaxation, including theoretical foundations and
3
historical context. Then I examine guided imagery and progressive muscle relaxation as used on
their own as well as in combination as part of group psychotherapy (see Baider et al., 1994, for
more). Throughout the review, I highlight themes in the research. Finally, I end by pointing out
limitations in the existing literature and exploring potential directions for future research.
Guided Imagery
Features of Guided Imagery
Guided imagery involves a person visualizing a mental image and engaging each sense
(e.g., sight, smell, touch) in the process. Guided imagery was first examined in a psychological
context in the 1960s, when the behavior theorist Joseph Wolpe helped pioneer the use .
1 Guided Imagery and Progressive Muscle Relaxation.docxjeremylockett77
1
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
Hannah K. Greenbaum
George Washington University
PSYC 3170: Clinical Psychology
Dr. Tia M. Benedetto
October 1, 2019
2
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
A majority of Americans experience stress in their daily lives (American Psychological
Association, 2017). Thus, an important goal of psychological research is to evaluate techniques
that promote stress reduction and relaxation. Two techniques that have been associated with
reduced stress and increased relaxation in psychotherapy contexts are guided imagery and
progressive muscle relaxation (McGuigan & Lehrer, 2007). Guided imagery aids individuals in
connecting their internal and external experiences, allowing them, for example, to feel calmer
externally because they practice thinking about calming imagery. Progressive muscle relaxation
involves diaphragmatic breathing and the tensing and releasing of 16 major muscle groups;
together these behaviors lead individuals to a more relaxed state (Jacobson, 1938; Trakhtenberg,
2008). Guided imagery and progressive muscle relaxation are both cognitive behavioral
techniques (Yalom & Leszcz, 2005) in which individuals focus on the relationship among
thoughts, emotions, and behaviors (White, 2000).
Group psychotherapy effectively promotes positive treatment outcomes in patients in a
cost-effective way. Its efficacy is in part attributable to variables unique to the group experience
of therapy as compared with individual psychotherapy (Bottomley, 1996; Yalom & Leszcz,
2005). That is, the group format helps participants feel accepted and better understand their
common struggles; at the same time, interactions with group members provide social support and
models of positive behavior (Yalom & Leszcz, 2005). Thus, it is useful to examine how stress
reduction and relaxation can be enhanced in a group context.
The purpose of this literature review is to examine the research base on guided imagery
and progressive muscle relaxation in group psychotherapy contexts. I provide overviews of both
guided imagery and progressive muscle relaxation, including theoretical foundations and
3
historical context. Then I examine guided imagery and progressive muscle relaxation as used on
their own as well as in combination as part of group psychotherapy (see Baider et al., 1994, for
more). Throughout the review, I highlight themes in the research. Finally, I end by pointing out
limitations in the existing literature and exploring potential directions for future research.
Guided Imagery
Features of Guided Imagery
Guided imagery involves a person visualizing a mental image and engaging each sense
(e.g., sight, smell, touch) in the process. Guided imagery was first examined in a psychological
context in the 1960s, when the behavior theorist Joseph Wolpe helped pioneer the use ...
1 Guided Imagery and Progressive Muscle Relaxation.docxcroftsshanon
1
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
Hannah K. Greenbaum
George Washington University
PSYC 3170: Clinical Psychology
Dr. Tia M. Benedetto
October 1, 2019
2
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
A majority of Americans experience stress in their daily lives (American Psychological
Association, 2017). Thus, an important goal of psychological research is to evaluate techniques
that promote stress reduction and relaxation. Two techniques that have been associated with
reduced stress and increased relaxation in psychotherapy contexts are guided imagery and
progressive muscle relaxation (McGuigan & Lehrer, 2007). Guided imagery aids individuals in
connecting their internal and external experiences, allowing them, for example, to feel calmer
externally because they practice thinking about calming imagery. Progressive muscle relaxation
involves diaphragmatic breathing and the tensing and releasing of 16 major muscle groups;
together these behaviors lead individuals to a more relaxed state (Jacobson, 1938; Trakhtenberg,
2008). Guided imagery and progressive muscle relaxation are both cognitive behavioral
techniques (Yalom & Leszcz, 2005) in which individuals focus on the relationship among
thoughts, emotions, and behaviors (White, 2000).
Group psychotherapy effectively promotes positive treatment outcomes in patients in a
cost-effective way. Its efficacy is in part attributable to variables unique to the group experience
of therapy as compared with individual psychotherapy (Bottomley, 1996; Yalom & Leszcz,
2005). That is, the group format helps participants feel accepted and better understand their
common struggles; at the same time, interactions with group members provide social support and
models of positive behavior (Yalom & Leszcz, 2005). Thus, it is useful to examine how stress
reduction and relaxation can be enhanced in a group context.
