M i n d f u l n e s s I n t e r v e n t i o n f o r C h i l d A b u s e S u r v i v o r s
m
Elizabeth Kimbrough and Trish Magyari
Center for Integrative Medicine, Department of Family and
Community Medicine, University of Maryland School of Medicine
m
Patricia Langenberg
Department of Epidemiology and Preventive Medicine,
University of Maryland School of Medicine
m
Margaret Chesney and Brian Berman
Center for Integrative Medicine, Department of Family and
Community Medicine, University of Maryland School of Medicine
Twenty-seven adult survivors of childhood sexual abuse participated
in a pilot study comprising an 8-week mindfulness meditation-based
stress reduction (MBSR) program and daily home practice of
mindfulness skills. Three refresher classes were provided through
final follow-up at 24 weeks. Assessments of depressive symptoms,
post-traumatic stress disorder (PTSD), anxiety, and mindfulness,
were conducted at baseline, 4, 8, and 24 weeks. At 8 weeks,
depressive symptoms were reduced by 65%. Statistically significant
improvements were observed in all outcomes post-MBSR, with
effect sizes above 1.0. Improvements were largely sustained until
24 weeks. Of three PTSD symptom criteria, symptoms of avoidance/
numbing were most greatly reduced. Compliance to class attendance
and home practice was high, with the intervention proving safe and
acceptable to participants. These results warrant further investigation
of the MBSR approach in a randomized, controlled trial in this patient
population. & 2009 Wiley Periodicals, Inc. J Clin Psychol 66: 17–33,
2010.
The authors would like to thank Laura Benzel for her skillful research coordination, and Mary Bahr-
Robertson for her astute management. We would like to express our sincere gratitude to our participants.
The intellectual and inspirational contributions of the faculty at the Center for Integrative Medicine, Jon
Kabat-Zinn and Tara Brach, are appreciated. We are most grateful for the commitment and generosity of
The Mental Insight Foundation, who provided the funding for this study.
Correspondence concerning this article should be addressed to: Elizabeth Kimbrough, Center for
Integrative Medicine, University of Maryland School of Medicine, Kernan Hospital Mansion, 2200
Kernan Drive, Baltimore, MD 21207-6665; e-mail: ekimbrough@compmed.umm.edu
JOURNAL OF CLINICAL PSYCHOLOGY, Vo l . 6 6 ( 1 ) , 1 7 — 3 3 ( 2 0 10 ) & 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). D O I : 1 0 . 1 0 0 2 / j c l p . 2 0 6 2 4
Keywords: child abuse; depression; post-traumatic stress disorder;
mindfulness; meditation
Introduction
Childhood Sexual Abuse
It is estimated that over a quarter of adult women in the United States are victims of
childhood sexual abuse (CSA; Briere & Elliott, 2003; Diehl & Prout, 2002; Felitti
et al., 1998; Lev-Wiesel, 2008), resulting in potentially enormous psychological scars
that can remain across the lifetime (Diehl & Prout, 2002; Polusny & Follette, 1995).
Depression and post-traumatic stress disorder (PTSD) are common in these trauma
survivors (Breslau, Davis, Peterson, & Schultz, 2000; Lev-Wiesel, 2008), occurring
often not as isolated conditions, but embedded in a complex trauma spectrum that
includes anxiety, substance abuse, self-efficacy, sleep issues, and somatic complaints
(Breslau, 2002; Breslau et al., 2000; Diehl & Prout, 2002; van der Kolk, Roth,
Pelcovitz, Sunday, & Spinazzola, 2005).
Psychological treatment for CSA survivors comprises traditional psychotherapy,
such as psychodynamic and supportive therapy (Bisson & Andrew, 2007), as well as
cognitive-behavioral therapy approaches for PTSD (Harvey, Bryant, & Tarrier,
2003). Prolonged exposure therapy (PE) and a variation of it, cognitive processing
therapy (CPT) share a strong evidence base (Foa et al., 1999; Foa, Rothbaum, Riggs,
& Murdock, 1991; Resick, Monson, & Chard, 2007; Resick, Nishith, & Griffin,
2003). However, exposure therapy has not been shown equivocally to surpass other
approaches for PTSD (Bisson & Andrew, 2007; Bryant, Moulds, Guthrie, Dang, &
Nixon, 2003; Marks, Lovell, Noshirvani, Livanou, & Thrasher, 1998; Rothbaum,
Astin, & Marsteller, 2005). That CPT was found to be equally effective with and
without its exposure component supports this (Resick et al., 2008). The case has been
made that exposure therapy is not suitable for all, with some patients and therapists
not willing to face its inherent distress, despite evidence of ultimate success (Follette,
2006; Orsillo & Batten, 2005; Rosen et al., 2004).
Recently, therapies incorporating mindfulness skills have been studied. Accep-
tance and commitment therapy (ACT) offers a combination of cognitive-behavioral
therapy, behavioral psychology, and mindfulness training (Hayes, Luoma, Bond,
Masuda, & Lillis, 2006). ACT has been proposed as a treatment for PTSD (Follette,
2006; Orsillo & Batten, 2005; Walser & Westrup, 2007), but as yet no clinical trials
have been published. Dialectical behavioral therapy (DBT) is a proven approach
that utilizes mindfulness skills primarily in treatment of borderline personality
disorder (Linehan, 2000), but few data are available on its use in the treatment of
PTSD. ACT and DBT are generally practiced in one-on-one therapeutic sessions.
Given the vast need of services for CSA trauma survivors, increased focus on
reducing healthcare costs, and the potential role of mindfulness in facilitating
healing, a group-based mindfulness method that may be more cost-effective, less
confronting, and is evidence-based could be an appealing choice. One such potential
program is mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1982).
Mindfulness-Based Stress Reduction
MBSR has been shown in several studies to be effective in reducing trauma spec-
trum symptoms such as depression, psychological distress, anxiety, sleep, and
18 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
somatic complaints (Carlson & Garland, 2005; Grossman, Niemann, Schmidt,
& Walach, 2004; Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985;
Kabat-Zinn, Lipworth, Burney, & Sellers, 1987; Kabat-Zinn et al., 1992; Miller,
Fletcher, & Kabat-Zinn, 1995; Pradhan et al., 2007; Shapiro, Bootzin, Figueredo,
Lopez, & Schwartz, 2003; Williams, Teasdale, Segal, & Kabat-Zinn, 2007).
Neuroscience research has shown MBSR to be associated with functional brain
changes and emotional and attention improvements (Davidson et al., 2003; Jha,
Krompinger, & Baime, 2007). Mindfulness is described as moment-to-moment, non-
judgmental attention and awareness actively cultivated and developed through
meditation (Kabat-Zinn, 2003). By continually bringing the mind back to present
moment awareness, mindfulness practice is thought to increase clarity, attention,
calmness, and emotional well-being. Didactic course material is presented to
engage awareness of the relative and malleable nature of thoughts and judgments
in a manner influenced by cognitive-behavioral therapy (Segal, Williams, &
Teasdale, 2002).
The efficacy of MBSR in reducing depressive and PTSD symptoms among trauma
survivors has not yet been established. Work toward this end currently is underway
in military and domestic abuse populations (King, 2008; Dutton, 2008). At present,
however, no study found in the literature has investigated the effect of MBSR with
CSA survivors on depressive and PTSD symptoms or other psychological outcomes.
To begin the process of testing MBSR for this indication, we conducted a feasibility
pilot study of MBSR among adult CSA trauma survivors. We hypothesized that
participation in MBSR would be associated with improvements in depressive
symptoms at 8 weeks, the study’s primary outcome. We also hypothesized that
participation in MBSR would be associated with improvements in secondary
outcomes of PTSD and anxiety symptoms, and mindfulness.
Methods
Participants
Adult CSA survivors were recruited through advertisements in Baltimore news-
papers and radio, informational flyers widely distributed through the state chapter of
registered social workers, CSA survivor networks and advocacy groups, and in
community health fairs. Respondents were screened by telephone and, if eligible,
were invited to the baseline session. Inclusion criteria included a history of CSA,
being aged 21 or older, and having a score at baseline on the General Severity Index
of the Brief Symptoms Inventory Z0.50. It is likely that thousands of CSA survivors
have been enrolled in public MBSR courses since its inception in the early 1970’s.
However, because this was the first research study, of which we were aware, to use
MBSR exclusively with CSA survivors, we wanted to take all possible precautions
for participant well-being. For this reason, all participants were required to be in
concurrent psychotherapy with a licensed practitioner. We felt this would allow a
safety net as well as a venue in which to process insights that arose in meditation or
in the MBSR class. After supplying information to the therapists about the study, a
requirement of enrollment was that therapists provide assent for their client’s
participation. Exclusion criteria included major psychiatric illness such as borderline
personality disorder or schizophrenia. Clear dissociative identity disorder manifested
as multiple personalities was excluded, while participants with dissociative identity
not otherwise specified were included. Potential participants also were excluded for
active alcohol or drug dependency, inability to attend study sessions, participation in
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Journal of Clinical Psychology DOI: 10.1002/jclp
a concurrent clinical trial, or scheduled major surgery. All patients remained on their
prescribed medication and under the regular care of their therapists throughout
the study.
