UNIVERSITY of CALGARY the Influence of Rumination, Distraction

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UNIVERSITY OF CALGARY

The Influence of Rumination, Distraction and Mindfulness on

Cardiovascular Recovery from Stress

Brenda Louise Key

A THESIS

SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF DOCTOR OF PHILOSOPHY

DEPARTMENT OF PSYCHOLOGY

CALGARY, ALBERTA

SEPTEMBER, 2010

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Abstract

The central aims of the present study were to determine if mindfulness and distraction inductions would decrease rumination following a stressor and to investigate whether changes in post stressor rumination would influence cardiovascular recovery.

Additional goals were to assess the influence of a brief mindfulness meditation intervention on rumination, mindfulness, depressed mood and symptoms of stress.

Cardiovascular and psychological data was collected from 101 undergraduate students during two identical laboratory-testing sessions 5 weeks apart. Each testing session included a 5-minute baseline period, 5-minute stress task and a 15-minute recovery period. Participants were randomized to one of three conditions: mindfulness, distraction or control. During the recovery period, participants in the distraction condition received a distraction induction, those in the control condition received no induction and those in the mindfulness condition received a mindfulness induction. Participants in the mindfulness condition also received a 4-week mindfulness meditation intervention during the period between laboratory testing sessions while participants in the distraction and control conditions received no intervention. Results indicated that, at testing session two, participants in the mindfulness condition showed the greatest decreases in post stressor state rumination compared to the other conditions. The conditions did not differ on cardiovascular reactivity or recovery at either testing session. Mindfulness participants reported increases in trait mindfulness and decreases in depressed mood, following the brief mindfulness meditation intervention, compared to participants who did not receive the intervention. The brief mindfulness intervention was not associated with changes in ii

trait rumination or symptoms of stress. The preliminary findings of the present study suggest the efficacy of a brief mindfulness meditation intervention for decreasing depressed mood, decreasing state rumination, in response to mental stress, and increasing mindfulness compared to a no-intervention control.

iii

Acknowledgements

I would first like to extend my sincere thanks to my supervisor, Dr. Tavis

Campbell, for his encouragement, guidance, and support throughout the completion of this dissertation. Your knowledge and enthusiasm for research and supervision have helped to make my graduate school experience a positive one. I would also like to thank my dissertation committee members, for their time and efforts in reviewing my dissertation. I wish to express my sincerest appreciation for the support of my classmates, who were there to encourage me through the struggles and celebrate the successes.

Finally, I would like to express my heartfelt gratitude to my husband, Mark, and to my parents, Barb and Gord, for their unwavering love and support throughout my journey toward becoming a clinical psychologist. Words cannot express how much I have appreciated your wholehearted encouragement of my pursuits in psychology – this dissertation is dedicated to you.

This research would not have been possible without financial support from the

Social Sciences and Humanities Research Council (SSHRC), a Ralph Steinhauer Award of Distinction (Alberta Advanced Education) and the University of Calgary. This funding is gratefully acknowledged.

Table of Contents Abstract……...... ii Acknowledgements...... iv Table of Contents...... v List of Tables ...... viii List of Figures...... ix List of Abbreviations ...... x INTRODUCTION ...... 1 Cardiovascular Responses to Stress...... 1 Cardiovascular Reactivity...... 1 Cardiovascular Recovery...... 3 Mechanisms Linking Cardiovascular Responses & Hypertension...... 4 Rumination...... 8 Theories of Rumination, Emotion & Arousal...... 11 Response Styles Theory of Rumination...... 12 Associative Network Theory ...... 13 Two Factor Theory of Emotion ...... 13 Rumination Arousal Model...... 14 Rumination & Cardiovascular Recovery...... 15 Interventions to Decrease Rumination...... 18 Distraction...... 18 Mindfulness...... 19 Mechanisms of Mindfulness...... 20 Research on Mindfulness & Rumination...... 22 Mindfulness versus Distraction as an Intervention for Rumination ...... 23 Use of Distraction, Rumination & Mindfulness to Influence Affect...... 26 Mindfulness & Cardiovascular Functioning...... 28 Goals of the Present Study...... 31 Hypotheses...... 31 v

METHOD…… ...... 34 Procedures...... 34 Randomization & Study Design ...... 34 Laboratory Testing Session...... 35 Mindfulness Intervention...... 37 Measures ...... 39 Data Analysis...... 44 RESULTS……...... 52 Participant Characteristics ...... 52 Hypotheses Results ...... 54 DISCUSSION...... 58 Caridiovascular Reactivity & Recovery ...... 60 Cardiovascular Reactivity...... 60 Cardiovascular Reactivity & the Mindfulness Intervention ...... 60 Other Meditation Interventions & Cardiovascular Reactivity...... 61 Cardiovascular Recovery...... 63 Cardiovascular Recovery & the Inductions ...... 63 Cardiovascular Recovery & the Mindfulness Intervention ...... 65 Other Interventions & Cardiovascular Recovery...... 66 Cardiovascular Recovery & Psychological Variables ...... 66 Cardiovascular Recovery & Trait Psychological Variables ...... 66 Cardiovascular Recovery & State Rumination...... 68 Factors Relevant to Both Cardiovascular Reactivity & Recovery...... 70 Floor Effects...... 70 Habituation...... 71 State Rumination...... 72 Differences Between Distraction & Mindfulness...... 74 Mindfulness Mechanisms & State Rumination ...... 76 Trait Mindfulness & Trait Rumination...... 78 vi

Trait Mindfulness...... 78 Trait Mindfulness Subscales...... 81 Trait Rumination...... 82 Mindfulness Intervention Adherence...... 84 Trait Mindfulness, Trait Rumination & Home Practice ...... 86 Association Between Trait Mindfulness other Psychological Variables...... 89 Depression & Symptoms of Stress ...... 91 Depression...... 91 Symptoms of Stress...... 95 Depression, Symptoms of Stress & Home Practice...... 96 Implications for the Rumination Arousal Model...... 98 Limitations & Strengths...... 101 General Conclusions, Implications & Future Directions...... 102 REFERENCES ...... 106 APPENDIX A: Visual Analogue Scales, Baseline...... 148 APPENDIX B: Visual Analogue Scales, Post Stressor...... 149 APPENDIX C: Induction Statements for Recovery Period...... 151 APPENDIX D: Stress Reactive Rumination Scale...... 152 APPENDIX E: Five Facet Mindfulness Questionnaire...... 153 APPENDIX F: Thought Reports ...... 155 APPENDIX G: Instructions for Thought Reports ...... 157 APPENDIX H: Statistical Assumptions ...... 158 APPENDIX I: Additional Stastical Tests Hypothesis Three...... 160 APPENDIX J: Mindfulness Group Booklet Given to Participants ...... 162 APPENDIX K: Mindfulness Meditation Program Facilitator Outline...... 182 APPENDIX L: Questionnaire Package ...... 184

vii

List of Tables TABLE 1: Participant Characteristics by Condition ...... 128 TABLE 2: State Rumination & Cardiovascular Reovery by Condtion at Time One...... 129 TABLE 3: Change in State Rumination & Cardiovascular Recovery by Condition...... 130 TABLE 4: Change in Psychological Measures by Condition ...... 131 TABLE 5: Changes in Cardiovascular Reactivity by Condition...... 132 TABLE 6: State Rumination & Cardiovascular Recovery Correlations ...... 133 TABLE 7: Effect Size: Change from Time one to Time two by Condition...... 134 TABLE 8: Meditation Home Practice & Psychological Outcomes...... 135 TABLE 9: Associations: Trait Rumination, Mindfulness & Cardiovascular Recovery..136 TABLE 10: Associations: Changes in Mindfulness & Psychological Outcomes ...... 137 TABLE 11: Correlations Rumination & Mindfulness...... 138

viii

List of Figures

FIGURE 1: Relative Blood Pressure Load due to Reactivity & Recovery ...... 139 FIGURE 2: Rumination Arousal Model...... 140 FIGURE 3: Study Design ...... 141 FIGURE 4: Laboratory Testing Session Flow Chart...... 142 FIGURE 5: State Rumination by Condition ...... 143 FIGURE 6: Trait Mindfulness by Condition ...... 144 FIGURE 7: Depressed Mood by Condition...... 145 FIGURE 8: Rumination Arousal Model & Predicted Relationaships ...... 146 FIGURE 9: Rumination Arousal Model & Observed Relationships...... 147

Hidden references (Clancy, 2004) (Nyklicek & Kuijpers, 2008; Shapiro, Oman, Thoresen, Plante, & Flinders, 2008) (Astin, 1997; Davidson et al., 2003) (Watkins, Teasdale, & Williams, 2003) (Millgard & Lind, 1998) (Guyton, 1991) (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008)

(Teasdale & Barnard, 1993; Wells & Matthews, 1994) (e.g. Speca, Carlson, Goodey, & Angen, 2000b; Carlson & Garland, 2005; Carlson, Speca, Patel, & Goodey, 2003)

List of Abbreviations

ANCOVA Analysis of covariance

ANOVA Analysis of variance

AUC Area under the curve

BDI-II Beck Depression Inventory II

BP Blood pressure bpm Beats per minute

CESD Center for Epidemiological Studies Depression Inventory

CD Compact Disc

C-SOSI Calgary Symptoms of Stress Inventory

DAH Differential Activation Hypothesis

DBP Diastolic blood pressure

ECG Electrocardiogram

FFMQ Five Factor Mindfulness Questionnaire

HR Heart rate

HRV Heart rate variability

HPA Hypothalamic Pituitary Adrenal

IAA Intention, Attention and Attitude

PEP Pre-ejection period

RSQ-RRS Response Styles Questionnaire-Ruminative Response Scale

RSA Respiratory sinus arrhythmia

RST Response Styles Theory

SBP Systolic blood pressure

SD Standard deviation

SES Socioeconomic Status

SNS Sympathetic Nervous System

S-REF Self-Regulatory Executive Function

SRRS Stress Reactive Rumination Scale

M Mean

MBCT Mindfulness Based Cognitive Therapy

MBSR Mindfulness Based Stress Reduction mmHg Millimetres of mercury

N Number of participants

VAS Visual analogue scale

TM Transcendental Meditation

xi 1

The Influence of Rumination, Distraction and Mindfulness on

Cardiovascular Recovery from Stress

Psychological responses to stress and their psychological correlates have been implicated in the development of hypertension (Obrist, 1981; Manuck, Kasprowicz, &

Muldoon, 1990; Light, 1981), however the mechanisms by which this risk is conveyed remain unclear. Rumination may play a role in this association by prolonging the psychological and physiological arousal that accompanies stress. The purpose of the present study was to evaluate the influence of mindfulness on rumination and to better characterize previously documented associations between rumination and cardiovascular recovery from stress.

Cardiovascular Responses to Stress

Cardiovascular Reactivity

Cardiovascular reactivity is generally defined as the change that occurs in the heart and blood vessels in response to mental stress (Obrist, Light, James, & Strogatz,

1987). Physiological changes that typically occur in stressful situations, such as increases in heart rate (HR) and blood pressure (BP), are part of a natural and adaptive response mechanism. In some cases this physiological response may be exaggerated relative to the demands of the stressor. According to the cardiovascular reactivity hypothesis, when individuals repeatedly respond to stressful stimuli in an exaggerated manner they set in motion a cascade of pathophysiologic events that may lead to tissue damage, system dysregulation and finally disease (Obrist et al., 1987; Lovallo & Gerin, 2003).

Consistent with the reactivity hypothesis, exaggerated cardiovascular reactivity has been implicated in the development of hypertension (Manuck et al., 1990; Carroll,

Ring, Hunt, Ford, & Macintyre, 2003; Treiber et al., 2003), however the strength of the prospective associations is typically modest (Carroll et al., 2001) . For example, results from a 10-year prospective study that evaluated BP reactivity and future BP indicated systolic blood pressure (SBP) reactivity accounted for 4.5% of the variance in future blood pressure status (Carroll et al., 2001). A more recent population-based study of

Norwegian men indicated that SBP reactivity at time one explained 9.4% of the variance in BP status 18 years later (Flaa, Eide, Kjeldsen, & Rostrup, 2008). Other longitudinal studies have found similar prospective associations between cardiovascular reactivity and

BP status or other indicators of cardiovascular health (i.e. calcification of arteries) at follow-up (Matthews, Woodall, & Allen, 1993; Matthews, Zhu, Tucker, & Whooley,

2006). A review of more than 20 prospective cardiovascular reactivity studies concluded that BP and HR responses to mental stress were independent predictors of future BP level and hypertension, with modest associations similar to those noted above (Treiber et al.,

2003). Although prospective research has demonstrated that cardiovascular reactivity is a statistically significant predictor of follow-up BP (e.g. Chida & Steptoe, 2010) its predictive power beyond that of traditional BP predictors has also been modest, accounting for between 1% to 2.9% of the additional variance (Carroll et al., 2003;

Carroll et al., 2001; Matthews et al., 1993; Markovitz, Raczynski, Wallace, Chettur, &

Chesney, 1998). Therefore, critics have questioned the relative value of cardiovascular

3 reactivity for predicting future BP levels and cardiovascular disease states (Steptoe, 2008;

Steptoe & Marmot, 2005).

Cardiovascular Recovery

A potential flaw in the cardiovascular reactivity hypothesis is that it focuses on the acute responses that occur during the presentation of laboratory stress tasks while ignoring the subsequent recovery period (Linden, Earle, Gerin, & Christenfeld, 1997).

Cardiovascular recovery is generally defined as the time period required for physiological functioning to return to baseline levels after encountering a stressor

(Linden et al., 1997). If acute elevations in physiological activation in response to mental stress are damaging to the cardiovascular system then variables that serve to prolong the stress related elevation (i.e. variables influencing cardiovascular recovery) may be damaging as well. Investigators have hypothesized that the total duration of BP elevation may be of greater importance in the development of hypertension relative to peak reactions to a stressors (Linden et al., 1997; Schwartz et al., 2003) (see Figure 1).

Consistent with this theory, Borghi and colleagues (Borghi, Costa, Boschi, Mussi,

& Ambrosioni, 1986) found that diastolic blood pressure (DBP) recovery from a cognitive challenge was a stronger predictor of future hypertension than cardiovascular reactivity in borderline hypertensive subjects at 5 year follow-up. Further evidence for this theory comes from a meta-analytic review of 69 studies which concluded that delayed DBP recovery from stress was related to hypertensive status at the time of assessment (not prospective studies) (Schuler & O'Brien, 1997). More recent findings have further confirmed the significance of cardiovascular recovery, beyond the

4 contribution of cardiovascular reactivity, as a predictor of future BP status (Steptoe &

Marmot, 2005; Stewart, Janicki, & Kamarck, 2006; Moseley & Linden, 2006; Heponiemi et al., 2007).

Mechanisms Linking Cardiovascular Reactivity & Recovery and Hypertension

While exaggerated cardiovascular reactivity and prolonged cardiovascular recovery have been prospectively linked to the development of sustained high BP, the mechanisms by which reactivity and recovery convey risk for hypertension have not been confirmed. Early reactivity models did not postulate a causal role for reactivity in the pathophysiology of hypertension, rather reactivity was originally conceived of as a marker of risk for future hypertension (Gerin et al., 2000). Over time, theoretical advances have led reactivity and recovery to be viewed as a possible casual factors in the development of hypertension.

The regulation of BP results primarily from actions of the kidneys, central and autonomic nervous systems, hypothalamic-pituitary-adrenal (HPA) axis, and vascular endothelium (Black, Bakris, & Elliott, 2001). Acute BP elevations in response to stress are usually attributed to sympathetic nervous system (SNS) activity but may also be influenced by attenuated endothelial nitric oxide production (Markovitz, Tucker, Lewis,

Sanders, & Warnock, 1998) and vagal withdrawal (Brosschot & Thayer, 1998). These short-term factors responsible for acute BP responses are believed to be different from the factors that contribute to sustained elevation in BP (Gibbons, 1998; Kaplan, 2001). In order to produce sustained high blood pressure, long-term physiological regulatory changes are necessary.

The concepts of allostasis and allostatic load provide the theoretical framework that links acute BP elevations and possible long-term physiological regulatory changes that may lead to hypertension. Allostasis is the maintaining of stability (or homeostasis) through change, while allostatic load refers to the wear and tear that the body experiences due to repeated cycles of allostasis as well as the inefficient turning-on and shutting-off of responses aimed at maintaining allostasis (McEwen & Seeman, 1999).

McEwan and Seeman (1999) propose that stress mediators (i.e. chemical messengers released as part of allostasis, e.g. catecholamines and cortisol) have short term protective and adaptive as well as long term damaging effects. In order to maintain allostasis the

“body pays a physical price to adapt” to various psychosocial challenges and adverse environments (McEwen & Seeman, 1999). Allostatic load can be subdivided into subtypes that include: repeated elevations of stress mediators over long periods of time

(i.e. a pattern of exaggerated cardiovascular reactivity) and failure to shut off the stress response efficiently (i.e. prolonged cardiovascular recovery).

Based on the allostatic load conceptualization both exaggerated cardiovascular reactivity and prolonged cardiovascular recovery may have deleterious effects on the cardiovascular system through the overarching mechanism of increased allostatic load

(McEwen, 1998). The causal mechanisms linking cardiovascular responses to stress

(exaggerated reactivity and prolonged recovery) and hypertension have not yet been verified but vascular remodelling and endothelial dysfunction have been proposed as regulatory changes associated with increased allostatic load that may result in hypertension (Gibbons, 1998).

Vascular remodelling involves alterations in vessel architecture, including decreased lumen diameter and rarefaction, in which the number of microvessels is reduced. Remodelling results from changes in blood flow and BP as well as changes in the level of vasoconstrictive (norepinephrine, angiotensin II) and vasodilatory (nitric oxide) substances. Vascular remodelling may facilitate the transition from an initial high cardiac output stage of hypertension to a high total peripheral resistance state resulting in sustained high blood pressure (Gibbons, 1998).

Endothelial dysfunction is another physiological adaptation that may be a causal pathway to hypertension. The endothelium is the innermost layer of blood vessels and contributes to regulation of vascular tone and blood flow through the production of vasoconstrictive and vasodilatory substances that act on vascular smooth muscle. Nitric oxide is an important endothelium-derived vasodilatory substance. Catabolism of nitric oxide may impair endothelial function, resulting in hypertension (Schwartz et al., 2003).

Individuals with hypertension typically demonstrate endothelial dysfunction in the form of attenuated endothelium-derived vasodilation (Egashira et al., 1995; Panza, Quyyumi,

Brush, Jr., & Epstein, 1990; Treasure et al., 1993). Millgard and Lind (1998) report that an induction of acute increases in blood pressure via a noradrenaline infusion was associated with impaired forearm endothelium-derived vasodilation among normotensive adults. These results suggest that it is possible for acute BP elevations to negatively affect endothelium-derived vasodilation. Additionally, normotensive individuals with a positive family history of hypertension have been shown to display attenuated endothelial function (Millgard, Hagg, Sarabi, & Lind, 2002). This study provides evidence to support

7 the hypothesis that a disruption in endothelial function may play a role in the development of hypertension.

Vascular remodelling and endothelial dysfunction may influence sustained BP levels through their action on the kidneys. Guyton (1991) suggests that the kidney’s regulation of sodium and water balance acts as the primary long-term determinant of the

BP level. It has been proposed that pathological changes such as vascular remodeling and endothelial dysfunction could lead to sustained changes in the renal set-point for BP regulation (Gibbons, 1998). This theory provides a mechanism by which vascular remodelling and endothelial dysfunction may play a role in the etiology of hypertension.

In their review of causal models of cardiovascular responses to stress and the development of cardiovascular disease, Schwartz and colleagues (2003) concluded that given these explanatory models (endothelial dysfunction and vascular remodelling) “the most deleterious effects would be expected when such responses (cardiovascular responses to stress) occur over a prolonged time period.” The authors suggest that given the endothelial dysfunction and vascular remodelling explanatory models future investigations regarding the link between cardiovascular responses to stress and hypertension should focus on cumulative duration of cardiovascular responses to stress

(i.e. cardiovascular recovery) (Schwartz et al., 2003).

Cardiovascular Reactivity and Recovery Summary

In summary, findings suggest that the evaluation of cardiovascular recovery in addition to the evaluation of cardiovascular reactivity (i.e. the evaluation of both the magnitude and the duration of a response) may be important in coming to a greater

8 theoretical understanding of the mechanisms underlying the association between stressors, physiological responses and hypertension. Furthermore, the assessment of cardiovascular reactivity and recovery together may enhance the ability to predict individuals at risk of developing sustained high BP.

Rumination

The tendency to ruminate is one personality factor that has been hypothesized to influence cardiovascular recovery (Brosschot & Thayer, 2003; Glynn, Christenfeld, &

Gerin, 2002; Gerin, Davidson, Christenfeld, Goyal, & Schwartz, 2006). Rumination has been conceptualized in many different ways (Siegle, Moore, & Thase, 2004; Nolen-

Hoeksema, 1998). In defining rumination it is important to attempt to delineate rumination from other types of repetitive thought. Several classes of unconstructive and constructive repetitive thought have been identified including rumination, depressive rumination, worry, planning/problem solving, perseverative cognition, and reflection

(Watkins, 2008). Each of these classes of repetitive thought will briefly be discussed in relation to rumination.

Depressive rumination. Depressive rumination differs from (general) rumination in that depressive rumination is more specific in regard to the content of the repetitive thought. Nolen-Hoeksema (1991) defines depressive rumination as “behaviours and thoughts that focus one’s attention on one’s depressive symptoms and on the implications of these symptoms.” Depressive rumination was deemed to be too narrow a focus for the current study as the mental stress task we employed could elicit a variety of emotions in addition to sadness and previous research demonstrating links between rumination and

9 cardiovascular recovery has focused on more general forms of rumination (e.g. Glynn et al., 2002; Verkuil, Brosschot, de Beurs, & Thayer, 2009; Gerin et al., 2006).

Worry. Worry and rumination appear to overlap considerably but with the focus of worry typically being proposed as future-oriented and rumination as typically involving dwelling on past events (McLaughlin, Borkovec, & Sibrava, 2007;

Papageorgiou & Wells, 1999; Watkins, Moulds, & Mackintosh, 2005; Ehring & Watkins,

2008). A recent study, however, suggests that time orientation may change over the course of rumination, such that individuals begin with a past focus, but increase in present and future related thoughts over the course of ruminating (McLaughlin et al.,

2007). Thus, rumination may not necessarily be wholly past focused. Nolen-Hoeksema,

Wisco, and Lyubomirsky (2008) propose that the distinction between rumination and worry lies in the theme of the repetitive thought. Specifically, they suggest that the theme of rumination is threat, loss, injustice and failure. Worry typically involves thoughts about future imagined catastrophes, uncertainties, and risks and is often conceptualized as an attempt to avoid negative events (Watkins, 2008). Further distinction between worry and rumination may be found in the outcomes associated with these types of repetitive thought. Watkins (2008) concludes that worry can serve a constructive function when it is objective, controllable and brief, while outcomes associated with rumination appear to consistently suggest that this type of repetitive thought is unconstructive. Worry was therefore disregarded as a potential focus for the current study due to the ambiguity regarding the psychological outcomes (constructive and unconstructive) associated with this type of repetitive thought.

Perseverative Cognition. Perseverative cognition has been defined as “the repeated or chronic activation of the cognitive representation of one or more psychological stressors” (Brosschot, Gerin, & Thayer, 2006). Perseverative cognition is therefore a broadly defined form of repetitive thought that encapsulates worry, rumination and other types of repetitive thought. Given the broad scope of this definition one would expect that perseverative cognition could be associated with both constructive and unconstructive consequences. Perseverative cognition is a relatively newly defined type of repetitive thought in comparison to the concepts of worry and rumination and therefore research explicitly evaluating the validity of this operational definition is relatively limited (Watkins, 2008). Perseverative cognition was eliminated as a possible focus of the current study primarily due to concerns that the definition would be too broad and prevent characterization of this type of repetitive thought as an unconstructive process.

Planning, Problem Solving and Reflection. Planning, problem solving and reflection involve thoughts that may have a negative valence however they are considered to be cognitive coping strategies and are generally agreed to be constructive in nature

(Watkins, 2008). Reflection is similar to rumination as it involves self-focus. However, in contrast to rumination, this self-focus is motivated by curiosity and is associated with increased self knowledge (Trapnell & Campbell, 1999).

The concept of rumination was chosen as the focus of the current study due to the existing theoretical framework linking rumination and cardiovascular responses to stress.

Additionally, rumination is generally agreed to be an unconstructive form of repetitive

11 thought (Watkins, 2008) and therefore an intervention that successfully decreases rumination may have valuable applications.

For the purposes of this study rumination is defined as repetitive thoughts focusing on problematic situations or events (i.e. stressors) as well as the emotions and symptoms these evoke and the possible consequences of the stressors (Thomsen,

Mehlsen, Christensen, & Zachariae, 2003). This operational definition was selected because it includes the concepts commonly encapsulated in definitions of rumination and delineates rumination from the potentially constructive forms of repetitive thoughts of problem solving and reflection. Several researchers have concluded that the tendency to ruminate is a relatively stable trait and that differences in the tendency to ruminate exist

(Just & Alloy, 1997; Knowles, Tai, Christensen, & Bentall, 2005; Nolen-Hoeksema &

Morrow, 1993). Thus, trait rumination is a cognitive style characterized by the tendency to focus on past stressors while state rumination is conceptualized as focusing on a past stressor at one particular moment in time.

Theories of Rumination, Emotion and Arousal

In order to illustrate potential mechanisms through which rumination may impair cardiovascular recovery it is important to consider theories that attempt to explain how rumination might prolong and amplify negative emotional states. The intensity and duration of negative emotional states is key because, while both positive and negative emotions lead to approximately equal acute arousal, only negative emotions have been associated with negative cardiovascular outcomes (Brosschot & Thayer, 2003). A possible explanation for this finding is that recovery tends to be longer when negative

12 emotions are present (Brosschot & Thayer, 2003). Therefore, understanding the relationship between rumination and negative emotions may help clarify the possible impact of rumination on cardiovascular recovery.

Response Styles Theory of Rumination

Nolen-Hoeksema’s (1991) response styles theory (RST) has been the most widely studied theory of depressive rumination. This theory characterizes rumination as a maladaptive response to distressing situations that represents a specific cognitive vulnerability factor in the onset and maintenance of depression. According to RST, individuals engage in depressive rumination because they believe that rumination about their mood and symptoms will enable them to better understand both themselves and the causes of their negative affect; however, the rumination actually serves to enhance low mood. Consistent with the RST hypothesis rumination has been shown to lead to increases in sad/depressed mood by focusing the individual’s attention on negative affect, rather than leading to increased self understanding (Lyubomirsky & Nolen-Hoeksema,

1995). Rumination does not facilitate active problem solving to change circumstances surrounding these symptoms; rather people who ruminate often remain fixated on their affect and symptoms without taking action to address them (Nolen-Hoeksema, 2000a).

Therefore, according to RST depressive rumination increases negative emotions and depressive symptoms (Hilt, McLaughlin, & Nolen-Hoeksema, 2010; Lyubomirsky,

Caldwell, & Nolen-Hoeksema, 1998).

Associative Network Theory

Rumination may intensify and prolong distress through several potential mechanisms. The associative networks theory (or semantic network theory) (Anderson &

Bower, 1973) may explain the relationship between rumination and several negative emotions. According to this theory emotions impose a fundamental organization structure on information stored in memory (Rusting & Nolen-Hoeksema, 1998). When an emotion is evoked, associated information will be activated and thus prolong and/or amplify the emotion. Consistent with this theory, rumination may amplify/prolong negative emotions such as anxiety, anger and sadness (Thomsen et al., 2003).