The purpose of this literature review is to examine the research base on guided imagery
and progressive muscle relaxation in group psychotherapy contexts. I provide overviews of both
guided imagery and progressive muscle relaxation, including theoretical foundations and
3
historical context. Then I examine guided imagery and progressive muscle relaxation as used on
their own as well as in combination as part of group psychotherapy (see Baider et al., 1994, for
more). Throughout the review, I highlight themes in the research. Finally, I end by pointing out
limitations in the existing literature and exploring potential directions for future research.
Guided Imagery
Features of Guided Imagery
Guided imagery involves a person visualizing a mental image and engaging each sense
(e.g., sight, smell, touch) in the process. Guided imagery was first examined in a psychological
context in the 1960s, when the behavior theorist Joseph Wolpe helped pioneer the use .
1 Guided Imagery and Progressive Muscle Relaxation.docxaulasnilda
1
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
Hannah K. Greenbaum
George Washington University
PSYC 3170: Clinical Psychology
Dr. Tia M. Benedetto
October 1, 2019
2
Guided Imagery and Progressive Muscle Relaxation in Group Psychotherapy
A majority of Americans experience stress in their daily lives (American Psychological
Association, 2017). Thus, an important goal of psychological research is to evaluate techniques
that promote stress reduction and relaxation. Two techniques that have been associated with
reduced stress and increased relaxation in psychotherapy contexts are guided imagery and
progressive muscle relaxation (McGuigan & Lehrer, 2007). Guided imagery aids individuals in
connecting their internal and external experiences, allowing them, for example, to feel calmer
externally because they practice thinking about calming imagery. Progressive muscle relaxation
involves diaphragmatic breathing and the tensing and releasing of 16 major muscle groups;
together these behaviors lead individuals to a more relaxed state (Jacobson, 1938; Trakhtenberg,
2008). Guided imagery and progressive muscle relaxation are both cognitive behavioral
techniques (Yalom & Leszcz, 2005) in which individuals focus on the relationship among
thoughts, emotions, and behaviors (White, 2000).
Group psychotherapy effectively promotes positive treatment outcomes in patients in a
cost-effective way. Its efficacy is in part attributable to variables unique to the group experience
of therapy as compared with individual psychotherapy (Bottomley, 1996; Yalom & Leszcz,
2005). That is, the group format helps participants feel accepted and better understand their
common struggles; at the same time, interactions with group members provide social support and
models of positive behavior (Yalom & Leszcz, 2005). Thus, it is useful to examine how stress
reduction and relaxation can be enhanced in a group context.
The purpose of this literature review is to examine the research base on guided imagery
and progressive muscle relaxation in group psychotherapy contexts. I provide overviews of both
guided imagery and progressive muscle relaxation, including theoretical foundations and
3
historical context. Then I examine guided imagery and progressive muscle relaxation as used on
their own as well as in combination as part of group psychotherapy (see Baider et al., 1994, for
more). Throughout the review, I highlight themes in the research. Finally, I end by pointing out
limitations in the existing literature and exploring potential directions for future research.
Guided Imagery
Features of Guided Imagery
Guided imagery involves a person visualizing a mental image and engaging each sense
(e.g., sight, smell, touch) in the process. Guided imagery was first examined in a psychological
context in the 1960s, when the behavior theorist Joseph Wolpe helped pioneer the use .
As her final thesis topic for London College of Osteopathy and Health Sciences (LCO) Diploma in Osteopathic Manual Practice (DOMP) program, Dr. Fadila Naji examines the effects of osteopathy on patients' psychology.
Effects of an Intensive 3-Week Yoga Retreat on Sense of Well Being in Cancer ...Yogacharya AB Bhavanani
Introduction: Cancer survivors are often severely affected physically, mentally and emotionally after passing through modern medical treatments. As Yoga conjointly emphasizes body-mind-spirit thus enhancing physical, mental, social and spiritual well-being, Kaivalyadhama Yoga Institute in Lonavla, India initiated a three week residential intensive retreat for cancer survivors to empower them in their journey, “back to health and wellbeing”. The aims and objectives of the present study is to evaluate the effects of this residential program for cancer patients on their psychological well being, and determine if or not these effects were sustained at follow up after three months.
Materials and Methods: The modes of reintegration used in this program were designed to specifically address the multidimensional needs of cancer survivors and incorporated various Yogic techniques including Asana, Pranayama, Mudra, Bandha, relaxation, silent meditation and chanting as well as education given in a group setting. Three standard psychological evaluation tools were used: WHO Quality of Life-BREF (WHOQOL-BREF), Profile of Mood States (POMS) and Hospital Anxiety and Depression Score (HADS). These were administered on first (D1) and last days (D20) of the program and repeated at follow up three months later (3M). Pre and post retreat (D1-D20) data was analyzed for 26 subjects using Students paired t-test while RMANOVA was used to compare pre-post retreat and follow up data of 19 subjects.