Procedure
Participants deemed eligible following baseline were asked to participate in the
MBSR class for 8 weeks, followed by an 8-week assessment visit. The intervention
then continued with participants invited to three MBSR refresher classes over
4 months, with the final assessment made 24 weeks post-baseline. Three cohorts of
participants took part: cohort 1 (n 5 9) took place during May–November 2007,
cohort 2 (n 5 7) during October 2007–April 2008, and cohort 3 (n 5 11) during
February–August 2008. Adverse events were monitored at each visit and were
reported in accordance with procedures of the University of Maryland Human
Research Protections Office, which approved the protocol (H-28934). All
participants provided written informed consent.
Outcome Measures
Depressive symptoms were measured by the Beck Depression Inventory Second
Edition (BDI-II) (Beck, Steer, Ball, & Ranieri, 1996; Beck, Steer, & Brown, 1996).
The BDI-II is a widely used, standardized, and validated self-report measure of
depressive symptom severity. The 21-item scale addresses affective, behavioral,
biological, cognitive, and motivational symptoms of depression in a series of
statements that are rated from 0 to 3 to indicate the severity of symptoms. The
summary score ranges from 0–63, with those in the range of 0–13 indicating minimal
depression, 14–19 mild, 20–28 moderate, and 29–63 severe (Beck, Steer, & Brown,
1996).
PTSD was measured by the PTSD checklist (PCL; Weathers et al., 1994). This
widely used, 17-item self-report scale was developed by the National Center for
PTSD. The PCL score is the sum of points from all 17 items on the questionnaire,
which are rated as not at all, a little bit, moderately, quite a bit, or extremely over the
past month on a 1–5 scale, respectively. The score ranges from 17 to 85, with higher
scores indicating greater symptom distress. The diagnostic properties of the PCL
have been validated and replicated (Blanchard, Jones-Alexander, Buckley, &
Forneris, 1996). The PCL also has been validated as a tool for identifying the
presence or diagnosis of PTSD, using an algorithm based on the DSM-IV criteria for
PTSD and validated against the gold-standard Clinician-Administered PTSD Scale
(Blanchard et al., 1996). The algorithm counts the number of items on the PCL
endorsed as moderately or worse in each of the three PTSD symptom clusters:
criterion B (reexperiencing), criterion C (avoidance/numbing), and criterion D
(hyperarousal). A diagnosis of PTSD is made if the participant has one or more
positive symptoms in criterion B, three or more in criterion C, and two or more in
criterion D (Blanchard et al., 1996).
Anxiety was measured using the Brief Symptom Inventory (BSI; Derogatis &
Melisaratos, 1983). The BSI includes a reliable and valid subscale for assessment of
anxiety. Scores on the anxiety subscale range from 0–4, with higher levels indicating
greater distress. The BSI also contains a summary measure of overall psychological
distress, called the general severity index (GSI). The GSI was used in the baseline
assessment as a screening tool. Those who scored less than 0.50 on the GSI were
ineligible for the study. This cut-off for psychological distress was based on our
20 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
previous study of MBSR with rheumatoid arthritis patients, where we observed an
apparent floor effect associated with low baseline levels of psychological distress in
the sample (Pradhan et al., 2007).
Mindfulness was measured by the Mindfulness Attention Awareness scale
(MAAS; Brown & Ryan, 2003). This scale was designed to assess the state
of mindfulness by evaluating one of its core characteristics, attention to what
is taking place in the present. Scores on the MAAS have been shown to
increase during mindfulness-based interventions and are associated with higher
positive affect and psychological health (Brown & Ryan, 2003; Carlson & Brown,
2005). The range of the MAAS score is 1–6, with higher scores indicating greater
mindfulness.
Adherence to home practice was recorded on practice logs. Each day, participants
were asked to record the total number of minutes spent on five home practices
(sitting meditation, walking meditation, the body scan, gentle yoga, and informal
practices). Seven days of practice were recorded on one form and handed in on a
weekly basis. Attendance at classes, the retreat, and refresher sessions was
monitored.
Qualitative data were collected at 4 weeks and 8 weeks, eliciting the participants’
views on the MBSR program and how it may or may not have impacted their lives.
These data will be described in another setting.
Intervention
The MBSR intervention used in this study followed the manual developed at the
University of Massachusetts Medical School.
Classes and homework. The MBSR course comprised 8 weekly, 2.5–3-hour
classes, and a 5-hour silent retreat. Formal meditation practices were introduced in
four formats: (a) sitting meditation, using aspects of the present moment as anchors
of attention (such as breath, sound, body sensations, or open awareness), as well as a
guided meditation to cultivate compassionate well wishes for self and others (sitting
meditation); (b) a progressive body awareness meditation (body scan); (c)
contemplative walking (walking meditation); and (d) gentle yoga stretching
exercises (gentle yoga). In addition, participants were asked to carry out certain
activities of daily life in a mindful fashion each week, including mindful
communication and mindful eating; these were called informal practices. Each
MBSR class session had four components: (a) learning and practicing formal
meditations; (b) learning and reinforcing informal practices; (c) inquiring into one’s
present moment experience in domains of physical, emotional, and cognitive
experience, while observing those experiences nonjudgmentally (mindful inquiry);
and (d) discussion of the previous week’s lessons and home practice experiences
(integration). Home practice had three components each week: (a) formal
meditations; (b) informal practices; and (c) reading the companion text Full
Catastrophe Living (Kabat-Zinn, 1990), which provides an articulation of the
concept and practice of mindfulness. Participants were asked to practice at home
20–30 minutes a day, 6 days a week from Week 1 to Week 8 (7 weeks), aided by
audio CDs.
Modifications. The classic MBSR intervention was augmented in two ways, both
related to the manner in which course content was taught, rather than changes to the
content itself. First, to reinforce safety, sensitive attention was given to the language
21Mindfulness Intervention for Child Abuse Survivors
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used to explain and direct class activities. Influenced by DBT and mindfulness-based
cognitive therapy (MBCT; Teasdale et al., 2000), this approach encouraged
participants to stay present to experience, while ensuring that the choice to go
forward or pull back in any meditation or exercise was theirs alone. In this way,
participants were encouraged to ‘‘titrate’’ their own meditative experience and
related exposure to present-moment experiences. Second, positive growth awareness
was reinforced by techniques drawn from the field of positive psychology. These
efforts included building on strengths, acknowledging one’s efforts and expressing
gratitude for those efforts, encouraging a sense of connection to others in the class,
and cultivating compassion for self and others.
Teacher. The class was taught by a highly experienced MBSR teacher, who
received her training through the Center for Mindfulness at the University of
Massachusetts Medical School, and has been trained in MBCT and DBT. She has
been leading MBSR classes for over a decade and has had a personal meditation
practice for more than 20 years.
Statistical Considerations and Analysis
A sample size (n 5 27) was calculated assuming an alpha error of 0.05 and a
beta error of 0.20, estimating a 25% reduction in the BDI-II and accounting for a
15% noncompletion rate, using baseline means and standard deviations estimated
from the MBSR literature on depressed patients.
Outcomes of depressive, PTSD, and anxiety symptoms, and mindfulness were
assessed at baseline, 4, 8, and 24 weeks. Mean symptom scores, and mean change
from baseline, were estimated in repeated measures regression analyses as
implemented by the Mixed procedure in SAS (SAS Software Version 9.2, Cary,
NC, Copyright 2008).
The magnitude of treatment effect was evaluated by Cohen’s d effect size
(calculated as 2t/
p
df). The effect of treatment on PTSD symptoms was dismantled
further by estimating the mean symptom scores by PTSD criteria B, C, and D
(reexperiencing, avoidance/numbing, hyperarousal). The effect of the program on
prevalence of PTSD was assessed by a chi-square test of the number of participants
meeting criteria for PTSD, at the baseline and 8-week assessment, according to the
algorithm on the PCL (Blanchard et al., 1996). To avoid the departure of
participants influencing this frequency count, we used a dataset in which missing
values were imputed as last value carried for this analysis. The association between
home practice and psychological outcomes at 8 weeks was assessed. This was
evaluated in linear regression models, with change in psychological outcome from
baseline to 8 weeks as the dependent variable, and the sum of hours of each specific
practice, as well as the sum of all practice time, separately, as the independent
variables. Student’s t tests were used to evaluate mean baseline differences among
those who left the study and those who completed it. Analyses were carried out on an
intent-to-treat basis, with all available participant data included, regardless of
compliance to protocol (Rothman & Greenland, 1998). To evaluate the effect of
missing data, all models were re-run with imputation as last value carried forward.
The results obtained with imputed data were very similar to those with original data,
with the direction, magnitude, and statistical significance maintained for all main
study outcomes; given this, we elected to use the original data in the final analyses.
The exception to this was a frequency count of participants meeting criteria for
PTSD, as discussed above.
