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MINDFUL ACCEPTANCE LOWERS STRESS REACTIVITY Lindsay
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Acceptance lowers stress reactivity:
Dismantling mindfulness training in a randomized controlled trial
Emily K. Lindsaya
Shinzen Youngb
Joshua M. Smythc
Kirk Warren Brownd
J. David Creswella
(in press, Psychoneuroendocrinology)
aCarnegie Mellon University; bUniversity of Vermont; cPennsylvania State University; dVirginia
Commonwealth University
Corresponding author: Emily K. Lindsay; Carnegie Mellon University Department of Psychology, 342C Baker
Hall, 5000 Forbes Avenue, Pittsburgh, PA 15213; phone: 412-268-8113; fax: 412-268-2798; email:
elindsay@andrew.cmu.edu
Word count: 6,690 (Introduction: 647; Discussion: 1,928)
Number of figures: 3
Number of tables: 2 (plus 1 supplementary online table)
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Abstract
Objective: Mindfulness interventions, which train practitioners to monitor their present-moment experience
with a lens of acceptance, are known to buffer stress reactivity. Little is known about the active mechanisms
driving these effects. We theorize that acceptance is a critical emotion regulation mechanism underlying
mindfulness stress reduction effects.
Method: In this three-arm parallel trial, mindfulness components were dismantled into three structurally
equivalent 15-lesson smartphone-based interventions: (1) training in both monitoring and acceptance
(Monitor+Accept), (2) training in monitoring only (Monitor Only), or (3) active control training (Coping
control). 153 stressed adults (mean age = 32 years; 67% female; 53% white, 21.5% black, 21.5% Asian, 4%
other race) were randomly assigned to complete one of three interventions. After the intervention, cortisol,
blood pressure, and subjective stress reactivity were assessed using a modified Trier Social Stress Test.
Results: As predicted, Monitor+Accept training reduced cortisol and systolic blood pressure reactivity
compared to Monitor Only and control trainings. Participants in all three conditions reported moderate levels of
subjective stress.
Conclusions: This study provides the first experimental evidence that brief smartphone mindfulness training
can impact stress biology, and that acceptance training drives these effects. We discuss implications for basic
and applied research in contemplative science, emotion regulation, stress and coping, health, and clinical
interventions.
Trial Registration: Clinical Trials NCT02433431
Key Words: mindfulness; acceptance; attention; stress reactivity; mechanisms; stress biology
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1. Introduction
Mindfulness meditation training has emerged as a leading stress reduction approach in recent years
(Creswell & Lindsay, 2014). For example, eight-week mindfulness interventions have been shown to reduce
physiological and subjective reactivity to acute stress challenge tasks (Britton et al., 2012; Hoge et al., 2013;
Nyklíček et al., 2013). Still, little is known about the active mechanisms of mindfulness interventions that drive
these stress reduction effects. Mindfulness training commonly involves using attention to monitor present-
moment experience while fostering acceptance of one’s current state (Bishop et al., 2004). One possibility is
that acceptance – defined as an orientation of noninterference and openness toward momentary sensory
experience (i.e., thoughts, emotions, body sensations, sights, and sounds) – is a critical emotion regulation
mechanism (Hölzel et al., 2011) underlying mindfulness training stress reduction effects (Lindsay & Creswell,
2017). In contrast to avoiding, altering, or focusing narrowly on salient negative stimuli, acceptance is an
attitude of receptivity and equanimity toward all momentary experiences that allows even stressful stimuli to
arise and pass without reactivity. Self-reported acceptance skills are associated with lower physiological and
neural stress reactivity (Paul et al., 2013; Shallcross et al., 2013), and emotional acceptance is an effective
strategy for regulating negative affect (Kohl et al., 2012) that may dampen physiological reactivity to emotional
stimuli (Dan-Glauser & Gross, 2015). To evaluate the importance of acceptance training as a stress reduction
mechanism in mindfulness interventions, we report the results of the first three-arm randomized controlled
dismantling trial that compares a full mindfulness training program (Monitor+Accept) to a mindfulness training
program without acceptance instructions (Monitor Only) and an active placebo controlled program (Coping
control).
Although there are now multiple evidence-based in-person mindfulness training interventions
demonstrating stress buffering effects (e.g., Mindfulness-Based Stress Reduction (MBSR); Creswell & Lindsay,
2014), a range of ‘remote’ (e.g., online; smartphone-based) mindfulness interventions are now widely used
(Creswell, 2016; Wahbeh et al., 2014). These remote interventions are more accessible, inexpensive, and
scalable compared to in-person interventions. Several studies have demonstrated benefits of two- to three-week
remote mindfulness interventions for increasing compassion (Lim et al., 2015) and reducing general stress
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perceptions (Cavanagh et al., 2013; Glück & Maercker, 2011), but no studies have tested whether brief remote
mindfulness training reduces acute physiological stress reactivity. The present study employed a 15-lesson
smartphone intervention to test its efficacy for reducing stress reactivity (Monitor+Accept vs. Coping control)
and to clarify the underlying components of mindfulness training that drive these effects (Monitor+Accept vs.
Monitor Only). By offering a high degree of experimental control (e.g., one instructor teaches all treatment
programs, content is standardized, social contact and discussion is controlled), this smartphone intervention
approach allowed for an experimental dismantling of the components unique to mindfulness training.
This study tests the primary hypothesis that acceptance training is a necessary component for
mindfulness intervention stress reduction effects. Stressed adults were randomly assigned to receive one of
three structurally equivalent programs: (1) Monitor+Accept (MA), standard mindfulness training with
instruction in both monitoring and acceptance techniques, (2) Monitor Only (MO), instructing monitoring
techniques only, or (3) Coping control, providing guidance in free reflection, analytic thinking, and problem
solving.1 After the two-week at-home intervention period and a pre-stress booster session, stress reactivity was
assessed using a modified Trier Social Stress Test (mTSST; Kirschbaum et al., 1993); exaggerated cortisol and
blood pressure responses to acute laboratory stressors are important markers of long term health outcomes (e.g.,
Cohen et al., 2002; Matthews et al., 2004). This pre-registered trial was designed to test the prediction that
Monitor+Accept mindfulness training would reduce cortisol, blood pressure, and subjective stress reactivity
compared to Monitor Only and control trainings.
2. Methods
2.1. Participants
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1 Mindfulness is conceptualized in relation to present moment experience, and as we later discuss, because this
study was designed to test whether acceptance modifies one’s relationship to momentary experience (Lindsay &
Creswell, 2017) in ways that reduce stress reactivity, we did not develop an Acceptance Only comparison
program.
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Enrolled participants were 153 stressed adults (mean age=32 years, SD=14; see Table 1 for baseline
characteristics) recruited from the Pittsburgh community via participant registries, community advertisements,
and mass emails to local organizations for a study testing smartphone training programs for managing stress.
Primary study analyses are reported on data available from 144 participants who completed study assessments;
N=4 participants discontinued before the post-intervention assessment, and N=5 discontinued participation
during the mTSST (see Figure 1 for CONSORT flow chart). No participants withdrew due to adverse effects.
