Assessing Mindfulness:

The Development of a Bi-Dimensional Measure of Awareness and Acceptance

A Thesis

Submitted to the Faculty

of

Drexel University

by

LeeAnn Cardaciotto

in partial fulfillment of the

requirements for the degree

of

Doctor of Philosophy

August 2005

© Copyright 2005

LeeAnn Cardaciotto. All Rights Reserved.

iiAcknowledgments

Many people have helped me through the process of completing this project. I would

first like to thank my committee chairperson, academic advisor, and mentor, Dr. James Herbert,

for his support, knowledge, and feedback during not only the dissertation process, but my entire

graduate career. I also would like to thank my committee members, Drs. Evan Forman, Michael

Lowe, Stephen Platek, and Ms. Peggy Vogt for their contributions to this project. I am very

grateful for the time and effort the following individuals dedicated to this research: Michael

Filoromo, III, Ethan Moitra, Maria del Mar Cabiya, Victoria Farrow, Melissa Gonzalez, Victoria

Thompson, and Peter Yeomans. Finally, I owe endless gratitude to my parents, Stan and Linda

Cardaciotto, for their unconditional love and encouragement, to Sean Adam for his tireless

assistance, patience, and support, as well as to my family and friends for their confidence and

reassurance.

iiiTable of Contents

LIST OF TABLES ...........................................................................................................vii

LIST OF FIGURES .......................................................................................................... ix

ABSTRACT........................................................................................................................ x

1. INTRODUCTION ....................................................................................................... 1

1.1 The Historical Roots of Mindfulness ................................................................. 1

1.2 Transition of Mindfulness into Psychology ....................................................... 2

1.3 Mindfulness in Clinical Psychology: the “Third Wave” of Behavior Therapy .. 5

1.3.1 “First Wave” of Behavior Therapy: Clinical Applications of the Experimental Analysis of Behavior ............................................ 5

1.3.2 “Second Wave” of Behavior Therapy: Expanded Emphasis on

Cognition .................................................................................... 6

1.3.3 “Third Wave” of Behavior Therapy: Mindfulness-Based Treatments .................................................................................. 7

1.4 Defining Mindfulness ...................................................................................... 11

1.5 Current Conceptualization of Mindfulness in Clinical Psychology ................ 12

1.6 The Relationship of Mindfulness to Meditation .............................................. 17

1.7 Constructs Related to Mindfulness .................................................................. 18

1.7.1 Modes of Mental Processing ..................................................... 18

1.7.2 Forms of Reflexive Consciousness ........................................... 20

1.8 The Relationship Between Mindfulness, Implicit Cognition, and Explicit Cognition ......................................................................................................... 24

1.9 Measures of Mindfulness ................................................................................. 25

1.10 Measures of Constructs Related to Mindfulness ............................................. 27

1.10.1 Measures of Metacognition ...................................................... 27

1.10.2 Measures of Reflexive Consciousness ...................................... 30

1.10.3 Measures of Acceptance ........................................................... 32

iv1.11 Measuring Mindfulness: The Current Study ................................................... 32

1.12 Integrating Awareness and Acceptance ........................................................... 35

1.13 Principal Aims of the Present Study ................................................................ 38

2. STUDY 1 – ITEM GENERATION AND SELECTION .......................................... 40

2.1 Method ............................................................................................................. 40

2.2 Results and Discussion .................................................................................... 41

3. STUDY 2 – FACTOR STRUCTURE AND INTERNAL CONSISTENCY ............ 42

3.1 Method ............................................................................................................. 42

3.1.1 Participants ............................................................................... 42

3.1.2 Measures and Procedure ........................................................... 42

3.2 Results and Discussion .................................................................................... 42

3.2.1 Exploratory Factor Analysis ..................................................... 42

3.2.2 Internal Consistency ................................................................. 43

4. STUDY 3 – VALIDATION ANALYSES WITH A NORMATIVE SAMPLE ....... 46

4.1 Method ............................................................................................................... 46

4.1.1 Participants ............................................................................... 46

4.1.2 Measures and Predictions ......................................................... 46

4.2 Results ............................................................................................................... 50

4.2.1 Measure Descriptives ................................................................ 50

4.2.2 Cross Validation ....................................................................... 51

4.2.3 Exploratory Factor Analysis ..................................................... 52

4.2.4 Internal Consistency ................................................................. 52

4.2.5 Convergent Validity .................................................................. 53

4.2.6 Discriminant Validity ............................................................... 53

4.2.7 Relationship to Measures of Psychopathology ......................... 54

4.3 Discussion .......................................................................................................... 55

v5. STUDY 4 – VALIDATION ANALYSES WITH A CLINICAL SAMPLE ............. 56

5.1 Method ............................................................................................................... 56

5.1.1 Participants ............................................................................... 56

5.1.2 Measures and Predictions ......................................................... 58

5.2 Results ............................................................................................................... 58

5.2.1 Measure Descriptives ................................................................ 58

5.2.2 Internal Consistency ................................................................. 58

5.2.3 Convergent Validity .................................................................. 59

5.2.4 Discriminant Validity ............................................................... 60

5.2.5 Relationship to Measures of Psychopathology ......................... 60

5.2.6 Cross Validation with Student Sample ..................................... 61

5.3 Discussion .......................................................................................................... 62

6. GENERAL DISCUSSION ........................................................................................ 63

6.1 Relationships Between the PHLMS and Other Constructs ............................... 63

6.2 Differences Between the Nonclinical and Clinical Samples ............................. 65

6.3 Implications for a Bi-dimensional Conceptualization of Mindfulness .............. 66

6.4 Clinical Implications .......................................................................................... 68

6.5 Limitations ......................................................................................................... 69

6.6 Directions for Future Research .......................................................................... 71

6.7 Conclusion ......................................................................................................... 71

LIST OF REFERENCES ................................................................................................. 73

APPENDIX A: DEFINITIONS OF MINDFULNESS .................................................... 87

APPENDIX B: MINDFULNESS QUALITIES AS DEFINED BY KABAT-ZINN (1990) ..................................................................................................... 89

APPENDIX C: LIST OF MEASURES OF MINDFULNESS AND RELATED CONSTRUCTS ............................................................................................ 90

APPENDIX D: ILLUSTRATION OF THE FOUR PSYCHOLOGICAL STATES ...... 91

viAPPENDIX E: LIST OF ITEMS AND PROCEDURES ADMINISTERED TO EXPERT JUDGES .................................................................................................... 92

APPENDIX F: LIST OF RETAINED ITEMS AND EXPERT JUDGES’ MEAN RATINGS ........................................................................................................... 98

APPENDIX G: RESULTS FROM DEVELOPMENT SAMPLE ANALYSES .......... 103

APPENDIX H: COPIES OF MEASURES ................................................................... 113

APPENDIX I: RESULTS FROM THE NONCLINICAL SAMPLE ANALYSES ..... 128

APPENDIX J: RESULTS FROM THE CLINICAL SAMPLE ANALYSES .............. 137

APPENDIX K: AN ACCEPTANCE-BASED MODEL OF SOCIAL ANXIETY DISORDER .................................................................................. 146

VITA .............................................................................................................................. 147

viiList of Tables

1. Clinical Definitions of Mindfulness............................................................................87

2. Non-Clinical Definitions of Mindfulness ..................................................................88

3. Mindfulness Qualities Defined by Kabat-Zinn (1990) ..............................................89

4. List of Measures of Mindfulness and Related Constructs .........................................90

5. List of Items and Procedures Administered to Expert Judges ...................................92

6. List of Retained Items and Expert Judge’s Mean Ratings .........................................98

7. Initial Factor Loadings for Items Completed by the Development Sample .............103

8. Initial Corrected Item-Subscale Correlations for Items Completed by the Development Sample ...............................................................................................105

9. Inter-item Correlations from Initial Items Completed by Development Sample......107

10. Descriptive Statistics of the Resulting 20 Items ......................................................108

11. Corrected Item-Subscale Correlations for Resulting 20 Items ................................110

12. Inter-item Correlations for the Resulting 20 Items ..................................................112

13. Copies of Measures ..................................................................................................113

14. PHLMS Descriptive Statistics from the Nonclinical Sample ..................................128

15. Factor Loadings for the PHLMS ..............................................................................130

16. PHLMS Corrected Item-Subscale Correlations from the Nonclinical Sample ........132

17. PHLMS Inter-item Correlations from the Nonclinical Sample ...............................134

18. Convergent Validity: Correlations of the PHLMS With Other Measures from the Nonclinical Sample ..................................................................................................135

19. Correlations of the PHLMS with Well-Being Variables Before and After

Controlling for Other Constructs in a Nonclinical Sample ......................................136

20. Total Number of Clinical Participants Diagnosed With Each Disorder ..................137

21. Descriptive Statistics for the PHLMS from the Clinical Sample .............................139

22. PHLMS Corrected Item-Subscale Correlations from the Clinical Sample ..............141

viii23. PHLMS Inter-item Correlations in the Clinical Sample ...........................................143

24. Convergent Validity: Correlations of the PHLMS With Other Measures in the Clinical Sample ..................................................................................................144

25. Correlations of the PHLMS with Well-Being Variables Before and After Controlling for Other Constructs in a Clinical Sample......................................................................145

ixList of Figures

1. Illustration of Four Psychological States ...........................................................................91 2. An Acceptance-Based Model of Social Anxiety Disorder ..............................................146

xAbstract

Assessing Mindfulness: The Development of a Bi-Dimensional Measure of Awareness and Acceptance

LeeAnn Cardaciotto James D. Herbert, Ph.D.

Mindfulness, a construct that has its roots in Buddhism, has been examined over the past thirty

years in different domains of mainstream psychology. Mindfulness has recently been

incorporated into several innovative psychotherapies as a main component of treatment.

However, there is no widely accepted definition of mindfulness in the field of clinical

psychology, nor has the construct been sufficiently operationalized. Further, there is no measure

to date that assesses the two key components of mindfulness, present-moment awareness and

acceptance. The purpose of this study was to develop a bi-dimensional measure of mindfulness

based on the two key constituents of the construct, present-moment awareness and nonjudgmental

acceptance. The psychometric evidence supports a clear two-factor solution, indicating that the

newly developed Philadelphia Mindfulness Scale (PHLMS) measures mindfulness and its key

constituents, acceptance and awareness. Content validation by expert judges yielded high ratings

of the representation of the components of mindfulness, good internal consistency was

demonstrated in both clinical and nonclinical samples, and relationships with other constructs

were largely as expected within the normative nonclinical samples. Although results from some

of the clinical sample validation analyses were contrary to expectations, significant differences

were found as predicted between the nonclinical and clinical samples. One noteworthy finding

was that the awareness and acceptance subscales were not correlated with each other, suggesting

that the potential role of these two constructs in mental health can be examined independently.

Implications, study limitations, and future directions are discussed.

1CHAPTER 1: INTRODUCTION

The Historical Roots of Mindfulness

Historically, mindfulness has been associated with spiritual movements rather than

mainstream psychology. Mindfulness is a primary technique used in Buddhist meditation, and

has its roots in Buddhism. Buddhism was founded in northern India in 500 B.C. by Siddharta

Gautama Buddha, a religious leader, in reaction to the suffering of poor, sick, aged, and dying

people (Kumar, 2002; Smith, 1986). According to Buddha’s doctrine of the Four Noble Truths,

existence is pervaded with suffering, which is a consequence of the automatic tendency of

attachment; the cessation of suffering can be achieved through the practice of the Eightfold Noble

Path. In the Eightfold Noble Path, Buddha outlined ways individuals could achieve nirvana, a

freedom from unhappiness, which includes understanding and sincerely following Buddhist

philosophy, adhering to moral guidelines concerning speech, conduct, and vocation, disciplining

the mind, and through meditation. The Eightfold Path allowed individuals to engage in the full

experience of life while decreasing the tendency to attach to phenomena (Kumar, 2002).

After Buddha’s death in 483 B.C., Buddhism remained inconsequential until a Mauryan

emperor, Asoka, converted to Buddhism in the 3rd century B.C. As Buddhism began to spread

from India to elsewhere in Asia, it split into different factions based on different interpretations of

Buddha’s teachings. Two main sects, Theravada Buddhism and Mahayana Buddhism, emerged.

Theravada Buddhists conservatively interpreted Buddha’s teachings, concentrated on the

emancipation of the individual based on his efforts, and focused primarily on meditation and

concentration, emphasizing a monastic life removed from society. Mahayana Buddhism was a

more liberal interpretation of the teachings of Buddha that accommodated a greater number of

people, stressing salvation through a life of good works and compassion. Although Theravada

Buddhism spread to Sri Lanka, Thailand, and Burma, and Mahayana Buddhism became popular

in Mongolia, Tibet, China, Japan, Korea, Vietnam, and Nepal, the latter sect spread more rapidly

due to the more liberal interpretation of Buddha’s teachings. Beginning about 150 A.D., trade

2between India and China brought the ideas and practices of Mahayana Buddhism to China

(Encyclopedia Britannica, 2003). By the 5th century, Buddhism became the dominant faith of

China, and it reached a peak by the 7th century. Meanwhile, in the 4th century, Buddhism was

introduced to Korea, and Ch’an, a sect of Chinese Buddhism, became the dominant school there

(Encyclopedia Britannica, 2003). From Korea, Buddhism was brought to Japan between 550 and

600 A.D. by missionaries sent by Korean royalty. By the 8th century, many sects of Buddhism

grew and prospered, and many different sects developed. Zen Buddhism, a sect of Mahayana

Buddhism, was introduced to Japan in the 9th century by Chinese Ch’an Buddhists, and became

popular around 1200 A.D. “Zen” is the Japanese word for the “Ch’an,” which is roughly

translated as “meditation” (Christian-Meyer, 1988). Zen Buddhism emphasizes an attitude of

nonattachment, meditation to develop enhanced self-awareness, focus on the present moment,

which results in a state of psychological freedom from suffering.

Buddhist meditation was made known most widely in the West through Japanese Zen

Buddhism. Immigrants from Asia who traveled to the United States in the 19th century

established communities and temples (Encyclopedia Britannica, 2003). However, when the

concept of Zen reached the United States, its impact was very limited (Smith, 1986). Although

Zen Buddhism was introduced at Chicago’s World’s Fair in 1893 (Benz, 1976; Smith, 1986), it

continued to have little impact on American culture.

Transition of Mindfulness into Psychology

In the 1940s and 1950s, Zen slowly grew in America through popular books, such as Zen

in the Art of Archery (Herrigel, 1953), Zen Buddhism and Psychoanalysis (Suzuki, Fromm, & De

Martino, 1960), and Psychotherapy East and West (Watts, 1961). However, by the late 1950s

and throughout the 1960s, meditation, based in Zen Buddhism, became more noticed through the

writings of major psychotherapists. For example, Jung (1961) made use of meditative symbols in

his writing. Psychotherapists showed interest in meditative techniques (Assagioli, 1965; Boss,

1965; Fingarette, 1963; Fromm, 1960; Stunkard, 1951), with many discussing meditation in

3relationship to psychoanalysis. For example, Zen was thought to be useful because it facilitated

uncovering the unconscious (Smith, 1986). Zen meditation was also viewed as consistent with

psychotherapy due to its emphasis on present-centered awareness, spontaneity, and acceptance

(Smith, 1986). For example, Buddhism placed importance on growth and evolution, causing it to

be embraced by existentialists and humanists in clinical psychology (Kumar, 2002). However, at

this time, the gradual popularization of meditation in psychology resulted in a conglomeration of

diverse Buddhist traditions (e.g., Tibetan Buddhism, Zen Buddhism).

Also during the 1960s through the 1970s, Americans were beginning to “look inward”

and experimented in ways to heighten awareness and broaden the boundaries of consciousness

through means of psychedelic drugs, hypnosis, and parapsychology. Increased attention was paid

to Eastern religion and culture, and meditation eventually caught the interest of experimental

psychologists. Meditation was grouped with dreaming, hypnosis, and psychedelic drugs as a type

of altered state of consciousness, because it was characterized by a qualitative change in the

overall pattern of mental functioning (Tart, 1972). Meditation was found to produce a state of

consciousness that could objectively be measured through electroencephalogram (EEG).

Individuals who meditated showed alpha wave activity associated with restful reductions in

metabolic rate (Anand, Chhina & Singh, 1961; Bagchi & Wenger, 1957), theta waves (e.g., lower

states of arousal associated with sleep) (Kasamatsu & Hirai, 1966), and even some delta activity,

which is typically found in deep sleep and comas (Green, Green, & Walters, 1976). However,

even though experimental psychologists were defining meditation as an altered state of

consciousness, teachers of Zen meditation continued to consider meditation a “consciousness-

raising” rather than a “consciousness-altering” experience (Smith, 1986). Physiological research

provided evidence to support this stance, and delineated two types of meditative states.

Individuals who engaged in concentrative approaches (e.g., Yoga meditators, transcendental

meditation) appeared to be unaware of distractions, as shown by the lack of alpha blocking (i.e.,

the cessation of alpha activity in response to a stimulus) (Anand et al.). Individuals engaging in

4mindfulness approaches (e.g., Zen and mindfulness meditation), however, demonstrated very

brief periods of alpha blocking and did not habituate to distractions, suggesting they experienced

each intrusion as if it was being experienced it for the first time (Kasamatsu & Hirai, 1966).

Individuals who engaged in mindfulness meditation were said to become fully aware of their

environment, calmly experiencing each moment without attachment or distraction. Thus,

mindfulness began to be examined and applied in psychology independent of its historical

Buddhist roots.

Empirical investigation of mindfulness continued, as it began to be examined outside the

domain of experimental psychology. In social psychology, Langer (1989a, 1989b) proposed two

states of being that involved cognitive and affective factors: mindfulness and mindlessness.

According to Langer, mindfulness is the development of a “limber state of mind” (Langer,

1989a, p. 70) that occurs when an individual creates new categories, is open to new information

and novelty, and is aware of more than one perspective (Langer, 1989a). Individuals who are

mindful are situated in the present, sensitive to context and perspective, and are actively drawing

novel distinctions (Langer 1992; Langer 2002). Mindfulness is distinguished from mindlessness,

behavior that occurs out of the habits of expert mastery, is trapped in rigid mind-sets, and is

oblivious to time or context. As mindless occurs with little or no conscious awareness, it often

leads to a single understanding of information and is governed by rule or routine (Langer 1989b;

Langer, 1992; Langer 2002). From Langer’s research, studies have examined mindfulness related

to health, business, and education. Research has examined the consequences of

mindfulness/mindlessness on health in the elderly, and results suggest that mindful conditions

(e.g., increasing control over one’s schedule) are related to decreased adverse health conditions

and increased longevity (for a review, see Langer & Moldoveanu, 2000). Studies of mindfulness

in the business field suggest that increases in mindfulness are related with increased creativity and

decreased burnout (for a review, see Langer & Moldoveanu, 2000). Research examining

mindfulness in educational settings has found that participants in mindful conditions are better

5able to use objects creatively when the need for a novel use of the object arises and demonstrate

increased attention, liking for the task, and improved memory (for a review, see Langer &

Moldoveanu, 2000). In addition, mindfulness has been found to be related to increases in

competence, memory, creativity, and positive affect, and decrease in accidents, human error, and

stress (Langer & Moldoveanu; Langer, 2000).

Mindfulness in Clinical Psychology: The “Third Wave” of Behavior Therapy

By the 1970s, mindfulness, specifically mindfulness meditation, was beginning to be

incorporated in psychotherapy. For example, it was examined in combination with bibliotherapy

(Boorstein, 1983), as an adjunction to psychotherapy in general (Kutz, 1985), and independently

as a short-term psychotherapy (Deatherage, 1975). Although these early endeavors represented

the application of mindfulness techniques in psychotherapy, beginning in the early 1990s several

innovative psychotherapies integrated the discipline of mindfulness, which more closely

resembled its Buddhist roots. These newly developed and promoted treatments emphasized that

present-moment awareness and acceptance are important aspects of mindfulness meditation

(Breslin, Zack, & McMain, 2002), and have been referred to as the “third wave” of behavior

therapy. Behavior therapy roughly can be categorized into three waves or generations that consist

of a set of dominants assumptions and methods.

“First Wave” of Behavior Therapy: Clinical applications of the experimental analysis of

behavior. Behavior therapy (BT), which grew out of the conceptual framework of behaviorism,

had its formal beginnings in the 1950s with simultaneous advances occurring in the United States,

South Africa, & Great Britain (Spiegler & Guevremont, 1993). Clinical traditions that proceeded

BT had a poor link to scientifically established principles, vague specification of interventions,

and weak scientific evidence in support of these interventions (Hayes, 2004). Thus, two features

of BT that distinguished it from existing clinical interventions at the time were the application of

principles from behavior analysis to clinical phenomena and the insistence on the empirical

evaluation of the BT interventions. The application of principles of operant conditioning

6developed by Skinner (1953) and those of classical conditioning by Wolpe (1958) for the

treatment of anxiety guided the development of BT during the 1950s. In the United States,

Lindsley and Ayllon, graduate students of B. F. Skinner at Harvard University, systematically

applied learning principles to change behaviors of psychiatric patients (Spiergler & Guevremont,

1993). In the early 1960s, Ayllon and Azrin, another former graduate student of Skinner,

developed the first comprehensive token economy (Spiergler & Guevremont, 1993). Meanwhile,

in South Africa, Wolpe developed several bedrock behavior therapies, including systematic

desensitization and assertiveness training; Wolpe’s approach focused on replacing maladaptive

responses (i.e., anxiety, avoidance) with more adaptive responses (i.e., relaxation, assertive

behavior). The development of BT in Great Britain was spearheaded by Eysenck, with similar

approaches to that of the United States and South Africa, which were developed independently.

As BT focused directly on problematic behavior, vague concepts and unobservable phenomena

generally were disregarded.

“Second Wave” of Behavior Therapy: Expanded emphasis on cognition. By the late

1960s, behavior therapists increasingly recognized that thoughts and feelings needed to be

addressed for an adequate analysis of and intervention for human problems. However,

associationism and behavior analysis were unable to provide an adequate account of human

language and cognition. As a paradigm shift legitimized cognition as a viable target for clinical

intervention, early cognitive mediational accounts of behavior change (e.g., Bandura, 1969) grew

into the cognitive therapy movements. Three major influences to the second wave of BT have

been identified: 1) the application of basic cognitive psychology constructs to the development of

clinical intervention, 2) the development of behavioral self-control procedures as cognitive

interventions (e.g., Thoresen & Mahoney, 1974), and 3) the emergence of cognitive therapies by

Ellis (1962) and A. T. Beck (1964, 1970), which were developed within a clinical setting rather

than within basic psychology (Craighead & Craighead, 2003). Cognition was addressed from a

clinically relevant point of view, as patients of different diagnostic populations were observed to

7engage in particular styles of cognitive processing. Thus, the new cognitive therapies focused on

the detection, correction, testing, and disputation of irrational or dysfunctional thoughts,

maladaptive cognitive schemas, and faulty information-processing styles. Behavioral principles

were combined with cognitive therapy to form cognitive behavior therapy, aimed at treating

problems related to overt cognition, behavior, and emotion.

“Third Wave” of Behavior Therapy: Mindfulness-based treatments. As previously

stated, the “third wave” of behavior therapy began in the early 1990s with the development of

innovative treatments that emphasize present-moment awareness and acceptance. Hayes (2004)

outlined the following features of this generation of clinical intervention:

Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experimental change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcome. (p. 658)

Treatments within the third wave can be categorized into two groups: interventions that are based

on mindfulness training (i.e., Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive

Therapy), and interventions that include mindfulness as a key component (i.e., Acceptance and

Commitment Therapy, Dialectical Behavior Therapy, Relapse Prevention).

Mindfulness-Based Stress Reduction (MBSR), formerly known as the Stress Reduction

and Relaxation Program (SR-RP; Kabat-Zinn, 1982, 1990), is a group treatment developed for

patients with chronic medical conditions, in which the foundation of the intervention involves

intensive training in mindfulness meditation (Reibel, Greeson, Brainard, & Rosenzweig, 2001).

Participants meet weekly for 2 to 2.5 hours of instruction and practice in mindfulness meditation

skills, coping skills, and discussion of homework assignments. Mindfulness meditation skills

include body scanning, sitting meditation with attention to the sensations of breathing, and Hatha

8Yoga postures, during which individuals are instructed to notice internal experiences but not to

become absorbed in their content (Kabat-Zinn, 1982). MBSR participants spend formal time

each day in mindfulness mediation practice, and eventually perform the moment-to-moment

awareness during daily living (Reibel et al.). MBSR has shown success in treating physical and

related psychological symptoms in individuals with chronic pain (Kabat-Zinn, 1982; Kabat-Zinn,

Lipworth, & Burney, 1985), generalized anxiety and panic disorders (Kabat-Zinn, Massion,

Kristeller, & Peterson, 1992), binge eating disorder (Kristeller & Hallet, 1999), psoriasis (Kabat-

Zinn et al., 1998), fibromyalgia (Kaplan, Goldenberg, & Galvin-Nadeau, 1993), and cancer

(Speca, Carlson, Goodey, & Angen, 2000). In addition, MBSR has led to significant increases in

mental clarity and well-being, as well as a reduction in body tension (Reibel et al.).

Mindfulness-Based Cognitive Therapy (MBCT; Teasdale, Segal, & Williams, 1995;

Segal, Williams, & Teasdale, 2002) was adapted from the SR-RP (Kabat-Zinn, 1982, 1990) to

prevent relapse of major depressive episodes. MBCT combines mindfulness techniques with

elements from cognitive therapy to facilitate a detached view of one’s thoughts, emotions, and

bodily sensations (e.g., “I am not my thoughts”). Thus, the goal of MBCT is to increase

awareness of moment-to-moment experience and bring attention to the present (Williams,

Teasdale, Segal, & Soulsby, 2000). Rather than changing the content of thoughts, MBCT aims to

change the awareness and relationship to thoughts. The attitude of non-judgment and that mental

events are not an aspect of the self is believed to prevent the escalation of the rumination of

negative thoughts (Teasdale et al., 1995). Research supports the use of MBCT, as it has been

found to be related to lower rates of depressive relapse for individuals with three or more

depressive episodes (Teasdale et al., 2000).

Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) was

developed under the premise that psychopathology is associated with attempts to control or avoid

negative thoughts or emotions. ACT teaches skills to decrease experiential avoidance, which

“occurs when a person is unwilling to remain in contact with particular private experiences (e.g.,

9bodily sensations, emotions, thoughts, memories, behavioral dispositions) and takes steps to alter

the form or frequency of these events and the contexts that occasion them” (Hayes et al., 1999, p.

58). Mindfulness increases willingness by enhancing awareness of an observing self, which then

fosters the deliteralization of thoughts and beliefs. Although ACT does not specifically promote

mindfulness as a treatment component or technique, the general approach and specific methods

and exercises are consistent with other mindfulness-based approaches (Baer, 2003). Research has

examined the successful use of ACT for depression (Zettle & Hayes, 1986; Zettle & Raines,

1989), anxiety disorders (Block, 2002; Block & Wulfert, 2000; Hayes, 1987), workplace stress

(Bond & Bruce, 2000), chronic pain (Geiser, 1992), schizophrenia (Bach & Hayes, 2002;

Gaudiano, Dalrymple, & Herbert, 2002), smoking cessation (Gifford, 2002), and substance abuse

(Hayes et al., 2002). In addition, there is evidence that a reduction in the believability of thoughts

occurs for individuals who receive ACT (Bach & Hayes, 2002; Zettle & Raines, 1989).

Dialectical Behavior Therapy (DBT; Linehan, 1993) combines elements of traditional

cognitive-behavioral approaches with Zen philosophy for the treatment of borderline personality

disorder. DBT views dysfunctional behavior as a consequence of an underlying dysfunction of

emotion regulation system, which is associated with negative affect and an inability to modulate

that affect (Linehan, 1993). In DBT, behavior change is fostered in the context of self-

acceptance, and mindfulness is a central strategy used to increase acceptance. Mindfulness,

emphasizing non-judgment and non-evaluation, is believed to function as an exposure strategy

that decreases automatic avoidance of emotion and fear responses (Linehan, 1993). Mindfulness

in DBT is organized somewhat differently in comparison to the other mindfulness-based

psychotherapies, as DBT teaches mindfulness “what” skills (i.e., observe, describe, participate)

and mindfulness “how” skills (i.e., nonjudgmentally, one-mindfully, effectively) (Baer, 2003).

Mindfulness exercises include using imaging to observe thoughts, feelings, and sensations,

observing breath by counting or coordinating with footsteps, and mindful awareness during daily

activities (Baer, 2003). Women diagnosed with borderline personality disorder who received

10DBT have shown a decrease in parasuicidal behaviors, anger, and dissociation, reduced

hospitalization days, and higher treatment retention rates (Linehan, Armstrong, Suarez, Allman,

& Heard, 1991). DBT skills, including mindfulness, have also been applied with success to

bulimia (Telch, Agras, & Linehan, 2000) and substance abuse (Linehan et al., 1999).

Relapse Prevention (RP; Marlatt & Gordon, 1985) is a treatment package designed to

avert relapses in substance abuse. Mindfulness is taught as a technique to cope with urges; for

example, the metaphor of “urge surfing” is used to encourage clients to “ride out” waves and

letting the urge pass without giving into them. In addition, RP uses mindfulness to teach that

urges cannot be eliminated, fostering observation and acceptance of urges (Baer, 2003).

The development of the mindfulness-based treatments marked the merger of the study of

mindfulness in clinical and research domains, as the emphasis on empiricism in behavior therapy

allowed the study of mindfulness to grow within applied and empirical psychology. Within the

past ten years, there has been increased interest in mindfulness in academic clinical psychology.

For example, the “acceptance and commitment therapy” listserv, founded by Stephen Hayes at

the University of Nevada, Reno in 2002, has close to 800 members. The “mindfulness” listserv,

recently established in 2002 by David Fresco at Kent State University, has over 220 members.

The rise in interest in mindfulness is also demonstrated by the formation of a Mindfulness and

Acceptance Special Interest Group (SIG) within the Association of the Advancement of Behavior

Therapy (AABT) in 2002. Over 150 individuals expressed interested in joining the SIG prior to

its creation. In addition, in conducting a PsychInfo database search using “mindfulness” as the

key word, 506 articles have been published since 1977. Of those articles, 76% have been

published within the past 10 years, and 24% have been published within the past year (i.e., 2004-

2005). Thus, the interest in mindfulness and mindfulness-based treatments is clearly growing

rapidly.

11Defining Mindfulness

Although interest in the construct of mindfulness has increased within the past ten years,

research has been hampered by a lack of clear operationalization of mindfulness. The construct

has been defined differently depending on the domain of psychology within which it is used.

Table 1 (Appendix A) lists clinical definitions of mindfulness and Table 2 (Appendix A) lists

nonclinical definitions found after a review of the literature. The nonclinical definitions are

divided into those found in the social psychology literature, and those found within writings

related to philosophy and mindfulness practice.

The clinical and social-psychological definitions have similarities. Both

conceptualizations emphasize flexible awareness in the present. In addition, the social-

psychological definition states that mindfulness is not vigilance or placing attention on a single

stimulus or object (Langer, 2002), which is similar to the clinical stance. However, there are

several ways in which the clinical conceptualization of mindfulness is distinct from the

nonclinical conceptualization. Unrelated historical and cultural backgrounds during the

development of the construct have resulted in differences in the definition and application of

mindfulness. Whereas the social-psychological perspective of mindfulness focuses only on the

cognitive processes of only what is occurring in the external environment, the clinical

mindfulness approach involves both stimuli internal and external to the individual. The social-

psychological applications are taught to increase learning and creativity, whereas the clinical

conceptualization of mindfulness has generally been applied to help individuals cope with

unpleasant or distressing experiences. Lastly, the social-psychological perspective does not

include the component of non-judgment emphasized in clinical perspective. Since there are

differences in the context in which the conceptualizations were developed, differences in

application, and they do not share key components in the definition, the current study will only

focus on the clinical conceptualization of mindfulness.

12Current Conceptualization of Mindfulness in Clinical Psychology

The clinical definitions of mindfulness are most similar to the Buddhist tradition, as

modern Western descriptions have generally remained consistent with Buddhist

conceptualizations (Bishop, 2002). In Satipatthana, or mindfulness, the mind is receptive and

registers what is observed (Goleman, 1978). Mindfulness in the Buddhist tradition has been

referred to as “bare attention,” or a non-discursive registering of events without reaction or

mental evaluation, which emphasizes the process of sustained attention rather than the content to

what is attended (Thera, 1972). Among Western descriptions in clinical psychology, the

definition or a variation of the definition of mindfulness provided by Kabat-Zinn (1990, 1994) is

most frequently cited (See Table 1, Appendix A). Kabat-Zinn (1990) enhanced the Buddhist

conceptualization of mindfulness by defining seven “mindfulness qualities” that refer to how one

attends to information during mindfulness. Shapiro, Schwartz, and Bonner (1998) elaborated the

list with five additional qualities, yielding a total of twelve mindfulness qualities: nonjudging,

nonstriving, acceptance, patience, trust, openness, letting go, gentleness, generosity, empathy,

gratitude, and loving kindness. The latter qualities added by Shapiro et al. were added to address

the affective qualities of mindfulness. See Appendix B for a list of the 12 qualities, excerpted

from Shapiro and Schwartz (2000).

Examination of Table 1 reveals that most of the definitions of mindfulness include

“present-moment awareness” as a component. Awareness is characterized as a continuous

monitoring of inner events and is the means by which humans observe (Deikman, 1996). It is

described as conscious awareness to one’s internal and/or external environment, which is placed

on present-moment experience, rather than past or future events (Roemer & Orsillo, 2003).

Attention is another state of consciousness that is related to awareness, defined as a heightened

sensitivity to a limited range of experience (Kosslyn & Rosenberg, 2001). Attention has been

associated with higher-quality moment-to-moment experiences. For example, increased attention

on the sensory experience of eating chocolate was related to higher ratings of pleasure (LeBel &

13Dube, 2001). However, enhanced attention also appears to have a dark side. Higher levels of

present-moment attention have been associated with higher levels of mood disturbance and stress

(Brown & Ryan, 2003). Further, the literature documents a positive relationship between

heightened attention to the self and negative mood states and even clinical disorders. For

example, self-focused attention may be associated with clinical levels of depression (Ingram,

Lumry, Cruet, & Sieber, 1987), test anxiety (Carver, Peterson, Follansbee, & Scheier, 1983;

Slapion & Carver, 1981), social anxiety (Hope & Heimberg, 1988), and alcohol consumption

(Hull, 1981; Hull, Levenson, Young, & Sher, 1983). Although mindfulness has been

characterized as a “regulation of attention (Astin, 1997, p. 100), the term awareness is more

accurate with regard to mindfulness. Attention is a heightened sensitivity to a restricted amount

of experience, which implies that experience outside of attention is ignored or disregarded.

Awareness is more consistent with mindfulness, since it is the continuous monitoring of all

experience.

In addition to present-moment awareness, how one is aware may also have consequences

for health and well-being. The second component of mindfulness is the way in which present-

moment awareness is conducted: nonjudgmentally, with an attitude of acceptance or compassion

toward one’s experience. Acceptance has been defined as “experiencing events fully and without

defense, as they are (Hayes, 1994, p. 30), during which one is open to the reality of the present

moment without being in a state of belief or disbelief (Roemer & Orsillo, 2003). During an

acceptance stance, one inhibits judgment, interpretation, and/or elaboration of internal events, and

makes no attempt to change, avoid, or escape from the internal experience (Bishop, 2002).

Acceptance as a component of mindfulness is in line with Buddhist tradition, as the Buddha

described the cessation of suffering as “giving up, renouncing, relinquishing, detaching”

(Dhammacakka Sutta, as cited in Hayes, 2002b). Acceptance in this context should not be

confused with passivity or resignation; instead, it is being present, rather than preoccupied, with

private events as they occur (Breslin et al., 2002). There is strong evidence for the negative

14consequences of stimuli that are deliberately ignored or avoided (i.e., through suppression,

distraction, or cognitive reframing). For example, thought suppression has been found to be

associated with heightened pain experience (Sullivan, Rouse, Bishop, & Johnston, 1997), and

suppression of urges to engage in alcohol consumption is related to increases in the expected

reinforcing effect of alcohol by heavy drinkers (Palfai, Monti, Colby, & Rohsenow, 1997). In

addition, thought suppression has been implicated in the etiology and/or maintenance of

depression, generalized anxiety disorder, specific phobia, posttraumatic stress disorder, and

obsessive-compulsive disorder (Purdon, 1999). In contrast, acceptance allows for the increased

contact of internal stimuli. Increased acceptance often appears to have paradoxical effects: “as

one gives up on trying to be different one immediately becomes different in a very profound way”

(Hayes, 1994, p. 20).

Acceptance appears to be most applicable to negative experiences or internal phenomena

(i.e., thoughts, feelings, memories, physical sensations). Although the absence of acceptance is

related to the presence of negative affect or experiences, research contradicts the tautology of

these constructs. For example, research has shown a decrease in stress and increase in the

propensity for innovation mediated by post-treatment experiential avoidance (i.e., acceptance)

scores (Bond & Bruce, 2000), a decrease in depression only following an increase in acceptance

(e.g., Hayes, 2005), and better outcomes following treatment for smoking cessation mediated by

psychological avoidance (Gifford et al., 2004). Thus, although the absence of acceptance and

negative private experiences are correlated, they are distinct constructs.

Although most descriptions of mindfulness reflect the components of awareness and

nonjudgmental acceptance, the distinction between the two is generally not emphasized. In fact,

Brown and Ryan (2003, 2004) argue on both theoretical and empirical grounds that the

acceptance component of mindfulness is redundant with the awareness component. It is often

assumed that increased present-focused awareness will necessarily occur with an attitude of

enhanced acceptance, and conversely that enhancing one’s stance of nonjudgmental acceptance

15will necessarily lead to increased awareness. However, the degree to which changes in either

component tend to impact changes in the other is an open question, and it should not be assumed

that the two components are inextricably linked. For example, high levels of awareness need not

be accompanied by high levels of acceptance. Research demonstrates that panic disorder is

associated with increased awareness of internal physiological cues (e.g., Ehlers & Breuer, 1992,

1996), but this awareness is not accepted nonjudgmentally. Conversely, one can adopt a highly

accepting perspective without necessarily being highly aware of ongoing experience.

Mindfulness has been shown to be related to symptom reduction and increased well-

being for individuals who receive a mindfulness-based treatment or mindfulness training. Several

mechanisms that lead to clinical change have been proposed. Mindfulness has been equated with

interoceptive exposure. Sustained, nonjudgmental awareness to uncomfortable private events in

the moment (e.g., thoughts, negative affect, physical sensations) may lead to desensitization

(Baer, 2003; Breslin et al., 2002; Hayes & Wilson, 2003). Prolonged observation of

uncomfortable private events over time may then encourage reduced emotional avoidance of

previously untolerated internal stimuli. Another proposed mechanism of action of mindfulness is

with regard to the relationship to internal stimuli. Research has suggested that people

automatically evaluate most if not all external stimuli immediately upon presentation (i.e., 250 ms

or less) without awareness or intention (Bargh & Ferguson, 2000). Similarly, thoughts and

feelings are considered to be experienced automatically or nonvolitionally, controlled by

processes that lie outside of awareness (Kirsch & Lynn, 1999). For these reasons, mindfulness

may lead to increased well-being by changing the relationship or perspective to one’s internal

processes, since they may not be able to be controlled. Referred to as “cognitive distancing,”

“deliteralization” (Hayes et al., 1999), or “decentered perspective” (Teasdale et al., 1995), during

mindfulness, thoughts are objectively viewed as “just thoughts” rather than as necessarily truths

or reality of the self. In addition, mindfulness may be a form of response substitution. The new

response, approaching situations with objective awareness, may cause the situation not to have

16inherent value, resulting in decreased emotional reactivity (Bishop, 2002). Lastly, mindfulness

may allow for the training of a new conditioned response (i.e., present-moment nonjudgmental

awareness) to cues of negative internal experiences, allowing for the extinction of the old

conditioned response of avoidance (Breslin et al.).

Regardless of the mechanism of action, several positive consequences of mindfulness

have been documented. As previously mentioned, symptom reduction has been noted for

individuals who received a mindfulness-based treatment. Mindfulness appears to interrupt cycles

of negative internal experiences, such as anticipatory anxiety of a future event, or rumination of a

past event. Beliefs, regarded as habits of thinking, feeling, and perceiving (Tart, 1994), determine

the manner in which one observes the external environment; mindfulness allows one to observe

beliefs and their potential consequences without accepting them as truth. As a result, an

increased range of responses become available, as habitual ways of responding are replaced with

intentional ways of responding that are chosen rather than automatically enacted (Hayes, 2002a;

Roemer & Orsillo, 2002; Breslin et al., 2002). For example, mindfulness may disrupt the flight-

or-fight reaction in anxiety-provoking situations, allowing for effective response rather than fear

or panic (Miller, Fletcher, & Kabat-Zinn, 1995). This may allow for the ability to engage in a

variety of coping responses, better control of attention needed for demanding tasks, or an increase

in feelings of self-efficacy and perceived control (Baer, 2003; Breslin et al., 2002; Trunnel,

White, Cederquist & Braza 1996). Although the purpose of mindfulness is not to induce

relaxation, nonjudgmental observation of physiological arousal or negative internal events may

evoke relaxation. Mindfulness may also lead to the focus on the process or intrinsic qualities of

an activity, allowing for the increase of pleasure experienced during an activity and a decrease of

negative mood associated with failing to achieve the extrinsic outcome (Borkovec, 2002).

Davidson and colleagues (2003) report that mindfulness meditation produces brain activation in a

region typically associated with positive affect, and beneficial effects of immune functioning. In

addition, Carlson, Speca, Patel, and Goodey (2003) found significant improvements in quality of

17life, symptoms of stress, and sleep quality in breast and prostate cancer patients after participation

in a mindfulness-based stress reduction program. Finally, there may be an evolutionary adaptive

value of nonjudgmental awareness on the present moment:

We are hard wired to process internal (e.g., primary emotional) and external information for use in our adaptation to our environments and in facilitation of our survival…It makes sense, then, that my prime directive as a living organism is to accurately process new information as it becomes available to me. The only real information that is available is that which exists in the present moment. When I am paying attention to this information, I do not have to judge it, categorize it, memorize it, or think about how I might use it in the future. I merely pay attention to it; my information processing systems will handle the rest. The information will be stored in memory, and when a future event occurs in the present, I can trust that an adequate, adaptive response will be elicited, because this is precisely what these systems were designed to do. (Borkovec, 2002, p. 78)

The Relationship of Mindfulness to Meditation

The terms “mindfulness” and “mindfulness meditation” are often used interchangeably.

Part of the confusion arises from the lack of operationalization of mindfulness, as some

definitions characterize it as a method or technique and others as a process. Mindfulness

meditation, also referred to as satipatana vipassana, awareness meditation, or insight meditation,

has similar roots to mindfulness in Mahayana Buddhism, (Kabat-Zinn, 1984). However,

mindfulness has been distinguished from mindfulness meditation, in that the latter is the practice

which emphasizes present-moment detached observation of a constantly changing field of

objects. Mindfulness meditation involves the development of a “watcher self” (Deatherage,

1975) and regularly setting time to practice being mindful (Robins, 2002). During mindfulness

meditation, one attends to breath and body sensations, and brings an attitude of acceptance to any

distraction that might occur (Breslin et al., 2002). As attention becomes stable, the practioner

allows the field of objects to expand to include all physical and mental events (e.g., thoughts,

memories, images, body sensations) as they occur in the moment (Kabat-Zinn, 1984). Thus,

mindfulness meditation is one technique or method that may increase the psychological state

described as mindfulness.

18 Mindfulness has also been distinguished from concentration-based meditation approaches

(e.g., Transcendental Meditation, relaxation meditation, Raj Yogi, samatha meditation) by the

way that the nature of attention and distraction is viewed. Although concentration-based

approaches have roots in Theravada Buddhism (Gunaratana, 1991), individuals engaging in

concentration-based approaches restrict the focus of attention to a single stimulus (e.g., a mantra,

sound, object, sensation, breathing process), and if attention drifts or is distracted, attention is

redirected to the object of focus (Baer, 2003; Logsdon-Conradsen, 2002). It is described as a

“forced” practice (Gunaratana, 1991). In contrast, observation during mindfulness practice

involves observation of the range of internal and/or external stimuli in one’s immediate

awareness (Baer, 2003; Logsdon-Conradsen, 2002), and “brings an attitude of acceptance to the

inevitable distractions that occur” (Breslin et al., 2002, p. 280). There is evidence that

concentration-based and mindfulness-based approaches are distinct processes. For example,

mindfulness practioners significantly outperformed concentrative practioners in the ability to pay

attention when unconditioned stimuli were presented (Logsdon-Conradsen, 2002). Thus, whereas

concentration-based meditation emphasizes controlling the focus of attention, a mindfulness

approach promotes opening the range of awareness.

Constructs Related to Mindfulness

As just discussed, other terms such as “mindfulness meditation” are often

interchangeably used with mindfulness. Further, several constructs appear to be related to

mindfulness. These constructs have been divided into two categories: modes of mental

processing and “reflexive consciousness” (i.e., the type and extent of knowledge about one’s self;

Baumeister, 1999).

Modes of mental processing. Mindfulness has been distinguished from other modes of

mental processing, specifically awareness, attention, cognition, and metacognitive processes.

Awareness, one component of consciousness, has been defined as the continuous monitoring of

inner events and the outer environment (Brown & Ryan, 2003). Attention, another component of

19consciousness, is the process of providing heightened sensitivity to a limited range of experience

(Kosslyn & Rosenberg, 2001). One type of mental process that one can be conscious of is

cognition, or the subjective experiences that one can know or become aware of, including all

mental or psychological experiences or states of which one can be conscious (Toneatto, 2002).

Related to mindfulness, Buddhism differentiates between perceptual cognition, the way events

inside and outside the body present to awareness, and conceptual cognition, the internal

experiences that co-emerge with perceptual cognition that can be descriptive (e.g., “that is a

noise”), analytic (e.g., “that is a loud noise”) or judgmental (e.g., “that is an annoying noise”)

(Toneatto, 2002). The latter type of cognition is most related to metacognitive processes.

Although awareness, attention, and cognition are clearly defined, the distinction between

metacognitive processes is not as apparent. Metacognition has been defined in multiple ways,

including the “beliefs and attitudes held about cognition” (Toneatto, 2002, p. 73); cognition about

cognition (Flavell & Ross, 1981); an active and reflective process that is focused toward one’s

cognitive activity (Allen & Armour-Thomas, 1991); and cognitive activity in which other

cognitive activities are the target of reflection (i.e., thinking about thinking) (Yussen, 1985). A

distinction has been made between metacognitive knowledge, factual knowledge that the content

of thoughts do not always correspond to the state of the world, and metacognitive insight, actually

experiencing thoughts as mental phenomena in the moment they occur (Teasdale, 1999; Teasdale

et al., 2002). Metacognitive awareness, classified as a type of metacognitive insight, is the extent

to which thoughts are experienced as mental events rather than as aspects of the self or direct

reflections of truth (Teasdale et al.). Further, metacognitive belief is the extent to which

individuals believe particular thoughts about one’s own cognitions are true.

Further complicating the operationalization of the different modes of mental processing is

that these terms are often used interchangeably. For example, Teasdale et al. (2002) write,

“metacognitive insight (awareness) refers to actually experiencing thoughts as thoughts (that is,

as events in the mind rather than as direct readouts on reality) in the moment they occur” (p. 286).

20By using both terms, the distinction between them is blurred. In addition, the definition of one

mode of mental processing is often used to define another. For example, whereas awareness was

earlier defined as the continuous monitoring of inner and outer environments, awareness has also

been defined in the mindfulness literature as, “the ability of the human mind to distinguish

cognition (e.g., thinking, feeling) from cognizing (e.g., to know that one is feeling or thinking)”

(Toneatto, 2002, p. 73); the latter definition closely resembles the definition of metacognitive

knowledge and metacognitive insight. The definitions of some of these terms have also been

domain-specific; for example, metacognition has been defined in relationship to

psychopathology, as “an awareness of how cognition contributes to depression” (Teasdale et al.,

p. 286). Metacognitive processing appears to be related to mindfulness. Mindfulness has been

described as a “kind of meta-cognitive ability in which the participant has the capacity to observe

his or her own mental processes” (Bishop, 2002, p. 74). However, as previously discussed,

mindfulness is the combination of present-moment awareness and acceptance of internal

experiences, rather than simply the ability to observe one’s mental processes.

Forms of reflexive consciousness. One of the earliest examinations of the monitoring of

behavior and internal states is with regard to self-monitoring, or the “self-observation and self-

control guided by situational cues to social appropriateness” (Synder, 1974, p. 526). Synder

outlined potential goals of self-monitoring, including to communicate accurately one’s emotional

state, to communicate an emotional state that may not be accurate with one’s experienced

emotional state, to conceal an inappropriate emotional state and appear unresponsive or to be

experiencing an appropriate emotional state. Synder depicted the self-monitoring individual as

one who is sensitive to the expression and self-presentation of others and one who uses these cues

as guidelines when monitoring his/her own self-presentation.

A more modern reference to self-monitoring from the behavior therapy literature is with

regard to the therapeutic assessment procedure of noticing actions, thoughts, or feelings by a

client in a naturalistic setting (Korotitsch & Nelson-Gray, 1999). Self-monitoring procedures are

21used for diagnostic assessment, to conduct a functional assessment, to select target behaviors for

treatment, and to monitor treatment (Korotitsch & Nelson-Gray, 1999). Self-monitoring

procedures have also been used as a cognitive-behavioral intervention, such as in daily food

records in treating bulimia (Agras & Apple, 1997) and worry records in treating generalized

anxiety disorder (Craske, Barlow, & O’Leary, 1992), due to the potential reactive effects (i.e.,

change in the frequency of a target behavior that is a result of the self-monitoring procedure).

Related to Synder’s (1974) construct of self-monitoring, self-awareness theory (Duval &

Wicklund, 1972) makes the distinction between attention directed inward toward the self and

attention directed outward toward the environment (Fenigstein, 1997). Three constructs have

been derived from self-awareness theory: self-awareness, self-consciousness, and self-focused

attention. The construct of self-awareness is described as a psychological state in which “the

existence of self-directed attention as a result of transient situational variables, chronic

dispositions, or both” (Fenigstein, Scheier, & Buss, 1975, p. 522). A distinction has been drawn

between private self-awareness, awareness of oneself from a personal perspective, and public

self-awareness, the awareness of oneself from the imagined perspective of others (Fejfar &

Hoyle, 2000). In contrast to self-awareness, a psychological state, trait differences in self

attention are referred to as self-consciousness or “the consistent tendency of persons to direct

attention inward or outward” (Fenigstein et al., 1975, p. 522). Self-consciousness has two

independent dimensions: private self-consciousness, the tendency to be aware of internal thoughts

and feelings, and public self-consciousness, the tendency to be cognizant in the outward display

of the self and reactions of others to the self (Fenigstein et al.). Increased private self-

consciousness has been found to be related to increased awareness of thoughts and feelings,

experience of bodily sensations, and affective reactivity to private events (Fenigstein, 1997).

However, critics of the Fenigstein et al. conceptualization of private self-consciousness have

argued that it is composed of two factors, self-reflectiveness and internal state awareness

(Anderson & Bohon, 1996). Self-reflectiveness has been found to correlate positively with

22measures of negative affect and neuroticism, whereas internal state awareness does not correlate

or correlates negatively (Trapnell & Campbell, 1999). The constructs of rumination (i.e.,

neurotic self-attentiveness) and reflection (i.e., intellectual self-attentiveness) have also been

delineated as separate components of private self-consciousness (Trapnell & Campbell, 1999).

Rumination, correlated with measures of neuroticism, is thought to be motivated by perceived

threats, loss, or injustices to the self, whereas reflection, associated with the dimension of

openness, is self-attentiveness motivated in curiosity or interest in the self (Trapnell & Campbell,

1999). Private self-consciousness has also been conceptualized as comprising of self-reflection

and insight (Grant, Franklin, & Langford, 2002). The third construct derived from self-awareness

theory is the construct of self-focused attention, which has been described as an awareness of

internally generated information (Ingram, 1990).

