Teaching Self-Care to Caregivers: Effects of Mindfulness-Based Stress Reduction on the Mental Health of Therapists in Training

Abstract

Preparation for the role of therapist can occur on both professional and personal levels. Research has found that therapists are at risk for occupationally related psychological problems. It follows that self-care may be a useful complement to the professional training of future therapists. The present study examined the effects of one approach to self-care, Mindfulness-Based Stress Reduction (MBSR), for therapists in training. Using a prospective, cohort-controlled design, the study found participants in the MBSR program reported significant declines in stress, negative affect, rumination, state and trait anxiety, and significant increases in positive affect and self-compassion. Further, MBSR participation was associated with increases in mindfulness, and this enhancement was related to several of the beneficial effects of MBSR participation. Discussion highlights the potential for future research addressing the mental health needs of therapists and therapist trainees. (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Full text

Teaching Self-Care to Caregivers: Effects of Mindfulness-Based
Stress Reduction on the Mental Health of Therapists in Training
Shauna L. Shapiro
Santa Clara University
Kirk Warren Brown
Virginia Commonwealth University
Gina M. Biegel
Kaiser Permanente
Preparation for the role of therapist can occur on both professional and personal levels.
Research has found that therapists are at risk for occupationally related psychological
problems. It follows that self-care may be a useful complement to the professional
training of future therapists. The present study examined the effects of one approach to
self-care, Mindfulness-Based Stress Reduction (MBSR), for therapists in training.
Using a prospective, cohort-controlled design, the study found participants in the
MBSR program reported significant declines in stress, negative affect, rumination, state
and trait anxiety, and significant increases in positive affect and self-compassion.
Further, MBSR participation was associated with increases in mindfulness, and this
enhancement was related to several of the beneficial effects of MBSR participation.
Discussion highlights the potential for future research addressing the mental health
needs of therapists and therapist trainees.
Keywords: mindfulness, meditation, therapist training, self-care
For mental health professionals, caring for
those who are emotionally stressed or distressed
is often itself stressful. Therapists commonly
experience “compassion fatigue” (Figley, 2002;
Weiss, 2004) due to the emotional labor that is
often a part of therapeutic work (Mann, 2004).
Stress-related psychological problems among
therapists are especially apparent among those
employed in such high-demand settings as hos-
pitals (Vredenburgh, Carlozzi, & Stein, 1999)
and among those working with populations who
present special emotional challenges to caregiv-
ers, including clients who have experienced
abuse (Coppenhall, 1995), trauma (Arvay &
Uhlemann, 1996) and/or have personality dis-
orders (Linehan, Cochran, Mar, Levensky, &
Comtois, 2000). Research suggests that psycho-
logical impairment affects a significant propor-
tion of direct service mental health profession-
als at some point in their careers (Coster &
Schwebel, 1997; Guy, Poelstra, & Clark, 1989).
The negative consequences of stress on help-
ing professionals include increased depression,
emotional exhaustion and anxiety (Radeke &
Mahoney, 2000; Tyssen, Vaglum, Gronvold, &
Ekeberg, 2001), psychosocial isolation (Penzer,
1984), decreased job satisfaction (Blegen,
1993), reduced self-esteem (Butler & Constantine,
2005), disrupted personal relationships (Myers,
1994), and loneliness (Lushington & Luscri,
2001). Stress may also harm professional ef-
fectiveness because it appears to negatively
impact attention and concentration (Skosnik,
Chatterton, & Swisher, 2000), impinge on
SHAUNA L. SHAPIRO is in the department of counseling a
Santa Clara University. She received her doctoral degree
from the University of Arizona. Her research interests in-
clude mindfulness, meditation, training therapists, and pos-
itive psychology.
KIRK WARREN BROWN is currently an assistant professor
of psychology at Virginia Commonwealth University. He
received his doctorate from McGill University. Dr. Brown’s
research centers on the role of attention to and awareness of
internal states and behavior in self-regulation and well-
being.
GINA M. BIEGEL is at the department of child and ado-
lescent psychiatry, Kaiser Permanente, San Jose, CA. She
has a master’s degree from Santa Clara University. Her
current research interest is mindfulness-based stress reduc-
tion with adolescents and health professionals.
