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Mindfulness-based self-regulation for psychotic disorders: a feasibility study

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Mindfulness-Based Self-Regulation for Psychotic Disorders: A Feasibility Study

Lisa Davis, MSW, LCSW

A dissertation submitted to the faculty of the University of Southern California in partial
fulfillment of the requirements for the degree of Doctor of Philosophy in the School of
Social Work

March 2014

ii

ACKNOWLEDGMENTS

This work would not have been possible without the unfaltering support and sacrifice of
my husband, Terence Davis. He kept me and our children fed, clothed, and happy so
that I could pursue my passion, expecting nothing in return. I am eternally in his debt. I
am grateful to John Brekke for standing behind me during this undertaking and for his
encouragement and belief in my ability; it enabled me to persist down a challenging
and, at times, daunting path. I found that it was worth the effort. I also gratefully
acknowledge the pioneering work of Jon Kabat-Zinn, who I met in 2005 when I
participated in a Mindfulness-Based Stress Reduction training program. He inspired me
to listen to my calling, which ultimately led me to this project. His authenticity and
generosity changed the trajectory of my life, an affect he has had on many, many
people. Lastly, this project could not have been completed without the unwavering
support of my family and friends, for which I am deeply grateful.

iii

Contents

LIST
OF
TABLES.......................................................................................................................................................vi

LIST
OF
FIGURES....................................................................................................................................................vii

ABSTRACT................................................................................................................................................................viii

1
Introduction.........................................................................................................................................................1

1.1
Background
and
significance...............................................................................................................2

1.1.1
Subjective
experience
in
psychosis..........................................................................................5

1.1.2
Functional
impairment
in
psychosis.......................................................................................9

1.1.3
Limitations
of
psychosocial
treatments
for
psychosis..................................................14

1.1.4
Mindfulness:

Definition
and
proposed
mechanisms
of
action.................................18

1.1.5
Mindfulness-‐based
treatment
models.................................................................................23

1.1.6
Mindfulness
for
psychotic
disorders:

Empirical
evidence
to
date.........................27

1.2
Rationale
for
the
study........................................................................................................................34

1.3
Development
of
a
novel
intervention...........................................................................................36

1.4
Purpose
statement................................................................................................................................37

1.5
Specific
Aims............................................................................................................................................38

1.6
Assumptions
and
limitations............................................................................................................39

1.7
Delimitations...........................................................................................................................................40

2
INTERVENTION
DESIGN.............................................................................................................................41

2.1
Overview
of
Mindfulness-‐Based
Self-‐Regulation
Training
(MBSRT)..............................41

2.2
Theoretical
foundation........................................................................................................................44

2.2.1
Self-‐Regulation
Theory...............................................................................................................44

2.2.2
Stress
and
Coping
Theory..........................................................................................................48

2.2.3
Self-‐Determination
Theory.......................................................................................................52

iv

2.3
Application
of
theory
to
intervention
design............................................................................55

2.4
Study
Hypotheses..................................................................................................................................57

2.5
Measurement
of
MBSRT
constructs..............................................................................................58

2.5.1
Overview
of
MBSRT
program
content.................................................................................59

2.5.2
Sample
MBSRT
session...............................................................................................................59

3
METHODOLGY.................................................................................................................................................62

3.1
Design
overview.....................................................................................................................................62

3.2
Participants..............................................................................................................................................64

3.2.1
Agency
context...............................................................................................................................64

3.2.2
Sample
selection............................................................................................................................64

3.2.3
Recruitment
and
informed
consent......................................................................................65

3.2.4
Medication
treatment..................................................................................................................66

3.3
Measures...................................................................................................................................................67

3.3.1
Demographic
measures..............................................................................................................67

3.3.2
Treatment
outcome
measures................................................................................................67

3.3.3
Treatment
acceptability/tolerability...................................................................................70

3.3.4
Treatment
integrity......................................................................................................................70

3.4
Intervention
development.................................................................................................................71

3.4.1
Manual
refinement.......................................................................................................................72

3.4.2
Development
of
treatment
integrity
measures................................................................73

3.5
Intervention
procedure......................................................................................................................75

3.6
Analytic
strategy....................................................................................................................................76

4
Results.................................................................................................................................................................78

4.1
Sample
characteristics.........................................................................................................................78

4.2
Treatment-‐related
variables.............................................................................................................78

4.2.1
Recruitment
and
Retention......................................................................................................78

4.2.2
Attendance.......................................................................................................................................80

v

4.2.3
Satisfaction
with
treatment......................................................................................................80

4.3
Treatment-‐outcome
variables.........................................................................................................84

4.3.1
Treatment
Outcome
Measures................................................................................................84

4.3.2
Exploratory
analyses:

Process
measures..........................................................................87

5
General
Discussion........................................................................................................................................88

5.1
Findings.....................................................................................................................................................88

5.1.1
Overview...........................................................................................................................................88

5.1.2
Feasibility
and
acceptability.....................................................................................................88

5.1.3
Interpretation
of
preliminary
treatment
effects.............................................................90

5.2
Limitations................................................................................................................................................99

5.3
Strengths................................................................................................................................................102

5.4
Lessons
learned
and
future
directions......................................................................................103

5.4.1
Recruitment
efforts...................................................................................................................103

5.4.2
Study
design
and
measurement..........................................................................................104

5.4.3
Treatment
uptake......................................................................................................................106

5.4.4
Intervention
content.................................................................................................................107

5.4.5
Treatment
integrity...................................................................................................................108

5.5
Special
clinical
considerations......................................................................................................109

5.6
Conclusion.............................................................................................................................................111

LIST
OF
REFERENCES.......................................................................................................................................113

APPENDIX
A
–
MBSRT
TREATMENT
INTEGRITY
MEASURE..........................................................130

vi

LIST
OF
TABLES

Table 1 - Measurement of MBSRT outcomes.......................................................................................58

Table 2 - Attendance of MBSRT sessions (N=21)..............................................................................80

Table 3 - Mindfulness-Based Self-Regulation Treatment Satisfaction Survey Results
(N=21)...............................................................................................................................................................81

Table 4 - Completers Pre- to Post-treatment Outcome Scores (N=21)...................................86

vii

LIST
OF
FIGURES

Figure 1 - Mindfulness-Based Self-Regulation Training intervention logic model..............55

Figure 2 - Handout from session 2 illustrating the stress response cycle..............................61

Figure 3 - CONSORT diagram of participants through the trial...................................................79

viii

ABSTRACT

Mindfulness-Based Self-Regulation for Psychotic Disorders: A Feasibility Study
Lisa Davis
Dissertation Committee Chair: John Brekke, Ph.D.

Even with advances in psychosocial rehabilitation, individuals with psychotic disorders
continue to experience subjective distress and widespread functional impairment.
Investigations of mindfulness treatments support the utility of the approach for this
population, but gaps in this area include a lack of treatments targeting self-regulatory
capacities to enhance multiple psychosocial domains affected by psychosis. In this
initial treatment development study, the treatment was manualized, its feasibility was
assessed, and an open trial of a new mindfulness intervention that combines
mindfulness training and cognitive-behavioral elements was conducted. Twenty-one
individuals with psychotic disorders receiving services at a psychosocial rehabilitation
program were provided with the 10-week group, entitled Mindfulness-Based Self-
Regulation Training (MBSRT). High recruitment and retention rates, along with a high
degree of treatment satisfaction reported by participants, suggests the treatment is
feasible to deliver and highly regarded by individuals with psychosis. Results showed
that participants achieved significant improvements in wellbeing and functioning
domains at post-treatment, with large effect sizes in most outcomes. In addition,
processes targeted by the intervention (mindfulness and self-regulation) improved
significantly over the course of treatment, and changes in processes were correlated
with changes in multiple outcome domains. Findings indicate that MBSRT is a
ix

promising treatment approach for psychotic disorders that warrants further testing in a
future randomized trial.

1

1 Introduction

Treatment of psychotic disorders has been subject to scientific and public debate
emphasizing the need for multimodal treatments to address the complex set of
biological, psychological, and socio-cultural factors underlying these disorders. Even
with advances in pharmacological and psychosocial rehabilitation treatments,
schizophrenia and other psychotic disorders typically result in persistent psychiatric
symptoms, subjective distress, and widespread functional impairment (reviewed by
Chien et al., 2013). The development of effective and comprehensive interventions to
improve multiple psychosocial domains is imperative for treating this population.
Mindfulness interventions have recently gained attention for their multifaceted
approach to improving subjective and functional outcomes for a variety of psychiatric
populations by promoting self-regulatory capacities (Chiesa et al., 2011). Interventions
focusing on training in mindfulness skills involve the intentional self-regulation of
attention to internal and external experiences occurring in the present moment, while
suspending judgment or cognitive evaluation of these stimuli (Baer, 2003). Preliminary
studies suggest the utility of mindfulness for psychotic disorders (Khoury et al., 2013),
however gaps in this emerging literature include a lack of treatments targeting the
regulation of multiple subjective and functional domains affected by psychosis. This
investigation sought to develop and evaluate the impact of a novel mindfulness
intervention guided by principles of Self-Regulation Theory (Gross, 2002) to enhance
self-regulated subjective experience and behavior for individuals with psychotic
disorders.

2

1.1 Background
and
significance

Psychotic disorders (i.e., schizophrenia spectrum and mood disorders with
psychotic features) are characterized by distressing psychiatric symptoms, deficits in
cognitive functioning, and a lack of motivation to initiate and sustain goal-directed
behavior, which interact to undermine subjective wellbeing as well as social and
occupational functioning (Green et al., 2004; Nakagami et al., 2010; Yamada et al.,
2010). Even with recent advances in psychosocial rehabilitation, up to two-thirds of
individuals with psychotic disorders are unable to achieve or maintain basic social roles
such as spouse, parent, employee, or integrated member of the community (Bellack et
al., 2007). Additionally, up to 60% of this population continues to experience subjective
distress associated with factors such as psychiatric symptoms and internalized self-
stigma, even while complying with pharmacological and psychosocial treatments
(Corrigan et al., 2006; Curson et al., 1988; Gaudiano, 2005). There are surprisingly few
effective treatments to improve psychosocial functioning and subjective well-being for
those who do not respond or only partially respond to pharmacological treatment, or are
responsive to medications but experience intolerable side effects (reviewed by Chien &
Yip, 2013).
Though the field of psychiatric rehabilitation developed in order to address the
complex and multidimensional needs of people with severe psychiatric disabilities,
evidence suggests that existing rehabilitation interventions tend to narrowly define and
emphasize outcomes that often fail to generalize to broad areas of psychosocial
functioning (reviewed by Chien et al., 2013). For example, social skills training
improves the proximate focus of interpersonal behaviors, but inconsistently impacts
real-world social functioning and has not effectively reduced symptom severity, relapse,

3

or rehospitalization (Kurtz & Mueser, 2008). Vocational interventions such as supported
employment have enabled approximately 40% of individuals with schizophrenia to
obtain competitive employment (Cook & Razzano, 2000), however, only about half are
able to maintain employment beyond a 6-month period (Kern et al., 2002; McHugo et
al., 1998). Further, cognitive remediation interventions for psychosis have shown
medium-sized effects (.30 to .48) in improving attention, processing and working
memory, and executive functioning (McGurk et al., 2007), but these improvements often
fail to generalize to areas such as vocational or social functioning without using
additional rehabilitation strategies (Wykes et al., 2011). Lastly, few psychosocial
treatments affect subjective domains such as internalized self-stigma and the sense of
meaning and purpose underlying intrinsic motivation, which are key features of recovery
in severe mental illness (Roe et al., 2006; Slade, 2010).
Investigations of mindfulness-based treatments suggest there may be the potential
for a more integrated approach to addressing the confluence of bio-psychosocial factors
that affect individuals with psychotic disorders by enhancing self-regulatory capacities
(Baer, 2006; Khoury et al., 2013). Self-regulation is a multi-dimensional construct
involving processes by which individuals attempt to influence the frequency or intensity
of emotional, motivational, or behavioral states in the service of social adaptation or
goal-directed pursuits (Aldao et al., 2010; Gross, 1998). Attempts to manage
distressing psychiatric symptoms, internalized self-stigma, and deficits in cognitive
functioning and motivation can be viewed in terms of such an inter-related system of
self-regulatory processes (Gross, 2002; Livingstone et al., 2009). Mindfulness
treatments have recently gained prominence in the psychological and cognitive

4

neuroscience literatures for their multifaceted approach to improving the self-regulation
of attention, emotion, and behavior in stress-related bio-behavioral disorders
(Chambers, 2008; Khoury et al., 2013). Mindfulness training involves the self-regulation
of an open and receptive form of attention: a non-judgmental and non-reactive
observing of moment-to-moment cognition, affective states, and bodily sensations
without cognitive evaluation or fixation on these stimuli (Brown & Ryan, 2004). Several
mindfulness-based treatments have also combined mindfulness training with traditional
cognitive and behavioral techniques in order to optimize cognitive and behavioral
changes for a range of clinical populations (reviewed by Chiesa & Serreti, 2011).
Preliminary evidence suggests that mindfulness-based interventions may improve
psychiatric symptoms and psychosocial functioning for people with psychotic disorders
(Khoury et al., 2013). However, gaps in this emergent literature include a lack of
treatments guided by a self-regulatory paradigm to address multiple domains of
subjective and functional impairment affected by psychosis. The present investigation
sought to develop and evaluate the impact of a group treatment, entitled “Mindfulness-
Based Self-Regulation Training” (MBSRT), which places the self-regulation of cognition,
emotion, and behavior at its core with a combination of mindfulness exercises and
cognitive-behavioral content tailored to address these inter-related domains for
psychosis. This study also evaluates changes in self-regulatory mechanisms proposed
to underlie the clinical efficacy of the program. Though improvement in self-regulatory
capacities has been theorized to act as a therapeutic mechanism of change associated
with mindfulness-based treatment approaches, no previous studies have empirically
examined this hypothesis among people with psychotic disorders.

5

In order to establish the theoretical rationale and empirical foundation for the
applicability of mindfulness for psychosis, and also for the design of the program under
study, a review of relevant literature will be examined. First, an overview of subjective
and functional impairments affecting people with psychotic disorders will be discussed.
Next, a summary and overview of current psychosocial treatments for psychosis, and
treatment gaps, will be examined. A definition of mindfulness and proposed
mechanisms of action associated with the construct will then be presented along with
evidence on the four major mindfulness treatment models informing the present study.
Lastly, findings from investigations of mindfulness specifically for people with psychotic
disorders will be examined. Chapter one will conclude with the purpose, rationale, and
specific aims for the present investigation.
1.1.1 Subjective
experience
in
psychosis

Subjective domains such as internalized self-stigma, low self-esteem, perceived
stress, and affective distress (i.e., depression and anxiety) have been shown to
reciprocally affect one another and significantly diminish quality of life for people with
psychotic disorders (Corrigan et al., 2006; Livingstone et al., 2009). Social exclusion
and perceived public stigma among this population are significant factors leading to the
internalization of self-devaluing attitudes, including viewing oneself as incompetent and
fundamentally less valuable than other members of society (Lysaker et al., 2008; Mak et
al., 2006; Markowitz, 2001). For example, individuals with schizophrenia who accept
stereotyped beliefs regarding mental illness have been shown to perceive themselves
as less competent and less lovable, and to display greater levels of social withdrawal
than those who do not accept such beliefs (Lysaker et al., 2008).

6

Other negative self-appraisals, such as the attribution of personal responsibility for
the cause of illness, are further associated with internalized self-stigma (Mak et al.,
2006). Internalized stigma in turn predicts low self-esteem for people with psychosis
(Ritsher & Phelan, 2004), and low self-esteem has been found to mediate the
relationship between internalized stigma and depressive symptoms for this population
(Yanos et al., 2008). Perceived public stigma and social rejection have also been
shown to predict stress appraisals, and when these exceed perceived coping resources
for people with psychotic disorders, it can lead to high levels of subjectively perceived
stress (Rusch et al., 2009). Thus, as Link and colleagues (2001) have theorized and
empirically demonstrated, the systematic devaluation and marginalization of persons
with mental illness leads to internalized negative self-appraisals, which in turn
exacerbate symptom severity and subjective distress and increase the likelihood of
repeated episodes of illness (e.g., Link & Phelan, 2001).
Individuals with psychotic disorders also exhibit high levels of mood disturbance
and affective distress. Up to 45% of people with schizophrenia, schizoaffective disorder
and bipolar disorder are diagnosed with a comorbid anxiety disorder, and as high as
65% evidence significant depressive symptoms (Cosoff & Hafner, 1998; Livingstone et
al., 2009). Individuals with schizophrenia report feeling negative emotions more often
than healthy controls (Suslow et al., 2003), and increases in anxiety, depression, and
irritability have been found to be an antecedent to the onset of psychotic symptoms and
acute relapse of psychosis (Freeman & Garety, 2003). Evidence also suggests that
negative emotional states, such as anxiety and depression, can be a consequence of
experiencing psychotic symptoms. For example, Chadwick et al. (2006; 2009) found

7

that auditory hallucinations perceived as malevolent and omnipotent were associated
with negative affect and depression among individuals experiencing psychosis. Other
researchers have linked psychotic symptoms with resultant global emotional distress
(e.g., Bach & Hayes, 2002; Gaudiano & Herbert, 2006). Thus, mood disturbance (i.e.,
anxiety and depression) may be implicated in the development and exacerbation of
psychotic symptoms, as well as being a consequence of psychotic experience.
Along with negative self-appraisals and affective states, individuals with psychotic
disorders frequently use dysfunctional self-regulatory strategies in an attempt to
regulate distressing experiences (Henry et al., 2007; Livingstone et al., 2009). Emotion
regulation is a broad construct that refers to processes by which individuals influence
emotional experience and expression (Gross, 2002). Cognitive reappraisal, for
example, is an emotion regulation strategy in which the individual changes the way a
situation is construed (e.g., viewing a stressful situation as an opportunity for growth) to
decrease its emotional impact (Gross, 2002). Alternatively, suppression is a strategy
that consists of inhibiting the outward expression or behavioral signs of emotions,
without altering the emotional impact of events (Gross, 2002). Emotion dysregulation
can be conceptualized as the use of inflexible strategies rather than the absence of self-
regulatory skills. For example, suppression may be an adaptive mechanism in a
situation where an individual is being evaluated, such as a job interview, but habitual
use of suppression has been associated with negative affect and poor psychosocial
functioning (Aldao et al., 2011).
While there is a paucity of emotion-oriented research in psychosis (Birchwood,
2003), studies have found that individuals diagnosed with psychotic disorders, with or

8

without affective symptoms, experience negative emotions (e.g., anger and shame)
more often than healthy controls (Suslow et al., 2003). Further evidence suggests that
individuals with psychosis may over rely on dysfunctional mechanisms to regulate
distressing internal stimuli (Livingstone, 2009). Livingstone et al. (2009) found that
people who had experienced psychosis were more likely to use dysfunctional emotion
regulation strategies, including rumination and suppression, than non-patient controls,
and were less likely to use effective strategies, such as cognitive reappraisal, than
controls. Related research has shown that individuals with schizophrenia demonstrate
difficulties with the amplification, but not suppression, of emotion expressive behavior as
compared to demographically matched non-clinical controls (Henry et al., 2007). Since
suppression has been found to reduce emotional expression without reducing the
experience of negative affective states (Henry et al., 2007), this self-regulatory style
may lead individuals with psychosis to experience a high degree of negative emotions
while demonstrating the outward expression of flat affect (Livingstone, 2009). Thus,
dysfunctional emotion regulation patterns may interfere with social interactions and the
development of social relationships (Gross, 2002).
A social functional conceptualization of emotion proposes that emotions
coordinate social interactions by providing information about others’ intentions and
motivating behaviors that benefit social bonds (Ekman, 1992). Though few studies
have examined a direct link between social impairment and emotion dysfunction in
psychotic disorders, Henry et al. (2007) found that difficulty with emotion amplification
among people with schizophrenia was significantly correlated with social withdrawal.
This finding may be related to a dynamic in which individuals with psychotic disorders

9

lack emotion expression and responsiveness to others, which in turn fails to elicit social
support and on-going reciprocal social interactions. This may lead individuals with
psychosis to feel discouraged and socially rejected, causing them to withdraw, and
further exacerbating negative symptoms.
Given the significant distress and self-regulatory deficits among people with
psychotic disorders, treatment approaches emphasizing self-regulatory skill
development at their core may be particularly beneficial for this population (Chadwick,
2006; Livingstone et al., 2009). This notion is further supported by data suggesting that
psychological interventions aimed at reducing distressing psychiatric symptoms (e.g.,
Cognitive-Behavioral Therapy) have failed to improve underlying emotion regulation
abilities for people with disorders such as schizophrenia (Birchwood, 2003). A primary
focus on changing underlying self-regulatory processes is consistent with a
mindfulness-based approach, which focuses on regulating responses to distressing
cognitions and emotions rather than attempting to control or alter their content directly
(Chadwick, 2006). This family of interventions and evidence supporting its applicability
to psychotic disorders will be discussed in more detail later in this chapter.
1.1.2 Functional
impairment
in
psychosis

It is widely recognized that psychotic disorders are associated with extensive
impairment in cognitive and psychosocial functioning. For example, up to two thirds of
individuals with schizophrenia are unable to develop enduring and satisfying
interpersonal relationships, achieve educational or work-related goals, sustain
independent living, and participate in community life (Bellack et al., 2007; Liberman et
al., 2002). Much effort has been applied to discovering key determinants of poor

10

functioning that can be addressed as psychosocial treatment targets for this
population.
Neurocognitive impairment is one of the major factors related to poor community
functioning among people with psychotic disorders (Green et al., 2004; Velligan et al.,
2006). Cognitive processing deficits, impacting domains such as attention, speed of
processing, working memory and problem-solving, have been consistently associated
with reduced long term functional outcomes, poor quality of life (Brekke et al., 2005;
Twamley et al., 2008), and poor rehabilitation outcomes (Wykes & Huddy, 2009).
However, there is evidence to suggest that real-world functional disability associated
with disorders such as schizophrenia is more severe than would be expected on the
basis of cognitive impairments alone (Velligan et al., 2006). For example, cognitive
ability and neuropsychological performance account for only 25% - 50% of the variance
in real-world functional outcomes (e.g., engagement in community activities and social
relationships) for this population (Bowie et al., 2006; Harvey et al., 1998). Recent
research points toward important intervening variables, such as motivational deficits
(Barch & Dowd, 2010) and defeatist attitudes and expectancies (Horan et al., 2010),
which may link primary cognitive deficits with more distal impairments in real-world
functioning.
Motivation has been defined as an internal state that serves to activate and
sustain goal-directed behavior (Eccles & Wigfield, 2002). Decrements in motivation
have recently been identified as a significant factor that interferes with numerous
functional domains for people with psychotic disorders, including: participation in
treatment, activity level, the fulfillment of work-related and social roles, and the