Specifically, rumination brings to mind negative events of the past as well as associated negative emotions. The activation of these memories likely potentiates further associated negative thoughts and emotions and increases the activated negative emotions. Based on the associative network theory it would be predicted that the physiological activation that accompanies negative emotions would be prolonged and/or increased as a result of rumination in a similar fashion to the way in which rumination prolongs and/or increases the emotions themselves.

Two Factor Theory of Emotion

Schachter and Singer’s (1962) two-factor theory of emotions leads to similar predictions regarding the amplification and prolonging of emotion as the associative network theory. The two-factor theory posits that emotions are fueled by autonomic arousal and the resultant emotion depends on the cognitive attribution for the arousal.

Nolen-Hoeksema and colleagues have presented evidence that rumination likely

14 exacerbates and prolongs emotions through a focus of attention on, and rehearsal of, the causes of a negative emotion (e.g. anger or sadness) (Rusting & Nolen-Hoeksema, 1998;

Lyubomirsky & Nolen-Hoeksema, 1993; Nolen-Hoeksema & Morrow, 1993; Hilt et al.,

2010; Rood, Roelofs, Bogels, Nolen-Hoeksema, & Schouten, 2009; Bohon, Stice,

Burton, Fudell, & Nolen-Hoeksema, 2008; Nolen-Hoeksema, 2000a). Based on the two- factor theory of emotion, it is proposed that rumination prolongs the autonomic arousal on which the emotion is based and that the arousal in turn serves to prolong the mood and this feedback continues in a cyclical fashion.

Rumination Arousal Model

A rumination arousal model has been proposed by Gerin and Pickering (2005) that is derived from both the associative network theory (Anderson & Bower, 1973) and the two-factor theory of emotion (Schachter & Singer, 1962). This model hypothesizes that engaging in rumination following an interaction that provokes negative emotion sets in motion an intertwined set of processes: the cognition leads to negative emotions (i.e. anger, sadness or anxiety) and the emotion produces elevated autonomic activation (e.g. causing BP elevation). The processes involved in this model may be synergistic: increased autonomic arousal may prolong negative emotions and vice-versa (two-factor theory) and the prolonged negative emotions may promote ruminative thoughts and vice- versa (associative network theory). The rumination arousal model proposes that these constructs comprise a “feed forward” model (Figure 2).

Moderator variables, such as trait dimensions and situational characteristics, may also influence the relationship between mental stress, rumination, affect and arousal in

15 this model (see Figure 2). In particular situational characteristics such as whether the mind is occupied with something in the present versus simply allowed to wander (and potentially ruminate) following a stressor may also influence the association between stressors, rumination, affect and arousal (Gerin et al., 2006). Personality traits such as cognitive style, including the tendency to ruminate, may influence the cognitions in response to the stressor and therefore also influence affect and arousal.

Theories of Rumination Summary

Although the above reviewed theories of rumination vary, they all support the conclusion that it prolongs and amplifies negative emotional states following a stressor.

The associative network theory proposes that rumination serves to activate associated negative memories and thus prolong negative emotions, while the associative network theory asserts that rumination prolongs the autonomic arousal on which the emotion is based. The rumination arousal model integrates both of these theories suggesting that rumination prolongs emotions and physiological arousal and also that continued physiological arousal may prolong and amplify emotion. Given the association between negative emotions and delayed cardiovascular recovery, rumination may also prolong recovery (as suggested by the rumination arousal model).

Rumination and Cardiovascular Recovery

Stressful events and the personality traits of the individual (e.g. the tendency to ruminate) interact to influence both psychological and physiological reactions to stressors

(Gerin & Pickering, 2005). Rumination can serve to prolong and/or amplify cognitive/emotional reactions to stressors (Nolen-Hoeksema, 2000b; Thomsen et al.,

2003). Consistent with the rumination arousal model, it is therefore plausible that rumination may also serve to prolong and/or amplify the accompanying physiological reactions such as increased BP and HR, through the repetition of thoughts associated with the stressor.

Evidence supporting the link between rumination and delayed cardiovascular recovery is beginning to emerge. The majority of studies that have investigated the influence of rumination on cardiovascular recovery have used a distraction manipulation in an attempt to prevent rumination (e.g. Glynn et al., 2002; Gerin et al. 2006). For example, in a study examining cardiovascular recovery following acute stressors in the laboratory, in normotensive undergraduate students, participants who were exposed to a distraction showed superior BP recovery compared to those without the distraction

(Glynn et al., 2002). A similar study evaluated the influence of a distraction versus no distraction condition on recovery following an anger recall task in normotensive undergraduate students. Trait rumination was assessed using a self-report measure and a thought sampling technique was used during the recovery period to assess state rumination. High trait ruminators in the no distraction condition had the poorest BP recovery (Gerin et al., 2006). Thus, the results demonstrated that rumination is associated with prolonged BP recovery while processes that interfere with rumination are associated with hastened BP recovery.

Although evidence regarding the link between rumination and poor cardiovascular recovery is building, previous investigations have failed to directly link state rumination with poor cardiovascular recovery. For example, Gerin and colleagues

(2006), in their comparison of cardiovascular recovery in distraction and no-distraction conditions, assessed state rumination during recovery as a manipulation check (to ensure that participants in the distraction condition were ruminating less than those in the no- distraction condition); however state rumination was not analysed as a predictor of cardiovascular recovery.

Recent research conducted to clarify the relationship between state rumination and cardiovascular recovery (Key, Campbell, Bacon, & Gerin, 2008) used a similar design to Gerin and colleagues (2006). A sample of high and low trait ruminators

(selected based on their scores on the Stress Reactive Rumination Scale – participants scoring in the top third or bottom third of the distribution were invited to participate) took part in a laboratory stress assessment in which cardiovascular reactivity and recovery from a public speaking stress task was measured. Findings indicated that state rumination was associated with poor cardiovascular recovery; however the relationship was observed only within low trait ruminators. The authors hypothesized that high trait ruminators may have difficulty recognizing when they are ruminating and this may have interfered with the measurement of self reported state rumination. Overall, the findings suggested that state rumination may be associated with poor cardiovascular recovery.

In summary, results suggest that trait rumination is associated with poor cardiovascular recovery. Additionally, processes that interfere with state rumination, such as distraction, are associated with improved cardiovascular recovery. These results are consistent with the rumination arousal model and suggest that rumination may be a

18 mechanism through which negative emotional stressors lead to delayed recovery, by maintaining negative affect and the associated autonomic arousal.

Interventions to Decrease Rumination

Distraction

Distraction is one potential intervention that may decrease rumination (Nolen-

Hoeksema & Morrow, 1993). Distracting responses include thoughts and behaviours that help divert attention away from a stressor and its implications and direct attention toward more pleasant or benign thoughts that are absorbing, engaging, and capable of providing positive reinforcement. Findings from Glynn et al. (2002) suggest that distraction may interfere with rumination and reduce its’ subsequent impact on cardiovascular recovery.

Distraction has also been used as an intervention to decrease rumination in the context of psychopathology. Within the framework of depression, the use of distraction (i.e. deliberately focusing on neutral or pleasant thoughts or engaging in activities that divert attention in a more positive direction) has been shown to decrease rumination and attenuate depressed mood (Nolen-Hoeksema & Morrow, 1993; Morrow & Nolen-

Hoeksema, 1990; Nolen-Hoeksema et al., 2008). (Linehan, 1993)

Unfortunately, distraction may only be a temporary solution to decrease rumination. Linehan (1993) has argued that both clinging to negative thoughts and feelings (ruminating) and pushing these thoughts and feelings away (distraction) are ineffective, unskilful means of handling distress. Both rumination and distraction require a degree of resistance, whether by refusing to let go of thoughts of the past (rumination) or by striving to keep unpleasant experiences out of conscious awareness entirely

(distraction). Thus, both strategies may ultimately increase negative cognitions (Wegner

& Zanakos, 1994; Wegner, 1994; Hayes, Strosahl, & Wilson, 1999). Less extreme forms of distraction, such as engaging in pleasant activities or interesting cognitive tasks, may have a positive influence because they occupy a portion of working memory (the memory system used to hold and manipulate information while mental tasks are carried out) that would otherwise support rumination (Erber & Tesser, 1992). Avoidance of stressor related thoughts prohibits the individual from engaging in the cognitive processing that may lead to the resolution of the stressor or to healthy changes in their perceptions of the stressor (Hamilton & Ingram, 2001). Therefore, distraction may be an effective strategy to reduce rumination in the short term, however distraction may not be an effective long term strategy. (Kabat-Zinn, 2003)

Mindfulness

Interventions that emphasize present moment awareness provide an alternative method to distraction for decreasing rumination. Mindfulness can be defined as “paying attention on purpose, in the present moment, non-judgmentally, to the unfolding of experience moment by moment” (Kabat-Zinn, 2003, p.145). Mindfulness involves the non-judgemental observance of the present moment while rumination is defined by repetitive thoughts dwelling on negative events from the past. Mindfulness based interventions are hypothesized to reduce repetitive and unproductive thought processes such as rumination. Although mindfulness, like rumination, requires attention to one’s internal state, mindfulness is characterized by direct experience of the current reality rather than elaborative thinking about one’s situation, with emphasis on the origin of the

20 stressor, the implications and negative impact (as is the case with rumination) (Clancy,

2004). Thus, the tendency to be mindful and the tendency to ruminate may be conceptualized as contrasting cognitive styles.

Mindfulness requires attentional regulation to shift focus to the present moment rather than thinking about the past, future or otherwise distracting oneself from the present moment. Several authors have argued that mindfulness is a naturally occurring characteristic (i.e. trait) that shows meaningful variation in non clinical and non meditating samples (Kabat-Zinn, 2003; Brown & Ryan, 2003). However, it is generally believed that a person’s natural tendency to be mindful (trait mindfulness) can be enhanced by developing a set of attentional skills through education and practice

(Carmody & Baer, 2008). For example, mindfulness based interventions such as

Mindfulness Based Stress Reduction (MBSR) focus on developing this mindfulness skill set (increasing state and trait mindfulness) and have been shown to enhance self-reported mindfulness skills (Kingston, Chadwick, Meron, & Skinner, 2007; Lau et al., 2006).

Mindfulness practice history (number of years of mindfulness meditation practice) is positively associated with self-reported trait mindfulness (Brown & Ryan, 2003).

Therefore, trait mindfulness may be considered a malleable cognitive style characterized by the tendency to intentionally focus on the present moment in a particular way whereas state mindfulness refers to present moment mindfulness at one particular point in time.

Mechanisms of Mindfulness

In their discussion of the mechanisms associated with mindfulness Shapiro and

Carlson (2006) defined three characteristics or axioms of mindfulness: intention (I),

21 attention (A) and attitude (A). These three axioms are considered to be interwoven aspects of a single process and are referred to as the IAA model of mindfulness. These axioms map directly on to the definition of mindfulness, i.e. paying attention (attention), on purpose (intention), non-judgmentally (attitude). Each of these three axioms of mindfulness will be briefly defined and discussed.

Attention is considered to be a fundamental component of mindfulness. In the context of mindfulness practice, paying attention involves observing one’s moment-to- moment internal and external experience. This involves suspending all the ways of interpreting experience and attending to experience itself, as it presents itself in the here and now (Shapiro & Carlson, 2006). Mindfulness therefore relies on and develops attentional abilities including the capacity to attend to a chosen object, the ability to shift focus and the ability to inhibit secondary elaborative processing. The second axiom of intention is considered crucial to understanding the process of mindfulness. However the intention associated with mindfulness practice is often dynamic and evolving because the reason for practicing may change over time (Shapiro & Carlson, 2006). The third axiom of attitude refers to the qualities that one brings to attention. The foundational attitudes associated with mindfulness can be summarized as “heart” qualities and include acceptance, kindness, openness, curiosity and a non-judgmental approach (Shapiro &

Schwartz, 2000). Through mindfulness training, an individual becomes increasingly able to take interest in each experience as it arises and also to allow what is being experienced to pass away (Shapiro & Carlson, 2006).

Building on these three axioms Shapiro and Carlson (2006) proposed that intentionally attending with openness and non-judgementalness leads to a significant shift in perspective that they term reperceiving. The authors suggested that reperceiving is a meta-mechanism of action that overarches additional direct mechanisms of mindfulness that lead to positive change. These direct mechanisms are thought to include increased self-regulation, values clarification, increased cognitive, emotional and behavioural flexibility and exposure. These variables each support and influence each other and can be seen as potential mechanism for other outcomes or as positive outcomes in and of themselves.

The specific mindfulness mechanisms that lead to decreases in rumination have not been confirmed, however the overarching mechanism of reperceiving may play an important role. For individuals high in trait rumination this type of repetitive thinking is a habitual pattern. Decreasing identification with emotions and thoughts and enhancing the ability to see these experiences as merely passing events in the mind is associated with a lower likelihood of responding in a habitual unhelpful manner (Baer, 2003;

Chambers, Gullone, & Allen, 2009; Shapiro & Carlson, 2009). The practice of mindfulness and the resulting reperceiving may enhance an individual’s ability to regulate their cognitive processes and inhibit the negative elaborative processes associated with rumination (Labelle, Campbell, & Carlson, 2010).

Research on Mindfulness and Rumination

Several studies suggest that mindfulness interventions have the ability to decrease ruminative thoughts (Jain et al., 2007; Teasdale et al., 2002; Ramel, Goldin, Carmona, &

McQuaid, 2004; Labelle et al., 2010; Teasdale, Segal, & Williams, 1995). For example, a recent randomized control trial that compared one month of mindfulness meditation versus relaxation training in 83 distressed students, revealed that meditation training was associated with less ruminative thoughts and behaviours than relaxation (Jain et al.,

2007). Furthermore, mediational analyses indicated that reductions in distress for the meditation group were partially mediated by reductions in rumination (Jain et al., 2007).

Labelle and colleagues (2010) also demonstrated an association between mindfulness and rumination in their waitlist control study of an MBSR program in 77 female oncology patients. Results similarly indicated that that the intervention resulted in significant decreases in rumination and depressive symptoms. Mediational analyses indicated that decreases in depressive symptoms were mediated by decreases in rumination.

In summary, both distraction and mindfulness interventions have been shown to decrease rumination in the short term (e.g. Nolen-Hoeksema, 1991, Jain et al. 2007).

However, distraction techniques may only provide a temporary solution, while mindfulness may be a more lasting approach to reducing rumination (see review below).

Mindfulness versus Distraction as an intervention for Rumination

Distraction and mindfulness have both been shown to reduce rumination however theories of cognitive processing (Teasdale & Barnard, 1993; Wells & Matthews, 1994) suggest that mindfulness may be superior to distraction for decreasing rumination. It has been proposed that rumination is supported by problems with metacognition, which is generally described as thinking about thinking (Nelson, Stuart, Howard, & Crowley,

1999). Metacognition includes monitoring of thoughts and emotions, and the capacity to

24 exert control over thoughts and feelings. Beliefs about thinking processes, such as how thinking works, how controllable and how normal it is, and about the functions and consequences of particular types of thinking are known as metacognitive beliefs.

Teasdale and Barnard (1993) and Wells and Matthews (1994) have similarly proposed that beliefs about one’s thoughts and appraisals of these thoughts play a role in the development and maintenance of emotional disorders through processes associated with rumination. Specifically, Wells’ Self-Regulatory Executive Function (S-REF) model

(Wells, 1999) describes a cognitive-attentional syndrome characterized by heightened self-focused attention, threat monitoring, ruminative processing and activation of dysfunctional beliefs. The intervention that follows from the S-REF model therefore focuses on enhancing attentional abilities of focusing, switching and dividing external attention. Teasdale’s Differential Activation Hypothesis (DAH) describes vulnerability to depressive relapse by activation of dysfunctional negative cognitions. The DAH theory similarly incorporates the role of beliefs about one’s thoughts and appraisal of these thoughts. The intervention that stems from this theory, Mindfulness Based Cognitive

Therapy (MBCT), focuses on “decentring” from the cascade of automatic negative thoughts associated with negative moods.

Attention and cognitive processes such as rumination are considered central in the development and maintenance of psychopathology in both the S-REF and DAH metacognitive models. Rumination is believed to be associated with maladaptive metacognitive beliefs that interfere with adaptive processing and maintain a ruminative style. These maladaptive beliefs include “positive” metacognitive beliefs (e.g.

25 ruminating about problems will somehow lead to their solution) and “negative” metacognitive beliefs (e.g. I should avoid negative thoughts) (Wells, 2009). Rumination is not seen as a form of active problem solving and does not typically lead to the resolution of problems (Wells, 2009). Additionally, striving to keep unpleasant thoughts and experiences out of conscious awareness entirely typically results in increases in distress and rumination over time (Wells, 2009). Positive beliefs about the benefits of rumination are likely to encourage individuals to engage in rumination and once rumination is activated, individuals may then appraise this process as uncontrollable and harmful (Papageorgiou & Wells, 2003). Mindfulness provides an alternative cognitive style that involves focusing attention on the present moment and taking the stance of an accepting observer. Mindfulness practice may assist in the development of more adaptive metacognitive beliefs (e.g. negative thoughts and feelings are simply passing events in the mind) and help individuals disengage from ruminative processing (Teasdale et al.,

1995).

While distraction may temporarily decrease rumination the thoughts and beliefs related to negative emotional stressors are still readily accessible in memory and are likely to recapture attention when the individual is no longer distracted (Singer &

Dobson, 2007). In order to produce lasting decreases in rumination changes in cognitive processing need to take place so that negative stressors can either be resolved or related to in a new way (other than rumination). Mindfulness training may lead to the development of a new method of relating to distressing thoughts that is counter to ruminative process and represents a change in cognitive processing. Metacognitive

26 theories therefore suggest that mindfulness may assist in the development of lasting adaptive metacognitive beliefs and skills that could help individuals disengage from rumination while distraction only temporarily interferes with rumination.

The Use of Distraction, Rumination and Mindfulness to Influence Affect

Mindfulness and distraction may influence cardiovascular recovery by reducing rumination. However these interventions may also influence cardiovascular recovery through another pathway: the manipulation of negative affect. As might be predicted, the association between negative affect and a ruminative response style tends to be fairly high (Ramel 2004), making it hard to disassociate components of mood versus rumination. Negative affect has also been shown to be associated with poor cardiovascular recovery (Brosschot & Thayer, 2003) and is thought to interact with rumination to prolong cardiovascular arousal as depicted in the rumination arousal model

(Figure 2) (Gerin et al., 2006). Due to the relationship between negative affect and delayed cardiovascular recovery, it may be important to consider the influence of distraction and mindfulness interventions on affect in order to elucidate the possible relationship between these interventions and cardiovascular recovery.

While there is some evidence that distraction may attenuate negative affect

(Broderick, 2005), recent investigations suggest that mindfulness may be relatively superior in this regard relative to distraction (Kuehner, Huffziger, & Liebsch, 2009;

Singer & Dobson, 2007; Broderick, 2005). Specifically, a study of the effects of a negative mood induction in 177 undergraduate students indicated that instructions designed to encourage distraction and mindfulness were both associated with decreased

27 dysphoric mood following the induction when compared to rumination instructions, but that distraction was not as effective as mindfulness at improving affect (Broderick, 2005).

Broderick suggests that distraction may weaken depressogenic cognitive routines and provide of an alternative focus of attention. However, she further hypothesized that mindfulness meditation may be a superior intervention to improve mood because it decreases the spread of activation of incompatible, negative cognitions, and might also reduce the risk of ineffective forms of distraction (e.g. repression and avoidance).

The impact of mindfulness on affect has predominantly been evaluated within the context of depressed mood, however recent studies have begun to focus on comparing distraction, mindfulness and rumination in the context of anxiety. For example, in a investigation of 96 undergraduate students exposed to an audio recording of personally relevant intrusive thoughts, results indicate that mindfulness is a more effective strategy for coping with intrusive thoughts and results in lower ratings of anxiety compared to distraction and rumination (Clancy, 2004). Henry (2003) also compared the influence of mindfulness and control inductions on anxiety. Results from this study (Henry, 2003), suggest that a mindfulness induction results in significant decreases in self reported anxiety prior to a speech task compared to a no instruction control condition. Participants in a distraction condition reported no change in anxiety and those in the rumination condition reported increases in anxiety (Henry, 2003). Consistent with metacognitive theory, the author suggested that mindfulness may result in a shift to a more adaptive cognitive style that involves the processing of negative thoughts with intentional present- moment awareness and acceptance (Henry, 2003). This approach may assist in the

28 disengagement from ruminative processing, and result in less cognitive avoidance and anxiety.

In summary, recent research investigating the influence of distraction, mindfulness and rumination indicates that both distraction and mindfulness interventions tend to improve negative affect and decrease anxiety in the context of stress; however, mindfulness tends to result in greater improvements in affect and anxiety levels when compared with distraction. Metacognitive theory suggests that mindfulness may result in a shift to a more adaptive cognitive style that aids in the processing of negative stimuli in a fashion that results in less anxiety and depressed mood (Wells, 2009) while distraction only provides a temporary reprieve from negative thoughts and associated affect.

Previously noted associations between rumination and negative affect lend support to the hypothesis that mindfulness interventions may be superior to distraction for the purpose of decreasing rumination.

Mindfulness and Cardiovascular Functioning

Research suggests that rumination serves to maintain negative emotions and cardiovascular arousal. Thus, it follows that mindfulness, which serves to lower the intensity and frequency of negative affect (Brown & Ryan, 2003) and to decrease the tendency to ruminate (Jain et al., 2007; Teasdale et al., 2002; Ramel et al., 2004;

Teasdale et al., 1995), may improve cardiovascular recovery.

Evidence regarding the impact of mindfulness on cardiovascular functioning is limited, with only one published study evaluating the impact of mindfulness meditation on cardiovascular responses (Ditto, Eclache, & Goldman, 2006) and one study

29 investigating the impact of acceptance oriented processing of emotion (a technique based on mindfulness principles) on cardiovascular responses (Low, Stanton, & Bower, 2008).

Ditto and colleagues (2006) examined the short-term autonomic and cardiovascular effects of a mindfulness technique (mindfulness body scan meditation) in 32 healthy students. Participants attended two laboratory assessments four weeks apart in which cardiovascular functioning was measured at baseline and after 20 minutes of treatment.

They were randomized to one of three treatment conditions: listening to a 20 minute mindfulness meditation body scan, listening to a 20 minute progressive muscle relaxation or sitting quietly for 20 minutes. Results indicated that participants in the mindfulness condition had larger baseline to treatment increases in respiratory sinus arrhythmia

(RSA), suggesting increased parasympathetic activity. This effect did not require extensive practice as it appeared in testing session one (when participants engaged in the mindfulness body scan treatment for the first time) prior to the participants’ 4-week practice period and second testing session (Ditto et al., 2006).

A follow-up study used a within subjects repeated measure design to evaluate the influence of mindfulness body scan compared to listening to an audio book in 30 healthy students. Results indicated that participants showed greater decreases in pre-ejection period (PEP), greater increases in RSA, greater decrease in respiration rate, greater increases in low frequency heart rate variability (HRV) and a sex specific greater decrease in DBP (only in women) during the mindfulness condition compared to the during the audio book condition (Ditto et al., 2006). Overall, the pattern of results

30 suggests that mindfulness meditation is associated with parasympathetic nervous system activation.

A more recent study (Low et al., 2008) evaluated the influence of mindful processing of a recent stressor. Specifically, Low and colleagues (2008) investigated the impact of three types of emotional processing writing tasks on heart rate recovery. Across two experimental sessions, 81 healthy participants were randomly assigned to write about an ongoing stressful experience while they either 1) evaluated the appropriateness of the emotional response, 2) attended to their emotions in an accepting way (consistent with mindfulness) or 3) described the objective details of the experience. Results demonstrated that writing about emotions in an accepting manner leads to more efficient heart rate recovery compared to the control group or processing emotions in an evaluative way.

Findings also indicated that processing emotions in an evaluative way inhibited habituation compared to the control and acceptance conditions (which did not differ on habituation). This investigation suggests that acceptance of emotions, a principle associated with mindfulness, may enhance cardiovascular recovery.

In summary, evidence regarding the impact of mindfulness interventions on cardiovascular functioning, and cardiovascular recovery following stress in particular, is limited. Previous findings suggest that mindfulness interventions are generally efficacious at reducing rumination. Furthermore, evidence suggests that mindfulness interventions may be superior to distraction at decreasing ruminative tendencies. Given the evidence and theoretical models linking rumination and negative affect with delayed cardiovascular recovery it seems plausible that a mindfulness intervention that decreases

31 rumination (and improves affect) may also result in improved cardiovascular recovery from stress.

Goals of the Present Study

The central goal of the current study was to evaluate the influence of a brief mindfulness intervention on rumination and cardiovascular recovery from stress.

Specifically, this study aimed to evaluate the impact of specific cognitive processes following stress (i.e. distraction and mindfulness) on cardiovascular recovery as well as whether brief training in mindfulness would influence cognitive processes following stress and subsequently influence cardiovascular recovery. To achieve these aims

participants were assigned to one of three conditions (mindfulness, distraction or control)

and rumination and cardiovascular recovery were assessed at two time points (pre and

post 4-week mindfulness intervention or 4-week waiting period) (see procedures). Based

on the previous literature examining the link between rumination, negative emotions and

cardiovascular recovery as well as the literature evaluating the influence of distraction

and mindfulness on rumination and negative affect, the following hypotheses were

proposed:

Primary Hypotheses Pre-Intervention Testing Session:

1. Participants in the mindfulness condition would report less state rumination (as

measured by thought reports) during recovery from a laboratory stress task compared

to participants in the control condition and the distraction condition.

2. Participants in the control condition would have poorer cardiovascular recovery from

a laboratory stress task compared to participants in the mindfulness condition and the

distraction condition.

Primary Hypotheses Post-Intervention Testing Session:

3. Participants in the mindfulness condition would show greater improvements (from

testing session one to testing session two) in state rumination (i.e. decreases in state

rumination) following a laboratory stress task in comparison to participants in the

distraction and control conditions.

4. Participants in the mindfulness condition would show greater improvements (from

testing session one to testing session two) in cardiovascular recovery from a

laboratory stress task in comparison to participants in the distraction and control

conditions.

Secondary Hypotheses:

5. A 4-week mindfulness intervention would result in larger decreases in trait

rumination and larger increases in trait mindfulness, from testing session one to

testing session two, compared to participants in the no intervention condition

(distraction and control conditions).

6. State rumination (as measured by thought reports) during recovery would be

associated with cardiovascular recovery such that higher levels of state rumination

would be associated with poorer cardiovascular recovery at testing session one and at

testing session two.

7. Participants in the mindfulness condition would show greater improvements (from

testing session one to testing session two) in depressed mood and symptoms of stress

in comparison to participants in the no intervention condition (distraction and control

conditions).

8. Time spent meditating during home practice (for those participants in the mindfulness

condition) would be associated with trait mindfulness, trait rumination, depressed

mood and symptoms of stress, such that more time meditating would be associated

with greater improvements on these scales.

9. Participants in the mindfulness condition would show greater improvements (from

testing session one to testing session two) in cardiovascular reactivity from a

laboratory stress task in comparison to participants in the no intervention condition

(distraction and control conditions).

10. Trait rumination and trait mindfulness would be associated with cardiovascular

recovery from a laboratory stress task at testing session one and testing session two

such that poorer cardiovascular recovery would be associated with greater trait

rumination and less trait mindfulness.

11. Changes in trait mindfulness, in participants in the mindfulness condition, would be

associated with changes in trait rumination, depressed mood and symptoms of stress

such that increases in trait mindfulness would be associated with decreases in trait

rumination, depressed mood and symptoms of stress.

Method

Participants

A sample of 114 undergraduate students was recruited through the online research participant pool at the University of Calgary (see power analysis below). Exclusion criteria included overt cardiovascular disease (including arrhythmia), current use of mood-altering medication (which could influence self-reports of rumination or mood), currently practicing daily mindfulness meditation or other forms of meditation, current use of anti-hypertensive medications and currently pregnant. Inclusion criteria included

University of Calgary student status, between the ages of 18 and 40 and available to participate during the allotted timeslots. All procedures and methods were approved by the University of Calgary Conjoint Faculties Research Ethics Board (see Appendix M and N).