CORRESPONDENCE CONCERNING THIS ARTICLE should be
addressed to Shauna L. Shapiro, Santa Clara University,
500 El Camino Real, Santa Clara, CA 95053. E-mail:
slshapiro@scu.edu
Training and Education in Professional Psychology Copyright 2007 by the American Psychological Association
2007, Vol. 1, No. 2, 105–115 1931-3918/07/$12.00 DOI: 10.1037/1931-3918.1.2.105
105

decision-making skills (Klein, 1996; Lehner,
Seyed-Solorforough, O’Connor, Sak, & Mullin,
1997), and reduce providers’ ability to establish
strong relationships with patients (Enochs &
Etzbach, 2004; Renjilian, Baum, & Landry,
1998). Further, stress can increase the likeli-
hood of occupational burnout (Rosenberg &
Pace, 2006), a syndrome that involves deper-
sonalization, emotional exhaustion, and a sense
of low personal accomplishment.
These findings highlight the importance of
self-care for health care providers. There is ev-
idence that younger and newer helping profes-
sionals are particularly susceptible to occupa-
tional stress (Skovholt & Ronnestad, 2003;
Vander-Kolk, 1982; Vredenburgh et al., 1999).
Thus, programs designed to teach self-care
skills to helping professional trainees (i.e., stu-
dents) may represent an important form of “pre-
ventive treatment” for individuals at risk for
later psychological problems (cf., Coster &
Schwebel, 1997).
Quantitative and interview research examin-
ing self-care and stress management for thera-
pists has suggested that several facets of self-
care are important, including self-awareness,
self-regulation or coping, and a balancing of
self and others interests (e.g., Baker, 2003;
Brady, Guy, & Norcross, 1995). Self-aware-
ness, defined in this context as an unbiased
observation of one’s inner experience and be-
havior, is thought to be foundational to self-care
(Baker, 2003; Norcross, 2000; Coster &
Schwebel, 1997) and important to successful
therapeutic work with clients (Baker, 2003). To
date, no research known to us has examined the
efficacy of interventions designed to enhance
self-awareness, self-regulation, or balance in
therapists or therapists in training, although a
recent qualitative report suggests that therapist
trainees find psychological benefit from such an
intervention (Newsome, Christopher, Dahlen, &
Christopher, 2006). A growing body of research
indicates that a stress reduction program that
emphasizes the cultivation of mindfulness may
enhance psychological well-being, mental
health, and physical health (see Baer, 2003;
Grossman, Niemann, Schmidt, & Walach,
2004, for meta-analytic reviews).
The mindfulness-based stress reduction pro-
gram (MBSR; Kabat-Zinn, 1990) is based on
the premise that enhancing the capacity to be
mindful—that is, to attend to present moment
experience in a receptive manner—will, over
time, reduce the identification with self-focused
thoughts and emotions that can lead to poorer
mental health (e.g., Brown, Ryan, & Creswell,
in press). Clinical research conducted over the
past 25 years has supported the efficacy of
MBSR for reducing distress and enhancing
well-being in individuals with a variety of med-
ical and psychiatric conditions (see reviews by
Baer, 2003; Bishop, 2002; Grossman et al.,
2004). More pertinent to the present study,
MBSR has also demonstrated efficacy in health
care professionals and trainees (Cohen-Katz,
Wiley, Capuano, Baker, Kimmel, & Shapiro,
2005; Rosenzweig, Reibel, & Greeson, 2003;
Shapiro, Astin, Bishop, & Cordova, 2005;
Shapiro, Schwartz, & Bonner, 1998). MBSR
was designed for application to any individual
facing stress, and the program can be flexibly
adapted to specific populations. The research
with health care providers and trainees in par-
ticular suggests that beginning mental health
professionals may also find benefit from the
self-care skills training offered in the MBSR
program.
The present study had three purposes. We
first sought to test the efficacy of MBSR in
enhancing the mental health of therapists in
training as measured by a variety of cognitive
and affective indicators. The importance of this
aim lies in promoting the well-being and stress
tolerance of trainees preparing to enter the de-
manding counseling and psychotherapy profes-
sions. Given the potential costs of stress on
mental health care professionals’ well being,
teaching future therapists’ ways of managing
stress seems imperative. In line with past
MBSR research, we predicted that relative to
controls, participants in the MBSR program
would show improvements in mental health and
well-being.
A second purpose was to examine the processes
by which MBSR achieves its beneficial effects.
