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Journal of Behavioral Medicine, Vol. 21, No. 6, 1998
0160-7715
/
98
/
1200-0581$15.00
/
0 Ó 1998 Plenum Publishing Corporation
581
Effects of Mindfulness-Based Stress Reduction on
Medical and Premedical Students
Shauna L. Shapiro,
1,3
Gary E. Schwartz,
1
and Ginny Bonner
2
Accepted for publication: March 9, 1998
The inability to cope successfully with the enormous stress of medical education
may lead to a cascade of consequences at both a personal and professional level.
The present study examined the short-term effects of an 8-week meditation-b ased
stress reduction intervention on premedical and medical students using a
well-controlled statistical design. Findings indicate that participation in the
intervention can effectively (1) reduce self-reported state and trait anxiety,
(2) reduce reports of overall psychological distress including depression, (3)
increase scores on overall empathy levels, and (4) increase scores on a measure
of spiritual experiences assessed at termination of intervention. These results (5)
replicated in the wait-list control group, (6) held across different experiments,
and (7) were observed during the exam period. Future research should address
potential long-term effects of mindfulness training for medical and premedical
students.
KEY WORDS: mindfulness meditation; medical education; stress-managem ent; anxiety; depression;
empathy; spirituality.
INTRODUCTION
How can we better prepare our future doctors for the stresses of medical
practice? Coping with stress appears to be one of the greatest challenges cur-
rently facing the medical profession (Lee, 1987). The inability to cope success-
fully with the enormous demands of medical school and medical practice may
1
Department of Psychology, University of Arizona, Tucson, Arizona 85719.
2
University Medical Center, University of Arizona, Tucson, Arizona 85719.
3
To whom correspondence should be addressed.
Shapiro, Schwartz, and Bonner582
lead to a cascade of consequences at both a personal levelÐ affecting doctors’
intra- and interpersonal lives (emotional
/
spiritual health as well as their physi-
cal health); and at a professional levelÐ in¯ uencing their effectiveness as doctors
by diminishing the quality of doctor±patient relationships. This study focused on
premedical and medical students in a preliminary attempt to examine a possible
complement to medical education which may prevent and
/
or reduce the harmful
effects of preparing to be a physician. The aims of the study were to assess the
ef® cacy of a short term mindfulness-based intervention (described below) to: (1)
decrease overall negative psychological symptoms including speci® c measures
of anxiety and depression, (2) potentially enhance the doctor-patient relationship
through the cultivation of empathy, and (3) foster spiritual growth and under-
standing. Ultimately it is hoped this intervention will help students adopt a more
balanced and humanistic approach to both their own lives and their patients’
lives.
Stress has been shown to have deleterious effects on one’ s physical and
mental well-being (Seyle, 1976, McCabe and Schneiderman, 1985, Jemmott et
al., 1983). The extreme stress levels inherent in the medical profession (and in
preparing for it), put premedical and medical students at risk for both physical
and psychological problems. Potential consequences of stress on medical stu-
dents’ lives include alcohol
/
drug abuse (Johnson, Michels, and Thom as, 1990),
interpersonal relationship dif® culties (Gallegos, 1990), depression and anxiety
(Pitts, Winokur, and Stewart, 1961; Salt, Nadelson, and Notman, 1984), and sui-
cide (Richings, Khara, and McDowell, 1986). Many of these problems develop
during medical school (Salt et al., 1994). A study by Salt and colleagues (1984),
reported that Harvard and Tufts medical students showed an increase in depres-
sion from 13% at the beginning of medical school, to 24.5% by the end of the
second year.
Stress may affect not only medical students’ personal well-being, but may
also have negative consequences on their professional effectiveness by dimin-
ishing the humanistic qualities fundamental to optimal patient care. Empathy,
de® ned by Rogers (1961) as (1) the capacity to understand, be sensitive to, and
feel what another is feeling, and (2) the ability to communicate this sensitiv-
ity to the person, is arguably a crucial element of the doctor±patient relation-
ship. Research suggests that the quality of the physician±patient relationship has
an impact on general patient well-being (Smith and Thompson, 1993), medical
compliance (Sbarbaro, 1990), and recovery from surgery (Anderson and Masur,
1989; Egbert, Battit, Welch, and Bartlett, 1964). However, rather than helping
students cultivate empathy, medical school may play a role in decreasing it. A
recent study found that empathy levels, measured by the Empathy Construct
Rating Scale (La Monica, 1981), decreased signi® cantly between entry to medi-
cal school and the end of the ® rst year (Pastore, Gambert, Plutchik, and Plutchik,
Mindfulness Intervention and Medical Education 583
1995). Medical school, therefore, appears an important time to focus on culti-
vating listening skills, an awareness of and sensitivity to patients’ needs, and a
compassion for their experiences.
Finally, spirituality may be a buffer to the negative effects of life stressors
(Kass, in press). It has been demonstrated that spirituality can enhance physical
and psychological well-being (Kass, 1995; Kass, Friedman, Lesserman, Zutter-
meister, and Benson, 1991) and predicts various health outcomes (Hawks, Hull,
Thalman, and Richins, 1995; Levin, 1994). Because premedical and medical stu-
dents face many stressors, it appears important to address their spiritual as well
their cognitive, behavioral, and emotional needs in an attempt to buffer against
the effects of stress. A ® nal goal of this intervention, therefore, is to help students
cultivate a deeper understanding of and openness to spirituality.