Procedures

Randomization and Study Design

Participants who volunteered for the experiment through the online recruitment system were randomized to one of three conditions: mindfulness, distraction or control

(see Figure 3). Participants were contacted by email, informed of the randomization design of the study and offered possible dates and times to participate. Subject numbers were randomized to one of the conditions using a three-digit random number generator procedure. All assignments were computer based and not predictable. Participants were assigned to a number based on the order that they volunteered for the study.

Randomization of a participant to a condition was concealed from the research assistants

35 until the morning of the testing session. The research assistants were not blind to the participant’s condition, as they administered the induction procedure (dependant on condition) to the participant during the laboratory testing session (see further details below).

All participants took part in two identical testing sessions 5-weeks apart (same protocol, time of day, and location). Those in the distraction condition received a distraction induction during the recovery period of the laboratory testing session, those in the control condition received no induction during the recovery period and those in the mindfulness condition received a mindfulness induction during the recovery period.

Participants in the mindfulness condition also received a 4-week mindfulness intervention during the period between laboratory testing sessions while participants in the distraction and control conditions received no intervention between the laboratory testing sessions.

Subjects in the mindfulness condition attended their first testing session in the week prior to the commencement of the mindfulness intervention and their second testing session occurred during the week after the intervention was completed.

Participants were blind to their condition until the end of the first testing session when they learned whether they would attend the 4-week intervention (based on their randomization) and they were not informed that a manipulation was performed during the recovery period of the testing session, that was dependant on their randomization.

Laboratory Testing Sessions

After obtaining informed consent participants filled out a questionnaire package

(Figure 3). Subjects were then instrumented with cardiovascular recording equipment and

36 sat quietly for 5 minutes during which baseline cardiovascular measures were recorded and visual analogue scales (VAS: see Appendix A) were administered to assess baseline mood and stress levels.

Stress Task. Participants were asked to speak about a recent stressful negative life event that they found difficult to stop thinking about. Subjects were instructed to choose a different speech topic at the second testing session to increase the probability that the stress task would result in a stress response (habituation to the stress task at the second testing session may have been increased if the same speech topic was chosen). They were given 2 minutes to mentally prepare their 5 minute speech. This task was designed to provoke a stress response and to bring to mind an event that has been ruminated about in the past, increasing the likelihood of rumination during the subsequent recovery period. Following the stress task participants were asked to complete the same VAS again (assessing mood and stress levels) as well as VAS assessing how upsetting the stress task was (see Appendix B). The experimenter then explained the state rumination assessment procedure that occurred during the recovery period.

Recovery Period. The 15-minute inductions were administered during the recovery period in audio format using a personal listening device (portable compact disc

(CD) player and headphones).

Mindfulness Induction. Participants were asked to focus their attention on mindfulness statements that were developed based on statements that have been used in previous investigations (Clancy, 2004; Henry, 2003) and guided mindfulness meditations

(Kabat-Zinn, 1990). The statements directed subject’s awareness to both internal and

37 external stimuli in the moment without evaluation or prediction of future events (see

Appendix C). For example, participants were asked to attend to statements such as

“observe the sensations of your breath passing in and out through your nostrils.” One statement was presented every 3 minutes.

Distraction Induction. Participants were asked to focus their attention on distracting statements that have been used in previous research (Clancy, 2004; Henry,

2003; Nolen-Hoeksema & Morrow, 1993). For example, they were asked to attend to such statements as “think about different routes to the University” (see Appendix C). One statement was presented every 3 minutes.

Control Induction. Participants were told to let their mind wander during the

recovery period (no further statements were presented to the participant).

Mindfulness Intervention (Nolen-Hoeksema & Morrow, 1993)

The development of the abbreviated mindfulness intervention was guided by the

work of Kabat-Zinn (1990). This abbreviated mindfulness intervention is congruent with

the mindfulness philosophy and is aimed specifically at cultivating mindfulness through

instruction in a number of core mindfulness practices. The intervention is four weeks in

duration and consists of four weekly 45-minute group sessions and home practice. Each

group session includes a didactic section and experiential exercises. Each group session

included a didactic section and experiential exercises. Participants received a CD

recording of guided mindfulness exercises, which they were instructed to listen to and

practice for at least 15 minutes per day, 5 days per week. They also received a booklet

38 that summarized key points from the educational material and clarified homework requirements.

The group sessions were led by a doctoral level clinical psychology student (the author) with previous experience co-leading a mindfulness meditation intervention with an experienced mindfulness practioner. Maximum group size was 8 students. A week by week description of the program content follows:

Week 1: A brief explanation of the intervention was provided including a review of the group guidelines. Participants were also given booklets and meditation CDs.

Mindfulness meditation was defined and explained, and participants were guided through an exercise focusing on full and relaxed breathing as well as a body scan. The homework requirements of 15 minutes formal meditation and ongoing informal mindfulness practice was reviewed.

Week 2: The key attitudes associated with mindfulness were introduced, these being: non-judging, patience, beginner’s mind, self-trust, non-striving, acceptance, and letting go. The group was asked to recount their experiences with their mindfulness practice over the last week and ask any questions they may have. A guided sitting meditation focusing on breath awareness was performed. The homework requirements were reviewed.

Week 3: Various mini-mindfulness strategies (brief exercises focusing on breath awareness) were introduced and briefly practiced, and a guided imagery meditation was performed. The group closed with a brief discussion about their mindfulness practice and the homework requirements were again reviewed.

Week 4: The exercises learned in previous weeks were reviewed, followed by a discussion of possible supports to continue the momentum and discipline of meditation practice. The class was then led through a walking meditation, and the final group discussion focused on integrating mindfulness meditation practice into one’s daily life.

Participants were asked to complete meditation logs, for the duration of the mindfulness intervention, in which they recorded the number of minutes spent meditating each day. They were request to complete 75 minutes of home practice each week.

Meditation logs were collected each week in an opaque envelope and participants were encouraged to report their home practice accurately regardless of whether they completed the requested amount of practice.

Similar mindfulness interventions have been successfully implemented with nurses (Mackenzie, Poulin, & Seidman-Carlson, 2006) and undergraduate students (Ditto et al., 2006). Mackenzie and colleagues (2006) intervention resulted in improvements in measures of burnout, relaxation, life satisfaction and job satisfaction while Ditto and colleagues (2006) reported changes in cardiovascular functioning (e.g. decreased heart rate while meditating). (Treynor, Gonzalez, & Nolen-Hoeksema, 2003; Fresco, Arney, Menni, Turk, & Heimber, 2009)

Measures

Psychosocial Measures

Demographic information. Participants reported the following demographic

information: age, sex, ethnicity and number of years in university. Participants also

denoted where they see themselves in terms of socioeconomic status (SES) using a ladder

technique developed by the MacArthur Foundation Network on SES and Health.

Perceived socioeconomic status is related to psychological and physical health (Adler,

Epel, Castellazzo, & Ickovics, 2000). This demographic data provided information about the sample and enabled comparisons between the characteristics of the mindfulness, distraction and control groups.

Stress Reactive Rumination Scale (SRRS). The SRRS (Robinson & Alloy,

2003) is a 25-item scale that was adapted from the Response Styles Questionnaire-

Ruminative Response Scale (RSQ-RRS; Nolen-Hoeksema & Morrow, 1991). The SRRS was developed by constructing items that were believed to assess the cognitive tendency to focus on the negative attributions and inferences that comprise the negative inferential style in response to major life stressors. Participants are asked to rate each of the 25 items on a scale of 0 to 100 based on how frequently they would respond to a stressful even in that manner. The reliability (retest reliability r = .71, p < .001) and internal consistency (α = .89) of this scale are considered adequate. The SRRS was chosen as the measure to assess rumination as this scale was designed to measure rumination in a college age sample and therefore contains instructions that may be particularly relevant to this population (see Appendix D). Furthermore, the scale was designed to measure rumination in a manner that is not confounded with depressive symptoms which is a limitation of many other self-report rumination scales (Robinson & Alloy, 2003).

Five Facet Mindfulness Questionnaire. The Five Facet Mindfulness

Questionnaire (FFMQ; see Appendix E) (Baer, Smith, Hopkins, Krietemeyer, & Toney,

2006) is a self-report instrument recently developed through factor analysis of five available mindfulness questionnaires, i.e. the Mindfulness Attention Awareness Scale

(Brown & Ryan, 2003), the Freiburg Mindfulness Inventory (Buchheld, Grossman, &

Walach, 2001), the Kentucky Inventory of Mindfulness Skills (Baer, Smith, & Allen,

2004), Cognitive and Affective Mindfulness Scale (Hayes & Feldman, 2004), and the

Mindfulness Questionnaire (MQ; Chadwick, Hember, Mead, Lilley, & Dagnan, 2005).

The FFMQ allows for a multifaceted assessment of mindfulness (Baer, Smith, Hopkins,

Krietemeyer & Toney, 2006). The five facets of mindfulness measured by the FFMQ are: observing, describing, acting with awareness, nonjudging of inner experience, and nonreactivity to inner experience. A total mindfulness score was calculated by summing the five facet scores. The FFMQ consists of 39 self-report items which participants are asked to answer on a 1-5 Likert rating scale. Although this is a new instrument in need of additional validation, initial findings suggest it exhibits good internal consistency and construct validity (Baer, Smith, Lykins, et al., 2008). The FFMQ is sensitive to changes in mindfulness levels over the course of an MBSR program (Carmody & Baer, 2008).

Beck Depression Inventory (BDI-II). The BDI-II (Beck, Steer, & Brown, 1996) is a 21-item self-report inventory designed to measure the presence and intensity of depressive symptomatology in both adult and adolescent populations. The questionnaire is presented in multiple-choice format with each item scored on a 4-point scale ranging from 0 (low intensity) to 3 (high intensity) with overall total scores ranging from 0 to 63.

The BDI-II has been employed extensively with both clinical and nonclinical populations, in addition to undergraduate samples (Dozois, Dobson, & Ahnberg, 1998).

The inventory has demonstrated very high internal consistency reliability (e.g. 0.91 -

0.93) among undergraduate students (Beck et al., 1996). The content validity is

42 considered to be extremely good as the inventory encompasses many major content domains of depression including sadness, pessimism, loss of pleasure, feelings of guilt, altered sleep patterns, irritability, fatigue, and loss of interest in sex, among other aspects

(Dozois & Covin, 2003). (Di Benedetto, Lindner, Hare, & Kent, 2005)

Calgary Symptoms of Stress Inventory (CSOSI). The CSOSI is a 56-item instrument used to measure physical, psychological, and behavioural symptoms of stress.

Items are rated on a five-point scale (“never” to “very frequently”), referring to the frequency of stress-related symptoms during the past week. Items form a total scale as well as 8 subscales: Depression, Anger, Muscle Tension, Cardiopulmonary Arousal,

Sympathetic Arousal, Neurological/Gastro-intestinal, Cognitive Disorganization and

Upper Respiratory Symptoms. The total scale and subscales have demonstrated good internal reliability (e.g. 0.80-0.95), and have been shown to correlate with other scales measuring symptoms of distress (Carlson & Thomas, 2007). The CSOSI is sensitive to change in symptoms of stress following psychosocial interventions (Carlson & Thomas,

2007).

Visual Analogue Scales (VAS). Three VAS were used to measure mood and stress levels at baseline (see Appendix A) and following the stressor during the laboratory testing session (see Appendix B). Similar measures have been used for rating subjective feelings and have been shown to be sensitive indices (e.g. Bond & Lader, 1974; Miller &

Ferris, 1993; Di Benedetto et al., 2005).

State Rumination. Participants were cued by a tone (over the personal listening device) to complete a thought report at 2.5, 5.5, 8.5, 11.5 and 14.5 minutes after the

43 commencement of the recovery period. Each thought report required participants to record whether they were thinking about the future, the past, or the present at the time of the tone (see Appendix G for state rumination instructions). Participants recorded their responses on the thought report from (see Appendix F) using a simple check mark to indicate one of the three categories (past, present or future). Responses indicating the participant was thinking about the past or future were considered as engaging in state rumination whereas responses indicating the participant was thinking about the present or most recent induction statement (in the mindfulness and distraction conditions) were considered as engaging in state rumination.

Laboratory Physiological Measures (O'Brien, Waeber, Parati, Staessen, & Myers, 2007)

Measurements of SBP and DBP (in mmHg) were obtained at 1-minute intervals

using an automatic, calibrated, oscillometric BP monitor (Accutor Plus, Data Scope

Corp., Mont Vale, NJ, USA) that has been validated and recommended by the European

Society of Hypertension (Mancia, De Backer, Dominiczak, & et al., 2007), and a BP cuff

on the upper part of the non-dominant arm. Appropriate sized BP cuffs were selected

according to the size of the participant’s arm. Research assistants received training in

accordance with the British Hypertension Society guidelines (Manuck, Kasprowicz,

Monroe, Larkin, & Kaplan, 1989) for measuring BP, including cuff placement, prior to

participant testing. Continuous measures of heart rate (in beats per minute (bpm)), were

recorded non-invasively via electrocardiogram (ECG), using three 3M Red Dot

disposable silver-silver chloride electrodes with Solid electrode gel (3M Health Care,

Nuess, Germany). Two electrodes were placed bilaterally on the upper rib cage, with a

44 ground spot electrode placed on the right hipbone. The sequence of heart beat intervals from the ECG were sampled at a rate of 1000 Hz. Recordings of heart rate were obtained and averaged for each minute by the Cardiac Output Program (C.O.P.) developed by Bio-

Impedance Technology (Chapel Hill, NC, and IBM PC).

Data Analysis

Power Analysis

In selecting a sample size for this study, the goal was to have 90% power to test the primary hypothesis regarding the ability of a mindfulness intervention to reduce state rumination in comparison to a control condition. The criterion for statistical significance was alpha = .05 (two-tailed).

Few studies exist that examine the ability of mindfulness interventions to reduce state rumination. The study that comes closest to evaluating the influence of a mindfulness intervention on state rumination was that of Jain and colleagues (2007). This study utilized daily reports of ruminative thoughts and behaviors (Daily Emotion Report:

Nolen-Hoeksema, Morrow, & Fredrickson, 1993) to assess rumination pre and post mindfulness intervention in comparison to an active control condition (relaxation intervention). Results demonstrated that reports of rumination for participants in the mindfulness condition decreased (M = -1.4, SD = 2.5) while reports of rumination increased in the control condition (M = 0.9, SD = 2.5). Given these observed changes in rumination a sample size of 25 participants per group was determined to be necessary to see a significant effect of a mindfulness intervention on state rumination in comparison to a control condition.

In order to account for a 20% attrition rate, approximately 30 participants were recruited for each group (mindfulness, distraction and control). Thus, a sample of over

90 students was recruited to participate in the study. Observed power for effect of the mindfulness intervention on state rumination in the mindfulness condition (change in state rumination M= -0.65, SD = 1.12) compared to the control condition (change in state rumination M= 0.25, SD = 1.19) was 88.9%.

Cardiovascular Data Reduction

Cardiovascular data was averaged for the baseline period and the stress task. To obtain baseline values, the recordings from the last four minutes of the five minute baseline period were averaged. Disregarding the first minute of measurement allows for adaptation to the instrumentation and surroundings and thus provides a more stable estimate of resting levels (Linden et al., 1997; Christenfeld, Glynn, & Gerin, 2000). The five BP readings taken during the stress task were used to calculate mean cardiovascular values for this task. To obtain reactivity values, change scores for each of the cardiovascular measures was calculated using the difference between baseline and stress response means.

To summarize the recovery data, an area-under-the-curve (AUC) technique was used to calculate a recovery value associated with the stressor task. AUC is considered to be a superior technique of summarizing recovery data in comparison with other methods, such as measuring time to recovery or calculating change scores at arbitrary intervals

(Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, 2003). As described by Pruessner and colleagues (2003), AUC is determined by taking the area bounded by a

46 cardiovascular recovery curve and a baseline, dividing it into trapezoids and summing the area of each trapezoid to create the AUC value. AUC was calculated in reference to baseline values rather than in reference to zero in order to emphasize changes over time and not the distance from zero (Pruessner et al., 2003).

Statistical Analysis

Four primary hypotheses as well as seven secondary hypotheses were tested.

These hypotheses were tested using a series of analyses of variance (ANOVAs) rather than using a multivariate analysis of variance (MANOVA). Although the use of

MANOVA has several advantages it also holds the potential for suppressing some significant univariate effects (i.e. increased risk of Type II error). Given the exploratory nature of this study the ANOVA procedure was deemed more appropriate. Group differences in post-intervention scores on the psychological and cardiovascular variables were analyzed using a series of repeated measures ANOVAs (RM-ANOVAs), with time as the repeated measure (see details for each hypothesis below). The Bonferroni correction was employed for follow-up tests of any statistically significant RM-ANOVA results that involved the three conditions. Although the Bonferroni correction is a conservative approach analyses revealed that all the follow-up results were robust to this correction. The distraction and control conditions were grouped together into a ‘no intervention’ condition (distraction and control conditions did not receive any treatment between the two testing sessions) for all hypotheses not involving the recovery period

(i.e. hypotheses 5-11), because there was no theoretical reason to predict that the distraction and control conditions would differ on hypotheses not involving the recovery

47 period (the distraction and control conditions differ only on manipulation during the recovery period).

Demographic, Baseline Characteristics and Stress Task. To confirm that participants randomized to the mindfulness, distraction and control conditions were comparable on categorical demographic variables such as sex, ethnicity, and current smoking status, at testing session one, Pearson chi-square tests were performed (e.g. gender x group). A series of one-way (condition: mindfulness, distraction, control)

ANOVAs were used to compare participants across the conditions on continuous demographic variables (i.e. age, BMI, and SES) and on trait mindfulness and trait rumination at testing session one. Pearson chi-square tests were performed on the variables of previous meditation experience, and interest in mindfulness (e.g. meditation experience x condition) to determine if participants in the three conditions differed on these indices at testing session one. Two one-way (condition: mindfulness, distraction, control) ANOVAs were used to compare participants across the conditions on changes in self-reported stress levels (using VAS) from baseline to post stressor at testing session one and at testing session two to confirm that participants across the conditions similarly found the stressor task stressful.

Non-completers. To investigate whether the participants who completed the study were comparable to non-completers on categorical variables such as gender, ethnicity, and current smoking status at testing session one a series of Pearson chi-square tests were performed. Participants who completed the study were compared to non- completers on continuous variables of interest at testing session one (i.e. age, BMI, SES,

48 state rumination, cardiovascular recovery, depressed mood, trait rumination, trait mindfulness, symptoms of stress) using a series of one-way (condition: completer, non- completer) ANOVAs.

Mindfulness Adherence. Descriptive statistics regarding mindfulness intervention attendance and homework completion based on the available homework logs were calculated for the mindfulness participants. Homework completion was calculated assuming participants practiced zero minutes if they did not hand in their practice log. As the mindfulness intervention was administered to five cohorts of participants a series of one-way (cohort: cohort 1, 2, 3, 4 and 5) ANOVAs were performed on attendance, homework completion, trait mindfulness at testing session one and change in trait mindfulness (from testing session one to testing session two) to ensure that the cohorts did not significantly differ on these variables.

Hypothesis 1. The hypothesis that participants in the mindfulness condition would report less state rumination during recovery from a stress task compared to participants in the other conditions was evaluated using a one-way (condition: mindfulness, distraction, control) between subjects ANOVA for state rumination at testing session one.

Hypothesis 2. A series of one-way (condition: mindfulness, distraction, control) between subjects ANOVAs for the cardiovascular recovery variables (i.e. SBP AUC,

DBP AUC, HR AUC) were used to test the hypothesis that participants in the control condition would have poorer cardiovascular recovery from a stress task compared to participants in the other conditions at testing session one.

Hypothesis 3. The prediction that participants in the mindfulness condition would show greater improvements in post-stressor state rumination (from testing session one to testing session two) in comparison to participants in the other conditions, was tested using a 3 (Condition: Mindfulness, Distraction, Control) X 2 (Time: Time 1, Time 2)

RM-ANOVA for state rumination.

Hypothesis 4. A series of 3 (Condition: Mindfulness, Distraction, Control) X 2

(Time: Time 1, Time 2) RM-ANOVAs for each of the cardiovascular recovery variables was used to evaluate the prediction that participants in the mindfulness condition would show greater improvements in cardiovascular recovery from a stress task (from testing session one to testing session two) in comparison to participants in the other conditions.

Hypothesis 5. A 4-week mindfulness intervention was predicted to result in greater decreases in trait rumination and increases in trait mindfulness (from testing session one to testing session two) compared to not receiving the intervention. This hypothesis was tested using two 2 (Condition: Mindfulness, No treatment) X 2 (Time:

Time 1, Time 2) RM-ANOVAs for trait mindfulness and trait rumination.

Hypothesis 6. The prediction that state rumination during recovery would be associated with cardiovascular recovery, such that higher levels of state rumination would be associated with poorer cardiovascular recovery (at both testing session one and testing session two), was evaluated using a series of Pearson correlations between state rumination and cardiovascular recovery variables (i.e. SBP AUC, DBP AUC, HR AUC) for testing session one and testing session two (e.g. association between state rumination at testing session one and cardiovascular recovery variables at testing session one).

Hypothesis 7. Two 2 (Condition: Mindfulness, No treatment) X 2 (Time: Time 1,

Time 2) RM-ANOVAs for the variables of depressed mood (BDI-II total score) and symptoms of stress (CSOSI total score) were used to test the hypothesis that participants in the mindfulness condition would show greater improvements in depressed mood and symptoms of stress (from testing session one to testing session two) in comparison to participants in the no treatment condition.

Hypothesis 8. Pearson correlations were used to assess the prediction that, for participants in the mindfulness condition, greater time spent in meditation home practice would be associated with greater decreases in trait rumination, depressed mood and symptoms of stress.

Hypothesis 9. The hypothesis that participants in the mindfulness condition will show greater improvements in cardiovascular reactivity from a laboratory stress task in comparison to participants in the no intervention condition was evaluated using a series of 2 (Condition: Mindfulness, No intervention) X 2 (Time: Time 1, Time 2) RM-

ANOVAs for the cardiovascular reactivity variables (i.e. HR reactivity, SBP reactivity, and DBP reactivity).

Hypothesis 10. The prediction that trait rumination and trait mindfulness would be associated with cardiovascular recovery at time on and testing session two was evaluated using Pearson correlations (i.e. correlations between psychological variables at testing session one and cardiovascular recovery at testing session one, as well as correlations between psychological variables at testing session two and cardiovascular recovery at testing session two).

Hypothesis 11. Pearson correlations were used to assess the hypothesis that increases in trait mindfulness, in participants in the mindfulness condition, would be associated with decreases in trait rumination, depressed mood and symptoms of stress.

All data analyses were performed using SPSS for Windows version 17.0 (SPSS

Inc., Chicago, IL, USA). The data was inspected to investigate whether the assumptions of the relevant statistical tests were met (see Appendix H). Where the statistical assumption of the Pearson chi-square test was not met (i.e. expected cell frequencies were not greater than five) Fisher’s Exact p-values have been reported (see Appendix H for further details). Mean cardiovascular baseline or stress task values were calculated based on the available values (missing values during these periods were not replaced).

Missing cardiovascular values during the recovery period were replaced with the mean of the value before and after the missing data point to maintain the integrity of the cardiovascular recovery curve as the AUC calculation requires a data point for each minute (Prussner et al., 2003). Missing questionnaire data was replaced with pro-rated values determined based on a participant’s mean score for the scale or subscale containing the missing value (FACIT Manual, 1997). Where psychosocial measures produced both a total score and subscale scores (i.e. FFMQ and CSOSI) initial analyses were performed with the total score and if results were significant then analyses of the subscales were also conducted. The central goal of the study was to evaluate the manipulation of state rumination and the influence this may have on cardiovascular recovery and not to evaluate the efficacy of a treatment; therefore intent to treat analysis was deemed overly conservative and only participants with both testing session one and

52 testing session two data were included in the final analyses. The criterion for statistical significance was alpha = 0.05 (two tailed) for all of the statistical analyses.

Results

Participant Characteristics

One hundred and fourteen participants were recruited for the study (see Figure 3).

Drop-out rates for the mindfulness, distraction and control groups were 6.1% (n = 2),

15% (n = 6) and 12.2% (n = 5) respectively, and did not differ, χ2(2) = 1.47, Fishers

Exact p = .463. The final sample consisted of 31 participants in the mindfulness

condition, 34 in the distraction condition and 36 in the control condition.

The entire set of participant who completed the study had a mean age of 21.9

(SD= 3.9) years, were primarily women (85.3%), mostly White (52.5%), in the normal

weight range (body mass index (BMI) M = 22.6, SD = 3.3) and of moderate self-reported

socioeconomic status (M = 5.4, SD = 1.1). A series of one-way ANOVAs indicated no

differences among participants in the three conditions on continuous demographic

variables (i.e., age, socioeconomic status, BMI) at testing session one (see Table 1).

Pearson Chi-Square analysis similarly revealed no differences among the conditions on

categorical demographic variables (i.e., sex, ethnicity, smoking status, see Table 1).

Participants’ mean baseline HR (M = 68.63, SD = 9.38), SBP (M = 110.34, SD = 9.29)

and DBP (M = 66.27, SD = 6.70) at testing session one were within the normal healthy

range.

A large proportion of participants reported that they had never practiced any form

of meditation previously (48.5%), while 31.7% said that they had tried meditation once or

53 twice, 10.9% indicated they meditated infrequently, 3.0% stated they meditated monthly,

2.0% reported they meditated weekly and 4.0% said they meditated regularly in the past but not currently. None of the participants indicated that they currently meditated daily.

The majority of participants indicated they would be interested in learning more about mindfulness meditation (54.5%) or maybe interested in learning more about mindfulness meditation (30.7%). Pearson Chi-Square analysis yielded no differences among the conditions on previous meditation experience χ2(5) = 10.75, Fishers Exact p = .255 or

interest in mindfulness meditation χ2(4) = 8.63, Fishers Exact p = .055. Similarly, a

series of one-way ANOVAs indicated no difference among conditions at testing session

one on trait mindfulness, F(2, 98) = 0.72, p = .490, or trait rumination F(2, 98) = 1.04, p

= .358. Two one-way ANOVAs investigating changes in reported stress levels from baseline to post stressor (as measured by VAS) suggested that participants across the three conditions did not differ on reported changes in stress at testing session one F(2, 98)

= 2.56, p = .083 (M= 17.12, SD = 26.64), or testing session two F(2, 98) = 0.05, p = .949

(M= 12.96, SD = 22.43).

Non-completers. Pearson chi-square tests indicated that participants who completed the study were no different from non-completers on any of the categorical demographic variables (i.e. sex, ethnicity, smoking status). ANOVA analysis similarly illustrated that participants who completed the study were not different from non- completers on continuous variables of interest at testing session one (i.e. age, BMI, SES, state rumination, cardiovascular recovery, depressed mood, trait rumination, trait mindfulness, and symptoms of stress).

Mindfulness Adherence. The majority of the participants in the mindfulness condition (64.5%, n = 20) attended all four of the mindfulness group sessions, while the remaining 35.5% (n = 11) attended three of the four groups. Similarly, 87.1% (n = 27) of the intervention participants handed in all four homework logs and the remaining 12.9%

(n = 4) handed in three homework logs. The mean number of minutes of meditation home practice completed by the mindfulness participants per week, assuming participants practiced zero minutes if they did not hand in their homework log, was 74.7 (SD =19.6) minutes (75 minutes was the requirement). Based on the submitted homework logs mean meditation home practice was 77.5 (SD = 19.8) minutes per week. A series of one-way

ANOVAs showed that the mindfulness group cohorts did not differ on attendance, F(4,

30) = 2.72, p =.052, mean minutes of meditation home practice based on available logs,

F(4, 30) = 2.52, p = .066, trait mindfulness at testing session one, F(4, 30) = 0.57, p

=.688, or change in trait mindfulness, F(4, 30) = 1.29, p = .300. The mean number of mindfulness participants per cohort was 6.2 (SD = 1.48).