Namely we sought to examine whether MBSR is
associated with increased mindfulness and if this
change is associated with positive outcomes. Little
is currently known about such processes. MBSR
focuses on the enhancement of the quality of
mindfulness, and it is this enhancement that is
believed to be responsible for the positive effects
of the intervention. With the recent development
of measures of the mindfulness construct (Baer,
Smith, & Allen, 2004; Brown & Ryan, 2003;
106 SHAPIRO, BROWN, AND BIEGEL

Walach, Buchheld, Buttenmuller, Kleinknecht, &
Schmidt, 2006), research has begun to test these
two propositions empirically. In an MBSR study
with nurses, Cohen-Katz et al. (2005) found that
scores on one measure of mindfulness, the
Mindful Attention Awareness Scale (MAAS;
Brown & Ryan, 2003), increased significantly
over the course of the 8-week program. In an
MBSR study with cancer patients, Brown and
Ryan (2003) found that increases in MAAS-
assessed mindfulness were related to declines in
mood disturbance and stress. The present study
sought to extend this process research on mind-
fulness enhancement through MBSR and the ef-
fects of that enhancement. We predicted that lev-
els of mindfulness would increase over the course
of the 8-week MBSR program with counseling
students, and that these increases would be related
to positive changes in mental health.
A final purpose of this study was to explore
the relation between mindfulness practice and
mental health outcomes. A primary component
of the MBSR program is in-class and home-
based practice of several mindfulness-based
skills, and it is widely believed that this skills
practice is related to positive outcomes of
the MBSR program (Carson, Carson, Gil, &
Baucom, 2004; Shapiro, Bootzin, Figueredo,
Lopez, & Schwartz, 2003). However, past re-
search examining the relation between amount
of mindfulness practice and degree of change in
affective, behavioral, and neurophysiological
outcomes has been mixed, with some reporting
positive findings (Carson et al., 2004; Shapiro et
al., 2003) and others null findings (e.g., Davidson,
Kabat-Zinn, & Schumacher, 2003). Given the
lack of clear, supportive evidence for the role of
mindfulness practice on MBSR outcomes, no
hypotheses concerning this relation were made
in the present study. However, given the impor-
tance of this issue for mindfulness intervention
research, we examined associations between the
type and amount of mindfulness practice per-
formed and the well-being-related outcomes of
the MBSR program.
Method
Participants
Study participants were recruited from a mas-
ter’s level counseling psychology program at a
small private Jesuit university. Student partici-
pants were enrolled in one of three graduate
courses: Stress and Stress Management, Psy-
chological Theory, and Research Methods. On
the first day of class in all three courses, stu-
dents were given a 5-minute introduction to the
study procedures and invited to participate.
There was no credit offered for participation,
and students were told it was completely vol-
untary. A total of 83 students were enrolled in
these courses in the Fall, 2004 term, and 64
elected to participate in the study and gave
written informed consent. Of the 22 students
enrolled in the intervention course (Stress and
Stress Management), all completed both the
baseline measures and the postcourse measures.
Of the 61 students enrolled in the two control
courses, 42 completed baseline measures,
and 32 completed the postcourse measures.
Data for the 54 participants (88.9% female) who
completed measures at both assessment points
were retained for analyses. Those who com-
pleted the study did not differ from noncom-
pleting participants on any of the demographic
or psychological variables collected at baseline,
all ps⬎.05. The average age of the 54 retained
participants was 29.2 years (SD ⫽9.07). The
majority (76.9%) were Caucasian, and the rest
were Latina/Latino (7.7%), Asian (5.8%),
Filipino (3.8%), African American (1.9%), Por-
tuguese, and Persian (each 1.9%); two (3.8%)
declined to indicate their race or ethnicity. The
majority of students were enrolled in their first
year (56.9%) or second year (29.4%) of gradu-
ate school; the remaining students were in their
third year (11.8%) and fourth year (2%).
Study Design and Procedures
The study was conducted using a prospec-
tive, nonrandomized, cohort-controlled de-
sign. The MBSR intervention was offered as
part of the Stress and Stress Management
course, while the other two courses noted
above served as cohort controls. All courses
were offered in the same academic term and
all three courses were required for the health
psychology master’s degree in counseling
psychology. During the first class in each
course, students were invited to participate in
the study and informed consent was obtained
from those interested. All demographic and
psychological measures were collected in the
first week of the academic term (Time 1); all
107SELF-CARE TRAINING FOR CAREGIVERS

psychological measures were again col-
lected 9 weeks later, in the final week of the
term (Time 2). One PhD-level instructor
taught the intervention course and one of the
control courses (Psychological Theory), and a
second PhD-level instructor taught the other
control group course (Research Methods).