22 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
Results
Figure 1 depicts the CONSORT flowchart (Moher, Schulz, & Altman, 2001). One
hundred thirteen potential participants responded to advertisements and flyers and
received a telephone screen. Of these, 23 people were not interested after hearing
more about the study, and 51 were found to be ineligible because of scheduling issues
(n 5 6), excluded psychiatric conditions (n 5 12), not being in concurrent
psychotherapy (n 5 29), no history of sexual abuse (n 5 2), or therapist refusing to
provide recommendation (n 5 2). Thirty-nine potential participants attended the
baseline visit, with some found to be ineligible because of excluded psychiatric
condition (n 5 3) or insufficient psychological distress (raw GSIo0.50) (n 5 9). Thus,
27 people were eligible and invited to participate. One enrolled participant dropped
out of the study before the first MBSR class and did not return for further study
assessments. In Week 2, one participant was asked to leave because of an excluded
psychological condition not identified at baseline. A participant left the study in Week
2, saying she was too busy with family to do the home practice and feared possible
revival of distress relating to her abuse. A fourth participant left the study in Week 5,
after securing a new job that did not allow her to attend study sessions. Finally, two
participants declined to participate in the 24-week assessment. Thus, numbers of
participants and retention rates at the 4-week, 8-week, and 24-week visits were n 5 24
(89%), n 5 23 (85%), and n 5 21 (78%), respectively. That 85% of participants were
Figure 1. CONSORT diagram, Mindfulness Intervention for Child Abuse Survivors (n 5 27).
23Mindfulness Intervention for Child Abuse Survivors
Journal of Clinical Psychology DOI: 10.1002/jclp
assessed for the main outcome at 8 weeks suggests good retention in the study. There
were no significant differences between completers and noncompleters with respect to
mean baseline psychological outcomes (data not shown).
There were no study-related adverse events at the moderate or higher level
reported at any time.
Sample Characteristics
Baseline demographic and lifestyle characteristics are described in Table 1. Most of
the participants were female (89%), white (78%), married or living with partner
(52%), had a college degree or higher (59%), and had family incomes below $50,000
a year (52%). The mean age was 45 (range 23–68). Ten participants (37%) were
taking antidepressant medication, two were taking antianxiety medication (7%), and
six (22%) were taking both antidepressants and antianxiety medication. Three
participants were smokers (11%), and most (93%) reported none or moderate
alcohol consumption.
Study Outcomes
Mean depressive, PTSD, anxiety symptoms, and mindfulness scores at the BL,
4-week, 8-week, and 24-week visits are shown in Figure 2. PTSD symptom clusters
of criterion B, C, and D are shown in Figure 3.
Depression
At baseline, the mean BDI-II was 22.1 (standard error [SE] 5 1.8), suggesting a
moderate level of major depression (Beck, Steer, & Brown, 1996). This was reduced
Table 1
Baseline Characteristics Mindfulness Intervention for Child Abuse Survivors (n 5 27)
Demographics Mean SD
Age 44.9 10.8
Number %
Female 24 89
White 21 78
Married or living with partner 14 52
Annual household income o$50,000 14 52
College degree or higher 16 59
Psychotropic medications
Antidepressant only 10 37
Antianxiety only 2 7
Both antidepressant and antianxiety 6 22
Lifestyle
Smoker 3 11
r7 servings of alcohol in past week 25 93
Baseline psychological measures Mean SD
Depression 22.1 9.8
PTSD symptoms 46.8 14.1
Anxiety 1.7 0.9
Mindfulness 3.0 0.9
Note: PTSD 5 post-traumatic stress disorder.
24 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
(improved) to 13.7 (1.7) by 4 weeks. At the end of the 8-week intervention, mean
depressive symptoms were significantly reduced to 7.8 (1.3), a 65% reduction from
baseline. Although mean depressive symptoms at 24 weeks rose to 12.4 (2.2), the
improvement from baseline remained statistically significant. The rise in depressive
symptoms between 8 weeks and 24 weeks may have clinical implications, suggesting
Figure 2. Mean outcome by visit, mindfulness intervention for child abuse survivors (n 5 27).
Figure 3. PTSD symptom clusters, mindfulness intervention for child abuse survivors (n 5 27).
25Mindfulness Intervention for Child Abuse Survivors
Journal of Clinical Psychology DOI: 10.1002/jclp
that a strategy for maintenance of effects is required; this is a problem throughout
the behavior change literature. The effect size for depression was 1.8 at 8 weeks and
1.0 at 24 weeks (Depression model F 5 35.7, df 5 65, po0.0001).
Anxiety
The mean anxiety score of 1.7 (0.2) at baseline suggested a high level of distress
situated in the 68th percentile of adult nonpatient norms (Derogatis, 1993). At
4 weeks, anxiety decreased (improved) to 1.0 (0.1). By the end of the 8-week
intervention, the anxiety score was significantly reduced to 0.9 (0.1), a 47% reduction
from baseline. This represents distress at the 61st percentile of nonpatient norms, a
drop of 7 percentile points from baseline. The improvement in anxiety was sustained
until the 24-week assessment, with mean score 1.0 (0.2). The effect size for anxiety
was 1.1 at 8 weeks and 0.9 at 24 weeks (Anxiety model F 5 15.0, df 5 65, po0.0001).
Mindfulness
The mean MAAS at baseline of 3.0 (0.2) represents a score that is lower than has
been seen in normative data from community or chronic disease samples or in
previous studies (Brown & Ryan, 2003; Carlson & Brown, 2005; Pradhan et al.,
2007). By 4 weeks, the mean score improved to 3.5 (0.2). By the end of the 8-week
intervention, the mean mindfulness score was significantly improved to 4.0 (0.2), a
33% increase from baseline, representing a level more like that seen in
nonpsychiatric community populations (Brown & Ryan, 2003; Carlson & Brown,
2005). By 24 weeks, the mean MAAS score of 3.8 (0.2) reflected little change from
8 weeks. The effect size for mindfulness was 1.2 at 8 weeks and 1.0 at 24 weeks
(Mindfulness model F 5 15.0, df 5 65, po0.0001).
PTSD Symptoms
The mean PCL score at baseline was 46.8 (2.7). This level of symptoms is higher than
the cutoff PCL score of 44.0, found to have high sensitivity and specificity in
predicting PTSD when measured against the Clinician Administered PTSD scale
(Blanchard et al., 1996). By 4 weeks, the mean PCL score improved to 38.2 (2.3). By
the end of the 8-week intervention, the mean PCL score was significantly improved
to 32.3 (1.9), a 31% reduction from baseline. By 24 weeks, the mean rose slightly to
34.7 (3.2), although it remained significantly improved from baseline. The effect size
for the PCL was 1.2 at 8 weeks and 0.8 at 24 weeks (PCL model F 5 37.9, df 5 65,
po0.0001).
Meeting Criteria for PTSD
At baseline, using the algorithm on the PCL (Blanchard et al., 1996), 15 participants
at baseline met criteria for PTSD. Using a dataset with missing values imputed as
last value carried forward, this number was reduced to seven participants by the
8-week visit. This represents a 53% reduction in the number of participants meeting
criteria for PTSD post-MBSR class (w2 5 4.91, p 5 0.03). By 24 weeks, this number
rose to nine participants, with the change from baseline no longer significant
(chi-square 5 2.70, p 5 0.10; data not shown).
26 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
PTSD Symptom Clusters
Avoidance/numbing symptom score was higher at study start than either the
reexperiencing or hyperarousal symptom clusters. From 19.4 (1.0) at baseline, the
mean was reduced (improved) to 15.9 (1.1) at 4 weeks. By the end of the 8-week
intervention, mean avoidance/numbing was significantly reduced to 13.0 (0.7), or by
33%. At 24 weeks, the mean increased slightly to 14.0 (1.4), while remaining
significantly lower than baseline. The effect size for avoidance/numbing was 1.4 at 8
weeks and 0.9 at 24 weeks (Avoidance/numbing model F 5 47.7, df 5 65, po0.0001).
Reexperiencing symptom score was mean 13.1 (1.0) at baseline. This was reduced
to 11.0 (0.8) at 4 weeks. By the end of the 8-week intervention, the reexperiencing
symptoms score was significantly reduced to mean 10.0 (0.8). This level was
maintained at 24 weeks with mean 9.9 (0.9). The effect size for reexperiencing was 0.7
at 8 weeks and 0.7 at 24 weeks (Reexperiencing model F 5 9.7, df 5 65, po0.0001).
Hyperarousal symptom score was mean 14.3 (1.0) at baseline. By 4 weeks, the
mean score was reduced to 11.2 (0.8). By the end of the 8-week intervention, mean
hyperarousal symptoms were significantly improved to mean 9.5 (0.6). The mean
score rose slightly at 24 weeks to 10.8 (1.0), while remaining significantly reduced
from baseline. The effect size for hyperarousal was 1.2 at 8 weeks and 0.6 at 24 weeks
(Hyperarousal model F 5 22.2, df 5 65, po0.0001).
Class Attendance
Attendance at the nine sessions (eight classes and one full-day retreat) was high.
