Download 1 EFFECT OF MBSR ON RUMINATION COULD MBSR REDUCE

Running Head: EFFECT OF MBSR ON RUMINATION
COULD MBSR REDUCE VULNERABILITY TO DEPRESSION BY REDUCING
RUMINATION? A PRELIMINARY REVIEW
Trainee Name
Nicola Motton, College of Life and Environmental Science,
University of Exeter
Supervisor
Willem Kuyken, College of Life and Environmental Science,
University of Exeter
Nominated journal
Clinical Psychology Review
Word count
3,969
This work is submitted in partial fulfilment of requirements for the doctorate in clinical
psychology
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EFFECT OF MBSR ON RUMINATION
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Abstract
Depression is a public health problem that commonly begins in childhood or adolescence and
is associated with functional impairment and depressive relapse in later life. Rumination is
strongly implicated in the onset and maintenance of depressive symptoms and depression.
Preventative interventions should target rumination as a means to reduce depressive
symptoms and offset the risk of depression. This review examines the literature relating to
whether Mindfulness-Based Stress Reduction (MBSR), an eight week intervention that aims
to reduce the distress that arises from physical or psychological problems, could be usefully
be applied with a non-clinical population as a preventative intervention, by examining
whether MBSR reduces rumination. The literature on this topic to date is limited and suffers
a number of methodological flaws, however the existing evidence supports the notion that
MBSR reduces rumination, at least in adults. Methodologically sound research is now
required to determine whether MBSR reduces rumination in children and adolescents, in
order to determine whether it could be used as a preventative intervention for depression.
Keywords: Mindfulness-based stress reduction, rumination, prevention, depressive
symptoms, depression.
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COULD MBSR REDUCE VULNERABILITY TO DEPRESSION BY REDUCING
RUMINATION? A PRELIMINARY REVIEW
The National Institute of Mental Health has highlighted that research should focus not
just on developing effective ways of treating and preventing the recurrence of mood
disorders, but also on ways of preventing new onsets of mood disorders (Hyman, 2001).
Given that depression that occurs in early life is associated with more chronic and recurrent
depression in adulthood (Coryell et al., 2009), and greater suicidality (Thompson, 2008;
Williams et al., 2012; Zisook et al., 2007) childhood or adolescence is a critical period for
preventative interventions to be introduced. Preventative interventions should target the
reduction of depressive symptoms, as they are strongly predictive of later depression (Pine,
Cohen, Cohen, & Brook, 1999; Shankman et al., 2009). Despite growing interest in
preventative interventions for depression in the last few years, with promising findings to
date (Cuijpers, van Straten, Smit, Mihalopoulos, & Beekman, 2008), a recent large scale RCT
(N = 5030) of classroom-based Cognitive Behavioural Therapy (CBT) found no reduction in
depressive symptoms in at-risk adolescents compared to an attention control group or usual
school provision (Stallard et al., 2012). This finding begs further consideration of what
methods of intervention may be more effective.
In order to reduce depressive symptoms and prevent depression, interventions must
target factors that explain their onset and maintenance. Rumination, defined as “behaviours
and thoughts that focus one’s attention on one’s depressive symptoms and on the implications
of these symptoms” (Nolen-Hoeksema, 1991, p. 569) has been strongly implicated in the
onset and maintenance of depression; rumination has been found in prospective studies to
predict higher levels of depressive symptoms following a stressful event, even after
accounting for baseline levels of depressive symptoms (Nolen-Hoeksema & Morrow, 1991).
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Rumination contributes to the maintenance and exacerbation of depressive symptoms in
adolescents (Burwell & Shirk, 2007), and predicts the onset of new depressive episodes in
adolescents (Broderick & Korteland, 2004), as well as adults (Nolen-Hoeksema, 2000). Some
research suggests rumination may serve as a mechanism through which other risk factors
such as neuroticism and self-criticism exert their effect on vulnerability to depression
(Kuyken, Watkins, Holden, & Cook, 2006; Spasojević & Alloy, 2001). Given the substantial
evidence that attests to the role of rumination in the onset and maintenance of depressive
symptoms and depression, interventions that aim to reduce depressive symptoms must reduce
rumination as a means to achieving this.
