Mindfulness Meditation as a Stress Management Intervention

Cheryl Fracasso
Walden University
Health Psychology: PSYC 8745
Summer 2007

ABSTRACT
This research paper will explore the various treatment applications of a specific
meditation technique referred to as mindfulness meditation. Mindfulness meditation is
very different from traditional methods of meditation in that it focuses on the present
moment concept of be here now, in contrast to traditional modes of meditation which
seek to invoke an altered state of consciousness beyond the realm of our five senses. The
basic concept of mindfulness meditation is rooted in Zen Buddhism and was originally
popularized in 1993 by Marcia Linehans cognitive-behavioral treatment for patients with
borderline personality disorder. Since then, mindfulness techniques have been used with
other populations suffering from difficult to treat disorders and are showing promising
results for treatment applications with mood disorders, relapse prevention with substance
and alcohol abuse patients, for various anxiety disorders, in addition to general stress
management and stress management with cancer patients. With the involvement of
managed care often limiting the amount of sessions professionals are authorized to care
for patients seeking treatment, finding a successful treatment that can be implemented in
a short time period is of critical importance to professionals who are involved with
traditional disorders that have been difficult to treat. Therefore, this research paper will
begin by defining what mindfulness meditation is, and will then critically evaluate how
mindfulness meditation is applied to the treatment of four disorders; namely, borderline
personality disorder, depression and dysphoric mood disorders, substance abuse
disorders aimed at relapse prevention, and anxiety disorders. In conclusion, mindfulness
meditation shows promising results for the treatment of traditionally difficult to treat
disorders which may be a cost-effective alternative. However, research is still in its
infancy and implications and suggestions for future research into mindfulness meditation
is imperative for practitioners seeking a sound treatment method aimed at reducing costs
and delivering quality care to their patients.

INTRODUCTION
What is Mindfulness Meditation?
Mindfulness meditation can be defined as a concept that embraces a be here
now present moment awareness, with a non-judgmental acceptance of everything going
on in both the outer and inner realms of awareness (Blume et al., 2006; Broderick, 2005;
Linehan, 1993; Semple, Reid, & Miller, 2005; Suzuki, 2004; Watkins, Teasdale, &
Williams, 2000; Witkiewitz, Marlatt, & Walker, 2005). This notion of mindfulness
meditation was originally popularized by Marcia Linehans (1993) cognitive-behavioral
treatment called dialectical behavioral therapy (DBT) for patients diagnosed with
borderline personality disorder (BPD). For example, Linehan (1993) refers to this
concept of being aware of the present moment as the wise mind which balances the
emotional mind with the rational mind. Linehan (1993) began using this technique
due to the emotional instability characterized by borderline patients in an attempt to help
patients become aware of their internal emotional states without reacting impulsively to
the passing states of anger, fear, or insecurity often experienced by the BPD patient. Due
to the enormous success of Linehans (1993) dialectical behavioral therapy (DBT) with
borderline patients, other researchers have now began exploring the concept of
mindfulness meditation in the treatment of depression, anxiety, substance abuse, stress
management, and pain reduction in cancer patients (Bishop, 2002; Blume et al., 2006;
Broderick, 2005; Kabat-Zinn, 2003; Proulx, 2003; Robinson et al., 2003; Semple, Reid,
& Miller, 2005; Watkins, Teasdale, & Williams, 2000; Witkiewitz, Marlatt, & Walker,
2005).

An example of a mindfulness session described by Semple and colleagues (2005)

begins with what they refer to as Mindful Eating with a raisin. Participants are first
instructed to become aware of sitting in their chair by examining the feel of fabric against
their skin, how the chair feels as they lean up against it in reference to cold, warm,
comfortable, or stiff (Semple, Reid, & Miller, 2005). Participants are then instructed to
observe the temperature, colors, and smell of the room; followed by examining their
internal state of awareness such as feelings of tension or anxiety (Semple, Reid, & Miller,
2005). Next, participants are given a raisin and instructed to observe the color, smell, and
texture of it as they slowly roll the raisin around in their fingertips (Semple, Reid, &
Miller, 2005). As participants are examining the raisin with all five of their senses, they
are then instructed to put the raisin in their mouth and slowly experience the taste and
texture of the raisin as they slowly chew it and experience the sensation of the raisin
going down their throat, all the way down into their stomach (Semple, Reid, & Miller,
2005). Following this mindfulness eating exercise, participants are then guided through a
three-minute breathing exercise which focuses attention on the present moment with an
unconditional acceptance of everything they feel both internally and externally (Semple,
Reid, & Miller, 2005).
It is important to note that the concept of mindfulness meditation as applied to
some of the western disorders described above is not based on principles of Zen
Buddhism; but rather, borrows certain concepts of Zen based on present moment
awareness (Suzuki, 2004). However, eastern philosophies based on Zen principles
incorporate a sense of unity and oneness with all of lifewhich radically departs from
our western modes of thinking which are based on individualism and a reductionist