The study design and hypotheses described here are pre-registered with Clinical Trials identifier
NCT02433431, and this report describes the stress reactivity outcome data (secondary trial outcomes). Eligible
participants were English-speaking smartphone owners (Android or iPhone) between the ages of 18-70 years2
who scored >5 on the 4-item Perceived Stress Scale (reflecting higher-than-average perceived stress; Cohen et
al., 1983; Cohen & Williamson, 1988; Warttig et al., 2013). To minimize the interference of medical conditions
and behaviors on primary stress and biological outcomes (and to ensure the safety of participants and research
staff), participant exclusion criteria included: chronic mental or physical disease; hospitalization for mental or
physical illness in the past 3 months; medication use that interferes with HPA axis or immune system
functioning; current antibiotic, antiviral, or antimicrobial treatment; use of oral contraceptives; and travel to
countries on CDC travel alert list in the past 6 months (for potential bloodborne pathogen exposure). Finally, in
order to test the effects of developing mindfulness skills in a novice population, those with a regular systematic
mind-body practice (greater than 2 times per week) were excluded. Written informed consent was obtained
from all participants, and all study procedures were approved by the Carnegie Mellon University IRB. Study
data was collected between February 2015 and April 2016. Trial recruitment was stopped when the goal of
enrolling 150 participants was reached.
Previous 8-week mindfulness intervention studies have demonstrated a medium effect size for stress
reactivity outcomes (Cohen’s d=.63; Nyklíček et al., 2013) and pilot 2-week online mindfulness training
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2 While initial plans involved enrolling an older sample, due to recruitment difficulties, the eligible age range
was expanded after enrolling four participants.
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interventions show small-medium effects on general stress perceptions (d=.37–. 46; Cavanagh et al., 2013;
Glück & Maercker, 2011). Thus, estimating an effect size of d=.52, G*Power calculated a total of N=147
participants needed to detect omnibus differences between three study conditions at 80% power using an
ANOVA (Faul et al., 2007). The stress reactivity data reported here were not analyzed until the complete
dataset was collected.
2.2. Procedure
Briefly, as part of the larger three-arm parallel trial, interested participants were pre-screened for
eligibility by telephone, then further screened at an in-person baseline assessment (which began between
2:00pm and 6:00pm). Subject IDs were assigned sequentially, and the study PI used a random number generator
to pre-assign one of three condition codes to each ID in blocks of 8, 16, or 24 using a 3-3-2 randomization
sequence (so that for every 8 participants enrolled, 3 were assigned to MA, 3 to MO, and 2 to control). Trained
study staff enrolled eligible participants and instructed participants to download their assigned intervention by
code (all participants were blind to study condition, and study staff were blind to condition in 76% of baseline
sessions3). Enrolled participants provided a dried blood spot (DBS) sample, completed a questionnaire and task
battery, and were oriented to the at-home study assessments and intervention. During three weeks of at-home
study activities, participants completed three consecutive days of pre-intervention experience sampling, a 14-
day intervention period (see Materials), and three consecutive days of post-intervention experience sampling.
Participants received study reminder texts and phone calls throughout the at-home period, and were able to call
or text our study hotline to ask questions or resolve technical issues. DBS and experience sampling outcomes
will be reported in other manuscripts.
The mTSST stress reactivity findings described in this report were assessed at post-intervention.
Participants returned for this assessment between 2:00pm and 6:00pm to control for diurnal variation in cortisol
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3 Study managers who contacted participants during the intervention period were not blind to condition code.
Study managers also served as experimenters in cases when blind research assistants were unavailable (e.g.,
during semester breaks). All mTSST evaluators were blind to condition.
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(mean=3:51pm; no differences between conditions: F(2,145)=0.30, p>.250). The appointment was an average
of 4.66 days (SD=1.88) after the at-home intervention (range: 3-12 days, with 86% of appointments occurring
within 5 days; see Table 2). In 89% of post-intervention sessions, experimenters were blind to study condition.
Participants first provided a DBS sample and then were seated, fitted with a blood pressure cuff, and
administered a post-intervention questionnaire and task battery (not reported here). During this time, the pre-
stress blood pressure (BP) reading (starting ~10 minutes after arrival) and a pre-stress saliva sample (~25
minutes after arrival) for cortisol assessment were taken (see Measures). A modified version of the Trier Social
Stress Test (mTSST; Kirschbaum et al., 1993) was used to manipulate social-evaluative stress reactivity in a
controlled laboratory setting. Participants heard pre-recorded instructions (2.5 minutes in length) for the speech
performance (“defend yourself against a false shoplifting charge”; Cohen et al., 2002; Franzen et al., 2011) and
were given three minutes to mentally prepare for the speech (BP Preparation period). Then, the lights were
dimmed for a 20-minute booster training based on condition assignment (BP Training period; see Interventions
for additional detail).
Next, two evaluators (blind to study condition) dressed in white lab coats and carrying clipboards
administered the mTSST (BP Performance period). Participants were videotaped giving a 5-minute speech
(mTSST speech) and performing 5 minutes of mental arithmetic (counting backwards from 2083 by 17s;
mTSST math). Evaluators maintained a cold and non-accepting attitude, giving critical feedback during the
speech task and pointing out errors during the math task. Participants completed subjective stress ratings after
the mTSST speech and after the mTSST math portions of the task (see Measures). If a participant expressed any
desire to quit during the mTSST, an evaluator confirmed by asking, “Would you like to discontinue the task?”
and, if affirmed, the experimenter returned to the room for debriefing. Otherwise, participants remained seated
for a 5-minute recovery period (BP Recovery period), after which the experimenter returned and removed the
blood pressure cuff. Participants then completed several post-mTSST questionnaires and tasks. Saliva samples
were taken exactly 25 and 35 minutes after the start of the mTSST to measure peak cortisol reactivity.
After all outcome measures were collected, participants filled out a training program evaluation. They
were then funnel debriefed to probe for suspicion about the evaluators and were fully debriefed on the nature of
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the mTSST to reduce distress (that the task was designed to be stressful, the evaluators were trained to be
critical, and their own performance was normative). Participants were informed of the primary aims of the study
(to test the active ingredients of mindfulness training), were given access to the training program of their choice,
and were compensated for their time. A final saliva sample for cortisol assay was taken exactly 60 minutes after
the start of the mTSST.
2.3. Materials
2.3.1. Intervention Programs
Participants were randomly assigned to receive one of three 15-lesson smartphone-based interventions
(described below and in Supplementary Table 1): Monitor+Accept, Monitor Only, or Coping control. To
maximize experimental control in isolating the effects of monitoring and acceptance instruction, all three
interventions were delivered by the same female voice (an experienced meditation instructor) and were matched
on attentional demand, length, structure, and delivery tone. To equalize expectancies at the baseline
appointment, all participants viewed the same 5-minute introductory video explaining how to prepare for and
what to expect in the training program, and “mindfulness” was not mentioned during the study period. During
the 14-day at-home intervention period, participants were expected to complete one 20-minute audio lesson
(tied to their condition assignment) each day, plus brief homework practice (3-10 minutes per day). Participants
were required to complete lessons in order and could not skip or repeat lessons. Each lesson trained specific
techniques through didactic explanation (what the technique was and how it would help), guided practice, and
self-guided practice. An unblinded study manager contacted all participants by phone on Days 3 and 9 of the
intervention program to answer training-specific questions, address difficulties, and encourage program
adherence. After the 14-day intervention period, the training program was deactivated (although a training
program of choice was provided upon study completion).
