Content uploaded by Barbara Stetson
Author content
All content in this area was uploaded by Barbara Stetson on Nov 05, 2018
Content may be subject to copyright.
Shorter communication
Mindfulness and acceptance are associated with exercise maintenance
in YMCA exercisers
q
Christi S. Ulmer
*
, Barbara A. Stetson, Paul G. Salmon
Department of Psychological and Brain Science, 317 Life Sciences Building, University of Louisville, Louisville, KY 40292, USA
article info
Article history:
Received 16 July 2009
Received in revised form
19 April 2010
Accepted 26 April 2010
Keywords:
Exercise
Adherence
Mindfulness
Acceptance
Suppression
Physical activity
abstract
Although most U.S. adults have initiated an exercise program at some time, only a fraction are able to
maintain consistent exercise. Instead, research suggests that intermittent exercise is commonplace
among U.S. adults, underscoring the importance of identifying factors associated with consistent exercise
at a level that promotes health and long-term maintenance of this activity. We proposed a theoretical
model in which mindfulness and acceptance may promote exercise initiation and maintenance. Mind-
fulness, acceptance, and suppression were examined as a function of exercise status in 266 YMCA
exercisers. Those who were successful at maintaining exercise tended to score higher on measures of
mindfulness and acceptance, and lower on measures of suppression. Findings are discussed in light of
our proposed theoretical model in which exercisers having greater mindfulness and acceptance are less
reactive; responding with more balanced appraisals to threats to their exercise regimen which in turn
promotes increased exercise maintenance. Future studies should utilize longitudinal design to examine
causal relationships between variables.
Published by Elsevier Ltd.
Introduction
With escalating rates of obesity and associated chronic disease,
it is critical that health care providers gain a better understanding
of the factors that support their patients’ability to achieve and
sustain recommended levels of physical activity. Although most US
adults have initiated exercise programs at some point in their lives
(Sallis et al., 1990), research suggests that considerably fewer adults
consistently meet guidelines for leisure-time physical activity
(Adams & Schoenborn, 2006). About half of adults are likely to
drop-out of structured exercise programs within 6 months of
initiation or fail to maintain physical activity at the intended level
(Buckworth & Dishman, 2002; Marcus, Bock, & Pinto, 1997).
Interventions designed to increase physical activity are often
effective, but the mechanisms by which these interventions work
are only partially understood. In our efforts to better understand
factors that promote physical activity, it may be important to
consider the ‘lived’experience of physical activity, which for many
is marked by pain, stiffness, soreness, low perceived self-efficacy,
and other negative qualities, especially among those who are
initiating a physical activity regimen. These unpleasant, avoidance-
promoting experiences may at least partially account for low
adherence and maintenance rates. The introduction of novel
constructs esuch as mindfulness and acceptance einto the
physical activity literature is warranted because they offer a means
of exploring the immediate or short-term experience of physical
activity, and the reasons for problematic adherence and mainte-
nance despite the long-term benefits. Mindfulness and acceptance
have emerged in recent years as substantive constructs that seem
to exert their influence across numerous psychological domains
(cognitive, affective and behavioral) relevant to varied mental
health issues. “Mindfulness”ehas been defined as “non-judg-
mental, present-oriented focused attention (Kabat-Zinn, 2003)”,
and psychological acceptance has been defined as, “the willingness
to remain in contact with and to actively experience particular
private experiences (e.g., bodily sensations, emotions, thoughts
memories, behavioral predispositions) that seem to accompany
functionally useful overt behaviors, pg. 2 (Hayes, Bissett, et al.,
1999)”. Experiential avoidance is the conceptual opposite of
acceptance and is described as “the tendency to try to change or
avoid difficult thoughts and feelings, pg. 993, (Gifford & Lillis,
2009)”. In acceptance-based therapeutic approaches, suppression,
the “conscious effort to avoid a particular thought (Wegner,
Schneider, Carter, & White, 1987)”, is considered to be one of the
primary emotion regulation strategies utilized to avoid emotionally
q
The views expressed in this presentation are those of the authors and do not
necessarily represent the views of the Department of Veterans Affairs.
*Correspondence to: Christi S. Ulmer, Durham VA Medical Center, Health
Services Research and Development, 508 Fulton Street, Durham, NC 27705, USA.
Tel.: þ1 919 286 0411x6593; fax: þ1 919 416 5832.
