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/ 19
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Caton: Garand EL, any AW, Goldin PR Gross
4 2017) Testing the minaines-to-mearing
tteory Esdence for mint postive emeton
requstn rom areanlys fongtusinal data
PLoS ONE 12(12):<0187727hpsoiorp
1018714ounalpone0t87727
Ear: Ousina Ooi Bangor ives, UNTED
aN600M
Received: amiary 25,2017
‘Accepted: September 29,2017,
Published: Decomber 6, 2017,
Copyright 22017 Garand eta. This san open
acces aril sod under teers of the
Creative Commons Atrbuon Lense, which
permis unesticed use, dsb, ant
reproduction nany mex, prove th rial
tute and source te rete.
Data Availabilty Statement: Te datasets been
epost tote arpa atthe Open
cence Framework, URL:htpsost ini
Funding: Thi esarch was supra by an MIM
ant RO TMHO76074, aware James J. Gross.
Eric. Garand vas supported by NIDA gant
109042033 and NCCI grant RSTATOOS295
hing the preparation of this marusrpt. The
contents soe the respons ofthe autos
an doesnot necessarily represent the ocal
views o he National nts of Heath
Testing the mindfulness-to-meaning theory:
Evidence for mindful positive emotion
regulation from a reanalysis of longitudinal
data
Eric L. Garland"?**, Adam W. Hanley", Phillipe R. Goldin‘,
1 College of Socal Work, University of Utah, Salt Lake City, Utah, United States of Amatica,2 Contoron
Minctuness and Integrative Heath Interveniton Development, Slt Lake City, Utah, United Stats of America,
3 Huntsman Cancer Institute, University o! Utah, Sal Lake iy, Utah, Untied States of America, 4 Betty
Irene Moore Schoo of Nursing, Univesity of Calforia Davis, Sacramento, California, Unitod States of
America, § Stanford Univers, Stanford, Calfomia, United States of America
james J. Gross*
* orc garland socwk tah edu
Abstract
Background and objective
The Mindfulness to Meaning Theory (MMT) provides a detailed process model of mindful
positive emotion regulation.
Design
We conducted a post-hoc reanalysis of longitudinal data (N = 107) derived from a RCT of,
‘mindfulness-based stress reduction (MBSR) versus cognitive-behavioral therapy (CBT)
{or social anxiety disorder to model the core constructs of the MMT (attentional control, decen-
tering, broadened awareness, reappraisal, and positive affect) in a multivariate path analysis,
Results
Findings indicated that increases in attentional control from baseline to post-training pre~
dicted increases in decentering by 3 months post-treatment (p<.01) that in tum predicted
increases in broadened awareness of interoceptive and exteroceptive data by 6 months
post-treatment (p<.001). In turn, broadened awareness predicted increases in the use
of reappraisal by 9 months post-treatment (p<.01), which culminated in greater positive
affect at 12 months post-treatment (p<.001). MBSR led to significantly greater increases
in decentering (p<.05) and broadened awareness than CBT (p<.05). Significant indirect,
effects indicated that increases in decentering mediated the effect of mindfulness training
(on broadening awareness, which in turn mediated enhanced reappraisal efficacy.
Conclusion
Results suggest that the mechanisms of change identified by the MMT form an iterative
Chain that promotes long-term increases in positive affectivity. Though these mechanisms
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 119 OPLOS | one
Mind postive emotion roguation
Competing interests: To authors hao declared
that no competing terest exist.
‘may reflect common therapeutic factors that cut across mindfulness-based and cognitive-
behavioral interventions, MBSR speciticaly boosts the MMT cycle by producing significantly
‘greater increases in decentering and broadened awareness than CBT, providing support for
the foundational assumption in the MMT that mindfulness training may be a key means of
stimulating downstream positive psychological processes,
Introduction
Cognitive, emotional, and physical health benefits have been linked to mindfulness, or the
_metacognitive tendency o intentionally attend tothe flow of experience with equanimity
4], Mindfulness is believed to be a natural psychological capacity [5] capable of being enhanced
by intentional practice [6], such as mindfal breathing meditations delivered within mindful
s-based interventions (MBIs)-interventions which have been shown in meta-analyses to
improve mental health (7] and physical functioning [8} The formal practice of minefulness
‘meditation involves repeated placement of attention onto an object while alternately acknow-
edging and letting go of distracting thoughts and emotions. Objects of mindfulness practice
can include the sensation of breathing; the sensation of walking; interoceptive and propriocep-
tive feedback about the body’ internal state, movement, and position; visual stimuli such a
candle flame or running water; mental contents such as thoughts or felings: or the quality of|
awareness itself. Such practices have been shown to increase the disposition to be mindful in
everyday life [9], and to produce changes in neurocognitive function consistent with inereased
attentional control, emotion regulation, and self-awareness [10].
‘At the same time, recent evidence demonstrates that activities other than meditation and
forms of clinical intervention other than MBIS can increase mindfulness. For instance, involve-
‘ment with cognitive behavioral therapy [11] and even washing dishes in an intentional manner
as an informal meditation practice (12] have been shown to increase mindfulness, As such, a
wide variety of pursuits may yield substantive changes in mindfulness. and thereby confer
downstream benefits of mindfulness on psychological and physical health. Given the benefits
‘of mindfulness and the diverse means by whieh it may be cultivated, mindfulness is positioned
as unique construct inthe service of promoting well-being.
In the pursuit of alleviating suffering, considerable empirical and theoretical efforts have
been made to clarify the mechanisms by which mindfulness reduces unpleasant cognitive,
«emotional, and physieal experiences [13~15]. However, considerably less effort has been
directed towards specifying the mechanisms by which mindfulness encourages positive experi-
ences and psychological well-being, Tis is an important oversight with clinical relevance,
given linkages between positive emotional processes and health [16,17]. Indeed, positive affect
stimulates the neuroendocrine, autonomic, and immune systems in salutary ways that are
independent of negative affect {18}, promote pain relief [19], and engender physical and psy-
chological benefits in part by enhancing higher-order cognitive atitudes and processes like
optimism [20], reappraisal [21], and meaningfulness in if [22] In turn, indices of eudaimonic
well-being, ke purpose in life, have been shown to predict improved function in physiological
systems involved inthe stress response [23] and are linked with a genomic profile that is
potentially health-generating [24].
Recently, the Mindfulness to Meaning Theory (MMT) [25] was proposed as a model of
‘mindful positive emotion regulation to fil the lacuna of formalized theory connecting mind-
fulness to more enduring, positive markers of health, such as eudaimonic well-being, The
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 2110 Mind postive emotion roguation
MMT provides a detailed process model explicating changes in downstream perceptual ten-
dencies as well as emotion regulation strategies proposed to emerge from the state of mindful-
ness. The MMT asserts that 1) engaging attentional control inthe face of stress fosters 2)
decentering from stress appraisals into a metacogaitive state, which yields a 3) broadening
‘of awareness to encompass previously unattended interoceptive and exteroceptive sensory
information. This novel contextual information is then 4) processed and integrated into new
adaptive reappraisal of self and world, ultimately 5) resulting in a durable form of positive
affectivity and the sense of meaningfulness in life. Though the MMT was originally developed
to account for the ways in Which mindfulness training (such as that afforded by MBIs) might
promote positive emotion regulation, the MMT does not specify mindfulness meditation per
se but instead specifies mechanisms implicated in the state and trait of mindfulness (eg.,atten-
tional control, decentering). Therefore, the MMT may delineate transtherapeutic processes
linking mindfulness to reappraisal and positive affect that arise asa result of any psychological
intervention capable of stimulating the state and trait of mindfulness. For full description of,
the MMT, see Garland and colleagues [26,27]
Key processes in the MMT linking mindfulness to reappraisal
Attentional contol, or the ability to sustain attention on an abject in the context of distraction
and deliberately shift (ie, r-orient) attentional focus [28], isa fundamental mechanism of
‘mindfulness. Dispostional mindfalnes, a psychological propensity strengthened by mindfal-
ness training [9] is positively associated with sustained attention [29,30] and the ability to re-
orient attention in the face of emotional stimuli [51]. Many MBs seek to promote both atten-
‘ional capacities (Le, focusing and shifting) through direct instruction on focused-attention
practices (i. attending to an identified object such as the breath) as well as open-monitoring
practices (ie, attending indiscriminately to the flux of experience) [32]. While evidence is not
conclusive [14] empirical research demonstrates that mindfulness training supports sustained.