MBSR Intervention Course
The Stress and Stress Management course
consisted of 10 weekly classes, meeting 3 hours
per week. The 8-week MBSR intervention began
in the third week; the intervention was modeled
after the well-established manualized treatment
program developed by Kabat-Zinn and colleagues
at the University of Massachusetts (e.g.,
Kabat-Zinn, 1982). MBSR includes both didac-
tic and experiential elements that focus on the
training of mindfulness-based meditative prac-
tices. These practices are designed to cultivate
an open or receptive attention to all stimuli that
enter the field of awareness on a moment-by-
moment basis. In particular, mindfulness prac-
tices are designed to enhance participants’ on-
going awareness of their sensory experiences,
thoughts, feelings, somatic sensations, and be-
haviors. MBSR is premised on the thesis that
bringing greater awareness to actual experience
in the “here and now” encourages a disengage-
ment from self-related thoughts (e.g., rumina-
tion) and emotions (e.g., anxiety) that can have
a detrimental effect on well-being (Leary,
2004).
The MBSR intervention included weekly
2-hour sessions wherein students received train-
ing in the following five mindfulness practices
(adapted from Kabat-Zinn, 1982). Sitting med-
itation involved a concentration of attention to
the sensations of breathing, while remaining
open to other sensory events, and to physical
sensations, thoughts, and emotions. The body
scan involved a progressive movement of atten-
tion through the body from toes to head while
observing physical sensations in each region.
Hatha yoga consisted of stretches and postures
designed to enhance mindful awareness of the
body and to balance and strengthen the muscu-
loskeletal system. A guided loving-kindness
meditation was also taught, which involved ex-
periential practice in compassion toward self
and others. Finally, participants were taught in-
formal practices which emphasized bringing
mindfulness into day-to-day life.
The non-MBSR portion of the course served
as an overview of stress and various nonmind-
fulness-based stress management techniques
(e.g., humor, exercise, hypnosis, social support,
acupuncture). This portion was entirely didactic
in nature and did not include experiential exer-
cises. Students were not instructed to practice
any of the techniques discussed. Once MBSR
began, students were asked to focus on the
mindfulness practices.
Control Group Courses
Like the Stress and Stress Management
course, both the Research Methods and Psycho-
logical Theory courses met 3 hours weekly
for 10 weeks under the guidance of trained
instructors. Thus, the intervention and control
group courses were structurally equivalent in
instructor attention, weekly and total duration,
and course modality (both were group-based).
The control group courses were entirely didactic
in nature and did not include experiential stress
management exercises. The Research Methods
course focused on research design, various sta-
tistical analyses, and critical reading of journal
articles. The Psychological Theory course of-
fered an overview of psychological theories in-
cluding psychodynamic, humanistic, behavior-
ist, and cognitive paradigms.
Pre- and Postcourse Measures
Mindfulness. The Mindful Attention
Awareness Scale (MAAS; Brown & Ryan,
2003) is a 15-item instrument assessing the fre-
quency with which an individual is openly at-
tentive to, and aware of, present events and
experiences. The scale assesses mindfulness of
both internal states (e.g., emotions) and overt
behavior (e.g., attention to tasks, social interac-
tions, etc.) on a 6-point Likert scale. Example
items of the scale include, “I could be experi-
encing some emotion and not be conscious of it
until some time later” and “It seems I am ‘run-
ning on automatic’ without much awareness of
what I’m doing.” Higher scores indicate higher
mindfulness. The MAAS has demonstrated
strong psychometric properties (Brown & Ryan,
2003; Carlson & Brown, 2005). In the present
study, internal consistency was acceptable
108 SHAPIRO, BROWN, AND BIEGEL

(Cronbach’s alpha ⫽.79) though slightly lower
than in past research (e.g., Brown & Ryan,
2003; this and all reported sample ␣’s are from
the Time 1 data).
Distress and well-being. In an attempt to
broadly assess psychological distress and well-
being, well-validated scales tapping several
cognitive and affective dimensions of experi-
ence were used. Positive and negative affect are
primary dimensions of subjective well-being
(Diener, 1984), and these were measured with
the 20-item version of the Positive and Negative
Affectivity Schedule (PANAS; Watson, Clark,
& Tellegen, 1988). Example adjectives in-
cluded interested and enthusiastic (positive af-
fectivity), and distressed and afraid (negative
affectivity). Scores on the 7-point scales indi-
cated higher levels of both positive and negative
affect. Both subscales showed acceptable levels
of internal consistency in this sample (␣⫽.88
and ␣⫽.83, respectively).