Mindfulness may be one such means of reducing rumination. Mindfulness has been
described as “the awareness that emerges through paying attention on purpose, in the present
moment, and non-judgementally to the unfolding of experience moment by moment” (KabatZinn, 2003, p. 145). In a theoretical sense, mindfulness represents a helpful alternative to the
over-engaged style of processing entailed by rumination that perpetuates low mood, as
mindfulness involves allowing emotions to pass in and out of awareness without overinvolvement (Kabat-Zinn, 1990). Indeed, correlational data suggest high trait mindfulness is
associated with greater wellbeing on a number of indicators, including lower levels of
depression and anxiety, greater life satisfaction and positive affect, and a lower tendency to
ruminate (Brown & Ryan, 2003). In recent years there has been growing interest in
mindfulness interventions, and a body of research has now accumulated that suggests
mindfulness is helpful for adults with a range of physical and psychological problems (Baer,
2003; Brown, Ryan, & Cresswell, 2007; Greeson, 2009, Grossman, Niemann, Schmidt, &
Walach, 2004, Hofmann, Sawyer, Witt, & Oh, 2010). In particular, mindfulness interventions
are effective at reducing depressive symptoms in adults (Deyo, Wilson, Ong, & Koopman,
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2009; Kuyken et al., 2008; Teasdale et al., 2000), and preliminary research with adolescents
suggests the same (Biegel, Brown, Shapiro, & Schubert, 2009).
Two of the most studied mindfulness interventions are Mindfulness Based Cognitive
Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR). MBSR was originally
developed as an intervention for outpatients with stress, chronic pain, and illness (KabatZinn, 2003). This eight-week group program aims to enhance individuals’ ability to be
mindful, and to apply mindfulness in their day-to-day lives (Samuelson, Carmody, KabatZinn, & Bratt, 2007). MBCT is also an eight-week group program aimed at enhancing
mindfulness through regular practice (Kuyken et al., 2008), however the program was
designed with the aim of preventing the recurrence of depression (Segal, Williams, &
Teasdale, 2002). This review focuses on MBSR, as arguably it is more appropriate than
MBCT for the purposes of reducing low-grade depressive symptoms and rumination in a
primarily non-clinical population, given that MBSR was designed for adults without a history
of significant psychological problems.
Understanding whether MBSR reduces rumination is an important question, as it is
essential that the processes, or mechanisms, that produce change in interventions are well
understood, in order that they may be enhanced to maximise effectiveness (Kazdin, 2007).
Mechanisms of change are derived from theory before being tested empirically (Labelle,
Campbell, & Carlson, 2010). In this instance, it is theorised that mindfulness interventions
reduce rumination as a result of teaching individuals to respond mindfully; examining the
literature on this question is an important first step to determining whether rumination may
serve as a mechanism of change for MBSR.
Existing research examining the mechanisms of change in MBSR has focused
predominantly on enhancing mindfulness (Labelle et al., 2010), providing strong evidence
that MBSR does indeed enhance mindfulness (Carmody & Baer, 2008; Cohen-Katz et al.,
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2005; Nyklíček & Kuipers, 2008; Shapiro, Brown, & Biegel, 2007), and enhanced
mindfulness mediates some of the benefits found in MBSR (e.g. Carmody & Baer, 2008).
Comparatively fewer studies have examined the effects of MBSR on rumination, and none of
the literature on mindfulness interventions with children and adolescents has examined
potential mechanisms of change (Harnett & Dawe, 2012).
There have been a number of reviews in recent years examining the application of
mindfulness interventions with adults (e.g. Baer, 2003) and children and adolescents (e.g.
Burke, 2009), however there are as yet no published reviews of the effect of MBSR on
rumination. This review examines the question of whether MBSR may have the potential to
be used as an intervention for reducing depressive symptoms and the risk of later depression,
by examining whether MBSR reduces rumination.
Search strategy
The following electronic databases were searched: PsycARTICLES, PsycINFO,
MEDLINE, JSTOR, Science direct, SCOPUS, ISI Web of Knowledge, Springer Link and
EBSCO e-journals. The search terms “rumination” and “mindfulness based stress reduction”
were used. Articles were included if the study measured the effect of a mindfulness-based
stress reduction course on levels of rumination. Dissertations and conference papers were
excluded from the review. Nine articles met criteria for inclusion.
The effect of MBSR on rumination
Table 1 summaries the studies included in this review. Studies are described in
chronological order culminating with the most recent research.
One of the first studies of MBSR that examined rumination also examined the effect
on depression, anxiety, and dysfunctional attitudes with 23 participants compared to a wait
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list control group of 11 participants (Ramel, Goldin, Carmona, & McQuaid, 2004). All
participants had a lifetime diagnosis of a mood disorder (one quarter met criteria for a current
depressive episode). Within-groups analyses were conducted with data from the 23
participants who completed MBSR, whereas between-groups analyses were conducted using
data from 11 intervention participants and 11 controls matched on age, gender, and baseline
score on the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh,
1961). Both within and between-groups analyses found participants who received MBSR
experienced reduced depression, anxiety, dysfunctional attitudes, and importantly,
rumination. Notably, greater amounts of mindfulness practice predicted greater reductions in
rumination, suggesting regular implementation of mindfulness may be enhance the benefits
of MBSR. Rumination accounted for reductions in depressive symptoms providing some
support for the meditational mechanism proposed in this review. The design benefited from a
control group, which enabled between-group comparisons to be made. However the sample
was small, and half the sample met criteria for an anxiety disorder in addition to a lifetime
diagnosis of a mood disorder. In addition, one quarter of the sample met criteria for a current
major depressive episode. The lack of homogeneity in the sample limits the generalisability
of the findings, limits the extent to which conclusions can be drawn as to how the
intervention affects individuals with different presentations, such as current or historical
depression or anxiety, and limits comparability with other studies. The authors acknowledge
randomisation would have enabled the effects of the intervention to be more conclusively
attributed to the intervention. Finally, the study had no follow-up period, thus it is unknown
whether changes were maintained over time.