Related to self-focused attention is the construct of absorption. Tellegen & Atkinson

(1974), in investigating correlates of hypnotic suggestibility, termed absorption as the “full

commitment of available perceptual, motoric, imaginative and ideational resources to a unified

representation of the attentional object” (Tellegen & Atkinson, 1974, p 274). They proposed that

this state of “total attention” is related to a heightened sense of reality to a focal object, decreased

distraction by external events, and an altered sense of reality and sense of self. Self-absorption,

or maladaptive self-focused attention, involves excessive, sustained and rigid attention to internal

information (Ingram, 1990).

Deikman (1982) described an observing self, or the center of all experience. When the

observing self is removed from the contents of consciousness, we are better able to “locate

ourselves in the observer instead of the contents—those patterns of emotions, thoughts, and

fantasies responsible for our pain” (Deikman, 1982, p. 99). Similarly, self-observation is defined

as “the conscious reflection and interpretation of one’s temporal stream of sensation, emotion,

and thought” (Horowitz, 2002, p. 115). Self-observation is thought to be adaptive, as it reduces

23the intensity of affect, obsessive thinking, and automatic response patterns (Deikman, 1982), and

aids in the ability to think more broadly and openly (Horowitz, 2002).

With regard to how one observes the self, Deikman (1982) defined the term

deautomatization as “an undoing of the automatic processes that control perception and

cognition” (p. 137). Through deautomatization, one disindentifies with automatic sequences,

which leads to a decrease in their impact and increased ability to choose an appropriate response.

Related to deautomatization, Safran & Segal (1990) have defined deautomization as the slowing

down a habitual mode of perceptual processing and increasing attention to details that would

otherwise not be processed, and decentering, changing the nature of one’s experience by having

the capacity to observe oneself and stepping out of one’s immediate experience.

Self-regulation, another construct regarding how one processes information about the

self, is the process by which a system regulates itself to achieve specific goals (Schwartz, 1984).

An engineering concept applied to living organisms, it was later expanded from automatic

response to include conscious self-regulation (Shapiro & Schwartz, 2000). Based on positive and

negative feedback loops, during conscious attentional self-regulation, bringing something to

conscious attention amplifies the feedback, which then leads to subsequent self-regulation

(Shapiro & Schwartz, 2000). Negative feedback loops lead to homeostasis, whereas positive

feedback loops lead to change, growth, or development (Shapiro & Schwartz, 1999). Techniques

that have been used to develop self-regulation include meditation, biofeedback, guided imagery,

progressive muscle relaxation, and exercise (Shapiro & Schwartz, 1999; Shapiro & Schwartz,

2000). Thus, self-regulation is the process by which a system preserves stability of functioning

and allows for flexibility in novel situations (Schwartz, 1984). Self-regulation is taught with the

goal of disease reduction and health enhancement by having individuals attend to themselves

(Shapiro & Schwartz, 1999).

Similar to the concept of self-regulation, Deci & Ryan (1980) developed a theory of self-

determination, which posits that behaviors are selected on the basis of conscious motives based

24on the evaluation of an anticipated outcome to provide the greatest satisfaction of those motives

that are salient at that time. According to this theory, individuals choose outcomes that are going

to satisfy the most conscious motives given the constraints of the situation. Distinguished from

automatic “mindless” behavior, self-determination is equated with “mindful” behavior (Deci &

Ryan, 1980, p. 42) due to the conscious enactment of behaviors consistent with one’s needs,

values, and interests.

Much of the literature regarding consciousness, awareness, and attention of the self is

focused on reflexive consciousness, which examines the type and extent of one’s knowledge

about the self. However, mindfulness differs from the constructs categorized as ‘reflexive

consciousness’ in various ways. Although mindfulness involves self-focused attention, the

attention is directed to develop a perspective on mental events allowing one to observe mental

events rather than the mental events being a part of oneself. Several of the constructs of reflexive

consciousness (e.g., self-monitoring, self-consciousness, self-awareness) are with regard to the

evaluation, scrutiny, or concern about the self, whereas the self-focus of mindfulness is by

definition nonevaluative. Similarly, increases in reflexive self-consciousness have been

associated with negative consequences and decreases in well-being, whereas mindfulness is

associated with and has predicted positive well-being and reduced disturbance (Brown & Ryan,

2003). Finally, mindfulness does not necessarily involve complete immersion in experience

characteristic of constructs such as absorption; instead mindfulness entails the observation of

experience in a detached way.

The Relationship Between Mindfulness, Implicit Cognition, and Explicit Cognition

The term “implicit cognitive processing” includes implicit cognition and other automatic

processes and is distinguished from more explicit cognitive phenomena that involve certain

functions of consciousness. The implicit-explicit distinction has also been referred to as unaware-

aware, unconscious-conscious, intuitive-analytic, direct-indirect, procedural-declarative, and

automatic-controlled (Greenwald & Banaji, 1995). The identifying feature of implicit cognition

25is that past experience influences responses even when it is not remembered or known by the

individual. Further, unlike explicit or conscious cognition, implicit cognition cannot be assessed

by self-report or introspection. A large body of research has shown that implicit cognitive

processes may impact behavior or elicit negative emotion, even when the individual is not aware

of this influence or is not deliberately attempting to utilize this information (Palfai & Wagner,

2004). Within clinical psychology, one of the key treatment goals in cognitive therapy is to help

patients identify their automatic processing strategies and replace them with deliberate ones,

breaking dysfunctional cognitive-interpersonal cycles. Thus, through psychoeducation, thought

monitoring, and challenging maladaptive thinking, patients become aware of their automatic

dysfunctional thought patterns and break the automatic association between cues and responses.

The intention of cognitive therapy is to influence implicit cognitions by addressing explicit

cognitions and changing behavior, although the degree to which one can actually change implicit

cognitions in this manner remains unclear. Although research has not examined the relationship

between mindfulness and implicit cognition, one could argue that the goal of mindfulness

techniques would not be to target implicit processes directly; instead, mindfulness exercises are

implemented to detach from explicit cognition or negative affect, which can then allow an

individual to act in a manner that is more consistent with his goals. However, unlike traditional

cognitive and cognitive behavior therapies that aim to change the content of explicit cognition,

the goal of mindfulness techniques simply is simply to observe conscious phenomena with a

stance of acceptance. Further, increasing mindfulness is in the service of behavior change, which

may then change implicit cognitive processes.

Measures of Mindfulness

Several instruments for assessing mindfulness recently have become available; see

Appendix C for a list of measures with abbreviated descriptions of the measures described below.

The Freiburg Mindfulness Inventory (FMI; Buchheld, Grossman, & Walach, 2001) was

developed with individuals in mindfulness meditation retreats, and assesses nonjudgmental

26present-moment observation and openness to negative experience. It consists of 30 items rated

according to how frequent each item has been experienced during a specific previous timeframe.

Items are rated on a 4-point Likert scale (i.e., ‘almost never’, ‘occasionally’, ‘fairly often’,

‘almost always’), and higher scores indicate higher mindfulness. Although four factors were

initially produced (i.e., attention to the present moment without personal identification with the

experience at hand; nonjudgmental attitude toward self and others; openness to one’s own

negative and positive perceptions, sensations, mood states, emotions, and thoughts; insightful

understanding of experience at a general level), the factor structure was unstable with time, and

data indicated the presence of a single factor. The FMI showed good internal consistency before

and after completion of a meditation retreat. Despite its adequate psychometric properties, the

FMI was designed only for use with individuals who have had prior exposure to the practice of

mindfulness meditation, and the authors note that some items’ meanings may not be clear to those

without meditation experience.

The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) was designed to

measure mindfulness or the “present-centered attention-awareness” (Brown & Ryan, 2003, p.

824). It consists of 15 items rated on a 6-point Likert scale (1 = almost always; 6 = almost

never), and higher scores indicate greater mindfulness. Items are distributed across cognitive,

emotional, interpersonal, physical, and general domains, and reflect an indirect approach (i.e.,

with higher scores reflecting lower mindfulness) to the assessment of mindfulness. For example,

items include, “I break or spill things because of carelessness, not paying attention, or thinking of

something else” and “I find it difficult to stay focused on what’s happening in the present,” which

are characteristic of mindless rather than mindful states. The MAAS was found to be a reliable

instrument for college-aged and general-adult populations, to discriminate between practitioners

and non-practitioners of mindfulness, and to predict well-being outcomes. Even though the

authors described mindfulness as having “an open receptivity to the present” (Brown & Ryan,

2003, p. 844) and having a foundation that “is perceptual and nonevaluative” (Brown & Ryan,

272003, p. 843), both of which imply an attitude of non-judgment, the MAAS only assesses the

present-moment attention and awareness component of mindfulness, and the authors explicitly

stated that items containing attitudinal components (e.g., acceptance) were excluded.

The Toronto Mindfulness Scale (TMS; Bishop et al., 2003) was created to assess the

attainment of a mindful state immediately following a meditation exercise. It consists of a single

factor describing a state of heightened awareness of bodily sensations, thoughts and feelings, as

well an observational stance characterized by curiosity, acceptance and experiential openness.

The TMS consists of 10 items that are rated on a 5-point Likert scale, and individuals rate the

degree to which the item describes what was just experienced (0 = not at all, 4 = very much).

Higher scores indicate higher levels of mindfulness. Items are worded in the past-tense to reflect

what was just experienced. For example, items include “I remained open to whatever thoughts

and feelings I was experiencing,” “I found myself observing unpleasant feelings without getting

drawn into them,” and “I approached each experience by trying to accept it, no matter whether it

was pleasant or unpleasant.” The TMS was found to be reliable and valid for individuals with

individuals with and without previous mindfulness meditation experience.

The Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004) is a

self-report inventory designed for the assessment of four mindfulness skills: observe, describe, act

with awareness, and accept without judgment. The measure’s conceptualization of mindfulness

skills was most strongly influenced by Linehan (1993), and the skills measured are most similar

to those taught in Dialectical Behavior Therapy. The observing skill emphasizes noticing or

attending to both internal and external phenomena. The describing skill is the ability to label or

note observed phenomena by covertly applying words; labels can be single words (e.g.,

“sadness”) or phrases (e.g., “here is my anger”). When one is engaging in the “act with

awareness” skill, s/he is entering wholly into an activity or focusing on one thing at a time. Last,

the “accept without judgment” skill emphasizes a nonjudgmental or nonevaluative stance about

present moment experience. The KIMS consists of 39 items that are rated on a 5-point Likert

28Scale ranging from 1 (never or very rarely true) to 5 (almost always or always true) according to

“your own opinion about what is generally true for you.” The measure was found to have high

internal consistency, adequate to good test-retest reliability, and validation analyses providing

support for the relationship between mindfulness and mental health (Baer et al., 2004).

The Cognitive and Affective Mindfulness Scale-Revised (CAMS-R; Feldman, Hayes,

Kumar & Greeson, 2003, 2004) assesses the awareness, attention, present-focus, and

acceptance/nonjudgment aspects of mindfulness. Items are specific to thoughts and feelings

rather than to all experiences, and since it does not require meditation training, it can assess

mindfulness acquired through life experiences, religious practices, and therapies that do not

directly teach mindfulness skills. The CAMS was an 18-item version that was sensitive to change

in mindfulness over the course of an integrative therapy for depression. That version was refined

through a series of psychometric studies that yielded the 12-item CAMS-R. Items are rated on a

4-point Likert scale (1 = not at all; 4 = almost always) according to “how much each of these

ways applies to you.” Items include, “I am preoccupied by the future,” “I can tolerate emotional

pain,” and “I try to notice my thoughts without judging them.” Higher scores on the CAMS-R

were associated with less experiential avoidance, thought suppression, rumination, worry, and

overgeneralization (i.e., spread of activation from a negative event to a negative sense of self)

(Feldman et al., 2003, 2004).

Measures of Constructs Related to Mindfulness

Prior to the development of mindfulness measures, only measures of constructs related to

mindfulness existed. They can be classified in one of three categories: (1) measures of

metacognition; (2) measures of reflective consciousness; (3) measures of acceptance. See

Appendix C for a list with abbreviated descriptions of the measures described below.

Measures of metacognition. There are currently three measures that assess meta-

cognitive processes. The Metacognitive Awareness Inventory (MAI; Schraw & Dennison, 1994)

is a 52-item inventory that measures adults’ metacognitive awareness, broken down into two

29categories, knowledge of cognition and regulation of cognition. Knowledge of cognition, or the

reflective aspect of metacognition, includes three subprocesses: “declarative knowledge (i.e.,

knowledge about the self and about strategies), procedural knowledge (i.e., knowledge about how

to use strategies), and conditional knowledge (i.e., knowledge about when and why to use

strategies)” (Schraw & Dennison, 1994, p. 460). Regulation of cognition includes processes that

aid the control of learning, including planning, comprehension monitoring, and evaluation

(Schraw & Dennison, 1994). Knowledge of cognition items include “I have control over how

well I learn” and “I am aware of what strategies I use when I study”, and regulation of cognition

items include “I set specific goals before I begin a task” and “I slow down when I encounter

important information.” Even though these factors were found to be reliable (Cronbach’s alpha =

.90) and intercorrelated (r = .54), the MAI is domain-specific, as items pertain to learning

performance.

The Meta-Cognitions Questionnaire (MCQ; Cartwright-Hatton & Wells, 1997) is a 65-

item self-report measure that measures beliefs about worry and intrusive thoughts. Based on

Wells’ (1995) meta-cognitive model of worry in generalized anxiety disorder, the measure was

developed to explore the relationship between metacognition (i.e., beliefs about worry and

selective attention to and monitoring of cognitive events), worry, and intrusions. Results

supported five distinct factors: Factor 1: positive beliefs about worry; Factor 2: negative beliefs

about the controllability of thoughts and corresponding danger; Factor 3: cognitive confidence;

Factor 4: negative beliefs about thoughts in general (including themes of superstition,

punishment, and responsibility); and Factor 5: cognitive self-consciousness (i.e., the tendency to

be aware of and monitor thinking). Factors 1, 2, and 4 are domain-specific to worry, as they

include items such as “Worrying helps me to avoid problems in the future” (Factor 1), “Worry is

dangerous for me” (Factor 2), and “If I did not control a worrying thought, and then it happened,

it would be my fault” (Factor 4). Factor 3 is specific to memory, and includes items such as, “I

have little confidence in my memory for words and names.” Although Factor 5 appears to be

30most related to the awareness component of mindfulness, it assesses cognitive self-consciousness

or preoccupation with thought processes (e.g., “I constantly examine my thoughts.”), and was

found to be positively correlated with worry and predict stress and emotional vulnerability

(Cartwright-Hatton & Wells, 1997). Further, even though the MCQ assesses metacognitive belief

about thoughts, it is domain-specific to generalized anxiety disorder.

The last measure related to metacognitive processes is the Metacognitive Awareness

Questionnaire (MAQ; Teasdale et al., 2001). The MAQ is a 9-item scale developed for patients

to rate the extent that their negative thoughts and feelings when depressed do not reflect reality.

The MAQ includes items such as, “If something has upset me, I try to put my judgments on hold

for a while” and “When I get low, my feelings show things in their true light.” Responses range

from 1 to 7 (1 = totally agree; 7 = totally disagree), and higher scores reflect greater

metacognitive awareness. The MAQ demonstrated adequate reliability internal consistency? (i.e.,

Cronbach’s alpha = .71). Although the measure includes some items that assess awareness of

cognition in general, the MAQ is domain-specific to depression.

Measures of reflexive consciousness. The Self-Monitoring Scale (SM; Snyder, 1974) is a

25-item true/false self-report measure that assesses concern for social appropriateness, sensitivity

to the expression and self-presentation of others in social situations as cues to social

appropriateness, and use of these cues to monitor and manage self-presentation and expressive

behavior. The SM includes items that describe concern for one’s presentation of social

appropriateness (e.g., “At parties and social gatherings, I do not attempt to do or say things that

others will like”); attention to appropriate self-expression (e.g., “When I am uncertain how to act

in social situations, I look to the behavior of others for cues”); the ability to control and/or modify

one’s expressive behavior (e.g., “Even if I am not enjoying myself, I often pretend to be having a

good time”); and the extent to which expressive behavior is consistent across situations (e.g., “In

different situations and with different people, I often act like very different persons”). Although

31the SM assesses the extent to which individuals are aware of their behavior, it is specific to the

observation of expressive behavior and self-presentation.

The Self-Consciousness Scale (SCS; Fenigstein et al., 1975) is a 23-item personality

measure developed to assess individual differences in self-consciousness (i.e., the tendency to

direct attention inward or outward). The measure was created to sample a variety of domains,

including preoccupation with one’s own past, present, or future behavior, awareness of one’s

attributes, sensitivity to inner feelings, introspective behavior, awareness of one’s appearance,

and concern over the appraisal of others (Fengistein, 1997). The measure has three subscales: (1)

Private self-consciousness, containing items such as, “I’m always trying to figure myself out” and

“I’m alert to changes in my mood;” (2) Public self-consciousness, assessed by items such as,

“I’m concerned about my style of doing things” and “I’m usually aware of my appearance;” and

(3) Social anxiety, containing items such as, “It takes me time to overcome my shyness in new

situations” and “Large groups make me nervous.” Items are rated on a four-point Likert scale (0

= “extremely uncharacteristic”; 4 = “extremely characteristic”), so that higher scores indicate

higher private self-consciousness, public self-consciousness, or social anxiety. Although the

private self-consciousness subscale most closely resembles mindfulness, it focuses solely on

thoughts and reflections of the self without including the component of acceptance.

The Rumination-Reflection Questionnaire (RRQ; Trapnell & Campbell, 1999) was

designed in response to the confounding of motivationally distinct dispositions, rumination and

reflection, by the SCS (Fenigstein et al., 1975). It was created to distinguish neurotic from

inquisitive self-focus. The measure has two subscales: (1) Rumination, containing items such as,

“Often I’m playing back over in my mind how I acted in a past situation;” and (2) Reflection,

containing items such as, “I love exploring my ‘inner’ self.” Items are rated on a 5-point Likert

scale (1 = ‘strongly disagree’; 5 = ‘strongly agree’), so that higher scores indicate higher

rumination or reflection. Although the reflection subscale most closely resembles mindfulness, it

32measures the extent to which individuals analyze or examine the “self” rather than internal

experiences (e.g., thoughts, feelings, images, memories) of the self.

The Self-Reflection and Insight Scale (SRIS; Grant, Franklin, & Langford, 2002) was

designed as an advancement of the private self-consciousness subscale (PrSCS) of the SCS

(Fenigstein, et al., 1975). The PrSCS is thought to comprise of two factors: internal state and

self-reflection (Grant et al., 2002). For this reason, the SRIS is a 20-item scale that consists of

two subscales, Self-Reflection (SRIS-SR) and Insight (SRIS-IN). SRIS-SR items include “I

frequently examine my feelings” and “It is important for me to evaluate the things that I do,” and

SRIS-IN items include “I am usually aware of my thoughts” and “I usually know why I feel the

way I do.” Items are rated on a 6-point Likert sale (1 = strongly disagree; 6 = strongly agree),

and higher scores indicate higher self-reflection and insight. Similar to the PrSCS subscale of the

SCS, the SRIS only measures reflection on cognitions and behavior and internal state awareness.

Measures of acceptance. The Acceptance and Action Questionnaire (AAQ; Hayes,

1996) is a 16-item measure that assesses the ability to accept undesirable internal events while

continuing to pursue desired goals. Items are rated on a 7-point Likert scale (1 = never true; 7 =

always true), with higher scores indicating less psychological acceptance. Items assess both the

acceptance (e.g., “I’m not afraid of my feelings”) and action (e.g., “If I promised to do something,

I’ll do it, even if I later don’t feel like it”) factors. The AAQ measures the acceptance component

of mindfulness, but does not specifically reference or assess awareness.

Measuring Mindfulness: The Current Study

As previously discussed, innovative treatments are being developed based on the

construct of mindfulness. A growing number of mindfulness-based interventions have recently

been operationalized, conceptualized, and empirically evaluated (Baer, 2003). A fundamental

problem in this area, however, is the absence of a reliable and valid measure of the construct that

is at the heart of these programs. Several authors have noted the need for a clear operational

definition of mindfulness (e.g., Bishop, 2002; Hayes & Wilson, 2003).

33The development of shared consensus regarding the key characteristics or components of mindfulness represents one of the most critical steps toward a program of research on the clinical use of mindfulness. The lack of a clear operational definition of mindfulness has given rise to considerable and unfortunate ambiguity in the field, such as the equation of mindfulness interventions with acceptance interventions or with meditation, the confusion between relaxation, and the like. Moreover, the lack of widespread consensus on this issue has hindered the progress of research on determining the active ingredients of mindfulness interventions and mechanisms of change. (Dimidjian & Linehan, 2003, p. 166)

Different methods and processes are described with the same term, and distinctions between

mindfulness and related concepts are unclear (Hayes & Wilson, 2003). The lack of an

operational definition of mindfulness has limited the scientific study of the construct (Bishop,

2002).

Bishop et al. (2004) recently proposed an operational definition of mindfulness that

focuses on two components: sustained attention to present experience, and an attitude of

openness, curiosity, and acceptance. Although a useful advance over earlier attempts to define

the construct, one problem with their definition is that any self-regulation of attention is

inconsistent with an attitude of thoroughgoing acceptance (Brown & Ryan, 2004). That is, one

cannot be fully open and accepting of the full range of psychological experience if one is

simultaneously attempting to direct attention in any particular way (e.g., away from external

stimuli, as in certain forms of concentrative meditation).

In addition to the lack of consensus with regard to an operational definition of

mindfulness, the construct has not been determined to be a process or method, as it is “treated

sometimes as a technique, sometimes as a more general method or collection of techniques,

sometimes as a psychological process that can produce outcomes, and sometimes as an outcome

in and of itself” (Hayes & Wilson, 2003, p. 161). Since mindfulness meditation has been

distinguished from mindfulness as a practice, mindfulness should be considered a process.

Whereas mindfulness meditation is one approach to enhance or develop mindfulness, mindfulness

should be considered “a way of being” (Miller et al., 1995, p. 198).

34Further adding to the confusion of the conceptualization of mindfulness is the lack of

consensus about whether mindfulness is a state or trait. This lack of consensus can be seen by

examining the mindfulness measures published to date. The TMS (Bishop et al., 2003) measures

the attainment of a mindful state immediately following a meditation exercise. The KIMS (Baer

et al., 2004) measures mindfulness as a trait, in that respondents are asked to rate items according

to “your own opinion about what is generally true for you.” Similarly, the CAMS (Hayes &

Feldman, 2004) instructs individuals to rate how each item “applies to you.” However, the

MAAS (Brown & Ryan, 2003) and FMI (Buchheld et al., 2001) treat mindfulness as a quasi-trait,

as respondents are asked to rate the occurrence of items within a certain time period. For

example, the MAAS asks respondents to rate items concerning “how frequently or infrequently

you currently have each experience.” Considering mindfulness as a quasi-trait implies that while

individuals may have the tendency to be mindful, specific levels of mindfulness can change over

time.

As a psychological process, mindfulness should have the potential to be measured. It

would be important to assess levels of mindfulness in individuals who receive mindfulness-based

interventions to help determine the hypothesized mechanisms of these treatments. However,

“such investigations would require a psychometrically sound measure of mindfulness, which the

field currently lacks” (Dimidjian & Linehan, 2003, p. 169). The current measures of mindfulness

(and related constructs) reviewed above are problematic for one of two reasons: (a) they are

domain-specific; and/or (b) they assess only a single component of mindfulness. For these

reasons, the current study proposes to develop an operational definition and a bi-dimensional

measure to assess mindfulness based on a conceptualization of the key components of

mindfulness, namely present-moment awareness and acceptance.

Acceptance and present-moment awareness appear to be central components of

mindfulness. Most of the clinical definitions explicitly include these concepts in defining

mindfulness. Moreover, the mindfulness-based interventions all emphasize acceptance and

35present-moment awareness as important aspects of mindfulness meditation, one method of

developing mindfulness (Breslin et al., 2002). It should be noted that the two dimensions of

mindfulness are with regard to the full range of stimuli that occur both internal and external to the

individual. This is distinct from the social-psychological literature, which describes mindfulness

as perceptual inputs only from the external environment (Brown & Ryan, 2003).

Integrating Awareness and Acceptance

As previously discussed, present-moment awareness and acceptance reflect the key

components of mindfulness. Present-moment awareness will be defined as continuous

monitoring awareness of ongoing internal and external experiences. Whereas high levels of

present-moment awareness reflect high monitoring, low levels of present-moment awareness

reflect a relative lack of monitoring. The second dimension, acceptance, is a nonjudgmental

stance toward one’s experience. High levels of acceptance are characterized by experiencing

events fully and without defense, and low levels are characterized by avoidance and/or by

attempts to control internal experience (Hayes, 1994). Thus, four psychological states can be

conceptualized by crossing the two dimensions of present-moment awareness and acceptance: (1)

mindfulness (high present-moment awareness, high acceptance); (2) “flow” (low present-moment

awareness, high acceptance); (3) unsuccessful experiential avoidance and/or control (high

present-moment awareness, low acceptance); and (4) successful experiential avoidance and/or

control (low present-moment awareness, low acceptance). See Appendix D for an illustration of

the four psychological states.

As previously discussed, mindfulness is characterized by nonjudgmental awareness to

internal and external experiences. During mindfulness, experiences are observed without

intention to control or avoid them. In an illustration of mindfulness of a bodily sensation:

As I write, there is a small knot at the top of my stomach. I focus on the feeling: a slight pressure, a full feeling at the top of my stomach. That feeling of pressure becomes the object of my attention. I don’t pull back from it. It is getting more intense, but I don’t detach from it: I come in close and touch it. There’s the feeling in my stomach, which is

36unpleasant. There’s mindfulness which is able to turn to it…Everything is focus on that sensation. We’re not trying to add to it, subtract from it, make it feel better, change it in any way. We try to experience it with no separation whatsoever…Instead of fighting the feeling, or turning away from it, we’re learning to turn toward it…We can learn to welcome the unwanted, simply because it is there and is our life in that moment.” (Rosenberg, 1998, pp. 66-67)

Experiences are not evaluated, judged, or believed, but instead simply acknowledged as mental

events. Mindfulness takes place without reference to self, (i.e., noting sensations as sensations,

thoughts as thoughts, etc.), and is characterized as present-moment observation, continuously

monitoring the evolution of one’s experiences in the moment; “if you are remembering your

second-grade teacher, that is memory. When you then become aware that you are remembering

your second-grade teacher, that is mindfulness” (Gunaratana, 1991, p. 152). Thus, mindfulness

reflects high levels of both present-moment awareness and acceptance.