11

fundamental components of learning including the development of goals, defining steps
to achieve those goals, and sustained action aimed at accomplishing goals (Choi &
Medalia, 2010; Nakagami, Hoe, & Brekke, 2010; Ryan & Deci, 2000). Though there is
still relatively little known about factors affecting motivation in psychosis, this area has
gained increasing attention due to its relevance to treatment and recovery-oriented
aims for people with severe mental illness.
Horan et al. (2006) found that motivational impairment among people with
schizophrenia was predictive of functioning in work, social, and independent living
domains. There is also evidence that intrinsic motivation mediates the relationship
between neurocognition and functional outcomes (Barch, 2005; Nakagami et al.,
2008), suggesting primary deficits in cognitive functioning intersect with motivation to
impact role functioning. Researchers have identified several important physiological
processes involved in disturbances in motivation, such as deficits in the mid-brain
dopamine system, that may impede incentive drives and approach behaviors (Barch &
Dowd, 2010). However, a prospective study by Nakagami et al. (2010) found that
changes in intrinsic motivation over time were independent of neurocognitive
functioning at baseline. These findings suggest that intrinsic motivation may be
malleable and that individuals can increase levels of intrinsic motivation regardless of
initial levels of neurocognitive functioning.
With regard to factors that may either increase or interfere with motivation, Choi et
al. (2010) found that individuals with schizophrenia who perceived a given task as
worthwhile showed greater expectations of success, which were in turn associated with
higher levels of motivation, even after accounting for baseline task performance and

12

neurocognitive functioning. They concluded that valuing a behavior is a central
determinant in increasing motivation and task performance for this population.
Evidence also suggests that motivational deficits mediate the relationship between
symptom severity and role functioning for people with psychotic disorders (Yamada,
Lee, Dinh, et al., 2010), indicating that psychiatric symptoms may reduce motivation
and, in turn, functioning. Together, these findings highlight two important points: 1) the
importance of motivation as an intervening variable linking primary neurocognitive
deficits with community functioning, and 2) valuing a behavior, along with alleviating
distressing symptoms, may improve motivation for people with psychotic disorders.
Another intervening variable related to functioning that may prove to be a
worthwhile psychosocial treatment target is negative beliefs and attitudes
characteristically associated with psychotic disorders (Beck et al., 2009; Grant & Beck,
2009; Horan et al., 2010). A cognitive formulation of poor functioning in schizophrenia
proposes that fundamental limitations in capacity lead to discouraging life
circumstances that give rise to negative attitudes, expectancies, and beliefs (Beck et
al., 2009). For example, individuals with schizophrenia may develop the belief that
they will fail at future endeavors or acquire an on-going expectation of social rejection.
These beliefs and expectancies, in turn, decrease motivation and promote avoidance
and negative symptoms such as social withdrawal, further disrupting functioning and
ultimately perpetuating such defeatist beliefs. In support of this framework, Grant and
Beck (2009) conducted a path analysis showing that defeatist beliefs partially mediated
the relationship between neurocognition and negative symptoms for people with
schizophrenia. They also conducted a separate path analysis demonstrating that

13

dysfunctional beliefs partially mediated the relationship between neurocognition and
quality of life for this population.
Building on Grant and Beck’s work (2009), Horan et al. (2010) used more
sophisticated structural equation modeling methods based on a sample of 111
individuals with schizophrenia and schizoaffective disorder, and found that negative
symptoms mediated the relationship between dysfunctional attitudes and community
functioning. The authors also found that neurocognitive capacity was indirectly related
to community functioning via dysfunctional attitudes. In total, these findings support a
theoretical formulation in which primary functional deficits in psychosis may engender
maladaptive beliefs and expectancies that in turn promote negative symptoms and
social withdrawal, ultimately disrupting engagement in community functioning. Such
evidence supports a growing recognition of the need for psychosocial interventions
targeting cognitive appraisal processes and their mediating impact on motivational
deficits and real-world functional outcomes in psychosis.
In summary, evidence related to subjective experience and functioning in
psychosis highlights the need for treatments that enhance the ability to regulate
attention, emotional disturbance, distressing cognitive appraisals, and motivation as
pathways toward improved community functioning and subjective wellbeing. As
previously mentioned, there are currently few interventions that attempt to improve
these inter-related areas of concern for this population (Chien et al., 2013; Kern et al.,
2009).

14

1.1.3 Limitations
of
psychosocial
treatments
for
psychosis

A biomedical focus in the treatment of severe mental illness has traditionally
emphasized outcomes such as symptom management and reduced psychiatric
hospitalizations (e.g. Perlick et al., 2008; Ventura et al., 2009). More recently, there is
growing recognition of person-centered views of recovery based on studies examining
first person narratives of people with severe mental illness (e.g., Ridgway, 2001; Roe
et al., 2004), which include elements such as hope, self-determination, agency,
meaning and purpose, and awareness (Onken et al., 2007). Person-centered recovery
suggests that, beyond simply coping with the demands of mental illness, individuals
may actively attempt to initiate processes of personal growth and change.
Furthermore, such growth processes may occur despite the presence of psychiatric
symptoms and their consequences (Roe & Chopra, 2003). The notion that mental
illness and mental health are distinct constructs that may coexist is also empirically
valid; for example, research has shown only modest correlations between measures of
depression and psychological wellbeing (-0.40 to -0.55; Ryff and Keyes, 1995; Slade,
2010).
Mindfulness-based treatments seek to redefine the self and promote the pursuit of
meaningful life activities by changing the way individuals relate to distressing
experiences (e.g., symptoms); therefore, positive change is not contingent upon the
removal or alteration of symptoms directly (Gaudiano et al., 2010). This approach is
congruent with a recovery-oriented philosophy and may also provide a multi-faceted
approach to targeting subjective and functional improvement. In contrast, many
existing psychosocial interventions tend to emphasize compartmentalized outcomes,

15

and may also target changes based on illness-related goals such as symptom control,
relapse prevention, and medication adherence (Chien et al., 2013).
In response to frequently occurring neurocognitive deficits in psychosis, a variety
of cognitive remediation approaches have been developed (e.g. cognitive-enhancing
drill and practice exercises; Kurzban, et al., 2010). Investigations of cognitive
remediation suggest domains related to attention, executive function and other
cognitive functions can be bolstered with training methods that involve performing
working memory and attention-related tasks over several sessions

(Chien et al., 2013).
Though cognitive remediation has shown medium-sized effects (0.30-0.48) in
improving attention, processing, working memory, and executive function (McGurk et
al., 2007), benefits from this approach often fail to generalize to broad areas of social
and occupational functioning (Wykes et al., 2011). A meta-analysis of 40 controlled
trials suggests that cognitive remediation is most effective in improving role functioning
when combined with other psychiatric rehabilitation strategies, such as vocational
training. Thus, treatments capitalizing on cognitive-enhancing techniques while also
providing multifaceted intervention strategies may be most advantageous for psychotic
disorders. These findings have relevance for treatments combining mindfulness
training, which involves the self-regulation of attention through repeated practice
exercises, with cognitive and behavioral strategies as a potential avenue for improving
both cognitive functioning and broader psychosocial domains in psychosis.
Psychoeducational programs for psychotic disorders generally provide information
about the nature of the mental illness and its treatment, access to community mental
health services, and problem-solving and coping skills to help manage symptoms

16

(Mueser & Glynn, 2013). Investigations of this approach have accumulated much
evidence indicating their efficacy in relapse prevention and improving treatment
compliance and satisfaction with mental health services (Xia et al., 2011). However,
studies suggest that, while psychoeducation alone is effective in increasing recipients’
knowledge, it often does not change illness-related behaviors and other important
psychosocial outcomes such as global functioning, insight into illness, and quality of life
(Bisbee & Vickar, 2012). Therefore, researchers recommend integrating
psychoeducational interventions into multi-component psychosocial programs in order
to yield more comprehensive and longer-term treatment gains than those typically
provided by psychoeducation alone (Chien et al., 2013; Xia et al., 2011).
Cognitive-Behavior Therapy (CBT), which involves actively examining distressing
beliefs and challenging distortions in habitual patterns of thinking, has been considered
a promising treatment for individuals with psychotic disorders whose symptoms are not
sufficiently managed by medication (Jones et al., 2011). Effect sizes related to
improvements in psychotic and affective symptoms using CBT are comparable to those
obtained for mindfulness-based treatments for psychosis (Khoury et al., 2013), but
average attrition rates in mindfulness investigations (12.14%) are smaller than those
demonstrated in most CBT studies (e.g., 22.5%; Westbrook and Kirk, 2005). Thus,
people with psychosis may be more receptive to a treatment that focuses on modifying
their relationship to distressing thoughts and symptoms rather than challenging such
experiences directly (Gaudiano & Herbert, 2006). More importantly, CBT alone shows
relatively low effects on relapse, re-hospitalization, and psychosocial functioning (Piling
et al., 2002; Tarrier et al., 2000). CBT also requires extensive experience and training

17

on the part of practitioners (Jones et al., 2011) as well as a long duration of treatment
(9-12 months; Turkington et al., 2006) to be effective, making it highly resource
intensive and costly. Investigations of mindfulness-based treatments have shown
clinical effects similar to those gained from CBT in significantly shorter time frames
(Ruiz, 2010).
Finally, a large body of evidence indicates social skills training (Liberman et al.,
1998), which involves social perception, processing skills, and behavioral responding,
is effective in improving the proximate focus of social competence for people with
psychotic disorders (e.g., Kopelowicz & Liberman, 2006). Three critical reviews
examining more than 50 controlled trials of the treatment suggest participants retained
improvement in specific social skill behaviors for up to two years post-treatment (Glynn
et al., 2002; Kopelowicz & Liberman, 2006; Piling et al., 2002). Results from recent
studies, however, are discouraging with regard to the generalization of treatment
effects to real-world social functioning, which tends to involve complexities like
assertiveness and job-related social skills (Glynn et al., 2002; Moriana et al., 2006).
Though current psychosocial treatment approaches for psychotic disorders have
their strengths and weaknesses, few treatments impact broad functional domains or
subjective experiences associated with a person-centered approach to recovery in
severe mental illness (e.g., a positive sense of self, a sense of meaning and purpose;
Slade, 2010).

As mentioned, mindfulness treatments emphasize redefining the self
and pursuing meaningful life goals despite the presence of mental illness, and may
also provide an integrated approach to addressing the cognitive, affective, and
behavioral factors associated with impairment in psychosis. Examination of research

18

on the construct of mindfulness and empirical evidence related to mindfulness-based
treatment investigations will provide further insight into the development of specific
methods used for the intervention under study.
1.1.4 Mindfulness:

Definition
and
proposed
mechanisms
of
action

One of the most commonly cited definitions of mindfulness is “The awareness
that emerges through paying attention on purpose, in the present moment, and non-
judgmentally to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p.
145). Mindfulness meditation originates in Buddhist traditions, but its underlying
principles can be found in a variety of traditions including phenomenology,
existentialism, and humanism (Baer, 2006). Mindfulness, which is essentially a quality
of awareness, is necessarily a universal and inherent human capacity. Interventions
based on this approach generally include two important dimensions: 1) directing
attention towards thoughts, feelings and sensations in the present, and 2) the intentional
suspension of judgment or cognitive evaluation of these stimuli (Brown & Ryan, 2004).
Instructions that are common to mindfulness training exercises include bringing
oneʼs attention to a sensory experience, such as breathing, and observing it carefully
(Baer, 2006). If bodily sensations or emotional states arise during mindfulness
practice, participants are instructed to acknowledge such experiences with an attitude
of interest and acceptance, while refraining from evaluating or judging the content. In
particular, no attempt is made to challenge or remove unwanted thoughts or feelings as
this would lead to struggle and an effort to manipulate present-moment reality. Instead,
thoughts, feelings, and sensations, whether pleasant or aversive, are observed with an
emphasis on noticing their transitory and ever-changing nature. Mindfulness practice

19

also involves the adoption of attitudes such as self-compassion and patience,
particularly in regards to painful or distressing experiences, which are frequently met
with negative self-judgment and avoidance (Kabat-Zinn, 1990).
The receptivity to present-moment experience that is characteristic of mindful
awareness can be contrasted with a state of aversion or avoidance, which constricts
and redirects attention in an attempt to avoid or escape an experience either mentally
or behaviorally (Brown & Ryan, 2004). Being ʻpresentʼ may also be contrasted with
states of mind characterized by pre-occupation with past events, fantasies, and worries
or plans for the future. The primary aim of mindfulness practice is to develop a
receptive state of mind that interrupts habitual patterns of perception and reactivity,
ultimately fostering equanimity and clear perception of present moment phenomena
without cognitive overlay (Kabat-Zinn, 2003).
Researchers have only recently begun to turn their attention towards identifying
possible mechanisms underlying the clinical efficacy associated with mindfulness
practices. Mindful awareness has been theorized to support the development of
metacognitive insight, defined as knowledge or insight into one’s own thinking
processes (Chadwick, 2006; Flavell, 1979). For example, observing on-going cognitive
phenomena may lead one to infer general properties of thought processes, such as a
recognition that thoughts are by nature transient and continually in flux. Since
mindfulness involves a receptive state of ‘being’ that is characterized by bare attention
and observation of internal and external stimuli, it can be expected to facilitate insight
regarding relationships among thoughts, feelings, sensations, and emotional and
behavioral reactions. The role of metacognitive insight as a change mechanism

20

underlying mindfulness has mainly received conceptual consideration; experimental
studies examining this relationship are needed.
Decentered awareness, a construct related to metacognitive insight, is defined as
experiencing thoughts as mere thoughts, or mental events, rather than as aspects of
the self or direct reflections of reality. Teasedale et al. (2002) have proposed that:
“rather than simply being their emotions, or identifying personally with negative
thoughts and feelings, patients relate to negative experiences as mental events in a
wider context or field of awareness” (Teasdale et al., 2002, p. 276). In several
controlled studies of Mindfulness-Based Cognitive Therapy for depression, Teasdale et
al. (2002; 2004) found that decentered awareness was associated with the interruption
of ruminative thought cycles and reduced vulnerability to depressive relapse.
However, these studies did not directly measure changes in mindfulness, and
conclusions regarding a direct relationship between these processes cannot be firmly
supported, though this is an important direction for further study.
Mindfulness has also been conceptualized as a self-regulatory process. Growing
evidence suggests the self-regulation of attention underlying mindfulness practice may
serve as a mediator of positive outcomes associated with this approach. Researchers
posit that two primary subsystems of attention regulation may be involved in the
development of mindful awareness: 1) attentional switching and 2) sustained attention

(Chambers et al., 2008). Mindfulness practices often use attentional switching, defined
as the ability to shift the focus of one’s attention between varying stimuli, through
systematic attention to different dimensions of experience including physical sensations,
cognitions, and emotional states. Sustained attention, or the ability to focus attention on

21

a particular stimulus for a prolonged period, is also an integral part of many mindfulness
exercises. For example, mindful awareness of breath involves directing attention
toward sensory experiences associated with breathing for an ongoing period of time.
There is evidence to support the relationship between mindfulness and increased
performance on neurocognitive measures

(e.g., Jha et al., 2007; 2010), an important
finding in light of evidence related to neurocognitive deficits for individuals with
psychotic disorders

(Green et al., 2004). For example, Jha et al.

(2007) found that 8
weeks of mindfulness training among a non-clinical population improved orienting for
treatment naive participants, and also that conflict monitoring and alerting were superior
in those with greater mindfulness experience. Wenk-Sormaz

(2005) similarly found that
brief mindfulness exercises provided to a non-clinical population (three 20-minute
sessions) were associated with less Stroop interference and more flexible word
production, indicating improved attentional control as compared to a control condition.
More recently, Jha et al.

(2010) found that decreases in working memory were
associated with less mindfulness practice time while increases in working memory were
associated with greater practice time for members of the military receiving mindfulness
training. Zylowska et al.

(2008) found improvement in attention and cognitive inhibition
for individuals with attention-deficit hyperactivity disorder after receiving an 8-week
mindfulness-based group. Also, increases in cortical thickness within attention-
associated areas of the pre-frontal cortex

(Lazar et al., 2005), along with greater
functional capacity within these sub-regions during attention-demanding tasks, have
been associated with life time hours of mindfulness training practice

(Brefczynski-Lewis

22

et al., 2007). Thus, mindfulness training may impact both the structure of attentional
networks and the regulation of cognitive processes associated with attention.
Emotion regulation is also theorized to act as a therapeutic mechanism
associated with mindfulness-based treatments. Gratz and Roemer (2004)
conceptualize emotion regulation as a multidimensional process involving awareness of
emotions and the flexible use of strategies to modulate their intensity and/or duration,
while simultaneously inhibiting impulsive behaviors and engaging in goal-directed
behavior. Mindfulness practices can be expected to promote emotional awareness
through the process of observing and describing emotional states, and also to teach
participants that emotions can be tolerated without immediately acting upon them.
Mindfulness may also diffuse threatening stimuli through non-judgmental contact with
feared experiences, a conceptualization that is related to the constructs of exposure and
desensitization (Borkovec, 2002). Evidence suggests that desensitization through
deliberate exposure to aversive stimuli is associated with increased ability to tolerate
distressing experiences, reduced emotional reactivity, and quicker recovery of
equilibrium after distressing experiences (Brown et al. 2007, Borkovec, 2002).
In spite of theoretical links between mindfulness-based treatments and adaptive
self-regulation, few studies have empirically examined whether this form of treatment
influences self-regulatory capacities. Leahey et al. (2008) found that, following a 10-
week mindfulness-based cognitive-behavioral intervention for eating disorders,
participants demonstrated significant improvements in binge eating and emotion
regulation (assessed by the Difficulties in Emotion Regulation Scale; Gratz & Roemer,
2004) from pre- to post-treatment. Tull et al. (2007) also found significant improvement

23

in anxiety, heroin cravings, and emotion regulation skills among heroin dependent
patients in residential substance abuse treatment after receiving a 6-week mindfulness-
based intervention. Relevant prospective studies show that, in general, increased use
of adaptive emotion regulation strategies predicts lower levels of negative affect and
anxiety and greater levels of positive affect over time (Berking et al., 2008). Though
preliminary evidence is promising, further investigations directly examining relationships
among mindfulness, emotion regulation skills, and clinical outcomes are required to
firmly support the role of mindfulness within a self-regulatory paradigm.
1.1.5 Mindfulness-‐based
treatment
models

Mental health professionals have recently identified a host of benefits derived
from interventions that integrate mindfulness with cognitive-behavioral techniques to
treat a wide range of psychological and medical disorders. The intervention developed
for the present study draws upon several of these models including: Mindfulness-Based
Stress Reduction (MBSR; Kabat-Zinn, 1990), Mindfulness-Based Cognitive Therapy for
Depression (MBCT; Teasdale et al., 2002), Acceptance and Commitment Therapy
(ACT; Hayes et al., 1999), and Person-Based Cognitive Therapy for Distressing
Psychosis (PBCT; Chadwick, 2006). A brief description and empirical findings related
to each of these models are summarized below.
Mindfulness-Based Stress Reduction: The most frequently cited application of
mindfulness training is Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1990),
originally developed for stress related to chronic pain (Kabat-Zinn, 1982). MBSR uses a
number of techniques to build present moment awareness, such as exercises
emphasizing mindful awareness of sensations associated with breathing and a body

24

scan meditation. Didactic information on stress reactivity is also provided. Several
studies of MBSR have found decreases in mood disturbance and symptoms of stress
as well as enhanced coping among cancer and heart disease patients (e.g. Carlson et
al., 2001; 2003). Additionally, studies of MBSR have demonstrated reduced anxiety
and depression for patients with various medical conditions (e.g. Speca, 2000) as well
as concurrent physiological improvements based on significant increases in left-sided
anterior activation of the brain, a pattern associated with positive affect (Davidson et al,
2003). A meta-analyses by Grossman et al. (2004) examining 20 empirical studies of
MBSR concluded that both controlled and uncontrolled studies showed consistent and
moderate effect sizes of approximately 0.5 (p < .0001) in reducing distress and
improving coping, leading the authors to conclude that MBSR is effective for both
clinical and non-clinical populations.
Mindfulness-Based Cognitive Therapy for Depression: Mindfulness-based
Cognitive Therapy for depression (MBCT), an 8-week group model that grew out of
MBSR, has shown significant reduction in depression and prevention of depressive
relapse (Teasdale et al., 2002). MBCT incorporates many elements of MBSR including
the body scan and sitting meditation, as well as yoga and walking meditation (Baer,
2006). In this model, didactic information is tailored to the nature of depression as
opposed to stress. Teasdale et al. (2002; 2004) found that changing one’s relationship
to thoughts rather than changing thought content (i.e., decentered awareness) is a key
factor in alleviating depressive symptoms and reducing relapse for depression.
In a randomized controlled clinical trial of 100 patients in remission from major
depression, Teasdale et al. (2002) found that participants receiving MBCT

25

demonstrated increased decentered awareness of negative thoughts and feelings and
reduced relapse at 4 months post-treatment compared to a treatment as usual
condition. These findings were replicated by Ma & Teasdale (2004) who found that 55
patients receiving MBCT compared to a treatment as usual control group showed
reduced depressive relapse rates ranging from 78% to 36% at one year post-treatment.
The authors concluded that decentered awareness fostered through MBCT is related to
significantly reduced dysfunctional thinking and reduced depressive relapse.
Chiesa and Seretti (2011) conducted a meta-analysis based on 16 investigations
of MBCT for psychiatric disorders (i.e., major depression, bipolar disorder, and various
anxiety disorders) and found that the augmentation of MBCT to standard care was
associated with lower relapse and recurrence rates for those with major depression, as
compared with standard care alone. They also found evidence to suggest the effect of
MBCT on the reduction of anxiety symptoms in bipolar patients and those with
generalized anxiety and panic disorder (discussed in more detail below).
Acceptance and Commitment Therapy: Acceptance and Commitment
Therapy (ACT), developed by Hayes et al. (1999), is a therapy approach based on
helping individuals acknowledge distressing experiences non-judgmentally as opposed
to avoiding or struggling with them, while simultaneously identifying and pursuing valued
life goals. The model consists of six core processes: 1) acceptance of private events
(i.e., thoughts, feelings, and sensations) as an alternative to avoidance, 2) cognitive
defusion as a means of creating non-literal contexts in which language and cognition
can be seen as relational processes, 3) non-judgmental contact with the present
moment through exercises designed to promote a mindful outlook, 4) developing a ‘self