An average of four to five days after the 14-day intervention period, participants received a 20-minute
booster training (lesson 15) during the post-intervention assessment (before the mTSST). Each booster lesson
began by addressing the upcoming performance task, encouraging participants to apply the skills learned
throughout the course during this challenge; the lesson then presented guided content from the training course
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that best represented the targeted skills. Guidance was interspersed with silent practice in 30- to 120-second
blocks, totaling an average of 13 minutes of silence (13.5 minutes in MA, 12.5 minutes in MO, 12.5 minutes in
control).
The intervention programs were developed in collaboration with leading mindfulness teacher Shinzen
Young and were based on his Unified Mindfulness system (Young, 2016b). MA and MO were designed to
systematically parse mindfulness instruction in (1) monitoring and (2) acceptance. See Supplementary Table 1
for an outline of lesson content in each training condition. Full intervention scripts are available for research
purposes by request.
2.3.1.1. Monitor + Accept (MA): MA participants first learned foundational concentration skills, which
enabled them to (1) monitor their present-moment body experience (in the lessons, this skill was referred to as
‘sensory clarity’) while (2) welcoming and accepting each experience (referred to as ‘equanimity’).
Specifically, concentration was described as an intrinsically rewarding state of stable attention (cf.
Csikszentmihalyi, 2000) on the intended target (in this intervention, the focus was physical and emotional body
experiences; e.g., physical sensations on the skin, muscle sensations, ongoing physiology, temperature changes,
sleepiness, etc., as well as body sensations related to emotions, such as anger, fear, sadness, impatience, interest,
joy, enthusiasm, anxiety, etc.). Monitoring (‘sensory clarity’) was explained in terms of two dimensions:
resolution (discriminating types of experiences; e.g., pleasant, unpleasant, neutral; physical vs. emotional; level
of intensity; locations and movement patterns of sensations) and sensitivity (detecting subtle sensations; e.g.,
faint sensations related to pleasant activities and emotions; fleeting waves of unpleasant emotions). Acceptance
(‘equanimity’) was trained through three tangible strategies that embody the attitude of acceptance: participants
were encouraged to (a) maintain a state of global body relaxation4, (b) mentally welcome all physical and
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4 In contrast to systematically relaxing each part of the body, the encouragement to maintain a sense of
relaxation throughout the body – while simultaneously allowing and accepting physical tension and
uncomfortable experiences – is a strategy that creates openness to sensory experiences and cultivates
nonreactivity and noninterference.
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emotional body experiences, and (c) use a gentle, matter-of-fact tone of voice (an ‘equanimity tone’) while
labeling these experiences.
2.3.1.2. Monitor Only (MO): The MO program trained participants only to concentrate on and (1)
monitor physical and emotional body experience (as described above), with no instruction on acceptance.
2.3.1.3. Coping control: The Coping control training program (referred to in the lessons as ‘MyTime’)
was developed to parallel the structure of MA and MO without encouraging focus on or acceptance of present
experience. Instead, participants were instructed to freely reflect and let their minds drift (in contrast to
concentration developed in MA and MO), reframe or reappraise past and anticipated events (with past and
future emphasis contrasting present-focused monitoring, and change strategies contrasting acceptance
strategies), and analyze and solve personal problems (again encouraging active change rather than acceptance of
momentary experiences). Although positive reappraisal may be a downstream consequence of practicing
mindfulness (cf. Garland et al., 2015), reappraisal is a change-based strategy that is not trained in mindfulness
or acceptance-based interventions (cf. Hayes, 2004) and is therefore suitable as a comparison technique. The
Coping control program was designed to be useful for managing stress (reinforcing common reappraisal and
coping strategies; cf. Carver et al., 1989; Ochsner & Gross, 2005) without training mindfulness and was
included to control for nonspecific effects of undergoing a training program (e.g., treatment expectancies, daily
time and effort toward the goal of reducing stress). Overall, this active Coping control program was expected to
modestly reduce subjective stress reactivity and minimally reduce biological stress reactivity.
2.3.2. Measures
2.3.2.1. Treatment Adherence: The smartphone training application automatically timestamped the
initiation and completion of each lesson in the 14-day at-home training period. This electronic timestamp was
used to calculate the total number of at-home lessons completed for each individual.
2.3.2.2. Treatment Expectancies: To evaluate whether all three training programs produced equivalent
perceived treatment benefits, participants completed an adapted 6-item Credibility/Expectancy Questionnaire
(Devilly & Borkovec, 2000) to assess their beliefs about the efficacy of the training program at post-
intervention (but before beginning the mTSST procedures). Logical (e.g., “how successful do you think this
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program was in reducing your stress symptoms?”) and emotional (e.g., “how much improvement in your
symptoms do you really feel occurred?”) subscales were averaged to create an overall measure of positive
treatment expectancies (Cronbach’s α=.95).
2.3.2.3. Salivary Cortisol: Four saliva samples were collected using Salivettes (Rommelsdorf,
Germany): (1) at the beginning of the final study appointment (an average of 26 minutes after arrival), (2) 25
minutes after the mTSST start (an average of 81 minutes after the pre-stress sample was collected), (3) 35
minutes after mTSST start, and (4) 60 minutes after mTSST start. Participants held Salivettes in their mouths
for two minutes during each collection period, and did not touch the samples with their hands. Bottled water
was provided during the session to increase hydration and help avoid sample loss due to lack of saliva, but
water was removed 10 minutes before each sample collection. Salivettes were stored at -20°C in a secure
laboratory freezer. Samples were shipped in one batch to Dresden, Germany for cortisol measurement. Cortisol
was measured using a high sensitivity chemoluminescence-immuno-assay (IBL International, Hamburg,
Germany). Intra- and inter-assay coefficients of variability in this laboratory are typically below 10%. Of the
576 samples collected from mTSST completers, 5.73% of Salivettes did not contain enough saliva to assay.
2.3.2.4. Blood Pressure: Oscillometric blood pressure was collected using an automatic
sphygmomanometer (Dinamap Carescape V100, General Electric Company, Finland). Systolic (SBP) and
diastolic (DBP) blood pressure were recorded at 2-minute intervals during five experimental epochs. Averages
of these 2-minute readings were calculated during a 5-minute Pre-Stress epoch (an average of 12 minutes after
arrival), the 3-minute mTSST speech Preparation epoch (an average of 41 minutes after the Pre-Stress
recording), the 20-minute booster Training epoch, the 12-minute mTSST Performance epoch, and a 5-minute
Recovery epoch directly after the mTSST. Participants were seated throughout the blood pressure measurement.
Due to equipment malfunction, data for one epoch was missing for N=4 participants (preparation or recovery),
data from two epochs was missing for N=1 participant (performance and recovery), and data from four epochs
was missing for N=1 participant (preparation through recovery).
2.3.2.5. Subjective Stress Reactivity: During the mTSST procedure, participants used visual analog
scales to rate their perceptions of stress immediately after the 5-minute speech task and again immediately after
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the 5-minute math task (Creswell et al., 2014; Hellhammer & Schubert, 2012). Specifically, after each task,
participants indicated how stressed, anxious, and insecure they felt by drawing a slash mark on a 140mm line
from 0 (not at all) to 100 (highly) (with intermediate anchors at 25, 50, and 75). Distance from 0 was measured
in centimeters, divided by 14, and multiplied by 100 to create a stress percentage score for each item. One
composite subjective stress reactivity score was created by averaging all six ratings (Cronbach’s α=.90), with
higher values representing greater stress perceptions.