E-mail address: christi.ulmer@va.gov (C.S. Ulmer).
Contents lists available at ScienceDirect
Behaviour Research and Therapy
journal homepage: www.elsevier.com/locate/brat
0005-7967/$ esee front matter Published by Elsevier Ltd.
doi:10.1016/j.brat.2010.04.009
Behaviour Research and Therapy 48 (2010) 805e809
distressing experience (Hoffmann & Asmundson, 2008). Thus,
suppression is congruent with experiential avoidance and counter
to acceptance.
These constructs are central aspects of newly developed clinical
interventions that have been effective in improving mental and
physical well-being (Baer, 2003; Hayes, Luoma, Bond, Masuda, &
Lillis, 2006). Among the best known of these interventions are
the Mindfulness-Based Stress Reduction (MBSR) program of Kabat-
Zinn and colleagues (Kabat-Zinn, 1990), and Hayes et al.’s Accep-
tance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson,
1999). In spite of the success of these interventions in certain
domains, relationships between mindfulness, acceptance, and
health-promoting behaviors in healthy adults have received very
little attention in the literature, although preliminary results are
promising.
Mindfulness and acceptance have been central components of
several health behavior change interventions. Mindfulness-based
interventions have been found to reduce coronary heart disease
risk (Edelman et al., 2006), and lower BMI and increase physical
activity (Tapper et al., 2009). ACT-based behavioral interventions
have been used successfully for weight loss (Lillis, Hayes, Bunting, &
Masuda, 2009), smoking cessation (Gifford et al., 2004), and blood
glucose regulation in type 2 diabetes (Gregg, Callaghan, Hayes, &
Glenn-Lawson, 2007).
Mindfulness and acceptance-based (MAB) interventions have
also been successfully employed to reduce anxiety and depression
(Baer, 2003; Hayes, Follette, & Linehan, 2004), a benefit that has
also been consistently demonstrated in exercise research. The
anxiolytic effects of exercise are comparable to those for CBT for
anxiety and better than those of other anxiety treatments (Wipfli,
Rethorst, & Landers, 2008), and exercise confers benefits for
depressed mood that are comparable to cognitive therapy (Mead
et al., 2009). Based upon the findings of MAB health interventions
cited above, one could theorize that mindfulness and acceptance
promote improved psychological well-being which in turns
promotes an increased ability to initiate and maintain exercise.
However, relationships between mindfulness, acceptance and
exercise have yet to be investigated.
The conceptual basis of mindfulness described herein rests on
the transactional model of stress first proposed by Lazarus and
Folkman (1984) and subsequently applied by Kabat-Zinn (1990)
to a mindfulness-based stress reduction (MBSR) intervention
model. The model proposes that non-judgmental, present-moment
awareness fosters effective, responsive appraisal of ongoing events
in a manner that counteracts habitual cognitive and physiological
reactions. Applied to exercise, the model predicts that sensations
associated with exercise initiation and maintenance esome of
which are inevitably unpleasant or even painful ewould elicit
balanced appraisals of experiences that might otherwise lead to
avoidant or suppressive behaviors (e.g., exercise drop-out). In the
current study, we examined mindfulness, acceptance, and
suppression as a function of exercise status in YMCA exercisers to
empirically evaluate this model as applied to exercise.
Method
Participants
Participants were adult community exercisers (N¼226)
recruited from seven regional YMCA facilities located in either
Louisville, Kentucky or Southern Indiana. Participants were
primarily middle-aged (M age ¼49.96, SD ¼14.73) Caucasian
(N¼194, 85.8%) females (N¼143, 65%) with a Mean BMI of 26.62
(SD ¼5.73). Most participants were married (N¼162, 71.7%) with
no children in the home (N¼133, 61.6%) and had some college
education (N¼203, 89.8%). About half of participants were
employed full-time (N¼120, 53.1%), about 1/5 were retired
(N¼45, 19.9%).
Procedures
Participants were screened at recruitment to assure that they
were at the facility to exercise, and were at least 21 years of age.
There were no other criteria for participation. Participants were
approached upon entering or leaving the YMCA facilities and
invited to participate in a study on the topic of exercise and health
behaviors. Those who assented received a description of the study
and signed an informed consent document. They were then given
a packet of study materials and a postage-paid envelope with
instructions to return it within two weeks.
