Professional Documents
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Abstract
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7 Two studies of a mindfulness training programme are presented. Study 1
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9 reports on a pilot investigation of the impact on wellbeing of the Breathworks
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12 mindfulness-based pain management programme. Significant positive change
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14 was found on self-report measures of depression, outlook, catastrophising,
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and pain self-efficacy in the Intervention Group, but not the Comparison
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19 Group. Particularly large effects were found for pain acceptance. These
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26 patients. Study 2 investigated alterations in mindfulness following participation
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28 in the Breathworks programme. Subjective and non-subjective measures of
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31 mindfulness were used. Scores on the Mindful Attention Awareness Scale
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33 (MAAS) were significantly higher at Time 2 in the Intervention Group, but not
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35 in the Comparison Group. There was no change on a measure of sustained
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intervention. These results are discussed with reference to the mechanisms of
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45 mindfulness.
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KEY PRACTITIONER MESSAGE:
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52 Evidence supporting the efficacy of Breathworks for wellbeing
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MAAS scores improved following mindfulness training
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57 Mindfulness may increase awareness of pleasant affect
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59 No change found on a measure of attention
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During the past twenty years, the literature describing psychological
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6 approaches to chronic pain has been dominated by coping approaches
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8 (Geisser et al., 1999) advocating control of unpleasant thoughts and feelings
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(e.g. cognitive behaviour therapy). More recently, a “third wave” (e.g. Hayes,
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13 2004) of psychological therapies has moved towards acceptance based
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15 approaches which encourage the individual to relinquish the psychological
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18 and emotional struggle with pain, and live a productive, valued life, in its
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20 presence.
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22 Within acceptance based approaches, mindfulness is promoted as a
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judgemental attention to, and awareness of, moment-by-moment experience
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32 (Kabat-Zinn, 1990). Despite ongoing debate within Western academic
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34 literature about the fundamental nature of mindfulness (e.g. Brown et al.,
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37 2008), there is evidence to suggest that the occurrence of mindful states is
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39 related to psychological benefits. For example, recent regression studies
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mindfulness been increasingly incorporated into western therapeutic
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6 approaches, including treatments for people with chronic pain.
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8 Of the growing number of therapeutic training programs available,
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Mindfulness-Based Stress Reduction (MBSR; Kabat-Zinn, 1982, 1990) is the
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13 most well known and widely researched. Typically, participants attend
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15 between eight and 10 weekly sessions during which they are taught
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18 mindfulness meditation techniques and yoga.
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20 Since the preliminary investigations during the 1980’s (Kabat-Zinn,
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22 1982; Kabat-Zinn et al., 1985; Kabat-Zinn et al., 1987), numerous publications
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25 have provided evidence supporting the efficacy of MBSR for the treatment of
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27 chronic pain (Kaplan et al., 1993; Randolf et al., 1999; Grossman et al., 2007;
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Morone et al., 2008). Outcome measures have included physical symptoms,
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32 mood and functional ability, with maintenance of benefits shown up to three
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34 (Grossman et al., 2007) and four years, post-intervention (Kabat-Zinn et al.,
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37 1987). Two recent review papers reported uncontrolled effect sizes (d)
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39 between .25 and .7 for MBSR studies involving pain patients (Baer, 2003;
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lesser extent, but the centrality of these components remains contested
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6 (Bishop et al., 2004; Brown & Ryan, 2004; Dimidjian & Linehan, 2003).
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8 The recent proliferation of mindfulness questionnaires reflects a
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concerted effort to address these issues (see Baer et al., 2006). However, this
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13 emphasis on self-report may be ill-advised due to the susceptibility of such
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15 methods to subjective bias such as demand characteristics, placebo effects
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18 and inaccuracy due to post-hoc reprocessing of information (Redelmeier &
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20 Kahneman, 1996).
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22 More specifically, there are particular problems with the subjective
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awareness itself is a core component of mindfulness, therefore, mindfulness
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32 questionnaires actually test participants’ “awareness of awareness”. This can
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34 confound subjective assessments. For example, less mindful individuals may
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37 overestimate levels of mindfulness due to a lack of awareness of mindful and
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39 mindless states. By contrast, individuals that are more mindful will be, by
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papers have included experimental measures to test the impact of
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6 mindfulness training on facets of mindfulness with non-clinical samples.