Results: Significant improvements were seen in all domains of QOL with significant reduction in all negative psychological states and improvement in vigour and total POMS score. There was significant decrease in anxiety, depression and overall rating on HADS with marked decrease in anxiety compared to depression. In pre-post and follow-up (D1, D20 and 3M) comparisons for 19 subjects, all components showed significant changes except social QOL. Though some of the benefits of the retreat are lost during follow up, none of the values reached level of significance except in anger subscale and even that was still lower than at start of retreat.
Discussion and Conclusion: The present study offers evidence of the beneficial psychological changes occurring after a three week intensive retreat for cancer survivors. This is in tune with previous reports. One of the biggest benefits may actually lie in the empowerment of the participants as they are given tools, which make them feel in control of their health and wellbeing. Changes are maintained in those who continue the practices even at three months follow up but are lost slowly in those who discontinued them. Even then, all parameters at three months follow up are still positive as compared to pre-retreat values. More rigorous and randomized controlled studies are required to validate these results in the future.
Abstract
Background: Across the country, nursing students are experiencing alarming amounts of stress. While stress is a common phenomenon, it has been shown to negatively impact nursing student performance and general health. One solution to this issue is mindfulness-based stress reduction (MBSR). Reported effects of MBSR include stress reduction; mindfulness; improvements in self-esteem; increase in general health; a decrease in anxiety; and an increase in empathy. Because MBSR is not widely included in nursing curricula, students are not learning stress reduction techniques needed to manage daily stress. Purpose: To address this gap, a DNP project was implemented at a university site. The project’s purpose was two-fold: To increase the knowledge of faculty and to provide educational resources for students. Methods: A toolkit was developed that included a Power Point presentation for faculty; a copy of the Perceived Stress Scale (PSS); and handouts on stress and MBSR techniques for students. Thirty-four faculty in an online family nurse practitioner program were offered the toolkit at one university in California; five faculty participated and completed the surveys. Results: Valuable data was obtained on the effectiveness of the presentation on faculty knowledge, perception, acceptance, and willingness to use the resources provided. Conclusion: When provided with a toolkit on stress and MBSR techniques, faculty became more aware of the significance of stress and stated they were willing to utilize the resources provided in future online classes.
1. Running Head: EXPLORING EXPECTED OUTCOMES 1
Exploring Expected Structural and Functional Outcomes of
Mindfulness Based Stress Reduction (MBSR) Training
Kyri Barilone
Johnson & Wales University
2. EXPLORING EXPECTED OUTCOMES 2
Exploring Expected Structural and Functional Outcomes of
Mindfulness Based Stress Reduction (MBSR) Training
Introduction
As the popularity of Eastern medicine practices and holistic health models are increasing
in Western culture, the use of mindfulness training is also rapidly increasing. As it is traditionally
referred to in Western psychological theory, Mindfulness Based Stress Reduction (MBSR) is the
process of working to gain moment-to-moment awareness in order to increase the ability to cope
in stressful situations (Kabat-Zinn, 1990). To do so, participants generally aim to observe
thoughts, feelings, and sensations in the present moment without judgment (Kabat-Zinn, 1990)
that is typically seen in the form of labeling these experiences as “good” or “bad.”
However, while MBSR is generally considered effective as a result of being linked to
positive changes in depression, anxiety, stress, empathy, self-compassion, etc. (Dobkin &
Hutchinson, 2013), there is insufficient data to support clinically accepted outcomes based on
neurological evidence. More specifically, there is a lack of empirical data to support common
structural and functional brain changes, and the resulting behavioral and cognitive changes,
associated with MBSR practice.
Background
Programs and Efficacy
While the traditional Kabat-Zinn (1990) model of MBSR training is comprised of eight
weekly 2-2½ hour sessions as well as a six hour retreat toward the end of the program, there are
numerous variations on this program that do not have a significant effect on outcomes.
Additionally, while the traditional model consists of sitting meditation, progressive awareness or
muscle relaxation, and gentle yoga (Kabat-Zinn, 1990), other mindfulness activities have also
3. EXPLORING EXPECTED OUTCOMES 3
proven effective. As such, mindfulness programs can be modified in order to accommodate
populations with various needs and assets.
As the MBSR program was designed to provide enough time for participants to grasp the
concepts of mindfulness and become autonomous in practicing these skills (Kabat-Zinn, 1982),
there is little empirical evidence regarding the required length to achieve these outcomes.