In response to the current literature, this intervention targeted premedical
and medical students in an attempt to address some of the deleterious conse-
quences of their intense and stressful lives. The intervention was modeled the
Stress Reduction and Relaxation Program (SR&RP) developed by Kabat-Zinn
and colleagues at the University of Massachusetts Medical Center (Kabat-Zinn,
1982). The present intervention was presented as an 8-week ª courseº in which
medical and premedical students underwent training in a class-like setting in the
practice of mindfulness meditation (formal practice) and its applications to daily
life (informal practice) (Kabat-Zinn, 1993).
Mindfulness meditation is a formal discipline that attempts to create greater
awareness and consequently greater insight in the practitioner. It goes beyond a
closed concentrative one-pointed meditation by introducing an openness to all
experiences. Mindfulness is a conscious moment to moment awareness, culti-
vated by systematically paying attention on purpose (Kabat-Zinn, 1990). The key
to mindfulness, however, is not simply attention. More importantly it is how one
attends. The intention one brings to the attention (practice) is crucial (Shapiro
and Schwartz, in press). The attention must embody compassion, impartiality,
and acceptance of self and others. Utilizing these qualities, one can cultivate
present moment attention in an objective (nonjudging), compassionate and gen-
tle way, open to whatever enters one’ s ® eld of awareness.
In the past 18 years since the Stress Reduction clinic at University of Mas-
sachusetts was founded, more than 7000 patients have gone through the Stress
Reduction and Relaxation Program (Kabat-Zinn, 1996). These patients have had
a wide range of medical diagnoses (AIDS, heart disease, cancer, chronic pain,
gastrointestinal disorders, hypertension, sleep disorders, depression, anxiety and
panic disorders), yet, ª all share the desire to control stress more effectively and
to utilize their inner resources to improve the quality of their livesº (Kabat-
Zinn, 1993, p. 260). The SR&RP is not intended to replace traditional medical
therapy, but to work adjunctly with it. Research demonstrates substantial effects
Shapiro, Schwartz, and Bonner584
associated with practicing mindfulness meditation such as decreases in anxiety,
hostility, and depression as well as decreases in medical symptoms (Kabat-Zinn
et al., 1992).
Those completing the SR&RP also evidence profound changes in their
beliefs and attitudes regarding themselves and their relationship to the world
(Kabat-Zinn, 1993, 1996). Patients show improvements in self-ef® cacy and moti-
vation and enhanced ability to approach stressful events as challenges instead of
threats (Kabat-Zinn, 1993). There is also evidence of a greater sense of con-
trol and the ability to let go of and accept events which are uncontrollable
(Astin, 1997). Upon completion of the SR&RP, people also report feeling a sense
of trust, closeness with other people and the environment (Kabat-Zinn, 1993).
Mindfulness meditation may not only connect one with him
/
herself, it may also
foster a sense of connectedness with others and with a greater whole (Shapiro and
Schwartz, in press). All of these positive psychological changes associated with
the cultivation of mindfulness have been linked to greater psychological
/
and
or physiological well-being (Antonovsky, 1987; Bandura, 1987; Kass, 1995;
McClelland, 1989; Russek and Schwartz, 1997; Schwartz, 1984; Seligman, 1975;
Shapiro, Schwartz, and Astin, 1997; Williams, 1985).
Despite the promising ® ndings regarding the effects of the SR&RP, these
studies have methodological limitations such as using self-selected samples and
not having adequate control groups (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth,
and Burney, 1985). Research is needed to test the effectiveness of a mindfulness-
based intervention using well controlled, experimental designs. The present study
used a matched wait-list control design in attempt to replicate ® ndings of current
literature while addressing some of its methodological limitations. This study
further expanded upon previous research by examining the potential bene® ts
of a mindfulness intervention to cultivate empathy, an outcome not previously
addressed in the literature. A further unique feature of the study was its focus
on medical and premedical students. It attempted to examine a possible com-
plement to medical education which may prevent the deleterious consequences
of stress as well as provide students with skills and knowledge to better prepare
them for their future roles as physicians.
It was hypothesized that a mindfulness-based intervention would (1) de-
crease overall psychological symptomatology measured by the Hopkins Symp-
tom Checklist Revised (SCL-90), including speci® c subscale measures of anxiety
and depression; (2) reduce both state and trait anxiety measured by the STAI-1
form; (3) cultivate empathy and mindful listening skills assessed using an
adapted version of the Empathy Construct Rating Scale; and (4) contribute to
an increase in spiritual experience
/
feelings measured by the revised edition of
the INSPIRIT assessed at termination of the intervention. Further, it was antici-
pated that the intervention would not be equally effective for all people depend-
ing on how greatly one was committed to the course in general and meditation
Mindfulness Intervention and Medical Education 585
practice in particular. Thus compliance was examined to determine if this vari-
able played a role in who bene® ts most from the intervention.
METHOD
Participants
Premedical and medical students were actively recruited to participate in the
mindfulness-based stress reduction intervention. The intervention was offered in
the form of an enrichment elective available to both medical and premedical
students. Brief presentations describing the ª Stress Reduction and Relaxationº
elective were given to the ® rst- and second-year medical students, the premedical
honors society, and the Fostering and Achieving Cultural Equity and Sensitivity
(FACES) premedical student group. Premedical students were offered one psy-
chology credit and the medical students were offered enrichment elective credit.
In addition, ¯ yers detailing the elective were distributed throughout the Medical
school and the University of Arizona campus and the prehealth student advisor
of® ce. Further, the premedical student advisors referred students to the program
and sent out information concerning the program to all those students on the
e-mail list.
Approximately 20 FACES students, 50 honors premedical students and 130
® rst- and second-year medical students were actively recruited (N
=
200). Inter-
ested students (approxim ately 95) ® lled out forms indicating their willingness
to be randomly assigned to a waiting list to take the course second session.