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8 Thus far, these investigations have primarily focused on the attention
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component, with mixed results. Some studies report enhanced attention
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13 control or regulation (Chambers et al., 2008; Jha et al., 2007; Tang et al.,
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15 2007; Wenk-Sormaz, 2005) and others report no improvements (Anderson et
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18 al., 2007; Ortner et al., 2007). The only study with a clinical sample (McMillan
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20 et al., 2002) found no improvement in attention following MBSR intervention
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22 for individuals with a traumatic brain injury. However, neurological damage
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Interestingly, although Anderson et al. (2007) found no advantage for
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32 MBSR upon attentional control, they did report changes on an object
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34 recognition measure i.e. a test of non-directed attention, which the authors
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37 equate to present-moment awareness. Moreover, Ortner et al. (2007) found
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39 that mindfulness training produced a reduction in interference by unpleasant
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Brown and Ryan (2003) used an implicit test of mindfulness to validate
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6 the Mindful Attention Awareness Scale (MAAS). Based on the premise that
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8 affect can operate outside awareness (Shevrin, 2000; Westen, 1998) they
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investigated the extent to which the MAAS mediated emotional awareness, as
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13 measured by the relationship between implicitly measured affect and self-
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15 report. They used the Implicit Association Test (IAT; Greenwald, et al., 1998)
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18 which is believed to measure automatic associations between categories.
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20 Brown and Ryan (2003) reported a non-significant correlation between implicit
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22 and explicit affect but the relation was mediated by the MAAS for high
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25 scorers. That is, for those with higher MAAS scores there was greater
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27 emotional awareness, supporting the validity of the MAAS with more mindful
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individuals. Of note, the questions on the MAAS are indirect, i.e. they
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32 measure less mindlessness (as opposed to more mindfulness), which may
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34 reduce the confounding problem described above (e.g. Brown & Ryan, 2003;
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37 McCraken et al., 2007).
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39 This effective utilisation of the IAT for measuring affect awareness
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prompted its inclusion in Study 2. The primary assumption of the IAT is that
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44 strongly associated attribute-concept pairs are easier (and thus quicker) to
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46 classify together than more weakly associated pairs (Farnham et al., 1999).
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48 Therefore, faster pairings of self-related words and pleasant affect words
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51 would indicate a more positive self-concept. Research demonstrates a highly
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53 consistent bias for pairing self and positive words quicker than self and
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negative words, known as an IAT effect (Farnham et al., 1999). The larger the
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58 IAT effect, the more positive the self-concept. An individual who is aware of
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60 their emotions should demonstrate a high degree of concordance between
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IAT effect and self-reported affect. That is, large IAT effects would accompany
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6 higher subjectively reported positive affect.
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8 However, the relationship between explicit measures and IAT results is
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not straightforward (Hoffman et al., 2005). For example, according to a recent
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13 meta-analysis by Hoffman and colleagues (2005), concordance rates are
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15 reduced when personal pronouns (e.g. as me, they, us) are used as target
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18 words. Brown and Ryan (2003) used personal pronouns and constructed a
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20 composite score of explicit affect by subtracting scores from trials involving
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22 unpleasant affect words from scores on trials involving pleasant affect words.
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represent end points on a single continuum (e.g. Berscheid, 1983; Diener &
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32 Emmons, 1985; Taylor, 1991). Thus, simply subtracting one score from the
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34 other may preclude the identification of post-mindfulness training alterations
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37 that specifically pertain to either positive or negative affect. Given that
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39 mindfulness may differentially enhance awareness of positive aspects of
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experience over more salient negative features (see Ortner et al., 2007)
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44 awareness of positive and negative traits may require separate analyses. In
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46 response to these issues, additional analyses were performed with the IAT
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48 data in Study 2.
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51 The work presented below attempts to build upon these experimental
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53 tests of the individual components of mindfulness and inform our
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understanding of the processes underlying the effectiveness of mindfulness.