Mean attendance was 7.1 (SD 5 2.5) classes among all participants, including drop-
outs. Of those remaining through the 8-week assessment, mean class attendance was
8.1 (1.0) of nine sessions. Of the three refresher sessions offered from Week 9 to
Week 24, the mean attendance was 1.6 (1.3).
Home Practice
Participants were asked to practice 20–30 minutes per day, 6 days per week. The time
participants reported spending on home practice in total from Weeks 1–8 was 35.7
hours (SD 5 26.6), or approximately 44 minutes per day, excluding reading time.
Participants reported mean 9.3 hours (SD 5 9.0) for sitting meditation, 3.6 (3.7) for
walking meditation, 7.7 (6.0) for body scan, 4.2 (4.2) for gentle yoga, and 10.8 (10.2)
for informal practices. There were no significant associations observed between
practice time and changes in psychological outcomes.
Discussion
We carried out an open pilot study of mindfulness-based stress reduction to reduce
symptoms of depression, PTSD, and anxiety among adult survivors of childhood
sexual abuse. Twenty-seven participants were enrolled, of whom 23 (85%) were present
for the assessment of the primary outcome of depressive symptoms at 8 weeks, which
suggests that retention in MBSR is possible in this patient population. The program
was found to be safe and favorably endorsed by participants, according to qualitative
data collected and per the high rate of class attendance and home practice.
Statistically significant changes in all outcomes were observed by 8 weeks,
remaining significant until the study’s conclusion at 24 weeks. Large effect sizes were
observed in all outcomes, with the highest being 1.8 for depressive symptoms at
8 weeks. According to Cohen, a medium effect size is meant to represent ‘‘an effect
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Journal of Clinical Psychology DOI: 10.1002/jclp
likely to be visible to the naked eye of a careful observer’’ (Cohen, 1992). This
underscores the potentially important clinical relevance of large effect sizes.
Symptom levels decreased in all three PTSD symptom criteria of reexperiencing,
avoidance/numbing, and hyperarousal. Among these, the effect size seen for
avoidance/numbing symptoms of 1.4 at 8 weeks was particularly strong.
There were no significant associations observed between practice time and changes
in psychological outcomes in our study. A similar lack of correlation has been
observed in some MBSR studies (Astin, 1997; Davidson et al., 2003; Gross et al.,
2004; Ramel, Goldin, Carmona, & McQuaid, 2004), while a positive relation has
been seen elsewhere (Carmody & Baer, 2008; Shapiro et al., 2003; Speca, Carlson,
Goodey, & Angen, 2000). In light of this inconsistency, further research is needed to
determine the extent to which home practice of MBSR skills is beneficial in achieving
psychological improvement, and for whom. It is possible that for some participants,
the class alone is sufficient. In addition, further research is needed to develop more
objective measures of adherence, given that self-report is vulnerable to over-
estimation of desired behaviors. It is also possible that psychological benefit may
result from participant activities not captured in a daily practice log, such as
practicing mindfulness throughout the day as challenges arise, responding with
compassion to internal judging or coming back to the present moment in a more
conscious way. The development of data collection methods to summarize such
experiences would improve our understanding.
A limitation of this study was the lack of a randomized control group. As such, it
is not possible to say whether these changes occurred as a result of regression to the
mean, the Hawthorne effect, or a placebo effect. However, the large effect sizes
observed suggest an impact in symptoms beyond that of a placebo response, and the
response appears sufficiently hearty to be tested against a control condition in a
randomized trial. This should be the next step of research. The sample size in this
study was small, thus making changes more susceptible to outliers. Another
potential methodological limitation was that participants were under concurrent
psychotherapy during the study. Thus, we cannot say whether the MBSR
intervention or the psychotherapy was responsible for the changes observed. It
must be noted, however, that despite already being in ongoing psychotherapy, in
many cases for decades, high levels of depressive and PTSD symptoms were
observed at baseline in this sample. This suggests that MBSR applied as an adjunct
to psychotherapy may be a useful strategy for these patients.
Specifically, our results suggest that participation in MBSR was significantly
associated with reduced depressive symptoms. This finding is consistent with many
previous studies of MBSR in varied patient populations (Carlson, Speca, Patel, &
Goodey, 2003; Gross et al., 2004; Kabat-Zinn et al., 1992; Miller, Fletcher, & Kabat-
Zinn, 1995; Reibel, Greeson, Brainard, & Rosenzweig, 2001; Speca, Carlson,
Goodey, & Angen, 2000). Several investigators have speculated on how this might
occur. Many suggest that decreased ruminative thinking and improved emotion
regulation are mechanisms underlying improvement in depression, and that these
occur through a shift toward a nonjudgmental and de-centered view of one’s
thoughts (Brown, Ryan, & Creswell, 2007; Follette, 2006; Orsillo & Batten, 2005;
Shapiro, Carlson, Astin, & Freedman, 2005; Teasdale et al., 2001; Williams et al.,
2007). The theoretical framework of mindfulness holds that the continual practice of
bringing one’s attention to the present moment, and allowing what is in that moment
simply to be, eventually leads to a shift in perception in which thoughts and feelings
may be observed as arising events. With increased ability to become witness to
28 Journal of Clinical Psychology, January 2010
Journal of Clinical Psychology DOI: 10.1002/jclp
thoughts, rather than immersed in their valence and content, there follows increased
psychological flexibility, enhanced emotion regulation, and reduced rumination
(Brown et al., 2007; Ramel et al., 2004; Shapiro et al., 2005; Teasdale et al., 2001;
Teasdale, Segal, & Williams, 1995; Williams et al., 2007).
An interesting observation in this study was that participation in MBSR was
associated with reductions in PTSD symptoms, most strongly among them
avoidance. Recent thinking in the field of trauma asserts that avoidance, the effort
to escape or hide from traumatic thoughts, feelings, or memories, is the core
psychological process underlying the development and continuation of PTSD
(Orsillo & Batten, 2005). Avoidant coping strategies include attempts to suppress
intrusive thoughts, to take oneself away from negatively evocative situations, engage
in substance use, or through emotional numbing (Follette, 2006). Therapeutic
approaches that prescribe the opposite of avoidance, i.e., acceptance, can serve as a
form of exposure and work to alleviate avoidant tendencies (Brown et al., 2007;
Follette, 2006; Orsillo & Batten, 2005). In offering acceptance of the present
moment, MBSR may be such a therapy. The mindfulness approach is that through
openness, curiosity, and acceptance of the present moment, one’s relationship with
negative thoughts is altered (Baer, 2005). By fostering a greater comfort level with
thoughts previously avoided, mindfulness practice allows them to surface and, as
such, mindfulness may serve as a form of exposure in its impact on PTSD symptoms
(Brown et al., 2007; Follette, 2006).
In addition to contributing to a survivor’s ability to be present to his or her own
painful emotional experience, mindfulness skills also may enhance one’s capacity to
be present in psychological therapy. In this way, mindfulness may potentiate
therapeutic work. The exploration of this synergy should be a topic of future
empirical investigation. Thus, MBSR may serve as a widely available, potentially
cost-effective way for clients to gain a foundation in mindfulness skills.
To the best of our knowledge, this is the first investigation of the effect of MBSR
to reduce negative psychological symptoms of adult survivors of childhood sexual
abuse. The study demonstrated that the intervention was feasible, safe, and
acceptable in this patient population. Further research is warranted to test the
intervention in a randomized, controlled trial.
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33Mindfulness Intervention for Child Abuse Survivors
Journal of Clinical Psychology DOI: 10.1002/jclp
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T h e D e v e l o p m e n t o f a B r i e f A c c e p t a n c e a n d M i n d f u l n e s s – B a s e d P r o g r a m
A i m e d a t R e d u c i n g S e x u a l R e v i c t i m i z a t i o n A m o n g C o l l e g e W o m e n W i t h
a H i s t o r y o f C h i l d h o o d S e x u a l A b u s e
�
Justin M. Hill,1 Peter M. Vernig,2 Jonathan K. Lee,2 Cynthia Brown,2
and Susan M. Orsillo2
1
Boston VA Healthcare System
2
Suffolk University
Women with a history of childhood sexual assault (CSA) are more likely to be revictimized; however, most
existing programs aimed at reducing sexual victimization do not expressly address the issue of
revictimization. The present study examined the efficacy of a brief mindfulness-based program in reducing
rates of sexual assault and revictimization in college women over the course of an academic semester.
Although the results were not statistically significant, a large-magnitude effect was noted, whereby
women with a history of CSA who participated in the program were less likely to be sexually assaulted
and raped at 2-month follow-up. & 2011 Wiley Periodicals, Inc. J Clin Psychol 67:969–980, 2011.