Because a common barrier to treatment is lack of time, one study on mindfulness was aimed at
understanding whether a shortened program could provide the same benefits as the traditional
eight-week model (Carmody & Baer, 2009). While the traditional model is still the most well
studied and empirically backed, this study demonstrated that mean contact hours and mean effect
were not significantly correlated. As such, the researchers argued that shorter programs or
programs that are modified to include fewer contact hours may be beneficial for populations who
do not have the time to complete a traditional eight-week model (Carmody & Baer, 2009). For
many individuals who feel they do not have the time to devote to the original eight-week model,
this information may provide a renewed opportunity for treatment.
Additionally, while mindfulness is often regarded as a solitary task, the idea of working
with others to improve MBSR skills has also proven an effective method. In a study that
explored a community-based approach to developing an MBSR program for parents and
caretakers of children with disabilities, caregivers partnered with researchers to develop a
program unique to their needs (Bazzano et al., 2015). In order to decrease stress in parents and
caretakers who may be overwhelmed with their responsibilities and anxiety over past and future
traumas, a curriculum was designed consisting of two daily class offerings each including
meditation practice, discussion around stressors and challenges, and gentle stretching (Bazzano
et al., 2015). As results showed a significant reduction in stress at the end of the eight-week trial
4. EXPLORING EXPECTED OUTCOMES 4
as well as at two months after the conclusion of the trial (Bazzano et al., 2015), it is clear that
this integration of a community-based approach is not a constraint to the efficacy of MBSR
training.
However, due to the lack of empirical data on long-term outcomes of Mindfulness Based
Stress Reduction, a group of researchers suggested a longitudinal study (Sarenmalm et al., 2013).
In this clinical randomized controlled trial, patients diagnosed with breast cancer would be
assigned to one of three groups: MBSR Intervention I (weekly group session and self instruction
program), MBSR Intervention II (self-instruction program only), or a control group (no MBSR
instruction) (Sarenmalm et al., 2013). In order to study the long-term effects, data would be
collected on participant well-being and immune response at baseline, 3, 6, and 12 months as well
as yearly for an additional four years in order to gain a long-term view of the changes related to
mindfulness that are not often depicted.
Of course, the most important factor in assessing an MBSR program is its efficacy. While
each MBSR program and study will inevitably result in different outcomes, there is a great deal
of consistency regarding how well MBSR programs work at achieving their desired outcomes. In
one study designed to examine potential psychological health benefits of a five-week MBSR
program, a curriculum consisting of two hours weekly for five weeks was implemented (Bergen-
Cico, Possemato, & Cheon, 2013). The curriculum included five hours of practice (sitting
meditation/breath work, body scan, moving meditation), and five hours of discussion integrated
into an academic course on addictive behaviors. At the close of the trial, results on the Kentucky
Inventory of Mindfulness Scale (KIMS) showed a statistically significant increase in
mindfulness (Bergen-Cico et al., 2013). However, while psychological distress described by trait
anxiety score was not statistically significant, psychological health improvement was
5. EXPLORING EXPECTED OUTCOMES 5
demonstrated by statistically significant improvement in scores for Observing, Acceptance,
Common Humanity, Isolation, and Self-judgment (Bergen-Cico et al., 2013).
While many studies focus on the observable effects of MBSR on participants, few focus
on the reasons these effects take place. As such, another study explored the relationship between
spirituality, mindfulness practice, and mental health (Greeson et al., 2011). While the original
hypothesis that changes in mindfulness following an MBSR program might explain changes in
spirituality, and therefore changes in quality of life, was not entirely supported by the results,
another model was consider a better fit. Instead, it was determined that MBSR-related increases
in spirituality and increases in mindfulness could have a reciprocal relationship with one another
(Greeson et al., 2011). As such, it is a possibility that mindfulness practices based on some
aspect of spirituality may have a positive effect on participant quality of life.
Subjective Outcomes
Because MBSR is associated with stress management and decreased arousal, a study was
conducted in order to assess the efficacy of MBSR in treating these symptoms in relation to
insomnia (Cincotta, Gehrman, Gooneratne & Baime, 2011). After undergoing the traditional
eight-week program of MBSR, participants showed lower levels of pre-sleep arousal and
insomnia symptoms based on self-reports (Cincotta et al., 2011). Although there were no
significant objective changes as measured by actigraphy, the results showed that subjective
changes alone might lead to perceived relief from insomnia symptoms (Cincotta et al., 2011),
thus allowing insomnia patients to have an easier time falling asleep.
Similarly, because cancer patients often experience sleep disturbance for years after
treatment, another study was aimed at discovering whether an MBSR intervention could improve
sleep quality (Andersen et al., 2013). Participants were randomly assigned to either an MBSR
6. EXPLORING EXPECTED OUTCOMES 6
program consisting of psycho-education, meditation, and gentle yoga or a control group where
they receive treatment as usual; using the Medical Outcome Study sleep scale, sleep quality was
measured at baseline, at the conclusion of the treatment, and at six and twelve months post-
treatment (Andersen et al., 2013). The results showed a significant improvement in sleep quality
post treatment, with the highest increase seen in those participants with the most severe
symptoms, but no long term changes (Andersen et al., 2013), which is evidence that continued
mindfulness practice could have a lasting effect on the sleep quality of patients suffering from
cancer and other medical conditions that result in sleep disruptions.
