Previous studies of Mindfulness-Based Stress Reduction have consistently documented correlations between self-reported changes in mindfulness, spirituality, and indicators of mental and physical health. However, little empirical research has explored the specific ways in which increases in daily spiritual experiences and mindfulness may, together, explain individual differences in the health benefits of Mindfulness-Based Stress Reduction, including improvements in health-related quality of life. This study provides preliminary evidence for changes in mindfulness as a mediating mechanism through which changes in spirituality may partly explain the mental health benefits of Mindfulness-Based Stress Reduction—a secular behavioral medicine intervention that focuses on intensive training in mindfulness meditation. The main findings from a relatively large group of apparently healthy but mentally stressed adults showed that increases in daily spiritual experiences were directly related to increases in mindfulness, which, in turn, was associated with improved mental health-related quality of life following Mindfulness-Based Stress Reduction. These data are consistent with the possibility that increases in spirituality, characterized by an awareness of and sense of connection with the transcendent in daily life, are not only an important outcome of mindfulness meditation training, but also a key mechanism by which Mindfulness-Based Stress Reduction produces mental health benefits.
The present findings are consistent with previous reports that mindfulness meditation training can enhance certain aspects of spirituality (Astin 1997
; Shapiro et al. 1998
), and that increases in spirituality following Mindfulness-Based Stress Reduction are associated with greater levels of mindfulness and mental health (Birnie et al. 2010
; Carmody et al. 2008
; Garland et al. 2007
). This investigation extends prior studies of bivariate relationships among these variables by comparing alternative path models that help elucidate possible mechanisms underlying the health benefits of Mindfulness-Based Stress Reduction. Although the original hypothesis that spiritual experiences mediate the relationship between enhanced mindfulness and improved health-related quality of life was not upheld, the data suggested an alternative possibility that mindfulness may partly explain the association between increased perceptions of spirituality and improved mental health following Mindfulness-Based Stress Reduction. The possibility that enhanced attention to and awareness of the divine, the transcendent, and the interconnectedness of all things engenders greater mindfulness and mental health is consistent with both Eastern contemplative traditions and Western psychological theory (Wallace and Shapiro 2006
In Buddhist teachings, a critical moment comes when a person’s meditation practice has developed sufficiently enough that the mind actually turns away from its usual absorption with shifting moment-by-moment worldly and sensory experience, and focuses instead on an also-present, more subtle quality of present-moment reality (Flickstein 2001
). Flickstein suggests this process of spiritual transformation in the Buddhist “path of purification” has similarity to a principle in Gestalt Psychology, the “figure/ground perception” (p. 158). Without claiming deep Buddhist realizations or extensive Gestalt transformations for the participants in this study, we do speculate that the training in mindfulness that our participants undertook perhaps enabled them to shift their “view,” moving more easily between the foreground and background of experience in ways that made their personal awareness and experience of the “spiritual” in their lives (whatever that meant to each of them) more apparent. For example, much as depressed patients are reported to benefit from becoming mindful and dis-identifying from the cognitions associated with depression (Segal et al. 2002
), it is conceivable that our participants may have noticed their own “foreground” experience of self-centered narratives or distractions more accurately; perhaps they were able to disengage from these “foreground” distractions more readily, and to more easily notice the everyday “background experiences” often associated with spirituality—for instance, beauty, joy, connection, and awe, all of which were measured by the Daily Spiritual Experiences Scale. We also wonder if their experience of more explicit inspiring or spiritually meaningful events may have been enhanced because of being more mindful of the entire experience.
One other explanation for the unexpected finding that increased mindfulness did not directly predict increased spirituality following Mindfulness-Based Stress Reduction may have been because the Daily Spiritual Experiences Scale was highly stable over time during the assessment period. Because over 75% of the variance in residualized DSES scores was explained by other variables the model, there was relatively little unique variability for increased mindfulness to explain. Furthermore, because the Cognitive and Affective Mindfulness Scale is limited to the assessment of thoughts and feelings, this specific measure of mindfulness may not have been independently associated with an increase in a transcendent sense of spiritual experiences above and beyond other variables.