To more specifically measure levels of stress
and distress, the 10-item version of the Perceived
Stress Scale (PSS; Cohen, Kamarck, &
Mermelstein, 1983; sample ␣⫽.87) was used
to assess the extent to which life situations are
appraised as stressful. An example item is, “In
the last month, how often have you felt nervous
and stressed?” Higher scores on the 5-point
scale indicate higher perceived stress. Anxiety
was measured at both state (“past week”) and
trait (“past month”) levels using the 20-item
State/Trait Anxiety Inventory (STAI;
Spielberger, 1983; sample state ␣⫽.95; sample
trait ␣⫽.96). Example items include, “I am
tense” and “I feel strained.” The STAI is scored
such that higher scores on the 7-point scale
reflect higher anxiety.
Rumination is a risk factor for depression and
was measured with the 12-item rumination por-
tion of the Reflection Rumination Questionnaire
(RRQ; Trapnell & Campbell, 1999; sample ␣⫽
.94). This 12-item subscale measures “rumina-
tive self-attention,” the tendency to dwell on,
rehash, or reevaluate events or experiences.
Higher scores on the 5-point scale indicate
higher rumination. An example item is, “Some-
times it is hard for me to shut off thoughts about
myself.” Finally, the 26-item Self-Compassion
Scale (Neff, 2003; sample ␣⫽.94) was used to
measure self-compassion based on an aggregate
of responses on 3 subscales: self-kindness ver-
sus self-judgment, common humanity versus
isolation, and mindfulness versus overidentifi-
cation. Example items include, “I try to be lov-
ing toward myself when I’m feeling emotional
pain” and “When times are really difficult, I
tend to be tough on myself” (reversed). Higher
scores on the 5-point scale indicate higher
self-compassion.
Daily Mindfulness Practice Diaries
Students in the MBSR course were asked to
complete daily mindfulness practice diaries for
the entire 8-week intervention so as to examine
the effects of practice on the study outcomes.
On these diaries, to be completed at the end of
each day, MBSR participants indicated the
number of minutes of sitting meditation, body
scan, yoga, and informal mindfulness practice
performed that day.
Results
Preliminary analyses showed that students in
the two control classes did not differ signifi-
cantly on any of the demographic or psycholog-
ical measures at the outset of the study (Time 1;
all ps⬎.05), so all data for these two classes
were combined into a single control group for
further analyses. Next, analyses showed that the
MBSR and control group did not differ on any
of the study measures at Time 1 except aca-
demic year: most control group participants
(70%) were in their first academic year, com-
pared to 38% of MBSR participants,
␹
2
(3) ⫽8.23, p⬍.05. Finally, Time 1, Time 2,
and Time 1 to Time 2 change scores showed no
gender differences in preliminary analyses (all
ps⬎.05), so gender will not be further
considered.
1
MBSR Intervention Effects on Well-Being
and Distress
To examine whether participation in the
MBSR program (vs. participation in the con-
trol courses) impacted levels of distress and
well-being, we conducted 2 (group) ⫻2
(time) mixed factorial analyses of variance
1
Due to the low numbers of minority participants in the
sample, differences in effects due to ethnic and racial status
were not tested.
109SELF-CARE TRAINING FOR CAREGIVERS

(ANOVAs) on each outcome variable, using
an alpha level of .05 as the criterion for sta-
tistical significance. Because preliminary
analyses showed that age and year in program
were related to one or more of the outcomes,
these measures were included as predictors
where relevant. Table 1 displays the primary
results of the ANOVAs. Participants in the
MBSR class showed significant improve-
ments on all 7 outcomes, relative to partici-
pants in the control group. In support of our
primary hypothesis, participants in the MBSR
intervention reported significant decreases in
perceived stress, negative affect, state and
trait anxiety, rumination, as well as signifi-
cant increases in positive affect and self-
compassion. Several main effects for age
were found, with older students showing
lower levels of negative affect, trait anxiety,
rumination, perceived stress, and higher self-
compassion. No main effects of year in pro-
gram were found, and there were no age ⫻
time or year ⫻time interaction effects. Fi-
nally, despite the fact that the MBSR and
control groups differed in year of program,
there were no year ⫻group interaction effects
on any outcome.
