Assessing Mindfulness: The Development of a Bi-Dimensional Measure of Awareness and Acceptance

A Thesis Submitted to the Faculty of Drexel University by LeeAnn Cardaciotto in partial fulfillment of the requirements for the degree of Doctor of Philosophy August 2005

 Copyright 2005 LeeAnn Cardaciotto. All Rights Reserved.

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Acknowledgments Many people have helped me through the process of completing this project. I would first like to thank my committee chairperson, academic advisor, and mentor, Dr. James Herbert, for his support, knowledge, and feedback during not only the dissertation process, but my entire graduate career. I also would like to thank my committee members, Drs. Evan Forman, Michael Lowe, Stephen Platek, and Ms. Peggy Vogt for their contributions to this project. I am very grateful for the time and effort the following individuals dedicated to this research: Michael Filoromo, III, Ethan Moitra, Maria del Mar Cabiya, Victoria Farrow, Melissa Gonzalez, Victoria Thompson, and Peter Yeomans. Finally, I owe endless gratitude to my parents, Stan and Linda Cardaciotto, for their unconditional love and encouragement, to Sean Adam for his tireless assistance, patience, and support, as well as to my family and friends for their confidence and reassurance.

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Table of Contents

LIST OF TABLES ...........................................................................................................vii LIST OF FIGURES .......................................................................................................... ix ABSTRACT........................................................................................................................ x 1. INTRODUCTION ....................................................................................................... 1 1.1 1.2 1.3 The Historical Roots of Mindfulness ................................................................. 1 Transition of Mindfulness into Psychology ....................................................... 2 Mindfulness in Clinical Psychology: the Third Wave of Behavior Therapy .. 5 1.3.1 1.3.2 1.3.3 1.4 1.5 1.6 1.7 First Wave of Behavior Therapy: Clinical Applications of the Experimental Analysis of Behavior ............................................ 5 Second Wave of Behavior Therapy: Expanded Emphasis on Cognition .................................................................................... 6 Third Wave of Behavior Therapy: Mindfulness-Based Treatments .................................................................................. 7

Defining Mindfulness ...................................................................................... 11 Current Conceptualization of Mindfulness in Clinical Psychology ................ 12 The Relationship of Mindfulness to Meditation .............................................. 17 Constructs Related to Mindfulness .................................................................. 18 1.7.1 1.7.2 Modes of Mental Processing ..................................................... 18 Forms of Reflexive Consciousness ........................................... 20

1.8 1.9

The Relationship Between Mindfulness, Implicit Cognition, and Explicit Cognition ......................................................................................................... 24 Measures of Mindfulness ................................................................................. 25

1.10 Measures of Constructs Related to Mindfulness ............................................. 27 1.10.1 Measures of Metacognition ...................................................... 27 1.10.2 Measures of Reflexive Consciousness ...................................... 30 1.10.3 Measures of Acceptance ........................................................... 32

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1.11 Measuring Mindfulness: The Current Study ................................................... 32 1.12 Integrating Awareness and Acceptance ........................................................... 35 1.13 Principal Aims of the Present Study ................................................................ 38 2. STUDY 1 ITEM GENERATION AND SELECTION .......................................... 40 2.1 2.2 Method ............................................................................................................. 40 Results and Discussion .................................................................................... 41

3. STUDY 2 FACTOR STRUCTURE AND INTERNAL CONSISTENCY ............ 42 3.1 Method ............................................................................................................. 42 3.1.1 3.1.2 3.2 Participants ............................................................................... 42 Measures and Procedure ........................................................... 42

Results and Discussion .................................................................................... 42 3.2.1 3.2.2 Exploratory Factor Analysis ..................................................... 42 Internal Consistency ................................................................. 43

4. STUDY 3 VALIDATION ANALYSES WITH A NORMATIVE SAMPLE ....... 46 4.1 Method ............................................................................................................... 46 4.1.1 4.1.2 Participants ............................................................................... 46 Measures and Predictions ......................................................... 46

4.2 Results ............................................................................................................... 50 4.2.1 4.2.2 4.2.3 4.2.4 4.2.5 4.2.6 4.2.7 Measure Descriptives ................................................................ 50 Cross Validation ....................................................................... 51 Exploratory Factor Analysis ..................................................... 52 Internal Consistency ................................................................. 52 Convergent Validity .................................................................. 53 Discriminant Validity ............................................................... 53 Relationship to Measures of Psychopathology ......................... 54

4.3 Discussion .......................................................................................................... 55

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5. STUDY 4 VALIDATION ANALYSES WITH A CLINICAL SAMPLE ............. 56 5.1 Method ............................................................................................................... 56 5.1.1 5.1.2 Participants ............................................................................... 56 Measures and Predictions ......................................................... 58

5.2 Results ............................................................................................................... 58 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.2.6 Measure Descriptives ................................................................ 58 Internal Consistency ................................................................. 58 Convergent Validity .................................................................. 59 Discriminant Validity ............................................................... 60 Relationship to Measures of Psychopathology ......................... 60 Cross Validation with Student Sample ..................................... 61

5.3 Discussion .......................................................................................................... 62 6. GENERAL DISCUSSION ........................................................................................ 63 6.1 Relationships Between the PHLMS and Other Constructs ............................... 63 6.2 Differences Between the Nonclinical and Clinical Samples ............................. 65 6.3 Implications for a Bi-dimensional Conceptualization of Mindfulness .............. 66 6.4 Clinical Implications .......................................................................................... 68 6.5 Limitations ......................................................................................................... 69 6.6 Directions for Future Research .......................................................................... 71 6.7 Conclusion ......................................................................................................... 71 LIST OF REFERENCES ................................................................................................. 73 APPENDIX A: DEFINITIONS OF MINDFULNESS .................................................... 87 APPENDIX B: MINDFULNESS QUALITIES AS DEFINED BY KABAT-ZINN (1990) ..................................................................................................... 89 APPENDIX C: LIST OF MEASURES OF MINDFULNESS AND RELATED CONSTRUCTS ............................................................................................ 90 APPENDIX D: ILLUSTRATION OF THE FOUR PSYCHOLOGICAL STATES ...... 91

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APPENDIX E: LIST OF ITEMS AND PROCEDURES ADMINISTERED TO EXPERT JUDGES .................................................................................................... 92 APPENDIX F: LIST OF RETAINED ITEMS AND EXPERT JUDGES MEAN RATINGS ........................................................................................................... 98 APPENDIX G: RESULTS FROM DEVELOPMENT SAMPLE ANALYSES .......... 103 APPENDIX H: COPIES OF MEASURES ................................................................... 113 APPENDIX I: RESULTS FROM THE NONCLINICAL SAMPLE ANALYSES ..... 128 APPENDIX J: RESULTS FROM THE CLINICAL SAMPLE ANALYSES .............. 137 APPENDIX K: AN ACCEPTANCE-BASED MODEL OF SOCIAL ANXIETY DISORDER .................................................................................. 146 VITA .............................................................................................................................. 147

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List of Tables

1. Clinical Definitions of Mindfulness............................................................................87 2. Non-Clinical Definitions of Mindfulness ..................................................................88 3. Mindfulness Qualities Defined by Kabat-Zinn (1990) ..............................................89 4. List of Measures of Mindfulness and Related Constructs .........................................90 5. List of Items and Procedures Administered to Expert Judges ...................................92 6. List of Retained Items and Expert Judges Mean Ratings .........................................98 7. Initial Factor Loadings for Items Completed by the Development Sample .............103 8. Initial Corrected Item-Subscale Correlations for Items Completed by the Development Sample ...............................................................................................105 9. Inter-item Correlations from Initial Items Completed by Development Sample......107 10. Descriptive Statistics of the Resulting 20 Items ......................................................108 11. Corrected Item-Subscale Correlations for Resulting 20 Items ................................110 12. Inter-item Correlations for the Resulting 20 Items ..................................................112 13. Copies of Measures ..................................................................................................113 14. PHLMS Descriptive Statistics from the Nonclinical Sample ..................................128 15. Factor Loadings for the PHLMS ..............................................................................130 16. PHLMS Corrected Item-Subscale Correlations from the Nonclinical Sample ........132 17. PHLMS Inter-item Correlations from the Nonclinical Sample ...............................134 18. Convergent Validity: Correlations of the PHLMS With Other Measures from the Nonclinical Sample ..................................................................................................135 19. Correlations of the PHLMS with Well-Being Variables Before and After Controlling for Other Constructs in a Nonclinical Sample ......................................136 20. Total Number of Clinical Participants Diagnosed With Each Disorder ..................137 21. Descriptive Statistics for the PHLMS from the Clinical Sample .............................139 22. PHLMS Corrected Item-Subscale Correlations from the Clinical Sample ..............141

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23. PHLMS Inter-item Correlations in the Clinical Sample ...........................................143 24. Convergent Validity: Correlations of the PHLMS With Other Measures in the Clinical Sample ..................................................................................................144 25. Correlations of the PHLMS with Well-Being Variables Before and After Controlling for Other Constructs in a Clinical Sample......................................................................145

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List of Figures

1. Illustration of Four Psychological States ...........................................................................91 2. An Acceptance-Based Model of Social Anxiety Disorder ..............................................146

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Abstract Assessing Mindfulness: The Development of a Bi-Dimensional Measure of Awareness and Acceptance LeeAnn Cardaciotto James D. Herbert, Ph.D.

Mindfulness, a construct that has its roots in Buddhism, has been examined over the past thirty years in different domains of mainstream psychology. Mindfulness has recently been incorporated into several innovative psychotherapies as a main component of treatment. However, there is no widely accepted definition of mindfulness in the field of clinical psychology, nor has the construct been sufficiently operationalized. Further, there is no measure to date that assesses the two key components of mindfulness, present-moment awareness and acceptance. The purpose of this study was to develop a bi-dimensional measure of mindfulness based on the two key constituents of the construct, present-moment awareness and nonjudgmental acceptance. The psychometric evidence supports a clear two-factor solution, indicating that the newly developed Philadelphia Mindfulness Scale (PHLMS) measures mindfulness and its key constituents, acceptance and awareness. Content validation by expert judges yielded high ratings of the representation of the components of mindfulness, good internal consistency was demonstrated in both clinical and nonclinical samples, and relationships with other constructs were largely as expected within the normative nonclinical samples. Although results from some of the clinical sample validation analyses were contrary to expectations, significant differences were found as predicted between the nonclinical and clinical samples. One noteworthy finding was that the awareness and acceptance subscales were not correlated with each other, suggesting that the potential role of these two constructs in mental health can be examined independently. Implications, study limitations, and future directions are discussed.

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CHAPTER 1: INTRODUCTION The Historical Roots of Mindfulness Historically, mindfulness has been associated with spiritual movements rather than mainstream psychology. Mindfulness is a primary technique used in Buddhist meditation, and has its roots in Buddhism. Buddhism was founded in northern India in 500 B.C. by Siddharta Gautama Buddha, a religious leader, in reaction to the suffering of poor, sick, aged, and dying people (Kumar, 2002; Smith, 1986). According to Buddhas doctrine of the Four Noble Truths, existence is pervaded with suffering, which is a consequence of the automatic tendency of attachment; the cessation of suffering can be achieved through the practice of the Eightfold Noble Path. In the Eightfold Noble Path, Buddha outlined ways individuals could achieve nirvana, a freedom from unhappiness, which includes understanding and sincerely following Buddhist philosophy, adhering to moral guidelines concerning speech, conduct, and vocation, disciplining the mind, and through meditation. The Eightfold Path allowed individuals to engage in the full experience of life while decreasing the tendency to attach to phenomena (Kumar, 2002). After Buddhas death in 483 B.C., Buddhism remained inconsequential until a Mauryan emperor, Asoka, converted to Buddhism in the 3rd century B.C. As Buddhism began to spread from India to elsewhere in Asia, it split into different factions based on different interpretations of Buddhas teachings. Two main sects, Theravada Buddhism and Mahayana Buddhism, emerged. Theravada Buddhists conservatively interpreted Buddhas teachings, concentrated on the emancipation of the individual based on his efforts, and focused primarily on meditation and concentration, emphasizing a monastic life removed from society. Mahayana Buddhism was a more liberal interpretation of the teachings of Buddha that accommodated a greater number of people, stressing salvation through a life of good works and compassion. Although Theravada Buddhism spread to Sri Lanka, Thailand, and Burma, and Mahayana Buddhism became popular in Mongolia, Tibet, China, Japan, Korea, Vietnam, and Nepal, the latter sect spread more rapidly due to the more liberal interpretation of Buddhas teachings. Beginning about 150 A.D., trade

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between India and China brought the ideas and practices of Mahayana Buddhism to China (Encyclopedia Britannica, 2003). By the 5th century, Buddhism became the dominant faith of China, and it reached a peak by the 7th century. Meanwhile, in the 4th century, Buddhism was introduced to Korea, and Chan, a sect of Chinese Buddhism, became the dominant school there (Encyclopedia Britannica, 2003). From Korea, Buddhism was brought to Japan between 550 and 600 A.D. by missionaries sent by Korean royalty. By the 8th century, many sects of Buddhism grew and prospered, and many different sects developed. Zen Buddhism, a sect of Mahayana Buddhism, was introduced to Japan in the 9th century by Chinese Chan Buddhists, and became popular around 1200 A.D. Zen is the Japanese word for the Chan, which is roughly translated as meditation (Christian-Meyer, 1988). Zen Buddhism emphasizes an attitude of nonattachment, meditation to develop enhanced self-awareness, focus on the present moment, which results in a state of psychological freedom from suffering. Buddhist meditation was made known most widely in the West through Japanese Zen Buddhism. Immigrants from Asia who traveled to the United States in the 19th century established communities and temples (Encyclopedia Britannica, 2003). However, when the concept of Zen reached the United States, its impact was very limited (Smith, 1986). Although Zen Buddhism was introduced at Chicagos Worlds Fair in 1893 (Benz, 1976; Smith, 1986), it continued to have little impact on American culture. Transition of Mindfulness into Psychology In the 1940s and 1950s, Zen slowly grew in America through popular books, such as Zen in the Art of Archery (Herrigel, 1953), Zen Buddhism and Psychoanalysis (Suzuki, Fromm, & De Martino, 1960), and Psychotherapy East and West (Watts, 1961). However, by the late 1950s and throughout the 1960s, meditation, based in Zen Buddhism, became more noticed through the writings of major psychotherapists. For example, Jung (1961) made use of meditative symbols in his writing. Psychotherapists showed interest in meditative techniques (Assagioli, 1965; Boss, 1965; Fingarette, 1963; Fromm, 1960; Stunkard, 1951), with many discussing meditation in

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relationship to psychoanalysis. For example, Zen was thought to be useful because it facilitated uncovering the unconscious (Smith, 1986). Zen meditation was also viewed as consistent with psychotherapy due to its emphasis on present-centered awareness, spontaneity, and acceptance (Smith, 1986). For example, Buddhism placed importance on growth and evolution, causing it to be embraced by existentialists and humanists in clinical psychology (Kumar, 2002). However, at this time, the gradual popularization of meditation in psychology resulted in a conglomeration of diverse Buddhist traditions (e.g., Tibetan Buddhism, Zen Buddhism). Also during the 1960s through the 1970s, Americans were beginning to look inward and experimented in ways to heighten awareness and broaden the boundaries of consciousness through means of psychedelic drugs, hypnosis, and parapsychology. Increased attention was paid to Eastern religion and culture, and meditation eventually caught the interest of experimental psychologists. Meditation was grouped with dreaming, hypnosis, and psychedelic drugs as a type of altered state of consciousness, because it was characterized by a qualitative change in the overall pattern of mental functioning (Tart, 1972). Meditation was found to produce a state of consciousness that could objectively be measured through electroencephalogram (EEG). Individuals who meditated showed alpha wave activity associated with restful reductions in metabolic rate (Anand, Chhina & Singh, 1961; Bagchi & Wenger, 1957), theta waves (e.g., lower states of arousal associated with sleep) (Kasamatsu & Hirai, 1966), and even some delta activity, which is typically found in deep sleep and comas (Green, Green, & Walters, 1976). However, even though experimental psychologists were defining meditation as an altered state of consciousness, teachers of Zen meditation continued to consider meditation a consciousnessraising rather than a consciousness-altering experience (Smith, 1986). Physiological research provided evidence to support this stance, and delineated two types of meditative states. Individuals who engaged in concentrative approaches (e.g., Yoga meditators, transcendental meditation) appeared to be unaware of distractions, as shown by the lack of alpha blocking (i.e., the cessation of alpha activity in response to a stimulus) (Anand et al.). Individuals engaging in

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mindfulness approaches (e.g., Zen and mindfulness meditation), however, demonstrated very brief periods of alpha blocking and did not habituate to distractions, suggesting they experienced each intrusion as if it was being experienced it for the first time (Kasamatsu & Hirai, 1966). Individuals who engaged in mindfulness meditation were said to become fully aware of their environment, calmly experiencing each moment without attachment or distraction. Thus, mindfulness began to be examined and applied in psychology independent of its historical Buddhist roots. Empirical investigation of mindfulness continued, as it began to be examined outside the domain of experimental psychology. In social psychology, Langer (1989a, 1989b) proposed two states of being that involved cognitive and affective factors: mindfulness and mindlessness. According to Langer, mindfulness is the development of a limber state of mind (Langer, 1989a, p. 70) that occurs when an individual creates new categories, is open to new information and novelty, and is aware of more than one perspective (Langer, 1989a). Individuals who are mindful are situated in the present, sensitive to context and perspective, and are actively drawing novel distinctions (Langer 1992; Langer 2002). Mindfulness is distinguished from mindlessness, behavior that occurs out of the habits of expert mastery, is trapped in rigid mind-sets, and is oblivious to time or context. As mindless occurs with little or no conscious awareness, it often leads to a single understanding of information and is governed by rule or routine (Langer 1989b; Langer, 1992; Langer 2002). From Langers research, studies have examined mindfulness related to health, business, and education. Research has examined the consequences of mindfulness/mindlessness on health in the elderly, and results suggest that mindful conditions (e.g., increasing control over ones schedule) are related to decreased adverse health conditions and increased longevity (for a review, see Langer & Moldoveanu, 2000). Studies of mindfulness in the business field suggest that increases in mindfulness are related with increased creativity and decreased burnout (for a review, see Langer & Moldoveanu, 2000). Research examining mindfulness in educational settings has found that participants in mindful conditions are better