Hypothesis 1. Results of a one-way ANOVA indicated that there was a difference among the conditions (i.e. mindfulness, distraction or control) on state rumination at testing session one F(2,98) = 11.31, p < .001. Follow-up tests revealed that, compared to the control condition, participants in the mindfulness (t(2) = 4.67, p

<.001) and distraction conditions (t(2) = 4.67, p <.001) reported less state rumination.

Participants in the mindfulness and distraction conditions did not differ on state rumination t(2) = 1.70, p = .227 (Table 2 & 7).

Hypothesis 2. Results of a series of one-way ANOVAs indicated that condition was not associated with any of the cardiovascular recovery variables at testing session one (Table 2).

Hypothesis 3. RM-ANOVA analysis indicated an interaction between condition and time on state rumination F(2, 98) = 4.71, p = .011. Follow-up tests comparing state rumination at testing session one to state rumination at testing session two within each of the conditions demonstrated that participants in the mindfulness condition reported less state rumination at testing session two t(1) = 3.00, p = .003 compared to testing session one. Self-reported state rumination remained unchanged from testing session one to testing session two in both the distraction t(1) = 1.15, p = .254 and control conditions t(1)

= 1.26, p = .212 (Table 3 & 7, Figure 5, Appendix I).

Hypothesis 4. RM-ANOVA analyses showed a main effect of time on HR recovery F(1, 98) = 17.74, p < .001 and SBP recovery F(1, 98) = 18.28, p < .001 such that HR recovery and SBP recovery improved from testing session one to testing session two. Similar analysis demonstrated that there was no main effect of time on DBP recovery. RM-ANOVA analysis indicated that there was no interaction between time and condition or a main effect of condition for all of the cardiovascular recovery variables (Table 3 & 7).

Hypothesis 5. Results of the RM-ANOVA analysis demonstrated there was a main effect of time on trait rumination F(1, 98) = 6.37, p = .013, such that trait rumination decreased from testing session one to testing session two. There was no main

56 effect of condition on trait rumination and no interaction between condition and time

(Table 4 & 7).

RM-ANOVA analysis indicated there was an interaction between condition and time on trait mindfulness F(1, 98) = 8.47, p = .004 such that participants in the mindfulness condition reported increases in trait mindfulness from testing session one to testing session two compared to those in the no intervention condition (Table 4 & 7,

Figure 6). Analysis of the subscales of the trait mindfulness measure indicated interactions between condition and time on observing F(1, 98) = 13.40, p < .001 and non- judging F(1, 98) = 6.37, p = .013 subscales, such that participants in the mindfulness condition reported increases in observing and non-judging from testing session one to testing session two compared to those in the no intervention condition. RM-ANOVA analysis indicated that there was no main effect of time, main effect of condition or an interaction between time and condition for the describing, acting with awareness, and non-reactive subscales of the trait mindfulness measure.

Hypothesis 6. The Pearson product moment correlations results showed associations between state rumination and HR recovery, r = 0.20, p = .046 as well as state rumination and SBP recovery, r = 0.24, p = .016 at testing session one. A similar correlation indicated no association between state rumination and DBP recovery at testing session one. Correlations between state rumination and cardiovascular recovery variables at testing session two also suggested no association (Table 6).

Hypothesis 7. RM-ANOVA analysis revealed an interaction between condition and time on depressed mood F(1, 98) = 5.06, p = .027 such that participants in the

57 mindfulness condition reported decreases in depressed mood from testing session one to testing session two compared to those in the no intervention condition (Table 4 & 7,

Figure 7).

Similar RM-ANOVA analysis for symptoms of stress indicated there was no main effect of time, main effect of condition, nor an interaction between time and condition

(Table 4 & 7).

Hypothesis 8. Pearson correlations demonstrated that greater time spent meditating during home practice was associated with greater decreases (improvements) in trait rumination r = -.415, p = .020 in mindfulness participants. Time spent meditating during home practice was not related to changes in trait mindfulness, depressed mood or symptoms of stress.

Hypothesis 9. RM-ANOVA analyses indicated a main effect of time on HR reactivity F(1, 98) = 26.66, p < .001, SBP reactivity F(1, 98) = 28.76, p < .001, and DBP reactivity F(1, 98) = 14.63, p < .001 such that reactivity improved from testing session one to testing session two. RM-ANOVA analysis indicated that there was no interaction between time and condition or a main effect of condition for any of the cardiovascular reactivity variables.

Hypothesis 10. Results of the Pearson correlations revealed that trait rumination and trait mindfulness at testing session one were not related to cardiovascular recovery at testing session one. Correlations similarly indicated that trait rumination and trait mindfulness at testing session two were not related to cardiovascular recovery at testing session two (Table 9).

Hypothesis 11. Pearson correlations showed that changes in total trait mindfulness were not associated with changes in depressed mood or symptoms of stress, in the mindfulness condition. Increases in total trait mindfulness were associated with decreases in trait rumination r = -.55, p < .001, in mindfulness participants. Further correlations between changes in trait rumination and the trait mindfulness subscales indicated that decreases in trait rumination were associated with increases in observing r

= -.48, p = .006, describing r = -.47, p = .008 and acting with awareness r = -.43, p = .017 subscales but not the non-reactivity or non-judgement subscales (Table 10 & 11).

Discussion

The central goal of the current study was to evaluate the influence of mindfulness and distraction on rumination and cardiovascular recovery from stress. Specifically, the study aimed to determine if mindfulness and distraction inductions would decrease rumination following a stressor and whether this decrease in rumination would translate into improved cardiovascular recovery from stress. Additional goals of the study were to investigate the influence of a brief mindfulness intervention on rumination and mindfulness as well as possible associated psychological outcomes (i.e. changes in depressed mood and symptoms of stress).

In order to achieve these aims 101 undergraduate student participants were

assigned to one of three conditions: mindfulness, distraction or control. All participants

took part in two identical testing sessions 5-weeks apart. During each testing session

participants completed self-report questionnaires and their cardiovascular reactivity and

recovery from a stress task was assessed. Participants in the distraction condition

59 received a distraction induction during the stress task recovery period, those in the control condition received no induction during the recovery period and those in the mindfulness condition received a mindfulness induction during the recovery period. Participants in the mindfulness condition also received a 4-week mindfulness intervention during the period between testing sessions while participants in the distraction and control conditions received no intervention.

The main findings of the study were that both the distraction and mindfulness inductions succeeded in interfering with state rumination at testing session one and state rumination decreased from testing session one to testing session two in the mindfulness condition compared to the distraction and control conditions. Other notable findings were that participants who completed the mindfulness intervention reported increases in trait mindfulness and decreases in depressed mood compared to those who did not receive the intervention. The distraction and mindfulness inductions as well as the mindfulness intervention did not appear to impact cardiovascular reactivity or recovery.

The results of this study will be further discussed in terms of: a) the impact of the inductions and intervention on cardiovascular reactivity and recover (hypotheses 2, 4, 6,

9 and 10), b) the impact of the inductions and intervention on state rumination

(hypotheses 1 and 3), c) the impact of the intervention on trait rumination and mindfulness (hypotheses 5, 8 and 11), d) the impact of intervention on psychological outcome measures (i.e. depressed mood and symptoms of stress) (hypothesis 7 and 8) and e) the implications of the results for the rumination arousal model.

Cardiovascular Reactivity and Recovery

One of the central goals of this study was to investigate the relationship between rumination and cardiovascular responses to stress and to explore whether attempts to influence state rumination (through inductions and an intervention) would translate into changes in cardiovascular responses.

Cardiovascular Reactivity

Cardiovascular Reactivity and the Mindfulness Intervention. The impact of the mindfulness intervention on cardiovascular reactivity was investigated in comparison to a no-intervention condition. There was no reason to predict that the distraction and control conditions would differ on hypotheses related to cardiovascular reactivity, because these conditions differed only on manipulation during the recovery period. The distraction and control conditions were therefore grouped together into a ‘no intervention’ condition and compared with the mindfulness condition for analyses investigating cardiovascular reactivity. Contrary to our hypothesis, results indicated that the mindfulness and no-intervention conditions did not differ in terms of changes in cardiovascular reactivity from testing session one to testing session two (Hypothesis 9).

A main effect of time was observed such that HR reactivity, SBP reactivity and DBP reactivity decreased from testing session one to testing session two in both conditions.

Thus, the mindfulness intervention had no impact on changes in cardiovascular reactivity from testing session one to testing session two. There was an overall habituation effect across conditions to the stress task between testing sessions (see discussion of habituation below).

The lack of an association between the mindfulness meditation intervention and cardiovascular reactivity may be explained by the theoretical orientation of mindfulness training. Mindfulness meditation encourages individuals to focus their attention fully on the present moment in a non-judgmental fashion (Ditto et al., 2006). Being fully present and mindful during an unfolding stressor may not serve to make appraisals of the event less stressful in the moment, but rather allow an individual to recover more quickly after the event by continuing to focus on the present moment and preventing rumination about the past stressor. In the current study the predicted mechanism of influence of mindfulness on cardiovascular responses was through rumination. As rumination occurs after an event, it follows that the mindfulness intervention may not have a significant impact on cardiovascular responses while the stressor is present (i.e. cardiovascular reactivity). Alternatively, the null findings regarding reactivity may be due to floor effects (see discussion below) associated with using a healthy undergraduate sample.

Other Meditation Interventions and Cardiovascular Reactivity. There are currently no published studies reporting the effects of a mindfulness meditation intervention on cardiovascular reactivity and recovery from stress. Evidence regarding the impact of mindfulness meditation on cardiovascular processes, more generally, is also limited, with only one published study evaluating the impact of mindfulness meditation on cardiovascular functioning in the laboratory (Ditto et al., 2006). Ditto and colleagues

(2006) assessed cardiovascular functioning while participants completed a mindful body scan guided by an audio recording. Results of this study suggested that mindfulness meditation was associated with greater parasympathetic nervous system innervation of

62 the heart (as assessed by high frequency heart rate variability) in comparison to a control group that listened to an audio book (Canter & Ernst, 2004).

Previous research evaluating the influence of meditation on cardiovascular reactivity has largely focused on transcendental meditation (TM). TM is a form of meditation in which the practitioner sits and repeats a mantra in a prescribed manner, typically for 15 minutes, twice a day, with eyes closed (Wenneberg et al., 1997). The findings regarding the impact of TM on cardiovascular reactivity have been mixed. For example, no significant changes were reported in either BP or HR reactivity to mental arithmetic, mirror start tracing, public speaking or an isometric handgrip task in a 4- month study comparing TM to a stress education control group in normotensive college students (Barnes, Treiber, & Davis, 2001). However, a study of TM in adolescents with elevated resting blood pressure (greater than 85th percentile) had some positive results

(Barnes et al., 2001). Compared to a health education control group, 2 months of training/practice in TM resulted in greater decreases in SBP and HR reactivity to a car driving simulation stressor task but not a social stressor task (Barnes et al., 2001). The authors hypothesized that TM participants may have exhibited decreased cardiovascular reactivity to the car driving simulator (but not the social stressor) at post-test due to improved perceptual-motor coordination and faster reaction time previously observed to be a result of TM (Manikonda et al., 2008).

A more recent study investigated the influence of 8-weeks of contemplative meditation combined with breathing techniques (CMBT) on cardiovascular reactivity to an arithmetic stress task, in patients with hypertension (Manikonda et al., 2008). The

CMBT intervention sessions consisted of slow abdominal breathing training and meditation techniques based on the Christian tradition. Results indicated that CMBT was associated with less BP reactivity at follow-up compared to the no-intervention control group (Glynn et al., 2002; Gerin et al., 2006). One potential difference between the meditation programs that have lead to improvements in cardiovascular reactivity and the intervention employed in the present study is length of the intervention. Previous studies have used interventions that ranged in length from 8 weeks to 2 months whereas the brief meditation intervention used in the current study was 4 weeks long. Moreover, studies showing improvements in cardiovascular reactivity following a meditation intervention have used samples with elevated resting BP (see discussion of floor effects below)

(Barnes et al., 2001; Manikonda et al., 2008). Further research confirming the ability of

TM and CBMT to reduce cardiovascular reactivity is necessary. Future research should also attempt to clarify the necessary factors (e.g. type of stressor, length of meditation intervention, resting BP of sample etc.) required to observe a change in reactivity. Testing a sample of participants with elevated resting BP, several types of laboratory stressors and an 8 week (or longer) mindfulness meditation intervention may improve the ability to observe an effect on cardiovascular reactivity.

Cardiovascular Recovery

Cardiovascular Recovery and Situational Characteristics (Inductions). It was hypothesized that participants in the control condition would have poorer cardiovascular recovery from a laboratory stress task compared to participants in the mindfulness condition and the distraction condition at testing session one (Hypothesis 2). Results

64 demonstrated that the inductions administered following the stressor (mindfulness, distraction or no-induction) did not impact cardiovascular recovery at testing session one.

This was the first study to evaluate the influence of a mindfulness induction on cardiovascular recovery, however previous investigations have assessed the impact of a distraction induction on recovery. The literature evaluating the association between distraction following a laboratory stressor and cardiovascular recovery indicates that distraction is associated with superior BP recovery compared to a no distraction condition

(Gerin et al., 2006; Glynn et al., 2002). It is possible that the distraction provided in the current study was not engaging enough to result in significant improvements in cardiovascular recovery. The distraction induction was designed to mirror the mindfulness induction in terms of temporal sequence. Specifically, elapsed time between the statements was required in the mindfulness condition to allow participants to experience present moment sensations. In an analogous fashion, the distraction induction was also punctuated by breaks. Distracting statements were presented every 3 minutes during the recovery period in the current study, whereas in Gerin and colleagues’ (2006) study, participants in the distraction condition were presented with a screen covered in brightly coloured posters, magazines and small puzzles that required manipulation.

Participants in distraction condition in Glynn and colleagues (2002) study were asked to read various moral-dilemma scenarios and then respond to questions about theses scenarios. The presentation of intermittent statements in the present study, may not have required as much attention as the distraction techniques used in previous studies (Chafin,

Christenfeld, & Gerin, 2008). Future studies comparing mindfulness and distraction

65 inductions may benefit from an increased frequency of distracting audio statements in order to better capture participant attention.

Cardiovascular Recovery and the Mindfulness Intervention. Across the two testing time points, it was predicated that participants in the mindfulness condition would show greater improvement in cardiovascular recovery in comparison to participants in the distraction and control conditions (Hypothesis 4). Contrary to this hypothesis, analyses indicate that HR and SBP recovery improved similarly in all of the conditions from testing session one to testing session two, while DBP recovery remained unchanged in all of the conditions. This finding implies that the brief mindfulness intervention did not improve cardiovascular recovery from the stress task and that participants habituated to the stress task regardless of condition (see discussion of habituation below).

This was the first study to investigate the impact of a brief mindfulness meditation intervention on cardiovascular recovery from stress. A growing body of literature indicates that training in mindfulness meditation leads to healthier patterns of emotional and behavioural responding to stress based on self report questionnaire measures (Linden et al., 1997). It remains unclear, however, whether self-reported improvements in emotional and behavioural responses to stress translate into improved cardiovascular recovery from stress. Further research investigating the impact of a longer and more intensive mindfulness meditation intervention in participants with elevated risk of developing hypertension (e.g. family history of hypertension, normatively elevated BP) may be necessary in order to observe associated changes in physiological recovery from a laboratory stressor (see discussion of floor effects below).

Other Interventions and Cardiovascular Recovery. Studies investigating cardiovascular responses to stress have historically focused on cardiovascular reactivity and not assed cardiovascular recovery (Gerin et al., 2006; Key et al., 2008). This tendency towards an exclusive focus on cardiovascular reactivity is also prevalent for studies evaluating the impact of interventions on cardiovascular responses to stress. A review of the literature indicates that there are currently no published studies that have focused on the impact of a psychosocial intervention (not just a manipulation during the laboratory testing session) on cardiovascular recovery from stress in the laboratory.

However, the influence of manipulations applied just before or after the stressor on cardiovascular recovery has been evaluated in previous investigations. For example,

Chafin et al. (2008) demonstrated that BP recovery from psychological stress was improved with brief post-stress exercise (participants alternately raised their knees 25 centimetres at 120 beats per minute for three minutes). Given these preliminary findings, further research investigating the ability to influence cardiovascular recovery through mindfulness and other stress management and behavioural interventions seems warranted.

Cardiovascular Recovery and Psychological Variables

Cardiovascular Recovery and Trait Psychological Variables. The relationship between trait psychological variables and cardiovascular recovery was investigated with the prediction that greater trait rumination and less trait mindfulness would be associated with poorer cardiovascular recovery (Hypothesis 10). Results indicated that trait rumination and trait mindfulness were not associated with cardiovascular recovery at

67 testing session one or testing session two. These findings did not support the predicted links between trait dimensions and cardiovascular recovery based on the rumination arousal model (Gerin et al. 2006) (see discussion of implications for the rumination arousal model below).

This was the first study to evaluate the influence of trait mindfulness on cardiovascular recovery. The prediction that increases in trait mindfulness would be associated with improved cardiovascular recovery was based on the assumption that increases in trait mindfulness would be accompanied by decreases in rumination and this decrease would translate into improvements in cardiovascular recovery. Previous studies investigating the association between cardiovascular recovery and trait rumination have indicated that lower levels of trait rumination are associated with enhanced cardiovascular recovery (Gerin et al., 2006; Key et al., 2008). For example, Key and colleagues (2008) reported that high trait rumination was associated with poorer DBP recovery from an emotional stressor in a group of high and low trait ruminators (selected for participation in the study based on scoring either in the top or bottom third on the

SRRS trait rumination measure). The current study did not select participants based on trait rumination levels and therefore may not have had the variability in levels of trait rumination necessary to observe significant effects on cardiovascular recovery. Based on the inclusion criteria of Key et al. (2008) 42 participants in the current study would be considered low trait ruminators and only 25 participants would be classified as high trait ruminators (relative to 39 high ruminators in Key et al.’s 2008 study). Ensuring that an ample sample of high trait ruminators (e.g. 40 participants) is included in future studies

68 may enhance the ability to observe associations between trait rumination and cardiovascular recovery as well as significant changes in trait rumination following a mindfulness intervention.

Cardiovascular Recovery and State Rumination. It was predicted that greater state rumination would be associated with poorer cardiovascular recovery across conditions at testing session one and at testing session two (Hypothesis 6). Results partially supported this hypothesis, as greater state rumination was associated with poorer

HR and SBP recovery, but only at testing session one. State rumination was not associated with any of the cardiovascular recovery variables at testing session two. The use of a healthy sample may have interfered with finding a relationship between DBP recovery and state rumination at testing session one (see discussion of floor effects below). Habituation may have lead to decreased variability in cardiovascular recovery at testing session two and hindered the ability to observe a relationship between state rumination and cardiovascular recovery at the second assessment (see discussion of habituation below).

While previous investigations have established a link between trait rumination and cardiovascular recovery (Verkuil et al., 2009), evidence supporting an association between state rumination and cardiovascular recovery is less conclusive (Glynn et al.,

2002; Gerin et al., 2006). The association between state rumination and cardiovascular recovery has often been assessed through the use of distraction conditions designed to prevent state rumination (Gerin et al., 2006); however the relationship between reported state rumination and recovery has rarely been directly assessed. For example, Gerin and

69 colleagues (2006) used the comparison of a distraction and no-distraction manipulation to investigate the influence of rumination on cardiovascular recovery. However, only 31% of participants in the no-distraction condition reported state rumination during the recovery period; therefore the comparison of distraction and no-distraction did not directly test the relationship between state rumination and cardiovascular recovery. A limitation of using distraction to evaluate the relationship between state rumination and recovery is that some state rumination may occur even when distraction is provided.

Additionally, in experimental conditions where a distraction is not provided, it cannot be assumed with certainty that participants are ruminating. In order to address this limitation, Key and colleagues (2008) directly assessed self-reported state rumination during the recovery from an emotional stress task. Results revealed that state rumination was associated with cardiovascular recovery but only in participants who had low levels of trait rumination. The authors hypothesized that participants who habitually ruminate

(i.e. high trait ruminators) may have difficulty identifying state rumination due to the automatic nature of this cognitive process, and therefore their self-reports of state rumination may not have been accurate. This challenge in assessing state rumination likely applies to the current study as well because a similar self-report measure of state rumination was used. Unfortunately, there is currently no consensus regarding a valid and easily applicable method to assess state rumination following a stressor that does not rely on the ability of the participant to reflect on their own thought processes.

To summarize, the literature examining the relationship between state rumination and cardiovascular recovery has significant limitations due to the experimental designs

70 used (e.g. use of distraction as a proxy to assume no state rumination) and difficulties with the assessment of state rumination. More sophisticated means of measuring state rumination, or the comparison of manipulations that ensure the prevention and induction of state rumination, are necessary to more clearly evaluate the relationship between cardiovascular recovery and state rumination in future research.

Factors Relevant to both Cardiovascular Reactivity and Recovery

Floor effects. A possible explanation for the lack of an association between the inductions or intervention and cardiovascular responses (i.e. reactivity and recovery) is the influence of floor effects. Differences in the methodology of calculating AUC prevent direct comparison of raw recovery scores between the current study and previous studies; however mean cardiovascular reactivity values indicate that participants evidenced less cardiovascular reactivity to mental stress compared to similar reactivity studies with healthy samples (e.g. Gerin et al., 2006). Specifically, reactivity values at testing session one for SBP and DBP were +16.0mmHg and +13.3mmHg respectively.

The previous investigation by Gerin and colleagues (2006) reported SBP and DBP reactivity of +30.7mmHg and +18.2mmHg respectively (Gerin et al., 2006). Comparison of these reactivity values suggests that participants in the current study evidenced a healthier reactivity response profile and/or the stress task used in the current study was less stressful than the anger recall task used in the previous study (e.g. Gerin et al., 2006).

Interestingly, inspection of resting cardiovascular values in the present study indicated that participants in the current study had lower baseline values compared to previous studies that investigated the impact of distraction on cardiovascular reactivity

71 and recovery. Specifically, participants in the current study had mean baseline cardiovascular values of SBP, M = 110.3 mmHg and DBP, M = 66.3 mmHg, respectively. Gerin and colleagues (2006) study of cardiovascular reactivity and recovery in response to an anger recall stress task in a healthy sample reported mean baseline values of SBP M = 120.0 mmHg, and DBP M = 70.0 mmHg.

Given the low baseline and reactivity values in the current study there may have been little room for improvement in terms of cardiovascular reactivity and recovery from stress. Future studies investigating the impact of distraction and mindfulness using a stress task that induces greater reactivity, in a sample with elevated baseline BP, may be necessary to evaluate the impact of such interventions on cardiovascular reactivity and recovery.

Habituation. Another potential explanation for the null findings regarding associations between condition and cardiovascular responses (i.e. reactivity and recovery) is that participants may not have appraised the stressor task as particularly stressful at testing session two. Reduced cardiovascular reactivity to the stressor at the second assessment may have interfered with the ability to observe differences in cardiovascular responses across the conditions. Greater cardiovascular reactivity to the stressor allows for greater variability in recovery and enhances the potential to find differential effects of the conditions on cardiovascular responses.

Repeated measure designs that evaluate cardiovascular responses to a stressor typically show smaller physiological responses to the same stress task at the second testing session (Jain et al., 2007). There was some variation in the stress task in the

72 current study as participants were asked to choose a different topic to speak about during the stress task at the second testing session; otherwise the stress task was the same at both sessions. Analysis of the effect of time on cardiovascular reactivity and cardiovascular recovery suggest that there was habituation to the stressor as a significant effect of time was seen across cardiovascular reactivity and recovery variables, with the exception of

DBP recovery. The data suggests that participants generally experienced less cardiovascular reactivity and enhanced cardiovascular recovery at the second testing session. There was also less variability in cardiovascular responses at testing session two with standard deviation values decreasing from testing session one to testing session two across all cardiovascular reactivity and recovery variables. Future studies that investigate the influence of an intervention on cardiovascular responses to stress across multiple time points should consider including a novel stress task at the second testing session or a stress task that results in large physiological responses to stress at both time points to allow for predicted habituation to the stressor.

State Rumination

One of the primary aims of this study was to produce changes in state rumination following a laboratory stressor. In order to achieve this goal attempts were made to influence state rumination through the manipulation of situational variables (i.e. with post stressor inductions). It was also predicted that attempts to influence trait rumination and trait mindfulness (with a brief mindfulness meditation intervention) would translate into changes in state rumination following a laboratory stressor.

The manipulation of situational variables, using post-stressor inductions, was largely successful in influencing state rumination. Specifically, it was hypothesized that participants in the mindfulness condition would report less state rumination during recovery from a laboratory stressor at testing session one compared to participants in the control and distraction conditions (Hypothesis 1). This prediction was partially supported. Participants in the mindfulness and distraction conditions reported less state rumination than those in the control condition, while the mindfulness and distraction conditions did not differ on state rumination. Results at testing session two demonstrated that participants in the mindfulness condition reported decreases in state rumination from testing session one to testing session two, while state rumination remained relatively unchanged from testing session one to testing session two in both the distraction and control conditions (Hypothesis 3). Combined, these results illustrate that, without mindfulness practice, the distraction and mindfulness inductions result in similar decreases in post stressor rumination. However, following a brief mindfulness meditation intervention, mindfulness appears to result in greater decreases in state rumination compared to distraction.

The results of the current study are consistent with studies indicating that distraction (e.g. Gerin et al. 2006) and mindfulness (Shapiro & Carlson, 2006) are associated with decreased state rumination. This was the first study to compare the influence of distraction and mindfulness on state rumination following an induction procedure as well as following a brief mindfulness intervention. The observed relationship between the mindfulness condition and decreases in state rumination (also

74 see discussion of trait rumination below) in the current study suggests that decreases in state rumination could be an active mechanism associated with positive outcomes (such as decreases in depressed mood). Decreases in rumination have been proposed as a key mechanism associated with improvements in mood following a mindfulness intervention

(e.g. Labelle et al. 2010). Future research investigating the influence of both standard (8- week) and brief mindfulness interventions would benefit from including the assessment of state rumination. Furthermore, future studies should conduct mediational analyses to determine whether decreases in state rumination are linked to positive psychological outcomes, such as decreases in depressed mood.

Differences Between Distraction and Mindfulness. Without knowledge or previous practice of mindfulness meditation the mindfulness induction may act largely similarly to a distraction. However, the addition of a brief mindfulness intervention

(participants in the mindfulness condition participated in a 4-week mindfulness intervention) likely served to further differentiate the mindfulness induction from the distraction induction. The mindfulness meditation intervention may have facilitated the development of core mindfulness skills that surpass the simple diversion of attention involved in distraction.

The core facets of mindfulness emphasized in the brief mindfulness intervention,

(used in the current study) are consistent with the IAA model. According to this model

(Shapiro & Carlson, 2006), mindfulness involves three main components: intention, attention and attitude. While the mindfulness induction provided in the current study (see

Appendix C) provides specific instruction about where to direct attention, instructions

75 regarding the attitude to adopt during this practice and the intention associated with this practice are not provided. Mindfulness participants received instruction on mindfulness attitudes during the brief mindfulness meditation intervention and were encouraged to adopt these attitudes during their meditation practice. The concept of intention associated with mindfulness meditation was also discussed during the brief intervention. Participants were invited to explore the possible benefits of mindfulness practice, identify those benefits that were most meaningful to them and adopt this goal as their intention associated with their meditation practice.