Do Changes in Mindfulness Occur and
Are They Associated With MBSR
Intervention Effects?
A second purpose of this study was to
examine whether the MBSR intervention is
associated with increases in mindfulness and
if so, whether the positive outcomes of MBSR
participation were related to increases in
mindfulness occurring over the course of the
program. Table 1 shows, using a mixed fac-
torial ANOVA, that MBSR participants
showed significant prepost course increases in
mindfulness relative to control group
participants.
To test whether prepost change in mindful-
ness predicted prepost change in each of the
well-being/distress outcomes for the MBSR
group, simple regression models were con-
structed. Residualized change scores were first
calculated on MAAS mindfulness and on each
outcome variable (Cohen & Cohen, 1983; Judd
& Kenny, 1981). In this pretreatment of the
data, Time 2 scores were adjusted for their
Time 1 values, so that only variance in residual
change in the outcome variables was left to be
explained by residual change in the mindfulness
predictor. Age was not related to any of the
outcome change scores so was not included as a
predictor in the models. Table 2 displays the
results of the regression analyses. Across the
seven distress and well-being outcomes, signif-
icant relations between change in mindfulness
and change in outcome were found in four mod-
els. Specifically, an increase in mindful atten-
tion and awareness from pre- to postinterven-
tion predicted a drop in rumination, trait anxi-
ety, and perceived stress, and an increase in
self-compassion. No predictive effects were
Table 1
Mean Scores by Group, Pre-Course (Time 1) and Post-Course (Time 2), and MBSR Intervention Effects
Variable
MBSR Control
p
inter
Time 1 Time 2 Time 1 Time 2
M (SD) M (SD) M (SD) M (SD)
PANAS positive affect 4.87 (0.75) 5.45 (0.94) 5.14 (0.74) 4.90 (0.95) .0002
PANAS negative affect 3.09 (0.90) 2.55 (1.01) 3.04 (1.03) 2.99 (0.89) .04
STAI anxiety, present 3.17 (1.19) 2.18 (1.09) 2.67 (1.11) 2.76 (1.01) .0005
STAI anxiety, past month 3.43 (0.90) 2.51 (0.77) 3.33 (1.05) 3.44 (1.14) .0002
PSS perceived stress 24.64 (7.81) 18.36 (5.15) 21.72 (7.14) 22.91 (7.54) .0001
RRQ rumination 3.42 (0.83) 2.78 (0.63) 3.15 (0.92) 3.11 (0.90) .0006
SCS self-compassion 18.06 (3.97) 20.92 (3.84) 19.41 (3.75) 19.22 (4.12) .0001
MAAS mindfulness 3.76 (0.80) 4.01 (0.51) 4.05 (0.64) 3.80 (0.62) .006
Note. n ⫽22 in MBSR group; n⫽32 in control group. The p
inter
column shows the ANOVA Group ⫻Time Interaction
Significance Levels. RRQ ⫽Reflection Rumination Questionnaire; PANAS ⫽Positive Affectivity Negative Affectivity
Schedule; STAI ⫽State/Trait Anxiety Inventory; PSS ⫽Perceived Stress Scale; SCS ⫽Self-Compassion Scale; MAAS ⫽
Mindful Attention Awareness Scale.
110 SHAPIRO, BROWN, AND BIEGEL

found in positive and negative affect and state
anxiety, all ps⬎.05.
Is Mindfulness Practice Time Associated
With MBSR Intervention Effects?
A final purpose of the study was to determine
whether amount of time spent in four mindful-
ness practices was related to the well-being and
distress outcomes. On average, participants in
the MBSR intervention reported spending 55.92
minutes per week (SD ⫽50.09) in all forms of
mindfulness practice. The most common prac-
tice reported was informal practice (M⫽60.41
min, SD ⫽62.74), followed by the body scan
(M⫽57.10 min, SD ⫽34.68), hatha yoga
(M⫽54.56 min, SD ⫽138.71), and then sitting
meditation (M⫽51.61 min, SD ⫽32.14). Re-
peated measures analyses of variance
(ANOVA) tested the effects of the mean num-
ber of weekly minutes of mindfulness practice
on prepost intervention changes in distress and
well-being. No significant effects of total
weekly mindfulness practice time over the 8
weeks of the MBSR program on prepost inter-
vention changes in distress and well-being were
found (all ps⬎.05). ANOVAs based on prac-
tice time over 8 weeks in each of the four
practices separately also failed to reveal signif-
icant effects on prepost MBSR changes in dis-
tress and well-being (all ps⬎.05).