A recent U.S. census found that 9.6 million women between the ages of 15 and 54 reported
experiencing childhood sexual assault (CSA) or abuse that occurred before 18 years of age
(Molnar, Buka, & Kessler, 2001). Approximately 27% of female college students report having
been the victim of CSA (Arata, 2002; Mayall & Gold, 1995), which is relatively consistent with
rates derived from other populations (e.g., community, inpatient). Regardless of specific
population, women who experience CSA are at increased risk for a wide range of psychological
difficulties including substance abuse (e.g., Wilsnack, Vogeltanz, Klassen, & Harris, 1997),
high-risk sexual behavior (e.g., Thompson, Potter, Sanderson, & Maibach, 1997), personality
disorders (e.g., Linehan, 1993), depressive symptoms (e.g., Jackson, Calhoun, Amick,
Maddever, & Habif, 1990), suicidal ideation and attempts (e.g., Jackson et al.), and
posttraumatic symptoms (Saunders, Villeponteaux, Lipovsky, Kilpatrick, & Veronen, 1992).
Childhood sexual assault is also associated with a significantly increased risk of future
victimization (revictimization; Gidycz, Coble, Latham, & Layman, 1993; Messman & Long,
1996; Wyatt, Guthrie, & Notgrass, 1992). Revictimization is defined in this study as having a
history of childhood sexual assault and an experience of being assaulted again in adolescence
or adulthood. Studies demonstrate that female undergraduates with a history of CSA are 1.5
to 2.5 times more likely to be assaulted as an adolescent or adult than college women without
CSA history (Arata, 2002; Gidycz et al., 1993; Mayall & Gold, 1995). Among female
undergraduate rape victims, one-half to two-thirds report having experienced CSA (Arata,
1999a; Koss & Dinero, 1989).
The extant research suggests that among college women, revictimization is associated with
increased psychological distress (Gold, Milan, Mayall, & Johnson, 1994). Revictimized college
women also receive significantly more lifetime psychiatric diagnoses compared with nonvictims
and are assigned a lifetime diagnosis of posttraumatic stress disorder (PTSD) at higher rates
than women with either a child-only or adult-only sexual assault history (Arata, 1999b).
�
This article was reviewed and accepted under the editorship of Beverly E. Thorn.
This article is based on the doctoral dissertation of Justin M. Hill submitted to Suffolk University.
Portions of this dataset were presented at the 2007 and 2008 annual meetings of the Association for
Behavioral and Cognitive Therapies.
Correspondence concerning this article should be addressed to: Justin M. Hill, Boston VA Healthcare
System, Psychology Dept, 150 S. Huntington Ave., Boston, MA 02130; e-mail: justin.hill2@va.gov
JOURNAL OF CLINICAL PSYCHOLOGY, Vo l . 6 7 ( 9 ) , 9 6 9 — 9 8 0 ( 20 1 1 ) & 2011 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). D O I : 1 0 . 1 0 0 2 / j c l p . 2 0 8 1 3
Given the prevalence of sexual assault on college campuses and the significant physical and
psychological sequelae, federal mandates require that all colleges and universities offer sexual
assault prevention programming (National Association of Student Personnel Administrators,
1994). Although many programs have been successful in changing attitudes toward sexual
victimization among college students, most have been unsuccessful at preventing sexual
victimization (e.g., Blackwell, Lynn, & Vanderhoff, 2004; Breitenbecher, 2000). Moreover, the
few programs that have been successful in reducing rates of sexual assault (e.g., Breitenbecher
& Gidycz, 1998; Hanson & Gidycz, 1993) have been ineffective in preventing revictimization.
One exception to this finding is a study conducted by Marx, Calhoun, Wilson, and Meyerson
(2001). Although they found no significant differences between an intervention specifically
aimed at preventing sexual revictimization and control groups in overall rates of
revictimization at 2-month follow-up, the program seemed to reduce the incidence of rape.
Among those who reported being victimized during the follow-up interval, significantly more
(30% vs 12%) women in the control group reported having been raped compared with the
intervention group.
It has been argued that one of the shortcomings of existing sexual assault prevention
programs is the absence of a guiding theoretical model (Bachar & Koss, 2001; Morrison,
Hardison, Mathew, & O’Neil, 2004; Yeater & O’Donohue, 1999). Messman-Moore and Long
(2003) argue that an all-encompassing, theoretical framework is needed to guide future
empirical studies of revictimization and, ultimately, the development of effective risk-
reduction programs. They encourage researchers to focus less on the specific behavioral
patterns and symptoms that may be associated with revictimization and more on a single
mechanism that may underlie and account for the diverse risk factors.
Polusny and Follette (1995) developed a theoretical model to account for revictimization
that has begun to accumulate some significant empirical support and may have implications
for risk reduction programming. The model is based on a more general theory of
psychopathology that suggests that many problematic behaviors and symptoms of
psychopathology are driven by experiential avoidance (Hayes, Wilson, Gifford, Follette, &
Strosahl, 1996). Experiential avoidance is defined by Polusny and Follette as an ‘‘unwillingness
to experience unpleasant internal events such as thoughts, memories, and affective states
associated with an abuse history, and subsequent attempts to reduce, numb, or alleviate these
negatively self-evaluated internal experiences’’ (p. 158). Follette (1994) proposed that women
with a history of CSA may be unwilling to experience unpleasant internal events related to
their abuse, and, thus, they might engage in a variety of behavioral strategies aimed at
temporarily avoiding or alleviating these abuse-related internal experiences. In support of this
model, Gibson and Leitenberg (2001) found that sexually assaulted women with a history of
CSA used more disengagement methods of coping with adult victimization than women
without such a history, and Marx and Sloan (2002) reported that experiential avoidance
mediated the relationship between CSA and psychological distress.
Unfortunately, many of the behavioral strategies used by CSA survivors to cope with their
internal experiences may actually increase their risk for revictimization. For example, drug
and alcohol use, commonly conceptualized as forms of emotional or experiential avoidance
(e.g., Briere & Runtz, 1993; Polusny & Follette, 1995), have been shown to increase a woman’s
risk of being sexually assaulted (e.g., Gidycz, Hanson, & Layman, 1995). Increased sexual
activity has also been theorized to modulate abuse-related emotional pain (Briere, 1996; Briere
& Runtz); however, frequency of sexual activity has been shown to be a predictor of sexual
revictimization (Fergusson, Horwood, & Lynskey, 1997; Himelein, 1995). An avoidant coping
style may also contribute to the diminished risk recognition found among some women with a
history of sexual assault (e.g., Wilson, Calhoun, & Bernat, 1999). If experiential avoidance is a
predominant coping strategy for CSA survivors and represents a risk factor for future
revictimization, then it follows that a program aimed at reducing experiential avoidance and
cultivating acceptance of internal experiences should reduce future rates of revictimization.
The present study examined whether a brief acceptance-based and mindfulness-based
intervention (based on the theoretical model proposed by Polusny & Follette, 1995) would
reduce rates of sexual victimization among female college students with and without CSA
970 Journal of Clinical Psychology, September 2011
history. Acceptance-based and mindfulness-based behavioral interventions have been shown
to be effective in treating anxiety and mood disorders (e.g., Forman, Herbert, Moitra,
Yeomans, & Geller, 2007; Koszycki, Benger, Shlik, & Bradwejn, 2007; Ma & Teasdale, 2004;
Roemer & Orsillo, 2007; Woods, Wetterneck, & Flessner, 2006), psychotic disorders (Bach &
Hayes, 2002; Guadiano & Herbert, 2006), substance use disorders (Gifford et al., 2004; Hayes,
Wilson et al., 2004), and couples distress (Christensen, Sevier, Simpson, & Gattis, 2004;
Christensen, Atkins, Yi, Baucom, & George, 2006; Jacobson, Christensen, Prince, Cordova, &
Eldridge, 2000). Further, mindfulness-based stress reduction has been shown to positively
affect depression, PTSD, and anxiety among CSA survivors (Kimbrough, Magyari,
Langenberg, Chesney, & Berman, 2010). However, to our knowledge, this approach has
not been tested as a possible means of reducing sexual revictimization.
The goal of the current study was to develop and test the effectiveness of a brief sexual
assault prevention program, informed by the existing theoretical and empirical literature, in
reducing revictimization among college women with a history of CSA. The program used
acceptance-based and mindfulness-based strategies aimed at increasing participants’ will-
ingness to notice and allow unpleasant thoughts, feelings, and physical sensations and to
decrease attempts to avoid or suppress these internal experiences. We specifically designed the
program to be brief (2 sessions), to be both consistent with standard practice (Marx et al.,
2001; Morrison et al., 2004) and to ensure that it would be feasible and cost-effective for use
on a college campus. Further, although we were interested in the affect of the program on
sexual victimization, we purposefully designed the program to be broad and general in
content. Thus, the program was described as a workshop aimed at reducing stress and
increasing well-being and no sexual assault-specific material was included. This approach is
consistent with the application of mindfulness-based stress reduction to a broad diversity of
participants with a variety of psychological and medical conditions. Mindfulness-based
interventions have been shown to affect a number of problematic areas among college students
including stress, sleep disturbance (Caldwell, Harrison, Adams, Quin, & Greeson, 2010), and
cigarette use (Bowen & Marlatt, 2009), suggesting that targeting experiential avoidance may
affect a broad constellation of risk behaviors. It has been argued that integrating strategies
that might reduce sexual victimization into broader programs that focus generally on healthy
development may be more beneficial and cost-effective than the development and delivery of a
variety of disparate programs (Morrison et al., 2004).