2.4. Analyses
Analyses were conducted with SPSS Statistics 23.0 software (IBM, Armonk, New York) and Stata/SE
14.0 (StataCorp, College Station, Texas). Preliminary analyses (conducted in SPSS) evaluated baseline success
of randomization using chi-square (for categorical variables) and ANOVA tests (for continuous variables). The
measure of treatment expectancies was evaluated as a covariate using ANOVA to test for significant differences
between conditions. ANOVAs were also used to test for condition differences in treatment adherence, post-
intervention procedures, and pre-stress cortisol and blood pressure. Finally, preliminary analyses checked the
success of the mTSST in inducing physiological stress; specifically, paired-samples t tests tested for differences
between pre-stress and peak mTSST cortisol and BP reactivity across the entire sample.
To test primary study predictions, ANOVAs (in SPSS) and Mixed Linear Models (MLMs; in Stata)
tested for condition differences on stress reactivity outcomes. MLMs are robust to missing data because they
model all available data, and were used for analyses that included time as a within-subject variable. Variables of
interest (time, study condition) were modeled as fixed effects using maximum likelihood estimation. The
repeated measures variable (time) was modeled with an unstructured covariance structure, with pre-stress values
used as the first repeated measure to test for time interactions with the predictor variable (study condition). If
included, covariates were modeled as fixed effects. Within each MLM, omnibus tests of condition differences at
each mTSST reactivity time point were conducted, and pairwise comparisons contrasted MA vs. MO and
control at each time point (accounting for pre-stress levels).
2.4.1. Cortisol reactivity analyses. First, because they were not normally distributed, raw cortisol values
were natural-log-transformed at each of four time points. Then, intervention condition differences in cortisol
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reactivity were tested in two steps. Area under the curve with respect to increase (AUC-I) was calculated with a
trapezoid formula (Pruessner et al., 2003) that subtracts out the pre-stress cortisol level in order to measure
reactivity (i.e., increase in cortisol from pre-stress levels): (cortisol 1 + cortisol 2)*81 mins/2 + (cortisol 2 +
cortisol 3)*10 mins/2 + (cortisol 3 + cortisol 4)*25 mins/2 – cortisol 1*(81+10+25). As this formula requires
data at all four time points, and one or more values was missing from N=14 (9.72%) participants, the
Expectation Maximization (EM) algorithm (based on all available cortisol data) was used to replace missing
values before calculating a total AUC-I for each participant. An ANCOVA then tested for condition differences
in cortisol AUC-I and pairwise comparisons contrasted MA with MO and control training. Then, an MLM
(which requires no missing data imputation) tested for condition differences in cortisol reactivity over time (pre-
stress, 25-, 35-, and 60-minutes post-mTSST), as well as omnibus and pairwise differences at each post-mTSST
time point (accounting for pre-stress levels). As menstrual cycle phase is known to impact cortisol reactivity
(Kirschbaum et al., 1999), all cortisol analyses controlled for follicular stage on the day of the post-intervention
session (women on menstrual cycle days 4-12 vs. all others, including men and post-menopausal women).
2.4.2. BP reactivity analyses. Intervention condition differences in SBP and DBP reactivity were tested
in MLMs focusing on the interaction between study condition and time (pre-stress, preparation, training,
performance, and recovery epochs), using all available data. Follow-up analyses within each MLM tested for
omnibus and pairwise condition differences in peak BP reactivity during the mTSST performance epoch
(accounting for pre-stress levels), the main contrast of interest.
2.4.3. Subjective stress reactivity analyses. ANOVAs were used to test for condition differences in
subjective stress reactivity.
3. Results
3.1. Preliminary Analyses
First, success of randomization on major demographic characteristics in the full randomized sample
(N=153) was evaluated. There were no pre-existing condition differences on age, sex, race, ethnicity, education,
or body mass index (BMI) (see Table 1A for details).
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Second, condition differences in the intervention and post-intervention assessment protocol were tested
among participants who returned at post-intervention (N=149; see Figure 1 and Table 1B for details).
Participants in all conditions were highly adherent to the training programs, with no condition differences in
treatment adherence (F(2,146)=0.40, p>.250). On average, participants completed 13.49 of the 14 at-home
lessons, and 75% of participants completed all 14 lessons (1.3% of participants completed fewer than 10
lessons). All participants who returned for the post-intervention assessment received booster lesson 15. There
were no condition differences in treatment expectancies (F(2,146)=1.55, p=.216), indicating similar perceptions
of treatment benefits across all three training conditions, and additional analyses that included treatment
expectancies as a covariate did not appreciably impact any of the primary outcomes (data not shown). At the
post-intervention assessment, there were no condition differences in pre-stress raw or log-transformed cortisol
levels (see Table 1B), time of first cortisol sample (M=4:18pm, SD=1:37; F(2,145)=.28, p>.250), or time of
peak cortisol sample (M=5:40pm, SD=1:37; F(2,144)=.22, p>.250). Similarly, there were no condition
differences in pre-stress systolic or diastolic blood pressure at the post-intervention assessment (see Table 1B).
In a final set of preliminary analyses, paired-samples t tests demonstrated the efficacy of the mTSST
manipulation in producing a physiological stress response. Across all participants with pre-stress and peak (25
minutes post-mTSST onset) saliva samples (N=135), there was a significant increase in log cortisol from pre-
stress to peak reactivity (t(134)=-4.06, p<.0005, d=.61), confirming that the mTSST produced a significant
neuroendocrine stress response. Similarly, there were significant increases in SBP (t(141)=-23.32, p<.0005,
d=1.59) and DBP (t(141)=-23.56, p<.0005, d=1.54) from pre-stress to mTSST performance, confirming that the
mTSST produced a significant cardiovascular stress response.
3.2. Primary analyses
3.2.1. Cortisol reactivity. First, to evaluate the hypothesis that MA training would reduce cortisol
reactivity in response to the mTSST to a greater degree than MO and control trainings, an ANOVA tested for
condition differences in log cortisol AUC-I (replacing missing data with EM estimated values) and an MLM
tested for time × condition interactions in log cortisol (using all available data). All cortisol analyses included
follicular phase as a covariate. There was a significant effect of study condition on log cortisol AUC-I
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(F(2,140)=3.20, p=.044; see Table 2 for descriptive statistics). Specifically, MA-trained participants had
significantly lower log cortisol AUC-I than MO- and control-trained participants (MA vs. MO: F(1,140)=4.44,
p=.037, d=.40; MA vs. control: F(1,140)=4.79, p=.030, d=.47). Second, using all available data, an MLM
revealed a significant main effect of time across study conditions (χ2(3)=176.65, p<.0005), a significant main
effect of study condition across all four time points (χ2(2)=6.25, p=.044), and, consistent with our primary
predictions, a significant time × condition effect on log cortisol (χ2(6)=12.80, p=.046). Figure 2 depicts this time
× condition interaction. Within this MLM (which accounts for pre-stress cortisol levels), planned comparisons
showed that MA-trained participants had significantly lower log cortisol at 25- and 35-minutes post-mTSST
compared to MO-trained participants (25-minutes: χ2(1)=6.05, p=.014, d=.50; 35-minutes: χ2(1)=6.26, p=.012,
d=.51) and control-trained participants (25-minutes: χ2(1)=7.26, p=.007, d=.62; 35-minutes: χ2(1)=5.98, p=.015,
d=.55) (see Table 2). There were no significant differences in cortisol reactivity between MO and control
interventions at any measurement point (all ps>.250).