Only those students willing to be randomly assigned to either the intervention
or control group were included in the study. 78 participants met these crite-
ria and were randomly assigned to an intervention group or a wait-list control
group. Randomization was matched for gender, race, and medical vs. premedical
status.
Design and Procedure
The design was a matched randomized experiment in which participants
were assigned to a 7-week mindfulness-based intervention or a wait-list control
group. Participants in the intervention group were then split into two classes
of 18 and 19 participants. The two intervention classes were equivalent except
each had a different facilitator in attempt to determine generality across experi-
menters. Participants in both the intervention group and control group were mea-
sured two times: (a) before intervention, and (b) shortly following the interven-
tion which was scheduled to coincide with exam period in an attempt to rigor-
Shapiro, Schwartz, and Bonner586
ously scrutinize the bene® ts of the intervention during an extremely high stress
period. To control for random effects and increase consistency across groups,
both intervention and control groups were assessed at the same time, date, and
location. The measures were given shortly after the ® nal SR&RP class. To avoid
bias induced by the meditative state of the class, there was a 15- to 20-minute
interim between class and administration of post measures. Students were asked
to get up and walk outside. A ® nal set of questionnaires was administered to the
wait-list control group after receiving the equivalent intervention in an attempt
to replicate the ® rst session’ s results. To avoid experimenter effects, assessment
measures were administered and collected by an undergraduate research assistant
not involved in the design of the research or the intervention. Further, all partic-
ipants were assigned a con® dential identi® cation number to which the primary
investigator did not have access.
Intervention
The intervention was presented as an 8-week elective in Stress Reduction
and Relaxation modeled after the program developed by Kabat-Zinn and col-
leagues (1982). The core of the program focused on training the students in
mindfulness. Participants received training in the following meditative practices
(adapted from Kabat-Zinn, 1982): (1) ª Sitting Meditationº involving awareness
of body sensations, thoughts, emotions while continually returning the focus of
attention to the breath; (2) ª Body Scan,º a progressive movement of attention
through the body from toes to head observing any sensations in the different
regions of the body; (3) ª Hatha Yoga,º which consisted of stretches and postures
designed to enhance greater awareness and to balance and strengthen the muscu-
loskeletal system. Inherent in all these techniques was an emphasis on mindful
breathing, continually bringing attention to the breath. In addition to these three
techniques, a ª lovingkindnessº and a ª forgivenessº meditation were introduced
(the loving kindness meditation is practiced during the all day retreat in Kabat-
Zinn’ s formal intervention, however, the forgiveness meditation is unique to the
present intervention).
Further, students participated in experiential exercises designed to cultivate
mindful listening skills and empathy (which are unique to the present interven-
tion). Didactic material was presented on the psychological and physiological
effects of stress and how to cope with stress. To facilitate sharing and social
support, the group split into smaller subsets each week to discuss their experi-
ences. ª Mindfulnessº was woven throughout all of the exercises, and was explic-
itly emphasized as the thread that interconnected the various components of the
intervention. The course consisted of seven sessions (2.5 hours each week) and
had weekly home practice assignments as well as daily journals.
Mindfulness Intervention and Medical Education 587
Measures
Standard demographic measures were obtained (ethnicity, age, gender, edu-
cation). Participants completed the following measures to assess the six principle
quantitative dependent variables:
Empathy. Participants completed an adapted version (half of the original
version of 84 items) of the Empathy Construct Rating Scale (ECRS) (La Monica,
1981) consisting of 42 items to provide a measure of overall level of empathy.
The 42 items were reported on a 5-point scale. The alpha coef® cient (.89) of this
adapted instrument suggests that it is highly reliable for this speci® c sample.
Psychological Distress. The Hopkins Symptom Checklist 90 (Revised)Ð
SCL-90-R (Derogatis, 1977), a 90-item Likert-scale (1±5) instrument consisting
of the following nine subscales: somatization, obsessive-compulsive, interper-
sonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation,
psychoticism, and an ª additional itemsº scale comprised of seven questions, ® ve
of which relate to disturbances in sleeping and eating provided a measure of
overall psychological distress, calculated as the ª General Severity Indexº (GSI).
Depression. Subscale 4 of the SCL-90 was used to assess depression. The
symptoms of the Depression dimension re¯ ect a range of the manifestations of
clinical depression. The scale consists of 13 Likert scale (1±5) questions to assess
symptoms of dysphoric mood and affect, signs of withdrawal of life interest,
lack of motivation, and loss of vital energy as well as feelings of hopelessness,
thoughts of suicide, and other cognitive and somatic correlates of depression.
State and Trait Anxiety. The State-Trait Anxiety Inventory (Form Y)Ð
STAI Form 1 (Spielberger, Gorsuch, and Lushene, 1970) 40-item self-report
instrument was used to measure both state and trait anxiety using a 1±4 Lik-
ert rating scale.
Spirituality. The Index of Core Spiritual ExperiencesÐ INSPIRIT devel-
oped by Kass and colleagues (1991) is a seven-item scale designed to assess two
characteristic elements of core spiritual experiences: (1) ª a distinct event and a
cognitive appraisal of that event which resulted in a personal conviction of God’ s
existence (or of some form of Higher Power as de® ned by the person),º and
(2) ª the perception of a highly internalized relationship between God (Spiritual
core) and the person.º Scores calculated for this measure range from 1±4 (with
higher scores re¯ ecting a greater number of spiritual experiences). This instru-
ment demonstrates high internal reliability, Kass and colleagues (1991) report
an alpha coef® cient of .9.