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58 However, before investigating these processes it is first necessary to establish
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60 the effectiveness of the mindfulness training programme itself. With these
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goals in mind, we present two studies; Study 1 evaluates the clinical utility of
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6 the mindfulness programme and Study 2 provides subjective and objective
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8 tests of attention and awareness before and after mindfulness training.
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Study 1
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13 Aims and Hypotheses
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15 This study involved a pilot investigation of the effects of the
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18 Breathworks mindfulness-based pain management programme on wellbeing.
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20 Breathworks teaches mindfulness embedded within the Buddhist foundation
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22 of “loving kindness” (see Salzberg, 2002). This is distinct from many Western
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developed (e.g. Grossman, 2008; Rosch, 2008).
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32 Wellbeing was assessed using questionnaires measuring physical and
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34 psychological functioning, pain-related catastrophising, pain self-efficacy and
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37 pain acceptance, all of which are believed to impact on role adjustment and
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39 disability (e.g. Adams & Williams, 2003; Cohen et. al., 2000; Flor & Turk,
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1988; Turk & Rudy, 1986; Keefe et al., 1997; Nicholas et al., 1992;
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44 McCracken & Eccleston, 2006). Positive change was predicted across time in
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46 the Intervention Group on all measures.
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48 Method
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51 Ethical Approval
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53 Both studies were approved by the Wiltshire Research Ethics
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Committee.
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58 Recruitment
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On registration, students attending the Breathworks Pain Management
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6 Programme provided written consent to participate in research. They
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8 continued to receive medical Treatment As Usual (TAU) throughout the
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duration of the study. Comparison Group participants were recruited from an
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13 out-patient pain clinic in the South West of England and all continued to
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15 receive unstructured pain-control TAU including medication, hydrotherapy,
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18 epidural and monthly peer support. See Figure 1 for details on participant flow
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20 through the study.
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22 Design
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participants factor was the Time at which participants were tested; either Pre-
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32 intervention (Time 1) or Post-intervention (Time 2). The dependent measures
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34 were the scores on the well-being measures.
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37 Participants
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39 In total, 33 Intervention Group participants contributed pre- and post-
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main causes of pain within the Intervention and Comparison Group were
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6 lower back pain (24% and 45% respectively), arthritis (26% and 20%), sciatic
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8 injury (18% and 10%) and fibromyalgia (18% and 10%). All participants had
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been experiencing pain between one and 15 years, with no significant
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13 differences between groups (Intervention Group: M = 5.64, SD = 2.4;
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15 Comparison Group: M = 7.1, SD = 3.6; p >.05). None of the participants
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18 reported changes to their medication regime over the duration of the study.
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20 Intervention
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22 Breathworks has been in existence since 2001 and there are currently
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are taken from people with any chronic pain condition. Other than living with
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32 chronic pain, the only prerequisite of the course is full engagement, including
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34 commitment to attend the group meetings and additional daily practice of
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37 between 30 and 45 minutes.
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39 Participants attended weekly group meetings (each lasting 2.5 hours)
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The body scan practice involves systematically moving awareness
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6 through each part of the body and noticing the presence of sensation in a
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8 detailed and precise way. This enables contact with the actual sensations of
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the body (as opposed to thoughts, ideas or fears about these sensations).
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13 Mindful movement involves bringing awareness to physical activity,
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15 thus allowing movement of the body within the limits of its physical capability.
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18 This is taught by means of a comprehensive sequence of movements based
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20 on yoga and Pilates.
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22 “Kindly awareness” is a meditation practice concerned with the
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25 development of loving kindness. In the practice there are five stages in which
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27 the individual brings a kindly attitude and intention to: 1) themselves; 2) a
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friend; 3) someone in the periphery of the person’s life; 4) someone with
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32 whom there is a difficult relationship; 5) all living things. Throughout each
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34 stage, awareness is brought to bear on shared experience and
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37 connectedness.
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39 Mindfulness in daily life involves bringing awareness to ordinary,
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Measures were administered before and after the programme for the
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6 Intervention Group (i.e. between 7 and 11 weeks apart, M = 10.39, SD =
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8 1.09), and at matched intervals for the Comparison Group (M = 10.30, SD =
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1.30).