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able to use objects creatively when the need for a novel use of the object arises and demonstrate increased attention, liking for the task, and improved memory (for a review, see Langer & Moldoveanu, 2000). In addition, mindfulness has been found to be related to increases in competence, memory, creativity, and positive affect, and decrease in accidents, human error, and stress (Langer & Moldoveanu; Langer, 2000). Mindfulness in Clinical Psychology: The Third Wave of Behavior Therapy By the 1970s, mindfulness, specifically mindfulness meditation, was beginning to be incorporated in psychotherapy. For example, it was examined in combination with bibliotherapy (Boorstein, 1983), as an adjunction to psychotherapy in general (Kutz, 1985), and independently as a short-term psychotherapy (Deatherage, 1975). Although these early endeavors represented the application of mindfulness techniques in psychotherapy, beginning in the early 1990s several innovative psychotherapies integrated the discipline of mindfulness, which more closely resembled its Buddhist roots. These newly developed and promoted treatments emphasized that present-moment awareness and acceptance are important aspects of mindfulness meditation (Breslin, Zack, & McMain, 2002), and have been referred to as the third wave of behavior therapy. Behavior therapy roughly can be categorized into three waves or generations that consist of a set of dominants assumptions and methods. First Wave of Behavior Therapy: Clinical applications of the experimental analysis of behavior. Behavior therapy (BT), which grew out of the conceptual framework of behaviorism, had its formal beginnings in the 1950s with simultaneous advances occurring in the United States, South Africa, & Great Britain (Spiegler & Guevremont, 1993). Clinical traditions that proceeded BT had a poor link to scientifically established principles, vague specification of interventions, and weak scientific evidence in support of these interventions (Hayes, 2004). Thus, two features of BT that distinguished it from existing clinical interventions at the time were the application of principles from behavior analysis to clinical phenomena and the insistence on the empirical evaluation of the BT interventions. The application of principles of operant conditioning

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developed by Skinner (1953) and those of classical conditioning by Wolpe (1958) for the treatment of anxiety guided the development of BT during the 1950s. In the United States, Lindsley and Ayllon, graduate students of B. F. Skinner at Harvard University, systematically applied learning principles to change behaviors of psychiatric patients (Spiergler & Guevremont, 1993). In the early 1960s, Ayllon and Azrin, another former graduate student of Skinner, developed the first comprehensive token economy (Spiergler & Guevremont, 1993). Meanwhile, in South Africa, Wolpe developed several bedrock behavior therapies, including systematic desensitization and assertiveness training; Wolpes approach focused on replacing maladaptive responses (i.e., anxiety, avoidance) with more adaptive responses (i.e., relaxation, assertive behavior). The development of BT in Great Britain was spearheaded by Eysenck, with similar approaches to that of the United States and South Africa, which were developed independently. As BT focused directly on problematic behavior, vague concepts and unobservable phenomena generally were disregarded. Second Wave of Behavior Therapy: Expanded emphasis on cognition. By the late 1960s, behavior therapists increasingly recognized that thoughts and feelings needed to be addressed for an adequate analysis of and intervention for human problems. However, associationism and behavior analysis were unable to provide an adequate account of human language and cognition. As a paradigm shift legitimized cognition as a viable target for clinical intervention, early cognitive mediational accounts of behavior change (e.g., Bandura, 1969) grew into the cognitive therapy movements. Three major influences to the second wave of BT have been identified: 1) the application of basic cognitive psychology constructs to the development of clinical intervention, 2) the development of behavioral self-control procedures as cognitive interventions (e.g., Thoresen & Mahoney, 1974), and 3) the emergence of cognitive therapies by Ellis (1962) and A. T. Beck (1964, 1970), which were developed within a clinical setting rather than within basic psychology (Craighead & Craighead, 2003). Cognition was addressed from a clinically relevant point of view, as patients of different diagnostic populations were observed to

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engage in particular styles of cognitive processing. Thus, the new cognitive therapies focused on the detection, correction, testing, and disputation of irrational or dysfunctional thoughts, maladaptive cognitive schemas, and faulty information-processing styles. Behavioral principles were combined with cognitive therapy to form cognitive behavior therapy, aimed at treating problems related to overt cognition, behavior, and emotion. Third Wave of Behavior Therapy: Mindfulness-based treatments. As previously stated, the third wave of behavior therapy began in the early 1990s with the development of innovative treatments that emphasize present-moment awareness and acceptance. Hayes (2004) outlined the following features of this generation of clinical intervention: Grounded in an empirical, principle-focused approach, the third wave of behavioral and cognitive therapy is particularly sensitive to the context and functions of psychological phenomena, not just their form, and thus tends to emphasize contextual and experimental change strategies in addition to more direct and didactic ones. These treatments tend to seek the construction of broad, flexible, and effective repertoires over an eliminative approach to narrowly defined problems, and to emphasize the relevance of the issues they examine for clinicians as well as clients. The third wave reformulates and synthesizes previous generations of behavioral and cognitive therapy and carries them forward into questions, issues, and domains previously addressed primarily by other traditions, in hopes of improving both understanding and outcome. (p. 658) Treatments within the third wave can be categorized into two groups: interventions that are based on mindfulness training (i.e., Mindfulness-Based Stress Reduction, Mindfulness-Based Cognitive Therapy), and interventions that include mindfulness as a key component (i.e., Acceptance and Commitment Therapy, Dialectical Behavior Therapy, Relapse Prevention). Mindfulness-Based Stress Reduction (MBSR), formerly known as the Stress Reduction and Relaxation Program (SR-RP; Kabat-Zinn, 1982, 1990), is a group treatment developed for patients with chronic medical conditions, in which the foundation of the intervention involves intensive training in mindfulness meditation (Reibel, Greeson, Brainard, & Rosenzweig, 2001). Participants meet weekly for 2 to 2.5 hours of instruction and practice in mindfulness meditation skills, coping skills, and discussion of homework assignments. Mindfulness meditation skills include body scanning, sitting meditation with attention to the sensations of breathing, and Hatha

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Yoga postures, during which individuals are instructed to notice internal experiences but not to become absorbed in their content (Kabat-Zinn, 1982). MBSR participants spend formal time each day in mindfulness mediation practice, and eventually perform the moment-to-moment awareness during daily living (Reibel et al.). MBSR has shown success in treating physical and related psychological symptoms in individuals with chronic pain (Kabat-Zinn, 1982; Kabat-Zinn, Lipworth, & Burney, 1985), generalized anxiety and panic disorders (Kabat-Zinn, Massion, Kristeller, & Peterson, 1992), binge eating disorder (Kristeller & Hallet, 1999), psoriasis (KabatZinn et al., 1998), fibromyalgia (Kaplan, Goldenberg, & Galvin-Nadeau, 1993), and cancer (Speca, Carlson, Goodey, & Angen, 2000). In addition, MBSR has led to significant increases in mental clarity and well-being, as well as a reduction in body tension (Reibel et al.). Mindfulness-Based Cognitive Therapy (MBCT; Teasdale, Segal, & Williams, 1995; Segal, Williams, & Teasdale, 2002) was adapted from the SR-RP (Kabat-Zinn, 1982, 1990) to prevent relapse of major depressive episodes. MBCT combines mindfulness techniques with elements from cognitive therapy to facilitate a detached view of ones thoughts, emotions, and bodily sensations (e.g., I am not my thoughts). Thus, the goal of MBCT is to increase awareness of moment-to-moment experience and bring attention to the present (Williams, Teasdale, Segal, & Soulsby, 2000). Rather than changing the content of thoughts, MBCT aims to change the awareness and relationship to thoughts. The attitude of non-judgment and that mental events are not an aspect of the self is believed to prevent the escalation of the rumination of negative thoughts (Teasdale et al., 1995). Research supports the use of MBCT, as it has been found to be related to lower rates of depressive relapse for individuals with three or more depressive episodes (Teasdale et al., 2000). Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) was developed under the premise that psychopathology is associated with attempts to control or avoid negative thoughts or emotions. ACT teaches skills to decrease experiential avoidance, which occurs when a person is unwilling to remain in contact with particular private experiences (e.g.,

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bodily sensations, emotions, thoughts, memories, behavioral dispositions) and takes steps to alter the form or frequency of these events and the contexts that occasion them (Hayes et al., 1999, p. 58). Mindfulness increases willingness by enhancing awareness of an observing self, which then fosters the deliteralization of thoughts and beliefs. Although ACT does not specifically promote mindfulness as a treatment component or technique, the general approach and specific methods and exercises are consistent with other mindfulness-based approaches (Baer, 2003). Research has examined the successful use of ACT for depression (Zettle & Hayes, 1986; Zettle & Raines, 1989), anxiety disorders (Block, 2002; Block & Wulfert, 2000; Hayes, 1987), workplace stress (Bond & Bruce, 2000), chronic pain (Geiser, 1992), schizophrenia (Bach & Hayes, 2002; Gaudiano, Dalrymple, & Herbert, 2002), smoking cessation (Gifford, 2002), and substance abuse (Hayes et al., 2002). In addition, there is evidence that a reduction in the believability of thoughts occurs for individuals who receive ACT (Bach & Hayes, 2002; Zettle & Raines, 1989). Dialectical Behavior Therapy (DBT; Linehan, 1993) combines elements of traditional cognitive-behavioral approaches with Zen philosophy for the treatment of borderline personality disorder. DBT views dysfunctional behavior as a consequence of an underlying dysfunction of emotion regulation system, which is associated with negative affect and an inability to modulate that affect (Linehan, 1993). In DBT, behavior change is fostered in the context of selfacceptance, and mindfulness is a central strategy used to increase acceptance. Mindfulness, emphasizing non-judgment and non-evaluation, is believed to function as an exposure strategy that decreases automatic avoidance of emotion and fear responses (Linehan, 1993). Mindfulness in DBT is organized somewhat differently in comparison to the other mindfulness-based psychotherapies, as DBT teaches mindfulness what skills (i.e., observe, describe, participate) and mindfulness how skills (i.e., nonjudgmentally, one-mindfully, effectively) (Baer, 2003). Mindfulness exercises include using imaging to observe thoughts, feelings, and sensations, observing breath by counting or coordinating with footsteps, and mindful awareness during daily activities (Baer, 2003). Women diagnosed with borderline personality disorder who received

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DBT have shown a decrease in parasuicidal behaviors, anger, and dissociation, reduced hospitalization days, and higher treatment retention rates (Linehan, Armstrong, Suarez, Allman, & Heard, 1991). DBT skills, including mindfulness, have also been applied with success to bulimia (Telch, Agras, & Linehan, 2000) and substance abuse (Linehan et al., 1999). Relapse Prevention (RP; Marlatt & Gordon, 1985) is a treatment package designed to avert relapses in substance abuse. Mindfulness is taught as a technique to cope with urges; for example, the metaphor of urge surfing is used to encourage clients to ride out waves and letting the urge pass without giving into them. In addition, RP uses mindfulness to teach that urges cannot be eliminated, fostering observation and acceptance of urges (Baer, 2003). The development of the mindfulness-based treatments marked the merger of the study of mindfulness in clinical and research domains, as the emphasis on empiricism in behavior therapy allowed the study of mindfulness to grow within applied and empirical psychology. Within the past ten years, there has been increased interest in mindfulness in academic clinical psychology. For example, the acceptance and commitment therapy listserv, founded by Stephen Hayes at the University of Nevada, Reno in 2002, has close to 800 members. The mindfulness listserv, recently established in 2002 by David Fresco at Kent State University, has over 220 members. The rise in interest in mindfulness is also demonstrated by the formation of a Mindfulness and Acceptance Special Interest Group (SIG) within the Association of the Advancement of Behavior Therapy (AABT) in 2002. Over 150 individuals expressed interested in joining the SIG prior to its creation. In addition, in conducting a PsychInfo database search using mindfulness as the key word, 506 articles have been published since 1977. Of those articles, 76% have been published within the past 10 years, and 24% have been published within the past year (i.e., 20042005). Thus, the interest in mindfulness and mindfulness-based treatments is clearly growing rapidly.

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Defining Mindfulness Although interest in the construct of mindfulness has increased within the past ten years, research has been hampered by a lack of clear operationalization of mindfulness. The construct has been defined differently depending on the domain of psychology within which it is used. Table 1 (Appendix A) lists clinical definitions of mindfulness and Table 2 (Appendix A) lists nonclinical definitions found after a review of the literature. The nonclinical definitions are divided into those found in the social psychology literature, and those found within writings related to philosophy and mindfulness practice. The clinical and social-psychological definitions have similarities. Both conceptualizations emphasize flexible awareness in the present. In addition, the socialpsychological definition states that mindfulness is not vigilance or placing attention on a single stimulus or object (Langer, 2002), which is similar to the clinical stance. However, there are several ways in which the clinical conceptualization of mindfulness is distinct from the nonclinical conceptualization. Unrelated historical and cultural backgrounds during the development of the construct have resulted in differences in the definition and application of mindfulness. Whereas the social-psychological perspective of mindfulness focuses only on the cognitive processes of only what is occurring in the external environment, the clinical mindfulness approach involves both stimuli internal and external to the individual. The socialpsychological applications are taught to increase learning and creativity, whereas the clinical conceptualization of mindfulness has generally been applied to help individuals cope with unpleasant or distressing experiences. Lastly, the social-psychological perspective does not include the component of non-judgment emphasized in clinical perspective. Since there are differences in the context in which the conceptualizations were developed, differences in application, and they do not share key components in the definition, the current study will only focus on the clinical conceptualization of mindfulness.

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Current Conceptualization of Mindfulness in Clinical Psychology The clinical definitions of mindfulness are most similar to the Buddhist tradition, as modern Western descriptions have generally remained consistent with Buddhist conceptualizations (Bishop, 2002). In Satipatthana, or mindfulness, the mind is receptive and registers what is observed (Goleman, 1978). Mindfulness in the Buddhist tradition has been referred to as bare attention, or a non-discursive registering of events without reaction or mental evaluation, which emphasizes the process of sustained attention rather than the content to what is attended (Thera, 1972). Among Western descriptions in clinical psychology, the definition or a variation of the definition of mindfulness provided by Kabat-Zinn (1990, 1994) is most frequently cited (See Table 1, Appendix A). Kabat-Zinn (1990) enhanced the Buddhist conceptualization of mindfulness by defining seven mindfulness qualities that refer to how one attends to information during mindfulness. Shapiro, Schwartz, and Bonner (1998) elaborated the list with five additional qualities, yielding a total of twelve mindfulness qualities: nonjudging, nonstriving, acceptance, patience, trust, openness, letting go, gentleness, generosity, empathy, gratitude, and loving kindness. The latter qualities added by Shapiro et al. were added to address the affective qualities of mindfulness. See Appendix B for a list of the 12 qualities, excerpted from Shapiro and Schwartz (2000). Examination of Table 1 reveals that most of the definitions of mindfulness include present-moment awareness as a component. Awareness is characterized as a continuous monitoring of inner events and is the means by which humans observe (Deikman, 1996). It is described as conscious awareness to ones internal and/or external environment, which is placed on present-moment experience, rather than past or future events (Roemer & Orsillo, 2003). Attention is another state of consciousness that is related to awareness, defined as a heightened sensitivity to a limited range of experience (Kosslyn & Rosenberg, 2001). Attention has been associated with higher-quality moment-to-moment experiences. For example, increased attention on the sensory experience of eating chocolate was related to higher ratings of pleasure (LeBel &

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Dube, 2001). However, enhanced attention also appears to have a dark side. Higher levels of present-moment attention have been associated with higher levels of mood disturbance and stress (Brown & Ryan, 2003). Further, the literature documents a positive relationship between heightened attention to the self and negative mood states and even clinical disorders. For example, self-focused attention may be associated with clinical levels of depression (Ingram, Lumry, Cruet, & Sieber, 1987), test anxiety (Carver, Peterson, Follansbee, & Scheier, 1983; Slapion & Carver, 1981), social anxiety (Hope & Heimberg, 1988), and alcohol consumption (Hull, 1981; Hull, Levenson, Young, & Sher, 1983). Although mindfulness has been characterized as a regulation of attention (Astin, 1997, p. 100), the term awareness is more accurate with regard to mindfulness. Attention is a heightened sensitivity to a restricted amount of experience, which implies that experience outside of attention is ignored or disregarded. Awareness is more consistent with mindfulness, since it is the continuous monitoring of all experience. In addition to present-moment awareness, how one is aware may also have consequences for health and well-being. The second component of mindfulness is the way in which presentmoment awareness is conducted: nonjudgmentally, with an attitude of acceptance or compassion toward ones experience. Acceptance has been defined as experiencing events fully and without defense, as they are (Hayes, 1994, p. 30), during which one is open to the reality of the present moment without being in a state of belief or disbelief (Roemer & Orsillo, 2003). During an acceptance stance, one inhibits judgment, interpretation, and/or elaboration of internal events, and makes no attempt to change, avoid, or escape from the internal experience (Bishop, 2002). Acceptance as a component of mindfulness is in line with Buddhist tradition, as the Buddha described the cessation of suffering as giving up, renouncing, relinquishing, detaching (Dhammacakka Sutta, as cited in Hayes, 2002b). Acceptance in this context should not be confused with passivity or resignation; instead, it is being present, rather than preoccupied, with private events as they occur (Breslin et al., 2002). There is strong evidence for the negative

14
consequences of stimuli that are deliberately ignored or avoided (i.e., through suppression, distraction, or cognitive reframing). For example, thought suppression has been found to be associated with heightened pain experience (Sullivan, Rouse, Bishop, & Johnston, 1997), and suppression of urges to engage in alcohol consumption is related to increases in the expected reinforcing effect of alcohol by heavy drinkers (Palfai, Monti, Colby, & Rohsenow, 1997). In addition, thought suppression has been implicated in the etiology and/or maintenance of depression, generalized anxiety disorder, specific phobia, posttraumatic stress disorder, and obsessive-compulsive disorder (Purdon, 1999). In contrast, acceptance allows for the increased contact of internal stimuli. Increased acceptance often appears to have paradoxical effects: as one gives up on trying to be different one immediately becomes different in a very profound way (Hayes, 1994, p. 20). Acceptance appears to be most applicable to negative experiences or internal phenomena (i.e., thoughts, feelings, memories, physical sensations). Although the absence of acceptance is related to the presence of negative affect or experiences, research contradicts the tautology of these constructs. For example, research has shown a decrease in stress and increase in the propensity for innovation mediated by post-treatment experiential avoidance (i.e., acceptance) scores (Bond & Bruce, 2000), a decrease in depression only following an increase in acceptance (e.g., Hayes, 2005), and better outcomes following treatment for smoking cessation mediated by psychological avoidance (Gifford et al., 2004). Thus, although the absence of acceptance and negative private experiences are correlated, they are distinct constructs. Although most descriptions of mindfulness reflect the components of awareness and nonjudgmental acceptance, the distinction between the two is generally not emphasized. In fact, Brown and Ryan (2003, 2004) argue on both theoretical and empirical grounds that the acceptance component of mindfulness is redundant with the awareness component. It is often assumed that increased present-focused awareness will necessarily occur with an attitude of enhanced acceptance, and conversely that enhancing ones stance of nonjudgmental acceptance