Shapiro, Schwartz, and Bonner588
There were two ancillary measures included. A daily journal was used to
measure compliance with meditation practice. Participants recorded the length
of their daily meditation practice and turned in the journal each week at the
beginning of class. Also, evaluation packets were ® lled out by participants upon
completion of class to assess the course and to gain written qualitative reports
of the impact of the course.
RESULTS
The high rate of completion of the program (97%, 36 of 37) was consistent
with previous studies of the SR&RP (Kabat-Zinn et al., 1992, Kabat-Zinn and
Chapman-Waldrop, 1988). One student did not complete the intervention due to
severe medical problem s for which she was hospitalized. Four of the participants
in the control group did not complete the post-measures. The ® nal count of par-
ticipants was 73, consisting of 32 males and 41 females, 35 premedical students
and 38 medical students. The majority of the participants were Caucasian (79%,
58), the rest of the sample were Hispanic (8%, six), Indian (5%, four), African
American (3%, two), and Asian American (3%, two).
Initial analyses were conducted to ensure that the matched randomization
across gender, ethnicity, and premedical
/
medical status was successful. Chi-
square demonstrated that none of the variables differed signi® cantly between
groups: gender v
2
(1, N
=
78)
=
1.30, p
> .
49; race v
2
(1, N
=
78)
=
4.62, p
> .
43;
premedical vs. medical v
2
(1, N
=
78)
=
.20, p
> .
64. A repeated measures Mul-
tivariate Analysis of Variance (MANOVA) was then run to compare the inter-
vention and control groups along the six outcome variables (depression, state
anxiety, trait anxiety, spirituality, empathy, and the GSI). Both pre- and post-
scores of the six outcome variables were entered as variates; the independent
variable was treatment group by time. The groups were found to differ signi® -
cantly at time 2 (post-intervention) K (6, 64)
=
.8005, p
< .
03. Multivariate Anal-
ysis of Covariance (MANCOVA) was performed to more conservatively protect
against both Type I error and the chance that covariables were in¯ uencing the
outcome. The pretest scores of the outcom e variables were entered as covariates
and the post-scores were entered as variates. MANCOVA reported a signi® cant
multivariate main effect for group K (6, 58)
=
.767, p
< .
02.
Post hoc Newman-Keuls tests revealed no signi® cant differences between
groups pretest scores ( p
> .
05 in all cases); however, signi® cant differences were
found between groups’ posttest scores ( p
< .
05 in all cases). Follow-up univari-
ate ANOVA (uncorrected because of the directional nature of the hypotheses)
further revealed that, compared with the control group, the intervention group
reported less depression F(1, 69)
=
8.18, p
< .
006), less state anxiety F(1, 69)
=
4.11, p
< .
05, less trait anxiety F(1, 69), p
< .
002, a decrease in GSI F(1, 69)
=
Mindfulness Intervention and Medical Education 589
6.62, p
< .
02, and increases in empathy F(1, 69)
=
4.3, p
< .
05, and spirituality
F(1, 69)
=
5.62, p
< .
02. ANOVAs were repeated with experimenter as a fac-
tor and no signi® cant differences were found ( p
> .
05). Figure 1a±f illustrates
these respective differences. It is important to note that the post-measures were
administered during exam period, thus all participants (both the treatment and
Fig. 1. Plot of means illustrating signi® cant multivariate treatment by time interaction for both inter-
vention and control groups. Graphs illustrate signi® cant positive changes for the intervention: (a)
state anxiety, (b) trait anxiety, (c) depression, (d) general severity index (GSI), (e) spirituality, (f)
empathy.
Shapiro, Schwartz, and Bonner590
control group) were under stress. Despite this, the intervention group demon-
strated signi® cant change in the predicted direction for all of the outcome vari-
ables.
In an attempt to examine direction and magnitude of change further, we
would have preferred to use Structural Equations Modeling in order to report
variance accounted for by the model and indices of ® t. However, due to the
relatively small sample size we were unable to do so. However, using similar
data analytic strategy, we were able to construct a path diagram. Data were sub-
jected to a series of multiple regressions using the SAS General Linear Model
procedure (SAS Institute, 1985). The regressions involved both continuous and
categorical variables. Change scores were constructed for the six outcome vari-
ables; and a compliance variable was created using a mean score of the total
minutes plus total number of times the participants meditated during the inter-
vention (control group was assigned a score of 0). All signi® cance tests were
performed hierarchically and regression weights were obtained through simul-
taneous least-squares estimation for the predictors found signi® cant by the hier-
archical tests.
The hierarchical order of the variables was as follows: treatment, compli-
ance, change in trait anxiety, change in state anxiety, depression, GSI, empa-
thy, spirituality. Each dependent variable became a predictor for the subsequent
dependent variable. To determine the best hierarchical order, speci® c alternative
models based on a priori theory were compared. Selection of the best model
was based on predetermined criteria that the model reporting the least number
of signi® cant model parameters would be most parsimonious. An example of a
comparison is evaluating a model where depression preceded trait anxiety against
a model in which trait anxiety preceded depression. There were a few rules that
were held constant across models. Trait anxiety was always entered before state
anxiety to ensure that any variance accounted for by trait anxiety would not be
misinterpreted as variance accounted for by state anxiety. Another constant was
derived from previous analyses reporting the depression subscale to be the heart
of the change in GSI. As a result, to avoid incorrect assignment of a direct effect,
depression always preceded GSI.
A single best model was selected based upon principled criteria (Fig. 2).
Compliance had a signi® cant direct negative effect on trait anxiety (b
=
± .
440,
p
< .
001), indicating that as compliance increased, trait anxiety decreased. Trait
anxiety appeared to be a central and integral component in the change demon-
strated in the ® ve remaining outcome variables. Trait anxiety had a signi® cant
direct positive effect on depression (b
=
.525, p
< .