Unfortunately, one systematic review of MBSR for low back pain based on three
randomized controlled trials found mixed results with one set of findings showing short-term
improvements in pain intensity and disability and another showing no short-term or long-term
improvements (Cramer, Haller, Lauche & Dobos, 2012). However, two additional larger RCTs
found short-term improvements of pain acceptance (Cramer et al., 2012). Overall, while these
findings provide inconclusive evidence for the efficacy of MBSR as a treatment for low back
pain, they did show a possibility that MBSR is effective in improving pain acceptance (Cramer et
al., 2012). Though this would not provide an actual decrease in pain, it demonstrates that MBSR
may provide some relief for individuals suffering from chronic pain.
Another area of mental health that has seen improvement through MBSR is Post
Traumatic Stress Disorder. In a study on the efficacy of mindfulness on PTSD symptoms in
survivors of childhood sexual abuse, adult survivors of childhood sexual abuse were recruited for
an eight-week program which consisted of 2.5-3 hour classes on sitting meditation, progressive
body awareness, walking meditation, and gentle yoga (Kimbrough, Magyari, Langenberg,
Chesney & Berman, 2010). Additionally, participants attended a 5-hour silent retreat and were
7. EXPLORING EXPECTED OUTCOMES 7
asked to practice informal mindfulness during daily activities in their home lives. Measurements
taken at baseline, 4 8, and 24 weeks showed statistically significant improvements in depressive
symptoms (65%) as well as improvement in the PTSD symptom criteria of avoidance/numbing
(Kimbrough et al., 2010). While this specific study focused on PTSD in childhood sexual abuse
survivors, the same principles could be applied to individuals suffering from PTSD for a variety
of reasons.
Similarly, in one study participants underwent the traditional Kabat-Zinn (1990) eight-
week MBSR program model while being assessed daily for changes in mindfulness, positive
affect, and negative affect (Snippe, Nyklíček, Schroevers & Bos, 2015). As was expected by the
researchers, the outcomes showed that changes in mindfulness precede rather than follow
changes in affect on a daily basis (Snippe et al., 2015). Additionally, the same-day correlations
between mindfulness and positive and negative affect were 0.45 and -0.47 (Snippe et al., 2015).
Interestingly, this data might mean that mindfulness practice is related to reduced negative affect
at the same or an increased degree to which it is related to increased positive affect.
Another study focused on individuals who had experienced a stroke or traumatic brain
injury and had been physically rehabilitated with no residual gross impairments (Johansson,
Bjuhr & Rönnbäck, 2012). Because these individuals suffer from increased mental fatigue from
which there was previously no effective treatment, researchers hoped that MBSR could improve
mental stamina in these patients. At the close of the trial, researchers were able to discern that
participation in the eight-week MBSR program did result in significant improvement on a self-
assessment on mental fatigue as well as on two neurological tests: Digit Symbol-Coding and the
Trail Making Test (Johansson et al., 2012). While this specific study focused on mental fatigue
8. EXPLORING EXPECTED OUTCOMES 8
in stroke and traumatic brain injury patients, these same improvements might also bee seen in
individuals who suffer from mental fatigue for a variety of other reasons.
Objective Outcomes
In order to examine the physiological effects of an MBSR program on cardiovascular and
cortisol activity during acute stress, a sample of healthy individuals with self-reported elevated
stress levels were randomly assigned to an MBSR group and a waitlist control group (Nyklíček,
Mommersteeg, Van Beugen, Ramakers & Van Boxtel, 2013). After using the standard MBSR
intervention (Kabat-Zinn, 1990), participants participated in a laboratory stress simulation using
mental arithmetic and speech tasks where measurements were taken consisting of systolic and
diastolic blood pressure, heart rate, heart rate variability, and salivary cortisol (Nyklíček et al.,
2013). After controlling for age, sex, body mass index, and beta-blockers, results showed a
significant decrease in overall systolic and diastolic blood pressure as well as decreased
variability in blood pressure (Nyklíček et al., 2013). While no other physiological changes were
significant, these findings alone may prove that mindfulness training is an effective
complementary therapy for patients suffering from hypertension or increased variability in blood
pressure.