An RCT conducted with medical students experiencing significant levels of stress
compared a condensed version of MBSR with somatic relaxation sessions and a wait-list
control group (Jain et al., 2007). Both interventions were delivered over four short (one and a
EFFECT OF MBSR ON RUMINATION
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half hour) sessions, and participants in each intervention attended a six-hour retreat. The aim
of the study was to compare the effect of MBSR and somatic relaxation on psychological
distress. The study found that both interventions significantly reduced distress and increased
positive mood states, with neither intervention significantly better at reducing distress or
increasing positive mood than the other. However MBSR participants showed a reduction in
rumination, and this reduction partially mediated the effect of the mindfulness intervention on
reducing distress. The benefit of including an active control is that it provides some evidence
of the specificity of the effects of MBSR, which in this instance demonstrated MBSR affects
rumination, unlike the relaxation intervention, and that this reduction accounted for the
reductions in distress. Although not strictly examining depressive symptoms, this study lends
support to the hypothesis that rumination could be a mechanism through which MBSR exerts
its effects. The limitations of this study were the relatively small sample size (N=81 across
three conditions), and the inclusion of exclusively medical students who had identified
themselves as experiencing significant levels of stress, which limits the generalisability of the
findings to other populations. The mindfulness intervention was also a condensed version of
MBSR, thus it is difficult to extrapolate what effects the full MBSR intervention may
achieve, and comparability across studies is not possible. Limitations aside, the RCT design
and comparison to an active treatment (somatic relaxation) was a strength of the design, and
enabled the unique effects of MBSR to be distinguished through comparison to a similar
intervention. This study suggests that even a shortened version of MBSR can reduce
rumination.
A study of 54 trainee therapists who completed an MBSR programme found participants who
completed the intervention reported decreased rumination and increased mindfulness and
self-compassion following intervention compared to controls (Shapiro et al., 2007).
Furthermore, increases in mindfulness were mediated by reductions in rumination, anxiety
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and stress, and increases in self-compassion. The participants who took part in the 8 week
MBSR programme imbedded in a 10-week stress management course, did so as a
compulsory aspect of their course, although study participation was voluntary. The control
group who had enrolled on a different course, received the same amount of contact time with
a trained instructor, but instead of receiving the MBSR intervention, the time was spent
studying research methods and psychological theory. The study benefited from inclusion of a
control group, however there was no randomisation, and group allocation was based on the
students’ course choice, which could have resulted in systematic differences between the
intervention and control group. The generalisability of the findings is also limited due to the
sample containing exclusively students. Because the intervention contained stress
management sessions in addition to MBSR, comparison with other studies is impaired, and
the specificity of the effects of MBSR cannot be examined from these data. Finally, no
follow-up data were collected; therefore it is not known whether the outcomes were
maintained over time.
Another study which employed an RCT design compared an adapted version of
MBSR to Easwaran’s Eight-Point Program (EPP; Easwaren, 1991), an intervention that
shares common components to MBSR, in 44 college students (Oman, Shapiro, Thoresen,
Plante, & Flinders, 2008). Both interventions reduced stress, increased forgiveness and
showed a trend towards significance in reducing rumination, all of which was maintained at
two-month follow-up. Generalisability of the findings is limited due to the sample consisting
exclusively of undergraduates from a Roman Catholic University. The small sample size
limited statistical power, which could have accounted for the observed reduction in
rumination not reaching statistical significance. The design was strengthened by a two-month
follow up period, allowing some measure of the maintenance of effects. A follow-up paper
that conducted meditational analyses on these data found that enhancing mindfulness
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Table 1
Characteristics and findings of studies measuring effect of MBSR on rumination.