scientific attitude towards reality, in contrast to an emphasis on wholeness found in

eastern traditions (Suzuki, 2004). With that being said, mindfulness meditation from a
western perspective has borrowed some of Zens concepts and applied them to western
disorders, but is not in any way representative of Zen in general (Suzuki, 2004). In fact,
from a postmodern perspective it could be adequately argued that a lot of our western
disorders have emerged as a result of an emphasis on individualism, as compared to
group cooperation and wholeness emphasized in a lot of other societiesbut that is a
topic for another paper in and of itself (Cushman, 1995).
DISCUSSION
Various Treatment Applications of Mindfulness Meditation
Borderline Personality Disorder
According to the DSM-IV-TR (2000), borderline personality disorder (BPD) is
characterized by an enduring pattern of instability that affects at least two of the
following areas: (1) cognition, (2) affectivity, (3) interpersonal functioning, or (4)
impulse control (Comer, 2004). Furthermore, this pattern of instability must occur
across a broad range of social situations, must significantly impair functioning, and must
consist of a long-standing trait that can be traced back to adolescence (Battle et al., 2004;
Comer, 2004). Accordingly, BPD patients display an enormous amount of instability in
their moods marked by very black and white thinking, display instability in their selfimage, and consequently in their relationships with others (Battle et al., 2004; Comer,
2004; Graybar & Boutilier, 2002). Due to this instability of moods and self-image, BPD
patients may fluctuate from being happy one moment, to feeling abandoned and angry the
next moment towards anyone who may grow tired of the BPDs bouts with instability

(Battle et al., 2004; Graybar & Boutilier, 2002). As a result, many BPD patients may try
to harm themselves, or threaten suicide in an attempt to alleviate the immense emotional
instability they experience, which consequently is reinforced every time they blow up
so-to-speak, towards those around them which ultimately ends up pushing others away
and leaving the BPD abandoned, which is exactly what their fear is (Battle et al., 2004;
Comer, 2004). Traditionally, due to the instability characterized by BPD patients,
treatment of BPD has presented numerous challenges to practitioners who struggle with
helping the BPD patient achieve a stable sense of identity and keeping the BPD patient in
therapy long enough to help them achieve this stability (Battle et al., 2004; Graybar &
Boutilier, 2002).
Linehans (1993) dialectical behavior therapy is based on the idea of reconciling
opposites, or rather dialectics, in an attempt to synthesize the BPDs dramatic shifts from
all or nothing type thinking. Although it is far beyond the scope of this paper to
adequately review Linehans (1993) DBT concepts, one of the exercises used by Linehan
(1993) is the concept of wise mind through mindfulness meditation. Accordingly,
Linehans (1993) strategies focus on teaching the borderline patient to focus on the
present moment problem while paying attention to the affect; ei:, present moment
feelings, rather than the content of what is causing the problem to begin with. By
helping a BPD focus on their feelings, Linehan (1993) suggests this will help the
borderline become more aware of the fact that they can survive the emotional turmoil
without having to severely over-react with statements and actions that they will later
regret. Some specific techniques that Linehan (1993) incorporates into mindfulness are
assisting the borderline patient with allowing the flow of emotions to come and go from

an unattached observers point of view which is referred to as focusing on tolerance. For

example, when a burst of anxiety or anger is present, Linehan (1993) directs her patients
to unconditionally observe these feelings without judging them as good or bad, in
addition to not reacting until the BPD patient can achieve a calmer state of inner balance.
By the repeated exposure to these techniques, BPD patients eventually learn that
emotional instability can be tolerated by focusing attention on the present moment and by
resisting the temptation to react impulsively. Although this is a very brief overview of one
technique used in Linehans (1993) DBT, the use of mindfulness has also been
incorporated into the treatment of various other disorders which we will explore next.
Depression and Dysphoric Mood Disorders
The DSM-IV-TR (2000) criteria for a major depressive episode requires that five
out of the following symptoms must be present for at least two weeks in order to qualify
as a major depressive episode: (1) feeling depressed most of the day almost everyday, (2)
decreased interest in activities or pleasure derived from activities that are normally
pleasant, (3) weight loss or weight gain, (4) disrupted sleep patterns marked by insomnia
or excessive sleeping, (5) psychomotor impairment almost daily, (6) loss of energy and
persistent feelings of fatigue, (7) excessive feelings of guilt or worthlessness, (8) an
impaired ability to concentrate or indecisiveness, (9) and recurring thoughts of suicide or
death almost daily (Comer, 2004). Accordingly, in order to be diagnosed with a major
depressive disorder, the DSM-IV-TR (2000) requires the presence of at least one major
depressive episode with no history of either a manic, or hypomanic episode as seen in
bipolar disorder (Comer, 2004).

