The Effects of Mindfulness-Based Group Intervention on the Mental Health of Middle-Aged Korean Women in Community

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1 RESEARCH ARTICLE The Effects of Mindfulness-Based Group Intervention on the Mental Health of Middle-Aged Korean Women in Community Woo Kyeong Lee 1 * & Hee Jeong Bang 2 1 Department of Clinical Psychology, Yong-in Mental Hospital, Korea 2 Ewha Womans University, Korea Abstract This study was conducted to develop a mindfulness and self-compassion enhancement intervention for middle-aged women who complained of emotional distress and to ascertain whether participation in the mindfulness-based programme was associated with an increase in psychological well-being and the improvement of psychological symptoms. The results showed that time by group interactions were significant in improving psychological well-being, depression, anxiety, hostility, somatization, positive affect (PA) and negative affect (NA). These results suggest that participants in the mindfulness and self-compassion group programme appeared to have enhanced psychological well-being and improved psychological distress. The study findings also suggest that mindfulness and self-compassion enhancement programme may be an intervention with potential for helping many individuals to learn to deal with emotional distress. Copyright 2010 John Wiley & Sons, Ltd. Received 5 April 2009; Accepted 11 December 2009; Revised 9 November 2009 Keywords mindfulness; self compassion; emotional distress *Correspondence Woo Kyeong Lee, Department of clinical psychology, Yong-in mental hospital, Kiheung Gu Sangha-Dong, 4, Kyunggi-Province, , Korea. wisemind96@dreamwiz.com Published online 26 March 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: /smi.1303 Introduction Stress issues are highly salient to mental health in the midlife period. Kennedy and Comko (1991) found that middle-aged women ranked role stress as their main health concern. From amongst the various psychosocial correlates of self-rated health, Thomas (1997) found that stress was most strongly correlated with mental health in a sample of middle-aged women. In Korea, many middle-aged women suffer from depression, anxiety and a culture-specific syndrome called HwaByung. According to a national survey in Korea (Seoul National Hospital, 2001), the life prevalence of depression is 4 per cent, women report depression three times more than men do. Therefore, many mental health professionals suggest that role-specific stress in the middle-aged woman can lead to increased psychological distress, depression, decreased life satisfaction and even suicide. It is clear that middle-aged women need support in addressing numerous role-specific stressors such as those associated with the mother role, wife role and caregiver role that are inherent in their lives. Programmes that have been developed to improve emotional well-being and mental health status are still Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd. 341

2 Mindfulness-Based Intervention W. K. Lee and H. J. Bang in their infancy in Korea and are typically directed towards a specific illness and a limited range of symptoms. Recently, mindfulness-based intervention research has provided substantial evidence for the decrease in various psychopathological symptoms, while enhancing mental health and emotional well-being. The mindfulness-based stress reduction (MBSR) intervention (Kabat-Zinn, 1990, 2003, 2005) encapsulates many of the characteristics of mindfulness but at its core is a focus on fostering mindfulness through close, receptive attention to present events and experiences. Mindfulness-based cognitive therapy (MBCT) has focused on treating psychopathology in targeted clinical patient populations. MBCT focused on increasing metacognitive awareness and present moment, along with non-judgmental awareness of negative thoughts and feelings in an at-risk depressive patient populations (Segal, Williams, & Teasdale, 2002). MBCT has been shown to be effective in reducing depressive symptoms in individuals with recurrent depression in four uncontrolled studies (Kenny & Williams, 2007; Teasdale, 1999a, 1999b; Teasdale, Segal, & Williams, 1995). Recently, another construct like self-compassion has been fueled by a larger trend towards integrating Buddhist constructs such as mindfulness with western psychological approaches. Mindfulness and self-compassion are intimately linked. Mindfulness refers to the ability to pay attention to one s present-moment experience in a non-judgmental manner. Self-compassion entails holding negative self-relevant emotions in mindful awareness, and generating feelings of kindness towards oneself and insight into the interconnected nature of the human experience (Neff, 2003a, 2003b). Self-compassion can be a powerful predictor of mental health. For example, self-compassion is negatively associated with self-criticism, depression, anxiety, rumination, thought suppression and neurotic perfectionism, while it is