attention capacity, generally in advanced meditators, 33,34] and augments attentional orient
ing capacity inthe carly stages of meditation [35,36]-this latter finding has been paralleled by
evidence ofthe effects of MBs on reducing attentional bias towards emotionally threatening
cues [37,38], Asa result of such enhanced attentional capacity, mindfulness practitioners (and
individuals who experience increased dispositional mindfulness through CBT and other inter-
ventions) may be better able to regulate their attention in response to distressing thoughts and
emotions Bete attentional regulation may promote decentering from dificult psychological
content as attentional resources can be more intentionally mobilized to initiate cognitive cop-
ing strategies
Decentering, the act of disengaging from sensory, cognitive or emotional phenomenon to
achieve a psychological or reflective distance in relation to internal experiences [39] is held to
be an essential mechanism of mindfulness by some theorists [340]. Other theorists suggest
that while decentering shares considerable conceptual overlap with mindfulness, decentering
isa distinct construct from mindfulness [40,41] that can also be stimulated by CBT [39]. In the
MMT, decentering is believed to lear working memory of tress appraisals, undo attentional
biases associated with stimulus-contingent, maladaptive cognitive schemas, nd disrupt auto-
‘matic behavioral repertoires. The MMT proposes that through decentering, attention is disen-
sgnged from habitual cognitive sets and broadened into a state of metacognitive awareness, a
:ode of apperception in which one monitors the object of cognition as wells the meta-level
of awareness in which dynamic models (eg. schemas) ofthe object level are contained (Le.,an
awareness ofthe quality of awareness itself [#2] In other words, the MMT operationalizes
dlecentering asthe proces by which the state of melacognitive awareness emerges, tate in
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 anne Mind postive emotion roguation
which both the attentional object and the field in which the object is perceived may exist in
awareness simultaneously. Recent conceptual models and related empirical evidence indicate
that decentering is inked with metacognitive awareness, as well as reduced reactivity to and
disidentification from thoughts [40]. Although models differ concerning whether decentering
‘or metacognitive awareness is taken as primary [25,40], the relationship between the con-
structs is commonly viewed as recursive. Moreover, contemplative science theories posit that
decentering is an inital stage in the existential progression towards deepening metacognitive
awareness ofthe field in which subject and object is construed-a form of metacognitive self
regulation that results in insight into the ‘intentionality of concepts’ and thereby enhances the
Aluidity of conceptual processing [43]. Regardless ofits relationship with decentering, meta-
cognitive awareness has been long held as a mechanism of mindfulness [4,14]. Hence, the
practice of mindfulness could be characterized as repeated instances of decentering from emo:
tional events and/or mental proliferation into a metacognitive state. Indeed, mindfulness train-
ing has been associated with increased decentering and metacognitive awareness [44~46],
In the MMT, the construct of broadened awareness of interoceptive and exteroceptive
information refers to increased access to perceptions of the internal milieu and the external
environment made possible by decentering into a metacognitive state-yielding contextual
information that was previously constrained by the narrowed attentional perspective induced
by stress and negative affective states. This expansion of te field of awareness is theorized to
{facilitate reconfiguration of appraisal by integrating previously unattended, positive contex-
tal features into apperception of neutral and negative events, resulting in a more balanced set
of interoceptive and exteroceptive information from which reappraisals can be generated. In
this way, broadened awareness of internal and external context is theorized in the MMT to be
instrumental in positive reappraisal, or the process through which stressful events are recon-
strued as benign, meaningful, or growth promoting [47]. In support ofthis contention, height-
ened levels of interoceptive awareness enhance electrophysiological and subjective markers of
reappraisal efficacy [18 and are associated with increased use of reappraisal [49]. Similarly,
attention shifting i linked with reappraisal efficacy [50] and increased attention to positive
information has been associated with the propensity to reconstrue adversity as a source of
personal growth [51]-a propensity that has been shown to be enhanced by mindfulness [52]
Hence, broadening awareness to encompass and process a larger array of contextual informa-
tion may provide the novel input necessary to construct a reappraisal narrative. For evidence
of a similar assertion see Wadlinger and Istacowitz [53]. In turn, experimental evidence indi-
cates that positively reappraising negative events enhances positive affectivity and psychologi-
cal well-being [21,54,55]
Unifying these conceptual and empirical considerations, the MMT proposes the mindful
veappraisal hypothesis [27], which states that mindful decentering promotes reappraisal by
broadening awareness, thereby increasing access to previously unattended contextual data
from which new appraisals can be constructed. In tur, reappraisal is identified within the
MMI asa primary, cognitive self-regulatory mechanism that may engender positive emotions
and ultimately introduce greater flexibility in the construction of meaning from experience.
Given relations between positive affect and health, the MMT may hold considerable utility for
the theory and practice of psychotherapeutic intervention.
The direct relation between mindfulness and reappraisal
Mounting evidence supports the mindfal reappraisal hypothesis indirectly by establishing
bivariate associations between these core constructs within the MMT’s theoretical framework
{13] Gor additional reviews establishing relations between attentional control, deentering
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 40 Mind postive emotion roguation
and broadened awareness, se [40]. The proposed relation between mindfulness and reap-
praisal hs also been supported by recent empirical work indicating a direct relation between
these two constructs (24). Itis particularly important to establish the direct relationship
between mindfulness and reappraisal a the conceptual nature of reappraisal is sometimes
posed to be antithetical tothe ostensibly non-conceptual state of mindfulness [56]. However,
better understanding the exchange between the non-conceptual mechanisms implicated in
‘mindfulness and the conceptual field of day-to-day life holds considerable clinical and theoret-
ical utility. Though the prospect of suspending conceptual processing for extended periods in
daily life is purportedly achievable for long-term meditators, re-engaging conceptual thought
(ie, appraisals) in the immediate wake of mindfulness remains a necessity for noviee mindful-
ness practitioners. Evidence from a number of correlational [57], quasi-experimental [58.59],
and experimental studies [11,60,61] suggests that mindfulness may support reappraisal. In
contrast to CBT which largely focuses on modifying propositional (i... declarative, semantic)
:meanings, mindfulness may bolster reappraisal by modifying implicational meanings relevant
to the stressor context and one’s broader sense of self [62]. Implicational meaning goes beyond
the explicit, conceptual framing of an experience toa felt, holistic interpretation ofthe experi-
ence, atype of meaning-making that has been theorized to be an especially potent means of
transforming one’s experience of affective distress [63]. Accessing metacognitive insight
through mindful decentering has been posited asa means of facilitating the remapping of |
mplicational meanings [43|-which hypothetically would result in contextual reappraisal
Furthermore, the relationship between mindfulness and positive reappraisal may operate in
an cross-lagged fashion such that increases in state mindfulness across time promote increases
in positive reappraisal, a finding recently observed in temporally-dynamic causal modeling
attempts [64]
The present study
Despite its theoretical coherence, empirical support for the MMT has been “patch-worked”
together by demonstrating bivariate relationships between the core model components in sep-
arate studies. Only one prior study has simultaneously examined linkages between multiple
core constructs specified in the MMT in a multivariate path analysis of cross-sectional data
obtained from a sample of eancer survivors [65], but this analysis was limited in its ability to
ascertain time-ordering ofthese constructs and their responsivity to intervention, To date,
‘no comprehensive examination of the MMTT has been conducted with longitudinal data. The
next step in testing and refining the MMT is to situate the identified, core model components
together in a single longitudinal analysis, investigating the entre theoretical model in response
to clinical intervention. To that end, in this post-hoc secondary data analysis, the MMT was
‘modeled with data from a RCT of participants with social anxiety disorder (SAD) who were
randomized to either 12 weeks of a mindfullness-based stress reduction (MBSR) course or
cognitive-behavioral therapy (CBT) delivered ina group format. Though this rial was
designed to examine the differentia efficacy and mechanisms of MBSR and CBT for social
anxiety, a numberof the mediating variables collected in this study map onto the MMT, We
employed the longitudinal dataset from this tril to conduct post-hoc modeling of the MMT
with the hope that the mechanistic insights gained from this secondary analysis might have
broader application.