15
will necessarily lead to increased awareness. However, the degree to which changes in either component tend to impact changes in the other is an open question, and it should not be assumed that the two components are inextricably linked. For example, high levels of awareness need not be accompanied by high levels of acceptance. Research demonstrates that panic disorder is associated with increased awareness of internal physiological cues (e.g., Ehlers & Breuer, 1992, 1996), but this awareness is not accepted nonjudgmentally. Conversely, one can adopt a highly accepting perspective without necessarily being highly aware of ongoing experience. Mindfulness has been shown to be related to symptom reduction and increased wellbeing for individuals who receive a mindfulness-based treatment or mindfulness training. Several mechanisms that lead to clinical change have been proposed. Mindfulness has been equated with interoceptive exposure. Sustained, nonjudgmental awareness to uncomfortable private events in the moment (e.g., thoughts, negative affect, physical sensations) may lead to desensitization (Baer, 2003; Breslin et al., 2002; Hayes & Wilson, 2003). Prolonged observation of uncomfortable private events over time may then encourage reduced emotional avoidance of previously untolerated internal stimuli. Another proposed mechanism of action of mindfulness is with regard to the relationship to internal stimuli. Research has suggested that people automatically evaluate most if not all external stimuli immediately upon presentation (i.e., 250 ms or less) without awareness or intention (Bargh & Ferguson, 2000). Similarly, thoughts and feelings are considered to be experienced automatically or nonvolitionally, controlled by processes that lie outside of awareness (Kirsch & Lynn, 1999). For these reasons, mindfulness may lead to increased well-being by changing the relationship or perspective to ones internal processes, since they may not be able to be controlled. Referred to as cognitive distancing, deliteralization (Hayes et al., 1999), or decentered perspective (Teasdale et al., 1995), during mindfulness, thoughts are objectively viewed as just thoughts rather than as necessarily truths or reality of the self. In addition, mindfulness may be a form of response substitution. The new response, approaching situations with objective awareness, may cause the situation not to have

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inherent value, resulting in decreased emotional reactivity (Bishop, 2002). Lastly, mindfulness may allow for the training of a new conditioned response (i.e., present-moment nonjudgmental awareness) to cues of negative internal experiences, allowing for the extinction of the old conditioned response of avoidance (Breslin et al.). Regardless of the mechanism of action, several positive consequences of mindfulness have been documented. As previously mentioned, symptom reduction has been noted for individuals who received a mindfulness-based treatment. Mindfulness appears to interrupt cycles of negative internal experiences, such as anticipatory anxiety of a future event, or rumination of a past event. Beliefs, regarded as habits of thinking, feeling, and perceiving (Tart, 1994), determine the manner in which one observes the external environment; mindfulness allows one to observe beliefs and their potential consequences without accepting them as truth. As a result, an increased range of responses become available, as habitual ways of responding are replaced with intentional ways of responding that are chosen rather than automatically enacted (Hayes, 2002a; Roemer & Orsillo, 2002; Breslin et al., 2002). For example, mindfulness may disrupt the flightor-fight reaction in anxiety-provoking situations, allowing for effective response rather than fear or panic (Miller, Fletcher, & Kabat-Zinn, 1995). This may allow for the ability to engage in a variety of coping responses, better control of attention needed for demanding tasks, or an increase in feelings of self-efficacy and perceived control (Baer, 2003; Breslin et al., 2002; Trunnel, White, Cederquist & Braza 1996). Although the purpose of mindfulness is not to induce relaxation, nonjudgmental observation of physiological arousal or negative internal events may evoke relaxation. Mindfulness may also lead to the focus on the process or intrinsic qualities of an activity, allowing for the increase of pleasure experienced during an activity and a decrease of negative mood associated with failing to achieve the extrinsic outcome (Borkovec, 2002). Davidson and colleagues (2003) report that mindfulness meditation produces brain activation in a region typically associated with positive affect, and beneficial effects of immune functioning. In addition, Carlson, Speca, Patel, and Goodey (2003) found significant improvements in quality of

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life, symptoms of stress, and sleep quality in breast and prostate cancer patients after participation in a mindfulness-based stress reduction program. Finally, there may be an evolutionary adaptive value of nonjudgmental awareness on the present moment: We are hard wired to process internal (e.g., primary emotional) and external information for use in our adaptation to our environments and in facilitation of our survivalIt makes sense, then, that my prime directive as a living organism is to accurately process new information as it becomes available to me. The only real information that is available is that which exists in the present moment. When I am paying attention to this information, I do not have to judge it, categorize it, memorize it, or think about how I might use it in the future. I merely pay attention to it; my information processing systems will handle the rest. The information will be stored in memory, and when a future event occurs in the present, I can trust that an adequate, adaptive response will be elicited, because this is precisely what these systems were designed to do. (Borkovec, 2002, p. 78) The Relationship of Mindfulness to Meditation The terms mindfulness and mindfulness meditation are often used interchangeably. Part of the confusion arises from the lack of operationalization of mindfulness, as some definitions characterize it as a method or technique and others as a process. Mindfulness meditation, also referred to as satipatana vipassana, awareness meditation, or insight meditation, has similar roots to mindfulness in Mahayana Buddhism, (Kabat-Zinn, 1984). However, mindfulness has been distinguished from mindfulness meditation, in that the latter is the practice which emphasizes present-moment detached observation of a constantly changing field of objects. Mindfulness meditation involves the development of a watcher self (Deatherage, 1975) and regularly setting time to practice being mindful (Robins, 2002). During mindfulness meditation, one attends to breath and body sensations, and brings an attitude of acceptance to any distraction that might occur (Breslin et al., 2002). As attention becomes stable, the practioner allows the field of objects to expand to include all physical and mental events (e.g., thoughts, memories, images, body sensations) as they occur in the moment (Kabat-Zinn, 1984). Thus, mindfulness meditation is one technique or method that may increase the psychological state described as mindfulness.

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Mindfulness has also been distinguished from concentration-based meditation approaches (e.g., Transcendental Meditation, relaxation meditation, Raj Yogi, samatha meditation) by the way that the nature of attention and distraction is viewed. Although concentration-based approaches have roots in Theravada Buddhism (Gunaratana, 1991), individuals engaging in concentration-based approaches restrict the focus of attention to a single stimulus (e.g., a mantra, sound, object, sensation, breathing process), and if attention drifts or is distracted, attention is redirected to the object of focus (Baer, 2003; Logsdon-Conradsen, 2002). It is described as a forced practice (Gunaratana, 1991). In contrast, observation during mindfulness practice involves observation of the range of internal and/or external stimuli in ones immediate awareness (Baer, 2003; Logsdon-Conradsen, 2002), and brings an attitude of acceptance to the inevitable distractions that occur (Breslin et al., 2002, p. 280). There is evidence that concentration-based and mindfulness-based approaches are distinct processes. For example, mindfulness practioners significantly outperformed concentrative practioners in the ability to pay attention when unconditioned stimuli were presented (Logsdon-Conradsen, 2002). Thus, whereas concentration-based meditation emphasizes controlling the focus of attention, a mindfulness approach promotes opening the range of awareness. Constructs Related to Mindfulness As just discussed, other terms such as mindfulness meditation are often interchangeably used with mindfulness. Further, several constructs appear to be related to mindfulness. These constructs have been divided into two categories: modes of mental processing and reflexive consciousness (i.e., the type and extent of knowledge about ones self; Baumeister, 1999). Modes of mental processing. Mindfulness has been distinguished from other modes of mental processing, specifically awareness, attention, cognition, and metacognitive processes. Awareness, one component of consciousness, has been defined as the continuous monitoring of inner events and the outer environment (Brown & Ryan, 2003). Attention, another component of

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consciousness, is the process of providing heightened sensitivity to a limited range of experience (Kosslyn & Rosenberg, 2001). One type of mental process that one can be conscious of is cognition, or the subjective experiences that one can know or become aware of, including all mental or psychological experiences or states of which one can be conscious (Toneatto, 2002). Related to mindfulness, Buddhism differentiates between perceptual cognition, the way events inside and outside the body present to awareness, and conceptual cognition, the internal experiences that co-emerge with perceptual cognition that can be descriptive (e.g., that is a noise), analytic (e.g., that is a loud noise) or judgmental (e.g., that is an annoying noise) (Toneatto, 2002). The latter type of cognition is most related to metacognitive processes. Although awareness, attention, and cognition are clearly defined, the distinction between metacognitive processes is not as apparent. Metacognition has been defined in multiple ways, including the beliefs and attitudes held about cognition (Toneatto, 2002, p. 73); cognition about cognition (Flavell & Ross, 1981); an active and reflective process that is focused toward ones cognitive activity (Allen & Armour-Thomas, 1991); and cognitive activity in which other cognitive activities are the target of reflection (i.e., thinking about thinking) (Yussen, 1985). A distinction has been made between metacognitive knowledge, factual knowledge that the content of thoughts do not always correspond to the state of the world, and metacognitive insight, actually experiencing thoughts as mental phenomena in the moment they occur (Teasdale, 1999; Teasdale et al., 2002). Metacognitive awareness, classified as a type of metacognitive insight, is the extent to which thoughts are experienced as mental events rather than as aspects of the self or direct reflections of truth (Teasdale et al.). Further, metacognitive belief is the extent to which individuals believe particular thoughts about ones own cognitions are true. Further complicating the operationalization of the different modes of mental processing is that these terms are often used interchangeably. For example, Teasdale et al. (2002) write, metacognitive insight (awareness) refers to actually experiencing thoughts as thoughts (that is, as events in the mind rather than as direct readouts on reality) in the moment they occur (p. 286).

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By using both terms, the distinction between them is blurred. In addition, the definition of one mode of mental processing is often used to define another. For example, whereas awareness was earlier defined as the continuous monitoring of inner and outer environments, awareness has also been defined in the mindfulness literature as, the ability of the human mind to distinguish cognition (e.g., thinking, feeling) from cognizing (e.g., to know that one is feeling or thinking) (Toneatto, 2002, p. 73); the latter definition closely resembles the definition of metacognitive knowledge and metacognitive insight. The definitions of some of these terms have also been domain-specific; for example, metacognition has been defined in relationship to psychopathology, as an awareness of how cognition contributes to depression (Teasdale et al., p. 286). Metacognitive processing appears to be related to mindfulness. Mindfulness has been described as a kind of meta-cognitive ability in which the participant has the capacity to observe his or her own mental processes (Bishop, 2002, p. 74). However, as previously discussed, mindfulness is the combination of present-moment awareness and acceptance of internal experiences, rather than simply the ability to observe ones mental processes. Forms of reflexive consciousness. One of the earliest examinations of the monitoring of behavior and internal states is with regard to self-monitoring, or the self-observation and selfcontrol guided by situational cues to social appropriateness (Synder, 1974, p. 526). Synder outlined potential goals of self-monitoring, including to communicate accurately ones emotional state, to communicate an emotional state that may not be accurate with ones experienced emotional state, to conceal an inappropriate emotional state and appear unresponsive or to be experiencing an appropriate emotional state. Synder depicted the self-monitoring individual as one who is sensitive to the expression and self-presentation of others and one who uses these cues as guidelines when monitoring his/her own self-presentation. A more modern reference to self-monitoring from the behavior therapy literature is with regard to the therapeutic assessment procedure of noticing actions, thoughts, or feelings by a client in a naturalistic setting (Korotitsch & Nelson-Gray, 1999). Self-monitoring procedures are

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used for diagnostic assessment, to conduct a functional assessment, to select target behaviors for treatment, and to monitor treatment (Korotitsch & Nelson-Gray, 1999). Self-monitoring procedures have also been used as a cognitive-behavioral intervention, such as in daily food records in treating bulimia (Agras & Apple, 1997) and worry records in treating generalized anxiety disorder (Craske, Barlow, & OLeary, 1992), due to the potential reactive effects (i.e., change in the frequency of a target behavior that is a result of the self-monitoring procedure). Related to Synders (1974) construct of self-monitoring, self-awareness theory (Duval & Wicklund, 1972) makes the distinction between attention directed inward toward the self and attention directed outward toward the environment (Fenigstein, 1997). Three constructs have been derived from self-awareness theory: self-awareness, self-consciousness, and self-focused attention. The construct of self-awareness is described as a psychological state in which the existence of self-directed attention as a result of transient situational variables, chronic dispositions, or both (Fenigstein, Scheier, & Buss, 1975, p. 522). A distinction has been drawn between private self-awareness, awareness of oneself from a personal perspective, and public self-awareness, the awareness of oneself from the imagined perspective of others (Fejfar & Hoyle, 2000). In contrast to self-awareness, a psychological state, trait differences in self attention are referred to as self-consciousness or the consistent tendency of persons to direct attention inward or outward (Fenigstein et al., 1975, p. 522). Self-consciousness has two independent dimensions: private self-consciousness, the tendency to be aware of internal thoughts and feelings, and public self-consciousness, the tendency to be cognizant in the outward display of the self and reactions of others to the self (Fenigstein et al.). Increased private selfconsciousness has been found to be related to increased awareness of thoughts and feelings, experience of bodily sensations, and affective reactivity to private events (Fenigstein, 1997). However, critics of the Fenigstein et al. conceptualization of private self-consciousness have argued that it is composed of two factors, self-reflectiveness and internal state awareness (Anderson & Bohon, 1996). Self-reflectiveness has been found to correlate positively with

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measures of negative affect and neuroticism, whereas internal state awareness does not correlate or correlates negatively (Trapnell & Campbell, 1999). The constructs of rumination (i.e., neurotic self-attentiveness) and reflection (i.e., intellectual self-attentiveness) have also been delineated as separate components of private self-consciousness (Trapnell & Campbell, 1999). Rumination, correlated with measures of neuroticism, is thought to be motivated by perceived threats, loss, or injustices to the self, whereas reflection, associated with the dimension of openness, is self-attentiveness motivated in curiosity or interest in the self (Trapnell & Campbell, 1999). Private self-consciousness has also been conceptualized as comprising of self-reflection and insight (Grant, Franklin, & Langford, 2002). The third construct derived from self-awareness theory is the construct of self-focused attention, which has been described as an awareness of internally generated information (Ingram, 1990). Related to self-focused attention is the construct of absorption. Tellegen & Atkinson (1974), in investigating correlates of hypnotic suggestibility, termed absorption as the full commitment of available perceptual, motoric, imaginative and ideational resources to a unified representation of the attentional object (Tellegen & Atkinson, 1974, p 274). They proposed that this state of total attention is related to a heightened sense of reality to a focal object, decreased distraction by external events, and an altered sense of reality and sense of self. Self-absorption, or maladaptive self-focused attention, involves excessive, sustained and rigid attention to internal information (Ingram, 1990). Deikman (1982) described an observing self, or the center of all experience. When the observing self is removed from the contents of consciousness, we are better able to locate ourselves in the observer instead of the contentsthose patterns of emotions, thoughts, and fantasies responsible for our pain (Deikman, 1982, p. 99). Similarly, self-observation is defined as the conscious reflection and interpretation of ones temporal stream of sensation, emotion, and thought (Horowitz, 2002, p. 115). Self-observation is thought to be adaptive, as it reduces

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the intensity of affect, obsessive thinking, and automatic response patterns (Deikman, 1982), and aids in the ability to think more broadly and openly (Horowitz, 2002). With regard to how one observes the self, Deikman (1982) defined the term deautomatization as an undoing of the automatic processes that control perception and cognition (p. 137). Through deautomatization, one disindentifies with automatic sequences, which leads to a decrease in their impact and increased ability to choose an appropriate response. Related to deautomatization, Safran & Segal (1990) have defined deautomization as the slowing down a habitual mode of perceptual processing and increasing attention to details that would otherwise not be processed, and decentering, changing the nature of ones experience by having the capacity to observe oneself and stepping out of ones immediate experience. Self-regulation, another construct regarding how one processes information about the self, is the process by which a system regulates itself to achieve specific goals (Schwartz, 1984). An engineering concept applied to living organisms, it was later expanded from automatic response to include conscious self-regulation (Shapiro & Schwartz, 2000). Based on positive and negative feedback loops, during conscious attentional self-regulation, bringing something to conscious attention amplifies the feedback, which then leads to subsequent self-regulation (Shapiro & Schwartz, 2000). Negative feedback loops lead to homeostasis, whereas positive feedback loops lead to change, growth, or development (Shapiro & Schwartz, 1999). Techniques that have been used to develop self-regulation include meditation, biofeedback, guided imagery, progressive muscle relaxation, and exercise (Shapiro & Schwartz, 1999; Shapiro & Schwartz, 2000). Thus, self-regulation is the process by which a system preserves stability of functioning and allows for flexibility in novel situations (Schwartz, 1984). Self-regulation is taught with the goal of disease reduction and health enhancement by having individuals attend to themselves (Shapiro & Schwartz, 1999). Similar to the concept of self-regulation, Deci & Ryan (1980) developed a theory of selfdetermination, which posits that behaviors are selected on the basis of conscious motives based

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on the evaluation of an anticipated outcome to provide the greatest satisfaction of those motives that are salient at that time. According to this theory, individuals choose outcomes that are going to satisfy the most conscious motives given the constraints of the situation. Distinguished from automatic mindless behavior, self-determination is equated with mindful behavior (Deci & Ryan, 1980, p. 42) due to the conscious enactment of behaviors consistent with ones needs, values, and interests. Much of the literature regarding consciousness, awareness, and attention of the self is focused on reflexive consciousness, which examines the type and extent of ones knowledge about the self. However, mindfulness differs from the constructs categorized as reflexive consciousness in various ways. Although mindfulness involves self-focused attention, the attention is directed to develop a perspective on mental events allowing one to observe mental events rather than the mental events being a part of oneself. Several of the constructs of reflexive consciousness (e.g., self-monitoring, self-consciousness, self-awareness) are with regard to the evaluation, scrutiny, or concern about the self, whereas the self-focus of mindfulness is by definition nonevaluative. Similarly, increases in reflexive self-consciousness have been associated with negative consequences and decreases in well-being, whereas mindfulness is associated with and has predicted positive well-being and reduced disturbance (Brown & Ryan, 2003). Finally, mindfulness does not necessarily involve complete immersion in experience characteristic of constructs such as absorption; instead mindfulness entails the observation of experience in a detached way. The Relationship Between Mindfulness, Implicit Cognition, and Explicit Cognition The term implicit cognitive processing includes implicit cognition and other automatic processes and is distinguished from more explicit cognitive phenomena that involve certain functions of consciousness. The implicit-explicit distinction has also been referred to as unawareaware, unconscious-conscious, intuitive-analytic, direct-indirect, procedural-declarative, and automatic-controlled (Greenwald & Banaji, 1995). The identifying feature of implicit cognition