Discussion
Preparation for the role of therapist can occur
on both professional and personal levels. Re-
search suggests that therapists, like other help-
ing professionals, are at risk for stress-related
psychological problems (e.g., Dryden, 1995).
Although sources of stress are well-studied in
mental helping professionals, implementation
of stress management interventions for this pop-
ulation is lacking (e.g., Edwards, Hannigan,
Fothergill, & Burnard, 2002). Training in self-
care may be a useful complement to the profes-
sional training of future therapists (e.g., Baker,
2003), and the present study was designed to
examine the mental health effects of one ap-
proach to self-care, based on the cultivation of
mindfulness, for therapists in training.
In support of our primary hypothesis, this
study found that a mindfulness-based stress re-
duction (MBSR) program was associated with
improvements in graduate counseling psychol-
ogy students’ mental health. Compared to co-
hort controls, students in the MBSR program
reported significant prepost course declines in
perceived stress, negative affect, state and trait
anxiety, and rumination, and significant in-
creases in positive affect and self-compassion.
These findings suggest that MBSR may not
only lower stress and distress but also enhance
the ability to regulate emotional states, as re-
flected in the declines in rumination. This may
be important in warding off depressive states
(Nolen-Hoeksema, Morrow, & Frederickson,
1993). In addition, the increases in self-
compassion are particularly relevant to the field
of counseling and therapy, as compassion for
self, as well as for clients, has been posited as an
essential part of conducting effective therapy
(Gilbert, 2006). Research demonstrates that
Table 2
Simple Regression of Pre- to Post-Intervention Residual Change in Study Outcomes on Pre- to Post-
Intervention Residual Change in Mindfulness (MAAS)
Outcome
Parameter estimates
BSE ␤
RRQ rumination ⫺.56 .18 ⫺.57
**
PANAS positive affect .25 .25 .22
PANAS negative affect ⫺.06 .38 ⫺.03
STAI anxiety, present .59 .41 .31
STAI anxiety, past month ⫺.79 .29 ⫺.52
**
PSS perceived stress ⫺5.56 1.49 ⫺.65
***
SCS self-compassion 2.95 .94 .58
**
Note. n ⫽22. MAAS ⫽Mindful Attention Awareness Scale; RRQ ⫽Reflection Rumination Questionnaire; PANAS ⫽
Positive Affectivity Negative Affectivity Schedule; STAI ⫽State/Trait Anxiety Inventory; PSS ⫽Perceived Stress Scale;
SCS ⫽Self-Compassion Scale.
**
p⬍.01.
***
p⬍.001.
111SELF-CARE TRAINING FOR CAREGIVERS

therapists who lack self-compassion and are
critical and controlling toward themselves, are
more critical and controlling toward their pa-
tients and have poorer patient outcomes (Henry,
Schacht, & Strupp, 1990). In general, the
present results support past research on the
mental health benefits of MBSR for helping
professionals and trainees (Cohen-Katz et al.,
2005; Rosenzweig et al., 2003; Shapiro et al.,
1998; Shapiro et al., 2005), while further sug-
gesting that MBSR may have broad-based ef-
fects on a number of cognitive and affective
qualities relevant to mental health.
Supporting our second hypothesis, this study
found that MBSR participation increased levels
of mindfulness. It has been assumed that MBSR
enhances mindfulness because this is the focus
of the program. However, to date, only one
published study has demonstrated that MBSR
participation is associated with significant in-
creases in mindfulness (Cohen-Katz et al.,
2005). Further, we tested, and found partial
support for our third hypothesis, namely that
increases in mindfulness were related to the
beneficial effects of MBSR on mental health.
Increases in mindful attention and awareness
were associated with declines in perceived
stress, anxiety, and rumination, and increases in
self-compassion. These findings provide sup-
port for the claim (Shapiro, Carlson, Astin, &
Freedman, 2006) that mindfulness is a central
feature of MBSR that is related to the positive
outcomes of the program. This latter result also
supports past MBSR research showing that in-
creases in MAAS-measured mindfulness are re-
lated to mental health enhancement (Brown &
Ryan, 2003). Together, these results suggest
that the enhancement of mindfulness that is
foundational to MBSR instruction may be at
least partially responsible for its beneficial
effects.