positively associated with life satisfaction and social connectedness (Neff, 2003a). Increased self-compassion has been found to predict enhanced psychological health over time (Gilbert & Procter, 2006), and to explain reduced stress following participation in a widely implemented stress-reduction programme (Shapiro, Astin, Bishop, & Cordova, 2005). The current study was designed to investigate the effects of MBCT along with self-compassion training on psychological well-being and psychological symptoms in a middle-aged women suffering from multiple role-specific distress. MBCT has been adopted as a main programme since it will be more beneficial to middle-aged women who complain of various psychological symptoms such as depression, anxiety, hostility and somatic symptom. Although directly teaching compassion is not a part of mindfulness-based psychotherapy (Segal et al., 2002), in some forms of mindfulness training, standard procedures are supplemented with loving-kindness meditations (Shapiro et al., 2005). Shapiro et al. (2005) have noted the possible advantages of explicitly combining mindfulness training and compassion work in treating depression and other disorders. There are several theoretical and practical reasons for MBCT as a primary intervention for enhancing psychological well-being of middle-aged women. First, the basic attitudes of mindfulness, such as letting go, acceptance, and non-striving, are theoretically congruent with the goal of reducing the role stress experienced by middle-aged women. Second, mindfulness meditation encourages the shifting of one s relationship to cognitions rather than challenging and changing the content of one s thoughts. This approach might be more appealing than challenging beliefs and attitudes. There are several other reasons behind combining MBCT with compassion training. Just as in mindfulness-based intervention, self-compassion involves turning one s wisdom and awareness inward, thereby promoting a perspective of connectedness and the recognition of one s mind state. A number of therapies are now focusing on the importance of helping people develop inner compassion and self-soothing abilities, especially noted in dialectical behaviour therapy (Linehan, 1993; Lynch, Chapman, Rosenthal, Kuo, & Linehan, 2006). Allen and Knight (2005) have also noted the possible advantages of explicitly combining mindfulness training and compassion work in treating some depression and other disorders. Gilbert and Procter (2006) have developed compassionate mind training (CMT) and reported that CMT had a significant impact on depression, anxiety, self-attacking, feelings of inferiority, submissive behaviour and shame. In addition, females tend to be more self-critical and have more of a ruminative coping style than males (Nolen-Hoeksema, Larson, & Grayson, 1999). Many middle-aged Korean women suffer from overload as members of the so-called sandwich generation and juggle the multiple roles of being a parent to their children and a caretaker to their elderly parents. In consideration of these facts, self- 342 Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd.

3 W. K. Lee and H. J. Bang Mindfulness-Based Intervention compassion training would help reduce their sense of guilt and self-critical contingent on multiple role-stress and create a self-soothing feeling. On the basis of these rationales, our primary hypothesis was that administering MBCT along with selfcompassion enhancement in a group programme for middle-aged women will result in the reduction of psychological symptoms and negative affect, and the enhancement of psychological well-being and positive affect. We also hypothesized that MBCT combined with self-compassion training would have positive benefits in increasing their mindfulness ability and self-compassion. Methods Participants Seventy-five women aged with no prior meditation experience of any form were recruited through urban community newspaper advertisements. None of the participants was paid for her involvement with the study. Figure 1 presents number of participants enrolled, randomized and included in the analysis (Altman et al., 2001). The following inclusion/exclusion criteria were employed. Included were those who complained depressive mood. Excluded were those with under medication for depression or any other psychiatric illness. Women respondents to the advertisements participated in an individual assessment session. The experimenter obtained informed consent and demographic data, administered the battery of self-report measures and assessed participants eligibility to participate in the study. Eligible participants were then randomly assigned to the MBCT + self-compassion or wait-list control condition by the research coordinator using a random numbers table. Inclusion in the wait-list control group did not mean that participants waiting time to start MBCT was artificially prolonged, as all of them subscribed at least 8 weeks before the start of their first MBCT-session. To check that the comparison group was comparable to the experimental group, we examined their sociodemographic characteristics and pre-test scores and found no differences either in sociodemographic or the experimental variables of interest in this study. The control group consisted of 42 individuals, while the experimental group consisted 33 Approached N = 75 (randomized) MBCT 33 allocated to intervention Wait-list control 42 allocated to comparison group 30 Analysed 3 did not complete allocated intervention 30 Analysed 12 excluded (dropped out) Figure 1 Participant flow Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd. 343

