Social Work Research Mindfulness
Content
Mindfulness Research in Social Work:
Conceptual and Methodological
Recommendations
Eric L. Garland
Mindfulness refers to a set of practices as well as the psychological state and trait produced
by such practices. The state, trait, and practice of mindfulness may be broadly characterized
by a present-oriented, nonjudgmental awareness of cognitions, emotions, sensations, and
perceptions without fixation on thoughts of past or future. Research on mindfulness has
proliferated over the past decade. Given the explosion of scientific interest in this topic,
mindfulness-based therapies are attracting the attention of clinical social workers, who seek
to implement these interventions in numerous practice settings. Concomitantly, research on
mindfulness is now falling within the scope and purview of social work scholars. In response
to the growing interest in mindfulness within academic social work, the present article
outlines six conceptual and methodological recommendations for the conduct of future
empirical studies on mindfulness. These recommendations have practical importance for
advancing mindfulness research within and beyond social work.
KEY WORDS:
evidence-based practice; meditation; mindfulness; randomized controlled trial; research methods
M
indfulness is linked with a set of crosscultural principles and practices originating in Asia more than 2,500 years
ago that have parallel manifestations in numerous
cultures around the world. With regard to its current academic usage, mindfulness refers to a psychological phenomenon that is now being studied for
its relevance to mental and physical health in fields
such as medicine, psychology, and neuroscience.
Across these fields, there is a growing body of literature that attests to the efficacy of mindfulness-based
therapies for a wide range of biobehavioral disorders.
According to a search of PubMed and CRISP databases conducted on October 4, 2009, there were
1,614 peer-reviewed journal articles on mindfulness
published in the scientific literature and 320 research
grants on mindfulness funded by the National Institutes of Health between 1998 and 2009. Indeed,
there is mounting empirical evidence of the role of
mindfulness in reducing stress and improving clinical
outcomes across diverse conditions such as depression (Teasdale et al., 2002), relationship difficulties
(Carson, Carson, Gil, & Baucom, 2004), irritable
bowel syndrome (Gaylord et al., 2011), criminal recidivism (Himelstein, 2011), chronic pain
(Rosenzweig et al., 2010), and addiction (Bowen
et al., 2006; Garland, Gaylord, Boettiger, & Howard,
doi: 10.1093/swr/svt038
© 2013 National Association of Social Workers
2010). Consequently, mindfulness-based interventions are becoming well-regarded for their therapeutic promise, as evidenced by recent publications in
mainstream, respected academic outlets, such as the
Journal of the American Medical Association (for example, Ludwig & Kabat-Zinn, 2008).
Given this burgeoning interest, mindfulnessbased interventions are attracting the attention of
clinical social workers who are increasingly implementing these treatments across diverse domains of
practice. Concomitantly, research on mindfulness
is now falling under the purview of social work
scholars, many of whom seek to determine the
comparative effectiveness of mindfulness-based
interventions and apply the construct of mindfulness to theories and models of social work practice.
In response to the growing interest in mindfulness
within academic social work, this article outlines
six conceptual and methodological recommendations for the conduct of future empirical research
on mindfulness.
INCREASE PRECISION IN
OPERATIONALIZATION OF THE CONSTRUCT
OF MINDFULNESS
To advance any field of scholarship, the precise
operationalization of constructs is a necessary first
439
step. Without such precision, empirical investigations of putatively identical phenomena may result
in widely divergent correlations between constructs of interest and inconsistent clinical outcomes
across studies. Ultimately, imprecise operationalization of constructs presents a severe threat to validity
that can undermine the quality of otherwise
well-designed research studies (Shadish, Cook, &
Campbell, 2002). Mindfulness research within and
outside of social work has been rife with this problem. An examination of Hick’s (2009) edited volume Mindfulness and Social Work clearly demonstrates
this issue. According to Hick, mindfulness is “an
orientation to our everyday experiences” ( p. 1); to
others in the edited volume, it is a “specific and
effective method of focusing the mind on the essence of experience” ( p. 45), a way to “mediate the
development of professional self-concept” ( p. 93),
“an approach for increasing awareness” ( p. 125),
an approach for “performing all activities with full
awareness” ( p. 154), and even a “necessary condition for an activist to become mature in her passion
and mission to fight for justice” (p. 178). This lack
of conceptual clarity should be rectified and a uniform, coherent set of definitions established, if mindfulness research within social work is to advance.
To that end, the following operationalizations of
mindfulness are offered. First, mindfulness is a state,
a naturalistic mindset characterized by an attentive
and nonjudgmental metacognitive monitoring of
moment-by-moment cognition, emotion, perception, and sensation without fixation on thoughts of
past and future (Garland, 2007; Lutz, Slagter,
Dunne, & Davidson, 2008). Mindfulness is metacognitive in the sense that it involves a meta-level
of awareness that monitors the content of consciousness while reflecting back upon the process
of consciousness itself (Nelson, Stuart, Howard, &
Crowley, 1999). Mindfulness is naturalistic in that
it is a basic and inherent capacity of the human
mind, although people differ in their ability and
willingness to actualize this state (Brown, Ryan, &
Creswell, 2007; Goldstein, 2002).
Second, mindfulness is a practice (or, more accurately, a set of practices) designed to evoke and foster the state of mindfulness. The practice of
mindfulness involves repeated placement of attention onto an object while alternately acknowledging and letting go of distracting thoughts and
emotions. Objects of mindfulness practice can
include the sensation of breathing; the sensation of
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walking; interoceptive (Craig, 2003) and proprioceptive (Brodal, 2004) feedback about the body’s
internal state, movement, and position; visual stimuli such as a candle flame or running water; mental
contents such as thoughts or feelings; or the quality
of awareness itself (Lutz et al., 2008). These practices are taught and trained in mindfulness-based
interventions.
Third, mindfulness is a trait or disposition that
may be developed over time through the repeated
practice of engaging in the state of mindfulness.
This trait may be characterized as the propensity
toward exhibiting nonjudgmental, nonreactive
awareness of one’s thoughts, emotions, experiences, and actions in everyday life (Baer, Smith,
Hopkins, Krietemeyer, & Toney, 2006). As a trait,
mindfulness is roughly normally distributed (Walach,
Buchheld, Buttenmüllerc, Kleinknechtc, & Schmidta,
2006). People vary in the extent to which they
exhibit mindful dispositions, yet this dispositionality can be strengthened through training. People
who participate in mindfulness-based interventions
evidence increases in trait mindfulness, which mediates the effects of training on clinical outcomes
(Carmody & Baer, 2008).
Thus, integral to mindfulness is the notion of
state by trait interaction, that is, recurrent activation of
the mindful state via mindfulness practices leaves
lasting traces that may accrue into durable changes
in trait mindfulness (Garland, Fredrickson, et al.,
2010), possibly mediated through neuroplasticity
and experience-dependent alterations in gene
expression (Garland & Howard, 2009). Indeed,
recent research suggests that mindfulness practice
can lead to increases in grey matter density in parts
of the brain that subserve emotion regulation,
learning, memory, and the ability to shift one’s
perspective (Holzel et al., 2011). More research is
needed to determine whether such neurobiological changes index the development of trait mindfulness over time resulting from mindfulness
training.
USE RANDOMIZED CONTROLLED DESIGNS
WHEREVER POSSIBLE
A large number of social work studies use nonexperimental and quasi-experimental research designs
that are subject to severe threats to internal validity
(Shadish et al., 2002). Despite the presence of these
threats, authors often overstep the data by making
causal claims from what are, at best, descriptive or
Social Work Research Volume 37, Number 4 December 2013
correlational findings. Studies that attempt to test
causal hypotheses (for example, hypotheses of
therapeutic efficacy) using suboptimal research
designs weaken the portfolio of social work
research and lower the esteem of the profession in
interdisciplinary venues.
This is an especially serious problem when it
comes to research on mindfulness, which is still
met with skepticism within many academic circles
as a “New Age” or “mystical” practice that
amounts to little more than a placebo. Hence, it is
essential to use research designs in mindfulness
research that can control for the effects of maturation, social desirability, expectancy, and placebo
effects.