The intention and attitude facets of mindfulness are the main factors that separate mindfulness from distraction, as distraction also involves alteration of attention.

However, the change in attention associated with distraction is somewhat different from mindfulness. Distraction could involve a shift of focus to any subject that is apart from the target to be distracted from, while mindfulness involves a shift of focus to present- moment experience (often internal to the individual, such as body sensations). Based on the results of the current study it appears that a simple attentional shift can significantly decrease state rumination (as seen at testing session one) and with practice, mindful attention appears to be superior to distraction for decreasing state rumination (from testing session one to testing session two). This result suggests that the components of intention, attitude and attention (i.e. paying attention on purpose, non-judgmentally, to the present moment) may be a superior approach to reduce rumination, compared to simply directing attention away from a targeted cognitive concept.

Mindfulness Mechanisms and State Rumination. The mechanisms of action of mindfulness in decreasing state rumination were not investigated in the current study.

However, the IAA model of mindfulness provides a theoretical framework that may explain the link between state rumination and mindfulness. This model posits that intentionally attending to experience with openness and non-judging leads to a shift in perspective that has been termed reperceiving. Reperceiving may enhance an individual’s ability to regulate cognitive processes and inhibit negative elaborative processes necessary for rumination (Labelle et al., 2010). Moreover, metacognitive theories suggest that mindfulness practice may assist in the development of more adaptive metacognitive beliefs, such as: negative thoughts and feelings are simply passing events in the mind and ruminating over past events is not beneficial. This adoption of new metacognitive beliefs may help individuals to decentre from a cascade of automatic negative thoughts and disengage from ruminative processing (Teasdale et al., 1995). The mechanisms of reperceiving and decentring similarly suggest that mindfulness may enhance the ability to disengage from rumination by relating to internal experiences in a more adaptive way.

The mechanisms of mindfulness responsible for psychological changes such as decreases in rumination are just beginning to be investigated empirically (e.g. Singer &

Dobson, 2007; Watkins, Teasdale, & Williams, 2003). The most recent study of proposed mindfulness mechanisms examined the influence of rumination, distraction, acceptance

(similar to mindfulness) or no training prior to a negative mood induction on metacognitive beliefs (Singer & Dobson, 2007). Consistent with mindfulness principles,

77 the acceptance training involved instructions on bringing awareness to the present moment and acknowledging thoughts and feelings that were present. The investigators predicted that acceptance training would be associated with the adoption of adaptive metacognitive beliefs (Singer & Dobson, 2007). Results indicated that acceptance training uniquely reduced negative attitudes towards feelings of sadness. Contrary to the study predictions acceptance training did not lead to reductions in positive beliefs about rumination (Singer & Dobson, 2007). The authors hypothesized that repeated training sessions may have had stronger effects on metacognitive beliefs and that floor effects may have influenced the results (participants reported low scores on positive beliefs about rumination prior to the training). Future research investigating the proposed mechanisms (i.e. changes in metacognitive beliefs) over the course of a mindfulness intervention would help to establish the mechanisms associated with mindfulness training that may lead to decreases in state rumination.

The current study adds to the growing literature suggesting that mindfulness inductions and brief mindfulness interventions can lead to decreases in state rumination.

Further research establishing the efficacy of brief mindfulness meditation training for decreasing state rumination is necessary. Rumination is associated with several forms of psychopathology (e.g. anxiety and depression) (Watkins, 2008) and therefore decreases in rumination may be associated with meaningful changes in psychological symptoms

(e.g. decreases in depressed mood). While a shift in the general tendency to ruminate in response to stressor (i.e. changes in trait rumination) would likely represent changes in cognitive style that are generalized to most situations, decreases in state rumination

78 suggest an increased ability to inhibit rumination in response to a specific stressor and this skill could be generalized to other settings/situations with further training and or practice (see discussion of trait rumination below).

A logical progression following the establishment of the efficacy of mindfulness interventions for decreasing rumination would be to investigate the proposed mechanisms of action associated with changes in state rumination using dismantling studies.

Mindfulness meditation interventions typically include several components (also see discussion of trait mindfulness below) and identifying the active mechanisms could allow for a streamlining of the intervention to make delivery more efficient yet maintain efficacy. The current study lays the foundation for future dismantling studies by indicating that mindfulness is superior to distraction for decreasing state rumination.

Trait Mindfulness and Trait Rumination

Trait Mindfulness. It was hypothesized that the brief mindfulness intervention would result in increases in trait mindfulness (Hypothesis 5). Consistent with this prediction, participants in the mindfulness condition reported increased trait mindfulness from testing session one to testing session two compared to participants in the no- intervention condition. This is the first evaluation of a 4-week mindfulness meditation intervention (four weekly training sessions of 45 minutes each) to show that the intervention results in increases in mindfulness. Previous studies of brief mindfulness interventions have largely not evaluated the construct of mindfulness, however a few recent studies have assessed mindfulness in the context of brief mindfulness interventions using questionnaires (Kingston et al., 2007; Zeidan, Gordon, Merchant, & Goolkasian,

2010b; Zeidan, Johnson, Diamond, David, & Goolkasian, 2010a). In two studies Zeidan and colleagues used the 30-item, self-report Freiburg Mindfulness Inventory (Walach,

Buchheld, Buttenmuller, Klienknecht, & Schmidt, 2006) to asses changes in mindfulness following a 3-day (Zeidan et al., 2010b) and 4-day (Zeidan et al., 2010a) mindfulness training intervention which involved 20 minutes of mindfulness training per day. In both cases the very brief intervention succeeded in increasing mindfulness in comparison to baseline values (Zeidan et al., 2010b) and in comparison to a control group that listened to an audio book for the same period of time (Zeidan et al., 2010a). Kingston and colleagues (2007) assessed mindfulness using the 39-item, self-report Kentucky

Inventory of Mindfulness Skills (Baer et al., 2004) and similarly demonstrated that participants in the 6-session (two 1-hour sessions per week) mindfulness intervention reported increases in mindfulness in comparison to participants in a guided visualization control group that received two 1-hour training sessions. The results of the current study therefore support emerging literature indicating that participation in brief mindfulness interventions, ranging in duration from 1-hour to 6-hours of training, is associated with increased mindfulness.

As other brief mindfulness meditation intervention have not assessed mindfulness using the FFMQ, it is not possible to compare raw scores for mindfulness with other brief interventions. However, it is possible to compare the results of the current study with those of Carmody and Baer (2008), as they assessed mindfulness using the FFMQ following an 8-week MBSR program in a sample with wide ranging problems (e.g. illness related stress, chronic pain, anxiety, personal stress). An examination of the raw

80 scores reveals that participants in the current study who completed the brief mindfulness intervention had a mean increase in total mindfulness on the FFMQ of 4.26 while the mean increase following the 8-week MBSR program was 17.94 (Carmody & Baer,

2008), indicating that increases in mindfulness were more substantial following an 8- week intervention. A comparison of pre and post scores across the two studies suggests that participants in the current study had relatively high levels of mindfulness at pre-test.

Specifically, mean pre-test total mindfulness in the current study was 130.36 while mean pre-test total mindfulness was 118.72 in Carmody and Baer’s (2008) study. The pre-test scores for participants in the present study were therefore similar to post-test mindfulness scores in the former study (i.e. Carmody & Baer, 2008, mean post-test = 136.66). This comparison suggests that participants in the current study were relatively ‘mindful’ at baseline and this may have left less room for improvement in mindfulness following the brief intervention (i.e. ceiling effects).

Although ceiling effects may have influenced the ability to observe increases in mindfulness, consistent with other studies of brief mindfulness programs, the effect size for increases in mindfulness from pre to post test was in the small to medium range (i.e. current study, d = 0.25, Kingston et al. 2007, d = 0.52). Previous research has established that the eight-week MBSR program also results in significant increases in mindfulness, with effect sizes in medium to large range (i.e. d = 0.47 - 0.91) (Shapiro, Brown, &

Biegel, 2007; Carmody & Baer, 2008; Shapiro et al., 2008).

Establishing that a mindfulness intervention leads to increases in mindfulness is an important step in understanding how mindfulness interventions may bring about

81 positive outcomes. When positive psychological or physiological outcomes result following a mindfulness intervention the assumption may be made that these improvements are the results of increases in mindfulness. However, mindfulness interventions typically involve several components other than mindfulness training that may lead to positive outcomes, such as social support associated with a group intervention, physical activity associated with the gentle yoga (included in MBSR) and relaxation associated with the practice of meditation and breathing focus. It is therefore imperative that changes in mindfulness be measured in order to determine whether it is this improvement that is associated with the positive outcomes or perhaps a more general factor of the program such as increased social support. The measurement of changes in general factors (e.g. increases in social support, increases in physical activity) in addition to the assessment of mindfulness would allow for comparison of the relative contributions of these changes to the assessed outcomes.

Trait Mindfulness Subscales. Analysis of the subscales of the trait mindfulness questionnaire indicated that participants in the mindfulness intervention condition reported increases in observing and non-judging from testing session one to testing session two compared to those in the no-intervention condition. Changes in mindfulness from testing session one to testing session two did not differ between the mindfulness and no-intervention conditions on the describing, acting with awareness, and non-reactive subscales of the trait mindfulness measure. This finding may reflect that the observing and non-judging facets are the first to develop when beginning the practice of mindfulness meditation. A previous study (Carmody & Baer, 2008) looking at the

82 development of the five facets on the FFMQ following MBSR in a group of individuals with mixed diagnoses indicated that the effect sizes for the observing and non-reacting facets were large while effect sizes for the non-judging, describing and acting with awareness were moderate. The authors hypothesized that observing and non-reacting facets of mindfulness may be precursors to more advanced mindfulness skills but acknowledged that the pattern of relative effect sizes of the facets may be different with more or less mindfulness practice. Results of the current study support the idea that observing may be one of the earliest facets to develop as significant increases in the observing and non-judging facets were noted following the brief intervention. One must first develop the capacity to observe experience before being able to describe one’s experience or act with awareness. It appears that the mindfulness exercises taught in this brief four-week intervention may have specifically enhanced non-judging. In order to determine whether the development of the observing facet is a precursor to the development of other facets of mindfulness, future research measuring the five facets at several time points (e.g. weekly) across the course of a mindfulness intervention is necessary. (Key & Campbell, 2006)

Trait Rumination. Contrary to our prediction, changes in trait rumination did not differ between the mindfulness and no-intervention conditions (Hypothesis 5). Trait rumination decreased from testing session one to testing session two in both conditions but this change did not differ significantly between the conditions. The effect sizes for the changes in trait rumination from testing session one to testing session two for the mindfulness intervention and no-intervention conditions were Cohen’s d = 0.38 and d =

0.09 respectively, indicating a small (non-significant) intervention effect on trait rumination. The data collected in this study does not offer an explanation as to why the no intervention condition experienced decreases in trait rumination, however regression towards the mean is one possible explanation. Inspection of mean trait rumination scores on the SRRS suggest that participants evidenced slightly elevated levels of trait rumination at pre-test in comparison to a similar sample of healthy undergraduate students (i.e. current study M = 425.1, Key & Campbell, 2006, M = 393.4).

Interestingly, although decreases in trait rumination did not differ between the no- intervention and mindfulness conditions in the present study, those who participated in the mindfulness intervention did show greater decreases in state rumination compared to the other conditions. The fact that the brief intervention had a significant impact on state but not trait rumination may suggest that participants in the mindfulness condition were able to enhance their ability to attend to the present moment when specifically asked to do so (as was the case during the post stressor mindfulness induction). However, this present moment focus and ability to inhibit rumination may not yet have generalized to become a consistent cognitive style applied to all situations. Further training and/or practice of mindfulness may be necessary in order to result in a consistent shift in general cognitive style and therefore further training and practice may also be necessary to see a change in trait rumination.

Previous studies of mindfulness interventions of various lengths have shown a significant impact on rumination (e.g. Jain et al., 2007; Ramel et al., 2004; Labelle et al.,

2010), however the distinction of whether this result reflects a change in state or trait

84 rumination is typically not discussed. Brief mindfulness meditation interventions may reduce state rumination while a longer (8-week) mindfulness intervention may be required to decrease trait rumination. Jain and colleagues (2007) is the only other study to investigate the effect of a brief mindfulness meditation intervention on rumination. Jain et al. (2007) assessed rumination following a 4-week mindfulness intervention using the

Daily Emotion Report (Nolen-Hoeksema, Morrow, & Fredrickson, 1993), a self-report questionnaire designed to assess distractive and ruminative thoughts and behaviours associated with depression. This questionnaire measures rumination over the course of a specific week (Peak, Overholser, DeJong, & Zaccariello, 2007) and therefore may reflect aspects of both state and trait rumination. Labelle and colleagues (2010) and Ramel et al.

(2004) assessed trait rumination following 8-week MBSR programs using the

Rumination –Reflection Questionnaire (Trapnell & Campbell, 1999) and the Response

Style Questionnaire (Nolen-Hoeksema & Morrow, 1991) respectively. The temporal wording and instructions of both of these questionnaires suggests that they likely assess trait rumination. These investigations similarly concluded that participation in an MBSR program was associated with decreases in trait rumination (Labelle et al., 2010; Ramel et al. 2004). The results of the current study therefore add to a base of literature suggesting that brief mindfulness interventions (4-weeks) can lead to decreases in state rumination while a longer mindfulness intervention may be necessary to result in decreases in trait rumination.

Mindfulness Intervention Adherence. Measuring adherence to an intervention ascertains whether participants received the full ‘dose’ of the intervention, and allows for

85 assessment of a dose-response relationship. Compliance may be even more important when the intervention is brief as there is only a small ‘dose’ of the intervention available.

In the current study, a majority of participants in the mindfulness condition attended all four of the mindfulness group sessions (64.5%), while the remaining attended three of the four groups. This attendance rate is similar to attendance rates reported for MSBR programs. For example, Speca and colleagues (2000) reported that 73.6% of participants attended six or seven of a possible seven mindfulness intervention sessions, while 26.4% attended four or five sessions. In the current study, participants in the mindfulness intervention were asked to complete 75 minutes of home practice each week and record their practice in a meditation log. The reported mean amount of meditation home practice completed per week was 74.7 minutes. This assessment of home practice allowed the investigation of whether the ‘dose’ of mindfulness practice during the brief mindfulness intervention impacted the degree of change in the outcome measures.

The importance of regular practice outside of class in establishing the capacity for everyday mindfulness, and the associated benefits, is clearly stated in several mindfulness-based programs. Commonly, 45 minutes of daily practice is recommended with mindfulness-based interventions (Segal, Williams, & Teasdale, 2002; Kabat-Zinn,

1990). Although the importance of home practice is emphasized in the delivery of mindfulness meditation interventions, the association between home practice and measured outcomes is often not reported in published studies (e.g. Manikonda et al.,

2008; Davidson et al., 2003; Shapiro, Schwartz, & Bonner, 1998). Studies that examine the correlation between home practice and intervention outcomes suggest mixed results.

For example, a study of MBSR with cancer outpatients demonstrated that meditation home practice was related to improvements in mood (Speca, Carlson, Goodey, & Angen,

2000a). In contrast, Astin (1997) found that practice time and symptom improvement were not correlated in a sample of college students completing MBSR, and Davidson

(2003) observed no relationship between reported practice and self-report outcome measures (e.g. positive and negative affect) in a sample of healthy employees who completed MBSR. It is imperative to determine whether home practice is important to obtain benefits associated with mindfulness based interventions because this practice involves a time commitment for participants. If home practice is not necessary or minimally necessary to achieve positive outcomes, then placing high time demands on participants may not be required. Reducing the requisite time commitment to complete a mindfulness meditation intervention may allow a greater number of individuals to incorporate this treatment into their schedules and experience the associated benefits.

Home practice may be closely related to certain outcomes (e.g. improving mood, Speca et al., 2000) but not others (e.g. increasing positive affect, Davidson et al. 2003). The measurement of home practice and analysis of the association between this practice and outcomes is the first step towards developing guidelines regarding the time commitment required to achieve specific benefits of the program. This information would aid in the development of efficient yet effective mindfulness meditation interventions.

Trait Mindfulness, Trait Rumination & Home practice. In the current study more time spent meditating during home practice was predicted to be associated with greater increases in trait mindfulness (Hypothesis 8). However, results indicate that time

87 spent meditating during home practice was not related to changes in trait mindfulness.

The previously discussed results indicating that trait mindfulness increased in the mindfulness condition compared to the control condition implies that most participants completed sufficient training in mindfulness meditation experience increases in mindfulness. The amount of variability in meditation practice over the four weeks may not have been sufficient to detect possible associations between practice and the development of trait mindfulness. Other studies of brief mindfulness meditation interventions (e.g. Jain et al. 2007, Kingston et al. 2007, Zeidan et al., 2010) did not report on the relationship between mindfulness and the amount of meditation practice, limiting across-study comparisons. Interventions delivered over a longer period might result in greater variability in the amount of home practice completed and make it possible to detect a link between practice and the development of mindfulness. Previous investigations of associations between home practice and the development of mindfulness in longer interventions have generally supported the importance of practice in developing mindfulness. For example, an investigation of a university-based MBSR course for individuals with a variety of problems (including illness-related stress, chronic pain, anxiety and stress) indicated that greater time spent in home practice was related to greater increases in mindfulness as measured by the FFMQ (Carmody & Baer, 2008).

Future studies are necessary to clarify the value of home practice for increasing trait mindfulness over the course of a brief mindfulness intervention.

The relationship between home practice and trait rumination was also assessed with results supporting the hypothesis that greater time spent meditating during home

88 practice would be associated with greater decreases in trait rumination was supported

(Hypothesis 8). The link between trait rumination and amount of home practice suggests that if participants had the opportunity to complete further mindfulness practice then significant decreases in trait rumination may have been observed. In line with the prediction that further mindfulness practice may have lead to decreases in trait rumination, studies of 8-week MBSR interventions have shown associated decreases in trait rumination (e.g. Labelle et al., 2010; Ramel et al., 2004). For example, Ramel and colleagues’ (2004) investigation of an 8-week MBSR program indicated that more meditation practice was related to less (trait) rumination at follow-up assessment. More specifically, the amount of meditation practice uniquely accounted for 15% of the variance in follow-up rumination levels after controlling for intake rumination.

The amount of meditation practice was associated with changes in trait rumination but not trait mindfulness suggesting that changes in trait rumination may be more sensitive (than changes in trait mindfulness) to the amount of meditation practice, when participants are completing a brief intervention. It may be the case that increases in trait mindfulness typically develop first while decreases in trait rumination are a secondary outcome of mindfulness meditation training and therefore more practice may be required to produce pronounced changes in trait rumination. While mindfulness and rumination are contrasting cognitive styles it is possible that participants would report an increased tendency to be mindful but also continue to react to stressful situations with a ruminative response style. Further mindfulness meditation practice may be necessary to generalize this cognitive style from non-stressful day-to-day experiences to the ability to

89 consistently respond to stress mindfully rather than with rumination. In order to establish the temporal order of the development of skills associated with mindfulness practice

(such as decreasing the tendency to ruminate and increasing the tendency to be mindful) studies assessing these traits at multiple time points in a longer mindfulness intervention would be necessary.

Associations between Trait Mindfulness & Other Psychological Outcomes. In order to establish that an increase in mindfulness is the key component in mindfulness based interventions that lead to positive outcomes (e.g. decreases in depression) it is necessary to first establish that increases in mindfulness are associated with the measured outcomes. Exploratory analysis of the associations between changes in trait mindfulness and measured psychological outcomes in participants who completed the mindfulness intervention indicate that changes in trait mindfulness were not associated with changes in depression or symptoms of stress (Hypothesis 11). Increases in trait mindfulness were associated with decreases in trait rumination in the mindfulness participants; however changes in trait rumination did not differ between the participants who completed the intervention and those that did not. Therefore this finding simply demonstrates that higher levels of trait mindfulness are associated with lower levels of trait rumination.

However, this relationship does not suggest that changes in trait rumination are a mechanism of action associated with the mindfulness intervention in the current study.

Previous studies evaluating associations between changes in mindfulness following a mindfulness intervention and positive outcomes have had varied results. For example, in their investigation of the impact of MBSR in cancer outpatients, Labelle and

90 colleagues (2010) demonstrated that changes in mindfulness did not mediate the association between MBSR participation and decreased depression. Conversely, Nylicek and Kuijpers (2008) found that mindfulness mediated changes in perceived stress and quality of life, while results from Shapiro et al. (2008) also suggest that increases in mindfulness mediated decreases in perceived stress. It is probable that some positive outcomes following a mindfulness intervention are associated with increases in mindfulness while other outcomes are not. Further research is needed to establish which outcomes (e.g. decreases in depression, decreases in rumination) appear to be most closely linked with the core aim of mindfulness interventions, i.e. increasing mindfulness

In summary, participation in a 4-week mindfulness meditation intervention was associated with increases in trait mindfulness compared to a no-intervention condition.

This increase in mindfulness did not appear to vary based on the amount of home practice. Greater time spent practicing mindfulness meditation at home was associated with greater decreases in trait rumination suggesting that, although the brief intervention did not lead to decreases in trait rumination, with the opportunity for further meditation practice significant decreases in trait rumination may have been observed. Increases in trait mindfulness were associated with decreases in trait rumination suggesting that increasing mindfulness may be closely linked to changes in the ability to inhibit rumination.

Depression and Symptoms of Stress

Depression

It was predicted that depressed mood would decrease in participants in the mindfulness condition compared to those in the no-intervention condition (Hypothesis 7).

Consistent with this hypothesis results demonstrated that participants in the mindfulness condition reported decreases in depressed mood, as measured by the BDI-II compared to the no-intervention condition. This is the first study to show decreases in depressive symptoms following a four-week mindfulness intervention.

Previous reviews of the impact of mindfulness based therapy (including MBCT and MBSR) on mood symptoms have come to divergent conclusions (Baer, 2003;

Toneatto & Nguyen, 2007). Baer (2003) interpreted the literature to suggest that mindfulness may be helpful for treating mood disorders, whereas Toneatto and Nguyen

(2007) concluded that mindfulness has no reliable effect on mood based on a qualitative review of a small number of studies (i.e. 15). Toneatto and Nguyen’s (2007) review has been criticized for including only controlled studies, thereby excluding a substantial portion of mindfulness research, and not conducting an effect size analysis or applying any other standard meta-analytic procedures (Hofmann, Sawyer, Witt, & Od, 2010). A more recent meta-analytic review (Hofmann et al., 2010) concluded that uncontrolled pre-post effect size estimates of mindfulness interventions were in the moderate range for reducing depressive symptoms (Hedge’s g = 0.59). The results of the current study are therefore in line with a growing body of literature suggesting that mindfulness meditation can reduce depressive symptoms.

The statistically significant impact seen on depressive symptoms in the current study were demonstrated in a healthy sample not experiencing elevated levels of depression (mean BDI-II at testing session one M = 8.1, indicating minimal depressive symptoms). Considering the possible influence of floor effects, it would be predicted that improvements in depressed mood could be more pronounced in a clinically depressed sample. Analysis of the effect size for changes in depressed mood from testing session one to testing session two revealed a medium effect size for the mindfulness condition (d

= 0.51) and a negligible effect in the no-intervention condition (d = 0.04). A recent meta- analytical review (Hofmann et al., 2010) confirmed that mindfulness interventions in patients with clinical depression were associated with large effect sizes (Hedge’s g =

0.95) for improving depressive symptoms while interventions not focused on samples with elevated levels of depression had a moderate effect on depressive symptoms

(Hedge’s g = 0.50). Therefore, the results of the current study echo previous results showing that mindfulness interventions can lead to moderate decreases in depressive symptoms in populations that are not clinically depressed.

The results of this study expand on these previous findings by illustrating that changes in mood symptoms can be seen following a brief mindfulness meditation intervention. Mindfulness intervention studies specifically targeting depression have generally used an 8-session (average 2 hours per-session) mindfulness intervention of

MBSR or MBCT with a requested average home practice of 315 minutes per week.

(Barnhofer et al., 2009; Kingston, Dooley, Bates, Lawlor, & Malone, 2007; Kenny &

Williams, 2007; Ramel et al., 2004; Speca et al., 2000a). The current study used a brief 4-

93 session (45 minutes per-session) mindfulness intervention with requested home practice of 75 minutes per week. The few studies that have investigated the impact of brief mindfulness interventions on mood have similarly suggested positive results. For example, Jain and Colleagues (Jain et al., 2007) investigated the impact of a brief mindfulness intervention based on the MBSR model that consisted of four 1.5 hour session. The requested amount of home practice was not identified however the mean amount of home practice completed was approximately 79 minutes per week. Results indicated that the intervention successfully alleviated psychological distress as indexed by the general symptom index of the Brief Symptom Inventory and increased positive states of mind as measured by the Positive States of Mind Scale.

A measure specific to depressive symptoms (such as the BDI) was not included in this study. Lane and colleagues (2007) similarly demonstrated that a brief mindfulness intervention lead to decreases in negative mood. Specifically, in their study of a four week (1-hour session per week) mindfulness meditation intervention results indicated that the intervention lead to decreases in psychological distress (as measured by the general symptom index of the Brief Symptom Inventory) and decreases in total mood disturbance

(as measured by the Profile of Mood States) (Lane, Seskevich, & Pieper, 2007). Similar to Jain et al. (2007) a measure specific to depressive symptoms was not included in Lane et al.’s (2007) study. Zeidan and colleagues (2010) measured depressive symptoms following a four-day (20 minutes per day) mindfulness intervention using the Center for

Epidemiological Studies Depression Inventory (CESD). Analysis indicated that in comparison to a control group that listened to an audio book, the mindfulness

94 intervention did not result in significant changes in depression (Zeidan et al., 2010a).

Taken together, the results of the current study and the results of Zeidan et al. (2010) suggest that a mindfulness intervention of 1-hour in total is not sufficient to result in decreases in depressed mood but a mindfulness intervention of 3-hours in total may result in improvements in depressed mood in healthy young adults. Decreases in depressed mood therefore likely require some practice and training to achieve, although 8-weeks of mindfulness intervention may not be necessary to see a significant impact on depressive symptoms.

The specific mechanisms associated with brief mindfulness meditation interventions that lead to decreases in depression have not been confirmed. It has been proposed that mindfulness practice may produce improvements in mood by reducing the tendency to react to negative mental and physical states with ruminative thought or maladaptive behaviour (e.g. avoidance) (Toneatto & Nguyen, 2007). Additionally, mindfulness meditation may lead to the early detection of signs of stress, rumination and physiological arousal and thereby afford the individual an opportunity to respond with more effective coping responses rather than maladaptive habitual responses (Salmon,

Sephton, Weissbecker, & et al., 2004). Based on this theory the ability to disengage from or inhibit from rumination may play an important role in decreasing depressive symptoms

(also see discussion of mindfulness mechanisms and state rumination above). Participants who received the mindfulness intervention in the current study reported decreases in state rumination, but no changes in trait rumination compared to participants who did not receive the intervention. This change in state rumination may suggest a shift in the

95 tendency to ruminate in response to stress and this change may have contributed to decreases in depressed mood. This study was not designed to test mediational questions.

Therefore further research investigating the influence of brief mindfulness meditation interventions on state rumination and depressed mood and mediational studies of whether decreases in rumination explain decreases in depressed mood are necessary.

Symptoms of Stress

Contrary to our prediction, participants in the mindfulness condition did not differ from those in the no-intervention condition in regards to changes in symptoms of stress

(Hypothesis 7). The only other study of a brief meditation intervention to investigate symptoms of stress indicated that, in 200 healthy adults interested in meditation, a 4- week (one 1.5 hour session per week) mantra based meditation intervention lead to decreases in perceived stress (as measured by the Perceived Stress Scale) from pre-test to post-test (Lane et al., 2007). Compared to the Perceived Stress Scale that measures stress more globally, the C-SOSI (used in the current study) measures more specific aspects of stress such as gastrointestinal problems, muscle tension and emotional irritability.