Method
Participants
Participants were selected from a pool of 95 undergraduate women enrolled in psychology
courses at a private, New England university, and who were at least 18 years of age and
completed a measure assessing CSA. Childhood sexual assault was defined as sexual contact
that ranges from fondling to intercourse occurring before the age of 17 years that (a) occurred
without consent or was unwanted, (b) was perpetrated by a family member, or (c) was
perpetrated by a person more than 5 years older than the participant. To maximize
participation in this effectiveness study, we did not use random assignment. Thirty-women
(31.7%) met criteria for CSA and all were invited to participate in the program, which was
described as a mindfulness-based program designed to increase the health and well-being of
female college undergraduates. Of the 15 who agreed to participate, three women dropped out
after the first session, leaving 12 women with CSA history participating in the full
program.
The remaining 20 women with CSA history were considered part of the no-program
comparison group. Independent samples t tests revealed that there were no significant
differences between women with and without CSA history who chose to participate in the
program compared with those who declined participation with regard to their reported
demographic information (age, academic year, race/ethnicity, religion, and previous
experience with yoga or mindfulness) or responses on the self-report questionnaires.
971Mindfulness and Sexual Revictimization
Although we predicted that the program would be most effective in reducing revictimiza-
tion, we also examined the affect of the program on sexual victimization among women
without a CSA history. From a practical standpoint, we felt that the program could be most
easily integrated into a college curriculum if it was offered to all women, regardless of their
sexual history, because college students may be hesitant to routinely disclose this private
information. To create a roughly comparable group, 25 women without a reported CSA
history were contacted and asked to participate in the program. Twenty-one women agreed
and four declined due to scheduling conflicts. An additional 24 women agreed to participate in
the no-intervention comparison group. Participants were primarily White (74.6%) and had a
mean age of 18.9 years (standard deviation [SD] 5 1.88). There were no significant differences
in ethnicity or religious affiliation between women with and without a history of CSA.
Measures
Sexual Experiences Survey (SES). The SES (Koss & Oros, 1982) is a self-report
instrument consisting of 10 yes/no items designed to assess various degrees of sexual
victimization. Two versions of this measure were administered. The first assessed history of
CSA defined as events that occurred before 17 years of age. The second (administered at
follow-up) asked respondents to indicate any sexual victimization that occurred in the
2-month period since the last assessment. The SES shows high test-retest reliability in college
samples and is significantly correlated with clinician-administered interviews (Koss & Gidyz,
1985). For the purpose of this study, sexual victimization is defined as a woman who
experiences any unwanted gesture from a man that is sexual in nature, ranging from fondling,
kissing, or petting to sexual intercourse with a man’s penis or another object.
Kentucky Inventory of Mindfulness Skills (KIMS). The KIMS (Baer, Smith, &
Allen, 2004) is a 39-item questionnaire designed to measure mindfulness, which comprises the
following four subscales: observing, describing (labeling noticed phenomena), acting with
awareness (engaging in present moment activity without distraction), and accepting without
judgment. Items are rated on a 5-point Likert scale, ranging from 1 (never or very rarely true)
to 5 (almost always or always true). The reliability and convergent validity (with measures of
experiential avoidance and mindfulness) of the measure have been established (Baer et al.).
Internal consistency in the current sample was evaluated with Cronbach’s a and ranged from
.76 to .88 at pretest and .84 to .93 at follow-up.
Acceptance and Action Questionnaire (AAQ). The AAQ (Hayes, Strosahl, Wilson,
Bissett, Pistorello, Toarmino et al., 2004) is a self-report measure that assesses the construct of
experiential avoidance (i.e., engaging in efforts to avoid or reduce the frequency of memories,
thoughts, feelings, and bodily sensations), and psychological flexibility (i.e., the inability or
unwillingness to take action in the face of distressing experiences). The items on the AAQ are
rated on a 7-point Likert scale ranging from 1 (never true) to 7 (always true). Higher scores
correspond to high experiential avoidance, whereas lower scores reflect acceptance and action.
The AAQ has demonstrated convergent validity with measures of thought suppression. There
have been many variations of the AAQ (7, 9, 16, 18, and 32 items) that are highly correlated
(Hayes, Strosahl, Wilson, Bissett et al., 2004). This study used the 16-item AAQ. Cronbach’s
a ranged from .73 at pretest to .76 at follow-up.
Program utility and practice questionnaire. A measure was developed to assess the
frequency with which participants practiced the mindfulness skills they learned from the
program and whether they planned to use the skills acquired from the program in the future.
Each item was rated on a 5-point Likert-type scale, ranging from 1 (about everyday) to 5 (never).
Procedure
All participants completed the study measures (i.e., SES, KIMS, and AAQ) during the initial
screening and groups were created as described above. Those who completed the
972 Journal of Clinical Psychology, September 2011
questionnaires received course credit regardless of whether they agreed to participate in the
program.
The intervention was conducted in two, 2-hour group sessions (spaced approximately 1
week apart) and comprised a combination of college women with and without a CSA history.
An overview of each session is presented in Table 1. One of three male master’s-level graduate
students facilitated each group of approximately five to eight women. To maximize
participation, scheduling conflicts of participants were accommodated and women did not
necessarily share the same group members or have the same facilitator in session 2 as they did
in session 1. A combination of psychoeducation and experiential exercises was used to
promote (a) awareness of internal responses to events, (b) observation of the present moment/
presence in one’s life, (c) awareness of the judgments one makes about her thoughts and
experiences, (d) the cultivation of a sense of compassion towards one’s internal experience, and
Table 1
An Overview of the Program
Session 1
Phase I (20 minutes)
� Greeting the group, introducing the facilitators
� Brief introduction of what they will be doing
� Discuss/list common college stressors
Phase II (20 minutes)
� Discuss ways of coping with stressors
� Coping strategies categorized into three domains
3 Social support, behavioral activation, internal control strategies
Phase III (30 minutes)
� Evaluating the strategy of attempting to control internal events such as thoughts, emotions, and
physiological sensations
3 Benefits/consequences to this strategy
Phase IV (30 minutes)
� Limits and costs of labeling, judging and attempting to control internal experiences will be
considered
� Finding the usefulness of ‘‘negative’’ emotions
� Acceptance/mindfulness as potential alternatives to internal control strategies
Phase V (20 minutes)
� Breathing exercise
� Distribute readings and self-monitoring forms
� Briefly review how the readings and self-monitoring forms may be helpful
Session 2
Phase I (20 minutes)
� Begin with a repeat of the breathing exercise that ended the first session
� Overview of readings, self-monitoring forms, and breathing exercises that they were asked to do in
between sessions
Phase II (20 minutes)
� Discussion about the basic concept of mindfulness to refresh participants
� Exercise in accepting our internal experiences
Phase III (30 minutes)
� Discussion about willingness and personal
values
� Sentence completion exercise to illustrate obstacles keeping us from our desired goals
Phase IV (30 minutes)
� ‘‘Passengers on a Bus’’ metaphor to highlight the importance of empowerment and practicing one’s
values
� Mountain Meditation exercise further emphasizing engaging in our lives that is consistent with our
values
Phase V (20 minutes)
� Summary of mindfulness in everyday life
� Handout self-monitoring forms, readings and take-home exercises
973Mindfulness and Sexual Revictimization
(e) the differentiation between internal experiences and behavior. The program did not contain
any sexual assault specific content.
Approximately 2 months (mean [M] 5 9.97 weeks) after the program was delivered,
participants completed a follow-up assessment that included the SES, KIMS, and AAQ, and
the Program Utility and Practice Questionnaire if they had participated in the program.
Although a longer follow-up period would have been preferable, to enhance feasibility, we
opted to conduct the entire study within a semester. Moreover, a 2-month follow-up was
consistent with the timeframe used in previous studies. Thirty-eight percent of sexual
prevention programs in a recent review had follow-up periods of less than 1 month and an
additional 34% followed participants from 1 to 3 months (Morrison et al., 2004). Further,
Marx and colleagues (2001) were able to detect the affect of a prevention program on
revictimization using a follow-up period of 2 months.
Seventy-one women completed follow-up assessments. Of the 32 women with CSA history,
two from the intervention group and two from the control group did not return to complete
the follow-up assessment. Within the no-CSA group, all 24 women from the no-intervention
control group completed the follow-up assessment. Two women from the intervention group
did not continue, one because of scheduling conflicts and the other could not be reached. This
left 71 women for inclusion in the treatment analyses, 29 in the intervention group (10 with
CSA, 19 without CSA) and 42 in the control group (18 with CSA, 24 without CSA). Monetary
compensation was provided for all of those who returned for follow-up assessment.
