Masaryk University
Faculty of Arts
Mindful Emotion Regulation
Habilitation thesis
PhDr. Miroslav Světlák, Ph.D. 2019
I declare that I wrote this habilitation thesis myself using the sources listed in the literature.
Date: Signature:
Acknowledgment
I am grateful to have been born at this time, in this place, among people I love.
Preface
The theme of the presented habilitation thesis reflects my clinical practice and research interests
of over the past 16 years. I started to study emotion regulation processes somewhat indirectly
within my postgraduate study at the Department of Physiology of the Faculty of Medicine at
Masaryk University in 2003, where I studied the motivations for smoking behavior. I was
primarily involved in the study of the transtheoretical model approach applied to smoking
acquisition and cessation in adolescent and adult smokers. Through the transtheoretical model
of behavioral changes, we were able to describe smoker’s motivational stages and the processes
of change they use at various stages (Svetlak & Kukleta, 2003, 2004, 2006a, 2006b; Svetlak,
Konecny, & Kukleta, 2007; Svetlak, 2007, 2010a; Svetlak et al., 2013).
Through the study of motivations for smoking acquisition and cessation, I came to the study of
the self-medication hypothesis, which posits that risky behaviors such as smoking, overeating,
and self-harm could be ways that some people regulate their dysregulated emotions or cognitive
deficits. For example, we found that symptoms of distress can act as triggers that evoke strong
urges to use tobacco and motivate smokers across all stages, including initiation and
experimentation, maintenance, and relapse (Svetlak et al., 2010). We found a similar
association between stress-related psychopathology and food cravings (Svetlak, 2010). We also
described a relationship between food craving and body weight in older school-age children
(Svetlak & Psenicova, 2012). In the context of smoking cessation and acquisition, we found
some significant differences in psychophysiological reactivity between smokers and
nonsmokers (Svetlak et al., 2010b).
The study of psychophysiology led me to the study of stress and stress reactivity on a more
general level (Roman, Svetlak, Damborska, & Kukleta, 2014). Concretely, we studied
electrodermal activity (EDA) during the Stroop task with the aim of determining whether a nonlinear
analysis of EDA and electroencephalograph (EEG) could provide new information about
psychophysiological reactivity to stress and stress-related psychopathology (Svetlak et al.,
2010c; Svetlak et al., 2013; Bob & Svetlak, 2011). During this period, I had the unique
opportunity to participate in the research of intracranial EEG analysis in patients with epilepsy
(Roman et al., 2013; Bob et al., 2014).
When I began working as a psychologist at the Department of Psychiatry of the Faculty of
Medicine of University Hospital Brno, in 2010, I started to deal with the topics of emotional
awareness and emotion regulation more intensively. It has become increasingly clear to me that
patients with various types of diagnoses have very low levels of emotional awareness and that
their emotion regulation strategies are very often non-adaptive (Svetlak, Roman, Damborska,
& Obereigneru, 2014). In daily life inpatient and outpatient practice, I have come to realize that
one of the main missions of the clinical psychologist is to help people become aware of what
they experience, how they regulate their emotions, and what mediates the relationship between
their experience and dysregulated emotions and behavior. In this context, I have begun thinking
about almost each resulting clinical picture as the original and creative way (even if nonadaptive)
that each person regulates emotions. For example, the central function of eating
disorders such as anorexia nervosa or bulimia nervosa can be understood as an attempt to
control unwanted or dysregulated emotions. The body dissatisfaction, self-loathing, and
excessive focus on body shape and weight can be understood as the displacement of primary
unprocessed negative emotions into the body. The dietary restrictions are then the way that
people with anorexia nervosa decrease emotional awareness and interoceptive sensitivity and
thus protect themselves from unwanted emotions. This is the often observed cascade from
emotional to behavioral dysregulation (Bernatova & Svetlak, 2017; Bernatova, Svetlak,
Roman, & Kasparek, 2017). We also addressed the topic of how to measure levels of emotional
awareness in adults and children (Svetlak, Bernatova, Pavlikova, & Winklerova, 2015; Svetlak,
Marsova, Bernatova, & Winklerova, 2017). We worked on the topic of dysregulated emotional
processing in the etiology of functional neurological disorders (Sojka, Bares, Kasparek, &
Svetlak, 2018).
As a clinical psychologist and psychotherapist trained in Gestalt psychotherapy, which
originated in phenomenology, existentialism, and field theory, I always focused on my own and
my patients’ subjective experience in the present moment during psychotherapy. My implicit
aim in psychotherapy is to help patients became aware of the process of organizing their
experience to have the choice to react in various ways. In this context, I gradually noticed the
similarity between my psychotherapeutic approach and mindfulness practice. In the last decade,
the association between emotional awareness, emotion regulation, and mindfulness have been
discussed with increasing frequency by psychologists and researchers from the affective
neurosciences field. For me, the mindfulness approach has become another effective method of
helping people to regulate their dysregulated emotions. I do not understand mindfulness
programs as replacing psychotherapy; I see them as another effective way to help people
without psychotherapy or as a way to augment psychotherapy. We started to use some basic
components of formal mindfulness practice in adolescent inpatients during relatively brief
hospitalizations (Svetlak, Theiner, & Kubicova, 2018). We prepared an eight-week online
mindfulness program based on mindfulness-based cognitive therapy for students, teachers, and
staff of Masaryk University (Svetlak et al., 2019). At the time of submission of this habilitation
thesis, 1500 people had already participated in this program. The eight-week program is
organized twice a year. Our main aim is to offer students a regular and evidence-based program
that helps them to support their mental health and acquire healthy mind habits. The same
program is being prepared by our research group for patients with cancer.
The topic of mindfulness is an important interest of mine, integrating my previous and current
personal, clinical, and research directions.
Annotation
People most often seek help from mental health professionals because of a form of suffering
that could generally be regarded as emotional dysregulation. Setting aside the diagnostic criteria
of international classification of mental and behavioral disorders, people generally seek help
because they feel and show the right emotion but at an inappropriate intensity (e.g.,
experiencing worry as anxiety), or they may feel the right emotion, but show it in an
inappropriate way (e.g., overeating instead of expressing anger), or they may feel and express
an inappropriate emotion (e.g., experiencing fear in a safe situation). They also often look for
help from mental health professionals when they are experiencing symptoms that at first sight
have nothing to do with emotions (e.g., insomnia, chronic fatigue, difficulty across different
organ systems, fibromyalgia, somatoform disorder, and conversions). These symptoms are
often classified as psychosomatic or medically unexplained; emotion processing is often a
significant etiological factor of these symptoms. In this context, it is evident that emotion
processing is a key etiological co-factor of many mental and somatic disorders. The way
emotions are regulated is an important mediator between feelings and mental and physical
health under stress. A general goal of any treatment should thus be to help patients regain
control over their emotions. Finding effective ways to do this is one of the major challenges for
mental health services.
In recent years, there has been an enormous increase in research evidence indicating that
mindfulness-based interventions (MBIs) are very effective in improving mental health in
healthy people and in those with various psychiatric or somatic conditions. MBI therapies are
increasingly being adopted in education and counseling to support mental health and in clinical
practice to treat various psychological disorders. It is evident that MBIs and follow-up programs
integrating mindfulness and psychotherapy present ways to change human experience at a
fundamental level through the ability to regulate emotions and thoughts. Many psychological
disorders have, at their core, emotion dysregulation; MBIs should be a basic method of
treatment in mental health care. To face this challenge, it is necessary to understand how
mindfulness practice works, what mediates its effect on mental and somatic health and disease,
and which concrete mechanisms investigated in Western science, especially in the field of
emotion regulation research, can describe and explain mindfulness.
This habilitation thesis aims to integrate the constructs of mindfulness and emotion regulation.
The thesis first describes traditional psychological models of emotion regulation, it
operationalizes the mindfulness concept, and it explains how mindfulness practice works and
what mediates the positive effects of MBIs. The thesis then explores how emotion regulation
processes differ from the mindfulness approach to emotion regulation in terms of the underlying
mechanisms they address. Another aim of the thesis is to answer the question of whether the
mindfulness approach is a unique emotion regulation strategy or a set of many of strategies that
could be called “mindful emotion regulation.”
One part of the thesis is also a presentation of some results of our research group verifying the
effectiveness of an eight-week online mindfulness program based on mindfulness-based
cognitive therapy (MBCT) for students, teachers, and staff of Masaryk University. The initial
results of our research group, describing the relationship between mindfulness and emotion
regulation, are also presented.
Contents
Introduction........................................................................................................................................... 13
Emotion regulation and dysregulation: a key topic for mental health professionals........................... 16
Clinical and research evidence that emotion regulation strategies mediate the relationship
between emotion and psychopathology .......................................................................................... 17
The concrete emotion regulation strategies associated with psychopathology .............................. 18
The nature of emotions......................................................................................................................... 21
The nature of emotions: from survival circuits to emotions............................................................. 21
The nature of feelings: from emotions to feelings............................................................................ 22
The core valuation of the world: “good for me” versus “bad for me” state..................................... 23
Emotional awareness: the conscious levels of experience ............................................................... 25
Neural systems involved in generating and monitoring emotions: from homeostatic regulation
to conscious feelings ..................................................................................................................... 27
Emotion regulation process: from emotions to their regulation.......................................................... 29
The conceptual framework of understanding emotion regulation................................................... 29
The process model of emotion regulation.................................................................................... 31
Nonconscious regulation of emotion................................................................................................ 35
Extinction and habituation............................................................................................................ 35
The influence of goals, values, beliefs, and attitudes on emotion regulation.............................. 36
Explicit – implicit emotion regulation continuum......................................................................... 37
Neural systems involved in emotion regulation ............................................................................... 38
Definition and classification of emotion regulation strategies ......................................................... 43
Definition of emotion regulation................................................................................................... 43
Classification of emotion regulation: How emotions are regulated ......................................... 44
Classification of emotion regulation: What is regulated and Why ........................................... 48
Why are emotions regulated? Needs, goals, and values .......................................................... 48
Need-oriented regulation...................................................................................................... 48
Goal-oriented emotion regulation ........................................................................................ 49
Person-oriented emotion regulation .................................................................................... 50
What is regulated: Targets ........................................................................................................ 52
Integrative model of emotion regulation.......................................................................................... 53
Mindfulness........................................................................................................................................... 55
How mindfulness relieves human suffering: the relevant origins of Buddhist teaching for clinical
practice.............................................................................................................................................. 55
The first Noble Truth ..................................................................................................................... 56
The second Noble Truth................................................................................................................ 57
The third Noble Truth.................................................................................................................... 57
The fourth Noble Truth ................................................................................................................. 58
How mindfulness relieves suffering: three strategies for change .................................................... 58
Change in the “what” that is processed........................................................................................ 58
Change in “how” experience is processed .................................................................................... 59
Change in the view........................................................................................................................ 60
Definition and mechanisms of mindfulness...................................................................................... 61
What is mindfulness...................................................................................................................... 61
The two-component model of mindfulness.............................................................................. 63
The first component – self-regulation of attention .............................................................. 64
Orientation to experience..................................................................................................... 65
Is mindfulness a state or a trait?................................................................................................... 67
Is mindfulness one technique?...................................................................................................... 69
Focused attention meditation................................................................................................... 69
Open monitoring....................................................................................................................... 69
Loving-kindness and compassion meditations.......................................................................... 70
Automatic self-transcending practice ....................................................................................... 70
Neural systems involved in mindfulness........................................................................................... 71
Therapeutic application of mindfulness............................................................................................ 75
Mindfulness-based stress reduction program .............................................................................. 76
Program structure and content................................................................................................. 76
Weeks 1 and 2........................................................................................................................... 77
Weeks 3 and 4........................................................................................................................... 78
Week 5 and 6............................................................................................................................. 78
Week 7....................................................................................................................................... 79
Week 8....................................................................................................................................... 79
The formal structure of sessions............................................................................................... 80
The all-day meditation session.................................................................................................. 80
Mindfulness-based cognitive therapy........................................................................................... 81
Program structure and content................................................................................................. 81
The three-minute space exercise.............................................................................................. 81
Deliberately bringing difficulties to mind in sitting meditation ................................................ 82
Cognitive therapy-based exercises............................................................................................ 82
Thoughts and feelings exercise ................................................................................................. 82
Discussion of automatic thoughts............................................................................................. 83
Moods, thoughts, and alternative viewpoints exercise............................................................ 83
Pleasure and mastery activities................................................................................................. 83
Effectivity of mindfulness.............................................................................................................. 85
Mindful in Medical School, Thanks to Facebook: Online Mindfulness-Based Mental Health Support
Program with Intensive Reminder System........................................................................................ 90
Methods ........................................................................................................................................ 93
Participants................................................................................................................................ 93
Procedure...................................................................................................................................... 93
Recruitment............................................................................................................................... 93
Data collection........................................................................................................................... 93
Program......................................................................................................................................... 94
Measures....................................................................................................................................... 95
Data analysis.............................................................................................................................. 97
Results ......................................................................................................................................... 100
Adherence ............................................................................................................................... 100
Differences between groups before the program .................................................................. 100
Program effectivity analysis .................................................................................................... 101
Discussion.................................................................................................................................... 107
Program effectivity analysis .................................................................................................... 108
Adherence ............................................................................................................................... 111
Limitations............................................................................................................................... 113
How does mindfulness practice work? ........................................................................................... 113
Mindfulness and basic personality traits: presumed moderators of the mindfulness effect......... 115
Mediators and mechanisms of mindfulness ............................................................................... 117
Attention regulation................................................................................................................ 119
Body and emotional awareness.............................................................................................. 119
Change in perspective on the self ........................................................................................... 122
Compassion and self-compassion ........................................................................................... 124
Emotion regulation.................................................................................................................. 126
Mindfulness and its predicted components: the mental health construction ............................... 126
Methods ...................................................................................................................................... 126
Participants.............................................................................................................................. 126
Measures................................................................................................................................. 127
Data analysis............................................................................................................................ 128
Results ......................................................................................................................................... 128
CFA model of mindfulness and related processes .................................................................. 128
Discussion.................................................................................................................................... 130
Mindfulness and emotion regulation.................................................................................................. 131
The answer the question one.......................................................................................................... 131
Emotions from the Buddhist perspective........................................................................................ 131
The Buddhist psychological model.................................................................................................. 133
Mindfulness and its time dynamics in emotion regulation: Gross’s processual model.............. 137
Is mindfulness a top-down or bottom-up regulation?................................................................ 139
How does mindfulness practice regulate emotions: could be mindfulness practice classified as an
emotion regulation or coping strategy?.............................................................................................. 144
The answer the question two.......................................................................................................... 144
Is mindfulness approach or avoidance coping? ...................................................................... 145
Is mindfulness emotion-focused coping or problem-focused coping?................................... 146
Is mindfulness a cognitive reappraisal? .................................................................................. 146
Is mindfulness alloplastic vs. autoplastic coping..................................................................... 147
Is mindfulness behavioral or cognitive coping? ...................................................................... 147
Is mindfulness proactive coping? ............................................................................................ 148
Is mindfulness exposure therapy? .............................................................................................. 148
Do mindfulness and psychotherapy have similar goals? ............................................................ 150
The neural bases of emotion regulation and mindfulness: where do they overlap? ................. 154
Mindful emotion regulation................................................................................................................ 156
The answer the question three....................................................................................................... 156
Conclusion....................................................................................................................................... 159
Future challenges ............................................................................................................................ 160
References........................................................................................................................................... 162
13
Introduction
A search for the word “mindfulness” in the abstract, title, or keywords of articles published
between 1970 and 2019 in the Scopus and the Web of Science databases shows 12,070
empirical scientific articles. In 1977, only three articles about mindfulness had been published;
in 2018 alone, 1,940 articles came out. Just for comparison, the same search for the term
“psychotherapy” showed 2,701 articles in 2018. The primary impulse behind the growing
number of articles was probably the foundation of a mindfulness-based stress reduction
(MBSR) program by Jon Kabat-Zinn at the University of Massachusetts in Boston in 1979.
Kabat-Zinn took a Buddhist meditation technique that was 2,500 years old, removed its
mysticism, and transplanted it to a university hospital in the United States. He defines
mindfulness as an “awareness that arises through paying attention, on purpose, in the present
moment, non-judgmentally” (Kabat-Zinn, 1990). The first published article about MBSR
described reduced pain and symptoms of negative mood in a group of 51 patients with chronic
pain (Kabat-Zinn, 1982).
An important milestone in the development of interest in mindfulness among scientists and
clinicians was the foundation of the Mind and Life Institute in 1991. Annual dialogues were
held there between the Dalai Lama and scientists and clinicians as well as regular summer
research meetings (Nicholas et al., 2017). Over the twenty-eight years since then, mindfulness
has become a hugely influential approach in clinical practice in the treatment and prevention of
many mental and physical diseases as well as a fundamental approach to supporting mental
health and well-being. The UK National Institute for Health and Clinical Excellence
recommends mindfulness-based cognitive therapy (MBCT) over other recommended
treatments (e.g., antidepressants) for preventing depressive relapse (Crane & Kuyken, 2012, as
cited in Van Dam et al., 2018). The impact of mindfulness on the general public was
documented in an extensive study by Ella Rhodes (2015) during which mindfulness training
was implemented in seventy-six schools in London, involving nearly 6000 students ages eleven
to fourteen. Scientific reports on mindfulness have been monitored and promoted by media of
all kinds. In February 2014, “Time” magazine even dedicated its front page to the topic with
the headline “The Mindful Revolution.” Unfortunately, the effect of mindfulness on various
medical conditions/diagnoses is often exaggerated and taken out of context; for this reason,
there is a growing misunderstanding among the general public about the potential benefits of
mindfulness practices (Van Dam et al., 2018). The interest of the public in mindfulness is
14
reflected in the increasing number of mindfulness-based mobile apps; a search identified 560
available applications (Mani et al., 2015). Mindfulness represents a new approach to health and
disease, but it is still necessary to ask the same questions as for any treatment approach: For
whom is this the best form of treatment? For what kind of suffering? In what period of life? In
what life context? It is essential to be able to answer these questions in order to protect patients
and the public from being harmed, cheated, disappointed, or dissatisfied. Answering these
questions will help practitioners to find an appropriate position for the mindfulness approach in
medicine and psychotherapy. This is the challenge for any mental health expert interested in
the mindfulness approach.
To face this challenge, it is necessary to understand how mindfulness practice works, what
mediates its effect on mental and somatic health and disease, and which concrete mechanisms
investigated in Western science can describe and explain mindfulness. Another critical question
is whether the mindfulness technique is a unique approach that enriches clinical practice and
provides a completely new component of treatment.
From the literature and a clinical perspective, distinct and interacting mechanisms are at play
in producing the benefits of mindfulness training. The common denominator in the background
of behavioral and experiential changes induced by mindfulness could be probably called
“enhanced self-regulation” or “emotion regulation” more specifically (Hölzel et al., 2011; Tang
et al., 2015). It seems that MBSR (Kabat-Zinn, 2013) and follow-up programs integrating
mindfulness and psychotherapy (Hayes & Wilson, 1994; Linehan, 1993; Segal, Williams, &
Teasdale, 2002) address the alteration of human experience at some fundamental level: the
ability to regulate emotions or the ability to regulate the core valuations of the world.
(Chambers, Gullone, & Allen, 2009; Aldao, Nolen-Hoeksema, & Schweizer, 2010). In a unique
article, Martin (1997) proposed mindfulness as a core psychotherapy process or even as a
common factor of psychotherapy. Horowitz (2002) shared a similar opinion. Mulder, Murray,
and Rucklidge (2017) wrote a review describing a common factor model for psychotherapy in
which mindfulness is implicitly included. Although the hypothesis that mindfulness is a
common factor of psychotherapy is very interesting, its verification is beyond the scope of this
habilitation thesis because of its complexity and the lack of empirical evidence in the literature.
On the other hand, the hypothesis that mindfulness is a unique emotion regulation strategy or a
set of many strategies is testable, and some authors have even reported on “mindful emotion
regulation” (Chambers et al., 2009). Moreover, clinical experience and research (e.g., Aldao et
15
al., 2010) have shown that people most often seek help from psychiatrists, clinical
psychologists, and psychotherapists because of emotional dysregulation. In this context, the
general goal of any treatment should be to help patients regain control over their emotions.
Finding effective ways to do this is one of the major challenges for mental health services. Each
psychotherapeutic approach has emotion regulation incorporated implicitly as one of its general
goals. A few therapeutic approaches even integrate some form of emotion regulation training
explicitly, including dialectical behavioral therapy (DBT; Linehan, 1993), emotion-focused
therapy (EFT; Greenberg, 2002), acceptance and commitment therapy (ACT; Hayes, Strosahl,
& Wilson, 1999), MBCT (Segal et al., 2002), MBSR (Kabat-Zinn, 1993), and emotionregulation
therapy (ERT; Mennin & Fresco, 2009). MBIs, including MBSR and MBCT, that
are used in clinical practice and Buddhist psychology and counseling (de Silva, 2014) have
emotion regulation as their core mechanism of effect on positive outcomes such as increasing
well-being and decreasing various symptoms of psychopathology (e.g., Goldberg et al., 2018).
The psychological investigation of emotion regulation can be dated back to Josef Breuer and
Sigmund Freud (1957) and Anna Freud (1936), who focused on psychological defenses/ego
defense mechanism, and to Richard S. Lazarus (1996), who focused on stress and coping.
Before the early 1990s, however, there were relatively few papers containing the term “emotion
regulation” (Gross, 2014, p. 3). A search for “emotion regulation” using the Scopus and Web
of Science databases in the abstract, title, or keywords of articles published between 1970 and
2019 shows 17,239 empirical scientific articles. In 1977, only one article about emotion
regulation was published; in 2018 alone, there were 2,222 articles. Emotion regulation research
is currently one of the fastest growing areas within the field of psychology (Gross, 2014, p. 3).
The goal of this theoretical thesis is to put mindfulness interventions into the context of emotion
regulation theory and to answer these questions:
1) To what extent can mindfulness be described in terms of emotion regulation theory?
2) Through which emotion regulation strategies does mindfulness practice lead to positive
outcomes?
3) Is mindfulness a unique emotion regulation strategy that could be called “mindful
emotion regulation”?
16
Emotion regulation and dysregulation: a key topic for mental health
professionals
People most often seek help from mental health professionals because of a form of suffering
that could generally be regarded as emotional dysregulation.
Ray et al. (in 2006, as cited in Neacsiu, Bohus, & Linehan, 2014) describe emotion
dysregulation as “the inability, even when one’s best efforts are applied, to change in a desired
way emotional cues, experiences, actions, verbal responses, and/ or nonverbal expressions
under normative conditions. Characteristics of emotion dysregulation include an excess of
aversive emotional experiences, an inability to regulate intense physiological arousal, problems
turning attention away from stimuli, cognitive distortions and failures in information
processing, insufficient control of impulsive behaviors related to strong emotions, difficulties
organizing and coordinating activities to achieve non-mood-dependent goals when emotionally
aroused, and a tendency to ‘freeze’ or dissociate under very high stress”.
Generally, people seek professional help when their emotional reactions are inappropriate in
one of three ways (Ekman, 2007). They may feel and show the right emotion but at an
inappropriate intensity (e.g., experiencing worry as anxiety); they may feel the right emotion,
but show it in an inappropriate way (e.g., overeating instead of expressing anger); or they may
experience an altogether inappropriate emotion (e.g., experiencing fear in a safe situation).
Many negative emotions are not triggered by real dangers; they are the result of the human
capacity for self-awareness and self-relevant thoughts. This capacity predisposes people to have
many feelings that are not associated with the process of life regulation but are instead the result
of the ability to think self-consciously. Leary and Gohar (2014, p. 377) describe how people’s
emotions are affected when they 1) compare themselves to their personal standards, 2) think
about themselves in the past and future, 3) evaluate their personal characteristics, and 4) think
about how they are perceived by other people.
On the other hand, people often seek help from mental health professionals with symptoms that
at first sight have nothing to do with emotions (e.g., insomnia, chronic fatigue, difficulty across
different organ systems, fibromyalgia, somatoform disorder, conversions, etc.). These
symptoms are often classified as psychosomatic or medically unexplained (Brown, 2004).
Emotion processing can be a significant etiological factor in these symptoms (e.g., Brown,
17
2004; Sojka et al., 20181
; Bernatova & Svetlak, 20172
). For example, Escobar et al. (1998)
indicate that 22% of primary care patients meet the criteria for an “abridged somatization”
construct. In a systematic review and meta-analysis, Haller et al. (2015) reveal that the
percentage of patients complaining of at least one medically unexplained symptom ranged from
40.2% to 49%.
Research and clinical practice repeatedly show that there is no problem with emotions in and
of themselves. Rather, the way emotions are regulated is an important mediator between the
emotions and mental and physical health (Nyklicek, Vingerhoets, & Zeelenberg, 2011). Many
concepts in psychological research, validated in daily clinical practice, explain and describe
these mediators and their effect on health and well-being. For example, Freud’s ego defense
mechanisms represent some mechanism or process defending the self against threatening
emotions such as blame, shame, and anxiety (Cramer, 1991; Freud, 1936). Other examples are
the concept of alexithymia (Sifneos, 1973), emotional disclosure (Pennebaker & Beall, 1986),
repression (Weinberger et al., 1979) and the Type C coping pattern (Temoshok, 1987). These
concepts describe mechanisms through which emotions can harm a person’s health.
Clinical and research evidence that emotion regulation strategies mediate
the relationship between emotion and psychopathology
Gross (2014) defines emotion regulation as a functional process that influences the intensity,
duration, and type of emotion experienced. The concept of emotion regulation is an integral
part of the etiological models of psychopathology and mental health (Aldao et al., 2010).
Numerous studies have documented that difficulties in emotion regulation represent a key
factor in the development and maintenance of psychopathology. Sloan et al. (2017) proposed
emotion regulation as a transdiagnostic construct or an underlying mechanism in
psychopathology. Studies have repeatedly documented that some emotion regulation strategies
and their combinations are associated with various mental diseases and that change at the level
1
Sojka, P., Bareš, M., Kašpárek, T., & Světlák, M. (2018). Processing of emotion in functional neurological
disorder. Frontiers in Psychiatry, 9(OCT) doi:10.3389/fpsyt.2018.00479
2
Bernatova, T., & Svetlak, M. (2017). Emotional and interoceptive awareness and its relationship to restriction
in young women with eating disorders and healthy controls: A cascade from emotional to behavioral
dysregulation. Activitas Nervosa Superior, 59(2), 78-86. doi:10.1007/s41470-017-0006-z
18
of emotion regulation can be an effective treatment in, for example, patients with borderline
personality disorders (e.g., Linehan, 1993).
At the most general level, emotion regulation strategies can be divided into two groups:
adaptive and maladaptive (Aldao et al., 2010). Maladaptive strategies are based primarily on
their relationship with the etiology and maintenance of clinical disorders. This division is the
logical outcome of efforts to describe mental health and disease using models of specific
psychopathologies incorporating emotion and emotion regulation/dysregulation. These models
include DBT (Linehan, 1993) in borderline personality disorder (BPD), major depressive
disorder (e.g., Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008), generalized anxiety disorder
(GAD; e.g., Mennin et al., 2007), bipolar disorder (e.g., Johnson, 2005), social anxiety disorder
(SAD; e.g., Kashdan & Breen, 2008), eating disorders (e.g., Bydlowski et al., 2005), alcoholrelated
disorders (e.g., Sher & Grekin, 2007), and substance-related disorders (e.g., Tice,
Bratslavsky, & Baumeister, 2001). These models demonstrate that the way the intensity,
duration, and meaning of emotions are modulated and modified has an essential effect on the
ability to cope with situations/stimuli adaptively or maladaptively.
The concrete emotion regulation strategies associated with
psychopathology
From the extensive research of stress and coping in the 1980s (e.g., Folkman & Lazarus, 1986)
and the development of cognitive-behavioral therapy (Beck, 1976), the most studied adaptive
emotion strategies were reappraisal and problem-solving; from the 1970s and the development
of mindfulness approaches (Kabat-Zinn, 1993), adaptive emotion strategies included
acceptance (Aldao et al., 2010).
Reappraisal is the strategy of reinterpreting emotional stimulus. For example, we can imagine
that a negative event had a positive outcome. The problem-solving strategy is a conscious
attempt to change a stressful situation. Emotions are not regulated directly, but by modifying
or eliminating stressors. Acceptance means seeing things as they are in the present moment,
non-judgmentally (Kabat-Zinn, 2013).
The most studied maladaptive emotion regulation strategies are suppression, avoidance, and
rumination (Aldao et al., 2010; Gross, 2014). Emotions, thoughts, experiences, and behavior
can be suppressed. For example, we can act in such a manner that an observer would be unable
19
to guess how we are feeling (Webb et al., 2012). Avoidance is conceptualized in experience
(Hayes et al., 1999) and in the behavioral (Mowrer, 1947) domain. The main function of
avoidance is withdrawing from aversive stimuli/situation. Nolen-Hoeksema et al., (2008) define
rumination in their “response style” theory as “a mode of responding to aversive situations that
involves repetitively and passively focusing on symptoms related to stress and on the possible
causes and consequences of these symptoms.” Rumination does not lead to active problem
solving to change the circumstances surrounding these symptoms. Instead, people who
ruminate remain fixated on the problems and their feelings about them without acting. In their
review, Gellatly and Beck (2016) document that catastrophization is another maladaptive
strategy of emotion regulation that is significantly associated with phobias, panic disorder,
health anxiety disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and
pain. Catastrophizing can be described as a tendency to explicitly emphasize the terror of an
experience.
In their meta-analytic review, Nolen-Hoeksema et al. (2008) documented that maladaptive
strategies such as avoidance, suppression, and rumination were positively associated, with
medium to large effects, with psychopathology (depression, anxiety, substance abuse, and
eating disorders). Conversely, adaptive strategies, such as problem-solving (medium to large
effect) and reappraisal (small to medium effect) are repeatedly negatively associated with
psychopathology. No association was found between acceptance and psychopathology. These
results support the notion that maladaptive strategies are more strongly related to
psychopathology than adaptive strategies are. This may indicate that the presence of a
maladaptive emotion regulation strategy has a more negative impact on mental health than the
absence of particular adaptive strategies (Aldao, Nolen-Hoeksema, & Schweizer, 2010).
In one of our studies (Marsova, 2016; results presented as a diploma thesis), we found that
adaptive (cognitive reappraisal) and maladaptive (suppression) emotion regulation strategies
mediated the relationship between emotion and prevailing positive/negative emotivity in 330
healthy adolescents. The level of emotional awareness was not found to have any influence on
this relationship. Results are summarized in Figure 1.
20
Figure 1 The path analysis of emotional awareness, emotional regulation strategies, and
positive and negative affect
It can be concluded that achieving adaptive emotion regulation is the main goal of education,
psychotherapy, and any health promotion program. The emotion regulation process is distinct
from the emotion generation process, both conceptually (the latter precedes the former) and
neurophysiologically (Ochsner, Silvers, & Buhle, 2012). Emotions are the primary target of
emotion regulation. To understand how emotion regulation works, it is necessary to have an
idea of how emotions are generated and how these automatic action programs are translated or
transformed to various levels of conscious experience in the form of conscious feelings.
21
The nature of emotions
The nature of emotions: from survival circuits to emotions
It is clear that an organism’s ability to determine the adaptive significance of stimuli is central
to survival. This is the case for both physical and psychological adaptation (Elliot, 2006). The
human body is a highly integrated system that consists of multiple subsystems working as an
integrated whole to sustain life. An important category of life-sustaining brain functions are the
survival circuits involved in defense3
, energy maintenance and nutritional supply, fluid balance,
thermoregulation, and reproduction (LeDoux, 2012). Survival circuits have their origins in
prehistoric mechanisms that were present in early life forms. These functions can be recognized
at a basic level even in single-cell organisms such as bacteria, which has the capacity to retract
from harmful chemicals and to accept chemicals that have nutritional value (Macnab &
Koshland, 1972). These general functions of life linked to specific brain circuits are highly
conserved across vertebrate brain structures and associated behavior in reaction to the internal
and external world (Damasio & Carvalho, 2013; LeDoux, 2012). In general, the main function
of survival circuits is to maintain homeostasis. On the most general level, the activation of these
circuits is manifested as approach or avoidance behavior. Activation of these neural circuits
leads to triggering “action programs.”
Damasio and Carvalho (2013) define these action programs as a set of innate physiological
actions triggered by changes in the internal or external environments and aimed at maintaining
or restoring homeostatic balance. The actions include changes in viscera and internal milieu
(for example, alterations in heart rate, breathing, and hormonal secretion), striated muscle (for
example, facial expressions and running) and cognition (for example, focusing attention and
favoring certain ideas and modes of thinking). Action programs include drives and emotions.
Drives are aimed at satisfying basic, instinctual physiological needs. Examples of such needs
include hunger, thirst, care of progeny, and attachment to mates. Emotions are action programs
largely triggered by external stimuli (perceived or recalled). Examples of basics emotions are
sadness, anger, surprise, fear, disgust, and joy (Ekman, 2007). On the most general level,
emotional responses appear to be organized in terms of a few fundamental dimensions,
including valence and arousal (Russell, 2003; Osgood, 1969; Osgood et al., 1975).
3
This topic was elaborated in detail: Roman, R., Světlák, M., Damborská, A., & Kukleta, M. (2014).
Neurophysiology of defence behaviour. [Neurofyziologie obranného chování] Ceska a Slovenska Psychiatrie,
110(2), 96-104.
22
The nature of feelings: from emotions to feelings
Action programs (emotion and drives) are triggered automatically, without conscious control
from the external (perceived via exteroceptive senses) or internal (via interoceptive system)
stimuli that are continually monitored in topographical homeostatic maps in the brain. Changes
in the internal environment (e.g. heart rate, levels of metabolites, high blood osmolarity, the
degree of contraction of visceral muscles) are displayed as neural interoceptive maps. Changes
in the external world are monitored as neural maps of the external world (Damasio & Carvalho,
2013). These topographical maps are also in many cases part of the executive neural network
triggering corrective homeostatic actions with the aim of correcting homeostatic deflections4
.
Changes in the body state induced via action programs are sensed by the interoceptive system,
displayed in sensory maps of the body, and may be experienced consciously as feelings
(Damasio, 1999). Damasio says that feelings “provide a subjective experiential window into
the processes of life regulation” and “allow a glimpse into ongoing homeostatic regulation,
ranging from basic processes such as metabolism to complex social emotions.” This process is
shown in Figure 2.