A low level of present-moment awareness and a high level of acceptance would liken to

the state of “flow,” “a subjective state that people report when they are completely involved in

something to the point of forgetting time, fatigue, and everything else but the activity itself”

(Csikszentmihalyi & Rathunde, 1993, p. 59). Conditions that evoke the state of flow are

conducive to deep concentration that “is so intense that there is no attention left over to think

about anything irrelevant or to worry about problems” (Csikszentmihalyi, 1990, p. 71). Although

attention is focused on the present during flow, it is characterized by a loss of self-consciousness

and self-awareness (Csikszentmihalyi & Rathunde, 1993). During the state of flow, time passes

more quickly, and there is a decrease in awareness as “thoughts, intentions, feelings and all the

senses are focused on the same goal” (Csikszentmihalyi, 1990, p. 41). Research suggests that for

individuals who report to be in the state of flow frequently, there is reduced mental activity in all

information channels with the exception of that involved in sustained attention of a flashing

stimulus (Holcomb, 1976). Activity during flow is considered autotelic, or rewarding in and of

itself, which may give reason for why individuals disregard typically unpleasant states such as

hunger, fatigue, and discomfort (Nakamura & Csikszentmihalyi, 2002). Thus, during the state of

37flow, awareness is reduced to what is decided as relevant for the present moment and

preoccupations or discomforts do not intrude, because behavior is intrinsically motivated. Flow

would be characterized by high levels of acceptance, since explicit attempts are not made to

regulate irrelevant preoccupations or discomforts. Instead, they are experienced without defense,

allowing attention to be redirected to the present moment and task at hand.

Whereas high levels of acceptance are characterized by experiencing events without

defense, low levels are characterized by attempts to avoid and/or control one’s experiences. A

low level of acceptance combined with high levels of present-moment awareness would result in

unsuccessful experiential avoidance, which is characteristic of accounts of various forms of

psychopathology. Experiential avoidance is “the phenomenon that occurs when a person is

unwilling to remain in contact with particular experiences (e.g., bodily sensations, emotions,

thoughts, memories, behavioral predispositions) and takes steps to alter the form or frequency of

these events and the contexts that occasion them” (Hayes et al., 1999, p. 58). Literature suggests

that deliberate attempts to control or avoid unpleasant experiences often paradoxically increase

the intensity of the experience. A large source of data supporting the negative consequences of

experiential avoidance and/or control comes from the thought suppression literature. For

example, when participants are told to suppress a thought, they will later show an increase in the

suppressed thought compared with those not given suppression directions (e.g., Clark, Ball, &

Pape, 1991; Wegner, Schneider, Carter, & White, 1987). The instruction for suppression may

stimulate the suppressed thoughts or emotion in a self-amplifying loop (Hayes, Wilson, Gifford,

Follette, & Strosahl, 1996), which may give reason for its relationship to rumination (Gold &

Wegner, 1995; Wenzlaff & Luxton, 2003), anticipatory anxiety (Craske, Miller, Rotunda &

Barlow, 1990), symptoms of obsessive compulsive disorder (McLaren & Crowe, 2003), dental

anxiety (Muris, Jongh, Merckelbach, Postema, & Vet, 1998), and somatic sensations such as pain

(Cioffi & Holloway, 1993). Experiential avoidance and/or control have also been implicated in

the etiology and maintenance of psychopathology. For example, research suggests that

38individuals with panic disorder have a heightened autonomic reactivity or sensitivity to internal

physical cues, and associated with this elevated autonomic reactivity is enhanced attentional

selectivity to the physiological sensations (e.g., Ehlers & Breuer, 1992, 1996). Since small

changes in physiological state are interpreted as catastrophic, individuals with panic disorder

attempt to avoid or control the autonomic arousal. However, the lack of acceptance of the arousal

only intensifies the sensations, leading to a reciprocal cycle of fear and sensations.

Finally, low levels of present-moment awareness and acceptance toward experience

would be characterized by successful experiential avoidance and/or control. When successful, the

unpleasant experiences can be avoided or controlled. For example, the focus in traditional

cognitive and behavior therapy, which has been shown to be successful in treating various

psychological disorders, is to change private experiences through methods such as relaxation and

cognitive restructuring. There also is evidence that attentional training, which promotes focus on

external events to reduce self-focus, reduces panic attacks and self-report tension without

exacerbating anxiety (Wells, 1990). However, these methods have limitations, as they may only

allow for temporary reprieve of the unpleasant internal experiences. Deliberate attempts to avoid

or control unpleasant events remind the individual of the avoided or controlled events, risking the

paradoxical elicitation of the event being avoided or controlled (Hayes, 2002a), which would

result in unsuccessful emotional avoidance (i.e., high present-moment awareness, low

acceptance).

Principal Aims of the Present Study

As previously discussed, there has recently been a marked increased in interest in the

construct of mindfulness in clinical psychology, as demonstrated by the rise in number of

publications, formation of listservs and interest groups, and study of psychological interventions

based on this construct. However, there is no accepted definition of mindfulness, nor has the

construct been sufficiently operationalized. Further, there currently exists no measure that clearly

assesses both of the key components of mindfulness, present-moment awareness and acceptance.

39For these reasons, the purposes of the proposed study were as follows: 1) To develop a bi-

dimensional measure of mindfulness based on the two key constituents of the construct, present-

moment awareness and nonjudgmental acceptance; 2) examine the factor structure of the

measure; 3) explore the internal consistency of items in nonclinical and clinical samples; and 4)

examine the convergent, discriminant, and incremental validity of the resulting measure in

nonclinical and clinical samples.

The Philadelphia Mindfulness Scale (PHLMS) was designed in stages which will be

described as four studies: 1) Item Generation & Selection; 2) Factor Analysis & Internal

Consistency; 3) Validation Analyses with a Normative Sample; 4) Validation Analyses with a

Clinical Sample.

40CHAPTER 2: STUDY 1 -- ITEM GENERATION AND SELECTION

Method

A pool at least twice the size of the anticipated size of the final scale is deemed sufficient

(DeVellis, 2003), and eight to ten items per dimension for multifactor constructs has been

suggested as an ideal scale length (Netemeyer, Bearden, & Sharma, 2003), which suggested that a

minimum of 20 items per dimension be generated. Although a total of 60 items was initially

anticipated, a total of 105 items (55 awareness items, 50 acceptance items) was generated from by

primary investigator, faculty and graduate students in clinical psychology, and individuals outside

of psychology. These individuals were provided with the definitions of awareness and

acceptance and asked to generate items that reflected the definitions. Microsoft Word was used

to determine the overall reading level of the items; items reflected a Grade 5 reading level, as it is

recommended that scales should not require reading skills beyond that of age 12 (Streiner &

Norman, 1995).

The list of items was submitted to a panel of three editorial judges (i.e., faculty and

graduate students who also serve as journal editors) so that items could be examined for clarity

and readability. Minor modification to the wording of several items was made based on their

feedback. Next, expert judges (i.e., experienced researchers of mindfulness and related

constructs) were recruited to establish the content validity of the initial items of the measure.

Given that five or more judges are recommended for establishing content and face validity

(Netemeyer, et al., 2003), six expert judges were recruited (4 males, 2 females). The revised list

of items and our definition of mindfulness (i.e., awareness and acceptance) was submitted to the

expert judges who rated how well each item measured the intended dimension of mindfulness

(i.e., awareness or acceptance), and also did not reflect the other dimension of mindfulness. Items

were rated on a 5-point Likert scale (1= ‘very poor’; 2 = ‘poor’; 3 = ‘fair’; 4 = ‘good’ 5 =’very

good’) for suitability. See Appendix E for the list of items and procedures administered to expert

judges.

41Results and Discussion

The V Index, a content validity coefficient (Aiken, 1996), was used for item retention.

The V Index provides an overall measure of content validity for N raters on a single scale for

multiple items; the value of V ranges from 0.00 to 1.00, and tables determining the statistical

significance of V can be found in Aiken (1985). Items were retained if they were rated by all

judges as highly reflecting one dimension of mindfulness (V > .71, p < .05) and simultaneously

not reflecting the other dimension (V < .29, p < .05). Thus, 58 items (29 awareness items, 29

acceptance items) were retained; see Appendix F for the list of retained items and the mean rating

by judges on each dimension for each item. Overall, findings suggest that expert judges found

the items to be good representations of acceptance and awareness, the two components of

mindfulness.

42CHAPTER 3: STUDY 2 -- FACTOR STRUCTURE AND INTERNAL CONSISTENCY

Method

Participants

204 undergraduate students (94 males, 106 females; 4 participants did not indicate

gender) in psychology courses at Drexel University served as the development sample in

exchange for extra course credit. It is recommended that six to ten times as many participants as

items is ideal (Gable, 1986), but 100-200 participants is considered sufficient for preliminary item

analysis (Clark & Watson, 1995; Kline, 1986). The participants’ ages ranged from 19 to 47 years

old, with a mean age of 21.9 years (SD = 3.83). Students’ year in school ranged from year 1 to

year 7, with a mean year in school of 3.53 (i.e., 65% of students in their 3rd or 4th year of school).

Participants’ self-identified race is as follows: 18.6% Asian/Pacific Islander, 10.3%

Black/African-American/Caribbean American, 1.0% Hispanic/Latino/Latina, 64.7%

White/Caucasian/European decent, 5.0% multi-racial, and 0.5% “other.”

Measures and Procedure

The items retained after expert ratings, along with a Demographic Information form,

were administered in a group format (see Appendix F for the list of items). Given that 5- and 6-

point Likert scales have been found to be most reliable (McKelvie, 1978), items were rated on a

5-point Likert Scale (0 = ‘never’; 1 = ‘rarely’; 2 = ‘sometimes; 3 = ‘often’; 4 = ‘very often’)

according to the frequency that participants experience the described item within the past week.

Results and Discussion

Exploratory Factor Analysis

Unrestricted and restricted (i.e., forced solution) factor analyses were conducted. A

principal components unrestricted factor analysis using a Promax (i.e., oblique) rotation initially

was conducted to determine item retention. An oblique rotation method was chosen, given that it

allows the factors to correlate and can provide more meaningful theoretical factors (Netemeyer et

al., 2003). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was .768; KMO

43elicits values between 0 and 1, with small values indicating that overall, the variables have too

little in common to warrant a factor analysis. KMO values of less than .49 have been deemed

unacceptable (Kaiser, 1974). Bartlett's Test of Sphericity, which tests the null hypothesis that the

correlation matrix is an identity matrix (i.e., all of the diagonal elements are 1 and all off diagonal

elements are 0) was significant. The unrestricted factor analysis produced a 17-factor solution

with eigenvalues greater than one that recovered 65.9% of the sample variance. However,

examination of eigenvalues and the scree plot revealed a marked gap between the first two factors

and the remaining factors (Factor 1 eigenvalue = 7.93, Factor 2 eigenvalue = 6.84, Factor 3

eigenvalue = 2.85; the first two factors accounted for 25.5% of the total variation across factors).

Floyd and Widaman (1995) argue that the use of eigenvalues greater than 1.0 can lead to an

overestimation of the number of factors to retain, and that the scree plot may be more useful in

identifying meaningful factors. Thus, based on scree plot results and consistent with theoretical

predictions, the most interpretable solution was a two-factor model. A principal components

factor analysis using a Promax rotation was conducted restricting the factor analysis to a two-

factor solution. Since loadings above .50 may be considered “very significant” (Hair, Anderson,

Tatham, & Black, 1998), items with loadings of .50 and higher on their respective subscale were

retained, resulting in 23 items (11 acceptance items, 12 awareness items). See Table G1 in

Appendix G for the list of the 23 items and factor loadings on each subscale.

Internal Consistency

Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and

Cronbach’s alpha coefficient) were conducted for the remaining items in each subscale.

Cronbach’s alpha coefficient was conducted to ensure satisfactory internal consistency. Different

levels of alpha have been determined as adequate; Kline (1986) suggests a minimum value of .60,

Nunnally (1978) suggests a minimum value of .70, and DeVellis (2003) has delineated the

following ranges: below .60 is unacceptable, .60 to .65 is undesirable, .65 to .70 is minimally

acceptable, .70 to .80 is respectable, .80 to .90 is very good, and the scale should be shortened if

44alpha is above .90. For the Awareness subscale, Cronbach’s alpha = .84, and for the Acceptance

subscale, Cronbach’s alpha = .87, suggesting very good internal consistency for both subscales.

Corrected item-to-total correlations are examined within each dimension for

multidimensional scales, and items with low corrected item-to-total correlations are

recommended for deletion (Netemeyer et al., 2003). For the Awareness subscale corrected item-

subscale total correlations ranged from .43 to .61, and for the Acceptance subscale, corrected

item-subscale total correlations ranged from .48 to .72. See Table G2 in Appendix G for

corrected item-subscale correlations for each item.

Inter-item correlations were calculated, and items within the same subscale that had a

minimum correlation of .15 and maximum correlation of .50 were retained (Clark & Watson,

1995). For the Awareness subscale, inter-item correlations ranged from .09 to .59. For the

acceptance subscale, inter-item correlations ranged from .17 to .66. See Appendix G, Table G3

for inter-item correlations.

Based on these analyses, items were eliminated to ensure that correlations remained

within the recommended parameters and to retain a maximum of 10 items on each subscale. For

the Awareness subscale, the item, “When I walk outside on a sunny day, I notice how the sun

feels on my skin” was deleted because it had an inter-item correlation of .09 with one item and an

inter-item correlation with another item of .59 (both correlations are outside the recommended

parameters). The item, “When my mood changes, I notice the event or the thought that caused it

to change” was deleted because it was redundant with other items and had an inter-item

correlation with another item of .52. For the Acceptance subscale, the item “I have thoughts I try

to avoid” was deleted because it had an inter-item correlation of .66.

Reliability analyses were re-conducted for each subscale of 10 items to examine the

internal consistency of the resulting measure. For the Awareness subscale, Cronbach’s alpha =

.81, corrected item-subscale total correlations ranged from .43 to .60, and inter-item correlations

ranged from .13 to .50. For the Acceptance subscale, Cronbach’s alpha = .85, item-subscale total

45correlations ranged from .47 to .67, and inter-item correlations ranged from .17 to .54. Only one

inter-item correlation (i.e., on the Awareness subscale) was below the recommended parameter,

and five inter-item correlations were above recommended parameter of .50 (i.e., on the

Acceptance subscale); however, the items were retained to ensure that there was a minimum of 10

items per subscale. See Table G4 in Appendix G for the mean and standard deviation of the

resulting 20 items, Table G5 for item-subscale total correlations, and Table G6 for inter-item

correlations.

46CHAPTER 4: STUDY 3 – VALIDATION ANALYSES WITH A NORMATIVE SAMPLE

Method

Participants

Five hundred fifty-nine university students (270 males, 283 females; 6 participants did

not indicate gender) were recruited from undergraduate psychology courses and participated in

exchange for extra credit. The participants’ ages ranged from 17 to 53 years, with a mean age of

20.12 years (SD = 3.49). Students’ year in school ranged from year 1 to beyond year 5, with a

mean year in school of 2.39 (i.e., 59.2% of students in their 1st or 2nd year of school).

Participants’ self-identified race was as follows: 19.0% Asian/Pacific Islander, 8.1%

Black/African-American/Caribbean American, 1.6% Hispanic/Latino/Latina, 0.7% Native

American, 64.4% White/Caucasian/European decent, 5.4% multi-racial, and 0.7% “other” or race

not listed.

Measures and Predictions

The refined measure was included in a packet that contained the following questionnaires

(see Appendix H for copies of these measures):

Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The MAAS is a 15-

item self-report inventory designed to measure the presence or absence of attention to and

awareness of what is occurring in the present moment. Items are rated on a 6-point Likert Scale

(1 = ‘almost always’; 6 = ‘almost never’), and total scores range from 15 to 90, with higher scores

indicating greater mindfulness. The MAAS was found to have good internal consistency, with

alphas ranging of .82 and .87 in student and adult samples (respectively). The MAAS

demonstrated adequate convergent, discriminant, and incremental validity. The MAAS showed

moderate positive correlations with openness to experience (r = .18 and .19, respectively),

attentiveness/receptivity to experience (r = .15 to .20), mindful engagement (r = .33 to .39), and

well-being variables such as vitality (r = .35 to .46), self-actualization (r = .43), and competence

(r = .39 to .68) (Brown & Ryan, 2003). The MAAS was found to be moderately inversely related

47to rumination (r = -.29 to -.39), depression (r = -.37 to -.53), and anxiety (r = -.26 to -.42) (Brown

& Ryan, 2003). The MAAS was not found to be related to private self-consciousness (r = -.05 to

.03) and self-monitoring (r = -.03) (Brown & Ryan, 2003). With regard to incremental validity,

all correlations between the MAAS and well-being variables (i.e., depression, anxiety, pleasant

affect, unpleasant affect, positive affect, negative affect, self-esteem) remained significant when

controlling for rumination, private self-consciousness, emotional intelligence, propensity to

achieve mindful states, neuroticism, extraversion, and social desirability (Brown & Ryan, 2003).

The MAAS has been demonstrated to reliably distinguish mindfulness practitioners from the

general adult population, and has predicted mood disturbance and stress during and after a

mindfulness-based intervention (Brown & Ryan, 2003). Since the MAAS measures attention to

and awareness of what is occurring in the present moment, positive correlations were expected to

be found between the MAAS and the PHLMS Awareness subscale. Further, since the authors

explicitly excluded items with an attitudinal component (e.g., acceptance), it was predicted that

the MAAS would not be related to the PHLMS Acceptance subscale.

Acceptance and Action Questionnaire (AAQ; Hayes, 1996, 2004). The AAQ is a 9-item

measure assessing the ability to accept undesirable thoughts and feelings while pursuing desired

goals. A 16-item version was initially developed, but the authors sought a shorter version.

However, since the authors note that the longer version may be more sensitive due to the larger

number of items (Hayes et al., 2004), the 16-item version was used in the present study. Items

are rated on a 7-point Likert scale (1 = ‘never true’; 7 = ‘always true’), and total scores range

from 16 to 112, with higher scores indicating less psychological acceptance. The AAQ has

demonstrated very good internal consistency, with alphas ranging from .89 to .92 (Bond & Bruce,

2000). Further psychometric studies are underway, but there are currently no other published

psychometric data on the AAQ. Since the AAQ Acceptance subscale measures the absence of

experiential avoidance, positive correlations between the AAQ Acceptance subscale and the

48PHLMS Acceptance subscale were expected. The AAQ Acceptance subscale was not predicted

to be related to the PHLMS Awareness subscale.

Rumination-Reflection Questionnaire (RRQ; Trapnell & Campbell, 1999). The RRQ is a

24-item self-report inventory designed to measure two types of self-focus: neurotic and

inquisitive/intellective. The measure has two scales: rumination, assessing neurotic self-

consciousness, and reflection, assessing intellective self-consciousness. Items are rated on a 5-

point Likert scale (1 = ‘strongly disagree’; 5 = ‘strongly agree’). Total Rumination and

Reflection scores both range from 12 to 60, so that higher scores indicate higher rumination or

reflection. The RRQ demonstrated excellent internal consistency, as alpha estimates exceeded

.90, and the mean inter-item correlation exceeded .40 for both scales (Trapnell & Campbell,

1999). The RRQ also demonstrated good convergent and discriminant validity (Trapnell &

Campbell, 1999). As neuroticism measures the tendency to experience negative affect, negative

correlations were expected between the RRQ Rumination subscale and the PHLMS, PHLMS

Acceptance subscale and PHLMS Awareness subscale. Since it assesses an inquisitive self-

consciousness, the RRQ Reflection subscale was expected to be moderately related to the

PHLMS and its subscales.

White Bear Suppression Inventory (WBSI; Wegnar & Zanakos, 1994). The WBSI is a

15-item self-report measure designed to measure thought suppression. Items are rated on a 5-

point Likert Scale (1 = ‘strongly disagree’; 5 = ‘strongly agree’), and total scores range from 15

to 75, with higher scores indicating greater tendency to suppress thoughts. The WBSI has been

found to have very good internal consistency, (alpha = .89; Muris, Merkelbach, & Horselenberg,

1996), and adequate stability over time (12 week test-retest correlation of r = .80; Muris et al,

1996). The WBSI has been found to have very good convergent validity with significant

correlations between the Beck Depression Inventory, the Maudsley Obsessive-Compulsive

Inventory, the State-Trait Anxiety Inventory, and the Anxiety Sensitivity Inventory (Muris et al.,

1996). As thought suppression seems to include an unwillingness to experience thoughts,

49correlations between the WBSI and the PHLMS Acceptance subscale were expected to be

negative.

Flow State Scale (FSS; Jackson & Marsh, 1996). The FSS is a 36-item questionnaire that

measures flow in sport and physical activity settings. Nine subscales represent the dimensions of

flow delineated by Csikszentmihalyi (1990): challenge-skill balance, action-awareness merging,

clear goals, unambiguous feedback, concentration on task at hand, sense of control, loss of self-

consciousness, transformation of time, and autotelic experience. Items are rated on a 5-point

Likert scale (1 = ‘strongly disagree’; 5 = ‘strongly agree’), and total scores range from 36 to 180,

with higher scores indicating greater flow. Internal consistency for the nine subscales was

determined to be reasonable (mean alpha = .83). Although the intended use is for immediately

after a flow experience, the instructions were modified for purposes of the present study. A brief

description of a flow experience was provided, and participants were asked to think back to a

similar experience that occurred within the past two weeks and answer the questions according to

how they felt during that experience. Since flow appears to have components of decreased

present-moment awareness with higher levels of acceptance, it was expected that FSS scores be

positively moderately related to the PHLMS Acceptance subscale and negatively related to the

PHLMS Awareness subscale.

Beck Depression Inventory-II (BDI-II; Beck, Ward, Mendelson, Mock, & Erbarugh,

1961; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item self-report measure of depression

that is routinely used in studies of depression and anxiety. The BDD-II is a modification of the

original BDI, containing the following new items: agitation, worthlessness, loss of energy, and

concentration difficulty. In addition, the BDI-II assesses both increases and decreases in appetite

within the same item and hypersomnia and hyposomnia within the same item. The BDI/BDI-II

has been the most widely used measure of depression in both clinical and research settings.

Dozois, Dobson, & Ahnberg (1998) established criteria for the BDI-II (0-12 = nondepressed; 13-

19 = dysphoric; 20-63 = dysphoric-depressed) based on cutoffs established by Kendall, Hollon,

50Beck, Hammen, & Ingram (1987) for the BDI. The BDI-II has good psychometric properties

(Beck, Steer, Ball & Ranieri, 1996). As previously noted, mindfulness is associated with reduced

symptomotology; thus, negative correlations between the BDI-II and the PHLMS and its

subscales were expected.

Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988; Beck & Steer, 1990).

The BAI is a 21-item self-report measure that is routinely used to measure symptoms of anxiety.

Items are rated on a 4-point Likert scale (0 = ‘not at all’; 3 = ‘severely’). Cutoff scores listed in

the BAI manual are: 0-7=minimal; 8-15=mild; 16-25=moderate; 26-63=severe. The BAI has

good psychometric properties (Beck et al., 1988; Dent & Salkovskis, 1986; Frydrich, Dowdall, &

Chambless, 1992). Normative percentile scores have also been established (Gillis, Haaga, &

Ford, 1995). Similar predictions as those made about the BDI-II were made regarding the BAI.

Marlow-Crowne Social Desirability Scale (M-C SDS; Crowne & Marlowe, 1960). The

M-C SDS is a 33-item true/false measure that assesses response bias (i.e., the degree to which

individuals attempt to present themselves in a favorable light). Scores range from 0 to 33, with

higher scores reflecting a greater degree of socially desirable responding. The M-C SDS has high

internal consistency (alpha = .88) and test-retest reliability (r = .89) (Crowne & Marlowe, 1960,

1964). Since true-false and Likert forms of the M-C SDS have been found to be significantly

correlated (Greenwald & O’Connell, 1970), a 5-point Likert version of the M-C SDS was used in

the present study to achieve higher precision and to increase the instrument’s sensitivity. Scores

on the M-C SDS were expected to show either no relation or only a modest relationship with the

PHLMS and its subscales.

Results

Measure Descriptives

The PHLMS total score ranged from 47 to 95, with a mean of 66.84 (SD = 7.27). The

PHLMS Acceptance subscale total score ranged from 13 to 47, with a mean of 30.19 (SD = 5.84),

and the PHLMS Awareness subscale total score ranged from 20 to 50, with a mean of 36.65 (SD

51= 4.93). See Table I1 in Appendix I for PHLMS item means and standard deviations. The AAQ

total score ranged from 41 to 104, with a mean of 72.29 (SD = 9.87), the AAQ Acceptance

subscale scores ranged from 12 to 49, with a mean of 29.65 (SD = 6.03), and the AAQ Action

subscale scores ranged from 23 to 61, with a mean of 42.64 (SD = 6.15). MAAS scores ranged

from 25 to 90, with a mean of 58.00 (SD = 10.48). FSS scores ranged from 36 to 180, with a

mean of 130.06 (SD = 18.49). WBSI scores ranged from 16 to 73, with a mean of 46.62 (SD =

10.01). The RRQ Rumination subscale scores ranged from 15 to 60, with a mean of 40.55 (SD =

7.83), and the RRQ Reflection subscale score ranged from 12 to 60, with a mean 38.65 (SD =

9.02). M-C SDS scores ranged from 53 to 129, with a mean of 99.26 (SD =11.59). The mean

BDI total score of 9.66 (SD = 7.15, range = 0 to 40) and mean BAI total score of 10.32 (SD =

8.78, range = 0 to 49) were within normative levels.