In the Goldin etal. trial [11], relative to.a wait-lst control, both CBT and MBSR signifi-
cantly improved anxiety while inereasing mindfulness and reappraisal, and increases in mind-
fulness and reappraisal did not significantly differ between these two active interventions. The
finding that MBSR significantly inereases reappraisal (without providing explicit reappraisal,
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 5/19 Mind postive emotion roguation
training) provides the strongest and most direct support for the mindful reappraisal hypothesis
of MMT yet. Though pedagogical and experiential techniques in CBT and MBSR may be sub-
stantively different, both treatment approaches appear to operate on common factors via
underlying transtherapeutic change mechanisms. Yet, mindfulness training through MBSR
_may specifically stimulate the MMT process by selectively targeting core MMT constructs inte-
gral to the practice of mindfulness (eg, decentering, broadening of awareness).
To model the change process in accordance with the MMT, we hypothesized that increases
in attentional control {from Time 1 (baseline) to Time 2 (immediately post-treatment) would
predict increases in decentering (by Time 3; 3 months post-treatment), that would in turn pre~
dict increases in broadened awareness of interoceptive and exteroceptive data (by Time 4;6
_months post-treatment). In turn, broadened would predict increased use of reappraisal (by
ime 5; 9 months post-treatment), which would culminate in greater positive affect (by Time
6; 12 months post-treatment). In addition to testing these hypothesized linkages between these
core constructs as specified by the MMT, we also tested the influence of MBSR vs CBT on ther-
peutic change in these constructs,
Materials and method
Participants and procedures
Participants (1 = 107) were included inthis study if they met criteria for a principal diagnosis,
of social anxiety disorder. Exclusion criteria included: involvement with psychotherapy or
pharmacotherapy during the previous year participation in CBT for an anxiety disorder dur-
ing the previous two years: history of mindfulness practice involvement either through an,
[MBSR course, long-term meditation retreat, or individual practice, and history or current neu-
rological disorder, cardiovascular disorder, thought disorder, bipolar disorder, or substance
use disorder.
Participants were randomized into one of three, 12-week conditions: 1) CBT, 2) MBSR, or
3) waitlist control. Following the waiting period, participants in the wait-ist were randornly
assigned and crossed over into ether CBT or MBSR. To maximize the effective sample size in
the present secondary data analysis, we examined data from all participants following random-
ization to CBI or MBSR (including those participants who were originally randomized to the
\ail-list condition). Pretreatment assessments, measuring attentional control, dispositional
‘mindfulness, emotion regulation and positive afect were also administered at posttreatment
and at 12 months aftr posttreatment. An abbreviated assessment battery, including measures
of dispositional mindfulness and emotion regulation, were also completed at three months, six
‘months and nine months posttreatment. Treatment was provided at no cost to participants
and they were paid $150 dollars to complete the follow-up assessments. Participants provided
written informed consent and Stanford University IRB approved this study.
Participant demographics are depicted in ‘Table 1. Further details pertaining to participant
characteristies, recruitment, screening, and retention are reported in Goldin et al. 1]
Interventions
MBSR. MBSR followed the standard curriculum [66] with the exception that instead of
holding a 1-day meditation retreat, participants had four additional weekly group sessions
between the standard Class 6 and to create 12 weekly 2.5 hous sessions to match the CBI pro-
tocol in duration and time. MBSR involves mindful breathing, body scan informal mindful-
ness, and lovingkindness meditation practices,
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 rio Mind postive emotion roguation
‘Table 1 Participant demographics (N=
Measure
Female, N (%) 58 (65%)
ge, (SD) 92.04 (8.19)
Race, N(%)
‘American indan/Alaskan Native 10%),
Asian 39 (36%)
‘oan American 11%)
Caucasian 49 46%)
Latino 96%)
Muttracial 86%),
1come level N (%)
Under $10,000, 706%)
'$10-25,000 310%)
'$25-50.000 16 (19%)
'850-75,000 12(15%)
$75-100,000 12 (15%)
(Over $100,000 28 (38%)
‘Yeats of Education, ($0) 16:59 (2.46)
Marital Status, N(%)
Single 60 (57%)
Marries 94 (2%)
Living with Partner 10 (10%)
Divorced 11%)
Other 11%)
psstoLor/10.137 our pone. 0187727001
CBT. CBT followed a standardized CBT group therapy protocol [67] and was delivered
lover 12 sessions of 2.5 hours each. Treatment involved psychoeducation, cognitive restructur-
ing skils, graduated exposure to feared social situations, and relapse prevention,
Measures
Attentional control. ‘The Attentional Control Scale (ACS; @ =.85 for focusingand « =.74
for shifting subscales in tis sample) isa 19-item measure scored on a7-point Likert scale (1 =
“strongly disagree” to 7 = “strongly agree”) that assesses respondents’ abilities to both focus
(When concentrating | ignore feelings of hunger or thirst”) as well as shift ("Tcan quickly
switch from one task to another”) attention [68
Decentering. The Five Facet Mindfulness Questionnaire's (EFMQ) non-reactivty sub-
scale (@-=.72 in this sample), is item scale measure on a 5-point Likert Seale (1 = "never
or very rarely true” to 5 = "very often or always true") was used to measure decentering [69]
The non-reactvity subscale includes items tapping key features of decentering including d
identification (e., "I watch my feelings without getting lost in them") and reduced reactiv-
ity (eq, "When I have distressing thoughts or images Tam able to just notice them without
reactio
Broadened awareness of interoceptive and exteroceptive data, ‘The FFMQ observing
subscale (a =.75 in this sample), isan 8-item measure scored on a5-point Likert Seale (1
“never or very rarely true” to 5 = "very often or always true”) that assesses respondents ten-
dencies to become aware of internal and external experiences (69) including pleasant and
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 7110 Mind postive emotion roguation
neutral perceptions and body sensations [70]. The FEMQ observing subscale reflects abroad
ening of awareness to encompass usually unattended neuteal (e,, sensations of bodily move-
‘ment, background sounds) or pleasant stimuli (eg. the sun on one’s fae, the breeze through
one’s hair). Such an expanded attentional capacity is theoretically consistent with the MMs
conceptualzation of attentional broadening as the part ofthe mindful self-regulation process
in which the practitioner's awareness, previously constricted by the stress response, expands to
include neutral and positive elements of the environment that had gone previously unnoticed
In that regard, higher scores on the obser facet are significantly correlated with increased
attentional alerting to novel stimuli [71], supporting our use of this measure to tap broadened
awareness of previously unattended data
Reappraisal. ‘The Emotion Regulation Questionnaire’s (RQ; a =,93 in tis sample) reap-
praisal self-efficacy subscale [54], isa 6:item measure scored on a 7-point Likert scale (1 =
“strongly disagree” to 7 = “strongly agree”) that assesses one’s self-reported ability to regulate
emotion by reconstruing the meaning of adverse situations (e.g, "When I telly want to, Tam
very capable of changing the way 'm thinking about a situation when I want to feel less nega
tive emotion”.