4 Mindfulness-Based Intervention W. K. Lee and H. J. Bang individuals. For the control group, all participants except three individuals were available for all the assessments (pre-test and post-test). For experimental group, 12 participants were lost to post-test. Five of them decided not to participate after a single session and seven of them simply did not complete post-test. Thus, complete data were available for final samples sizes of 30 in the experimental group and 30 in the wait-list control group. This study was approved by the Research Ethics Board of the University of Ewha Womens study, Faculty of Psychology. Intervention The current intervention consisted of eight 2½ h sessions, one session per week. The programme draws on mainly MBCT manualized treatment as developed by Segal et al (2002). Participants received training in the following meditative practices: (1) sitting meditation, involving awareness of body sensations, thoughts, and emotions while continually returning the focus of attention to the breath; (2) body scan, a progressive movement of attention through the body from toes to head, observing any sensations in the different regions of the body and (3) 3-min breathing space, that focuses on the breath, the body, and what is happening in the present moment. Inherent in all these techniques is an emphasis on mindfulness, continually brining attention to the present moment. In addition to the mindfulness exercises, a loving kindness meditation was included in an attempt to middle-aged women develop greater compassion for themselves. Participants received materials and a meditation audiofile. The atmosphere of the group was warm, safe and open, facilitating participants to share their direct experiences of mindfulness and difficulties in their life. The intervention was led by a clinical psychologist (first author) with 2 years experience in MBSR and 10 years experience in CBT. Participants assigned to the waitlist control condition received the equivalent MBCT intervention immediately after the experimental group completed the intervention. They were told that the mindfulness meditation-based course would be offered following previous sessions if they wanted to enroll at that time (Table I). Table I. The contents of sessions Session asked to fill out the questionnaires in the week before their first programme session. At the last session, participants in the experimental group were given the post-test questionnaire set, and they were asked to return them via mail. Participants in the control group also filled out the questionnaire at two time points, equally spread in time. They were mailed the first packet of questionnaires were asked to fill out the questionnaire and to return these via mail to the first author. Measures Mindfulness-based cognitive therapy Psychological well-being (PWB) PWB is a self-report inventory that measures six dimensions of psychological well-being (Ryff, 1989; Ryff & Keyes, 1995); environmental mastery, self-acceptance, purpose in life, personal growth, positive relations with others, and autonomy. We used the reduced 18-item version of the scale that had been translated into Korean (Kim et al., 2001). Positive and negative affect Compassion training 1 Automatic pilot Loving kindness meditation 2 Dealing with barriers Loving kindness meditation 3 Mindfulness of the Loving kindness meditation breath 4 Staying present Loving kindness meditation 5 Allowing/letting be Loving kindness meditation 6 Thoughts are not facts Loving kindness meditation 7 How can I best take Loving kindness meditation care of myself 8 Closure Loving kindness meditation This study employed the widely used Positive and Negative Affect Schedule (PANAS: Watson, Clark, & Tellegen, 1988). The 10-item negative affect subscale assesses the degree to which participants are experiencing moods such as upset or nervous ; the 10-item positive affect subscale assesses moods like excited and proud. We used Korean Version of Cho (2007). Cho reported Cronbach s alpha coefficent of positive affect (PA; 0.88) and negative affect (NA; 0.84). Procedure Participants filled out the questionnaires at two time points. Participants in the experimental group were Beck Depression Inventory-I (BDI) The BDI is a self-rated scale that was development by Beck, Ward, Meldalson, Mock, and Erbaugh (1961) to 344 Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd.