Measures
Exercise maintenance
Following from the premise that consistent exercise produces
greater health benefits than intermittent exercise, we examined
self-reported exercise maintenance over the previous year to
facilitate a comparison of participants on exercise consistency.
Exercise maintenance status was determined using the following
questions from an exercise status questionnaire developed for this
study: 1) “Have you exercised regularly for the past year?”(Regular
Exerciser); 2) “Over the previous year, have you missed 1 full week
of exercise?”;3)“Over the previous year, have you missed 2
continuous weeks of exercise?”; and 4) “Over the previous year,
have you missed 3 continuous weeks of exercise?”Dichotomous
variables (yes/no) were created from participants’response to these
items, and responses were then collapsed to create an ordinal
variable reflecting the number of missed weeks of exercise.
Achievement of activity guidelines
In addition to assessing the consistency of exercise (exercise
maintenance) among study participants, we also wanted to know if
participants were meeting federal guidelines for physical activity
since adhering to these guidelines should confer specific health
benefits. Although more recent guidelines are available, the current
study was designed to assess adherence with the federal guidelines
for physical activity in effect when the study was conducted.
Namely, that “all Americans engage in moderate intensity physical
activities for at least 30 min on 5 or more days of the week, or if
they engaged in vigorous-intensity physical activity for 3 or more
days per week for 20 or more minutes per occasion (Centers for
Disease Control and American Academy of Sports Medicine,
1995).”The International Physical Activity Questionnaire (IPAQ:
Craig et al., 2003) was used to quantify physical activity for
purposes of determining whether guidelines were achieved. The
IPAQ is a nine-itemquestionnaire in which the respondent provides
the number of days per week and minutes and hours per day spent
in various activities over the previous one-week period. Based upon
self-reported physical activity on the IPAQ for the “last 7 days”,
adherence to federal physical activity guidelines was determined
using total number of minutes in moderate to vigorous activity per
week.
Success in meeting exercise goals
Self-reported perceived success in meeting exercise goals was
determined using the Revised Causal Dimension Scale (CDS:
McAuley, Duncan, & Russell, 1992). The CDS is a measure of causal
attributions regarding the perceived cause for an event. The exer-
cise version of the measure includes the following statement at the
top of the page, “Please list the main reason why you have been
C.S. Ulmer et al. / Behaviour Research and Therapy 48 (2010) 805e809806
successful or unsuccessful in meeting your exercise goal(s).”
Participants’responses were coded as either reflecting perceived
success or perceived failure in meeting exercise goals. Thus, success
in meeting exercise goals was coded dichotomously (yes/no) based
upon their response to this CDS item.
Mindfulness
Mindfulness was assessed with both the Mindful Attention and
Awareness Scale (MAAS: Brown & Ryan, 2003) and the Frieberg
Mindfulness Inventory (FMI: Walach, Buchheld, Buttenmuller,
Kleinknecht, & Schmidt, 2006). In accordance with Baer, Smith,
Hopkins, Krietemeyer, and Toney (2006), the MAAS was chosen
to assess “dispositional”mindfulness, and the FMI was chosen to
assess mindfulness as a skill. Accordingly, the MAAS and FMI are
labeled as trait mindfulness and state mindfulness, respectively, in
the table and on the figure. The MAAS is a 15-item self-report
measure of “individual differences in the frequency of mindful
states over time (pg. 824)”(Brown & Ryan, 2003). In a series of
validation studies conducted by the authors of the measure, the
MAAS demonstrated high internal validity (alpha ¼.87), high test-
retest reliability (r¼.81, p<.0001), and good convergent and
discriminant validity. The FMI is a 14-item self-report measure of
mindfulness with satisfactory internal consistency (alpha ¼.86),
and convergent validity with related constructs.
Acceptance versus experiential avoidance
The Acceptance and Action Questionnaire (AAQ-9: Hayes,
Strosahl, et al., 2004) was used to assess experiential avoidance.
In eight samples totaling more than 2400 participants, experiential
avoidance as assessed by the AAQ-9 was associated with greater
psychopathology, depression, and anxiety, as well as specific fears,
trauma, lower quality of life, and with suppression as measured
using the White Bear Suppression Inventory (WBSI).