4
Presented in more detail in the chapter “Neural systems involved in generating and monitoring emotions: from
homeostatic regulation to conscious feelings”
23
Figure 2 Drives, emotions, and feelings (Damasio & Carvalho, 2013)
The core valuation of the world: “good for me” versus “bad for me” state
The subjectively experienced feelings associated with activated action programs (emotions,
drives, and implicit homeostatic programs) serve as or are integrated with the motivation state
associated with action/behavior. In this context, emotions can be viewed as “push” forces that
predispose people to act in a certain way (Frijda, 1987). Each object is valuated according to
its feeling tone, which falls into one of three categories: pleasant, unpleasant, or neutral. The
approach and avoidance responses represent the fundamental motivational forces that organize
the behavior of every living organism on the planet5
. Even a single-cell amoeba is equipped
5
Approach and avoidance concepts and constructs have been utilized across a range of scholarly disciplines,
theoretical traditions, and empirical content areas. Scholars have made use of the approach-avoidance distinction
for well over 2000 years. Elliot (2008) states that it first appeared in the writings of the ancient Greek philosopher
Democritus of Abdera (460–370 B.C.E.). Democritus articulated an ethical hedonism in which the immediate
pursuit of pleasure and avoidance of pain were prescribed as the guide for human action (pp. 4). William James,
in his classic Principles of Psychology, describes pleasure and pain as “springs of action,” noting that pleasure is
a “tremendous reinforcer” of behavior and pain a “tremendous inhibitor” of behavior. Wilhelm Wundt also
conceptualized pleasure and pain as unique psychic elements brought into consciousness by sensation, emotion,
and cognition. The approach to pleasure and the avoidance of displeasure are basic motivational forces underlying
psychodynamic activity in Sigmund Freud’s theory. He divided the superego into two parts—the ego ideal,
24
with at least some basic form of approach-avoidance mechanism that produces or regulates
movement toward potentially beneficial stimuli and away from potentially harmful stimuli
(Schneirla, 1959). Lewin (1935) described the approach motivation as the energization of
behavior by, or the direction of behavior toward, positive stimuli (objects, events, possibilities),
whereas the avoidance motivation may be defined as the energization of behavior by, or the
direction of behavior away from, negative stimuli (objects, events, possibilities). This process
between stimuli and basic “awareness” of the actual state/present moment that triggers behavior
is described in Figure 3. Avoidance or approach as a behavior can be triggered automatically
without conscious processing or awareness of the core evaluations that trigger the behavior. For
example, we can jump away from a snake in the forest and then find out that it was just a tree
branch on the ground (automatic avoidance) or we can decide not to go to the forest because of
a bad feeling (conscious avoidance). In both cases, the survival circuits were activated. The
difference is in the time dynamics and the level of conscious processing of survival circuit
activation. For instance, the approach motivation could be activated by stimuli with high
valence and medium-level arousal, and the avoidance motivation could be activated by stimuli
with negative valence and high arousal6
.
representing what the person should do, and the conscience, representing what the person should not do.
Elaboration of this theory of motivation is more explicit in the work of Edward Thorndike. In his “law of effect,”
he described how responses followed by satisfaction are more likely to appear and responses followed by
discomfort are less likely to be presented. Ivan Petrovic Pavlov describes his observation about two types of
reflexive responses to stimuli, an orienting response toward the stimulus and a defensive response away from the
stimulus. Burrhus Frederic Skinner, in his theory of operant conditioning, distinguished between reinforcers that
strengthen responses and punishing stimuli that weaken responses and differentiated positive reinforcement (the
provision of a positive) from negative reinforcement (the removal of a negative). Raymond Cattell describes two
basic motives: the innate motives of exploration (an appetitive motive) and escape to security (an aversive motive).
It is evident from this short historical overview that the approach-avoidance distinction has been elaborated in all
the major theories explaining behavior.
6
We applied this theory in a study that examined children’s emotional responses to cigarette text warnings:
Světlák, M., Hodoval, R., Damborská, A., Pilát, M., Roman, R., Černík, M., Bob, P. (2013). The emotional impact
of the text of cigarette package health warnings on older school age and adolescent children. [Emoční reakce
vyvolaná textovými zdravotními varováními na obalech tabákových výrobků u dětí staršího školního věku a
adolescentů] Cesko-Slovenska Pediatrie, 68(2), 78-91.
25
Figure 3 The process from stimuli to motivation
Emotional awareness: the conscious levels of experience
It seems clear that there are always some conscious feelings associated with the processes of
life regulation (Damasio, 1999). Emotion is a multifaceted phenomenon and consists of sets of
physiological (autonomic, immune, endocrine), motor (movement, facial expression),
cognitive, and subjective changes that arise from conscious or nonconscious core valuations
depending on stimulus characteristics, context, and the individual’s currently active goals
(Etkin, Büchel, & Gross, 2015). It is thus possible to be aware of the different levels of this
phenomenon. The level of emotional awareness varies interindividually and intraindividually
as a function of disposition, individual experience, and learning (Lane & Schwartz, 1987).
Emotional awareness can be defined as the extent to which one can identify and describe one’s
own emotions (Moon & Berenbaum, 2009). It represents the ability to consciously perceive and
be aware of emotional states as well as the ability to match emotional experiences with
appropriate semantic categories. Interoception refers to the conscious experiencing of internal
bodily changes (Garfinkel et al., 2015). It is clear that conscious feelings originate from the
perception of the bodily sensations and their dynamic changes (Damasio, 1999) and that the
ability to consciously perceive and be aware of somatic components of affective states is both
the basis of an authentic experience of self (Dolhanty & Greenberg, 2007) and necessary for
adaptive emotion regulation (Gross, 2014).
Interoceptive sensitivity to the somatic component of emotional signals is a necessary condition
for higher cognitive/verbal processing of emotions. It means connecting specific symbolic
representations (verbal) with specific classes of somatic states (Damasio, 1999). On the other
hand, the inability to become aware of this component and a deficit in its conscious and verbal
26
processing can intensify and prolong an unwanted emotional state (Subic-Wrana et al., 2010;
Ciarrochi, Caputi, & Mayer, 2003).
Lane and Schartz (1987) suggest the cognitive-developmental theory of levels of emotional
awareness (LEA). The authors posited five levels of emotional awareness, with each level
representing a hierarchical increase in differentiation and integration from the previous level.
According to this theory, it is possible to differentiate our experiences: the implicit expression
of affective arousal in the form of physical sensations such as heart rate, breathing, and sweating
(LEA 1); action tendencies represented in basic motivational states such as avoidance or
approach (LEA 2); explicit representation of affective arousal as distinct feeling states such as
sadness, happiness, and anger (LEA 3); a blend of feelings at one time, such as happy and sad
together (LEA 4); and awareness of different blends of feelings in the self and others (LEA 5).
The peripheral physiological arousal/somatic sensations and action tendencies associated with
emotion are implicit in the sense that they occur automatically and do not require conscious
processing to be executed. If conscious attention is focused only on a somatic sensation or
action tendencies, emotion is implicit. To be able to name it as a basic emotion requires
processing at higher levels. LEA 3, LEA 4, and LEA 5 are conscious emotional experiences at
different levels of complexity; they reflect explicit emotion awareness. The LEA theory puts
implicit and explicit processes on the same continuum (Lane, 2008). Individuals may differ in
the level of emotional awareness they are capable of at any moment. Each level represents a
different component of the emotional experience, and each level is also a potential object of
emotion regulation.
Greater emotional awareness is associated with higher self-reported impulse control (Lane,
2000), greater openness to feelings (Lane et al., 1990) and a higher level of well-being
(Ciarrochi et al., 2003). In contrast, lower levels of emotional awareness were found in patients
with borderline personality disorder (BPD; Levine, 1997), posttraumatic stress disorder (PTSD;
e.g., Frewen et al, 2008), obesity, anorexia nervosa and bulimia nervosa (e.g., Bydlowski et al.,
2005; Bernatova & Svetlak, 2017), and various psychosomatic diseases (Subic-Wrana, et al.,
2005). It seems that emotional awareness is an important ability necessary for adaptive emotion
regulation, well-being, and mental and somatic health (Lane, 2008).
In the context of this thesis, it is important to mention that physical and emotional awareness
are among the components proposed to describe the mechanisms through which mindfulness
27
has positive outcomes on health (Alsubaie et al., 2017; Hölzel et al., 2011; López et al., 2018;
Tang et al., 2015).
Neural systems involved in generating and monitoring emotions: from
homeostatic regulation to conscious feelings
Many regions in the brain are included in generating drives and emotions. These areas can be
found at different levels of the central nervous system. The most frequently mentioned areas
that are key in the core evaluations of internal and external stimuli include the amygdalae, the
ventral striatum, the ventromedial prefrontal cortex (vmPFC), and the insular cortex (Ochsner
et al., 2012).
The amygdalae are responsible for fast and automatic responses to aversive stimuli without
conscious control, and they are responsible for the expression of fear. The revolutionary studies
by Joseph LeDoux in rodents (reviewed in LeDoux, 2012) and functional imaging and lesion
results in human studies (Whalen & Phelps, 2009) show that the amygdalae play a key role in
Pavlovian defense conditioning.
The ventral striatum (nucleus accumbens) is involved in learning which cues (ranging from
social signals, like smiling faces, to actions, to abstract objects) predict rewarding or reinforcing
outcomes (O’Doherty, 2004).
The ventromedial prefrontal cortex (vmPFC) is a key structure for integrating affective
valuations of specific stimuli generated by the amygdalae and ventral striatum and inputs from
other regions, including the medial temporal lobe memory systems that provide historical
context for the stimuli, and also inputs from the brainstem motivational and prefrontal control
areas (e.g., dorsolateral prefrontal cortex, dlPFC) that provide information about current
behavioral goals (Ochsner et al., 2012; Etkin et al., 2015). The vmPFC has direct reciprocal
connections with appraisal systems such as the amygdalae and ventral striatum (Ochsner &
Gross, 2005).
The insula, which is a higher order topographic map of the body state via interoceptive input
integration (Craig, 2009), has also been implicated in negative affective experience in general.
The posterior-anterior functional gradient in the insula, with posterior regions associated with
primary representations of sensations from the body and anterior regions associated with
28
interoceptive awareness of the body and in motivational and affective states, has been described
(Critchley et al., 2004). The integration successively includes homeostatic, environmental,
hedonic, motivational, social, and cognitive activity to produce a “global emotional moment”
that represents the sentient self at one moment in time (Craig, 2009). Duquette (2017) made an
exciting attempt to integrate these neuroscientific findings with psychotherapy.
The brainstem structures, such as the nucleus tractus solitarius, area postrema, parabrachial
nucleus, ventral tegmental area, other monoamine nuclei, substantia nigra and the red nucleus,
periaqueductal gray, the deep layers of the superior colliculus, and the hypothalamus (Damasio
& Carvalho, 2013) are also involved in generating corrective homeostatic actions. These
interconnected areas generate basic actions that are subsequently monitored via the
interoceptive system and topographically mapped in the brainstem and remapped at the higher
floors of the central nervous system (Craig, 2002; 2009).
The nucleus tractus solitarius, parabrachial nucleus, periaqueductal gray, and superior
colliculus display topographic maps of body states and represents the first order level of
monitoring that Damasio (2003) terms the “proto-self”. At the level of the cerebral cortex, a
few areas are described that play key roles in conscious awareness of what is happening in the
body in the present moment (Damasio, 2003; Craig 2002; 2009; Critchley et al., 2004). The
insular and somatosensory cortices are topographically organized maps of the body, and thus
provide neural substrates of second-order level of monitoring of conscious feelings. The
anterior cingulate cortices (ACC) also exhibit a mapped organization (Etkin, Egner, & Kalisch,
2011). However, it is more critical in emotional regulation (Etkin et al., 2015). The dorsal
regions of the ACC are involved in monitoring the extent to which current reappraisals are
changing emotional responses in the desired direction (Botvinick, Cohen, & Cameron, 2004).
The feelings we perceive from our bodies include temperature, pain, itch, tickle, sensual touch,
muscular and visceral sensations, vasomotor flush, hunger, thirst, air hunger, and others related
to the body’s state. The main parts of interoception are chemosensation, thermo-algic sensation
(temperature and pain perception), visceral sensation, and partly proprioception. This
information is obtained via the main interoceptive pathways such as vagus nerve and the lamina
I spino-thalamo-cortical pathway. The lamina I spino-thalamo-cortical pathway is an afferent
way conveying both thermo-algic and chemosensory information from most tissues of the body
to the spinal cord and brainstem (trigeminal nucleus). The vagus nerve carries signals from
visceral systems (cardiovascular, respiratory, gastrointestinal, and genito-urinary systems) to
29
the nucleus tractus solitarius in the lower brainstem. Additional structures involved in
interoception are the circumventricular organs as specialized structures involved in homeostatic
functions, such as energy metabolism and water balance (Damasio & Carvalho, 2013).
Structures including the amygdalae, ventral striatum, ventral pallidum, and other parts of the
basal ganglia and basal forebrain sectors are key structures in generating homeostatic actions
such as the core evaluation of stimuli salience (ventral striatum) and the triggering of motor,
endocrine, and autonomic actions (amygdaloid nuclei). These emotion-generating areas do not
appear to represent topographic maps of the body. However, the actions they generate are
monitored at many levels of the nervous system (Damasio, 2003; Damasio & Carvalho, 2013).
Emotion regulation process: from emotions to their regulation
The conceptual framework of understanding emotion regulation
The process of valuation is at the core of emotions. An action program/emotion is automatically
activated whenever we encounter external or internal biologically significant stimuli. From this
perspective, an emotion can be described as a perception–valuation–action (PVA) sequence
(Figure 4; Ochsner, 2014) in which input from the external or internal world is perceived and
valued. The result of core valuation triggers the set of action programs (emotion, drives) that
alter the homeostasis (physiological and psychological) in general. The effect of the action is
perceived via a feedback loop. For example, air hunger (the urge to breath) motivates
awakening from sleep (internal stimuli); fear might motivate avoidance of a dangerous
situation; and joy may lead to an individual repeating an action/behavior.
Figure 4 Perception–valuation–action (PVA) sequence (Figure 1; Ochsner, 2014; Etkin et al.,
2015)
30
The emotion regulation process is started when the action/emotional reaction itself (the action
output of an emotional-reactivity PVA sequence) becomes the target of another PVA sequence
(Figure 5) or when there is a conflict between different emotional-reactivity PVAs in
determining behavior.
Emotion is a multifaceted phenomenon, so the effect of emotion regulation can be seen across
all modalities of emotional responses, including behavior, physiology, thoughts, and feelings.
Each modality or level of emotional awareness is a potential trigger of emotion regulation. On
the most general level, emotional responding appears to be organized in terms of a few
fundamental dimensions, including valence, arousal, and approach-avoidance (Russell, 2003;
Osgood, 1969; Osgood et al., 1975). The influence of emotion regulation on people’s emotional
states is therefore likely to be similarly dimensional. In other words, emotion regulation may
not be so much concerned with getting people in or out of discrete emotional states like anger,
sadness, or joy. Rather, emotion regulation may change people’s emotional states along the
mentioned dimensions (Koole, 2009).
Figure 5 A valuation perspective on emotional reactivity and regulation (Etkin et al., 2015)
31
The process model of emotion regulation
The process model of emotion regulation by Gross (1998) is perhaps the most widely used
model to date. The model highlights five points along a temporal dimension at which
individuals can regulate their emotions. These five stages represent five families of the emotion
generation and regulation process (see Figure 6).
Figure 6 The process model of emotion regulation (Gross, 1998; 2014)
The movement in the figure from left to right represents the process of emotion regulation in
time. The feedback arrow shows that each selected emotion regulation strategy changes the
primary stimuli and thus the triggering situation. It is thus possible to change the inner and outer
reality by changing its valuation or its modulation. In the context of this thesis, this part of the
emotion regulation process is significant for categorizing mindfulness practice. A process
model is a tool enabling the analysis of the emotion-generative process beyond emotion
regulation.
Situation selection is the first step in this process. It reflects the fact that it is possible to choose
the situation which is or is not associated with desired emotions. For example, we can call a
friend with whom we can have a good time and who always makes us laugh; we can turn off a
television program because of an unpleasantly scary plot.
Situation modification refers to directly modifying a situation to alter its emotional impact.
For instance, while writing an article, we can jump to less demanding parts to avoid frustration
or anger. Although such strategies are undoubtedly effective (Davis, Gross, & Ochsner, 2011),
they can be difficult to study (Ochsner, 2012).
32
Attentional deployment is the process of directing attention within a given situation to
influence emotions (Gross, 2014). One of the most common strategies of this emotion
regulation process is distraction. For example, we can focus our attention on something positive
that is unrelated to the focal emotion or emotional stimulus (such as inner thoughts and fantasies
or something outside the stimulus) in order to distract ourselves. We might distract ourselves
from the unpleasantness of removing an adhesive bandage by counting trees out the window or
by listening to music or singing silently. The second most commonly studied strategy is
selective attention, which involves shifting the focus of attention toward or away from stimuli
or their attributes (Ochsner, 2012). For example, smokers do not see the health warnings on the
cigarette package. These types of strategies differ from situation selection in that they do not
involve physically altering the proximity or relationship to an emotional stimulus, but instead
they manipulate attention so as to change the emotional response.
Cognitive change refers to the selection of situation meaning. It is possible to choose the
meaning of a situation. An example is the central idea of logotherapy: when people are no
longer able to change a situation, they are challenged to change themselves (Frankl, 1963).
Cognitive change can be applied to an external condition (e.g., “It does not matter that the car
is broken, I can go on foot, which is healthy”) or to an internal situation (e.g., “Writing this
habilitation thesis is a gift and opportunity to study the topic of emotion regulation in depth”).
The most commonly studied cognitive change strategy is reappraisal (Ochsner, 2012).
The last group of emotion regulatory processes is response modulation. These are attempts to
influence emotions after they already have been triggered. Examples include the strategy of
using relaxation to relieve anxiety or using alcohol to reduce physiological responses such as
cardiac hyperactivity. The most commonly studied strategy in this group is suppression.
At the broadest level, Gross (2014) distinguishes between antecedent- and response-focused
emotion regulation strategies. Antecedent-focused strategies represent whatever we do before
the emotion response appears and changes our behavior and peripheral physiological response.
Such strategies include the first three stages of the process model: situation selection, situation
modification, and attentional deployment. An example of an antecedent-focused regulation is
not watching the online news to protect ourselves from anxiety. Response-focused strategies
refer to processes that are activated when an emotion is already underway. These strategies
include cognitive change and response modulation. An example of a response-focused emotion
regulation strategy is hiding our anxiety and fear from our children when taking them to the
33
doctor. The operational definitions of each process as used in different studies are in the
systematic review and meta-analysis by Webb et al. (2012), summarized in Table 1. They
describe the taxonomy of emotion regulation processes defined in Gross’s model, which maps
the relationship between emotion regulation processes and specific emotion regulation
strategies and strategy subtypes.
34
Table 1 A taxonomy for linking emotion regulation processes with specific strategies and strategy subtypes (Webb et al., 2012)
Process Strategy Subtype Definition
Attentional deployment Distraction Active positive
distraction
The instructions explicitly direct participants to think about something positive that is
unrelated to the focal emotion or emotional stimulus, in order to distract themselves.
Passive positive
distraction
Participants are provided with emotionally positive materials or a task that is positive and
unrelated to the focal emotion or emotional stimulus.
Active neutral
distraction
The instructions explicitly direct participants to think about something neutral that is
unrelated to the focal emotion or emotional stimulus, in order to distract themselves
Passive neutral
distraction
Participants are provided with materials or a task that is neutral and unrelated to the focal
emotion or emotional stimulus.
Concentration Concentrate on feelings The instructions direct participants to attend to, focus on, make judgments about, or relive
their emotional experience.
Concentrate on causes
and implications
The instructions direct participants to think about the causes, meanings, or consequences of
or the reasons for their feelings.
Concentrate–mixed The instructions direct participants to concentrate on feelings, causes, and implications.
Cognitive change Reappraisal Reappraise emotional
response
Participants are instructed to interpret the focal emotion in a particular manner. For example,
participants may be told that the emotion is normal or that they should accept or not judge
the emotion.
Reappraise emotional
stimulus
Participants are instructed to reinterpret the emotional stimulus (the context or the cause of
the emotion). For example, participants might be asked to imagine that a negative event had
a positive outcome.
Reappraise via
perspective taking
The instructions ask participants to alter the impact of the emotional stimulus by adopting a
more or a less objective perspective. For example, participants may be asked to imagine
themselves in the situation depicted or may be asked to be objective or to view the stimulus
as detached observers.
Reappraisal–mixed The instructions are framed such that the strategy could involve reappraising the emotional
response and/or reappraising the emotional stimulus and/or reappraisal via perspective
taking.
Response modulation Suppression Suppress the expression
of emotion
Participants are instructed to hide the way that they are feeling (e.g., not to smile) and are
told to act in such a manner that an observer could not guess how they are feeling.
Suppress the experience
of emotion
Participants are instructed to control their emotional experience. Participants are told to
control or not allow themselves to experience the focal emotion.
Suppress thoughts of
the event eliciting
emotion
Participants are instructed to control thoughts of or not allow themselves to think about the
emotion-eliciting event.
Suppression–mixed Participants are instructed both to hide the focal emotion and to control or not allow
themselves to experience that emotion.
35
Nonconscious regulation of emotion
There are many intentional, conscious forms of emotion regulation. Significant evidence from
clinical practice and empirical studies show that emotion regulation and self-regulation have
nonconscious/implicit/automatic forms that operate independently of conscious control (see
review in Bargh & Williams, 2007). Gyurak and Etkin (2014) conceptualize emotion regulation
as occurring along a spectrum, from conscious, effortful, and controlled regulation (which they
call explicit) to unconscious, possibly effortless, and automatic regulations (implicit). Bargh
and Williams (2007) defined nonconscious emotion regulation “as the unintentional, automatic,
and relatively effortless control of one’s exposure to, processing of, and response to emotionally
evocative events.” The implicit emotion regulation mode is essential for the understanding of
mindful emotion regulation, especially after long-term training.
In their dual process model of emotion regulation, Gyurak, Gross and Etkin, (2011) report
various implicit emotion regulation strategies, such as the regulation of emotional conflict and
congruency effect, anticipatory response to emotional stimuli, and error-related regulation. For
the purposes of this thesis, the most important are extinction and habituation regulation and the
influence of goals, values, beliefs, and attitudes on emotion regulation.
Extinction and habituation
Extinction and habituation are basic forms of learning also shared with invertebrate animals.
These strategies are crucial for adaptive responses to emotional challenges. These processes are
blended with implicit and explicit emotion regulation processes (e.g., Olsson & Phelps, 2007).
Extinction involves the repeated presentation of a conditioned stimulus (CS), previously
associated with aversive stimuli (unconditioned stimuli, UC) and able to trigger defensive
behavior, in the absence of the aversive stimuli. Through repeated presentation without an
aversive outcome, a new inhibitory memory is formed between the harmless stimulus and
absence of an aversive outcome, such that the conditioned defensive reaction is no longer
elicited. Extinction can happen without conscious awareness. However, consciously registering
the extinction process facilitates extinction (Lovibond, 2004). It is very important for
psychotherapy processes. One element is the patient’s experience of a safe relationship with the
psychotherapist and the second element is the verbal reflection of it. Conscious framing can
then facilitate the process of fear extinction in exposition to significant others.
36
The neural circuits supporting extinction include the ventral anterior cingulate cortex (vACC)
and the amygdalae. Specifically, the vACC and vmPFC reduce fear responses through
interconnection with the amygdalae and hippocampus during extinction learning and recall of
extinction memories (reviewed by Gyurak & Etkin, 2014). The vACC is a neural correlate of
the regulation of emotional conflict (Egner et al., 2008). More successful extinction is
associated with activation of the dorsal anterior cingulate cortex (dACC) (Milad et al., 2009).
Habituation is an adaptive reduction of the initial response to biologically significant stimuli
that is no longer associated with reward or punishment. The activity of the amygdalae decrease
as participants are exposed repeatedly to the new stimuli (e.g., Hare et al., 2008). The vmPFC
and vACC also play important roles in habituation (Heilbronner & Hayden, 2016). During the
habituation process, the activation of the vmPFC and vACC is negatively correlated with
amygdala activity (Hare et al., 2008). Extinction and habituation are processes that are impaired
in people with PTSD and GAD. The decreased activity of vmPFC and vACC and increased
amygdala activity at the same time has been repeatedly documented in people with emotion
dysregulation (Ochsner, 2012).
The influence of goals, values, beliefs, and attitudes on emotion regulation
The primary function of attitudes is to provide a rapid assessment of objects in the environment
to facilitate appropriate behavior in a timely fashion (Jones, Kirkland, & Cunningham, 2014).
Attitudes, goals, and beliefs can be implicit and they can be activated automatically. Fazio et
al. (1986), in the context of the findings of numerous experiments indicating that lexical
decisions for concepts associated with the prime were facilitated by exposure to the prime (e.g.,
Schneider & Shiffrin, 1977), showed that that a similar priming effect is apparent for attitudes.
Studies from this area have concluded that attitudes, goals, and beliefs automatically influence
what is perceived, how it is interpreted, and how it is evaluated (reviewed by Fazio, 2001).
For example, Tamir et al. (2007) documented that the habitual use of emotion regulation is
related to an individual’s implicit theories about emotions. Mindfulness is also an implicit
theory about emotions in some respects. Some people view emotions as static and unchangeable
(entity theorists), and some as more transient and thus ‘‘regulate-able’’ (incremental theorists).
In their longitudinal study, Tamir et al. (2007) found that the beliefs of entity theorists were
related to lower emotion regulation, self-efficacy perceptions, and less use of cognitive
37
reappraisal. These results indirectly support the notion that education alone can have an effect
on emotion regulation. It also indirectly supports the hypothesis that awareness of emotions as
transient events in the stream of experience is a more adaptive strategy.
Explicit – implicit emotion regulation continuum
Frequent use of an explicit strategy can quickly render the initiation of the strategy more
implicit during regulation, thus making it more implicit over time (Gyurak et al., 2011). In terms
of reinforcement learning, experience with concrete emotion regulation strategies influences
how the emotions will be regulated. Reinforcement learning has an essential role in developing
ego-defense mechanisms (McWilliams, 2011, p. 113), which are excellent representations of
implicit emotion regulation strategies. Several recent studies show that the habitual use of
reappraisal strategies for emotion regulation is an effective mediator between emotions and
positive psychosocial outcomes (Gross & John, 2003; Magar, Phillips, & Hosie, 2008; Richards
& Gross, 2000). Williams et al. (2009) documented that nonconscious reappraisal priming helps
those who do not spontaneously use reappraisal strategies in their emotion regulation attempts
to a greater extent than explicit instructions to reappraise would. Mauss et al. (2007) revealed
that people who habitually reappraise their emotions respond more adaptively to an emotional
stimulus than those who use reappraisal strategies less frequently. Concretely, low reappraisers
report experiencing more anger and negative emotions and have a worse cardiac output profile
than those who use reappraisal more during situations triggering anger. These studies have
documented that emotion regulatory goals, attitudes, values, and beliefs are effective and
important forms of implicit emotion regulation (Gyurak et al., 2011).
Implicit emotion regulation strategies that were explicit initially are accessible to conscious
processing. The paths to awareness of these strategies can be mediated through psychotherapy
and mindfulness practice as well. Awareness depends on the level of automaticity and the
meaning and the power of the preceding emotion to which the strategy is a response (this is
especially true with ego defense mechanisms). Implicit strategies such as ego defense
mechanisms, habituation, and extinction can sometimes prevent such strong and threatening
emotions that awareness of the background of this regulation is almost impossible without the
support of psychotherapy. In this context, psychotherapy and mindfulness are complementary
to one another, and one follows the other. To be successful in psychotherapy, it is necessary to
learn some basic aspects of mindfulness (Martin, 1997). To overcome some aversive states that
38
often appear during mindfulness practice, support from psychotherapy is needed, especially
with unintegrated traumatic experiences (Epstein, 1995).
The valuations of emotional reactions may be inherent or learned through experience and they
may be driven by contextual factors or individual goals. People’s primary emotional responses
presumably reflect their emotional sensitivity, whereas their secondary emotional responses
presumably reflect emotion regulation (Koole, 2009). Emotional sensitivity is influenced by
any variable that influences a person’s initial emotional response to a situation, including
temperament, stimuli characteristics, the context of the situation, and individual experience
(Koole, 2009). For example, it is evident that caregivers may play a key role in learning and
regulating children’s emotional states7
(Fonagy et al., 2002), and it has also been shown that
natural environments can promote recovery from stress more rapidly than urban environments
(Van den Berg, Hartig, & Staats, 2007). The action output of the emotion-regulation PVA
sequence is the process of emotion regulation itself, which may be carried out consciously or
nonconsciously and may potentially target any component of the emotional-reactivity PVA
sequence (Etkin et al., 2015).
Neural systems involved in emotion regulation
Neuro-imaging studies focusing on the neural basis of emotion regulation strategies might
provide particular insights into the understanding of mindfulness as a specific emotion
regulation strategy. The understanding of which brain areas are activated or deactivated when
people regulate their emotions can help understand the effects of mindfulness practice. It also
can help clarify whether mindfulness could be described as a top-down or bottom-up emotion
regulation strategy.
In general, the neural basis of emotion regulation is found in interactions between a regulation
network, involving the prefrontal, parietal, and cingulate systems that implement control and
inhibition processes and regulated subcortical systems such as the amygdalae or the ventral
striatum that are involved in emotion generation and affective appraisal. More precisely, the
ventromedial prefrontal cortex (vmPFC), dorsomedial prefrontal cortex (dmPFC), dorsolateral
7
This topic was elaborated in detail: Světlák, M., Roman, R., Obereignerů, R., Damborská, A. (2014). How do
you feel “ here and now”? Neural correlates of emotional awareness [Jak se cítíte „teď a tady“? Neuronální pozadí
emočního uvědomění]. Psychoterapie, 2, 132-141.
39
prefrontal cortex (dlPFC), ventrolateral prefrontal cortex (vlPFC), inferior parietal cortex (IPC),
and the anterior cingulate cortex (ACC) are considered to be the neural background underlying
emotion control (Etkin et al., 2015; Dörfel et al., 2014; Ochsner et al., 2012). It has been
repeatedly verified that the dlPFC plays a crucial role in all regulation strategies because of its
importance in executive processes, especially for the manipulation of stimuli in working
memory (e.g., Dörfel et al., 2014). The differences in neural activation within different emotion
regulation strategies are presented in Table 2. Strategies associated with increased activity in
the prefrontal brain regions and their inhibitory influence on emotion-generative brain regions,
such as the amygdalae, are classified as top-down regulations (Ochsner, 2012). Strategies that
are characterized by direct reduced reactivity of the “lower” emotion-generative brain regions
without cognitively reappraised stimuli and without the active recruitment of “higher” brain
regions, such as the PFC (Chiesa, Serretti, & Jakobsen, 2013) are called bottom-up strategies.
The critical question is whether top-down emotion regulation strategies are always the most
appropriate, and whether there are other effective forms of emotion regulation that are not based
on top-down mechanisms.
In their valuable review, Etkin et al. (2015) propose distinguishing between model-free and
model-based emotion regulation. This conceptual distinction allows the integration of
neuroscientific findings and different modes of regulating emotions. The distinction between
these two modes of emotion regulation is conceptually essential for explaining the running
process between effortful and automatic emotion regulation. This conceptual distinction also
makes it possible to understand what happens during the process of learning and why different
neural correlates are found in various practice stages in mindfulness meditation.
Model-free emotion regulation is primarily based on prediction error feedback. The best
example of this model is fear conditioning and emotional conflict regulation. Through learning
in the form of classical and operational conditioning, an implicit emotion regulation model is
reached that helps get from a “bad for me” state to a “good for me” state. At the neural level,
fear-conditioned stimulus activates regions such as the amygdalae, insula, dorsal dACC, and
PAG (LeDoux, 2012).
Fear extinction is a different process, involving activating the vACC–vmPFC during fearconditioned
stimuli without the occurrence of aversive unconditioned stimuli (e.g., Etkin et al.,
2011). Many studies have documented that vACC–vmPFC activation is a general neural
correlate of fear extinction when fear is inhibited (Lissek et al., 2014). In other words, this is
40
the neural correlate for putting an individual into a more “good for me” state. Concrete emotion
regulation strategies such as attentional deployment or ego defense mechanisms such as denial
are automatically used to get to a “good for me” state.
Model-based emotion regulation is associated with an internal model with the aim of guiding
experience and behavior. It can be categorized as an explicit emotion regulation. In fact, an
internal model is referenced in all forms of explicit emotion regulation, even though the specific
strategies may differ (e.g., suppression, reappraisal, and situation selection). For example, it is
possible to use reappraisal to decrease negative emotions by seeking various meanings of
stimulus (such as someone’s tears reflecting joy rather than sadness). Unlike the model-free
regulation, frontoparietal regions such as the vlPFC, dlPFC, PC, pre-SMA, and SMA are
recruited (Buhle et al., 2013). An intact working memory capacity is required to construct
and/or make use of internal models. This is probably one reason that children with ADHD are
unable to behave according to their teacher’s verbal recommendations. Schmeichel, Volokhov,
and Demaree (2008) described a negative relation between reappraisal ability and working
memory capacity. Qin et al. (2009) showed that acute stress impairs working memory and
decreases dlPFC activity, consequently disrupting the ability to reappraise and reduce
autonomic system responses (ANSr) to aversive stimuli. Figure 7 shows the main differences
in emotion regulation neural backgrounds. The emotion generative structures such as the
amygdalae are primarily inhibited with vACC and vmPFC in model-free regulation. This is the
most observed neural correlate of extinction, habituation, emotional conflict adaptation, and
anticipatory response to emotional stimuli (Gyurak & Etkin, 2014). On the other hand, emotion
generative structures are more inhibited with the lateral prefrontal cortex in model-based
regulation. This is the most observed neural correlate of cognitive reappraisal and verbal
labeling (Gyurak & Etkin, 2014).
41
Figure 7 Schematic of model-based and model-free emotion regulation (Etkin et al., 2015)
42
Table 2 The associations between neural structures and concrete emotion regulation strategies
Strategy Explicit Study
Cognitive
Reappraisal
Activation: dmPFC, dlPFC, vlPFC, and posterior parietal lobe Buhle et al., 2014;
Ochsner & Gross,
2005
Distraction Activation: ACC, vlPFC, PC, Left IPC
Deactivation: left and right amygdala
Dörfel et al., 2014;
McRae et al., 2010
Reinterpretation Activation: left dlPFC, left vlPFC, OFC
Deactivation: left and right amygdala, reductions in insula activation
Ochsner et al., 2012;
Dörfel et al., 2014;
Buhle et al., 2013
Detachment Activation: right dlPFC, bilateral IPC, dACC, dorsal and anterior portions of the mPFC, right superior frontal cortex,
right angular gyrus
Ochsner et al., 2012;
Dörfel et al., 2014
Expressive
Suppression
Activation: bilateral dmPFC, right dlPFC, left vlPFC, SMA, Pre-SMA Phillips et al. 2008
Reinterpretation
to Expressive
Suppression
Superior frontal gyrus and the posterior part of the middle frontal gyrus was more strongly activated by
Reinterpretation as compared to Expressive Suppression. The superior frontal sulcus and the supplementary motor
area (SMA) were more active during Expressive Suppression than during Reinterpretation.
Vrticka et al., 2011
Detachment to
Expressive
Suppression
Expressive Suppression produced late vmPFC, dlPFC, and ACC responses, decreased negative emotion behavior and
experience, but increased amygdala and insular responses. Detachment produced enhanced (early) responses in dPFC,
amPFC, vlPFC, and OFC.
Goldin et al., 2008
Reappraisal to
Distraction
Reappraisal produced activation of OFC as compared to Distraction. Both strategies were successful in reducing
subjective emotional state and lowered activity in the bilateral amygdalae.
Kanske et al., 2011
Reinterpretation
to Distraction
Both strategies resulted in decreased activation in the amygdala. Distraction relative to Reinterpretation led to greater
increases in dmPFC, bilateral dlPFC, and vlPFC and several left-sided clusters in temporal cortex. Distraction relative
to Reinterpretation led to greater decreases in amygdala activation and to greater increases in activation in posterior
frontal cortex, right lateral PFC, and bilateral superior parietal cortex. Reinterpretation specifically activated left
vlPFC, while Distraction uniquely activated left dlPFC. All regulation strategies inhibited amygdala activity.