Specifically, the Perceived Stress Scales measures the degree to which common situations are appraised as stressful (Cohen, Kamarck, & Mermelstein, 1983).

Past research regarding the eight-week MBSR program has demonstrated that mindfulness practice can result in decreases in symptoms of stress. For example, results of an investigation of the effects of MBSR in cancer outpatients indicated that the program effectively decreased symptoms of stress as measured by the Symptoms of

Stress Inventory (Carlson, Speca, Patel, & Goodey, 2004). It is possible that further

96 mindfulness practice, beyond a four-week intervention, is necessary to see significant decreases in specific symptoms of stress.

The healthy sample used in the current study may have also interfered with the ability to find a significant impact on symptoms of stress, as participants may not have experienced elevated levels of stress at testing session one. Unfortunately, the C-SOSI is a relatively new measure and there is no published data reporting raw values of this measure that the scores in the current study can be compared to. A recent unpublished manuscript that investigated the impact of an MBSR program in 268 cancer outpatients indicated that at pre-test mean total symptoms of stress on the C-SOSI was 57.22 and the mean post-test total score was 40.71 (Todd, Carlson, & Garland, 2009). The mean pre- test total score on the C-SOSI in the current study was 45.86, suggesting that, in comparison to cancer outpatients, the participants in the current study were not experiencing elevated levels of stress at testing session one. While the positive impact of a brief mindfulness intervention on general perceived stress has been previously established (Lane et al., 2007) further research is necessary to determine of a brief intervention can also lead to decreases in specific symptoms of stress. The used of a sample of individuals experiencing elevated levels of stress at pre-test would be advisable in future research exploring the impact of a brief mindfulness based intervention on symptoms of stress.

Depression, Symptoms of Stress & Home Practice. In the current study greater time spent meditating during home practice was predicted to be associated with greater decreases in depressed mood and symptoms of stress (Hypothesis 8). Results

97 demonstrate that time spent meditating during home practice was not related to changes in depressed mood or symptoms of stress.

Consistent with the results of the current study, Jain and colleagues (2007) demonstrated that the amount of home practice was not related to decreases in psychological distress (as indexed by the general symptom index of the Brief Symptom

Inventory) or increases in positive states of mind (as measured by the Positive States of

Mind Scale) following a 4-week mindfulness intervention. Perhaps over the course of a brief intervention, in-session practice may play an important role in contributing to outcomes such as decreases in depressed mood, and home practice may have less of an influence. The amount of time in meditation home practice and the number of meditation intervention sessions attended did not vary considerably across participants. Specifically,

64.5 % of participants attended all four sessions, while the remaining participants attending three sessions and the standard deviation for minutes of home practice was SD

= 19.62. Because of the limited variability in attendance and home practice the association between these variables and outcomes such as decreases in depressed mood could not be adequately assessed.

In summary, the current study demonstrated that a four-week mindfulness intervention can lead to decreases in depressive symptoms compared to a no-intervention condition. This finding builds on previous investigations suggesting that abbreviated mindfulness programs can lead to improvements in mood and a traditional 8-week mindfulness intervention can lead to decreases in depressed mood. This improvement in depressive symptoms was not dependant on the amount of home practice. The brief

98 intervention did not appear to have a significant impact on symptoms of stress and the amount of home practice was not associated with changes in symptoms of stress.

Implications for the Rumination Arousal Model

The current study was designed to test several of the premises put forth by the rumination arousal model (see Figure 8). The results from the current study will next be discussed in terms of the implications for this model (see Figure 9).

The rumination arousal model suggests that the situational characteristics (e.g. is the person induced to be mindful or distracted) as well as the trait characteristics of the individual (e.g. tendency to respond to stress with rumination or mindfulness) interact to determine whether an individual will engage in state rumination following a stressor. The model further proposes that state rumination influences the experienced affect and the cardiovascular activity in response to the stressor. This study aimed to manipulate both situational and trait characteristics to test the anticipated relationships within the model.

The situational characteristics were manipulated by applying distraction, mindful or no induction immediately following the stressor. In an attempt to manipulate trait characteristics, some participants received a brief mindfulness meditation intervention.

The central aim of this intervention was to influence levels of trait mindfulness and trait rumination.

Several of the relationships proposed in the rumination arousal model were supported. Situational characteristics (i.e. mindfulness, distraction or control inductions) were associated with state rumination. Specifically, at the first testing session participants who received a mindfulness or distraction induction following the stressor

99 reported less state rumination than those who received no induction. At the second testing session, the mindfulness induction was associated with the least state rumination followed by the distraction induction and no induction conditions. These results suggest that, with some practice, the practice of mindfulness following a stressor is superior to using distraction for preventing state rumination, however distraction is associated with less state rumination than no induction. To summarize, these findings suggest that manipulation of the situational characteristics (with post stressor inductions) can influence state rumination, with a mindfulness induction leading to the least state rumination.

The rumination arousal model also incorporates the importance of trait variables influencing post stressor rumination. A brief mindfulness meditation intervention was implemented in an attempt to influence the trait variables of rumination and mindfulness.

Participation in the intervention was associated with increases in trait mindfulness but did not result in decreases in trait rumination. The impact of the intervention on state rumination was also directly tested. Results indicated that although the intervention did not lead to decreases in trait rumination, participants who received the intervention reported less state rumination compared to those who did not. Increases in trait mindfulness associated with the intervention are a possible mechanism leading to decreases in state rumination following stress, however this study was not designed to test mediational hypotheses. Therefore the assertion of the rumination arousal model that changes in trait variables (i.e. trait mindfulness) may be associated with changes in state rumination was partially supported.

100

The proposed links between state rumination and cardiovascular activity in the rumination arousal model were largely not supported by the results of the present study.

The exception was that greater state rumination was associated with poorer HR and SBP recovery at testing session one; however this relationship was not replicated at testing session two. Manipulation of the situational characteristics (using post stressor distraction, mindfulness or no induction) did not influence cardiovascular reactivity or recovery. Similarly, the brief mindfulness meditation intervention and the associated increases in trait mindfulness did not translate into changes in cardiovascular reactivity or recovery.

The associations between the intervention and cardiovascular activity as well as between the situational characteristics and cardiovascular activity were also tested.

Consistent with the largely null findings regarding the relationship between state rumination and cardiovascular activity, results suggest that the situational manipulation and the intervention do not influence cardiovascular reactivity or recovery. Although the situational manipulation and the intervention were associated with changes in state rumination, this did not translate into changes in cardiovascular responses to stress.

Consistent with this finding the situational manipulation and intervention also did not influence cardiovascular activity.

In conclusion, the predicted relationships between trait dimensions and state rumination as well as between situational characteristics and state rumination were largely supported by the findings of the current study. The predicted relationship between state rumination and cardiovascular reactivity and recovery was not supported. Further

101 research confirming the relationships observed in the current study is necessary. In particular it would be advantageous to further evaluate the proposed relationships between state rumination and cardiovascular activity in a sample with an increased risk of hypertension (e.g. participants with a parental history of hypertension, obese participants) and possible associated exaggerated cardiovascular reactivity and poor cardiovascular recovery. Additionally, the use of a larger sample to allow for meditational analyses is necessary to support the proposed mechanisms and links within the rumination arousal model.

Limitations and Strengths

In addition to the previously discussed problems with using a sample of healthy

undergraduate students (i.e. low levels of depression, rumination, symptoms of stress and

healthy cardiovascular responses to stress at testing session one) some further limitations

of the current study should be noted. Men were relatively under-represented in the

sample, which may limit the generalizability of the results. In addition to limitations

related to the sample the design of the study also had some limitations. Unfortunately,

due to the nature of the intervention, it was not possible to blind participants to their

condition. Participants were aware when they were in and active treatment condition and

this knowledge may have influenced their responses to self-report measures. Future

research evaluating the effects of brief mindfulness interventions would benefit from

including an active control condition such as relaxation, health education or sham

meditation to help control the influence of expectancy on self-report and to establish the

benefits of mindfulness training beyond basic treatment effects (e.g. attention).

102

The assessment of state rumination may also be seen as a limitation in the current

study. Self-report of state rumination requires the ability to reflect on one’s own

cognitions and participants in this study likely had varying abilities to notice and report

state rumination. In an attempt to enhance the assessment of state rumination participants

were provided with instructions and examples of different cognitive focuses and asked to

categorize their thoughts into one of three simple categories (past, present or future). The

direct assessment of cognitive processes is challenging and an effective, validated

method of assessing post stressor rumination would enhance future studies regarding the

relationship between state rumination and cardiovascular responses to stress.

The current study also had several strengths including the use of a control group

and a distraction group for comparison with the mindfulness condition. The use of a

general social stressor task may also be seen as a study strength. Previous studies

evaluating the influence of rumination on cardiovascular recovery have typically used a

stress task that evokes anger. The use of the stress task that could evoke a variety of

emotions allows for greater potential generalizability of the findings.

General Conclusions, Implications and Future Directions

Additional goals were to assess the influence of a brief mindfulness meditation intervention on rumination, mindfulness, depressed mood and symptoms of stress.

103

Results indicated that participants in the mindfulness condition (who received a post stressor mindfulness induction and a 4-week mindfulness meditation intervention) showed the greatest decreases in post stressor state rumination (from testing session one to testing session two) compared to participants in the distraction condition (who received a post stressor distraction induction and no intervention) and control condition (who received no post stressor induction and no intervention). Although the mindfulness condition was associated with changes in state rumination, these changes did not translate into improvements in cardiovascular reactivity or recovery. In terms of the impact of the brief mindfulness meditation intervention, mindfulness participants reported increases in trait mindfulness and decreases in depressed mood compared to participants who did not receive the intervention. The brief mindfulness intervention was not associated with changes in trait rumination or symptoms of stress.

The superiority of mindfulness over distraction for improving state rumination is a notable finding. Interestingly, mindfulness and distraction inductions at testing session one had a similar influence on state rumination; however after completing further mindfulness meditation practice (attending the brief mindfulness meditation intervention in between the testing sessions) participants in the mindfulness condition reported greater decreases in state rumination compared to the distraction condition. This result suggests that, with practice, mindfulness may be a superior approach for decreasing post stressor rumination in comparison to distraction. The implications regarding the ability of mindfulness to reduce rumination are potentially broad in range as rumination plays a role in several forms of psychopathology (Labelle et al., 2010; Ramel et al., 2004).

104

However, the brief mindfulness intervention was not associated with changes in trait rumination, indicating that mindfulness participants were able to inhibit rumination when prompted (in the laboratory testing session) but that this skill had not become their default or general pattern of cognitive responding to stress. Links between the amount of meditation home practice and changes in trait rumination suggest that with further mindfulness practice participants may report decreases in trait rumination as well as decreases in state rumination. Studies of 8-week MBSR programs demonstrate that decreases in trait rumination are associated with participation in longer mindfulness meditation interventions (Grossman, Niemann, Schmidt, & Walach, 2004). Future research evaluating the efficacy of a brief mindfulness intervention for decreasing rumination and evaluating other possible psychological benefits of this intervention is needed.

The efficacy of the brief mindfulness meditation intervention to result in self-

reported psychological changes after 4-weeks of practice is promising. Traditional 8-

week mindfulness based interventions have received a great deal of research attention

over the last decade and as such it has been established that 8-week programs results in

wide-ranging benefits, including symptoms of depression and anxiety, chronic pain,

sleep, and physical as well as psychological dimensions of quality of life (e.g. Jain et al.,

2007; Lane et al., 2007; Kingston et al., 2007; Lengacher et al., 2009; Tang et al., 2007).

Although literature demonstrating the benefits of abbreviated mindfulness programs is

limited, preliminary research, including the present study, suggests that these programs

also have the potential to improve various areas of psychological functioning (e.g.

105 decreased rumination, depressed mood). Brief mindfulness interventions require a limited time commitment compared to traditional MBSR programs and may offer some similar benefits. The reduced time demands on participants and facilitators may enhance the dissemination of mindfulness meditation training. Brief mindfulness meditation interventions could provide a cost and time efficient opportunity for individuals to be introduced to mindfulness meditation, especially where barriers prevent attendance of an

8-week intervention. Future research is necessary to confirm and extend the preliminary findings of the present study suggesting the efficacy of a brief mindfulness meditation intervention for decreasing depressed mood, decreasing state rumination and increasing mindfulness compared to a no-intervention control.

106

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Table 1: Participant Characteristics by Condition Demographic Condition Statistical Analyses Variable Mindfulness Distraction Control Total Results

Age 22.8 (4.5) 21.8 (3.6) 21.2 (3.6) 21.9 (3.9) F(2,98) = 1.29 p = .280 BMI 23.1 (3.4) 22.9 (3.4) 22.1 (3.2) 22.7 (3.3) F(2,98) = 0.81 p = .488 SES 5.5 (1.0) 5.3 (1.0) 5.4 (1.3) 5.4 (1.1) F(2,98) = 0.33 p = .724 Sex χ2 (2) = 0.33 p = .883 Women 87.1% (n=27) 82.4% (n=28) 86.1% (n=31) 85.3% (n=86) Men 12.9% (n=4) 17.6% (n=6) 13.5% (n=5) 14.7% (n=15) Ethnicity χ2 (8) = 9.83 p = .347 White 61.3% (n=19) 41.2% (n=14) 55.6% (n=20) 52.5% (n=53) Black 0.0% (n=0) 5.9% (n=2) 0.0% (n=0) 2.0% (n=2) Asian 19.4% (n=6) 26.5% (n=9) 30.6% (n=11) 25.7% (n=26) Hispanic 6.5% (n=2) 2.9% (n=1) 0.0% (n=0) 3.0% (n=3) Other 12.9% (n=4) 23.5% (n=8) 13.9% (n=5) 16.8% (n=17) Smoking χ2 (4) = 5.51 p = .269 Non-smoker 77.4% (n=24) 94.1% (n=32) 80.6% (n=29) 84.3% (n=86) Past smoker 16.1% (n=5) 2.9% (n=1) 8.1% (n=3) 8.8% (n=9) Current smoker 6.5% (n=2) 2.9% (n=1) 10.8% (n=4) 6.9% (n=7) Note. Continuous variables are reported as mean (standard deviations); categorical variables are listed as column-wise percentages

(number of participants). BMI = Body Mass Index; SES = Socio-economic Status, SES was rated on a scale of 1-9 with 9 representing 128 high SES. For Pearson Chi-Square analyses Fishers Exact p-values are reported.

Table 2

Hypothesis 1& 2: State Rumination and Cardiovascular Recovery by Condition at Testing session one

Condition Statistical Analyses Outcome Measure Mindfulness Distraction Control ANOVA Results

State Rumination 1.45 (1.15) 1.94 (1.23) 2.78 (1.10) F(2,98) = 11.32 p < .001* Cardiovascular Recovery HR AUC 21.65 (41.35) 28.69 (51.95) 31.92 (62.91) F(2,98) = 0.31 p = .735 SBP AUC -29.35 (55.61) -19.57 (54.83) -20.18 (65.90) F(2,98) = 0.28 p = .760 DBP AUC -53.64 (88.38) -59.57 (55.45) -67.11 (78.81) F(2,98) = 0.27 p = .763 Note. Values reported as mean (standard deviation), State Rumination was indexed by thought reports. CV recovery was indexed by AUC where more AUC represents poorer CV recovery. CV= cardiovascular, HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure, AUC = area under the curve. * p < .05

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Table 3

Hypothesis 3 & 4: Change in State Rumination and Cardiovascular Recovery by Condition

Condition Statistical Analyses Change: Time 1 to Time 2 RM-ANOVA Results Outcome Measure Mindfulness Distractio Control Time Effect Condition Effect Interaction Effect n State Rumination -0.65 -0.24 +0.25 F(1,98) = 3.11 p = .081 F(2,98) = 24.84 p < .001* F(2,98) = 4.71 p = .011* (1.11) (1.28) (1.19)

CV Recovery

HR AUC -13.86 -25.85 -30.35 F(1, 98) = 17.74 p < .001* F(2,98) = 0.09 p = .916 F(2,98) = 0.87 p = .423 (39.74) (45.46) (61.20)

SBP AUC -25.06 -29.73 -23.95 F(1,98) = 18.28 p < .001* F(2,98) = 0.37 p = .694 F(2,98) = 0.84 p = .919 (53.85) (53.43) (59.08)

DBP AUC -23.62 +3.20 -19.54 F(1,98) = 2.64 p = .108 F(2,98) = 0.83 p = .440 F(2,98) = 1.03 p = .361 (71.63) (58.93) (86.58)

Note. Change reported as Mean (Standard Deviation). Decreases in state rumination and decreases in CV recovery represent improvements. State Rumination was indexed by thought reports. CV recovery was indexed by AUC. CV= cardiovascular, HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure, AUC = area under the curve. * p < .05

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Table 4

Hypothesis 5 & 7: Change in Psychological Measures by Condition

Condition Statistical Analyses Change: Time 1 to Time 2 RM-ANOVA Results Outcome Measure Mindfulness No Time Effect Condition Effect Interaction Effect Intervention Trait Mindfulness +4.26 -4.46 F(1,98) = 0.004 p = .947 F(1,98) = 3.26 p = .074 F(1,98) = 8.47 p = .004* (16.65) (17.73)

Trait Rumination -52.90 -13.96 F(1,98) = 6.37 p = .013* F(1,98) = 0.42 p = .518 F(1,98) = 2.16 p = .145 (139.16) (152.23)

Depressed Mood -2.40 -0.24 F(1,98) = 7.23 p = .008* F(1,98) = 2.47 p = .120 F(1,98) = 5.06 p = .027* (4.66) (5.98)

Symptoms of Stress -4.13 -1.88 F(1,98) = 2.32 p = .131 F(1,98) = 0.01 p = .931 F(1,98) = 0.33 p = .569 (25.09) (27.07)

Note. Change reported as Mean (Standard Deviation). Decreases in trait rumination, depressed mood and symptoms of stress represent improvements, whereas increases in trait mindfulness represent improvements. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction Rumination Scale, Depressed mood was indexed by the Beck Depression Inventory II, Symptoms of stress was indexed by the Total subscale of the Calgary Symptoms of Stress Inventory. * p < .05

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Table 5

Hypothesis 9: Change in Cardiovascular Reactivity by Condition

Condition Statistical Analyses Change: Time 1 to Time 2 RM-ANOVA Results Outcome Measure Mindfulness No-Intervention Time Effect Condition Effect Interaction Effect

CV Reactivity

HR Reactivity -4.01(8.86) -4.68 (9.76) F(1, 98) = 26.67 p < .001* F(1,98) = 0.09 p = .916 F(1,98) = 0.16 p = .692

SBP Reactivity -4.68 (7.33) -2.95 (6.75) F(1,98) = 28.76 p < .001* F(1,98) = 0.72 p = .397 F(1,98) = 1.48 p = .227

DBP Reactivity -2.80 (7.33) -2.75 (6.75) F(1,98) = 14.63 p < .001* F(1,98) = 1.06 p = .306 F(1,98) =0.001 p = .977

Note. Change reported as Mean (Standard Deviation). Decreases in CV reactivity represent improvements. CV reactivity was indexed using change scores. CV= cardiovascular, HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure. * p < .05

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Table 6

Hypothesis 6: State Rumination and Cardiovascular Recovery Correlations

State Rumination Cardiovascular Time 1 Recovery Variable Correlation Significance

Time 1 HR AUC r = .201 p = .046* SBP AUC r = .239 p = .016* DBP AUC r = .149 p = .136 State Rumination Time 2 Time 2 HR AUC r = -.157 p = .124 SBP AUC r = .075 p = .457 DBP AUC r = .055 p = .582

Note. Greater AUC represents poorer cardiovascular recovery. HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure, AUC = area under the curve. * p < .05

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Table 7

Effect Size: Change from testing session one to testing session two by Condition

Effect Size by Condition Outcome Measure Mindfulness Distraction Control

State Rumination 0.57 0.18 -0.21 CV Recovery HR AUC 0.35 0.69 0.50 SBP AUC 0.47 0.57 0.40 DBP AUC 0.43 -0.05 0.21 Mindfulness No intervention Trait Mindfulness 0.25 -0.25 Trait Rumination 0.38 0.09 Depressed Mood 0.51 0.04 Symptoms of Stress 0.16 0.07 CV Reactivity HR Reactivity 0.45 0.48 SBP Reactivity 0.64 0.44 DBP Reactivity 0.40 0.41

Note. Cohen’s d effect size was calculated comparing testing session one values vs. testing session two values within each of the conditions. Negative effect size indicates that the direction of change reflects a decline in performance. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction Rumination Scale, Depressed mood was indexed by the Beck Depression Inventory II, Symptoms of stress were indexed by the Total subscale of the Calgary Symptoms of Stress Inventory. CV = Cardiovascular, HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure, AUC = area under the curve.

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Table 8

Hypothesis 8: Meditation home practice and psychological outcomes

Time in Meditation Home Practice Change in Psychological Outcome Variable Correlation Significance

Trait Mindfulness r =.157 p = .339 Trait Rumination r = -.415 p = .020* Depressed Mood r = -.114 p = .540 Symptoms of Stress r = -.236 p = .201 Note. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction Rumination Scale, Depressed mood was indexed by the Beck Depression Inventory II, Symptoms of stress was indexed by the Total subscale of the Calgary Symptoms of Stress Inventory. Negative correlation values indicate that greater time in meditation home practice is associated with greater decreases in the psychological outcome variable. Increases in trait mindfulness are considered desirable, while deceases in trait rumination, depressed mood and symptoms of stress are desirable. * p < .05

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Table 9

Hypothesis 10: Associations Trait Rumination, Trait Mindfulness and Cardiovascular Recovery

Trait Rumination Trait Mindfulness Cardiovascular Testing session one Testing session one Recovery Variable Correlation Significance Correlation Significance

Testing session one HR AUC r = .085 p = .400 r = -.018 p = .860 SBP AUC r = -.018 p = .855 r = -.036 p = .720 DBP AUC r = -.058 p = .567 r = .007 p = 941 Trait Rumination Trait Mindfulness Testing session two Testing session two Testing session two HR AUC r = .034 p = .737 r = .040 p = .696 SBP AUC r = .022 p = .829 r = -.094 p = .353 DBP AUC r = .051 p = .611 r = -.166 p = .098 Note. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction Rumination Scale, CV recovery was indexed by AUC. CV= cardiovascular, HR = Heart rate, SBP = Systolic blood pressure, DBP = diastolic blood pressure, AUC = area under the curve. Greater AUC reflects poorer CV recovery, therefore positive correlations indicated that poorer CV recovery is associated with greater trait rumination or greater trait mindfulness. * p < .05

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Table 10

Hypothesis 11: Associations between changes in Trait Mindfulness and Changes in Trait Rumination, Depressed Mood, and Symptoms of Stress, in Mindfulness Participants

Change in Trait Mindfulness Change in Psychological Outcome Variable Correlation Significance

Trait Rumination r = -.555 p = .001* Depressed Mood r = -.192 p = .300 Symptoms of Stress r = -.340 p = .061 Note. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction Rumination Scale, Depressed mood was indexed by the Beck Depression Inventory II, Symptoms of stress was indexed by the Total subscale of the Calgary Symptoms of Stress Inventory. * p < .05

Table 11

Correlations Rumination and Mindfulness Time 1 Time 2 State Trait Trait Sate Trait Trait Rumination Rumination Mindfulness Rumination Rumination Mindfulness Time 1 State Rumination r = .053 r = -.024 r = .624 r = .135 r = -.247 p = .599 p = .808 p < .001* p = .179 p = .013

Trait Rumination r = .053 r = -.496 r = -.022 r = .653 r = -.292 p = .599 p < .001* p = .829 p < .001* p = .003*

Trait Mindfulness r = -.024 r = -.496 r = .046 r = -.310 r = .671 p = .808 p < .001* p = .648 p = .002* p < .001*

Time 2 State Rumination r = .624 r = -.022 r = .046 r = .136 r = -.210 p < .001* p = .829 p = .648 p = .177 p = .036*

Trait Rumination r = .135 r = .653 r = -.310 r = .136 r = -.350 p = .179 p < .001* p = .002* p = .177 p < .001*

Trait Mindfulness r = .247 r = -.292 r = .671 r = -.210 r = -.350 p = .013* p = .003* p < .001* p = .036* p < .001*

Note. Trait mindfulness was indexed by the Five Factor Mindfulness scale, Trait rumination was indexed by the Negative Inferential Style subscale of the Stress Reaction, State rumination was indexed by thought reports.

* p < .05 138

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Figure 1. Relative blood pressure load due to acute reactivity and delayed recovery

Acute Reactivity Delayed Recovery

Note: Gray shaded area represents the blood pressure load

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Figure 2. Rumination-arousal model

Trait Dimensions (e.g. trait rumination, trait mindfulness) negative affect (e.g. anger, anxiety)

emotion Emotional related experience thoughts

autonomic activation Situational characteristics (e.g. distraction, state mindfulness, state rumination)

Adapted from Gerin & Pickering (2005)

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Figure 3. Study design

Participants recruited through online system

Randomization N = 114

Mindfulness Condition Distraction Condition Control Condition Testing Session 1: Testing Session 1: Testing Session 1: Baseline Questionnaires Baseline Questionnaires Baseline Questionnaires Lab Stress Testing Lab Stress Testing Lab Stress Testing Mindfulness induction Distraction induction No induction N = 33 N=40 N=41

4-Week 4-Weeks 4-Weeks Mindfulness No No Intervention Intervention Intervention Drop-outs = 2 Drop-outs = 6 Drop-outs = 5

Testing Session 2: Testing Session 2: Testing Session 2: Post Questionnaires Post Questionnaires Post Questionnaires Lab Stress Testing Lab Stress Testing Lab Stress Testing Mindfulness induction Distraction induction No induction N= 31 N=34 N=36

Figure 4. Laboratory testing session flow chart

Stress Consent (session 1) Baseline CV Task Recovery Period & & Questionnaires measurements Assigned Induction

20 min 10 min 5 min 15 min

10 min 2 min 2 min 2 min Assess State VAS* Rumination Instrumentation Explain Stress VAS* & instructions De-instrumentation & Task for state rumination Debriefing (session 2) assessment

VAS = Visual Analogue Scales

CV = Cardiovascular 142

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Figure 5. State rumination by condition (Hypothesis 3)

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Figure 6. Trait mindfulness by condition (Hypothesis 5)

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Figure 7. Depressed mood by condition (Hypothesis 7)

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Figure 8. Rumination arousal model and predicted relationships in the current study

Mindfulness Meditation Intervention

Trait Dimensions: Trait Rumination Trait Mindfulness Negative Affect

Emotional Stressor State Rumination

Situational characteristics: Cardiovascular Inductions: Distraction, Reactivity & Mindfulness, Rumination Recovery

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Figure 9. Rumination arousal model and observed relationships in the current study

Mindfulness Meditation Intervention Trait Characteristics

Trait Mindfulness

Trait Rumination Negative Affect

Emotional Stressor State Rumination

Situational Characteristics: Cardiovascular Inductions: Distraction, Reactivity & Mindfulness, Rumination Recovery

Legend Relationship supported Relationship not supported

Mixed Findings

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Appendix A

Visual Analogue Scales: Baseline

How are feeling at the moment?

1. Are you feeling stressed?

Not at all Extremely Stressed Stressed

2. Are you feeling angry?

Not at all Extremely Angry Angry

3. Are you feeling sad or down?

Not all Extremely Sad/Down Sad/Down

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Appendix B

Visual Analogue Scales: Post Stressor

Rating of Negative Emotional Stressor Spoken about During Stress Task:

1. At the time of this event how upsetting would you say this event was for you?

Not at all Extremely Upsetting Upsetting

2. How upsetting did you find it talking about this event today?

Not at all Extremely Upsetting Upsetting

3. Would you say that this event and the issues or emotions surrounding it have been resolved?

Not all Completely Resolved Resolved

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How are you feeling at the moment?