Suppression
The WBSI (Wegner & Zanakos, 1994) is a 15-item self-report
measure of thought suppression. The WBSI is a reliable instrument
with internal consistency alphas ranging from .87 to .89, a 1-week
testeretest correlation of .92, and a 3 week to 3 month testeretest
correlation coefficient of .69. In the validation study, the WBSI
demonstrated adequate convergent validity with measures of
depression and anxiety.
Analyses
Mean scores on mindfulness, acceptance and suppression were
compared by exercise maintenance category. The assumptions for
comparing groups with parametric statistics were met for all
measures. One-way ANOVAs were used to compare mean scores by
exercise maintenance status for all analyses. Due to multiple
comparisons, the Bonferroni correction was used to adjust signifi-
cance level. Assuming an average correlation of .40 across
measures, an alpha level of p¼.05, and a two-tailed comparison,
the Bonferroni corrected significance level was p.02.
Results
In preliminary analyses, the data were examined to determine if
the exercise or mindfulness and acceptance variables were corre-
lated with demographic characteristics of the participants. Level of
education was found to be correlated with certain measures, as
follows: WBSI (r¼.19, p<.05) and the AAQ-9 (r¼.25, p<.01).
Participants who were successful at meeting their exercise goals
(F¼11.89, p¼.001) and those endorsing regular exercise over the
previous year (F¼19.47, p<.001) were older than their counter-
parts. A higher percentage of men than women were successful at
meeting their exercise goals (X
2
¼4.48, p¼.03). Regular exercisers
had a lower BMI than non-regular exercisers (F¼7.84, p¼.006).
Age, gender and BMI were otherwise unrelated to exercise main-
tenance. All analyses included the appropriate demographic cova-
riate/s (age, gender, BMI, or education) as discussed above, if they
were related to both the independent and dependent variables.
Table 1 summarizes mean mindfulness, acceptance and
suppression scores for study participants by exercise maintenance
category. Scores that differ significantly (p.02) by category are
indicated in bold. Participants who perceived themselves to be
successful in meeting their exercise goals scored higher on
measures of acceptance [F(1,192) ¼7.52, p¼.007] and state
mindfulness [F(2,192) ¼5.27, p¼.02],and reported less suppression
[F(1,195) ¼6.51, p¼.01]. Participants missing 1 week of exercise
over the previous year scored higher in acceptance [F(1,199) ¼6.05,
p<.02] and lower in state mindfulness [F(1, 205) ¼5.42, p¼.02].
Participants missing 2 consecutive weeks of exercise over the
previous year scored lower in acceptance [F(1,198) ¼8.10, p¼.005]
and trait mindfulness [F(1,199) ¼5.41, p¼.02] and higher in
suppression [F(1,201) ¼6.73, p¼.01]. Participants missing 3
consecutive weeks of exercise scored significantly lower in accep-
tance [F(1,199) ¼7.82, p¼.006] and suppression [F(1,202) ¼7.19,
p¼.008]. Fig. 1 depicts differences in mindfulness, acceptance and
suppression scores by exercise maintenance category. Acceptance
levels differed by the number of weeks of missed exercise over the
previous year, with those endorsing 0 weeks of missed exercise
having significantly higher levels of acceptance than those missing
3 weeks of exercise [F(3,195) ¼3.91, p¼.01]. None of the measures
discriminated those who achieved physical activity guidelines from
those who did not, nor did they discriminate those endorsing
regular exercise for the past year from those who did not. Higher
levels of mindfulness and acceptance and lower suppression were
related to fewer missed exercise sessions, more regular exercise,
and greater perceived success in meeting exercise goals across all
measures.
Discussion
The findings of our study suggest that YMCA exercisers who are
successful at maintaining exercise tended to have higher scores on
mindfulness and acceptance measures, and lower suppression
scores. Although our cross-sectional data do not permit causal
inferences, they raise two interesting questions: Are individuals
who are drawn to exercise more mindful and accepting? Does
exercise promote mindfulness and acceptance? Both of these are
possible explanations for our findings. It may be also be that both
are true, with mediation by additional variables being possible as
well.
The consistent pattern across measures of higher mindfulness
and acceptance and lower suppression among those maintaining
exercise suggests a robust relationship, and prompts us to consider
how these factors may impact physical activity initiation and
maintenance? Consistent with the transactional model of stress, we
suggest that mindfulness and acceptance intervene between
activity-related cognitions/emotions and overt behavior in a way
that facilitates one’s ability to respond to rather than react to
cognitive, behavioral or emotional threats to physical activity.
