Mechanisms of action

As evidence for the utility of MBSR has become more established, the line of questioning within research has shifted more from whether mindfulness is effective to how it actually brings about those results (Baer, 2011, p. 242). As Baer (2003, p. 140) stated, “The empirical evaluation of any intervention requires clear operational definitions of concepts and procedures, and the identification of conceptually sound mechanisms that may account for changes produced by the intervention.” At this time, an understanding of the mechanisms through which both mindfulness and the MBSR program support individuals is regarded to be in its early stages. The following section will firstly review those mechanisms of mindfulness considered to be important followed by other factors which may also provide MBSR participants benefits, namely, group factors.

At the broadest level, mindfulness can viewed as an act or state of

consciousness which includes the faculties of awareness and attention (Brown & Ryan, 2003). Awareness can be likened to the overarching field of consciousness which monitors a person’s internal and external environment; it is the background or the field in which phenomena make contact with a person’s consciousness. Attention, on the other hand, is the capacity and process of focusing on objects within that broader field of awareness (Westen, 1999). A helpful analogy is that of a diffuse light (awareness) covering a broad range of objects. This light can be concentrated through the use of a magnifying glass (attentional focus) to provide greater clarity to a smaller

area at the expense of the larger field (Perls, Hefferline, & Goodman, 1951). Awareness and attention are interrelated and the manner in which they are intentionally employed is a central feature of mindfulness (Shapiro et al., 2006). Indeed, attention regulation is seen to be a central feature of many descriptions of mindfulness and its mechanisms of action (Brown, Ryan, & Creswell, 2007a; Carmody, 2009).

The intentional application of attention and awareness with ‘mindful’ attitudes allows individuals, according to Shapiro et al. (2006), to develop a perspective on their thoughts, emotions and experiences which they argue is a central overarching mechanism by which mindfulness elicits positive outcomes. This change in

perspective is termed reperceiving and is characterised by a “rotation in consciousness in which what was previously “subject” becomes “object”” (Shapiro et al., 2006, p. 377). For instance, rather than viewing a self-critical thought as an accurate and true reflection of reality, individuals develop an ability to not identify or become attached to the content of the thought, thereby witnessing narratives or feelings without being caught up in them. In this way, reperceiving shares much similarity with the processes of decentering (mentally stepping back to observe one’s experience; Fresco et al., 2007), deautomization (reducing habitual/automatic behaviours, perceptions, cognitions), and metacognitive awareness (awareness of one's thinking processes; Teasdale, 1999). Of all these terms, it is decentering which is most often used in the literature — even more so than reperceiving — but at their core is a similarity held by many researchers to be integral to the benefits of mindfulness: an ability for a person to not identify with the content of their experience and assume the mental posture of an observer, less troubled and attached to what may arise (i.e. thoughts, emotions,

sensations). Relaxation, consequently, can often flow on from this reduction in reactivity through this change in perspective.

A further mechanism posited to stem closely from the ability to reperceive or decenter from one’s experience is the disruption and reduction of ruminative thinking (Chiesa et al., 2014; Jain et al., 2007; Oman et al., 2008; Teasdale et al., 2002). Rumination is defined as repetitively thinking about one’s own problems and emotions without taking action to address the cause of the problem and is strongly associated with depression (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008) and so influencing the process of rumination with mindfulness has delivered positive outcomes. For example, Teasdale’s clinical work in the area of depression places the ability to become aware of one’s thoughts — termed metacognitive awareness in this context — question their accuracy, and become aware of their transience, as a central means in disrupting depressogenic thinking associated with negative mood (Teasdale, Segal, & Williams, 1995). Interestingly, in studies comparing MBSR with other interventions such as somatic relaxation (Jain et al., 2007) or Easwaran’s Eight Point Program (Oman et al., 2008; Shapiro et al., 2008), only MBSR participants

experienced significant reductions in ruminative thinking, further supporting the disruption of this process as a mechanism of change linked to mindfulness.