26

as context’ perspective, 5) defining valued life directions, and 6) developing patterns of
action that are linked to these values. Structured mindfulness exercises, such as those
featured in MBSR and MBCT, are not included in ACT.
ACT has shown efficacy in treating a variety of mental health disorders (Hayes et
al., 2004; Bach & Hayes. 2002). A recent meta-analysis of this approach based on 18
randomized controlled trials (n=917; Powers et al., 2009) showed that ACT is superior
to wait-list, psychological placebo, and treatment as usual conditions based on
outcomes such as reduced re-hospitalization for people with psychosis (Bach & Hayes,
2002), stress related to chronic pain (Dahl et al., 2004), smoking cessation (Gifford et
al., 2004), and emotion regulation among individuals with Borderline Personality
Disorder (Gratz & Gunderson, 2006). Still, ACT did not outperform other established
therapies such as cognitive-behavior therapy and systematic desensitization for
treatment targets such as depression and anxiety (Powers et al., 2009). A
comprehensive review of ACT found that several studies based on the model employ
short interventions that have long-lasting effects, however, the authors also highlighted
the need for more comparisons between this method and established treatments such
as CBT in order to determine the superiority of the approach (Ruiz, 2010).
Person-Based Cognitive Therapy for Distressing Psychosis: Person-Based
Cognitive Therapy (PBCT; Chadwick, 2006) incorporates CBT and mindfulness
practices for people with psychotic disorders, emphasizing acceptance of voice hearing.
PBCT teaches participants to accept unpleasant experiences associated with auditory
hallucinations through decentered awareness, shortened (10 minute) formal
mindfulness exercises, and cognitive therapy techniques such as challenging negative

27

self-schema. Preliminary studies support the promise of this treatment approach in
reducing symptom-associated distress and improving clinical functioning for individuals
with schizophrenia and schizoaffective disorder, particularly those experiencing
treatment-resistant auditory hallucinations (Dannahy et al., 2011). Evidence supporting
this treatment model is detailed further below.
1.1.6 Mindfulness
for
psychotic
disorders:

Empirical
evidence
to
date

A growing body of evidence suggests mindfulness interventions may be
particularly helpful in alleviating distress associated with symptoms, such as auditory
hallucinations and paranoid ideation, as well as improving functional capacities among
people with psychotic disorders (Davis & Kurzban, 2012; Khoury et al., 2013). In their
systematic review of mindfulness-based treatments for psychosis, Davis and Kurzban
(2012) examined mindfulness-based interventions that integrate cognitive-behavioral
components as well as mindfulness training as a stand-alone method for individuals
with severe mental illness (i.e., schizophrenia, schizoaffective disorder, and bi-polar
disorder). Studies investigating mindfulness interventions with cognitive and behavioral
components included two randomized controlled trials of the ACT model for inpatients
with psychosis. These studies found reduced re-hospitalization rates for ACT
participants and significant decreases in the believability of delusions and hallucinations
as compared to TAU (Bach and Hayes, 2002; Gaudiano & Herbert, 2006). Gaudiano &
Herbert (2006) also found that believability, or the degree of conviction in the validity of
hallucinations, mediates the relationship between the frequency of hallucinations and
the distress associated with them. These findings support the notion that changing

28

one’s relationship to psychotic symptoms, as opposed to changing their content or
frequency, is a therapeutic mechanism of change for people with psychosis.
Additional studies of mindfulness combined with CBT examined in the review
included two investigations of MBCT for people with bipolar disorder. One randomized
controlled trial of the intervention found significantly lower anxiety and depression in the
MBCT condition as compared to a wait-list control group (Williams et al., 2008), while a
second open trial of the intervention for bipolar disorder found improvements in
depression and mindfulness skills from pre- to post-intervention that did not reach
statistical significance (Weber et. al., 2010). Thus, conclusions regarding the efficacy of
the program for bipolar disorder remain unclear. Based on uncontrolled trials of PBCT,
the authors similarly concluded that this approach shows promise but requires further
evidence to demonstrate the efficacy of the treatment. For example, PBCT trials
demonstrated medium-sized effects related to improvements in psychosocial
functioning and wellbeing at post-treatment and at 3-month follow-up (Dannahy et al.,
2011), but did not include a control group.
Qualitative studies of mindfulness as a stand-alone treatment for psychosis that
were reviewed also provided some insight into therapeutic processes associated with
mindfulness for this population. Abba et al. (2008) found that participants with
schizophrenia had a sense of self defined as abnormal, bad and worthless in
relationship to psychotic experiences prior to a group mindfulness intervention. The
treatment enabled them to redefine their relationship to psychotic experiences through a
three stage process: awareness of psychotic symptoms, allowing psychosis to come
and go without reacting, and reclaiming power by acceptance of psychosis and the self.

29

Overall, results from this review suggest that mindfulness for psychosis may improve
symptom-associated distress and clinical functioning, while also reducing psychiatric
hospitalization (Davis & Kurzban, 2012). The review highlights the need for greater
methodological rigor among mindfulness investigations and further understanding of
change mechanisms associated with treatments. In particular, changes in cognitive
processes and emotion regulation posited to undergird mindfulness approaches have
not been examined among individuals with psychosis receiving mindfulness
interventions.
Since this first published review of mindfulness for psychosis (Davis & Kurzban,
2012), there have been several recent studies that continue to indicate the utility of the
approach for this population. For example, further support for ACT was demonstrated
in a blind randomized trial of the intervention for 27 outpatients with psychosis who were
randomized to either 10 individual sessions of ACT plus TAU, or TAU alone (White et
al., 2011). Participants were evaluated at baseline and at 3-months post-baseline. The
ACT group showed significantly greater increases in mindfulness skills, and a
significantly greater reduction in depression and negative symptoms as compared to
controls. In addition, changes in mindfulness were positively associated with changes
in depression. These findings provide support for mindfulness as a therapeutic
mechanism of change associated with affective distress, though specific pathways that
may link these processes require further investigation. For example, it may be that
mindfulness impacts emotion regulation, which in turn reduces affective distress;
alternatively, mindfulness may affect other direct or indirect pathways to wellbeing.

30

On the basis of promising findings related to the ACT model for people with
psychosis, researchers have begun to formulate additional treatment models integrating
acceptance-based strategies from ACT with traditional CBT protocols. For example,
Shawyer et al. (2012) developed “Treatment of Resistant Command Hallucinations”
(TORCH). The model includes belief modification, noticing voices rather than believing
or acting on them, and supporting modules such as motivational interviewing, relapse
prevention, and coping skills. Forty-three participants with command hallucinations
were randomized to either 15 sessions of TORCH, or a control condition consisting of
Befriending (one-on-one social conversation). The TORCH participants subjectively
reported greater improvement in command hallucinations compared to the Befriending
condition, but there were no significant group differences in primary or secondary
outcome measures (e.g., symptoms and quality of life) based on blinded assessment
data. Thus, it remains unclear whether acceptance strategies combined with CBT
improves outcomes above and beyond social support.
In a related study, Gaudiano et al. (2013) developed a treatment combining
elements of behavioral activation and acceptance strategies from ACT for people with
major depressive disorder with psychotic features entitled “Acceptance-Based
Depression and Psychosis Therapy” (ADAPT). Fourteen patients receiving ADAPT
along with pharmacotherapy showed significant decreases in depressive and psychotic
symptoms, and significant increases in psychosocial functioning, at post-treatment and
at a 3-month follow-up. In addition, treatment process measures (e.g., acceptance,
mindfulness, values) significantly improved over the course of treatment, and changes
in process measures were correlated with symptoms. Thus, ADAPT combined with

31

pharmacotherapy may be a promising approach for psychotic depression, but requires
further investigation in controlled studies.
A recent hybrid model incorporating mindfulness and psychoeducation for people
with schizophrenia is the Mindfulness-Based Psychoeducation Program (MBPP) for
Chinese patients with schizophrenia (Chien & Lee, 2013). MBPP increases patients’
understanding of schizophrenia, its treatment, and community services available and
teaches coping skills combined with mindfulness training exercises. The program
comprises 12 biweekly sessions with 5-6 participants; each session is two hours in
duration. The protocol also incorporates Chinese cultural tenets, such as a focus on
interdependence. Chien and Lee (2013) conducted a multisite randomized controlled
trial with 96 Chinese patients with schizophrenia, who received either MBPP or TAU, in
Hong Kong. Compared to those in usual care, participants receiving MBPP showed
significantly greater improvements in insight into illness, symptom severity, psychosocial
functioning, and number and length of rehospitalizations at an 18-month follow-up.
Notably, this is one of the few studies showing significant long-term effects based on a
mindfulness intervention for schizophrenia. Limitations include the lack of data related
to process measures to elucidate therapeutic mechanisms for change.
Loving-kindness meditation (LKM) is a specific mindfulness practice in which
participants are instructed to focus their attention on their heart region and begin by
contemplating an individual for whom they have warm and loving feelings (Salzberg,
1995). These feelings are gradually extended toward the self and to others through a
guided meditation process. Johnson et al. (2009) conducted a series of case studies
examining an LKM group to reduce negative symptoms associated with schizophrenia

32

and found that participants displayed increased emotional expression and reported
feeling more connected to others in social situations after receiving the group. A follow-
up study by Johnson et al. (2011) examined a LKM group for 18 individuals with
schizophrenia spectrum disorders experiencing significant negative symptoms.
Participants reported significant increases in the frequency and intensity of positive
emotions, increased self-acceptance, and felt more in control and satisfied with their
lives. Additionally, participants reported significant decreases in anhedonia. Though
the uncontrolled study design precludes any causal inferences about the efficacy of
LKM for negative symptoms of schizophrenia, results support the feasibility of the
intervention and its preliminary treatment promise for this population.
An intervention related to LKM is Recovery After Psychosis (RAP), developed for
people with psychosis in forensic clinical settings to improve depression, self-esteem,
compassion towards the self, shame and help seeking (Laithwaite et al., 2009). The
RAP program is based on Compassionate Mind Training (CMT) originally developed by
Gilbert (2009; 2013) to help people with shame-proneness and an internalized self-
critical style generate self-compassion and the ability to self-soothe and regulate affect.
Laithwaite et al. (2009) conducted an uncontrolled pilot test of RAP with 18 individuals
diagnosed with schizophrenia, schizoaffective disorder, and bipolar affective disorder in
an inpatient forensic setting. The 10-week group included topics such as understanding
psychosis, recovery, and compassion. Findings demonstrated significant improvements
in depression, self-esteem and general psychopathology at post-treatment and at a 6-
week follow-up. Moderate to small changes were also found in measures of social
comparison and shame, suggesting that participants improved their ability to respond to

33

self-attacking thoughts. However, significant changes were not found on the self-
compassion scale; the authors postulated that compromised attachment experiences
may interfere with this population’s ability to generate compassion. These preliminary
results are notable because of the paucity of treatments for forensic populations with
psychosis.
Finally, a recent meta-analysis by Khoury et al. (2013) aggregated results from
13 investigations of mindfulness for psychotic disorders. Based on a combined total of
468 participants, results suggest mindfulness interventions are moderately effective in
pre-post studies and demonstrate small to moderate effect sizes in studies using a
control group. Mindfulness interventions were moderately effective in reducing negative
and affective symptoms and in increasing functioning and quality of life. Surprisingly,
only half of the studies included a validated measure of mindfulness or other proposed
mechanisms of change, such as acceptance and compassion. Those that did, found
increased levels of mindfulness, acceptance, and compassion at the end of treatment,
and that changes in these domains were correlated with clinical outcomes. These
findings provide preliminary support for mindfulness, acceptance, and compassion as
active components of clinical efficacy. Results from this meta-analysis are limited by a
small number of included studies and a high degree of heterogeneity related to
treatment protocols and sample characteristics. However, they support the basic
hypothesis that mindfulness interventions are effective in improving subjective and
functional outcomes for people with psychotic disorders.
In summary, mindfulness-based treatments for people psychosis show promise
in reducing psychiatric symptoms and improving indices of subjective wellbeing and

34

functioning. Along with a need for increased methodological rigor, gaps in this area
include the need for a program guided by a self-regulatory paradigm for psychosis
tailored to address distressing cognitive appraisals associated with psychosis (Horan et
al., 2010), maladaptive emotion regulation processes (Livingstone et al., 2009) and
decrements in intrinsically-motivated goal-striving (Barch & Dowd, 2010), which have
been shown to undermine real-world functioning and quality of life for this population
(Kern et al., 2009). This type of therapy may be particularly advantageous for people
with psychotic disorders, particularly those living in the community who are susceptible
to experiences of social rejection and interpersonal stress (Corrigan et al., 2006), to
improve psychosocial functioning and live more rewarding and valued lives. The
previous review also highlights the need for mindfulness investigations that measure
proposed therapeutic mechanisms of action for people with psychosis.
1.2 Rationale
for
the
study

The development of a novel mindfulness-based self-regulation program for people
with psychotic disorders was undertaken to: 1) respond to the lack of currently available
psychosocial treatments that improve self-regulatory capacities affecting wellbeing and
engagement in meaningful and satisfying behavioral pursuits for people with psychotic
disorders, and 2) advance the nascent field of mindfulness-based treatment approaches
for psychosis by addressing limitations of existing mindfulness treatment protocols and
investigations among this population.
First, there is increased recognition and demand for person-centered interventions
that facilitate recovery-oriented outcomes such as psychological wellbeing, a positive
sense of self, self-determination, and behavioral pursuits that support a sense of

35

meaning and purpose for people with psychotic disorders (Kern et al., 2009). Still, the
majority of psychosocial interventions currently used in community settings target
narrow and clinically focused outcomes (e.g., symptom control, relapse prevention, and
medication adherence; Chien et al., 2013). Evidence suggests the development of a
mindfulness intervention to impact recovery-oriented domains, undertaken in this study,
may be effective for psychotic disorders (Davis & Kurzban, 2012; Khoury et al., 2013)
and is congruent with a person-centered focus on promoting wellbeing and value-driven
behavior as opposed to removing aspects of illness (Slade, 2010).
Second, the present investigation seeks to address limitations pertaining to current
investigations of mindfulness treatments for psychosis. MBSRT tailors didactic material,
cognitive-behavioral exercises, and mindfulness training to enhance self-regulated
subjective experience and behavior for a population with wide-ranging subjective and
functional impairment. In addition, this study is the first the author is aware of to
measure changes in self-regulation associated with a mindfulness treatment for people
with psychotic disorders. Enhanced self-regulatory capacities have been theorized to
act as a therapeutic mechanism of change associated with this form of treatment (Gratz
& Roemer, 2004), but few studies have examined this hypothesis empirically.
Lastly, this study is the first to examine whether mindfulness training may affect
changes in cognitive functioning for people with psychotic disorders. The regulation of
attention is a proposed mechanism of the self-regulatory paradigm under study, and
previous research has demonstrated that mindfulness training can modify attentional
networks and improve cognitive functioning

among non-clinical populations (e.g., Jha et
al., 2007; 2010). There is much to be gained from investigating whether this approach

36

may improve cognitive deficits for people with psychotic disorders, since such
impairments are frequently occurring and consistently related to more distal problems in
real-world functioning (Green et al., 2004; Velligan et al., 2006).
1.3 Development
of
a
novel
intervention

The previous review explicates the rationale for the development of a novel, self-
regulation focused mindfulness intervention for psychosis. Onken and colleagues
(1997), along with others (e.g., Nezu & Nezu, 2007; Rounsaville et al., 2001), have
proposed a Stage Model of Behavioral Therapies Research to outline a logical
sequence of progressive steps for the development of clinical innovations through
efficacy and effectiveness research. The initial stage of developing a new treatment, or
Stage I of the model, is primarily concerned with specifying a treatment rationale and
treatment guidelines that allow for an evaluation of the feasibility and preliminary
efficacy of the protocol (Rounsaville et al., 2001). Stage II involves specifying standards
to train and evaluate therapists and discriminate treatment effects from
comparison/control approaches through the use of randomized controlled clinical trials.
Lastly, Stage III evaluates the dissemination and transportability of the intervention
within the clinical community based on effectiveness trials in a range of settings with
diverse patient groups.
In order to lay the ground work to conduct a full-scale efficacy trial during Stage
II, the overall aims of stage I development of an untested treatment include manual
writing, pilot/feasibility testing, and adherence/competence measurement development
(Rounsaville et al., 2001). Developing a well specified treatment manual has several
key functions that facilitate rigorous psychotherapy research throughout the multi-

37

staged treatment development process, including providing a basis for comparing
different treatments, outlining criteria for the training of evaluation of therapists, defining
treatment goals and a means of linking treatment processes with outcomes, and
providing the necessary materials for replication of clinical trials, among others (Nezu &
Nezu, 2007). Therapy manual development is the core work of Stage I, along with a
pilot trial of the treatment protocol to determine: 1) whether the investigator can recruit
sufficient numbers of the target population and the treatment is acceptable to patients
(e.g., they are retained in the trial), 2) that the program is feasible to deliver in proposed
treatment settings, 3) that there is clinically significant change in at least one outcome
domain over the course of treatment, and 4) the likely effect size to be used to
determine sample size during a stage II trial (Rounsaville et al., 2001). The purpose
and focus of the present study, which comprises the development and evaluation of a
previously untested treatment approach, fits Stage I criteria as defined by the Stage
Model of Behavioral Therapies Research. Based on this framework, details regarding
the purpose and specific aims of this investigation are delineated below.
1.4 Purpose
statement

The purpose of this study is to evaluate the feasibility and acceptability of a novel
self-regulation focused intervention that combines mindfulness training and cognitive-
behavioral elements to improve functioning and subjective wellbeing for people with
psychotic disorders. This pilot project aims to manualize a new treatment protocol and
gather evidence of preliminary treatment effects to determine if a more methodologically
rigorous testing of the efficacy of this intervention in future studies is warranted, and
also to guide the design of future studies in this area. Mindfulness-Based Self-

38

Regulation Training (MBSRT; Copyright © Lisa Davis) is guided by a self-regulatory
paradigm to address the regulation of attention, emotion, and behavior, which are inter-
related domains that interact to undermine psychosocial functioning and quality of life
for people with psychosis (Horan et al., 2010; Kern et al., 2009). From a theoretical
standpoint, combining mindfulness training and cognitive-behavioral elements could
lead to a more potent intervention to promote a range of recovery-oriented outcomes for
a population with wide-ranging subjective and functional impairment.
1.5 Specific
Aims

Specific aims for this study are based on Stage I of the Stage Model of Behavioral
Therapies research (Nezu & Nezu, 2007; Onken et al., 1997; Rounsaville et al., 2001).
Recommended activities for the development of a novel treatment during this stage
include: treatment conceptualization and drafting of a treatment manual, iterative testing
and refinement of the treatment protocol in an open trial of the intervention, and
preliminary development of treatment integrity measures for future trials. Rounsaville
and colleagues (2001) emphasize the need for refinement of the therapy protocol and
research methods that incorporate feasibility data and feedback from stakeholders in
order to finalize a manual and research protocol that sufficiently sets the stage for future
efficacy trials.
Based on these guidelines, specific study aims are: 1) Develop a treatment manual
specifying a theoretical treatment rationale and methods for administering MBSRT that
incorporates feedback from clinicians and investigators, 2) Conduct pilot and feasibility
testing of the initial MBSRT manual with one group composed of 6 - 8 individuals
diagnosed with a psychotic disorder (i.e., schizophrenia spectrum or mood disorder with

39

psychotic features) in a psychosocial rehabilitation setting; revise the manual and
assessment battery to incorporate feasibility data and feedback from participants,
clinicians, and investigators, 3) Develop a preliminary treatment integrity measure for
future trials to evaluate providers’ adherence to manualized guidelines for implementing
specific intervention components and level of competence in delivering the MBSRT
intervention, and 4) Refine the MBSRT manual based on data gathered from further
pilot testing with two groups (6 -8 individuals per group) of individuals with psychotic
disorders in a psychosocial rehabilitation setting; the groups will run sequentially, and
time will be incorporated for continued feedback from stakeholders.
1.6 Assumptions
and
limitations

There are two major assumptions underlying the present study design and
implications based on this study. First, it was assumed that all participants responded
honestly and accurately to self-reported measurement items. Second, it was assumed
the methods used were reliable and valid for this study population.
This investigation was also limited by several factors. Participation in the study
was restricted to participants receiving services at the study site who agreed to
participate. It was also limited to the number of participants who remained in the study,
the amount of time and resources available to conduct the study, and the reliability of
measures used. Lastly, due to limited resources resulting in a relatively small sample
size, statistical power to detect changes from pre- to post-treatment was limited.

40

1.7 Delimitations

This study does not include follow-up assessment of treatment outcomes beyond
post-treatment, therefore, it was not designed to examine the durability of treatment
effects of a mindfulness intervention for people with psychotic disorders.
Although this investigation applied a self-regulation paradigm, it was not the intent of
this study to measure potential changes related to the self-regulation of physiological
processes. Content of this study focused on emotion regulation and behavioral
regulation effecting psychosocial functioning; physiological processes related to
allostatic systems (e.g., heart rate variability), neuroendocrine, and immune systems,
previously found to be impacted by mindfulness, were not addressed as part of this
investigation.