Positive affect. ‘The Positive Affect and Negative Affect Scale’s (PANAS; c= 81 inthis,
sample) positive affect subscale isa 10-item measure scored on a 5-point Likert sale (1 = "very
slightly or not ata” to 3 = “extremely) that assesses positive affect using a variety of adjectives
characteristic of positive emotions.
Statistical analysis
‘Multivariate path analysis was used to model the core constructs in the MMT theory: atten:
tional control, decentering, broadened awareness, reappraisal, and positive affect. Each vari-
able in the model was regressed on its pretreatment score, o reflect a residualized change
score, To represent the autoregressive nature of the data more accurately, each successive
data point was modeled as its own observed variable with its own error term to account for
‘measurement error. Variables in the model were organized in a temporally progressive fash-
jon according to the MMT such that attentional control was measured at posttreatment,
decentering at three months after posttreatment, broadened awareness at six months after
posttreatment, reappraisal at nine after months posttreatment and positive affect at 12
‘months after posttreatment. We chose to create residualized change scores with pretreat-
‘ment levels to account for the learning and cumulative change that occurred within treat-
‘ment as well as in the follow-up period for those variables that were measured at later time
points, Though we could have created change scores that only reflected successive change
(eg, T2073, T3 tT, ete), this approach would have not taken into account the influence
of psychological development that may have occurred during and after the MBSR and CBT.
interventions, which we thought would be critical to the process described by the MMT.
Finally, treatment group membership was represented as an exogenous variable in the
‘model, with effects of treatment modeled via paths the from the treatment geoup indicator to
the variables representing residualized change in attentional control, decentering, broadened
awareness, reappraisal, and positive affect.
Because our hypothetical model, like all causal models, is prone to specification error, other
alternative models were assessed to ensure that significant path coefficients identified were not
artifactual. To that end, alternative model configurations were examined in which we replaced
cach variable at each time point in an exhaustive fashion, to test whether variable combinations
and linkages that were not specified in the MMT fit the data better.
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 arto Mind postive emotion roguation
Fig 1. Final mutivariate path mode! ofthe mindfulness-to-meaning theory. Not: Change was computed
in roskualizd change scores (olow- up lovels adjusted for pro-treatmont levels). Allpaths aro statistically
significant. Mode twas excellent, ‘d's 1.17, p= 22, CFI =.87, AMSEA =. 04 (00,08).
ipso org/10.197 oral pone 01677279001
Results
Multivariate path analysis
{n the multivariate path model, all paths in the MMT model were significant (Fig 1) and
‘model ft was excellent (/'/d= 1.17, p= 22, CF =.97, RMSEA = 04 (00, 08). With respect
to treatment group differences, we observed significant direct effects from the variable repre-
senting treatment condition to decentering and broadened awareness: MBSR was associated
with significantly greater inereases in decentering by Time 3 (B = 1.82, SE = .83,p = .028) and
broadened awareness by time 4 (B = 175, SE = 92, p=.049) than CBT. No other between-
groups differences were observed.
In support of our hypotheses, change in attentional control by Time 2 (post-treatment) was
significantly associated with change in decentering by Time 3 (3 month follow-up). Similarly,
change in decentering was significantly associated with change in broadened awareness by
Time 4 (6 month follow-up). In turn, change in broadened awareness was significantly associ-
ated with change in reappraisal by Time 5 (9 month follow-up). Finaly, change in reappraisal
1was significantly associated with change in positive affect by Time 6 (12 month follow-up)
‘The fall model accounted for 42% ofthe variance in change in positive affect by Time 6.
Because significant between groups differences were observed for decentering and broad-
ened awareness, we tested whether changes in these variables mediated the effect of treatment
(MBSR vs, CBT) using the SPSS PROCESS 2.13 macro with bootstrapping procedures
Unstandardized indirect effects were computed for each of 1,000 bootstrapped samples, and
the 95% confidence interval was computed by determining the indirect effects at the 2.5th and
97.5th percentiles. Significance ofthe indirect effect was indicated by the upper and lower lim-
its of the 95% confidence interval not spanning zero. This method has been recommended as
superior toa normal theory approach to testing mediation (eg, Sobel test) because it does not
assume normality ofthe indirect effect sampling distribution [72]. First, we examined the indi-
rect effect of MBSR vs. CBT on increases in broadened awareness (by 6 month follow-up) via
increases in decentering (by 3 month follow-up). The indirect effect was significant, B= 1.20,
SE = 47 (95% Cl: 38, 2.27). Next, we observed a significant indirect effect of MBSR vs. CBT
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 0710 ‘BPLOS | ov Ma pea ert reton
‘Table. Fitindices for fin
multivariate path model (Model 1) and alternative model specifications.
Mode! eration x | at) p | cr TU) RMSE”
Posttreatment SMonths Months 9 Months 2Months
1 Atention NonReacting ‘Observing Reappraisal | Poste Affect 9887 31 22 | 97.93 8
2 Amention |X | Observing | x | Reappraisal | | NonReacting | | Postive Affct 43.60 3107 | 92 | 83.06
3 attention | —- | Reappraisal | x | Observing | — | Nonfeacting | X | Positive Affect 4920 31 02 | 90 | 78 | o7
4 Attention Reappraisal | — | NonReacting Observing |X | Postive Affect 52.98 31 008 | 88 | 75.08
5S Positve tect —- | Observing | x | Reappraisal | X | NonReacting |x Atenon 5053. 31.015 | 87 | 72.08
6 Attention NonReacting | X | Reappraisal | X | Observing | X Positive Affect $4.67 31 005 | 85 | 69.09
7 Positive fact. | NonReacting |X | Reaporatsal | X | Observing | X | Alen 54.89 31 005 | 62 | 62.00
8 Positive Affect —- | NonReacting | —- | Observing | — | Reappraisal | | Alten 5773 31 002 | a3 | 64 09
9 Positive Affect Reappraisal |X | Observing NonReacting | X | Attention | 58.44 31 | on2 | 83 | 64 09
10 Positive Atfoct Observing NonReactng |X | Reappraisal Atentn 61.11 31 | oot | 82 62 10
11 Positive Atfoct Reappraisal | | NonReacting Obsorving |X | Altonton | €258 31 | 001 | 82 | 6110
Note: indicates a significant path between constructs, whereas an X indicates a nonsignificant path between constructs. Constructs were entered into the
‘model as residualized change scores by covaryng pre-treatment laves of each variable. All permutations were not possible due ta tha fact hat attentional
‘conto an positive atfect were only measured at post-treatment and 12-months follow-up time points
pst on 197 Goural pone 01677271002
‘on increases in reappraisal (by 9 month follow-up) via increases in broadened awareness (by 6
‘month follow-up), B= .16, SE =.09 (95% Cl 01, 40). Taken together, these findings indicate
that mindfalness-training related increases in decentering mediate the ellect of mindfulness
training on broadening awareness, which in turn mediates enhanced reappraisal efficacy.