5 W. K. Lee and H. J. Bang Mindfulness-Based Intervention assess severity of depression. Twenty-one items are rated on a four-point scale with the total score obtained from the sum of all items. Lee and Song (1991) assessed the validity and the reliability of the Korean version of the scale. The Cronbach s alpha coefficent of Korean version BDI was Symptom Checklist-90-Revision (SCL-90-R) The standardized SCL-90-R was administered to assess the severity of psychopathology. The original scale, which was developed by Derogatis, Rickels, and Rock (1976) was standardized to the version of Kim et al. (1984) and could be conveniently rated on an outpatient basis. The scale consists of various subscale, thereby facilitating the detection of psychopathology. Mindfulness scale This mindfulness scale was developed by Korean psychologist Park (2006). This scale consists of 20 items that assess mindfulness skill. Park identified four factors, such as decentred attitude, non-judgmental acceptance, present awareness and attention. Park reported a Cronbach s alpha coefficent of Self-compassion scale (SCS; Neff, 2003a) The SCS is a 26-item questionnaire designed to measure three components of self-compassion: selfkindness (being kind and understanding toward oneself rather than harshly self-critical), common humanity (viewing one s negative experiences as a normal part of the human condition) and mindful acceptance (holding painful thoughts and feelings in mindful awareness rather than over-identifying with them). Neff reported a Cronbach s alpha coefficient of In the present study, we used a version of the scale that had been translated into Korean (Kim et al., 2008). Kim et al. reported a Cronbach s alpha coefficent of Data analysis Group differences in demographic data were analysed using chi-square test, and group differences in age, education level and baseline variables were analysed using independent t-tests. After the 8-week programme, repeated measures analysis of variance (ANOVA) were used to contrast the performance of both groups. To control for Type I error due to multiple comparisons, Bonferroni correction (p = 0.05/n) was applied. SPSS/ PC Version 13 (SPSS Inc., Chicago, IL, USA) was used for statistical analysis. Results As shown on Table II, participants in the MBCT and wait-list control groups were similar with respect to demographic characteristics. In order to assess the impact of intervention on psychological symptoms and psychological well-being, a series of repeated measures multivariate ANOVAs and univariate ANOVAs were conducted on pre-and posttreatment scores within each group of measures. In order to minimize Type I error, a modified Bonferroni procedure was used. As shown on Table II, there were significant time group effects with regard to PWB [F(1, 58) = 15.38, p < 0.01], PANAS-PA [F(1, 58) = 16.85, p < 0.01], PANAS-NA [F(1, 58) = 7.61, p < 0.05], SCL- 90-R depression [F(1,58) = 15.60, p < 0.01], SCL-90-R anxiety [F(1, 58) = 14.03, p < 0.01], SCL-90-R hostility [F(1,58) = 34.11, p < 0.01] and SCL-90-R somatization [F(1, 58) = 15.88, p < 0.01]. Similarly, there were significant assessment and improvement effects observed in regard to the process variable, mindfulness [F(1, 58) = 9.42, p < 0.05] and self-compassion [F(1, 58) = 47.78, p < 0.01] (Table III). Discussion The purpose of this study was to determine whether MBCT combined with self-compassion training is Table II. Demographic characteristics of MBCT group versus the wait-list group MBCT (n = 30) Wait-list (n = 30) χ or t p Age (years) (5.41) (6.17) t = Education (years) (1.90) (2.24) t = Marital status (married) [n (%)] 26 (86.7) 24 (80) χ = MBCT: Mindfulness-based cognitive therapy. Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd. 345