41

2 INTERVENTION
DESIGN

2.1 Overview
of
Mindfulness-‐Based
Self-‐Regulation
Training
(MBSRT)

The MBSRT program is intended to serve as an adjunctive psychosocial
treatment to be delivered in combination with pharmacotherapy and basic psychosocial
rehabilitation services (e.g., medication management and case management) for
people with psychotic disorders. MBSRT uses a closed group format, meaning that a
group is formed and stays together for a specific time period. The program comprises
10 weekly sessions - each session lasts 2 hours in duration with a short break after the
first half. The MBSRT model includes three core therapeutic components to promote
adaptive self-regulation: 1) formal mindfulness training, 2) psycho-education, and 3)
cognitive-behavioral exercises.
Component One: Mindfulness Training: The first component, mindfulness
training, consists of exercises adapted from the Mindfulness-Based Stress Reduction
program (MBSR; Kabat-Zinn, 1990). Mindful eating, mindfulness of the breath, the
body scan, and mindful movement exercises are implemented in sessions, followed by
a guided discussion in which participants reflect on their experiences during the
exercise, as is found in MBSR. Mindfulness training in MBSRT differs from MBSR in
the following ways: 1) the length of exercises is significantly shortened, 2)
guidance/instructional comments are verbalized more frequently in order to reduce
periods of silence that may be distressing for people with psychosis (Chadwick, 2006),
and 3) the overall format of sessions has been modified to address cognitive
impairments and for ease of delivery in a psychosocial rehabilitation setting (e.g., overall

42

session length has been shortened, visual aids are used to explain mindfulness
concepts, and the full-day retreat found in MBSR has been removed).
The mindfulness training component of MBSRT is designed to target several
inter-related domains that undergird a self-regulatory paradigm. First, mindfulness
exercises are aimed at improving self-awareness and processes related to the
regulation of attention (e.g., sustaining attention and attentional switching), which have
been shown to be impaired among people with psychotic disorders and associated with
more distal outcomes related to community functioning (Velligan et al., 2006). Second,
mindfulness training can be expected to help regulate affective states through the
development of decentered awareness (Teasedale et. al, 2002). For example, a
significant amount of distress may arise from relating to psychotic symptoms in a
particular way, such as fighting against voices, ruminating on paranoid ideation, and
self-recrimination regarding the presence of symptoms (Chadwick, 2006). Relating
mindfully to such symptoms includes acceptance of these experiences, without fixation,
and can be empowering and calming for people with psychotic disorders. Lastly,
mindfulness training aims to enhance the regulation of distress associated with specific
self-appraisals, such as those related to self-stigma and low self-esteem, through the
internalization of non-judgmental and self-accepting attitudes infused throughout
exercises.
Component Two: Psychoeducation: The second core component of MBSRT
is psychoeducation. This component consists of two sub-components: 1) stress
reactivity and the stress response cycle as it relates to psychotic disorders, and 2)
common dysfunctional attitudes/beliefs among individuals with psychotic disorders. The

43

first sub-component is aimed at helping participants identify links between stress
triggers, physiological arousal, symptom exacerbation, and maladaptive attempts to
restore homeostasis (i.e., dysregulation). Content in this module conveys didactic
information about the concept of self-regulation and adaptive self-regulatory strategies.
The second psycho-educational sub-component is focused on common dysfunctional
beliefs about self and others in psychosis, such as an expectation of social rejection or
the notion that most people cannot be trusted, and the way these beliefs may reinforce
maladaptive relational patterns. The psycho-educational component as a whole is
aimed at increased understanding of the role of appraisal in stress and dysregulated
functioning in psychosis, as well as providing information on strategies to regulate
adaptive behavior in the face of distressing appraisals and emotions.
Component Three: Cognitive-Behavioral Exercises: The third core
component of MBSRT, cognitive-behavioral exercises, consists of three sub-
components: 1) the ABC formulation of cognitive appraisal and coping (Chadwick,
2006; Ellis, 1962), 2) identification of pleasure and mastery activities and development
of a personalized self-care plan (Teasedale et al., 2002), and 3) identification of values,
goals, and action steps in pursuit of goals (Hayes et al., 1999). The values/goals
component was adapted from material found in the ACT intervention. This component
as a whole aims to improve coping, self-care, and intrinsically motivated goal-striving.
In combination, the three core MBSRT elements are intended to impact the regulation
of attention, distressing appraisals and affective states, and behavioral functioning. A
more complete description of intervention procedures for each of these areas can be
found in the MBSRT treatment manual.

44

2.2 Theoretical
foundation

The intervention under study was guided by three overarching theoretical
frameworks: 1) Self-Regulation Theory (Gross, 2002), 2) Stress and Coping Theory
(Lazarus & Folkman, 1984), and 3) Self-Determination Theory (Deci & Ryan, 2000).
2.2.1 Self-‐Regulation
Theory

Self-Regulation Theory describes processes by which individuals attempt to
manage the form, frequency, or intensity of emotional, motivational, or behavioral states
in the service of social adaptation or individual goals (Aldao et al., 2010; Gross, 1998).
Optimal self-regulation can be viewed as the ability to flexibly gain access to a range of
thoughts and feelings while maintaining sufficient behavioral control to allow for effective
functioning (Thompson, 1994). Dysregulation has been defined as the use of rigid
strategies that interfere with cognitive, emotional, or social functioning as opposed to
the absence of self-regulatory strategies (Livingstone et al., 2009). Individual emotion
regulation strategies can be internally or behaviorally focused. Internally focused
strategies include mechanisms such as cognitive reappraisal, a cognitive process
whereby stressful situations are reconstrued to be seen in a positive light, and
suppression, which is characterized by the inhibition of emotion expression (Aldao et al.,
2010). A behaviorally focused strategy may involve seeking instrumental or emotional
support from others (Gross, 1998).
Though no particular emotion regulation strategy in itself can be deemed
functional or dysfunctional without taking into account the context in which it is used
(Gross, 1998; Livingstone et al., 2009), evidence suggests that regular use of some
strategies is more adaptive than others. Generally, three emotion-regulation strategies
are theorized to support wellbeing and effective functioning across clinical as well as

45

non-clinical populations; reappraisal, problem-solving, and acceptance (Aldao et al.,
2010). Three strategies theorized to be risk factors for psychopathology are
suppression, avoidance, and rumination. A meta-analysis by Aldao et al. (2010)
examining 114 studies of emotion regulation strategies across various mental health
disorders indicates that rumination, avoidance, and suppression are associated with
increased levels of psychopathology, while acceptance, reappraisal and problem-
solving are associated with reduced psychopathology.
Over the past decade, theories of self-regulation have evolved to help elucidate
various forms of psychopathology that may be targeted by mental health treatment
approaches. Previously, conceptualizations of self-regulation equated control of
negative emotions and behaviors with adaptive self-regulation, thereby assuming
negative emotions to be inherently disruptive and problematic (e.g., Zeman & Garber,
1996). Newer conceptualizations include the recognition that efforts to control or avoid
negative emotions or unwanted experiences may not always be effective or
advantageous (e.g., Hayes et al., 2006). In fact, there is evidence to support the notion
that attempts to control unwanted experiences may paradoxically increase mood and
behavioral disturbances. For example, studies suggest that suppression of particular
thoughts may result in their increased frequency and salience (Wegner & Erber, 1992)
and attempts to suppress aversive emotions may similarly increase their intensity
(Salters-Pedneault et al., 2004). Current emotion-regulation models of eating disorders
and substance abuse disorders have also shown that avoidance of difficult
psychological experiences is associated with maladaptive compensatory behaviors,
such as binge eating and increased substance use (Polivy & Herman, 2002; Sher &

46

Grekin, 2007). Thus, a more clinically useful approach to understanding emotion
regulation can be found among theories emphasizing the functionality of all emotions
along with the ability to influence impulsive or maladaptive behavior as a key to adaptive
self-regulation (Cole et al., 1994; Linehan, 1993).
According to a functional approach, attempts to influence the intensity or
duration of an emotion may be adaptive when such efforts allow the individual to reduce
impulsivity and gain greater control over behavior without attempting to escape an
emotion altogether (Gratz & Roemer, 2004; Thompson & Calkins, 1996). This
conceptualization provides an important distinction between emotional control and a
more adaptive alternative, controlling one’s behavior and impulses during experiences
of emotional distress. A functional approach is based on the notion that both pleasant
and aversive emotions are functional in that they provide important information to
coordinate a variety of activities, such as those related to social interactions or goal-
directed pursuits (Gross, 2002). This theoretical formulation arises from an evolutionary
context in which emotions, particularly aversive states, developed as an important tool
to guide behavior based on environmental conditions, demands, and potential threats
(Gratz and Gunderson, 2006). This framework can be considered an acceptance-
based approach that encourages awareness and receptivity to a full range of emotional
experience, emphasizing adaptive ways of responding to distress as opposed to
controlling or removing negative emotions as the basis for effective regulation.
Drawing from a functional emotion regulation framework and empirical evidence
supporting it (e.g., Salters-Pedneault et al., 2004), Gratz and Roemer (2004) have
conceptualized adaptive self-regulation to be a multidimensional process involving the

47

awareness and acceptance of emotions along with the ability to inhibit impulsive
behavior, even in the face of emotional distress. This conceptualization also
emphasizes the flexible use of situationally-appropriate strategies to influence the
intensity or duration of emotional states. Importantly, the ability to modulate emotion is
desirable in large part because it yields the willingness to experience difficult emotions
that may otherwise interfere with the pursuit of meaningful life goals and activities.
Therefore, awareness and acceptance of emotions can be seen as a pre-condition for
adaptive strategies to be employed, but this process serves the larger end of sustaining
behavioral patterns that are chosen by the individual as opposed to driven by impulsivity
(Hayes et al., 2006). Based on this framework, emotional and behavioral regulation
processes are highly intertwined (Gratz and Roemer 2004).
Acceptance and mindfulness-based treatments are well suited to promote
adaptive self-regulation as defined within a functional emotion regulation framework.
For example, mindfulness exercises consist of moment-to-moment observation and
labeling of affective experience, thereby promoting emotional awareness and the
differentiation of nuanced emotional states (Gratz and Roemer 2004; Kabat-Zinn, 1990).
Furthermore, exercises involve a non-judgmental stance and an emphasis on letting go
of evaluations of emotions as ‘good’ or ‘bad’, which can be expected to facilitate
acceptance of difficult emotions in particular. Mindfulness training has also been
theorized to facilitate the decoupling of emotions and behavior by providing an
opportunity to experience aversive emotions without immediately acting upon urges
associated with them. One factor thought to undergird several forms of
psychopathology is the experience of emotions and behavioral responses as

48

inseparable; for example, an individual may experience depression and withdrawal from
social interaction as one. The process of observing emotions and their associated
urges, which is central to mindfulness practice, may facilitate awareness of their
separateness and lead to greater influence over behavioral responses to impulses.
Additionally, interventions such as MBSRT provide didactic material that explicitly
frames emotions as evolutionarily adaptive and encourages participants to view them as
neither inherently good nor bad, but rather as valuable information.
2.2.2 Stress
and
Coping
Theory

Like self-regulation, coping is theorized to be a multidimensional process
involving cognitive, behavioral, and emotional efforts used to manage environmental
demands, the purpose of which is to enhance wellbeing and functioning (Folkman,
1984). However, coping can be defined based on efforts to manage past or present
stressful situations in an attempt to compensate for perceived harm or loss (Lazarus &
Folkman,1984), whereas self-regulatory efforts may be aimed at processes that
maximize potential and are not inherently stressful (e.g., learning or practicing a skill).
Another key difference is that the transactional model of stress and coping, developed
by Lazarus and Folkman (1984), identifies cognitive appraisal as central to the person-
environment transaction resulting in the upheaval associated with stress. According to
this framework, primary appraisal involves appraising a stimulus as benign, challenging,
or threatening, while secondary appraisal involves weighing coping resources against
the perceived demands of a situation. The disequilibrium associated with the stress
response results from evaluation of one’s coping resources as insufficient to meet the
perceived demands of threatening or challenging stimuli.

49

Although multiple biopsychosocial processes impact the stress process (e.g.,
cortical, neuroendocrine, and autonomic systems; Goldstein & McEwen, 2002),
cognitive appraisal processes fundamentally determine the way in which people
organize a phenomenological experience of stress (Lewis, 2001). Constructing a
subjective perception of stress involves the attribution of meaning to life events and
situations according to their perceived relevance to the individual, a process that is
shaped by the individual’s personal history and sociocultural and environmental context.
This evaluative process, or appraisal, moderates the person-environment transaction
and leads to variable responses to environmental stimuli (Lazarus & Folkman, 1984).
For example, exposure to the same stressor may result in one individual reacting with
hopelessness and passivity while the same situation may prompt anger and defiance in
another, or optimism and proactive action in yet another. Though oneʼs ability to
successfully adapt to stress depends of several factors, including the severity and
chronicity of stressors, ultimately the work of Lazarus (1984) and others reveals that the
way in which the individual perceives and responds to stressors will determine whether
stress leads to distress and long-term patterns of maladaptive functioning.
As previously mentioned, the stress and coping process begins with a primary
appraisal of the nature of a stimulus. If the stimulus is perceived as challenging or
threatening, physiological processes involved in the stress response are activated along
with the subjective experience of stress (Lazarus & Folkman, 1984). Research has
shown that some primary appraisal processes may be executed in an automatic and
rapid manner, without conscious deliberation (Bargh & Chartrand, 1999). For example,
a meta-analysis conducted by Ambady and Rosenthal (1992) found that evaluations

50

about the intentions of others generally occur in less than 30 seconds. Researchers
theorize that implicit appraisals of threatening stimuli (e.g., facial expressions, loud
sounds) occur rapidly and unconsciously to promote survival and have therefore been
favored evolutionarily (Ohman & Wiens, 2002). Such automatic or implicit appraisals of
sensory stimuli (e.g., auditory and visual information) are then relayed to processing
areas of the cortex where the threat value is assessed (LeDoux, 2002).
Importantly, implicit evaluations of stimuli as threatening may be shaped by
previous experience of stimulus-reinforcement contingencies (LeDoux, 2002). For
example, if an individual has experienced a stimulus (e.g., facial expression) in the
context of threat or harm, a stimulus-reinforcement contingency may become implicitly
conditioned. As a result, future exposure to the stimulus may automatically activate the
stress response, including neural activity from the amygdala and involvement of the
hypothalamic-pituitary-adrenal (HPA) axis (Goldstein & McEwen, 2002). This process
has important implications for the development of mindful awareness, which involves a
broadening of attention and clear perception of novel stimuli in the present (Brown &
Ryan, 2004) as a means of countering conditioned patterns of perception based on past
experiences that may habitually trigger stress reactivity.
Following the complex physiological and cognitive processes underlying primary
appraisal, the individual may deem his or her coping resources inadequate to meet the
demands of a threatening situation. According to Lazarus & Folkman’s (1984) theory,
this secondary appraisal will likely initiate the biopsychosocial stress response, followed
by coping efforts to resolve the disequilibrium associated with stress. Such efforts can
be categorized into two broad types of coping, avoidant or approach-based. Approach-

51

oriented coping involves directly addressing stressors through attempts to either alter
the stressful situation itself, or respond to the situation through mechanisms such as
problem-solving or seeking support and guidance. Conversely, avoidant coping is
marked by attempts to withdraw from sources of stress through mechanisms such as
denial and social withdrawal. Numerous studies have shown that approach-oriented
strategies, such as positive reappraisal and problem-solving, are associated with
reduced psychiatric hospitalization (Phillips et al., 2009) enhanced social functioning
(Andres et al., 2003; Yanos et al., 2003), independent living skills (Kopelowicz et al.,
2003) and improved work functioning (McGurk & Mueser, 2006) for people with
psychotic disorders. In contrast, avoidant coping mechanisms such as social
withdrawal and cognitive and behavioral disengagement have been associated with
symptom exacerbation and failure to maintain community tenure for this population
(Boschi et al., 2000; Meyer, 2001;Wiedl, 1992).
The application of mindfulness skills in promoting approach coping parallels the
process of awareness and acceptance in a self-regulatory context. Mindfulness training
involves turning attention toward present-moment phenomena, such as cognitive
appraisals and associated emotional responses, and as such can be seen as an
approach behavior that is fundamentally incompatible with patterns of denial and
avoidance. The development of decentered awareness associated with mindfulness
practice may also moderate the impact of distressing cognitive appraisals by allowing
individuals to step back from thoughts and feelings and re-perceive threatening stimuli
(Garland et al., 2009; Shapiro et al., 2006). Garland et al. (2009) argue that decentered
awareness may facilitate the coping mechanism of positive reappraisal in particular

52

because “for one to re-construe his or her appraisal of a given event as positive, one
must disengage and withdraw from the initial appraisal into a momentary state of meta-
cognitive awareness” (p. 4). Once this initial disengagement has occurred through
mindful awareness, the individual may re-engage with the stressful situation after
reframing it in a manner that supports a personal sense of meaning and hope, ultimately
promoting adaptive coping and resilience.
There is also evidence to suggest that adaptive coping with psychosis may be
congruent with a mindfulness and acceptance-based treatment approach. For example,
in studies by Romme and colleagues (1992; 1996) individuals with schizophrenia
reported coping effectively with psychosis based on the ability to integrate hallucinatory
experiences without evaluating these experiences as necessarily negative, along with
the pursuit of daily activities regardless of symptoms. The authors concluded that
individuals who cope successfully with psychotic disorders are active agents in framing
the meaning of psychotic experiences and choosing methods to act upon symptoms,
rather than viewing themselves as passive recipients of distressing experiences. Such
findings lend support to the notion that key aspects of mindfulness practice, such as
non-judgmental observation of psychotic experiences and decentered awareness, may
align with theoretical mechanisms underlying Stress and Coping Theory (Lazarus &
Folkman, 1984) to augment pathways toward resilient coping with psychosis.
2.2.3 Self-‐Determination
Theory

Self-Determination Theory (SDT) proposes that the satisfaction of innate
psychological needs for autonomy, competence, and social relatedness are essential
for the expression of optimal functioning and wellbeing (Ryan & Deci, 2000; Deci &

53

Ryan, 2000). Satisfaction of these needs is theorized to lead to the internalization of
self-regulatory mechanisms that support motivation to enact complex behaviors and
function effectively. SDT defines motivation as an internal state or desire to initiate and
sustain goal-directed behavior (Deci & Ryan, 2000). Traditionally, motivation has been
categorized as intrinsic or extrinsic based on whether it is inherently derived from an
internal state in the former, or externally derived from tangible rewards in the latter (Deci
& Ryan, 1985).
Intrinsically motivated behaviors are maintained as a result of intangible rewards
such as interest, meaning, purpose, or enjoyment associated with activity, as opposed
to external rewards such as monetary gain. Studies based on SDT have shown that
opportunities for self-direction enhance intrinsic motivation because they allow people a
greater feeling of autonomy (Ryan & Deci, 2000). For example, teachers who are
autonomy supportive as opposed to controlling elicit greater intrinsic motivation and
desire for challenge among their students (e.g., Flink et al., 1990). The SDT framework
suggests that environments which support behavior perceived as self-determined or
self-authored are likely to lead to the internalization of self-regulatory structures that
foster intrinsically, as opposed to extrinsically, motivated behavior (Ryan & Deci, 2000).
Intrinsic motivation has, in turn, been associated with psychological wellbeing and
effective psychosocial functioning (Deci & Ryan, 2000).
SDT elucidates theoretical distinctions regarding varying types of self-regulatory
mechanisms that have important ramifications for individuals with psychotic disorders.
For instance, introjected self-regulation is a process in which behaviors are controlled
by specific contingencies and anticipated consequences rather than personally

54

endorsed values (Deci & Ryan, 2000). Introjected self-regulation may lead an
individual, for example, to obtain a job to avoid external consequences such as
punishment, or based on internal consequences such as gaining self-worth or avoiding
guilt or shame (Deci & Ryan, 2000). Deci and Ryan (2000) point out that these
regulations are “within the person, but still relatively external to the self” (p. 236). In
contrast, integrated self-regulation denotes the internalization of attitudes and values
through a process in which the individual has “fully accepted them by bringing them into
harmony or coherence with other aspects of their values or identity” (Deci & Ryan,
2000, p. 236). For example, if an individual pursues physical exercise because he or
she views the behavior as congruent with personally endorsed values, he or she will
perform the behavior more autonomously and can be expected to better maintain the
behavior with greater commitment than, for example, exercising to please someone
else.
The theoretical processes underlying SDT suggest that eliciting self-identified
and personally endorsed values, and linking them with patterns of action, is likely to
support perceived autonomy, integrated self-regulation and intrinsic motivation.
Especially because patterns of avoidance, guilt, and shame commonly influence
behavior among individuals with psychotic disorders (Mak et al., 2006; Markowitz,
2001), interventions facilitating behavior shaped by clearly defined and endorsed values
as an alternative to avoidance or social compliance may improve motivation and
functioning for this population (Deci and Ryan, 2000; Hayes et al., 1999). In support of
this premise, ACT (Hayes et al., 1999), a therapy approach that includes values
clarification and goal-setting, has demonstrated improved social functioning and lower

55

re-hospitalization rates for people with psychosis

(Bach & Hayes, 2002; Gaudiano &
Herbert, 2006). The ACT model defines values as “verbally construed global desired
life consequences” that “permit actions to be coordinated and directed over long time
frames” (Hayes et al., 1999, p. 129). This conceptualization is highly congruent with the
constructs of integrated self-regulation and intrinsic motivation as defined within SDT.
ACT has also demonstrated improvement in the self-management of diabetes

(Gregg et
al., 2007) and recovery from substance abuse

(Hayes et al., 2004), eating disorders

(Baer et al., 2006), and disability resulting from chronic illness

(Wicksell et al., 2007). A
study by Lundgren and colleagues (2008) also found that values clarification mediated
improvements in seizure management among individuals with epilepsy.
2.3 Application
of
theory
to
intervention
design

Relationships among theoretical constructs, intervention methods, and treatment
outcomes associated with MBSRT are represented in the model depicted below.
Figure 1 - Mindfulness-Based Self-Regulation Training intervention logic model

56

As can be seen in Figure 1, MBSRT is designed based on an understanding of
factors leading to problems in subjective well-being and functioning (reviewed in
Chapter 1) for people with psychotic disorders. An approach to treating these problem
factors was conceptualized based on the three theoretical frameworks previously
elucidated: Self-Regulation Theory (Gross, 2002), Stress and Coping Theory

(Lazarus &
Folkman, 1984) and Self-Determination Theory

(Ryan & Deci, 2000).
The application of Self-Regulation Theory to MBSRT informs the following specific
intervention components: 1) Mindfulness training as a method to facilitate regulated
attention and accurate perception of cognitive and emotional states along with response
flexibility, 2) Psychoeducational content aimed at increasing participants’ understanding
of emotional and behavioral dysregulation and adaptive self-regulation, and 3) Values
clarification and goal setting to facilitate regulated behavioral patterns. The application
of Stress and Coping Theory to the protocol involves the following specific intervention
components: 1) Mindfulness training as the basis for approach-oriented coping and the
re-perceiving of stress appraisals in a way that promotes resilience, and 2)
Psychoeducational material aimed at conveying links among stress appraisal, coping
and self-care, and 3) Cognitive-behavioral exercises (e.g., the ABC model of appraisal
and coping, identifying pleasure and mastery activities) as a means of decreasing stress
and improving coping. The application of Self-Determination Theory to the protocol
involves the following specific intervention components: 1) Mindfulness training as a
method to increase awareness of values and integrated self-regulation, and 2)

57

Cognitive- behavioral exercises involving the identification of values, goals, and specific
action steps aimed at initiating and sustaining intrinsically motivated goal striving.
In this way, the three theoretical frameworks guided intervention methods
theorized to impact three major types of changes depicted in the model: 1) changes in
subjective wellbeing (i.e., self-esteem, internalized self-stigma, perceived stress,
psychiatric symptoms, self-determination, and psychosocial recovery), 2) changes in
functioning (i.e., cognitive functioning, role functioning, and motivation), and 3) changes
in therapeutic processes (i.e., mindful awareness and emotion regulation). It should be
noted that the present study focuses on feasibility testing and is not designed to
examine mediation effects associated with proposed mechanisms of change.
Therefore, the intervention logic model does not depict temporal relationships between
process and outcome measures at this stage.
2.4 Study
Hypotheses

Based on the treatment rationale and intervention design outlined above, the
specific hypotheses for the study are as follows: 1) Participants in the MBSRT
intervention will demonstrate significant improvements in subjective outcome measures
of perceived stress, psychiatric symptom severity, self-esteem, internalized self-stigma,
self-determination, and psychosocial recovery from pretest to posttest, 2) Participants
in the MBSRT intervention will demonstrate significant improvements in functional
outcome measures of cognitive functioning, intrinsic motivation, and role functioning,
from pretest to posttest, and 3) Participants in the MBSRT intervention will demonstrate
significant improvements in process measures of mindfulness and emotion regulation
from pretest to posttest.