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13 Wellbeing Measures
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15 The Depression, Anxiety and Positive Outlook Scale (DAPOS; Pincus
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18 et al., 2004) was developed from factor analyses of the Beck Depression
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20 Inventory (BDI; Beck et al., 1961) and the Hospital Anxiety and Depression
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22 Scale (HADS; Zigmond & Snaith, 1983) in order to create a new questionnaire
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25 that captured the strengths, while avoiding the pitfalls of each. The 11-item,
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27 three-factor questionnaire (Depression, Anxiety and Positive Outlook) has
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demonstrated good validity and reliability (Pincus et al., 2004).
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32 The Chronic Pain Acceptance Questionnaire (CPAQ; McCracken et al.,
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34 2004) is a 20-item, two factor (Activity Engagement and Pain Willingness)
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37 questionnaire, adapted through the process of factor analysis from the
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39 original, longer version (Geiser, 1992 - unpublished). The CPAQ has
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subscales (Rumination, Magnification and Helplessness) has been reported
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6 (Sullivan et al., 1995; Osman et al., 1997) and replicated with a clinical pain
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8 sample (Osman et al., 2000).
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SF-36 Health Survey (Ware, 1993) is a widely-used measure of
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13 generic physical and psychological health status and functioning. Good
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15 psychometric properties have been reported for the two main subscales and
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18 the total score (e.g. Brazier et al.,1992; Jenkinson et al., 1993). To assess
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20 overall functional disability, the total score was used.
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22 Pain scale: Following the guidance of Jenson and Karoly (1992), a 10-
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25 point rating scale measured the intensity of average pain. The validity of
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27 numerical scales is evidenced by significant positive correlations with other
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measures of pain (e.g. Jensen et al., 1986; 1989).
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32 Missing Values
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34 Missing values were rare, accounting for less than 2% of all data
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37 values and no specific patterns were evident to suggest non-random errors.
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39 As is customary in the field, missing values were replaced with the individual’s
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underlying constructs associated with the results. To protect against type I
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6 error, the p value for statistical significance was set at .01 for all wellbeing
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8 measures.
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Results
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13 Means and standard deviations for each of the wellbeing
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15 questionnaires are given in Table 1. A 2 (Group: Intervention versus
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18 Comparison) × 2 (Time: 1 versus 2) ANOVA with repeated measures on the
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20 second factor was conducted upon the scores for each of the questionnaire
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22 scales and subscales. Results are reported in Table 2, including the F value
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and effect size (partial Eta squared: 2p). At Time 1, there were no significant
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27 differences between the Intervention and Comparison Group on any of the
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indices.
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32 Inspection of the means in Table 1 indicates that positive change
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34 occurred on all wellbeing measures in the Intervention Group. In addition,
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37 statistically significant interactions (p<.01) between Group and Time were
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39 found on the Depression and Positive Outlook subscales of the DAPOS, the
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Activity Engagement subscale and total score of the CPAQ, and the
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44 Magnification subscale of the PCS. Analysis of the simple effects indicated
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46 that these interactions were due to positive change across time in the
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48 Intervention Group but not the Comparison Group.
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51 Interactions on the Willingness subscale of the CPAQ, the PSEQ and
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53 the PCS Rumination and Helplessness subscales were marginally significant
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(.01 < p < .07). Planned comparisons indicated that changes in scores from
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58 Time 1 to Time 2 occurred in the Intervention Group but not the Comparison
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Medium to large effect sizes (.08 < 2p < .42) were found for all
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6 significant results, with a particularly large effect associated with the change in
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8 CPAQ total score in the Intervention Group.
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The changes across time on the Anxiety subscale of the DAPOS and
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13 the Pain Intensity scale were non-significant. There was a main effect of time
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15 on the SF-36 due to changes in both groups.
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18 Discussion
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20 This is the first quantitative evaluation of the Breathworks pain
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22 management programme, and evidence regarding the immediate effects on
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positive outlook, pain acceptance and pain catastrophising. These interactions
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32 reflected greater changes over time within the Intervention Group than in the
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34 Comparison Group. Marginally significant interactions (.01< p <.07) were
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37 found on indices of willingness, pain self-efficacy, rumination and
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39 helplessness. Once again, improvements over time were greater for the
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Intervention Group than for the Comparison group. Moreover, effect sizes
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44 were medium to large on all significant indices.