Author(s)
Study
Design
Pre-post
betweenparticipant
Mindfulness
intervention
8 week MBSR
Jain et al.,
2007
RCT
Shapiro et
al., 2007
Betweenparticipant
, pre-post
Condensed
MBSR over 4 x
1½ hour sessions,
and one 6 hour
retreat
8 week MBSR
imbedded in 10
week stress
management
course
Oman et
al., 2008
RCT: Prepost, f/up
betweengroup
Ramel et
al., 2004
Adapted MBSR
Control
Wait list
control
Somatic
relaxation
sessions + wait
list control
Sessions in
research
methods and
psychological
theory with
trained
instructor
Easwaran’s
Eight-Point
Program (EPP;
Easwaren,
1991)
Participants
N
Adults with
34
history of mood
disorder (1/4
currently
depressed)
Highly stressed 81
medical students
FollowOutcomes
up
None
Reduced rumination
(reduced depression,
anxiety and dysfunctional
attitudes)
Rumination
Measure
RSQ
None
Reduced rumination
(both active conditions
reduced distress and
increased positive mood)
DER
RRQ
Trainee
therapistsparticipation in
MBSR was
compulsory to
their course
54
None
Reduced rumination
(increased mindfulness
and self-compassion)
College students
44
2
month
Trend towards significance RRQ
in reducing rumination
(improved stress,
increased forgiveness)
Enhancement of
mindfulness mediated
reductions in rumination
(Shapiro et al., 2008)
EFFECT OF MBSR ON RUMINATION
Deyo et
al., 2009
11
Withinparticipant
, pre-post
8 week MBSR
None
Self-selected
adults with
psychological
and/or physical
health problems
Women who
had completed
cancer treatment
22
Labelle et
al., 2010
Pre-post
between
participant
8 week MBSR
Wait-list
control
MartínAsuero &
GarcíaBanda
,2010
Campbell
et al.,
2012
Withinparticipant
pre-post
8 week MBSR
Pre-post
between
participant
8 week MBSR
None
77
None
None
Predominantly
health care
professionals
29
3
month
Wait-list
control
Women
receiving cancer
treatment
70
None
Reduced rumination
(Fewer depressive
symptoms, better overall
wellbeing)
Reduced rumination
(depressive symptoms
reduced, mindfulness
increased), reductions in
rumination mediated the
impact of MBSR on
depressive symptoms
Reduced rumination
Reduced rumination
(enhanced mindful
attentiveness)
RRQ
RRQ
ECQ
RRQ
Reduced rumination
RRS
(increased mindfulness,
increased self-compassion,
decreased fear of emotions
and difficulties regulating
emotions)
Note. DER = Daily Emotion Report (Nolen-Hoeksema, Morrow, & Fredrickson, 1993); RSQ = Rumination subscale of the Response Style
Questionnaire (RSQ; Nolen-Hoeksema & Morrow, 1991); RRQ = The Rumination-Reflection Questionnaire (Trapnell & Campbell, 1999); RSQ
= Ruminative Responses Scale (Nolen-Hoeksema & Morrow, 1991), ECQ = Emotional Control Questionnaire (Roger & Najarian, 1989).
Robins et
al., 2012
RCT: prepost
between
participant
8 week MBSR
Wait-list
control
Non-clinical
adult sample
41
2
month
EFFECT OF MBSR ON RUMINATION
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accounted for reductions in rumination (Shapiro, Oman, Thoresen, Plante, & Flinders, 2008).
This provides further support for the hypothesis explored in this paper; that improving
mindfulness reduces rumination.
A study of MBSR for 22 adults with a range of physical and psychological problems
who self-selected for an MBSR program, found participants reported less rumination,
enhanced mindfulness, fewer depressive symptoms, and improved overall wellbeing
following the programme (Deyo et al., 2009). A trend approaching statistical significance
between increases in mindfulness and reductions in rumination was observed. This study was
limited however by the lack of control group, small sample size, and reliance on self-report
measures. Additionally the heterogeneity of the sample curtails the generalisability of the
findings. Nevertheless MBSR reduced rumination and suggested this may be related to
enhancements in mindfulness.
A study of 77 women who had completed cancer treatment investigated the effects of
MBSR using a wait-list control design (Labelle et al., 2010). Participants who received the
intervention reported significantly reduced rumination, in addition to reduced depressive
symptoms and increased mindfulness relative to controls. Furthermore, reductions in
tendency to ruminate mediated the effect of MBSR on depressive symptoms. Mindfulness
was not found to significantly mediate the effect of MBSR on depressive symptoms. This
finding directly supports the hypothesis that reduction in depressive symptoms following
MBSR is at least in part accounted for by reducing rumination. This study was limited
however by lack of randomisation and comparison to an active control condition, and lacked
any follow-up. A further limitation of this study was that the sample included exclusively
women, which is particularly limiting given that women tend to ruminate more than men
(Nolen-Hoeksema & Jackson, 2001). Therefore it is difficult to conclude whether these
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findings would also apply to men, as it is possible different processes promote or reduce
rumination in women than men.
A within-groups pre-post study of the effect of MBSR on 29 professionals found
reductions in rumination, and reduced distress and negative affect following the intervention,
which was maintained at 3-month follow-up (Martín-Asuero & García-Banda, 2010). This
study was limited by the lack of a control condition, however it benefited from the longest
follow-up period in any of the studies in this review, suggesting that MBSR may reduce
rumination for up to 3 months.