Despite acknowledged long-term health benefits, initiating and
sustaining physical activity is often inherently stressful when seen
through the lens of sedentary adults. The experience of physical
activity, especially for new initiates is often stressfully unpleasant,
marked by pain, stiffness, soreness, low perceived self-efficacy, and
other negative qualities. “I don’tfeel like exercising”captures the
daunting, pre-activity emotional state of many who undertake the
process of becoming physically fit. Those who persevere through
C.S. Ulmer et al. / Behaviour Research and Therapy 48 (2010) 805e809 807
this initial and inevitable period of adaptation must then contend
with the issue of maintenance: How does one sustain the interest,
or at least persistence, to stay physically active without giving up in
the face of boredom, variable progress, injury, justifiable lapses,
competing priorities, and the like? Somehow, one must learn to
balance what may be stressful, even unpleasant, experiences on
a day-to-day basis against the longer-term potential benefits of
becoming and staying active. ‘Being mindful’provides a potentially
effective means of navigating exercise-related challenges through
a combination of present-moment acuity and an accepting, non-
judgmental attitude.
The original conceptual model of mindfulness proposed by
Kabat-Zinn (1990) was based on the transactional stress model that
emphasized the importance of appraisal in determining whether or
not specific circumstances constitute stressors. According to this
model, mindfulness fosters present-moment awareness, accurate
appraisal and responsive coping with respect to circumstances that
may otherwise elicit habitual, non-conscious stress reactivity. In
more recent conceptualizations, mindfulness has been character-
ized as fostering effective self-regulation via ‘decentering’or
‘reperceiving’ea cognitive shift toward accurate appraisals and
away from automated reactivity (Garland, Gaylord, & Park, 2009;
Shapiro, Carlson, Astin, & Freedman, 2006). Kabat-Zinn’s original
model is consistent with empirical evidence pointing to greater
cognitive and behavioral flexibility in those with greater mindful-
ness and acceptance (Shapiro et al., 2006).
Early clinical applications of mindfulness helped medical
patients cope with chronic pain by emphasizing the importance of
careful discrimination of moment-by-moment experiential shifts
(pain-ful versus pain-free moments), separating pain related
thoughts from actual sensations, and working within one’s existing
capabilities and limits (Kabat-Zinn, 2003). Accomplished endur-
ance athletes report mindful-like states in the context of long-
distance running, focusing predominantly on present-moment
physical and physiological sensations while attending to, but not
being over-invested in, the inevitable flow of cognitive events
(thoughts, memories, etc.) that accompany such experiences
(Salmon, Hanneman, & Harwood, in press). It is plausible to suggest
that a similar pattern of non-judgmental, present-focused aware-
ness may operate in other potentially stressful circumstances, such
as exercise initiation and maintenance.
Finally, mindfulness and acceptance may facilitate relapse
prevention in those who have successfully initiated an exercise
regimen. From a mindful/accepting orientation, behavior lapses are
viewed in benign terms. They are experiences to be accepted and
viewed with openness and curiosity, an orientation that may lessen
the likelihood of further progression into relapse (Salmon,
Santorelli, Sephton, & Kabat-Zinn, 2009). Although few health
behaviors are maintained on an invariant schedule and episodic
variation is to be expected, mindfulness and acceptance may inter-
vene when occasional episodic lapses would otherwise increase in
frequency to the point of relapse, jeopardizing health benefits.
Limitations of this study include the use of retrospective recall
data and subjective assessments of exercise adherence in the
context of a cross-sectional research design. Measures of exercise
maintenance and perceived goal achievement were dichotomous in
nature, which may limit the variability of data and detailed aspects
of the relapse process. Subsequent studies of the process of exercise
maintenance may benefit from use of continuous measures. Use of
a convenience sample comprised of relatively high socioeconomic
status (SES), physically active, and predominantly Caucasian
participants limits generalization of findings. Finally, since we did
not record information on the percentage of YMCA members
approached who declined to participate, we cannot rule out the
possibility that those who assented were systematically different in
terms of mindfulness, acceptance or exercise than those who
declined participation, resulting in sample selection bias.
In spite of the limitations of our study, we introduced several
novel constructs into the exercise maintenance literature and
provided a theoretical and empirical basis for their inclusion in
Table 1
Mean scores by exercise status (controlling for related demographic factors).