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2.5 Measurement
of
MBSRT
constructs

Table 1 below summarizes the measurement of MBSRT constructs.
Table 1 - Measurement of MBSRT outcomes
Outcome Domain Measure

Subjective outcomes

1. Self-esteem

Rosenberg Self-esteem Scale (Rosenberg, 1965)

2. Internalized stigma Internalized Stigma of Mental Illness Scale (Ritsher & Phelan,
2004)

3. Perceived stress Perceived Stress Scale (Cohen, 1983)

4. Psychiatric
symptoms

Brief Symptom Inventory (Derogatis, 1992)

5. Self-determination The Self-Determination Scale (Sheldon et al., 1996)

6. Psychosocial
recovery

Recovery Assessment Scale (Corrigan et al., 2004)

Functional outcomes

7. Cognitive functioning Brief Assessment of Cognition in Schizophrenia (Keefe, 2004)

8. Role functioning A) Behavior and Symptom Identification Scale (Eisen et al.,
1994)

B) The Role Functioning Scale (Goodman, 1993)

9. Intrinsic motivation Quality of Life Scale (Heinrichs, 1984)

Process outcomes

10. Mindfulness

Southampton Mindfulness Questionnaire (Chadwick et al., 2008)

11. Self-regulation Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004)

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2.5.1 Overview
of
MBSRT
program
content

1. Mindfulness training (in-group practice):

 Mindful eating – raisin eating exercise
 Sitting meditation – mindfulness of breath, body, feelings, thoughts
 Body scan – systematic awareness brought to each area of the body
 Chi-Gong and/or stretching – mindful awareness of the body
 Mindful Walking- mindful awareness of sensory experience of walking
 Loving kindness meditation – positive intention toward self and others
 Various guided mindfulness exercises – e.g., Mountain Meditation,
Leaves in a Stream, etc.
 Guided Inquiry – discussion after each exercise
2. Psycho-education:

 Stress-reactivity and responding to stress
 Dysfunctional attitudes/beliefs and alternative adaptive coping

3. Cognitive-behavioral exercises:

 ABC formulation of cognitive appraisal, distress, and coping
 Wellness and self-care – pleasure/mastery activities and self-care plan
 Values clarification, goal-setting, and action steps. Focus is on 1-2
priority areas (e.g., social relationships, work, spirituality, leisure)

4. Mindfulness practice between sessions:
 Formal practice – once per day using exercises on MP3 player
 Informal practice - STOP exercise, deliberate awareness of routine
activities such as eating, walking, showering, and interpersonal
communication
2.5.2 Sample
MBSRT
session

Session 2: Stress Reactivity, Symptoms and Responding to Stress

I. Home practice review (15m). Review between session practice
experiences. Check-in with each participant to explore observations of
thoughts, feelings, sensations, and the way the individual handled or
responded to these experiences while practicing (e.g., How did you work
with voices/worries distracting you? Were you able to come back to your

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breathing at any point? What was different for you when you were able
to come back to the sensation of breathing?) For those that did not
practice, explore barriers (e.g., difficulty concentrating, boredom, voice
hearing).
II. Review mindfulness concept using glitter ball (10m). Ask
participants what they remember from last week, and to explain their
understanding of mindfulness. Use the glitter ball to provide a visual
representation of mindfulness practice. The swirling glitter in the ball
represents constant thinking, feeling, and sensations whirling around
inside. Once we stop and settle in (hold the glitter ball still) and don’t
engage, the flecks settle to the bottom and a space opens up for clear
seeing - without needing to remove anything from the ball. Take this
opportunity to clarify misconceptions about mindfulness (e.g., it’s not
making the mind go blank, or getting rid of/removing unpleasant
experiences).
III. Body scan practice (10m). Conduct a 10-minute body scan, bringing
attention to each area of the body and noticing when attention wanders.
IV. Guided inquiry following mindfulness exercise (15m). The group
leader helps participants reflect on thoughts, feelings, and sensations
that arose during the exercise using Socratic questioning. Emphasis is
on themes such as the inevitably of getting ‘pulled into’ thoughts, feeling,
voices, etc. Other important themes include the problem with expecting
to feel relaxed and ideas of failure connected to doing it ‘wrong’ (see
chapter 2 for more details).
V. Short (10 minute) break.
VI. Discussion of stress triggers (20m). Elicit participants’ definition of
stress, situations that trigger stress, reactions to stress, and how they
tend to cope. Write participants’ responses on the board.
VII. Reacting to stress versus responding with awareness (20m). The
group leader provides a clear view of the link between stress, psychiatric
symptoms, and maladaptive behaviors using handouts and drawing the
stress cycle on the board. In stress reactivity, automatic patterns of
reacting that are sustained by lack of awareness compound and
exacerbate inherently stressful situations. In contrast to automatic
patterns of stress reactivity, mindfully relating to stressors allows the
individual to exert influence over the stress cycle.
VIII. Discussion of STOP exercise (10m). Give participants the STOP
handout. Briefly describe each step (Stop, Take a breath mindfully,
Observe, and Proceed) and the way the exercise can be used during
routine activities or stressful situations.
IX. Discuss upcoming home practice (10m). The home practice
assignment for week 2 is: 1) listen to “Breathing Practice” on the MP3
player once each day, 2) listen to “Intro to STOP” one time, and 3) listen
to “STOP” once each day.

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Figure 2 - Handout from session 2 illustrating the stress response cycle

62

3 METHODOLGY

3.1 Design
overview

Based on the developmental aims of this investigation, the Stage Model of
Behavioral Therapies (Rounsaville et al., 2001) was applied to the study design. The
present study fits Stage I criteria of the model and is suited for the following
recommended research activities: 1) use of a preliminary version of a treatment manual
with a small number of participants without a control condition, 2) use of a large number
of treatment outcome and exploratory process measures to gain insight into the effects
of the treatment, and 3) use of open-ended questions eliciting feedback from
participants about the intervention. Guided by Stage I aims, the present study used an
uncontrolled, pre-post pilot test of the MBSRT intervention in order to refine treatment
content and create a manual incorporating feedback from investigators, participants,
feasibility indicators, and input from staff at a psychosocial rehabilitation agency. The
intervention was conducted in a group format with 7 - 8 participants per group. A broad
assessment battery was administered to evaluate changes in subjective wellbeing,
psychosocial functioning, and processes related to mindfulness and self-regulation.
The study protocol was approved by the University of Southern California Institutional
Review Board, the Los Angeles Department of Mental Health Human Subjects
Research Committee, and the Pacific Clinics Institutional Review Board.
Acceptability and tolerability of the intervention were assessed based on the
following four dimensions: 1) recruitment, 2) retention, 3) consumer satisfaction with
treatment, and 4) significant change in at least one clinical outcome domain over the

63

course of treatment (Rounsaville et al., 2001). Data on recruitment was collected,
including the number of eligible subjects screened, the number excluded for each
specific exclusion criteria, and the number of eligible consumers that agreed to
participate (see CONSORT diagram in chapter 4). A recruitment rate was calculated
based on the ratio of enrolled subjects to total eligible subjects (Patten et al., 2010).
Retention was assessed based on the proportion of participants that completed the
follow-up assessment, as well as the number of sessions attended. Measures of
treatment satisfaction and treatment outcome measures are discussed further below.
MBSRT was offered as an adjunct to routine care (i.e., anti-psychotic medication
and case management) at Pacific Clinics (PC), a psychosocial rehabilitation program for
individuals with severe mental illness in Los Angeles County. The treatment was pilot
tested with a total of 21 people (three groups) from existing caseloads at the two PC
sites (The William H. Compton Wellness Center in Pasadena and Pacific Clinics-Portals
Division in Los Angeles). The groups were led by the investigator, Lisa Davis. Ms.
Davis is a licensed clinical social worker with 15 years of clinical experience; she was
trained to implement MBSR in 2005 by the program’s originator, Dr. Jon Kabat-Zinn.
Lisa delivered MBSR in hospital and mental health settings over the course of four
years and drew from this training and clinical experience in formulating and delivering
the intervention under study. All pre- and post-treatment assessment measures were
administered by a research assistant (RA). The RA has extensive research experience
working with individuals with psychotic disorders, including previous experience
administering the measures used for this study.

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3.2 Participants

3.2.1 Agency
context

Pacific Clinics, the largest contract provider of mental health treatment in
California, provides a range of social, vocational, and mental health programs for
individuals with severe mental illness as well as other clinical populations. Intensive
services are provided with the goal of maximum community integration. Rehabilitation
services include monitoring of psychotropic medications, case management, on-site
training and rehabilitative experiences to supported work, and social and living
opportunities in the community. Pacific Clinics was chosen as the recruitment site
based on several factors: the comprehensive, intensive, and skillful delivery of services
increased the likelihood that participants would maintain their relationship with the
agency and complete the study; the philosophy of the agency is congruent with the
recovery-oriented goals of the study; and the agency has a long standing relationship
with Dr. John Brekke, the investigator’s doctoral chair. The consumer population has
the following characteristics: 65% are diagnosed within the schizophrenia spectrum,
64% male, average age of 39 years, 45% African American, 40% Caucasian, 14%
Latino, and 1% Asian.
3.2.2 Sample
selection

Study participants met the following inclusion criteria: (i) diagnosed with a
psychotic disorder (i.e. schizophrenia spectrum disorder or mood disorder with
psychotic features), (ii) able to provide informed consent, (iii) fluent in English, and (iv)
were between the ages of 18 – 65 years. The exclusion criteria were: (i) diagnosed
with Mental Retardation or an identifiable neurological disorder, and (ii) met criteria for
drug or alcohol abuse or dependence in the prior six months. At baseline, the

65

Structured Clinical Interview of DSM-IV (SCID-I; First et al., 1997) was administered to
ensure that participants met the diagnostic inclusion/exclusion criteria.
3.2.3 Recruitment
and
informed
consent

A presentation was given by the investigator at Pacific Clinics to inform staff
about the study. Flyers describing the study were distributed to mental health
consumers by Pacific Clinics’ staff and also posted in common areas within the clinic.
Consumers interested in learning more about the study turned in a response sheet,
located on the lower portion of the flyer, indicating their name and contact information.
The flyer described the study in simple terms and also included the phone number of
the investigator for individuals interested in gathering more information. The
investigator collected response sheets from agency staff and contacted potential
participants to conduct a brief screening over the telephone to establish general
eligibility for the study. Consumers who expressed interest in the study and passed this
initial screening were scheduled to meet with the investigator who explained study
procedures, including the informed consent process, in a private office at Pacific Clinics.
Careful evaluation of whether potential subjects had an understanding of the
purpose of clinical research, the nature of the treatment and the options they have
should they decide to no longer participate was undertaken. Potential participants were
given a detailed verbal and written description of the study followed by written bullet
points reiterating key points about study procedures. To verify whether individuals
recruited for the study had the capacity to provide informed consent, the following
assessment questions were used: 1) Name two things that you will be doing if you
decide to participate in this study, 2) Please identify two potential risks that may occur if

66

you were to participate in this study, 3) What would you do if you were to experience
distress or discomfort while participating in this study? and, 4) What would you do if you
decided that you no longer want to participate in this study? If the participant failed to
demonstrate an understanding of the study and the nature of his or her involvement, or
was judged by the investigator as such, they were not enrolled into the investigation.
Once the informed consent process was complete and written informed consent
to participate in the study was obtained, participants were referred to the RA, who
administered the Structured Clinical Interview of DSM-IV (SCID-I; First et al., 1997) to
verify diagnostic criteria along with baseline self-report questionnaires and interviewer-
rated measures. Participants were told that an appreciation gift ($20) would be given to
them at the conclusion of each assessment interview (pre- and post-treatment), with an
additional $20 for individuals who attend all group sessions and complete the entire
study. The amount of compensation was determined so as not to be coercive.
3.2.4 Medication
treatment

All study participants received pharmacotherapy provided by a psychiatrist at
Pacific Clinics during the study period, which typically involved the prescription of an
anti-psychotic medication and other medications as appropriate. Releases of
information were obtained so that the investigator could consult with the prescribing
psychiatrist to verify names of all medications prescribed to study participants.
Information on medication adherence during the study period was gathered based on
self-report data and was verified with agency staff.

67

3.3 Measures

The present study contains three main types of measures: demographic measures,
treatment outcome/process measures, and acceptability/tolerability measures.
Demographic information collected at baseline is designed to reflect key sample
characteristics. Treatment outcome measures evaluate subjective wellbeing and
functional outcomes targeted by the intervention and process measures assess
proposed therapeutic mechanisms of change to be tested as treatment mediators in
future trails. Acceptability/tolerability measures include recruitment and retention rates,
a standardized measure of treatment satisfaction, and open-ended treatment
satisfaction questions administered to participants during a post-treatment interview. As
a preliminary measure of treatment integrity, a self-reported facilitator adherence check-
list was used to monitor whether the group leader/investigator adhered to content for
each session as outlined in the MBSRT treatment manual.
3.3.1 Demographic
measures

Participants were asked to report information such as their age, gender,
race/ethnicity, housing status, occupational status, and educational history. Self-report
data was also gathered on substance use during the study period.
3.3.2 Treatment
outcome
measures

Subjective wellbeing: Subjective outcomes were assessed with the following
measures: Self-esteem was measured using The Rosenberg Self-Esteem Scale,

a self-
report measure of global self-esteem that has been successfully used with individuals
diagnosed with psychotic disorders

(Gioia & Brekke, 2003); it has been widely shown to
be both reliable and valid (Robins et al., 2001). The Internalized Stigma of Mental

68

Illness Scale (ISMIS) is a self-report survey assessing feelings of alienation and
negative stereotype endorsement. The measure has shown evidence of high internal
consistency, test-retest reliability, and factorial and convergent validity

(Ritsher et al.,
2003). Perceived stress was measured using the Perceived Stress Scale (PSS), a well-
validated self-report measure of the degree to which situations in the past month are
appraised as uncontrollable and overwhelming

(Cohen et al., 1983); the measure has
been used in several mindfulness investigations (e.g., Carmody & Baer, 2008).
The Brief Symptom Inventory (BSI), a widely used and well-validated self-report
measure, evaluates the severity of symptoms such as anxiety, depression, and
psychotic symptoms, and has been used with people with psychotic disorders as well as
in studies of MBSR (Deragotis, 1992; Shapiro et al., 2005). The Self-Determination
Scale (SDS) measures the extent to which people function in a self-determined way
(sub-scales include awareness of self and perceived choice); it has shown good internal
consistency and adequate test-retest reliability (Sheldon et al., 1996). Lastly, the
Recovery Assessment Scale (RAS; Corrigan et al., 2004) is a self-report survey that
evaluates five dimensions of recovery in severe mental illness: hope, willingness to ask
for help, goal orientation, reliance on others, and identity not dominated by symptoms.
The measure has demonstrated good internal consistency, and confirmatory factor
analyses support its five-factor structure.
Functioning: Changes in functioning were evaluated based on a combination of
self-report measures, interviewer-rated measures, and objective tests (i.e., cognitive
functioning). The Behavior and Symptom Identification Scale (BASIS-32) is a self-
report measure that assesses functioning across five domains: relation to self/others,

69

daily living/role functioning, depression/anxiety, impulsive behavior, and psychosis

(Eisen et al.,1999).

It has demonstrated high internal consistency, test-retest reliability,
and concurrent and discriminant validity. The Role Functioning Scale (RFS; Goodman
et al., 1993) contains items representing four domains of community functioning (work,
independent living, family, and social functioning) that are interviewer-rated based on
data from a semi-structured interview. Previous evidence suggests that after interview
training, the intra-class correlation (ICC) among three interviewers on the RFS scale
was > 0.80 (Brekke et al., 2009). Intrinsic motivation was also assessed based on an
interviewer-rated format derived from the Quality of Life Scale (QLS), which uses data
from open-ended probes to create a single score for three domains of intrinsic
motivation (curiosity, purpose, and motivation; Heinrichs, 1984). Evidence suggests
these items load onto a single-factor with acceptable internal consistency

(Nakagami et
al., 2008). Lastly, the Brief Assessment of Cognition in Schizophrenia (BACS) is a pen-
and paper battery of cognitive tests to assess verbal memory, working memory, motor
speed, executive function and verbal fluency

(Keefe et al., 2004; 2008). It has
demonstrated high concurrent validity and test-retest reliability in patients with
schizophrenia and healthy controls with minimal practice effects.
Process outcomes: Additional self-report measures were administered as a
means of assessing theorized change mechanisms targeted by the intervention. The
Southampton Mindfulness Questionnaire (SMQ) is a self-report survey that evaluates
trait mindfulness in relationship to mindfully responding to psychotic symptoms
(Chadwick et al., 2008). The SMQ was developed specifically for people with psychotic
disorders, and has shown good internal consistency and concurrent and discriminant

70

validity. The Difficulties in Emotion Regulation Scale (Gratz & Roemer, 2004) was used
to evaluate emotion-regulation skills; the measure has shown high internal consistency,
good test-retest reliability, and adequate construct and predictive validity.
3.3.3 Treatment
acceptability/tolerability

Measures of treatment acceptability and tolerability were administered to assess
participants’ perception of the utility of the treatment and treatment satisfaction. The
Client Satisfaction Questionnaire - 8 (CSQ-8), an 8-item scale that yields a total score
reflecting participants’ satisfaction with services, was completed at the end of the 10-
week intervention (Attkisson & Zwick, 1982). Additionally, a post-treatment interview
was administered based on the following open-ended questions: 1) What did you like
about the MBSRT intervention? 2) In what ways was the intervention helpful or useful
to you? 3) What specific skills, topics, or parts of the group experience were most
helpful to you? and 4) What were some things about the intervention that you wished
could be different or that you didn’t like? As previously mentioned, measures of
recruitment, retention, and attendance were also considered with regard to treatment
feasibility.
3.3.4 Treatment
integrity

Two main types of quality assurance were taken to maximize the likelihood that
the investigator was following intervention procedures as intended. First, a fidelity
check-list developed for this study (MBSRT Adherence Scale –see Appendix A) was
completed immediately after each session by the investigator as an adherence self-
monitoring device. The MBSRT Adherence Scale was developed to lay the groundwork
for fidelity assessment in future trials of the intervention. The scale outlines individual

71

components of MBSRT using a checklist of central topics and exercises covered within
each session of the clearly defined MBSRT treatment protocol. Further details
regarding development of the measure are discussed later in this chapter.
In addition, each group session was audio-recorded and periodic review and
feedback based on recorded material was provided by an expert in mindfulness-based
treatment, Dr. Robert Stahl. Dr. Stahl is certified to teach helping professionals deliver
MBSR through the Center for Mindfulness in Medicine, Health Care, and Society, and
has been delivering the program for over 25 years. Dr. Stahl helped train the
investigator to implement MBSR in 2005. Consultation sessions with Dr. Stahl
provided an opportunity to monitor whether key components of the intervention were
delivered skillfully and to address questions or concerns on the part of the investigator.
Mindfulness exercises, such as mindfulness of the breath and body, along with guided
inquiry after each exercise were implemented based on modifications to the MBSR
protocol. Consultation with Dr. Stahl helped ensure that mindfulness training and
interactive group discussions were delivered competently.
3.4 Intervention
development

The goal of the intervention development process was to develop a theoretically
and empirically driven mindfulness intervention based on a self-regulatory paradigm to
improve quality of life for people with psychotic disorders. A primary consideration was
to develop an intervention that meets the needs of staff and consumers in a real-world
mental health agency to increase the likelihood that the intervention will be adopted
and sustained in such settings. Thus, the development process was informed by
multiple sources of information including: the three theoretical frameworks previously

72

mentioned (i.e., Self-Regulation Theory, Stress and Coping Theory, Self-Determination
Theory), published peer-reviewed research on existing mindfulness interventions, the
investigator’s clinical experience in community mental health and prior mindfulness
training, consultation with the investigator’s doctoral chair (Dr. Brekke) and an expert in
mindfulness-based treatments (Dr. Stahl), feedback from participants in the pilot study,
and collaboration with administrators and clinical staff at a psychosocial rehabilitation
program; Pacific Clinics in Los Angeles, CA.
3.4.1 Manual
refinement

The development of the present intervention and the associated manual involved
an iterative process, with considerable effort put forth to refine the protocol in
collaboration with a local mental health agency. MBSRT was conducted three times
and the manual was modified based on input from consultants, PC staff, and
participants. The investigator conducted structured, open-ended interviews with all
participants after they completed the program to elicit their opinions about the
treatment and suggestions for future groups (presented in chapter 4). Clinical staff
attended groups in an observer/participant role and provided feedback regarding their
observations and suggestions during private meetings with the investigator.
Feedback gathered from these sources resulted in the following changes to the
treatment protocol: 1) group sessions were expanded from 1.5 to 2 hours, 2) more
frequent use of images and metaphors to describe mindfulness processes and
practices was added to each session, 3) additional session handouts were developed
and used more extensively to clarify specific intervention components and help
participants retain key information (e.g., the values and goal-setting component), and

73

4) more frequent use of mindful movement exercises was added to the protocol to
balance sitting exercises. General feedback from participants and staff regarding
aspects of the intervention, such as the pacing of sessions, also resulted in
modifications to the investigator’s overall style of facilitating the group. For example,
based on participant feedback, guided inquiry after mindfulness exercises was kept
more focused with less discussion of participants’ general life stressors. These
modifications were incorporated into the narrative of the treatment manual.
3.4.2 Development
of
treatment
integrity
measures

Treatment integrity has been defined as the extent to which clinicians adhere to
the specific elements of a therapy protocol and demonstrate competence in delivering
the protocol (Waltz et al., 1993). The development of an instrument designed to
capture both the adherence and competence components of MBSRT in future trials
was one of the aims of this preliminary study. Evaluation of these indicators is crucial
in helping to reduce differential adherence and/or competence in treatment delivery,
thereby reducing unexplained variability in findings and increasing their internal and
external validity (Bellg et al., 2004).
A challenge to measuring fidelity in mindfulness-based interventions is that
mindfulness is a multifaceted construct that is difficult to operationalize and quantify.
Mindfulness-based intervention developers have noted that the embodiment of
qualities associated with mindfulness on the part of the therapist (e.g., authenticity,
being present, non-judging) are a key part of this approach that is uniquely challenging
to measure with accuracy (Dimidjian & Linehan, 2003). Though few treatment integrity
measures for mindfulness-based treatments have been developed to date, Chawla et

74

al. (2010) recently tested a comprehensive measure that captures both adherence and
competence components of a group mindfulness-based intervention for adults with
substance abuse disorders, entitled “Mindfulness-Based Relapse Prevention” (MBRP).
The 8-week group involves two-hour weekly sessions consisting of mindfulness
meditation practices and related relapse prevention exercises.
The MBRP integrity scale was used as the basis for developing a preliminary
MBSRT integrity measure (see Appendix A). The format, structure, and some aspects
of treatment content found in MBRP overlap with the MBSRT protocol. The MBRP
integrity scale is also the first published measure to quantify the therapist’s ability to
embody the spirit of mindfulness and other core mindfulness themes that are
applicable to mindfulness-based approaches in general. Additionally, investigation of
the measure has shown evidence of its reliability and validity. In the context of a
randomized controlled trial of MBRP efficacy, Chawla et al. (2010) examined 44
randomly selected treatment sessions that were rated by independent raters for
adherence and competence using the scale. The authors found evidence of high inter-
rater reliability for all treatment and competence ratings, adequate internal consistency
for competence scales, and a high degree (90%) of adherence to component delivery.
As with the MBRP instrument, the MBSRT integrity scale consists of two main
sections: an adherence and a competence section. The adherence section measures
the degree to which group facilitators adhere to the components of each group session.
Adherence was further broken down into two sub-sections: adherence to individual
session components and adherence to discussion of key concepts. The adherence to
session components scale, developed for this study, consists of a checklist of the

75

central topics and exercises covered within each session of the clearly defined MBSRT
treatment manual. It determines the extent to which group facilitators implement each
of the topics and exercises within each group session.
Congruent with the MBRP
measure, adherence to each item is rated on a three-point scale (1=absent, 2=partial,
and 3=compete).

