RUNNING HEAD: EFFICACY OF MINDFULNESS-BASEDSTRESS REDUCTION 1?? Efficacy of Mindfulness-based Stress Reduction as Treatment for Psychological and Physical AilmentNicolette M LawrenceBay Path University ? Mindfulness based stress reduction (MBSR) is an integrative form of therapy taught in the framework of an 8-week long training course. Incorporating elements of cognitive behavioral therapy (CBT) and Eastern philosophy, the program was created by Jon Kabat-Zinn in 1979 as a way for patients to cope with stress and emotions (Barbosa et al., 2013). Kabat-Zinn defines mindfulness in his 1994 book as “paying attention in a particular way: on purpose, in the present moment and non-judgmentally.” General MBSR courses require 2.5 hours per week in the classroom, one full day retreat, and various take home assignments. Concepts taught include meditation, body scanning, and performing regular tasks mindfully (ex. eating one meal mindfully). These lessons focus around the ideas of focused attention, decentering and emotional regulation (Zoogman et al., 2015). Finally, sessions include group discussions where participants learn self-compassion and empathy.It has been posited through many clinical and non-clinical trials that MBSR training has a positive impact on the reduction of many psychological and physiological issues including anxiety, depression, stress, chronic pain, and neural health and telomere length (Gu et al., 2015). However, this form of therapy is not without it’s downside. Issues with universal access and the high drop-out rate have led to the adaptation of the program by various therapists working to include specific demographics or attain higher program retention. The benefit of MBSR training to psychological health has been well documented. Grossman (2004) published a meta-analysis detailing both clinical and non-clinical studies of MBSR training to have a moderate effect size (d=0.5) on both mental and physical health. It has been shown to lead to significant reduction in generalized anxiety disorder (Hoge et al., 2015), reduction in depression relapse rates (Baer, 2003), reduction in levels of chronic stress (Chen et al., 2013) and moderate increases in empathy and the feeling of interconnectedness (Barbosa et al., 2013). However, one of the challenges with documenting the impact of MBSR techniques on psychological health has been the level of inconsistency among these findings. There are several studies that document results seemingly above or below Grossman’s assertion of MBSR’s moderate effect size. For instance, a study conducted by Barbossa et al. (2013) showed graduate healthcare students experienced an average 85% reduction in anxiety post MBSR training. Similarly, Hoge et al. produced a large effect size (d=1.06) in a 2013 study using MBSR teachings to reduce general anxiety and chronic stress (2013). Although reduction in anxiety post MBSR was statistically significant, Chen et al. recorded only a 5 point decrease in self rating anxiety scored (SAS) with a large standard deviation amongst Chinese nurses (46.6±11.6 vs. 41.4 ± 10.4) which is considered low to moderate. Looking at parents of special needs children, Bazzano et al. (2013) showed post-MBSR patients to have a 33% reduction in anxiety, which significantly pales in comparison to the Barbossa et al. estimate of an 85% reduction in healthcare students. One of the possible reasons for the amount of variation seen among psychological benefits could be due a change in the diversity of the sample population. For example, it has been well documented that parents of special needs children experience levels of stress and anxiety far above the general population due to the pressures of caretaking and the anxiety over potential declines in the child health. These levels might vary in intensity and composition to those experienced by healthcare graduate students, giving rise to this discrepancy in the effect of MBSR on mental health. Furthermore, the use of MBSR in patients with clinical vs. non-clinical diagnoses of anxiety and stress seems to produce different outcomes. Zoogman et al. (2014) showed that this discrepancy was significant, with clinical effect sized much larger than non-clinical (d=0.5 vs. d=0.2). Finally, there has been some assertion that the level training of the MBSR instructor can impact the outcomes of the therapy, with less qualified instructors producing smaller reductions in anxiety and stress than those who have been rigorously trained (Zoogman et al., 2014). Overall though, based on a large body of evidence MBSR does seem to be positively correlated with reduction in generalized anxiety, chronic stress, depression and feelings of mental well-being. The effect of MBSR on physical health has not been studied nearly as rigorously as the effect on mental health, so it’s total impact is not yet fully understood. In terms of general health, meditation techniques have been shown to lower systolic blood pressure and slightly reduce diastolic blood pressure and heart rate (Chen et al., 2013). In the meta-analysis conducted by Grossman et al. studies utilizing MBSR to alleviate chronic pain had a moderate effect size (d=0.42). Although the body of evidence is still relatively small at this time, there does seem to be a negative correlation between chronic pain and MBSR treatment. Interestingly, studies have shown that MBSR training and meditation cause measurable changes in brain structure and activity. In a review published by Tang et al. (2015), MBSR in both clinical and non-clinical trials increases the volume of grey matter in the left caudate nucleus, left hippocampus, cerebellum and left middle temporal gyrus. It was also concluded to cause an increase in hippocampal volume. The hippocampus is involved in memory processing, and it is presumed by researchers that the MBSR techniques are in essence exercising the hippocampal muscle and reducing atrophy. MRIs performed during meditation and mindfulness exercise show enhanced activity in several distinct areas of the