Results
Preintervention Group Differences
A series of analyses were conducted to explore preintervention differences in study variables
among participants in the different groups and conditions. Results revealed that there was no
significant main effect of group (Wilks’ L 5 .92, p 5 .08, Z2p ¼ :09), although univariate results
indicated that women with a history of CSA scored significantly lower than those without such
a history on the Accept subscale of the KIMS, F(1,92) 5 8.74, p 5 .004, Z2p ¼ :09. Contrary to
expectations, women with and without a history of CSA did not differ significantly in
experiential avoidance as measured by the AAQ, t(93) 5 1.36, p 5 .18, r2pb ¼ :02. There were
no significant differences between those participants who were selected to receive the
intervention and those who were not on any study variables.
Sexual Victimization at Follow-up
Of the participants who completed follow-up surveys (n 5 71), 12.7% (9) reported that they
experienced sexual victimization between Time 1 and Time 2. Furthermore, 21.4% (n 5 6) of
those with CSA history reported experiencing victimization during the follow-up interval
compared with 7.0% (n 5 3) without CSA history; however, although effect size estimate
suggest that this is a moderate difference (j 5 .21), it is not statistically significant (Fisher’s
exact test, p 5 .38).
A chi-square analysis revealed that there was no significant difference in reported
victimization rates between participants in the intervention group compared with those in the
control group (collapsed across CSA history; 13.8% (n 5 4) compared with 11.9% (n 5 5),
respectively, j 5 .03). With regard to rape victimization, participants from the no-intervention
control group reported a higher incidence of rape (9.5%, n 5 7, vs. 0%, n 5 0), and although
this difference yielded a moderate effect size (j 5 .14), it is not statistically significant (Fisher’s
exact test, p 5 .12).
Sexual Revictimization at Follow-Up
The analyses conducted for sexual revictimization at follow-up included only those with a
history of CSA. A total of 21.4% of women experienced a revictimization over the 2-month
follow-up period. Although the women with CSA history who participated in the intervention
974 Journal of Clinical Psychology, September 2011
were less likely to be victimized than those with CSA history who did not receive the
intervention (10.0%, n 5 1, compared with 27.8%, n 5 5), and this difference is moderate in
size (j 5 .21), it was not found to be statistically significant (Fisher’s exact test, p 5 .28).
Further, 22.0% (n 5 9) of those with CSA history who did not receive the intervention
reported at least one attempted or completed rape compared with 0% (n 5 0) in the
intervention group. Although effect size estimates suggest this is a moderate difference
(j 5 .21), it is not statistically significant (Fisher’s exact test, p 5 .15). Among women with
CSA history who reported a sexual assault during the follow-up interval, 80.0% (n 5 8) in the
comparison group reported rape compared with 0% (n 5 0) in the intervention group. Again,
this difference was not statistically significant (Fisher’s exact test, p 5 .33), but the phi value
suggests a strong effect (j 5 .63).
Program Affect on Acceptance and Mindfulness. To investigate the program’s
effectiveness on participants’ levels of acceptance and mindfulness, a 2 (Group:
Intervention�Control)�2 (Time: Pre-screening�2-month follow-up) repeated measures
multivariate analysis of variance (MANOVA) was performed. No significant interaction was
observed (Wilks’ L 5 .88, p 5 .12, Z2p ¼ :12). Univariate analyses revealed that participants in
the intervention group scored significantly higher on the Observe subscale of the KIMS
between Time 1 and Time 2 compared with those in the control group, F(5, 65) 5 7.15, po.05,
Z2p ¼ :09. No differences between those with and without CSA history emerged (see Table 2).
A 2 (Group: Intervention�Control)�2 (CSA Status: with CSA�without CSA)�2
(Time: Pre-screening�2-month follow-up) repeated measures MANOVA was performed to
investigate the program’s effectiveness at increasing the levels of acceptance and mindfulness
specifically among participants with a history of CSA. Box’s test of equality of covariance
measures indicated that there were no violations of assumptions (p 5 .37). The Time of
Measurement�CSA interaction was not significant, L 5 .92, F(5, 63) 5 1.03, p 5 .41,
Z2p ¼ :08, nor was the Time of Measurement�Group interaction, L 5 .90, F(5, 63) 5 1.37,
p 5 .25, Z2p ¼ :10. The Time of Measurement�Group�CSA History interaction was also not
significant, L 5 .95, F(5, 63) 5 .64, p 5 .67, Z2p ¼ :05. Furthermore, univariate analyses
Table 2
Means and Standard Deviations for Study Measures for Program Participants at Pretreatment
and Follow-Up
Control Intervention
CSA (n 5 18) No CSA (n 5 24) CSA (n 5 10) No CSA (n 5 19)
Measure Pre Post Pre Post Pre Post Pre Post
KIMS-OBS
a
30.65 28.40 28.26 27.57 29.42 29.75 25.88 28.33
(7.97) (6.80) (5.89) (6.36) (4.70) (6.35) (6.4) (7.33)
KIMS-DES 25.28 25.22 28.08 26.58 29.00 28.30 26.21 27.42
(6.69) (8.26) (5.78) (7.25) (5.19) (6.93) (6.91) (6.27)
KIMS-ACT 27.80 26.17 29.41 27.32 29.30 27.80 29.16 28.58
(5.93) (7.05) (4.66) (6.51) (5.36) (6.34) (6.09) (5.10)
KIMS-ACC 29.28 30.61 33.32 33.00 29.90 29.20 34.16 34.16
(7.40) (8.56) (6.76) (6.65) (5.20) (7.86) (5.67) (7.37)
AAQ 64.79 67.28 63.77 62.38 64.10 65.40 61.11 59.05
(14.14) (9.52) (10.92) (13.11) (8.94) (9.69) (8.52) (12.09)
Note. Values in parentheses represent standard deviation. CSA 5 childhood sexual assault; KIMS-
OBS 5 Kentucky Inventory of Mindfulness Skills: Observe subscale; KIMS-DES 5 Kentucky Inventory
of Mindfulness Skills: Describe subscale; KIMS-ACT 5 Kentucky Inventory of Mindfulness Skills: Act
with awareness subscale; KIMS-ACC 5 Kentucky Inventory of Mindfulness Skills: Accept subscale;
AAQ 5 Acceptance and Action Questionnaire.
a
Significant difference at po.05 for the intervention group from pretreatment to follow-up for No CSA.
975Mindfulness and Sexual Revictimization
revealed that the program did not significantly affect levels of acceptance and mindfulness
specifically among women with a history of CSA from Time 1 to Time 2 (see Table 2).
Program Utility and Practice
Those who reported practicing mindfulness exercises at least once during the follow-up
interval (n 5 15) were significantly less likely to be victimized compared with those who did not
(n 5 14; 0% vs. 29.0%; Fisher’s exact test, p 5 .04, j 5 .40). Ninety-three percent of
participants reported that they would use the skills acquired in the program in the future.
Discussion
The victimization rates found in this study provide further evidence that sexual victimization
among college women is a significant issue. Approximately 37% of female undergraduates
who initially agreed to participate in the study reported a history of CSA and 12.7% of
participants experienced some form of sexual victimization during the follow-up period. This
rate is slightly lower than those found in previous studies (e.g., Breitenbecher & Gidycz, 1998;
Breitenbecher & Scarce, 1999; Hanson & Gidycz, 1993). The revictimization rate during the
follow-up period (regardless of participants’ assigned group) was 21.4%. Comparably, the
revictimization rates reported in previous studies were 27% to 28% (e.g., Breitenbecher &
Gidycz; Hanson & Gidycz; Marx et al., 2001). In the current study, women with CSA history
were revictimized at a rate that was approximately three times higher (although this result was
not statistically significant) than women without CSA history, adding support to the notion
that having a history of CSA is a risk factor for future sexual victimization.
Consistent with previous research (e.g., Breitenbecher & Gidycz, 1998; Breitenbecher &
Scarce, 1999; Gidycz et al., 2001), the program in the current study was not effective at
reducing overall rates of sexual assault, though it may have had some affect on rape risk.
Similar to the findings by Gidycz and colleagues, in this study, women in the control group
were more likely to experience a rape-related victimization compared with those who received
the program (9.5% vs. 0%). Although effect size estimates suggest this is a moderate
difference, it was not statistically significant.
The percentage of women in the control group who reported revictimization during the
follow-up period (27.8%) is consistent with those in previous studies (Breitenbecher & Gidycz,
1998; Hanson & Gidycz, 1993; Marx et al., 2001). In contrast, among program participants,
reported rates of revictimization in the current study (10%) were lower than the 21%–28%
rate reported in other studies (Breitenbecher & Gidycz; Hanson & Gidycz; Marx et al.). It is
important to note, however, that although reported rates of revictimization between the
intervention and control groups were estimated to be of a moderate size, they were not found
to be statistically significant. Unfortunately, the small sample size makes it difficult to interpret
this finding. However, it may suggest that an acceptance-based and mindfulness-informed
approach could have some promise.
General sexual assault prevention programs have not been successful at reducing
revictimization among women with CSA history. For example, Hanson and Gidycz (1993)
found roughly equivalent rates of revictimization (attempted/completed rape) among women
who participated in their prevention program (15%) compared with those who did not (12%).