A wait-list controlled study of 70 women who were receiving cancer treatment found
in between-groups analyses that MBSR reduced rumination and increased mindful attention
in participants who received the intervention compared to controls (Campbell, Labelle, Bacon,
Faris, & Carlson, 2012). There were a number of limitations to the study however including
lack of randomisation, lack of an active control condition, and lack of follow-up. As noted
with the previous study of women who had completed cancer treatment (Labelle et al., 2010),
an exclusively female sample is limiting given the gender difference in rumination (NolenHoeksema & Jackson, 2001), thus further research with equal gender distribution across
study arms is required.
The most recent study that examined the effect of MBSR on rumination was an RCT
that measured the effects on emotion regulation in a non-clinical sample of adults (Robins,
Keng, Ekblad, & Brantely, 2012). A non-significant trend towards reduced rumination was
observed following the intervention, however by 2-month follow-up, within-groups analyses
found participants who had received the intervention reported significantly lower levels of
rumination. The authors suggest that mindfulness practice may have accounted for the
observed reduction in rumination at follow-up, which is consistent with the notion that it is
the direct application and regular practice of mindfulness that may account for the effects of
EFFECT OF MBSR ON RUMINATION
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MBSR. However this study did not measure mindfulness practice thus it is not possible to
draw this conclusion from these data. A notable strength of this study was the randomised
controlled design, which allowed the observed findings to be attributed to the intervention,
and inclusion of a follow-up period, enabling examination of the effects across time.
Discussion
This review sought to examine whether MBSR has the potential to serve as an
intervention for reducing depressive symptoms and the risk of later depression, by examining
whether MBSR is effective at reducing rumination. The 9 studies reviewed here provide
preliminary evidence that MBSR reduces rumination, at least with adults. In relation to
rumination as a mechanism of change for reducing depressive symptoms, a number of studies
examined the relationship between increases in mindfulness and reductions in rumination
following MBSR, with one study concluding that reductions in rumination mediated the
effect of MBSR on depressive symptoms (Labelle et al., 2010), and another that reductions in
rumination mediated the effect of MBSR on distress (Jain et al., 2007). This supports the
hypothesis that rumination may be a mechanism through which MBSR could reduce
depressive symptoms. One factor that warrants future investigation is mindfulness practice;
two studies found the extent to which participants practiced mindfulness was related to more
positive outcome (Ramel et al., 2004; Shapiro et al., 2008), and one study attributed the
finding that rumination reduced at follow-up but not post-intervention to the result of
practice, although practice had not been measured (Robins et al., 2012). Theoretically it could
be expected that more frequent practice of mindfulness reduces rumination to a greater
extent, a habitual thinking patterns are likely to take repeated practice to overcome. Future
research should measure participant practice across time to explore whether greater practice
does indeed predict better outcome.
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Further research is warranted regarding the impact of MBSR on rumination, as the
existing literature contains methodological flaws. The literature in this area is limited; only 9
articles were available for review. Most studies utilised a pre-post between-participant
design, however three studies randomly allocated participants to condition (Jain et al., 2007;
Oman et al., 2008; Robins et al., 2012). Two studies had no control condition (Deyo et al.,
2007; Martín-Asuero & García-Banda, 2010), however three studies included an active
control, either somatic relaxation sessions, or the Easwaran’s Eight-Point Program (EPP;
Easwaren, 1991), a programme which shares some similarity with mindfulness as it involves
regular meditation practice using passages of text. Only two studies included a follow-up
(Martín-Asuero & García-Banda, 2010; Robins et al., 2012), the longest follow-up period
was 3 months. Three studies did not deliver “pure” MBSR, one was condensed to a shorter
four-session programme with a 6-hour retreat, one followed an adapted programme, and
another was embedded in a longer stress management course (Jain et al., 2007; Oman et al.,
2008; Shapiro et al., 2007). The participants varied from self-selected community samples
with no particular psychological or physical difficulties, to adults with serious physical health
conditions or stress. All studies relied exclusively on self-report measures of rumination.
The dearth of randomised controlled studies and comparison to active treatments
limits the extent to which the observed reduction in rumination in most studies can be
attributed to MBSR and not participant characteristics or non-specific treatment effects.
Comparability between studies is limited due to several studies delivering adapted MBSR
programmes. In addition, adaptations to the MBSR interventions were described in limited
detail, rendering replication of these studies challenging. The use of heterogeneous samples
also limits comparability and hinders conclusions regarding which individuals benefit most
from MBSR. Additionally, many studies used small samples, which could have accounted for
the non-significant reductions in rumination found in two studies (Oman et al., 2008; Robins
EFFECT OF MBSR ON RUMINATION
16
et al., 2012). Larger samples would have increased statistical power. All studies used selfreport measures exclusively. Future research could employ experimental designs to provide a
richer test of the hypothesised benefits of mindfulness, for example to measure whether
participants who have received MBSR recover quicker from a low mood induction task as a
result of reduced rumination. Finally, although a number of studies included follow-up
assessments, the longest follow-up period was three-months, thus it is difficult to conclude to
what extent reductions in rumination can be maintained over time.