ly, a series of 10 alternative model configurations were examined, replacing each
variable at each time point to consider all permutations (able 2).'The proposed model the-
oretically consistent with the MMT (Model 1) was the only model in which all paths were
significant and fit was excellent
cussion
‘The Mindfulness to Meaning Theory (MMT) specifies a novel model of mindful positive emo-
tion regulation. Findings from the present multivariate reanalysis of longitudinal data from a
sample of treatment-seeking participants with social anxiety disorder suggest that the the
peutic mechanisms specified by the MMT are significantly and prospectively associated in the
temporal order proposed by the theory. More specifically, findings suggest thatthe mecha-
nisms of change identified by the MMT-attentional control, decentering, broadened aware-
ness, and reappraisal-form an iterative chain that promotes long-term increases in positive
affectivity in tis clinica population. Indeed, an increased ability to focus and shift attention
by the end of treatment appears to support the tendency to decenter from distressing thoughts,
and feelings by three months after treatment, In tur, increased decentering capacity by three
‘months posttreatment predicted greater tendencies toward broadened awareness of interocep-
tive and exteroceptive information. Broadening of awareness by six months post-treatment
was associated with growth in reappraisal self-efficacy by nine months after treatment, suggest-
ing that inereased access to novel contextual information may fuel adaptive reconstrual ofthe
‘meaning of adverse life events. Ultimately, increases in reappraisal occasioned increased posi-
tive affect by one year after treatment, Mindfulness-based intervention (ie, MBSR) appears
to specifically boost this longitudinal cycle of therapeutic change by producing significantly
greater increases in decentering and broadened awareness than CBT that mediated the effect
(of mindfulness training on downstream processes-providing support for the foundational
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 10119 Mind postive emotion roguation
assumption in the MMT that mindfulness meditation may be a key means of stimulating posi-
tive psychological states
The MMT and common mechanisms of therapeutic change
Though significant between-groups differences were observed for decentering and broadened
awareness, the MMI’s proposed mechanisms of change may reflect common therapeutic
mechanisms that cut across mindfulness-based and cognitive-behavioral interventions, Rigor
ous RCTS comparing mindfulness-based interventions and CBT have failed to show differen-
tial treatment effects on a whole range of mechanisms, including dispositional mindfulness,
reappraisal, self-efficacy, acceptance, catastrophizing, and positive and negative afect
[11,73,74). To be clear, given the relative paucity of studies that have compared mindfulness to
CBT with respect to their mechanisms of ation, iis likely thatthe therapeutic mechanisms
differentiating mindfulness from CBT have not yet been measured and identified in a clinical,
trial (for example, these treatments may differ with regard tothe extent to which they induce
rnondual awareness and other modes of existential awareness, see [43]. However, itis also pos-
sible that any form of therapy that enhances state and trait mindfulness might stimulate the
cascade of cognitive-affective processes implicated in the MMT.
Goldin etl. [11] contend thatthe capacity for metacognitive awareness, reflected by
enhanced attentional control coupled with a decentered stance towards the objects of atten-
tion, may reflect a central change mechanism encouraged by both CBT and MBSR-a conten
tion supported by results from this study. While CBT aims to promote decentering through
explicit training inthe practice of attending to and disputing negative thoughts through
thought records, MBSR promotes decentering through the practice of mindfulness, which
involves re-orienting attention to breath and body sensations to disengage from mental and
«emotional proliferation while attending to such psychological contents from a non-reactive
stance. In both cases, the capacity to decenter from distressing thoughts and feelings is
grounded in the bility to shift and sustain attention on salient psychological experiences
‘without becoming overwhelmed by emotional distress, Regardless ofthe therapeutic means
employed, decentering appears to be a common mechanism underlying the effects of mindfal-
ness and reappraisal [75]. Nonetheless, in the present study, MBSR led to significantly greater
Increases in decentering as assessed by the FFMQ non-reactviy subscale than CBT (as well as
significantly greater increases in broadened awareness as assessed by the FEMQ observe sub-
scale), suggesting that mindfulness training may yield specific benefits with regard to stimulat-
ing the cascade of positive psychological mechanisms specified in the MMT.
Furthermore, similar improvements in participants’ abilities to cognitively reappraise in
both the CBT and MBSR groups appears to support the MMT's claim regarding the close con-
nection between decentering, broadened awareness, and reappraisal. Interestingly, while CBT
provides direct instruction in reappraisal, MBSR does not. The organic development of reap-
praisal capacities in MBSR participants lends further support forthe mindfl reappraisal
hypothesis of the MMT, which posits that mindfulness enhances the capacity for reappraisal
[27], Recent, temporally dynamic growth curve modeling complements earlier cross-sectional
research [57] by indicating that the trajectory of increases in state mindfulness (i.e., decenter
ing) over the course of a mindfulness-based intervention is positively associated with increases
in reappraisal frequency over that same time period (See SI File Footnote 1 for more detail)
[64], Present study findings expand upon this observation by implicating the role of broadened
awareness to contextual information as a mediator of the decentering-reappraisal relation. In
‘MBSR, this broadening may be the result of cultivating awareness of interoceptive and extero-
ceptive sensations and perceptions inthe context of formal and informal meditation, practices
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 49 Mind postive emotion roguation
which may counter biased information processing due to the attentional narrowing that occurs
in response to negative emotions [76]. Comparatively, in CBT the empirical identification of
confirmatory and disconfirmatory evidence for maladaptive beliefs and cognitions may be one
‘method by which the cognitive-behavioral approach promotes broadened awareness of inter-
nal and external context and thereby facilitates reappraisal,
Implications for treatment development
The attentional and cognitive capacities examined in the present study were found to support
greater increases in positive affect over the course ofa year-providing support for the notion
that positive cognitive-emotional states interact to produce durable improvements psychologi-
cal well-being [76]. Insofar as both CBT and MBSR have been shown to ameliorate psychologi-
cal distress and target the aforementioned mechanisms of attentional and cognitive regulation
(albeit through distinct therapeutic techniques), it may be that psychological interventions
designed to explicitly address both the attentional, metacognitive training foundational to
MBSR, as wel as the cognitive reappraisal training explicated in CBT would be even more eff-
cacious than either ofthese therapeutic approaches in isolation,
In that regard, Mindfulness Oriented Recovery Enhancement (MORE) is a recently devel:
‘oped! mindfulness-based intervention informed by the MMTT that integrates traditional mind~
fulness meditation techniques with explicit cognitive reappraisal training [77,78]. A recent
randomized controlled trial (N= 180) provided preliminary evidence for the comparative
superiority of MORE to CBT [79], with participation in MORE associated with significantly
greater improvements in affect and craving among a sample of inpatients with a variety of co-
‘occurring psychiatric and substance use disorders. Within a behavioral medicine context,
‘MORE has been shown to produce clinically significant improvements in chronic pain symp-
toms and prescription opioid misuse [80]. However, whether interventions like MORE which
combine explicit training in mindfulness and reappraisal promote stronger coupling between
constructs specified in the MMT or lead to better treatment outcomes than CBT or MBSR are
empirical questions that should be explored by future randomized controlled trials.