From 1990 through the early 2000s, many studies on mindfulness used randomized wait-list control groups (for example, Astin, 1997; Davidson
et al., 2003; Shapiro, Schwartz, & Bonner, 1998;
Speca, Carlson, Goodey, & Angen, 2000). This
type of research design is capable of controlling for
history and maturation threats to validity as well as
creating statistically comparable groups at baseline,
and thus it represents a significant advance over
nonrandomized or quasi-experimental studies with
comparison groups. Yet, wait-list controlled designs
remain vulnerable to threats to validity stemming
from expectancy and placebo effects, which can be
substantial (Shapiro, 1981).
Given these concerns, for much of the past decade, mindfulness researchers have used randomized
controlled trial designs in which participants are
randomly assigned to either a mindfulness-based
intervention or a credible, therapeutically active
control condition. Perceived intervention credibility can be measured with self-report scales, such as
Borkovec and Nau’s (1972) Attitudes Towards
Treatment Questionnaire, and statistically controlled (if necessary) in analyses of covariance. Such
scales contain items assessing the extent to which
the research interventions are perceived to be logical treatments for the targeted clinical condition
and how confident participants are that they will
reduce their symptoms. Ideally, participants would
perceive control treatments to be equally credible
to experimental mindfulness interventions (for
example, Garland, Gaylord, et al., 2010; Gaylord
et al., 2011). Expectancy effects can also be minimized through careful advertising of the research.
For example, a flyer that contains the statement
“We are conducting research on mindfulness-
Garland / Mindfulness Research in Social Work
based treatments for cocaine addiction” is inherently flawed, as it suggests the treatment of
interest or preference and potentially introduces
expectancy effects that may confound study results. In contrast, research advertisements should
conceal the identity of the experimental and
control treatments. For instance, the same flyer
would minimize expectancy effects by stating,
“We are conducting research to compare the effectiveness of two forms of treatment for cocaine
addiction: a mindfulness-based treatment and a
support group.”
Moreover, the presence of significant main
effects of time on clinical outcome variables suggests that the control condition may have been
therapeutically active; yet, the presence of a significant Treatment × Time interaction term in the
hypothesized direction indicates that the experimental mindfulness treatment led to significantly
larger therapeutic change over time than the control treatment. For example, in a randomized controlled trial of psychosocial treatments for irritable
bowel syndrome, Gaylord et al. (2011) found that
participants in a mindfulness training intervention
and a conventional support group experienced significant reductions in abdominal pain; yet, relative
to those in the support group, participants in the
mindfulness training intervention experienced significantly greater reductions over the course of
training.
The use of credible, therapeutically active control groups may eliminate confounds introduced
by expectancy and placebo effects as well as
other nonspecific therapeutic factors such as attention by a caring professional, group dynamics, social support, empathy, and the therapeutic alliance
(Castonguay, Goldfried, Wiser, Raue, & Hayes,
1996; Duncan, Miller, & Sparks, 2007). When a
study of a mindfulness-based intervention identifies significant clinical outcomes within the context of this rigorous research design, it may provide
evidence against the “Dodo bird verdict” (for a review, see Budd & Hughes, 2009). However, it should
be noted that a study comparing a mindfulness-based
intervention to a no-treatment control is asking a
substantively different question than a study comparing a mindfulness-based intervention to an
active placebo control condition. In the former
case, the design allows one to measure the efficacy
of participation in a mindfulness-based intervention; whereas in the latter case, the design allows
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INVESTIGATE THERAPEUTIC MEDIATORS
AND USE DISMANTLING DESIGNS
one to measure the efficacy of the active ingredient
in a mindfulness-based intervention, that is, the
practice of mindfulness itself. It should be noted
that many active control conditions are not merely
placebo controls, but instead are legitimate, established treatments. For example, Kuyken et al.
(2008) compared mindfulness-based cognitive
therapy (MBCT) to maintenance of antidepressant
medication as a means of preventing depression
relapse. Thus, studies that use an active control
group can ascertain whether mindfulness training is
“more effective” than alternative treatments, in
contrast to studies with a no-treatment control
condition that answer the more basic question,
“Is participation in a mindfulness-based intervention associated with positive clinical outcomes?”
This is not to say that nonexperimental
research designs have no place in mindfulness
research. To the contrary, much can be learned
about the associations between trait mindfulness
and related constructs using cross-sectional or
longitudinal research. However, it is imperative
that authors draw careful conclusions that do not
overstep the data. For instance, a prospective
observational study of 339 individuals undergoing
a mindfulness-based stress and pain management
course found that participants reported significant
improvements in trait mindfulness, positive reappraisal coping, catastrophizing, and perceived stress
over eight weeks of training (Garland, Gaylord,
& Fredrickson, 2011). Further, the association
between increases in trait mindfulness and decreases
in stress was partially mediated by increases in positive reappraisal but not by decreases in catastrophizing. Although these findings are potentially
clinically useful, one cannot conclude that mindfulness training caused the observed changes. At
best, one can only conclude that these changes
occurred while participants were engaged in a
mindfulness training program. Findings such as
these are relevant only to the extent that they
are interpreted with great precision; otherwise,
they will remain unpublished or, worse, be published and tarnish the reputation of mindfulness
researchers within and beyond academic social
work.
Several key observational, quasi-experimental,
and experimental research studies that represent
the broad scope of research on mindfulness as a
state, trait, and practice are presented in Table 1.
Social work, as an applied field, is often myopically
focused on clinical outcomes to the exclusion of
more basic forms of scientific research. However,
asking the question “By what processes does this
treatment work?” is often a key step in refining and
optimizing an intervention (Kazdin & Kendall,
1998; Kraemer, Wilson, Fairburn, & Agras, 2002).
For instance, if an initial study reveals that increases
in trait nonreactivity mediate the therapeutic effect
of mindfulness training on chronic pain (compare,
Garland, Gaylord, Palsson, et al., 2012), mindfulness interventions tested in future clinical research
projects might emphasize techniques designed to
increase nonreactivity in order to boost treatment
effect sizes. Thus, examining therapeutic mediation
could enable social work researchers to determine
how mindfulness-based interventions might be
targeted most effectively to the populations and to
identify problems of greatest interest to clinical
social workers in the field. Therapeutic mediation
can be tested by a number of statistical methods, including canonical regression procedure (Baron &
Kenny, 1986), bootstrapping (Preacher & Hayes,
2004), structural equation modeling (Kline, 1998), or
latent growth curve approaches (Preacher, Wichman,
MacCallum, & Briggs, 2008), among others.
Moreover, by establishing the mediators of treatment, one can assess whether a treatment is internally consistent with the theoretical orientation in
which it is grounded (Hayes, Strosahl, & Wilson,
1999). This is important, both for maintaining theoretical coherence and preventing reductionism
and subsequent dismissal by researchers operating
from other theoretical orientations. As one prominent example of this issue, mindfulness practices
have been construed by some as relaxation techniques, believed to reduce stress via evocation of a
relaxation response (Benson, Beary, & Carol,
1974). However, mindfulness meditation has been
shown to produce significantly different cardiovascular and autonomic effects than relaxation training
(Ditto, Eclache, & Goldman, 2006), findings that
argue against the reductionistic construal of mindfulness practice as a mere relaxation technique. Further, a randomized controlled trial demonstrated that
whereas both mindfulness practice and relaxation
training led to reduced distress, mindfulness practice
alone led to significant decreases in ruminative
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Garland / Mindfulness Research in Social Work
Table 1: Select Key Studies Representing the Broad Scope of Research on Mindfulness as a State, Trait, and Practice
Study
Sample
Design
Operationalization of Mindfulness
or Related Phenomena
Pertinent Results
Bowen et al.
(2009)
168 adults with substance use
disorders
RCT of MBRP versus
standard substance use
treatment services
Trait mindfulness assessed by the FFMQ;
acceptance assessed by the AAQ
MBRP participants, relative to the control group, reported significantly
fewer days of drug and alcohol use. Relative to the control group,
MBRP led to significant increases in acceptance and the Acting with
Awareness subscale of the FFMQ.