Future research that aims to further examine the potential of MBSR to reduce
rumination requires larger samples to maximise statistical power, must randomise
participants drawn from homogenous groups to either MBSR or an active control, measure
outcomes at multiple time points, and include a lengthy follow-up period. Mediation analyses
will provide a first step to unpicking whether rumination does indeed mediate the effects of
MBSR. In addition, the effect of quantity of mindfulness practice on outcome requires further
investigation.
Conclusions
Despite the methodological weaknesses of the literature, the evidence reviewed here
suggests that MBSR can reduce rumination, at least with adults. This finding is particularly
significant given the strong links between rumination and depressive symptoms (Burwell &
Shirk, 2007) and the later onset of depression (Broderick & Korteland, 2004; NolenHoeksema, 2000). Further research is required to determine whether MBSR, through
reducing rumination, can reduce depressive symptoms and prevent depression. It is
particularly pertinent that this question is examined with children and adolescents, as this age
group is arguably a critical period to introduce interventions aimed at reducing depressive
symptoms, given that half of all psychological disorders occur for the first time during
EFFECT OF MBSR ON RUMINATION
17
childhood or adolescence (Kessler et al., 2005; Patel, Flisher, Hetrick, & McGorry, 2007),
with 75% of adults who meet criteria for major depressive disorder having experienced their
first episode prior to the age of 18 (Kim-Cohen et al., 2003). This review suggests that MBSR
may be effective in reducing rumination in adults, however it is currently unknown whether
the same is true for children or adolescents. There are as yet no studies of mindfulness
interventions with children or adolescents that have investigated the mechanisms of change
(Harnett & Dawe, 2012), although literature in this area is growing (Burke, 2009). Research
on the effects of MBSR on rumination in children and adolescents should begin initially with
piloting and feasibility studies, and progress to evaluation studies (Craig et al., 2008).
This review suggests that MBSR reduces rumination in adults. Research must now
investigate whether this finding applies to children and adolescents, as an intervention that
reduces rumination would reduce one of the key risk factors for depressive symptoms and
depression (Burwell & Shirk, 2007; Broderick & Korteland, 2004; Nolen-Hoeksema, 2000).
If the findings of this review can be replicated with children and adolescents, MBSR may
well have the potential to be used as an intervention for the reduction of depressive symptoms
and prevention of depression.
EFFECT OF MBSR ON RUMINATION
18
References
Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and
empirical review. Clinical Psychology: Science and Practice, 10, 125-143.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for
measuring depression. Archives of General Psychiatry, 4, 561-571.
Biegel, G. M., Brown, K. W., Shapiro, S. L., & Schubert, C. (2009). Mindfulness-based
stress reduction for the treatment of adolescent psychiatric outpatients: A randomized
clinical trial. Journal of Consulting and Clinical Psychology, 77, 855-866.
Broderick, P. C., & Korteland, C. (2004). A prospective study of rumination and depression
in early adolescence. Clinical Child Psychology and Psychiatry, 9, 1359-1045.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role
in psychological wellbeing. Journal of Personality and Social Psychology, 82, 822848.
Brown, K. W., Ryan, R. M., & Cresswell, J. D. (2007). Mindfulness: Theoretical foundations
and evidence for its salutary effects. Psychological Inquiry, 18, 211-237.
Burke, C. A. (2009). Mindfulness-based approaches with children and adolescents: A
preliminary review of current research in an emergent field. Journal of Child and
Family Studies, 19, 133-144.
EFFECT OF MBSR ON RUMINATION
19
Burwell, R. A., & Shirk, S. R. (2007). Subtypes of rumination in adolescence: Associations
between brooding, reflection, depressive symptoms, and coping. Journal of Clinical
Child and Adolescent Psychology, 36, 56-65.
Campbell, T. S., Labelle, L. E., Bacon, S. L., Faris, P., & Carlson, L. E. (2012). Impact of
mindfulness-based stress reduction on attention, rumination and resting blood
pressure in women with cancer: A waitlist-controlled study. Journal of Behavioural
Medicine, 35, 262-271.
Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of
mindfulness, medical and psychological symptoms and well-being in a mindfulnessbased stress reduction program. Journal of Behavioural Medicine, 31, 23-33.
Cohen-Katz, J., Wiley, S. D., Capuano, T., Baker, D. M., Kimmel, S., & Shapiro, S. (2005).