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46 These findings are consistent with the growing body of literature on the
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48 efficacy of mindfulness-based interventions for chronic pain and, given the
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51 importance of wellbeing factors in the functional adjustment of patients
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53 (Adams & Williams, 2003; Cohen et. al., 2000; Flor & Turk, 1988; Turk &
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Rudy, 1986; Keefe et al., 1997; Nicholas et al., 1992; McCracken & Eccleston,
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58 2006), these outcomes are greatly encouraging.
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As predicted, scores for the SF-36 increased over time in the
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6 Intervention Group. However, there was a similar improvement over time in
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8 the control group precluding further conclusions on functional outcome. The
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null result on the DAPOS Anxiety subscale is difficult to explain. However,
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13 relative to other mindfulness-based interventions, the Breathworks course
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15 involves less direct exposure work, the process through which anxiety may be
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18 optimally reduced (e.g. Kabat-Zinn, 1982; 1992).
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20 There was no change across time on the Pain Intensity scale, which is
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22 surprising given the multifaceted nature of pain and the interactions between
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25 cognitive and emotional factors and the subjective experience of pain (i.e.
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27 Gate Control Theory: Melzack & Casey, 1968; Melzack & Wall, 1965).
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However, this finding most likely reflects the acceptance ethos of the
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32 Breathworks programme and the absence of direct attempts to reduce pain.
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34 Improved wellbeing without pain reduction reinforces the importance of pain
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37 acceptance for clinical outcome. This is reinforced by the relatively large effect
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39 size found on the total score of the CPAQ (2p = .42). This result is not
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methods of measurement were employed. This is the first study involving a
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6 chronic pain sample in which core components of mindfulness have been
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8 experimentally assessed, in addition to self-report.
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Post-intervention changes reflecting improved mindfulness were
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13 expected in the Intervention Group but not in the Comparison Group on all
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15 measures, across time. Furthermore, given that mindfulness may free up
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18 resources for processing positive aspects of experience (e.g. Ortner et al.,
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20 2007) a greater improvement was anticipated in awareness of pleasant stimuli
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22 rather than unpleasant stimuli.
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25 Method
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27 Recruitment
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Recruitment methods were identical to Study 1.
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32 Participants
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34 Of the 33 Breathworks students who participated in Study 1, a
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37 subgroup of 12 volunteered to complete additional mindfulness measures.
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39 This subgroup was comparable to the group as a whole, in terms of
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bias (C) were computed. Explicit affect was measured using the subjective
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6 ratings of affect and implicit affect was assessed using the IAT effect (see
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8 below for further details).
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Procedure
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13 The time of day at which mindfulness tests were administered was
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15 approximately equivalent (within one hour) on both testing occasions to
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18 minimise the impact of medication and diurnal fluctuation in pain intensity
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20 (Folkard et al., 1976; Jamison & Brown, 1991). Mindfulness measures were
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22 completed in a quiet room, with the researcher present, who read aloud
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Measures
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32 The Mindful Attention Awareness Scale (MAAS, Brown & Ryan, 2003),
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34 is a 15-item, single factor, indirect self-report measure of emotional
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37 awareness and attention. Good psychometric properties reported in the
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39 original paper (Brown & Ryan, 2003) have been replicated with chronic pain
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patients (McCracken & Thompson, 2009), cancer patients (Carlson & Brown,
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44 2005) and student samples (MacKillop & Anderson, 2007), and incremental
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46 validity has been demonstrated (Zvolensky et al., 2006). Moreover, MAAS
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48 scores were recently shown to correlate negatively with attention lapses as
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51 measured by a Continuous Performance Task (Schmertz et al., 2009).