Carmody &
Baer (2008)
174 adults with a wide range of Prospective observational
stress, chronic pain, and
study of MBSR
anxiety issues
Trait mindfulness assessed by the FFMQ;
time spent in formal mindfulness
practice
Increases in trait mindfulness were significantly associated with time
spent in formal mindfulness practice. Increases in trait mindfulness
mediated the effects of time spent in mindfulness practice on
psychological symptoms, stress, and well-being.
Feldman,
Greeson, &
Senville
(2010)
190 female college students
State mindfulness (decentering) assessed by MT participants reported significantly greater state mindfulness
(decentering) relative to the other two conditions. Relative to the
the TMS; frequency of or reactivity to
other conditions, a 15-minute session of MT reduced negative
repetitive thoughts
reactions to repetitive thoughts.
Garland,
Gaylord,
et al. (2010)
53 alcohol-dependent adults in RCT of MORE versus an
long-term residential
addiction support group
treatment
Thought suppression (that is, a construct
that is the opposite of mindfulness)
assessed by the WBSI
MORE participants, relative to those in the support group, experienced
significantly larger decreases in stress and thought suppression.
Among MORE participants, decreases in thought suppression were
associated with decreased fixation on alcohol cues and increased heart
rate variability recovery from stress and alcohol cues.
Gaylord et al.
(2011)
75 female patients with
irritable bowel syndrome
RCT of MT versus a
support group
Trait mindfulness assessed by the FFMQ
MT participants, relative to those in the support group, experienced
significantly decreased abdominal pain and increased quality of life.
The effect of MT on these clinically significant outcomes was
mediated by increases in trait mindfulness (nonreactivity).a
Holzel et al.
(2011)
33 healthy adults either
participating or waiting to
participate in a MBSR
course
Quasi-experiment
comparing MBSR to
wait-list control group
Trait mindfulness assessed by the FFMQ;
changes in brain structure assessed by
structural magnetic resonance imaging
MBSR participants, relative to those in the wait-list control group,
reported significant increases in trait mindfulness and exhibited
significant increases in grey matter concentration in left
hippocampus, cingulate cortex, cerebellum, and temporo-parietal
junction.
Kuyken et al.
(2010)
123 patients treated with
antidepressants who had ≥ 3
depressive episodes
RCT of MBCT versus
continued
antidepressants
Trait mindfulness assessed with the KIMS;
self-compassion assessed with the SCS
The therapeutic effects of MBCT were mediated by increases in trait
mindfulness and self-compassion over the course of treatment.
MBCT moderated the association between cognitive reactivity and
depression.
Teasdale et al.
(2002)
100 patients in remission or
recovery from major
depression
RCT of MBCT versus
treatment as usual (for
example, doctor)
Metacognitive awareness assessed by the
MACAM
MBCT participants, relative to the control group, experienced
significantly fewer occurrences of depression relapse. MBCT led to
significantly increased metacognitive awareness.
Random assignment to 15
minutes of MT, LKM,
or PMR
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Notes: MBRP = mindfulness-based relapse prevention; AAQ = Acceptance and Action Questionnaire (Hayes et al., 2004); FFMQ = Five-Facet Mindfulness Questionnaire (Baer et al., 2006); LKM = loving-kindness meditation; KIMS = Kentucky Inventory of Mindfulness
Skills (Baer, Smith, & Allen, 2004); MACAM = Measure of Awareness and Coping in Autobiographical Memory (Moore, Hayhurst, & Teasdale, 1996); MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction;
MORE = mindfulness-oriented recovery enhancement; MT = mindfulness training; PMR = progressive muscle relaxation; RCT = randomized controlled trial; SCS = Self-Compassion Scale (Neff, 2003); TAU = treatment as usual; TMS = Toronto Mindfulness Scale (Lau et al.,
2006); WBSI = White Bear Suppression Inventory (Wegner & Zanakos, 1994).
a
These mediational data are presented in Garland, Gaylord, Palsson et al. (2012).
As interest in mindfulness grows, there is a need to
further specify and operationalize the measurement
of mindfulness and its therapeutic effects in both
clinical and basic science research programs. A
number of questionnaires currently are used to
quantify both state and trait mindfulness in studies,
such as the Five-Facet Mindfulness Questionnaire
(Baer et al., 2006) and the Toronto Mindfulness
Scale (Lau et al., 2006). Although these scales can
be useful, measurement instruments that rely on
self-report are vulnerable to reactivity to being in
an experimental condition, experimenter expectancies, social desirability biases, and misinterpretation of question items (Shadish et al., 2002).
Moreover, it should be recognized that questionnaire items are proxies for latent variables that can
only imperfectly capture the essence of the construct under investigation (DeVellis, 2003). Any
one operationalization may inadequately represent
the construct of interest (Shadish et al., 2002).
As such, research on mindfulness as a state, trait, or
practice that solely relies upon self-report instruments is subject to the same social influences and
mono-operation biases as research on other psychosocial phenomena.
To counter the limitations of self-report measures, mindfulness researchers may benefit from
using behavioral and physiological measures of
mindfulness and its therapeutic effects. In the past
decade, there has been an explosion of studies in
the psychological, medical, and neuroscientific literature investigating the therapeutic mechanisms of
mindfulness using an array of sophisticated research
methodologies, including cognitive tasks (for example, Garland, Boettiger, Gaylord, West Chanon,
& Howard, 2012; Zeidan, Johnson, Diamond,
David, & Goolkasian, 2011), psychophysiological
measures (for example, Garland, 2011; Ditto et al.,
2006), and neuroimaging techniques (for example,
Farb et al., 2010; Froeliger, Garland, Modlin, &
McClernon, 2012). Yet, in spite of the application
of ever-increasing methodological rigor to research
on mindfulness in these fields, few social work
scholars have dared to tread into this domain.
Whereas the implementation of many of biobehavioral methods (such as functional magnetic resonance imaging or DNA microarrays) requires years
of specialized training not offered in most social
work doctoral programs, other methods, such as the
measurement of heart-rate variability, cortisol assays,
and certain performance-based tasks derived from
cognitive neuroscience, may be within reach of a
wider range of social work researchers.
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thoughts that partially mediated its therapeutic effect
on distress (Jain et al., 2007). Such results suggest that
mindfulness practice exerts therapeutic effects by
modifying cognitive processes, a finding that accords
with extant theory on mindfulness.
It is also crucial to prevent the obscurations of
eclecticism that can confound attempts to establish
the efficacy of specific intervention techniques.
Although treatments that have received robust
empirical support, such as cognitive behavior therapy (CBT), use multiple modes of intervention
(for example, CBT includes cognitive restructuring, behavioral activation, exposure, behavioral
experiments, and other techniques), research on
multimodal treatment packages remains subject to
criticism. For instance, Longmore and Worrell
(2007) review evidence that the addition of cognitive restructuring to behavioral activation techniques does not significantly increase treatment
effects, suggesting that the cognitive component of
CBT is neither necessary nor sufficient for therapeutic change. The most commonly researched
form of mindfulness training, mindfulness-based
stress reduction (MBSR) (Kabat-Zinn, 1990), is
also a multimodal treatment, which uses both
mindfulness techniques and hatha yoga postures.
Although the efficacy of MBSR has been established in a number of trials (Chiesa & Serretti,
2009), it remains to be seen whether the therapeutic effects of the program derive more from its
mindfulness or yoga components. To that end, dismantling studies are needed that partial out the
differential effects of mindfulness treatment components by randomly assigning participants to
receive one or more aspects of the multimodal
intervention package (Shadish et al., 2002). However, it is important to note that multimodal treatments are designed to promote synergistic effects
by using different techniques that when combined
produce more powerful clinical outcomes than the
individual approaches alone (for an example of a
recent multimodal mindfulness intervention, see
Garland, 2013). As such, dismantling studies are
needed to complement, rather than supplant, research
on multimodal mindfulness-based interventions.