To account for the large number of correlations calculated using this sample and in an

effort to balance Type 1 and Type 2 error, only those with p < .01 were deemed significant. The

PHLMS Awareness subscale (r = .60, p < .0001) and the PHLMS Acceptance subscale (r = .74, p

< .0001) were significantly related to the PHLMS Total score. However, there was not a

significant relationship between the Acceptance and Awareness subscales (r = -.10, p = .025).

Cross Validation

Cross validation analyses were conducted between the first student sample (i.e., the

development sample, N = 204) and the second student sample (i.e., the validation sample, N =

559). No significant differences were found for gender (χ² (1, N = 753) = .20, p = .658) or race

χ² (6, N = 752) = 2.93, p = .818). However, there were significant differences between samples

for students’ year in school (χ² (6, N = 753) = 150.70, p <.0001) and age (t(761) = 6.07, p <

.0001), with the development sample being older and having the higher year in school. However,

no significant differences were found between both samples for the PHLMS Total score (t(322.9)

= -1.20, p > .05), the PHLMS Acceptance subscale (t(761) = -.67, p > .05), or the PHLMS

Awareness subscale (t(761) = -1.13, p > .05).

52Exploratory Factor Analysis

Unrestricted and restricted (i.e., forced solution) factor analyses were conducted. A

principal components unrestricted factor analysis using a Promax (i.e., oblique) rotation initially

was conducted to determine item retention. The Kaiser-Meyer-Olkin (KMO) measure of

sampling adequacy was .850. Bartlett's Test of Sphericity was significant. The unrestricted

factor analysis produced a four-factor solution with eigenvalues greater than one that recovered

46.2% of the sample variance. However, examination of eigenvalues and the scree plot revealed

a marked gap between the first two factors and the remaining factors (Factor 1 eigenvalue = 4.03,

Factor 2 eigenvalue = 3.04, Factor 3 eigenvalue = 1.13; the first two factors accounted for 35.4%

of the total variation across factors). Thus, consistent with theoretical predictions, the most

interpretable solution was a two-factor model. A principal components factor analysis using a

Promax rotation was conducted restricting the factor analysis to a two-factor solution. As

expected, awareness items loaded onto one factor (Factor 1), and acceptance items loaded onto

the other factor (Factor 2), with loadings ranging from .50 to .75. See Table I2 in Appendix I for

the list of items and factor loadings.

Internal Consistency

Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and

Cronbach’s alpha coefficient) were conducted for the entire measure and each subscale. Internal

consistency was respectable for the PHLMS (Cronbach’s alpha = .72) and for the Awareness

subscale (Cronbach’s alpha = .75), and internal consistency was very good for the Acceptance

subscale (Cronbach’s alpha = .82). Corrected item-to-total correlations were conducted within

each subscale. For the Awareness subscale corrected item-subscale total correlations ranged from

.34 to .51, and for the Acceptance subscale, corrected item-subscale total correlations ranged

from .40 to .64. See Table I2 in Appendix I for corrected item-subscale correlations for each

item. Inter-item correlations were calculated. For the Awareness subscale, inter-item

53correlations ranged from .13 to .36, and for the Acceptance subscale, inter-item correlations

ranged from .17 to .53. See Table I4 in Appendix I inter-item correlations.

Convergent Validity

Correlations of the PHLMS with others measures were conducted to assess for

convergent and discriminant validity. To account for the large number of correlations calculated

using this sample and in an effort to balance Type 1 and Type 2 error, only those with p < .01

were deemed significant. As predicted, the PHLMS Total score was moderately related to the

MAAS (r = .40, p < .0001) and the AAQ Acceptance subscale (r = .50, p < .0001), and it was

modestly correlated with flow (r = .23, p<.0001) and reflection (r = .23, p > .0001). The PHLMS

Total score showed a modest negative correlation with rumination (r = -.33, p < .0001) and a

moderate negative correlation with thought suppression (r = -.43, p < .0001). Although the

PHLMS Acceptance showed a large and significant correlation with the AAQ Acceptance

subscale (r = .54, p <.0001), it was found not to be related significantly to flow (r = .10, p =

.018). As predicted, the PHLMS Acceptance subscale showed a large negative correlation with

thought suppression (r = -.52, p < .0001) and a moderate negative correlation with rumination (r

= -.40, p < .0001). The PHLMS Awareness subscale correlated significantly at a modest level

with the MAAS (r = .21, p < .0001), and showed a moderate correlation with the construct

reflection (r = .36, p < .0001). However, contrary to predictions, the PHLMS Awareness

subscale showed a modest positive correlation with flow (r = .21, p < .0001). An unexpected

finding was that the MAAS was correlated more strongly with the PHLMS Acceptance subscale

(r = .32, p < .0001) than with the PHLMS Awareness subscale. See Table I5 in Appendix I for

list of correlations between the PHLMS, PHLMS Acceptance subscale, PHLMS Awareness

subscale, and other measures.

Discriminant Validity

Weak negative relationships were found between the PHLMS and social desirability.

The M-C SDS was weakly and negatively correlated with the PHLMS Total (r = -.18, p < .0001)

54and the PHLMS Acceptance subscale (r = -.13, p = .001), indicating higher mindfulness and

acceptance are weakly associated with less social desirability. There also was a weak relationship

between the PHLMS Awareness subscale and social desirability (r = -.10, p =.020), but the

correlation was not statistically significant at the p < .01 level. Partial correlations were

conducted between the PHLMS Total and subscale scores and the measures of depression and

anxiety, controlling for social desirability. See Table I6 in Appendix I for correlation values. In

sum, the relationship between the PHLMS and both depression and anxiety remained significant

after controlling for social desirability. Likewise, after controlling for social desirability, the

relationship between the PHLMS Acceptance subscale and both depression and anxiety remained

significant. There continued to be no relationship between depression and anxiety and the

PHLMS Awareness subscale after controlling for social desirability.

Relationship to Measures of Psychopathology

The PHLMS generally showed a negative relationship with measures of

psychopathology. Specifically, there was a moderate negative relationship between PHLMS total

score and depression (r = -.34, p < .0001) and a modest negative relationship with anxiety (r = -

.25, p < .0001). Similarly, the PHLMS Acceptance subscale was moderately and negatively

related to depression (r = -.35, p < .0001) and anxiety (r = -.33, p < .0001). However, the

PHLMS Awareness subscale did not correlate significantly with depression (r = -.08, p = .056) or

anxiety (r = .03, p =.538). See Table I6 in Appendix I for correlations between the PHLMS and

well-being variables.

Incremental validity was examined for the PHLMS Acceptance and Awareness subscales

to determine if the PHLMS subscales add to the predictive validity already provided by other

measures of constructs closely related to acceptance and awareness. Partial correlations were

conducted between the PHLMS Acceptance subscale and measures of psychopathology (i.e.,

BDI-II and BAI), controlling for acceptance (i.e., AAQ Acceptance subscale score) and thought

suppression (i.e., WBSI total score). The PHLMS Acceptance subscale showed small negative

55correlations with both depression and anxiety after controlling for acceptance and thought

suppression. Likewise, partial correlations were conducted between the PHLMS Awareness

subscale and measures of psychopathology, controlling for attention/awareness (i.e., MAAS total

score) and flow (i.e., FSS total score). There was no relationship between the PHLMS

Awareness subscale and depression and anxiety after controlling for attention/awareness as well

as after controlling for flow. See Table I6 in Appendix I for partial correlations.

Discussion

In sum, the results support the construct validity of the PHLMS as a bi-dimensional

measure of mindfulness. A second exploratory factor analysis supports a two-factor solution,

with awareness and acceptance items loading onto their respective subscale. The results support

adequate to good internal consistency and convergent and discriminant validation analyses

generally yielded expected results. Further the PHLMS total score and the PHLMS Acceptance

subscale were both negatively related to two mental health variables (i.e., depression and

anxiety), and these relationships were retained after controlling for social desirability. Further,

incremental validity was established for both the PHLMS and PHLMS Acceptance subscale using

a conservative approach (i.e., controlling for the same and related constructs). However, PHLMS

Awareness scores were not found to be related to depression or anxiety; this finding will be

further discussed in the General Discussion.

56CHAPTER 5: STUDY 4 – VALIDATION ANALYSES WITH A CLINICAL SAMPLE

Method

Participants

Fifty-two clinical outpatients (23 males, 29 females) were recruited from an urban

outpatient psychiatry clinic and participated in exchange for monetary compensation ($5.00).

The participants’ ages ranged from 18 to 80 years old, with a mean age of 40.78 years (SD =

12.04). Participants’ self-identified race was as follows: 67.3% Black/African-

American/Caribbean American, 7.7% Hispanic/Latino/Latina, 19.2% White/Caucasian/European

decent, and 5.8% multi-racial. Regarding participants’ marital status, 11.5% of participants were

married, 5.8% widowed, 30.8% divorced/annulled, 3.8% separate, 42.3% never married, 1.9%

chose “other” for marital status, and 3.8% of participants did not respond to this item. The

majority of participants’ did not receive education beyond 12th grade (highest level of education:

17.3% grade 6 or less; 34.6% grade 7 to 12; 13.5% graduated high school/high school equivalent;

19.2% part college; 3.8% graduated 2 year college; 5.8% graduated 4-year college; 1.9% part

graduate/professional school; 1.9% completed graduate/professional school; 1 participant did not

respond to this item). Regarding participants’ occupational status, 51.9% of participants were on

disability, 28.8% were unemployed, 11.5% were students, 1.9% had part-time employment, 1.9%

were retired, and 1.9% indicated “other” for primary occupation; 1 participant did not respond to

item regarding primary occupation.

Diagnostic information was obtained from the medical records of 48 participants;

diagnostic information was not available for 4 participants. One caveat of the diagnostic

information is that structured clinical interviews were not conducted; instead, patients’ diagnoses

were made by their primary therapist (i.e., psychiatrist, licensed clinical psychologist, licensed

clinical social worker, or masters-level clinician), and should therefore be regarded with

appropriate caution. Regarding participants’ primary diagnosis, 66.7% had a primary diagnosis

of a Mood Disorder, 10.4% had a primary diagnosis of a Psychotic Disorder, 8.3% had an

57Anxiety Disorder, 8.3% had a primary diagnosis of a Substance-Related Disorder, 4.2% had a

primary diagnosis of an Adjustment Disorder, and 1 participant had a primary diagnosis of Pain

Disorder Associated with Psychological Features. More than half (54.2%) of the sample had at

least 1 comorbid Axis I diagnosis. Examining all Axis I diagnoses, 79.2% had an Axis I

diagnosis of a Mood Disorder, 37.5% had a Substance-Related Disorder, 29.2% had an Anxiety

Disorder, 12.5% had a Psychotic Disorder, and 4.2% had an Impulse-Control Disorder; 1

participant had an Axis I diagnosis of Pain Disorder Associated with Psychological Features, 1

participant was diagnosed with Attention Deficit Hyperactivity Disorder, 1 participant with

Bereavement, and 1 participant was diagnosed with Partner Relational Problem. See Table J1 in

Appendix J for the number of individuals diagnosed with specific disorders within the disorder

classes listed above. 79.2% of participants’ Axis II diagnoses were deferred, 14.6% had no Axis

II diagnosis, and the remaining participants had traits, Personality Disorder NOS, or a rule-out

diagnosis on Axis II. 85.4% participants had at least 1 medical condition listed on Axis III, and

the majority of diagnoses (79.2%) were chronic medical illness (e.g., HIV, Hepatitis C, obesity,

asthma, migraines, hypertension, high cholesterol, pain, Crohn’s Disease, gastrointestinal reflux

disease, hearing impairment). All but 1 participant had at least 1 psychosocial stressor listed on

Axis IV (e.g., single parent, unemployment, housing issues, grief, history of abuse, legal

problems), with 37.5% of participants having two or more stressors. In sum, the clinical sample

largely consisted of minority participants with chronic mental illness, multiple physical and

psychosocial stressors, who do not have higher than a high school education and receive

disability or are unemployed.

58Measures and Predictions

The same measures and predictions were used as in Study 3.

Results

Measure Descriptives

The PHLMS total score ranged from 46 to 82, with a mean of 59.73 (SD = 7.17), the

PHLMS Acceptance subscale total score ranged from 12 to 37, with a mean of 24.62 (SD = 5.48),

and the PHLMS Awareness subscale total score ranged from 22 to 50, with a mean of 35.11 (SD

= 5.39). See Table J2 in Appendix J for PHLMS item means and standard deviations. MAAS

scores ranged from 17 to 90, and had a mean of 53.19 (SD = 15.30). The AAQ Total scores

ranged from 38 to 97, with a mean of 58.65 (SD = 10.76), the AAQ Acceptance subscale scores

ranged from 10 to 45, with a mean of 23.25 (SD = 6.58), and the AAQ Action scores ranged from

23 to 54, with a mean of 35.39 (SD = 6.70). The RRQ Rumination subscale scores ranged from

24 to 58, with a mean of 42.76 (SD = 7.40), and the RRQ Reflection subscales scores ranged

from 19 to 58 and had a mean of 36.38 (SD = 7.09). FSS scores ranged from 71 to 155 and had a

mean of 118.82 (SD = 20.60), WBSI scores ranged from 25 to 75 and had a mean of 56.65 (SD =

12.15), and the M-C SDS scores ranged from 74 to 126 and had a mean of 98.10 (SD = 12.09).

The mean BDI total score of 24.0 (SD = 15.86, range = 0 to 51) can be classified as “dysphoric-

depressed” and the mean BAI total score of 20.7 (SD = 16.25, range = 0 to 62) is classified as

“moderate.”

The PHLMS Awareness subscale (r = .65, p < .0001) and the PHLMS Acceptance

subscale (r = .67, p < .0001) were both significantly and moderately related to the PHLMS Total

score. However, there was not a significant relationship between the Acceptance and Awareness

subscales (r = -.13, p = .357).

Internal Consistency

Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and

Cronbach’s alpha coefficient) were conducted for the entire measure and each subscale. Internal

59consistency was minimally acceptable for the PHLMS (Cronbach’s alpha = .66), and it was

respectable for the Awareness subscale (Cronbach’s alpha = .75), and Acceptance subscale

(Cronbach’s alpha = .75).

Corrected item-to-total correlations were conducted within each subscale. For the

PHLMS Awareness subscale, corrected item-subscale total correlations ranged from .10 to .62,

and for the Acceptance subscale, corrected item-subscale total correlations ranged from .23 to

.65. See Table J3 in Appendix J for corrected item-subscale correlations for each item. Inter-

item correlations were calculated. For the PHLMS Awareness subscale, inter-item correlations

ranged from .01 to .60, and for the PHLMS Acceptance subscale, inter-item correlations ranged

from -.04 to .57. See Table J4 in Appendix J inter-item correlations.

Convergent Validity

Correlations of the PHLMS with others measures were conducted to assess for

convergent and validity and are shown in Table J5 in Appendix J. To account for the large

number of correlations calculated using this sample, only those reaching an alpha level of p < .01

were deemed significant. The PHLMS was found to be moderately correlated with the MAAS (r

=.43, p < .01), have a large correlation with flow (r =.52, p < .0001), and moderately negatively

correlated with thought suppression (r = -.39, p < .01) and rumination (r = -.37, p < .01).

Although the PHLMS showed a modest correlation with the AAQ Acceptance subscale (r = .29,

p = .039) a small correlation with the RRQ Reflection subscale (r = .16, p = .278), neither

correlation was significant at the conservative alpha level of p < .01. The PHLMS Acceptance

subscale was found to moderately negatively correlate with rumination (r = -.43, p <.01).

Although the PHLMS Acceptance subscale was moderately correlated with the AAQ Acceptance

subscale (r = .31, p = .025) and flow (r = .28, p = .049); although not quite reaching the

conservative alpha level of .01 established to protect family-wise error, these correlations

approached significance at that level and were significant at the conventional .05 level. Further,

the PHLMS Acceptance subscale showed a moderate negative correlation with thought

60suppression (r = -.35, p = .01). The PHLMS Awareness subscale moderately correlated with the

MAAS (r = .40, p <.01). However, contrary to predictions, the PHLMS Awareness subscale

positively correlated with flow (r = .41, p < .01).

Discriminant Validity

There was a modest correlation between the M-C SDS and the PHLMS (r = -.26, p =

.067); although the correlation did not reach the conservative alpha level of .01 established to

protect family-wise error, the correlation approached significance at the conventional .05 level.

Although there were small correlations between the PHLMS Acceptance subscale (r = -.15, p =

.309), and the PHLMS Awareness subscale (r = -.19, p = .186), the correlations were not

statistically significant. The relationship between the PHLMS total score and depression and

anxiety were not maintained after controlling for social desirability. Specifically, the partial

correlations between the PHLMS and depression (r = -.34, p = .020) and anxiety (r = -.34, p =

.017) approached significance at the conservative alpha level of .01, but were statistically

significant at the conventional .05 alpha level. In addition, the relationship between the PHLMS

subscales and depression and anxiety were not significant after controlling for social desirability.

See Table J6 in Appendix J for partial correlations between the M-C SDS and the PHLMS and its

subscales.

Relationship to Measures of Psychopathology

With regard to measures of psychopathology, the PHLMS was found to be moderately

negatively correlated with both depression (r = -.41, p < .01) and anxiety (r = -.42, p < .01).

However, neither PHLMS subscale was found to be related at the p < .01 level with depression or

anxiety; see Table J6 in Appendix J for correlations between the PHLMS and measures of

psychopathology.

Partial correlations between the PHLMS subscales and measures of psychopathology

(i.e., depression, anxiety) were conducted to assess incremental validity. There continued to be

no relationship between the PHLMS Acceptance subscale and depression and anxiety after

61controlling for acceptance variables (i.e., AAQ Acceptance subscale; WBSI total score).

Likewise, there was no relationship between the PHLMS Awareness subscale and depression and

anxiety after controlling for awareness variables (i.e., MAAS total score; FSS total score). See

Table J6 in Appendix J for correlations between the PHLMS and measures of psychopathology.

Cross Validation with Student Sample

Cross validation analyses were conducted between the student validation and clinical

samples to examine differences in responses. No differences for gender between both samples

were found (χ² (1, N = 605) = .40, p = .525). However, there were significant differences

between samples for race (χ² (6, N = 610) = 162.27, p < .0001), as the majority of participants in

the student sample were White and the majority of participants in the clinical sample were

Black/African American/Caribbean American. The clinical participants also were significantly

older than the student participants (t(50.8) = -12.21, p <.0001). As expected, significant

differences were found between the student and clinical samples for the PHLMS Total score

(t(609) = 6.75, p < .0001), PHLMS Acceptance subscale (t(609) = 6.62, p < .0001), and PHLMS

Awareness subscale (t(609) = 2.14, p < .05), with student participants showing higher levels of

mindfulness (PHLMS Total score mean difference of 7.11), acceptance (PHLMS Acceptance

subscale mean difference of 5.57), and awareness (PHLMS Awareness subscale mean difference

of 1.54). A 2 (groups) by 2 (subscale) mixed factorial ANOVA with repeated measures on the

latter factor was conducted to examine if the difference between the student and clinical samples

was larger for the Acceptance subscale than the Awareness subscale. The main effect for group

was significant (F(1,609) = 213.44, p < .0001) indicating that students generally scored

significantly higher than clinical participants. A main effect for type of measure was found

(F(1,609) = 45.58, p < .0001) indicating that awareness scores were generally higher than

acceptance scores. Further, the interaction was significant (F(1,609) = 12.06, p = .001),

indicating that students scored significantly higher on acceptance than awareness.

62 Cross validation analyses also were conducted for the other measures. The clinical

sample was significantly more depressed (t(51.9) = -7.09, p < .0001) and anxious (t(53.54) = -

4.89, p < .0001) than the student normative sample. The student normative sample scored

significantly higher on the AAQ Acceptance subscale (t(609) = 7.26, p < .0001), the MAAS

(t(55.5) = 2.22, p < .05), on the FSS (t(608) = 4.11, p < .0001), and on the RRQ Reflection

subscale (t(65.8) = 2.13, p <.05). Results also indicate that the clinical sample had higher levels

of thought suppression (t(607) = -6.72, p < .0001). However, no significant differences were

found between both samples for reflection or social desirability.

Discussion

In summary, the PHLMS showed good internal consistency within a clinical sample. In

addition, similar to the student sample, the PHLMS Awareness and Acceptance subscales were

not correlated. However, correlations with related measures did not entirely provide evidence for

convergent and discriminant validity within this sample. Further, although mindfulness was

found to be negatively related to both depression and anxiety, the individual subscales were not

(although they approached significance for several measures). However, significant differences

on the PHLMS and its subscales were found between nonclinical and clinical participants,

indicating that the measure can distinguish between groups expected to differ in levels of

mindfulness, awareness, and acceptance.

63CHAPTER 6: GENERAL DISCUSSION

One purpose of the present project was to develop and provide initial validation of a

theoretically-based self-report measure of mindfulness. The psychometric evidence suggests that

the PHLMS adequately measures mindfulness and its key constituents, acceptance and

awareness. Content validation by expert judges, experienced researchers of mindfulness and

related constructs, yielded high ratings of the representation of the components of mindfulness. A

clear two-factor solution was demonstrated in the initial nonclinical sample and confirmed in a

second nonclinical sample. Further, good internal consistency was demonstrated in both clinical

and nonclinical samples.

The second aim of the present research was to create an operational definition of

mindfulness based on its constituents. The two-factor solution supports a bi-dimensional

conceptualization of mindfulness. Further, since there are individual differences in mindfulness

but levels of mindfulness can change at any given time, the current project conceptualizes

mindfulness as a quasi-trait. Thus, the following operational definition of mindfulness is

proposed: Mindfulness is the tendency to be highly aware of one’s internal and external

experiences in the context of an accepting, nonjudgmental stance toward those experiences.

Relationships Between the PHLMS and Other Constructs

Relationships with other constructs were largely as expected within the normative

nonclinical sample. The PHLMS was related to measures of awareness, acceptance, flow and

reflection, and negatively correlated with measures of thought suppression and rumination. As

predicted, the PHLMS Acceptance subscale was found to be positively related to measures of

acceptance and negatively related to rumination and thought suppression, but contrary to

expectations, the Acceptance subscale was not found to be related to flow. As predicted, the

PHLMS Awareness subscale was related to measures of awareness and reflection. In addition,

contrary to expectations, it was related to flow.

64An interesting finding was the relationship between the PHLMS Acceptance subscale and

the MAAS, which was slighter stronger than the relationship between the PHLMS Awareness

subscale and the MAAS. Brown and Ryan (2003, 2004) created the MAAS to be a dispositional

measure of mindfulness, which they conceptualize to be an open or receptive attention to and

awareness of ongoing events and experience. These authors initially developed a measure of

mindfulness with two factors, presence (i.e., attention/awareness) and acceptance. However,

validation analyses showed that the acceptance factor did not provide explanatory advantage over

that shown by the presence factor alone, which led them to conclude that acceptance, as a distinct

construct, is redundant in mindfulness. Therefore, items from the presence factor only were used

to form the MAAS. Although Brown and Ryan (2003) state that items with attitudinal

components (e.g., acceptance, empathy, trust) were purposefully excluded in the presence factor,

the presence and acceptance factors were moderately correlated in the .20 to .35 range across

several samples (Brown and Ryan, 2004). Thus, although the face validity of the items suggests

that the MAAS only measures awareness/attention, unlike the PHLMS, it confounds awareness

and acceptance; MAAS items appear to reflect accepting awareness. On the other hand, the

PHLMS subscales were not correlated, indicating that acceptance and awareness are separate

constituents of mindfulness and can be examined individually. Since the MAAS appears to

measure acceptance-oriented awareness, it is not surprising that it correlated with both PHLMS

subscales.

Although relationships with other constructs were largely as expected within the

normative sample, some predictions were not supported by results from the clinical sample.

There was a relationship between the PHLMS and measures of awareness and flow, and there

was a negative relationship with rumination. However, contrary to expectations, the PHLMS was

not related to the AAQ Acceptance subscale, a measure of acceptance. The PHLMS Acceptance

subscale was only found to be negatively related to rumination; other predictions for this subscale

with regard to convergent and discriminant validity were not supported. Likewise, the PHLMS

65Awareness subscale was found to be positively related to both awareness and flow, even though it

was expected that the PHLMS Awareness subscale would be negatively related to flow. Further,

although the PHLMS was found to be negatively correlated with both depression and anxiety,

none of the relationships between the PHLMS subscales and variables of mental health (i.e.,

depression and anxiety) were significant, and the relationships between the PHLMS and

depression and anxiety were not maintained after controlling for social desirability. Since a

relationship was found between overall mindfulness and depression and between overall

mindfulness and anxiety, but no relationship was found between acceptance or awareness with

depression and anxiety, the results suggest that awareness and acceptance together may be related

to mental illness. However, there are limitations to these results that reduce confidence in these

findings. Given the small size of the clinical sample, post-hoc power analyses reveal a power of

11% (using a small effect size), which reduced the ability to detect significant results between the

PHLMS subscales and mental health variables. Another reason for the lack of relationship

between acceptance and awareness with the mental health variables in the clinical sample could

be that the scope of the measures of depression and anxiety may have been too limited to measure

general psychopathology or mental health. Results indicate that the clinical participants only had

moderate levels of anxiety, and only 50% of the sample had a diagnosis of a mood and/or anxiety

disorder. Future research should consider examining more inclusive inventories of psychiatric

symptoms, measures of adaptive functioning, or both.

Differences Between the Nonclinical and Clinical Samples

Even though results from some of the clinical sample validation analyses were contrary

to expectations, as predicted, significant differences were found between the nonclinical and

clinical samples. Comparison of these groups showed significantly lower scores of mindfulness,

acceptance, and awareness in the clinical population, providing additional support for the

relationship between mindfulness and mental health. However, the reason for the difference in

mindfulness, acceptance, and awareness between these samples remains unclear. Future research

66should examine the differences in mindfulness between normative and clinical populations,

controlling for variables such as socioeconomic status and education to elucidate the relationship

between mindfulness and mental health.