In another study designed to investigate the medical benefits of MBSR, effects of MBSR
on the autonomic nervous system and the cardiovascular system were investigated using two
studies based on various MBSR techniques (Ditto, Eclache & Goldman, 2006). In Study 1,
participants were randomly assigned to a meditation group, a progressive muscle relaxation
group, or a waitlist control group then participated in two laboratory sessions four weeks apart
where they practiced their assigned technique; in Study 2, participants participated in two
laboratory sessions where they either practiced meditation or listened to an audiotape of a
9. EXPLORING EXPECTED OUTCOMES 9
popular novel (Ditto et al., 2006). In both studies, heart rate, cardiac respiratory sinus arrhythmia
(RSA), and blood pressure were monitored. Results showed greatest increase in RSA during
meditation and a decrease in cardiac pre-ejection period, which may explain how sympathetic
and parasympathetic activities account for the lack of change in heart rate (Ditto et al., 2006),
which is often questioned in trials regarding MBSR effects on cardiology such as Nyklíček et al.
(2013) as mentioned above.
MBSR may also be effective in treating numerous other medical conditions. For example,
in another study, a group of post-treatment breast cancer survivors were randomly assigned to
either an MBSR group or a “Usual Care” control group (Lengacher et al., 2014). With measures
taken for perceived stress, depressive symptoms, state anxiety, trait anxiety, and aggregate
mental and physical health using various assessments at baseline and six weeks, results showed a
significant reduction of fear of recurrence and an increase in physical functioning which led to a
decrease in perceived stress and anxiety (Lengacher et al, 2014). As these results demonstrate,
the decrease in fear of recurrence as a result of mindfulness training was related to improved
physical functioning, a concrete example of the potential physical health benefits of MBSR
training.
Mindfulness Neuroscience
While the functional magnetic resonance imaging (fMRI) technique has often been used
to assess changes associated with mindfulness practice, it is suggested by some researchers that
this technique be combined with other measures in order to get a more comprehensive
understanding of the benefits of MBSR (Tang & Posner, 2013). However, using the fMRI
technique, it has been noted that there are some common changes associated with mindfulness
training: in the first stage of mindfulness training, attentional control is practiced which results in
10. EXPLORING EXPECTED OUTCOMES 10
changes to the lateral prefrontal cortex and parietal areas; in the intermediate stage of
mindfulness practice, diverse brain networks are utilized in order to deal with distraction; finally,
in the last stage of mindfulness practice, meditation is sustained through the anterior cingulate
cortex, which is accompanied by high parasympathetic activity (Tang & Posner, 2013). In
theory, what this means is that over time, mindfulness works on a variety of neurological
systems and structures in order to increase attention in the prefrontal cortex as well as to increase
the calming effects of the parasympathetic nervous system over time.
Finally, while it has often been thought that intelligence is a static ability, recent
psychological research has shown that sensorimotor and emotional awareness may be linked to
cognition and therefore intelligence (Heydenfeldt, Herkenhoff & Coe, 2011). By the same vein,
this is drawing a link between mindfulness training and neuroplasticity. According to Jaeggi et
al., working memory, or the ability to think in the moment, is related to an important element of
attaining mind fitness (as cited in Heydenfeldt et al., 2011). Moreover, according to Stanley and
Jha, the Mind Fitness Training Institute has developed a Mindfulness-Based Mind Fitness
Training (MMFT) program designed to increase performance in military personnel working in
high-stress environments by utilizing mindfulness practice to increase situational awareness,
adaptability, and mental agility (as cited in Heydenfeldt et al., 2011). As programs such as these
become more visible, the use of mindfulness for a variety of facets of mind fitness will surely
follow.
While the current research on mindfulness provides conclusive evidence for the efficacy
of MBSR based on various criteria, it does not provide a conclusive understanding of the
neurological changes to be expected from mindfulness training. As neuropsychology is quickly
becoming the new standard in evidence-based mental health practice, this study is aimed at
11. EXPLORING EXPECTED OUTCOMES 11
describing the expected structural and functional changes resulting from MBSR practice as well
as the related changes in behavior and cognition.
Method
Participants
After obtaining approval from the Institutional Review Board, participants will be
recruited through a local recruitment campaign including fliers, online postings, and
advertisements in local publications. Respondents will be screened for the following criteria as
adapted from Robins, Keng, Ekblad and Brantley (2012): (1) at least eighteen years of age but
below sixty-five years of age; (2) no prior participation in an MBSR course; (3) no regular
(defined as thirty minutes or more per week) meditative practice including meditation, yoga, or
contemplative prayer; (4) able to attend MBSR practices at designated times; (5) willing to
commit to practice of mindfulness during daily activities; (6) able and willing to undergo
neurological imaging including an fMRI, and MRI, and a PET scan at designated times over a
period of one year.