6 Mindfulness-Based Intervention W. K. Lee and H. J. Bang Table III. Comparison of mean and standard deviation of dependent measures over time by group Measure MBCT group (N = 30) Wait-list group (N = 30) F ES Pre M (SD) Post M (SD) Pre M (SD) Post M (SD) Time group Time group PWB (10.64) (12.91) (7.09) (10.78) 15.38** PANAS PA (6.68) (6.50) (6.41) (6.78) 16.85** NA (9.26) (7.83) (9.41) (8.99) 7.61* BDI (7.52) 5.90 (6.96) (8.36) (8.14) 15.60** SCL Anxiety (7.81) (5.86) (8.37) (7.48) 14.03** Hostility (5.14) (3.28) (5.32) (5.51) 34.11** Somatic (6.46) (6.03) (8.25) (7.16) 15.88** Mindfulness (16.69) (11.64) (17.60) (16.04) 9.42* SCS (17.24) (16.97) (13.45) (14.37) 47.78** * p < 0.05; ** p < MBCT: Mindfulness-based cognitive therapy; PA: positive affect; NA: negative affect; PANAS: Positive and Negative Affect Schedule; ES: effect size; PWB: Psychological well-being; SCL: Symptom Checklist; SCS: Self-compassion scale; BDI: Beck depression inventory; SD: standard deviation. effective in reducing psychological symptoms and enhancing emotional well-being in middle-aged women who suffer from many psychological distress. The results revealed that post-treatment psychological symptoms scores were significantly lower than the baseline scores. These results are consistent with a previous report (Williams, Kolar, Reger, & Pearson, 2001), which suggested that mindfulness-based intervention can reduce psychological symptoms in the general population. Studies from different patient groups have shown that meditation-based therapy results in immediate post-treatment improvements in anxiety and depressive symptoms (Miller, Fletcher, Kabat-Zinn, 1995; Shapiro, Schwartz, & Bonner, 1998). Moreover, self-compassion and mindfulness also improved significantly. A recent study by Shapiro et al. (2005) examined whether participation in a Mindfulness-Based Reduction course would increase self-compassion levels. Although our programme is somewhat different from the MBSR, these results showed that MBCT combined with self-compassion training also increased the participants mindfulness and self-compassion levels. MBCT was originally designed for depressive patients. Segal et al. (2002) suggested that MBCT for depression could reduce rumination and prevent relapses in depressive patients. Furthermore, the relationship between rumination and depressive symptoms has been well-documented (Nolen-Hoeksema & Morrow, 1991). In this study, rumination was not directly checked; however, we suspect that depressive symptoms and rumination were found to have improved after the administration of MBCT. Therefore, we conclude that MBCT combined with self-compassion might be a useful intervention in relieving psychological distress, especially anxiety, depression, hostility and somatic symptoms. A significant limitation of this study is generalization. Most participants were middle-aged females, thus it is not very clear as to whether the results are fully applicable to other populations including middle-aged males. Other limitations of this study include its relatively small sample size and correspondingly reduced statistical power of assessing precise changes over time, or differences in treatment effect that may be associated with covariates. Furthermore, this study relied entirely upon self-reports. Thus, the limitation of this study is the inability to discern whether the positive results are true or if they represent demand characteristics. Besides the constraints on self-report, this study did not include any other physiological or behavioural measures of well-being. Future research could include a multidimensional outcome measures, which captures physiological or behavioural changes. Furthermore, the present study did not include follow-up data, as a result of which one cannot ensure that the programme effects will persist after terminating the programme. Despite these limitations, this study had several strengths. The current findings are consistent with research in that mindfulness can be cultivated and that it is beneficial for one s well-being. Furthermore, 346 Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd.