The second sub-component of the adherence section, Adherence to
Discussion of Key Concepts, captures key concepts that are fundamental to a
mindfulness approach in general and was modified only slightly from its original format.
An example of an item from this scale is: “To what extent does the therapist encourage
noticing and being aware of present moment experience?”

The competence section of the MBSRT integrity measure captures the degree of
competence with which intervention methods are implemented by the therapist. The
competence section comprises four subscales, the first three of which include:
therapist skill in embodying the spirit of mindfulness, skill in implementing guided
inquiry, and ‘Other’ (e.g., overall quality of sessions; Chawla et al., 2010). Items from
these subscales, which represent universal elements of a mindfulness approach, were
used directly in the MBSRT integrity measure. The fourth sub-scale, entitled ‘Session-
Specific Topics’, measures the degree of competence with which specific session
topics and exercises are implemented by the therapist. This subscale was modified to
represent original items developed from the MBSRT treatment protocol. Competence
is assessed based on a Likert-type 5-point scale, where 1=poor and 5=excellent.
3.5 Intervention
procedure

The MBSRT intervention includes 10 weekly group sessions lasting 2 hours each.
Participants receiving the intervention were met by the investigator in the waiting room

76

at Pacific Clinics and led to a private room in the clinic where the group was held. A
healthy snack was provided to participants at the beginning of each group session. As
is outlined in the treatment manual, the first group session began with the investigator
introducing herself, giving a brief overview of the purpose of the group, and inviting
participants to introduce themselves and their hopes for the group. All handout
materials, exercises, and didactic material discussed in the treatment manual were
delivered across all group conditions (see MBSRT treatment manual).
3.6 Analytic
strategy

Guided by the early developmental aims of this study (Rounsaville et al., 2001),
the data analysis plan comprised an evaluation of treatment-related variables to assess
the acceptability of the intervention along with outcome variables to provide an initial
estimate of intervention effects. Analyses of treatment outcomes were conducted for
completers (defined below), as well as for an intention-to-treat (ITT) sample. ITT
analyses included all participants who attended the first session with the last
observation carried forward method for drop-outs (Altman et al., 2001). This approach
provides a conservative estimate of treatment outcome by minimizing the potential bias
of early termination due to treatment failure. Means and standard deviations were
calculated for the variables of interest, and a paired t test statistic was used to compare
pre-treatment and post-treatment means of each variable. As is congruent with the
aims of a feasibility study, multiple comparisons were conducted among outcome
measures. In order to control for inflated Type I error, a simple Bonferroni correction
was applied. Rather than judging statistical significance at the α=.05 level, a critical
value of p=.003 (.05 divided by a total of 18 comparisons) was used.

77

For exploratory purposes, Pearson correlations were conducted using pre- to
post-treatment change scores between process and outcome measures to determine
whether changes in treatment outcomes may be related to changes in processes
targeted by the intervention. Within-subject change scores were generated from the
difference in values pre-treatment to post-treatment (i.e., T2 - T1). In addition, based on
theory suggesting that increased levels of mindful awareness can be expected to lead
to improvements in emotion regulation (Gratz & Roemer, 2004), an exploratory
regression analysis was conducted to examine changes in mindfulness as a predictor of
changes in emotion regulation, while controlling for the cognitive functioning of
participants at baseline (the BACS composite score was included as an independent
variable in the model along with the mindfulness change score). Cognitive scores at
baseline were included as a covariate based on evidence suggesting that attention and
other cognitive capacities significantly impact processes inherent in mindful awareness
(Chambers et al., 2008).
Within-subjects effect sizes were calculated using the formula (M
post
–
M
pre
)/SD
post to pre change
to provide an indication of the magnitude of treatment effects
(Grisson & Kim, 2005). Effect sizes were reported based on Cohen’s (1988) d statistic
with the following recommended conventions: small (d= .20), medium (d= .50) and
large (d= .80). Finally, open-ended feedback received from participants at the end of
treatment was reviewed.

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4 Results

4.1 Sample
characteristics

The average age of the 23 participants at baseline was 45.3 years (SD=9.61;
range= 29-59 years) and 62% were female. The ethnic distribution was as follows:
38% African American, 24% Latino, 24% Caucasian, and 14% other. Seventy-one
percent of participants had completed a high school education. With regard to marital
status, 5% of the participants were currently married and 71% had never been married.
Twenty-four percent of participants were diagnosed with schizophrenia, 43% were
diagnosed with schizoaffective disorder, 29% were diagnosed with bi-polar disorder with
psychotic features, and 1% was diagnosed with major depression with psychotic
features. The average length of illness among the sample was 19 years (SD=10.62).
Overall, psychiatric symptom severity at baseline (as measured by the Brief Symptom
Inventory; Deragotis, 1992) was in the moderate range [mean score=2.5, SD=0.60;
possible range: 1 (not at all) – 5 (extreme)].
4.2 Treatment-‐related
variables

4.2.1 Recruitment
and
Retention

Participant flow throughout the trial is documented in a CONSORT diagram in
Figure 3 below. A total of 38 potential participants completed a response sheet
indicating they were interested in the study. Five people failed to qualify for the study,
two people declined participation upon hearing the details of the study, and two people
did not respond to telephone calls after initial completion of the study flyer. Twenty-nine
participants provided written consent to participate in the study and completed baseline
measures. Out of the 29 participants, 6 failed to attend the intervention. Thus, 23

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participants began the intervention, with each group consisting of 7 – 8 participants. A
recruitment rate, calculated as the ratio of the number of enrolled subjects (29 people)
to total eligible subjects (31 people – comprised of the 29 who enrolled in the study plus
2 who were eligible but declined participation), yielded a 93% recruitment rate (Patten et
al., 2010). From the 23 participants who started the intervention, 21 completed the
program, yielding a 91% completion rate.

Figure 3 - CONSORT diagram of participants through the trial

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4.2.2 Attendance

From a total of 23 participants who began the intervention, two participants
withdrew before the third session and were considered drop-outs (one citing time
commitment issues and once citing a move out of the area). Twenty-one participants,
who attended the first through the last session and had not more than three absences,
were considered completers of the intervention. Among the 21 completers, the average
number of sessions attended was 8.81 (SD=0.98) out of ten. Sessions that were not
attended were appropriately cancelled 89% of the time (i.e., participant called or
informed the group leader in advance). A breakdown of number of sessions attended
by participants can be seen in Table 2 below.
Table 2 - Attendance of MBSRT sessions (N=21)
Number of Sessions 7
Sessions
8
Sessions
9
Sessions
10
Sessions
Percentage of sessions attended
out of 10
9% 29% 33% 29%

Aggregated Attendance Results

Mean (SD)
Average number of sessions attended 8.81 (0.98)

4.2.3 Satisfaction
with
treatment

Results from the CSQ-8 (Attkisson & Zwick, 1982) administered at the end of
treatment indicated a high degree of satisfaction with treatment among participants.
The average score on the CSQ-8 was 3.74 (SD=0.31) based on a range of 1 (poor/low
satisfaction) to 4 (excellent/high satisfaction). A breakdown of participant feedback
within each response category is provided below.

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Table 3 - Mindfulness-Based Self-Regulation Treatment Satisfaction Survey Results
(N=21)

Client Satisfaction Questionnaire (CSQ-8) 1-2
Poor/fair
(%)
3
Good
(%)
4
Excellent
(%)
How would you rate the quality of service you received? 0 34% 66%
Did you get the kind of service you wanted? 0 24% 76%
To what extent has our program met your needs? 0 48% 52%
If a friend were in need of similar help, would you
recommend our program to him or her?

0 5% 95%
How satisfied are you with the amount of help you received?

0 29% 71%
Have the services you received helped you to deal more
effectively with your problems?

0 14% 86%
In an overall, general sense, how satisfied are you with the
service you received?

0 29% 71%
If you were to seek help again, would you come back to our
program?

0 10% 90%
Aggregated Treatment Satisfaction Survey
Results

Mean (SD)
Client satisfaction score (range 1-4) 3.74 (0.31)

Participants provided additional feedback about the treatment in response to open-
ended questions administered at post-treatment. Comments in response to the
question, “What did you like about the MBSRT intervention?” included the following:
• Exercises on the MP3 player that we used at home, listening helped me calm my
anxiety.
• I learned to not be so hard on myself
• Interacting with the group members and not being judged, we could be real

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• The tools we got like the STOP exercise, it helped me to stop, look, and listen to
what’s going on, and not blow up.
• The mindful movements really helped me feel calm and unwind, that really helps
me with my stress.
• It made me more mindful that I have a choice to be stressed out or not. I have a
choice in how I look at things. You don’t know you have so much control over
your own emotions until you learn this.
• It made me more aware of what’s going on inside of me and outside of me. I pay
more attention to what I’m believing, then I can have more of an effect on myself
• I liked the values and the goals the best. I have changes I want to make and the
assignments in group helped me work on that.
• The exercises helped me to worry less about my thoughts. I feel like I can
process my thoughts and break them down, then I stop and think – that’s a
thought, and then I don’t react so much.
Comments in response to the question, “In what ways was the intervention helpful
or useful to you?” included the following:
• It helped me grow and accept myself. Letting go and accepting was hard – I’m
not used to not being down on myself.
• It was an adventure. It made me feel hopeful that there is some help. I realize
that it’s how I deal with myself.
• The meditation and the mindfulness exercises and talking about it afterwards – it
helped me deal with strong emotions and not let things escalate.
• I learned how to cope with stress and talk to people about what I’m really feeling.
The self-care part really helped me because I can revert back to old habits.
• The group allowed me to take a better look at myself and how I treat myself. I’m
more damaging to myself than anyone. I was always blaming and thinking
others are doing things to me.
• The group made me more aware. When I walk into a room I’m looking- there
might be a trigger for anxiety. I’m more aware of those triggers and when I notice
the trigger, I see what it stirs up in me. I learned how to not add to the trigger
and make it bigger. If I step back, I can deal with the situation.
• I notice things, like I feel the hot water on my skin when I take a shower. When
I’m aware of that, I’m focusing on the present – my mood becomes good and I
feel more positive – less focused on negative thoughts.

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• The group helped me be more compassionate with myself. There was no
situation growing up where I learned it was okay to feel compassion toward
myself.
Comments in response to the question, “What specific skills, topics, or parts of
the group experience were most helpful to you?” included the following:
• The explanation and guidance comments on the MP3 player
• The ABC model, it helped me realize how I perceive myself and other people
• Mindfulness exercises and self-care
• The RAIN exercise (mindfully relating to emotions) and STOP exercise
• Mindful movements, not putting ourselves down, goals and branching out
• Mindful movements, being in observation mode
• The ABC model and identifying what I value
• Mindfulness exercises and the values and goals
• Home practice
• Mindful breathing. All the pieces worked together.
• Changing the way I view myself
• The break was really helpful
Comments in response to the question, “What were some things about the
intervention that you wished could be different or that you didn’t like?” included the
following:
• Discussion after the exercises got confusing and people went off on tangents.
• The group needed to be longer.
• There was too much talking during the check-in, people need to stay on track.
• Parts in the middle were too slow, and the values and goals were too rushed at
the end.
• We were too crunched for time. I got anxious about the group running over.

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• I needed more explanation and examples for the goals and values part. The
handout for that part was overwhelming. It needs to be simpler and explained
more clearly.
• The discussion after the exercises went on too long. A suggestion would be to
have a question and answer format.
• I wish there could be some kind of follow-up with the group. Like meeting again
to keep things going.
4.3 Treatment-‐outcome
variables

4.3.1 Treatment
Outcome
Measures

Treatment completers (n=21): Results of paired-samples t-tests examining
changes in outcome variables and treatment effect sizes for the 21 participants who
completed the intervention are presented in Table 4. Significant results were found
across treatment outcome domains, with virtually all outcomes indicating improvement
among completers. In addition, treatment effect sizes were large for the majority of
outcome domains. Significant improvements in pre- to post-intervention scores were
observed in the following subjective wellbeing scales: The Brief Symptom Inventory
(t=6.58, p<.001); The Internalized Stigma of Mental Illness Scale (t=4.10, p<.001); The
Perceived Stress Scale (t=5.29, p<.001); The Recovery Assessment Scale (t=-3.59,
p=.002); and the Rosenberg Self-Esteem scale (t=-3.81, p=<.001). Significant
improvements in pre- to post-intervention scores were observed in the following
functioning scales: The Behavior and Symptom Identification Scale (BASIS-32; t=5.24,
p<.001); The Brief Assessment of Cognition in Schizophrenia – Executive Functioning
subscale (t=-3.39, p<.001); The Role Functioning Scale (t=-4.52, p<.001); and The
Quality of Life/Intrinsic Motivation Scale (t=-5.14, p<.001). It should be noted that with
the simple Bonferroni correction applied, which is a highly conservative approach given

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the small sample size for this study, changes in The Self-Determination Scale (t=-3.08,
p=.006) can be considered significant at a trend level.
Composite scores were used to compare means for each of the outcome
domains (except cognitive functioning). Additional t-tests were conducted to assess
changes in the social functioning and daily living/role functioning subscales of the
BASIS-32 in order to gain more detailed information regarding changes in functional
domains. Results suggest both social functioning (t=5.63, p<.001) and role functioning
(t=4.04, p<.001) subscales significantly improved from pre- to post-intervention.
Significant improvements in pre- to post-intervention scores were also observed in the
following process measures: The Southampton Mindfulness Questionnaire (t=-4.65,
p<.001) and the Difficulties in Emotion Regulation Scale (t=3.61, p=.003). Changes in
verbal memory, working memory, verbal fluency, and motor functioning from pre to
post-treatment were not significant.
Changes in self-determination (d= .67) and executive functioning (d= .74) reflect, on
average, a medium-sized treatment effect. Changes in all other treatment and process
outcomes reflect a large-sized treatment effect (d= .78 to 1.44) based on Cohen’s
(1988) recommended conventions.
ITT analyses (n=23): Along with analyses for completers, paired-samples t-tests
evaluating all outcome measures were conducted using an intent-to-treat sample of the
23 participants who began the intervention. Results indicate that all outcome measures
showing significant change for completers were also significant for the full intent-to-treat
sample at the α=.01 level.

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Table 4 - Completers Pre- to Post-treatment Outcome Scores (N=21)
Scale Pre-Tests
Mean (SD)
Post-Tests
Mean (SD)
T
statistic
P value d
The Behavior and Symptom
Identification Scale
Relation to self and others
Daily living/role functioning
The Brief Symptom Inventory
The Internalized Stigma of Mental
Illness Scale

1.36 (0.51)
1.72 (0.84)
1.46 (0.74)
2.48 (0.59)
1.38 (0.46)
0.67 (0.45)
0.68 (0.59)
0.70 (0.69)
1.72 (0.46)
0.94 (0.51)
5.24
5.63
4.04
6.58
4.10
< .001
< .001
< .001
< .001
< .001
1.14
1.23
.88
1.44
.89
The Perceived Stress Scale 2.25 (0.57) 1.48 (0.48) 5.29 < .001 1.15
The Self-Determination Scale 3.35 (0.75) 3.91 (0.56) -3.08 .006 .67
The Recovery Assessment Scale 3.81 (0.64) 4.25 (0.42) -3.59 .002 .78
Brief Assessment of Cognition in
Schizophrenia

BACS Verbal Memory 33.38
(11.45)
33.81
(13.50)
-0.22 .832
BACS Working memory 14.48
(4.61)
15.29
(3.84)
-1.07 .296
BACS Verbal Fluency 46.62
(11.80)
46.95
(12.60)
-0.21 .839
BACS Motor Function 40.76
(12.25)
42.43
(12.81)
-1.31 .207
BACS Executive Functioning 13.14 (3.90) 15.52 (3.53) -3.39 < .001 .74
The Rosenberg Self-Esteem
Scale

1.71 (0.53) 2.18 (0.54) -3.81 < .001 .83
The Southampton Mindfulness
Questionnaire

2.33 (0.90) 3.69 (0.77) -4.65 < .001 1.01
The Difficulties in Emotion
Regulation Scale

2.26 (0.53) 1.65 (0.34) 3.61 .003 .93
The Role Functioning Scale 4.27 (0.95) 4.92 (1.24) -4.52 < .001 1.17
The Quality of Life Scale
Intrinsic Motivation
3.49 (0.76) 4.42 (1.04) -5.14 < .001 1.33
* The Behavior and Symptom Identification Scale and The Difficulties in Emotion Regulation
Scale are scored such that lower scores indicate better functioning

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4.3.2 Exploratory
analyses:

Process
measures

To explore relationships among proposed therapeutic processes and treatment
outcomes, Pearson correlations were examined between change scores from process
measures (i.e., mindfulness and emotion regulation) and change scores from wellbeing
and functioning measures. Consistent with the proposed therapeutic mechanisms of
the intervention, increases in mindfulness were significantly correlated with
improvements in role functioning (r= 0.57, p=.01), self-determination (r= 0.47, p=.03),
perceived stress (r= -0.40, p=.05), psychosocial recovery (r= 0.61, p=.01), and symptom
severity (r= -0.54, p=.01). Improved emotion regulation was also significantly
associated with improvements in role functioning (r= 0.71, p=.01), self-determination (r=
0.70, p=.01), perceived stress (r= -0.68, p=.01), psychosocial recovery (r= 0.64, p=.01),
and symptom severity (r= -0.66, p=.01). Thus, relationships among changes in
therapeutic processes and outcomes were significant for 5 out of 9 treatment outcome
domains. In addition, findings from an exploratory regression analysis suggest that
changes in mindfulness were a significant predictor of changes in emotion regulation,
while controlling for baseline cognitive functioning (β=0.58, p=.02).