McRae et al. 2010
Reinterpretation
to Detachment
Detachment let to stronger activation in right vmPFC and IPC. Reinterpretation showed greater activation in left and
right lateral PFC including dlPFC and vlPFC, but also in precentral gyrus, temporal gyrus and supramarginal gyrus.
Both strategies showed reduced activation in left posterior insula and left amygdala.
Ochsner et al., 2004
Notes: ACC – anterior cingulate cortex; amPFC – anterior medial prefrontal cortex; dACC – dosal anterior cingulate; dmPFC – dorsomedial prefrontal cortex; IPC – inferior
parietal cortex; mPFC – medial prefrontal cortex; OFC – orbitofrontal cortex; PC – parietal cortex; dPFC – dorsal prefrontal cortex; dlPFC – dorsolateral prefrontal cortex;
vlPFC – ventrolateral prefrontal cortex; SMA - supplemental motor area; pre-SMA – pre-supplemental motor area.
43
Definition and classification of emotion regulation strategies
Definition of emotion regulation
From the clinical and daily life perspective, it is possible to define emotion regulation at the
lowest level with examples: I look for the positive side of things; I tell myself that there are
worse things in life; I wore my lucky socks the day of the exam; I read everything I could find
about it, and I had a nice hot bath. People use countless such real-time responses to deal with
conditions in the external or internal world that induce emotion, stress, or stress-related
emotions. The potential variety of emotion-regulation strategies is enormous, given that any
activity that affects people’s emotions may be considered as an emotion regulation (Koole,
2009). Regardless of how often people are exposed to emotional stimuli, they usually resist
being carried away by the actual immediate emotional influence of the event. During emotion
regulation, people may increase, maintain, or decrease positive and negative emotions (Koole,
2009). The general aim of emotion regulation could be defined as the effort people make to get
closer to the emotional state that they want. Actions in reaction to emotions should lead to the
achievement of a more “good for me” state or a less “bad for me” state (Etkin et al., 2015).
Emotion regulation is defined as the extrinsic and intrinsic processes responsible for
monitoring, evaluating, and modifying emotional reactions, especially their intensive and
temporal features, to accomplish one’s goal (Thompson, 1994). Gross (2014) defines emotion
regulation as a functional process that influences the intensity, duration, and type of emotion
experienced. Gyurak and Etkin (2014) conceptualize emotion regulation as occurring along a
spectrum from conscious, effortful, and controlled regulation (which they called explicit) to
unconscious, and possibly effortless, or automatic regulation (implicit). In its broadest sense,
emotion regulation subsumes the regulation of all states that are emotionally charged, including
moods, stress, and positive or negative affect.
The mentioned studies dealing with the association between regulation strategies and
psychopathology are limited to a few well-defined strategies. In contrast, clinical experience
shows an endless wealth of possible ways by which people regulate their emotions. To make
the topic easier, it is possible to ask three basic questions:
1) How are emotions regulated? The answer is concrete emotion processing and behavior
(classification);
44
2) Why are emotions regulated? The answer is the goal of the process (personal needs,
goals, experience); and
3) What is regulated? The answer is every component of emotion (physiology and
cognition).
The “how” question also has other aspects, such as the time dynamic of the emotion regulation.
The question was framed with the PVA sequence and process model above.
Classification of emotion regulation: How emotions are regulated
Many different classifications of emotion regulation strategies have been proposed. The
potential number of emotion regulation strategies is huge, and many classifications are just
phenomenological, without an explanation of the underlying process (Koole, 2009). To be able
to classify mindfulness intervention as an emotion regulation strategy, these classifications need
to be described and defined.
One of the most cited and actually one of the first studies to deal with the classification of
emotion strategies focused on strategies for changing a bad mood (Thayer, Newman, &
McClain, 1994). It described 32 categories for methods of changing a bad mood. Using
exploratory factor analysis, it identified six general factors describing typical ways to try to
change a bad mood: active mood management (e.g., relaxation techniques, stress
management, sex, humor, and exercise), seeking pleasurable activities and distraction (e.g.,
humor, engaging in a hobby, listening to music, avoiding thing or people, and controlling
thoughts), passive mood management (e.g., television, coffee, and eating), social support,
ventilation, and gratification (e.g., talking to someone, engaging in emotional activity –
crying, screaming), direct tension reduction (e.g., drugs, alcohol, sex), and withdrawalavoidance
(e.g., trying to be alone, avoiding things or people). They also identified three
general groups/factor of strategies/activities employed for short-term energy enhancement:
activity: physical, social, cognitive (e.g., going outside, exercising, or doing something to keep
busy), reduced activity and rest (e.g., taking a shower, sleeping, or watching television),
caffeine, food, and passive stimulation (e.g., drinking coffee, eating something, or smoking)
and three general factors describing strategies used to reduce nervousness, tension, or anxiety:
emotional expression, food, and drugs (e.g., alcohol, cigarettes, drugs, or music), muscle
release, cognitive control, and stress management (e.g., relaxation techniques, taking a
45
shower, or stress management) and pleasant distraction (e.g., shopping, engaging in a hobby,
sex, reading or writing, or exercise). The authors concluded that exercise was the most effective
mood-regulating behavior, and that one of the best general strategies for changing a bad mood
is a combination of relaxation, stress management, cognitive activity, and exercise techniques
(Thayer, Newman, & McClain, 1994).
Parkinson and Totterdell’s (1999) taxonomy classified different affect regulation strategies.
This taxonomy was developed by asking participants to sort 162 relatively distinct affect
regulation strategies into meaningful categories. The primary distinction emerging from this
analysis was between cognitive and behavioral strategies (i.e., between strategies involving
thought and those involving physical action), between diversion and engagement strategies, and
between active distraction and direct avoidance, and for specific lower-level groupings of
strategies relating to venting, reappraisal, and seeking social support. The results are
summarized in Table 3. These two classifications are based on factor analysis (the first one)
and rational sorting (the second one), which involves grouping items that share common
features and separating items that differ.
The constructs of coping theory and coping strategies are closely related to emotion regulation
(Lazarus, 1996). Coping can be defined as an individual’s cognitive and behavioral efforts to
manage stress (Lazarus & Folkman, 1984). In the context of survival circuits and the process
of core evaluation, the experience of stress is mediated through the experience of an aversive
affect triggered and perpetuated with an event (any perceived object). The key antecedent of
psychobiological stress response is the appraisal of what the stressful event is and what it is not.
The physiological stress response changes into chronic stress through the using of maladaptive
coping and emotion regulation strategies (Ayers & de Visser, 2011, p. 55). A very valuable
review by Skinner et al. (2003) found 400 concrete coping strategies and proposed several
concepts that are potentially useful for emotion regulation categorization. The authors sorted
the strategies into fourteen higher order coping categories. In addition to problem-focused
strategies, their classifications included categories of emotion regulation (e.g., emotion-focused
coping, avoidance, appraisal, and proactive coping). The results of this review are summarized
in Table 4.
46
Table 3 Classification of affect regulation strategies (Parkinson & Totterdell, 1999).
Cognitive Behavioral
Diversion
Disengagement Avoid thinking about
the problem
Avoid problematic
situations
Distraction Seek
pleasure or
relaxation
Think about
something pleasant
Think relaxing
thoughts
Do something
pleasant
Do something
relaxing
Reallocate
resources
Think about
something that
occupies attention
Perform a
demanding activity
Engagement Reappraise (usually
affect-directed)
Think about how to
solve the problem
(usually situation-
directed)
Vent feelings
(usually affect-
directed
Seek help or comfort
from others
Take action to solve
the problem (usually
situation-directed)
47
Table 4 Higher-order coping categories (Skinner et al., 2003).
Category Definition
Emotion-focused coping vs. problemfocused
coping
“Coping that is aimed at managing or altering the problem causing the distress” vs. “coping that is
directed at regulating emotional responses to the problem”
Problem-focused coping vs. emotionfocused
coping vs. appraisal-focused
coping
“Dealing with the reality of the situation seeks to modify or eliminate the source of the stress” vs.
“handling emotions aroused by a situation response whose primary function is to manage the
emotions aroused by stressors and thereby maintain affective equilibrium” vs. “primary focus on
appraising and reappraising a situation . . . involves attempts to define the meaning of a situation”
Responses that modify the situation vs.
responses that function to control the
meaning of the problem vs. responses that
function for the management of stress
“Responses that change the situation out of which the strainful experience arises” vs. “responses
that control the meaning of the strainful experience after it occurs but before the emergence of
stress” vs. “responses that function more for the control of the stress itself after it has emerged”
Approach vs. avoidance “Cognitive and emotional activity that is oriented either toward or away from threat”
Engagement vs. disengagement “Responses that are oriented toward either the source of stress, or toward one’s emotions and
thoughts” vs. “responses that are oriented away from the stressor or one’s emotions/thoughts”
Control vs. escape “Proactive take-charge approach” vs. “staying clear of the person or situation or trying not to get
concerned about it”
Primary vs. secondary vs. relinquishment of
control coping
“Efforts to influence objective events or conditions vs. efforts to maximize one’s fit with the current
situation vs. relinquishment of control”
Assimilation (vs. helplessness)
Accommodation (vs. rigid perseverance)
“Transforming developmental circumstances in accordance with personal preferences” and
“Adjusting personal preferences to situational constraints”
Alloplastic vs. autoplastic coping “Coping directed toward changing the environment vs. directed toward changing the Self “
Volitional, effortful, controlled vs.
involuntary, automatic coping
Responses to stress that involve volition and conscious effort by the individual vs. responses that
are automatized and not under conscious control
Behavioral vs. cognitive coping “Taking action or doing something” vs. “mental strategies and self-talk”
Social vs. solitary coping “Utilize methods that involve other people” vs. methods that can “be done alone”
Proactive coping “Efforts undertaken in advance of a potentially stressful event to prevent it or modify its form
before it occurs”
Direct vs. indirect coping “Coping in which an individual emits an overt motor behavior to deal with a stressful event” vs.
coping in which “the organism responds to the stressful event by enlisting the aid of a conspecific”
48
Classification of emotion regulation: What is regulated and Why
Emotion regulation can be described from the perspective of what people usually do with their
emotion when they regulate it (classification) and in which time manner (process model, Gross,
1998; PVA model, Etkin et al., 2015). Koole (2009) offers the classification of emotionregulation
strategies in terms of their targets and functions. This approach allows the
organization of research findings on emotion regulation strategies in a meaningful whole and
also provides a framework for the integration of psychological concepts such as coping and ego
defense mechanisms.
Why are emotions regulated? Needs, goals, and values
The question “why” is answered by the functions of emotion regulation. The functions of
emotion regulation are a fundamental category for characterizing different emotion strategies,
a category that is independent of which emotion-generating system outcome is targeted (Koole,
2009).
Need-oriented regulation
The first motivational force behind emotion regulation is hedonic needs that are aimed at
promoting pleasure and preventing pain. Approach and avoidance are the fundamental
motivational forces that organize the behavior of every living organism on the planet. Lewin
(1935) described approach motivation as the energization of behavior by, or the direction of
behavior toward, positive stimuli (objects, events, possibilities), whereas avoidance motivation
may be defined as the energization of behavior by, or the direction of behavior away from,
negative stimuli (objects, events, possibilities). The core valuation of incoming stimuli operates
automatically on subcognitive and subcortical information processing (e.g., LeDoux, 1999;
Panksepp, 1999). This kind of emotion regulation often has an impulsive quality, and it is shortterm
oriented (Tice et al., 2001). In this mode of regulation, we maximize short-term emotional
benefits at the expense of long-term well-being. For instance, in their three experiments, Tice,
et al. (2001) found that participants regulated their emotions under emotional distress by eating
a fattening snack, seeking immediate gratification, and engaging in procrastination. Such
impulsive self-regulation disruptions are usually inconsistent with long-term goals.
Dysregulated behavior, such as binge-eating or non-suicidal self-injury, often occurs during
49
times of emotional distress and it is thus very probably in some cases a means of emotion
regulation driven by need (Selby, Anestis, & Joiner, 2008).
On an attentional level, need-oriented emotional regulation is evident in subjects with
repressive coping. When these subjects are faced with threatening information, they tend to
shift attention to the positive aspects of the situation (Langens & Morth, 2003) to avoid
unpleasurable feelings. Repressors also have a lower level of emotional awareness and lower
introspective ability (Lane et al., 2000). Ego defense mechanisms are another example of needoriented
emotion regulation. Negative affects, such as shame, guilt, and anxiety, can be
activated when an internal or external event violates the preferred view of the self. In such
cases, it is necessary for the self to have some mechanism or process to defend itself against the
threatening implications of this event (e.g., Baumeister, Dale, & Sommer, 1998). Denial is a
simple example of this process. Denial is the simple refusal to face certain facts. If these facts
are highly upsetting or represent potential damage to self-esteem, denial can be, in principle, a
very useful defense mechanism (Baumeister et al., 1998). It is fast, automatic, and without
conscious control. The distinction between denial and repression, as with repressive coping, is
sometimes unclear and difficult to distinguish in a meaningful way (Cramer, 1998). The needoriented
function of emotional regulation has model-free emotion regulation in its background.
Although hedonic needs are important, they cannot explain the full range of emotion-regulation
processes. For instance, social interactions often require people to remain “cool and collected,”
and hence may lead people to down-regulate both negative and positive moods (Erber & Erber,
2000).
Goal-oriented emotion regulation
The second function of emotion regulation is goal oriented. A single verbally reportable goal
or attitude directs this emotional regulation in combination with beliefs about the benefit of
particular emotional states. Goals generally represent a top-down strategy of emotion
regulation. Achieving the goals is mediated by attention (Posner & Rothbart, 2007). In this
context, attention is a primary target for goal-oriented emotion regulation strategies. It is an
example of model-based strategies. The ability to use distracting stimuli is a key factor in the
goal-oriented regulation of attention. An example of this in everyday life is telling sad people
to stop thinking about sad things. Recent studies show that concrete distractors (e.g., “Think
50
about a red Ferrari”) are more effective than simple neutral instructions (e.g., “Do not think
about it”) and even more effective than thought suppression (Wegner et al., 1993; Wegner,
1994; Wegner & Gold, 1995). For instance, self-distraction could involve reading a book
instead of ruminating before going to sleep. Clinical research has found that depressed
individuals have difficulty finding suitable self-distracters (Wenzlaff, Wegner & Roper, 1998;
Joorman & Siemer, 2004). Another goal-oriented emotion regulation strategy is cognitive
reappraisal. This is the process by which the emotional impact of an event is changed by
changing the subjective evaluation of it, for example by using humor. Cognitive reappraisal is
the most frequently investigated process of emotion regulation, coupled with suppression
(Gross, 2014). Research in affective neuroscience repeatedly reveals that cognitive reappraisal
is a top-down emotion regulation strategy and reappraisal activates some of the same brain
regions as tasks involving top-down attention control (Ochsner et al., 2012). Suppression is
another goal-oriented strategy. It can be focused on the body, thoughts, behavior, or feelings.
Focusing this strategy on the body is expressive suppression (Gross, 2014), in which emotional
expressions are actively inhibited. For example, we might take deep breaths to keep calm and
suppress the urge to cry. Studies show that expressive suppression does not prevent the
experience of unwanted emotion, despite the body expression inhibition (Gross, 2014). Chang
et al. (2018) documented that individuals who reported greater tendencies to regulate emotions
via expressive suppression have greater projection biasing memory of negative emotions.
Robinson and Demaree (2007) describe “expressive dissonance,” a discrepancy between inner
experience and outer expression. This can be often observed within individual psychotherapy
in which patients manage their behavior based on their inner beliefs and past experiences
instead of on the demands of the present moment. The opposite of expressive suppression is
venting, which is a popular strategy for controlling anger and aggression (Bushman et al., 2001).
Catharsis theory predicts that venting anger should get rid of it and should, therefore, reduce
subsequent aggression. Although venting is widely recommended, research indicates that
venting anger increases anger and aggression and heightens the activation of angry thoughts
and action tendencies (Bushman, 2002).
Person-oriented emotion regulation
This function of emotion regulation is characterized by a holistic focus. Whereas need-oriented
and goal-oriented emotion regulation focus only on some aspects of emotional or task-related
51
functioning, person-oriented emotion regulation is related to the functioning of the whole
person (Koole, 2009). Integration is the primary signature of this function: the integration and
coordination of different and often antagonistic personality systems (negative versus positive
emotions; body versus mind; top-down versus bottom-up processing). Person-oriented emotion
regulation is different from the need-oriented strategies associated with long-term benefits
(Koole, 2009).
The research by Koole (2009) is in the counter-regulation principle category, which is defined
by Rothermund et al. (2008) as attentional biases that prevent the perseveration of current
motivational or emotional states. According to this principle, when we experience a negative
emotion, positive information captures our attention, fostering the processes of positive
reappraisal and dampening negative feelings of sadness, frustration, or anger. Counterregulation
is also a highly adaptive mechanism when positive emotions are experienced;
allocating attention to negative information when experiencing intense positive emotions
allows for a more balanced and realistic view of the current situation (Schwager & Rothermund,
2014).
Another person-oriented emotion regulation strategy is putting traumatic experience and related
strong emotions in perspective (Van der Kolk & Fisler, 1995). This means that an emotional
experience is integrated into the larger narrative network of life, and emotions are downregulated
through this network. The integration of aversive emotional experiences is an
essential form of emotion regulation, and it is the key implicit goal of individual psychotherapy,
regardless of the psychotherapeutic approach. Expressive writing is an example of downregulating
emotions by integrating the emotional experience in a narrative network/
autobiographical memory. There is evidence that this improves both physical and psychological
health (Pennebaker, 2018). Autobiographical narratives are considered to affect the downregulation
of emotions (Pascuzzi & Smorti, 2017). Functions of emotion regulation and
different strategies mentioned in Koole’s model (2009) are summarized in Figure 8.
There is not yet a clear explanation of how people resolve conflicts between need-, goal-, and
person-oriented functions. Koole’s model describes options of emotional regulation, and the
individual experience in the process of reinforcement learning, physical maturation, and
spiritual growth determine the ratio and context of the use of concrete emotion regulation.
52
In general, each integrative whole-body feeling can be reduced on the basic emotional
dimension of valence. We compare our desired emotions, feelings, beliefs, goals, and attitudes
with our actual state, and the difference is always implicitly or explicitly valuated. The result
of this core valuation is a positive or negative state (“bad for me” or “good for me”). This notion
is closed to the cybernetic self-regulation model of Carver and Scheier (1981). They supposed
a tendency to maintain a steady state or equilibrium. Given this overarching goal of maintaining
a steady state, emotional responses represent a break in the equilibrium that should, according
to the theory, automatically provoke emotion-regulatory responses.
Figure 8 Functions and associated strategies of emotion regulation (Koole, 2009).
What is regulated: Targets
Emotion regulation is always directed at manipulating emotional response (actions in PVA
model generated by survival circuits). Emotion is a multifaceted phenomenon that can be
described on many levels, including physiological (autonomic nervous system reactivity,
immune system, endocrine system), motor/behavioral (movement, facial expression), cognitive
(attention, memory, thinking), and subjective (feelings8
). Our emotions depend on what is
currently available to our conscious awareness (in the process from emotion to feeling). In their
developmental theory of emotional awareness, Lane and Schwartz (1987) distinguish five
8
Feelings can be classified as cognition as well (Damasio, 1999; Schwartz and Lane, 1987).
53
levels of emotional experience (described in this thesis in the chapter on emotional awareness).
The inputs for emotional regulation are the first three levels: somatic sensations (e.g., heartbeat,
sweating), action tendencies (basic motivational states such as avoidance and withdrawal), and
basic emotions (e.g., sadness, anger, fear, joy). Each level of emotional expression can be a
target of emotion regulation.
For example, people with social anxiety may be afraid of blushing, and they usually want to
regulate just this expression/symptom. In other cases, people may want to regulate their
unpleasurable thoughts (most often they are aggressive, sexual, or religious). Among the three
most widely studied emotion regulation mediator systems are attention, knowledge, and bodily
expressions of emotion (Koole, 2009). The question “What is regulated?” identifies the target
of the concept of emotion regulation.
Integrative model of emotion regulation
Figure 9 presents an integration of the presented models. It integrates time dynamics, targets,
functions, and classifications of emotion regulation. Each inner and outer stimulus is perceived
and valuated in a “core valuation process” as pleasant, aversive, or natural. The result of this
process is an emotion (action) that manifests as a behavioral, physiological, feeling, and thought
change. These reactions are targets of emotion regulation, which is influenced and driven by
individual goals, is regulated at some level (body, knowledge, attention), and is regulated with
various inherent or learned methods (classification). Each emotion regulation leads to the
change of perceived inner or outer stimuli via a feedback loop. The whole process can be
implicit or explicit. Perception is influenced through antecedent-focused strategies (situation
selection, situation modification, and attentional deployment). Valuation can be influenced
through cognitive change. Response/action can be changed or modified with response
modulation.
54
Figure 9 The integrative model of emotion regulation
55
Mindfulness
How mindfulness relieves human suffering: the relevant origins of
Buddhist teaching for clinical practice
The Buddhist analysis of the nature and origins of suffering can be summarized in the Four
Noble Truths. These truths are four key insights explaining how to awaken and how to find
greater freedom and lasting peace and happiness (Teasdale & Chaskalson, 2011). Buddhism
credits these insights to Gautama Buddha. Siddhartha Gautama (also known as the Buddha, the
Enlightened One, or The Awakened) was from a large clan called the Shakyas in Lumbini (in
what is now Nepal). He became profoundly dissatisfied with the life of pleasure he had been
leading. He posed one of the basic human questions: “What is the ultimately satisfying way of
being, and how can we escape from human suffering?” He left his life of luxury and comfort to
achieve enlightenment in reaction to this existential emptiness. At the end of his spiritual
journey, as an act of compassion, he offered the Four Noble Truths as a guide for others seeking
a more satisfying life.
With only some exaggeration, it could be said that the individuals who seek psychotherapy or
MBSR and MBCT are in the same position as the Buddha was. At the start, they are mostly
looking for relief from stress, pain, sadness, or recurrent depression, rather than the resolution
of some existential disease. They just want to be in a “good for me” state. Suffering is the first
step in seeking a spiritual path. Anyone could be the Buddha. Everyone shares the same
existential emptiness which is covered with the fragile hope of an endless life without suffering.
The denial of transience and the unpredictability of life represent a deep alienation from reality
and thus from the self (Epstein, 1995, p. 49). To maintain this illusion, people spend a huge
amount of energy protecting themselves from the overwhelming truth that everything will die
at some point.
The key concept of Buddhist learning is dukkha, a Pali9
word with no real adequate English or
Czech translation. Dukkha is often translated as suffering, but this translation can be quite
misleading (Teasdale & Chaskalson, 2011). A better translation, as the Buddha probably
thought it, is “dissatisfaction”. It reflects the fact, that transient things in the world are not able
to bring the relief of suffering caused by profound dissatisfaction in life. For this reason, many
9
Pali is one of the ancient Indian languages in which the Buddha’s teachings were first recorded.
56
people prefer not to translate dukkha, and simply use the Pali word. Dukkha is a central
component of the Four Noble Truths.
The first Noble Truth
The first Noble Truth can be expressed very simply: suffering dukkha is a key part of life. This
is the universal experience of every human being. We are all in the same boat together, whether
we are teachers, patients, clients, psychologists, or doctors. All of us share two things: suffering
and the simple wish to be happy and not suffer. This realization can help us feel a greater sense
of connection and compassion for all human beings (Teasdale & Chaskalson, 2011).
Buddhist teachings helpfully distinguish three domains or bases of dukkha (Teasdale &
Chaskalson, 2011): unsatisfactoriness related to situations of “ordinary” obvious suffering,
unsatisfactoriness related to change, and unsatisfactoriness related to conditionality.
The Buddha saw that unpleasant or uncomfortable physical sensations or emotional feelings
are inherent in life. He shows that these sensations and feelings are not, in and of themselves,
the problem. Dukkha is a result of the way we relate to unpleasant feelings and somatic
sensations. One level of suffering is pain, which is inherent in our lives. A second level, which
increases suffering, is ruminating about what pain will mean if are ill for a whole month and
how it will influence the money in the bank account that we need for summer vacation. Another
example is depression. The first imaginary arrow of a simple feeling of sadness is transformed
into a more intense and persistent state of depression when we add the second imaginary arrow
of ruminative thinking (Teasdale & Chaskalson, 2011).
The second source of suffering is our desire for happiness and joy to continue indefinitely. The
third source of dukkha is our unrealistic desire for the world to be predictable and under our
full control.
A fundamental source of human suffering is the belief that our self and self-related experience
exist as an objective structure or object. The essence of Buddhist psychology lies in the teaching
that there is no such thing as a permanent, unchanging self (Olendzki, 2010). We usually talk
about our thoughts and feelings with faith that they are the truth. We overidentify with them.
This faith is in the background of the permanent protection of our self. We believe in their
existence so much that we also experience injury when anybody says anything unpleasant about
57
us. For example, when anybody says anything that contradicts our own thoughts and feelings
about ourselves.
Viewed as a medical parallel, the first Noble Truth is the diagnosis. Suffering is inherent to all
human beings. Suffering in its various forms is the symptom or disease for which our patients
seek help.
The second Noble Truth
The key insight of the second Noble Truth is that the immediate cause of suffering is tḁnha,
which is translated from Pali as craving or attachment to desire. The key message of the second
Noble Truth is that the experience itself is not the problem; the problem is our relationship to
the experience and our need to have it be a particular way (Teasdale & Chaskalson, 2011). The
suffering is generated by our unwillingness to simply let everything, including life, go in its
natural way. We want to have our life (e.g., things, people, relationships, health, youth) forever,
although life is uncertain, unstable, and finite. This attachment is the cause of suffering. The
problem is not in the satisfaction of our basic needs; our existence depends on their satisfaction,
and needs like hunger, thirst, sexual appetite can be satisfied. The problem is that we want to
satisfy our needs in some specific way (e.g., I do not want just to have a place to live, I want a
house with a garden), we want to experience satisfaction for controlled lengths of time (e.g.,
I'm not grateful for sex and love at this time, I want to experience pleasure constantly) and we
want to be some specific self (e.g., It is not enough for me read the book, I want to remember
it all).
The medical parallel of the second Noble Truth is a description of the etiology of the symptom
being suffered. The attachment to life and to our notion of how life should be is a predisposing,
precipitating, and perpetuating factor of suffering.
The third Noble Truth
The cessation of dukkha comes with the cessation of desire and attachment. As we are the
ultimate cause of our own suffering, we also have the potential to resolve it. It is not possible
to change the laws of life, but it is possible to change the response to them.
58
The medical parallel of the third Noble Truth is a description of therapy.
The fourth Noble Truth
There is a path that leads from dukkha. Buddhist teachings offer a program of practice, the
Noble Eightfold Path, to bring dukkha to an end. The Eightfold Path is a set of ethical, moral,
and practice recommendations: right understanding, right aspiration, right speech, right bodily
action, right livelihood, right effort, right mindfulness, and right concentration (DeSilva, 2014).
Mindfulness is a core component of this path to freedom and awakening (Teasdale
&Chaskalson, 2011).
The medical parallel of the fourth Noble Truth is the concrete steps of therapy. Mindfulness is
the primary focus of contemporary mindfulness-based applications such as MBSR and MBCT.
How mindfulness relieves suffering: three strategies for change
Imagine that you get an email from your boss at 10:00 pm on a Sunday evening. He
unexpectedly wants to talk about something important immediately on Monday morning. You
are surprised and frightened. You find yourself upset and irritable, dwelling on thoughts about
the email. You think about the reasons for the meeting and create catastrophic scenarios. You
probably start to ruminate and find it difficult to fall asleep. People undergoing mindfulness
training usually report that they are increasingly able to cope with such situations and to stop
their prolonged stress reaction. How does mindfulness training work in these situations?
Teasdale & Chaskalson (2011) consider three possible explanations for such a transformation
of suffering.
Change in the “what” that is processed
Attention is automatically attracted to important stimuli in the environment. Our attention is
reactive, and our minds usually focus on aspects of experience that support suffering. In the
context of an upsetting email, we may have learned to selectively attend to memories and
thoughts related to the origins of the upset (e.g., “What did I do wrong?”). Such selective
59
retrieval from memory represents ruminative thought patterns that are thought to be an
important etiological factor in depressed or angry emotions (Watkins, 2008).
In contrast to this automatic reaction, it is possible to consciously allocate our attention to
particular objects or classes of objects. For example, we can switch from the habitual disposition
to attend to memories and thoughts related to a distressing email and, instead, intentionally
attend to relatively neutral sensory stimuli, such as the breath or the sounds in our environment.
In that way, we change the contents of our thoughts so that they are less likely to create further
suffering (Teasdale & Chaskalson, 2011). Maintaining the focus of attention on the sensations
in the body and on the movements of the breath is the first step of most MBI training and many
forms of Buddhist insight meditation.
Change in “how” experience is processed
To change the “how” with which we process experience, the mindful response to the distress
that is induced by an unexpected email involves a shift from ruminating about the email and its
effects and future consequences, to an awareness of the thoughts, feelings, and bodily sensations
known directly and experientially, as aspects of experience at the moment. Suffering is a result
of our rigid need for experiences to be different from how they actually are, as described in the
second Noble Truth. This process represents the error-related regulation implicit in emotion
regulation strategy (Etkin et al., 2015). Mindfulness makes it possible to allow things to be just
as they are. A mindful response to the upset of the email is a deliberate stance of letting the
experience of the moment, the unpleasant thoughts, feelings, and bodily sensations, be just as
they are, to hold the experience in awareness, and through pure observation, to start to
understand the link between the modes of thinking and suffering (Teasdale & Chaskalson,
2011). This process enables the knowledge that suffering is the result of a way of thinking. This
knowledge cannot be reached through education; it must be lived and experienced repeatedly.
The change in “how” is shown in the foundations of mindfulness practice presented by KabatZinn
(2014, p. 20), who states that seven basic attitudes to experience are important for the
transformation of suffering: non-judging, patience, beginner’s mind, trust, non-striving,
acceptance, and letting go. Shapiro et al. (2006) define mindfulness as an intention to kindly
pay attention. They design a three-component model of mindfulness: intention, attention, and
attitude. The model pillar of attitude involves accessing experience with acceptance, non-
60
judgment, curiosity, and kindness. This is the core change of perception induced with
mindfulness: open to whatever appears.
Change in the view
Buddhist teaching states that basic emotions can be activated on the basis of ignorance. In
Buddhist literature, of ignorance, anger, and greed are referred to as the “Three Poisons”
(DeSilva, 2014). They are referred to in this way because they arise as a result of the mistaken
experience of the separation of the perceiver, the perceived object, and the act of perception,
which are understood to be inseparable (Chambers et al., 2009). They then give rise to higherorder
emotions in the background of human suffering: desire, jealousy, anger, pride, and
ignorance (DeSilva, 2014). The ignorance involves looking through a lens that: (1) presents
experience in terms of independently existing, enduring objects and selfs, rather than in terms
of dynamic and transitory processes; and (2) leads us to identify personally with experiences as
“me” or “mine,” when in fact they are impersonal phenomena that arise as a function of certain
conditions. In principle, suffering can be transformed by changing the prism through which we
view the world. Mindfulness helps create new lenses.
The fundamental assumption of Buddhism and Buddhist psychology is that there is no such
thing as a permanent, unchanging self (Epstein, 1988). The self is more of a process in the
present moment than a solid structure stored in the autobiographical memory. Meditation
practice leads to enhanced internal awareness, and meditators usually report that they can
observe mental processes with increasing clarity; meditation facilitates a detachment from
identification with the static sense of self (Hölzel et al., 2011). This change in perspective of
the self is often subjectively experienced as a feeling of freedom and liberation. Half the
participants in a study by Allen et al. (2009) reported that MBCT led to “a new perspective on
their depression-related thoughts and feelings that can be summarized as ‘These thoughts and
feelings are not me’.” In the email example, this would involve making the unpleasant thoughts
and emotions the focus of attention as events in the stream of consciousness, rather than viewing
them as “me.”
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Definition and mechanisms of mindfulness
What is mindfulness
The historical context of the definition of mindfulness is very complex and complicated. Many
Buddhist traditions are involved in the historical development of the definition. In a study of
the historical depth behind definitions of mindfulness, Anālayo (2019) states that early Buddhist
thought and practices developed from about the fifth to the third century BCE. The source
material for this earliest phase in the history of Buddhism, which forms the common starting
point for the different Buddhist traditions in existence today, are the “early discourses.” These
early discourses are found in the textual collections called Nikāyas in Pali, as well as in parallel
collections known as Āgamas. These Āgama parallels have for the most part not yet been
translated from Chinese, Sanskrit, and Tibetan into English. There is thus not very much
available information about early forms of Buddhism. It is evident that each Buddhist tradition,
in its own specific historical and social context, developed an approach to and understanding
of mindfulness (Anālayo, 2019). This process can be also seen in current clinical mindfulnessbased
approaches that define mindfulness in various contexts and functions.
A detailed summary of the Buddha’s teachings are described in the Buddhist canonical texts
called Abhidhamma Pitaka (Mendis, 2006). Their origin is dated to sometime around the third
century BCE, 100 to 200 years after the death of the Buddha. These texts include the
reorganization and generalization of the Buddha’s teachings. They are presented in a common
language and narrative form in Sutras; the texts are extensive and extremely detailed in their
analysis and classification of awareness and mental states (Grabovac, Lau, & Willett, 2011).
To better understand what mindfulness is, it is necessary to ask the question “What does
mindfulness do?” Early Buddhism defines mindfulness as a mental faculty (Pali indriya,
Sanskrit indriya, Chinese 根, Tibetan dbang po). Mindfulness is considered to be
“remembering” in one of its aspects (Anālayo, 2019). It consists of remembering to be aware
and pay attention to the present moment. In this process or practice, the practitioner is reminded:
“Remember: be aware!” (Siegel, Germer, & Olendzki, 2009). This view shows a constant close
connection between the function of memory and attention (Vago & Silbersweig, 2012). The
English translation of the Pali word sati connotes awareness, attention, and remembering
(Siegel et al., 2009). Sati is translated as a “Všímavost” in the Czech language (Frýba, 2003;
Benda, 2007).
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The best known and most widespread definition of mindfulness in the West is that of KabatZinn
(1990), the founder of MBSR: “Mindfulness is an awareness that arises through paying
attention, on purpose, in the present moment, non-judgmentally.” Williams (2007, p. 47), the
founder of MBCT, has defined mindfulness as “the awareness that arises from paying attention
on purpose, in the present moment and non-judgmentally to things as they are.”