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is that past experience influences responses even when it is not remembered or known by the individual. Further, unlike explicit or conscious cognition, implicit cognition cannot be assessed by self-report or introspection. A large body of research has shown that implicit cognitive processes may impact behavior or elicit negative emotion, even when the individual is not aware of this influence or is not deliberately attempting to utilize this information (Palfai & Wagner, 2004). Within clinical psychology, one of the key treatment goals in cognitive therapy is to help patients identify their automatic processing strategies and replace them with deliberate ones, breaking dysfunctional cognitive-interpersonal cycles. Thus, through psychoeducation, thought monitoring, and challenging maladaptive thinking, patients become aware of their automatic dysfunctional thought patterns and break the automatic association between cues and responses. The intention of cognitive therapy is to influence implicit cognitions by addressing explicit cognitions and changing behavior, although the degree to which one can actually change implicit cognitions in this manner remains unclear. Although research has not examined the relationship between mindfulness and implicit cognition, one could argue that the goal of mindfulness techniques would not be to target implicit processes directly; instead, mindfulness exercises are implemented to detach from explicit cognition or negative affect, which can then allow an individual to act in a manner that is more consistent with his goals. However, unlike traditional cognitive and cognitive behavior therapies that aim to change the content of explicit cognition, the goal of mindfulness techniques simply is simply to observe conscious phenomena with a stance of acceptance. Further, increasing mindfulness is in the service of behavior change, which may then change implicit cognitive processes. Measures of Mindfulness Several instruments for assessing mindfulness recently have become available; see Appendix C for a list of measures with abbreviated descriptions of the measures described below. The Freiburg Mindfulness Inventory (FMI; Buchheld, Grossman, & Walach, 2001) was developed with individuals in mindfulness meditation retreats, and assesses nonjudgmental

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present-moment observation and openness to negative experience. It consists of 30 items rated according to how frequent each item has been experienced during a specific previous timeframe. Items are rated on a 4-point Likert scale (i.e., almost never, occasionally, fairly often, almost always), and higher scores indicate higher mindfulness. Although four factors were initially produced (i.e., attention to the present moment without personal identification with the experience at hand; nonjudgmental attitude toward self and others; openness to ones own negative and positive perceptions, sensations, mood states, emotions, and thoughts; insightful understanding of experience at a general level), the factor structure was unstable with time, and data indicated the presence of a single factor. The FMI showed good internal consistency before and after completion of a meditation retreat. Despite its adequate psychometric properties, the FMI was designed only for use with individuals who have had prior exposure to the practice of mindfulness meditation, and the authors note that some items meanings may not be clear to those without meditation experience. The Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003) was designed to measure mindfulness or the present-centered attention-awareness (Brown & Ryan, 2003, p. 824). It consists of 15 items rated on a 6-point Likert scale (1 = almost always; 6 = almost never), and higher scores indicate greater mindfulness. Items are distributed across cognitive, emotional, interpersonal, physical, and general domains, and reflect an indirect approach (i.e., with higher scores reflecting lower mindfulness) to the assessment of mindfulness. For example, items include, I break or spill things because of carelessness, not paying attention, or thinking of something else and I find it difficult to stay focused on whats happening in the present, which are characteristic of mindless rather than mindful states. The MAAS was found to be a reliable instrument for college-aged and general-adult populations, to discriminate between practitioners and non-practitioners of mindfulness, and to predict well-being outcomes. Even though the authors described mindfulness as having an open receptivity to the present (Brown & Ryan, 2003, p. 844) and having a foundation that is perceptual and nonevaluative (Brown & Ryan,

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2003, p. 843), both of which imply an attitude of non-judgment, the MAAS only assesses the present-moment attention and awareness component of mindfulness, and the authors explicitly stated that items containing attitudinal components (e.g., acceptance) were excluded. The Toronto Mindfulness Scale (TMS; Bishop et al., 2003) was created to assess the attainment of a mindful state immediately following a meditation exercise. It consists of a single factor describing a state of heightened awareness of bodily sensations, thoughts and feelings, as well an observational stance characterized by curiosity, acceptance and experiential openness. The TMS consists of 10 items that are rated on a 5-point Likert scale, and individuals rate the degree to which the item describes what was just experienced (0 = not at all, 4 = very much). Higher scores indicate higher levels of mindfulness. Items are worded in the past-tense to reflect what was just experienced. For example, items include I remained open to whatever thoughts and feelings I was experiencing, I found myself observing unpleasant feelings without getting drawn into them, and I approached each experience by trying to accept it, no matter whether it was pleasant or unpleasant. The TMS was found to be reliable and valid for individuals with individuals with and without previous mindfulness meditation experience. The Kentucky Inventory of Mindfulness Skills (KIMS; Baer, Smith, & Allen, 2004) is a self-report inventory designed for the assessment of four mindfulness skills: observe, describe, act with awareness, and accept without judgment. The measures conceptualization of mindfulness skills was most strongly influenced by Linehan (1993), and the skills measured are most similar to those taught in Dialectical Behavior Therapy. The observing skill emphasizes noticing or attending to both internal and external phenomena. The describing skill is the ability to label or note observed phenomena by covertly applying words; labels can be single words (e.g., sadness) or phrases (e.g., here is my anger). When one is engaging in the act with awareness skill, s/he is entering wholly into an activity or focusing on one thing at a time. Last, the accept without judgment skill emphasizes a nonjudgmental or nonevaluative stance about present moment experience. The KIMS consists of 39 items that are rated on a 5-point Likert

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Scale ranging from 1 (never or very rarely true) to 5 (almost always or always true) according to your own opinion about what is generally true for you. The measure was found to have high internal consistency, adequate to good test-retest reliability, and validation analyses providing support for the relationship between mindfulness and mental health (Baer et al., 2004). The Cognitive and Affective Mindfulness Scale-Revised (CAMS-R; Feldman, Hayes, Kumar & Greeson, 2003, 2004) assesses the awareness, attention, present-focus, and acceptance/nonjudgment aspects of mindfulness. Items are specific to thoughts and feelings rather than to all experiences, and since it does not require meditation training, it can assess mindfulness acquired through life experiences, religious practices, and therapies that do not directly teach mindfulness skills. The CAMS was an 18-item version that was sensitive to change in mindfulness over the course of an integrative therapy for depression. That version was refined through a series of psychometric studies that yielded the 12-item CAMS-R. Items are rated on a 4-point Likert scale (1 = not at all; 4 = almost always) according to how much each of these ways applies to you. Items include, I am preoccupied by the future, I can tolerate emotional pain, and I try to notice my thoughts without judging them. Higher scores on the CAMS-R were associated with less experiential avoidance, thought suppression, rumination, worry, and overgeneralization (i.e., spread of activation from a negative event to a negative sense of self) (Feldman et al., 2003, 2004). Measures of Constructs Related to Mindfulness Prior to the development of mindfulness measures, only measures of constructs related to mindfulness existed. They can be classified in one of three categories: (1) measures of metacognition; (2) measures of reflective consciousness; (3) measures of acceptance. See Appendix C for a list with abbreviated descriptions of the measures described below. Measures of metacognition. There are currently three measures that assess metacognitive processes. The Metacognitive Awareness Inventory (MAI; Schraw & Dennison, 1994) is a 52-item inventory that measures adults metacognitive awareness, broken down into two

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categories, knowledge of cognition and regulation of cognition. Knowledge of cognition, or the reflective aspect of metacognition, includes three subprocesses: declarative knowledge (i.e., knowledge about the self and about strategies), procedural knowledge (i.e., knowledge about how to use strategies), and conditional knowledge (i.e., knowledge about when and why to use strategies) (Schraw & Dennison, 1994, p. 460). Regulation of cognition includes processes that aid the control of learning, including planning, comprehension monitoring, and evaluation (Schraw & Dennison, 1994). Knowledge of cognition items include I have control over how well I learn and I am aware of what strategies I use when I study, and regulation of cognition items include I set specific goals before I begin a task and I slow down when I encounter important information. Even though these factors were found to be reliable (Cronbachs alpha = .90) and intercorrelated (r = .54), the MAI is domain-specific, as items pertain to learning performance. The Meta-Cognitions Questionnaire (MCQ; Cartwright-Hatton & Wells, 1997) is a 65item self-report measure that measures beliefs about worry and intrusive thoughts. Based on Wells (1995) meta-cognitive model of worry in generalized anxiety disorder, the measure was developed to explore the relationship between metacognition (i.e., beliefs about worry and selective attention to and monitoring of cognitive events), worry, and intrusions. Results supported five distinct factors: Factor 1: positive beliefs about worry; Factor 2: negative beliefs about the controllability of thoughts and corresponding danger; Factor 3: cognitive confidence; Factor 4: negative beliefs about thoughts in general (including themes of superstition, punishment, and responsibility); and Factor 5: cognitive self-consciousness (i.e., the tendency to be aware of and monitor thinking). Factors 1, 2, and 4 are domain-specific to worry, as they include items such as Worrying helps me to avoid problems in the future (Factor 1), Worry is dangerous for me (Factor 2), and If I did not control a worrying thought, and then it happened, it would be my fault (Factor 4). Factor 3 is specific to memory, and includes items such as, I have little confidence in my memory for words and names. Although Factor 5 appears to be

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most related to the awareness component of mindfulness, it assesses cognitive self-consciousness or preoccupation with thought processes (e.g., I constantly examine my thoughts.), and was found to be positively correlated with worry and predict stress and emotional vulnerability (Cartwright-Hatton & Wells, 1997). Further, even though the MCQ assesses metacognitive belief about thoughts, it is domain-specific to generalized anxiety disorder. The last measure related to metacognitive processes is the Metacognitive Awareness Questionnaire (MAQ; Teasdale et al., 2001). The MAQ is a 9-item scale developed for patients to rate the extent that their negative thoughts and feelings when depressed do not reflect reality. The MAQ includes items such as, If something has upset me, I try to put my judgments on hold for a while and When I get low, my feelings show things in their true light. Responses range from 1 to 7 (1 = totally agree; 7 = totally disagree), and higher scores reflect greater metacognitive awareness. The MAQ demonstrated adequate reliability internal consistency? (i.e., Cronbachs alpha = .71). Although the measure includes some items that assess awareness of cognition in general, the MAQ is domain-specific to depression. Measures of reflexive consciousness. The Self-Monitoring Scale (SM; Snyder, 1974) is a 25-item true/false self-report measure that assesses concern for social appropriateness, sensitivity to the expression and self-presentation of others in social situations as cues to social appropriateness, and use of these cues to monitor and manage self-presentation and expressive behavior. The SM includes items that describe concern for ones presentation of social appropriateness (e.g., At parties and social gatherings, I do not attempt to do or say things that others will like); attention to appropriate self-expression (e.g., When I am uncertain how to act in social situations, I look to the behavior of others for cues); the ability to control and/or modify ones expressive behavior (e.g., Even if I am not enjoying myself, I often pretend to be having a good time); and the extent to which expressive behavior is consistent across situations (e.g., In different situations and with different people, I often act like very different persons). Although

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the SM assesses the extent to which individuals are aware of their behavior, it is specific to the observation of expressive behavior and self-presentation. The Self-Consciousness Scale (SCS; Fenigstein et al., 1975) is a 23-item personality measure developed to assess individual differences in self-consciousness (i.e., the tendency to direct attention inward or outward). The measure was created to sample a variety of domains, including preoccupation with ones own past, present, or future behavior, awareness of ones attributes, sensitivity to inner feelings, introspective behavior, awareness of ones appearance, and concern over the appraisal of others (Fengistein, 1997). The measure has three subscales: (1) Private self-consciousness, containing items such as, Im always trying to figure myself out and Im alert to changes in my mood; (2) Public self-consciousness, assessed by items such as, Im concerned about my style of doing things and Im usually aware of my appearance; and (3) Social anxiety, containing items such as, It takes me time to overcome my shyness in new situations and Large groups make me nervous. Items are rated on a four-point Likert scale (0 = extremely uncharacteristic; 4 = extremely characteristic), so that higher scores indicate higher private self-consciousness, public self-consciousness, or social anxiety. Although the private self-consciousness subscale most closely resembles mindfulness, it focuses solely on thoughts and reflections of the self without including the component of acceptance. The Rumination-Reflection Questionnaire (RRQ; Trapnell & Campbell, 1999) was designed in response to the confounding of motivationally distinct dispositions, rumination and reflection, by the SCS (Fenigstein et al., 1975). It was created to distinguish neurotic from inquisitive self-focus. The measure has two subscales: (1) Rumination, containing items such as, Often Im playing back over in my mind how I acted in a past situation; and (2) Reflection, containing items such as, I love exploring my inner self. Items are rated on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree), so that higher scores indicate higher rumination or reflection. Although the reflection subscale most closely resembles mindfulness, it

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measures the extent to which individuals analyze or examine the self rather than internal experiences (e.g., thoughts, feelings, images, memories) of the self. The Self-Reflection and Insight Scale (SRIS; Grant, Franklin, & Langford, 2002) was designed as an advancement of the private self-consciousness subscale (PrSCS) of the SCS (Fenigstein, et al., 1975). The PrSCS is thought to comprise of two factors: internal state and self-reflection (Grant et al., 2002). For this reason, the SRIS is a 20-item scale that consists of two subscales, Self-Reflection (SRIS-SR) and Insight (SRIS-IN). SRIS-SR items include I frequently examine my feelings and It is important for me to evaluate the things that I do, and SRIS-IN items include I am usually aware of my thoughts and I usually know why I feel the way I do. Items are rated on a 6-point Likert sale (1 = strongly disagree; 6 = strongly agree), and higher scores indicate higher self-reflection and insight. Similar to the PrSCS subscale of the SCS, the SRIS only measures reflection on cognitions and behavior and internal state awareness. Measures of acceptance. The Acceptance and Action Questionnaire (AAQ; Hayes, 1996) is a 16-item measure that assesses the ability to accept undesirable internal events while continuing to pursue desired goals. Items are rated on a 7-point Likert scale (1 = never true; 7 = always true), with higher scores indicating less psychological acceptance. Items assess both the acceptance (e.g., Im not afraid of my feelings) and action (e.g., If I promised to do something, Ill do it, even if I later dont feel like it) factors. The AAQ measures the acceptance component of mindfulness, but does not specifically reference or assess awareness. Measuring Mindfulness: The Current Study As previously discussed, innovative treatments are being developed based on the construct of mindfulness. A growing number of mindfulness-based interventions have recently been operationalized, conceptualized, and empirically evaluated (Baer, 2003). A fundamental problem in this area, however, is the absence of a reliable and valid measure of the construct that is at the heart of these programs. Several authors have noted the need for a clear operational definition of mindfulness (e.g., Bishop, 2002; Hayes & Wilson, 2003).

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The development of shared consensus regarding the key characteristics or components of mindfulness represents one of the most critical steps toward a program of research on the clinical use of mindfulness. The lack of a clear operational definition of mindfulness has given rise to considerable and unfortunate ambiguity in the field, such as the equation of mindfulness interventions with acceptance interventions or with meditation, the confusion between relaxation, and the like. Moreover, the lack of widespread consensus on this issue has hindered the progress of research on determining the active ingredients of mindfulness interventions and mechanisms of change. (Dimidjian & Linehan, 2003, p. 166) Different methods and processes are described with the same term, and distinctions between mindfulness and related concepts are unclear (Hayes & Wilson, 2003). The lack of an operational definition of mindfulness has limited the scientific study of the construct (Bishop, 2002). Bishop et al. (2004) recently proposed an operational definition of mindfulness that focuses on two components: sustained attention to present experience, and an attitude of openness, curiosity, and acceptance. Although a useful advance over earlier attempts to define the construct, one problem with their definition is that any self-regulation of attention is inconsistent with an attitude of thoroughgoing acceptance (Brown & Ryan, 2004). That is, one cannot be fully open and accepting of the full range of psychological experience if one is simultaneously attempting to direct attention in any particular way (e.g., away from external stimuli, as in certain forms of concentrative meditation). In addition to the lack of consensus with regard to an operational definition of mindfulness, the construct has not been determined to be a process or method, as it is treated sometimes as a technique, sometimes as a more general method or collection of techniques, sometimes as a psychological process that can produce outcomes, and sometimes as an outcome in and of itself (Hayes & Wilson, 2003, p. 161). Since mindfulness meditation has been distinguished from mindfulness as a practice, mindfulness should be considered a process. Whereas mindfulness meditation is one approach to enhance or develop mindfulness, mindfulness should be considered a way of being (Miller et al., 1995, p. 198).