4. Are you feeling stressed?

Not at all Extremely Stressed Stressed

5. Are you feeling angry?

Not at all Extremely Angry Angry

6. Are you feeling sad or down?

Not all Extremely Sad/Down Sad/Down

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Appendix C

Induction Statements for the Recovery period

Audio Introductory Instructions

Control Welcome, Please allow your mind to wander. When you here a tone please fill out the thought report form.

Mindfulness & Distraction Welcome. When you here a tone please fill out the thought report form. Please try your best to keep your mind focused on the following statements:

Mindfulness Induction Statements: 1. Observe the sensations of your breath passing in and out through your nostrils 2. Be aware of being present in this room; sounds, smells, sensations in your body 3. Observe any thoughts that may come into your mind without judgement, allowing them to rise and fall as they will 4. Observe the sensations of your breath filling and emptying your lungs 5. Be aware of the sensations that are currently present in your body

Distraction Induction Statements: 1. Think about different routes to the University of Calgary 2. Think about the names of stores in the local mall 3. Think about the weather today 4. Think about the size and shape of the University of Calgary campus and all the buildings 5. Think about the floor plan of your house or apartment and all it’s contents

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Appendix D

Stress Reactive Rumination Scale

Scale |______|______|______|______|______|______|______|______|______|______| 0 10 20 30 40 50 60 70 80 90 100 Not focus Focus on Focus on on this at all this somewhat this to a great extent

College students experience many stressful events. Examples of these events include failing an exam, getting fired from a job, serious injury or physical illness, death of a close friend or family member, being rejected by a current romantic interest, not having enough friends, and many others. People think and do many different things when they experience stressful events. Please read each of the items below and indicate how frequently you would think or do each item in response to a stressful event. A 100 would indicate that you would focus on this to a great extent in response to a stressful event. Please indicate what you would do, and not what you think you should do.

1. Ask someone to help you overcome your problem. _____ 2. Try to find something positive in the situation or something you’ve learned. _____ 3. Think about how the stressful event is all your fault. _____ 4. Think about how the negative event will negatively affect your future. _____ 5. Think about what the occurrence of the event means about you. _____ 6. Think about how things could have gone differently. _____ 7. Think about the possibility that things will never get better. _____ 8. Think about how terrible the stressful event is. _____ 9. Think about the stressful event and wish it had gone better. _____ 10. Think about how bleak your future looks. _____ 11. Think that the cause of the event will lead to additional stressful events in your life.__ 12. Help someone else with something, to distract yourself. _____ 13. Think about the causes of the stressor. _____ 14. Do something to take your mind off your problem(s). _____ 15. Go to a favorite place to get your mind off of the stressor. _____ 16. Ruminate about how the stressor will affect other areas of your life. _____ 17. Concentrate on your work. _____ 18. Think about how important the stressful event is to you. _____ 19. Think “No matter what I do my life will never get better.” _____ 20. Make a plan to overcome the problem. _____ 21. Think about how futile life is. _____ 22. Think about how bad your life is in general. _____ 23. Think about how things like this always happen to you. _____ 24. Think about how hopeless your situation is. _____ 25. Think that the event means that you will be unable to cope with events in the future._

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Appendix E

Five Facet Mindfulness Questionnaire

Please rate each of the following statements using the scale provided. Write the number in the blank that best describes your own opinion of what is generally true for you.

1 2 3 4 5 never or very rarely sometimes often very often or rarely true true true true always true _____ 1. When I’m walking, I deliberately notice the sensations of my body moving. _____ 2. I’m good at finding words to describe my feelings. _____ 3. I criticize myself for having irrational or inappropriate emotions. _____ 4. I perceive my feelings and emotions without having to react to them. _____ 5. When I do things, my mind wanders off and I’m easily distracted. _____ 6. When I take a shower or bath, I stay alert to the sensations of water on my body. _____ 7. I can easily put my beliefs, opinions, and expectations into words. _____ 8. I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise distracted. _____ 9. I watch my feelings without getting lost in them. _____ 10. I tell myself I shouldn’t be feeling the way I’m feeling. _____ 11. I notice how foods and drinks affect my thoughts, bodily sensations, and emotions. _____ 12. It’s hard for me to find the words to describe what I’m thinking. _____ 13. I am easily distracted. _____ 14. I believe some of my thoughts are abnormal or bad and I shouldn’t think that way. _____ 15. I pay attention to sensations, such as the wind in my hair or sun on my face. _____ 16. I have trouble thinking of the right words to express how I feel about things _____ 17. I make judgments about whether my thoughts are good or bad. _____ 18. I find it difficult to stay focused on what’s happening in the present.

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_____ 19. When I have distressing thoughts or images, I “step back” and am aware of the thought or image without getting taken over by it. _____ 20. I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. _____ 21. In difficult situations, I can pause without immediately reacting. _____ 22. When I have a sensation in my body, it’s difficult for me to describe it because I can’t find the right words. _____ 23. It seems I am “running on automatic” without much awareness of what I’m doing. _____24. When I have distressing thoughts or images, I feel calm soon after. _____ 25. I tell myself that I shouldn’t be thinking the way I’m thinking. _____ 26. I notice the smells and aromas of things. _____ 27. Even when I’m feeling terribly upset, I can find a way to put it into words. _____ 28. I rush through activities without being really attentive to them. _____ 29. When I have distressing thoughts or images I am able just to notice them without reacting. _____ 30. I think some of my emotions are bad or inappropriate and I shouldn’t feel them. _____ 31. I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow. _____ 32. My natural tendency is to put my experiences into words. _____ 33. When I have distressing thoughts or images, I just notice them and let them go. _____ 34. I do jobs or tasks automatically without being aware of what I’m doing. _____ 35. When I have distressing thoughts or images, I judge myself as good or bad, depending what the thought/image is about. _____ 36. I pay attention to how my emotions affect my thoughts and behavior. _____ 37. I can usually describe how I feel at the moment in considerable detail. _____ 38. I find myself doing things without paying attention. _____ 39. I disapprove of myself when I have irrational ideas.

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Appendix F

Thought Reports (State Rumination Assessment)

Thought Reports - Control Condition

What were you thinking about at the time of the tone? (please check one box at each time)

Time 1 ⁪ ⁪ ⁪ The Present Moment The Future The Past

Time 2 ⁪ ⁪ ⁪ The Present Moment The Future The Past

Time 3 ⁪ ⁪ ⁪ The Present Moment The Future The Past

Time 4 ⁪ ⁪ ⁪ The Present Moment The Future The Past

Time 5 ⁪ ⁪ ⁪ The Present Moment The Future The Past

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Thought Reports – Distraction and Mindfulness Conditions

What were you thinking about at the time of the tone? (please check one box at each time)

Time 1 ⁪ ⁪ ⁪ ⁪ The Past Present Moment Present Moment The Future Instructions Other

Time 2 ⁪ ⁪ ⁪ ⁪ The Past Present Moment Present Moment The Future Instructions Other

Time 3 ⁪ ⁪ ⁪ ⁪ The Past Present Moment Present Moment The Future Instructions Other

Time 4 ⁪ ⁪ ⁪ ⁪ The Past Present Moment Present Moment The Future Instructions Other

Time 5 ⁪ ⁪ ⁪ ⁪ The Past Present Moment Present Moment The Future Instructions Other

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Appendix G

Instructions for Thought Reports (State Rumination Assessment)

General Instructions: Next you will be sitting quietly for 15 minutes and listening to this CD. You will be hearing a tone at intervals throughout the next 15 minutes. After you hear the tone please indicate what you were thinking about at the time you heard the tone on the thought report form. We have divided thoughts into 3 main categories: thoughts about the present, the past or the future. Each time you will need to decide which category your thoughts would fit into the best.

For example… Examples for Control Condition: If you were thinking about something that happened last week, earlier today or even earlier in this laboratory session you would indicate “thinking about the past”

If you were thinking about something you need to do later today, or maybe next week you would indicate “thinking about the future”

If you were thinking about how you are feeling at the moment or what you hear or see right now then you would indicate “thinking about the present”

Examples for Distraction and Mindfulness Conditions: If you were thinking about something that happened last week, earlier today or even earlier in this laboratory session you would indicate “thinking about the past”

If you were thinking about something you need to do later today, or maybe next week you would indicate “thinking about the future”

If you were thinking about the last statement that was played over the audio device then you would indicate “thinking about the instructions”

If you were thinking about something else related to the present moment: what you hear, see or feel right now you would indicate “thinking about Other present moment” for example if you were thinking about your stomach rumbling because you are hungry you would indicate “thinking about Other present moment”

Additional Instructions for Distraction and Mindfulness Conditions: Do your best to try and keep you mind focused on the statements played over the audio device; however, we understand that your mind may wander from this task. Please do your best to report honestly were your mind was at the time of the tone.

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Appendix H

Statistical Assumptions

Pearson Chi-Square test Assumptions: 1) Expected cell frequencies must be greater than five When this assumption is violated the Fisher Exact test should be used. Therefore for analysis that resulted in cell frequencies less than five the Fisher’s Exact p-value was substituted for the Chi-square p-value (all Chi-square analysis violated this assumption therefore Fisher’s exact was used throughout results section). ANOVA and RM-ANOVA Assumptions: 1) Variables are normally distributed The ANOVA test controls the Type I error rate well under conditions of skew, kurtosis and non-normality (Glass et al., 1972), therefore no adjustments were made to the data in the current study to ensure a normal distribution. 2) Homogenity of variance (Between subjects ANOVA) The ANOVA test is fairly robust to violations of assumptions of homogeneity of variance when sample sizes are equal (Fields, 2009). However, when sample sizes are unequal ANOVA is not robust to violations of homogeneity of variance. In the current study the analyses involving three conditions had relatively equal sample sizes across the groups, however in analyses involving two conditions (where distraction and control participants were grouped together) the sample sizes were unequal. Levene’s test (which tests homogeneity of variance) was inspected and found to be non-significant for all relevant analyses indicating that this assumption was met. 3) Homogeneity of covariance matrices (RM-ANOVA) Box’s M test is used to test whether the assumption of homogeneity of covariance matrices is met. If sample sizes are unequal and Box’s M is significant at p< .001 then robustness is not guaranteed (Tabachnick & Fidell, 2001). Box’s M test was inspected for all relevant analyses and found to be non-significant (based on p < .001) indicating that this assumption was adequately met.

159

4) Sphericity (RM-ANOVA) The assumption of sphericity is always met when the repeated measure variable has only two levels. In the current study the repeated measure variable was time, which only had two levels, therefore the assumption of sphericity was met in all analyses. 5) Independence of observations In RM-ANOVA it is expected that scores in the repeated measure will be non- independent, however scores on the between subjects factor should be independent. As participants were tested individually the study protocol increased the likelihood that participants’ results would not be influenced by each other. There is no statistical analysis that tests the assumption of independence of observations. Outliers All dependant variable data was inspected for outliers. Outliers were identified in the HR AUC data and BDI-II data. Participant #5088 was excluded from all HR AUC analysis, as their data value for time one HR AUC (-266.0) was greater than three standard deviations below the mean. Participant #5044 was excluded from all HR AUC analysis, as their data from time one to time two was greatly inconsistent suggesting an instrumentation error (T1 HR base = 61, T2 HR base = 41.75). Participant #5110, #5113 and #5051 were identified as falling greater than three standard deviations above the mean on the BDI-II and therefore were excluded from all analyses involving the BDI-II.

Statistical Assumptions References Glass, G.V., Peckham, P.D. & Sanders, J.R. (1972). Consequences of failure to meet assumptions underlying the fixed effects analyses of variance and covariance. Review of Educational Research, 42(3), 237-288. Fields, A. (2009). Discovering statistics using SPSS (3rd ed.) Sage Publications Inc. Thousand Oaks, CA. Tabachnick, B.G. & Fidell, L.S. (2001). Using multivariate statistics (4th ed.). Boston: Allyn & Bacon.

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Appendix I

Additional Statistical Tests Hypothesis Three

Additional Follow-up Tests

It was determined that the focus of the statistical analyses involving the three conditions would be on changes over-time and therefore the follow-up tests for the significant interactions on RM-ANOVA results would investigate changes over-time within each of the conditions. An alternative method to conducting the follow-up tests

(i.e. comparing the three conditions at time two) was determined to be of less interest and therefore these results are included in the appendix for interested readers. These results are Bonferonni corrected for three comparisons.

RM-ANOVA analysis indicated an interaction between condition and time on state rumination F(2, 98) = 4.71, p = .011. Follow-up tests comparing the conditions at time two showed that participants in the mindfulness condition reported less state rumination compared to those in the distraction condition t(2) = 2.92, p = .013 and the control condition t(2) = 7.31, p < .001. Participants in the distraction group reported less state rumination compared to those in the control condition t(2) = 4.45, p < .001 (Figure

6).

Controlling for Baseline Characteristics

Pearson Chi-Square analysis indicated that the three conditions did not significantly vary on baseline characteristics, however difference on interest in mindfulness neared significance, χ2(4) = 8.63, Fishers Exact p = .055. Therefore the RM-

161

ANOVA analysis was repeated using interest in mindfulness as a covariate. Results indicated that including the covariate did not alter the findings, F = 4.60, p =.012.

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Appendix J

Mindfulness Group Booklet Given to Participants

Mind-RACER Mindfulness Meditation Four-Week Stress Reduction Program

Facilitated by: Brenda Key [email protected]

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Table of Contents

Program Description ………………………………………………………………3

Week 1

Group Ground Rules ……………………………………………………………..4

What is Mindfulness? …………………………………………………………….5

Benefits of Mindfulness Meditation ……………………………………………6

Diaphragmatic Breathing ………………………………………………………..7

Week 2

Mindfulness Meditation Attitudes ……………………………………………8-9

Sitting Meditation Practice ……………………………………………………..10

Week 3

Mini Mindfulness Exercises ……………………………………………………11

Imagery ……………………………………………………………………………..12

Week 4

Walking Meditation ..………………………………………………………….…13

Suggested Resources ……………………………………………………………14

Sleep Exercise …………………………………………………………………….15

Additional Materials

Acknowledgments …………………………………………..……………………16

Homework logs …………………………………………………………………17-20

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Program Description Mindfulness Meditation: Four-week Stress Reduction Program

Program Overview In developing the mindfulness intervention we were guided by the work of John Kabat-Zinn (1990). This abbreviated mindfulness intervention is congruent with the mindfulness philosophy. The intervention is 4-weeks in duration and consists of four weekly 45-minute group sessions and home practice. Each group session will include a teaching section and experiential exercises. You will receive a CD of guided mindfulness exercises, which you will be asked to listen to and practice for at least 15 minutes per day, 5 days per week. You also receive a manual (this booklet) that summarizes key points from the educational material and clarifies your homework requirements. You will be asked to homework logs, for the duration of the mindfulness intervention, in which you will record the number of minutes spent meditating each day.

Week 1: You are given your booklet and meditation CD. A brief explanation of the course is provided including a review of the group rules. Mindfulness meditation is defined and explained. You are led through an exercise focusing on full and relaxed breathing and guided awareness of bodily sensation. The homework requirements of 15 minutes meditation and ongoing informal mindfulness practice are reviewed. Week 2: The key attitudes associated with mindfulness meditation are introduced and the class is asked to recount their experiences with their mindfulness practice over the last week and ask any questions they may have. A guided sitting meditation focusing on breath awareness is performed. The homework requirements of 15 minutes formal meditation and ongoing informal mindfulness practice are reviewed. Week 3: Various min-mindfulness strategies are introduced and briefly practiced. A guided imagery meditation is performed. The class closes with a brief group discussion about their mindfulness practice. The homework requirements of 15 minutes formal meditation and ongoing informal mindfulness practice are reviewed. Week 4: The class begins with a review of the exercises that have been learned. Possible supports to keep the momentum and discipline of meditation practice are discussed. The class is led through a walking or imagery meditation. The final group discussion focuses on integrating meditation practice into one’s daily life.

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Group Ground Rules

To assure that the group is a safe and respectful place for all members, we ask that you follow these ground rules:

Attendance Please be present and on time for meetings. If you are unable to attend please let us know by emailing: [email protected]

Commitment In agreeing to participate in this group you are taking on the commitment of attending all four of the weekly group sessions and to practice what you have learned at home. In order to get the full benefits of the program you need to participate fully. Please bring this booklet and your filled out homework logs to each session.

Confidentiality You are welcome to share your experiences about meditation practice with the group. Please do not disclose information about what other group members have discussed during a session to individuals outside of the group.

Self-responsibility We encourage you to participate as fully as possible in a way which feels right to you. Your right not to disclose information on any topic of discussion will be respected.

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What is Mindfulness?

Mindfulness refers to the concept of developing awareness in the present moment and of all that is happening - in the moment - without judging or evaluating your experience.

Often, we spend much of our lives either reliving the past or planning for the future and tend to miss the only time that we actually do our living – the present.

Mindfulness meditation uses this concept of moment-to-moment awareness to help us simply BE where we are, rather than in the past or future. Directing attention to the ongoing flow of breath serves to anchor awareness in present moment experience, promoting clarity of perception and calmness of body and mind.

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Benefits of Mindfulness Meditation

Here are some of the benefits that you may experience while meditating:

• Calms the body, mind and spirit • Trains us to let go of past regret and future worries so that we can live more fully in the present moment • Help us find peacefulness and clarity in the hectic world • Decreases levels of anxiety and mood disturbance • Slows the heart rate and can decrease blood pressure • Decreases levels of stress hormones • Decreases pain levels and the experience of pain • Strengthens the body’s immune system

These benefits of meditation continue for some time after formal practice

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Diaphragmatic Breathing

• Most of the time we are unaware of the quality of our breathing • Diaphragmatic breathing is a way to deepen and lengthen the breath, which results in deep relaxation and tension reduction • It is the first step in the practice of meditation

The Diaphragmatic Breath

During inhalation the diaphragm When the diaphragm relaxes during

contracts downward and the exhalation the abdomen contracts abdomen expands

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Mindfulness Meditation Attitudes

Several attitudes serve as the foundation of mindfulness meditation practice:

Non-Judging: Mindfulness is cultivated by assuming a stance of impartial witness to our own experience. This requires that we become aware of the constant stream of evaluative and judging mind, things become neither ‘good’ nor ‘bad’ – but simply present or absent.

Patience: Patience demonstrates that we understand and accept that things have their own schedule for unfolding. We tend, particularly, to be impatient with ourselves, expecting that we ‘should’ be able to calm the mind, stop the thoughts, or get over whatever is upsetting us. These things have their own schedule; the mind has a ‘mind of its own’ and patience allows us to simply observe the unfolding of the mind and body over time.

Beginner’s Mind: In order to be able to see the richness of the present moment, it helps to cultivate a mind that is willing to see everything as if for the first time. We tend to become jaded and think we’ve seen or done it all. With beginner’s mind the joys of the world as it unfolds around us become new again, as if we are all children – freed from our old expectations based on past experiences.

Self- Trust: You are your own best guide. It is far better to trust your own feelings and intuition than get caught up in the authority of ‘experts’. If at anytime something doesn’t feel right to you, pay attention, examine your feelings, and trust in your intuition and your own basic wisdom and goodness

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Mindfulness Meditation Attitudes Continued

Non-Striving: Meditation is different from all other human activity: we do it not with a goal or destination in mind, but rather with a mind towards simply being – not doing. There is no goal other than for you to be conscious of yourself as you are in the moment.

Acceptance: Acceptance involves seeing things as they actually are in the present. We may not like it but if that’s the way things are, so they are. Sooner or later we all must come to terms with things as they are and accept them. Acceptance allows us to cease struggling to change things that are beyond our ability to control and is the first step in any genuine process of change. Only with acceptance can the mind become free.

Letting Go: Letting go, also known as “non-attachment”, is fundamental to the mindfulness meditation practice. In our minds, there are often things we want to hold on to (pleasant thoughts and feelings) or push away (unpleasant experience). With letting go, we put aside the tendency to elevate some parts of our experience and reject others – simply letting our experience be what it is, accepting things as they are without judging, and realizing the constantly changing nature of all experience.

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Sitting Mindfulness Meditation Practice

1. Find a comfortable position on a cushion, chair or the floor in which your torso is upright and your back is straight, allowing your breath to flow easily into your belly. 2. Focus your attention on the movement of your breath as it flows deep into the lungs and expands the belly (diaphragmatic breathing). 3. Continuing to attend to the breath. Allow your body to relax. 4. Maintain attention to the breath as you inhale and exhale, noting the sensation of the breath as it moves through different parts of the body. 5. When you become distracted, simply note “thinking” and let go of the thought – gently guide your attention back to your breath. 6. Continue!

Discomfort: Meditating in one position for an extended period of time may lead to feelings of discomfort in the body. If this should happen simply note the sensation. Continue to meditate and the feelings may cease or diminish. If the discomfort persists you may readjust. However, do so mindfully: first making a mental note of the intention to move, then moving purposefully.

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Mini Mindfulness Exercises • Mini mindfulness exercises are focused breathing techniques that help reduce anxiety and tension immediately! • You can do them with your eyes open or closed (but make sure that your eyes are open when you are driving!) • You can do them any place, anytime, no one will know that you are doing them

Ways to do a mini Switch to diaphragmatic breathing. If you are having trouble, try breathing in through your nose and out through your mouth, or take a deep breath. You should feel your stomach rising as you breath in, and falling as you breath out. If you are having trouble you can try lying in your back or stomach, this will make you more aware of your breathing pattern. Remember, it is impossible to breath diaphragmatically if you are holding your stomach in! So relax your stomach muscles.

Mini Version 1 Count very slowly, to yourself, from ten down to zero – one number for each breath. Thus, with the first breath you say “ten” to yourself, with the next breath you say “nine” etc. If you start to feel light headed or dizzy slow down the counting. When you get to zero, see how you are feeling. If you are feeling better great! If not, try doing it again.

Mini Version 2 As you inhale count slowly up to four; as you exhale count slowly back down to one. Thus, as you inhale you say to yourself “one, two, three, four.” As you exhale you say to yourself “four, three, two, one.” Do this several times.

Mini Version 3 After each inhalation, pause for a few seconds; after you exhale, pause again for a few seconds. Do this for several breaths

Good Times to do a Mini • When stuck in traffic • When put on hold during a phone call • While waiting in a waiting room • When someone says something that bothers you • At red lights • In the dentist chair • When you feel overwhelmed by what you need to accomplish • While standing in line • When in pain • Anytime!

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Imagery

What is imagery?

Imagery can be considered a process of directed or intentional daydreaming. It is a way of using the imagination to help mind and body perform as desired. It is not strictly visual, but rather involves all the senses including smell, taste, touch and hearing. Imagery can combat stress, pain, and anxiety and even improve concentration and performance.

Principles of Imagery

1. Our bodies don’t discriminate between images created in the mind and reality – imagined images can create the same bodily experiences as real events. For example, reading a recipe for a favourite dish may make you salivate. On the negative side, we can experience all the physical effects of stress simply by imagining or re-living stressors.

2. In a relaxed state we are more capable of learning, changing and healing. Imagery can help us achieve relaxation. Athletes often use imagery to help them achieve a calm and energized alertness, which can enhance their performance.

3. Using imagery in preparation for challenges or to change our current level of arousal helps to give us a sense of mastery over what is happening to us.

Imagery is a form of Meditation

Intentionally brining our attention to a chosen image and experiencing this image through all of our senses is a form of meditation. The image serves as an anchor for your attention - just as in any other form of mindfulness meditation - if you notice that your attention has drifted away from your chosen image, gently guide it back.

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Walking Meditation

What is walking meditation? Walking meditation is a form of meditation in action. In walking meditation we use the experience of walking as our focus. We become mindful of our experience while walking, and try to keep our awareness involved with the experience of walking.

Why walking meditation? Usually we walk for a reason. The most common one is that we want to get somewhere. Of course the mind tends to think about where it wants to go and what it is going to do there. When we practice walking meditation, we are not trying to get anywhere. It is sufficient to just be with each step, realizing that you are just where you are and be there completely.

How to do walking meditation Walking meditation can be done in several different ways. You may focus on the sensation in your feet or your legs, or alternatively, felling your whole body moving. You can also integrate awareness of your breathing with the experience of walking. You can walk at a normal pace or more slowly than usual and you can choose to focus your attention any aspect of your experience while walking.

A simple walking meditation To begin this simple walking meditation make the specific intention to do it for a period of time, say ten minutes, in a place where you can walk slowly. It is a good idea to focus on one aspect of your walking rather than changing your focus throughout the meditation.

We begin by making an effort to be fully aware as one foot contacts the ground, as the weight shifts to it, as the other foot lifts and moves ahead and then comes down to make contact with the ground in its turn. As with the other forms of mindfulness meditation, when the mind wanders away from the feet or the legs or the feelings of walking, we simply bring it back when we become aware of it. To deepen our concentration, we do not look around at the sights, but keep our gaze focused in front of us.

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Mindfulness Meditation Resources

General Information http://mindfulnesscalgary.ca Website includes details of local Mindfulness programs, links to other mindfulness programs and poetry.

Readings: Mind-Body/Healing Meditation *Kabat-Zinn, J. (1990) Full Catastrophe Living: Using the wisdom of your body and mind to face stress, pain and illness. NY: Bantam Doubleday.

Khalsa, Dharma-Singh & Stauth (2001). Meditation as Medicine: Activate the power of your healing force. NY: Simon and Schuster.

Seigel, B. (1993). How to live between office visits: A guide to love and health NY: Harper Collins. See also: Peace, Love and Healing (1989) and Love, Medicine and Miracles (1986).

Speigel, D. (1993) Living beyond limits. NY: Times Books.

Readings: Meditation/Spiritual Kabat-Zinn, J. (1994). Wherever you go, there you are. New York: Hyperion

Tolle, Eckhart. (1999) The Power of now: A guide to spiritual enlightenment. Novato CA: New World Library.

Levine, S. (1991). Guided Meditations, explorations and healings. NY: Doubleday.

Levy J. & levy, M. (1999) Simple Meditation & Relaxation. Berkeley, CA: Conari Press.

Venerable Henepola Gunaratana. (1991). Mindfulness in Plain English. Sommerville Massachusetts: Wisdom Publications

Audio Guided Meditation Kabat-Zinn, J. (1980) Mindfulness Meditation Practice Series 1 Kabat-Zinn, J. (1994) Mindfulness Meditation Practice Series 2 Kabat-Zinn, J. (2005) Mindfulness Meditation Practice Series 3

* = the mindfulness program you have participated in is based on this book

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Sleep Exercise

This elegant little technique can put you to sleep and help you sleep more peacefully.

It uses a 2-to-1 breath (breathing out for twice as long as the time you breath in)

1. Get into bed and pay close attention to your breath

There shouldn’t be any pauses, jerks, or shakiness. Eliminate even the pauses between the inhalation and exhalation.

2. Take: • 8 breaths lying on your back • 16 breaths lying on your left side • 32 breaths lying on your right side

3. Repeat if you are still awake

Very few people complete this exercise…. Sweet dreams

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Acknowledgments

This 4-week Mindfulness Intervention is based on John Kabat-Zinn’s Mindfulness Based Stress Reduction program described in the book: “Full Catastrophe Living: Using the wisdom of your body and mind to face stress, pain and illness.” Adjustments have been made to make the program suitable to a 4-week format and for the purposes of evaluation through empirical research. This program booklet and the accompanying audio CDs are an abbreviated and adapted version of the materials used for the Mindfulness Based Stress Reduction Program developed by Michael Speca, Linda Carlson and Shirley MacMillan for the Department of Psychosocial Resources at the Tom Baker Cancer Centre. Due to the abbreviated nature of this mindfulness intervention and the nature of the adaptation of the program for research purposes, this 4-week program is not equivalent to the standard 8-week Mindfulness Based Stress Reduction program.