Intuitively, everybody practicing mindfulness has their own working definition, operationalized
through the contents of everyday practice. There is no single universally accepted technical
definition of “mindfulness” nor any agreement about the detailed components of the underlying
concept to which it refers (Van Dame et al., 2018). The ambiguity of the mindfulness concept
also reflects the existence of many self-reported scales of mindfulness. In a systematic review
of mindfulness outcome measures, Park et al. (2013) reported ten existing scales. The number
of methods reflects the diversity of the definitions of mindfulness that have been proposed
(Williams et al., 2014). Each available questionnaire represents an attempt to operationalize
mindfulness by self-reported items describing its essence (Baer et al., 2006). The review by
Baer et al. (2006) shows that current mindfulness scales have important conceptual differences,
and none can be strongly recommended. It is evident that mindfulness is a multifaceted
construct (Baer et al., 2006). One attempt to verify the factor structure and to integrate
frequently used questionnaires (the Mindfulness Attention Awareness Scale, MAAS, Brown &
Ryan, 2003; the Freiburg Mindfulness Inventory, FMI; Buchheld, Grossman, & Walach, 2001;
the Kentucky Inventory of Mindfulness Skills, KIMS; Baer, Smith, & Allen, 2004; the
Cognitive and Affective Mindfulness Scale, CAMS; Feldman et al., 2004; and the Mindfulness
Questionnaire, MQ; Chadwick et al., 2005) into one multifaceted tool is the Five Facet
Mindfulness Questionnaire (FFMQ, Baer et al., 2001). The FFMQ received the highest possible
rating for two properties, internal consistency and construct validation by hypothesis testing
(Park et al., 2013). A factor analysis of the various methods confirmed that at least four of the
identified factors are components of an overall mindfulness construct and that the factor
structure of mindfulness may vary with meditation experience (Baer et al., 2006). It yielded
five facets of mindfulness: observing (attending to or noticing internal and external stimuli,
such as sensations, emotions, cognitions, sights, sounds, and smells); describing (mentally
labeling these stimuli with words); acting with awareness (attending to one’s current actions,
as opposed to behaving automatically or absentmindedly); nonjudging of inner experience
(refraining from evaluating one’s sensations, cognitions, and emotions); and nonreactivity to
63
inner experience (allowing thoughts and feelings to come and go, without attention-getting
caught in them).
Another source of ambiguity is the existence of various psychotherapeutic approaches
incorporating mindfulness, such as dialectical behavioral therapy (Linehan, 1993), acceptance
and commitment therapy (Hayes et al., 1999), and mindfulness-based cognitive therapy
(MBCT; Segal et al., 2002). These interventions, referred to collectively as “third wave
cognitive therapies” (Hayes, 2004), have provided the initial cognitive operationalization of
mindfulness upon which much of the current psychological literature is based (Chambers et al.,
2009). The mindfulness-based programs used in clinical and counseling practice are very
complex, and it is not clear which processes and mechanisms of the positive effect of the
program are activated.
In their critical review, Van Dame et al. (2017) urge scientists, practitioners, instructors, and
the public news media to move away from relying on the broad, umbrella rubric of
“mindfulness” and toward more explicit and differentiated explanations of exactly what mental
states, processes, and functions are being taught, practiced, and investigated.
The two-component model of mindfulness
A growing number of theoretical studies have attempted to operationalize the mindfulness
concept. In their oft-cited review, Bishop et al. (2004) define mindfulness as follows:
“Broadly conceptualized, mindfulness has been described as a kind of nonelaborative,
nonjudgmental, present-centered awareness in which each thought, feeling, or sensation that
arises in the attentional field is acknowledged and accepted as it is.” They further state that: “in
the state of mindfulness, thoughts and feelings are observed as events in mind, without overidentifying
with them and without reacting to them in an automatic, habitual pattern of
reactivity. This dispassionate state of self-observation is thought to introduce a ‘space’ between
one’s perception and response. Thus, mindfulness is thought to enable one to respond to
situations more reflectively (as opposed to reflexively).”
Bishop et al. (2004) provide a two-component definition of mindfulness as a state. The first
component involves the self-regulation of attention. It represents the focusing of attention and
its maintenance on the present experience from moment to moment. The object of attention is
64
whatever appears. The second component involves the attitude of openness, acceptance, and
curiosity toward whatever arises.
The first component – self-regulation of attention
A basic Buddhist practice of mindfulness meditation involves sustaining selective attention
moment by moment on a chosen object. In focused attention meditation, the chosen focus is
usually the breath. In this practice, attention is focused on the sensations caused by respiration.
In the manner of open monitoring practice, attention is focused on the dynamically changing
stream of consciousness in the present moment (feelings, thoughts, somatic sensations, and
perceptions).
To be able to sustain attention, it is necessary to constantly monitor the quality of focus. At
first, the attention wanders away from the chosen object, and the typical instructions across
various mindfulness approaches are to recognize the wandering and bring the attention back to
the chosen object. For example, while we are trying to focus our attention on our breathing in
the abdominal area, we might notice that our attention shifts to a pain in our shoulder. We then
“release” this distraction and return to the breathing in the abdomen. This practice fosters and
develops three attention skills: monitoring the locus of attention, disengaging from distraction,
and shifting attention back to its intended target (Lutz et al., 2008).
Bishop et al. (2004) describe sustained attention and attention shifting as key components of
mindfulness meditation practice. This description of mindfulness meditation practice as a
process makes it possible to conceptualize it with the help of cognitive psychology concepts. It
is thus possible to hypothesize, based on the self-regulation model, that the development of
mindfulness practice will be associated with increased performance in sustained attention and
attention switching (Bishop et al., 2004). Attentional processes underlying mindfulness are
often measured with the attention network test (Fan et al., 2002). It is still unclear how different
meditation practices differentially affect the specific attentional components (Tang et al., 2015).
For example, MacCoon et al. (2014) did not find any differences in the performance of
sustained attention between MBSR and active control in a longitudinal randomized trial study.
In contrast, they did find some evidence for improved visual discrimination when comparing
mindfulness trial subjects with control subjects.
65
Another process underlying mindfulness is the inhibition of secondary elaborative processing
of thoughts, feelings, and sensations that arise in the stream of consciousness. This refers to
experiences and the mindfulness practice recommendation that rather than get caught up in the
ruminative and elaborative thought and feeling stream of experience, it is better to only observe
it without amplifying it. This is not thought suppression: thoughts and their contents are
welcome, but the meaning is not the target of attention. Mindfulness thus involves the capacity
to be aware of internal and external events and occurrences as phenomena, “rather than as the
objects of a conceptually constructed world” (Olendzki, 2005, p. 253). This is a kind of metacognition.
It could be objectively measured using tasks that require the inhibition of semantic
processing, such as Stroop tasks. For instance, greater dlPFC responses were found during
executive processing within an emotional Stroop task in healthy individuals after six weeks of
mindfulness training (Allen et al., 2012).
One more attentional process underlying mindfulness practice as defined by Bishop et al. (2004)
could be described as an increased sensitivity or capacity to perceive the world through a
“beginner mind” lens. The authors expected that this process could be measured using tasks in
which successful performance depends on detecting stimuli in an unexpected setting. These
tests are not usually standard parts of neuropsychological test batteries such as attentional tests.
Their unique variants are found as parts of experimental designs of various studies (e.g., Jiang,
Summerfield, & Egner, 2013; Kumaran & Maguire, 2006). Performance in this ability has not
yet been experimentally measured in mindfulness research.
Orientation to experience
Orientation to experience or, more precisely, attitude to mindfulness practice is the second core
component of mindfulness (Bishop et al., 2004). This conception is very close to the attitude
component in the mindfulness model by Shapiro et al. (2006). This component involves the
commitment to maintain an attitude of curiosity about where the mind wanders, no matter where
it is. Practitioners do not try to produce a particular state such as relaxation or the change of
experience; they simply take note of whatever appears in the present moment in the changing
and unstoppable stream of consciousness.
The key part of this component is acceptance, one of the basic attitudes in mindfulness practice
as described in MBSR by Kabat-Zinn (2013). Acceptance means seeing things as they actually
66
are in the present moment. In mediation practice, we cultivate acceptance by taking each
moment as it comes and being with it fully, as it is. The practitioner is reminded to be receptive
and open to whatever they are feeling, thinking, or seeing, and to accept it because it is here
right now (Kabat-Zinn, 2013, pp. 27). The stance of curiosity and acceptance during
mindfulness practice could be monitored in the use of cognitive and behavioral strategies to
avoid aspects of an experience. The effect of mindfulness practice should lead to a decrease in
the measures of repressive coping and avoidance. Changes in some emotional regulation
strategies such as rumination, self-blame, other blame, and suppression, are also possible. The
relationship between mindfulness and emotion regulation will be elaborated in detail in the last
part of the thesis. Another measure in which mindfulness has an effect on orientation to
experience can be found in openness to experience and conscientiousness (NEO Five-Factor
Inventory, NEO-FFI; Costa & McCrae, 1992). The association between openness,
conscientiousness, and mindfulness was proved in a recent meta-analysis (Giluk, 2009). A
change in attributed importance to life satisfaction components is also possible10
. Emotional
distress would be experienced as less unpleasant and threatening because of the change of
subjective meaning via acceptance (Bishop et al., 2004).
Self-observation is another subcomponent of orientation to experience. Mindfulness practice
leads to greater sensitivity to a variable and dynamically changing stream and content of
consciousness. Consequently, practitioners are more aware of the complexity of the mind. In
other words, practitioners have a higher sampling rate of our awareness. For example, they
could experience an increase in emotional awareness (LEAS11
; Lane et al., 1990).
Further, via mindfulness practice, practitioners start to realize that life events are transient and
do not represent inherent aspects of the self or valid reflections of reality (Segal et al., 2002).
Mindfulness training encourages participants to notice specific details of their environment and
accept all experiences without judging or avoiding them. It is likely to improve autobiographical
memory specificity, which refers to the ability to retrieve memories of specific personal events
that happened at particular times and locations. Mindfulness leads to reducing over generic
10
The results of our research group dealing with this topic are presented below.
11
A Czech version of this test for children and adults was translated and standardized by our research group.
Světlák, M., Bernátová, T., Pavlíková, E., & Winklerová, L. (2015). Measuring emotional awareness - A pilot study
of psychometric properties of the Czech adaptation of the levels of emotional awareness scale. Ceska a Slovenska
Neurologie a Neurochirurgie, 78(6), 680-686. doi:10.14735/amcsnn2017197
Světlák, M., Marsová, K., Bernátová, T., & Winklerová, L. (2017). Emotional awareness in adolescents - A pilot
study of psychometric properties of the Czech adaptation of the levels of emotional awareness scale for children
LEAS-C. Ceska a Slovenska Neurologie a Neurochirurgie, 80(2), 197-207. doi:10.14735/amcsnn2017197
67
encoding of situations and the suppression of unpleasant memory retrieval (Williams et al.,
2000). Deficits in emotion regulation, such as ruminative thinking, are associated with reduced
autobiographical memory specificity (Williams et al., 2007). The structure of the twocomponent
model of mindfulness is described in Figure 10.
Figure 10 Two-component model of mindfulness (Bishop et al., 2004).
Is mindfulness a state or a trait?
Cross-sectional studies raise the important question of whether mindfulness practitioners could
have “pre-existing” differences linked to their interest in meditation, personality, and
temperament (Wheeler, Arnkoff, & Glass, 2016). Guendelman, Medeiros, and Rampes (2017)
describe different usages of the mindfulness concept: 1) dispositional mindfulness, understood
as a mental trait or stable characteristic of personality, which can vary between and within
individuals across time, 2) mindfulness as practice, referring to the concrete formal and
informal practice of mindfulness meditation, and 3) mindfulness as a state, representing the
first-person non-judgmental and accepted experience of the present moment. Vago and
Silbersweig (2012) describe mindfulness as 1) a temporary state of non-judgmental, non-
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reactive, present-centered attention and awareness that is cultivated during meditation practice,
2) an enduring trait that can be described as a dispositional pattern of cognition, emotional, or
behavioral tendency, 3) a meditation practice, and 4) an intervention. There are at least eight
self-reported scales for measuring dispositional mindfulness (reviewed by Park et al., 2013).
For instance, Brown and Ryan (2003) show that both dispositional and state mindfulness predict
self-regulated behavior and positive emotional states. In their volumetric analysis of structural
MRI images obtained from 155 healthy adults, Taren, Creswell, and Gianaros (2013) revealed
that higher dispositional mindfulness is associated with decreased gray matter volume in the
right amygdala and the left caudate. These neural associations persist even after controlling for
demographic and individual difference factors (i.e., age, total gray matter volume, neuroticism,
depression). Brown et al. (2012) showed that higher dispositional (trait) mindfulness is
associated with lower cortisol reactivity following psychosocial stress. Dispositional
mindfulness was also found to be associated with decreased connectivity within the midline
regions, including the PCC and mPFC during resting state functional connectivity fMRI (Way
et al., 2010). The medial parts of the brain are part of the default mode network (DMN), which
is related to mind-wandering and self-referential processing (Qin and Northoff, 2011). The
DMN represents the regions that are active when the brain is not engaged in task-induced
activity (Gusnard et al., 2001). Creswell et al. (2007) found that levels of dispositional
mindfulness were related to higher activations in the right vmPFC and right vlPFC and major
deactivation of the right amygdala in an affect labeling task during fMRI. Longitudinal studies
have revealed that transient meditation states can be transformed through time and practice to
trait mindfulness (Tang et al., 2015; Coleman & Davidson, 2017). Brefczynski-Lewis et al.
(2007) report an inverted U-shape relationship between frontal activity and meditator expertise.
These results show that the more trained subjects showed less frontal activity. This supports the
notion of an altered core valuation process. This is moreover the implicit aim of meditation: to
transform from an effortful practice to an effortless way of mindfully being. Dispositional
mindfulness is usually assessed through self-reported questionnaires; this is an important
methodological shortcoming.
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Is mindfulness one technique?
How are meditation practices to be categorized? There is a growing consensus that at least two
broad categories of meditation techniques can be discerned12
: focused attention and open
monitoring (Lutz et al., 2008; Tang et al., 2015). Some authors add loving-kindness practices
to this classification (Lippelt et al., 2014). Travis and Shear (2010) suggest a fourth category of
meditation practice, automatic self-transcending, which includes techniques designed to
transcend their own activity.
Focused attention meditation
Focused attention (FA) practices are based on the concentration of attention on a particular
external or internal object while ignoring all irrelevant stimuli (most often it is breath, body
sensations, or a mantra; Kabat-Zinn, 2005; Lutz et al., 2008). For example, while we are
focusing our attention on our breathing in the abdominal area, we might notice that our attention
has shifted to a pain in our shoulder. We then “release” this distraction and return to the intended
breathing in the abdomen. This practice fosters and develops three attention skills: monitoring
the locus of attention, disengaging from distraction, and shifting attention back to its intended
target (Lutz et al., 2008). This meditation process is associated with power increases in high
frequency EEG beta2 and gamma activity (Travis & Shear, 2010). In their meta-analysis
dealing with the functional neuroanatomy of meditation, Fox et al. (2016) categorize mantra
recitation meditation as a different subdivision of FA. Mantra meditation is a form of
“transcendental meditation” and involves the repetition of a sound, word, or sentence (repeated
aloud or silently in one’s mind) with the goals of maintaining focus and avoiding mindwandering
(Travis, 2014). Mantra meditation differs from FA in that the object of focus is a
voluntary verbal-motor production instead of breath or body sensations.
Open monitoring
Open monitoring (OM) practice involves bringing attention to the present moment in a nonjudgmental
manner. Practitioners observe all mental, physical, and exteroceptive contents
(thoughts, emotions, sensations, perceptions via sensors, etc.) as they naturally arise from
12
A detailed description of the neural correlates of each category is presented in the next chapter.
70
moment to moment without focusing on any of them. In OM, the goal is to be open to any
experience with an accepting attitude (Kabat-Zinn, 2005). It is characterized by increased theta
activity in EEG (Travis and Shear, 2010).
Loving-kindness and compassion meditations
The basic point of the loving-kindness (LK) meditation is to focus kind and loving energy
toward oneself and others. Loving-kindness meditation involves generating feelings of
kindness, love, and joy toward the meditators themselves, then progressively extending these
feelings to imagined loved ones, acquaintances, strangers, enemies, and eventually all living
beings (Kabat-Zinn, 2005; Lutz et al., 2008). Sentences are usually repeated during the
meditation: “May I be free from suffering,” “May I be as happy and healthy as it is possible for
me to be,” and “May I have ease of being” (Williams & Penman, 2011). The content of the
sentences varies somewhat. Compassion meditation and loving-kindness meditation are
overlapping. Neff (2003) operationalized self-compassion as consisting of three main elements:
kindness, a sense of common humanity, and mindfulness. Self-kindness entails being warm and
understanding toward oneself when suffering, failing, or feeling inadequate, rather than selfflagellating
with criticism (Neff, 2003).
Automatic self-transcending practice
Automatic self-transcending (AST) practice could be characterized by the absence of a focus
of attention, individual control, and effort. It is reflected in alpha1 activity in EEG (Travis &
Shear, 2010). AST includes meditations that transcend the steps of meditation practice. They
begin with thinking and end with “being” or wakefulness without customary mental and
emotional content (Travis, 2014). Transcendental meditation can be described as ‘‘thinking” a
mantra—a meaningless sound—and going back to it when the mantra is forgotten. The mantra
can be seen as a vehicle for transcending rather than as a technique of keeping the mantra in
awareness, thereby differing from FA (Travis & Parim, 2017). This understanding differs from
Fox et al. (2016), who classify the mantra recitation meditation as a different subdivision of
FA.
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Figure 11 How meditation practices are to be categorized
Only the first three categories are relevant to the current thesis. These are also components of
frequently used mindfulness-based programs. Of course, this categorization is not intended to
be exhaustive. This classification is a pragmatic resolution organized according to the available
evidence in recent studies dealing with mindfulness. Different forms of meditation can be found
in almost all cultures and religions (Tang et al., 2015), including various yogic traditions. Fox
et al. (2016) mention the yoga exercises of visualization meditation and withdrawal of the
senses (pratyahara in Sanskrit), non-dual awareness practices, yoga nidra (literally “sleep
yoga”), and dream yoga (“lucid” dreaming), practices that are investigated only marginally or
not at all.
Neural systems involved in mindfulness
A growing number of studies have demonstrated changes in brain structures induced by
mindfulness meditation. Multiple measurements have been used to investigate the effects on
both gray and white matter. Studies have captured cortical thickness, gray-matter volume, and
density. It is evident from the recent literature that the effects of meditation might involve largescale
brain networks; individual studies have reported various findings in multiple brain
regions, including the subcortical gray and white matter, cerebral cortex, brainstem, and
cerebellum (Tang et al., 2015). It is not surprising that the effect of mindfulness
training/meditation is the result of the interplay of multiple complex cognitive and affective
72
processes with many neural networks in the background. Even though many studies have been
done over the past twenty years in the neuroscience of mindfulness, this mini-review focuses
only on a recent meta-analysis of results. Only a meta-analysis can provide a description of
regular neural functional and structural patterns beyond the mindfulness effect because of the
huge heterogeneity of study results and their varied methodological quality.
In their systematic review and meta-analysis of morphometric neuroimaging in meditation
practitioners using an activation likelihood estimation (ALE), Fox et al. (2014) arrived at eight
brain regions consistently altered in meditators across the studies (global effect size Cohen’s d=
0.46; r = .19): 1) the frontopolar cortex: related to enhanced meta-awareness following
meditation practice, 2) the sensory cortices and 3) the insular cortex: related to body awareness,
4) the hippocampus: related to memory processes, 5) the anterior cingulate cortex and midcingulate
cortex and 6) orbitofrontal cortex: areas related to self and emotion regulation, 7) the
superior longitudinal fasciculus and 8) corpus callosum: structures related to intra- and interhemispherical
communication. This meta-analysis did not evaluate the study results according
to forms of meditation practice. Most mindfulness-based programs such as MBSR, MBCT,
integrative body-mind training (IBMT), and DBT are very complex and composed of multiple
categories of meditation practice (focused attention meditation is almost always combined with,
or followed by, open monitoring and compassion types of meditation). In general, numerous
studies mix practitioners from multiple traditions in their analyses. Fox et al. (2016) considered
this limitation in their subsequent meta-analysis, in which they described distinct neural
correlates of distinct patterns of meditation practice. The results are presented in Table 5.
Another meta-analytic study based on ALE with the goal of testing whether there are consistent
activations across studies, independent of the meditative technique, that could represent a core
cortical network for meditation (Sperduti, Martinelli, & Piolino, 2012). The authors included
only studies conducted on expert meditators. Activations were found in the left entorhinal
cortex (parahippocampus, thought to control the mental stream of thoughts and possibly stop
mind wandering), left caudate body (thought, with the putamen, to have a role in attentional
disengagement from irrelevant information, allowing a meditative state to be achieved and
maintained), and the medial prefrontal cortex (mPFC, probably supports enhanced selfawareness
during meditation). The mPFC (especially BA 10) is associated with self-referential
processing (e.g., Northoff et al., 2006). A recent meta-analysis performed by van der Meer et
al. (2010) shows that the mPFC is usually activated when subjects are asked to decide if an
73
adjective refers to them. The authors did not find the expected activations in the lateral
prefrontal cortex, anterior cingulate cortex (ACC), or parietal lobe, as is often reported in the
literature (see studies above). These results suggest that the cortical structures responsible for
attentional and cognitive control are not a key network underlying meditation in meditation
experts. These results also open the discussion about the relationship between meditation
experience and different neural networks of practice background. Brefczynski-Lewis et al.
(2007) report an inverted U-shape relationship between frontal activity and meditator expertise.
These results show that the more trained subjects showed less frontal activity. This suggests the
disengagement of attentional control within meditation training. This neural process pattern
(less activity in the lateral areas of the frontal cortex during meditation practice) may show a
meditation session dynamic in which the frontal regions are activated at the beginning of
meditation to allow the other structures to maintain the meditative state, as was suggested by
Travis and Wallace (1999) and Newberg and Iverson (2003).
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Table 5 Distinct neural correlates of distinct patterns of meditation practice (Fox et al., 2016)
Category Structure Study
Focused Attention Activation Fox et al., 2016
Pre-motor cortex (BA 6)
Dorsal anterior cingulate cortex (BA 24)
The dorsolateral prefrontal cortex (BA 8/9)
Deactivation
Ventral posterior cingulate cortex (BA 31)
Left inferior parietal lobule (BA 39)
Mantra recitation meditation Activation Fox et al., 2016
Posterior dorsolateral prefrontal cortex/left premotor cortex (BA 6/8)
Pre-supplementary motor cortex supplementary motor cortex (BA 6)
Putamen/lateral globus pallidus including the fusiform gyrus, cuneus (BA 18),
moreover, precuneus (BA7)
Deactivation
Left anterior insula (BA 13)/claustrum
Open monitoring meditation Activation Fox et al., 2016
Insula (BA 13)
Left inferior frontal gyrus (BA 44/45)
Pre-supplementary motor area (BA 32)
Supplementary motor area (BA 6)
Premotor cortex (BA 6)
Smaller (non-significant) clusters were observed in the rostrolateral prefrontal cortex (BA 10) and middorsolateral
prefrontal cortex (BA 9/46).
Deactivation
Right thalamus
Loving-kindness and
compassion meditation
Activation
Right anterior insula/frontal operculum (BA 13) and secondary somatosensory areas extending into the
anterior inferior parietal lobule (BA 2/40), parieto-occipital sulcus (BA 23/31).
Fox et al., 2016
Note: BA – Brodmann area
75
Therapeutic application of mindfulness
The first documented clinical effect of MBI was described in patients with chronic pain (KabatZinn,
1982) for whom mindfulness brought relief from the pain.
A few therapeutic approaches incorporate mindfulness explicitly, including dialectical
behavioral therapy (Linehan, 1993), acceptance and commitment therapy (ACT; Hayes et al.,
1999), mindfulness-based cognitive therapy (MBCT; Segal et al., 2002) and mindfulness-based
stress reduction (MBSR; Kabat-Zinn, 1993). Currently, there is so much literature on these
mindfulness-based approaches that it is no longer possible to summarize them. MBIs such as
MBSR and MBCT, the ones most used in clinical practice, are presented here as the most
representative and applicable in clinical practice. These two approaches are also the background
for closely related interventions developed for specific populations. These include mindfulnessbased
childbirth and parenting (MBCP; Bardacke, 2012), mindfulness-based eating awareness
training (MB-EAT; Kristeller, Wolever, & Sheets, 2013), mindfulness-based elder care
(MBEC; McBee, 2008), and mindfulness-based relapse prevention (MBRP) for addictive
behavior (Bowen, Chawla, & Marlatt, 2011). Buddhist psychology and counseling (de Silva,
2014) are also psychotherapy approaches integrating mindfulness, but this is beyond the scope
of this thesis because it is a complex topic13
.
The difference between MBCT and MBSR depends partly on the client group at which the
course is aimed. MBSR was originally aimed at people with chronic pain and stress (KabatZinn,
1982). MBCT was aimed at people with an affective disorder, especially those with
recurrent depression (Segal, Williams, & Teasdale, 2002). There are now many “generic” forms
of both programs adapted to make it relevant to anyone from nonclinical populations seeking
stress reduction and support of well-being. In this context, a recent meta-analysis conducted by
Parsons et al. (2017) comparing the effects of MBCT and MBSR on physical and psychological
functioning did not document any significant differences.
Mindfulness techniques, as part of the “third wave” of cognitive and behavioral therapies, help
to target contexts and functions of psychological phenomena, not just their form (Hayes, 2016).
Unlike other therapeutic strategies, such as cognitive behavioral therapy, MBIs do not
13
Presented in detail in Czech in Ennenbach, M. (2018). Buddhistická psychoterapie: Techniky pro uzdravující
změny. Praha: Fontána, or in Epstein, M., (2013). Myšlenky bez myslitele: psychoterapie z pohledu buddhismu.
Praha: MAITREA
76
emphasize changing the contents of mental events as much as changing the awareness of and
relationship to them (Segal et al., 2002). Participants learn to disempower emotionally charged
thoughts or attitudes by bringing to their experience a sense of “allowing” it to be just as it is,
without a constant need for the situation to match their desired states (Segal et al., 2002). This
chapter described how mindfulness relieves human suffering and introduce two main MBI
programs that are considered essential in this area (MBSR and MBCT).
Mindfulness-based stress reduction program
Mindfulness-based stress reduction (MBSR) was developed as an outpatient program at the
University of Massachusetts Medical School in 1979. Jon Kabat-Zinn based it on his own
experience with vipassana (insight) meditation, a practice that originated in the Theravada
Buddhist tradition. It was developed for patients with chronic pain and stress-related conditions.
Program structure and content
The changes are based on the general framework of a manualized eight-week program of
meditation and gentle Hatha yoga training. Participants attend weekly group sessions with ten
to thirty participants with a wide range of disorders and conditions, where they are introduced
to formal meditation practices, gentle yoga, and psychosocial education. The program also
includes a silent meditation retreat day that falls in the second half of the course. Group
members are asked to practice yoga and meditation for approximately forty-five minutes a day
as homework (45 min/day; averages reported of 246 min/week). Participants are encouraged to
keep a diary to describe their practice and reflections and insights. Formal meditation practices
include focused attention on breathing, body scans and open monitoring of sounds, thoughts,
feelings, and bodily sensations.
Group sessions generally last for 2.5 hours and focus on group meditation practice and
discussion of these practices. Other commonly discussed themes include stress and the body,
habitual patterns of reactivity, and creative ways to respond to stress. Group dialogue on
difficulties in performing practices and insights gained are valuable components of an MBSR
course. During these dialogues, instructors model key components of mindful awareness, such
as noticing the body sensations that accompany different thoughts and impulses. As part of the
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weekly homework, courses often include diary exercises, which are later discussed in the group
setting. Commonly, participants spend a week taking notice of pleasant events, then a week on
unpleasant events, and another week on monitoring stressful communications. However,
common even to these externalized practices, there is an emphasis on how these events occurred
from an interoceptive perspective (i.e., how one felt in one’s body during these events).
Weeks 1 and 2
The first group’s mindfulness activity is the raisin exercise, conducted during the first session.
Participants are guided through a slow process of observing all the aspects of raisins and the
process of eating them (for details, see Kabat-Zinn, 2013, p. 15–16). The raisin exercise
provides an opportunity to be mindful in an activity often done in so-called “automatic pilot
mode,” or without awareness.
The practice of these first two weeks focuses on formal and informal practice development
(Kabat-Zinn, 2013, p. 77). It includes formal training, especially body scan meditation sitting
meditation, as well as what is called “informal practice” – cultivating mindfulness in daily life.
Patients/participants are supported in bringing moment-to-moment awareness to routine
activities such as waking up in the morning, brushing their teeth, taking a shower, drying their
body, getting dressed, eating, driving, taking out the garbage, shopping, cooking, doing the
dishes, even checking their email. The list could be endless. The aim is to “experience what
you are doing in a fully embodied way as you are actually doing it” (Kabat-Zinn, 2013, p. 160).
Body scan meditation is a practice that reestablishes contact with the body. Within this practice,
attention is directed to any sensations in the fingers, the thumbs, then the palms and backs of
the hands, then, in turn, the wrists, the forearms, the elbows, the upper arms, then returning to
the shoulders. Then we move into the neck and throat, and finally all the regions of the face,
the back of the head, and the top of the head. In MBSR, the body scan is practiced intensively
for at least the first four weeks of the program. The body scan is the first formal practice of
MBSR. It provides the foundation for all the other meditation practices that patients will work
with later, including sitting meditation. Through body scan practice, the patients learn to keep
their attention focused over an extended period (for more details, see Kabat-Zinn, 2013, p. 77).
78
In the first two weeks of the program, patients practice the body scan at least once a day, six
days a week, using a Body Scan Meditation CD they receive from the trainer14
.
The sitting meditation is referred to as a core of the formal meditation practice. Participants
start with this in the second week of the training. It consists of five exercises: sitting with the
breath, sitting with the breath and the body as a whole, sitting with sound, sitting with thoughts
and feelings, and sitting with choiceless awareness (Kabat-Zinn, 2013, p. 54–74).
Weeks 3 and 4
An integral part of MBSR is mindful yoga, aimed at cultivating strength, balance, and
flexibility. The practice starts in the second week of the training. It is composed of basic
exercises from hatha yoga. Participants learn concrete exercise at the second session. They also
get pictures of the exercises and a CD with an audio exercise guide. Participants practice body
scan meditation and mindful yoga training. Participants also continue in practice of sitting
meditation for fifteen to twenty minutes a day in week 3 and up to thirty minutes a day in week
4.
For some participants, sitting or lying still, as required by sitting meditation and the body scan,
can be uncomfortable, irritating, and aversive. Walking meditation can be helpful to them, and
it is also one of the basic parts of MBSR formal practice. It includes slow, deliberate walking
to practice focusing on the sensations in the body while moving. Participants are encouraged to
notice when their minds wander off and to gently bring their attention back to the sensations of
walking.
The informal practice in week 3 involves being aware of one pleasant event a day. Participants
are encouraged to keep a calendar for the week, noting the pleasant experience. In week 4, there
is support to do the same thing for one unpleasant or stressful event a day.
Week 5 and 6
In weeks 5 and 6, participants are advised to stop doing the body scan for a while and replace
it with forty-five minutes of guided sitting meditation practice, alternating with mindful yoga.
14
A CD with all the recordings needed for the MBSR program was translated and recorded in Czech by Jaroslav
Chýle. He is the first certificated MBSR teacher in the Czech Republic. Relevant information can be found at
www.mbsr.cz
79
The guidance on the CD is recommended. At this time, participants are also advised to try
sitting meditation without guidance once a week. The various modes of sitting meditation as
described above can be used or combined. For example, participants can start with focusing on
the breath as a primary object of attention and then they can freely continue in open monitoring
focusing. In weeks 5 and 6, participants at the stress reduction clinic alternate forty-five minutes
of sitting meditation one day with yoga practice the next. If they do not do the yoga, then they
can alternate sitting meditation with body scans during this week. They are also allowed to do
just sitting meditation (Kabat-Zinn, 2013, p. 161).
Week 7
Week 7 is dedicated to practicing without the CD for guidance. The aim is to encourage selfdirected
practice and increasing self-reliance (Kabat-Zinn, 2013, p. 162). Participants can
combine yoga, sitting meditation, and body scanning for forty-five minutes a day. They are
encouraged to experiment, perhaps by using two or even three of the different practices together
on the same day (for example, thirty minutes of yoga followed by fifteen minutes of sitting).
Week 8
In week 8 of MBSR, participants come back to the CDs. In this week, they are encouraged to
practice with the CD with the aim of experiencing guidance after the period without guidance
in week 7. There is a notion in MBSR that this comeback deepens the meditation practice by
revealing differences between self-guided practice and original guidance. It can reveal the
practitioner’s mindfulness practice. At this point of mindfulness practice, participants recognize
that they now have at least some familiarity, if not intimacy, with all four of the formal
mindfulness practices of MBSR.
Loving-kindness meditation is not a standard practice in MBSR. It is usually offered during the
all-day meditation session (Kabat-Zinn, 2013). However, not all MBSR programs include the
all-day session. In their review, Carmody and Baer (2009) revealed that only thirteen of the
thirty published studies of MBSR (43%) included it.
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The formal structure of sessions
Each weekly session includes a group discussion in which participants share their experience
and mindfulness practice development. It is known as an inquiry into this approach. This part
of the training provides social support and helps relationship development; it is also an
opportunity for the mindfulness teacher to facilitate mindfulness development by focusing on
a detailed exploration of the participants’ experience while modeling a curious, interested, open,
nonjudgmental, and accepting stance toward them no matter how they are (Baer, 2014, p. 9).
The incorporation of poetry and metaphors is an important part of MBSR sessions. MBSR
instructors include the reading of poetry and excerpts from novels in their weekly sessions to
illustrate important elements of mindfulness which are difficult to express using ordinary
language. The use of metaphors or symbols to describe complex phenomenon is usual in
psychotherapy as well.
The all-day meditation session
The all-day session is usually held on a weekend day between week 6 and 7. Participants engage
in sitting and walking meditations, body scans, yoga, and mindful eating (lunch) over the course
of six to eight hours. Most of the day is spent in silence, except for instructions provided by
trainer and a period of sharing at the end of the day.
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Figure 12 Mindfulness practices in MBSR
Mindfulness-based cognitive therapy
Mindfulness-based cognitive therapy (MBCT) was developed to target the specific challenges
inherent in chronic mood disorders. It combines systematic mindfulness training with
cognitive-behavioral therapy (CBT) to help people with a history of depression learn vital skills
(Segal et al., 2012). MBCT was developed to help people learn to recognize automatic
cognitive–affective–behavioral patterns, adopt a more decentered perspective, and relate to
their experience with curiosity, patience, equanimity, and compassion (Kuyken & Evans, 2014,
p. 33).
MBCT is based largely on MBSR. Many of its parts are the same. The raisin exercise, body
scan, sitting meditation, yoga, and walking meditation are incorporated into MBCT, along with
informal practices of mindfulness in daily life. Poetry and metaphors are also incorporated
(Baer, 2014, p. 13).
Program structure and content
The MBCT program usually involves groups between eight and thirteen participants, as in
group psychotherapy. The length of sessions ranges from two to two-and-a-half hours according
to participants’ actual needs and topics. The full-day retreat takes place between the sixth and
seventh weeks of the program. Meditation practices include the body scan, gentle yoga, and
mindful walking, as well as sitting meditation practices with a focus on the breath, sounds, body
sensations, and thoughts, as in MBSR. Each session includes a report about the home practice.
MBCT also has specifically developed exercises.