‘Summary and limitations
Despite the results from this study resonating with previous theoretical and empirical work,
limitations should also be noted. First, our ability to model the MM'T was constrained by the
‘measures collected during this clinical tral, This was a post-hoc secondary data analysis that,
attempted to fit clinical trial data to the MMT, and as such, we were limited to the variables
that were available in the dataset. In that regard, no direct measure of decentering was avail-
able, and so we employed the non-reactivity subscale ofthe FFMQ to assess this construct
Such use is justified because ofthe face validity of the items with respect to the construct of
ddecentering, as well as previous findings indicating decentering and the non-reactvity sub-
sale are highly interrelated, N = 461, r=.74 [81), potentially measuring a common, underly
ing construct, However, it should be noted that decentering and non-reactivity are not
identical constructs. Decentering refers tothe ability to view one’s experience as mental events
as opposed to representations of realty, whereas non-reactivty refers to the ability to remain
equanimous in the face of distressing thoughts and felings, and ability that can ostensibly be
achieved through decentering. In that regard, theorizing by Bernstein etal. suggests that
decentering itself is comprised of metacognitive awareness, disidentfication, and reduced
reactivity [40]. The FFMQ non-reactivty subscale includes items pertaining to at least two of|
these processes: disdentification (eg, “I watch my feelings without geting lost in them") and
reduced reactivity (¢g.,"When I have distressing thoughts or images Tam able just to notice
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 W219 Mind postive emotion roguation
them without reaction”), On the other hang, it should be noted that recent factor analytic
research did not fully support Bernstein and colleagues’ three proposed metacognitive pro-
cesses of decentering [82]. Also in this particular study, the FFMQ non-reactvity subscale was
classified as a measure of “intentional non-reactive meta-awareness” and shown to be signifi-
cantly but modestly correlated with the ability to intentionally adopt a decentered perspective
(82), suggesting that the non-reactivty subscale may partially capture key elements of decen-
tering but not completely reflect the construct, Though vigorous debate continues around the
operationalization and measurement of the decentering, the present study was limited in its
reliance on the FFMQ non-reactivity subscale, which may not provide a nuanced and fall
representation of this construct.
Similarly, the FEMQ observe facet is more circumscribed in scope than the MMT concept
of broadened awareness, which pertains to attention to wide a range of contextual data from
hich reappraisals can be generated. In contrast the FFMQ observe facet specifies awareness
of limited set of sensorial and perceptual experiences. Further, complete modeling of the
MMT was impossible due to the dataset’s lack of a measure of meaning in life, which is con-
ceptualized as the distal output of the proposed mindfulness-to-meaning process [26]. Future
investigations should ensure the robustness of the MMI by using other measures ofthe pro-
posed constructs, including neurocognitive tasks and psychophysiological assays.
Second, generalizability of these results re limited due to this sample being constituted by
individuals with social anxiety disorder, It may be thatthe relationships observed in tis study
will differ across individuals with other types of psychological disorders. Continued examina~
tion of the MMT in a range of linical and non-clinical samples is encouraged. Also, this study
used a modified, 12-week version of MBSR to match the CBT intervention in terms oftime-
in-treatment. Itis not known how the MMT would map onto a standard length version of
MBSR.
Lastly, the temporal dynamics ofthe MMTT are far from established: i isnot yet known on
‘what timescale (eg, seconds, minutes, hours days, or longer) the process of mindful positive
emotion regulation unfolds. The time points studied in this investigation were predetermined
by exigencies in the parent clinical tral from which the present data are derived, In that regard,
though research by Fredrickson and colleagues suggests that positive affect may broaden the
scope of attention [83], the current analysis is unable to ascertain whether inclusion of positive
affect and attention atthe other time points might have resulted in better fit indices compared
to the current established model. Is ikely that the MMT might be expressed differently
within a given emotion regulatory episode as compared to its expression across numerous
«emotion regulatory episodes (such as what might occur across the 12 months of data collection
inthe present study). Moreover, though our aim was to model the core constructs of the MMT
withthe available data, itis possible that other model specifications with fewer variables or dif
ferent variables might have fit the data better. ‘That said, the proposed model was the bes fi
ting of 10 alternative models tested. In addition, the temporally dynamic change process may
have differed in within-group analyses, which are empirically justified when the null hypothe-
sis of measurement invariance is rejected (See SI File Footnote 2 for more detail). For malti-
group path modeling, >100 cases/observations per group are required [84]. In that regard, in
disaggregated multivariate path modeling efforts, the analysis was underpowered and our
[MMT model did not fit the observed data well when the treatment arms were analyzed sepa-
rately (See $1 File Footnote 3 for more detail). Thus, in the present dataset the MMT model
only fit the observed data when the sample was analyzed asa whole with treatment geoup mod-
eled as an exogenous variable,
The MMT proposes that linkages between mindfulness and reappraisal emerge at multiple
levels of temporal resolution, in keeping with iterative process models of emotional experience
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 13/19 Mind postive emotion roguation
[85] and extended process models of emotion regulation [86]. In that regard, the MMT asserts
that inthe immediate wake ofa stressor, attentional control and decentering attenuate nega-
tive attentional biases and maladaptive elaborative habits, allowing reappraisal to enter into
the iterative emotion regulatory process to modulate the impact of a negative event. Over
_more extendled periods of time, recurrently cultivating metacognitive awareness enables reflec-
tive processes to magnify the affective benefits of reappraisal and generate eudaimonic wel-
being, It is possible that flexible postive emotion regulation requires initial momentary dis-
engagement from elaborative self-referential processing through mindfulness asa precursor to
_more temporally-extended metacognitive reflection on the sel-in-context when hedonic goals
‘must be balanced by eudaimonic values [87]. In that regard, new contemplative science models
suggest that metacognitive self-regulation through mindfulness may facilitate fluid reconstrual
of the implicational meaning of one’s self-concept and view of reality via decentering and
_more advanced modes of existential awareness in which conceptual representations of self and
world become de-reified (43
‘To unpack these questions, more research is needed to explore the MMT at different levels
of temporal resolution. Further, the MMT should be modeled through studies designed in an
4 priori fashion to test the hypotheses integral to this theory. For instance, lab-based mindfal-
ness inductions could be used to test the effects of mindfulness mediation on boosting perfor-
_mance-based measures of reappraisal via attentional control, decentering and broadening of
awareness, the latter of which might be measured with cognitive assays like the global-local
task [88]. Or, ecological momentary assessments could be used as in recent studies [89] to
examine time-lagged relations between moment-to-moment changes in attention, decenter-
ing, broadened awareness, reappraisal, and positive affect.
‘The present study should be considered heuristic rather than confirmatory because this was
‘post-hoc secondary data analysis modeling the MMT with existing data not originally col-
lected for this purpose. Moreover, it isnot yet known whether these findings can be general-
ined beyond social anxiety disorder. Nonetheless this study makes several novel contributions
to psychological science, including providing the first longitudinal test of proposed linkages
between core MMT components, as well as expanding understanding of core change mecha-
nisms operating during both CBT and MBSR. Though formal mindfulness meditation appears
to uniquely stimulate the mindful positive emotion regulation process by boosting decentering
and broadened awareness to a greater extent than CBT, from a transtherapeutic perspective
[90], durable positive affectivity may arise from reappraising the meaning of daily adversity, a
second-order valuation process [86] fueled by increased apperception of what is beautiful, life
affirming, or good in life-an awareness made possible by cultivating attentional capacity in
service of decentering from the varieties of mental suffering,
Supporting information
SI File, Footnotes.