3.2.2. BP reactivity. MA training was also hypothesized to significantly reduce BP stress reactivity
compared to MO and control trainings. To test for condition differences in SBP, an MLM using all available
data revealed a significant main effect of time (χ2(4)=1066.22, p<.0005), a significant main effect of study
condition (χ2(2)=6.45, p=.040), and a marginal time × condition interaction (χ2(8)=14.91, p=.061). Figure 3A
depicts the time × condition interaction on SBP. Consistent with predictions, there were significant condition
differences in SBP during the mTSST Performance period (see Table 2). Planned comparisons (accounting for
pre-stress SBP) showed that MA-trained participants had significantly lower SBP during the mTSST
Performance compared to MO- and control-trained participants (MA vs. MO: χ2(1)=4.34, p=.037, d=.41; MA
vs. control: χ2(1)=10.16, p=.001, d=.72). MA-trained participants also had significantly lower SBP during the
mTSST recovery period compared to control participants (χ2(1)=4.77, p=.029, d=.48).
An MLM using all available data did not support our hypothesis that MA training would significantly
reduce DBP reactivity; there was a significant main effect of time (χ2(4)=660.48, p<.0005), no main effect of
study condition (χ2(2)=4.18, p=.124), and no time × condition interaction on DBP (χ2(8)=10.52, p=.230) across
the post-intervention assessment (see Figure 3B). Although there were significant condition differences in DBP
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during the mTSST Performance period in isolation (with significant contrasts between MA vs. MO: χ2(1)=5.23,
p=.022, d=.45, and MA vs. control: χ2(1)=5.80, p=.016, d=.53; see Table 2), planned comparisons that account
for pre-stress DBP showed no differences between MA-trained participants compared to MO- and control-
trained participants (MA vs. MO: χ2(1)=1.68, p=.195, d=.25; MA vs. control: χ2(1)=2.63, p=.105, d=.35).
We had no specific hypotheses comparing MO vs. control, and MO-trained participants did not have
significantly lower SBP reactivity (χ2(1)=1.82, p=.177, d=.26) or DBP reactivity (χ2(1)=0.23, p>.250, d=.09)
during the mTSST Performance period compared to control-trained participants.
3.2.3. Subjective stress reactivity. Finally, an ANOVA tested the hypothesis that MA training would
reduce subjective stress reactivity compared to MO and control training. Contrary to this prediction, there were
no condition differences in average subjective stress reactivity (see Table 2).
4. Discussion
Acceptance training has been theorized as an essential component of mindfulness interventions for
improving affective reactivity, stress, and health outcomes (Lindsay & Creswell, 2017), but no mechanistic
dismantling studies have tested this hypothesis. This study provides the first experimental evidence that
acceptance is a critical component of mindfulness training for reducing biological stress reactivity; without
acceptance training (i.e., in the Monitor Only training condition), mindfulness stress buffering effects are
diminished or eliminated. Specifically, Monitor+Accept training reduced both neuroendocrine (salivary
cortisol) and sympathetic nervous system (systolic blood pressure only) stress reactivity biomarkers compared
to Monitor Only and control training. Acceptance may help to regulate stress reactivity by facilitating the
acknowledgement of (Teper & Inzlicht, 2013) and subsequent disengagement from (i.e., letting go; Vago &
Nakamura, 2011) all momentary sensory experiences, even difficult or stressful ones.
This study has a number of notable features. It is the first study to show that brief smartphone-based
mindfulness training can impact objective biological stress outcomes. This smartphone format also provided a
platform for dismantling the active components of mindfulness training, which allowed us to address
mechanistic questions. By tightly controlling the intervention content, we were able to observe the unique
contributions of attention monitoring and acceptance training beyond non-mindfulness-specific treatment
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elements (i.e., stress management and reappraisal skills in the placebo comparison program). Additionally,
study attrition using this brief smartphone approach was much lower than the typical rates observed in longer
group-based mindfulness programs (3% in this study) and program adherence was high (96%). The
generalizability of this approach is somewhat limited by disparities in smartphone ownership (among lower SES
and older adults; Poushter, 2016), although smartphone ownership continues to rise in these populations (e.g.,
increasing 12 percentage points among both lower-income and older Americans from 2015 to 2016; Smith,
2017). Moreover, program adherence would likely be lower outside the context of a structured study
intervention (Rahmati et al., 2012). Still, these findings demonstrate value in implementing smartphone-based
mindfulness interventions for a large proportion of stressed adults who lack resources for more expensive,
intensive, and potentially inaccessible in-person mindfulness programs.
The present findings have important basic and applied implications. Among mindfulness intervention
researchers and contemplative scientists, this study contributes evidence to an ongoing debate about the
importance of acceptance in contemporary mindfulness training interventions (e.g., Grossman & Van Dam,
2011). On one hand, mindfulness is translated simply as a state of clear awareness (Bodhi, 2011; Desbordes et
al., 2015; Quaglia et al., 2014); on the other hand, acceptance training is considered a skillful means for learning
mindfulness (Dreyfus, 2011) and is an active treatment element in mindfulness and other “third-wave”
interventions (Mennin et al., 2013). By comparing mindfulness interventions that include or exclude an
acceptance training component, this study shows that learning to accept one’s experiences produces measurable
biological stress reduction effects. These results are consistent with Buddhist monastic training, the culture of
origin for secular mindfulness training. In the Buddhist paradigm, monitoring (vipaśyanā) leads to sensory
clarity and insight (prajñā), whereas acceptance (i.e., equanimity, the ability to experience pleasure and pain
without interference) reduces craving (rāga) and aversion (dvesha), the necessary causes (samuccaya) for
suffering (duhkha) (Young, 2016b, 2016a). For basic researchers, these findings contribute to a growing
understanding of acceptance as an emotion regulation mechanism (Kohl et al., 2012), an approach that has
received less attention than other response-focused strategies (e.g., cognitive reappraisal). Likewise, among
stress and coping researchers, this study sheds new light on the construct of acceptance; this intentional form of
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experiential acceptance stands in contrast to the form of acceptance that resembles passive resignation and is
generally associated with poor outcomes in the health psychology literature (e.g., Reed et al., 1994). These
findings suggest the value of including (or emphasizing) acceptance training in existing stress management
interventions. While some psychotheraupeutic programs offer extensive acceptance skills modules (e.g., ACT;
Hayes et al., 2011), most stress management programs offer little formal instruction in acceptance. Exploring
the conditions under which acceptance training is beneficial (e.g., training dosage, individual differences in
adopting acceptance strategies) is an important research direction.
Although MA training reduced biological markers of stress reactivity (cortisol, systolic blood pressure),
contrary to initial predictions there were no condition differences in self-reported stress during the mTSST.