In contrast, the current program, specifically informed by research and theory on
revictimization, had a moderate effect in reducing reported rates of revictimization
(attempted/completed rape) among women who participated in the program (0%) compared
with those who did not (22%), although this difference was not statistically significant. These
results are similar to those reported by Marx and colleagues (4% vs. 11%), who also tailored
their program to the specific needs of revictimized women. Marx also found that among those
who reported a revictimization, women who participated in the program were less likely to
report having been raped (12% vs. 30%). Similarly, in the current study, 80% of women in the
control group compared with 0% of women who participated in the program reported being
raped. Although this difference was not statistically significant, it is important to note that the
976 Journal of Clinical Psychology, September 2011
effect size was large and, at follow-up, none of the women in the intervention group reported
being revictimized by rape.
Contrary to initial hypotheses, the acceptance-based and mindfulness-based risk reduction
program did not significantly decrease experiential avoidance nor increase mindfulness. In
contrast to previous studies (e.g. Batten, Follette, & Aban, 2001; Marx & Sloan, 2002), women
with CSA history in the current study did not score significantly higher on the AAQ than
women without such a history at baseline. Based on the norms developed from undergraduate
samples comprised primarily of women (Hayes et al., 2004), the mean scores on the AAQ
reported by women in the control and intervention groups at Time 1 (M 5 approximately 64
and 62, respectively) and Time 2 (M 5 approximately 64 and 61, respectively) were slightly
lower than those of female, nonclinical norms (M 5 approximately 67). We did find that
women with CSA history were significantly less accepting of their internal experiences at
baseline as measured by the KIMS; however, the program was not effective at significantly
increasing participants’ levels of mindfulness at follow-up. Although the risk reduction
program comprised a number of clinical methods aimed at increasing mindfulness and
acceptance of internal experiences, it may be that the relatively brief intervention was not
powerful enough to produce measurable changes on these outcome variables.
The fact that the program seemed to be effective at increasing participants’ ability to
observe internal sensations despite its brevity suggests that observing internal sensations may
be a mindfulness skill that takes less time and effort to cultivate. Moving from an increased
awareness and observation of one’s internal experiences to a nonjudgmental, compassionate
acceptance of uncomfortable thoughts and feelings is likely a process that takes considerable
practice and support (Orsillo, Roemer, & Holowka, 2005). Therefore, a longer and more
involved program may be needed to achieve these desired effects.
This study was a preliminary effort aimed at developing and examining the potential benefit
of an acceptance-based and mindfulness-based risk reduction program. Consequently, it is
limited by a number of methodological shortcomings. The method of recruitment may have
created a sample bias, in which individuals with higher levels of experiential avoidance
refrained from volunteering to participate in the study. Further, because participants were not
randomly assigned to groups, those in the intervention group may have been more willing to
engage in acceptance and mindfulness than those in the control group.
There is significant variation in the way that CSA is defined and measured in the literature,
and the definition used in the current study, which included sexual experiences occurring
before 17 years of age, likely produced a heterogeneous sample of those with both childhood
and adolescent sexual assault histories, which could limit the generalizability of the findings to
other samples. Further, several features and contextual factors related to CSA that could
affect response to the program (e.g., chronicity of abuse, relationship with perpetrator, age at
first victimization, use of drugs or alcohol to avoid painful associated emotions, sexual activity
level) were not assessed in the current study. The reliance on self-report measures of
victimization is also less than ideal, as guilt, shame, and demand characteristics may have
influenced participant disclosure.
Another limitation is that group composition and facilitator were not held constant between
sessions 1 and 2. Thus, group process and working alliance may have varied as a function of
group members and program leaders. Additionally, it is possible that a male experimenter
leading the groups could have triggered some discomfort in the CSA survivors. However, the
fact that the program was not described as a sexual assault prevention program and sexual
assault was never mentioned during the interventions reduces the likelihood of this being a
significant factor.
One of the potential advantages of using mindfulness skills to reduce risk is that they can be
taught to a relatively large and diverse audience in a time and cost efficient manner. However,
we chose to first examine the potential benefit of this newly developed program in a smaller
sample, which may have made it difficult to detect potential group differences, and decreased
the external validity of our findings.
Another limitation to the study is the relatively short amount of time between preintervention
and follow-up (M 5 9.97 weeks). Although other studies had similar follow-up intervals
977Mindfulness and Sexual Revictimization
(e.g., Breitenbecher & Gidycz, 1998; Gidycz et al., 1993; Marx et al., 2001), there is some
evidence that incorporating additional longer term follow-up assessments allows the potential
effects of a program to be more easily detected (e.g., Gidycz et al., 1995, 2001). Given the
small sample in the present study, concerns over the affect of attrition (especially over a break
between semesters) led to the decision to conduct follow-up assessment as soon after the
intervention as possible.
Although the risk reduction program developed for the current study had only few
statistically significant effects on outcome, the effect sizes ranged from small to large. The
proportion of women with CSA history who were sexually assaulted or raped was notably lower
among those who participated in the program and compares favorably to previous studies.
Further, it is worth noting that the effect sizes appear promising, particularly for reducing
the incidence of rape among individuals with CSA history. Future research addressing the
methodological limitations noted here is important to fully examine the potential affect of
acceptance-based and mindfulness-based programs on revictimization. In addition to
increasing the frequency and depth of mindfulness training (as well as amount of practice
time between sessions), it may be useful to consider integrating components that have been
found to be relatively successful in other programs (e.g., Hanson & Gidycz, 1993; Marx et al.,
2001). Finally, it should be emphasized that programs such as the one in the current study are
designed to enhance skills with hope that the likelihood of sexual victimization will be
minimized. These skills do not control the perpetrator’s behavior and in no way divert
responsibility for the assault from the perpetrator to the victim.
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980 Journal of Clinical Psychology, September 2011
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Module 8
Mindfulness Intervention Research Paper Part 2
Purpose
The purpose of this 2-part assignment is to examine how mindfulness and mindfulness-based interventions are used to facilitate healing and recovery for individuals with histories of trauma
.
Students will have selected and received approval from the instructor regarding a population of focus and trauma type (e.g., bullying, disasters, physical abuse, sexual abuse). In part 1 of this research paper, students will have reviewed the literature and will have described how mindfulness has been used for their chosen topic.
In Part 2 of the research paper, students will select a specific mindfulness-based intervention and evaluate the effectiveness of the intervention based on their appraisal of the current literature.
Directions
1. Describe how you conducted your literature review, including steps and processes for locating and critiquing relevant articles. What search terms and keywords were used?
2. Briefly describe in your inclusion criteria. What articles were included and why?
3. Briefly describe and critique each article that was included in your literature review. Briefly describe each article’s strengths and limitations.
4. Were there any themes across the articles that were included in your review? If so, what did you learn?
5. Briefly answer your research question.
(Research Question)!!!!!!!!!!!!!!!
Is Mindfulness- Based Intervention effective in reducing PTSD symptoms among sexual abuse survivors?
Grading Criteria
|
Criteria |
Points |
Description |
|||
|
Paper is well-organized, clear, free of typos and grammatical errors |
40 |
The paper is extremely well organized and completely free of grammatical errors and typos. |
|||
|
Student has critically assessed the literature on the effectiveness of a mindfulness-based intervention for their chosen topic. |
60 |
The student has done an exemplary job in their assessment of the effectiveness of a mindfulness-based intervention for their chosen topic. |
|||
|
Student has examined the literature on a mindfulness-based intervention for their chosen topic. |
The student has done an exemplary job in their examination of existing research on an intervention for their chosen topic |
||||
|
Sources are appropriately integrated throughout the paper and are cited using APA style |
The paper does an exemplary job of integrating source and using APA format. |
||||
|
Student has included sources that are rooted in rigorous and reputable research methods |
The sources chosen are exceptional. The sources are rooted in rigorous and reputable research |
||||
|
Total |
220 |
A quality assignment will meet or exceed all of the above requirements. |
.
Rubric
| Mindfulness Intervention Research Paper Part 2 | ||
|
Ratings |
Pts |
|
|
This criterion is linked to a Learning Outcome Paper is well-organized, clear, free of typos and grammatical errors |
||
|
40 pts |
||
|
This criterion is linked to a Learning Outcome
Student has critically assessed the literature on the effectiveness of a mindfulness-based intervention for their chosen topic. |
60 pts |
|
|
This criterion is linked to a Learning Outcome
Student has examined the literature on a mindfulness-based intervention for their chosen topic. |
40 pts Highest Level of performance 35 pts Very Good or High Level of Performance 30 pts Acceptable Level of Performance 20 pts Failing Level of Performance |
|
|
This criterion is linked to a Learning Outcome Student has included sources that are rooted in rigorous and reputable research methods |
40 pts Highest Level of performance 35 pts Very Good or High Level of Performance 30 pts Acceptable Level of Performance 20 pts Failing Level of Performance |
|
|
This criterion is linked to a Learning Outcome
Assignment Criteria Sources are appropriately integrated throughout the paper and are cited using APA Style. |
40 pts Highest Level of performance 35 pts Very Good or High Level of Performance 30 pts Acceptable Level of Performance 20 pts Failing Level of Performance |