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53 A Continuous Performance Task (CPT) was created to measure
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sustained and focused attention. The standard CPT was modified for use with
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58 adults to include a measure of response inhibition (Epstein et al., 1998). Four
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60 hundred stimuli (in the form of uppercase letters) were flashed on to the
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centre of a computer screen at the rate of one per 130 milliseconds, with 600
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6 milliseconds between letters (Klee & Garfinkel, 1983). Participants were
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8 required to press the space bar immediately following presentation of any
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letter except an X and inhibit responding on presentation of an X. The letter X
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13 constituted 10% of stimulus presentations.
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15 A computerised Implicit Association Test (IAT) was constructed to
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18 measure automatic associations between self and affective states. The
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20 content and format of the IAT were identical to that used by Brown and Ryan
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22 (2003) and the reader is referred to that paper for further details. The IAT
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the screen or the category named in the top right-hand corner of the screen.
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32 Participants indicated their choice by pressing a button on the left or right side
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34 of the keyboard, respectively. Categories were presented in concept pairs,
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37 with one category presented on each side of the screen. Four categories,
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39 consisting of two concept pairs were used. One concept pair related to the
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self and was labelled “Me” and “Not Me”. The target words for this pair were:
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44 me, my, mine, I, participant’s name (“Me” category); they, them, their, other
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46 (“Not Me” category). The other concept pair related to affect and was labelled
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48 “Pleasant” and “Unpleasant”, for which the target words were: happy,
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51 enjoying, pleased, joyful (“Pleasant”); angry, depressed, frustrated, unhappy
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53 (“Unpleasant”).
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Initially, two practice blocks involved categorising the target word when
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58 only the relevant concept pair was shown (simple blocks). For example, for
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60 the target word “angry” the categories “Pleasant” and “Unpleasant” were
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shown. The “Me/Not Me” categories were presented first (block 1) followed by
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6 the “Pleasant/Unpleasant” categories (block 2). This was followed by another
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8 practice (block 3) but this time with all four categories shown, with one
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category from each concept pair on the left and the other on the right. So, for
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13 example, the categories “Me” and “Pleasant” were shown on the left of the
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15 screen and the categories “Not Me” and “Unpleasant” were shown on the
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18 right. Data were collected from block 4 which was identical to block 3. Block 5
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20 was a simple practice block in which the “Me” and “Not Me” categories
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22 swapped screen sides with each other. Block 6 was a combined practice
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25 block involving all four categories but this time with a different combination on
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27 each side of the screen. So, this time, the categories “Me” and “Unpleasant”
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appeared on the left and “Not Me” and “Pleasant” appeared on the right. Data
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32 were collected from block 7 which was identical to block 6.
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34 The ordering was counterbalanced so that half the participants began
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37 with the “Me/Pleasant” and “Not Me/Unpleasant” combinations and the other
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39 half began with the “Me/Unpleasant” and “Not Me/Pleasant” combinations,
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with the same order presented at time 1 and time 2. Each target stimulus was
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44 presented twice within each block. Reaction times and errors were recorded.
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46 Again, following Brown and Ryan (2003), awareness of affect was
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48 tested by assessing the correlation between the IAT effect and a
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51 corresponding explicit measure. The explicit measure contained the same
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53 affect words as the IAT and required participants to respond on a 7-point
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Likert-type scale (1 = not at all; 7 = extremely) to the question: “At the present
57
58 time, to what degree are you experiencing the following emotion?”
59
60 Analytic strategy
1
2
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All data sets were initially examined for distribution normality and
4
5
6 outliers. MAAS results were analysed in the same way as the wellbeing
7
8 measures in Study 1. Non-parametric tests were applied to the non-subjective
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mindfulness data due to distribution instability.
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13 Results
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15 Table 3 provides means and standard deviations for all three
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18 mindfulness measures, and z scores for the IAT and explicit affect measure.
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20 There were no significant differences between the groups at Time 1 on any of
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22 the measures.
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24
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34 statistic d prime (d’). Essentially d’ reflects the proportion of non-X trials on
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37 which the space bar was depressed (correct hits) minus the proportion of X
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39 trials on which the space bar was depressed (false hits). Inspection of the
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than 20% of items, leaving 12 participants in each group. There were no
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6 differences between these two groups on demographic and pain indices.