USE BEHAVIORAL AND PHYSIOLOGICAL
MEASURES OF MINDFULNESS AND
THERAPEUTIC CHANGE
The use of such measures not only helps probe
into questions of mechanism, but also provides a
means with which to triangulate self-reports of
change. For instance, Garland, Gaylord, et al. (2010)
conducted a randomized controlled pilot trial comparing the efficacy of a novel mindfulness-oriented
cognitive intervention, mindfulness-oriented recovery
enhancement (MORE), to that of an addiction
support group for persons in long-term recovery
from alcohol dependence. Results indicated that,
relative to the support group, MORE led to significant reductions in self-reported stress and thought
suppression, but no changes in craving were observed. This null finding might have suggested that
this mindfulness-based intervention, although generally therapeutically active, did not lead to changes
addiction-specific factors. Yet, many clients in recovery are resistant to the term “craving” and are reticent to endorse experiencing it, particularly those in
long-term residential treatment where the pressure
to conform to social, cultural, and programmatic
mores is high. Fortunately, non-self-report measures
of alcohol cue-reactivity were assessed, including a
dot probe task and a psychophysiological protocol,
which determined the degree to which participants’
attention was fixated on alcohol cues and the extent
of heart-rate variability recovery from alcohol cueexposure, respectively. MORE was found to modify
both of these attentional and autonomic mechanisms
implicated in alcohol dependence, suggesting that
mindfulness training does in fact exert addictionspecific therapeutic effects. Moreover, individual
difference analyses of change scores revealed that
among participants in the mindfulness intervention,
reductions in self-reported thought suppression were
correlated with decreases in attentional fixation on
alcohol cues and increases in heart rate variability
recovery from such cues. Thus, in a biopsychosocial
research methodology, data from self-report measures, cognitive tasks, and psychophysiological methods converged in a theoretically sensible and mutually
informative manner.
Psychophysiological research notwithstanding,
investigators in a field as applied as social work
should take pains to carefully document the specific, behavioral outcomes of mindfulness as state,
trait, and practice. For instance, variables such as
frequency and duration of hospitalizations, number
of arrests, and latency to re-incarceration are clearly
quantifiable, clinically important, and reflective of
real-world intervention impacts. Researchers could
Garland / Mindfulness Research in Social Work
assess whether changes in more proximal psychological variables mediate the effect of mindfulness
practice on these distal clinical outcomes.
USE A MIXED-METHODS APPROACH
Although researchers are increasingly using more
rigorous methodologies to investigate mindfulness,
little is known about how individuals utilize mindfulness states, traits, and practices in their everyday
lives to cope with stressors and emotional challenges. Furthermore, the phenomenology of the
change process as persons undergo mindfulness
training remains unspecified. Although these areas
of inquiry are to some extent tractable to quantitative research methods, they may also be fruitfully
addressed through qualitative means.
Insofar as mindfulness is a first-person phenomenon, that is, one that is directly accessible only to
the person who is experiencing it (Depraz, Varela,
& Vermersch, 2003), first-person accounts are necessary to capture the essence of the experience of
mindfulness as it is perceived by those participating
in mindfulness-based interventions. Grounded theory analyses of qualitative data derived from these
reports may be used to triangulate etic theoretical
conceptualizations of mechanisms by which mindfulness facilitates coping (for example, Garland,
Schwarz, Kelly, Whitt, & Howard, 2012).
Data derived from in-depth interviews may be
integrated with data from psychometric instruments, psychophysiological assessments, and so on.
Such a mixed-methods approach would capture
the interpenetrating qualitative and quantitative
aspects of mindfulness. One might, for example,
complement findings of mindfulness-induced
changes in physiological stress reactivity with a
“thick description” (Padgett, 1998) of how individuals exhibiting such changes have learned to
cope differently with distressing thoughts and
emotions after mindfulness training. To that end,
techniques such as protocol analysis (Ericsson &
Simon, 1993) can be useful to precisely elucidate
the mental steps and procedures taken by participants of mindfulness-based interventions as they
apply mindfulness skills to coping with adversity.
REMAIN MINDFUL OF CULTURAL AND
CONTEXTUAL CONSIDERATIONS
The Buddhist tradition from which mindfulness has
been abstracted is grounded in a sort of ecological systems theory, known as pratityasamutpada, sometimes
445
translated as interdependent co-arising or what the
venerable meditation teacher Thich Nhat Hanh
simply called “interbeing” (Hanh, 1988). Pratityasamputpada is the notion that all things are interrelated and depend on one another for their
existence. According to this notion, any being or
entity is in fact the summation of an infinite number
of causal forces extending from the past through the
present and into the future. For example, the life of a
human being in any given moment is influenced by
the state of the world in that moment, in turn composed of environmental conditions, global and
national political structures, cultural traditions, economic forces, community events, and social relationships. However, in a reciprocal fashion, the state of
the world is conditioned by each human life; indeed,
our every action changes the shape and contour of
the world, in both a literal and figurative sense.
In light of these considerations, social work
researchers should remain mindful of the cultural
and contextual forces that influence the implementation and acceptability of mindfulness-based interventions and the state of mindfulness itself. Clinical
interventions are not delivered in a vacuum; they
are delivered in a social, cultural, economic, and
political context. It is notable that the overwhelming majority of studies on mindfulness have been
conducted with samples of white, middle- to upperclass individuals. For example, of the eight studies
presented in Table 1, only the studies conducted by
Bowen et al. (2009) and Garland, Gaylord, et al.
(2010) included a racially and socioeconomically
diverse sample. Mindfulness may indeed have a different meaning for vulnerable persons facing poverty, homelessness, violence, and trauma who do
not have the benefit of advanced education, economic resources, or political capital. Social work
researchers are uniquely poised to assess interaction
effects between client characteristics, sociocultural
context, mindfulness training, and clinical outcomes.
Moderation analyses (Baron & Kenny, 1986) could
be used to determine the effects of mindfulness training on persons from different social strata and ethnic
backgrounds. Such population-specific data should
be integrated into a feedback loop that informs
implementation of mindfulness-based interventions
in the field. In addition, principles endorsed in treatment manuals of mindfulness-based interventions
(for example, Garland, 2013) should be couched in
widely accessible vocabulary instead of sectarian and
academic jargon. These practices will lead to the
446
optimization of mindfulness-based interventions for
the focal populations and problems of interest to the
social work profession.
CONCLUSION
The past decade has witnessed a proliferation of
research on mindfulness, both within and beyond
social work. Studies of mindfulness-based therapies
may increasingly attract attention from the social
work profession inasmuch as they illuminate the
efficacy and cost-effectiveness of new forms of
intervention. For example, a randomized controlled trial found that among persons in remission for
major depression, MBCT was more effective in
reducing residual depressive symptoms and improving quality of life than antidepressant medication,
yet was of comparable financial cost (Kuyken
et al., 2008). Moreover, mindfulness-based interventions may address emerging threats to public
health and social welfare; in that regard, a recent
early stage clinical trial identified significant therapeutic effects of MORE on co-occurring prescription opioid misuse and chronic pain, a problem of
increasing medical and sociological significance
(Garland et al., 2013). In addition to its fiscal and
clinical efficacy, mindfulness is congruent with the
strengths-based approach and empowerment ethos
of social work. As a means of developing selfregulatory capacity, mindfulness practices enhance
coping and thereby promote resiliency. Given the
natural fit between mindfulness and the overarching
practice philosophy of the social work profession,
there is a great need for social work researchers to
thoughtfully engage in this important domain of
inquiry.
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Eric L. Garland, PhD, is associate professor, College of Social
Work, and associate director, Integrative Medicine, Supportive
Oncology and Survivorship Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, 84112; e-mail:
[email protected].
