Clinical Handbook of Mindfulness (46 page)

training may exert beneficial outcomes. These mechanisms include reduced

rumination
(Segal et al., 2002),
desensitization through exposure to negative emotion
(Linehan, 1993),
and improved ability to behave constructively when experiencing unpleasant emotions or sensations
(Kabat-Zinn, 1982).

Chapter 9 Assessment of Mindfulness

159

Lykins and Baer (in press)
showed that the acting with awareness,
nonjudging
and
nonreactivity
facets of mindfulness completely mediated the rela-

tionships between meditation experience and rumination, fear of emotion,

and ability to engage in goal-directed behavior when upset. Two of these

variables also were shown to partially mediate relationships between mind-

fulness and psychological well-being. Overall, results support the idea that

increased mindfulness improves psychological functioning by reducing rumi-

nation and fear of emotion.

In another recent study,
Carmody and Baer (2008)
administered the FFMQ

to 174 individuals with stress, anxiety, and illness-related complaints who

completed MBSR, an 8-week group program based on the intensive practice

of several forms of mindfulness meditation (see other chapters in this volume

for more detail). Scores on all five facets of mindfulness increased signifi-

cantly from pre- to post-treatment. For four of the facets (all but
describing
)

increases were related to the amount of home practice of meditation exer-

cises that participants completed during the program. Increases in mind-

fulness also were shown to mediate the relationship between extent of

home practice and improvement in psychological symptoms and stress lev-

els. Weaker findings for the
describing
facet may not be surprising in this

case, as MBSR places very little emphasis on verbal labeling of experiences.

In contrast, DBT and ACT include exercises for the labeling of emotions, cog-

nitions, and sensations. Study of the
describing
facet with these interventions

is warranted.

Overall, preliminary evidence from studies of the FFMQ supports two gen-

eral conclusions. First, the five subscales of the FFMQ appear to measure

skills that are cultivated by the practice of mindfulness, both in long-term

meditators and in relative novices. Second, increases in levels of mindfulness

appear to be related to changes in other aspects of psychological functioning

that promote well-being.

Assessment of Mindfulness as a State

The instruments discussed in previous sections measure a trait-like general

tendency to be mindful in daily life. In contrast,
Bishop et al. (2004)
view mindfulness as a state-like quality that occurs when attention is intentionally

directed to sensations, thoughts, and emotions, with an attitude of curios-

ity, openness, and acceptance. The Toronto Mindfulness Scale (TMS; Lau

et al.,
2006)
assesses attainment of a mindful state during an immediately preceding meditation session. Participants first practice a meditation exercise for about 15 minutes and then rate the extent to which they were aware

and accepting of their experiences during the exercise. This instrument

has two factors. The
curiosity
factor reflects interest and curiosity about

inner experiences and includes items such as “I was curious to see what my

mind was up to from moment to moment.” The
decentering
factor empha-

sizes awareness of experiences without identifying with them or being car-

ried away by them, and includes items such as “I experienced myself as

separate from my changing thoughts and feelings.” Findings showed good

internal consistency for each factor and significant correlations with other

measures of self-awareness. Scores increased with participation in MBSR,

and decentering scores predicted reductions in psychological symptoms and

160

Ruth A. Baer, Erin Walsh, and Emily L. B. Lykins

stress levels. This measure has good psychometric properties and is likely to

be useful in the study of mindfulness meditation. However, as the authors

note, scores reflect the experience of mindfulness during a specific medita-

tion session and may not be related to the tendency to be mindful in ordi-

nary daily life. The authors also recommend multiple assessments, because

the extent to which a mindful state was attained during a single medita-

tion session may not reflect participants’ general tendency to be mindful

while meditating, due to factors such as fatigue or stress on a particular

occasion.

Mindfulness as a state has also been assessed using experience sampling

in participants asked to carry pagers for a few weeks
(Brown & Ryan, 2003).

When paged at quasi-random intervals during each day, participants immedi-

ately responded to a subset of MAAS items asking about the extent to which

they were attending to their activity of the moment or were behaving auto-

matically. Results showed that momentary-state mindfulness was significantly

correlated with baseline levels of trait mindfulness as assessed by the original

form of the MAAS. State mindfulness also predicted higher levels of positive

emotion and autonomy and lower levels of negative emotion while engaged

in the activity of the moment.

Assessment of Closely Related Constructs

Acceptance

Acceptance has been most comprehensively described in writings on ACT

(Hayes et al., 1999; Hayes & Strosahl, 2004)
and usually refers to willingness to experience a wide range of internal experiences (such as bodily

sensations, cognitions, and emotional states) without attempting to avoid,

escape, or terminate them, even if they are unpleasant or unwanted. Accep-

tance is generally an issue when attempts to avoid or escape these experi-

ences are harmful or counterproductive. This is often true in situations that

involve competing contingencies or approach-avoidance conflicts
(Dougher,

1994).
For example, initiating conversation with a stranger may offer both reinforcing and punishing consequences (social interaction and development of a relationship versus shame or humiliation if rejected) and may

therefore elicit anxiety. Avoiding the anxiety by refraining from conversa-

tion will be counterproductive if it perpetuates loneliness. Attempts to elim-

inate the anxiety with alcohol or drugs may be harmful if these substances

contribute to socially inappropriate or ineffective behavior or maladaptive

health consequences. Thus, acceptance of feelings of anxiety (allowing them

to be present while continuing with goal-consistent behavior) may be more

adaptive.