Acceptance Trait mindfulness State mindfulness Suppression
NMean NMean NMean NMean
Have you exercised regularly for the past year? No 28 37.75 28 62.25 27 39.25 26 31.97
Yes 164 40.52 164 63.26 172 40.61 170 28.78
Participant perceives success in meeting their exercise goals? No 33 36.97 33 59.51 33 37.42 33 33.98
Yes 153 40.95 152 63.63 159 41.08 156 28.19
Were physical activity guidelines met over the previous 7 days? No 43 38.95 44 61.41 42 39.94 42 31.00
Yes 144 40.88 143 63.41 151 40.53 147 28.32
Over the previous year, have you missed 1 full week of exercise? No 44 42.39 47 65.72 46 42.46 47 26.90
Yes 156 39.51 154 62.05 160 39.84 154 29.71
Over the previous year, have you missed 2 continuous weeks of exercise? No 116 41.37 116 64.44 121 41.33 118 27.25
Yes 83 38.57 84 60.77 84 39.19 84 31.65
Over the previous year, have you missed 3 continuous weeks of exercise? No 148 41.01 148 63.50 155 40.91 151 27.80
Yes 52 37.92 52 61.19 51 39.15 52 32.91
Number of Missed weeks of exercise over the previous year 0 43 42.65
a
46 65.87 45 42.71 45 26.69
17240.49 69 63.41 75 40.42 72 27.59
23239.69 32 60.09 34 39.40 33 29.77
35237.92
a
52 61.19 51 39.15 52 32.91
Note. Means in a column having the same subscript are significantly different.
Fig. 1. Mindfulness, acceptance, and suppression by the number of missed weeks of
exercises.
C.S. Ulmer et al. / Behaviour Research and Therapy 48 (2010) 805e809808
future research. Future studies should focus on lower SES and less
active adult populations. Use of a longitudinal design would permit
assessment of possible causal relationships among exercise main-
tenance, mindfulness, and acceptance constructs, and ultimately
contribute to the development and testing of intervention models.
Research has shown that both exercise and MAB interventions
reduce anxiety and depression, suggesting a directional effect. It
may also be that these factors, in combination, directly impact
exercise initiation and maintenance as well. Additional research is
needed investigating all factors concurrently.
Acknowledgements
The first author was funded by a Department of Veterans Affairs
HSR&D Career Development Award CDA 09-218. The authors would
like to thank Chelsea Rothschild, M.A, Jeff Meyer, Ph.D., and Jason
Bonner M.A. for their assistance on this project.
References
Adams, P. F., & Schoenborn, C. A. (2006). Health behaviors of adults: United States,
2002e04. Vital Health Statistics, 10.
Baer, R. (2003). Mindfulness training as a clinical intervention: a conceptual and
empirical review. Clinical Psychology: Science and Practice, 10,125e143.
Baer, R. A., Smith, G. T.,Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report
assessment methods to explore facets of mindfulness. Assessment, 13,27e45.
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: mindfulness and
its role in psychological well-being. Journal of Personality and Social Psychology,
84, 822e848.
Buckworth, J. D., & Dishman, R. K. (2002). Exercise psychology. Champaign, IL:
Human Kinetics Publishers.
Centers for Disease Control and American Academy of Sports Medicine. (1995).
Physical activity and public health. A recommendation from the Centers for
disease control and prevention and the American college of Sports medicine.
JAMA, 273, 402e407.
Craig, C., Marshall, A. L., Sjostrom, M., Bauman, A., Booth, M. L., Ainsworth, B. E.,
et al. (2003). International physical activity questionnaire: 12-country reliability
and validity. Medicine & Science in Sports and Exercise, 35, 1381e1395.
Edelman, D., Oddone, E. Z., Liebowifz, R. S., Yancy, W. S., Olsen, M. K., Jeffreys, A. S.,
et al. (2006). A multidimensional integrative medicine intervention to improve
cardiovascular risk. Journal of General Internal Medicine, 21,728e734.
Garland, E., Gaylord, S., & Park, J. (2009). The role of mindfulness in positive
reappraisal. Explore, 5(1), 37e44.
Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M.,
Rasmussen-Hall, M. L., et al. (2004). Applying a functional acceptance based
model to smoking cessation: an initial trial of acceptance and commitment
therapy. Behavior Therapy, 35, 689e705.