(DOCX)
Author Contributions
Conceptualization: Fric L. Garland, Adam W. Hanley, Phillipe R. Goldin, James J. Gross.
Formal analysis: Eric L. Garland, Adam W. Hanley.
Funding acquisition: James J. Gross.
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 arg Mind postive emotion roguation
Investigation: Phillipe R. Goldin, James J. Gross.
‘Methodology: Eric L. Garland, Phillipe R. Goldin, James J. Gross.
Project administration: Phillipe R. Goldin, James J. Gross.
Resources: James J. Gross.
Software: Adam W. Hanley.
Supervision: Phillipe R. Goldin, James J. Gross.
Validation: Eric L. Garland, Adam W. Hanley, James J. Gross.
Writing - original draft: Eric L. Garland, Adam W. Hanley, Phillipe R. Goldin, James J,
Gross.
Writing - review & editing: Eric L. Garland, Adam W. Hanley, Phillipe R. Goldin, James J
Gross.
References
1. Desbeordes G, Gard, Hoge EA, Hele BK, KerrC, Lazar SW, el Moving beyond mindtuness: tin:
ing equarimty as an outcome measure in medtation and contemplative research, Mindluness. 2015
6380-372.
2. Kabat Zinn J. Wherever you go, thee you are: Mindfulness mediation in veryday if [internet
Hyperion; 1994, htpe:/books google com/books hi-enslr-Bid-QnYBXIX2BPWCRO-Ind pg
PRIGAdg-mindlulnese+seeingsthings-as+they--aredolsbd6hePYPagsig=trMvulFn
jWtixwVOOWIIi7e°
3. Shapiro SL, Carlson LE, Astin JA, Freedman B. Mechanisms of mindfulness. J Cin Psychol. 2006; 62
373-86. htipsloior/10.1002jep. 20287 PMID: 16385481
4. Teasdale ID. Metacognition, mindtulness, and the medication of mood dsorders. Cin Peychol Psy
‘hohe. 1099; 6: 148-155,
5. Garland EL. Gaylord SA, Park J. The role of mincunass in positive reappraisal. Exploe NY. 2000; 5
37-44, htps/ido.og/10.1016).xplore 2008.10.001 PMID: 19114262
6. Kiken LG, Garland EL, Bluth K, Palsson OS, Gaylord SA Froma state otra trajectories of state
minatulness in mediation during intervention predict changes in trait mindfulness. Personal Inve Di-
fer. 2015; 81-41-46.
7. GoyalM, Singh S, Sbinga EM, Gould NF, Rowlané-Seymour A, Sarma R, etal. Mecitation programs
{or psychological stress and well-being: a systematic review and meta-analysis. JAMA Intern Med.
2014; 174: 57-368. iips:/d0org/10.1001jamaintermed 2013 13018 PMID: 24595106
8. Gatink RA, ChuP, Busschbach JUV, Benson H, Friochione GL, Hunink MGM, Standardised Mindful
nes-Based Interventonsin Heaincare: An Overview of Systematic Reviews and Meta-Analyses of
CTs. PLOS ONE. 2015; 10: 60124344 iips/doL.0r9/10-1871/journal pore. 0124344 PMID:
25881019
9. Carmody), ae RA, Relationships between mindtuness practioe and levels of mindluiness, medical
land psychological symptoms and wel-being in a mingfuness-based stress reduction program. J Behav
Mod: 2008; 31: 23-83. hiis:/do.org/10.1007/s10865-007-9130-7 PMID: 17899351
10. Tang Y-¥, Hetzel BK, Posner MI. The neuroscience of mindluness mediation. Nat Rev Neurosci
2015; 16: 213-225. fps oi or/ 10. 10383916 PMID: 25783512
11. Gols PR, Morison A, Jazair H, Brozovich F, Heimberg R, Gross JW. Group CBT versus MBSR for
social anxiety disorder: randomized controlled tal J Consult Cin Psycho. 2016; 84: 427. hips.
‘rg/10-10379p000009 PMID: 26950037
12. Hanley AW, Wamer AR, Dehli VM, Canto Al, Gatand EL. Washing dishes to wash the eshes: Brit
instruction in an informal mindulness practice. Mindfulness. 2015; 6: 1095-1103,
18, Hole BK, Lazar SW, Gard, Schuman OilvierZ, Vago DR, Ott U. How does mindless madtation
\work? Proposing mechanisms of action ftom a conceptual and neural perspective, Perspect Psychol
Sei, 2011; 6 597-558, ips fd org/101177/174569161 119671 PMID: 25168576
14, TangY-¥, Hoizel BK, Posner MI. The neuroscience of mindtuness meditation. Nat Rev Neurosci
2015; 16: 213-225, hips coi or/ 0. 10383816 PMID: 25783512
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 15/19 Mind postive emotion roguation
18
16.
1”
18.
19.
20.
a.
a
a
2.
26.
2.
2.
2.
at.
2.
a7.
‘Vago DA, Sibersieig DA. Set-awareness,soll-requlation, and sl-ranscendence (S-ART):a frame-
work for understanding the neurobiological mechanisms of mindfulness. Front Hum Neurosci 2012; 6,
‘Avalable: ip/ier.ncb nlm nih gow pmecariciesPMC3480633"
Pressman SD, Bown SL_Postve affect: A pathway to better physical health, Post Emet Integrating
Light Sides Dark Sides. 2014; 183-205,
Pressman SD, Cohen S. Does positive affect influence health? Psychol Bul, 2006; 191: 825. hps:/
/401.0%9/10.108710088-2908. 131 6.825 PMID: 16351529
Dockray 8, Steptoe A. Postve affect and psychobologcal processes, Neuraso| Bobehav Rev. 2010;
£35: 69-75. hitps//doorg/10.1016/,neubiorev.2010.01.006 PMID: 20087225
Finan PH, Garland EL. The role of postveaffectin pain and its teetment. Clin J Pain 2015;31: 177—
187. htps/do\or/10.1087/AP.0000000000000082 PMID: 24751543
‘Sogorsttom SC, Sophion SE. Optimistic Expectancios and Call Mediated immunty The Rol of Pos
tive Affect. Psychol Sci 2010, 21: 448-485. itso ory/10.1 177108567376 0262081 PMID:
20424085
Tugado MM, Fediickson BL. Resilient indviduals use postive emotions te bounce back from negative
‘ematonal experiences. J Pers Soc Psychol. 2004; 86: 820-883, ips /do|org/10.1097/0022-8514 88,
2.320 PMID: 14769087
king LA, Hicks JA, Krul JL, Del Gaiso AK. Postve affect and the experiance of mearing inte. J Pers
Soc Peychol.2006; 90: 178-196. hos /doi.org/10.1037/0022-25 4.901.178 PMID: 16448317
“lio S,Slatcher RB, Ong AD, Gruenowald TL Purpose in ie predict allostaticload ten years later J
Psychosom Fes. 2015; 79: 451-457. hps:/dol org 10.1016 jpsychores.2015 08.013 PMID:
2052022
Fredrickson BL, Growon KM, Coffey KA, Algoo SB, Frestino AM, Arevalo JM, otal. A functional gono-
mic perspective on human wel-being. Proc Natl Acad So. 2018; 110: 13864-1689. iips://d0.019/10.