Implications for a Bi-dimensional Conceptualization of Mindfulness

Without a scientific understanding of psychological processes, data on technologies can

collect and form an ever-expanding list. As Hayes and Wilson (2003) note, “mindfulness is

currently in a somewhat similar situation. The procedure is being specified, and there are data

supportive of its impact…but its scientific analysis is just beginning. No scientific analysis yet

seems adequate to account for the impact of mindfulness” (p. 161). Several of the new “third-

wave” therapies (e.g., Mindfulness-Based Stress Reduction; Mindfulness Based Cognitive

Therapy) include mindfulness as a central component and link the benefits of these treatments to

mindfulness, but how mindfulness may be working to reduce symptoms and increase

psychological well-being has not been empirically examined. Thus, from a scientific perspective,

it is important to question the assumption that the construct of mindfulness as described in pre-

scientific writings has beneficial effects. It also will be important to deconstruct the global idea

of “mindfulness” in order to examine empirically its constituents. Further, it will be important to

separate mindfulness from its association with meditation. Due to its history, mindfulness, even

as a process, is often linked to the practice (i.e., technique) of mindfulness meditation (e.g.,

Bishop et al., 2004). However, any method that increases awareness and acceptance

simultaneously should be considered a mindfulness method, which allows for new techniques to

be developed and empirically tested. For these reasons, the present study attempted to examine

the construct of mindfulness through the lens of science in order to determine its composition and

which of those components are related to psychological functioning.

One important finding from the present research was that the two subscales of the

PHLMS were not correlated with each other in either sample. These results suggest that

awareness can be disambiguated from acceptance. In the development of the MAAS, Brown &

67Ryan (2003, 2004) discuss how acceptance as a distinct construct is functionally redundant in

mindfulness. Although results from their research supported a two-factor conceptualization of

mindfulness, consisting of presence (i.e., awareness and attention) and acceptance, they report

that the acceptance factor did not provide any explanatory advantage over the presence factor

alone. Brown and Ryan (2004) further describe how they operationally defined mindfulness as

“an open or receptive attention to and awareness of ongoing events and experience” (p. 245), and

that mindfulness subsumes an acceptance of what occurs. However, confounding the two

components of mindfulness not only questions whether the beneficial effects of increased

mindfulness are due to increased awareness, increased acceptance, or both, but the individual

effects of acceptance and awareness in theoretical models of psychopathology become obscured.

Consideration of the construct of mindfulness and its constituent components suggests

alternative theoretical mechanisms than those found in traditional cognitive behavior therapies.

One exemplar of these mechanisms is seen in an acceptance-based model of social anxiety

disorder recently proposed by Herbert and Cardaciotto (in press). The figure in Appendix K

illustrates how phobic social situations, in the context of a predisposition toward social anxiety,

produce both physiological arousal and negative thoughts related to social evaluation. As

anxiety-related feelings and thoughts are elicited, they in turn trigger an increase in internal

awareness and a decrease in awareness of external cues (i.e., self-focused attention). At this next

stage, the acceptance component is critical; the effects of increased awareness of internal arousal

will depend upon the individual’s level of acceptance. In the context of a high level of

acceptance, the cognitive and physiological arousal is noticed without attempts to control, escape

from, or avoid it, resulting in minimal impact on behavioral performance. On the other hand, in

the context of low acceptance, strategies (e.g., rationalizing thoughts, distraction techniques,

thought suppression) are attempted in order to control or alter the form and/or frequency of

thoughts and feelings, and even though these strategies sometimes work temporarily, they often

fail. For example, thought suppression has been related to heightened pain experience (Sullivan,

68Rouse, Bishop, & Johnston, 1997), increased anxiety (Koster, Rassin, Crombez, & Naring, 2003),

and poorer ratings of quality of sleep (Harvey, 2003). Further, not only do attempts to control or

alter one’s private experiences often fail, but they can paradoxically lead to even further increases

in anxiety-related arousal. This vicious cycle of increased arousal, increased awareness, and

further efforts at experiential avoidance and/or control can produce behavior disruption, as one is

preoccupied with controlling unpleasant thoughts and feelings, which may lead to further

attempts at experiential avoidance and/or control. Thus, even though both awareness and

acceptance are included in the model by Herbert and Cardaciotto, acceptance is proposed to be

the construct that provides beneficial or protective effects.

Results from the present research support predictions about the differential effects of

awareness and acceptance. In the second nonclinical sample, whereas lower levels of depression

and anxiety were found to be related to higher levels of acceptance, awareness was found not to

be related to depression and anxiety. In addition, although the nonclinical sample had

significantly higher levels of both awareness and acceptance relative to the clinical sample, the

magnitude of the difference between the clinical and nonclinical mean awareness scores and both

samples’ mean acceptance scores was significantly different: the magnitude of difference was

greater for the samples’ mean acceptance scores, which supports its unique role in positive mental

health. Although these results are preliminary and are in need of replication and extension, they

are highly provocative and warrant further investigation. Thus, confounding awareness and

acceptance in the investigation of mindfulness may obscure their individual effects in the etiology

or maintenance of psychopathology. Further, the PHLMS provides a way to study these

differential effects, which did not exist until now.

Clinical Implications

Although the PHLMS was developed for both clinical and research purposes, its use in

clinical settings may be premature at this time. Findings from the present study do warrant future

research to explore the utility of the PHLMS with psychiatric populations. Specifically, higher

69levels of mindfulness in clinical patients were found to be associated with less depression and

anxiety. Higher levels of mindfulness were also related to lower levels of thought suppression

and rumination, two processes associated with psychopathology (e.g., Purdon, 1999; Thomsen,

Mehlsen, Christensen, & Zachariae, 2003). In addition, higher levels of acceptance were also

related to less rumination. If future research not only further validates the PHLMS with clinical

populations but confirms the differential role of acceptance in psychopathology, the measure may

be useful clinically, especially to track patients’ progress in “third wave” acceptance- and

mindfulness-based treatments.

Limitations

Several limitations of this research should be noted. As previously discussed, limitations

include the lack of statistical power needed to detect significant results with regard to the clinical

sample, as well as the limited scope of mental health measurement. Another limitation concerns

the construct and measurement of flow. First, the FSS was designed to be used immediately or

soon after a flow experience; however, the current project modified the FSS instructions so that a

retrospective approach to data collection could be taken, asking participants to recall a recent

flow experience. Responses may have been influenced by the passing of time, as participants

may have not been able to recall accurately their experiences that previously occurred during the

flow experience. Second, although the FSS has shown good internal consistency, validation data

is quite limited, questioning the utility of the measure. The third limitation concerns the

conceptualization of flow. Although it was predicted that the Acceptance subscale would be

positively related to flow and the Awareness subscale would be negatively related to flow, these

results were not found, and instead, the Awareness subscale was found to be positively correlated

with flow in both the nonclinical and clinical samples. The current project conceptualized flow as

consisting of high levels of acceptance and low levels of awareness. Although this

conceptualization is consistent with several of the dimensions of flow (i.e., “action-awareness

merging,” in which there is no awareness of self as separate from the actions one is performing;

70“loss of self-consciousness,” in which lack of focus on the information normally used to represent

to oneself who one is), flow is also characterized as including “intense and focused concentration

on what one is doing in the present moment” (Nakamura & Csikszentmihalyi, 2002, p. 90).

Several items on the FSS capture this quality of heightened attention (e.g., “My attention was

focused on what I was doing;” “It was no effort to keep my mind on what was happening”),

which may be related to certain awareness items on the PHLMS. To conduct convergent and

discriminant validation analyses, further studies should find other means of measuring high levels

of acceptance during decreased present-moment awareness.

The inclusion of solely reverse items on the PHLMS Acceptance subscale also may be a

limitation. Although direct-scored items were generated, they were eliminated after content

validity ratings by expert judges, factor analytic procedures, and internal consistency analyses.

Similar occurrences were reported by Brown and Ryan (2003) in the development of the MAAS,

in which the entire measure is reverse-scored, and by Baer et al. (2004) in the development of the

KIMS, in which one of four subscales is reverse-scored. Brown and Ryan demonstrated that the

indirect and direct measurement of their conceptualization of mindfulness were conceptually and

psychometrically equivalent, and noted that statements reflecting less mindfulness may be easier

for individuals to access and rate. Further, since it was the “Accept without Judgment” subscale

that is reverse-scored in the KIMS, Baer et al. propose that the lack nonjudgmental attitude

toward one’s private experiences may also be easier to recognize and report.

Although using student participants as normative samples to examine factor structure and

to conduct validation studies may be another limitation, research suggests that meaningful

variations in mindfulness can be shown in populations without meditation experience (Baer et al.,

2004; Brown & Ryan, 2003; Kabat-Zinn, 2003). This notion is supported by the present project,

in that relationships between mindfulness, acceptance, and awareness and other constructs were

found within the student sample. Since the results from the small clinical sample included in the

present project are limited, a high priority for future research should be to conduct further

71validation analyses with larger clinical samples to examine the potential utility of the PHLMS in

clinical populations. In addition, the PHLMS should be validated with individuals who have

extensive experience with mindfulness (e.g., regular mindfulness meditators), to provide further

evidence that the measure can discriminate between groups expected to differ in degree of

mindfulness.

Directions for Future Research

There are several other directions for future research to be considered. For example,

predictive validity could be conducted by examining whether training in mindfulness or receiving

a mindfulness-based therapy results in higher PHLMS scores. These scores should also be

compared to changes in mindfulness scores after receiving a non-mindfulness-based

psychotherapy. Further, the PHLMS could be used to address the larger question of mechanisms

of action not only in mindfulness-based therapies, but in non-mindfulness-based treatments as

well. For example, Teasdale et al. (2001) proposed that traditional cognitive therapy may prevent

depressive relapse by training patients to change the way in which depression-related material is

processed and the relationship patients have with dysfunctional thoughts, rather than by changing

belief in the thought content. This suggests that mindfulness could be a mechanism of action in

non-mindfulness-based treatments as well. Until now, research has not clearly distinguished the

two components of mindfulness; the present research is the first to clearly disentangle these

components. Future research is needed to follow up on the results suggesting that the acceptance

component is related to beneficial outcomes. Lastly, future research could examine the

relationship of awareness of internal and external stimuli; although one might expect them to

correlate, increased awareness of internal stimuli may lead to decreased awareness of external

stimuli.

Conclusion

There is a marked increased in interest surrounding the construct of mindfulness in

clinical psychology, particularly in the development and study of psychological interventions that

72include mindfulness as a central component. However, there is still no accepted definition of

mindfulness, and the construct has not been sufficiently operationalized. As acceptance and

present-moment awareness appear to be central components of mindfulness (as most definitions

of mindfulness in clinical psychology and mindfulness-based interventions explicitly include

these concepts), we propose a conceptualization of mindfulness consisting of both acceptance and

awareness. Further, the present project provides support for the use of the PHLMS to measure

this construct and its two constituent components. Defining mindfulness as the tendency to have

acceptance, a nonjudgmental stance towards one’s experience, and awareness, a continuous

monitoring of ongoing internal and external stimuli, along with the development of the PHLMS

based on this conceptualization, sets the stage for the scientific investigation of this ancient

construct.

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87Appendix A: Definitions of Mindfulness

Table A1

Clinical Definitions of Mindfulness

Author Definition Baer (2003) The nonjudgmental observation of the ongoing stream of

internal and external stimuli as they arise (p. 125) Boorstein, S. (1983) Technique that focuses precisely on each thought or

affect as it arises in consciousness. (p. 176) Epstein (1995) Mindful attention: Pay precise attention, moment by

moment, to exactly what you are experiencing, right now, separating out your reactions from the raw sensory events

Hayes & Wilson (2003) Set of techniques (that is, a method) designed to encourage deliberate, nonevaluative contact with events that are here & now. (p. 163)

Kabat-Zinn (1990) Nonjudgmental moment-to-moment awareness Kabat-Zinn (1994) Paying attention in a particular way: on purpose, in the

present moment, and nonjudgmentally. (p. 4) Kabat-Zinn (2003) Awareness that emerges through paying attention on

purpose, in the present-moment, and nonjudgmentally to the unfolding of experience moment by moment (p. 145)

Marlatt & Kristeller (1999) Bringing one’s complete attention to the present experience on a moment-to-moment basis

Martin (1997) A state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view. (pp. 291-292)

Miller, Fletcher, Kabat-Zinn (1995) A universal human attribute in that it has to do with a particular way of paying attention…The effort to pay attention, nonjudgmentally, to present-moment experience and sustain this attention over time…Witness-like observing and self-reporting of the moment by moment unfolding of one’s experience. (p. 193)

Robins (2002) Nonjudgmental awareness of one’s experience as it unfolds moment by moment. (p. 55)

Toneatto (2002) Mindful attention: the primary and most effective tool taught by the Buddha for reducing or correcting the tendency to engage in erroneous metacognitive activity. In mindful attention, the client is encouraged to observe the display of cognitive events occurring within ordinary awareness (the everyday, untrained mind) but refrain from engaging in any metacognitive (i.e., judgmental activity). (p. 76)

88Table A2

Non-Clinical Definitions of Mindfulness

Author Definition Social Psychology Literature

Brown & Ryan (2003) State of being attentive to and aware of what is taking place in the present; enhanced attention to and awareness of current experience or present reality. (p. 822)

Langer (1989a) Sensitivity to or awareness of contexts Langer (1992) A state of conscious awareness characterized by active

distinction drawing that leaves the individual open to novelty and sensitive to both context and perspective. (p. 289)

Langer (2000) Actively drawing distinctions and noticing new things—seeing the familiar in the novel and the novel in the familiar. (p. 222)

Langer (2002) A flexible state of mind—an openness to novelty, a process of actively drawing novel distinctions. (p. 214)

Langer & Moldoveanu (2000) Process of drawing novel distinctions. It does not matter whether what is noticed is important or trivial, as long as it is new to the viewer. Actively drawing these distinctions keeps us situated in the present. It also makes us more aware of the context and perspective of our actions than if we rely upon distinctions and categories drawn in the past. (pp. 1-2)

Philosophical/Spiritual LiteratureBraza (1997) Mindfulness is a technique that teachers intent alertness. It

means becoming fully aware of each moment and of your activity in that moment. (p. 5)

Gunaratana (1991) Mindfulness is mirror-thought. It reflects only what is presently happening and in exactly the way it is happening. There are no biases. Mindfulness is non-judgmental observation. It is the ability of the mind to observe without criticism. (p. 151)

Hanh (1976) Keeping one’s consciousness alive to the present reality. (p. 11)

Harvey (2000) A kind of bare attention which sees things as if for the first time…as they really are. (p. 246)

Hirst (2003) Requires the person to attend, to be consciously aware of, the emergent nature of phenomena in consciousness and to recognize the nature of attachments made to these phenomena as they occur; Awareness of being aware. (p. 360)

Horowitz (2002) Attention to the experienced qualities of the self in the present moment and space rather than being preoccupied with what happened in the past or fantasies in the distant futures. (p. 125)

Tart (1994) Complex, open, honest awareness of everything all of the time. (p. 26)

Thera (1972) The clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception. (p. 5)

89Appendix B: Mindfulness Qualities Defined by Kabat-Zinn (1990)

Quality Definition Nonjudging Impartial witnessing, observing the present

moment-by-moment without evaluation and categorization

Nonstriving Non-goal oriented, remaining unattached to outcome or achievement, not forcing things

Acceptance Open to seeing and acknowledging things as they are in the present moment; acceptance does not mean passivity or resignation, rather a clearer understanding of the present so one can more effectively respond

Patience Allowing things to unfold in their time, brining patience to ourselves, to others, and to the present moment

Trust Trusting both oneself, one’s body, intuition, emotions, as well as trusting that life is unfolding as it is supposed to

Openness Seeing things as if for the first time, creating possibility by paying attention to all feedback in the present moment

Letting go Non-attachment, not holding onto thoughts, feelings, experiences; however, letting go does not mean suppressing

Gentleness Characterized by a soft, considerate and tender quality; however, not passive, undisciplined or indulgent

Generosity Giving into the present moment within a context of love and compassion, without attachment to gain or thought of return

Empathy The quality of feeling and understanding another person’s situation in the present moment—his or her perspectives, emotions, actions (reactions)—and communicating this to the person

Gratitude The quality of reverence, appreciating and being thankful for the present moment

Lovingkindness A quality of embodying benevolence, compassion and cherishing, a quality filled with forgiveness and unconditional love

Note. Excerpted from “The role of intention in self-regulation: Toward intentional systemic

mindfulness,” by S. L. Shapiro and G. E. Schwartz, 2000, In M. Boekaerts, M. Zeidner, & P. R.

Pintrich (Eds.), Handbook of self-regulation, p. 263.

90Appendix C: List of Measures of Mindfulness and Related Constructs

Measure Author Intended Use Limitation Acceptance and Action Questionnaire (AAQ)

Hayes (1996) Measures the ability to accept undesirable internal events while continuing to pursue desired goals

Only measures the acceptance component of mindfulness

Cognitive Affective Mindfulness Scale (CAMS)

Feldman, Hayes, Kumar, & Greeson (2004)

Measures awareness, attention, present-focus, & nonjudgment/acceptance

Only assesses thoughts & feelings; does not assess other phenomena

Freiburg Mindfulness Inventory (FMI)

Buchheld, Grossman, & Walach (2001)

Measures nonjudgmental present-moment observation & openness to negative experience

Designed for use with experienced meditators

Kentucky Inventory of Mindfulness Skills (KIMS)

Baer, Smith, & Allen (2004)

Measures four mindfulness skills: observing, describing, acting with awareness, accepting without judgment

Most similar to mindfulness as it is taught in DBT

Meta-Cognitions Questionnaire (MCQ)

Cartwright-Hatton & Wells (1997)

Measures beliefs about worry and intrusive thoughts

Domain-specific to generalized anxiety disorder

Metacognitive Awareness Inventory (MAI)

Schraw & Dennison (1994)

Measures metacognitive awareness (i.e., knowledge of cognition and regulation of cognition)

Domain specific to learning performance

Metacognitive Awareness Questionnaire (MAQ)

Teasdale et al. (2001) Measures the extent that negative thoughts and feelings do not reflect reality when depressed

Domain-specific to depression

Mindful Attention Awareness Scale (MAAS)

Brown & Ryan 2003) Measures present-centered attention-awareness

Only assesses present-moment attention and awareness; excludes attitudinal components (e.g., acceptance)

Rumination-Reflection Questionnaire (RRQ)

Trapnell & Campbell (1999)

Distinguishes neurotic from inquisitive self-focus

Measures the extent to which individuals analyze the “self” rather than internal experiences of the self

Self-Consciousness Scale (SCS)

Fenigstein et al. (1975) Measures individual differences in self-consciousness

Focuses solely on thoughts about the self without including components of acceptance

Self-Monitoring Scale (SM)

Snyder (1974) Measures concern for social appropriateness, sensitivity to the expression and self-presentation of others, and use of cues to monitor self-expressive behaviors

Specific to the observation of expressive behavior and self-presentation

Self Reflection and Insight Scale (SRIS)

Grant, Franklin, & Langford (2002)

Measures internal state and self-reflection

Only measures reflection on internal state awareness

Toronto Mindfulness Scale (TMS)

Bishop et al. (2003) Measures attainment of a mindfulness state immediately following a meditation exercise

Cannot be used outside of mindfulness meditation training

91Appendix D: Illustration of the Four Psychological States

ΑωαρενεσHigh

High

Low

Low

Mindfulness “Flow”

Unsuccessful Experiential Avoidance/ Control

Successful Experiential Avoidance/ Control

Αχχεπτανχ

Αωαρενεσσ

Αχχεπτανχ

92Appendix E: List of Items and Procedures Administered to Expert Judges

PART I – AWARENESS ITEMSAwareness: the continuous monitoring of ongoing internal and external stimuli Acceptance: nonjudgmental stance toward one’s experience Please rate how well the following items reflect awareness AND acceptance according to the definitions above. Reverse scored items (e.g., “I finish a meal and realize I did not notice tasting the food”) should be rated for how well they would discriminate awareness from non-awareness (and acceptance from non-acceptance). In other words, if you judge an item to reflect either very low or very high awareness, please assign it a relatively high ranking. 1 2 3 4 5 Very Poor Poor Fair Good Very Good Awareness Acceptance

_____ _____ When the room is quiet, I hear sounds like a clock ticking or air

coming out of the vents.

_____ _____ I notice when I’m hungry.

_____ _____ I analyze what I do and why I do them.

_____ _____ I notice my surroundings when walking down the street.

_____ _____ I block out sound when I’m focused on an activity.

_____ _____ I can tell when I feel anxious because of changes inside my body.

_____ _____ I am always thinking something.

_____ _____ I am aware of what thoughts are passing through my mind.

_____ _____ I have a keen sense of smell.

_____ _____ I don’t know what mood I am in until after it has passed.

_____ _____ When I am focused on a task, I am not aware of what I am thinking

or feeling.

_____ _____ I am aware of thoughts I’m having when my mood changes.

_____ _____ When I wake up in the morning, I take time to process my thoughts.

_____ _____ During my last meal, I was aware of the texture of the food I was

eating.

_____ _____ When talking with other people, I am aware of their facial and body

expressions.

_____ _____ When talking with other people, I am aware of the emotions I am

experiencing.

93Awareness Acceptance

_____ _____ I often react to a situation without knowing where my emotions are

coming from.

_____ _____ I take time in my daily routine to consider my feelings and

emotions.

_____ _____ When I listen to music, I pay attention to all aspects (words, tune,

rhythm).

_____ _____ When I shower, I am aware of how the water is running over my

body.

_____ _____ When I am startled, I notice what is going on inside my body.

_____ _____ I am a sensitive person.

_____ _____ I experience physical symptoms when experiencing an emotion.

_____ _____ I feel a broad range of emotions.

_____ _____ I feel very few emotions.

_____ _____ Whenever my emotions change, I am conscious of them

immediately.

_____ _____ I daydream a lot.

_____ _____ When someone asks how I am feeling, I can identify my emotions

easily.

_____ _____ I get startled easily.

_____ _____ I notice how my thoughts influence my emotions.

_____ _____ I finish walking or driving a short distance and realize I did not

notice the journey.

_____ _____ I finish a meal and realize I did not notice tasting the food.

_____ _____ I often do not hear what someone has told me even though I was

having a conversation with them.

_____ _____ I notice how my mood is affected by the food I eat.

_____ _____ When my mood changes, I notice the event or the thought that

caused it to change.

_____ _____ I think more about what happened before and what might happen

later than what is happening right now.

_____ _____ I notice that my mind is constantly “thinking.”

_____ _____ Sometimes I feel anger or sadness without knowing what caused

it.

_____ _____ I do things without paying much attention.

_____ _____ I rush through activities without paying attention to what I’m doing.

94Awareness Acceptance _____ _____ I do many tasks like I am on “auto-pilot.”

_____ _____ I am aware of my emotions.

_____ _____ I realize I'm experiencing an emotion as soon as I have it.

_____ _____ When I feel sad, I am conscious of it.

_____ _____ I am sensitive to a change in my emotions.

_____ _____ I can tell how my behavior is affecting others.

_____ _____ When I get scared, I feel my muscles tense up.

_____ _____ When I go outside, I notice my surroundings.

_____ _____ When I do something I enjoy, hours pass without me noticing.

_____ _____ I notice changes inside my body, like my heart beating faster or my

muscles getting tense.

_____ _____ When I walk outside on a sunny day, I notice how the sun feels on

my skin.

_____ _____ I become absorbed into whatever task I am working on.

_____ _____ I notice how my thoughts and emotions feel inside my body.

_____ _____ When I walk outside, I am aware of smells or how the air feels

against my face.

_____ _____ Compared to most people I am very perceptive of my surroundings.

95PART II – ACCEPTANCE ITEMS Acceptance: nonjudgmental stance toward one’s experience Awareness: the continuous monitoring of ongoing internal and external stimuli Please rate how well the following items reflect acceptance AND awareness according to the definitions above. Reverse scored items (e.g., “If I have unpleasant thoughts or feelings, I try to get rid of them”) should be rated for how well they would discriminate acceptance from non-acceptance (and awareness from awareness). In other words, if you judge an item to reflect either very low or very high acceptance, please assign it a relatively high ranking. 1 2 3 4 5 Very Poor Poor Fair Good Very Good Awareness Acceptance _____ _____ When I don’t want to think of something, I try to push the thoughts

out of my head.

_____ _____ If I have unpleasant thoughts or feelings, I try to get rid of them.

_____ _____ It is okay to have unpleasant thoughts or feelings.

_____ _____ Feeling anxious or depressed is something to be concerned

about.

_____ _____ If I feel pain, I don’t do anything to make it go away.

_____ _____ I don’t like feeling down or sad.

_____ _____ If I have an itch, I will do anything to scratch it.

_____ _____ When I have a bad memory, I try to distract myself to make it go

away.

_____ _____ I don’t mind feeling too hot or too cold.

_____ _____ It’s okay to be anxious.

_____ _____ It’s normal for thoughts and feelings to come and go.

_____ _____ I harp on the negative events that happened to me that day.

_____ _____ When something does not go as planned, I can accept the results for

what they are.

_____ _____ I feel okay with the negative experiences in my life.

_____ _____ When I think of the accomplishments in my life, I can accept them

for what they are.

_____ _____ Events that cause pain are okay.

_____ _____ It’s okay when someone lets me down.

_____ _____ I enjoy being with people who are different than I am.

96Awareness Acceptance _____ _____ I feel unlucky, as if I started life out a few cards short of the

deck.

_____ _____ I become angry when I think about my past.

_____ _____ My emotions get in the way of tasks I try to complete.

_____ _____ I sometime have to take a day off because of my emotional state.

_____ _____ I can feel sad, upset, or anxious and still do what I have to do.

_____ _____ I take medication or drink alcohol to escape my feelings.

_____ _____ It is important to control feelings like anxiety or anger.

_____ _____ I try to distract myself when I feel unpleasant emotions.

_____ _____ I can have negative thoughts without getting into a bad mood.

_____ _____ I can listen to criticism openly without reacting or getting defensive.

_____ _____ I don’t let feeling afraid or depressed stop me from doing the things

I want to do.

_____ _____ I try to change my mood if I don’t like it.

_____ _____ I wish I’d be able to stop thinking about things I’ve said in the past.

_____ _____ There are aspects of myself I don’t want to think about.

_____ _____ I put unwanted thoughts out of mind.

_____ _____ I try to put my problems out of mind.

_____ _____ There are things I try not to think about.

_____ _____ I have thoughts I try to avoid.

_____ _____ I try to stay busy to keep thoughts or feelings from coming to mind.

_____ _____ It is important always to feel happy or positive.

_____ _____ When I am standing outside and get cold, I try to do things to make

myself warmer.