001), state anxiety (b
=
.541,
p
< .
001), and a signi® cant negative effect on empathy (b
=
± .
390, p
< .
001).
Thus, a decrease in trait anxiety led to decreased depression, decreased state
anxiety and an increase in empathy. Depression had a signi® cant positive effect
on change in GSI (b
=
.695, p
< .
001) and a signi® cant negative effect on spir-
Mindfulness Intervention and Medical Education 591
Fig. 2. Path diagram: A model of the pathways through which change occurred. Coef® cients are
standardized beta-weights. All pathway coef® cients are signi® cant P
< .
05.
ituality (b
=
± .
308, p
< .
01). State anxiety also had a signi® cant negative effect
on spirituality (b
=
± .
249, p
< .
033) evidencing that a decrease in depression
and state anxiety results in an increase in spirituality.
This data analytic strategy was designed to establish a path diagram esti-
mating direct and indirect effects of the treatment in an attempt to explain the
way in which change occurred. The model demonstrates both the magnitude and
direction of the effects. It is important to note, however, that the path diagram is
exploratory and meant to be used heuristically. The path diagram can suggest a
causal theory, but it cannot prove it. Causal connections at each step, therefore,
are only hypothetical. Our goal in producing this model is both to build a theory
and to generate ideas for future study.
Replication
Seeking to replicate the ® ndings of the ® rst session intervention group, the
same measures were administered to the wait-list control group after participa-
tion in the intervention. Unfortunate ly, due to a clerical error, the trait anxiety
measure was not administered. MANOVA was conducted within groups using
only control participants. Pre- and post-scores were analyzed across the three
measurement times (time 1 and time 2
=
pre-intervention, time 3
=
post-interven-
tion. To replicate the previous study as closely as possible, post-measures were
again administered at the end of the last session during exam period. Results
Shapiro, Schwartz, and Bonner592
replicated ® ndings from the previous group, demonstrating signi® cant change
across the ® ve outcome variables K (10, 22)
=
.2593, p
< .
001.
Post hoc Newman Keuls revealed that scores did not differ signi® cantly at
time 1 or time 2 (both pre-intervention); however, they did differ signi® cantly
with time 3 (post-intervention). Follow-up univariate ANOVA further illustrated
that, compared with time 1 and time 2, at time 3 the participants reported less
state anxiety at F(2, 62)
=
16.29, P
< .
001, less depression F(2, 62)
=
3.37,
P
< .
05, a decrease in GSI F(2, 62)
=
6.33, P
< .
01, as well as increases in
reported empathy F(2, 62)
=
15.5, P
< .
001, and spirituality F(2, 62)
=
10.83,
P
< .
002. Graphs plotting the means of the outcome variables at time 1, time 2,
and time 3 can be seen in Fig. 3a±e.
DISCUSSION
The stress inherent in the medical profession (and in preparation for it)
has numerous deleterious consequences for premedical and medical students’
psychological well-being as well as their professional effectiveness. Preparation
for the physician role should occur on many levels, including care of the personal
well-being of students in training. There is a need for studies exploring possible
complements to medical education. To contribute to the foundation of future
research in this area, an intervention should ® rst demonstrate successful short-
term effects before de® nitive future implications can be addressed. The present
study explored the short-term effects before de® nitive future implications can
be addressed. The present study explored the short-term effects of an 8-week
mindfulness-based intervention on premedical and m edical students using a well-
controlled statistical design.
Review of Findings
The data indicate that participation in a mindfulness-based stress reduction
intervention can effectively (1) reduce self-reports of overall psychological dis-
tress including depression, (2) reduce self-reported state and trait anxiety, (3)
increase scores on overall empathy levels, and (4) increase scores on a measure
of spiritual experiences assessed at termination of the intervention. These results
(5) replicated in the wait-list control group, (6) held across experimenters, and (7)
were observe during the exam period. Further, analysis demonstrated that one’ s
compliance with treatment played an important role in outcome. Finally, the
path diagram provided a hierarchic model of the changes, making the change in
(reported) trait anxiety the mechanism through which subsequent changes occur.
This is consistent with Lesh’ s study (1970), which demonstrated that reducing
Mindfulness Intervention and Medical Education 593
Fig. 3. Replication of ® ndings of Fig. 1 with the control group after having received intervention.
Plot of means across three time periods (time 1 and time 2
=
pre-interventio n, time 3
=
post-interven-
tion). Scores on the ® ve outcome variables did not differ signi® cantly at time 1 or time 2; however,
they did differ signi® cantly at time 3: (a) state anxiety, (b) depression, (c) GSI, (d) spirituality, (e)
empathy.
Shapiro, Schwartz, and Bonner594
stress and anxiety through meditation led to greater compassion and empathy in
counselors.
The observed reductions in psychological symptomatology are consistent
with the ® ndings of previous research studying mindfulness-based interventions
(Kabat-Zinn et al., 1992; Astin, 1997), and provide evidence that the interven-
tion is effective in a nonclinical population. Scores on the empathy measure
increased signi® cantly, suggesting that the intervention may have helped stu-
dents cultivate listening skills and develop new, more compassionate perspec-
tives and paradigms to approach their own lives as well as their future patients’
lives. Finally, although the observed change in spirituality is statistically signi® -
cant, interpreting change scores on the INSPIRIT in terms of clinical signi® cance
is dif® cult. However, despite the challenge of measuring and interpreting spir-
ituality, including the spiritual dimension of an individual seems consequential
given that research indicates spiritual well-being plays a role in health (Kass,
1995; Kass et al., 1991; Levin, 1994).