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5 General
Discussion

5.1 Findings

5.1.1 Overview

The principal aim of this investigation was to develop and evaluate a novel,
manual-guided mindfulness-based intervention to enhance self-regulatory capacities
and quality of life for people with psychotic disorders. Findings of high recruitment and
retention rates and high measures of treatment satisfaction suggest the treatment
protocol is feasible to deliver and highly regarded among participants with psychotic
disorders. The exploratory treatment outcome data indicate that participation in the 10-
week intervention was associated with significant improvement in virtually all outcome
domains, including indices of subjective wellbeing, functioning and treatment processes
from pre- to post-intervention. Together, these findings support further testing to
evaluate the efficacy of the intervention and the specific contribution of theorized
treatment mediators using a more rigorous controlled design.
5.1.2 Feasibility
and
acceptability

A primary aim of this study was to gather evidence to evaluate the feasibility and
acceptability of the treatment protocol. Results indicate a high ratio of the number of
enrolled participants to the total number of eligible participants for the study (i.e., 93%
recruitment rate), suggesting it is feasible to recruit individuals with psychotic disorders
for a mindfulness-based group intervention in a psychosocial rehabilitation setting.
Additionally, a high retention of participants throughout the 10-week intervention
suggests the treatment protocol was acceptable for this population. The attrition rate for
the study (9%) was substantially smaller than the attrition rate found in most CBT

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studies (22.5%; Westbrook & Kirk, 2005), and was slightly smaller than the average
attrition rate in prior mindfulness investigations (12.14%; Khoury et al., 2013). Lastly,
participants attended an average of 8.81 (SD=0.98) sessions out of 10, indicating a high
degree of consistency in their participation in the intervention. Overall, high rates of
recruitment, retention, and attendance indicate that individuals with psychotic disorders
seeking treatment in community-based psychosocial rehabilitation programs can be
adequately recruited and retained for this form of group mindfulness-based treatment.
Results related to treatment satisfaction and the perceived utility of the treatment
were overwhelmingly positive. The average score on the CSQ-8 (Attkisson & Zwick,
1982) was 3.74 (SD=0.31) based on a range of 1 (low satisfaction) to 4 (high
satisfaction), indicating a high degree of overall treatment satisfaction. Participants’
feedback in response to open-ended questions at the end of the 10-week intervention
also shed light on their views with regard to treatment processes. For example, inquiry
regarding what participants liked about MBSRT yielded feedback on specific skills and
topics covered in group (e.g., mindful eating, mindful movements, RAIN – mindfulness
of emotion), aspects of the group process such as not feeling judged, and increased
feelings of self-acceptance and less emotional reactivity resulting from group methods.
In response to inquiry about what was helpful or useful about the treatment
approach, all of the mindfulness exercises used over the course of treatment were
mentioned at least once, including the STOP exercise (Stop,Take a breath, Observe,
Proceed), RAIN (mindfulness of emotions), mindful eating, mindful movements,
mindfulness of breath, and pre-recorded exercises on the MP3 player used for home
practice. Other helpful aspects of the group experience that were often mentioned

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included increased awareness and less reactivity to environmental triggers of stress,
greater self-compassion and self-acceptance, and improved ability to engage in self-
care and desired activities. In response to inquiry about what specific exercises, skills
or topics were most helpful, group topics often mentioned included mindfulness
exercises as well as the ABC model of appraisal and coping, values and goals
exercises, and self-care planning. Finally, the most frequently recommended
suggestion for improvement included the provision of more time and/or less material so
that group sessions would not feel as rushed.
5.1.3 Interpretation
of
preliminary
treatment
effects

Hypothesis #1. It was hypothesized that participants in the MBSRT intervention
would demonstrate significant improvements in subjective outcomes of perceived
stress, psychiatric symptom severity, self-esteem, internalized self-stigma, self-
determination, and psychosocial recovery from pre-test to post-test. As mentioned,
significant improvements in pre- to post-intervention scores among participants were
observed in measures of perceived stress, psychiatric symptom severity, self-esteem,
internalized self-stigma, and psychosocial recovery as hypothesized. Based on a
conservative significance criteria (α = .003), improvements in self-determination were
observed at a trend level (P=.006).
The stress reduction effects of mindfulness training among non-clinical
populations have been well established in the literature (Grossman et al., 2004), but it is
noteworthy that significant reductions in perceived stress were obtained in a sample of
mentally ill individuals with low socio-economic status, multiple mental health risk
factors, and other indices of personal and social distress (Davis et al., 2012). Among

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individuals with psychosis living in the community, mindfulness training may be an
effective means of stress reduction and may therefore be a useful component in the
prevention of stress-precipitated relapse and repeated episodes of illness (Nuechterlein
& Dawson,1984). Significant reductions in symptom severity found in this investigation
have also been observed in other mindfulness studies, including those targeting
individuals with psychotic disorders (Khoury et al., 2013). As a functional emotion
regulation framework suggests (Gratz & Roemer, 2004), awareness and receptivity to a
full range of emotions and cognitions along with the inhibition of impulsivity, a core
feature of mindful awareness, may help individuals with psychosis regulate both stress
and symptomatic experiences more effectively. Reductions in perceived stress and
symptom severity may have also been facilitated by an improved coping orientation
associated with the intervention. Receptivity to present-moment phenomena through
mindfulness can be expected to counter avoidant coping patterns and promote greater
willingness to directly and openly address various sources of distress. Didactic and
cognitive-behavioral elements of MBSRT may further augment the development of an
approach-based orientation through an emphasis on self-care planning and the
identification of specific coping strategies. These clinical methods likely worked in
concert to help participants reduce both perceived stress and symptom severity.
Though the present study did not measure increases in positive affect, it is also
possible that mindfulness training allowed participants to actively develop pleasurable
and positive experiences that mitigated the impact of perceived stress and symptom-
associated distress. Evidence supporting this notion includes a study by Davidson et al.
(2003) in which participants were assigned to either a wait-list control group (n=16) or

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an 8-week MBSR course (n=25). As in previous studies, anxiety was significantly
reduced in the treatment group as compared to the control condition. Importantly,
though, immediately following the group and at a 4-month follow-up,
electroencephalogram monitoring revealed that meditators showed increases in left-
sided anterior brain activation, a pattern that has been repeatedly linked with positive
and approach-related emotions (reviewed by Davidson, 2000). Relatedly, Johnson et
al. (2011) conducted a Loving-Kindness meditation group for 18 individuals with
schizophrenia experiencing negative symptoms and found increased frequency and
intensity of positive emotions and decreased anhedonia at post-treatment. Though
loving-kindness meditation is specifically designed to evoke a positive state, non-
directive mindfulness exercises that emphasize general present-moment awareness
may also help participants become more attentive to positive experiences that would
otherwise be overlooked or minimized. Brown and Ryan (2003) propose that being in a
state of open and receptive awareness can enhance the richness and clarity of the
moment and allow individuals to savor positive experiences that are normally ‘glossed
over.’ This is consistent with anecdotal evidence from group discussions, in which
participants often described feeling less rushed and overwhelmed with daily hassles,
more relaxed, and greater enjoyment of ordinary activities as a result of engaging in
mindfulness practice.
Results also indicate the intervention was associated with improvements in self-
esteem and internalized self-stigma. For people with psychotic disorders, self-
acceptance is continuously threatened by negative judgments of the self and psychotic
experiences, as well as the internalization of societal stigma (Chadwick, 2006; Corrigan

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et al., 2006). Mindfulness training, which has been conceptualized as a relational
process, may have helped participants redefine a more positive relationship with self.
For example, mindfulness exercises involve adopting attitudes of interest, patience, and
compassion toward the self. This process may have resulted in the internalization of
positive self-views that can be expected to help ameliorate the impact of frequently
occurring negative self-appraisals. In addition, Teasedale and colleagues (2002) found
that the decentered awareness underlying mindfulness practice allows participants to
observe negative thoughts without identifying with them personally. This process may
have allowed participants to view negative self-appraisals as simply being ‘mental
events’ that are transitory in nature rather than a reflection of their core self or essence.
In this way, the skill of non-reactive observing that underlies mindfulness practice may
allow participants to shift attention flexibly from stimulus to stimulus, avoiding either
losing a sense of self or becoming overly identified with or defined by a particular
stimulus (i.e., negative self-appraisal). Another possibility is that mindfulness may help
improve self-concept through intermediate processes such as feeling less overwhelmed
and more positive emotions, or feeling a greater sense of agency and personal control
over processes that maintain distress (e.g., letting go of reactions).
Other components of MBSRT may have also lessened participants’ identification
with negative self-views. For example, the ABC formulation uses participant examples
of distressing experiences to illustrate the attribution of meaning to events in an
automatic and reflexive manner. The exercise emphasizes intentionally ‘stepping back’
from such appraisals and viewing them with greater objectivity and skepticism. Thus,
participants may have acquired active cognitive strategies to reduce the influence of

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negative self-appraisals while also internalizing an implicitly more positive way of
relating to the self through mindfulness practices.
Participation in the intervention was also associated with improvement in the
subjective domains of psychosocial recovery and self-determination. Psychosocial
recovery has been defined as a process in which individuals with severe mental illness
may discover hope, a sense of personal agency, and meaning/purpose despite the
presence of symptoms (Roe & Chopra, 2003). Self-determination, which involves
perceived choice and autonomy in making important life decisions, is highly related to
the recovery construct (Onken et al., 2007). Mindfulness training in MBSRT may have
facilitated a shift in perspective and increased participants’ sense of personal meaning
and agency in the face of challenges posed by mental illness. For example, it has been
proposed that mindfulness facilitates a shift in perspective based on the ability to view
moment-to-moment experience directly and clearly, without the overlay of cognitive
evaluation (Kabat-Zinn, 1990). The result is “an undoing of the automatic processes
that control perception and cognition” (Deikman,1982, p. 137). This re-perceiving may
foster clarity with regard to values and expectations that have been conditioned by
family, social, and cultural contexts, allowing people to reflect upon them with greater
objectivity (Shapiro et al., 2006). Ultimately, this process may have allowed participants
to identify values and behaviors perceived as authentic and truer for them, thereby
increasing their sense of self-authored meaning/purpose and self-determination.
A related aspect of mindfulness training that may impact self-determination is the
development of an internal locus of control resulting from ‘choicefulness’ with regard to
the regulation of attention and awareness. Particularly because individuals with

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psychosis often feel controlled by symptoms such as auditory hallucinations that can be
perceived as omnipotent and malevolent (Chadwick, 2006), the ability to regulate
awareness and one’s response to these stimuli may increase a sense of personal
control over processes that maintain distress (e.g., letting go of reacting or struggling
against voices), allowing the individual to feel a greater sense of agency. In support of
this notion, Dannahy et al. (2011) found that individuals with psychosis receiving a 12-
week group mindfulness intervention (PBCT; Chadwick, 2006) in an open trial (n=50)
demonstrated significant reductions in the perceived control voices had over them at
post-treatment. The values clarification and goal-setting component of MBSRT is
intended to capitalize on this sense of agency with material explicitly aimed at defining
chosen values and behavioral steps associated with them. Thus, the combination of
mindfulness and behavioral exercises may have led to increases in purpose, goal-
orientation and autonomy related to self-determination and psychosocial recovery.
Hypothesis #2. It was hypothesized that participants in the MBSRT intervention
would demonstrate significant improvements in functional measures of cognitive
functioning, role functioning, and intrinsic motivation from pre-test to post-test.
Significant improvements in pre- to post-intervention scores among participants were
observed in measures of cognitive functioning, intrinsic motivation, and role functioning
as hypothesized.
As previously mentioned, the cognitive mechanisms theorized to undergird
mindfulness practice include attentional switching and sustained attention, which are
integral components of mindfulness exercises (Chambers et al., 2008). These domains
can be viewed as elements of an ‘executive’ branch of the attentional system

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responsible for focusing on selected aspects of the environment, a construct known as
executive functioning (Posner & DiGirolamo, 2000). In particular, executive functioning
involves the coordination of cognitive resources that allows individuals to inhibit over-
learned or automatic behavior in favor of processing novel stimuli and executing planful
or intentional behavior. This conceptualization maps onto processes inherent in mindful
awareness, a state that is fundamentally incompatible with automatic processes of
perception and cognition. The cognitive enhancing effects of mindfulness training have
been previously demonstrated among non-clinical populations (e.g., Chambers et al.,
2007; Jha et al., 2007), but improvements in executive functioning in a clinical sample
with widespread neurocognitive impairment as a core feature of illness is noteworthy,
albeit preliminary based on this open trial.
Mindfulness training may be an effective cognitive-enhancing component of
treatment for psychotic disorders, with the unique benefit that it is low-cost and
designed to be easily incorporated into participants’ lives for potentially long-lasting and
self-sustaining benefit (Davis & Kurzban, 2012). Other aspects of cognitive functioning
examined in this study, including verbal memory, working memory, verbal fluency and
motor function, did not significantly improve following the 10-week intervention. It is
possible that processes associated with mindfulness training may not impact these
domains for people with psychotic disorders, or it may be that the present intervention
lacked the necessary ‘dose’ of training to impact them. Additionally, low statistical
power for the present investigation may have interfered with the detection of potential
effects in these areas. Since this is the first study to examine changes in cognitive

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functioning based on mindfulness for psychosis, further investigation into this line of
inquiry represents an important direction for future research.
Significant increases in intrinsic motivation observed in this investigation may be
related to processes previously discussed with regard to self-determination and
psychosocial recovery. Intrinsically motivated goal striving, fueled by intangible rewards
related to interest, meaning, and purpose (Deci & Ryan, 2000), may have been
impacted by the re-perceiving mechanism previously described, which can be expected
to facilitate a clear and authentic sense of meaning and purpose among participants.
Once again, values clarification and goal-setting exercises also likely contributed to
increases in intrinsic motivation by promoting value-driven behavior. Intrinsic motivation
has in turn been associated with improved role functioning for people with psychotic
disorders (Nakagami et al., 2008), therefore, enhanced motivation may have influenced
changes in role functioning observed in the study. Behavioral exercises aimed at goal-
directed behavior may have also directly impacted improvements in role functioning.
Especially since research has shown that improvements in functioning and
improvements in subjective experience do not automatically generalize to one another
for this population (Brekke & Long, 2000; Brekke et al., 2001), the combination of
mindfulness training and behavioral strategies may be more potent than either one
alone in affecting subjective aspects of intrinsic motivation and actual behavioral
change.
Hypothesis #3. Lastly, it was hypothesized that participants in the MBSRT
intervention would demonstrate significant improvements in process measures of
mindfulness and emotion regulation. Significant improvements in pre- to post-

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intervention scores among participants were observed in measures of mindfulness and
emotion regulation as hypothesized. These findings provide preliminary support for the
theoretical formulation underlying the treatment protocol; specifically, the combination of
mindfulness training and other CBT-based methods employed may facilitate the
therapeutic mechanisms of mindfulness and emotion regulation capacities. Further,
exploratory analyses demonstrated that increases in mindfulness and emotion
regulation skills were correlated with improvements in perceived stress, symptom
severity, self-determination, recovery, and role functioning. These results also provide
initial support the notion that mindfulness and self-regulation may be active ingredients
associated with change in a variety of recovery-oriented domains using this form of
treatment for psychosis.
An exploratory regression analysis indicates that increases in mindfulness are
associated with increased emotion regulation capacities, even while controlling for the
cognitive functioning of participants at baseline. As is congruent with Self-Regulation
Theory (Gratz & Roemer, 2004; Gross, 2002), these results suggest that increased
awareness and acceptance of a full range of cognitive and affective experiences (i.e.,
mindfulness) may facilitate improved self-regulatory capacities. Since mindfulness is
inextricably linked with attentional capacity, it is notable that changes in mindfulness are
associated with changes in emotion regulation abilities while accounting for the
neurocognitive capacity of participants at baseline. Though a controlled investigation
assessing these variables at multiple measurement points is required to support the
proposed ordering of change processes proposed here and the utility of mindfulness for

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a population with neurocognitive impairment, these preliminary results are promising
and warrant further investigation into these lines of inquiry.
Finally, MBSRT was associated with large-sized treatment effects for the majority
of outcome domains. Improvements in self-determination (d= .67) and cognitive
functioning (d= .74) reflect a medium-sized treatment effect, however all remaining
changes in outcomes reflect a large effect size in the intended direction [subjective
wellbeing (d= .78 to d=1.44) and functioning (d= .88 to d=1.33)]. In addition, there were
large-sized improvements in treatment processes, including mindfulness (d= 1.01) and
emotion regulation (d= .93). To put the obtained effect sizes in some context, they
compare favorably with most previous uncontrolled studies of mindfulness interventions
for psychosis. For example, in their meta-analysis, Khoury et al. (2013) found medium-
sized effects on average for pre-post studies in this area, though Gaudiano et al. (2013)
recently found large reductions in depressive (d= 2.13) and psychotic symptoms (d=
2.13) in an open trial of mindfulness for psychosis (n=14). Based on results from this
investigation, it is reasonable to propose that the treatment under study contributed to a
large magnitude of clinical improvement among participants from pre- to post-treatment,
but a more rigorous study design is needed to increase confidence that such changes
are attributable to the intervention.
5.2 Limitations

Many of the limitations of the current study are also the features that define it as
Stage I pilot research (Rounsaville et al., 2001). First, the study used a relatively small
convenience sample and therefore has limited generalizability. Second, the lack of a
randomized controlled design means that it is possible observed changes were due

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either to factors outside the group, or were non-specific effects of being in a therapeutic
group. For example, social support gained through group processes may have
contributed to the overall positive response observed in this study. The reported pre-
post-changes could also reflect regression to the mean or placebo effect. In addition,
the provision of concurrent pharmacotherapy makes it more difficult to associate
observed improvement with the intervention under study, but it should be noted that
none of the participants in the study were medication naïve [(average 19 years on
medication (SD=10.62)].
There were also several limitations stemming from the multifaceted role of the
investigator, who also acted as the therapist and treatment developer for this study.
First, acting as the primary investigator and therapist could potentially lead to bias in the
data collection process. To address this concern, a research assistant administered all
assessments at baseline and post-treatment. However, the therapist/investigator
conducted post-treatment interviews, therefore, bias cannot be ruled out with regard to
qualitative data gathered in this study. Second, during participation in the study,
development of a therapeutic relationship between participants and the researcher may
have resulted in participants feeling obliged to remain in the study to please the
researcher rather than due to experienced benefits or interest in mindfulness. Third, the
multifaceted role of the investigator and her knowledge of all aspects of the research
may have influenced her toward achieving desired outcomes and effects (e.g., exerting
extra effort to work with participants not demonstrating effects from mindfulness
practice), albeit without the researcher’s awareness. Finally, the investigator has
extensive experience as a clinician in community mental health and has completed

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advanced training in the delivery of MBSR. Therefore, findings in this study may lack
generalizability based on differences between the investigator’s background and typical
psychosocial rehabilitation staff.
With regard to measures, the cognitive measure used for this study (BACS;
Keefe et al., 2008) is an instrument designed to evaluate aspects of cognition found to
be most impaired and most strongly correlated with outcome in patients with
schizophrenia (e.g., verbal memory, working memory, executive functioning). While the
format was designed to align with cognitive domains affected by schizophrenia, these
same domains have been repeatedly shown to be impaired among people with bi-polar
disorder, though the degree of severity may be less for bi-polar individuals (Dickerson et
al., 2004; Krabbendam et al., 2005). Also, the content of testing material (e.g., Tower of
London – test of executive functioning) was not modified and has been administered in
measures that have proven valid and reliable for a variety of populations (e.g., Wechsler
Adult Intelligence Scale; Wechsler, 1997). Though it may be viewed as a limitation that
BACS was not specifically designed for people with bi-polar disorder, evidence from this
investigation supports the reliability of the measure when used with this population; the
Chronbach’s alpha for the present sample is: α= .71. In fact, preliminary support for
use of the measure with other psychotic populations based on this study may be seen
as a contribution to the literature. A further measurement limitation in this study is that
there were no follow-up assessments beyond post-treatment to evaluate the durability
of the observed treatment effects over time. Finally, there were no independent
treatment integrity checks conducted by impartial observers or evaluators in this study.
Though the investigator took steps to self-monitor adherence to the treatment protocol,

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it is possible that the treatment was delivered inconsistently across the three groups
conducted during this trial, thereby increasing unexplained variability in findings.
Overall, results should be interpreted with caution and require controlled replication.
5.3 Strengths

Despite the limitations inherent in this investigation, methodological strengths of the
study also merit attention. First, the study did not rely exclusively on self-report
measures. Outcomes were assessed in a multi-modal fashion that included self-report,
interviewer-rated measures, and objective measures (i.e., cognitive testing). Also, all of
the measures used (including treatment satisfaction) were standardized measures.
Regardless of method used, results consistently indicated improvement from pre- to
post-treatment. Second, the therapy developed during this investigation is theoretically
driven by principles of Self-Regulation Theory (and additional complementary theories)
and is manualized. Third, the treatment was developed in collaboration with staff and
consumers at a community-based agency and therefore has ecological validity.
Including stakeholders in the development process can help bridge the gap between
practice and research. Lastly, it is notable that current literature suggests being White,
female gender and high socio-economic status are factors associated with participation
in mindfulness and other alternative medicine approaches in the general population
(Tindle et al., 2005). The present investigation is one of the few to examine this
approach with a sample largely consisting of African American and Latino mental health
consumers from a low socioeconomic background. It is a contribution to the literature to
examine a mindfulness treatment in this more racially diverse sample of individuals
lacking in socioeconomic resources.

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5.4 Lessons
learned
and
future
directions

A primary purpose of feasibility testing is to identify aspects of the study design and
research protocol that are both problematic and/or beneficial in order to guide the
design of future studies in this area. Below are some strategies that may help improve
similar studies in the future.
5.4.1 Recruitment
efforts

Overall, results indicating a high recruitment rate for this study support the
recruitment procedures that were utilized. This aspect of feasibility may be explained
based on several factors. For example, on most days during the recruitment period, the
investigator was on-site to answer questions about the study and have face-to-face
interactions with consumers and staff at Pacific Clinics. Previous research shows that
face-to-face involvement in recruitment procedures is more successful than other
strategies (e.g., telephone or poster; Polit & Beck, 2004; Worawong, 2008). Another
possible factor affecting the feasibility of recruitment is the high level of support from
administration and staff at the study site. Meetings were held with clinical and
administrative staff to discuss details of the study and elicit staff feedback about study
procedures in order to gain their buy-in with regard to the clinical approach and
research aims. Also, careful consideration was given to minimizing any increase in staff
workload resulting from the study (e.g., the investigator made reminder calls to
participants, set up materials for group, etc.). It should be noted, however, that the
investigator’s doctoral chair (Dr. John Brekke) has a long-standing research partnership
with the study site, which also likely contributed to their support and involvement in the
study. Lastly, retention rates for the study were also high. Among other factors, it is
possible that the screening process for the study was detailed and clear enough to allow

104

participants to fully understand the nature of the commitment involved, thereby
decreasing the likelihood of treatment drop-out.
5.4.2 Study
design
and
measurement

Future investigations would benefit from greater methodological rigor to determine
whether MBSRT is both effective and efficacious. In order to evaluate the potential
efficacy of MBSRT, a randomized controlled design comparing the treatment protocol
with an active treatment control group, such as a CBT or social support group, should
be implemented. This will provide a better understanding of whether improvement after
receiving the treatment may be attributable to the intervention procedure, and whether
such improvements provide benefit beyond other related approaches. If the efficacy of
MBSRT is supported through controlled trials, dismantling studies will eventually be
needed to determine effects of specific treatment components that may serve as active
ingredients affecting specific treatment outcome domains.
The present study also did not include measurement of general therapeutic
factors that may have contributed to or accounted for changes in outcomes. In order to
parse out specific from non-specific effects, a measure of social support may be used in
the future to serve as a covariate in outcome analyses. Chadwick (2005) has also
employed an assessment of therapeutic factors in studies of mindfulness groups for
psychosis that may be useful for future studies in this area. The assessment includes
items relating to eight therapeutic factors (Altruism, Group Cohesiveness, Universality,
Interpersonal Learning, Mindfulness, Catharsis, Self-understanding and Instillation of
Hope) based on Yalom’s (1995) conceptualization of group process. Participants rank
each factor from most (ranked 1) to least (ranked 8) important at post-treatment.