7 W. K. Lee and H. J. Bang Mindfulness-Based Intervention this study provides initial support for integrating selfcompassion intervention into MBCT. In South Korea, mindfulness and self-compassion-based psychological intervention is still in its infancy. Most stress management programmes for women here are developed to help mothers cope with their mentally ill children. However, this intervention in our study has been devised to promote internal growth and enhance the psychological well-being of middle-aged women who suffer from various role stresses. Future research could begin to examine the possible synergistic contributions of MBCT combined with self-compassion intervention. One may hopeful that this study, along with future controlled trials, will help elucidate the clinical benefits of using a mindfulness combined with self-compassion approach to enhance psychological well-being. Also, a large sample size and randomized controlled studies are necessary to confirm our results. In conclusion, this study provides important evidence that mindfulness-based group intervention results in positive effects on mental health. Collectively, these findings suggest that mindfulness and self-compassion training can have meaningful effects on the emotional well-being of middle-aged women who suffer from several psychological symptoms. REFERENCES Allen, N.B., & Knight, W.E.J. (2005). Mindfulness, compassion for self, and compassion for others. Implications for understanding the psychopathology and treatment of depression. In P. Gilbert (Ed.), Compassion: Conceptualisation, research and use in psychotherapy (pp ). London: Routledge. Altman, D.G., Schulz, K.F., Moher, D., Egger, M., Davidoff, F., Elbourne, D., et al., the CONSORT Group (2001). The revised CONSORT statement for reporting randomized trials: Explanation and elaboration. Annals of Internal Medicine, 134, Beck, A.T., Ward, C., Meldalson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, Cho, Y.R. (2007). Assessing emotion dysregulation: Psychometric properties of the Korean version of the difficulties in emotion regulation scale. The Korean Journal of Clinical Psychology, 26(4), Derogatis, L.R., Rickels, K., & Rock, A.F. (1976). The SCL-90 and the MMPI: A step in the validation of a new self-report scale. British Journal of Psychiatry, 128, Gilbert, P., & Procter, S. (2006). Compassionate mind training for people with high shame and self-criticism: Overview and pilot study of a group therapy approach. Clinical Psychology & Psychotherapy, 13, Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York: Bantam Doubleday Dell Publishing. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: past, present, and future. Clinical Psychology: Science & Practice, 10(2), Kabat-Zinn, J. (2005). Coming to our sense. New York: Hyperion. Kennedy, J., & Comko, R. (1991). Health needs of midlife women. Nursing Management, 22, Kenny, M.A., & Williams, J.M.G. (2007). Treatmentresistant depressed patients show a good response to mindfulness based cognitive therapy. Behavior Research and Therapy, 45(3), Kim, K.I., Kim, J.W., & Won, H.T. (1984). Korean manual of Symptom Checklist-90-Revision. Seoul, Korea: Chung Ang Aptitude. Kim, M. S., Kim, H. W., & Cha, K.H. (2001). Analyses on the construct of psychological well-being of Korean male and female adults. Korean Journal of Social and Personality, 15(2), Kim, K.E., Yi, G.D., Cho, Y.R., Chai, S.H., & Lee, W.K. (2008). The validation study of the Korean version of the Self-Compassion Scale. Korean Journal of Health Psychology, 13(4), Lee, Y.H., & Song, J.Y. (1991). A study of the reliability and the validity of the BDI, SDS, and MMPI-D Scales. Journal of Clinical Psychology, 10(1), Linehan, M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York: Guilford. Lynch, T.R., Chapman, A.L., Rosenthal, M. Z., Kuo, J.R., & Linehan, M. (2006). Mechanisms of change in dialectical behaviour therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62, Miller, J.J., Fletcher, K., & Kabat-Zinn, J. (1995). Three- Year Follow-up Clinical Implications of Mindfulness Meditation-Based Stress Reduction Intervention in the Treatment of Anxiety Disorders. General Hospital Psychiatry, 17(3), Neff, K.D. (2003a). The development and validation of a scale to measure self-compassion. Self and Identity, 2, Neff, K.D. (2003b). Self-compassion: an alternative conceptualization of a healthy attitude toward oneself. Self and Identity, 2, Nolen-Hoeksema, S., & Morrow, J. (1991). A prospective study of depression and posttraumatic stress symptoms Stress and Health 26: (2010) 2010 John Wiley & Sons, Ltd. 347

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