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Homework Log Week 1

Name:______Homework Assignment Week 1: • Listen to body scan meditation (track 2 on CD) once a day for 5 days • Record your practice and any comments about your experience • Try to notice when you are not being mindful of the present moment in your everyday life

Dates Total Minutes Comments in Meditation Day 1

Day 2

Day 3

Day 4

Day 5

Total Weekly Minutes:

Hand in Homework Log at next mindfulness session

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Homework Log Week 2

Name:______Homework Assignment Week 2: • Listen to either the sitting meditation (track 3) or body scan meditation (track 2) once a day for 5 days • Record your practice and any comments about your experience • When you notice that you are not being mindful of the present moment in your everyday life try to bring your focus back to what you are doing at that moment

Dates Total Minutes Comments in Meditation Day 1

Day 2

Day 3

Day 4

Day 5

Total Weekly Minutes:

Hand in Homework Log at next mindfulness session

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Homework Log Week 3

Name:______Homework Assignment Week 3: • Listen to either the imagery lake meditation (track 4) or another meditation of your choosing once a day for 5 days • Record your practice and any comments about your experience • Continue to practice noticing when you are not being mindful and shifting your attention back to the present moment in your everyday life • Try doing a mini-mindfulness exercise when you need to re-focus or relax

Dates Total Minutes Comments in Meditation Day 1

Day 2

Day 3

Day 4

Day 5

Total Weekly Minutes:

Hand in Homework Log at next mindfulness session

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Homework Log Week 4

Name:______Homework Assignment Week 4: • Listen to any meditation of your choosing (tracks 2-4) once a day for 5 days • Record your practice and any comments about your experience • Continue to practice noticing when you are not being mindful and shifting your attention back to the present moment in your everyday life • Use mini-mindfulness exercise when you need to re-focus or relax

Dates Total Minutes Comments in Meditation Day 1

Day 2

Day 3

Day 4

Day 5

Total Weekly Minutes:

Hand in Homework Log at your next laboratory testing session

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Appendix K

Mindfulness Meditation Program Facilitator Outline

Mindfulness Program Facilitator Outline

Week 1 • Introduce self, students introduce general info • Hand out materials (booklets and CDs) – participants keep these materials • Group ground rules: o Go through homework logs • Group member introductions • What is mindfulness – discussion, how much of time in life are you mindful • Benefits of mindfulness – discussion: what are some of the areas that you would like to improve on, or how can you see mindfulness benefiting you? • Diaphragmatic breathing – what is it, how to do it, exercise seated with hand on stomach • Body Scan meditation – lead through body scan • Wrap up o Homework and homework log o Next meeting time and place o Any questions Week 2 • Collect Homework sheets – any questions about filling out sheets • Discuss homework – difficulties fitting it in, falling asleep, time of day that worked, days easier to focus than others, how feel afterwards, differences how affected you day to day • Questions concerns: CDs worked okay, any questions about ‘doing it right’ • Mindfulness attitudes o Describe each one o Which you want to work on o Which find difficult to imagine how you would do o Which would be hardest for you o Person who is the opposite o How would these attitudes be beneficial • Sitting meditation o Read through explanation o Handling discomfort o Any questions o Different positions

• Homework: o Listen to sitting meditation or body scan (maybe alternate)

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o Try to notice when you are not being mindful in your daily life and make an effort to bring attention back to the present moment o Try to use the mindful attitudes in your practice and every day life Week 3 • Collect Homework sheets – any questions about filling out sheets • Discuss homework – difficulties fitting it in, falling asleep, time of day that worked, days easier to focus than others, how feel afterwards, differences how affected you day to day • Any questions about mindful attitudes, experiences trying to be mindful? • Comparison of sitting versus body scan • Questions concerns: CDs worked okay, any questions about ‘doing it right’ • Mini-mindfulness exercises o What can use for & when o Not forcing the breath o Go through the examples o When would it be helpful for you to use them? • Imagery meditation o Read through explanation o Principles of imagery o Any questions o Imagery meditation • Homework: o Listen to lake meditation (track 4) or other track of choosing o Try to notice when you are not being mindful in your daily life and make an effort to bring attention back to the present moment o Use mini mindfulness exercises

Week 4 • Collect Homework sheets • Discuss homework – how like imagery meditation, which position, where and when, which energizing vs. relaxing and when – use mini’s where and when • Sleep exercise – nostril breathing, theory behind the exercise • Walking meditation – how use walking as formal meditation, adjusting to do in public • Review of program & feedback – review each of the types of meditation, what have you gotten the most from, what parts would you like to continue with in the future, what challenges did you find in the program • Keeping the practice going – resources, books, yoga • Homework: o Important to continue with practice until the time of your testing (& why) o Listen to any track of choosing - which ones think will do o Try to notice when you are not being mindful in your daily life and make an effort to bring attention back to the present moment o Continue to use mini mindfulness exercises o Bring homework sheets to testing session!!

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Appendix L

Questionnaire Packet (excluding the SRRS and FFM)

Consent Form Name of Researcher, Faculty, Department, Telephone & Email: Researcher: Brenda Key, M.Sc. Supervisor: Tavis Campbell, Ph.D., Faculty of Social Sciences, Department of Psychology, 220- 7490, [email protected] Title of Project: The Influence of Rumination, Distraction and Mindfulness on Cardiovascular Recovery From Stress

This consent form, a copy of which has been given to you is only part of the process of informed consent. If you want more details about something mentioned here, or information not included here, you should feel free to ask. Please take the time to read this carefully and to understand any accompanying information.

The University of Calgary Conjoint Faculties Research Ethics Board has approved this research study.

Purpose of the Study:

The purpose of this study is to evaluate the association between rumination, distraction and mindfulness and cardiovascular responses to stress.

What Will You Be Asked To Do?

If you agree to participate you will:

Be randomized to one of two possible conditions. In both conditions you will take part in two laboratory assessments five weeks apart.

Each laboratory assessment session is approximately 1.5 hours in length. During the laboratory stress assessment participants will first fill out a questionnaire package. This will take about 30 minutes. Participants will then be instrumented with non-invasive equipment to measure cardiovascular function (e.g. heart rate and blood pressure). This will involve placement of a blood pressure cuff on your arm and recording sensors on

185 either side of the rib cage and neck. All procedures for physiological recording are safe, painless and involve no needles.

Participants will next engage in a standard laboratory stressors task called the public speaking task. For this task participants are asked to speak for five minutes about a recent stressful life event. Following the stress task participants will sit quietly for 15 minutes during which you will listen to an audio recording with simple instructions guiding your attention.

If you are randomized to the first condition in addition to attending the 2 assessment sessions you will also receive a 4-week stress intervention in which you will be asked to attend a 30-minute weekly group session (a total of 4 sessions) that will teach a stress management technique based on mindfulness meditation. You will also be encouraged to practice the stress management techniques that you learn at home for approximately 15 minutes per day. If you are in this condition you will attend your first laboratory stress assessment session prior to the intervention and the second assessment after the completion of the intervention. You are free to withdraw from the intervention and/or the study at anytime without penalty. You will not be requested to disclose any personal information during the group sessions; regardless any discussions that take place during the group session will remain confidential and will not be disclosed outside the group.

Participants in the second condition (who did not receive the stress intervention during the study) will be offered a self-guided (home based) version of the stress intervention following the completion of their second laboratory stress assessment. The self-guided version of the intervention includes an audio CD with instructions and guided exercises as well as an information booklet. You are free to decline the self-guided materials that will be offered to you.

You are free to choose not to participate in this study, without penalty. If you agree to participate in this study, you may withdraw from this study at anytime. Withdrawing from this study will not result in a penalty of any kind. You may also withdraw your authorization for us to use your data at anytime, without penalty.

You may find some of the questions in the questionnaire package or during the laboratory assessment session to be sensitive in nature. You are free to choose not to answer any question, without penalty.

What Type of Personal Information Will Be Collected?

Two general types of research material will be acquired: (1) Non-invasive measures of cardiovascular function (e.g. blood pressure); (2) Questionnaire data of demographic characteristics, psychosocial traits and medical history. All material will be used exclusively for the purposes of this research and will remain confidential.

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What Happens to the Information I Provide?

Participation is completely voluntary, anonymous and confidential. You are free to discontinue participation at any time during the study. All of the data that we collect from you will be identified by code number only (your name will not be on any of the questionnaires or physiological data files that we collect). Data linking participants’ code number and contact information will be stored in a password protected database only accessible by the principal researcher. No one except the research assistant and the principle researcher will be allowed to see any of the answers to questionnaires or other collected data. Only group information will be summarized for any presentation or publication of results. No personally identifiable information will be used in the eventual publication of this study. To ensure confidentiality, all study records will be stored in locked files. This consent form will be stored separately from other study records in a locked file. Information linking your name, contact information and study number (including this informed consent form) will be destroyed after the study is complete. Data collected in this study will be retained for a period of 5 years in a locked cabinet in the Behavioral Medicine Laboratory following which it will be destroyed.

Are there Risks or Benefits if I Participate?

You will be awarded 6 bonus credits for your participation in the following study.

The main goal of this study is to examine cardiovascular responses to a standard laboratory stress task and therefore this task is inherently stressful.

If you experience distress as a result of your participation in this study, we advise you that the university offers a confidential counselling service to all current students. Students may receive three sessions free per academic year. The Counselling Centre is located at MacEwan Student Centre – Room 375 and will accept either walk-in or telephone calls (220-5893) to make an Intake appointment with a counsellor.

Potential benefits include an assessment of cardiovascular functioning including blood pressure. We can provide with some feedback about this if you wish. Additionally, participants will have the opportunity to learn about a stress management technique.

In signing this form, I fully understand that I am participating in this study as part of my educational experience in the Department of Psychology. In exchange for my time, I expect to gain some understanding of research and some ideas currently being explored in Health Psychology. If after the study I feel I have not gained sufficient educational benefit, or have other concerns regarding this experience, I may register my concerns with the Chair of the Psychology Research Participation system, Dr. Glen Bodner. He

187 will insure that my comments are acted upon with no fear that I will be identified personally. Dr. Bodner can be reached at: [email protected]

Signatures (written consent) Your signature on this form indicates that you (1) understand to your satisfaction the information provided to you about your participation in this research project, and (2) agree to participate as a research subject. In no way does this waive your legal rights nor release the investigators, sponsors or involved institutions from their legal and professional responsibilities. You are free to withdraw from this research project at any time. You should feel free to ask for clarification or new information throughout your participation.

Participant’s Name: (please print) ______

Participant’s Signature: ______Date: ______

Researcher’s Name: (please print) ______

Researcher’s Signature: ______Date: ______Questions/Concerns

If you have any further questions or want clarification regarding this research and/or your participation, please contact:

Ms. Brenda Key Department of Psychology/Faculty of Social Sciences [email protected]

And Dr. Tavis Campbell Department of Psychology/Faculty of Social Sciences 220-7490, [email protected]

If you have concerns about the way you’ve been treated as a participant, please contact Bonnie Scherrer, Ethics Resource Officer, Research Services Office, University of Calgary at 403 220-3782; email: [email protected]

A copy of this consent form has been given to you to keep your records and reference. The investigator has also kept a copy of the consent form.

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DEMOGRAPHICS

1. Your date of birth: ______/______/______

Month / Day / Year

2. Are you male or female? O male O female

3. How would you describe your primary racial or ethnic group?

О White, Caucasian О Black, African American О Native American, Eskimo, Aleut O Asian or Pacific Islander O Hispanic, Latino O Other Specify ______

4. What year of study are you in ?

О 1st year of undergraduate О 2nd year of undergraduate О 3rd year of undergraduate O 4th year of undergraduate O 5th year of undergraduate O Other Specify ______

5. What is your major ?

О Psychology O Other Specify ______

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GENERAL HEALTH

Please answer the following questions to the best of your ability.

1. Please list any prescription medications you take regularly or occasionally ______

2. Please describe any major illnesses, health problems or hospitalizations you have had during your adult life. ______

3. Has a doctor ever told you that your blood pressure was high? Yes ______No ______

If yes, please give the date it was found to be high: ______/______/______

4. Have you ever been prescribed medication to lower your blood pressure? Yes ______No ______

If yes, specify drug name ______Are you currently taking any such medication Yes ______No ______

5. Have you had any medical or surgical problems during the last year? Yes ______No ______Please specify ______

6a. Have you ever been diagnosed with Depression or a Depressive disorder (e.g. dysthmia)? No ____ Yes ____

6b. If Yes, what was the specific diagnosis and when were you diagnosed:______

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7a. Have you ever been diagnosed with an Anxiety Disorder? No ____ Yes ____

7b. If Yes, what was the specific diagnosis and when were you diagnosed:______

8. Do you currently have the conditions listed below (check yes, no, or don’t know)

YES NO Don’t Know High blood pressure Chest pains or angina Irregular heart beat (palpitations) Abnormal electrocardiogram (ECG) History of Heart attack History of Stroke/ TIA Any other heart or circulatory problem Diabetes Asthma History of Cancer or current diagnosis Anemia High cholesterol Thyroid disease Depression Anxiety Other mental health disorder Heavy alcohol use Drug dependency Other(s) Please Specify: ______

9a. Do you use illicit recreational drugs (e.g. Marijuana, Stimulants, Narcotics etc.) No ____ Yes ____

9b. If yes, Has your drug use ever caused you work, family or legal problems, etc.? No ____ Yes ____

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9c. If Yes, please explain: ______

10. How many cups of caffeinated beverages (coffee, tea or cola) do you typically consume in an average day ? (check one)

___ None ___ 1 cup ___ 2-3 cups ___ 4-5 cups ___ 6 or more cups

11. How much alcohol (beer, wine and/or liquor) do you consume in a typical day? (check one)

___ None ___ Occasional drink ___ 1-2 drinks ___ 3-4 drinks ___ 5 drinks or more

12. What is your smoking status? (check one)

___ Current smoker ___ Non-smoker (never smoked) Go to next Questionnaire ___ Past smoker (smoked and quit) Go to Question 15

13a. If you are a current smoker, approximately how many cigarettes do you smoke in an average day? _____

13b. What age did you start smoking? _____

13c. How many times have you tried to quit? _____

13d. How many total years have you smoked, subtracting out years you may have quit in- between? _____

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14a. If you are a past smoker, approximately how many cigarettes did you smoke in an average day? _____

14b. What age did you start smoking? ____

14c. What age did you quit smoking? ____

14d. How many total years did you smoke, subtracting out years you may have quit in- between? _____

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INSTRUCTIONS:

Think of this ladder as representing where people stand in the Canada. At the top of the ladder are the people who have the most money, most education, and most respected jobs. At the bottom are the people who have the least money, least education, and least respected jobs or no job. The higher up you are on this ladder, the closer you are to the people at the very top, and the lower you are, the closer you are to the people at the very bottom.

Where would you place yourself on this ladder? Please place an "X" over the circle on the rung where you think you stand at this time in your life, relative to other people in Canada.

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Meditation Experience

1. How would you describe your past experience with meditation?

О I have never meditated О I have meditated once or twice О I meditate infrequently O I meditate monthly O I meditate weekly O I meditate daily O I have meditated regularly in the past but don’t currently Specify when and how often ______

2. What do you know about Mindfulness Meditation?

О I have never heard of mindfulness meditation О I have heard of mindfulness meditation but I don’t know anything about it О I have some general knowledge about mindfulness meditation O I know quite a bit about mindfulness meditation O I have extensive knowledge about mindfulness meditation O Other Specify______

3. Are you interested in learning more about Mindfulness Meditation?

О No, I am NOT interested in learning more about mindfulness meditation О Yes, I am interested in learning more about mindfulness meditation O I maybe interested in learning more about mindfulness meditation If Maybe Please elaborate ______

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BDI-II

This questionnaire consists of 21 groups of statements. Please read each group of statements carefully, and then pick out the one statement in each group that best describes the way you have been feeling during the past two weeks, including today. Circle the number beside the statement that you have picked. If several statements in the groups seem to apply equally well, circle the highest number for that group. Be sure that you do not choose more than one statement for any group including item 16 and item 18.

1. Sadness 6. Punishment Feelings 0 I do not feel sad. 0 I don’t feel I am being punished 1 I feel sad much of the time. 1 I feel I may be punished 2 I am sad all the time. 2 I expect to be punished 3 I am so sad or unhappy that I can’t stand it. 3 I feel I am being punished

2. Pessimism 7. Self-Dislike 0 I am not particularly discouraged about the 0 I feel the same about myself as ever. future 1 I have lost confidence in myself 1 I feel more discouraged about my future 2 I am disappointed in myself than I used to be. 3 I dislike myself 2 I do not expect things to work out for me. 3 I feel my future is hopeless and will only get 8. Self Criticalness worse. 0 I don’t criticize or blame myself more than usual. 3. Past Failure 1 I am more critical of myself than I used to 0 I do not feel like a failure. be. 1 I have failed more than I should have. 2 I criticize myself for all of my faults. 2 As I look back, I see a lot of failures. 3 I blame myself for everything bad that 3 I feel I am a complete failure as a person happens.

4. Loss of Pleasure 9. Suicidal thoughts or Wishes 0 I get as much pleasure as I ever did from the 0 I don’t have any thoughts of killing myself things I enjoy. 1 I have thoughts of killing myself, but I 1 I don’t enjoy things as much as I used to. would not carry them out 2 I get very little pleasure from the things I 2 I would like to kill myself used to enjoy. 3 I would kill myself if I had the chance 3 I can’t get any pleasure from the things I used to enjoy. 10. Crying I don’t cry any more than usual 5. Guilty Feelings I cry more than I used to 0 I don’t feel particularly guilty I cry over every little thing 1 I feel guilty over many things I have done I feel like crying, but I can’t. or should have done. 2 I feel quite guilty most of the time. 3 I feel guilty all of the time

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11. Agitation 17. Irritability 0 I am no more restless or wound up than 0 I am no more irritated now than usual. usual. 1 I more irritable than usual. 1 I feel more restless or wound up than usual. 2 I am much more irritable than usual. 2 I am so restless or agitated that it’s hard to 3 I am irritable all the time. stay still. 3 I am so restless or agitated that I have to 18. Changes in Appetite keep moving or doing something. 0 I have not experienced any change in my appetite. 12. Loss of interest 1a My appetite is somewhat less than usual. 0 I have not lost interest in other people or 1b My appetite is somewhat greater than usual. activities. 2a My appetite is much less than before. 1 I am less interested in other people or things 2b My appetite is much greater than usual. than before. 3a I have no appetite at all. 2 I have lost most of my interest in other 3b I crave food all the time. people or things. 3 It’s hard to get interested in anything. 19. Concentration Difficulty 0 I can concentrate as well as ever. 13. Indecisiveness 1 I can’t concentrate as well as usual. 0 I make decisions about as well as ever. 2 It’s hard to keep my mind on anything 1 I find it more difficult to make decisions for very long. than usual. 3 I find I can’t concentrate on anything. 2 I have much greater difficulty in making decisions than I used to. 20. Tiredness or Fatigue 3 I have trouble making any decisions. 0 I am no more tired or fatigued than usual. 14. Worthlessness 1 I get more tiered or fatigued more easily 0 I do not feel I am worthless. than usual. 1 I don’t consider myself as worthwhile and 2 I am too tired or fatigued to do a lot of useful as I used to. things I used to do. 2 I feel mote worthless as compared to other 3 I am too tired or fatigued to do most of people. the things I used to do. 3 I feel utterly worthless 21. Loss of interest in Sex 15. Loss of Energy 0 I have not noticed and recent change in 0 I have as much energy as ever my interest in sex 1 I have less energy than I used to have. 1 I am less interested in sex than I used to 2 I don’t have enough energy to do very much. be 3 I don’t have enough energy to do anything. 2 I am much less interested in sex now 3 I have lost interest in sex completely 16. Changes in Sleeping Pattern 0 I have not experienced any change in my sleep pattern. 1a I sleep somewhat more than usual 1b I sleep somewhat less than usual. 2a I sleep a lot more than usual. 2b I sleep a lot less than usual. 3a I sleep most of the day. 3b I wake up 1-2 hours early & can’t get back to sleep.

197

C-SOSI

This questionnaire is designed to measure the different ways people respond to stressful situations. The questionnaire contains sets of questions dealing with various physical, psychological and behavioral responses. We are particularly interested in the frequency with which you may have experienced these stress related symptoms during the past week.

Kindly select the frequency with which you may have experienced these symptoms during the past week. Never Infrequently Sometimes Often Very frequently

Stress is often accompanied by a variety of emotions. During the last week, have you felt: 1 Like life is entirely hopeless 0 1 2 3 4 2 Unhappy and depressed 0 1 2 3 4 3 Alone and sad 0 1 2 3 4 4 That worrying gets you down 0 1 2 3 4 5 Like crying easily 0 1 2 3 4 6 That you wished you were dead 0 1 2 3 4 7 Frightening thoughts keep coming back 0 1 2 3 4 8 You suffer from severe nervous exhaustion 0 1 2 3 4

Does it seem: 9 You become mad or anger easily 0 1 2 3 4 When you feel angry, you act angrily toward most 10 0 1 2 3 4 everything 11 You are easily annoyed and irritated 0 1 2 3 4 12 That little things get on your nerves 0 1 2 3 4 13 Angry thoughts about an irritating event keep bothering you 0 1 2 3 4 14 You let little annoyances build up until you just explode 0 1 2 3 4 15 Your anger is so great that you want to strike something 0 1 2 3 4

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Kindly select the frequency with which you may have experienced these symptoms during the past week. Never Infrequently Sometimes Often Very frequently

Muscle tension is a common way of experiencing stress. Have you noticed excessive tension, stiffness, soreness or cramping in the muscles in your: 16 Shoulders 0 1 2 3 4 17 Neck 0 1 2 3 4 18 Back 0 1 2 3 4 19 Jaw 0 1 2 3 4 20 Forehead 0 1 2 3 4 21 Eyes 0 1 2 3 4 22 Hands or arms 0 1 2 3 4 23 Tension headaches 0 1 2 3 4

Have you noticed any of the following symptoms when not exercising: 24 Thumping of your heart 0 1 2 3 4 25 Rapid or racing heart beats 0 1 2 3 4 26 Rapid breathing 0 1 2 3 4 27 Irregular heart beats 0 1 2 3 4 28 Difficult breathing 0 1 2 3 4 29 Pains in your heart of chest 0 1 2 3 4

Do you experience: 30 Difficulty in staying asleep at night 0 1 2 3 4 31 Hot or cold spells 0 1 2 3 4 32 Having to get up in the night to urinate 0 1 2 3 4 33 Sweating excessively even in cold weather 0 1 2 3 4 34 Having to urinate frequently 0 1 2 3 4 35 Early morning awakening 0 1 2 3 4 36 Flushing of your face 0 1 2 3 4

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Kindly select the frequency with which you may have experienced these symptoms during the past week. Never Infrequently Sometimes Often Very frequently

37 Difficulty in falling asleep 0 1 2 3 4 38 Breaking out in cold sweats 0 1 2 3 4

Have you experienced: 39 Feeling faint 0 1 2 3 4 40 Feeling weak and faint 0 1 2 3 4 41 Spells of severe dizziness 0 1 2 3 4 42 Nausea 0 1 2 3 4 43 Blurring of your vision 0 1 2 3 4 44 Severe pains in your stomach 0 1 2 3 4

Does it seem: You must do things very slowly to do them without 45 0 1 2 3 4 mistakes 46 You get directions and orders wrong 0 1 2 3 4 Your thinking gets completely mixed-up when you have to 47 0 1 2 3 4 do things quickly 48 You have difficulty in concentrating 0 1 2 3 4 49 You become suddenly frightened for no good reason 0 1 2 3 4 50 You become so afraid you can't move 0 1 2 3 4

Have you experienced: 51 Colds 0 1 2 3 4 52 Hoarseness 0 1 2 3 4 53 Colds with complications (e.g. Bronchitis) 0 1 2 3 4 54 Nasal stuffiness 0 1 2 3 4 55 Having to clear your throat often 0 1 2 3 4 56 Sinus headaches 0 1 2 3 4

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Brenda Key The Influence of Rumination, Mindfulness and Distraction on Cardiovascular Recovery From Stress Debriefing Form

Thank-you for participating in this study. The purpose of this study was to evaluate the association between different response styles to stress and cardiovascular recovery following stress. We specifically focused on three possible responses to stress: rumination, distraction and mindfulness. Rumination involves going over the stressful event repeatedly in ones mind. Distraction involves focusing attention on events other than the stressor. Mindfulness involves remaining focused on the present moment. Previous research suggests that individuals who ruminate following a stressor tend to have poorer (delayed) cardiovascular recovery following exposure to laboratory stress (i.e. their blood pressure and heart rate take longer to return to pre-stress levels).

In the present study, it was hypothesized that participants who were allowed to ruminate (instructed to let their mind wander) would have poorer cardiovascular recovery compared to individuals who were instructed to remain focused on the present moment (to be mindful) and individuals who were distracted following the laboratory stress task. Additionally, we predicted that participants who took part in the 4-week mindfulness intervention would have improved cardiovascular recovery after completing the program (from laboratory assessment 1 to laboratory assessment 2) and that this improvement in cardiovascular recovery would be greater than the improvement shown by those participants who did not receive the 4-week intervention.

These hypotheses are based on the theory that rumination following stress prolongs and amplifies negative mood and also prolongs and amplifies the physiological arousal that accompanies negative mood. Mindfulness interventions have been shown to decrease ruminative thought processes and also improve mood. Therefore, it was predicted that individuals who were instructed to be mindful following stress and received a mindfulness intervention would have improved cardiovascular recovery from stress.

Your cardiovascular responses will be averaged and pooled together with the responses of other participants to test these ideas. Researchers believe that frequent and prolonged activation of the cardiovascular system may ultimately contribute to the development of sustained high blood pressure among individuals at increased risk by virtue of having predisposing factors such as a family history of high blood pressure. Prolonged activation of the cardiovascular system is thought to be damaging to blood vessel walls and this is the proposed mechanism that links poor cardiovascular recovery with sustained high blood pressure.

If our hypothesis is supported rumination will need to be further evaluated as a risk factor for the development of high blood pressure or alternatively as a factor that explains the link between other risk factors and the development of hypertension. Additionally, the

201 possibility of utilizing mindfulness based stress reduction interventions in order to decrease rumination and improve cardiovascular recovery will also need to be further explored.

I also asked you to fill in some questionnaires that asked about your stress levels, mood, and medical history. These questionnaires will allow me to accurately describe the group of people who participated in the study. Please be assured that this information, along with all other information collected in this study, including cardiovascular data, will be kept confidential. Additionally, any information that you disclosed during the mindfulness intervention will remain confidential.

If you wish, I can give you feedback based on your cardiovascular responses measured during the 2 laboratory stress assessments. This information cannot be used diagnostically to indicate that you have cardiovascular problems, however I can provide you information on whether your cardiovascular recovery improved from the first laboratory assessment to the second. If you are concerned about your cardiovascular functioning, we would encourage you to discuss the matter with your family doctor.

If you were a participant that did not receive the 4-week mindfulness intervention you will be offered a self-guided version of this 4-week intervention. This package will include an audio CD with guided mindfulness exercises as well as an information booklet. If you have any questions about the self-guided intervention please feel free to ask now or contact me at a later date (see contact information below). There is no obligation that you take the self-guided mindfulness intervention materials or that you complete the self-guided intervention.

If after completing this study you feel concerned about your stress levels, please contact your family doctor or make an appointment to speak with a counsellor at the University of Calgary’s Counselling Centre (located at MacEwan Student Centre - Room 375, 220- 5893).

If you have further questions or concerns about this study please feel free to inquire now, if questions arise after you have left please contact me (or my supervisor):

Brenda Key Department of Psychology Graduate student in clinical psychology [email protected]

Supervisor: Dr. Tavis Campbell Department of Psychology [email protected]