Several possibilities could explain this effect. It may be that all three active training programs compared in this
study were effective for decreasing perceptions of stress; participants in all programs reported equivalent
treatment benefits, and each program focused on stress management (e.g., the control program reinforced
reappraisal and coping strategies). It’s also possible that the self-report stress instrument was prone to well-
known response-set biases (Nisbett & Wilson, 1977), or was not sensitive to unique ways that mindfulness
trained participants perceive stress. For example, our stress scale did not distinguish between intensity of
experience and perceived suffering (similar to intensity and unpleasantness dimensions commonly measured in
the pain literature; cf., Price et al., 1987). Monitoring may make the experience of discomfort sensorially richer,
while acceptance may lessen the associated suffering (i.e., intensity is not problematic or viewed as unpleasant),
dimensions not captured in this stress instrument. Alternatively, although acute psychological and biological
stress responses are commonly dissociated, differences in emotion regulation strategy use (e.g., avoidance vs.
monitoring; reappraisal vs. acceptance) may moderate psychophysiological correspondence (for a review, see
Campbell & Ehlert, 2012). It’s possible that, by increasing awareness of subtle body cues, the Monitor+Accept
intervention increased coherence between stress biology (e.g., cortisol) and self-reported stress. Indeed,
previous work indicates that meditation experience increases the accuracy of self-reporting on physical
sensations (Fox et al., 2012) and mindfulness improves access to implicit emotional states (Brown & Ryan,
2003). Exploratory analyses showed that indeed there was a marginally stronger association between self-
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reported stress and cortisol reactivity (AUC-I) in the MA condition (r(55)=0.27, p=.043) compared to the MO
(r(54)=0.18, p=.201) and control conditions (r(35)=-0.08, p>.250) (MA vs. control z=1.59, p=.056). Though
consistent with the theory that monitoring one’s body experiences with acceptance facilitates greater openness
and access to subtle body cues, this finding requires replication.
While this study supports the Monitor and Acceptance Theory (MAT; Lindsay & Creswell, 2017)
prediction that explicit training in both monitoring and acceptance are necessary for reducing biological stress
reactivity, it raises additional questions. Contrary to MAT, which presents evidence that the self-reported
tendency to monitor one’s experiences may intensify reactivity (e.g., Desrosiers et al., 2014; Pearson et al.,
2015), there was no evidence that Monitor Only training exacerbated subjective or biological stress responses
compared to control training (which was expected to slightly reduce reactivity). Instead, these findings are more
consistent with MAT’s alternative prediction that structured monitoring practice, in contrast to the dispositional
tendency to monitor in the absence of meditation training, may promote adaptive outcomes. It’s possible that,
by simply acknowledging unpleasant stimuli without psychological resistance, systematically monitoring one’s
experiences may begin to engender an implicit orientation of acceptance. Or, strengthening one’s attentional
resources may by itself promote mental clarity and help to regulate emotions (Wadlinger & Isaacowitz, 2011).
Given the evidence that acceptance training facilitates reductions in biological stress reactivity, one
open question is whether acceptance alone is sufficient for driving these effects. Although this study aimed to
test the active mechanisms of mindfulness training where acceptance is taught in conjunction with monitoring
practice, some may see value in testing acceptance-only interventions (e.g., using a psychoeducational rather
than experiential acceptance training approach). A major challenge in developing acceptance interventions
devoid of attention monitoring training is how to instruct the orientation of acceptance toward experiences
without first bringing attention to those experiences. In this Monitor+Accept intervention and in standardized
mindfulness interventions, acceptance is trained in relation to monitored experience; thoughts, sensations, and
emotions monitored in the present moment are acknowledged with acceptance and equanimity. Moreover,
recent theorizing posits synergistic roles for monitoring and acceptance in reducing stress: monitoring draws
attention to emotional stimuli, and orienting toward negative states with acceptance transforms one’s
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relationship to these experiences in ways that attenuate negative reactivity (Lindsay & Creswell, 2017).
Nonetheless, the present results identify an opportunity to investigate whether training in acceptance skills only
might be a more efficient way to improve stress-related health outcomes.
It is important to acknowledge that our conclusions about mindfulness components and stress reactivity
are based on a 14-lesson mindfulness program plus a booster session. More research is needed to evaluate
whether the booster session is a necessary condition for reducing biological stress reactivity (i.e., it was
essential for activating the skills developed through the training program) or whether the effects of 14 days of
mindfulness training persist without this skills reminder session prior to stress exposure. Although some acute
interventions can shift one’s perspective in ways that promote a more adaptive physiological response to stress
(e.g., shifting from self-promotion to compassionate goals; appraising stress as functional; Abelson et al., 2014;
Jamieson et al., 2012), these single session inductions are quite different from the intervention approach tested
here. Given that previous evidence shows no benefits of mindfulness training for reducing biological stress
reactivity after 3 training sessions (with the 3rd session similarly acting as a booster session immediately before
mTSST performance; Creswell et al., 2014), the effects observed here likely hinge upon the development of
mindfulness skills over the course of 14 lessons. Still, these findings raise broad empirical questions about the
comparative efficacy, efficiency, and longevity of stress reduction interventions that induce acute mindset shifts
vs. those that develop new, more ingrained skills for responding to stress.
Relatedly, this study lends evidence to a developmental trajectory of mindfulness stress buffering
effects. Whereas previous research shows that 8 weeks (but not 3 sessions) of mindfulness training reduces
biological stress reactivity (Creswell et al., 2014; Nyklíček et al., 2013), we now show that an intermediate dose
- two weeks of daily mindfulness training plus a booster session - is effective for reducing biological reactivity.
Similarly, these findings contribute to research on the skill development of monitoring and acceptance.
Although acceptance inductions have been shown to attenuate physiological responding to mild emotional
stimuli (e.g., Campbell-Sills et al., 2006; Dan-Glauser & Gross, 2015; Hofmann et al., 2009), these brief
inductions are not effective for those inexperienced with acceptance strategies (e.g., Blacker et al., 2012; Evans
et al., 2014); for many, acceptance is a skill that takes time to develop (Baer, Carmody, & Hunsinger, 2012).
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Our results imply that two weeks of training is sufficient to develop acceptance skills that effectively reduce the
biological impact of stress. These findings prompt questions for further research in establishing the long-term
growth, maintenance, and stability of attention monitoring and acceptance skills and their effects on stress
reactivity (e.g., whether more extensive training in monitoring alone becomes equally effective as monitoring
with acceptance training; the importance of continued formal practice for maintaining benefits).
Finally, one important open question concerns the value of these acute stress reactivity effects for long-
term health and disease outcomes. Since greater cortisol and blood pressure reactivity to laboratory stress
predict certain health risks (e.g., respiratory infections, cardiovascular disease; Cohen et al., 2002; Matthews et
al., 2004), it’s possible that reduced stress reactivity effects like those observed here may confer some
protection against stress-related symptoms and disease risk among stressed adults (cf. Loucks et al., 2015).
4.1. Conclusions
This study provides the first experimental evidence that brief remote mindfulness training is effective
for reducing cortisol and systolic blood pressure reactivity to stress, and learning to accept one’s experiences is
critical for driving these effects. By changing the way individuals relate to and respond to stressors, acceptance
may reduce their biological stress responses to threatening events.
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5. Author Contributions
EL and JC developed the study concept. All authors contributed to the study design. EL prepared study
materials. SY and EL developed interventions. Testing and data collection were performed by trained research
assistants. EL performed the data analysis and interpretation under the supervision of JC, JS, and KB. EL
drafted the manuscript, and all authors provided critical revisions. All authors approved the final version of the
manuscript for submission.