Original manuscript received May 19, 2011
Final revision received August 3, 2011
Accepted August 4, 2011
Advance Access Publication December 19, 2013
Social Work Research Volume 37, Number 4 December 2013
Conceptual and Methodological
Recommendations
Eric L. Garland
Mindfulness refers to a set of practices as well as the psychological state and trait produced
by such practices. The state, trait, and practice of mindfulness may be broadly characterized
by a present-oriented, nonjudgmental awareness of cognitions, emotions, sensations, and
perceptions without fixation on thoughts of past or future. Research on mindfulness has
proliferated over the past decade. Given the explosion of scientific interest in this topic,
mindfulness-based therapies are attracting the attention of clinical social workers, who seek
to implement these interventions in numerous practice settings. Concomitantly, research on
mindfulness is now falling within the scope and purview of social work scholars. In response
to the growing interest in mindfulness within academic social work, the present article
outlines six conceptual and methodological recommendations for the conduct of future
empirical studies on mindfulness. These recommendations have practical importance for
advancing mindfulness research within and beyond social work.
KEY WORDS:
evidence-based practice; meditation; mindfulness; randomized controlled trial; research methods
M
indfulness is linked with a set of crosscultural principles and practices originating in Asia more than 2,500 years
ago that have parallel manifestations in numerous
cultures around the world. With regard to its current academic usage, mindfulness refers to a psychological phenomenon that is now being studied for
its relevance to mental and physical health in fields
such as medicine, psychology, and neuroscience.
Across these fields, there is a growing body of literature that attests to the efficacy of mindfulness-based
therapies for a wide range of biobehavioral disorders.
According to a search of PubMed and CRISP databases conducted on October 4, 2009, there were
1,614 peer-reviewed journal articles on mindfulness
published in the scientific literature and 320 research
grants on mindfulness funded by the National Institutes of Health between 1998 and 2009. Indeed,
there is mounting empirical evidence of the role of
mindfulness in reducing stress and improving clinical
outcomes across diverse conditions such as depression (Teasdale et al., 2002), relationship difficulties
(Carson, Carson, Gil, & Baucom, 2004), irritable
bowel syndrome (Gaylord et al., 2011), criminal recidivism (Himelstein, 2011), chronic pain
(Rosenzweig et al., 2010), and addiction (Bowen
et al., 2006; Garland, Gaylord, Boettiger, & Howard,
doi: 10.1093/swr/svt038
© 2013 National Association of Social Workers
2010). Consequently, mindfulness-based interventions are becoming well-regarded for their therapeutic promise, as evidenced by recent publications in
mainstream, respected academic outlets, such as the
Journal of the American Medical Association (for example, Ludwig & Kabat-Zinn, 2008).
Given this burgeoning interest, mindfulnessbased interventions are attracting the attention of
clinical social workers who are increasingly implementing these treatments across diverse domains of
practice. Concomitantly, research on mindfulness
is now falling under the purview of social work
scholars, many of whom seek to determine the
comparative effectiveness of mindfulness-based
interventions and apply the construct of mindfulness to theories and models of social work practice.
In response to the growing interest in mindfulness
within academic social work, this article outlines
six conceptual and methodological recommendations for the conduct of future empirical research
on mindfulness.
INCREASE PRECISION IN
OPERATIONALIZATION OF THE CONSTRUCT
OF MINDFULNESS
To advance any field of scholarship, the precise
operationalization of constructs is a necessary first
439
step. Without such precision, empirical investigations of putatively identical phenomena may result
in widely divergent correlations between constructs of interest and inconsistent clinical outcomes
across studies. Ultimately, imprecise operationalization of constructs presents a severe threat to validity
that can undermine the quality of otherwise
well-designed research studies (Shadish, Cook, &
Campbell, 2002). Mindfulness research within and
outside of social work has been rife with this problem. An examination of Hick’s (2009) edited volume Mindfulness and Social Work clearly demonstrates
this issue. According to Hick, mindfulness is “an
orientation to our everyday experiences” ( p. 1); to
others in the edited volume, it is a “specific and
effective method of focusing the mind on the essence of experience” ( p. 45), a way to “mediate the
development of professional self-concept” ( p. 93),
“an approach for increasing awareness” ( p. 125),
an approach for “performing all activities with full
awareness” ( p. 154), and even a “necessary condition for an activist to become mature in her passion
and mission to fight for justice” (p. 178). This lack
of conceptual clarity should be rectified and a uniform, coherent set of definitions established, if mindfulness research within social work is to advance.
To that end, the following operationalizations of
mindfulness are offered. First, mindfulness is a state,
a naturalistic mindset characterized by an attentive
and nonjudgmental metacognitive monitoring of
moment-by-moment cognition, emotion, perception, and sensation without fixation on thoughts of
past and future (Garland, 2007; Lutz, Slagter,
Dunne, & Davidson, 2008). Mindfulness is metacognitive in the sense that it involves a meta-level
of awareness that monitors the content of consciousness while reflecting back upon the process
of consciousness itself (Nelson, Stuart, Howard, &
Crowley, 1999). Mindfulness is naturalistic in that
it is a basic and inherent capacity of the human
mind, although people differ in their ability and
willingness to actualize this state (Brown, Ryan, &
Creswell, 2007; Goldstein, 2002).
Second, mindfulness is a practice (or, more accurately, a set of practices) designed to evoke and foster the state of mindfulness. The practice of
mindfulness involves repeated placement of attention onto an object while alternately acknowledging and letting go of distracting thoughts and
emotions. Objects of mindfulness practice can
include the sensation of breathing; the sensation of
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walking; interoceptive (Craig, 2003) and proprioceptive (Brodal, 2004) feedback about the body’s
internal state, movement, and position; visual stimuli such as a candle flame or running water; mental
contents such as thoughts or feelings; or the quality
of awareness itself (Lutz et al., 2008). These practices are taught and trained in mindfulness-based
interventions.
Third, mindfulness is a trait or disposition that
may be developed over time through the repeated
practice of engaging in the state of mindfulness.
This trait may be characterized as the propensity
toward exhibiting nonjudgmental, nonreactive
awareness of one’s thoughts, emotions, experiences, and actions in everyday life (Baer, Smith,
Hopkins, Krietemeyer, & Toney, 2006). As a trait,
mindfulness is roughly normally distributed (Walach,
Buchheld, Buttenmüllerc, Kleinknechtc, & Schmidta,
2006). People vary in the extent to which they
exhibit mindful dispositions, yet this dispositionality can be strengthened through training. People
who participate in mindfulness-based interventions
evidence increases in trait mindfulness, which mediates the effects of training on clinical outcomes
(Carmody & Baer, 2008).
Thus, integral to mindfulness is the notion of
state by trait interaction, that is, recurrent activation of
the mindful state via mindfulness practices leaves
lasting traces that may accrue into durable changes
in trait mindfulness (Garland, Fredrickson, et al.,
2010), possibly mediated through neuroplasticity
and experience-dependent alterations in gene
expression (Garland & Howard, 2009). Indeed,
recent research suggests that mindfulness practice
can lead to increases in grey matter density in parts
of the brain that subserve emotion regulation,
learning, memory, and the ability to shift one’s
perspective (Holzel et al., 2011). More research is
needed to determine whether such neurobiological changes index the development of trait mindfulness over time resulting from mindfulness
training.
USE RANDOMIZED CONTROLLED DESIGNS
WHEREVER POSSIBLE
A large number of social work studies use nonexperimental and quasi-experimental research designs
that are subject to severe threats to internal validity
(Shadish et al., 2002). Despite the presence of these
threats, authors often overstep the data by making
causal claims from what are, at best, descriptive or
Social Work Research Volume 37, Number 4 December 2013
correlational findings. Studies that attempt to test
causal hypotheses (for example, hypotheses of
therapeutic efficacy) using suboptimal research
designs weaken the portfolio of social work
research and lower the esteem of the profession in
interdisciplinary venues.
This is an especially serious problem when it
comes to research on mindfulness, which is still
met with skepticism within many academic circles
as a “New Age” or “mystical” practice that
amounts to little more than a placebo. Hence, it is
essential to use research designs in mindfulness
research that can control for the effects of maturation, social desirability, expectancy, and placebo
effects.