The three-minute space exercise
The three-minute breathing space is specifically designed for MBCT. It is a short formal
exercise which allows participants to step out of automatic pilot at any time, and re-establish
awareness of the present moment. It is composed of three steps (each practiced for
approximately one minute). The first step is to focus awareness on the range of internal
82
experiences in the current stream of awareness in the present moment. The participant asks,
“What is my experience right now?” and notices any bodily sensations, thoughts, and emotions
that are present. A stance of non-judgmental acceptance and openness is encouraged. No
experience is pushed away or suppressed. The participant acknowledges all of them, even if
they are unpleasant or unwanted. The second step is to focus full attention on the movements
and sensations of breathing, noticing each inhalation and exhalation as it occurs. The third step
is to expand awareness to the body as a whole, including posture and facial expression, and to
notice the sensations that are present, again with acceptance and without judgment (Baer, 2014,
p. 13). The breathing space is introduced in session 3 of the eight-week program. Participants
are encouraged to practice it several times a day.
Deliberately bringing difficulties to mind in sitting meditation
The purpose of this exercise is to counteract the intuitive tendency to avoid difficult or painful
feelings. The exercise is introduced and trained in week 5. Within this exercise, the participants
are encouraged to call to mind difficult or troubling issues or problems deliberately. The aim is
to notice where in the body associated sensations arise. Participants learn that difficulties can
be named, faced, and worked with, and that avoidance is not necessary and may be maladaptive.
Participants may realize that their attitude toward aversive experience is hostility rather than
kindliness (Baer, 2014, p. 14). This training even more concretely addresses the general
mindfulness attitudes such as acceptance, trust, and letting go.
Cognitive therapy-based exercises
Even though MBCT does not include traditional cognitive therapy focusing on the awareness
and recognition of maladaptive cognitive schemas, it integrates several exercises based on
elements of cognitive therapy that emphasize a decentered approach to internal experience.
Thoughts and feelings exercise
In week 2, participants are asked to close their eyes and imagine walking down the street and
seeing someone they know on the other side. The participant smiles and waves, but the other
83
person walks by without seeming to notice. Participants are invited to describe the thoughts,
feelings, and sensations they experience when imagining this scenario. The ABC model
developed by Beck (1995) is applied as a theoretical background. In this model, a situation (A)
leads to a thought or interpretation (B) which leads to a feeling or emotion (C). The key idea of
this model is that different thoughts at point B can lead to different emotions at point C.
Participants learn that those thoughts are not facts. Another fundamental result of this process
is that it shows participants that they are not always aware of the valuations occurring at point
B, even though those valuations may have powerful emotional effects. Because
thoughts/valuations have a strong influence on emotions, it is important to be more aware of
them. Practicing mindfulness skills helps develop this awareness (Baer, 2014, p. 15).
Discussion of automatic thoughts
Week 4 includes a discussion of maladaptive cognitive schemas related to depression or
dysphoria. The participant is taught that some depressive or stressful thoughts or convictions
(e.g., “I am not a good person”) are symptoms of depression rather than true statements about
themselves. The main aim of this learning is to help people see thoughts as mental events rather
than as representations of truth or reality.
Moods, thoughts, and alternative viewpoints exercise
This exercise is trained in week 6. It again involves imagining scenarios of different daily life
situations. The aim is to demonstrate to participants that thoughts have a powerful influence on
feelings. Practicing mindfulness of thoughts will help remember that thoughts are not facts and
that thoughts can be allowed to come and go.
Pleasure and mastery activities
This exercise occurs in week 7. It is based on the recognition that taking action can be a critical
step in the prevention of prolonged distress reactions, even in depressive episodes. When the
mood is low, motivation to be active is also low. However, lowered activity levels often worsen
distress and related emotions such as depression and anxiety. It is thus important to be able to
84
increase activity level even when the motivation to do so is low. Participants recognize that
they have two general options for reacting to stress and negative moods: pleasure and mastery
activities. Pleasure activities are fun or enjoyable, such as watching a movie, talking with a
friend, or eating a delicious dessert. Mastery activities provide a sense of accomplishment,
pride, or satisfaction in having achieved something, such as playing sports, walking, or
completing work-related tasks. Participants are asked to generate lists of such activities that
they could engage in at times when their mood is low. These lists then become useful in the
development of relapse prevention action plans (Baer, 2014, p. 17).
Loving-kindness meditation is sometimes included in MBCT, depending on the participants.
For example, MBCT for depressive relapse does not include loving-kindness meditation
because of the risk that it may trigger rumination and self-criticism in people vulnerable to
depression (Baer, 2014; Segal et al., 2013). In contrast, it is commonly included in MBCT
programs for stress reduction (Williams & Penman, 2011).
85
Figure 13 Mindfulness practices in MBCT
Effectivity of mindfulness
Ruth Baer (2014), editor of the extensive text Mindfulness-Based Treatment Approaches:
Clinician’s Guide to Evidence Base and Applications, gives a detailed overview of the effective
application of the MBIs (especially MBSR and MBCT) in various clinical settings. The authors
describe the mindfulness approach to recurrent depression, resistant depression, bipolar
disorder, generalized anxiety disorder, overeating and obesity, relapse prevention for addictive
behavior, for children, stress reduction, childbirth and parenting, chronic pain, cancer recovery,
and strengthening resilience. This list is expanded by the author Fabrizio Didonna (2009) who
edited the book Clinical Handbook of Mindfulness. The authors show that MBIs can be also
used in the treatment of OCD (obsessive-compulsive disorder), suicidality, borderline
86
personality disorder, eating disorders, trauma and PTSD (post-traumatic stress disorder),
ADHD (Attention Deficit Hyperactivity Disorder), and psychosis.
Despite the numerous methodological problems that more and more authors have recently
raised (e.g., Nicholas et al., 2017; Tang et al., 2015), the effectiveness of MBI on improving
mental health has been repeatedly documented in healthy people (e.g., Antoine et al., 2018;
Keng et al., 2011; Tomlinson et al., 2018) and in people with various psychiatric or somatic
conditions (e.g., Goldberg et al., 2018; Rahimi-Ardabili et al., 2018). It has specifically been
effective in treating a number of physical complaints such as chronic pain (Kabat-Zinn, 1982),
psoriasis (Kabat-Zinn et al., 1998), fibromyalgia (Kaplan, Goldenberg, & Galvin-Nadeau,
1993), and many symptoms associated with cancer (Tacon, Caldera, & Ronaghan, 2004). The
results also show that mindfulness is effective in the management of severe and chronic physical
conditions in children and adolescents (Thompson & Gauntlett-Gilbert, 2008). The mindfulness
efficacy has also been proved in preventing relapse of major depression (e.g., Segal et al., 2002)
and its residual depressive symptoms (Kingston et al., 2007). It has also been effective in
treating anxiety (Evans et al., 2008) and psychosis (Bach & Hayes, 2002; Gaudiano & Herbert,
2006). Many studies have also revealed a significant effect of MBIs in eating disorders
(Fairburn, Cooper, & Shafran, 2003; Kristeller & Hallett, 1999; Telch, Agras, & Linehan,
2000). Table 6 summarizes the results of five recent systematic reviews and meta-analyses that,
in addition to the effectivity, also describe the mediators and mechanisms of MBI effects. The
original results of our research group are presented and discussed in the next chapter. The study
assessed the effect of an online version of the MBCT program for stress reduction in medical
students.
In their comprehensive meta-analysis, Khoury et al. (2013) showed that MBIs are moderately
effective in pre-post comparisons (n = 72; Hedge’s g = .55), in comparisons with waitlist
controls (n = 67; Hedge’s g = .53), and when compared with other active treatments (n = 68;
Hedge’s g = .33) and other psychological treatments (n = 35; Hedge’s g = .22) such as
psychoeducation, supportive therapy, relaxation, imagery, and art-therapy. MBIs were more
effective in treating psychological disorders than it was in treating physical or medical
conditions.
In their review, Chiesa, Brambilla, and Serretti (2010) conclude that MBIs could enhance the
regulation of negative emotions through increased activity of frontal cortical structures
inhibiting automatic amygdala activation. They also documented significant overlap between
87
brain areas activated during MBI practice, psychotherapy, and pharmacotherapy, and those
activated by expectancy in placebo studies. The authors suggested that MBI practice,
psychotherapy, and placebo act through a top-down regulation, while antidepressants could act
through a bottom-up process. In general, their results support the notion that MBIs target
specific brain areas related to emotions and emotional regulation, as has been repeatedly
observed in other interventions, particularly psychotherapy.
88
Table 6 The effectivity of MBIs and mediators of its effect
Study Type of study Intervention Participants Effect on
↑/↓
Mediators Mechanism Moderator
Quaglia et al.,
2016
Systematic review and
meta-analysis
MBSR Healthy and clinical
populations
Mindfulness ↑
Beneficial intervention
outcomes↑
Mindfulness Not
monitored
Not
monitored
Van der
Velden et al.,
2015
Systematic review MBCT Patients with recurrent
major depressive disorder
Depression↓
Mindfulness skills↑
Meta-awareness↑
Self-compassion↑
Rumination↓
Worry↓
Cognitive reactivity↓
Mindfulness skills↑
Rumination↓
Worry↓
Self-compassion↑
Suppression of
negative thoughts ↓
Meta-awareness↑
Decentering↑
Autobiographical
memory specificity?
Not
monitored
Not
monitored
(Gu, et al.,
2015)
Systematic review and
meta-analysis
MBCT
MBSR
Healthy and clinical
populations
Depression↓
Stress↓
Anxiety↓
Negative affect↓
Mindfulness↑
Mindfulness↑ Not
monitored
Not
monitored
Depression↓
Stress↓
Global psychological
symptoms↓
Stress and anxiety↓
Repetitive negative
thinking↓
(worry and
rumination)
Depression↓
Anxiety↓
Anger expression
(Inconsistent results) ↓
Self-compassion↑
Recurrent depression↓ Cognitive and
emotional reactivity↓
Stress↓
Mood ↑
Psychological
flexibility↑
Khoury et al.,
2013
Comprehensive meta-
analysis
MBSR,
MBCT
Healthy and clinical
populations
Anxiety ↓
Depression ↓
Stress ↓
Not
monitored
Not
monitored
Not
monitored
89
Study Type of study Intervention Participants Effect on
↑/↓
Mediators Mechanism Moderator
Parsons et al.,
2017
Systematic review and
meta-analysis
MBSR,
MBCT
Healthy and clinical
populations
Psychological
functioning ↑
Physical functioning ↑
Self-reported home
practice ↑
Not
monitored
Not
monitored
Shapiro et al.,
2011
Randomized controlled
trial
MBSR Undergraduate students Mindfulness ↑
Rumination↓
Well-being↑
Self-compassion↑
Hope↑
Empathy↑
Forgiveness↑
Not monitored Not
monitored
Pretreatment
trait
mindfulness
90
Mindful in Medical School, Thanks to Facebook: Online MindfulnessBased
Mental Health Support Program with Intensive Reminder System15
Studies have repeatedly documented that medical students have a higher prevalence of burnout
and severe distress symptoms than the general population (Dahlin et al., 2005; Dyrbye et al.,
2006; Ishak et al., 2013). Almost half of them experience these symptoms during their studies;
from 5 to 10% report suicidal ideation (Dyrbye et al., 2008). The prevalence of burnout
syndrome develops over the course of medical education and may persist beyond medical
school among residents (Thomas, 2004). Burnout is mainly related to the inadequacies of the
learning and work environment (Dyrbye & Shanafelt, 2016). From this point of view,
developing a preventive program in this area is a fundamental need for medical faculty teachers
and health psychologists. Such a program could positively influence the mental and physical
health of medical students, and it could significantly influence the medical practice itself
through a fundamental attitude shift among doctors toward themselves and their patients
(Epstein, 2017).
Mindfulness-based mental health support programs for medical students are promising.
Growing evidence from studies conducted with medical students indicates that stress reduction
programs based on mindfulness are beneficial in terms of reducing negative emotions and stress
while enhancing mindfulness, empathy, and self-compassion (Dobkin & Hutchinson, 2013;
Rosenzweig et al., 2003; Shapiro et al., 1998; Warnecke et al., 2011). This is also reflected in
the increasing number of mindfulness centers associated with medical schools and mindfulnessrelated
activities offered to medical students in the United States (Barnes et al., 2017); a similar
analysis has not been performed in Europe.
For any treatment, the goal is an approach that will be effective, with minimal economic costs
and maximum selected population impact. It is necessary to distinguish the level of change at
which the intervention/treatment should be focused. If successful processes of change are
efficiently addressed at the right time, intervention could be effective without requiring the
deeper analytical level offered by individual psychotherapy (Norcross et al., 2011; Prochaska,
1997). It is unlikely that a single program will work for all participants, but a connection with
a technological platform can reach more people and is more likely to address people who are
15
Svetlak, M., Linhartova, P., Knejzlikova, T., Kosa, B., Sumec, R., Hornickova, V., Jarolinova, K., Lucanska,
K., Slezackova, A., Kasparek, T. (submited to Applied Psychology: Health and Well-Being). Mindful in Medical
School, Thanks to Facebook: Online Mindfulness-Based Mental Health Support Program with Intensive Reminder
System
91
already ready for a change. There has therefore been an increasing effort to transfer
mindfulness-based programs to online versions (Fish et al., 2016).
Even though the therapist-client relationship and dialogue are irreplaceable, online
interventions offer some advantages, especially for people who are functioning at a good or
adequate personality level. Online programs 1) are easily accessible; 2) are anonymous; 3) are
available 24/7 to people during the course of their daily life; 4) do not necessarily require the
involvement of a therapist educated in mindfulness; 5) are less expensive; and 6) save time
(Andersson & Cuijpers, 2009; Andersson & Titov, 2014; Spijkerman et al. 2016). Almost half
of the people in one study would prefer an online format of mindfulness meditation intervention
to a face-to-face format (Wahbeh et al., 2014). The preference for online delivery is reflected
in the increasing number of mindfulness-based mobile apps; a search identified 560 available
applications (Mani et al., 2015).
Increasing evidence supports the advantages and effectiveness of online mindfulness-based
programs (Cavanagh et al., 2018; Fish et al., 2016; Spijkerman et al., 2016). The online format
of MBI has been shown to be effective in supporting mental health and reducing
psychopathology symptoms in patients with cancer (Kubo et al., 2018; Zernicke et al., 2014,
2016), in healthy subjects (Cavanagh et al., 2018; Querstret et al., 2018), and in patients with
depression (Lappalainen et al., 2015), anxiety (Krusche et al., 2013), tinnitus (Hesser et al.,
2012), chronic pain (Dowd et al., 2015), and fibromyalgia (Davis & Zautra, 2013).
There are important differences in the construction, length, and delivery of interventions in the
mindfulness programs currently delivered by technology without facilitator involvement (Fish
et al., 2016). These programs vary on the spectrum of interventions, ranging from Audio CDs
combined with regular phone call reminders (Altschuler et al., 2012) to web-based programs
combined with regular email reminders (Cavanagh et al., 2018; Krusche et al., 2012). A review
by Fish et al. (2016) revealed some elements that should be included in future programs,
including a modular course structure, use of different materials within the same course (e.g.,
text, audio, videos, and printouts), and an e-learning approach. From a clinical point of view,
each similar online program should have two perspectives. One is the perspective of delivery
and of teaching the original content of the selected program – formal and informal practice in
MBSR or mindfulness-based cognitive therapy (MBCT); the second perspective is that of
helping people to be fully absorbed in the program in each present moment.
92
We developed a program that integrates these components. Our program also integrates a faceto-face
approach, which is common for mindfulness programs in which the facilitator is
involved through the introductory lecture and participants are able to meet the whole
mindfulness team who prepared the program. Our main aim is to offer students a regular and
evidence-based program which helps them to support their mental health and acquire healthy
mind habits. Many researchers and practitioners agree that mindfulness meditation, through the
nonjudgmental awareness of experiences in the present moment, produces beneficial effects on
well-being and ameliorates stress-related symptoms (Alsubaie et al., 2017; Hölzel et al., 2011;
López et al., 2018; Tang et al., 2015) through the increase of resilience, positive emotions, more
frequent use of adaptive emotion regulation strategies, satisfaction with life, subjective quality
of life, and self-compassion (Hölzel et al., 2011).
We hypothesize that an eight-week online mindfulness program will induce a subjectively
assessed increase in basic facets of mindfulness, resilience, positive emotions, the frequency of
adaptive emotion regulation strategies, satisfaction with life, self-compassion, and quality of
life. Specifically, we assume that the importance attributed to the quality of life components
will be lower at the end of the program, with an unchanged satisfaction with life. The
fundamental assumption of Buddhism and Buddhist psychology is that there is no such thing
as a permanent, unchanging self (Epstein, 1988). The self is more of a process in the present
moment than a solid structure stored in autobiographical memory. Meditation practice leads to
enhanced internal awareness, and meditators usually report that they can observe mental
processes with increasing clarity; meditation facilitates a detachment from identification with
the static sense of self (Hölzel et al., 2011). This change in perspective of the self is often
subjectively experienced as a feeling of freedom and liberation. This shift in the perception and
awareness of the transient nature of the self reflects the understanding that things of the external
world are also transient. The result of this change in perspective could be monitored as the
decreased subjective importance of the life satisfaction components.
93
Methods
Participants
In total, 312 Masaryk University medical students participated in the study (mean age 22.2
years with SD 2.9, 81% women). Of those, 239 subjects agreed to take part in an eight-week
online mindfulness program. The control group was formed from 73 students who did not get
into the Self-Development for Medical Students course due to the limited capacity. This subject
runs at the same time as the on-line program. The students were offered credit for remaining in
the study as a control. The university’s ethics committee approved the study, and all participants
gave their written informed consent.
Procedure
Recruitment
All subjects were university students recruited through advertisements on the website and
Facebook page of the Department of Psychology and Psychosomatics of the Medical Faculty
of Masaryk University. The advertisement was also posted to the web news portal of Masaryk
University, MUNI.ONLINE.CZ, one month before the program started. The opportunity to
participate in the program was announced during lectures at the department and on notice
boards at the faculty. Self-Development for Medical Students is an optional course that is offered
every semester. The interest in the subject usually exceeds the class capacity, and many students
are often waitlisted for the next semester. Students are chosen for the course randomly by lot.
Data collection
The program participants completed baseline questionnaires before the introductory lecture
(pen and pencil method). The waitlist group completed the questionnaire during an
informational meeting before the Self-Development for Medical Students course started. The
data collection took place in the same week in both groups. The control measure at the end of
the program was created in Google Forms. The link to the questionnaires was sent individually
through email to each participant. The notification was sent three times, with a one-week
spacing between notifications.
94
Program
The program was divisible into three parts: 1) the introductory lecture, 2) the program itself,
and 3) the reminders to practice. The introductory lecture lasted 90 minutes and had eight parts:
1) introduction of the lecture team, 2) assignment to a Facebook group (for ethical and legal
reasons, each student had to be included in the group personally), 3) motivation section aimed
at documenting the positive effect of mindfulness on mental and physical health, 4) introduction
of the foundations of mindfulness practice and its basic attitudes (Kabat-Zinn, 2013), 5) focus
on commitment, self-discipline, intentionality, and personal vision, 6) introduction of basic
approaches to formal and informal mindfulness practice, 7) introduction of the structure and
delivery mode of the program, and 8) discussion. Our online program followed the structure
and content of the two most-researched mindfulness-based stress reduction programs, MBSR
(Kabat-Zinn, 2013) and MBCT (Segal et al., 2002). The formal part of the program was run in
precise accordance with the book Mindfulness: A Practical Guide to Finding Peace in a Frantic
World (Williams & Penman 2011). The “reminder messages” of the program were based on the
books The Mindfulness Solution: Everyday Practices for Everyday Problems (Siegel, 2010) and
Full Catastrophe Living (Revised Edition): Using the Wisdom of Your Body and Mind to Face
Stress, Pain, and Illness (Kabat-Zinn, 2013). The program ran for over eight weeks, during
which participants were asked to practice mindfulness formally and informally six days of the
week. The course was organized into eight modules. Each week’s module started on Monday
morning with a pdf file in which the plan for the whole week was presented and explained. The
pdf files ranged from three to five pages; a summary of the whole program is presented in
chapter 4: “A Week-by-Week Summary of the Program” (Williams & Penman, 2011).
Reminders to practice were delivered through Facebook Messenger. They consist of
encouragement reminders, incentives, explanations, and recommendations for formal and
informal mindfulness practice. There were 456 reminders in the course of the program (from
seven to twelve per day). The first reminder was always sent at 7:30 a.m. and the last one at 9
p.m. The others were delivered with one or two hours spacing within the day. The intensive
reminder system was a reaction to our clinical experience and to frequent patient statements of
how great it would be if somebody could remind them of important things from their
psychotherapy sessions at the right moment in their daily life, before problematic behaviors,
thoughts, and emotions appeared. The frequent reminders were in accordance with the need to
activate the processes of change, including stimulus control, which is activated by using
reminders and cues encouraging healthy behavior as substitutes for those that encourage
95
unhealthy behavior (Norcross et al., 2011). The structure and content of the reminders are
presented in Table 1. Audio recordings recommended in the book (Williams & Penman, 2011)
were available for download at the “Books for Better Living” website, Mindfulness Meditation
Downloads (2012), where every recommended meditation is freely available (Meditation 1,
Mindfulness of Body and Breath; Meditation 2, The Body Scan; Meditation 3, Mindful
Movement; Meditation 4, Breath and Body; Meditation 5, Sounds and Thoughts; Meditation 6,
Exploring Difficulty; Meditation 7, Befriending; and Meditation 8, The Three-Minute
Breathing Space). The foundations of mindfulness practice and its basic attitudes were
presented via short videos (from 2’19” to 4’14”) on YouTube.com, with each attitude presented
by Jon Kabat-Zinn (Kabat-Zinn, 2015). Students had the opportunity to share their experiences
and questions with others within the Facebook group. Sharing was repeatedly encouraged via
reminders aimed at helping the participants get social support from the group. Participants also
had the opportunity to communicate in writing with the lecture team regarding any questions
or difficulties about formal and informal practice. Participation in the program was completely
free.
Measures
The Five Facet Mindfulness Questionnaire (FFMQ; Baer et al. 2006, 2008) is a widely used
tool that measures dispositional mindfulness. The questionnaire has five subscales: Describe,
Observe, Act with Awareness, Nonjudging of Inner Experience, and Nonreactivity to Inner
Experience. The items are rated from 1 = “never or very rarely true” to 5 = “very often or always
true”. Higher scores indicate higher mindfulness. All items from the Act with Awareness and
Nonjudge subscales and half of the items in the Describe subscale are reverse-worded. The
internal consistency of the subscales ranges between Cα = 0.72 – 0.92.
The Subjective Emotional Balance Questionnaire (SEBQ; Kozeny, 1993) assesses prevailing
positive and negative emotional experiencing. The questionnaire has two subscales (Positive
Emotional Experiences and Negative Emotional Experiences), with eighteen items each. The
items are evaluated on a scale from 1 = “almost never” to 5 = “very often”. The internal
consistency was found to be Cα = 0.93 for both scales.
The Perceived Stress Reactivity Scale (PSRS; Schlotz et al., 2011) is a questionnaire assessing
individual typical reactivity to everyday life stressors. The scale has twenty-three items (with
96
twelve items reverse-worded) and five subscales: Prolonged Reactivity (four items), Reactivity
to Work Overload (five items), Reactivity to Social Conflict (five items), Reactivity to Failure
(four items), and Reactivity to Social Evaluation (five items). The items are rated from 0 (lowstress
reactivity) to 2 (high-stress reactivity). The internal consistency of the subscales ranges
between Cα = 0.71 – 0.91.
The Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski & Kraaij, 2007) assesses
a set of cognitive emotion regulation strategies. It has thirty-six items and nine subscales with
four items in each subscale: Self-blame, Acceptance, Rumination, Positive refocusing, Refocus
on Planning, Positive Reappraisal, Putting into Perspective, Catastrophizing, and Others-blame.
The subscale Rumination was excluded from this study due to its low internal consistency. The
items are rated from 1 = “almost never” to 5 = “almost always”. The internal consistency of the
subscales ranges between Cα = 0.68 – 0.83.
The Satisfaction with Life Scale (SWLS; Diener et al., 1985) measures overall satisfaction with
life with five items rated from 1 = “strongly agree” to 7 “strongly disagree”. The internal
consistency ranges between Cα = 0.80 – 0.96.
The Brief Resilience Scale (BRS; Smith et al., 2008) measures the ability to recover from
stressful situations. The BRS has six items rated from 1 = “absolutely agree” to 5 = “absolutely
disagree”. The internal consistency was reported to be between Cα = 0.80 – 0.91.
The Self-Compassion Scale-Short Form (SCS-SF; (Raes et al., 2011) measures individual
compassion for oneself. The SCS-SF is a short form of the twenty-six item Self-Compassion
Scale (SCS; Neff, 2003) and has a high correlation with the full SCS (r ≥ 0.97). The SCS-SF
has twelve items and six subscales with two items in each subscale: Self-Kindness, SelfJudgment,
Common Humanity, Isolation, Mindfulness, and Over-identified. The items are rated
from 1 = “never” to 5 = “always”. The internal consistency was found to be Cα = 0.86.
Subjective Quality of Life Analysis (SQUALA; Zannotti & Pringuey, 1992) measures the
quality of life defined as a difference between the importance and the satisfaction. The
questionnaire investigates the subjective perspective of the respondent’s life situation. The
respondents evaluate their satisfaction in the areas of life they consider important. The tool has
twenty-three areas mapping both internal and external factors affecting everyday life. The
questionnaire has two parts: the first is about the importance and the second about satisfaction.
The respondents assess both on a scale from 1 = “very satisfied” to 5 = “very disappointed”.
97
The result is a comparison between the two parts. The internal consistency was found to be
between Cα = 0.82 – 0.90 (Chrastina et al., 2014).
Data analysis
All data analysis was conducted with IBM SPSS Version 21 (IBM Corp 2012). For the analysis,
the participants were divided into three groups: program group consisted of participants who
completed full program, program-dropout group consisted of participants who started, but did
not finish the program, and control group consisted of participants on a waitlist who were not
included in the program at all and only filled in the test batteries. First, initial differences in
average scores of thirty-three continuous dependent variables between the program group,
program-dropout group, and control group before the program were compared using
MANOVA and Bonferroni post-hoc tests. Further, pre- and post-program differences in thirtythree
continuous dependent variables were compared within the program group by paired ttests.
Bonferroni correction was applied, resulting in a significance threshold of p = 0.002.
Finally, program and control groups were compared by independent sample t-tests with
Bonferroni correction in the variables which had changed after the program within the program
group, to indicate whether this change is specific for the program group.
98
Table 1 Program structure and content
Type of
intervention
Intervention examples Total1 Total
original2
Welcome message Good morning. Today is the first day of your mindfulness journey. Please read today’s pdf file,
“The First Mindfulness Week” which you can find on the news feed right now. You will get a clear
idea of what is waiting for you in the first week and where our shared path will take us.
333
33
Formal practice
reminder
Have you had time yet today to practice the mindful body and breathe exercise? It is hard to find
time and there is no need to feel guilty if you haven’t done it yet. But try to find eight minutes
today.
26 24
Informal practice
reminder
Maybe you are having lunch, drinking coffee, going somewhere, or waiting for something. Try to
be in fully aware contact with this activity. Without judgement, with patience, with curiosity and
acceptance of everything that is happening.
33 31
Be in the present
moment reminder
Take a moment to stop and look around. Just be fully aware of where you are and whether your
mind is in this place.
71 60
Focus on breathing
reminder
Take a moment to acknowledge your breath. Inhale and exhale, nothing more. Do not rush and do
not try to change, just acknowledge it fully.
53 31
Focus on body
sensations
reminder
Take a few moments to realize what feelings you feel in your body. Be aware of where your clothes
are touching your body. If you are standing, be aware of the feelings of your legs and feet. If you
are sitting, note the sensations at the point where your body touches the chair.
24 20
Focus on sensory
inputs reminder
Look around you. Take a moment to be aware of what you see, what you hear, what you smell, the
taste in your mouth.
17 5
Observe thoughts
and feelings
reminder
Stop for a little while and notice from moment to moment what is happening, how your thoughts
and feelings appear and how they disappear.
29 25
Basic attitudes
reminder
Patience means to be open to every moment, to receive it in its fullness, and to know that things can
only take place in their own time. Give this principle two minutes today.
22 20
Personal vision
reminder
Maybe you are not following the instructions. Maybe the instructions are just frustrating and
upsetting. Maybe you wonder what it’s all about. Try to return to your vision before going to bed,
remember why you are in the program and what is important to you.
6 4
Mindfulness
metaphors
In the ocean, at a depth of three to six meters, only subtle waves and tranquility are felt, even when
there is a great storm on the surface. It is similar when we focus on breathing in the belly. We
9 9
99
perceive an area of the body that is far from the head, and thus far below the surface of our raging
mind.
Mindfulness
education
The mindfulness exercise begins with focusing attention on breathing and continues on to body
sensations, feelings, thoughts, and ultimately comes the experience of self. Gradually, we react
increasingly less reactively to everything that appears and gain a greater sense of freedom. Instead
of running away from difficult emotions, we are increasingly able to cope with any reaction.
59 56
Time, sleep, work,
and study stress
Sometimes it is difficult to sleep in the evening because we cannot get rid of some thoughts. The
more we try, the worse it is. Letting things and thoughts be, letting them go at the right time is an
important life skill. Remember the principle “let it go”.
11 11
Compassion and
gratitude reminder
Try to say to yourself: May I be free from suffering. May I be as happy and healthy as it is possible
for me to be. May I have ease of being. May I learn to not be stuck in the past. May I be able to
accept everything that life brings to me.
Whatever you eat today, try to acknowledge where the food comes from, the laws of nature and the
people to whom we owe gratitude.
10 9
Self-compassion
reminder
In this moment, let yourself be as you are. 27 23
Change in
perspective on the
self-reminder
Often, we are unhappy because we cling to a particular image of ourselves. But if everything is
transient, no picture actually exists. So why bother with something that is not real?
9 9
Summary at the
end of the day
The evening is a time of peace, a return from the outside world to the inner realm. It is also a time
when we often admit many more things that are troublesome to us. Be sensitive and note how many
past or future concerns there are. Try the three-minute breathing space exercise. Let yourself be led
by Mark Williams or do it by yourself, if you know it now. Good night.
174
17
1
Total number of reminders; 2
Total number of original reminders that were not repeated; 3
This number does not match the total number of days in the entire program. It would
otherwise be 48 days. Some welcome messages, however, included more than just greetings and so they were included in other type of intervention subgroups. 4
This number
does not match the total number of days in the entire program. It would otherwise be 48 days. Some summaries at the end of the day, however, included more than just
summary greetings and so they were also included in other type of intervention subgroups.
100
Results
Adherence
From the 239 subjects who participated in the program, 135 (56.5%) completed the program in
the sense that they completed a post-program test battery (program group), leaving 104 (43.5%)
subjects who probably dropped out during the program or simply did not complete the postprogram
test battery (program-dropout group). In the control group (students waitlisted for the
Self-Development for Medical Students course), 73 subjects completed the post-program test
battery (control group).
Differences between groups before the program
Initial differences between the program group (N=135), program-dropout group (N=104), and
control group (N=73) before the program were analyzed in demographic variables and target
scales. Differences in sex frequencies (84% women in the program group, 76% women in the
program-dropout group, and 75% women in control group) were analyzed using a chi-square
test; no significant differences were found (Χ2
(4) = 5.33, p = 0.256). Differences in average
scores of thirty-three continuous dependent variables (age, five FFMQ subscales and total
score, two SEBQ subscales, five PSRS subscales and score, eight CERQ subscales, SWLS
score, BRS score, six SCS-SF scores, and two SQUALA scores) were compared using
MANOVA and post-hoc tests with Bonferroni correction. Significant group effects were found
in the FFMQ subscales Act with Awareness (F (2) = 8.873, p < 0.001, η2
= 0.054) and
Nonreactivity to Inner Experience (F (2) = 4.129, p = 0.017, η2
= 0.026); and in the PSRS
subscales Reactivity to Work Overload (F (2) = 7.337, p = 0.001, η2
= 0.045) and Reactivity to
Social Evaluation (F (2) = 3.323, p = 0.037, η2
= 0.021). Descriptive statistics of the four scales
are displayed in Table 2. Bonferroni post-hoc test revealed that the control group showed higher
FFMQ subscales Act with Awareness and Nonreactivity to Inner Experience and lower PSRS
subscales Reactivity to Work Overload and Reactivity to Social Evaluation than the program
group. There were no significant differences between the program group and the programdropout
group. No significant difference was found between these two groups at the program
start in simple self-efficacy, as measured through the question “How much do you believe that
you will follow the program requirements for eight weeks?” The item was rated from 1 = “I do
not believe I can do it” to 10 = “I believe I can do it”: program group 7.41 ± 1.78; program-
101
dropout group 7.22 ± 1.99; t (236) = 0.783, p = 0.43. One significant difference was found
between the control group and program-dropout group: higher scores of the FFMQ subscale
Act with Awareness in the control group.
Table 2 Descriptive statistics of variables in which statistical differences were found between
the groups before the start of the program
Dependent
variable
Group M SD
p value of Bonferroni
post-hoc tests
Program
(N 135)
Dropout
(N 104)
Control
(N 73)
FFMQ
Act Awareness
program 2.80 0.70 - = 1.000 < 0.001
program-dropout 2.86 0.63 - - = 0.004
control 3.19 0.67 - - FFMQ
Non-
reactivity
program 2.68 0.63 - = 0.729 = 0.013
program-dropout 2.77 0.58 - - = 0.250
control 2.92 0.54 - - PSRS
Reactivity
to work overload
program 1.37 0.43 - = 0.336 < 0.001
program-dropout 1.28 0.45 - - = 0.069
control 1.13 0.44 - - PSRS
Reactivity
to social
evaluation
program 1.33 0.42 - = 0.318 = 0.041
program-dropout 1.24 0.45 - - = 0.989
control 1.18 0.40 - - Note.
Higher scores indicate higher mindfulness in FFMQ subscales and higher perceived stress
in PSRS.
Program effectivity analysis
To assess the effects of the program, we first ran a series of thirty-two paired t-tests between
scores before and after the program in the program group separately. We used Bonferroni
correction resulting in a statistical threshold of p = 0.002. Descriptive statistics of the scores
before and after the program for the program group in all scales together with the results of the
paired t-tests are displayed in Table 3. Significant differences were found in all FFMQ subscales
and in total FFMQ scores, with higher scores after the program; in both SEBQ subscales, with
higher scores in the positive subscale and lower scores in the negative subscale after the
102
program; in all PSRS subscales and in its total score, with lower scores after the program; in
the CERQ subscales Self-blame, Positive Reappraisal, and Catastrophization, with lower scores
in Self-Blame and higher scores in Positive Reappraisal and Catastrophization after the
program; in SWLS, with higher score after the program; in the SCS-SF subscales SelfKindness,
Isolation, Mindfulness, and Over-identified, with higher scores in the Self-Kindness
and Mindfulness scales and lower scores in the Isolation and Over-identified scales after the
program; and in the SQUALA importance scale, with lower scores after the program.