The effects of mindfulness-based stress reduction on nurse stress and burnout, Part II:
A quantitative and qualitative study. Holistic Nursing Practice, 19, 26–35.
Coryell, W., Solomon, D., Leon, A., Fiedorowicz, J. G., Schettler, P., Judd, L., & Keller, M.
(2009). Does major depressive disorder change with age? Psychological Medicine, 39,
1689-1695.
Craig, P., Dieppe, P., Macintryre, S., Mitchie, S., Nazareth, I., Petticrew, M. (2008).
Developing and evaluating complex interventions: The new Medical Research
Council guidance. BMJ, 337, 979-983. Last accessed 3rd May 2013. Doi:
10.1136/bmj.a1655.
EFFECT OF MBSR ON RUMINATION
20
Cuijpers, P., van Straten, A., Smit, F., Mihalopoulos, C., & Beekman, A. (2008). Preventing
the onset of depressive disorders: A meta-analytic review of psychological
interventions. American Journal of Psychiatry, 165, 1272-1280.
Deyo, M., Wilson, K. A., Ong, J., & Koopman, C. (2009). Mindfulness and rumination: Does
mindfulness training lead to reductions in the ruminative thinking associated with
depression? EXPLORE: The Journal of Science and Healing, 5, 265-271.
Easwaran, E. (1991). Meditation: A simple eight-point program for translating spiritual
ideals into daily life (2nd ed.). Tomales, CA: Nilgiri Press.
Greeson, J. M. (2009). Mindfulness research update: 2008. Complementary Health Practice
Review, 14, 10-18.
Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress
reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research,
571, 35-42.
Harnett, P. H., & Dawe, S. (2012). Review: The contribution of mindfulness-based therapies
for children and families and proposed conceptual integration. Child and Adolescent
Mental Health, 17, 195-208.
Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulnessbased therapy on anxiety and depression: A meta-analytic review. Journal of
Consulting and Clinical Psychology, 78, 169-183.
EFFECT OF MBSR ON RUMINATION
21
Hyman, S. E. (2001) Mood disorders in children and adolescents: An NIMH perspective.
Biological Psychiatry, 49, 962-969.
Jain, S., Shapiro, S. L., Swanick, S., Roesch, S.C., Mills, P. J., Bell, I., & Schwartz, G. E. R.
(2007). A randomized controlled trial of mindfulness meditation versus relaxation
training: Effects on distress, positive states of mind, rumination, and distraction.
Annals of Behavioural Medicine, 33, 11-21.
Kabat-Zinn, J. (1990). Full catastrophe living: The program of the Stress Reduction Clinic at
the University of Massachusetts Medical Center. New York: Delta.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context; Past, present, and future.
Clinical Psychology; Science and Practice, 10, 144-156.
Kazdin, A. E. (2007). Mediators and mechanisms of change in psychotherapy research.
Annual Review of Clinical Psychology, 3, 1-27.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005).
Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the
national comorbidity survey replication. Archives of General Psychiatry, 62, 593-602.
Kim-Cohen, J., Caspi, A., Moffitt, T. E., Harrington, H., Milne, B. J., & Poulton, R. (2003).
Prior juvenile diagnoses in adults with mental disorder: Developmental follow-back
of a prospective-longitudinal cohort. Archives of General Psychiatry, 60, 709-717.
EFFECT OF MBSR ON RUMINATION
22
Kuyken, W., Byford, S., Taylor, R. S., Watkins, E., Holden, E., White, K., . . . Mullan, E.
(2008). Mindfulness-based cognitive therapy to prevent relapse in recurrent
depression. Journal of Consulting and Clinical Psychology, 76, 966-978.
Kuyken, W., Watkins, E., Holden, E., & Cook, W. (2006). Effect of personality trait
neuroticism on depression is mediated by rumination. Journal of Affective Disorders,
96, 39-47.
Labelle, L. E., Campbell, T. S., & Carlson, L. E. (2010). Mindfulness-based stress reduction
in oncology: Evaluating mindfulness and rumination as mediators of change in
depressive symptoms. Mindfulness, 1, 28-40.
Martín-Asuero, A., & García-Banda, G. (2010). The mindfulness-based stress reduction
program (MBSR) reduces stress-related psychological distress in healthcare
professionals. The Spanish Journal of Psychology, 13, 895-903.
Nolen-Hoeksema, S. (1991). Responses to depression and their effects on the duration of
depressive episodes. Journal of Abnormal Psychology, 100, 569-582.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed
anxiety/depressive symptoms. Journal of Abnormal Psychology, 3, 504-511.
Nolen-Hoeksema, S., & Jackson, B. (2001). Mediators of the gender difference in rumination.
Psychology of Women Quarterly, 25, 37-47.
EFFECT OF MBSR ON RUMINATION
23
Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and
posttraumatic stress symptoms after a natural disaster: The 1989 Loma Prieta
Earthquake. Journal of Personality and Social Psychology, 61, 115-121.