brain: the anterior cingulate cortex (involved in attention control), several prefrontal regions (involved in emotional reregulation), and insula, medial prefrontal cortex and posterior cingulate cortex (involved in self-awareness) (Tang et al., 2015). These MRI results correlate with the findings of Zeidan et al. (2014) in a study that monitored the brain of participants with and without mindfulness training during exposure to distractions. Finally, MBSR training has been associated with greater telomere length and telomerase activity. It is well established that telomeres play a role in aging and mortality. When a cell divides, its DNA undergoes replication. Because of the way the primer is bound, a small amount of DNA on the end of the molecule is lost each replication cycle. Telomeres are segments of DNA located on the ends of DNA molecules that serve to buffer the loss each replication. Eventually, if the telomere has been totally degraded replication can start to chew into more important pieces of DNA. Telomerase is an enzyme that actively replaces the pieces of telomere that are lost after replication. Mature cells cease to produce telomerase, and while increased telomerase in adult cells can prevent information loss, it has also been associated with cancer cell formation (cell gains immortality) (Schutte et al., 2015). One study showed that on average, telomeres in leukocytes were longer in participants of MBSR training than in control patients (Schutte et al., 2015). Telomere degradation has also been associated with conditions of chronic stress and anxiety, so it is possible MBSR training is indirectly slowing telomerase shortening by reducing these factors. Schutte et al (2013) showed through the use of 4 randomized controlled trials that telomerase activity was higher in mononuclear blood cells from individuals who have undergone MBSR training. This study boasted a moderate effect size (d=0.46). A marginal increase in telomerase activity in blood cells is associated with a better functioning immune system. It has been documented that individuals living with chronic stress fall ill more often than those with low to normal levels of stress, which could in part be due to reduced telomerase activity in blood cells. That being said, participants of MBSR with higher levels of telomerase have a lower chance of falling ill than the control groups. MBSR training seems to have a measurable positive impact on both psychological and physiological well being of participants. Unfortunately due to structured course design there are several demographics that could benefit from the techniques but are ill suited for the traditional MBSR format. Several studies have tried to satisfy this problem by attempting to adapt the MBSR course in a way that better reaches these excluded groups. In the study conducted by Bazzano et al (2013) addressing questions regarding the efficacy of MBSR in parental caregivers to special needs children, several adaptations were made to the traditional course design to improve its accessibility. First, the researchers partnered with local community resources and worked together to decide what elements to modify for the maximum level of inclusion. Due to the large Hispanic population in the area, the course was made available in English and Spanish. Because parents of special needs children often have trouble leaving their care position to engage in personal activities, fully qualified respite care workers were offered to participants free of charge. Weekly courses were offered twice a day rather than once (morning and evening), and taxi services were provided at no cost for those who may not have a reliable source of transportation. Finally, the full day retreat was shortened to just 4 hours taking into account the difficulty caregivers have with leaving their homes for long periods of time. Because of these modifications and with the help of community partnership, the study was able to include a wide array of demographics, and maintained a low drop out rate. This is not the only example of course alterations in an effort to include diverse populations. While studying the impact of MBSR in Chinese nurses, Chen et al (2012) adapted the program to focus more on traditional Chinese Buddhist teachings in an attempt to make the course more tailored to an Asian cultural mindset. Because previous studies had shown that Chinese nurses rarely make time for self-reflection, sessions were increased in number and decreased in time. Although results were still modest, the course modifications allowed this form of therapy to be used on a unique demographic. Finally, in a study focused on using MBSR to help adolescents cope with stress and anxiety, Zoogman et al. (2014) detailed the many changes that were needed for the course to be accessible to children. The delivery system was modified so it could be included as a classroom curriculum, with shortened sessions to compensate for shorter overall attention spans in children and young adults. For young children, teachings focused on paying attention to things in their environments over the traditional teachings of introspective thinking and self-analysis. The training was modified to focus more heavily on elements of CBT than traditional MBSR courses, which has been shown to work better in among the teenage demographic. Finally some adolescent MBSR courses included abbreviated training sessions for the parents in an effort to ensure they could assist with various take home assignments and daily practice. Mindfulness Based Stress Relief training has documented far-reaching effects on psychological and physiological health. From reduction in anxiety to increased immune function, this form of therapy could be highly beneficial to a wide range of demographics if some aspects of the classical course structure can be altered depending on the specific demographic of the individual. Through attention to specific needs, ideally participation in MBSR programs would increase and drop out rate would decrease.