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Further adding to the confusion of the conceptualization of mindfulness is the lack of consensus about whether mindfulness is a state or trait. This lack of consensus can be seen by examining the mindfulness measures published to date. The TMS (Bishop et al., 2003) measures the attainment of a mindful state immediately following a meditation exercise. The KIMS (Baer et al., 2004) measures mindfulness as a trait, in that respondents are asked to rate items according to your own opinion about what is generally true for you. Similarly, the CAMS (Hayes & Feldman, 2004) instructs individuals to rate how each item applies to you. However, the MAAS (Brown & Ryan, 2003) and FMI (Buchheld et al., 2001) treat mindfulness as a quasi-trait, as respondents are asked to rate the occurrence of items within a certain time period. For example, the MAAS asks respondents to rate items concerning how frequently or infrequently you currently have each experience. Considering mindfulness as a quasi-trait implies that while individuals may have the tendency to be mindful, specific levels of mindfulness can change over time. As a psychological process, mindfulness should have the potential to be measured. It would be important to assess levels of mindfulness in individuals who receive mindfulness-based interventions to help determine the hypothesized mechanisms of these treatments. However, such investigations would require a psychometrically sound measure of mindfulness, which the field currently lacks (Dimidjian & Linehan, 2003, p. 169). The current measures of mindfulness (and related constructs) reviewed above are problematic for one of two reasons: (a) they are domain-specific; and/or (b) they assess only a single component of mindfulness. For these reasons, the current study proposes to develop an operational definition and a bi-dimensional measure to assess mindfulness based on a conceptualization of the key components of mindfulness, namely present-moment awareness and acceptance. Acceptance and present-moment awareness appear to be central components of mindfulness. Most of the clinical definitions explicitly include these concepts in defining mindfulness. Moreover, the mindfulness-based interventions all emphasize acceptance and

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present-moment awareness as important aspects of mindfulness meditation, one method of developing mindfulness (Breslin et al., 2002). It should be noted that the two dimensions of mindfulness are with regard to the full range of stimuli that occur both internal and external to the individual. This is distinct from the social-psychological literature, which describes mindfulness as perceptual inputs only from the external environment (Brown & Ryan, 2003). Integrating Awareness and Acceptance As previously discussed, present-moment awareness and acceptance reflect the key components of mindfulness. Present-moment awareness will be defined as continuous monitoring awareness of ongoing internal and external experiences. Whereas high levels of present-moment awareness reflect high monitoring, low levels of present-moment awareness reflect a relative lack of monitoring. The second dimension, acceptance, is a nonjudgmental stance toward ones experience. High levels of acceptance are characterized by experiencing events fully and without defense, and low levels are characterized by avoidance and/or by attempts to control internal experience (Hayes, 1994). Thus, four psychological states can be conceptualized by crossing the two dimensions of present-moment awareness and acceptance: (1) mindfulness (high present-moment awareness, high acceptance); (2) flow (low present-moment awareness, high acceptance); (3) unsuccessful experiential avoidance and/or control (high present-moment awareness, low acceptance); and (4) successful experiential avoidance and/or control (low present-moment awareness, low acceptance). See Appendix D for an illustration of the four psychological states. As previously discussed, mindfulness is characterized by nonjudgmental awareness to internal and external experiences. During mindfulness, experiences are observed without intention to control or avoid them. In an illustration of mindfulness of a bodily sensation: As I write, there is a small knot at the top of my stomach. I focus on the feeling: a slight pressure, a full feeling at the top of my stomach. That feeling of pressure becomes the object of my attention. I dont pull back from it. It is getting more intense, but I dont detach from it: I come in close and touch it. Theres the feeling in my stomach, which is

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unpleasant. Theres mindfulness which is able to turn to itEverything is focus on that sensation. Were not trying to add to it, subtract from it, make it feel better, change it in any way. We try to experience it with no separation whatsoeverInstead of fighting the feeling, or turning away from it, were learning to turn toward itWe can learn to welcome the unwanted, simply because it is there and is our life in that moment. (Rosenberg, 1998, pp. 66-67) Experiences are not evaluated, judged, or believed, but instead simply acknowledged as mental events. Mindfulness takes place without reference to self, (i.e., noting sensations as sensations, thoughts as thoughts, etc.), and is characterized as present-moment observation, continuously monitoring the evolution of ones experiences in the moment; if you are remembering your second-grade teacher, that is memory. When you then become aware that you are remembering your second-grade teacher, that is mindfulness (Gunaratana, 1991, p. 152). Thus, mindfulness reflects high levels of both present-moment awareness and acceptance. A low level of present-moment awareness and a high level of acceptance would liken to the state of flow, a subjective state that people report when they are completely involved in something to the point of forgetting time, fatigue, and everything else but the activity itself (Csikszentmihalyi & Rathunde, 1993, p. 59). Conditions that evoke the state of flow are conducive to deep concentration that is so intense that there is no attention left over to think about anything irrelevant or to worry about problems (Csikszentmihalyi, 1990, p. 71). Although attention is focused on the present during flow, it is characterized by a loss of self-consciousness and self-awareness (Csikszentmihalyi & Rathunde, 1993). During the state of flow, time passes more quickly, and there is a decrease in awareness as thoughts, intentions, feelings and all the senses are focused on the same goal (Csikszentmihalyi, 1990, p. 41). Research suggests that for individuals who report to be in the state of flow frequently, there is reduced mental activity in all information channels with the exception of that involved in sustained attention of a flashing stimulus (Holcomb, 1976). Activity during flow is considered autotelic, or rewarding in and of itself, which may give reason for why individuals disregard typically unpleasant states such as hunger, fatigue, and discomfort (Nakamura & Csikszentmihalyi, 2002). Thus, during the state of

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flow, awareness is reduced to what is decided as relevant for the present moment and preoccupations or discomforts do not intrude, because behavior is intrinsically motivated. Flow would be characterized by high levels of acceptance, since explicit attempts are not made to regulate irrelevant preoccupations or discomforts. Instead, they are experienced without defense, allowing attention to be redirected to the present moment and task at hand. Whereas high levels of acceptance are characterized by experiencing events without defense, low levels are characterized by attempts to avoid and/or control ones experiences. A low level of acceptance combined with high levels of present-moment awareness would result in unsuccessful experiential avoidance, which is characteristic of accounts of various forms of psychopathology. Experiential avoidance is the phenomenon that occurs when a person is unwilling to remain in contact with particular experiences (e.g., bodily sensations, emotions, thoughts, memories, behavioral predispositions) and takes steps to alter the form or frequency of these events and the contexts that occasion them (Hayes et al., 1999, p. 58). Literature suggests that deliberate attempts to control or avoid unpleasant experiences often paradoxically increase the intensity of the experience. A large source of data supporting the negative consequences of experiential avoidance and/or control comes from the thought suppression literature. For example, when participants are told to suppress a thought, they will later show an increase in the suppressed thought compared with those not given suppression directions (e.g., Clark, Ball, & Pape, 1991; Wegner, Schneider, Carter, & White, 1987). The instruction for suppression may stimulate the suppressed thoughts or emotion in a self-amplifying loop (Hayes, Wilson, Gifford, Follette, & Strosahl, 1996), which may give reason for its relationship to rumination (Gold & Wegner, 1995; Wenzlaff & Luxton, 2003), anticipatory anxiety (Craske, Miller, Rotunda & Barlow, 1990), symptoms of obsessive compulsive disorder (McLaren & Crowe, 2003), dental anxiety (Muris, Jongh, Merckelbach, Postema, & Vet, 1998), and somatic sensations such as pain (Cioffi & Holloway, 1993). Experiential avoidance and/or control have also been implicated in the etiology and maintenance of psychopathology. For example, research suggests that

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individuals with panic disorder have a heightened autonomic reactivity or sensitivity to internal physical cues, and associated with this elevated autonomic reactivity is enhanced attentional selectivity to the physiological sensations (e.g., Ehlers & Breuer, 1992, 1996). Since small changes in physiological state are interpreted as catastrophic, individuals with panic disorder attempt to avoid or control the autonomic arousal. However, the lack of acceptance of the arousal only intensifies the sensations, leading to a reciprocal cycle of fear and sensations. Finally, low levels of present-moment awareness and acceptance toward experience would be characterized by successful experiential avoidance and/or control. When successful, the unpleasant experiences can be avoided or controlled. For example, the focus in traditional cognitive and behavior therapy, which has been shown to be successful in treating various psychological disorders, is to change private experiences through methods such as relaxation and cognitive restructuring. There also is evidence that attentional training, which promotes focus on external events to reduce self-focus, reduces panic attacks and self-report tension without exacerbating anxiety (Wells, 1990). However, these methods have limitations, as they may only allow for temporary reprieve of the unpleasant internal experiences. Deliberate attempts to avoid or control unpleasant events remind the individual of the avoided or controlled events, risking the paradoxical elicitation of the event being avoided or controlled (Hayes, 2002a), which would result in unsuccessful emotional avoidance (i.e., high present-moment awareness, low acceptance). Principal Aims of the Present Study As previously discussed, there has recently been a marked increased in interest in the construct of mindfulness in clinical psychology, as demonstrated by the rise in number of publications, formation of listservs and interest groups, and study of psychological interventions based on this construct. However, there is no accepted definition of mindfulness, nor has the construct been sufficiently operationalized. Further, there currently exists no measure that clearly assesses both of the key components of mindfulness, present-moment awareness and acceptance.

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For these reasons, the purposes of the proposed study were as follows: 1) To develop a bidimensional measure of mindfulness based on the two key constituents of the construct, presentmoment awareness and nonjudgmental acceptance; 2) examine the factor structure of the measure; 3) explore the internal consistency of items in nonclinical and clinical samples; and 4) examine the convergent, discriminant, and incremental validity of the resulting measure in nonclinical and clinical samples. The Philadelphia Mindfulness Scale (PHLMS) was designed in stages which will be described as four studies: 1) Item Generation & Selection; 2) Factor Analysis & Internal Consistency; 3) Validation Analyses with a Normative Sample; 4) Validation Analyses with a Clinical Sample.

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CHAPTER 2: STUDY 1 -- ITEM GENERATION AND SELECTION Method A pool at least twice the size of the anticipated size of the final scale is deemed sufficient (DeVellis, 2003), and eight to ten items per dimension for multifactor constructs has been suggested as an ideal scale length (Netemeyer, Bearden, & Sharma, 2003), which suggested that a minimum of 20 items per dimension be generated. Although a total of 60 items was initially anticipated, a total of 105 items (55 awareness items, 50 acceptance items) was generated from by primary investigator, faculty and graduate students in clinical psychology, and individuals outside of psychology. These individuals were provided with the definitions of awareness and acceptance and asked to generate items that reflected the definitions. Microsoft Word was used to determine the overall reading level of the items; items reflected a Grade 5 reading level, as it is recommended that scales should not require reading skills beyond that of age 12 (Streiner & Norman, 1995). The list of items was submitted to a panel of three editorial judges (i.e., faculty and graduate students who also serve as journal editors) so that items could be examined for clarity and readability. Minor modification to the wording of several items was made based on their feedback. Next, expert judges (i.e., experienced researchers of mindfulness and related constructs) were recruited to establish the content validity of the initial items of the measure. Given that five or more judges are recommended for establishing content and face validity (Netemeyer, et al., 2003), six expert judges were recruited (4 males, 2 females). The revised list of items and our definition of mindfulness (i.e., awareness and acceptance) was submitted to the expert judges who rated how well each item measured the intended dimension of mindfulness (i.e., awareness or acceptance), and also did not reflect the other dimension of mindfulness. Items were rated on a 5-point Likert scale (1= very poor; 2 = poor; 3 = fair; 4 = good 5 =very good) for suitability. See Appendix E for the list of items and procedures administered to expert judges.

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Results and Discussion The V Index, a content validity coefficient (Aiken, 1996), was used for item retention. The V Index provides an overall measure of content validity for N raters on a single scale for multiple items; the value of V ranges from 0.00 to 1.00, and tables determining the statistical significance of V can be found in Aiken (1985). Items were retained if they were rated by all judges as highly reflecting one dimension of mindfulness (V > .71, p < .05) and simultaneously not reflecting the other dimension (V < .29, p < .05). Thus, 58 items (29 awareness items, 29 acceptance items) were retained; see Appendix F for the list of retained items and the mean rating by judges on each dimension for each item. Overall, findings suggest that expert judges found the items to be good representations of acceptance and awareness, the two components of mindfulness.

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CHAPTER 3: STUDY 2 -- FACTOR STRUCTURE AND INTERNAL CONSISTENCY Method Participants 204 undergraduate students (94 males, 106 females; 4 participants did not indicate gender) in psychology courses at Drexel University served as the development sample in exchange for extra course credit. It is recommended that six to ten times as many participants as items is ideal (Gable, 1986), but 100-200 participants is considered sufficient for preliminary item analysis (Clark & Watson, 1995; Kline, 1986). The participants ages ranged from 19 to 47 years old, with a mean age of 21.9 years (SD = 3.83). Students year in school ranged from year 1 to year 7, with a mean year in school of 3.53 (i.e., 65% of students in their 3rd or 4th year of school). Participants self-identified race is as follows: 18.6% Asian/Pacific Islander, 10.3% Black/African-American/Caribbean American, 1.0% Hispanic/Latino/Latina, 64.7% White/Caucasian/European decent, 5.0% multi-racial, and 0.5% other. Measures and Procedure The items retained after expert ratings, along with a Demographic Information form, were administered in a group format (see Appendix F for the list of items). Given that 5- and 6point Likert scales have been found to be most reliable (McKelvie, 1978), items were rated on a 5-point Likert Scale (0 = never; 1 = rarely; 2 = sometimes; 3 = often; 4 = very often) according to the frequency that participants experience the described item within the past week. Results and Discussion Exploratory Factor Analysis Unrestricted and restricted (i.e., forced solution) factor analyses were conducted. A principal components unrestricted factor analysis using a Promax (i.e., oblique) rotation initially was conducted to determine item retention. An oblique rotation method was chosen, given that it allows the factors to correlate and can provide more meaningful theoretical factors (Netemeyer et al., 2003). The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was .768; KMO

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elicits values between 0 and 1, with small values indicating that overall, the variables have too little in common to warrant a factor analysis. KMO values of less than .49 have been deemed unacceptable (Kaiser, 1974). Bartlett's Test of Sphericity, which tests the null hypothesis that the correlation matrix is an identity matrix (i.e., all of the diagonal elements are 1 and all off diagonal elements are 0) was significant. The unrestricted factor analysis produced a 17-factor solution with eigenvalues greater than one that recovered 65.9% of the sample variance. However, examination of eigenvalues and the scree plot revealed a marked gap between the first two factors and the remaining factors (Factor 1 eigenvalue = 7.93, Factor 2 eigenvalue = 6.84, Factor 3 eigenvalue = 2.85; the first two factors accounted for 25.5% of the total variation across factors). Floyd and Widaman (1995) argue that the use of eigenvalues greater than 1.0 can lead to an overestimation of the number of factors to retain, and that the scree plot may be more useful in identifying meaningful factors. Thus, based on scree plot results and consistent with theoretical predictions, the most interpretable solution was a two-factor model. A principal components factor analysis using a Promax rotation was conducted restricting the factor analysis to a twofactor solution. Since loadings above .50 may be considered very significant (Hair, Anderson, Tatham, & Black, 1998), items with loadings of .50 and higher on their respective subscale were retained, resulting in 23 items (11 acceptance items, 12 awareness items). See Table G1 in Appendix G for the list of the 23 items and factor loadings on each subscale. Internal Consistency Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and Cronbachs alpha coefficient) were conducted for the remaining items in each subscale. Cronbachs alpha coefficient was conducted to ensure satisfactory internal consistency. Different levels of alpha have been determined as adequate; Kline (1986) suggests a minimum value of .60, Nunnally (1978) suggests a minimum value of .70, and DeVellis (2003) has delineated the following ranges: below .60 is unacceptable, .60 to .65 is undesirable, .65 to .70 is minimally acceptable, .70 to .80 is respectable, .80 to .90 is very good, and the scale should be shortened if

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alpha is above .90. For the Awareness subscale, Cronbachs alpha = .84, and for the Acceptance subscale, Cronbachs alpha = .87, suggesting very good internal consistency for both subscales. Corrected item-to-total correlations are examined within each dimension for multidimensional scales, and items with low corrected item-to-total correlations are recommended for deletion (Netemeyer et al., 2003). For the Awareness subscale corrected itemsubscale total correlations ranged from .43 to .61, and for the Acceptance subscale, corrected item-subscale total correlations ranged from .48 to .72. See Table G2 in Appendix G for corrected item-subscale correlations for each item. Inter-item correlations were calculated, and items within the same subscale that had a minimum correlation of .15 and maximum correlation of .50 were retained (Clark & Watson, 1995). For the Awareness subscale, inter-item correlations ranged from .09 to .59. For the acceptance subscale, inter-item correlations ranged from .17 to .66. See Appendix G, Table G3 for inter-item correlations. Based on these analyses, items were eliminated to ensure that correlations remained within the recommended parameters and to retain a maximum of 10 items on each subscale. For the Awareness subscale, the item, When I walk outside on a sunny day, I notice how the sun feels on my skin was deleted because it had an inter-item correlation of .09 with one item and an inter-item correlation with another item of .59 (both correlations are outside the recommended parameters). The item, When my mood changes, I notice the event or the thought that caused it to change was deleted because it was redundant with other items and had an inter-item correlation with another item of .52. For the Acceptance subscale, the item I have thoughts I try to avoid was deleted because it had an inter-item correlation of .66. Reliability analyses were re-conducted for each subscale of 10 items to examine the internal consistency of the resulting measure. For the Awareness subscale, Cronbachs alpha = .81, corrected item-subscale total correlations ranged from .43 to .60, and inter-item correlations ranged from .13 to .50. For the Acceptance subscale, Cronbachs alpha = .85, item-subscale total

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correlations ranged from .47 to .67, and inter-item correlations ranged from .17 to .54. Only one inter-item correlation (i.e., on the Awareness subscale) was below the recommended parameter, and five inter-item correlations were above recommended parameter of .50 (i.e., on the Acceptance subscale); however, the items were retained to ensure that there was a minimum of 10 items per subscale. See Table G4 in Appendix G for the mean and standard deviation of the resulting 20 items, Table G5 for item-subscale total correlations, and Table G6 for inter-item correlations.