From 1990 through the early 2000s, many studies on mindfulness used randomized wait-list control groups (for example, Astin, 1997; Davidson
et al., 2003; Shapiro, Schwartz, & Bonner, 1998;
Speca, Carlson, Goodey, & Angen, 2000). This
type of research design is capable of controlling for
history and maturation threats to validity as well as
creating statistically comparable groups at baseline,
and thus it represents a significant advance over
nonrandomized or quasi-experimental studies with
comparison groups. Yet, wait-list controlled designs
remain vulnerable to threats to validity stemming
from expectancy and placebo effects, which can be
substantial (Shapiro, 1981).
Given these concerns, for much of the past decade, mindfulness researchers have used randomized
controlled trial designs in which participants are
randomly assigned to either a mindfulness-based
intervention or a credible, therapeutically active
control condition. Perceived intervention credibility can be measured with self-report scales, such as
Borkovec and Nau’s (1972) Attitudes Towards
Treatment Questionnaire, and statistically controlled (if necessary) in analyses of covariance. Such
scales contain items assessing the extent to which
the research interventions are perceived to be logical treatments for the targeted clinical condition
and how confident participants are that they will
reduce their symptoms. Ideally, participants would
perceive control treatments to be equally credible
to experimental mindfulness interventions (for
example, Garland, Gaylord, et al., 2010; Gaylord
et al., 2011). Expectancy effects can also be minimized through careful advertising of the research.
For example, a flyer that contains the statement
“We are conducting research on mindfulness-
Garland / Mindfulness Research in Social Work
based treatments for cocaine addiction” is inherently flawed, as it suggests the treatment of
interest or preference and potentially introduces
expectancy effects that may confound study results. In contrast, research advertisements should
conceal the identity of the experimental and
control treatments. For instance, the same flyer
would minimize expectancy effects by stating,
“We are conducting research to compare the effectiveness of two forms of treatment for cocaine
addiction: a mindfulness-based treatment and a
support group.”
Moreover, the presence of significant main
effects of time on clinical outcome variables suggests that the control condition may have been
therapeutically active; yet, the presence of a significant Treatment × Time interaction term in the
hypothesized direction indicates that the experimental mindfulness treatment led to significantly
larger therapeutic change over time than the control treatment. For example, in a randomized controlled trial of psychosocial treatments for irritable
bowel syndrome, Gaylord et al. (2011) found that
participants in a mindfulness training intervention
and a conventional support group experienced significant reductions in abdominal pain; yet, relative
to those in the support group, participants in the
mindfulness training intervention experienced significantly greater reductions over the course of
training.
The use of credible, therapeutically active control groups may eliminate confounds introduced
by expectancy and placebo effects as well as
other nonspecific therapeutic factors such as attention by a caring professional, group dynamics, social support, empathy, and the therapeutic alliance
(Castonguay, Goldfried, Wiser, Raue, & Hayes,
1996; Duncan, Miller, & Sparks, 2007). When a
study of a mindfulness-based intervention identifies significant clinical outcomes within the context of this rigorous research design, it may provide
evidence against the “Dodo bird verdict” (for a review, see Budd & Hughes, 2009). However, it should
be noted that a study comparing a mindfulness-based
intervention to a no-treatment control is asking a
substantively different question than a study comparing a mindfulness-based intervention to an
active placebo control condition. In the former
case, the design allows one to measure the efficacy
of participation in a mindfulness-based intervention; whereas in the latter case, the design allows
441
INVESTIGATE THERAPEUTIC MEDIATORS
AND USE DISMANTLING DESIGNS
one to measure the efficacy of the active ingredient
in a mindfulness-based intervention, that is, the
practice of mindfulness itself. It should be noted
that many active control conditions are not merely
placebo controls, but instead are legitimate, established treatments. For example, Kuyken et al.
(2008) compared mindfulness-based cognitive
therapy (MBCT) to maintenance of antidepressant
medication as a means of preventing depression
relapse. Thus, studies that use an active control
group can ascertain whether mindfulness training is
“more effective” than alternative treatments, in
contrast to studies with a no-treatment control
condition that answer the more basic question,
“Is participation in a mindfulness-based intervention associated with positive clinical outcomes?”
This is not to say that nonexperimental
research designs have no place in mindfulness
research. To the contrary, much can be learned
about the associations between trait mindfulness
and related constructs using cross-sectional or
longitudinal research. However, it is imperative
that authors draw careful conclusions that do not
overstep the data. For instance, a prospective
observational study of 339 individuals undergoing
a mindfulness-based stress and pain management
course found that participants reported significant
improvements in trait mindfulness, positive reappraisal coping, catastrophizing, and perceived stress
over eight weeks of training (Garland, Gaylord,
& Fredrickson, 2011). Further, the association
between increases in trait mindfulness and decreases
in stress was partially mediated by increases in positive reappraisal but not by decreases in catastrophizing. Although these findings are potentially
clinically useful, one cannot conclude that mindfulness training caused the observed changes. At
best, one can only conclude that these changes
occurred while participants were engaged in a
mindfulness training program. Findings such as
these are relevant only to the extent that they
are interpreted with great precision; otherwise,
they will remain unpublished or, worse, be published and tarnish the reputation of mindfulness
researchers within and beyond academic social
work.
Several key observational, quasi-experimental,
and experimental research studies that represent
the broad scope of research on mindfulness as a
state, trait, and practice are presented in Table 1.
Social work, as an applied field, is often myopically
focused on clinical outcomes to the exclusion of
more basic forms of scientific research. However,
asking the question “By what processes does this
treatment work?” is often a key step in refining and
optimizing an intervention (Kazdin & Kendall,
1998; Kraemer, Wilson, Fairburn, & Agras, 2002).
For instance, if an initial study reveals that increases
in trait nonreactivity mediate the therapeutic effect
of mindfulness training on chronic pain (compare,
Garland, Gaylord, Palsson, et al., 2012), mindfulness interventions tested in future clinical research
projects might emphasize techniques designed to
increase nonreactivity in order to boost treatment
effect sizes. Thus, examining therapeutic mediation
could enable social work researchers to determine
how mindfulness-based interventions might be
targeted most effectively to the populations and to
identify problems of greatest interest to clinical
social workers in the field. Therapeutic mediation
can be tested by a number of statistical methods, including canonical regression procedure (Baron &
Kenny, 1986), bootstrapping (Preacher & Hayes,
2004), structural equation modeling (Kline, 1998), or
latent growth curve approaches (Preacher, Wichman,
MacCallum, & Briggs, 2008), among others.
Moreover, by establishing the mediators of treatment, one can assess whether a treatment is internally consistent with the theoretical orientation in
which it is grounded (Hayes, Strosahl, & Wilson,
1999). This is important, both for maintaining theoretical coherence and preventing reductionism
and subsequent dismissal by researchers operating
from other theoretical orientations. As one prominent example of this issue, mindfulness practices
have been construed by some as relaxation techniques, believed to reduce stress via evocation of a
relaxation response (Benson, Beary, & Carol,
1974). However, mindfulness meditation has been
shown to produce significantly different cardiovascular and autonomic effects than relaxation training
(Ditto, Eclache, & Goldman, 2006), findings that
argue against the reductionistic construal of mindfulness practice as a mere relaxation technique. Further, a randomized controlled trial demonstrated that
whereas both mindfulness practice and relaxation
training led to reduced distress, mindfulness practice
alone led to significant decreases in ruminative
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Garland / Mindfulness Research in Social Work
Table 1: Select Key Studies Representing the Broad Scope of Research on Mindfulness as a State, Trait, and Practice
Study
Sample
Design
Operationalization of Mindfulness
or Related Phenomena
Pertinent Results
Bowen et al.
(2009)
168 adults with substance use
disorders
RCT of MBRP versus
standard substance use
treatment services
Trait mindfulness assessed by the FFMQ;
acceptance assessed by the AAQ
MBRP participants, relative to the control group, reported significantly
fewer days of drug and alcohol use. Relative to the control group,
MBRP led to significant increases in acceptance and the Acting with
Awareness subscale of the FFMQ.