Although not hypothesized, this study exam-
ined whether the amount of mindfulness prac-
tice over the course of the MBSR program was
related to changes in psychological distress
and well-being. No significant relations were
found, a finding of other research as well (e.g.,
Davidson et al., 2003). The experiential practice
of mindfulness skills is an important component
of the MBSR program and is believed to carry
some of the responsibility for its benefits. The
sample in the present study was not large, and
this may have inhibited our ability to detect
significant effects for practice time. Also, the
average weekly time spent in mindfulness prac-
tice was quite limited, and the effects of practice
on psychological outcomes may only appear
when some critical threshold of practice time
has been met. In this regard, it is notable that in
Carson et al.’s (2004) study showing that the
amount of mindfulness practice was related to a
number of intrapersonal and interpersonal out-
comes, the average participant practiced 32
minutes per day (224 min per week), 4 times
more than the average participant in the present
study. That said, it is likely that quality of
practice time is potentially as relevant to out-
comes as the quantity thereof.
2
This issue de-
serves consideration in future research.
The study findings suggest implications for
further research on therapist trainee self-care.
Graduate counseling and other mental health
care training programs are challenged to find
ways to support the health and well-being of
students while offering professional training in
therapy knowledge and skills (Shapiro, Shapiro,
& Schwartz, 2000). That the introduction of a
brief mindfulness-based intervention into the
graduate curriculum demonstrated a number of
mental health benefits in this study suggests that
research should further explore the utility of
MBSR and other awareness-based self-care
programs as a complement to core trainee
curricula.
Limitations and Future Research
The present study was limited in several ways
and suggests several possibilities for future re-
search. Most notably, this study was not a ran-
domized trial. The study was cohort-controlled,
as all participants were graduate counseling
psychology students. No meaningful differ-
ences between MBSR and control group partic-
ipants were found at baseline, but the lack of
randomization did not allow us to control for
potential motivational differences that may
have affected course selection and subsequent
experience. For example, all three courses were
required for the minor in health psychology, but
only the control group courses were required for
the general MA in counseling psychology.
2
We thank an anonymous reviewer for pointing out this
distinction.
112 SHAPIRO, BROWN, AND BIEGEL

Therefore, the majority of students in the Stress
Management course likely had a particular in-
terest in health psychology that may have led to
motivational differences from those taking the
control group courses. However, motivation or
expectation can create or exacerbate group dif-
ferences when intervention and active control
group programs are structurally divergent
(Baskin, Tierney, Minami, & Wampold, 2003),
and in this regard it is notable that the MBSR
and control group courses in this study were
structurally equivalent in course modality, in-
structor attention, and both weekly class time
and total course duration. However, research
using randomized controlled study designs
would help to control for potential motivational
effects.
The sample sizes in the present study were
relatively small, and research using larger sam-
ples is required to test the reliability of the
results found here. Also, most participants were
women, and it is possible that men and women
may respond differently to the MSBR program,
although no evidence for gender differences has
been reported in past research. Another limita-
tion in generalizability is that all participants
were students in a small private graduate pro-
gram. These results might not apply to doctoral
students or to students at larger and/or public
universities. Future research could explore the
effects of MBSR with other graduate psychol-
ogy populations and in clinical training sites,
where the effects of MBSR participation on
clinician-client interaction and therapy out-
comes might be explored.
Finally, future research would do well to in-
clude follow-up assessments to determine
whether the positive effects of the MBSR pro-
gram found here are lasting. It would be espe-
cially useful to know whether MBSR participa-
tion, and the enhancement of mindfulness that
appears to be achieved through the program,
can help to inoculate beginning counselors and
therapists against the stresses of their new de-
manding profession. The effects of mindfulness
training on positive affect and self-compassion
found here may help to enhance professional
skills, reflected in a greater kindness toward,
and acceptance of clients and patients, and this
could also be explored in future research. Future
longitudinal research could help to answer these
questions.
Conclusion
Recent years have witnessed an increase in
the number of educational programs designed to
train the “whole person,” many of them using
contemplative methods (Garrison Institute,
2005). Yet research to determine the specific
benefits and applications of such methods has
only begun. We believe that individuals training
for demanding helping professions may repre-
sent a particularly suitable population for in-
struction in such methods. The present study
found that one contemplative approach, based
on the cultivation of mindfulness, had mental
health benefits for therapists in training. It is
hoped this study will help to build a foundation
for future research investigating a variety of
potential benefits of mindfulness training for
prospective therapists.
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Accepted December 18, 2006 䡲
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