107Spras, 19054191 10 PMID: 23808 162
Garland EL. Farb NA, Goldin PR, Fredickson BL Mindluness Broadens Awareness and Bulls Eudal-
‘monic Meaning: A Process Model af Mindful Posive Emation Regulation, Psychol In, 2018; 26:293-
$34, hitps/do\or/10.1080/1087840X 2015, 1064296 PMID: 27087785,
Garand EL Farb NA, Goldin PR, Fredckson BL Mindtuness Broadens Awareness and Bulls Eudai-
‘monic Meaning: A Process Model at Mindful Posive Emotion Regulation Peychol Ing 2018; 26:293-
314. htps:/do\or/ 10. 1080/1047840X.2018, 1064204 PMID: 27087765,
Garland EL. Farb NA, Goldin PR, Fredickson BL The Minafuinessto Meaning Theory: Extensions,
‘Applications, and Challenges a the Atrtion-Appraisal-Emotion Intrtace. Psychol ing, 2015; 25
377-987. hiips:/idoLorg/10.1080/1047840X 2018. 1092493,
opting JB, Buonocore MH, Mangun GR. The neural mochanisms of top;down atontional conto,
Nat Neuroscl 2000; 3: 284-291, niips/do,0/10.1038/72099 PMID: 10700262
Ruocco AC. DrokogluE. Detineating the contributions of sustained attention and working marry to
individual diterenoes in mindluness, Personal Indiv Diller 2013: 54: 226-20 ped. org"0,
1016), paid. 2012.08 037
SSchmerte Sk, Anderson PL, Robins DL. The elton between sel report mindluness and performance
‘on tasks of sustained attention. J Psychopathol Behav Assess. 2009; 31: 60-66
Garland EL. Bostigar CA, Gaylord S, Chanon VW, Howard MO. Mingtuness is inversely associated
with alcoho atlentonal bias among recovering alcohol depondent adults. Cogn Ther es. 2011; 1-10
Lutz A, Slagter HA, Dunne JD, Davidson RJ. Atlenon regulation and monitoring in meditation, Trends
Cogn Sei. 2008; 12: 165-8. htps/co\org10. 1016) s.2008.01.005 PMID: 18329523
MacLean KA, Ferer€, Aichole SR, Bridwel DA, Zanesco AP, Jacobs TL, etal. Intensive meditation
taining impraves perceptual discrimination and sustained attention. Psychol Sci 2011.21: 820-29,
‘Valentine ER, Sweet PLG. Meditation and attention: A comparison ofthe effects of concentratve and
mincfulness medtation on sustained attention. Ment Health Rebg Cu, 1998; 2: 69-70. hitps:/do\. oro!
10.1080/13674673908206352
vvan den Hurk PAM, GlomvniF, Gielen SC, Speckens AEM, Barendregt HP. Greater efitency in aten-
tional processing related to mindulness mediation QJ Exp Psychol. 2010; 63: 1168-1 180. hips/do,
‘or/10.108017870210803240365,
Jha A, Krompingor J, Baime M. Mindtunoss training modifies subsystems of attention. Cogn Afoct
Behav Neurosci, 2007; 7: 108-118. PMID: 17672382
Garland EL, Howard MO. Mindluiness-viented recovery enhancement reduces pain attentional bias in
‘chronic pain patents, Psychother Psychosom. 2019; 82 311-318. hips:/doiorg10.1159)00084868
Pao: 23942278
PLOS ONE | ips: org/10.157 journal pone.0187727 December 6, 2017 16/19 Mind postive emotion roguation
39,
40,
a.
a
2.
5s.
or.
5,
‘Vago DA, Nakamura Y. Selective Attentional Bias Towards Pain-Related Thre in Fibromyalgia: Pre
liminary Evidence for Effects of Mindtuness Mecitation Training, Cogn Ther Res. 2011; 14.
Fresco DM, Segal ZV, BuisT, Kennedy S. Relationship of postreatment decenterin and cognitive
react to relapse in major dapression. J Cansut Cin Psyehol 2007: 75: 447-85, hipaa: 07/10.
$1037/0022.006X. 753.447 PMID: 17563161
Bemstein A, Hadash Y,Lichtash Y, Tanay G, Shepherd K, Fresco DM, Decentering and Related Con-
sttucs: A Citical Review and Metacogntwe Processes Model, Perspect Psycho Sc 2015; 10: 589
{617 hiips:/doorg/10.1177/174560 1615504577 PMID: 25385900
Saver , Baer RA. Mindfulness and decentering 2s mechanisms of change in mindtuiness-and accep-
tance-based interventions, Assess Mindiuness Accept Process Clents lum Theory Pract Change
2010; 25-50.
Nelson TO, Stuart AB, Howard, Crowley M, Metacogniton and cnical psychology: A preliminary
‘ramework or research ana pratice. Can Psychol Psychother. 1999; 6: 73-79,
DDoree D. Defining Contemplative Science: The Metacogntive Se-Regulatory Capacty ofthe Mind,
Context o Meditation Practice and Modes of Existential Awareness. Front Psychol. 2016, 7 ps.
‘g/10.3880psyg.2016.01788 PMID:27000817
“Teasdale JD, Moore RG, Hayhurst H, Pope M, Willams S, Segal ZV. Metacogntveavaeness and
prevention of relapse in depression: empincal evidence. J Consult Clin Psychol. 2002; 70: 275-87.
Pub: 11952166
Feliman G, Greeson J, Semvile J. Diferential effects of minal breathing, progressive muscierelaxa
tion, and loving-kindness mediation on decenterig anc negative reactions to repettve thoughts.
Behav Fes Ther. 2010; 48: 1002-101, tp//60.0rg/1. 1016). brat-2010.06.006 PMID: 20633873.
Jankowski T, Hlas P. Motacognitive model of mindtunoss. Conscious Cogn. 2014; 28: 64-80 its:/
{40 01g/10.1616), concog.201 406,005 PMID: 25088535
Lazarus Ri Folkman S, Stress, appraisal, and coping, New York: Springer; 1964
Fst J, Gramann K, Hebert GM, Polatos 0. On the embodiment af emotion regulation: nteroceptive
awareness facltates reappraisal. Soc Cogn Alfoct Neurosci 2013; 8: 911-817. hips/co\ org 10.
‘osa/scaninss089 PMID: 22953520
ever A, Polates O, Vermeulen N, Grynberg . nteroceptive sensitiv faciltates both antecedent
and sponse focused emotion regulation stratogos. Personal Inivd Dir. 2015; 87: 20-28. tos!
{0 rg/10.1016) paid:2015.07.014
Manera V, Samson AC, Pers, Leo A, Gross. The eyes have The role a atention in cognitive reap-
praisalo Social stimu. Emotion 2014; 14: 833-899, tps:/do.ry/10.1037/20087350 PMID: 25046244
Chan MW, Ho SM, Tedeschi RG, Leung OW. The valence of atontional bias and cancer-related rumi-
nation in postraumate stress and posttraumatic growth among women with breast cancer. Psychoon-
‘cology. 2011; 20: 544-552. ps: org/10.1002/pon.1761 PMID: 20878854
Labela LE, Lawlor Savage L, Campbell TS, Fars P, Carlson LE. Does selt