Since ruminationor the tendency to dwellis often observed in patients with

depression, cognitive-behavioral treatments have focused on techniques which
incorporate distraction to break the cycle of repeatedly focusing on negative moods
(Broderick, 2005; Watkins, Teasdale, & Williams, 2000). However, Broderick (2005)
argues that using distraction to break the negative cycle of rumination may only offer
short-term benefits, and as a result may actually prolong the symptoms of depression due
to avoiding or suppressing the negative emotion to begin with. Accordingly, Broderick
(2005) conducted a study on 177 participants to examine the effectiveness of mindfulness
meditation compared to techniques which utilize distraction.
Broderick (2005) hypothesized that both mindfulness meditation and techniques
which utilize distraction would be more effective in treating depression compared to
rumination; and furthermore, that mindfulness meditation would be more effective than
techniques which utilize distraction in reducing negative moods. As Broderick (2005)
hypothesized, the experimental group who received mindfulness meditation showed a
reduction of negative moods compared to the control group who simply received
traditional distraction methods to break the rumination cycle. Because rumination is often
associated with prolonged negative moods (Watkins, Teasdale, & Williams, 2000),
Broderick (2005) points out it is important for clinicians to find a successful method to
break the rumination cycle. Consequently, Broderick (2005) suggests mindfulness
meditation may offer a more successful method of breaking the rumination cycle in
comparison to distraction. However, Broderick (2005) also notes several limitations and
implications for future research which will be discussed at the end of this paper.

Substance Abuse Relapse Prevention

According to the DSM-IV-TR (2000) criteria used to diagnose a substance abuse
disorder, a person must show significant distress or impairment resulting from a
maladaptive pattern of use with at least one of the following symptoms within a one year
period: (1) continued substance use which impairs functioning at school, the work place,
or home; (2) continued substance use in places or situations where it may be dangerous
(such as when operating an automobile or machinery at work), (3) continued legal
problems as a result of substance use, or (4) continuing to use the substance despite social
or interpersonal problems as a result of the use (Comer, 2004). Consequently, the World
Health Organization reports that substance abuse is becoming a serious public health
problem globally, with estimates as high as 185 million people who report abusing drugs
and alcohol (Witkiewitz, Marlatt, & Walker, 2005). Accordingly, the demand for
successful treatment and relapse prevention is becoming a primary concern for
practitioners involved with the treatment of substance abusers (Witkiewitz et al., 2005).
Traditionally, drug and alcohol treatment methods have been based on the
disease model of addiction which suggests complete abstinence as advocated by
cognitive-behavioral models, in addition to Narcotics Anonymous (NA) and Alcoholics
Anonymous (AA) (Blume et al, 2006; Witkiewitz et al., 2005). However, Witkiewitz and
colleagues (2005) suggest that due to the high relapse rate seen amongst abusers, in
addition to the substantial economic and individual costs associated with this disorder
that it is imperative that a cost-effective and empirically sound treatment is found to
alleviate this growing societal problem. Witkiewitz and colleagues (2005) suggest
mindfulness meditation shows promising results as an alternative treatment to traditional

CBT, AA, and NA models by teaching clients how to disrupt the craving cycle by
embracing the present moment and allowing the discomfort of withdrawal to pass while
maintaining an unattached observer point of view. According to Witkiewitz and
colleagues (2005), this nonjudgmental observer stance taught in mindfulness meditation
may countercondition the addictive cycle of craving by implementing relaxation in the
place of the previously conditioned positive and negative reinforcements associated with
addiction.
In support of this view, Blume and colleagues (2006) from the University of
Washington conducted a study on 305 inmates diagnosed with a substance abuse
disorder prior to their incarceration. Participants in Blume and colleagues (2006) study
were taught a 10 day mindfulness meditation course which taught inmates basic
principles of Zen Buddhism, the Four Noble Truths and how they are associated with
human suffering, in addition to teaching Zen principles based on the illusion of
separateness from others. Furthermore, participants were taught meditation techniques
that move away from the small mind which consists of individual concerns, while
embracing concepts of the big mind which consists of spiritual unity and wholeness
with all of life (Blume et al., 2006; Suzuki, 2004). Specifically, participants were taught
to experience their cravings as impermanent events that they do not have to react to,
while allowing their mind to let go of negative or destructive thought patterns
associated with their addiction (Blume et al., 2006). A be here now attitude was
fostered within the treatment sessions which incorporated experiencing all five senses in
relation to the color, texture, smell, sound, and dimensions of the roomin addition to