7
8 In line with previous research, there was a significant IAT effect in both
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groups at both time points. Thus, participants responded significantly more
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13 quickly on the consistent pairings (i.e. “Me”/”Pleasant” and “Not
14
15 Me”/”Unpleasant”), than on the inconsistent pairings (i.e. “Me”/”Unpleasant”
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18 and “Not Me”/”Pleasant”). There were no differences in IAT effect from Time 1
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20 to Time 2 (Intervention, z = -.68, Comparison, z = -.31). That is, implicit affect
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22 did not change over time. This was as predicted – mindfulness training was
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24
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explicit measures of affect.
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32 The explicit measure of current affect found that participants
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34 predominantly reported pleasant rather than unpleasant affect. In the
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37 Intervention Group the difference between pleasant and unpleasant explicit
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39 affect was non-significant at Time 1 but was significant at Time 2. There were
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2
3
The IAT effect was also calculated separately using the responses to
4
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6 the five pleasant traits and the five negative traits (excluding trials on which
7
8 personal pronouns acted as target words). Within the Intervention Group data
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at Time 1 there was a non-significant trend towards a negative correlation
12
13 between explicit and implicit scores, for the pleasant traits (rs (9) = -.47). This
14
15 trend was reversed at Time 2 and there was a non-significant positive
16
17
18 correlation (rs (10) = .37). This is in contrast to the Comparison Group data, in
19
20 which there was no correlation at either time point (Time 1, rs (10) = -.028;
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22 Time 2, rs (10) = -.007). One outlying value (> 2 SD from mean) was removed
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24
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34 Discussion
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37 Self-reported mindfulness, as measured by the MAAS, improved
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39 following the Breathworks course. This suggests that people perceived
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This finding is consistent with the hypothesis that mindfulness enables greater
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6 awareness of a wider range of experience, as opposed to a narrowed focus
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8 on the most emotionally salient aspects of the perceptual field, such as pain
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11
and negative mood (Melbourne Academic Mindfulness interest Group, 2006).
12
13 Further support for this idea was that implicit pleasant affect was significantly
14
15 greater than implicit unpleasant affect pre- and post-intervention (the IAT
16
17
18 effect), whereas the difference on the explicit measure was significant post-
19
20 intervention only. There is, therefore, some evidence that awareness of
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22 inherently positive implicit affect improved following mindfulness training.
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There were no changes on any of the indices of the CPT, despite the
31
32 inclusion of an inhibition component within the measure. A number of possible
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34 explanations are considered. First, lack of power in the analyses could be
35
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37 responsible, although this seems unlikely given the essentially equivalent
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39 performance of both groups across time. Second, perceptual CPTs may lack
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Two aims were addressed in this study: Firstly, to provide pilot data on
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6 the effectiveness of the Breathworks mindfulness training programme on
7
8 indices of wellbeing, and secondly to investigate the impact of the course on
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multiple measures of mindfulness.
12
13 Preliminary evidence has been provided for the immediate efficacy of
14
15 the Breathworks course on important indices related to the impact of chronic
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17
18 pain. Particularly large effects were found for pain-acceptance in the absence
19
20 of reduced pain intensity, and a trend towards increased awareness of
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22 pleasant affect was identified in the data. These findings provide further
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24
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outcomes, and the mechanisms by which it does so, large scale regression
31
32 studies are required.
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34 The measurement of mindfulness is in its infancy. This is the first study
35
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37 to use both subjective and objective methodology to evaluate a mindfulness-
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39 based intervention with a clinical pain population. Improved MAAS scores
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2
3
A number of limitations of this study should be noted. Small sample
4
5
6 sizes threaten the validity of results, and effect sizes should be interpreted
7
8 with caution. Nonetheless, reliable differences have been found on many of
9
10
11
the key measures and these findings, alongside the trends found within the
12
13 mindfulness measures, could provide helpful stimuli for future research.
14
15 Clinical outcome studies can be criticised for the self-selection of
16
17
18 participants. However, there is no evidence that Breathworks participants
19
20 were particularly susceptible to mindfulness training given the equivalence of
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22 Intervention and Comparison Group MAAS scores at Time 1. Moreover,
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24
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psychological interventions. At the outset, participants often report scepticism
31
32 about the utility of mindfulness training. Thus, placebo effects are likely to be
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34 minimal. Notwithstanding these observations, the implementation of an RCT
35
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37 represents a fundamental next step.