The Acceptance and Action Questionnaire (AAQ;
Hayes, Strosahl, et al.,

2004)
is a nine-item self-report instrument whose items describe elements of experiential avoidance, including negative evaluation of and attempts to

control or avoid unpleasant internal stimuli, and inability to take constructive

action while experiencing these stimuli. If reverse scored, it serves as a mea-

sure of acceptance. Its internal consistency is adequate (alpha = 0. 70), and it

is correlated with many forms of psychopathology. A revised version by Bond

and Bunce
(2003)
includes 16 items and has two subscales: Willingness and
Chapter 9 Assessment of Mindfulness

161

Action. The first measures willingness to experience negative thoughts and

feelings and includes items such as “I try hard to avoid feeling depressed or

anxious.” The Action subscale measures ability to behave consistently with

goals and values even while having unpleasant thoughts and feelings and

includes items such as “When I feel depressed or anxious, I am unable to

take care of my responsibilities.” A revised version of the AAQ is currently in

development.

Measures based on the AAQ but modified for specific populations have

also been developed. For example, the Chronic Pain Acceptance Question-

naire (CPAQ;
McCracken, 1998; McCracken & Eccleston, 2003;
McCracken, Vowles & Eccleston,
2004)
measures recognition that pain may not change, ability to refrain from fruitless efforts to avoid or control pain, and engaging

in valued life activities despite the presence of pain. Items include, “I am

getting on with the business of living no matter what my pain level is.” Inter-

nal consistency is good (alpha = 0. 85). Scores are correlated positively with

daily activity level and improved work status and negatively with depres-

sion, anxiety, and disability, even when pain intensity is controlled. Also

derived from the AAQ, the Acceptance and Action Diabetes Questionnaire

(AADQ;
Gregg, Callaghan, Hayes, & Glenn-Lawson, 2007)
assesses acceptance of diabetes-related thoughts and feelings and ability to engage in val-

ued actions while having these experiences (e.g., “I do not take care of

my diabetes because it reminds me that I have diabetes”). Internal consis-

tency is high (alpha = 0. 94), and scores improved significantly in a group

of diabetics who participated in an ACT workshop, but not for those in

a control condition. Other measures currently in development include the

AAQ-Weight
(Lillis & Hayes, 2008)
for weight loss and weight maintenance contexts, and the Avoidance and Fusion Questionnaire for Youth (AFQ-Y;
Greco, Ball, Dew, Lambert, & Baer, 2008),
a measure for children and adolescents.

Decentering

Decentering is defined as the ability to observe one’s thoughts and feelings

as temporary events in the mind, rather than reflections of the self that are

necessarily true (Fresco, Moore, et al., 2007). It includes taking a present-

focused, nonjudgmental stance toward thoughts and feelings and accepting

them as they are
(Fresco, Segal, Buis, & Kennedy, 2007).
Decentering (also called distancing) has long been recognized as an important process in cognitive therapy for depression
(Beck, Rush, Shaw, & Emery
,
1979),
but is often viewed as a step in the process of changing thought content rather than as

an end in itself. Patients in cognitive therapy learn to adopt a decentered per-

spective on thoughts by viewing them as ideas to be tested, rather than truths

(Hollon & Beck
,
1979).
However, they then go on to dispute distorted thoughts and generate more rational ones. Several authors have suggested

that decentering alone may be the central ingredient in the effectiveness

of cognitive therapy in preventing relapse of depression (Ingram & Hol-

lon,
1986;
Segal et al., 2002).
It is a central ingredient in MBCT, which uses the intensive practice of mindfulness meditation to teach decentering, which in turn reduces rumination and lowers the likelihood of

relapse.

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Ruth A. Baer, Erin Walsh, and Emily L. B. Lykins

Decentering can be measured with two recently developed tools. The Mea-

sure of Awareness and Coping in Autobiographical Memory (MACAM; Moore,

Hayhurst, & Teasdale,
1996)
is a vignette-based, semistructured clinical interview in which participants are asked to imagine themselves in several mildly

depressing situations and to feel the feelings that would be elicited. They

are then asked to recall specific occasions from their own lives that the

vignettes bring to mind and to describe these occasions in detail, including

their feelings and how they responded to them. Responses are tape recorded,

and trained raters then code the responses for the presence of decentering

or awareness of thoughts and feelings as separate from the self. Teasdale

et al.
(2002)
found that decentering scores were higher for a group of never-depressed adults than for a previously depressed group. Previously depressed

patients who completed MBCT showed larger increases in decentering than a

control group who received treatment as usual. Finally, lower baseline levels

of decentering predicted earlier relapse following treatment for depression

with either cognitive therapy or medication. Overall, these findings support

the idea that the ability to adopt a decentered perspective on thoughts and

feelings is centrally related to recovery from depression and prevention of

relapse.

Although the MACAM appears to have good psychometric properties, it

is time consuming and difficult to use. For this reason, Fresco, Moore, et al.

(2007) conducted a psychometric evaluation of the experiences question-

naire (EQ), a rationally derived self-report instrument designed by Teasdale

to assess decentering and rumination. Analyses by Fresco et al. (in press)

yielded an 11-item decentering factor, which includes items such as “I can

observe unpleasant feelings without being drawn into them” and “I can sep-

arate myself from my thoughts and feelings.” The EQ showed good inter-

nal consistency and was correlated in expected directions with measures

of depressive rumination, experiential avoidance, emotion regulation, and

depression. Depressed patients showed lower levels of decentering than

healthy controls (Fresco et al., in press). In a second study, Fresco, Segal,