Gifford,E. V., & Lillis, J.(2009). Avoidanceand inflexibilityas a common clinical pathway
in obesity and smoking treatment. Journal of Hea lth Psychology, 14,992e996.
Gregg, J. A., Callaghan, G. M., Hayes, S. C., & Glenn-Lawson, J. L. (20 07). Improving
diabetes self-management through acceptance, mindfulness, and values:
a randomized controlled trial. Journal of Consulting and Clinical Psychology, 75,
336e343.
Hayes, S. C., Bissett, R. T., Korn, Z., Zettle, R. D., Rosenfarb, I. S., Cooper, L. D., et al.
(1999). The impact of acceptance versus control rationales on pain tolerance.
Psychological Record, 49,33e47.
Hayes, S. C., Follette, V. M., & Linehan, M. M. (2004). Mindfulness and acceptance:
Expanding the cognitive-behavioral tradition. New York: Guilford Press.
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and
commitment therapy: model, processes and outcomes. Behaviour Research and
Therapy, 44,1e25.
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment
therapy. New York: Guilford Press.
Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D.,
et al. (2004). Measuring experiential avoidance: a preliminary test of a working
model. The Psychological Record, 54, 553e578.
Hoffmann, S. G., & Asmundson, G. J. (2008). Acceptance and mindfulness-based
therapy: new wave or old hat? Clinical Psychology Review, 28,1e16.
Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind
to face stress, pain, and illness. New York: Delta.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: past, present,
and future. Clinical Psychology: Science and Practice, 10,144e156.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and
mindfulness to improve the lives of the obese: a preliminary test of a theoret-
ical model. Annals of Behavioral Medicine, 37,58e69.
McAuley, E., Duncan, T. E., & Russell, D. W. (1992). Measuring causal attributions:
the revised Causal Dimension Scale (CDSII). Personality and Social Psychology
Bulletin, 18(5), 566e573.
Marcus, B. H., Bock, B. B., & Pinto, B. M. (1997). Initiation and maintenance of
exercise behavior. In D. S. Gochman (Ed.), Handbook of health behavior research
II: Provider determinants. New York: Plenum Press.
Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A.
(2009). Exercise for depression. Cochrane Database of Systematic Reviews.
Sallis, J. F., Hovell, M. F., Hofstetter, R., Elder, J. P., Faucher, P., Spry, V. M., et al. (1990).
Lifetime history of relapse from exercise. Addictive Behaviors, 15,573e579.
Salmon, P., Hanneman, S., & Harwood, B. Associative/Dissociative cognitive strate-
gies in sustained physical activity: literature review and proposal for a mind-
fulness-based conceptual model. The Sport Psychologist, in press.
Salmon, P., Santorelli, S. F., Sephton, S. E., & Kabat-Zinn, J. (2009). Intervention
elements promoting adherence to mindfulness-based stress reduction (MBSR)
programs in a clinical behavioral medicine setting. In S. A. Shumaker, J. K. Ock-
ene, & K. A. Rekert (Eds.), The handbook of health behavior change (3rd ed.). (pp.
271e286).
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of
mindfulness. Journal of Clinical Psychology, 62, 373e386.
Tapper, K., Shaw, C., Ilsley, J., Hill, A. J., Bond, F. W., & Moore, L. (2009). Exploratory
randomised controlled trial of a mindfulness-based weight loss intervention for
women. Appetite, 52, 396e404.
Walach, H., Buchheld, N., Buttenmuller, V., Kleinknecht, N., & Schmidt, S. (2006).
Measuring mindfulnessethe Freiburg mindfulness Inventory (FMI). Personality
and Individual Differences, 40, 1543e1555.
Wegner, D. M., Schneider, D. J., Carter, S. R., & White, T. L. (1987). Paradoxical effects
of thought suppression. Journal of Personality and Social Psychology, 53,5e13.
Wegner, D. M., & Zanakos, S. (1994). Chronic thought suppression. Journal of
Personality and Social Psychology, 62,615
e640.
Wipfli, Rethorst, C. D., & Landers, D. M. (2008). The anxiolytic effects of exercise:
a meta-analysis of randomized trials and doseeresponse analysis. Journal of
Sport & Exercise Psychology, 30, 392e410.
C.S. Ulmer et al. / Behaviour Research and Therapy 48 (2010) 805e809 809