Nolen-Hoeksema, S., Morrow, J., & Fredrickson, B. L. (1993). Response styles and the
duration of episodes of depressed mood. Journal of Abnormal Psychology, 102, 2028.
Nyklíček, I., & Kuipers, K. (2008). Effects of mindfulness-based stress reduction intervention
on psychological well-being and quality of life: Is increased mindfulness indeed the
mechanism? Annals of Behavioral Medicine, 35, 331–340.
Oman, D., Shapiro, S. L., Thoresen, C. E., Plante, T. G., & Flinders, T. (2008). Meditation
lowers stress and supports forgiveness among college students: A randomized
controlled trial. The Journal of American College Health, 56, 569-578.
Patel, V., Flisher, A. J., Hetrick, S., & McGorry, P. (2007). Mental health of young people: A
global public-health challenge. Lancet, 369, 1302-1313.
Pine, D. S., Cohen, E., Cohen, P., & Brook, J. (1999). Adolescent depressive symptoms as
predictors of adult depression: Moodiness or mood disorder? American Journal of
Psychiatry, 156, 133-135.
EFFECT OF MBSR ON RUMINATION
24
Ramel, W., Goldin, P. R., Carmona, P. E., & McQuaid, J. R. (2004). The effects of
mindfulness meditation on cognitive processes and affect in patients with past
depression. Cognitive Therapy and Research, 28, 433-455.
Robins, C. J., Keng, S., Ekblad, A. G., & Brantely, J. G. (2012). Effects of mindfulness-based
stress reduction on emotional experience and expression: A randomized controlled
trial. Journal of Clinical Psychology, 68, 117-131.
Roger, D., & Najarian, B. (1989). The construction and validation of a new scale for
measuring emotion control. Personality and Individual Differences, 10, 845-853.
Samuelson, M., Carmody, J., Kabat-Zinn, J., & Bratt, M. A. (2007). Mindfulness-based stress
reduction in Massachusetts correctional facilities. The Prison Journal, 87, 254-268.
Segal, Z. V., Wiliams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive
therapy for depression: A new approach to preventing relapse. New York: Guildford
Press.
Shankman, S. A., Lewinsohn, P. M., Klein, D. N., Small, J. W., Seeley, J. R., & Altman, S.
E. (2009). Subthreshold conditions as precursors for full syndrome disorders: A 15year longitudinal study of multiple diagnostic classes. Journal of Child Psychology
and Psychiatry, 50, 1485-1494.
EFFECT OF MBSR ON RUMINATION
25
Shapiro, S. L., Brown, K. W., & Biegel, G. M. (2007). Teaching self-care to caregivers:
Effects of mindfulness-based stress reduction on the mental health of therapists in
training. Training and Education in Professional Psychology, 1, 105-115.
Shapiro, S. L., Oman, D., Thoresen, C. E., Plante, T. G., & Flinders, T. (2008). Cultivating
mindfulness: Effects on well-being. Journal of Clinical Psychology, 64, 840-862.
Spasojević, J., & Alloy, L. B. (2001). Rumination as a common mechanism relating
depressive risk factors to depression. Emotion, 1, 25-37.
Stallard, P., Sayal, K., Phillips, R., Taylor, J. A., Spears, M., Anderson, R., . . . Montgomery,
A. A. (2012). Classroom-based cognitive behavioural therapy in reducing symptoms
of depression in high risk adolescents: Pragmatic cluster randomised controlled trial.
BMJ, 345, e6058. Last accessed 3rd May 2013. doi: 10.1136/bmj.e6058.
Teasdale, J. D., Segal, Z. V., Williams, J. M. G., Ridgeway, V. A., Soulsby, J. M., & Lau, M.
A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based
cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615-623.
Thompson, A. H. (2008). Younger onset of depression is associated with greater suicidal
intent. Social Psychiatry and Psychiatric Epidemiology, 43, 538-544.
Trapnell, P. D., & Campbell, J. D. (1999). Private self-consciousness and the five-factor
model of personality: Distinguishing rumination from reflection. Journal of
Personality and Social Psychology, 76, 284-304.
EFFECT OF MBSR ON RUMINATION
26
Williams, J. M. G., Barnhofer, T., Crane, C., Duggan, D. S., Shah, D., Brennan, K., . . .
Russell, I. T. (2012). Pre-adult onset and patterns of suicidality in patients with a
history of recurrent depression. Journal of Affective Disorders, 138, 173-179.
Zisook, S., Lesser, I., Stewart, J. W., Wisniewski, S. R., Balasubramani, G. K., Fava, M., . . .
Rush, A. J. (2007). Effect of age at onset on the course of major depressive disorder.
The American Journal of Psychiatry, 164, 1539-1546.