_____ _____ I am comfortable with experiencing whatever emotion I'm feeling at

the time.

_____ _____ I feel like I'm flooded with emotions that I can't control.

_____ _____ I wish I could control my emotions more easily.

_____ _____ My emotions are too much for me to handle.

_____ _____ If there is something I don’t want to think about, I’ll try many

things to get it out of my mind.

_____ _____ Whenever I feel an extreme emotion, such as sadness or anger, I try

to stop it.

_____ _____ I tell myself that I shouldn’t feel sad.

_____ _____ I tell myself that I shouldn’t have certain thoughts.

97Awareness Acceptance

_____ _____ I avoid situations that will make me upset.

_____ _____ I do not tolerate situations I cannot change.

_____ _____ When I am outside and a cold wind blows, I do things so I won’t

feel cold.

98Appendix F: List of Retained Items and Expert Judges’ Mean Ratings

1 2 3 4 5

Very Poor Poor Fair Good Very Good

AWARENESS ITEMS

Mean Rating: Mean Rating: Awareness Acceptance 4.50 1.67 When the room is quiet, I hear sounds like a clock ticking or air

coming out of the vents.

3.83 1.33 I notice when I’m hungry.

4.33 1.67 I notice my surroundings when walking down the street.

4.50 2.00 I can tell when I feel anxious because of changes inside my

body.

4.67 2.17 I am aware of what thoughts are passing through my mind.

4.67 2.00 I am aware of thoughts I’m having when my mood changes.

4.83 2.00 During my last meal, I was aware of the texture of the food I was

eating.

5.00 2.00 When talking with other people, I am aware of their facial and

body expressions.

4.50 2.17 When talking with other people, I am aware of the emotions I am

experiencing.

4.33 1.83 When I listen to music, I pay attention to all aspects (words,

tune, rhythm).

4.83 1.83 When I shower, I am aware of how the water is running over my

body.

4.33 2.00 When I am startled, I notice what is going on inside my body.

994.33 2.17 Whenever my emotions change, I am conscious of them

immediately.

4.17 2.00 When someone asks how I am feeling, I can identify my

emotions easily.

4.17 1.40 I finish walking or driving a short distance and realize I did not

notice the journey.

4.33 1.40 I finish a meal and realize I did not notice tasting the food.

3.83 1.40 I often do not hear what someone has told me even though I was

having a conversation with them.

3.83 2.00 I notice how my mood is affected by the food I eat.

3.83 1.60 When my mood changes, I notice the event or the thought that

caused it to change.

4.17 1.40 I do things without paying much attention.

4.17 1.40 I rush through activities without paying attention to what I’m

doing.

4.17 1.40 I do many tasks like I am on “auto-pilot.”

4.33 1.80 When I feel sad, I am conscious of it.

4.50 1.40 I am sensitive to a change in my emotions.

4.17 2.00 When I get scared, I feel my muscles tense up.

4.33 2.00 I notice changes inside my body, like my heart beating faster or

my muscles getting tense.

4.50 1.83 When I walk outside on a sunny day, I notice how the sun feels

on my skin.

4.50 1.67 When I walk outside, I am aware of smells or how the air feels

against my face.

1003.83 1.33 Compared to most people I am very perceptive of my

surroundings.

101ACCEPTANCE ITEMS

Mean Rating: Mean Rating: Awareness Acceptance 2.00 4.33 When I don’t want to think of something, I try to push the

thoughts out of my head.

1.67 4.33 If I have unpleasant thoughts or feelings, I try to get rid of them.

1.67 4.67 It is okay to have unpleasant thoughts or feelings.

1.67 3.83 Feeling anxious or depressed is something to be concerned

about.

1.83 4.00 When I have a bad memory, I try to distract myself to make it go

away.

1.50 4.67 It’s okay to be anxious.

1.50 4.00 When something does not go as planned, I can accept the results

for what they are.

1.33 3.83 I feel okay with the negative experiences in my life.

1.33 4.00 When I think of the accomplishments in my life, I can accept

them for what they are.

1.67 3.83 Events that cause pain are okay.

1.67 4.17 I take medication or drink alcohol to escape my feelings.

1.67 4.17 It is important to control feelings like anxiety or anger.

1.67 4.17 I try to distract myself when I feel unpleasant emotions.

2.17 4.17 I can have negative thoughts without getting into a bad mood.

1.83 4.17 I don’t let feeling afraid or depressed stop me from doing the

things I want to do.

1.67 3.83 There are aspects of myself I don’t want to think about.

2.00 4.17 I put unwanted thoughts out of mind.

1.67 4.00 I try to put my problems out of mind.

1021.67 4.00 There are things I try not to think about.

1.83 4.17 I have thoughts I try to avoid.

1.67 4.17 I try to stay busy to keep thoughts or feelings from coming to

mind.

1.33 4.50 It is important always to feel happy or positive.

1.50 4.00 I wish I could control my emotions more easily.

1.67 4.17 If there is something I don’t want to think about, I’ll try many

things to get it out of my mind.

2.17 4.33 Whenever I feel an extreme emotion, such as sadness or anger, I

try to stop it.

1.67 4.00 I tell myself that I shouldn’t feel sad.

1.50 4.17 I tell myself that I shouldn’t have certain thoughts.

1.50 4.17 I avoid situations that will make me upset.

1.33 4.00 I do not tolerate situations I cannot change.

103 Appendix G: Results from Development Sample Analyses

Table G1

Initial Factor Loadings for Items Completed by the Development Sample

Item Acceptance subscale Awareness subscale

9. I am aware of what thoughts are passing .106 .506

through my mind.

10. When I have a bad memory, I try to distract .533 .001

myself to make it go away.

11. I am aware of thoughts I’m having when my .082 .579

mood changes.

15. When talking with other people, I am aware of .043 .503

their facial and body expressions.

17. When talking with other people, I am aware of .107 .653

the emotions I am experiencing.

21. When I shower, I am aware of how the water is .033 .538

running over my body.

23. When I am startled, I notice what is going on -.052 .634

inside my body.

25. Whenever my emotions change, I am conscious .073 .603

of them immediately.

26. I try to distract myself when I feel unpleasant .568 -.158

emotions.

27. When someone asks how I am feeling, I can .258 .562

identify my emotions easily.

10432. There are aspects of myself I don’t want to think .636 .005

about.

36. I try to put my problems out of mind. .528 .013

37. When my mood changes, I notice the event or the .050 .596

the thought that caused it to change.

38. There are things I try not to think about. .678 -.081

40. I have thoughts I try to avoid. .742 -.003

42. I try to stay busy to keep thoughts or feelings .668 .010

from coming to mind.

46. I wish I could control my emotions more easily. .626 -.003

48. If there is something I don’t want to think about, .721 -.042

I’ll try many things to get it out of my mind.

51. I notice changes inside my body, like my heart -.362 .604

beating faster or my muscles getting tense.

52. I tell myself that I shouldn’t feel sad. .559 -.043

53. When I walk outside on a sunny day, I notice how -.134 .514

the sun feels on my skin.

54. I tell myself that I shouldn’t have certain .670 -.021

thoughts.

55. When I walk outside, I am aware of smells or .059 .543

how the air feels against my face.

105Table G2

Initial Corrected Item-Subscale Correlations for Items Completed by the Development Sample

______________________________________________________________________________

Corrected Item-Subscale

Awareness Items Correlation

9. I am aware of what thoughts are passing through my mind. .45

11. I am aware of thoughts I’m having when my mood changes. .49

15. When talking with other people, I am aware of their facial and body .43

expressions.

17. When talking with other people, I am aware of the emotions I am .61

experiencing.

21. When I shower, I am aware of how the water is running over my body. .51

23. When I am startled, I notice what is going on inside my body. .54

25. Whenever my emotions change, I am conscious of them immediately. .53

27. When someone asks how I am feeling, I can identify my emotions .48

easily getting tense.

37. When my mood changes, I notice the event or the thought that caused it .51

to change.

51. I notice changes inside my body, like my heart beating faster or my .46

muscles.

53. When I walk outside on a sunny day, I notice how the sun feels on my .46

skin.

55. When I walk outside, I am aware of smells or how the air feels against .54

my face.

106

______________________________________________________________________________

Corrected Item-Subscale

Acceptance Items Correlation

10. When I have a bad memory, I try to distract myself to make it go away .48

26. I try to distract myself when I feel unpleasant emotions. .53

32. There are aspects of myself I don’t want to think about. .55

36. I try to put my problems out of mind. .48

38. There are things I try not to think about. .63

40. I have thoughts I try to avoid. .72

42. I try to stay busy to keep thoughts or feelings from coming to mind. .61

46. I wish I could control my emotions more easily. .52

48. If there is something I don’t want to think about, I’ll try many things to .67

get it out of my mind.

52. I tell myself that I shouldn’t feel sad. .50

54. I tell myself that I shouldn’t have certain thoughts. .61

______________________________________________________________________________

107Table G3

Inter-item Correlations from Initial Items Completed by Development Sample

Awareness Items

Item: #9 #11 #15 #17 #21 #23 #25 #27 #37 #51 #53 #55

Item9 --- .35 .23 .34 .25 .27 .31 .24 .36 .24 .21 .25

Item11 .35 --- .16 .40 .28 .37 .50 .32 .52 .21 .09 .13

Item15 .23 .16 --- .48 .25 .27 .16 .0 .22 .27 .25 .30

Item17 34 .40 .48 --- .29 .34 .0 .45 .46 .32 .28 .31

Item21 .25 .28 .25 .29 --- .37 .29 .26 .19 .26 .41 .47

Item23 .27 .37 .27 .34 .37 --- .42 .27 .35 .40 .23 .31

Item25 .31 .50 .16 40 .29 .42 --- .33 .46 .24 .15 .26

Item27 .24 .32 .30 .45 .26 .27 .33 --- .34 .16 .24 .33

Item37 .36 .52 .22 .46 .19 .35 .46 .34 --- .25 .15 .22

Item51 .24 .21 .27 .32 .26 .40 .24 .16 .25 --- .38 .34

Item53 .21 .09 .25 .28 .42 .23 .15 .24 .15 .38 --- .59

Item55 .25 .13 .30 .31 .47 .31 .26 .33 .22 .34 .59 ---

Acceptance Items

Item: #10 #26 #32 #36 #38 #40 #42 #46 #48 #52 #54

Item10 --- .51 .28 .29 .24 .31 .31 .29 .47 .29 .32

Item26 .51 --- .20 .35 .31 .42 .37 .30 .50 .31 .32

Item32 .28 .20 --- .23 .49 .52 .47 .42 .37 .33 .34

Item36 .29 .35 .23 --- .45 .39 .37 .21 .54 .19 .28

Item38 .24 .31 .49 .45 --- .66 .44 .35 .51 .29 .41

Item40 .31 .42 .52 .39 .66 --- .45 .45 .51 .47 .53

Item42 .31 .37 .47 .37 .44 .45 --- .33 .52 .36 .41

Item46 .29 .30 .42 .21 .35 .45 .33 --- .36 .30 .41

Item48 .47 .50 .37 .54 ..51 .51 .52 .36 --- .26 .43

Item52 .29 .31 .33 .17 .29 .47 .36 .30 .26 --- .56

Item54 .32 .32 .34 .28 .41 .53 .41 .41 .43 .56 ---

108Table G4

Descriptive Statistics of the Resulting 20 Items

Awareness Items Mean SD Min Max

9. I am aware of what thoughts are passing 4.13 .71 2 5

through my mind.

11. I am aware of thoughts I’m having when 3.52 .80 1 5

my mood changes.

15. When talking with other people, I am aware 4.12 .75 2 5

of their facial and body expressions.

17. When talking with other people, I am aware 3.86 .82 2 5

of the emotions I am experiencing.

21. When I shower, I am aware of how the 3.25 1.10 1 5

water is running over my body.

23. When I am startled, I notice what is going 3.01 .98 1 5

on inside my body.

25. Whenever my emotions change, I am 3.50 .82 1 5

conscious of them immediately.

27. When someone asks how I am feeling, I 3.48 .93 1 5

can identify my emotions easily.

51. I notice changes inside my body, like my 3.67 .96 1 5

heart beating faster or my muscles getting

tense.

55. When I walk outside, I am aware of smells 3.64 1.01 1 5

or how the air feels against my face.

109

Acceptance Items Mean SD Min Max

10. When I have a bad memory, I try to distract 3.00 .96 1 5

myself to make it go away.

26. I try to distract myself when I feel 2.76 .79 1 5

unpleasant emotions.

32. There are aspects of myself I don’t want 3.16 1.15 1 5

to think about.

36. I try to put my problems out of mind. 2.98 .76 1 5

38. There are things I try not to think about. 2.75 .88 1 5

42. I try to stay busy to keep thoughts or 3.24 .96 1 5

feelings from coming to mind.

46. I wish I could control my emotions more 2.72 1.15 1 5

easily.

48. If there is something I don’t want to think 2.93 .89 1 5

about, I’ll try many things to get it out of

my mind.

52. I tell myself that I shouldn’t feel sad. 3.15 .93 1 5

54. I tell myself that I shouldn’t have certain 3.17 .98 1 5

thoughts.

110Table G5

Corrected Item-Subscale Correlations for Resulting 20 Items

______________________________________________________________________________

Corrected Item-Subscale

Awareness Items Correlation

9. I am aware of what thoughts are passing through my mind. .44

11. I am aware of thoughts I’m having when my mood changes. .48

15. When talking with other people, I am aware of their facial and body .43

expressions.

17. When talking with other people, I am aware of the emotions I am .60

experiencing.

21. When I shower, I am aware of how the water is running over my body. .50

23. When I am startled, I notice what is going on inside my body. .55

25. Whenever my emotions change, I am conscious of them immediately. .52

27. When someone asks how I am feeling, I can identify my emotions .47

easily.

51. I notice changes inside my body, like my heart beating faster or my .44

muscles getting tense.

55. When I walk outside, I am aware of smells or how the air feels against .50

my face.

111______________________________________________________________________________

Corrected Item-Subscale

Acceptance Items Correlation

10. When I have a bad memory, I try to distract myself to make it go away. .49

26. I try to distract myself when I feel unpleasant emotions. .53

32. There are aspects of myself I don’t want to think about. .54

36. I try to put my problems out of mind. .47

38. There are things I try not to think about. .60

42. I try to stay busy to keep thoughts or feelings from coming to mind. .61

46. I wish I could control my emotions more easily. .51

48. If there is something I don’t want to think about, I’ll try many things to .67

get out of my mind.

52. I tell myself that I shouldn’t feel sad. .49

54. I tell myself that I shouldn’t have certain thoughts. .60

______________________________________________________________________________

112Table G6

Inter-item Correlations for the Resulting 20 Items

Item9 Item10 Item11 Item15 Item17 Item21 Item23 Item25 Item26 Item27

Item9 --- .02 .35** .23** .34** .25** .27** .31** .05 .24**

Item10 .02 --- -.00 .03 -.01 .04 .08 .00 .51** .06

Item11 .35** -.00 --- .16* .40** .28** .37** .50** -.04 .32** Item15 .23** .03 .16* --- .48** .25** .27** .16* -.08 .30**

Item17 .34** -.01 .40** .48** --- .29** .34** .40** -.04 .45**

Item21 .25** .04 .28** .25** .29** --- .27** .29** -.07 .26** Item23 .27** .08 .37** .27** .34** .37** --- .42** -.08 .27**

Item25 .31** .00 .50** .16* .40** .29** .42** --- -.09 .33**

Item26 .05 .51** -.04 -.08 -.04 -.07 -.08 -.09 --- .02 Item27 .24** .06 .32** .30** .45** .26** .27** .33** .02 ---

Item32 Item36 Item38 Item42 Item46 Item48 Item51 Item52 Item54 Item55 Item9 .08 .08 .11 .19** .07 .11 .24** .13 .05 .25** Item10 .28** .29** .24** .31** .29** .47** -.12 .29** .32** .02 Item11 -.07 .02 .01 .19** -.02 .02 .21** .02 .14* .13

Item15 -.06 .15* .00 .13 -.03 .04 .27** -.03 -.10 .30** Item17 .05 .09 .06 .13 .04 .03 .32** .03 -.01 .31** Item21 .00 .04 -.04 .11 -.06 .01 .26** -.06 .02 .47**

Item23 -.07 .08 -.01 .06 -.05 -.04 .40** -.04 -.00 .31** Item25 .02 .02 .05 .16* -.06 .01 .24** .01 .09 .26**

Item26 .20** .35** .31** .37** .30** .50** -.22** .31** .32** -.07** Item27 .12 .10 .13 .32** .19** .09 .16* .11 .14* .33**

Item32 Item36 Item38 Item42 Item46 Item48 Item51 Item52 Item54 Item55 Item32 --- .23** .49** .47** .42** .37** -.18** .33** .34** .05 Item36 .23** --- .45** .37** .21** .54** -.12 .17* .28** .05 Item38 .49** .45** --- .44** .35** .51** -.34** .29** .41** -.01 Item42 .47** .37** .44** --- .33** .52** -.12 .36** .41** .18** Item46 .42** .21** .35** .33** --- .36** -.22** .30** .41** .03 Item48 .37** .54** .51** .52** .36** --- -.27** .26** .43** .09 Item51 -.18** -.12 -.34** -.12 -.22** -.27** --- -.20** -.22** .34** Item52 .33** .17* .29** .36** .30** .26** -.20** --- .56** .07 Item54 .34** .28** .41** .41** .41** .43** -.22** .56** --- -.05 Item55 .05 .05 -.01 .18** .03 .09 .34** .07 -.05 ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the

0.05 level (2-tailed).

113

Appendix H: Copies of Measures

114PHLMS

Instructions: Please circle how often you experienced each of the following statements within the past week. 1. I am aware of what thoughts are passing through my mind. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 2. I try to distract myself when I feel unpleasant emotions. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 3. When talking with other people, I am aware of their facial and body expressions. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 4. There are aspects of myself I don’t want to think about. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 5. When I shower, I am aware of how the water is running over my body. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 6. I try to stay busy to keep thoughts or feelings from coming to mind. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 7. When I am startled, I notice what is going on inside my body. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 8. I wish I could control my emotions more easily. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 9. When I walk outside, I am aware of smells or how the air feels against my face. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 10. I tell myself that I shouldn’t have certain thoughts. 1 2 3 4 5 Never Rarely Sometimes Often Very Often

115 11. When someone asks how I am feeling, I can identify my emotions easily. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 12. There are things I try not to think about. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 13. I am aware of thoughts I’m having when my mood changes. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 14. I tell myself that I shouldn’t feel sad. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 16. If there is something I don’t want to think about, I’ll try many things to get it out of my mind. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 17. Whenever my emotions change, I am conscious of them immediately. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 18. I try to put my problems out of mind. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 19. When talking with other people, I am aware of the emotions I am experiencing. 1 2 3 4 5 Never Rarely Sometimes Often Very Often 20. When I have a bad memory, I try to distract myself to make it go away. 1 2 3 4 5 Never Rarely Sometimes Often Very Often

116MAAS

Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be. 1 = almost always 2 = very frequently 3 = somewhat frequently 4 = somewhat infrequently 5 = very infrequently 6 = almost never _______ 1. I could be experiencing some emotion and not be conscious of it until some time later. _______ 2. I break or spill things because of carelessness, not paying attention, or thinking of

something else. _______ 3. I find it difficult to stay focused on what’s happening in the present. _______ 4. I tend to walk quickly to get where I’m going without paying attention to what I experience

along the way. _______ 5. I tend not to notice feelings of physical tension or discomfort until they really grab my

attention. _______ 6. I forget a person’s name almost as soon as I’ve been told it for the first time. _______ 7. It seems I am “running on automatic” without much awareness of what I’m doing. _______ 8. I rush through activities without being really attentive to them. _______ 9. I get so focused on the goal I want to achieve that I lose touch with what I am doing right

now to get there. _______ 10. I do jobs or tasks automatically, without being aware of what I’m doing. _______ 11. I find myself listening to someone with one ear, doing something else at the same time. _______ 12. I drive places on “automatic pilot” and then wonder why I went there. _______ 13. I find myself preoccupied with the future or the past. _______ 14. I find myself doing things without paying attention. _______ 15. I snack without being aware that I’m eating.

117AAQ-R

Below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following scale to make your choice.

1-------------------2--------------------3----------------------4--------------------5-------------------6------------------7 never very seldom seldom sometimes frequently almost always always true true true true true true true _______ 1. I am able to take action on a problem even if I am uncertain what is the right thing to do.

_______ 2. When I feel depressed or anxious, I am unable to take care of my responsibilities.

_______ 3. I try to suppress thoughts and feelings that I don’t like by just not thinking about them.

_______ 4. It’s OK to feel depressed or anxious.

_______ 5. I rarely worry about getting my anxieties, worries, and feelings under control.

_______ 6. In order for me to do something important, I have to have all my doubts worked out.

_______ 7. I’m not afraid of my feelings.

_______ 8. I try hard to avoid feeling depressed or anxious.

_______ 9. Anxiety is bad.

_______10. Despite doubts, I feel as though I can set a course in my life and then stick to it.

_______11. If I could magically remove all the painful experiences I’ve had in my life, I would do so.

_______12. I am in control of my life.

_______13. If I get bored of a task, I can still complete it.

_______14. Worries can get in the way of my success.

_______15. I should act according to my feelings at the time.

_______16. If I promised to do something, I’ll do it, even if I later don’t feel like it.

118RRQ

For each of the statements located on the next three pages, please indicate your level of agreement or disagreement by circling one of the scale categories below each statement. Use the scale as shown below. 1. My attention is often focused on aspects of myself I wish I’d stop thinking about.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 2. I always seem to be rehashing in my mind recent things I’ve said or done.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 3. Sometimes it is hard for me to shut off thoughts about myself.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 4. Long after an argument or disagreement is over with, my thoughts keep going back to what happened.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 5. I tend to “ruminate” or dwell over things that happen to me for a really long time afterward.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 6. I don’t waste time rethinking things that are over and done with.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 7. Often I’m playing back over in my mind how I acted in past situations.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 8. I often find myself reevaluating something I’ve done.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 9. I never ruminate or dwell on myself for very long.

1 2 3 4 5 strongly disagree disagree neutral agree strongly disagree

11910. It is easy for me to put unwanted thoughts out of my mind.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 11. I often reflect on episodes in my life that I should no longer concern myself with.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 12. I spend a great deal of time thinking back over my embarrassing or disappointing moments.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 13. Philosophical or abstract thinking doesn’t appeal to me that much.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 14. I’m not really a meditative type of person.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 15. I love exploring my “inner” self.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 16. My attitudes and feelings about things fascinate me.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 17. I don’t really care for introspective or self-reflective things.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 18. I love analyzing why I do things.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 19. People often say I’m a “deep,” introspective type of person.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree

120 20. I don’t care much for self-analysis.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 21. I’m very self-inquisitive by nature.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 22. I love to meditate on the nature and meaning of things.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 23. I often love to look at my life in philosophical ways.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree 24. Contemplating myself isn’t my idea of fun.

1 2 3 4 5

strongly disagree disagree neutral agree strongly disagree

121 FSS

Psychologists have described times when people get very absorbed in an activity they're doing. They call this a "flow" experience. A flow experience occurs when you are totally involved in what you are doing, you are not aware of your surroundings, and time seems either to slow down or to pass by really quickly. You shut out the whole world because you are concentrating on the activity that you are doing. Your mind doesn't wander or think of anything but the activity that you are absorbed in. Please think back to such an experience that occurred within the past two weeks. Some people have these experiences often, while others rarely do. Do your best to identify some experience similar to what was described above, even if it is not exactly the same. Think about how you felt during the experience and answer the questions below using the rating scale. There are no right or wrong answers. Just circle the number that best matches your experience. Rating Scale: Strongly Neither agree Strongly disagree Disagree nor disagree Agree agree 1 2 3 4 5 1. I was challenged, but I believed my skills 1 2 3 4 5 would allow me to meet the challenge. 2. I made the correct movements without 1 2 3 4 5 thinking about trying to do so. 3. I knew clearly what I wanted to do. 1 2 3 4 5 4. It was really clear to me that I was doing 1 2 3 4 5 well. 5. My attention was focused entirely on what I 1 2 3 4 5 was doing. 6. I felt in total control of what I was doing. 1 2 3 4 5 7. I was not concerned with what others may 1 2 3 4 5 have been thinking of me. 8. Time seem to alter (either slowed down or sped up). 1 2 3 4 5 9. I really enjoyed the experience. 1 2 3 4 5 10. My abilities matched the high challenge of 1 2 3 4 5 of the situation. 11. Things just seemed to be happening automatically. 1 2 3 4 5 12. I had a strong sense of what I wanted to do. 1 2 3 4 5 13. I was aware of how well I was performing. 1 2 3 4 5 14. It was no effort to keep my mind on what 1 2 3 4 5 was happening. 15. I felt like I could control what I was doing. 1 2 3 4 5

12216. I was not worried about my performance 1 2 3 4 5 during the event. 17. The way time passed seemed to be different 1 2 3 4 5 than normal. 18. I loved the feeling of that performance and 1 2 3 4 5 want to capture it again. 19. I felt I was competent enough to meet the 1 2 3 4 5 high demands of the situation. 20. I performed automatically. 1 2 3 4 5 21. I knew what I wanted to achieve. 1 2 3 4 5 22. I had a good idea while I was performing 1 2 3 4 5 about how well I was doing. 23. I had total concentration. 1 2 3 4 5 24. I had a feeling of total control. 1 2 3 4 5 25. I was not concerned with how I was 1 2 3 4 5 presenting myself. 26. It felt like time stopped while I was performing. 1 2 3 4 5 27. The experience left me feeling great. 1 2 3 4 5 28. The challenge and my skills were equally 1 2 3 4 5 at a high level. 29. I did things spontaneously and automatically 1 2 3 4 5 without having to think. 30. My goals were clearly defined. 1 2 3 4 5 31. I could tell by the way I was performing how 1 2 3 4 5 well I was doing. 32. I was completely focused on the task at hand. 1 2 3 4 5 33. I felt in total control of my body. 1 2 3 4 5 34. I was not worried about what others may 1 2 3 4 5 have been thinking of me. 35. At times, it almost seemed liked things were 1 2 3 4 5 happening in slow motion. 36. I found the experience extremely rewarding. 1 2 3 4 5

123WBSI

This survey is about thoughts. There are no right or wrong answers, so please respond to each of the items below. Be sure to answer every item by circling the appropriate letter beside each.