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CHAPTER 4: STUDY 3 VALIDATION ANALYSES WITH A NORMATIVE SAMPLE Method Participants Five hundred fifty-nine university students (270 males, 283 females; 6 participants did not indicate gender) were recruited from undergraduate psychology courses and participated in exchange for extra credit. The participants ages ranged from 17 to 53 years, with a mean age of 20.12 years (SD = 3.49). Students year in school ranged from year 1 to beyond year 5, with a mean year in school of 2.39 (i.e., 59.2% of students in their 1st or 2nd year of school). Participants self-identified race was as follows: 19.0% Asian/Pacific Islander, 8.1% Black/African-American/Caribbean American, 1.6% Hispanic/Latino/Latina, 0.7% Native American, 64.4% White/Caucasian/European decent, 5.4% multi-racial, and 0.7% other or race not listed. Measures and Predictions The refined measure was included in a packet that contained the following questionnaires (see Appendix H for copies of these measures): Mindful Attention Awareness Scale (MAAS; Brown & Ryan, 2003). The MAAS is a 15item self-report inventory designed to measure the presence or absence of attention to and awareness of what is occurring in the present moment. Items are rated on a 6-point Likert Scale (1 = almost always; 6 = almost never), and total scores range from 15 to 90, with higher scores indicating greater mindfulness. The MAAS was found to have good internal consistency, with alphas ranging of .82 and .87 in student and adult samples (respectively). The MAAS demonstrated adequate convergent, discriminant, and incremental validity. The MAAS showed moderate positive correlations with openness to experience (r = .18 and .19, respectively), attentiveness/receptivity to experience (r = .15 to .20), mindful engagement (r = .33 to .39), and well-being variables such as vitality (r = .35 to .46), self-actualization (r = .43), and competence (r = .39 to .68) (Brown & Ryan, 2003). The MAAS was found to be moderately inversely related

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to rumination (r = -.29 to -.39), depression (r = -.37 to -.53), and anxiety (r = -.26 to -.42) (Brown & Ryan, 2003). The MAAS was not found to be related to private self-consciousness (r = -.05 to .03) and self-monitoring (r = -.03) (Brown & Ryan, 2003). With regard to incremental validity, all correlations between the MAAS and well-being variables (i.e., depression, anxiety, pleasant affect, unpleasant affect, positive affect, negative affect, self-esteem) remained significant when controlling for rumination, private self-consciousness, emotional intelligence, propensity to achieve mindful states, neuroticism, extraversion, and social desirability (Brown & Ryan, 2003). The MAAS has been demonstrated to reliably distinguish mindfulness practitioners from the general adult population, and has predicted mood disturbance and stress during and after a mindfulness-based intervention (Brown & Ryan, 2003). Since the MAAS measures attention to and awareness of what is occurring in the present moment, positive correlations were expected to be found between the MAAS and the PHLMS Awareness subscale. Further, since the authors explicitly excluded items with an attitudinal component (e.g., acceptance), it was predicted that the MAAS would not be related to the PHLMS Acceptance subscale. Acceptance and Action Questionnaire (AAQ; Hayes, 1996, 2004). The AAQ is a 9-item measure assessing the ability to accept undesirable thoughts and feelings while pursuing desired goals. A 16-item version was initially developed, but the authors sought a shorter version. However, since the authors note that the longer version may be more sensitive due to the larger number of items (Hayes et al., 2004), the 16-item version was used in the present study. Items are rated on a 7-point Likert scale (1 = never true; 7 = always true), and total scores range from 16 to 112, with higher scores indicating less psychological acceptance. The AAQ has demonstrated very good internal consistency, with alphas ranging from .89 to .92 (Bond & Bruce, 2000). Further psychometric studies are underway, but there are currently no other published psychometric data on the AAQ. Since the AAQ Acceptance subscale measures the absence of experiential avoidance, positive correlations between the AAQ Acceptance subscale and the

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PHLMS Acceptance subscale were expected. The AAQ Acceptance subscale was not predicted to be related to the PHLMS Awareness subscale. Rumination-Reflection Questionnaire (RRQ; Trapnell & Campbell, 1999). The RRQ is a 24-item self-report inventory designed to measure two types of self-focus: neurotic and inquisitive/intellective. The measure has two scales: rumination, assessing neurotic selfconsciousness, and reflection, assessing intellective self-consciousness. Items are rated on a 5point Likert scale (1 = strongly disagree; 5 = strongly agree). Total Rumination and Reflection scores both range from 12 to 60, so that higher scores indicate higher rumination or reflection. The RRQ demonstrated excellent internal consistency, as alpha estimates exceeded .90, and the mean inter-item correlation exceeded .40 for both scales (Trapnell & Campbell, 1999). The RRQ also demonstrated good convergent and discriminant validity (Trapnell & Campbell, 1999). As neuroticism measures the tendency to experience negative affect, negative correlations were expected between the RRQ Rumination subscale and the PHLMS, PHLMS Acceptance subscale and PHLMS Awareness subscale. Since it assesses an inquisitive selfconsciousness, the RRQ Reflection subscale was expected to be moderately related to the PHLMS and its subscales. White Bear Suppression Inventory (WBSI; Wegnar & Zanakos, 1994). The WBSI is a 15-item self-report measure designed to measure thought suppression. Items are rated on a 5point Likert Scale (1 = strongly disagree; 5 = strongly agree), and total scores range from 15 to 75, with higher scores indicating greater tendency to suppress thoughts. The WBSI has been found to have very good internal consistency, (alpha = .89; Muris, Merkelbach, & Horselenberg, 1996), and adequate stability over time (12 week test-retest correlation of r = .80; Muris et al, 1996). The WBSI has been found to have very good convergent validity with significant correlations between the Beck Depression Inventory, the Maudsley Obsessive-Compulsive Inventory, the State-Trait Anxiety Inventory, and the Anxiety Sensitivity Inventory (Muris et al., 1996). As thought suppression seems to include an unwillingness to experience thoughts,

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correlations between the WBSI and the PHLMS Acceptance subscale were expected to be negative. Flow State Scale (FSS; Jackson & Marsh, 1996). The FSS is a 36-item questionnaire that measures flow in sport and physical activity settings. Nine subscales represent the dimensions of flow delineated by Csikszentmihalyi (1990): challenge-skill balance, action-awareness merging, clear goals, unambiguous feedback, concentration on task at hand, sense of control, loss of selfconsciousness, transformation of time, and autotelic experience. Items are rated on a 5-point Likert scale (1 = strongly disagree; 5 = strongly agree), and total scores range from 36 to 180, with higher scores indicating greater flow. Internal consistency for the nine subscales was determined to be reasonable (mean alpha = .83). Although the intended use is for immediately after a flow experience, the instructions were modified for purposes of the present study. A brief description of a flow experience was provided, and participants were asked to think back to a similar experience that occurred within the past two weeks and answer the questions according to how they felt during that experience. Since flow appears to have components of decreased present-moment awareness with higher levels of acceptance, it was expected that FSS scores be positively moderately related to the PHLMS Acceptance subscale and negatively related to the PHLMS Awareness subscale. Beck Depression Inventory-II (BDI-II; Beck, Ward, Mendelson, Mock, & Erbarugh, 1961; Beck, Steer, & Brown, 1996). The BDI-II is a 21-item self-report measure of depression that is routinely used in studies of depression and anxiety. The BDD-II is a modification of the original BDI, containing the following new items: agitation, worthlessness, loss of energy, and concentration difficulty. In addition, the BDI-II assesses both increases and decreases in appetite within the same item and hypersomnia and hyposomnia within the same item. The BDI/BDI-II has been the most widely used measure of depression in both clinical and research settings. Dozois, Dobson, & Ahnberg (1998) established criteria for the BDI-II (0-12 = nondepressed; 1319 = dysphoric; 20-63 = dysphoric-depressed) based on cutoffs established by Kendall, Hollon,

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Beck, Hammen, & Ingram (1987) for the BDI. The BDI-II has good psychometric properties (Beck, Steer, Ball & Ranieri, 1996). As previously noted, mindfulness is associated with reduced symptomotology; thus, negative correlations between the BDI-II and the PHLMS and its subscales were expected. Beck Anxiety Inventory (BAI; Beck, Epstein, Brown, & Steer, 1988; Beck & Steer, 1990). The BAI is a 21-item self-report measure that is routinely used to measure symptoms of anxiety. Items are rated on a 4-point Likert scale (0 = not at all; 3 = severely). Cutoff scores listed in the BAI manual are: 0-7=minimal; 8-15=mild; 16-25=moderate; 26-63=severe. The BAI has good psychometric properties (Beck et al., 1988; Dent & Salkovskis, 1986; Frydrich, Dowdall, & Chambless, 1992). Normative percentile scores have also been established (Gillis, Haaga, & Ford, 1995). Similar predictions as those made about the BDI-II were made regarding the BAI. Marlow-Crowne Social Desirability Scale (M-C SDS; Crowne & Marlowe, 1960). The M-C SDS is a 33-item true/false measure that assesses response bias (i.e., the degree to which individuals attempt to present themselves in a favorable light). Scores range from 0 to 33, with higher scores reflecting a greater degree of socially desirable responding. The M-C SDS has high internal consistency (alpha = .88) and test-retest reliability (r = .89) (Crowne & Marlowe, 1960, 1964). Since true-false and Likert forms of the M-C SDS have been found to be significantly correlated (Greenwald & OConnell, 1970), a 5-point Likert version of the M-C SDS was used in the present study to achieve higher precision and to increase the instruments sensitivity. Scores on the M-C SDS were expected to show either no relation or only a modest relationship with the PHLMS and its subscales. Results Measure Descriptives The PHLMS total score ranged from 47 to 95, with a mean of 66.84 (SD = 7.27). The PHLMS Acceptance subscale total score ranged from 13 to 47, with a mean of 30.19 (SD = 5.84), and the PHLMS Awareness subscale total score ranged from 20 to 50, with a mean of 36.65 (SD

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= 4.93). See Table I1 in Appendix I for PHLMS item means and standard deviations. The AAQ total score ranged from 41 to 104, with a mean of 72.29 (SD = 9.87), the AAQ Acceptance subscale scores ranged from 12 to 49, with a mean of 29.65 (SD = 6.03), and the AAQ Action subscale scores ranged from 23 to 61, with a mean of 42.64 (SD = 6.15). MAAS scores ranged from 25 to 90, with a mean of 58.00 (SD = 10.48). FSS scores ranged from 36 to 180, with a mean of 130.06 (SD = 18.49). WBSI scores ranged from 16 to 73, with a mean of 46.62 (SD = 10.01). The RRQ Rumination subscale scores ranged from 15 to 60, with a mean of 40.55 (SD = 7.83), and the RRQ Reflection subscale score ranged from 12 to 60, with a mean 38.65 (SD = 9.02). M-C SDS scores ranged from 53 to 129, with a mean of 99.26 (SD =11.59). The mean BDI total score of 9.66 (SD = 7.15, range = 0 to 40) and mean BAI total score of 10.32 (SD = 8.78, range = 0 to 49) were within normative levels. To account for the large number of correlations calculated using this sample and in an effort to balance Type 1 and Type 2 error, only those with p < .01 were deemed significant. The PHLMS Awareness subscale (r = .60, p < .0001) and the PHLMS Acceptance subscale (r = .74, p < .0001) were significantly related to the PHLMS Total score. However, there was not a significant relationship between the Acceptance and Awareness subscales (r = -.10, p = .025). Cross Validation Cross validation analyses were conducted between the first student sample (i.e., the development sample, N = 204) and the second student sample (i.e., the validation sample, N = 559). No significant differences were found for gender ( (1, N = 753) = .20, p = .658) or race (6, N = 752) = 2.93, p = .818). However, there were significant differences between samples for students year in school ( (6, N = 753) = 150.70, p <.0001) and age (t(761) = 6.07, p < .0001), with the development sample being older and having the higher year in school. However, no significant differences were found between both samples for the PHLMS Total score (t(322.9) = -1.20, p > .05), the PHLMS Acceptance subscale (t(761) = -.67, p > .05), or the PHLMS Awareness subscale (t(761) = -1.13, p > .05).

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Exploratory Factor Analysis Unrestricted and restricted (i.e., forced solution) factor analyses were conducted. A principal components unrestricted factor analysis using a Promax (i.e., oblique) rotation initially was conducted to determine item retention. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was .850. Bartlett's Test of Sphericity was significant. The unrestricted factor analysis produced a four-factor solution with eigenvalues greater than one that recovered 46.2% of the sample variance. However, examination of eigenvalues and the scree plot revealed a marked gap between the first two factors and the remaining factors (Factor 1 eigenvalue = 4.03, Factor 2 eigenvalue = 3.04, Factor 3 eigenvalue = 1.13; the first two factors accounted for 35.4% of the total variation across factors). Thus, consistent with theoretical predictions, the most interpretable solution was a two-factor model. A principal components factor analysis using a Promax rotation was conducted restricting the factor analysis to a two-factor solution. As expected, awareness items loaded onto one factor (Factor 1), and acceptance items loaded onto the other factor (Factor 2), with loadings ranging from .50 to .75. See Table I2 in Appendix I for the list of items and factor loadings. Internal Consistency Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and Cronbachs alpha coefficient) were conducted for the entire measure and each subscale. Internal consistency was respectable for the PHLMS (Cronbachs alpha = .72) and for the Awareness subscale (Cronbachs alpha = .75), and internal consistency was very good for the Acceptance subscale (Cronbachs alpha = .82). Corrected item-to-total correlations were conducted within each subscale. For the Awareness subscale corrected item-subscale total correlations ranged from .34 to .51, and for the Acceptance subscale, corrected item-subscale total correlations ranged from .40 to .64. See Table I2 in Appendix I for corrected item-subscale correlations for each item. Inter-item correlations were calculated. For the Awareness subscale, inter-item

53
correlations ranged from .13 to .36, and for the Acceptance subscale, inter-item correlations ranged from .17 to .53. See Table I4 in Appendix I inter-item correlations. Convergent Validity Correlations of the PHLMS with others measures were conducted to assess for convergent and discriminant validity. To account for the large number of correlations calculated using this sample and in an effort to balance Type 1 and Type 2 error, only those with p < .01 were deemed significant. As predicted, the PHLMS Total score was moderately related to the MAAS (r = .40, p < .0001) and the AAQ Acceptance subscale (r = .50, p < .0001), and it was modestly correlated with flow (r = .23, p<.0001) and reflection (r = .23, p > .0001). The PHLMS Total score showed a modest negative correlation with rumination (r = -.33, p < .0001) and a moderate negative correlation with thought suppression (r = -.43, p < .0001). Although the PHLMS Acceptance showed a large and significant correlation with the AAQ Acceptance subscale (r = .54, p <.0001), it was found not to be related significantly to flow (r = .10, p = .018). As predicted, the PHLMS Acceptance subscale showed a large negative correlation with thought suppression (r = -.52, p < .0001) and a moderate negative correlation with rumination (r = -.40, p < .0001). The PHLMS Awareness subscale correlated significantly at a modest level with the MAAS (r = .21, p < .0001), and showed a moderate correlation with the construct reflection (r = .36, p < .0001). However, contrary to predictions, the PHLMS Awareness subscale showed a modest positive correlation with flow (r = .21, p < .0001). An unexpected finding was that the MAAS was correlated more strongly with the PHLMS Acceptance subscale (r = .32, p < .0001) than with the PHLMS Awareness subscale. See Table I5 in Appendix I for list of correlations between the PHLMS, PHLMS Acceptance subscale, PHLMS Awareness subscale, and other measures. Discriminant Validity Weak negative relationships were found between the PHLMS and social desirability. The M-C SDS was weakly and negatively correlated with the PHLMS Total (r = -.18, p < .0001)

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and the PHLMS Acceptance subscale (r = -.13, p = .001), indicating higher mindfulness and acceptance are weakly associated with less social desirability. There also was a weak relationship between the PHLMS Awareness subscale and social desirability (r = -.10, p =.020), but the correlation was not statistically significant at the p < .01 level. Partial correlations were conducted between the PHLMS Total and subscale scores and the measures of depression and anxiety, controlling for social desirability. See Table I6 in Appendix I for correlation values. In sum, the relationship between the PHLMS and both depression and anxiety remained significant after controlling for social desirability. Likewise, after controlling for social desirability, the relationship between the PHLMS Acceptance subscale and both depression and anxiety remained significant. There continued to be no relationship between depression and anxiety and the PHLMS Awareness subscale after controlling for social desirability. Relationship to Measures of Psychopathology The PHLMS generally showed a negative relationship with measures of psychopathology. Specifically, there was a moderate negative relationship between PHLMS total score and depression (r = -.34, p < .0001) and a modest negative relationship with anxiety (r = .25, p < .0001). Similarly, the PHLMS Acceptance subscale was moderately and negatively related to depression (r = -.35, p < .0001) and anxiety (r = -.33, p < .0001). However, the PHLMS Awareness subscale did not correlate significantly with depression (r = -.08, p = .056) or anxiety (r = .03, p =.538). See Table I6 in Appendix I for correlations between the PHLMS and well-being variables. Incremental validity was examined for the PHLMS Acceptance and Awareness subscales to determine if the PHLMS subscales add to the predictive validity already provided by other measures of constructs closely related to acceptance and awareness. Partial correlations were conducted between the PHLMS Acceptance subscale and measures of psychopathology (i.e., BDI-II and BAI), controlling for acceptance (i.e., AAQ Acceptance subscale score) and thought suppression (i.e., WBSI total score). The PHLMS Acceptance subscale showed small negative

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correlations with both depression and anxiety after controlling for acceptance and thought suppression. Likewise, partial correlations were conducted between the PHLMS Awareness subscale and measures of psychopathology, controlling for attention/awareness (i.e., MAAS total score) and flow (i.e., FSS total score). There was no relationship between the PHLMS Awareness subscale and depression and anxiety after controlling for attention/awareness as well as after controlling for flow. See Table I6 in Appendix I for partial correlations. Discussion In sum, the results support the construct validity of the PHLMS as a bi-dimensional measure of mindfulness. A second exploratory factor analysis supports a two-factor solution, with awareness and acceptance items loading onto their respective subscale. The results support adequate to good internal consistency and convergent and discriminant validation analyses generally yielded expected results. Further the PHLMS total score and the PHLMS Acceptance subscale were both negatively related to two mental health variables (i.e., depression and anxiety), and these relationships were retained after controlling for social desirability. Further, incremental validity was established for both the PHLMS and PHLMS Acceptance subscale using a conservative approach (i.e., controlling for the same and related constructs). However, PHLMS Awareness scores were not found to be related to depression or anxiety; this finding will be further discussed in the General Discussion.

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CHAPTER 5: STUDY 4 VALIDATION ANALYSES WITH A CLINICAL SAMPLE Method Participants Fifty-two clinical outpatients (23 males, 29 females) were recruited from an urban outpatient psychiatry clinic and participated in exchange for monetary compensation ($5.00). The participants ages ranged from 18 to 80 years old, with a mean age of 40.78 years (SD = 12.04). Participants self-identified race was as follows: 67.3% Black/AfricanAmerican/Caribbean American, 7.7% Hispanic/Latino/Latina, 19.2% White/Caucasian/European decent, and 5.8% multi-racial. Regarding participants marital status, 11.5% of participants were married, 5.8% widowed, 30.8% divorced/annulled, 3.8% separate, 42.3% never married, 1.9% chose other for marital status, and 3.8% of participants did not respond to this item. The majority of participants did not receive education beyond 12th grade (highest level of education: 17.3% grade 6 or less; 34.6% grade 7 to 12; 13.5% graduated high school/high school equivalent; 19.2% part college; 3.8% graduated 2 year college; 5.8% graduated 4-year college; 1.9% part graduate/professional school; 1.9% completed graduate/professional school; 1 participant did not respond to this item). Regarding participants occupational status, 51.9% of participants were on disability, 28.8% were unemployed, 11.5% were students, 1.9% had part-time employment, 1.9% were retired, and 1.9% indicated other for primary occupation; 1 participant did not respond to item regarding primary occupation. Diagnostic information was obtained from the medical records of 48 participants; diagnostic information was not available for 4 participants. One caveat of the diagnostic information is that structured clinical interviews were not conducted; instead, patients diagnoses were made by their primary therapist (i.e., psychiatrist, licensed clinical psychologist, licensed clinical social worker, or masters-level clinician), and should therefore be regarded with appropriate caution. Regarding participants primary diagnosis, 66.7% had a primary diagnosis of a Mood Disorder, 10.4% had a primary diagnosis of a Psychotic Disorder, 8.3% had an

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Anxiety Disorder, 8.3% had a primary diagnosis of a Substance-Related Disorder, 4.2% had a primary diagnosis of an Adjustment Disorder, and 1 participant had a primary diagnosis of Pain Disorder Associated with Psychological Features. More than half (54.2%) of the sample had at least 1 comorbid Axis I diagnosis. Examining all Axis I diagnoses, 79.2% had an Axis I diagnosis of a Mood Disorder, 37.5% had a Substance-Related Disorder, 29.2% had an Anxiety Disorder, 12.5% had a Psychotic Disorder, and 4.2% had an Impulse-Control Disorder; 1 participant had an Axis I diagnosis of Pain Disorder Associated with Psychological Features, 1 participant was diagnosed with Attention Deficit Hyperactivity Disorder, 1 participant with Bereavement, and 1 participant was diagnosed with Partner Relational Problem. See Table J1 in Appendix J for the number of individuals diagnosed with specific disorders within the disorder classes listed above. 79.2% of participants Axis II diagnoses were deferred, 14.6% had no Axis II diagnosis, and the remaining participants had traits, Personality Disorder NOS, or a rule-out diagnosis on Axis II. 85.4% participants had at least 1 medical condition listed on Axis III, and the majority of diagnoses (79.2%) were chronic medical illness (e.g., HIV, Hepatitis C, obesity, asthma, migraines, hypertension, high cholesterol, pain, Crohns Disease, gastrointestinal reflux disease, hearing impairment). All but 1 participant had at least 1 psychosocial stressor listed on Axis IV (e.g., single parent, unemployment, housing issues, grief, history of abuse, legal problems), with 37.5% of participants having two or more stressors. In sum, the clinical sample largely consisted of minority participants with chronic mental illness, multiple physical and psychosocial stressors, who do not have higher than a high school education and receive disability or are unemployed.