Limitations and Future Research
Although this study found signi® cant results consistent with the hypotheses
using a well-controlled design, there are many limitations and suggestions for
future research. It was not in the scope of this study to assess the long-term
effects of the intervention; as a result, it cannot be concluded that the short-term
changes produced will be useful in helping students deal with the future stress of
being a physician or even the ongoing stressors associated with medical school.
The results of this study will only have implications for health care if the effects
of the intervention are enduring; this question should be answered by future
research. Another limitation is the generalizability of the results. It is dif® cult to
generalize from a population of medical and premedical students who voluntarily
chose to enroll in a ª Stress Relaxation and Reductionº elective. Experimenter
effects and social desirability are other potential limitations. It is possible that
students wanted to please the experimenter, and thus answered the self-report
measures accordingly. In attempt to guard against this, all students were given
con® dential identi® cation numbers, the researcher did not administer or collect
any of the data, and the two groups were led by different experimenters.
The placebo effect is another potential confound; however, it can be viewed
as a part of the healing process that should not be eliminated (White, Tursky,
and Schwartz, 1985). The only way placebo effect can be investigated is to use
placebo control groups in a prospective, randomized study. A further limita-
tion of this study was that it included no comparison group receiving alternative
treatment (i.e., progressive relaxation, biofeedback). It is suggested that future
research compare different interventions to determine if effects are speci® c to
Mindfulness Intervention and Medical Education 595
the mindfulness intervention or generalize across stress-management techniques.
In addition, all assessment measures were self-report psychological question-
naires which are intrinsically limited and open to response bias. Future research
is encouraged to explore the physiological effects of mindfulness intervention
as well as the psychological effects.
Explanatory Mechanisms
A ® nal suggestion for future research is to tease out explanatory mech-
anisms of how the intervention worked. The 8-week course was a multimodal
intervention, including experiential exercises to cultivate mindful listening skills
and empathy, didactic material on coping and stress, and provided group social
support in addition to the formal meditation practice. Although at the foundation
of each of these components was mindfulness, it is dif® cult to determine to what
degree each uniquely contributed to the effects found. For example, the degree to
which expression and social support individually contribute to the overall effects
of mindfulness intervention is dif® cult to decipher. The intervention provides
an empathic, safe environm ent where participants are encouraged to share their
experiences, feelings, and dif® culties. Therefore, it is possible that some of the
effects are brought about through participants’ expression of emotions and dis-
closure of personal stories. The literature con® rms that both social support and
disclosure enhance psychological and physical well-being (Pennebaker, Kiecolt-
Glaser, and Glaser, 1988; Fawzy et al. 1993; Spiegel, Bloom, Kraemer, and
Gottheil, 1989; Berkman, 1995). Future research should focus on more de® nitive
designs, for example, comparing the mindfulness training to a traditional social
support group.
Further, because of the complexity inherent in mindfulness practice itself,
there are probably multiple pathways by which it positively affects health. One
possible hypothesis is that mindfulness training provides a powerful cognitive-
behavioral coping tool (Kabat-Zinn et al. 1992; Astin, 1997). Current theory
posits that it is the cognitive-emotional appraisal of situations that determines
the stress subsequently experienced (Beck, 1976; Ellis, 1962; Lazarus and Folk-
man, 1984). The intervention encourages alternative paradigms, and new inter-
pretations of stress. It invites the participants to view stress as a challenge
instead of a threat. However, mindfulness differs from cognitive-behavior ther-
apy. One crucial difference is that cognitive behavior therapy places an emphasis
on distinguishing thoughts as positive or negative, whereas mindfulness simply
acknowledges them (Kabat-Zinn et al., 1992). Another important difference is
that cognitive-behavior therapy teaches coping skills to use during stressful or
anxiety producing moments, whereas mindfulness is not just a coping tool but a
ª way of being,º to be practiced in all moments (Kabat-Zinn et al., 1992). Mind-
Shapiro, Schwartz, and Bonner596
fulness involves adopting a new life perspective (Shapiro and Schwartz, in press)
which one carries through all situations, continuously, moment to moment.
In addition, like other meditative practices, mindfulness meditation can
facilitate physiological relaxation (Benson, 1975), which may partially contribute
to reduction in psychological symptomatology. However, in contrast to other
relaxation techniques, mindfulness meditation may foster ª insightº (Kabat-Zinn
et al., 1985), providing practitioners with a deeper and clearer view of them-
selves and their problems. Further comparisons are needed to determine if the
effects of the intervention are speci® c to mindfulness meditation or span across
the multiple relaxation techniques (Shapiro, 1982).
Finally, a strong case can be made that self-regulation is a crucial mech-
anism which may contribute to the changes in psychological and physical
health found in mindfulness-based stress reduction intervention. According to
Schwartz’ s systems model of self-regulation (1984, 1989), a ª systemº maintains
stability of functioning as well as ¯ exibility and the capacity to change in novel
circumstances through continual feedback loops that connect all subsystems to
the larger whole. The model further posits that disregulation and subsequent
disease stem from disconnection of feedback loops as a result of not attending
to crucial messages within the system. When disregulation occurs, attention is
needed to reestablish connectedness which in turn enhances health. Humans can
be thought of as systems, composed of subsystems, and part of larger suprasys-
tems (e.g., families, communities, cultures). Thus, a potential hypothesis is that
mindfulness serves to increase the amount of attention and connection in the
ª systemº thereby leading to greater psychophysiolo gical regulation, balance, and
health (Shapiro and Schwartz, in press).