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Inclusion of such a measure may help discern the degree to which participants view the
importance of non-specific elements of group treatment. A further recommendation for
future trials is the systematic monitoring of participation in other non-study treatments
(beyond medication usage) among participants during the trial. Data on non-study
treatments accessed by participants will provide the ability to account for variability in
outcomes associated with such factors.
There are several recommendations with regard to measurement of potential
treatment mediators and methods to examine mediation effects. First, future studies in
this area should include a broader measure of mindfulness. The mindfulness measure
used for the present study (SMQ; Chadwick et al., 2008) was designed specifically to
capture mindfully responding to psychotic symptoms. Though this is a primary concern
given the population and clinical focus of the intervention, including a more general
measure of mindfulness along with the SMQ (e.g., the Mindful Attention Awareness
Scale; Brown & Ryan, 2003) would provide a more thorough assessment of whether the
treatment impacts a key therapeutic mechanism of change, namely increased
mindfulness across a variety of situations. Along these lines, other potential treatment
mediators that may account for changes associated with MBSRT should be measured
in future trials, such as measures of acceptance and self-compassion. Changes in
these processes have been identified as therapeutic mechanisms in other similar
mindfulness treatments (Khoury et al., 2013), and including them in future studies would
help to gain a better understanding of what accounts for the clinical efficacy underlying
this treatment approach. Finally, these potential mediators would need to be assessed
at different time points during the study (e.g., baseline, mid-treatment, post-treatment,

106

and follow-up) in order to establish the temporal relationships that can identify possible
mediations effects (Holmbeck, 1997). For example, it would be important to establish
that process changes precede clinical changes in wellbeing and functioning.
5.4.3 Treatment
uptake

In order to monitor whether participants are responding to MBSRT and applying the
treatment as intended, measures of treatment uptake should be developed and used in
future trials (Carroll & Nuro, 2002). For example, at the end of each group session,
participants’ understanding of the content of the preceding session can be assessed
through the use of a short questionnaire. An uptake questionnaire can be developed
based on content outlined in the MBSRT treatment manual. Examples of items that
may be used to evaluate this aspect of treatment uptake include the following:
Sessions 1/2
Being mindful means:
a) Making my mind full of ideas
b) Being aware of thoughts, feelings, and experiences in the present moment
c) Blanking my mind and making it empty for a while
Sessions 3/4
Stress is:
a) An emotional feeling that will pass
b) When I cannot control my frustration
c) A combination of thoughts, feelings, and the way my body responds to
pressures and difficult experiences
Sessions 5/6

What are values?
a) Having good behavior out in public
b) Following the rules of society and trying to be accepted by others
c) Choices about what is most important to me in my life

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Another aspect of uptake involves tracking the way in which participants apply
mindfulness skills and other skills from the group in daily life. A separate questionnaire
can be developed to evaluate the use of mindfulness and other self-regulatory skills in
situations outside the group such as interpersonal communication and social
interactions, stressful situations, and neutral daily activity. Similarly, it would be
important to assess specific steps participants take toward identified goals outside of
the group, obstacles that are encountered, and the way in which group skills may have
been applied to respond to these obstacles. This data would provide greater
understanding of elements of the protocol that may require modification based on
incorrect application or a lack of utilization.
5.4.4 Intervention
content

Future studies may evaluate whether varying the ‘dose’ of mindfulness training
used in the protocol may affect observed outcomes. The present study used the
adapted format of mindfulness meditation indicated by Chadwick (2005), with reduced
10-15 minute practice times and reduced periods of silence during the practice.
Participants in the intervention tolerated the 10-15 minute exercises well; no adverse
experiences were reported and some participants expressed interest in having longer
periods to practice mindfulness meditation. Though caution is warranted with regard to
lengthening exercises too much, it may be that some individuals gain greater benefit
from longer periods of practice. Since mindfulness training for psychosis is a relatively
new approach, little is known about this area. Future studies may compare varying
doses of mindfulness training among different treatment conditions to gain further
insight into this question.

108

Participants’ comments at post-treatment also raised an interesting potential
direction for treatment development. Several participants commented that exercises
related to the ABC model of appraisal gave them insight into the intentions and
dispositions of others and enabled them to take others’ reactions toward them less
personally. Exercises in this component aimed to help participants identify the way in
which events may be imbued with meaning shaped by personal history, beliefs and
other factors that influence perception. The purpose was to allow participants to
recognize that appraisals often held as ‘truth’, and acted upon as such, may be viewed
with greater objectivity and skepticism. Many participants spontaneously generalized
this principle to their interpretation of others’ behavior as being similarly shaped by such
influences. Participants who gained this awareness reported that it was particularly
helpful in allowing them to see a given situation from another’s perspective and respond
more flexibly and less defensively. Thus, future iterations of the protocol may build
upon the ABC model to target social cognition; a construct that refers to the mental
operations underlying social interactions, such as perceiving, interpreting, and
generating responses to others (Kern et al., 2009). Lastly, It is recommended that
future studies examine variations in the treatment format and length. Participants’ most
frequently cited difficulty with the program was that it seemed too rushed. It may be that
increasing the number of sessions and/or reducing the amount of material in each
session would improve the protocol.
5.4.5 Treatment
integrity

As mentioned, the developmental aims of this study along with limited resources
significantly constrained attempts to evaluate adherence and competence aspects of

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MBSRT treatment integrity. In the future, an evaluation of the intervention as
implemented by clinicians other than the investigator with independent adherence and
competence checks are needed. This will allow a more comprehensive and accurate
assessment of fidelity and its impact on clinical outcomes.
5.5 Special
clinical
considerations

There are several clinical considerations affecting the potential therapeutic value
of MBSRT that warrant attention. First, the therapist models a non-judgmental and
accepting attitude, and willingness to ʻbe presentʼ with, rather than trying to ʻfixʼ or
change participantsʼ difficulties. Studies of mindfulness for psychosis show that this
stance may paradoxically lead to reductions in symptom-associated distress and
maladaptive coping by helping participants internalize a different way of relating to
difficult experiences (Gaudiano et al., 2013; Hayes et al., 1999). Specifically, this
stance may suggest a way for participants to let go of internal struggle and attempts to
try and control, suppress or get rid of unwanted experiences, a relational style which
has been shown to inadvertently increase distress (Salters-Pedneault et al., 2004).
Modeling this acceptance and ʻbeing presentʼ with difficulties can be particularly hard
because most clinicians associate good therapy and their own competence with solving
or alleviating distress, a position that is not unreasonable given the very real urgency for
people with psychosis to change distressing life circumstances. This dilemma requires
an ability to manage the tension between two opposing forces, acceptance and change,
for both clinician and participants.
Second, regular between-session practice of mindfulness exercises is a central
feature of most mindfulness interventions (Kabat-Zinn, 1990). Research has shown that

110

time spent engaging in home practice is significantly related to increased levels of
mindfulness and improvement in measures of symptoms and wellbeing (Carmody &
Baer, 2008). Assignment of between-session practice and discussion of home practice
is a part of each MBSRT session, however, taking a firm or coercive stance with regard
to home practice in mindfulness groups for psychosis has been cautioned against in the
literature (Chadwick, 2006). Though participants who report not practicing should be
reassured this is not a failing on their part, the challenge for the therapist is to not miss
an opportunity to inquire in a collaborative and non-judgmental way about what may be
interfering with attempts to practice in-between sessions (Chadwick, 2006). Ultimately,
the therapist must accept the validity of participantsʼ position and the possibility that at-
home practice is not ʻworkableʼ at this time. However, this attitude should be balanced
with openness to the possibility that participants may be underestimating their
capacities, a view that may have been reinforced based on previous experiences in the
mental health system. This is a fine line for the therapist to walk.
Lastly, MBSRT should be tailored to the needs of group members receiving the
intervention. In particular, participants demonstrating more severe cognitive deficits
may require simpler language to convey treatment concepts and a focus on concrete
behavioral goals and self-regulatory strategies. For example, the investigator worked
with participants who appeared confused by more subtle aspects of mindfulness
practice or reported feeling ʻlostʼ during mindfulness exercises in several ways.
Strategies in this situation included guiding the individual to repeatedly return attention
to the bottom of the feet, or place a hand on the abdomen during mindful breathing.

111

These types of experiences may help orient individuals who are either overwhelmed by
symptoms or having difficulty regulating attention by anchoring them in the present
through physical sensory stimuli. In addition, the explanation of mindfulness and self-
regulatory concepts was modified to incorporate simpler language and more visual aids
for participants who struggled to grasp treatment content. If a key concept or exercise
did not seem sufficiently conveyed to the group as a whole, a review of pertinent
information was incorporated into the following session. Therefore, it is recommended
that the overall pacing of groups, as well as strategies for individual group members, be
tailored to the needs and capacities of participants.
5.6 Conclusion

Results of the current feasibility trial suggest that MBSRT is a promising treatment
option for individuals with psychotic disorders receiving psychosocial rehabilitation, but
will require further controlled research to support its efficacy. Though this preliminary
investigation precludes assuming that elements of MBSRT were either a necessary or
sufficient cause of clinical improvement, promising feasibility data and significant
treatment effects demonstrated in this trial should be viewed within the wider context of
previous research demonstrating the therapeutic effects of mindfulness for psychosis
(Khoury et al., 2013, 2003). Based on growing evidence in this area and contributions
of this study, it is reasonable to propose that mindfulness training contributed to clinical
improvement in the present sample, and to recommend more rigorous empirical
investigation of the current treatment protocol. A future randomized trial with sufficient
power will allow analysis of group and time interaction effects, and also for analysis of
process variables to understand more about mechanisms of change. Overall, this study

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supports the growing recognition that mindfulness-based treatment for psychosis is a
promising area for future research and clinical application.

113

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130

APPENDIX
A
–
MBSRT
TREATMENT
INTEGRITY
MEASURE

Mindfulness-Based Self-Regulation Training
Adherence and Competence Instrument
Draft Version: 2/5/2014
Lisa Davis, MSW, LCSW, PhD Candidate

Note: The Mindfulness-Based Self-Regulation Training (MBSRT) Adherence and
Competence instrument is a preliminary draft of a fidelity measure. It has been
developed based on modification of the Mindfulness-Based Relapse Prevention
treatment integrity measure (Chawla et al., 2010).

131

The Mindfulness-Based Self-Regulation Training Adherence Scale
The MBSRT adherence scale consists of two parts:
I. Adherence to the individual components of each MBSRT session
II. Discussion of key concepts in the guided inquiry portion of each session
I. Adherence to individual session components:
Adherence to the individual components of MBSRT is assessed using a checklist of the
central topics and exercises covered within each session of the MBSRT treatment
manual. The checklist is used to determine the extent to which the group facilitators
implement each of the components. This scale was based on the overall format and
some items from the Mindfulness-Based Relapse Prevention Adherence Scale (Chawla
et al., 2010), and was modified to fit the content of the MBSRT treatment protocol.
Each component is rated on a three-point scale. A rating of 0 indicates the facilitator
skipped over the component completely (absence), a rating of 1 indicates the
component was only partially completed or was not adequately conveyed (partial), and
a rating of 2 indicates the component was completely and clearly conveyed (complete).

Mindfulness-Based Self-Regulation Training - Session Adherence
Scale

Session 1: Orientation to MBSRT
Absent
0
Partial
1
Complete
2
NOTES
1 Introductions and ice breaker (10m)
2 Orientation to group format/structure (10m)
3 Expectations for group rules/guidelines (10m)
4 What is mindfulness? (15m)
5 Purpose and rationale of MBSRT (15m)
6 Break (10m)
7 Raisin exercise (15m)
8 Guided Inquiry: raisin-eating - being ‘present’
changes the quality of experience (15m)

9 Importance of home practice in general and practice
for the upcoming week (10m)

10 Distribute MP3 players and handouts

132

Session 2: Stress Reactivity, Symptoms and
Responding to Stress
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Review of mindfulness concept using glitter ball
(10m)

3 Body scan practice - emphasis on the wandering
mind and the challenge of regulating attention (10m)

4 Guided inquiry following mindfulness exercise (15m)

5 Break (10m)

6 Discussion of stress triggers (20m)

7 Reacting to stress versus responding with awareness
(20m)

8 Discussion of STOP exercise (10m)

9 Distribute handouts, discuss home practice (10m)

Session 3: ABC Formulation of Appraisal,
Distress, Mindfulness and Coping
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Sitting practice – mindful breathing emphasizing
‘letting go’ of evaluating and judging experience
(15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 Introduction to ABC formulation using participant
examples: it’s not the event/symptom that causes
distress, but the meaning attached (30m).

6 Discussion of 3-minute breathing space (10m)

7 Distribute handouts, discuss home practice (10m)

133

Session 4: Dysfunctional Attitudes and Mindfully
Relating to Thoughts
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Sitting practice – emphasis on observing thoughts
passing through- e.g., clouds in the sky/leaves in a
stream (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 Review ABC formulation focusing on common
dysfunctional beliefs and attitudes in mental illness,
and maladaptive coping (20m)

6 Mindfully relating to thoughts: thoughts are not facts
(20m)

7 Distribute handouts, discuss home practice (10m)

Session 5: Mindfully Relating to Emotions:
Turning Towards the Difficult
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 RAIN practice – mindfulness of emotions
emphasizing acceptance of difficult emotions, ‘turning
towards’ the difficult (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 Discussion of attachment and aversion – the trap of
avoiding the unpleasant (20m)

6 Reframing emotions as ‘energy in motion’ (20m)

7 Distribute handouts, discuss home practice (10m)

134

Session 6: How Can I Best Take Care of Myself?
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Loving-kindness meditation - emphasizing
intentionally adopting a patient/caring attitude toward
self and others (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 Self-care questions: What drains/agitates me? What
feels nurturing/positive? (20m)

6 Self-Care planning: What pleasure and mastery
activities can I plan and commit to? (30m)

7 Distribute handouts, discuss home practice (10m)

Session 7: Balancing Acceptance and Motivation
for Change Part I: Defining Valued Directions
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Mindful walking - emphasizing staying ‘present’ and
aware while taking action (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 What are values? Eulogy exercise (20m)

6 Values as the basis for intrinsic motivation (10m)

7 Values, Goals, and Actions worksheet – each person
identifies 1-2 value domains to work on in group
(20m)

8 Distribute handouts, discuss home practice (10m)

135

Session 8: Balancing Acceptance and Motivation
for Change Part II: Defining Goals and Action
Steps
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Mindful Chi-Gong - emphasizing staying ‘present’
and aware while taking action (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 How do I operationalize goals based on my values?
Differentiate values from goals (20m)

6 How do I operationalize action steps based on my
goals? (20m)

7 Each person shares a value and related goal – and
commits to one action step between now and next
week (15m)

8 Distribute handouts, discuss home practice (10m)

Session 9: Balancing Acceptance and Motivation
for Change Part III: Dealing with Barriers
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Mountain meditation - emphasizing the observer self
– or witness- that brings stability within constant
change (15m)

3 Guided inquiry following mindfulness exercise (15m)

4 Break (10m)

5 Discussion of internal and external barriers related to
action steps (15m)

6 Participants report on last weeks action step and
formulate the next step (15m)

7 Distribute handouts, discuss home practice (10m)

136

Session 10: Mindful Living: Using What Has
Been Learned
Absent
0
Partial
1
Complete
2
NOTES
1 Home practice review (15 min)

2 Body scan practice – brining attention to each area of
the body (15m)

3 Guided inquiry - recalling body scan from beginning
of group as compared to current experience (15m)

4 Break (10m)

5 Discussion of initial expectations of the group.
Identify what has been learned (15m)

6 Discuss feelings about ending. Acknowledge one
another and group support (15m)

7 Each person identifies one reason to continue
practices, and a realistic daily/weekly plan after group
ends (15m)

8 Closing ritual: The Summer Day (10m)

137

II. Adherence to discussion of key concepts:
Adherence to the discussion of key mindfulness concepts is assessed for each session
of MBSRT based on the five items listed below. These items were originally developed
for the Mindfulness-Based Relapse Prevention Adherence Scale (Chawla et al., 2010),
and represent common elements of several mindfulness-based treatments (e.g., Segal
et al., 2002). The five items assess the degree to which the facilitator addresses the
concepts outlined below while responding to practice review discussions and questions
and comments during general group discussions. Item number five was modified
slightly to fit the content of the MBSRT treatment focus. Each of the five key concepts
is rated on a three-point scale. A rating of 0 indicates the facilitator did not discuss the
key concept at all (no evidence), a rating of 1 indicates the concept was only partially
discussed or was not adequately conveyed (slight evidence), and a rating of 2 indicates
the concept was completely and clearly conveyed (definite evidence).
Mindfulness-Based Self-Regulation Training - Key Concept
Adherence Scale
Please assess the therapist on a scale from 0 to 2. Please focus
on the skill of the therapist, taking into account how difficult the
participant seems to be.
No
Evidence
0
Slight
Evidence
1
Definite
Evidence
2
1 NOTICING/AWARENESS of CURRENT EXPERIENCE:
To what extent does the therapist encourage noticing and being
aware of present moment experience?

2 ACCEPTANCE of CURRENT EXPERIENCE:
To what extent does the therapist encourage bringing curiosity
and a non-judgmental attitude to whatever arises in the present
moment, regardless of whether it is pleasant, unpleasant, or
neutral?

3 ACCEPTANCE vs. AVERSION:
To what extent does the therapist introduce the differences
between relating to one’s experiences from a standpoint of
acceptance as opposed to aversion?

4 ACCEPTANCE and MINDFUL ACTION:
To what extent does the therapist discuss the importance of
stepping out of auto-pilot as a means of engaging in mindful
action, and/or to what extent does the therapist describe the
relationship between acceptance and skillful/mindful action?

138

5 COMMITMENT to PRACTICE:
To what extent does the therapist address the relevance of group
members’ commitment to home practice (both formal and
informal) and how that may relate to changing ingrained and
maladaptive patterns of coping behavior.

The Mindfulness-Based Self-Regulation Training Competence Scale

The competence section of the MBSRT fidelity instrument contains four subscales:
therapist skill in modeling the spirit of mindfulness, skill in implementing guided inquiry,
skill in conveying session-specific topic areas (apart from mindfulness exercises and
guided inquiry), and Other (e.g., skill in delivering mindfulness exercises and overall
quality of sessions). Three of these subscales were originally developed for the
Mindfulness-Based Relapse Prevention program competence scale (Ability to
Model/Embody the Spirit of Mindfulness, Inquiry, and Other; Chawla et al., 2010). The
Session-Specific Topics subscale was developed based on original elements from the
clearly outlined MBSRT treatment protocol. However, it should be noted that items 15 –
18 represent material drawn from the Acceptance and Commitment Therapy protocol
(ACT; Hayes et al., 1999) and were developed based on items from the ACT fidelity
scale (Luoma, Hayes, and Walser, 2007). Each item is measured on a 5-point scale,
where 1=poor and 5=excellent.

Mindfulness-Based Self-Regulation Training – Competence Scale
Please assess the therapist for style, approach, and overall quality of delivery using a
scale from 1 to 5. Please focus on the skill of the therapist, taking into account how
difficult the participants seem to be.
Poor = 1 Satisfactory = 2 Good = 3 Very Good = 4 Excellent = 5

ITEM RATING
I. Ability to Model/Embody the Spirit of Mindfulness

1 Therapists’ ability to elicit feedback and draw participants out vs.
‘teaching at’ them
1 2 3 4 5
2 Therapists’ ability to keep discussion focused on present moment
experience
1 2 3 4 5
3 Therapists’ ability to be non-judgmental and accepting of
whatever participants bring up
1 2 3 4 5

139

II. Inquiry

4 Therapists’ ability to highlight participant’s raw experience in the
moment
1 2 3 4 5
5 Identifying and distinguishing thoughts, feelings, and body
sensations
1 2 3 4 5
6 Distinguishing from typical way of experiencing things
1 2 3 4 5
7 Highlighting relationship to purpose of program and participants’
lives
1 2 3 4 5
III. Session-Specific Topics (not mindfulness practice or guided
inquiry)

8 Therapists’ ability to convey the purpose and rationale of the
MBSRT group
1 2 3 4 5
9 Therapists’ ability to present the stress reactivity and stress
response cycle clearly, distinguishing between the two
1 2 3 4 5
10 Therapists’ ability to present the ABC formulation of appraisal,
distress, and coping using participant examples
1 2 3 4 5
11 Therapists’ ability to convey the concept of mindfully relating to
thoughts
1 2 3 4 5
12 Therapists’ ability to convey the concept of mindfully relating to
emotions
1 2 3 4 5
13 Therapists’ ability to convey the rationale for self-care in MBSRT
and effectively use the wellbeing questions to facilitate discussion
(What drains/agitates me? What nurtures me?)
1 2 3 4 5
14 Therapists’ ability to convey the significance of pleasure/ mastery
activities and help participants generate a plan to use both
1 2 3 4 5
15 Therapists’ ability to help participants clarify valued life directions
1 2 3 4 5
16 Therapists’ ability to help participants distinguish between values
and goals
1 2 3 4 5
17 Therapists’ ability to help participants identify valued life goals
and specific action steps linked to them
1 2 3 4 5
18 Therapists’ ability to encourage participants to commit to action
steps in the presence of barriers (e.g., fear of failure) and to use
mindfulness skills to sustain motivation in the face of barriers
1 2 3 4 5

140

19 Therapists’ ability to help participants indentify a reason to
continue practices after group ends, and realistic plan for doing
so
1 2 3 4 5
IV. Other

20 Therapist addresses and clarifies expectations and
misconceptions about mindfulness meditation
1 2 3 4 5
21 Pacing of session and focus on session topic
1 2 3 4 5
22 Ability of therapists to work as a team
1 2 3 4 5
23 Overall quality of delivery of meditation exercises
1 2 3 4 5
24 Overall session quality
1 2 3 4 5

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Asset Metadata

Creator Davis, Lisa (author)

Core Title Mindfulness-based self-regulation for psychotic disorders: a feasibility study

School School of Social Work

Degree Doctor of Philosophy

Degree Program Social Work

Publication Date 04/14/2014

Defense Date 03/13/2014

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag mindfulness,OAI-PMH Harvest,psychosocial treatment,psychotic disorders,self-regulation,severe mental illness

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Brekke, John S. (committee chair), Chou, Chih-Ping (committee member), Wenzel, Suzanne L. (committee member)

Creator Email lisadavi@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-377913

Unique identifier UC11296537

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Document Type Dissertation

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