6. Acknowledgements
This research was supported by the Yoga Science Foundation, the Mind & Life Institute Varela and 1440 award
programs, and the American Psychological Association. Recruitment was supported by the National Institutes
of Health (grant number UL1TR000005). These funding sources had no involvement in study design; data
collection, analysis, or interpretation; writing of this report; or the decision to submit this article for publication.
We thank Bill Koratos, Todd Mertz, Emily Barrett, Stephanie Nash, and fleetCreature for their work on the
smartphone app, Hayley Rahl, Alexa Smith, Lauren Simicich, and Vevette Yang for help with study
management, and the many research assistants who collected and processed data.
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Roeser (Eds.), Handbook of Mindfulness in Education (pp. 29–45). Springer New York.
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Figure 1.
CONSORT flow chart.
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Table 1.
A. Baseline characteristics of randomized participants.
Full Sample Monitor + Monitor Only Control Condition
Characteristic (N=153) Accept (N=58) (N=58) (N=37) Difference
Statistic
Age in years 32.42 (13.68) 32.76 (14.21) 32.64 (12.93) 31.54 (14.31) F(2,150)=0.10
Sex χ2(2)=0.75
Female 103 (67.32%) 39 (67.24%) 41 (70.69%) 23 (62.16%)
Male 50 (32.68%) 19 (32.76%) 17 (29.31%) 14 (37.84%)
Race χ2(8)=14.49
American Indian/Alaska Native 1 (0.65%) 0 (0.00%) 0 (0.00%) 1 (2.70%)
Asian 33 (21.57%) 15 (25.86%) 13 (22.41%) 5 (13.51%)
Black/African American 33 (21.57%) 14 (24.14%) 16 (27.59%) 3 (8.11%)
White/Caucasian 81 (52.94%) 28 (48.28%) 28 (48.28%) 25 (67.57%)
Bi- or Multi-Racial 5 (3.27%) 1 (1.72%) 1 (1.72%) 3 (8.11%)
Ethnicity χ2(2)=1.40
Hispanic or Latino 7 (4.58%) 2 (3.45%) 2 (3.45%) 3 (8.11%)
Not Hispanic or Latino 146 (95.42%) 56 (96.56%) 56 (96.56%) 34 (91.89%)
Education Level χ2(14)=14.26
GED 3 (1.96%) 1 (1.72%) 1 (1.72%) 1 (1.72%)
High School Diploma 20 (13.07%) 9 (15.52%) 10 (17.24%) 1 (2.70%)
Technical Training 1 (0.65%) 1 (0.65%) 0 (0.00%) 0 (0.00%)
Some College 41 (26.80%) 15 (25.86%) 12 (20.69%) 14 (37.84%)
Associate Degree 10 (6.54%) 4 (6.90%) 2 (3.45%) 4 (10.81%)
Bachelor’s Degree 48 (31.37%) 15 (25.86%) 21 (36.21%) 12 (32.43%)
Master’s Degree 26 (16.99%) 10 (17.24%) 11 (18.97%) 5 (13.51%)
MD, PhD, JD, PharmD 4 (2.61%) 3 (5.17%) 1 (1.72%) 0 (0.00%)
Body Mass Index (BMI)a 24.96 (5.38) 24.64 (4.81) 25.32 (5.64) 24.90 (5.88) F(2,148)=0.23
B. Characteristics of full sample of participants at post-intervention assessment.
Full Sample Monitor + Monitor Only Control Condition
Characteristic (N=149) Accept (N=56) (N=56) (N=37) Difference
Statistic
Intervention Adherenceb 13.49 (1.20) 13.44 (1.52) 13.60 (0.91) 13.39 (1.04) F(2,146)=0.40
Post-Intervention days elapsedc 4.66 (1.88) 4.61 (1.60) 4.46 (1.72) 5.03 (2.43) F(2,146)=1.03
Treatment Expectancies 5.37 (1.90) 5.71 (1.77) 5.26 (2.02) 5.05 (1.86) F(2,146)=1.55
Pre-Stressd Raw Cortisol (nmol/l)e 3.13 (2.13) 3.27 (2.39) 2.75 (1.36) 3.49 (2.62) F(2,137)=1.49
Pre-Stressd Log Cortisol (nmol/l)e 0.95 (0.62) 0.96 (0.66) 0.89 (0.51) 1.02 (0.69) F(2,137)=0.53
Pre-Stressd SBP (mmHg) 113.66 (13.27) 111.94 (9.79) 113.82 (15.37) 116.05 (14.37) F(2,146)=1.07
Pre-Stressd DBP (mmHg) 66.48 (9.11) 65.17 (6.65) 67.35 (10.65) 67.14 (9.80) F(2,146)=0.93
Note: Data are reported as means (SD) or numbers (%). SBP = Systolic Blood Pressure; DBP = Diastolic Blood Pressure.
aData for N=151 with BMI available.
bNumber of lessons completed of the 14 at-home lessons.
cNumber of days elapsed between end of 14-lesson at-home intervention and post-intervention assessment.
d‘Pre-Stress’ refers to resting levels at the post-intervention assessment before modified Trier Social Stress Test
administration.
eData for N=140 participants with saliva available.
*p<.05
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Figure 2.
Log salivary cortisola during the post-intervention assessment as a function of study condition.
Note: Error bars reflect +/- 1 standard error. Shaded area highlights modified Trier Social Stress Test (mTSST)
Performance period.
aData adjusted for follicular phase (cycle days 4-12 vs. not).
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Table 2.
mTSST stress reactivity outcomes in each condition.
mTSST Sample Monitor + Monitor Only Control Condition
Outcome (N=144) Accept (N=55) (N=54) (N=35) Difference
Statistic
Log Cortisol (AUC-I)a 16.20 -2.25 23.23 27.62 F(2,140)=3.20*
(EM estimation) [5.62, 26.78] [-19.06, 14.56] [6.31, 40.16] [6.60, 48.64]
Log Cortisola 1.27 1.04 1.31 1.54 χ2(2)=9.09*
(25 minutes post-mTSST; N=136) [1.14, 1.39] [0.83, 1.25] [1.10, 1.51] [1.28, 1.80]
Log Cortisola 1.15 0.91 1.21 1.40 χ2(2)=8.18*
(35 minutes post-mTSST; N=135) [1.01, 1.28] [0.69, 1.13] [0.99, 1.43] [1.13, 1.68]
Log Cortisola 0.80 0.62 0.85 1.02 χ2(2)=4.01
(60 minutes post-mTSST; N=135) [0.65, 0.96] [0.37, 0.87] [0.60, 1.10] [0.71, 1.33]
Systolic BP (mmHg) 139.89 134.51 140.93 146.64 χ2(2)=11.71*
(mTSST Performance; N=142) [137.18, 142.60] [130.12, 138.91] [136.51, 145.35] [141.12, 152.15]
Diastolic BP (mmHg) 81.36 78.57 82.76 83.56 χ2(2)=7.67*
(mTSST Performance; N=142) [79.80, 82.93] [76.04, 81.10] [80.21, 85.30] [80.38, 86.73]
Subjective Stress Reactivity 49.54 48.53 48.52 51.55 F(2,141)=0.22
(mTSST Performanceb) [45.55, 53.52] [42.23, 54.84] [42.16, 54.88] [43.65, 59.46]
Note: Data are reported as means [95% Confidence Interval]. AUC-I = Area Under the Curve with respect to Increase; EM
= Expectation Maximization; mTSST = modified Trier Social Stress Test; BP = Blood Pressure.
aData adjusted for follicular phase (menstrual cycle days 4-12 vs. all else).
bAverage of subjective stress ratings following Speech & Math tasks.