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nonjudgmentally allowing all their thought and feelings to pass without reacting to them
(Blume et al, 2006).
At 3 month follow-up, Blume and colleagues (2006) found the participants who
received mindfulness meditation while incarcerated significantly less likely to of abused
alcohol or drugs after their release. However, Blume and colleagues (2006) note several
limitations to their study which will be discussed in the closing section of this paper.
Anxiety Disorders
According to the DSM-IV-TR (2000) criteria for generalized anxiety disorder, a
client must exhibit continuous worry and anxiety for a period of six months, in addition
to the inability to control worrying about various events (Comer, 2004). Additionally, the
DSM (2000) requires that clients must exhibit at least three of the following symptoms
which cause distress or significant impairment: (1) restlessness, (2) fatigue, (3)
irritability, (4) muscle tension, or (5) sleep disturbances (Comer, 2004). Accordingly,
mindfulness meditation techniques are also being implemented in the treatment of
anxiety disorders and are showing promising results as an alternative treatment (Roemer
& Orsillo, 2002). Roemer and Orsillo (2000) suggest the key ingredient to treating
anxiety disorders addressed in mindfulness meditation is focused attention aimed at
breathing, relaxing, and being in the present moment; in contrast to anxiety and worry
seen in generalized anxiety disorder. Since research in mindfulness meditation has shown
promising results for the treatment of generalized anxiety disorder in adults, Semple,
Reid and Miller (2005) point out that relatively little research has been done on children.
Accordingly, Semple, Reid, and Miller (2005) conducted a 6- week pilot study on five

11

children to address the feasibility of implementing mindfulness techniques for the

treatment of anxiety.
Although this was a small sample size, Semple, Reid and Miller (2005) found
mindfulness techniques were easily taught to children and may very well be an
alternative intervention to treating anxiety disorders in children due to the emphasis on
focused attention and being in the present moment.
CONCLUSIONS AND DIRECTIONS FOR FUTURE RESEARCH
Mindfulness meditation as a viable treatment option for borderline personality
disorder, depression, and substance abuse relapse prevention shows promising results
(Blume et al., 2006; Linehan, 1993). However, there are several limitations and enormous
implications for future research in order to consider mindfulness meditation a sound
treatment method which could improve treatments outcomes in these traditionally known
difficult to treat disorders. For example, Broderick (2005) discusses several limitations
to his study of 177 participants with depression which utilized mindfulness meditation
techniques in comparison to techniques which utilize distractions. Because participants
were only compared from derived data in one session, the long-term effects of
mindfulness meditation is unknown. Broderick (2005) suggests longitudinal studies are
needed to assess the long-term benefits of mindfulness meditation, in comparison to
traditional techniques which utilize distraction to break the rumination cycle often
observed in depression.
Blume and colleagues (2006) also note several limitations to their study which
examined mindfulness meditation in 305 incarcerated inmates. Namely, Blume and
colleagues (2006) note that their study was not a randomly controlled design and

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therefore, cannot be generalized to the general population. Furthermore, Blume and

colleagues (2006) note that their 3 month follow-up period may be too short to judge
whether the use of mindfulness meditation techniques were effective in the long-run.
However, in spite of the limitations of the study design, Blume and colleagues (2006)
note implications for future research could first begin by replicating their study with a
randomized controlled design; along with evaluating the effectiveness of mindfulness
meditation techniques in a non-incarcerated population diagnosed with substance abuse
disorders. Furthermore, Blume and colleagues (2006) suggest that mindfulness
meditation techniques may offer a cost-effective alternative to the current treatment
methods which incorporate CBT, NA, and AA, in addition to lowering the stigma
associated with partaking in these treatment options. Additionally, Semple and colleagues
(2005) suggest that the use of mindfulness meditation for anxiety disorders needs to be
examined in children since problems with attention is often implicated in anxiety
disorders and may also be a viable treatment option for attention-deficit disorder.
Overall, the use of mindfulness meditation shows promising results, may reduce
the stigma associated with traditional treatment methods associated with having a
disorder, and may prove to be a cost-effective method to deliver quality care to patients
with difficult to treat disorders.

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