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Measures and Predictions The same measures and predictions were used as in Study 3. Results Measure Descriptives The PHLMS total score ranged from 46 to 82, with a mean of 59.73 (SD = 7.17), the PHLMS Acceptance subscale total score ranged from 12 to 37, with a mean of 24.62 (SD = 5.48), and the PHLMS Awareness subscale total score ranged from 22 to 50, with a mean of 35.11 (SD = 5.39). See Table J2 in Appendix J for PHLMS item means and standard deviations. MAAS scores ranged from 17 to 90, and had a mean of 53.19 (SD = 15.30). The AAQ Total scores ranged from 38 to 97, with a mean of 58.65 (SD = 10.76), the AAQ Acceptance subscale scores ranged from 10 to 45, with a mean of 23.25 (SD = 6.58), and the AAQ Action scores ranged from 23 to 54, with a mean of 35.39 (SD = 6.70). The RRQ Rumination subscale scores ranged from 24 to 58, with a mean of 42.76 (SD = 7.40), and the RRQ Reflection subscales scores ranged from 19 to 58 and had a mean of 36.38 (SD = 7.09). FSS scores ranged from 71 to 155 and had a mean of 118.82 (SD = 20.60), WBSI scores ranged from 25 to 75 and had a mean of 56.65 (SD = 12.15), and the M-C SDS scores ranged from 74 to 126 and had a mean of 98.10 (SD = 12.09). The mean BDI total score of 24.0 (SD = 15.86, range = 0 to 51) can be classified as dysphoricdepressed and the mean BAI total score of 20.7 (SD = 16.25, range = 0 to 62) is classified as moderate. The PHLMS Awareness subscale (r = .65, p < .0001) and the PHLMS Acceptance subscale (r = .67, p < .0001) were both significantly and moderately related to the PHLMS Total score. However, there was not a significant relationship between the Acceptance and Awareness subscales (r = -.13, p = .357). Internal Consistency Reliability analyses (i.e., inter-item correlations, corrected item-to-total correlations, and Cronbachs alpha coefficient) were conducted for the entire measure and each subscale. Internal

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consistency was minimally acceptable for the PHLMS (Cronbachs alpha = .66), and it was respectable for the Awareness subscale (Cronbachs alpha = .75), and Acceptance subscale (Cronbachs alpha = .75). Corrected item-to-total correlations were conducted within each subscale. For the PHLMS Awareness subscale, corrected item-subscale total correlations ranged from .10 to .62, and for the Acceptance subscale, corrected item-subscale total correlations ranged from .23 to .65. See Table J3 in Appendix J for corrected item-subscale correlations for each item. Interitem correlations were calculated. For the PHLMS Awareness subscale, inter-item correlations ranged from .01 to .60, and for the PHLMS Acceptance subscale, inter-item correlations ranged from -.04 to .57. See Table J4 in Appendix J inter-item correlations. Convergent Validity Correlations of the PHLMS with others measures were conducted to assess for convergent and validity and are shown in Table J5 in Appendix J. To account for the large number of correlations calculated using this sample, only those reaching an alpha level of p < .01 were deemed significant. The PHLMS was found to be moderately correlated with the MAAS (r =.43, p < .01), have a large correlation with flow (r =.52, p < .0001), and moderately negatively correlated with thought suppression (r = -.39, p < .01) and rumination (r = -.37, p < .01). Although the PHLMS showed a modest correlation with the AAQ Acceptance subscale (r = .29, p = .039) a small correlation with the RRQ Reflection subscale (r = .16, p = .278), neither correlation was significant at the conservative alpha level of p < .01. The PHLMS Acceptance subscale was found to moderately negatively correlate with rumination (r = -.43, p <.01). Although the PHLMS Acceptance subscale was moderately correlated with the AAQ Acceptance subscale (r = .31, p = .025) and flow (r = .28, p = .049); although not quite reaching the conservative alpha level of .01 established to protect family-wise error, these correlations approached significance at that level and were significant at the conventional .05 level. Further, the PHLMS Acceptance subscale showed a moderate negative correlation with thought

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suppression (r = -.35, p = .01). The PHLMS Awareness subscale moderately correlated with the MAAS (r = .40, p <.01). However, contrary to predictions, the PHLMS Awareness subscale positively correlated with flow (r = .41, p < .01). Discriminant Validity There was a modest correlation between the M-C SDS and the PHLMS (r = -.26, p = .067); although the correlation did not reach the conservative alpha level of .01 established to protect family-wise error, the correlation approached significance at the conventional .05 level. Although there were small correlations between the PHLMS Acceptance subscale (r = -.15, p = .309), and the PHLMS Awareness subscale (r = -.19, p = .186), the correlations were not statistically significant. The relationship between the PHLMS total score and depression and anxiety were not maintained after controlling for social desirability. Specifically, the partial correlations between the PHLMS and depression (r = -.34, p = .020) and anxiety (r = -.34, p = .017) approached significance at the conservative alpha level of .01, but were statistically significant at the conventional .05 alpha level. In addition, the relationship between the PHLMS subscales and depression and anxiety were not significant after controlling for social desirability. See Table J6 in Appendix J for partial correlations between the M-C SDS and the PHLMS and its subscales. Relationship to Measures of Psychopathology With regard to measures of psychopathology, the PHLMS was found to be moderately negatively correlated with both depression (r = -.41, p < .01) and anxiety (r = -.42, p < .01). However, neither PHLMS subscale was found to be related at the p < .01 level with depression or anxiety; see Table J6 in Appendix J for correlations between the PHLMS and measures of psychopathology. Partial correlations between the PHLMS subscales and measures of psychopathology (i.e., depression, anxiety) were conducted to assess incremental validity. There continued to be no relationship between the PHLMS Acceptance subscale and depression and anxiety after

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controlling for acceptance variables (i.e., AAQ Acceptance subscale; WBSI total score). Likewise, there was no relationship between the PHLMS Awareness subscale and depression and anxiety after controlling for awareness variables (i.e., MAAS total score; FSS total score). See Table J6 in Appendix J for correlations between the PHLMS and measures of psychopathology. Cross Validation with Student Sample Cross validation analyses were conducted between the student validation and clinical samples to examine differences in responses. No differences for gender between both samples were found ( (1, N = 605) = .40, p = .525). However, there were significant differences between samples for race ( (6, N = 610) = 162.27, p < .0001), as the majority of participants in the student sample were White and the majority of participants in the clinical sample were Black/African American/Caribbean American. The clinical participants also were significantly older than the student participants (t(50.8) = -12.21, p <.0001). As expected, significant differences were found between the student and clinical samples for the PHLMS Total score (t(609) = 6.75, p < .0001), PHLMS Acceptance subscale (t(609) = 6.62, p < .0001), and PHLMS Awareness subscale (t(609) = 2.14, p < .05), with student participants showing higher levels of mindfulness (PHLMS Total score mean difference of 7.11), acceptance (PHLMS Acceptance subscale mean difference of 5.57), and awareness (PHLMS Awareness subscale mean difference of 1.54). A 2 (groups) by 2 (subscale) mixed factorial ANOVA with repeated measures on the latter factor was conducted to examine if the difference between the student and clinical samples was larger for the Acceptance subscale than the Awareness subscale. The main effect for group was significant (F(1,609) = 213.44, p < .0001) indicating that students generally scored significantly higher than clinical participants. A main effect for type of measure was found (F(1,609) = 45.58, p < .0001) indicating that awareness scores were generally higher than acceptance scores. Further, the interaction was significant (F(1,609) = 12.06, p = .001), indicating that students scored significantly higher on acceptance than awareness.

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Cross validation analyses also were conducted for the other measures. The clinical sample was significantly more depressed (t(51.9) = -7.09, p < .0001) and anxious (t(53.54) = 4.89, p < .0001) than the student normative sample. The student normative sample scored significantly higher on the AAQ Acceptance subscale (t(609) = 7.26, p < .0001), the MAAS (t(55.5) = 2.22, p < .05), on the FSS (t(608) = 4.11, p < .0001), and on the RRQ Reflection subscale (t(65.8) = 2.13, p <.05). Results also indicate that the clinical sample had higher levels of thought suppression (t(607) = -6.72, p < .0001). However, no significant differences were found between both samples for reflection or social desirability. Discussion In summary, the PHLMS showed good internal consistency within a clinical sample. In addition, similar to the student sample, the PHLMS Awareness and Acceptance subscales were not correlated. However, correlations with related measures did not entirely provide evidence for convergent and discriminant validity within this sample. Further, although mindfulness was found to be negatively related to both depression and anxiety, the individual subscales were not (although they approached significance for several measures). However, significant differences on the PHLMS and its subscales were found between nonclinical and clinical participants, indicating that the measure can distinguish between groups expected to differ in levels of mindfulness, awareness, and acceptance.

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CHAPTER 6: GENERAL DISCUSSION One purpose of the present project was to develop and provide initial validation of a theoretically-based self-report measure of mindfulness. The psychometric evidence suggests that the PHLMS adequately measures mindfulness and its key constituents, acceptance and awareness. Content validation by expert judges, experienced researchers of mindfulness and related constructs, yielded high ratings of the representation of the components of mindfulness. A clear two-factor solution was demonstrated in the initial nonclinical sample and confirmed in a second nonclinical sample. Further, good internal consistency was demonstrated in both clinical and nonclinical samples. The second aim of the present research was to create an operational definition of mindfulness based on its constituents. The two-factor solution supports a bi-dimensional conceptualization of mindfulness. Further, since there are individual differences in mindfulness but levels of mindfulness can change at any given time, the current project conceptualizes mindfulness as a quasi-trait. Thus, the following operational definition of mindfulness is proposed: Mindfulness is the tendency to be highly aware of ones internal and external experiences in the context of an accepting, nonjudgmental stance toward those experiences. Relationships Between the PHLMS and Other Constructs Relationships with other constructs were largely as expected within the normative nonclinical sample. The PHLMS was related to measures of awareness, acceptance, flow and reflection, and negatively correlated with measures of thought suppression and rumination. As predicted, the PHLMS Acceptance subscale was found to be positively related to measures of acceptance and negatively related to rumination and thought suppression, but contrary to expectations, the Acceptance subscale was not found to be related to flow. As predicted, the PHLMS Awareness subscale was related to measures of awareness and reflection. In addition, contrary to expectations, it was related to flow.

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An interesting finding was the relationship between the PHLMS Acceptance subscale and the MAAS, which was slighter stronger than the relationship between the PHLMS Awareness subscale and the MAAS. Brown and Ryan (2003, 2004) created the MAAS to be a dispositional measure of mindfulness, which they conceptualize to be an open or receptive attention to and awareness of ongoing events and experience. These authors initially developed a measure of mindfulness with two factors, presence (i.e., attention/awareness) and acceptance. However, validation analyses showed that the acceptance factor did not provide explanatory advantage over that shown by the presence factor alone, which led them to conclude that acceptance, as a distinct construct, is redundant in mindfulness. Therefore, items from the presence factor only were used to form the MAAS. Although Brown and Ryan (2003) state that items with attitudinal components (e.g., acceptance, empathy, trust) were purposefully excluded in the presence factor, the presence and acceptance factors were moderately correlated in the .20 to .35 range across several samples (Brown and Ryan, 2004). Thus, although the face validity of the items suggests that the MAAS only measures awareness/attention, unlike the PHLMS, it confounds awareness and acceptance; MAAS items appear to reflect accepting awareness. On the other hand, the PHLMS subscales were not correlated, indicating that acceptance and awareness are separate constituents of mindfulness and can be examined individually. Since the MAAS appears to measure acceptance-oriented awareness, it is not surprising that it correlated with both PHLMS subscales. Although relationships with other constructs were largely as expected within the normative sample, some predictions were not supported by results from the clinical sample. There was a relationship between the PHLMS and measures of awareness and flow, and there was a negative relationship with rumination. However, contrary to expectations, the PHLMS was not related to the AAQ Acceptance subscale, a measure of acceptance. The PHLMS Acceptance subscale was only found to be negatively related to rumination; other predictions for this subscale with regard to convergent and discriminant validity were not supported. Likewise, the PHLMS

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Awareness subscale was found to be positively related to both awareness and flow, even though it was expected that the PHLMS Awareness subscale would be negatively related to flow. Further, although the PHLMS was found to be negatively correlated with both depression and anxiety, none of the relationships between the PHLMS subscales and variables of mental health (i.e., depression and anxiety) were significant, and the relationships between the PHLMS and depression and anxiety were not maintained after controlling for social desirability. Since a relationship was found between overall mindfulness and depression and between overall mindfulness and anxiety, but no relationship was found between acceptance or awareness with depression and anxiety, the results suggest that awareness and acceptance together may be related to mental illness. However, there are limitations to these results that reduce confidence in these findings. Given the small size of the clinical sample, post-hoc power analyses reveal a power of 11% (using a small effect size), which reduced the ability to detect significant results between the PHLMS subscales and mental health variables. Another reason for the lack of relationship between acceptance and awareness with the mental health variables in the clinical sample could be that the scope of the measures of depression and anxiety may have been too limited to measure general psychopathology or mental health. Results indicate that the clinical participants only had moderate levels of anxiety, and only 50% of the sample had a diagnosis of a mood and/or anxiety disorder. Future research should consider examining more inclusive inventories of psychiatric symptoms, measures of adaptive functioning, or both. Differences Between the Nonclinical and Clinical Samples Even though results from some of the clinical sample validation analyses were contrary to expectations, as predicted, significant differences were found between the nonclinical and clinical samples. Comparison of these groups showed significantly lower scores of mindfulness, acceptance, and awareness in the clinical population, providing additional support for the relationship between mindfulness and mental health. However, the reason for the difference in mindfulness, acceptance, and awareness between these samples remains unclear. Future research

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should examine the differences in mindfulness between normative and clinical populations, controlling for variables such as socioeconomic status and education to elucidate the relationship between mindfulness and mental health. Implications for a Bi-dimensional Conceptualization of Mindfulness Without a scientific understanding of psychological processes, data on technologies can collect and form an ever-expanding list. As Hayes and Wilson (2003) note, mindfulness is currently in a somewhat similar situation. The procedure is being specified, and there are data supportive of its impactbut its scientific analysis is just beginning. No scientific analysis yet seems adequate to account for the impact of mindfulness (p. 161). Several of the new thirdwave therapies (e.g., Mindfulness-Based Stress Reduction; Mindfulness Based Cognitive Therapy) include mindfulness as a central component and link the benefits of these treatments to mindfulness, but how mindfulness may be working to reduce symptoms and increase psychological well-being has not been empirically examined. Thus, from a scientific perspective, it is important to question the assumption that the construct of mindfulness as described in prescientific writings has beneficial effects. It also will be important to deconstruct the global idea of mindfulness in order to examine empirically its constituents. Further, it will be important to separate mindfulness from its association with meditation. Due to its history, mindfulness, even as a process, is often linked to the practice (i.e., technique) of mindfulness meditation (e.g., Bishop et al., 2004). However, any method that increases awareness and acceptance simultaneously should be considered a mindfulness method, which allows for new techniques to be developed and empirically tested. For these reasons, the present study attempted to examine the construct of mindfulness through the lens of science in order to determine its composition and which of those components are related to psychological functioning. One important finding from the present research was that the two subscales of the PHLMS were not correlated with each other in either sample. These results suggest that awareness can be disambiguated from acceptance. In the development of the MAAS, Brown &

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Ryan (2003, 2004) discuss how acceptance as a distinct construct is functionally redundant in mindfulness. Although results from their research supported a two-factor conceptualization of mindfulness, consisting of presence (i.e., awareness and attention) and acceptance, they report that the acceptance factor did not provide any explanatory advantage over the presence factor alone. Brown and Ryan (2004) further describe how they operationally defined mindfulness as an open or receptive attention to and awareness of ongoing events and experience (p. 245), and that mindfulness subsumes an acceptance of what occurs. However, confounding the two components of mindfulness not only questions whether the beneficial effects of increased mindfulness are due to increased awareness, increased acceptance, or both, but the individual effects of acceptance and awareness in theoretical models of psychopathology become obscured. Consideration of the construct of mindfulness and its constituent components suggests alternative theoretical mechanisms than those found in traditional cognitive behavior therapies. One exemplar of these mechanisms is seen in an acceptance-based model of social anxiety disorder recently proposed by Herbert and Cardaciotto (in press). The figure in Appendix K illustrates how phobic social situations, in the context of a predisposition toward social anxiety, produce both physiological arousal and negative thoughts related to social evaluation. As anxiety-related feelings and thoughts are elicited, they in turn trigger an increase in internal awareness and a decrease in awareness of external cues (i.e., self-focused attention). At this next stage, the acceptance component is critical; the effects of increased awareness of internal arousal will depend upon the individuals level of acceptance. In the context of a high level of acceptance, the cognitive and physiological arousal is noticed without attempts to control, escape from, or avoid it, resulting in minimal impact on behavioral performance. On the other hand, in the context of low acceptance, strategies (e.g., rationalizing thoughts, distraction techniques, thought suppression) are attempted in order to control or alter the form and/or frequency of thoughts and feelings, and even though these strategies sometimes work temporarily, they often fail. For example, thought suppression has been related to heightened pain experience (Sullivan,