SUMM ARY
Although the explanatory mechanisms of the mindfulness intervention are
yet unclear, the results of this study may have important implications across
many levels. A number of novel features are introduced that have not been pre-
viously reported on in the context of mindfulness-based stress management. The
study documents the potential effectiveness of mindfulness training to enhance
premedical and medical students’ psychological
/
spiritual well-being as well as
help cultivate skills to use in their future roles as physicians. It explores the mul-
tiple pathways by which a mindfulness-based intervention may help premedical
and medical students in their personal as well as professional lives. The signif-
icant ® ndings are strengthened because data acquisition postintervention coin-
cided with subjects’ exam periods and also because these ® ndings were repli-
cated with the wait-list control group. The short-term results are encouraging,
and suggest that this intervention may prove a useful complement to medical
Mindfulness Intervention and Medical Education 597
and premedical education. Further, these ® ndings give strength to the hypothesis
that mindfulness can be thought of as ª preventive medicineº for future doctors,
helping them cultivate a ª way of beingº that may foster healing and growth in
their own lives as well as skills to effectively help others heal and grow in the
future. The present study helps provide a foundation by establishing the imme-
diate effectiveness of mindfulness-based intervention from which future, more
sophisticated studies can build to examine the long-term implications (both for
the well-being of our doctors and for their sensitivity to their patients) of inte-
grating mindfulness training into medical education.
ACKNOWLEDGMENTS
We wish to thank Drs. Dan Shapiro, Varda Shoham, and John Allen for
their invaluable advice and suggestions throughout the study. We also wish to
thank Dr. Lynn Nadel for facilitating the implementation of the intervention.
Further, we would like to thank Drs. A. J. Figueredo and John P. Kline for their
statistical input and advice. Finally, we thank all of the premedical and medical
students who participated in this study.
REFERENCES
Anderson, K. O., and Masur, F. T. III (1989). Psychological preparation for invasive medical and
dental procedures. J. Behav. Med. 6: 1±40.
Antonovsky, A. (1987). Unraveling the Mystery of Health: How People Manage Stress and Stay
Well, Jossey-Bass, San Francisco.
Astin, J. (1997). Stress-Reduction Through Mindfulness Meditation: Effects on Psychological Symp-
tomatology, Sense of Control, and Spiritual Experiences. Master ’s thesis, submitted for publi-
cation.
Bandura, A., O’ Leary, A., Taylor, C. B., Gauthier, J., and Gossard, D. (1987). Perceived self-ef® cacy
and pain control: Opioid and nonopioid mechanisms. J. Person. Soc. Psychol. 53: 563±571.
Beck, A. T. (1976). Cognitive Therapy and the Emotional Disorders, International Universities Press,
New York.
Benson, H. (1975). The Relaxation Response, Morrow, New York.
Berkman, L. (1995). The role of social relations in health promotion. Psychosomat. Med. 57:
245±254.
Derogatis, L. (1977). The SCL-90-R: Administration, Scoring and Procedures Manual 1, Clinical
Psychometric Research, Baltimore.
Egbert, L. D., Battit, G. E., Welch, C. E., and Bartlett, M. K. (1964). Reduction of postoperative pain
by encouragement and instruction of patients. A study of doctor±patient rapport. New Engl. J.
Med. 270: 825±827.
Ellis, A. (1962). Reason and Emotion in Psychotherapy , Lyle Stuart, New York.
Fawzy, F., Fawzy, N., Hyun, C., Elashoff, R., Guthrie, D., Fahey, F., and Morton, D. (1993). Malig-
nant melanoma: Effects of an early structured psychiatric intervention, coping, and affective
state on recurrence and survival 6 years later. Arch. Gen. Psychiat. 50: 681±689.
Gallegos, K. V., Bettinardi-Angre s, K., and Talbott, G. D. (1990). The effect of physician impairment
on the family. Maryland Med. J. 39: 1001±1007.
Shapiro, Schwartz, and Bonner598
Hawks, S. R., Hull, M. L., Thalman, R. L., and Richins, P. M. (1995). Review of spiritual health: Def-
inition, role, and intervention strategies in health promotion. Am. J. Health Promot. 9: 37±1378.
Jemmott, J. B., Borysenko, J. Z., Borysenko, M., McClelland, D. C., Chaptman, R., Meyer, D.,
and Benson, H. (1983). Academic stress, power motivation, and decrease in salivary secretory
immunoglobulin A secretion rate. Lancet 1: 1400±1402.
Johnson, N. P., Michels, P. J., and Thomas, J. C. (1990). Screening tests identify the prevalence of
alcohol use among freshman medical students and among students’ family of origin. J. South
Carolina Med. Assoc. 86: 13±14.
Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain patients based
on the practice of mindfulness mediation: Theoretical considerations and preliminary results.
Gen. Hosp. Psychiat. 4: 33±47.
Kabat-Zinn, J. (1993). Mindfulness meditation: Health bene® ts of an ancient Buddhist practice. In
Goleman and Gurin (Eds.), Mind
/
Body Medicine , Consumer Reports Books, New York, pp.
259±275.
Kabat-Zinn, J. (1996). Mindfulness meditation: What it is, what it isn’ t, and its role in health care
and medicine. In Haruki, Ishii, Y., and Suzuki, M. (Eds.), Comparative and Psychological Study
on Meditation , Eburon, Netherlands, pp. 161±170.
Kabat-Zinn, J., and Chapman-Wald rop, A. (1988). Compliance with and outpatient stress reduction
program: Rates and predictors of program completion. J. Behav. Med. 11(4): 333±352.
Kabat-Zinn, J., Lipworth, L., and Burney, R. (1985). The clinical use of mindfulness meditation for
the self-regulation of chronic pain. J. Behav. Med. 8: 163±190.