Again, another mechanism of mindfulness which stems from reperceiving or decentering is exposure. In Shapiro and colleagues’ (2006) MBSR informed model of mindfulness, reperceiving allows difficult thoughts and emotions to emerge and remain in the field of awareness with less reactivity (e.g., avoidance, repression), allowing a desensitization towards and extinction of responses associated with these stimuli (see also Hölzel, Lazar, et al., 2011; Kabat-Zinn et al., 1992). This mechanism may be particularly helpful where avoidance maintains or exacerbates particular

problems such as anxiety. In this way, exposure can also be seen as affecting another conceptually close process termed experiential avoidance, that is, the tendency to avoid unpleasant stimuli or events, which has also shown to be reduced through mindfulness training and is held as an important mechanism of change (Chambers, Foley, Galt, Ferguson, & Clutton, 2012; Chiesa et al., 2014). Through developing a greater tolerance towards unpleasant feelings and thoughts, individuals are more likely to experience stimuli that cause discomfort, reduce its intensity over time, and expand their cognitive, emotional, and behavioural flexibility to respond (Shapiro et al., 2006).

Given the range of mechanisms described above, it is not surprising that increased emotional-regulation is similarly held by many scholars to be a pivotal mechanism and construct to understand how mindfulness exerts its benefits. Emotion regulation refers to the adjustment of one’s emotional responses by the application of regulatory actions (Ochsner & Gross, 2005). For example, in a model of the

mechanisms of mindfulness developed by Hölzel, Lazar, et al. (2011), emotion regulation is seen to manifest in two ways. First, mindfulness helps individuals approach and experience emotions more adaptively (i.e., with acceptance and nonjudgment) and secondly, as a result of being more open to the experience of emotion through exposure, extinction of conditioned responses and reconsolidation of new meanings is made possible. Shapiro et al., (2006, p. 380) similarly view increased self-regulation as a further mechanism, whereby “systems maintain stability of

functioning and adaptability to change…based on feedback loops”. A greater

awareness of one’s experience and an increased ability to not identify with immediate thoughts and emotions also supports individuals in choosing among a wider range of options in the regulation of their wellbeing. Indeed, a range of evidence supports the

notion that increased mindfulness is associated with more adaptive emotion regulation in both clinical and nonclinical populations (Coffey & Hartman, 2008; Erisman & Roemer, 2010; Feldman, Harley, Kerrigan, Jacobo, & Fava, 2009; Mitmansgruber, Beck, Höfer, & Schüßler, 2009).

Of course, as mentioned when exploring definitions of mindfulness, the regulation of one’s attention and emotions would be difficult without certain attitudes being present (Shapiro et al., 2006). Again, the specific attitudes taught within MBSR include: nonjudgement, patience, acceptance, beginners mind, trust, letting go, and non-striving. For example, acceptance has been found to mediate outcomes in

workplace stress and quitting smoking in studies using Acceptance and Commitment Therapy — a mindfulness-based intervention — (Bond & Bunce, 2000; Gifford et al., 2004) while self-compassion, a related construct, has also been found to be

significantly higher following practice in mindfulness meditation and is also argued to be a psychological mechanism (Chiesa et al., 2014; Lykins, 2009; Shapiro, Brown, & Biegel, 2007). Though many of the specific attitudes taught in MBSR are not reported as mechanisms of change (e.g., beginners mind), these attitudes are implicit in how mindfulness is explained, practised, and therefore likely play some role in affecting outcomes — particularly because they are interrelated.

Lastly, although the above discussion focussed on mindfulness, there are also potential mechanisms of action which stem from the format and delivery of

mindfulness in group settings. For example, Wyatt, Harper, and Weatherhead (2014) reviewed qualitative studies where individuals with mental health problems

participated in mindfulness-based interventions with the aim of identifying common experiences across interventions. One such finding was that participants often reported themes connected to feeling supported and having their difficulties

normalized, and so the group itself — not mindfulness — also contributed to their outcomes. Malpass et al. (2012) reported similar findings in their meta-ethnographic study where, in addition to reduced stigma, participants of group mindfulness-based interventions also often reported reductions in feelings of isolation and that the group supported motivation to continue and increased learning. These findings are

significant in the context of this current research as PhD students often experience isolation and significant time pressures, so increased motivation and feelings of social support may have a strong impact on their experience of a brief MBI.