Carmody &
Baer (2008)
174 adults with a wide range of Prospective observational
stress, chronic pain, and
study of MBSR
anxiety issues
Trait mindfulness assessed by the FFMQ;
time spent in formal mindfulness
practice
Increases in trait mindfulness were significantly associated with time
spent in formal mindfulness practice. Increases in trait mindfulness
mediated the effects of time spent in mindfulness practice on
psychological symptoms, stress, and well-being.
Feldman,
Greeson, &
Senville
(2010)
190 female college students
State mindfulness (decentering) assessed by MT participants reported significantly greater state mindfulness
(decentering) relative to the other two conditions. Relative to the
the TMS; frequency of or reactivity to
other conditions, a 15-minute session of MT reduced negative
repetitive thoughts
reactions to repetitive thoughts.
Garland,
Gaylord,
et al. (2010)
53 alcohol-dependent adults in RCT of MORE versus an
long-term residential
addiction support group
treatment
Thought suppression (that is, a construct
that is the opposite of mindfulness)
assessed by the WBSI
MORE participants, relative to those in the support group, experienced
significantly larger decreases in stress and thought suppression.
Among MORE participants, decreases in thought suppression were
associated with decreased fixation on alcohol cues and increased heart
rate variability recovery from stress and alcohol cues.
Gaylord et al.
(2011)
75 female patients with
irritable bowel syndrome
RCT of MT versus a
support group
Trait mindfulness assessed by the FFMQ
MT participants, relative to those in the support group, experienced
significantly decreased abdominal pain and increased quality of life.
The effect of MT on these clinically significant outcomes was
mediated by increases in trait mindfulness (nonreactivity).a
Holzel et al.
(2011)
33 healthy adults either
participating or waiting to
participate in a MBSR
course
Quasi-experiment
comparing MBSR to
wait-list control group
Trait mindfulness assessed by the FFMQ;
changes in brain structure assessed by
structural magnetic resonance imaging
MBSR participants, relative to those in the wait-list control group,
reported significant increases in trait mindfulness and exhibited
significant increases in grey matter concentration in left
hippocampus, cingulate cortex, cerebellum, and temporo-parietal
junction.
Kuyken et al.
(2010)
123 patients treated with
antidepressants who had ≥ 3
depressive episodes
RCT of MBCT versus
continued
antidepressants
Trait mindfulness assessed with the KIMS;
self-compassion assessed with the SCS
The therapeutic effects of MBCT were mediated by increases in trait
mindfulness and self-compassion over the course of treatment.
MBCT moderated the association between cognitive reactivity and
depression.
Teasdale et al.
(2002)
100 patients in remission or
recovery from major
depression
RCT of MBCT versus
treatment as usual (for
example, doctor)
Metacognitive awareness assessed by the
MACAM
MBCT participants, relative to the control group, experienced
significantly fewer occurrences of depression relapse. MBCT led to
significantly increased metacognitive awareness.
Random assignment to 15
minutes of MT, LKM,
or PMR
443
Notes: MBRP = mindfulness-based relapse prevention; AAQ = Acceptance and Action Questionnaire (Hayes et al., 2004); FFMQ = Five-Facet Mindfulness Questionnaire (Baer et al., 2006); LKM = loving-kindness meditation; KIMS = Kentucky Inventory of Mindfulness
Skills (Baer, Smith, & Allen, 2004); MACAM = Measure of Awareness and Coping in Autobiographical Memory (Moore, Hayhurst, & Teasdale, 1996); MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness-based stress reduction;
MORE = mindfulness-oriented recovery enhancement; MT = mindfulness training; PMR = progressive muscle relaxation; RCT = randomized controlled trial; SCS = Self-Compassion Scale (Neff, 2003); TAU = treatment as usual; TMS = Toronto Mindfulness Scale (Lau et al.,
2006); WBSI = White Bear Suppression Inventory (Wegner & Zanakos, 1994).
a
These mediational data are presented in Garland, Gaylord, Palsson et al. (2012).
As interest in mindfulness grows, there is a need to
further specify and operationalize the measurement
of mindfulness and its therapeutic effects in both
clinical and basic science research programs. A
number of questionnaires currently are used to
quantify both state and trait mindfulness in studies,
such as the Five-Facet Mindfulness Questionnaire
(Baer et al., 2006) and the Toronto Mindfulness
Scale (Lau et al., 2006). Although these scales can
be useful, measurement instruments that rely on
self-report are vulnerable to reactivity to being in
an experimental condition, experimenter expectancies, social desirability biases, and misinterpretation of question items (Shadish et al., 2002).
Moreover, it should be recognized that questionnaire items are proxies for latent variables that can
only imperfectly capture the essence of the construct under investigation (DeVellis, 2003). Any
one operationalization may inadequately represent
the construct of interest (Shadish et al., 2002).
As such, research on mindfulness as a state, trait, or
practice that solely relies upon self-report instruments is subject to the same social influences and
mono-operation biases as research on other psychosocial phenomena.
To counter the limitations of self-report measures, mindfulness researchers may benefit from
using behavioral and physiological measures of
mindfulness and its therapeutic effects. In the past
decade, there has been an explosion of studies in
the psychological, medical, and neuroscientific literature investigating the therapeutic mechanisms of
mindfulness using an array of sophisticated research
methodologies, including cognitive tasks (for example, Garland, Boettiger, Gaylord, West Chanon,
& Howard, 2012; Zeidan, Johnson, Diamond,
David, & Goolkasian, 2011), psychophysiological
measures (for example, Garland, 2011; Ditto et al.,
2006), and neuroimaging techniques (for example,
Farb et al., 2010; Froeliger, Garland, Modlin, &
McClernon, 2012). Yet, in spite of the application
of ever-increasing methodological rigor to research
on mindfulness in these fields, few social work
scholars have dared to tread into this domain.
Whereas the implementation of many of biobehavioral methods (such as functional magnetic resonance imaging or DNA microarrays) requires years
of specialized training not offered in most social
work doctoral programs, other methods, such as the
measurement of heart-rate variability, cortisol assays,
and certain performance-based tasks derived from
cognitive neuroscience, may be within reach of a
wider range of social work researchers.
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Social Work Research Volume 37, Number 4 December 2013
thoughts that partially mediated its therapeutic effect
on distress (Jain et al., 2007). Such results suggest that
mindfulness practice exerts therapeutic effects by
modifying cognitive processes, a finding that accords
with extant theory on mindfulness.
It is also crucial to prevent the obscurations of
eclecticism that can confound attempts to establish
the efficacy of specific intervention techniques.
Although treatments that have received robust
empirical support, such as cognitive behavior therapy (CBT), use multiple modes of intervention
(for example, CBT includes cognitive restructuring, behavioral activation, exposure, behavioral
experiments, and other techniques), research on
multimodal treatment packages remains subject to
criticism. For instance, Longmore and Worrell
(2007) review evidence that the addition of cognitive restructuring to behavioral activation techniques does not significantly increase treatment
effects, suggesting that the cognitive component of
CBT is neither necessary nor sufficient for therapeutic change. The most commonly researched
form of mindfulness training, mindfulness-based
stress reduction (MBSR) (Kabat-Zinn, 1990), is
also a multimodal treatment, which uses both
mindfulness techniques and hatha yoga postures.
Although the efficacy of MBSR has been established in a number of trials (Chiesa & Serretti,
2009), it remains to be seen whether the therapeutic effects of the program derive more from its
mindfulness or yoga components. To that end, dismantling studies are needed that partial out the
differential effects of mindfulness treatment components by randomly assigning participants to
receive one or more aspects of the multimodal
intervention package (Shadish et al., 2002). However, it is important to note that multimodal treatments are designed to promote synergistic effects
by using different techniques that when combined
produce more powerful clinical outcomes than the
individual approaches alone (for an example of a
recent multimodal mindfulness intervention, see
Garland, 2013). As such, dismantling studies are
needed to complement, rather than supplant, research
on multimodal mindfulness-based interventions.