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39 The absence of objective functional outcome measures reduces the
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3
This study provided evidence regarding the immediate effects of the
4
5
6 Breathworks programme but long-term consequences are, as yet, unknown.
7
8 Research from other longitudinal studies shows that meditation practice and
9
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11
associated benefits, are maintained between 3-months and 4-years post-
12
13 intervention (Grossman et al., 2007; Kabat-Zinn et al., 1987; Morone et al.,
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15 2008) and are related to functional outcomes such as return to work (Cohen
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17
18 et. al.,2000; Adams & Williams, 2003). Subsequent research is required to
19
20 assess the longevity of the benefits reported here.
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21
22 Acknowledgement
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24
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25 Most importantly we thank all the participants who gave their time so
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27 generously. Thank you to Gary Hennessy and Mike Osborn for their
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enthusiasm and support throughout the duration of this research. Thanks also
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32 to Jeremy Gauntlett-Gilbert and Reg Morris for helpful comments on previous
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34 drafts of the manuscript.
35
36
37 References
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39 Adams, J.H., & Williams, A.C. (2003). What affects return to work for
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n=20 n=13
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23 Comparison Group Intervention Group
24 Treatment as usual. Breathworks programme completed.
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n=18 n=12 n=20
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28 Participant completes Study 1 questionnaires.
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Table 1: Self-report wellbeing measures: means and standard deviations.
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7 Intervention Control
8
9 Time 1 Time 2 Time 1 Time 2
10
11 DAPOS N 21 21 20 20
12 Depression Mean 12.52 10.10 11.55 11.70
13 SD 3.57 3.35 4.74 4.03
14
15 Anxiety Mean 7.43 6.71 6.20 6.25
16 SD 2.79 2.69 3.12 3.14
17
18 Positive Outlook Mean 9.48 10.71 10.50 9.85
19 SD 1.44 2.53 2.98 2.94
20
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21 CPAQ N 24 24 20 20
22 Activities engagement Mean 35.08 42.67 35.25 35.65
23 SD 10.51 10.81 9.99 9.21
24
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31 PSEQ N 33 33 20 20
32 Mean 31.58 36.42 31.70 31.45
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39 Rumination Mean 8.29 5.68 7.90 7.55
40 SD 4.82 3.68 4.53 4.43
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Table 2: Self-report wellbeing measures: 2*2 ANOVA results.
4
5
6
7 Note: Time = main effect of time; Group x Time = Interaction; Intervention Group - Time =
8 simple effect of Time within the Intervention Group.
9
2
10 Note: * = p <.01; p = partial Eta squared: A small effect is 0.01 to 0.06, a medium effect is
11 0.06 to 0.14, and a large effect is 0.14 and higher.
12
13
14 Measure F df MSE 2p
15 DAPOS
16 Depression Time 4.20* 1,39 6.33 .10
17 Group x Time 5.21* 1,39 6.33 .12
18 Intervention Group - Time 9.78* 1,39 6.33 .20
19
20 Anxiety Time .71 1,39 2.26 .02
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Table 3: Means, standard deviations and z scores for the mindfulness
4
5 measures.
6
7 Note:* = p < .05; ** = p < .01; z = Wilcoxon Signed Ranks Test statistic of difference between
8 pleasant and unpleasant scores
9
10 Intervention Comparison
11 Time 1 Time 2 Time 1 Time 2
12 MAAS N 12 12 18 18
13 Mean 3.35 4.09 3.55 3.72
14 SD .66 .62 .94 1.06
15
16 CPT N 12 12 18 18
17 d’ Mean 2.61 2.63 2.02 2.18
18 SD .62 .99 1.11 1.40
19
20 IAT effect N 12 12 12 12
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25 Explicit affect N 12 12 12 12
26 (pleasant – unpleasant) Mean .74 2.13 1.73 2.01
27 SD 1.90 1.24 1.71 2.84
28 Z -1.16 -3.06** -2.59** -1.96*
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