Kabat-Zinn, J., Massion, A. O., Kristeller, J., Peterson, L. G., Fletcher, K. E., Pbert, L., Lenderking,
W. R., and Santorelli, S. (1992). Effectiveness of a meditation based stress reduction program
in the treatment of anxiety disorders. Am. J. Psychiat. 149: 936±943.
Kass, J. (1995). Contributions of religious experience to psychological and physical well-being:
Research evidence and an explanatory model. In VandeCreek, L. (Ed.), Spiritual Needs and
Pastoral Services: Readings in Research, Journal of Pastoral Care Publications, Decatur, Geor-
gia, pp. 189±213.
Kass, J., Friedman, R., Leserman, J., Zuttermeister, P., and Benson, H. (1991). Health outcomes and
a new measure of spiritual experience. J. Sci. Study Rel. 30(2): 203±211.
Kass, J. (1997). Tapping into Something Greater than Ourselves: The Health Effects of Spirituality
(manuscript submitted).
La Monica, E. (1981). Construct validity of an empathy instrument. Res. Nurs. Health 4: 389±400.
Lazarus, R. S., and Folkman, S. (1984). Stress, Appraisal, and Coping, Springer, New York.
Lee, C. (1987). Professionals in medical settings: The research evidence in the 1980s. J. Org. Behav.
Mgt. 8: 195±213.
Lesh, T. V. (1970). Zen meditation and the development of empathy in counselors. J. Human. Psy-
chol. 10: 39±74.
Levin, J. S. (1994). Religion and health: Is there an association, is it valid, and is it causal? Soc.
Sci. Med. 38: 1475±1482.
McCabe, P. M., and Schneiderman, N. (1985). Psychophysiologic reactions to stress. In Schneider-
man, N., and Tap, J. T. (Eds.), Behavioral Medicine: The Biopsychosocial Approach, Erlbaum,
Hillsdale, NJ.
McClelland, D. C. (1989). Motivational factors in health and disease. Am. Psychol. 44(4): 675±683.
Pastore, F. R., Gambert, S. R., Plutchik, A., and Plutchik, R. (1995). Empathy Training for Medical
Students. New York Medical College (unpublished manuscript).
Pennebaker, J. W., Kiecolt-Glaser, J. K., and Glaser, R. (1988). Disclosure of traumas and immune
function: Health implications for pschotherapy. J. Consult. Clin. Psychol. 56: 239±245.
Pitts, F. N., Winokur, G., and Stewart, M. A. (1961). Psychiatric syndromes, anxiety symptoms and
responses to stress in medical students. Am. J. Psychiat. 118: 333±340.
Richings, J. C., Khara, G. S., and McDowell (1986). Suicide in young doctors. Brit. J. Psychiat.
149: 475±478.
Rogers, C. R. (1961). On Becoming a Person, Houghton Mif¯ in Company, Boston, MA.
Russek, L., and Schwartz, G. E. (1997). Feelings of Parental Caring Predict Health Status in Midlife:
A 35-year follow-up of the Harvard Mastery of Stress Study. Behav. Med. 20: 1±13.
Mindfulness Intervention and Medical Education 599
Salt, P., Nadelson, C., and Notman, M. (1984). Depression and Anxiety Among Medical Students.
New Research Abstract 13, APA Annual Meeting, Los Angeles.
SAS Institute (1985). SAS User’s Guide: Statistics, Version 5, SAS Institute, Cary, North Carolina.
Sbarbaro, J. A. (1990). The patient±physician relationship: Compliance revisited. Ann. Allergy 64:
325±331.
Schwartz, G. E. (1984). Psychobiology of health: A new synthesis. In Hammonds, B. L., and
Scheirer, C. J. (Eds.), Psychology and Health: Master Lecture Series (Vol. 3), American Psy-
chological Association, Washington, D.C., pp. 145±195.
Seligman, M. E. P. (1975). Helplessness: On Depression, Development and Death, Freeman, San
Francisco.
Selye, H. (1976). The Stress of Life (rev. ed.), McGraw-Hill, New York.
Shapiro, D. H. (1982). Overview: Clinical and physiological comparisons of meditation with other
self-control strategies. Am. J. Psychiat. 139: 267±274.
Shapiro, D. H., Schwartz, C. E., and Astin, J. (1996). Controlling ourselves, controlling our world:
Psychology’ s role in understanding positive and negative consequences of seeking and gaining
control. Am. Psychol. 51(12): 1213±1230.
Shapiro, S. L., and Schwartz, G. E. (in press). The role of intention in self-regulati on: Toward inten-
tional systemic mindfulness. In Boekaerts, M., Pintrich, P. R., and Zeidner, M. (Eds.), Handbook
of Self-Regulation , Academic Press, New York.
Smith, T. C., and Thompson, T. L. (1993). The inherent, powerful therapeutic value of a good
physician±patient relationship. Psychosomat. Med. 34: 763±766.
Spiegel, D., Bloom, J., Kraemer, H. C., and Gottheil, E. (1989). Effect of psychosocial treatment on
survival of patients with metastatic breast cancer. Lancet 2: 888±891.
Spielberger, C. D., Gorsuch, R. C., and Lushene, R. E. (1970). Manual for the State-Trait Anxiety
Inventory, Consulting Psychologists, Palo Alto.
White, L., Tursky, B., and Schwartz, G. E. (Eds.) (1985). Placebo: Theory, Research and Mecha-
nisms, Guilford Press, New York.
Williams, R. B., Jr., Barefoot, J. C., and Shekelle, R. B. (1985). The health consequences of hostility.
In Chesney, M. A., and Rosenman, R. H. (Eds.), Anger and Hostility in Cardiovascular and
Behavioral Disorders, Hemisphere
/
McGraw-Hill, New York, pp. 173±185.