Table 3 Descriptive statistics and paired t-test results for pre- and post-program scores within
the program group
Scale Time M SD t df p d
FFMQ Describe
pre 3.05 0.82
-5.602 134 < 0.001 -0.364
post 3.38 0.75
FFMQ Observe
pre 3.20 0.73
-5.918 134 < 0.001 -0.593
post 3.56 0.58
FFMQ
Act Aware
pre 2.80 0.70
-6.127 134 < 0.001 -0.554
post 3.17 0.69
FFMQ
Nonjudge
pre 3.09 0.85
-7.051 134 < 0.001 -0.655
post 3.54 0.81
FFMQ
Non-Reactivity
pre 2.68 0.63
-6.833 134 < 0.001 -0.562
post 3.03 0.60
FFMQ
Total
pre 2.97 0.49
-8.928 134 < 0.001 -0.776
post 3.34 0.49
SEBQ
Negative
emotivity
pre 2.48 0.66
3.699 134 < 0.001 0.378
post 2.26 0.68
SEBQ Positive
emotivity
pre 3.41 0.68
-3.322 134 < 0.002 -0.240
post 3.58 0.73
PSRS Prolonged
Reactivity
pre 1.03 0.41
5.741 133 < 0.001 0.484
post 0.82 0.44
PSRS
Reactivity to
Work
Overload
pre 1.37 0.43
7.661 134 < 0.001 0.620
post 1.10 0.43
PSRS Reactivity
to Social
Conflict
pre 1.35 0.42
6.218 134 < 0.001 0.545
post 1.14 0.44
PSRS Reactivity
to Failure
pre 1.41 0.40
6.975 134 < 0.001 0.614
post 1.17 0.37
PSRS Reactivity
to Social
Evaluation
pre 1.33 0.42
7.281 134 < 0.001 0.614
post 1.11 0.45
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PSRS
Total
pre 1.30 0.30
10.087 133 < 0.001 0.880
post 1.07 0.33
CERQ
Self-Blame
pre 3.21 0.74
4.357 134 < 0.001 0.377
post 2.95 0.75
CERQ
Acceptance
pre 3.41 0.70
-3.224 134 < 0.002 -0.267
post 3.60 0.73
CERQ Positive
refocusing
pre 2.43 0.84
-3.001 134 = 0.003 -0.275
post 2.66 0.83
CERQ Refocus
on planning
pre 3.07 0.65
-0.512 134 = 0.609 -0.045
post 3.10 0.69
CERQ Positive
reappraisal
pre 3.31 1.00
-4.280 134 < 0.001 -0.356
post 3.60 0.93
CERQ Putting
into perspective
pre 3.38 0.92
-0.746 134 = 0.457 -0.061
post 3.43 0.90
CERQ
Catastrophizing
pre 2.17 0.78
-3.166 134 < 0.002 -0.289
post 2.39 0.61
CERQ Others-
blame
pre 1.91 0.65
-1.952 134 = 0.053 -0.182
post 2.03 0.70
SWLS
pre 4.57 1.13
-4.408 134 < 0.001 -0.357
post 4.85 1.18
BRS pre 2.86 0.92
-3.067 134 = 0.003 -0.267
post 3.06 0.93
SCS-SF Self-
Kindness
pre 2.94 0.87
-4.778 134 < 0.001 -0.388
post 3.27 0.86
SCS-SF Self-
Judgment
pre 2.77 1.11
2.593 134 = 0.011 0.225
post 2.54 1.06
SCS-SF
Common
Humanity
pre 2.84 0.78
-1.716 134 = 0.088 -0.142
post 2.96 0.84
SCS-SF
Isolation
pre 3.51 0.83
7.688 134 < 0.001 0.673
post 2.94 0.90
SCS-SF
Mindfulness
pre 3.34 0.86
-3.468 134 < 0.001 -0.298
post 3.58 0.76
SCS-SF Over-
identified
pre 3.79 0.81
7.119 134 < 0.001 0.629
post 3.28 0.91
SQUALA
Satisfaction
pre 2.07 0.33
0.345 134 = 0.731 0.031
post 2.06 0.43
pre 2.47 0.43
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SQUALA
Importance
post 2.26 0.53 5.895 134 < 0.001 0.545
Note. Statistical threshold was set to p = 0.002 resulting from Bonferroni correction on the number of tests (0.05 /
32 and rounded).
Next, we computed the differences between pre- and post-program scores in the twenty-four
dependent variables in which we found a significant effect of the program in the program group
(Table 4). The differences were then compared between the program group and control group
using independent sample t-tests to analyze whether the effects observed in the previous
analysis were specific for the program group. Again, we used Bonferroni correction resulting
in a statistical threshold of p = 0.002. Significant differences in pre- and post-program scores
between the program and control groups were found in all FFMQ subscales and in its total
score; in the SEBQ positive emotivity scale; in the PSRS Prolonged Reactivity, Reactivity to
Work Overload, and Reactivity to Social Evaluation subscales and in its total score; in the
CERQ Self-Blame and Positive Reappraisal scales; in the SCS-SF scales Self-Kindness,
Isolation, and Over-identified; and in the SQUALA Importance scale.
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Table 4 Descriptive statistics for differences between pre- and post-program scores and results
of independent sample t-tests between program and control groups
Scale Group M SD t df p d
FFMQ Describe
program 0.33 0.70
4.297 206 < 0.001 0.678
control -0.08 0.51
FFMQ Observe
program 0.36 0.68
4.460 187.02 < 0.001 0.585
control -0.02 0.62
FFMQ
Act Aware
program 0.37 0.70
5.698 206 < 0.001 0.840
control -0.18 0.61
FFMQ
Nonjudge
program 0.45 0.73
4.721 189.336 < 0.001 0.667
control 0.03 0.53
FFMQ
Non-Reactivity
program 0.35 0.59
5.585 206 < 0.001 0.821
control -0.13 0.58
FFMQ
Total
program 0.37 0.48
7.581 185.59 < 0.001 1.071
control -0.08 0.36
SEBQ Negative
emotivity
program -0.22 0.70
-2.645 206 = 0.009 -0.378
control 0.06 0.78
SEBQ Positive
emotivity
program 0.17 0.60
3.287 206 < 0.002 0.472
control -0.13 0.67
PSRS Prolonged
Reactivity
program -0.21 0.43
-3.448 205 < 0.002 -0.484
control 0.01 0.48
PSRS Reactivity
to Work
Overload
program -0.27 0.40
-7.207 206 < 0.001 -1.060
control 0.17 0.43
PSRS Reactivity
to Social
Conflict
program -0.21 0.40
-2.893 206 = 0.004 -0.427
control -0.05 0.35
PSRS Reactivity
to Failure
program -0.24 0.40
-2.331 206 = 0.021 -0.329
control -0.11 0.39
PSRS Reactivity
to Social
Evaluation
program -0.22 0.35
-4.984 206 < 0.001 -0.714
control 0.03 0.35
PSRS
Total
program -0.23 0.26
-6.428 205 < 0.001 -0.962
control 0.02 0.26
CERQ
Self-Blame
program -0.27 0.71
-3.770 134 < 0.001 -0.556
control 0.13 0.73
CERQ
Acceptance
program 0.20 0.71
2.491 206 = 0.014 0.362
control -0.05 0.67
program 0.29 0.80
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CERQ Positive
reappraisal
control -0.10 0.86 3.336 206 < 0.002 0.470
CERQ
Catastrophizing
program 0.22 0.80
-.383 206 = 0.702 -0.051
control 0.26 0.76
SWLS
program 0.28 0.73
2.361 206 = 0.019 0.339
control 0.00 0.91
SCS-SF Self-
Kindness
program 0.33 0.80
3.653 206 < 0.001 0.537
control -0.10 0.80
SCS-SF
Isolation
program -0.57 0.86
-3.849 206 < 0.001 -0.570
control -0.10 0.79
SCS-SF
Mindfulness
program 0.23 0.78
2.954 206 = 0.004 0.422
control -0.11 0.83
SCS-SF Over-
identified
program -0.51 0.83
-3.611 206 < 0.001 -0.531
control -0.08 0.79
SQUALA
Importance
program -0.20 0.40
-4.458 206 < 0.001 -0.658
control 0.04 0.33
Note. Statistical threshold was set to p = 0.002 resulting from Bonferroni correction on the number of tests (0.05 /
24 and rounded). Presented differences were computed by subtraction of pre-program scores from post-program
scores. Thus, a positive mean difference indicates higher scores after the program than before the program, and s
negative mean difference indicates lower scores after the program than before the program.
Finally, we compared differences between the program and control groups after the program in
the four variables in which the groups differed before the start of the program using independent
t-tests with a statistical threshold of p = 0.01 (0.05 / 4 and rounded). Descriptive statistic and
results of the t-tests are displayed in Table 5. Whereas differences between groups in the FFMQ
subscale Act with Awareness and the PSRS subscale Reactivity to Social Evaluation
disappeared, with students from the program group closer to controls, we found differences
between the groups in the FFMQ Nonreactivity to Inner Experience subscale and the PSRS
Reactivity to Work Overload subscale, with higher scores in the Nonreactivity to Inner
Experience and lower scores in the Reactivity to Work Overload scale in the program group
than in the control group.
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Table 5 Descriptive statistics and results of independent t-tests of differences between program
and control group in dependent variables after program which exhibited the difference between
groups before the program
Dependent variable Group M SD T df p d
FFMQ
Act Aware
program 3.17 0.69
1.532 206
=
0.127
0.221
control 3.01 0.76
FFMQ
Non-Reactivity
program 3.03 0.60
2.863 206
=
0.005
0.436
control 2.79 0.50
PSRS Reactivity to
Work Overload
program 1.10 0.43 -
3.098
206
=
0.002
-
0.442control 1.29 0.43
PSRS Reactivity to
Social Evaluation
program 1.11 0.45 -
1.637
206
=
0.103
-
0.220control 1.21 0.46
Discussion
The results of the presented pilot study revealed that participants who completed the online
mindfulness-based program for mental health and well-being support have significantly
reduced perceived stress, negative affectivity, and frequency of using some non-adaptive
emotion regulation strategies, and increased reported mindfulness, self-compassion, positive
affect experience, resilience, frequency of using adaptive emotion regulation strategies, and
feelings of life satisfaction. Our hypothesis was confirmed in the significant decrease of
attributed importance to the quality of life conditions. The study affirms that mindfulness
interventions can be effectively delivered via social networks in medical students. In our study,
we introduced an online original complex mindfulness program based on MBSR (Kabat-Zinn,
2013) and MBCT (Segal et al., 2002), combining a face-to-face approach (introductory lecture)
with text, audio, video, and e-learning components integrated into a unique intensive reminder
system using support psychotherapy principles.
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Program effectivity analysis
The results confirmed the hypotheses that the program would induce a subjectively assessed
increase in basic facets of mindfulness, positive emotions, frequency of using adaptive emotion
regulation strategies, satisfaction with life, self-compassion, and subjective quality of life.
Moreover, resilience increased on borderline significance. The greatest effect of change
(medium and large) in all components of mindfulness as defined by FFMQ confirmed good
program targeting. The confirmation of the differences between the program and control groups
validate the effect of the program itself. The effect sizes detected in our study are comparable
with the mean results of other studies (Cavanagh et al., 2018; Krusche et al., 2012, 2013;
Querstret et al., 2018). They also matched the results of a recently published standardized
review of a meta-analysis of randomized controlled trials for MBSR and MBCT, which
demonstrated a significant improvement in depressive symptoms (d =0.37), anxiety (d =0.49),
stress (d =0.51), quality of life (d = 0.39), and physical functioning (d = 0.27; Gotink et al.,
2015). The effect on perceived stress and reactivity is even greater in our study (d = 0.88). The
number of observed effects and magnitude of effects sizes in other programs in medical students
(Barnes et al., 2017; Rosenzweig et al., 2003; Warnecke et al., 2011) supports the hypothesis
that our online mindfulness-based program for mental health support conducted in medical
students can be similarly effective to versions with facilitator.
Emotional regulation is one proposed component through which mindfulness works (Alsubaie
et al., 2017; Hölzel et al., 2011; López et al., 2018; Tang et al., 2015). Increased emotion
regulation induced by mindfulness probably involves a mix of the many implicit and explicit
regulation strategies and processes comprehensively described by Gross (2014). In this respect,
our study brings new knowledge thanks to the examination of mindfulness program effectivity
on specific emotion regulation strategies. Two major effects have been observed: medical
students who underwent the program, in comparison with the control group, increased the use
of positive reappraisal and decreased the use of self-blame. Moreover, they increased the use
of acceptance, but the difference in acceptance change between the program and control groups
did not survive correction for multiple comparisons. Further, we found increased
catastrophizing which, however, appeared both in the program and control groups. The
unexpected increase of catastrophizing could be hypothetically explained as a temporal side
effect of the increased general awareness and emotional awareness associated with mindfulness
training (Hölzel et al., 2011). Catastrophizing increasing after an MBSR program in female
high school students was described in another study (Shahidi et al., 2017), but the authors did
109
not discuss it. In a psychometric model, Jermann et al. (2009) presented a negative association
between mindfulness and catastrophizing. We could expect that this increase will fade with
continuing mindfulness practice (Tang et al., 2015) or stay at the same level while modulated
by acceptance and other mindfulness attitudes such as trust, letting go, and patience, which are
expected to increase under the mindfulness training. The increase of acceptance could be
considered as a protective factor. Mindfulness training develops the ability to be in contact with
whatever appears in the present moment, even negative thoughts and expectations. It does not
change the contents of the mind; it changes the attitude to the contents. The changes in the
relations among the distinct and interacting mechanisms producing the benefits of mindfulness
training are the next research frontier.
We confirmed the hypothesis that the importance attributed to the quality of life components
would be lower at the end of the program, with an unchanged satisfaction with partial
components of quality of life proposed in SQUALA. The decrease of importance, with a
medium-sized effect, while maintaining unchanged components of life satisfaction represents
a specific shift induced by the program, and it is a new result in this area. This result is also
interesting in the light of increased overall feeling of life satisfaction measured by SWLS
induced by the program. Mindfulness techniques, as part of the “third wave” of cognitive and
behavioral therapies, help to target contexts and functions of psychological phenomena, not just
their form (Hayes, 2016). Unlike other therapeutic strategies, such as cognitive behavioral
therapy, MBIs do not emphasize changing the contents of mental events as much as changing
the awareness of and relationship to them (Segal et al., 2002). Participants learn to disempower
emotionally charged thoughts or attitudes by bringing to their experience a sense of “allowing”
it to be just as it is, without a constant need for the situation to match their desired states (Segal
et al., 2002). It could be suggested that by staying in the experience of a present moment in a
non-reactive, accepting way and by witnessing the impermanence of mental phenomena,
participants learn to strengthen their inner resources and trust the ever-changing conditions of
everyday life, instead of constantly relying on external factors to make their life better. This
could make them less overly dependent on these factors and therefore mark the factors as less
important in terms of life satisfaction. We could hypothesize that a decrease of importance is a
specific marker of mindfulness-induced change, and it is a mediator between mindfulness and
its positive outcomes. This change could be related to the process of “decentering” (Fresco et
al., 2007), defined as disengaging the self from the event, that is commonly reported as an
important factor regarding mindfulness mechanisms (Lebois et al., 2015). For example,
110
decentering mediated a decrease in anxiety in an MBSR program with university students
(Fresco et al., 2007). To verify this mediation model, a larger data sample is needed; this is the
next goal for our research group.
It is a priority in mindfulness research to understand the mechanism/s by which mindfulness
exerts its positive influence (Hölzel et al., 2011). The present findings indirectly support the
notion, as did previous studies (e.g., Querstret et al., 2018; Spijkerman et al., 2016; Virgili,
2015), that formal and informal daily mindfulness meditation practices increase mental health.
We found a significant increase in all mindfulness facets (d = 1.1). Reported mediation models
reveal that each mindfulness component has a different impact on symptoms and well-being.
Baer et al. (2006) found that Nonjudge had the highest correlations with psychological
symptoms, neuroticism, thought suppression, difficulty regulating emotion, and experiential
avoidance, compared to all other facets. Act-aware had the second highest correlation with all
of these measures other than experiential avoidance. Nonjudge and Act-aware may be the most
important mindfulness facets in predicting psychological symptoms, with Act-aware having
particular relevance for depression. Nonjudge predicting lower levels of depression, anxiety,
and stress was replicated repeatedly (Cash & Whittingham, 2010; Querstret et al., 2018). Our
program was aimed to help students develop mindfulness practice and foster self-compassion.
While mindfulness training was an explicit goal of the program, encouraging self-compassion
was implicit, incorporated in the manner in which the reminders were presented (for details, see
Table 1). In accordance with many studies (e.g. Baer et al., 2012; Finlay-Jones et al., 2018;
Neff, 2003) self-compassion is probably the second mechanism that mediated the change of
measured outcomes in our program. The effectiveness of online programs in fostering selfcompassion
has been documented (Krieger et al., 2016).
Although we did not find any significant differences between the program and dropout groups,
statistical analysis revealed that the control group showed higher FFMQ Act with Awareness
and Nonreactivity to Inner Experience subscales and lowered PSRS Reactivity to Work
Overload and Reactivity to Social Evaluation subscales than the program group at the start of
the program.
It is very difficult to interpret these results because people were not assigned randomly to the
control group. Control group participants were primarily interested in the Self-Development
course; although they were able to enter the Mindfulness program, they did not. SelfDevelopment
for Medical Students is an optional subject offered every semester. The interest
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in the subject usually exceeds the teaching capacity. Students were chosen for the course
randomly by lot. The rest of the applicants are waitlisted for the next semester. The
advertisement at the Masaryk University web news portal read: “Join the mindfulness-based
stress reduction program” so it probably appealed to students with higher rates of stress
symptoms. It can be assumed that students with possible higher levels of mindfulness traits
were not interested in such a program. Unfortunately, we do not have any information regarding
their previous mindfulness experience.
However, important results are that the differences between the program and control groups
observed before the program disappeared after the program completion, meaning that students
who underwent the program had equaled the controls in variables in which they previously
manifested decrease. More specifically, in case of FFMQ subscale Nonreactivity to Inner
Experience and PSRS subscale Reactivity to Work Overload the students who underwent the
program reached even higher scores than controls after the program. However, it is important
to note that the relatively high baseline levels reported in this sample meant there was more
capacity for change from baseline.
Adherence
A primary condition of any intervention program is good participant adherence. We did not
focus on adherence, but the presented study revealed some results contributing to this area of
interest. Of the 239 subjects who participated in the program, 56.5% completed the program in
that they completed the post-program test battery. This rate of attrition corresponds
approximately to the findings of similar studies. Cavanagh et al. (2013) reported that 52.3% of
web-based study participants completed questionnaires at pre- and post-intervention. The same
research group documented 68% completed questionnaires at pre- and post-intervention in
another study (Cavanagh et al. 2018). Forbes et al. (2018) presented similar results (53.3%).
Howells et al. (2016) used a smartphone app to deliver mindfulness training and reported a 77%
dropout rate. A dropout rate of 25% was described by Querstret et al. (2018) in their four-week
mindfulness online program. Previous studies raised expectations that high mindfulness traits
at the start of program would predispose the participants to adherence (Forbes et al., 2018), but
our results differed. No significant difference between the program and dropout groups was
found in the mindfulness traits measured by FFMQ. This confirms the investigation by
Cavanagh et al. (2018) showing no significant differences between participants who completed
112
the study and those who dropped out in mindfulness baseline. The current study also found that
adherent and non-adherent participants did not significantly differ in any of the remaining
measured variables. Levels of perceived stress, use of emotion regulation strategies, and
subjective emotional balance did not predict who would complete the questionnaires at the postintervention
stage. No difference was found in quantified self-efficacy in the sense of an
individual’s belief in his or her innate ability to achieve goals and complete the program.
In fact, we do not know if there is an association between adherence to the program and the
motivation to complete a relatively time-consuming test battery. No difference between the
groups at the program start indicates such an association and we were unable to clarify a
relationship based on the present results. One explanation is that the program ends before the
exam period and many students may have decided that they did not have time for it.
Adherence is a primary condition of any successful treatment or preventive program. One
program is not likely to suit all the participants. From the transtheoretical approach in
psychotherapy (Norcross et al., 2011), we know that people with some kind of suffering are a
heterogeneous group in the sense of their readiness to change. The finding that the frequency
and severity of obstacles are not significantly associated with adherence to an online program
(Forbes et al., 2018) shows that the readiness to change could be an important hypothetical
variable. Different modes of the program could be delivered according to the stage of change
(Velicer et al., 2000). From this point of view, readiness to change is another variable that
should be incorporated into the research on web-based program adherence. The advantage of
mindfulness-based programs on an online platform is the huge population impact. Programs
address many people in different stages of change. A significant subgroup of people could be
expected to drop out because of their unpreparedness to change. However, this does not mean
that they would not make any change, and it does not mean that they could not benefit from the
program in a subsequent round. In this context, it is necessary to create new programs and seek
new, more effective variants. However, finished interventions should be offered regularly by
the stable structure of institutions providing health support. The aim is not to help everybody
but to support those who are ready.
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Limitations
The pilot study design does not allow us to eliminate the possibility that the positive results of
online mindfulness programs could be explained by the fact that everyone who did not benefit
dropped out (Forbes et al., 2018). We did not use a randomized waitlist control design;
participants in the control group were self-selected for credits and did not want to attend the
program at all. Our pilot study did not include any follow-up control, so we are not able to
evaluate the reported induced change over time. We also did not evaluate any possible
mediation effects among variables. We have no evidence of how much added value the
intensive reminder system via Facebook had. The effectiveness and attrition rates of our
program are comparable with the results of other studies that did not use such an intensive
reminder system (Cavanagh et al., 2018, 2013; Krusche et al., 2012, 2013; Querstret et al.,
2018).
The results of this pilot study are promising. However, they must be seen as preliminary.
Replication in a randomized controlled trial with clinical measures/diagnoses and a longer
follow-up period is necessary.
How does mindfulness practice work?
MBIs have quite broad outcome effects on many somatic, social, emotional, and behavioral
problems. It has been shown that MBIs increase the quality of life and well-being. Compared
to the extensive evidence base for the effectiveness of MBSR and MBCT, relatively few studies
have tested the mechanisms of action which causally connect changes that occur during MBIs
with psychological outcomes. In general, in the context of psychotherapy research, it is known
that therapy “works,” i.e., is responsible for change, but there is little knowledge of why or how
it works (Kazdin, 2007). Similarly, it is well known that MBIs “work,” i.e., are responsible for
change, but there is little knowledge of why or how they works and how these effects come
about. Randomized controlled trials (RCT) have repeatedly shown that treatment leads to more
therapeutic change than no treatment. In this case, it is possible to say that treatment causes the
change. However, these studies do not answer why the intervention led to change or how the
change came about. In his key article in psychotherapy research, Kazdin (2007) defines
important concepts to be distinguished in research: cause, mediator, mechanism, and moderator.
114
The mediator is a construct or component that shows significant statistical relations between
intervention and treatment but may not explain the exact mechanisms through which change
comes about. Something that mediates change may not necessarily explain the processes of
how the change came about. Also, the mediator could be a proxy for one or more other variables
or be a general construct that is not necessarily intended to explain the mechanisms of change
(Kazdin, 2007). A mediator may be a guide that points to possible mechanisms but is not
necessarily a mechanism.
The mechanism refers to a greater level of specificity than the term “mediator” and reflects the
steps or processes through which therapy (or some independent variable) actually unfolds and
produces the change (Kazdin, 2007). Mechanism explains how the intervention transforms into
events that lead to the outcome. This is easily confused with the notion of mediation.
The moderator is a characteristic that modulates the direction or magnitude of the relationship
between and independent and dependent variables (Kazdin, 2007). If the relationship between
MBIs and stress reduction is different for men and women, sex is a moderator of the relation.
Moderators are related to mediators and mechanisms because they suggest that different
processes might be involved (e.g., for men and women, dispositional mindfulness).
The theoretical model of Kazdin (2007) describing the process of change between treatment
and outcome is presented in Figure 14. A better understanding of which mechanisms lead to
change is a necessary step on the path to tailor-made treatment.
Figure 14 The process of change between intervention and outcome (Kazdin, 2007)
The main implicit goal of MBI is to develop mindfulness skills that lead to non-judgmental and
non-reactive acceptance of all experiences, which in turn results in positive psychological
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outcomes (Kabat-Zinn, 1982; Segal et al., 2002). As in psychotherapy, it is necessary to answer
the question “How does mindfulness work and through what mechanisms is its effect
mediated?” Figure 15 represents the application of Kazdin’s model on the mindfulness effect
on problems with falling asleep.
Figure 15 The example of the process of change between MBSR and one of its outcomes
Mindfulness and basic personality traits: presumed moderators of the
mindfulness effect
Few studies in contemporary literature have assessed basic personality traits and their
relationship to mindfulness. However, the description of this relationship is crucial for the better
conceptualization of mindfulness and for better understanding of the interaction between
personality and mindfulness practice. Thompson and Waltz (2007, p. 1876) questioned whether
“everyday mindfulness may shape personality or personality may shape everyday mindfulness
or whether both are shaped by other factors”. The understanding of this interaction is crucial.
In her extensive meta-analysis, Giluk (2009) found the relationship between mindfulness and
personality traits derived from the five-factor model of personality (Big Five; neuroticism,
extraversion, openness to experience, agreeableness, and conscientiousness (Barrick, Mount, &
Judge, 2001) and positive and negative affects as basic dimensions of basic personality
reactivity that reflects general personality affective levels (Watson & Clark, 1984). Her results
revealed that while all the traits display appreciable relationships with mindfulness, the
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strongest relationships are found with neuroticism (-0.58), conscientiousness (0.44), positive
affect (0.41), and negative affect (-0.51).
Only a few studies have been carried out with the aim of describing the relationship between
mindfulness and temperament dimensions (Crescentini & Capurso, 2015). Haimerl and
Valentine (2001) used Cloninger’s psychobiological model of temperament and character to
describe basic dimensions of temperament (TCI; Cloninger et al., 1993). This model describes
the neurobiological and genetic bases of personality (four temperamental traits: Novelty
Seeking, Persistence, Reward Dependency, and Harm Avoidance) with their interaction with
life experiences (character). Character consists of three dimensions measuring the maturity of
the self at three levels: intrapersonal (Self-Directedness, mapped on concepts such as selfesteem
and self-efficacy), interpersonal (Cooperativeness, expressing the capacity to be
empathic, tolerant, and compassionate), and transpersonal (Self-Transcendence, measuring the
tendency toward spirituality and creativeness). In their cross-sectional study, Haimerl and
Valentine (2001) compared the TCI character profiles of three groups of Buddhist meditators
with different lengths of meditation experience. They found that expert meditators obtained
higher scores in all three aspects of the character profile than naive subjects, and they also
scored higher than beginners on the cooperativeness trait. Moreover, beginners scored higher
than naive individuals on the self-transcendence scale. No differences in temperament
dimensions were found.
Campanella et al. (2014) investigate the effects of eight weeks of consistent practice of
mindfulness meditation on the personality profiles measured with TCI (Cloninger, 1993). Their
results suggest that eight weeks of mindfulness meditation training might be sufficient to
modify the descriptions people give of themselves, especially with regards to the three
dimensions related to self-concept in the sense of the three-character subscale (SelfDirectedness,
Cooperativeness, and Self-Transcendence). Again, no specific effect of the
mindfulness training on any temperament scale was found.
In line with this direction of research, Wupperman et al. (2008) found that deficits in
mindfulness predict borderline symptoms in a healthy population, independently of
neuroticism.
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Mediators and mechanisms of mindfulness
From the literature and a clinical perspective, distinct and interacting mechanisms are at play
in producing the benefits of mindfulness training. The common denominator in the background
of behavioral and experiential changes induced by mindfulness could be probably called
“enhanced self-regulation” (Hölzel et al., 2011; Tang et al., 2015). The components most often
proposed and verified to describe the mechanisms through which mindfulness works are:
attention regulation, body awareness, emotional awareness, emotion regulation, change in
perspective on the self, and compassion and self-compassion (Alsubaie et al., 2017; Hölzel et
al., 2011; López et al., 2018; Tang et al., 2015). Mediators and mechanisms beyond the
mindfulness effect verified by studies are presented in Table 5. The review of all components
proposed by other authors is in Table 6 and Figure 16. The large number of proposed
mechanisms indicates the complexity of individual change induced with mindfulness training.
This chapter aims to describe what the components of mindfulness meditation are believed to
be and how they mediate the relationship between MBI and its outcomes. The emotion
regulation mechanisms are discussed in a separate chapter because the integration of emotional
regulation and mindfulness is the main aim of this habilitation thesis. The original results of our
research group are also presented and discussed.
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Table 6 Mediators and mechanisms beyond the mindfulness effect
Authors Mechanisms Authors Mechanisms
Baer et al., 2006 Observing Brown et al., 2007 Insight
Describing Exposure
Acting with awareness Non-attachment
Non-judging of inner experience Enhanced mind-body functioning
Nonreactivity to inner experience Integrated functioning
Shapiro et al., 2006 Intention Tang et al., 2015 Attentional control
Attention Emotion regulation
Attitude Self-awareness
Kabat-Zinn, 1990 Acceptance Vago and Silbersweig, 2012 Self-awareness
Non-judging Self-transcendence
Patience Intention and motivation
Beginners mind Attention regulation
Trust Emotion regulation
Non-striving Extinction and reconsolidation
Letting be Prosociality, improving social cognition
Non-attachment and de-centering
Hölzel et al., 2011 Attention regulation Grabovac et al., 2011 Acceptance and compassion
Body awareness Concentration/attention regulation
Emotion regulation (reappraisal,
exposure, extinction, reconsolidation)
Ethical practices
Insight into characteristics of mental objects
Change in perspective on the self Attachment/aversion to feelings
Decreased mental proliferation
Neff, 2003 Self-compassion Baer, 2003 Exposure
Cognitive change
Self-management
Relaxation
Acceptance
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Figure 16 The review of all components proposed by other authors
Attention regulation
Attention regulation is probably the essential component of the effects of mindfulness practice.
It is described in detail in the “Self-regulation of attention” chapter.
Body and emotional awareness
Emotional awareness can be defined as the extent to which one can identify and describe one’s
own emotions (Moon & Berenbaum, 2009). It is the ability to consciously perceive and be
aware of emotional states as well as the ability to match emotional experiences with appropriate
semantic or symbolic categories. Interoception refers to the sensing of internal bodily changes
(Garfinkel et al., 2015). Conscious feelings originate from the perception of bodily sensations
and their dynamic changes (Damasio, 1999). The ability to consciously perceive and be aware
of the somatic components of affective states is the basis of the authentic experience of the self
(Dolhanty & Greenberg, 2007); this ability is necessary for adaptive emotion regulation (Gross,
2014). The increase of emotional awareness usually represents the first step of psychotherapy
at the most fundamental level. It is necessary to identify feelings and be aware of how the
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feelings are associated with adaptive (e.g., chatting with a close friend) or nonadaptive behavior
(e.g., overeating or self-injury).
In mindfulness practice, attention is focused on sensory experiences of breathing, sensory
experiences related to emotions, or other bodily sensations. Meditators report that mindfulness
practice leads to a higher physical and emotional awareness and emotional clarity (Cooper,
Yap, & Batalha, 2018). In this context, mindfulness practice helps to keep practitioners in good
contact with emotions and their physiological components. It is then possible to observe the
whole phenomenon of emotion, how it arises, where and how it is experienced in the body, and
with what thoughts, memories, and behavior it is associated. This exposure to emotions in a
non-judgmental, accepting, and open manner initiates a greater awareness of which emotions
are just the result of ignorance and which are authentic information about the present moment.
Mindfulness training supports the ability to monitor emotions and acknowledge them as they
are. Emotions are explored in this process with the aim of understanding how they work and
how they influence thoughts and behavior. Good contact with emotions makes it possible to
recognize the process of valuation at its start and thus to regulate it.
Buddhist learning states that basic emotions can be activated on the basis of ignorance. In
Buddhist literature, ignorance, anger, and greed are referred as the “Three Poisons” (DeSilva,
2014). They are referred to in this way because they arise as a result of the mistaken experience
of the separation of the perceiver, the perceived object, and the act of perception, which are
understood to be inseparable (Chambers et al., 2009). They then give rise to higher-order
emotions in the background of human suffering: desire, jealousy, anger, pride, and ignorance
(DeSilva, 2014). During mindfulness practice, practitioners start to differentiate between
primary, secondary, and instrumental emotions (Greenberg, 2004). Primary emotions are the
first spontaneous responses to stimuli, such as fear in response to a threat. Secondary emotions
are a response to primary emotions, usually if the primary emotion was unacceptable in some
way. A secondary emotion often reflects a defense mechanism against the primary emotion due
to an aversive meaning in the past. The secondary emotion often occurs first in therapy or
meditation. Instrumental emotions are those that have been learned and reinforced through
interpersonal experience (Greenberg, 2004). Through non-judgmental acceptance and
openness, it is possible to move beyond the secondary and instrumental emotions to the primary
emotions. Greater emotional awareness is associated with higher self-reported impulse control
(Lane, 2000), greater openness to feelings (Lane et al., 1990), and a higher level of well-being
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(Ciarrochi et al., 2003). Lower levels of emotional awareness were found in patients with
borderline personality disorder (BPD; Levine, 1997), posttraumatic stress disorder (PTSD; e.g.,
Frewen et al., 2008), obesity, anorexia nervosa and bulimia nervosa (e.g., Bydlowski et al.,
2005; Bernatova & Svetlak, 2017), and various psychosomatic diseases (Subic-Wrana, et al.,
2005). It seems that emotional awareness represents an important ability necessary for adaptive
emotion regulation, well-being, and mental and somatic health (Lane, 2008).
In the context of this thesis, it is important to mention that physical and emotional awareness
are components that have been proposed to describe the mechanisms through which
mindfulness has its positive outcomes on health (Alsubaie et al., 2017; Hölzel et al., 2011;
López et al., 2018; Tang et al., 2015).
Although experienced meditators and even participants of MBSR or MBCT eight-week
programs report an increased level of body awareness, few studies have presented empirical
evidence to verify these claims (Hölzel et al., 2011). There are many self-reported measures of
the level of body awareness in the literature and research (Mehling et al., 2009). However, this
construct has not yet been sufficiently explored. Body awareness is also represented in items of
the Five Facet Mindfulness Questionnaire, in the subscale Observe, which covers the awareness
of body sensations (e.g., Item 1: “When I’m walking, I deliberately notice the sensations of my
body moving”), hearing, smelling, seeing, interoception, thoughts, and emotions (e.g., Item 11:
“I notice how foods and drinks affect my thoughts, bodily sensations, and emotions”). Increases
in the scores on this scale were induced with our mindfulness-based stress reduction program.
The same change in this scale was described in another study (Carmody & Baer, 2008).
Studies using the heartbeat detection task as a standard measure of interoceptive awareness
found no evidence that meditators perform higher than people with no meditation experience
(Khalsa et al., 2008; Nielsen & Kaszniak, 2006). Results are mixed and contradictory; another
study shows that expert meditators have significantly better introspective accuracy than novices
and that meditation experience also significantly predicted individual introspective accuracy.
These results suggest that long-term meditators provide more accurate introspective reports
than novices (Fox et al., 2012).
The indirect results support the hypothesis that the mindfulness that raises physical and
emotional awareness can be derived from neuroscience research. The neural structures
associated with physical and emotional awareness, such as the insular cortex, are repeatedly
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found to be activated during meditation. Studies have shown higher activation following
mindfulness training (e.g., Tang et al., 2009; Farb et al., 2013). Greater cortical thickness in
experienced meditators was documented in this area (Lazar et al., 2005). These results can be
interpreted to mean that enhanced insula activity in meditators represents the amplified
awareness of present-moment experience (Tang et al., 2015).