Materials/Measures
Following the completion of a demographics questionnaire, two assessments will be used
to evaluate changes in mindfulness. The first is a questionnaire designed to assess the twelve
qualities of mindfulness described by Snyder (2002, p. 640): acceptance (open to seeing and
acknowledging things as they are in the present moment); loving kindness (a quality embodying
benevolence, compassion, forgiveness, and cherishing); generosity (giving in the present
moment without attachment to gain or return); non-judgment (observing the present moment by
moment without evaluation or categorization); empathy (understanding the perspective,
emotions, actions, or reactions or another and communicating this to them); letting go (not
12. EXPLORING EXPECTED OUTCOMES 12
holding on to thoughts, feelings, or experiences); openness (seeing things as if for the first time);
trust (trusting that life is unfolding as it is supposed to); gratitude (the quality of reverence,
appreciating, and being thankful for the present moment); non-striving (remaining unattached to
outcome or achievement); patience (allowing things to unfold in their time); and gentleness
(characterized by a soft, considerate, and tender nature).
The second assessment is based on the Baer, Smith, Hopkins, Krietemeyer, and Toney
self-report questionnaire (as cited in Heydenfeldt et al., 2011) measures five facets of mindful
behavior: nonreactivity to inner experience; observing/noticing/attending to sensations,
perceptions, thoughts, and feelings; acting with awareness/automatic
pilot/concentration/nondistraction; describing/labeling with words; and nonjudging of
experience. In conjunction, these two assessments will allow for both quantitative and qualitative
analysis in changes cognition and behavior relative to mindfulness training.
In order to assess neurological changes, various neuroimaging techniques will be
implemented. Because an MRI (magnetic resonance imaging) is used to reveal brain anatomy
(Nguyen, 2015), this will be used to determine structural changes. In order to asses functional
changes, two neuroimaging techniques will be used: an fMRI (functional magnetic resonance
imaging), which displays which parts of the brain are most active based on oxygen use, and a
PET (positron emission tomography), which uses radioactive molecules known as tracers to
track which parts of the brain metabolize these tracers (Nguyen, 2015). The resulting images
should provide a comprehensive view of the different structural and functional brain changes
resulting from MBSR practice.
13. EXPLORING EXPECTED OUTCOMES 13
Design/Procedure
This research will be carried out using a randomized controlled trial in which the
independent variable is an MBSR program while the dependent variables include cognitive and
behavioral components of mindfulness as well as structural and functional neurological changes.
The study will begin by collecting demographic data, through a questionnaire disseminated by
email, from all participants who will be randomly numbered in order to preserve anonymity. This
data will be recorded in a secure file and used to randomly assign participants into either the
MBSR group (Group A) or the control group (Group B). At that point, participants will be
contacted to schedule initial evaluations where the following data will be assessed recorded:
results of the Baer, Smith, Hopkins, Krietemeyer, and Toney self-report questionnaire (as cited
in Heydenfeldt et al., 2011), results of the questionnaire on mindfulness qualities (Snyder, 2002),
and the results of an MRI, an fMRI, and a PET scan. Participants will then be scheduled either
for dates and times to attend the MBSR program, or for dates and times to return for further
testing.
Participants in Group A will then undergo an MBSR program adapted from the
traditional Kabat-Zinn model (1982). This will be an eight-week program comprised of seven
2½-hour classes and a six-hour class during week seven. Unlike the original model, the first half-
hour of each two-hour session will focus on psychoeducation on the topic of Mindfulness Based
Stress Reduction (Kabat-Zinn, 2004). The remaining two hours will be divided equally between
sitting meditation/breath work, progressive awareness, active meditation, and a period for
discussion. The six-hour class will be comprised of an hour of sitting meditation/breath work, an
hour of gentle yoga, an hour-long mindfulness labyrinth walk, a half hour of progressive muscle
14. EXPLORING EXPECTED OUTCOMES 14
relaxation, a half hour of guided imagery, an hour for discussion, and an hour-long break for a
silent lunch.
The measures listed above will be recorded for members of Group A at baseline, at the
end of the eight-week program, at six months post-intervention, and at one year post-
intervention. For members of Group B, these measures will be recorded at the same intervals as
Group A less the measurement taken for those individuals at the close of the intervention. The
following table (Table 1) outlines a suggested timeline for the study at a total of 68 weeks:
Table 1
Research Timeline
Research Phase
Week Number
(Cumulative Week Number) Activities
Pre-Intervention Week 1 (Week 1) Deploy recruitment campaign
Weeks 2-5 (Week 5) Screen respondents to determine eligibility
Week 6 (Week 6) Assess participant demographics
Week 7 (Week 7) Input demographics and randomly assign to group
Week 8 (Week 8) Collect all measures for baseline
Intervention Weeks 1-6 (Week 14)
Group A – 2½-hour MBSR class
Group B – N/A
Week 7 (Week 15)
Group A – 6-hour MBSR class
Group B – N/A
Week 8 (Week 16)
Group A – 2½-hour MBSR class
Group B – N/A
Post-Intervention Week 24 (Week 40) Collect all measures
Week 52 (Week 68) Collect all measures
Analysis
As results are measured, data will be recorded and the qualitative data from the
mindfulness quality questionnaire will be coded to allow for quantitative analysis. While both
measures utilize a five-point Likert scale, the Baer et al. self-report questionnaire lists possible
responses as on a scale of 1-5 while the mindfulness quality questionnaire lists possible
responses as (Strongly Disagree, Disagree, Unsure, Agree, or Strongly Agree). As such, data
15. EXPLORING EXPECTED OUTCOMES 15
from the mindfulness quality questionnaire will be coded so that Strongly Disagree = 1, Disagree
= 2, Unsure = 0, Agree = 3, Strongly Agree = 4. Using this method, possible correlations
between changes in mindfulness related cognitions and behaviors would be explored. These
results will also be used to ensure that the MBSR intervention was successful overall.