Although Mindfulness-Based Stress Reduction is designed as a secular program, over 60% of the participants in this study identified with a spiritual or religious group, and half of the participants reported taking the mindfulness course to explore or deepen their sense of spirituality. Meditation and mindfulness have roots in various religious traditions (Kabat-Zinn 2003
; Walsh and Shapiro 2006
), and this study found that over 50% of survey respondents said that taking Mindfulness-Based Stress Reduction deepened their sense of spirituality. This finding is consistent with our observation that, following Mindfulness-Based Stress Reduction, 63% of survey respondents reported practicing meditation, mindfulness, or contemplative prayer at least 4–5 times per week, whereas only 13% reported such a level of meditative practice before the course. Although we did not measure participation in private religious activities other than meditation and contemplative prayer, it is also possible that participants may have used mindfulness principles, such as present-moment attention and kind-hearted compassion, to bolster religious beliefs and practices such as forgiveness, empathy, or altruistic acts of kindness that are shared among many faith traditions (Kristeller and Johnson 2005
). It is also possible that whatever our subjects “saw” or experienced in their daily lives that was spiritually inspiring, including religious ceremonies or other practices, somehow strengthened their motivation and capacity to be more mindful, as articulated by Western Buddhist teachers (Goldstein and Kornfield 1987
). Future studies are needed to formally assess this possibility, since religious and spiritual beliefs and their associated behaviors and biology may represent an important mechanism linking contemplative practices to improved mental and physical health (Park 2007
; Wachholtz et al. 2007
In contrast to results concerning mental health, physical health did not increase significantly across the 8-week Mindfulness-Based Stress Reduction program. Whereas at least two previous outcome studies (Carmody and Baer 2008
; Carmody et al. 2008
) documented a significant association between increased mindfulness following Mindfulness-Based Stress Reduction and reduced self-reported medical symptoms, the current study did not find a significant relationship between increased mindfulness and improved physical health as measured by health-related quality of life. Self-rated physical health following Mindfulness-Based Stress Reduction in this study also was not significantly associated with changes in spirituality. These predicted relationships may have been absent because the study sample, on average, had a normal level of physical functioning and well-being at baseline. Several previous studies of self-selected community Mindfulness-Based Stress Reduction program participants with lower levels of self-rated physical health at study entry reported significant improvement in physical health-related quality of life following mindfulness meditation training (Reibel et al. 2001
; Rosenzweig et al. 2010
; Roth and Robbins 2004
). Thus, it is possible that a ceiling effect may have limited further improvements in physical health-related quality of life in the current study. Moreover, a restricted range of variance in physical health-related quality of life scores may have made it difficult to detect relationships with other measures. Alternatively, Mindfulness-Based Stress Reduction as an intervention may not have a strong effect on the physical component of the Short Form Health Survey (Plews-Ogan et al. 2005
). Based on the present findings, future studies should test the possibility that baseline health and quality of life may serve to moderate the association between changes in mindfulness, spirituality, and physical dimensions of health-related quality of life. Specifically, there is a need to test whether changes in spirituality partially explain changes in mindfulness and quality of life in less physically healthy populations.
Home meditative practice during the 8-week Mindfulness-Based Stress Reduction program was not independently associated with changes in mindfulness when simultaneously accounting for baseline levels of mindfulness, the non-specific effect of high course expectations, and demographic variables, including age, gender, and income. This finding adds to mixed evidence for the direct association of adherence to home practice with Mindfulness-Based Stress Reduction outcomes (Vettese et al. 2009
). Results did suggest that an individual’s expectancy to benefit from Mindfulness-Based Stress Reduction plays a modest explanatory role in determining course-related changes in spirituality and in mindfulness. These findings are consistent with a wealth of medical literature, which reports an association between positive expectancy and non-specific treatment effects (Harrington 1999
; Stewart-Williams and Podd 2004
). While expectancy may be considered a component of the placebo response, it is also closely related to motivation and may direct intentions and behavior (Delsignore and Schnyder 2007
; Maddux et al. 1986
; Wigfield 1994
). Thus, expectancy may be an important component of the treatment effect that should be included in future research on the psychological mechanisms of Mindfulness-Based Stress Reduction.
The study had a number of limitations that also merit discussion. Because there was no randomized control or comparison group, the potential mediating mechanism identified in this study cannot be interpreted as a causal pathway. In addition, three rather than two measurement time points are necessary to establish temporal precedence – a key criterion for formal mediation. Participants in this study were sampled from a self-pay community Mindfulness-Based Stress Reduction program, and generalizability is limited by the lack of ethnic and social diversity in the sample. Another limitation was the use of self-report measures. Self-report of mindfulness may not provide accurate assessment, particularly for individuals with little to no meditation experience (Grossman 2008
). Self-report of spirituality using the Daily Spiritual Experiences Scale may have been confounded by items such as gratitude, peace, and harmony, which can contribute to both spirituality and positive mental health (Koenig 2008
). Whereas survey assessments of both mindfulness and spirituality risk oversimplifying these highly complex constructs, there was relatively little item overlap across the self-report scales used in this study, which helped guard against merely tautological associations. Another limitation is that outcomes measures may have been biased towards participants who were different at baseline in terms of prior meditative experience or spiritual motivation for taking Mindfulness-Based Stress Reduction. Finally, because the initial confirmatory hypothesis test failed to support our conceptual model, we proceeded to use a more exploratory approach to derive the best fitting model of the data, while limiting the number of post-hoc modifications. Our linear approach was overly simplistic. Because traditional teachings and modern theories suggest that relationships between mindfulness meditation practice, spirituality, and health are complex and interdependent, investigators are encouraged to conceptualize and systematically compare more than one a priori model of the data.
In conclusion, this study generated a new hypothesis that daily spiritual experiences are not only an important outcome of mindfulness meditation training, but that they may also be part of a key mechanism underlying mental health benefits. Future studies are needed to (a) replicate these initial results using a controlled study design, (b) establish causal directionality and temporal precedence by including three or more time points, and (c) test whether effects are similar or different as a function of sample characteristics, such as motivations for course participation and baseline levels of physical health. Future research might also further explore the intriguing mechanism of figure/ground reversal and its relationship to mindfulness practice, spirituality, and quality of life.