*p<.05
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Figure 3.
A. Systolic blood pressure responses during the post-intervention assessment as a function of study condition.
B. Diastolic blood pressure responses during the post-intervention assessment as a function of study condition.
Note: Error bars reflect +/- 1 standard error. Shaded area highlights modified Trier Social Stress Test (mTSST)
Performance period.
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Supplementary Table 1.
Lesson content of each intervention program.
!
Monitor!+!Accept!
Monitor!Only!
Coping!control!
Lesson!1!
!"#$%&'(#)%":!Intro!to!the!course!
and!three!core!skills:!!
• Concentration:!ability!to!
maintain!focus!on!present-
moment!experiences!
• Clarity!(!"#$%"&$#'):!ability!to!
pinpoint!exactly!what!you’re!
experiencing!in!each!moment!
• Equanimity()*++,-%.#+,/:!
openness!to!experience!
!"#$%&'(#)%":!Intro!to!the!course!
and!two!core!skills:!!
• Concentration:!ability!to!
maintain!focus!on!present-
moment!experiences!
• Clarity!(!"#$%"&$#'):!ability!to!
pinpoint!exactly!what!you’re!
experiencing!in!each!moment!
!
!"#$%&'(#)%":!Intro!to!the!course!
(MyTime)!and!three!core!skills:!!
• Reflection:!guided!exploration!of!
thoughts;!mind!can!wander!
where!it!wants!
• Analytic!Thinking:!analyze!and!
think!deeply!about!thoughts!and!
ideas!that!occur!during!reflection!
• Problem-Solving:!techniques!for!
tackling!problems!that!are!
apparent!through!analytic!
thinking!
Lesson!2!
*%"(+"#$,#)%"-!:!developing!a!
deeper!understanding!of!
concentration!
*%"(+"#$,#)%"-!:!developing!a!
deeper!understanding!of!
concentration!
.+/0+(#)%"-!:!choosing!to!control!
thought!content!or!get!lost!in!mind!
wandering!
Lesson!3!
*%"(+"#$,#)%"-!!:!concentrating!
continuously!on!body!experience!
*%"(+"#$,#)%"-!!:!concentrating!
continuously!on!body!experience!
.+/0+(#)%"-!!:!letting!the!mind!
wander!toward!pleasant!thoughts!
or!toward!or!away!from!unpleasant!
thoughts!
Lesson!4!
*%"(+"#$,#)%"-!!!:!maintaining!focus!
on!body!experience!while!listening!
to!someone!speak!(with!topic!
options)!
*%"(+"#$,#)%"-!!!:!maintaining!
focus!on!body!experience!while!
listening!to!someone!speak!(with!
topic!options)!
.+/0+(#)%"-!!!:!pleasant!guided!
imagery!with!option!to!let!the!mind!
drift!
Lesson!5!
*%"(+"#$,#)%"-!1:!labeling!body!
experiences!to!maintain!focus!
*%"(+"#$,#)%"-!1:!labeling!body!
experiences!to!maintain!focus!
.+/0+(#)%"-!1:!reflecting!on!
Shakespeare!monologues!
Lesson!6!
*%"(+"#$,#)%"-1:!labeling!different!
types!of!body!experiences!
*%"(+"#$,#)%"-1:!labeling!different!
types!of!body!experiences!
2",03#)(-45)"6)"7-!:!remembering!a!
positive!experience!and!considering!
how!to!make!future!experiences!
more!positive!
Lesson!7!
89',"):)#3-!:!maintaining!global!
body!relaxation!to!promote!
equanimity!
*0,$)#3-!:!discriminating!different!
types!and!patterns!of!body!
sensations!
2",03#)(-45)"6)"7-!!:!imagining!a!
positive!experience!in!the!future!
(e.g.,!goal!achievement)!
Lesson!8!
89',"):)#3-!!:!promoting!
equanimity!by!intentionally!using!a!
matter-of-fact!tone!of!voice!when!
labeling!
*0,$)#3-!!:!detecting!subtle!or!faint!
body!sensations,!and!increasing!
sensual!fulfillment!by!detecting!
subtle!pleasure!
2",03#)(-45)"6)"7-!!!:!reframing!a!
past!negative!experience!
Lesson!9!
*0,$)#3-!:!discriminating!different!
types!and!patterns!of!body!
sensations!
*0,$)#3-!!!:!introduction!to!six!types!
of!sensory!discrimination!with!
respect!to!body!experience:!
quality,!quantity,!spatiality,!instant!
of!onset,!what!triggers!what,!types!
of!change!
2",03#)(-45)"6)"7-!1:!reframing!an!
anticipated!future!negative!
experience!
Lesson!10!
*0,$)#3-!!:!detecting!subtle!or!faint!
body!sensations,!and!increasing!
sensual!fulfillment!by!detecting!
subtle!pleasure!
*0,$)#3-!1:!recognizing!physical!and!
emotional!themes!of!body!
experience!
;$%<0+:=>%0?)"7-!:!time!
management!and!planning!out!your!
day!
Lesson!11!
89',"):)#3-!!!:!developing!
equanimity!by!applying!a!
welcoming!attitude!toward!all!
experiences!!
*0,$)#3-1:!recognizing!“energy!
flow”!(changes)!in!body!experience!
;$%<0+:=>%0?)"7-!!:!time!
management!and!reflecting!on!
yesterday’s!plans!and!
accomplishments!
Lesson!12!
*0,$)#3-!!!:!recognizing!four!basic!
categories!of!body!experience!
(physical,!emotional,!restful,!
*0,$)#3-1!:!exploring!three!basic!
categories!of!body!experience!
(physical,!emotional,!“energy!
;$%<0+:=>%0?)"7-!!!:!identifying!a!
problem!and!the!causes!of!stress!
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“energy!flow”)!
flow”)!
Lesson!13!
89',"):)#3-!1:!integrating!the!
three!equanimity!strategies:!body!
relaxation,!tone!of!voice,!
welcoming!attitude!
*0,$)#3-1!!:!choosing!to!focus!on!
one!or!all!three!themes!of!body!
experience!
;$%<0+:=>%0?)"7-!1:!considering!
barriers!and!solutions!to!a!problem!
Lesson!14!
*%'$@+-.+?)+A:!guided!practice!
through!the!major!strategies!
learned!in!the!preceding!13!lessons-
*%'$@+-.+?)+A:!guided!practice!
through!the!major!strategies!
learned!in!the!preceding!13!lessons-
*%'$@+-.+?)+A:!guided!practice!
through!the!major!strategies!
learned!in!the!preceding!13!lessons-
!
Lesson!15!
(Booster!!
Training)!
• applying!clarity!and!equanimity!
techniques!to!a!challenging!
situation!!
• applying!three!equanimity!
strategies!to!body!focus!!
• applying!clarity!techniques!to!a!
challenging!situation!
• monitoring!physical,!emotional,!
and!“energy!flow”!themes!in!
the!body!!
• applying!MyTime!skills!to!a!
challenging!situation!!
• letting!the!mind!wander!toward!
pleasant!thoughts!or!toward!or!
away!from!unpleasant!thoughts!
!