USE BEHAVIORAL AND PHYSIOLOGICAL
MEASURES OF MINDFULNESS AND
THERAPEUTIC CHANGE
The use of such measures not only helps probe
into questions of mechanism, but also provides a
means with which to triangulate self-reports of
change. For instance, Garland, Gaylord, et al. (2010)
conducted a randomized controlled pilot trial comparing the efficacy of a novel mindfulness-oriented
cognitive intervention, mindfulness-oriented recovery
enhancement (MORE), to that of an addiction
support group for persons in long-term recovery
from alcohol dependence. Results indicated that,
relative to the support group, MORE led to significant reductions in self-reported stress and thought
suppression, but no changes in craving were observed. This null finding might have suggested that
this mindfulness-based intervention, although generally therapeutically active, did not lead to changes
addiction-specific factors. Yet, many clients in recovery are resistant to the term “craving” and are reticent to endorse experiencing it, particularly those in
long-term residential treatment where the pressure
to conform to social, cultural, and programmatic
mores is high. Fortunately, non-self-report measures
of alcohol cue-reactivity were assessed, including a
dot probe task and a psychophysiological protocol,
which determined the degree to which participants’
attention was fixated on alcohol cues and the extent
of heart-rate variability recovery from alcohol cueexposure, respectively. MORE was found to modify
both of these attentional and autonomic mechanisms
implicated in alcohol dependence, suggesting that
mindfulness training does in fact exert addictionspecific therapeutic effects. Moreover, individual
difference analyses of change scores revealed that
among participants in the mindfulness intervention,
reductions in self-reported thought suppression were
correlated with decreases in attentional fixation on
alcohol cues and increases in heart rate variability
recovery from such cues. Thus, in a biopsychosocial
research methodology, data from self-report measures, cognitive tasks, and psychophysiological methods converged in a theoretically sensible and mutually
informative manner.
Psychophysiological research notwithstanding,
investigators in a field as applied as social work
should take pains to carefully document the specific, behavioral outcomes of mindfulness as state,
trait, and practice. For instance, variables such as
frequency and duration of hospitalizations, number
of arrests, and latency to re-incarceration are clearly
quantifiable, clinically important, and reflective of
real-world intervention impacts. Researchers could
Garland / Mindfulness Research in Social Work
assess whether changes in more proximal psychological variables mediate the effect of mindfulness
practice on these distal clinical outcomes.
USE A MIXED-METHODS APPROACH
Although researchers are increasingly using more
rigorous methodologies to investigate mindfulness,
little is known about how individuals utilize mindfulness states, traits, and practices in their everyday
lives to cope with stressors and emotional challenges. Furthermore, the phenomenology of the
change process as persons undergo mindfulness
training remains unspecified. Although these areas
of inquiry are to some extent tractable to quantitative research methods, they may also be fruitfully
addressed through qualitative means.
Insofar as mindfulness is a first-person phenomenon, that is, one that is directly accessible only to
the person who is experiencing it (Depraz, Varela,
& Vermersch, 2003), first-person accounts are necessary to capture the essence of the experience of
mindfulness as it is perceived by those participating
in mindfulness-based interventions. Grounded theory analyses of qualitative data derived from these
reports may be used to triangulate etic theoretical
conceptualizations of mechanisms by which mindfulness facilitates coping (for example, Garland,
Schwarz, Kelly, Whitt, & Howard, 2012).
Data derived from in-depth interviews may be
integrated with data from psychometric instruments, psychophysiological assessments, and so on.
Such a mixed-methods approach would capture
the interpenetrating qualitative and quantitative
aspects of mindfulness. One might, for example,
complement findings of mindfulness-induced
changes in physiological stress reactivity with a
“thick description” (Padgett, 1998) of how individuals exhibiting such changes have learned to
cope differently with distressing thoughts and
emotions after mindfulness training. To that end,
techniques such as protocol analysis (Ericsson &
Simon, 1993) can be useful to precisely elucidate
the mental steps and procedures taken by participants of mindfulness-based interventions as they
apply mindfulness skills to coping with adversity.
REMAIN MINDFUL OF CULTURAL AND
CONTEXTUAL CONSIDERATIONS
The Buddhist tradition from which mindfulness has
been abstracted is grounded in a sort of ecological systems theory, known as pratityasamutpada, sometimes
445
translated as interdependent co-arising or what the
venerable meditation teacher Thich Nhat Hanh
simply called “interbeing” (Hanh, 1988). Pratityasamputpada is the notion that all things are interrelated and depend on one another for their
existence. According to this notion, any being or
entity is in fact the summation of an infinite number
of causal forces extending from the past through the
present and into the future. For example, the life of a
human being in any given moment is influenced by
the state of the world in that moment, in turn composed of environmental conditions, global and
national political structures, cultural traditions, economic forces, community events, and social relationships. However, in a reciprocal fashion, the state of
the world is conditioned by each human life; indeed,
our every action changes the shape and contour of
the world, in both a literal and figurative sense.
In light of these considerations, social work
researchers should remain mindful of the cultural
and contextual forces that influence the implementation and acceptability of mindfulness-based interventions and the state of mindfulness itself. Clinical
interventions are not delivered in a vacuum; they
are delivered in a social, cultural, economic, and
political context. It is notable that the overwhelming majority of studies on mindfulness have been
conducted with samples of white, middle- to upperclass individuals. For example, of the eight studies
presented in Table 1, only the studies conducted by
Bowen et al. (2009) and Garland, Gaylord, et al.
(2010) included a racially and socioeconomically
diverse sample. Mindfulness may indeed have a different meaning for vulnerable persons facing poverty, homelessness, violence, and trauma who do
not have the benefit of advanced education, economic resources, or political capital. Social work
researchers are uniquely poised to assess interaction
effects between client characteristics, sociocultural
context, mindfulness training, and clinical outcomes.
Moderation analyses (Baron & Kenny, 1986) could
be used to determine the effects of mindfulness training on persons from different social strata and ethnic
backgrounds. Such population-specific data should
be integrated into a feedback loop that informs
implementation of mindfulness-based interventions
in the field. In addition, principles endorsed in treatment manuals of mindfulness-based interventions
(for example, Garland, 2013) should be couched in
widely accessible vocabulary instead of sectarian and
academic jargon. These practices will lead to the
446
optimization of mindfulness-based interventions for
the focal populations and problems of interest to the
social work profession.
CONCLUSION
The past decade has witnessed a proliferation of
research on mindfulness, both within and beyond
social work. Studies of mindfulness-based therapies
may increasingly attract attention from the social
work profession inasmuch as they illuminate the
efficacy and cost-effectiveness of new forms of
intervention. For example, a randomized controlled trial found that among persons in remission for
major depression, MBCT was more effective in
reducing residual depressive symptoms and improving quality of life than antidepressant medication,
yet was of comparable financial cost (Kuyken
et al., 2008). Moreover, mindfulness-based interventions may address emerging threats to public
health and social welfare; in that regard, a recent
early stage clinical trial identified significant therapeutic effects of MORE on co-occurring prescription opioid misuse and chronic pain, a problem of
increasing medical and sociological significance
(Garland et al., 2013). In addition to its fiscal and
clinical efficacy, mindfulness is congruent with the
strengths-based approach and empowerment ethos
of social work. As a means of developing selfregulatory capacity, mindfulness practices enhance
coping and thereby promote resiliency. Given the
natural fit between mindfulness and the overarching
practice philosophy of the social work profession,
there is a great need for social work researchers to
thoughtfully engage in this important domain of
inquiry.
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Eric L. Garland, PhD, is associate professor, College of Social
Work, and associate director, Integrative Medicine, Supportive
Oncology and Survivorship Program, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, 84112; e-mail:
[email protected].
Original manuscript received May 19, 2011
Final revision received August 3, 2011
Accepted August 4, 2011
Advance Access Publication December 19, 2013
Social Work Research Volume 37, Number 4 December 2013