Change in perspective on the self
The change in perspective of the self is another often-mentioned mechanism through which
mindfulness could and probably does have a positive effect on mental health. This process has
been termed “reperceiving” or “decentering” (Carmody et al., 2009; Fresco et al., 2007).
Grabovac et al. (2011) also include the metacognitive awareness concept, which they propose
has a central role in the current models of change mechanisms. Shapiro et al. (2006) introduced
the concept of “reperceiving,” defined as a “meta mechanism” of the mindfulness effect.
The term “metacognitive awareness” is often used interchangeably with the term
metacognition. This concept is not new for Western psychology. The therapeutic use of this
concept was mentioned in the 1950s by Carl Rogers, who wrote “the thoughts and emotions
that we take to be so real and are so worried about do not exist in the way that we imagine
them…they do exist, but we can know them in a way that is different from identifying with
them” (Rogers, 1959, as cited in Grabovac et al., 2011, p. 161). Metacognitive awareness is
also a key concept in CBT and MBCT (Segal et al., 2002). An analysis of meditation diaries of
participants in an MBSR program reported by Kerr, Josyula, and Littenberg (2011) described
this observing attitude as the “observer perspective.” This change in perspective of the self is
often subjectively experienced as a feeling of freedom, liberation, and happiness.
Teasdale et al. (1995, p. 285) defined metacognitive awareness as the process by which
“negative thoughts and feelings are seen as passing events in the mind rather than as inherent
aspects of self or as necessarily valid reflections of reality.”
Mindfulness is unique in promoting meta-awareness of emotion regulation strategies (Farb et
al., 2014). Mindfulness serves as a meta-strategy; it cultivates awareness of regulatory habits.
When we are aware of options and freedom of choice, then it is possible to choose more flexibly
between regulatory responses rather than automatically defaulting to strategies. This does not
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mean that the other techniques do not work. It suggests that mindfulness may enhance
regulation by increasing flexibility in regulatory strategy selection. By cultivating an attitude
of acceptance and curiosity in response to events, mindfulness provides an opportunity to tailor
regulatory responses to address both personal coping capacity and changing situational
demands. It provides freedom of choice and the time to choose an appropriate reaction.
Whereas more advanced and longer practice of the meditation is required to experience
disidentification from the static sense of self, a de-identification from some parts of mental
content is often experienced even in the earliest stages of meditation practice (Hölzel et al.,
2011). However, it is difficult to operationalize the perspective on the self, and the empirical
research in this area thus far is still in the early stages.
The change of this process is most often measured qualitatively. There are also some selfreported
measurements such as the Experiences Questionnaire (Fresco et al., 2009) and the
Toronto mindfulness scale (Lau et al., 2006), both of which explicitly monitor decentering.
Decentering scores have been shown to be higher in meditators than those without meditation
practice, and decentering subscale scores increase with meditation experience (Davis, Lau, &
Cairns, 2009). Changes in decentering are associated with decreased symptoms and intensity
of stress (Lau et al., 2006). The decentering subscales of the two questionnaires significantly
correlate with the other measures of mindfulness, including MAAS, FMI, CAMS, MQ, KIMS,
and FFMQ (for details, see Park et al., 2013; Lau et al., 2006).
The contemplative neuroscience research has revealed some results which could be considered
as neural correlates of decentering. Dispositional mindfulness is often found to be associated
with decreased connectivity within the midline regions, including the PCC and mPFC during
resting state functional connectivity fMRI (Way et al., 2010). The medial parts of the brain are
part of the DMN, which is related to mind-wandering and self-referential processing (Qin and
Northoff, 2011). The DMN represents regions that are active when the brain is not engaged in
a task-induced activity (Gusnard et al., 2001). Based on the whole range of experimental results,
DMN activity and its connectivity with other parts of the brain leading to decreased
involvement of the habitual mode of self-reference might be affected in some way by
mindfulness meditation practice (Jang et al., 2010).
Farb et al. (2007) demonstrated a strong coupling between the right insula (viscero-somatic
neural images of the body state) and the mPFC (regions supporting cognitive-affective
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representations of the self) in novices that was uncoupled in the participants who were
experienced in mindfulness. These results suggest a fundamental neural dissociation between
two distinct forms of self-awareness (open monitoring vs. narrative perspective) that are
habitually integrated but can be dissociated through mindfulness training. These results support
the notion that mindfulness practice can lead to emotional non-response to experience because
of the disconnection of perception from self-referential thoughts. This change following MBI
is consistent with the notion that mindfulness training allows for a distinct experiential mode in
which thoughts, feelings, and bodily sensations are viewed less as being good or bad or integral
to the “self” and treated more as transient mental events that can be simply observed (Williams
et al., 2007, as cited in Farb et al., 2007, p. 320).
Compassion and self-compassion
Christin Neff (2003), the leading researcher in the field of self-compassion and promoter of its
application into psychotherapy, explains that “compassion involves being touched by the
suffering of others, opening one’s awareness to others’ pain and not avoiding or disconnecting
from it, so that feelings of kindness toward others and the desire to alleviate their suffering
emerge. It also involves offering nonjudgmental understanding to those who fail or do wrong,
so that their actions and behaviors are seen in the context of shared human fallibility. Selfcompassion,
therefore, involves being touched by and open to one’s suffering, not avoiding or
disconnecting from it, generating the desire to alleviate one’s suffering and to heal oneself with
kindness. Self-compassion also involves offering nonjudgmental understanding to one’s pain,
inadequacies, and failures, so that one’s experience is seen as part of the larger human
experience.” The concept of compassion and self-compassion is a crucial part of Buddhist
philosophy, and it is almost a new concept for Western psychology. Western psychological
research has focused more on concepts such as self-esteem or self-efficacy (for review, see
Neff, 2003).
Self-compassion can be operationalized in three components: self-kindness versus selfjudgment,
common humanity versus isolation, and mindfulness versus overidentification. Selfkindness
is an attitude of being warm and understanding toward ourselves when we suffer, fail,
or feel inadequate, rather than flagellating ourselves with self-criticism. Common humanity
represents the attitude to ourselves and the awareness that human destiny is often difficult, and
that we are not alone in our suffering. To be aware of and in contact with our whole experience
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(pleasant and unpleasant) without suppression or avoidance is necessary for self-compassion.
To be able to be self-kind we need to accept who we are. Being mindful of our suffering is the
way to self-compassion (Germer & Neff, 2013). Self-kindness and thus self-compassion is a
crucial attitude to oneself in mindfulness practice. Without it, mindfulness training would be
the training in frustration instead of a spiritual path to “enlightenment” or to acceptance of “full
catastrophe living” (Kabat-Zinn, 2013).
Self-compassion is associated with numerous psychological variables supporting mental health
such as optimism, happiness, curiosity, openness to new experience, and emotional intelligence
(e.g., Neff, Rude, & Kirkpatrick, 2007). In their meta-analysis, MacBeth and Gumley (2012)
documented a significant relationship with a large effect between compassion and
psychopathology. They support the concept that compassion is an important explanatory
variable in understanding mental health and resilience. Although many people fear that selfcompassion
will weaken their motivation and performance, research repeatedly shows that selfcompassion
actually enhances motivation (Gilbert et al., 2011) and has no negative impact on
performance; in fact, people with higher levels of self-compassion are less afraid of failure
(Neff, Hsieh, & Dejitterat, 2005) and more likely to try again when they do fail (Neely et al.,
2009). Moreover, self-compassion has been found to be negatively related to maladaptive
perfectionism (Neff, 2003). A mediation analysis by Keng et al. (2012) revealed that an increase
in self-compassion mediates the effects of MBSR on worry and fear of emotion.
Self-compassion is considered a key mechanism in the background of MBI effectivity (e.g.,
Neff, 2003; Kabat-Zinn, 2013; Segal et al., 2012). One study, for instance, showed an increase
in self-reported self-compassion in healthcare professionals who took an MBSR program
(Shapiro et al., 2005; 2007). Self-compassion has also been revealed as a mediator between
MBIs and treatment outcome measures (see Table 4). Similarly, Kuyken et al. (2010) found
that increases in mindfulness and self-compassion after MBCT participation mediated the link
between MBCT and depressive symptoms at the fifteen-month follow-up visit. Neff and
Germer (2013) developed a program to teach self-compassion skills called Mindful Self-
Compassion.
Compassion for others also represents a crucial foundation of Buddhist teaching. It is evident
that mindfulness practice also leads to the development of prosocial behavior, such as
mentalizing, empathy, and experience sharing. Meditators also show higher activation of the
prosociality neural circuitry than non-meditators (Vago & Silbersweig, 2012).
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Emotion regulation
A growing body of literature suggests that the psychological effects of mindfulness have been
mainly through its facilitation of adaptive emotion regulation (e.g., Tang et al., 2015; Hölzel et
al., 2011). The main question of this thesis is what concrete emotion regulation strategies are
developed, improved, and maintained under MBI. This theme will be addressed in the final
chapter of the thesis. Partial results from one study of our research group are also presented.
Mindfulness and its predicted components: the mental health
construction16
To address the question of what mindfulness relates to, we conducted a correlational study on
the healthy subject who participated in our on-line program. Only research sample
characteristic, methods, data analysis, and results are presented with the aim of contributing our
own results. Predicted mechanism of mindfulness is presented and discussed above.
Methods
Participants
The sample included 432 Czech undergraduate students of Masaryk University (332 were
women (77%), and 100 were men (23%); the average age of the respondents was 23.01±3.75;
the range was from 18 to 56). Students can be divided into three groups according to their study
subject (45.3% medical students, 38.1% students of humanities, and 22.6% natural sciences).
The samples were made up of students who completed a course at our department (Selfdevelopment
group for medical students or Mindfulness-based stress reduction on-line
program). The data were collected under the supervision of a research assistant; participants
completed a paper-and-pencil test battery comprising eight questionnaires presented in a fixed
16
Linhartova, P., Svetlak, M., Sirucek, J., Knejzlikova, T., Kosa, B., Sumec, R., Hornickova, V., Jarolinova, K.,
Lucanska, K., Slezackova, A., Kasparek, T. (prepared for submission to Mindfulness). Mindfulness and its
predicted components: the mental health construction
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order. The assessment took approximately 60 minutes. The university ethics committee
approved the study, and all participants gave their written informed consent.
Measures
The Five Facet Mindfulness Questionnaire (FFMQ; Baer et al., 2006, 2008) is a widely used
tool measuring dispositional mindfulness. The questionnaire has five subscales: Describe,
Observe, Act with Awareness, Nonjudging of Inner Experience, and Nonreactivity to Inner
Experience. The items are rated from 1 = “never or very rarely true” to 5 = “very often or always
true.” Higher scores indicate higher mindfulness. All items from the Act with Awareness and
Nonjudge subscales and half of the items in the Describe subscale are reverse-worded. The
internal consistency of the subscales ranges between Cα = 0.72 – 0.92.
The Subjective Emotional Balance Questionnaire (SEBQ; Kozeny, 1993) assesses prevailing
positive and negative emotional experiencing. The questionnaire has two subscales (Positive
Emotional Experiences and Negative Emotional Experiences), with eighteen items each. The
items are evaluated on a scale from 1 = “almost never” to 5 = “very often”. The internal
consistency was found to be Cα = 0.93 for both scales.
The Perceived Stress Reactivity Scale (PSRS; Schlotz et al., 2011) is a questionnaire assessing
typical individual reactivity to everyday life stressors. The scale has twenty-three items (with
twelve items reverse-worded) and five subscales: Prolonged Reactivity (four items), Reactivity
to Work Overload (five items), Reactivity to Social Conflict (five items), Reactivity to Failure
(four items), and Reactivity to Social Evaluation (five items). The items are rated from 0 (lowstress
reactivity) to 2 (high-stress reactivity). The internal consistency of the subscales ranges
between Cα = 0.71 – 0.91.
The Cognitive Emotion Regulation Questionnaire (CERQ; Garnefski & Kraaij, 2007) assesses
a set of cognitive emotion regulation strategies. It has thirty-six items and nine subscales with
four items in each subscale: Self-blame, Acceptance, Rumination, Positive Refocusing,
Refocus on Planning, Positive Reappraisal, Putting into Perspective, Catastrophizing, and
Others-blame. The subscale Rumination was excluded from this study due to its low internal
consistency. The items are rated from 1 = “almost never” to 5 = “almost always.” The internal
consistency of the subscales ranges between Cα = 0.68 – 0.83.
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The Satisfaction with Life Scale (SWLS; Diener et al., 1985) measures overall satisfaction with
life with five items rated from 1 = “strongly agree” to 7 “strongly disagree.” The internal
consistency ranges between Cα = 0.80 – 0.96.
The Brief Resilience Scale (BRS; Smith et al., 2008) measures the ability to recover from
stressful situations. The BRS has six items rated from 1 = “absolutely agree” to 5 = “absolutely
disagree”. The internal consistency was reported to be between Cα = 0.80 – 0.91.
The Self-Compassion Scale-Short Form (SCS-SF; (Raes et al. 2011) measures individual
compassion for oneself. The SCS-SF is a short form of the twenty-six item Self-Compassion
Scale (SCS; Neff 2003) and has a high correlation with the full SCS (r ≥ 0.97). The SCS-SF
has twelve items and six subscales with two items in each subscale: Self-Kindness, SelfJudgment,
Common Humanity, Isolation, Mindfulness, and Over-identified. The items are rated
from 1 = “never” to 5 = “always”. The internal consistency was found to be Cα = 0.86.
Data analysis
All CFA models were estimated using the lavaan package (Rosseel, 2012) in R (v. 3.4.0).
Robust maximum likelihood (RML) based on a full-information matrix (FIML) was used as the
estimation method. In the first step, a thorough factor structure analysis of the Mindfulness
scale was performed to determine the best model. In the second step, factor structure analysis
of the rest of the scales was performed17
. If possible, models using item parcels instead of
individual items as observed variables were preferred to reduce the total number of parameters
to estimate in the overall model. After applying the finding from the first two steps, an overall
CFA model including all investigated scales was performed and the relationships between the
concepts were examined. All figures were created using Lucidchart (Lucid software Inc., 2018).
Results
CFA model of mindfulness and related processes
Latent factor models verified separately for the individual scales entered the overall CFA model
of mindfulness and related processes as presented above. Thus, the model consisted of four
17
For clarity, factor structure analyses of mindfulness and related measures are not presented
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lower-order and one higher-order mindfulness factors, two factors of the Emotional
Experiencing scale, five lower-order and one higher-order factor of the Perceived Stress
Reactivity scale, two factors of the Emotion Regulation questionnaire, eight factors of the
Cognitive Emotion Regulation questionnaire, one Resilience factor, one Satisfaction factor, and
six Self-compassion factors. The proposed model reached a good fit (X2
= 2788.51, df = 1719,
X2
/2 = 1.62, CFI = 0.92, TLI = 0.91, RMSEA = 0.04, SRMR = 0.05). Figure 17 displays
associations between the mindfulness higher-order latent factor and all other latent factors in
the model. Moderate-to-high positive correlations were found between mindfulness and the
Positive experiencing subscale from EEQ, the Reappraisal subscale from ERQ, the Positive
Refocusing, Refocus on Planning, Positive Reappraisal, and Putting into Perspective subscales
from CERQ, the Resilience scale, Satisfaction scale, and the Self-kindness, Common
Humanity, and Mindfulness subscales from SC. Moderate-to-high negative correlations were
found between mindfulness and the Negative Experiencing subscale from EEQ, the Stress scale
and the Self-blame and Catastrophizing subscales from CERQ, and the Self-judgement,
Isolation and Over-identified subscales from SC. No significant association was found between
mindfulness and the Suppression subscale from ERQ, or the Acceptance and Other-blame
subscales from CERQ.
Figure 17 Graphical representation of associations between mindfulness higher-order latent
factor and other latent factors included in the model of mindfulness related processes
Note. All coefficients are presented standardized. * p < 0.05, ** p < 0.01, *** p < 0.001
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Discussion
The results are in line with the expected mechanisms and mediators of the mindfulness effect
proposed and cited above. This supports the close positive associations between mindfulness
and self-compassion, resilience, and positive emotivity and the close negative associations with
stress reactivity and negative emotivity. Our results also confirm the general assumption that
mindfulness is related to adaptive emotion regulation strategies such as Positive Refocusing,
Refocus on Planning, Positive Reappraisal, Reappraisal, and Putting into Perspective. On the
other hand, as was expected, our analysis revealed a negative association between mindfulness
and non-adaptive emotion regulation strategies such as Self-blame and Catastrophizing. No
expected association between mindfulness and Acceptance and Suppression was found. We are
not able to explain this result. Maybe the selected subscales are not sensitive to concrete
emotion regulation strategies.
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Mindfulness and emotion regulation
The answer the question one
Enhanced emotion regulation has been suggested to underlie many of the beneficial effects of
mindfulness meditation (e.g., Tang et al., 2015). For example, just as we found in our study,
Feldman et al. (2007) found a significant correlation between self-reported mindfulness and
self-reported use of adaptive emotion regulation strategies. However, it is not clear through
which emotion regulation strategies mindfulness practice leads to positive outcomes. There is
also currently no consensus on how mindfulness could be classified on the continuum between
top-down vs. bottom-up and explicit vs. implicit emotion regulation strategies (Chambers et al.,
2009; Chiesa et al., 2013). Further, there is not consensus among clinicians and researchers of
whether the mindfulness is a unique emotion regulation strategy that could be called “mindful
emotion regulation.” It is unclear how much MBI differs in its psychological and
neurobiological mechanisms from common Western psychological approaches such as
psychotherapy (Chiesa et al., 2010). To clarify this ambiguity, at least in the field of emotional
regulation, mindfulness practice will be compared with emotion regulation concepts. It will be
put into the context of:
1) emotion regulation time dynamic
2) the direction of emotion regulation (top-down vs. bottom-up)
3) classification of emotion regulation (type of strategy, coping)
4) neurophysiological correlates of emotion regulation
Emotions from the Buddhist perspective
In general, the main function of survival circuits is to maintain homeostasis. On the most
general level, the activation of these circuits is manifested as approach or avoidance behavior.
Activation of these neural circuits leads to triggering “action programs.” Damasio and Carvalho
(2013) define these programs as a set of natural physiological actions triggered by changes in
the internal or external environments and aimed at maintaining or restoring homeostatic
balance. Emotions are action programs largely triggered by external stimuli (perceived or
recalled). Damasio writes that “feelings provide a subjective experiential window into the
processes of life regulation. Feelings allow a glimpse into ongoing homeostatic regulation,
ranging from basic processes such as metabolism to complex social emotions”. This theory
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explains how emotion originates at the physiological level with the aim of preserving life and
providing the organism/ human a basic compass in reality. Although emotions can occur
without self-awareness (action programs, implicit reactions), the capacity for self-awareness
and self-relevant thought predisposes people to have many emotions that are not associated
with the process of life regulation (discussed in chapter “The nature of emotions: from survival
circuits to emotions”) but are instead the result of the ability to think consciously. Leary and
Gohar (2014, p. 377) describe how people’s emotions are affected when they 1) compare
themselves to their personal standards, 2) think about themselves in the past and future, 3)
evaluate their personal characteristics, and 4) think about how they are perceived by other
people.
Mindfulness involves classifying any emotion that results from the basic misinterpretation of
reality outlined above as “disturbing.” Through the increasing performance of meta-awareness,
it is possible to become the witnesses and the observers of the appraisal process, and to be able
to reflect what has been previously reflexively adopted or conditioned. Through mindfulness
practice, it becomes possible to differentiate between the adaptive appraisal of reality (feelings)
and habitual and automatic appraisals that are the results of misinterpretations of reality. For
instance, we can feel frustration and aggression in a traffic jam because of the idea that we are
extraordinary and important. The aggression is thus the result of a misinterpretation of reality18
.
The emotion regulation could be activated as a cognitive reappraisal (“I have time to listen to
my favorite song on the radio”) or emotional suppression (“I will stop the expression of
aggression in order to look like a positive person, which matches my self-concept”). In
mindfulness training, we observe our aggression with acceptance, in a non-judgmental manner,
and with the trust that just as it appeared, it also disappears. Through the process of observation,
practitioners usually find that aggression and frustration are the result of misinterpretation (“I
am too entitled to be stuck in a traffic jam”). The regulation of disruptive emotions takes place
through inside and understanding to the disruptive emotion development process. The
fundamental point is that emotion regulation cannot be understood conceptually; it must be
instead experienced directly (Chambers et al., 2009). The embodiment of mindfulness is one of
the most important competencies of mindfulness teachers/trainers in MBI training (Williams,
Crane & Soulsby, 2007). However, this should also apply to psychotherapists.
18
Of course, in the case of defending the family from a poisonous snake, aggression is completely appropriate.
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The Buddhist psychological model
Mindfulness practice transforms the very foundations of how we perceive our experience. Even
though regulation of suffering (negative feelings) was the primary goal of the Buddha’s spiritual
search and spiritual path, and it is the primary motive of most people at the start of the practice,
emotion regulation is not the primary goal of mindfulness training. The path to enhanced
emotion regulation affects deeper levels of self-regulation.
The Buddhist psychological model (BPM) designed by Grabovac et al. (2011) and based on the
original Buddhist texts called the Abhidhamma Pitaka (Mendis, 2006) explains the mentioned
change very clearly.
According to the BPM, attentional resources are limited: an individual can only be aware of
one object at a time. From this point of view, experience is a continual stream of consciousness
composed of a series of sense impressions and mental events arising and passing away. The
film movement, frame by frame, is a useful metaphor for the moment by moment awareness
process.
In agreement with the core evaluation process described in the chapter “The core valuation of
the world: ‘good for me’ versus ‘bad for me’ state,” any object in awareness has some feeling
tone, which falls into one of three categories: pleasant, unpleasant, or neutral. The integration19
successively includes homeostatic, environmental, hedonic, motivational, social, and cognitive
activity to produce a “global emotional moment” that represents the sentient self at one moment
of time (Craig, 2009). The authors’ term “feeling tone,” as used in their BPM, does not refer to
complex emotions, such as fear, joy, or anger. It is rather the immediate and spontaneous
affective experience of this awareness of a physical sensation or mental event (Mendis, 2006).
Each object has its valence. This value sign often goes unnoticed and can serve as the key
trigger to a chain reaction of thoughts (including emotions) and actions that can lead to
suffering. The habitual response to the feelings associated with objects is to approach the
pleasant ones and avoid the unpleasant ones, and usually to ignore the neutral ones. The
Buddhist terms for these reactions are attachment and aversion, respectively (Grabovac et al.,
19
The posterior-anterior functional gradient in the insula with posterior regions associated with primary
representations of sensations from the body and anterior regions associated with interoceptive awareness of the
body and in motivational and affective states is described (Critchley et al., 2004).
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2011). These habitual reactions rapidly following the initial sense impression are manifested as
mental events (thought, memory, emotion) and subsequent behavior. The integral premise of
the BPM is that attachment and aversion arise in reaction to the feeling state itself rather than
to the object. This premise is in line with the everyday experience that everything is judged, no
matter what is real. The actual feeling tone determining whether the feeling will be pleasant,
unpleasant, or neutral depends more on past individual experiences, culture, and other
influences. For example, we may see a slice of cheese, and that may be associated with some
feeling tone. The tone of experience determines how we habitually react with thoughts,
emotions, and actions. Our reaction does not, in fact, say anything about the cheese. This
process is called “mental proliferation” in BPM. It is described in Figure 18. It originates as a
series of mental events that have been triggered by an initial mental event or sense impression.
The mental event that follows the initial feeling is also associated with another feeling. In this
context, many subsequent mental events (emotions, feelings) have little to do with the sense
impression that started the process and thus with the “real” world. It is possible to realize that
through the process of mental proliferation it is possible to lose contact with the present moment
and the real world even while having the notion of living in it. Mindfulness training is the
approach for returning to the “here and now.” According to the BPM, “not being aware of how
this pattern of attachment and aversion can lead to mental proliferation helps to keep the entire
process habitual.”
According to the BPM, there are three main mindfulness practice goals: 1) perceive impressions
and mental events as transient (arising and passing away), 2) realize that suffering is the result
of habitual reactions (i.e., attachment and aversion) to the feelings of a sense impression or
mental event, and a lack of awareness of this process, and 3) perceive impressions and mental
events as not containing or constituting any lasting, separate entity that could be called a self.
It could be concluded that all sensory and mental events share the three universal characteristics
of impermanence, suffering, and not-self. Suffering, including clinical symptoms, is a result of
the habitual attachment/aversion reaction to transient feelings and mental proliferation in their
background. Symptom reduction (in the clinical sense) is not the explicit aim of Buddhist
practices; symptom reduction or disappearance through the mindfulness practice can be
explained as a result of the disruption of habitual reactions and mental proliferation. Vago and
Silbersweig (2012) call this “biased self-processing.” The authors of the BPM explain that
“improvement in wellbeing occurs when sensory and mental events are allowed to naturally
arise and fall away, without subsequent cognitive processing arising from either attachment or
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aversion. Sense impressions and mental events are still experienced as pleasant, unpleasant, or
neutral; however, if there is no attachment, aversion, and thus no mental proliferation,
adventitious suffering is not experienced.” Within this framework, Vago and Silbersweig
(2012) say that “mindfulness is described to reduce such biases through specific forms of mental
training that develop meta-awareness of self (self-awareness), an ability to effectively manage
or alter one’s responses and impulses (self-regulation), and the development of a positive
relationship between self and other that transcends self-focused needs and increases prosocial
characteristics (self-transcendence).”
Insight plays the central role in the model. It refers to a direct, non-conceptual understanding
(Dorjee, 2010) reached through the repeated awareness and experience of the three
characteristics (impermanence, suffering, and not-self) in the process of meditation. During
mindfulness practice, we begin to understand these characteristics on a nonverbal, experiential
level. More than understanding, it is living in the present moment. Poetically, it can be
compared to taking off dark glasses. More scientifically, it is a real change of paradigm through
which the world is perceived and interpreted.
Mindfulness practice leads to processing experiences through plain exploration regardless of
the valence of the stimuli/events. This kind of exploration creates an opportunity for insight
into mental habits. It reduces automatic efforts to control feelings and experiences. It is more
than an education in how the minds work: the knowledge is obtained through direct observation.
The knowledge is experienced; it is not just information that is provided.
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Figure 18 The mental proliferation process in time (redesigned by Grabovac et al., 2011)
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The BPM shows that enhanced emotion regulation, one of the beneficial effects of mindfulness
meditation, is a result of a deep change of the world view. It is a change of the paradigm through
which the world is perceived and interpreted. Suffering, experiencing through negative
emotions (e.g., fear, anxiety, sadness), is reduced through the insight into the very essence of
living. Even though mindfulness cannot be described as a whole as an emotion regulation and
coping strategy, this description serves to clarify the mindfulness concept.
Mindfulness and its time dynamics in emotion regulation: Gross’s processual
model
In the process model of emotion regulation designed by Gross (2002), mindfulness could be
situated at the stage of attention deployment (Farb et al., 2014, p. 550). Attentional deployment
represents the process of directing attention within a given situation to influence emotions
(Gross, 2014). One of the most common representatives of this emotion regulation strategy
family is distraction. Distraction is when attention is focused on a concrete object (usually the
breath or another body sensation) in the FA mode of mindfulness regulation.
In one of our studies (Svetlak, Theiner, & Kubicova, 2018) we tested the hypothesis that a
simple mindfulness exercise leads to a change of actual emotional state and a greater sense of
control over thoughts. Our study was performed on hospitalized children (N = 20; mean age
14.2 ± 1.3; the total amount of all mindfulness exercises was 119). A self-reported scale was
used for measuring the emotional state. Two standardized exercises from Eline Snel’s book
Sitting Still Like a Frog were used. Results indicate that mindfulness meditation leads to
decreased negative affect in adolescents (actual feeling, bad vs good, before 4.9±2.68, after
5.2±2.53, p<0.02; negative emotions, before 6.8±2.0, after 6.2±2.46, p<0.001; negative somatic
sensations, before 6.6±2.1, after 6.1±2.2 p<0.02). No effect of meditation on control over
thoughts and self-esteem was found. Significant correlation was found between subjective
success and change of actual feeling (R=0.27, p<0.01), self-esteem (R=0.26, p<0.01) and
control over thoughts (R=0.49, p<0.01). Our results indicate that simple mindfulness practices
can help children deal with negative emotions and that the mediator of this effect is probably
distraction (attention focused on breath and body sensations).
Unlike distraction, mindfulness is performed with acceptance rather than withdrawal from any
emotional experience (Kabat-Zinn, 2014). The open monitoring mode of mindfulness practice
does not involve choosing any aspect of the continuously changing experience with the aim of
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influencing emotions, as in attentional deployment20
. Instead of it, attention is paid to
everything in a non-judgmental and accepting manner. Immediate emotional responses are not
regulated, but accepted as they are. They are observed with interest and curiosity; as they
appear, the emotional responses themselves become objects of observation. In this context,
mindfulness is opposed to expressive suppression (Chambers et al., 2009).
Through raising awareness, mindfulness makes it possible to better understand how and by
what situations are selected and modulated. For instance, we can realize how we organize our
world according to our need to be honored. This awareness can change our habitual
organization of experience, opening us to new situations and then changing the experience
itself. This notion is supported with findings that the better detection of one’s bodily signals
facilitates the selection and implementation of antecedent-focused as well as response-focused
emotion regulation strategies (Kever et al., 2015). For instance, experiential avoidance of
unpleasant emotions has been demonstrated to cause psychological harm (Hayes, 2003). The
mindfulness process makes it possible to observe habitual and novel appraisals and responses.
This altered perception of the situation permits the generation of new responses rather than
mapping experience into a preexisting conceptual field (Farb et al., 2014, p. 551). Mindfulness
is able to change conditions (rigid views and assumptions) of suffering (Teasdale & Chaskalson,
2011). The final goal of Buddhism that is fulfilled through mindfulness practice is to achieve
enlightenment. This could be described as a permanent, radical change in perception that stops
the automatic process of identification that turns certain aspects of sensate and mental
experience into a separate self (Grabovac et al., 2011).
Figure 19 Process model of emotion regulation: mindfulness practice targets
20
It is close to the phenomenological reduction process of the incoming data called horizontalization in the
phenomenology of Edmund Husserl.
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In growing and deepening mindfulness practice, the effect gradually expands to other stages of
the emotion regulation process. Mindfulness is thus antecedent-focused emotion regulation and
response-focused emotion regulation as well. However, it directly excludes response
modulation in the sense of suppression.
While the majority of emotion regulation strategies target emotions that are being experienced
with the aim of regulating them towards a “good for me” state, mindfulness changes the
perception and valuation of the world. The habitual core valuations are changed, and the
subsequent emotions are changed due to this process.
Mindfulness is paradoxical and the instruction to focus directly on negative emotions goes
against the inherent tendency to avoid unpleasant stimuli. This process is close to exposure
therapy. The non-judgmental, accepting, curious, and open attitude to experience facilitate the
process of extinction: original emotions are diminished or they lose original arousal and valence
through repeated exposure. Through this process, we regulate emotions at the situation selection
and situation modification stage. The non-judgmental attention practice can be internalized as
a default baseline of perception. This basic setting can be achieved only through the regular
formal practice of mindfulness meditation.
Is mindfulness a top-down or bottom-up regulation?
Chiesa et al. (2013) suggested that a better understanding of whether mindfulness involves a
top-down or bottom-up emotion regulation strategy could have important clinical implications.
Psychotherapy frequently relies upon top-down regulation, such as cognitive reappraisal, to
regulate unpleasant emotions (e.g., Roffman et al., 2005). Many bottom-up strategies are
involved in the psychotherapy process, but they are implicit and beyond the control of study
designs (for example, the calm voice of the therapist, safe room, time limits, grading, pacing,
etc.). If mindfulness training is primarily a bottom-up process, MBI represents an explicit form
of implicit therapeutic processes. The integration of classical psychotherapy and MBI is
Buddhist psychotherapy (DeSilva, 2014).
Mindfulness could be described as a top-down emotion regulation strategy because it uses
positive cognitive reappraisal and thus involves regulation of prefrontal cortex areas on
emotion-generative brain regions (e.g., Garland et al., 2010; Quirk & Beer, 2006). Top-down
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mindfulness-based emotion regulation strategies correspond to affect labeling, mindful
detachment, meta-awareness, and cognitive reappraisal, among others, for which cognition and
thought processes are the primary targets of the strategy.
Other authors suggest that mindfulness is a bottom-up strategy because of findings that the
modulation of emotion-generative brain regions is possible without cognitively reappraising
emotionally salient stimuli (e.g., Chambers et al., 2009). This kind of emotion regulation
strategy has been termed bottom-up because it is characterized by a directly reduced reactivity
of “lower” emotion-generative brain regions without the active recruitment of “higher” brain
regions, such as the prefrontal cortex (Chiesa et al., 2013). Mindfulness has been described as
“the awareness that arises from paying attention on purpose, in the present moment and nonjudgmentally
to things as they are” (Williams, 2007, p. 47). It is immediately clear that this
conception distinguishes mindfulness from regulatory efforts to improve the hedonic tone of
experience, such as using cognitive reappraisal to make stimuli less aversive (Farb et al., 2014,
p. 549).
For example, Westbrook et al. (2013) asked smokers to watch specific craving-inducing images
during fMRI, using “mindful attention” vs. “passive viewing” as craving regulation strategies.
The mindful attention was found to be associated with subjectively reported craving and also
with decreased activation in the subgenual ACC (sg-ACC), and reduced functional connectivity
between this same region and bilateral anterior insula (AI) and ventral striatum (VS).
Interestingly, at the same time, no activation of the PFC as the main structure for top-down
emotion regulation was detected. This is surprising because we would expect that following the
instructions to use mindful attention would require the working memory capacity associated
with dlPFC activity, at least for the inexperienced subject. The authors consider these findings
to support the notion that mindfulness emotion regulation is more bottom-up than top-down
regulation.
In their review, Chiesa et al. (2013) report various studies supporting both top-down and
bottom-up modes of mindfulness regulation. They suggest that different neural correlates of
mindfulness practice, corresponding to different emotion regulation strategies, could vary as a
function of 1) of the amount of meditation practice (e.g., long-term vs. short-term mindfulness
experience), 2) study design (investigation of mindfulness vs. rest), 3) type of experimental task
(e.g., the use of emotional, verbal stimuli vs. the use of painful stimuli), and 4) specific
definition on mindfulness (OM vs. FA).
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It seems that results could be interpreted that bottom-up emotion regulation strategy is observed
in long-term meditators and top-down emotion regulation strategy in novice practitioners (Tang
et al., 2015). This is in accordance with the results of Brefczynski-Lewis et al. (2007), who
reported an inverted U-shape relation between frontal activity and meditator expertise. These
results show that more trained subjects showed less frontal activity. This suggests the
disengagement of attentional control within meditation training. This neural process pattern
(less activity of frontal cortex lateral areas within meditation practice) may also show a
meditation session dynamic in which frontal regions are activated at the beginning of a
meditation to allow the other structures to maintain the meditative state, as was suggested by
Travis and Wallace (1999) and Newberg and Iverson (2003).