Additionally, neurologists will analyze the resulting MRIs, fMRIs, and PET scans in
order to determine if structural and functional changes have taken place. If statistically
significant changes have taken place, it will be necessary to code these changes according to
their strength in order to explore possible correlations between these neurological changes and
the possible cognitive and behavioral changes described above. For example, it would be
possible to compute a correlation between an observed neurological change and either a reported
change in mindfulness based on the questionnaires, or more specifically, a reported change in a
specific area such as empathy on the mindfulness qualities survey. The would show possible
evidence for relationships between certain areas of the brain and certain aspects of mindfulness
that may not have been previously evident.
All data will be used to compare differences among members of Group A and Group B in
order to ensure that the MBSR intervention was the most likely cause of any resulting changes.
By taking measures for both groups at baseline, six months post-intervention, and one year post-
intervention, it is possible to account for any other time related changes such as aging and the
increase in knowledge that occurs through daily life.
Finally, neurologists and neuropsychologists will review the structural and functional
changes in the brain in order to determine the resulting behavioral and cognitive changes that are
commonly seen as a result of these changes. If consistent changes are found, this will provide
empirical evidence behind the efficacy of mindfulness from a neuropsychological perspective.
16. EXPLORING EXPECTED OUTCOMES 16
Discussion
Limitations
While this study has the potential to provide a great deal of information on the complex
relationships between mindfulness, cognition, behavior, and neurological structure and
functioning, it is also quite intricate and therefore poses several limitations. Firstly, when using
human participants there are always certain limitations that arise including lack of responses to
recruitment efforts, lack of respondents who meet necessary criteria, and a sample that might not
be entirely representative despite efforts to the contrary.
Additionally, because this study will be carried out over the course of more than a year,
the likelihood that participants will drop out over time is higher than for a brief study. Moreover,
because subjective measures are being used, there is always possibility for error due to
participants responses not aligning with their actual behavior and cognitions for a variety of
reasons including a fear of giving truthful responses, an impulse to answer questions in a way the
participant feels they are compelled to, and poor personal awareness.
Moreover, because there will be several different neurological imaging techniques used
to assess brain changes, the way professionals interpret these results may not be consistent with
one another. Also, there is always a possibility that false correlations may come up between
factors that are not actually related.
A final drawback to this study is the resources that would be required to see it through. In
order to carry out such a complex study a great deal of time and money would be required. As
such it would be necessary to apply for grants and various other forms of funding. In addition, it
may be beneficial to partner with a teaching or research hospital in order to share knowledge and
resources.
17. EXPLORING EXPECTED OUTCOMES 17
Of course, this study design does have advantageous factors as well. By using a well-
respected MBSR program model, the likelihood of achieving valid results is greatly increased.
Additionally, by using randomized assignment it is much more likely that intra-group differences
will be minimized. Finally, by taking measures at various points throughout the study, the effects
of time on outcomes are minimized.
Ethical Considerations
At present, the only clear ethical issue with this study design is the lack of intervention
for those participants in the control group (Group B). While these participants are not in any
direct harm as a result of not receiving an intervention, the principle of benevolence dictates that
some form of MBSR training be offered to these participants as a result of it’s obvious benefits.
As such, it is suggested that after the final measures have been collected, members of Group B
are offered access to materials on mindfulness or an opportunity to participate in an MBSR
program if possible. Additionally, it may be beneficial to further incentivize participation for
those members assigned to the control group by offering additional compensation of a reasonable
nature.
By adhering to these guidelines, it is likely that the suggested study would provide a great
deal empirical evidence for the common structural and functional neurological changes seen as a
result of Mindfulness Based Stress Reduction and the resulting cognitive and behavioral changes
that can be expected while providing participants with a safe and worthwhile experience.
18. EXPLORING EXPECTED OUTCOMES 18
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