A = Strongly disagree B = Disagree C = Neutral or don’t know D = Agree E = Strongly agree

1. There are things I prefer not to think about. A B C D E 2. Sometimes I wonder why I have the thoughts A B C D E I do. 3. I have thoughts that I cannot stop. A B C D E 4. There are images that come to mind that I A B C D E cannot erase. 5. My thoughts frequently return to one idea. A B C D E 6. I wish I could stop thinking of certain things. A B C D E 7. Sometimes my mind races so fast I wish I A B C D E could stop it. 8. I always try to put problems out of mind. A B C D E 9. There are thoughts that keep jumping into A B C D E my head. 10. There are things that I try not to think about. A B C D E 11. Sometimes I really wish I could stop thinking. A B C D E 12. I often do things to distract myself from my A B C D E thoughts. 13. I have thoughts that I try to avoid. A B C D E 14. There are many thoughts that I have that I A B C D E don’t tell anyone. 15. Sometimes I stay busy just to keep thoughts A B C D E from intruding on my mind.

124M-C SDS

INSTRUCTIONS: Please respond to the following items using the scale below. 1. Before voting, I thoroughly investigate the qualification of all the candidates. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 2. I never hesitate to go out of my way to help someone in trouble. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 3. I have never intensely disliked anyone. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 4. It is sometimes hard for me to go on with my work if I am not encouraged. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 5. On occasion I have had doubts about my ability to succeed in life. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 6. I sometimes feel resentful when I don’t get my way. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 7. I am always careful about my manner of dress. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 8. My table manners at home are as good as when I eat out in a restaurant. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 9. If I could get into a movie without paying and be sure I was not seen I would probably

do it. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree

125 10. On a few occasions, I have given up doing something because I thought too little of my

ability. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 11. I like to gossip at times. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 12. There have been times when I felt like rebelling against people in authority even

though they were right. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 13. No matter who I’m talking to, I’m always a good listener. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 14. I can remember “plying sick” to get out of something. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 15. There have been occasions when I took advantage of someone. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 16. I’m always willing to admit it when I make a mistake. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 17. I always try to practice what I preach. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 18. I don’t find it particularly difficult to get along with loud mouthed, obnoxious people. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree

12619. I sometimes try to get even rather than forgive and forget. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 20. When I don’t know something I don’t at all mind admitting it. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 21. I am always courteous, even to people who are disagreeable. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 22. At times I have really insisted on having things my own way. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 23. There have been occasions when I felt like smashing things. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 24. I would never think of letting someone else be punished for my wrongdoing. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 25. I never resent being asked to return a favor. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 26. I have never been irked when people expressed ideas very different from my own. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 27. I never make a long trip without checking the safety of my car. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 28. There have been times when I was quite jealous of the good fortune of others. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree

127 29. I have almost never felt the urge to tell someone off. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 30. I am sometimes irritated by people who ask favors of me. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 31. I have never felt that I was punished without cause. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 32. I sometimes think when people have a misfortune they only got what they deserved. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 33. I have never deliberately said something that hurt someone’s feelings. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree

128Appendix I: Results from the Nonclinical Sample Analyses

Table I1

PHLMS Descriptive Statistics from the Nonclinical Sample

Item Mean SD Min Max

1. I am aware of what thoughts are passing 4.29 .70 1 5

through my mind.

2. I try to distract myself when I feel unpleasant 2.70 .84 1 5

emotions.

3. When talking with other people, I am aware 4.22 .73 1 5

of their facial and body expressions.

4. There are aspects of myself I don’t want to 3.15 .93 1 5

think about.

5. When I shower, I am aware of how the water 3.31 1.15 1 5

is running over my body.

6. I try to stay busy to keep thoughts or feelings 3.28 .92 1 5

from coming to mind.

7. When I am startled, I notice what is going on 3.01 1.02 1 5

inside my body.

8. I wish I could control my emotions more 2.97 1.09 1 5

easily.

9. When I walk outside, I am aware of smells 3.74 .94 1 5

or how the air feels against my face.

10. I tell myself that I shouldn’t have certain 3.23 .96 1 5

thoughts.

12911. When someone asks how I am feeling, I 3.63 .86 1 5

can identify my emotions easily.

12. There are things I try not to think about. 2.93 .86 1 5

13. I am aware of thoughts I’m having when 3.66 .78 1 5

my mood changes.

14. I tell myself that I shouldn’t feel sad. 3.16 .97 1 5

15. I notice changes inside my body, like my 3.72 .89 1 5

heart beating faster or my muscles getting

tense.

16. If there is something I don’t want to think 2.81 .95 1 5

about, I’ll try many things to get it out of

my mind.

17. Whenever my emotions change, I am 3.44 .86 1 5

conscious of them immediately.

18. I try to put my problems out of mind. 2.95 .90 1 5

19. When talking with other people, I am 3.63 .83 1 5

aware of the emotions I am experiencing.

20. When I have a bad memory, I try to distract 3.00 1.05 1 5

myself to make it go away.

130Table I2

Factor Loadings for the PHLMS

Acceptance Awareness

Item Subscale Subscale

1. I am aware of what thoughts are passing .090 .512

through my mind.

2. I try to distract myself when I feel unpleasant .602 -.004

emotions.

3. When talking with other people, I am aware of .063 .542

their facial and body expressions.

4. There are aspects of myself I don’t want to think .593 .110

about.

5. When I shower, I am aware of how the water is -.012 .542

running over my body.

6. I try to stay busy to keep thoughts or feelings .585 .016

from coming to mind.

7. When I am startled, I notice what is going on -.068 .502

inside my body.

8. I wish I could control my emotions more easily. .561 -.016

9. When I walk outside, I am aware of smells or -.036 .577

how the air feels against my face.

10. I tell myself that I shouldn’t have certain .653 .022

thoughts.

11. When someone asks how I am feeling, I can .152 .503

identify my emotions easily.

13112. There are things I try not to think about. .752 .049

13. I am aware of thoughts I’m having when my -.121 .587

mood changes.

14. I tell myself that I shouldn’t feel sad. .592 -.025

15. I notice changes inside my body, like my heart -.100 .565

beating faster or my muscles getting tense.

16. If there is something I don’t want to think about, .692 -.092

I’ll try many things to get it out of my mind.

17. Whenever my emotions change, I am conscious -.008 .589

of them immediately.

18. I try to put my problems out of mind. .627 .022

19. When talking with other people, I am aware of .050 .673

the emotions I am experiencing.

20. When I have a bad memory, I try to distract .513 -.070

myself to make it go away.

132Table I3

PHLMS Corrected Item-Subscale Correlations from the Nonclinical Sample

Corrected Item-Subscale

PHLMS Awareness Subscale Item Correlation

1. I am aware of what thoughts are passing through my mind. .36

3. When talking with other people, I am aware of their facial and body .39

expressions.

5. When I shower, I am aware of how the water is running over my body. .41

7. When I am startled, I notice what is going on inside my body. .38

9. When I walk outside, I am aware of smells or how the air feels against .45

my face.

11. When someone asks how I am feeling, I can identify my emotions easily. .34

13. I am aware of thoughts I’m having when my mood changes. .45

15. I notice changes inside my body, like my heart beating faster or my .44

muscles getting tense.

17. Whenever my emotions change, I am conscious of them immediately. .43

19. When talking with other people, I am aware of the emotions I am .51

experiencing.

Corrected Item-Subscale

PHLMS Acceptance Subscale Item Correlation

2. I try to distract myself when I feel unpleasant emotions. .49

4. There are aspects of myself I don’t want to think about. .47

6. I try to stay busy to keep thoughts or feelings from coming to mind. .46

8. I wish I could control my emotions more easily. .45

10. I tell myself that I shouldn’t have certain thoughts. .53

13312. There are things I try not to think about. .64

14. I tell myself that I shouldn’t feel sad. .48

16. If there is something I don’t want to think about, I’ll try many things to .59

get it out of my mind.

18. I try to put my problems out of mind. .50

20. When I have a bad memory, I try to distract myself to make it go away .40

134Table I4

PHLMS Inter-item Correlations from the Nonclinical Sample

Item 1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 Item1 --- .03 .23** .04 .20** -.04 .16** .04 .24** .02 Item2 .03 --- -.02 .25** .01 .35** -.08 .27** .02 .27** Item3 .23** -.02 --- .02 .21** .07 .15** -.07 .32** -.01 Item4 .04 .25** .02 --- -.02 .31** -.00 .37** -.03 .37** Item5 .20** .01 .21** -.02 --- -.03 .26** -.04 .34** -.06 Item6 -.04 .35** .07 .31** -.03 --- -.11* .23** -.02 .26** Item7 .16** -.08 .15** -.00 .26** -.11* --- -.12** .25** -.04 Item8 .04 .27** -.07 .37** -.04 .23** -.12** --- -.03 .33** Item9 .24** .02 .32** -.03 .34** -.02 .25** -.03 --- -.06 Item10 .02 .27** -.01 .37** -.06 .26** -.04 .33** -.06 ---

Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20

Item1 .22** .06 .24** -.01 .14** -.02 .24** .03 .24** -.01 Item2 -.07 .35** -.11 .27** -.06 .44** -.04 .30** .01 .29**

Item3 .23** .01 .21** .01 .19** -.05 .22** .03 .29** .00 Item4 .11* .37** -.05 .29** -.04 .28** .06 .22** .08 .19**

Item5 .14** -.01 .27** -.07 .28** -.06 .17** .00 .24** -.03 Item6 .04 .40** -.07 .23** -.07 .37** -.04 .31** .01 .17**

Item7 .20** .01 .19** -.06 .33** -.12** .16** -.05 .24** -.05 Item8 .05 .35** -.07 .31** -.09* .29** -.04 .23** -.02 .18**

Item9 .17** -.09* .17** -.04 .30** -.14** .19** -.02 .27** -.09 Item10 .06 .53** -.10* .34** -.03 .33** -.03 .30** -.02 .25** Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20

Item11 --- .03 .22** .09* .14** .01 .24** .14** .26** -.01

Item12 .03 --- -.10* .36** -.08 .43** -.00 .42** .02 .33**

Item13 .22** -.10* --- -.17** .25** -.11* .37** -.07 .39** -.12**

Item14 .09* .36** -.17** --- -.06 .34** -.04 .32** -.06 .23**

Item15 .14** -.08 .25** -.06 --- -.18** .27** -.07 .30** -.10*

Item16 .01 .43** -.11* .34** -.18** --- -.07 .42** -.03 .38**

Item17 .24** -.00 .37** -.04 .27** -.07 --- -.09* .38** -.09*

Item18 .14** .42** -.07 .32** -.07 .42** -.09* --- -.06 .31**

Item19 .26** .02 .39** -.06 .30** -.03 .38** -.06 --- -.04

Item20 -.01 .33** -.12** .30** -.10* .38** -.09* .31** -.04 ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the

0.05 level (2-tailed).

135Table I5

Convergent Validity: Correlations of the PHLMS With Other Measures from the Nonclinical

Sample

Correlation with Correlation with Correlation with

Measure PHLMS Acceptance PHLMS Awareness PHLMS Total

AAQ Acceptance .54** .10 .50**

MAAS .32** .21** .40**

WBSI -.52** -.03 -.43**

FSS .10 .21** .23**

RRQ Reflection -.02 .36** .23**

RRQ Rumination -.40** -.02 -.33**

PHLMS Awareness -.10 -- .60**

PHLMS Acceptance -- -.10 .74**

Note. *p < .01, **p < .001

136Table I6

Correlations of the PHLMS with Measures of Psychopathology Before and After Controlling for

Other Constructs in a Nonclinical Sample

PHLMS

Total

Well-Being Zero-order PHLMS Total controlling for:

variable correlation social desirability

BDI (depression) -.34** -.30**

BAI (anxiety) -.25** -.23**

PHLMS

Acceptance

Well-Being Zero-order PHLMS Acceptance Subscale controlling for:

Variable correlation social desirability AAQ Acceptance WBSI

BDI (depression) -.35** -.33** -.25** -.17**

BAI (anxiety) -.33** -.32** -.26** -.19**

PHLMS

Awareness

Well-Being Zero-order PHLMS Awareness Subscale controlling for:

variable correlation social desirability MAAS (awareness) FSS

BDI (depression) -.08 -.05 .01 -.02

BAI (anxiety) .03 .04 .09 .06

Note. *p < .01; **p < .001

137Appendix J: Results from the Clinical Sample Analyses

Table J1

Total Number of Clinical Participants Diagnosed With Each Disorder

Disorder Frequency Percentage

Mood Disorders

Bipolar I Disorder 5 10.4%

Depressive Disorder NOS 7 14.6%

Major Depressive Disorder 16 33.3%

Major Depressive Disorder with psychotic features 3 6.3%

Mood Disorder NOS 6 12.5%

Premenstrual Dysphoric Disorder 1 2.1

Anxiety Disorders

Anxiety Disorder NOS 3 6.3%

Generalized Anxiety Disorder 1 2.1%

Obsessive Compulsive Disorder 2 4.2%

Panic Disorder with Agoraphobia 2 4.2%

Posttraumatic Stress Disorder 5 10.4%

Specific Phobia 1 2.1%

Psychotic Disorders

Psychosis NOS 2 4.2%

Schizoaffective Disorder 2 4.2%

Schizophrenia 2 4.2%

Adjustment Disorders

Adjustment Disorder with depression 1 2.1%

138Adjustment Disorder with mixed anxiety & depression 1 2.1%

Substance Disorders

Alcohol Dependence 4 8.7%

Alcohol Dependence in Full Sustained Remission 1 2.1%

Alcohol Abuse 1 2.1%

Cannabis dependence 1 2.1%

Cocaine dependence 2 4.2%

Cocaine dependence in early Full Remission 1 2.1%

Opiate Dependence 2 4.2%

Opiate dependence in Full Sustained Remission 1 2.1%

Polysubstance dependence 1 2.1%

Polysubstance in Early Full Remission 1 2.1%

Polysubstance dependence Full Sustained Remission 1 2.1%

Substance Abuse in Remission 1 2.1%

Impulse-Control Disorders

Impulse Control D/O NOS 1 2.1%

Intermittent Explosive D/O 1 2.1%

Other

Attention Deficit/Hyperactivity Disorder 1 2.1%

Bereavement 1 2.1%

Pain Disorder 1 2.1%

Partner Relational Problem 1 2.1%

139Table J2

Descriptive Statistics for the PHLMS from the Clinical Sample

Mean SD Min Max

1. I am aware of what thoughts are passing 3.70 .94 1 5

through my mind.

2. I try to distract myself when I feel unpleasant 2.50 .96 1 5

emotions.

3. When talking with other people, I am aware 3.87 .97 2 5

of their facial and body expressions.

4. There are aspects of myself I don’t want to 2.46 1.04 1 5

think about.

5. When I shower, I am aware of how the water 3.62 1.19 1 5

is running over my body.

6. I try to stay busy to keep thoughts or feelings 2.46 .90 1 4

from coming to mind.

7. When I am startled, I notice what is going on 3.36 .99 1 5

inside my body.

8. I wish I could control my emotions more. 2.08 .95 1 4

easily.

9. When I walk outside, I am aware of smells 3.62 .97 2 5

or how the air feels against my face.

10. I tell myself that I shouldn’t have certain 2.71 1.05 1 5

thoughts.

11. When someone asks how I am feeling, I 3.33 1.02 1 5

can identify my emotions easily.

14012. There are things I try not to think about. 2.21 .91 1 4

13. I am aware of thoughts I’m having when 3.46 .83 2 5

my mood changes.

14. I tell myself that I shouldn’t feel sad. 2.92 1.13 1 5

15. I notice changes inside my body, like my 3.52 .96 1 5

heart beating faster or my muscles getting

tense.

16. If there is something I don’t want to think 2.46 .94 1 5

about, I’ll try many things to get it out of

my mind.

17. Whenever my emotions change, I am 3.21 1.02 1 5

conscious of them immediately.

18. I try to put my problems out of mind. 2.54 1.06 1 5

19. When talking with other people, I am 3.42 .83 2 5

aware of the emotions I am experiencing.

20. When I have a bad memory, I try to distract 2.27 .89 1 4

myself to make it go away.

141Table J3

PHLMS Corrected Item-Subscale Correlations from the Clinical Sample

Corrected Item-Subscale

PHLMS Awareness Subscale Item Correlation

1. I am aware of what thoughts are passing through my mind. .42

3. When talking with other people, I am aware of their facial and body .25

expressions.

5. When I shower, I am aware of how the water is running over my body. .27

7. When I am startled, I notice what is going on inside my body. .50

9. When I walk outside, I am aware of smells or how the air feels against .45

my face.

11. When someone asks how I am feeling, I can identify my emotions easily. .57

13. I am aware of thoughts I’m having when my mood changes. .62

15. I notice changes inside my body, like my heart beating faster or my .10

muscles getting tense.

17. Whenever my emotions change, I am conscious of them immediately. .51

19. When talking with other people, I am aware of the emotions I am .49

experiencing.

Corrected Item-Subscale

PHLMS Acceptance Subscale Item Correlation

2. I try to distract myself when I feel unpleasant emotions. .27

4. There are aspects of myself I don’t want to think about. .27

6. I try to stay busy to keep thoughts or feelings from coming to mind. .34

8. I wish I could control my emotions more easily. .60

14210. I tell myself that I shouldn’t have certain thoughts. .44

12. There are things I try not to think about. .65

14. I tell myself that I shouldn’t feel sad. .23

16. If there is something I don’t want to think about, I’ll try many things to .64

get it out of my mind.

18. I try to put my problems out of mind. .43

20. When I have a bad memory, I try to distract myself to make it go away .35

143Table J4

PHLMS Inter-item Correlations in the Clinical Sample

Item1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 Item1 --- -.29* .28* .00 .20 .04 .33* .16 .03 -.03 Item2 -.29* --- -.20 -.04 .34* .09 -.07 .30* .13 .17 Item3 .28 -.20 --- .10 .07 -.11 .19 .01 .24 -.10 Item4 .00 -.04 .10 --- -.25 .08 -.18 .34* -.17 .16 Item5 .20 .34* .07 -.25 --- -.03 .27 -.04 .31* .10 Item6 .04 .09 -.11 .08 -.03 --- -.17 .17 -.09 .29* Item7 .33* -.07 .19 -.18 .27 -.17 --- -.10 .43** .00 Item8 .16 .30* .01 .34* -.04 .17 -.10 --- -.20 .34* Item9 .03 .13 .24 -.17 .31* -.09 .43** -.20 --- -.19 Item10 -.03 .17 -.10 .16 .10 .29* .00 .34* -.19 ---

Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20

Item1 .43** .28* .33* -.09 .13 .09 .21 .12 .24 .12 Item2 .03 .37** -.32* -.04 -.12 .37** -.21 .17 .05 .09 Item3 .20 -.100 .18 -.15 -.11 .01 .07 .17 .20 -.07 Item4 .08 .27 -.03 .21 -.01 .16 .13 .31* .20 -.14 Item5 .38** .22 .08 -.10 .01 .07 .05 .17 -.01 .08 Item6 -.21 .31* -.21 .15 .20 .44** -.30* .06 -.11 .21 Item7 .34* .10 .34* .09 .04 -.14 .32* .00 .23 -.03 Item8 .08 .57** -.25 .12 -.15 .49** -.28* .33* .11 .35* Item9 .23 -.02 .49** -.03 .03 -.08 .22 -.06 .33* -.13 Item10 .05 .39** -.32* .16 -.16 .51** .00 .07 -.04 .17 Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20

Item11 --- .11 .28* -.05 -.06 -.02 .48** .12 .55** .03

Item12 .11 --- -.24 .17 .07 .48** -.11 .41** .04 .24

Item13 .28* -.24 --- -.07 .33* -.38** .60** -.07 .48** -.25

Item14 -.05 .17 -.07 --- .13 .07 .17 .20 -.03 .18

Item15 -.06 .07 .33* .13 --- -.29* .21 .07 .04 -.21

Item16 -.02 .48** -.38** .07 -.29* --- -.27* .32* -.08 .37**

Item17 .48** -.11 .60** .17 .21 -.27* --- -.017 .48** -.26

Item18 .12 .41** -.07 .20 .07 .32* -.017 --- -.09 .34*

Item19 .55** .04 .48** -.03 .04 -.08 .48** -.09 --- -.37**

Item20 .03 .24 -.252 .18 -.21 .37** -.26 .34* -.37** ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the

0.05 level (2-tailed).

144Table J5

Convergent Validity: Correlations of the PHLMS With Other Measures in the Clinical Sample

Correlation with Correlation with Correlation with

Measure PHLMS Acceptance PHLMS Awareness PHLMS Total

AAQ Acceptance .31 .07 .29

MAAS .17 .40* .43*

WBSI (thought suppression) -.35 -.16 -.39*

FSS (flow) .28 .41* .52**

RRQ Reflection -.07 .27 .16

RRQ Rumination -.43* -.05 -.37*

PHLMS Awareness -.13 -- .65**

PHLMS Acceptance -- -.13 .67**

Note. *p < .01, **p < .001

145Table J6

Correlations of the PHLMS with Measures of Psychopathology Before and After Controlling for

Other Constructs in a Clinical Sample

PHLMS Total

Well-Being Zero-order PHLMS Total Score controlling for:

variable correlation social desirability

BDI-II (depression) -.41* -.34

BAI (anxiety) -.42* -.34

PHLMS

Acceptance

Well-Being Zero-order PHLMS Acceptance Subscale controlling for:

variable correlation social desirability AAQ Acceptance WBSI

BDI-II (depression) -.28 -.22 -.19 -.15

BAI (anxiety) -.29 -.22 -.19 -.17

PHLMS

Awareness

Well-Being Zero-order PHLMS Awareness Subscale controlling for:

variable correlation social desirability MAAS (awareness) FSS

BDI-II (depression) -.25 -.20 -.07 -.03

BAI (anxiety) -.27 -.21 -.13 -.02

Note. *p < .01

146Appendix K: An Acceptance-Based Model of Social Anxiety Disorder

Physiological arousal

& Cognitions related to

social evaluation

Increased awareness of

cognitions and physiological

arousal (self-focused

attention)

Low levels of acceptance

Experiential control/

avoidance Behavioral disruption

Social Situation

Predisposition (genetic and/or

learned)

147Vita

LEEANN CARDACIOTTO EDUCATION

2000 - 2005 Drexel University, Philadelphia, PA (formerly MCP Hahnemann University) Candidate for Doctorate in Clinical Psychology, received September 2005 Masters of Arts in Clinical Psychology, received August 2002 1996 - 2000 Franklin & Marshall College, Lancaster, PA; GPA: 3.71 Bachelor of Arts in Psychology, Minor in Sociology, received May 2000 Magna Cum Laude, Honors in Psychology

SELECTED RESEARCH EXPERIENCE 2000 - 2005 Anxiety Research & Treatment Program Drexel University, Philadelphia, PA 2001 - 2004 “Friend to Friend Program,” Children’s Hospital of Philadelphia, Philadelphia, PA 2002 - 2003 Parent-Child Project, Children’s Hospital of Philadelphia, Philadelphia, PA

SELECTED CLINICAL EXPERIENCE

2004 - 2005 Psychological Intern, Long Island Jewish Medical Center, Glen Oaks, NY 2000 - 2004 Anxiety Research & Treatment Program, Drexel University, Philadelphia, PA 2003 - 2004 Student Counseling Center, Drexel University, Philadelphia, PA 2002 - 2003 Outpatient Psychiatry, Drexel University College of Medicine, Philadelphia, PA 2001 - 2002 ADHD Clinic, Children’s Hospital of Philadelphia, Philadelphia, PA 2001 - 2002 Lindens Neurobehavioral Program, Bancroft NeuroHealth, Haddonfield, NJ

SELECTED TEACHING EXPERIENCE

2004 - 2004 Course Instructor: “Positive Psychology,”Drexel University 2003 - 2003 Course Instructor: “General Psychology,” Drexel University 2004 - 2004 Course Instructor: “General Psychology,” Drexel University

SELECTED PUBLICATIONS AND PRESENTATIONS

Herbert, J.D., & Cardaciotto, L. (in press). A Mindfulness-Based Perspective for Social Anxiety Disorder. Chapter to appear in S. Orsillo & L. Roemer (Eds.), Acceptance and Mindfulness-Based Approaches to Anxiety: Conceptualization and Treatment (Kluwer/Penum).

Cardaciotto, L. & Herbert, J. D. (2004). Cognitive behavior therapy for social anxiety disorder in the context of Asperger’s Syndrome: A single-subject report. Cognitive & Behavioral Practice, 11, 75-81.

Wilkins, V. M., Cardaciotto, L., & Platek, S. M. (2003). Uncertain what uncertainty monitoring monitors. Behavioral & Brain Sciences, 26(3), 356.

Cardaciotto, L., & Herbert, J. D. (2005, November). The Development of a Bi-Dimensional Measure of Mindfulness: The Philadelphia Mindfulness Scale (PHLMS). In J. D. Herbert & L. Cardaciotto (chairs), The Conceptualization and Assessment of Mindfulness. Symposium accepted for presentation at the annual meeting of ABCT, Washington, D.C.

Cardaciotto, L., Herbert, J. D., Gaudiano, B. A., Nolan, E. M., & Dalrymple, K. L. (2002, November). Treating social anxiety disorder with cognitive behavior therapy in the context of Asperger’s syndrome: A single-subject report. Poster presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Reno, NV.

SELECTED HONORS, DISTINCTIONS, AND AWARDS

• Autism SIG Annual Student Research Award, Association for the Advancement of Behavior Therapy, 2002

• Phi Beta Kappa, Franklin & Marshall College, 2000 • Psi Chi (National Honor Society in Psychology), Franklin & Marshall College, 1998-2000