In this context, mindfulness practice at the start can be understood as model-based emotion
regulation (Figure 7; Etkin et al., 2015). The first stages of mindfulness practice are associated
with an internal model with the aim of guiding experience and behavior. It can actually be an
explicit emotion regulation. For example, we may reappraise a present experience to neutralize
negative emotion by understanding emotions and thoughts as mental events without significant
meanings. It is necessary to have continual reminders in the first months of practice. Unlike the
model-free regulation, frontoparietal regions such as the vlPFC, dlPFC, PC, pre-SMA, and
SMA are recruited (Buhle et al., 2013). It requires an intact working memory capacity to
construct and make use of internal models and intact attention. For instance, Allen et al. (2012)
reported that after six-week mindfulness training participants displayed greater dorsolateral
prefrontal cortex responses during executive processing (an affective Stroop task), consistent
with increased recruitment of top-down mechanisms to resolve the conflict.
However, with increasing practice, the model-based regulation (mindfulness) becomes more
automatic with fewer demands on will and effort. It could be imagined that advanced
mindfulness practice is also based on model-free emotion regulation, without involving dPFC
areas activity (Figure 7). The best example of this model is fear conditioning and fear extinction.
Through learning (classical and operational conditioning), an implicit emotion regulation model
is reached which helps move from a “bad for me” state to a “good for me” state. Many studies
have repeatedly documented that vACC–vmPFC activation is a general neural correlate of fear
extinction when fear is inhibited (Lissek et al., 2014). In the context of bottom-up regulation,
mindfulness could be seen as exposure therapy. Mindfulness practice supports being in full
contact with experience with openness, acceptance, and non-judgment. This means exposure to
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everything that appears in the present moment. The progressive and repeated exposure to
experience without avoidance represents the basis of extinction and thus to bottom-up emotion
regulation. From a neurobiological perspective, mindfulness practice leads to the development
of implicit emotion regulation. Repeated effortful (“top-down”) mindfulness practice can then
be transformed by the creation of new patterns of implicit meaning.
Mindfulness emotion regulation is gradually integrated into the automatic mode of emotion
regulation. Access to the conscious and willful base mindfulness regulation continues with
some additional automation in regulation. For this reason, it can be difficult to find the rest state
in studies of experienced meditators. The rest state is actually habitual mindful emotion
regulation (Tang et al., 2015). These changes in fundamental reactivity to experience are
probably mediated through the process of neuroplasticity. This means that experiential factors
(mindfulness practice) shape the neural circuits underlying emotion generation and regulation
(Davidson & Mcewen, 2012). A number of studies seem to suggest that mindfulness meditation
induces changes in brain structures and functions. It is possible that mindfulness affects the
brain structure by inducing dendritic branching, synaptogenesis, myelinogenesis, or even adult
neurogenesis. It is also likely that mindfulness training positively affects autonomic regulation
and immune activity, which may lead to neuronal preservation, restoration, and inhibition of
apoptosis (Tang et al., 2015). The influence of mindfulness practice on the enzyme telomerase
activity in immune cells has been repeatedly described (e.g., Daubenmier et al., 2012;
Lengacher et al., 2014; Schutte & Malouff, 2014).
While regulation is an explicit aim of emotion regulation, mindfulness practice does not actually
focus on emotion regulation. Paradoxically, the opened, non-judgmental acceptance and
curious attitude to experience is in direct contradiction to regulation. From this point of view,
the “regulation” (implicit) is rather a by-product of mindfulness practice than its explicit goal.
Chambers et al. (2009, p. 569) describe mindfulness as “systematic retraining of awareness and
nonreactivity, leading to defusion from whatever is experienced, and allowing the individual to
more consciously choose those thoughts, emotions, and sensations they will identify with rather
than habitually reacting to them.” It seems that mindfulness is a bottom-up regulation in its
conceptual origins.
This paradox also shows the importance of motivation to train in mindfulness. The desire to
reduce stress creates a predisposition to be constantly in control, a top-down mode of regulation.
In contrast, the desire to live mindfully as a valuable attitude to life and world creates openness
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to whatever comes, and changes in emotional reactivity are simply incidental. Shapiro and
Schwartz (2000) point out that “when Western psychology attempted to extract the essence of
mindfulness practice from its original religious/cultural roots, we lost, to some extent, the aspect
of intention, which for Buddhism was enlightenment and compassion for all beings. It seems
valuable to explicitly bring this aspect back into our model mindfulness.” The differences in
meditation instructions and individual attitudes employed by different teachers and traditions
could be related to significantly different neurobiological findings.
Figure 20 Polarities of mindfulness concept and their relationship to the length of the practice
(derived from Etkin et al., 2015; Tang et al., 2015)
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How does mindfulness practice regulate emotions: could be
mindfulness practice classified as an emotion regulation or coping
strategy?
The answer the question two
This chapter aims to classify mindfulness as concrete emotion regulation and coping strategy.
The total comparison of concrete emotion regulation and coping strategies (Classification of
emotion regulation) and mindfulness practice is given in Table 7. As in the previous chapter, a
simple comparison shows that mindfulness can be described through many emotion regulation
and coping strategies.
According to the classification of affect regulation strategies bu Parkinson and Totterdell (1999)
mindfulness is in direct contradiction to cognitive and behavioral disengagement in the higher
group diversion (“avoid thinking about the problem” and “avoid problematic situations”).
Mindfulness, as it is developed in MBI, instead uses distraction on the cognitive and behavioral
level. On the cognitive level, it relocates resources through the occupation of attention. At the
basic level of MBI programs, people learn to focus their attention on objects such the breath or
the body. Under stress or aversive affects, people usually find that this kind of distraction can
lead to relief. People can be aware of only one object at a time. On the behavioral level,
practitioners sit in a meditation position or practice mindful yoga, thereby doing something
relaxing or performing demanding activity. In this context, Grabovac et al. (2011) speak of a
certain risk in relation to attention regulation strategies such as using distraction. Attention
regulation strategies are effective, useful, and popular with patients (e.g., three-minute
breathing space in MBCT). A potential risk is that people may unintentionally strengthen their
aversive reactions to unpleasant feelings; for example, during an aversive reaction, patients may
preferentially redirect their attention to the breath to achieve immediate symptom reduction via
attention regulation rather than deepening fundamental mindfulness principles such as
examining the transience, suffering, and not-self characteristics of the feelings.
Mindfulness can be classified in the higher-order group “Engagement” at the cognitive and
behavioral level. On the cognitive level, the initial attitude that emotion is the only mental event
is actually cognitive reframing or a change of meaning. Mindfulness can be understood as
cognitive reappraisal at a process level rather than a content level (Chambers et al., 2009). In
this context, the meaning of all experience (thoughts, emotions, sensations) is cognitively
reappraised at the start of mindfulness practice. Behavioral engagement is the result of the
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cognitive change in experience processing: the acceptance and insight into the origins of human
suffering support adaptive behavior. However, behavioral paradigms with high ecological
validity that would verify this are still missing. Even though the first objective methods of
dispositional mindfulness evaluation are beginning to emerge (e.g. breath-counting test;
Levinson et al., 2014), with the promised results (Wong et al., 2018), the subjective selfreported
scales are currently the most widely used method of evaluating mindfulness.
Coping is closely related to emotion regulation; in fact, they overlap. In the context of survival
circuits and the process of core evaluation, the experience of stress is mediated through the
experience of aversive affect triggered and perpetuated with the event (any perceived object).
The critical antecedent of the psychobiological stress response is the appraisal of what the
stressful event is and what it is not. Consciously experienced feelings are actually setup points
in the process of maintaining bio-psycho-spiritual homeostasis. On the basis of these feelings,
the outer source of aversive stimuli/stressors may be changed (the behavioral component of
coping), or the experience may be changed through coping strategies and emotion regulation.
The general aim is to reach a “good for me” state. It is supposed that coping can regulate
behavior, emotion, or attention (Skinner & Edge, 1998).
According to the classification of coping categories suggested by Skinner et al. (2003) as
described in Table 4, mindfulness could be described as a coping strategy in many aspects (see
Table …..).
Is mindfulness approach or avoidance coping?
Mindfulness is unambiguously approach coping. To accept reality, whatever it is, represents
the essence of mindfulness approach. Mindfulness practice supports being in contact with
whatever appears in an open, accepting, curious, and non-judgmental manner. Avoidance is in
direct contradiction to mindfulness practice.
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Is mindfulness emotion-focused coping or problem-focused coping?
In the context of the second Noble Truth, mindfulness practice targets both sides of the coping
category “emotion-focused coping versus problem-focused coping.” While problem-focused
coping is aimed at managing or altering the problem causing the distress (stressful job or
relationship, diagnosis, place) in the original Western conception, the cause of the distress in
the Eastern conception or in mindfulness practice is ignorance and attachment to things and
experience. The key message of the second Noble Truth is that experience itself is not the
problem—the problem is our relationship to the experience—our need to have it be a particular
way (Teasdale & Chaskalson, 2011).
Is mindfulness a cognitive reappraisal?
Cognitive reappraisal differs fundamentally from mindfulness in that thoughts and emotions
are just mental events that do not require a response or even cognitive reappraisal. CognitiveBehavioral
Therapy (CBT) works with emotion and thoughts as merely appraisals rather than
facts, but ultimately the notion remains that appraisals can be changed to be more acceptable
and less distressing (Chambers et al., 2009). In contrast to this, mindfulness does not change
the value of mental events in any aspect. MBIs develop a capacity to simply allow these mental
events to come and go.
In fact, mindfulness is a sort of cognitive reappraisal. The initial attitude that emotion is only
mental events is cognitive reframing or change of meaning. Mindfulness can be understood as
cognitive reappraisal at a process level rather than a content level (Chambers et al., 2009). In
this context, the meaning of all experience (thoughts, emotions, sensations) is cognitively
reappraised at the start of mindfulness practice. In initial training, it is necessary to be reminded
of this repeatedly. Therefore, the dlPFC is more activated in the early stage of mindfulness
training associated with effortful doing (Tang et al., 2015). This new cognitive reappraisal in
working memory is necessary in every moment at the start of mindfulness practice. Early
Buddhist teachings define mindfulness as a mental faculty (Pāli indriya, Sanskrit indriya,
Chinese 根, Tibetan dbang po). In this context, mindfulness is “remembering” in one of its
aspects (Anālayo, 2019). It consists of remembering to be aware and pay attention to the present
moment. In this process or practice, the practitioner is reminded: “Remember: be aware!”
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(Siegel et al., 2009). This shows a close, constant connection between the function of memory
and attention (Vago & Silbersweig, 2012).
Is mindfulness alloplastic vs. autoplastic coping
Alloplastic coping is directed toward changing the environment and autoplastic coping is
directed toward changing the self (Perrez & Reicherts, 1992). Mindfulness practice primarily
changes the approach to reality itself. Practitioners start to realize how experience is formed,
gradually recognizing habitual patterns in the continuous judgment of everything as
pleasurable, unpleasurable, and neutral, and gradually finding that all sensory and mental events
are seen to share the three characteristics of impermanence, suffering, and notself (Grabovac et
al., 2011). Through the insight that there is no such thing as a permanent, unchanging self, the
observer and thus the perceived world are changed. Mindfulness is thus autoplastic coping.
From the field and system theory, the change of the perceiver changes the other parts of the
environmental field. Mindfulness practice gradually leads to the change of the environment
(including relationships) and thus it is also a kind of alloplastic coping strategy.
Is mindfulness behavioral or cognitive coping?
In their review, Thayer, Newman, and McClain (1994) concluded that one of the best general
strategies to change a bad mood is a combination of relaxation, stress management, cognitive
activity, and exercise techniques. Mindfulness practice, as described in the context of MBSR
and MBCT, could be seen as combination of behavioral and cognitive coping. On the behavioral
level (exercise), practitioners sit in a meditation position or practice mindful yoga. Group
members of MBSR and MBCT are asked to practice yoga and meditation for approximately
forty-five minutes a day as homework (45min/day; averages reported of 246 min/week).
Participants are encouraged to keep a diary to describe their practice and reflections and
insights. Formal meditation practices include focused attention on breathing, body scans, and
open monitoring of sounds, thoughts, feelings, and bodily sensations. Participants are also
introduced to psychosocial education. Mindfulness practice involves some aspect of relaxation
(Hölzel et al., 2011).
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Is mindfulness proactive coping?
Mindfulness could be categorized as proactive coping. It is defined as efforts “undertaken in
advance of a potentially stressful event to prevent it or modify its form before it occurs”
(Aspinwall & Taylor, 1997, p. 417). Mindfulness is an everyday practice regardless of whether
the practitioner is suffering; it is practiced every day because of commitment and trust. The
higher stress reactivity and shorter stress recovery time are just by-products of day-to-day
practice. That is why many mindfulness teachers emphasize the importance of commitment,
personal vision, attitude, and intention for the mindfulness practice (Kabat-Zinn, 2013; Shapiro,
2006).
Is mindfulness exposure therapy?
The similarity between exposure therapy and mindfulness is noticeable. Mindfulness practice
supports being in full contact with experience with openness, acceptance, and non-judgment.
This means exposure to everything that appears in the present moment. In principle, it is the
same strategy as in exposure therapy.
Exposure therapy is a primary method of behavioral therapy for reducing fear and anxiety.
Patients are exposed to fear-provoking stimuli and prevent their usual response with the aim of
helping them experience their fear without the avoidance response that fears usually reinforce.
This new experience supports the process of extinction. Instead of the fear response, patients
acquire a sense of safety in the presence of the formerly feared stimuli. In general, extinction
cannot be reached because of the behavioral and cognitive avoidance of fear- and anxietyinducing
situations (Borkovec & Costello, 1993). The essential extinction mechanisms are the
experience of relaxation during exposure to fear-inducing stimuli (Wolpe, 1958). Mindfulness
is similar to exposure therapy and supports extinction in two ways:
1. It changes the attitude to experience. Everything is just a transitory event in the stream
of experience. It is possible to observe it without having to respond. Original avoidance
is transformed to approach through attitudes such as acceptance, openness, nonjudgment,
trust, patience, curiosity (Kabat-Zinn, 2013).
2. Mindfulness practice also involves some aspect of relaxation (Hölzel et al., 2011). For
example, experienced mindfulness meditators have shown a faster decrease in skin
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conductance in response to aversive stimuli (Goleman & Schwartz, 1976). Zeidan et al.
(2010) showed that even brief meditation training has beneficial effects on
cardiovascular variables such as heart rate (its decrease). The influence of mindfulness
on decreased blood pressure (de la Fuente, Franco, & Salvator, 2010), decreased cortisol
levels (Carlson et al., 2007), decreased breathing rate (Lazar et al., 2005) and decreased
skin conductance response (Austin, 2006) were also described. In their systematic
review, Kaur and Singh (2018) documented that meditation is closely related to
psychophysiological parameters associated with relaxation.
Taken together, mindfulness practice helps stay exposed to experience, whatever it is, in the
kind of processing which supports the relaxation state. This is also true for psychotherapy. As
Hunt (1998) concludes in his article: “The only way out is through.” Practitioners repeatedly
and progressively expose themselves to emotions without avoiding them. It is a necessary
experience to know that nothing will happen and it is also necessary for the exploration of the
fundamental patterns of the functioning of the mind. Interestingly, in our research,21
we found
a significant increase with a large effect in the Non-reactivity subscale of FFMQ.
A network of brain regions that are crucial for the extinction of conditioned fear responses and
the retention of extinction are discussed in detail in the chapter “Habituation and extinction.”
The key structure of this network is the ventromedial prefrontal cortex (vmPFC) because it is
necessary for a successful recall of the extinction. The other structures associated with
extinction are the hippocampus (Milad et al., 2007), which is essential for context safety
signaling, and the amygdalae, which has a crucial role during the acquisition and expression of
conditioned fear (LeDoux, 2000). The structure of this network is down-regulated by the
vmPFC and the hippocampus (Ochsner, 2012).
Interestingly, there is increasing evidence that the effect of mindfulness training has a similar
neuronal background as exposure therapy. The overlap of brain regions involved and the
processual similarity between both methods suggest that mindfulness training might enhance
the ability to extinguish conditioned fear by affecting the brain network associated with safety
21
Svetlak, M., Linhartova, P., Knejzlikova, T., Kosa, B., Sumec, R., Hornickova, V., Jarolinova, K., Lucanska,
K., Slezackova, A., Kasparek, T. (submited to Applied Psychology: Health and Well-Being). Mindful in Medical
School, Thanks to Facebook: Online Mindfulness-Based Mental Health Support Program with Intensive Reminder
System
150
signaling (Tang et al., 2015). For example, Hölzel et al. (2008) found that cumulative hours of
meditation training were positively correlated with gray matter concentration in the vmPFC in
experienced meditators. Goldin and Gross (2010) also described that people with social anxiety
disorders had reduced amygdala activation following eight weeks of mindfulness practice.
These findings suggest that mindfulness meditation supports the process of extinction and it is
similar to exposure therapy in some aspects.
Do mindfulness and psychotherapy have similar goals?
In a unique article, Jeffery Martin (1997) proposed mindfulness as a core psychotherapy process
or even as a common factor of psychotherapy. Horowitz (2002) shared a similar opinion.
Mulder et al. (2017) wrote a review describing a common factor model for psychotherapy in
which mindfulness is implicitly included. In their transtheoretical analysis of psychotherapy
approaches, Prochaska and Norcross (2003) show that many psychotherapeutic approaches
differ in their content, but they work with the same processes of change. In other words, the
theory of psychopathology suggests what needs to be changed. The theory of the processes of
change tells how the change occurs. From a clinical and psychotherapeutic perspective point of
view, many implicit and explicit aims are very similar to the ones derived from mindfulness
practice.
Van der Velden et al. (2015) describe some processes/mechanisms of change which are shared
by mindfulness training and CBT. Similarities between mindfulness and psychoanalysis are
analyzed and described by Mark Epstein (1995). At the most general level, all psychotherapy
approaches support patients being able to recognize the automatic and habitual dysfunctional
cognitive processes that are important in the etiology of their suffering; these approaches thus
probably also enhance the capacity to be mindful in some aspects.
1) We support patients being able to recognize the automatic and habitual dysfunctional
cognitive processes.
2) We help them to increase their emotional awareness to be able to recognize their
nonadaptive reactions and their origins in time.
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3) We teach them to develop a meta-awareness to be able to observe their thoughts and
feelings as temporary and automatic events in the mind instead of as facts or true
descriptions.
4) We help them to develop the ability to relate to their current experience in a wider,
decentered perspective as a transient mental event rather than reflections of the self or
as necessarily accurate reflections on reality. We often remind them that current
thoughts are more memories of historical interpretation than messages about their
current value. In the psychotherapeutic approaches to shame, we often teach them to be
aware that shame is the way they felt in the past in a concrete situation with a concrete
person; it is not objective information about them in the present moment.
5) We help them to shift their attention from what happened in the past to the person to
whom it happened. We support them gaining insight into how they construct their
experience in the present moment (Epstein, 1995, p. 133).
6) We teach them to be able to stay with their experience without avoidance or withdrawal,
to have an opportunity to explore the experience in a new context and with new attitudes
(Epstein, 1995, p. 133). From this point of view, mindfulness training helps patients to
develop essential self-functions necessary for successful psychotherapy (Kepner, 1995,
p. 42). The development of self-functions such as modulation of stimulation, bodily
awareness, and so on is a fundamental step in the treatment of many mental disorders
(e.g., GAD, eating disorders) and especially for the treatment of adult survivors of
childhood abuse and for patients with personality disorders with lower levels of
personality organization, such as narcissistic and borderline personality disorder
(Linehan, 1993).
It is not still clear how much MBIs differ in their psychological and neurobiological
mechanisms from the mechanisms observed in common Western psychological approaches,
such as psychotherapy (Chiesa et al., 2010). It seems that psychotherapy and mindfulness are
complementary to one another, and one follows the other. To be successful in psychotherapy,
it is necessary to learn some basic aspect of mindfulness (Martin, 1997). To overcome some
aversive states which often appear during mindfulness practice, we need support from
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psychotherapy especially with unintegrated traumatic experience (Epstein, 1995) and during
the development of basic self-functions (Kepner, 1995). Unlike psychotherapy, the aims of
MBIs are usually clear. The general and explicit goal is to increase mindfulness throughout
daily life. It is paradoxical sometimes for people with concrete problems such as anxiety or a
chronic headache.
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Table 7 Specific emotion regulation strategies and strategy subtypes and their relation to mindfulness
Emotion
regulation and coping Mindfulness
Emotion
regulation and coping Mindfulness
Habituation Responses that function for the management of stress3
Extinction Approach3
Cognitive reappraisal Avoidance3
Expressive suppression Disengagement3
Thought suppression Engagement3
Active mood management1
Control: “Proactive take-charge approach”3
Seeking pleasurable activities and distraction1
Escape3
Passive mood management1
Primary relinquishment of control coping3
Social support, ventilation, and gratification1
Secondary relinquishment of control coping3
Direct tension reduction1
Relinquishment of control3
Withdrawal-avoidance1
Assimilation3
Activity: physical, social, cognitive1
Accommodation3
Caffeine, food, and passive stimulation1
Alloplastic coping3
Reduced activity and rest1
Autoplastic coping3
Emotional expression, food, and drugs1
Volitional, effortful, controlled coping3
Muscle release, cognitive control, and stress management1
Involuntary, automatic coping3
Pleasant distraction1
Behavioral coping3
Cognitive and behavioral disengagement2
Cognitive coping3
Cognitive and behavioral distraction2
Social3
Cognitive and behavioral engagement2
Solitary3
Emotion-focused coping3
Proactive coping3
Problem-focused coping3
Direct coping3
Appraisal-focused coping3
Indirect coping3
Responses that modify the situation3
Concentrate–mixed4
Responses that function to control the meaning3
Reappraise emotional response4
Active positive distraction4
Reappraise emotional stimulus4
Passive positive distraction4
Reappraise via perspective taking4
Active neutral distraction4
Reappraisal–mixed4
Passive neutral distraction4
Suppress the expression of emotion4
Concentrate on feelings4
Suppress the experience of emotion4
Concentrate on causes and implications4
Suppress thoughts of the emotion-eliciting event4
Suppression–mixed4
1
Thayer, Newman, and McClain, 1994; 2
Parkinson and Totterdell, 1999; 3
Skinner et al., 2003; 4
Webb et al., 2012
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The neural bases of emotion regulation and mindfulness: where do they
overlap?
Another way to conceptualize and define mindfulness is a simple comparison of its described
neural correlates with the neural correlates associated with the emotion regulation process. At
the most general level, emotion regulation is mediated through interactions between the
prefrontal, parietal, and cingulate systems that control and inhibit the subcortical systems such
as the amygdalae or the ventral striatum that are involved in emotion generation and affective
appraisal (Ochsner, 2012). Concretely, the ventromedial prefrontal cortex (vmPFC),
dorsomedial prefrontal cortex (dmPFC), dorsolateral prefrontal cortex (dlPFC), and
ventrolateral prefrontal cortex (vlPFC), inferior parietal cortex (IPC), and the anterior cingulate
cortex (ACC) are often discussed as the common brain regions supporting emotion regulation
(e.g., Dörfel et al., 2014; Ochsner et al., 2012). Table 8 focuses on the structures that are
activated in different conditions such as meditation or emotional regulation.
The simple comparison shows that emotion regulation and mindfulness share the same brain
systems involved in emotion control. The comparison also reveals that at a neural level
mindfulness practice has an impact on more neural structures and functional circuits than
emotion regulation. This evidence could support the hypothesis that mindfulness has a unique
underlying neurocognitive mechanism. This comparison also documents the relation between
the length of the mindfulness practice and the involvement of neural structures, as discussed in
the chapter “Is mindfulness a top-down or bottom-up regulation?”
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Table 8 Comparison of neural structures involved in emotion regulation processes and
mindfulness practice
↑/↓ Explicit
emotion
regulation
Implicit
emotion
regulation
Mindfulness –
Dispositional
Mindfulness –
Non-experts
Mindfulness –
Experts
dmPFC ↑ ↓
dlPFC ↑ ↓
dlPFC ↓
vlPFC ↑ ↓
vmPFC ↑
mPFC ↑ ↓
mPFC ↓
IPC ↑
PPC ↑ ↓
dACC ↑ ↓
PCC
SMA
Left and right
amygdalae ↓
Ventral striatum ↓
OFC ↑ ↓
Insula ↓
Insula ↑
Thalamus ↑
Somatosensory
cortex ↑
Hippocampus ↑
Corpus callosum ↑
Entorhinal cortex ↑
Left caudate body ↑
Notes: dACC – dorsal anterior cingulate cortex; dlPFC – dorsolateral prefrontal cortex; dmPFC – dorsomedial
prefrontal cortex; IPC – inferior parietal cortex; PCC – posterior cingulate cortex; SMA – supplementary motor
area; vmPFC – ventromedial prefrontal cortex; vlPFC – ventrolateral prefrontal cortex; mPFC – medial prefrontal
cortex
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Mindful emotion regulation
The answer the question three
The aim of this thesis is to propose a basic framework for a better understanding of emotion
regulation changes induced with mindfulness practice and to find whether “mindful emotion
regulation” exists as a unique emotion regulation strategy and, if so, how it differs and overlaps
with described implicit/explicit and top-down and bottom-up emotion regulation strategies.
The uniqueness of emotion regulation induced with mindfulness practice is based on a paradox.
It does not focus primarily on emotion regulation. The enhanced emotion regulation that has
been suggested as underlying many of the beneficial effects of mindfulness meditation (e.g.,
Tang et al., 2015) is not an explicit goal of mindfulness practice. In fact, the regulation of
emotions is a result of a deep change in the practitioner’s view of the world. More scientifically,
it is a real change of the paradigm through which the world and experiences are perceived and
interpreted22
. Suffering and experiencing through negative emotions (e.g., fear, anxiety,
sadness) are reduced through insight into the very essence of living (the three universal
characteristics: impermanence, suffering, and not-self). In other word, attitudes are changed to
reality.
In this context, it could be supposed that emotion regulation is induced through the change of
implicit attitudes to emotion. Formal and informal practice support the development of
fundamental attitudes to reality such as openness, curiosity, acceptance, non-judging, patience,
beginner’s mind, trust, non-striving, letting be, compassion, and self-compassion. Everyday
practice changes the explicit top-down and will-driven attitudes to more implicit and automatic
ones. This notion is in agreement with neuroscience results documenting the shift from topdown
to bottom-up regulation induced by mindfulness practice. In the context of affective
priming research results (e.g., Schneider & Shiffrin, 1977; reviewed by Fazio, 2001) it is
evident that attitudes, goals, and beliefs automatically influence what is perceived, how it is
interpreted, and how it is evaluated. Although there is not enough experimental evidence in the
literature supporting this notion, Bergeron, Almgren-Doré, and Dandeneau (2016) show that
implicit mindfulness attitudes, regardless of the participant’s level of trait mindfulness, induce
a greater decline in cortisol during the early recovery stage compared to those in the control
22
From the Buddhist perspective, no practical distinction is made between awareness of perceptions (through
senses) and cognitions (i.e., mental events). They are processed in the same manner during mindfulness practice
(Grabovac et al., 2011).
157
condition. In the context of emotion regulation, the influence of attitudes on cognitive
reappraisal activation was also documented (Williams et al., 2009). The influence of implicit
theories about emotions on emotion regulation has also been documented (Tamir et al., 2007).
Mindfulness (Buddhist teaching) could be thus seen as an implicit theory about emotions in
some aspects.
Changes induced by mindfulness practice can be described as emotion regulation and coping
strategies at some level, but these concepts are not able to describe the whole of mindfulness
practice. It can be understood as cognitive reappraisal at a process level rather than a content
level (Chambers et al., 2009), through which the initial attitude that thoughts, emotions, and
sensations are only mental events is reframed, changing the meaning of experiences as a whole.
Mindfulness could be understood as complex emotion regulation training with a unique
underlying neurocognitive mechanism encompassing many emotional regulation strategies
from top-down and bottom-up groups. Mindfulness is a unique approach that integrates various
emotional regulation strategies into one interconnected whole. It changes the explicit strategies
of emotion regulation into implicit ones through formal and informal practice. Some concrete
emotion regulation strategies (e.g., cognitive reappraisal) help regulate emotions only in an
emotional situation; the mindfulness approach leads to the continual regulation of experiences
as they occur. In mindfulness practice, practitioners regulate experience (not just emotions) to
be more realistic and thus less painful. From this point of view, emotion regulation is just a byproduct
of the deeper and more complex transformation induced by mindfulness.
Mindfulness practice activates, develops, and supports a variety of emotion regulation
processes. These include top-down processes involving attention focusing, voluntary cognitive
control, conscious monitoring, and explicit regulatory functions; and bottom-up processes,
which are affect driven, based on emotion functions that modulate arousal, valence, and the
encoding of subjective value regarding the triggering stimuli (Guendelman et al., 2017).
Mindfulness practice helps to distinguish between feelings that provide a “real” subjective
experiential window into the processes of life regulation (e.g., anxiety that helps avoid a
dangerous person) and those feelings that are the result of the habitual attachment/aversion
reaction to transient feelings and the mental proliferation in their background (e.g., sadness at
the beginning of a vacation that it will end). Although emotions can occur without selfawareness
(action programs, implicit reactions), our capacity for self-awareness and self-
158
relevant thought predispose us to have many emotions that are not associated with the process
of life regulation (discussed in the chapter “The nature of emotions: from survival circuits to
emotions”) but are the result of our ability to think consciously about ourselves. Leary and
Gohar (2014, p. 377) state that people’s emotions are affected when they 1) compare themselves
to their personal standards, 2) think about themselves in the past and future, 3) evaluate their
characteristics, and 4) think about how they are perceived by other people. Mindfulness practice
helps practitioners to see experiences clearly in their “default mode.”
While the research of emotion regulation is very often based on the very simple and pregnant
paradigm of one strategy compared to a control condition, mindfulness practice and its effects
are very complex, and it is hard to compare it with a concrete emotion regulation strategy. It is
probably more suitable to view particular results from emotion regulation studies as jigsaw
pieces from which the final picture of mindfulness is assembled. Lutz et al. (2015) stated that
mindfulness meditation should be conceived as “a family of complex emotional and attentional
regulatory strategies developed for various ends.” Moreover, emotions are a multifaceted
phenomenon that is regulated on different levels according to the different individual goals at
different periods of life (Koole, 2009), mindfulness training, or individual psychotherapy.
Emotion regulation can be the reason people start to practice mindfulness; it is also often the
reason that clinicians recommend mindfulness training, but emotion regulation is not the goal
of mindfulness. To regulate emotions is inconsistent with the very fundamentals of
mindfulness, such as openness, acceptance, and curiosity. Mindfulness practice leads to
processing experience through plain exploration, regardless of the valence of the stimuli. This
kind of exploration creates an opportunity for insight into mental habits and reduces automatic
efforts to control feelings and experiences. Mindfulness is more than an education in how the
mind works; this knowledge is obtained through direct observation. Knowledge is not just
information; it is experienced and lived. The embodiment of mindfulness is one of the most
important competences of mindfulness teachers/trainers in MBI training (Williams, Crane, &
Soulsby, 2007). This should also apply to psychotherapists.
There is no agreement among authors whether “mindful emotion regulation” is a necessary
concept. Most authors do not refer to it explicitly. There is no clear and single definition of
mindful emotion regulation in the literature. Guendelman et al., (2017) conclude that it is a
unique emotion regulation strategy that results from encountering diverse emotional states from
a mindful mental state that includes awareness and acceptance. Chambers, et al. (2009) wrote:
159
“Mindful emotion regulation represents the capacity to remain mindfully aware at all times,
irrespective of the apparent valence or magnitude of any emotion that is experienced. It does
not entail the suppression of the emotional experience, nor any specific attempts to reappraise
or alter it in any way.”
Conclusion
It has been almost forty years since the founding of MBSR. There is no doubt that MBIs are
effective in improving mental health in healthy people and in those with various psychiatric or
somatic conditions. It is evident that MBIs and follow-up programs integrating mindfulness and
psychotherapy address changes of human experience on a fundamental level: the ability to
regulate emotions and thoughts. Since people most often seek help from mental health
professionals because of emotional dysregulation, MBIs should be one of the basic methods of
choice in mental health care.
Mindfulness practice mediated through MBIs is unique in promoting meta-awareness of
emotion regulation strategies (Farb et al., 2014). Mindfulness serves as a meta-strategy that
leads to the shift from the contents of consciousness to the process of consciousness itself.
Through the increasing performance of meta-awareness, mindfulness helps practitioners to be
the witnesses and the observers of the appraisal process (cognitive biases), and it supports the
ability to see what has been previously reflexively adopted or conditioned (self-awareness).
Through the insight into the impermanence of experience, mindfulness reduces the urgency to
react to impulses continually emerging in the mind (self-regulation). The uniqueness of
mindfulness is also in its support of the development of a positive relationship between the self
and other that transcends self-focused needs and increases prosocial characteristics (selftranscendence).
More than a concept or a scientific construct, mindfulness is a non-conceptual
phenomenological attentional process (Vago & Silbersweig, 2012) that represents the universal
principle or process of change that is also common in psychotherapy (Martin, 1997; Murray &
Rucklidge, 2017). At the level of emotion regulation research, MBIs support the development
of adaptive emotion regulation and coping strategies and reduce the nonadaptive ones.
Daily mindfulness in formal and informal practice and the associated deepening insight into
how emotions arise lead practitioners to a state where many emotions disappear and thus, no
160
longer require regulation. Mindfulness practice induces a deep transformation of the way of
being. Enhanced emotion regulation is only one piece of this transformation.
There is currently no research to compare the differences between the long-term effect of
mindfulness practice and individual psychotherapy, in which the structure/character of the
personality is also transformed.
Future challenges
Mindfulness is much more than just another method in the biomedical model context. It not
only relieves symptoms; it returns the practitioner to the mind’s factory settings, supporting
health through its unique nature (Kabat-Zinn, 2013). I do not share the enthusiastic belief that
mindfulness is the cure for everything and everybody. I think that it offers a new approach to
health and disease, but it is still necessary to ask the same questions as for any treatment
approach: For whom is this the best form of treatment? For what kind of suffering? In what
period of life? In what life context? I find it important to be able to answer these questions in
order to protect our patients and the public from being harmed, cheated, disappointed, or
dissatisfied. Answering these questions will help practitioners to find an appropriate position
for the mindfulness approach in medicine and psychotherapy, unimpaired by misunderstanding.
This is the first challenge for any mental health expert. For this reason, MBIs should be
indicated and guided only by experienced physicians and psychologists.
If we agree that mindfulness is an effective approach, our second challenge should be to search
for effective ways to deliver this method/approach to our patients and to teach it our colleagues
and students. Healthcare professionals are almost never trained in how to teach their patients
and colleagues. The problem in medicine is not that there are not enough effective methods.
The problem is that we are often unable to introduce these methods well and motivate our
patients or we do not live according to our own recommendations. I agree with Christiane Wolf
(2015), the author of the book The Clinician’s Guide to Teaching Mindfulness, that the most
important quality a mindfulness facilitator brings into the classroom is the embodiment of
mindfulness and compassion. This comes partly out of a person’s character and partly from
their life experience. However, mostly—in this setting—it comes out of a regular, dedicated
personal mindfulness practice. Kabat-Zinn (2013) says that the teacher is the intervention. That
observation is also known from psychotherapy.
161
The third and final challenge from my point of view is somewhat paradoxical. We should
protect mindfulness from a strictly biomedical research approach. Evidence is needed, and it is
necessary for many outcomes, but everybody knows that a cup of coffee is always more than
caffeine tablet.
162
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