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Rouse, Bishop, & Johnston, 1997), increased anxiety (Koster, Rassin, Crombez, & Naring, 2003), and poorer ratings of quality of sleep (Harvey, 2003). Further, not only do attempts to control or alter ones private experiences often fail, but they can paradoxically lead to even further increases in anxiety-related arousal. This vicious cycle of increased arousal, increased awareness, and further efforts at experiential avoidance and/or control can produce behavior disruption, as one is preoccupied with controlling unpleasant thoughts and feelings, which may lead to further attempts at experiential avoidance and/or control. Thus, even though both awareness and acceptance are included in the model by Herbert and Cardaciotto, acceptance is proposed to be the construct that provides beneficial or protective effects. Results from the present research support predictions about the differential effects of awareness and acceptance. In the second nonclinical sample, whereas lower levels of depression and anxiety were found to be related to higher levels of acceptance, awareness was found not to be related to depression and anxiety. In addition, although the nonclinical sample had significantly higher levels of both awareness and acceptance relative to the clinical sample, the magnitude of the difference between the clinical and nonclinical mean awareness scores and both samples mean acceptance scores was significantly different: the magnitude of difference was greater for the samples mean acceptance scores, which supports its unique role in positive mental health. Although these results are preliminary and are in need of replication and extension, they are highly provocative and warrant further investigation. Thus, confounding awareness and acceptance in the investigation of mindfulness may obscure their individual effects in the etiology or maintenance of psychopathology. Further, the PHLMS provides a way to study these differential effects, which did not exist until now. Clinical Implications Although the PHLMS was developed for both clinical and research purposes, its use in clinical settings may be premature at this time. Findings from the present study do warrant future research to explore the utility of the PHLMS with psychiatric populations. Specifically, higher

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levels of mindfulness in clinical patients were found to be associated with less depression and anxiety. Higher levels of mindfulness were also related to lower levels of thought suppression and rumination, two processes associated with psychopathology (e.g., Purdon, 1999; Thomsen, Mehlsen, Christensen, & Zachariae, 2003). In addition, higher levels of acceptance were also related to less rumination. If future research not only further validates the PHLMS with clinical populations but confirms the differential role of acceptance in psychopathology, the measure may be useful clinically, especially to track patients progress in third wave acceptance- and mindfulness-based treatments. Limitations Several limitations of this research should be noted. As previously discussed, limitations include the lack of statistical power needed to detect significant results with regard to the clinical sample, as well as the limited scope of mental health measurement. Another limitation concerns the construct and measurement of flow. First, the FSS was designed to be used immediately or soon after a flow experience; however, the current project modified the FSS instructions so that a retrospective approach to data collection could be taken, asking participants to recall a recent flow experience. Responses may have been influenced by the passing of time, as participants may have not been able to recall accurately their experiences that previously occurred during the flow experience. Second, although the FSS has shown good internal consistency, validation data is quite limited, questioning the utility of the measure. The third limitation concerns the conceptualization of flow. Although it was predicted that the Acceptance subscale would be positively related to flow and the Awareness subscale would be negatively related to flow, these results were not found, and instead, the Awareness subscale was found to be positively correlated with flow in both the nonclinical and clinical samples. The current project conceptualized flow as consisting of high levels of acceptance and low levels of awareness. Although this conceptualization is consistent with several of the dimensions of flow (i.e., action-awareness merging, in which there is no awareness of self as separate from the actions one is performing;

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loss of self-consciousness, in which lack of focus on the information normally used to represent to oneself who one is), flow is also characterized as including intense and focused concentration on what one is doing in the present moment (Nakamura & Csikszentmihalyi, 2002, p. 90). Several items on the FSS capture this quality of heightened attention (e.g., My attention was focused on what I was doing; It was no effort to keep my mind on what was happening), which may be related to certain awareness items on the PHLMS. To conduct convergent and discriminant validation analyses, further studies should find other means of measuring high levels of acceptance during decreased present-moment awareness. The inclusion of solely reverse items on the PHLMS Acceptance subscale also may be a limitation. Although direct-scored items were generated, they were eliminated after content validity ratings by expert judges, factor analytic procedures, and internal consistency analyses. Similar occurrences were reported by Brown and Ryan (2003) in the development of the MAAS, in which the entire measure is reverse-scored, and by Baer et al. (2004) in the development of the KIMS, in which one of four subscales is reverse-scored. Brown and Ryan demonstrated that the indirect and direct measurement of their conceptualization of mindfulness were conceptually and psychometrically equivalent, and noted that statements reflecting less mindfulness may be easier for individuals to access and rate. Further, since it was the Accept without Judgment subscale that is reverse-scored in the KIMS, Baer et al. propose that the lack nonjudgmental attitude toward ones private experiences may also be easier to recognize and report. Although using student participants as normative samples to examine factor structure and to conduct validation studies may be another limitation, research suggests that meaningful variations in mindfulness can be shown in populations without meditation experience (Baer et al., 2004; Brown & Ryan, 2003; Kabat-Zinn, 2003). This notion is supported by the present project, in that relationships between mindfulness, acceptance, and awareness and other constructs were found within the student sample. Since the results from the small clinical sample included in the present project are limited, a high priority for future research should be to conduct further

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validation analyses with larger clinical samples to examine the potential utility of the PHLMS in clinical populations. In addition, the PHLMS should be validated with individuals who have extensive experience with mindfulness (e.g., regular mindfulness meditators), to provide further evidence that the measure can discriminate between groups expected to differ in degree of mindfulness. Directions for Future Research There are several other directions for future research to be considered. For example, predictive validity could be conducted by examining whether training in mindfulness or receiving a mindfulness-based therapy results in higher PHLMS scores. These scores should also be compared to changes in mindfulness scores after receiving a non-mindfulness-based psychotherapy. Further, the PHLMS could be used to address the larger question of mechanisms of action not only in mindfulness-based therapies, but in non-mindfulness-based treatments as well. For example, Teasdale et al. (2001) proposed that traditional cognitive therapy may prevent depressive relapse by training patients to change the way in which depression-related material is processed and the relationship patients have with dysfunctional thoughts, rather than by changing belief in the thought content. This suggests that mindfulness could be a mechanism of action in non-mindfulness-based treatments as well. Until now, research has not clearly distinguished the two components of mindfulness; the present research is the first to clearly disentangle these components. Future research is needed to follow up on the results suggesting that the acceptance component is related to beneficial outcomes. Lastly, future research could examine the relationship of awareness of internal and external stimuli; although one might expect them to correlate, increased awareness of internal stimuli may lead to decreased awareness of external stimuli. Conclusion There is a marked increased in interest surrounding the construct of mindfulness in clinical psychology, particularly in the development and study of psychological interventions that

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include mindfulness as a central component. However, there is still no accepted definition of mindfulness, and the construct has not been sufficiently operationalized. As acceptance and present-moment awareness appear to be central components of mindfulness (as most definitions of mindfulness in clinical psychology and mindfulness-based interventions explicitly include these concepts), we propose a conceptualization of mindfulness consisting of both acceptance and awareness. Further, the present project provides support for the use of the PHLMS to measure this construct and its two constituent components. Defining mindfulness as the tendency to have acceptance, a nonjudgmental stance towards ones experience, and awareness, a continuous monitoring of ongoing internal and external stimuli, along with the development of the PHLMS based on this conceptualization, sets the stage for the scientific investigation of this ancient construct.

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Appendix A: Definitions of Mindfulness

Table A1 Clinical Definitions of Mindfulness

Author Baer (2003) Boorstein, S. (1983) Epstein (1995) Hayes & Wilson (2003) Kabat-Zinn (1990) Kabat-Zinn (1994) Kabat-Zinn (2003) Marlatt & Kristeller (1999) Martin (1997) Miller, Fletcher, Kabat-Zinn (1995) Definition The nonjudgmental observation of the ongoing stream of internal and external stimuli as they arise (p. 125) Technique that focuses precisely on each thought or affect as it arises in consciousness. (p. 176) Mindful attention: Pay precise attention, moment by moment, to exactly what you are experiencing, right now, separating out your reactions from the raw sensory events Set of techniques (that is, a method) designed to encourage deliberate, nonevaluative contact with events that are here & now. (p. 163) Nonjudgmental moment-to-moment awareness Paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally. (p. 4) Awareness that emerges through paying attention on purpose, in the present-moment, and nonjudgmentally to the unfolding of experience moment by moment (p. 145) Bringing ones complete attention to the present experience on a moment-to-moment basis A state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view. (pp. 291-292) A universal human attribute in that it has to do with a particular way of paying attentionThe effort to pay attention, nonjudgmentally, to present-moment experience and sustain this attention over timeWitnesslike observing and self-reporting of the moment by moment unfolding of ones experience. (p. 193) Nonjudgmental awareness of ones experience as it unfolds moment by moment. (p. 55) Mindful attention: the primary and most effective tool taught by the Buddha for reducing or correcting the tendency to engage in erroneous metacognitive activity. In mindful attention, the client is encouraged to observe the display of cognitive events occurring within ordinary awareness (the everyday, untrained mind) but refrain from engaging in any metacognitive (i.e., judgmental activity). (p. 76)

Robins (2002) Toneatto (2002)

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Table A2 Non-Clinical Definitions of Mindfulness
Author Brown & Ryan (2003) Langer (1989a) Langer (1992) Langer (2000) Langer (2002) Langer & Moldoveanu (2000) Definition Social Psychology Literature State of being attentive to and aware of what is taking place in the present; enhanced attention to and awareness of current experience or present reality. (p. 822) Sensitivity to or awareness of contexts A state of conscious awareness characterized by active distinction drawing that leaves the individual open to novelty and sensitive to both context and perspective. (p. 289) Actively drawing distinctions and noticing new things seeing the familiar in the novel and the novel in the familiar. (p. 222) A flexible state of mindan openness to novelty, a process of actively drawing novel distinctions. (p. 214) Process of drawing novel distinctions. It does not matter whether what is noticed is important or trivial, as long as it is new to the viewer. Actively drawing these distinctions keeps us situated in the present. It also makes us more aware of the context and perspective of our actions than if we rely upon distinctions and categories drawn in the past. (pp. 1-2) Philosophical/Spiritual Literature Mindfulness is a technique that teachers intent alertness. It means becoming fully aware of each moment and of your activity in that moment. (p. 5) Mindfulness is mirror-thought. It reflects only what is presently happening and in exactly the way it is happening. There are no biases. Mindfulness is non-judgmental observation. It is the ability of the mind to observe without criticism. (p. 151) Keeping ones consciousness alive to the present reality. (p. 11) A kind of bare attention which sees things as if for the first timeas they really are. (p. 246) Requires the person to attend, to be consciously aware of, the emergent nature of phenomena in consciousness and to recognize the nature of attachments made to these phenomena as they occur; Awareness of being aware. (p. 360) Attention to the experienced qualities of the self in the present moment and space rather than being preoccupied with what happened in the past or fantasies in the distant futures. (p. 125) Complex, open, honest awareness of everything all of the time. (p. 26) The clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception. (p. 5)

Braza (1997) Gunaratana (1991)

Hanh (1976) Harvey (2000) Hirst (2003)

Horowitz (2002) Tart (1994) Thera (1972)

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Appendix B: Mindfulness Qualities Defined by Kabat-Zinn (1990)

Definition Impartial witnessing, observing the present moment-by-moment without evaluation and categorization Nonstriving Non-goal oriented, remaining unattached to outcome or achievement, not forcing things Acceptance Open to seeing and acknowledging things as they are in the present moment; acceptance does not mean passivity or resignation, rather a clearer understanding of the present so one can more effectively respond Patience Allowing things to unfold in their time, brining patience to ourselves, to others, and to the present moment Trust Trusting both oneself, ones body, intuition, emotions, as well as trusting that life is unfolding as it is supposed to Openness Seeing things as if for the first time, creating possibility by paying attention to all feedback in the present moment Letting go Non-attachment, not holding onto thoughts, feelings, experiences; however, letting go does not mean suppressing Gentleness Characterized by a soft, considerate and tender quality; however, not passive, undisciplined or indulgent Generosity Giving into the present moment within a context of love and compassion, without attachment to gain or thought of return Empathy The quality of feeling and understanding another persons situation in the present momenthis or her perspectives, emotions, actions (reactions) and communicating this to the person Gratitude The quality of reverence, appreciating and being thankful for the present moment Lovingkindness A quality of embodying benevolence, compassion and cherishing, a quality filled with forgiveness and unconditional love Note. Excerpted from The role of intention in self-regulation: Toward intentional systemic Nonjudging mindfulness, by S. L. Shapiro and G. E. Schwartz, 2000, In M. Boekaerts, M. Zeidner, & P. R. Pintrich (Eds.), Handbook of self-regulation, p. 263.

Quality

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Appendix C: List of Measures of Mindfulness and Related Constructs

Measure Acceptance and Action Questionnaire (AAQ) Cognitive Affective Mindfulness Scale (CAMS) Freiburg Mindfulness Inventory (FMI) Kentucky Inventory of Mindfulness Skills (KIMS)

Author Hayes (1996)

Feldman, Hayes, Kumar, & Greeson (2004) Buchheld, Grossman, & Walach (2001) Baer, Smith, & Allen (2004)

Meta-Cognitions Questionnaire (MCQ) Metacognitive Awareness Inventory (MAI) Metacognitive Awareness Questionnaire (MAQ) Mindful Attention Awareness Scale (MAAS)

Cartwright-Hatton & Wells (1997) Schraw & Dennison (1994) Teasdale et al. (2001)

Intended Use Measures the ability to accept undesirable internal events while continuing to pursue desired goals Measures awareness, attention, present-focus, & nonjudgment/acceptance Measures nonjudgmental present-moment observation & openness to negative experience Measures four mindfulness skills: observing, describing, acting with awareness, accepting without judgment Measures beliefs about worry and intrusive thoughts Measures metacognitive awareness (i.e., knowledge of cognition and regulation of cognition) Measures the extent that negative thoughts and feelings do not reflect reality when depressed Measures present-centered attention-awareness

Limitation Only measures the acceptance component of mindfulness Only assesses thoughts & feelings; does not assess other phenomena Designed for use with experienced meditators Most similar to mindfulness as it is taught in DBT Domain-specific to generalized anxiety disorder Domain specific to learning performance Domain-specific to depression Only assesses presentmoment attention and awareness; excludes attitudinal components (e.g., acceptance) Measures the extent to which individuals analyze the self rather than internal experiences of the self Focuses solely on thoughts about the self without including components of acceptance Specific to the observation of expressive behavior and self-presentation Only measures reflection on internal state awareness Cannot be used outside of mindfulness meditation training

Brown & Ryan 2003)

Rumination-Reflection Questionnaire (RRQ)

Trapnell & Campbell (1999)

Distinguishes neurotic from inquisitive self-focus

Self-Consciousness Scale (SCS)

Fenigstein et al. (1975)

Measures individual differences in self-consciousness

Self-Monitoring Scale (SM)

Snyder (1974)

Self Reflection and Insight Scale (SRIS) Toronto Mindfulness Scale (TMS)

Grant, Franklin, & Langford (2002) Bishop et al. (2003)

Measures concern for social appropriateness, sensitivity to the expression and self-presentation of others, and use of cues to monitor self-expressive behaviors Measures internal state and selfreflection Measures attainment of a mindfulness state immediately following a meditation exercise

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Appendix D: Illustration of the Four Psychological States

High

Flow Low

Mindfulness
High

Successful Experiential Avoidance/ Control

Low

Unsuccessful Experiential Avoidance/ Control

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Appendix E: List of Items and Procedures Administered to Expert Judges

PART I AWARENESS ITEMS

Awareness: the continuous monitoring of ongoing internal and external stimuli Acceptance: nonjudgmental stance toward ones experience
Please rate how well the following items reflect awareness AND acceptance according to the definitions above. Reverse scored items (e.g., I finish a meal and realize I did not notice tasting the food) should be rated for how well they would discriminate awareness from nonawareness (and acceptance from non-acceptance). In other words, if you judge an item to reflect either very low or very high awareness, please assign it a relatively high ranking. 1 2 3 4 5 Very Poor Poor Fair Good Very Good
Awareness Acceptance

_____
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____
_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

When the room is quiet, I hear sounds like a clock ticking or air coming out of the vents. I notice when Im hungry. I analyze what I do and why I do them. I notice my surroundings when walking down the street. I block out sound when Im focused on an activity. I can tell when I feel anxious because of changes inside my body. I am always thinking something. I am aware of what thoughts are passing through my mind. I have a keen sense of smell. I dont know what mood I am in until after it has passed. When I am focused on a task, I am not aware of what I am thinking or feeling. I am aware of thoughts Im having when my mood changes. When I wake up in the morning, I take time to process my thoughts. During my last meal, I was aware of the texture of the food I was eating. When talking with other people, I am aware of their facial and body expressions. When talking with other people, I am aware of the emotions I am experiencing.

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Awareness Acceptance

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

I often react to a situation without knowing where my emotions are coming from. I take time in my daily routine to consider my feelings and emotions. When I listen to music, I pay attention to all aspects (words, tune, rhythm). When I shower, I am aware of how the water is running over my body. When I am startled, I notice what is going on inside my body. I am a sensitive person. I experience physical symptoms when experiencing an emotion. I feel a broad range of emotions. I feel very few emotions. Whenever my emotions change, I am conscious of them immediately. I daydream a lot. When someone asks how I am feeling, I can identify my emotions easily. I get startled easily. I notice how my thoughts influence my emotions. I finish walking or driving a short distance and realize I did not notice the journey. I finish a meal and realize I did not notice tasting the food. I often do not hear what someone has told me even though I was having a conversation with them. I notice how my mood is affected by the food I eat. When my mood changes, I notice the event or the thought that caused it to change. I think more about what happened before and what might happen later than what is happening right now. I notice that my mind is constantly thinking. Sometimes I feel anger or sadness without knowing what caused it. I do things without paying much attention. I rush through activities without paying attention to what Im doing.

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Awareness Acceptance

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

I do many tasks like I am on auto-pilot. I am aware of my emotions. I realize I'm experiencing an emotion as soon as I have it. When I feel sad, I am conscious of it. I am sensitive to a change in my emotions. I can tell how my behavior is affecting others. When I get scared, I feel my muscles tense up. When I go outside, I notice my surroundings. When I do something I enjoy, hours pass without me noticing. I notice changes inside my body, like my heart beating faster or my muscles getting tense. When I walk outside on a sunny day, I notice how the sun feels on my skin. I become absorbed into whatever task I am working on. I notice how my thoughts and emotions feel inside my body. When I walk outside, I am aware of smells or how the air feels against my face. Compared to most people I am very perceptive of my surroundings.

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PART II ACCEPTANCE ITEMS

Acceptance: nonjudgmental stance toward ones experience Awareness: the continuous monitoring of ongoing internal and external stimuli
Please rate how well the following items reflect acceptance AND awareness according to the definitions above. Reverse scored items (e.g., If I have unpleasant thoughts or feelings, I try to get rid of them) should be rated for how well they would discriminate acceptance from nonacceptance (and awareness from awareness). In other words, if you judge an item to reflect either very low or very high acceptance, please assign it a relatively high ranking. 1 Very Poor
Awareness Acceptance

2 Poor

3 Fair

4 Good

5 Very Good

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

When I dont want to think of something, I try to push the thoughts out of my head. If I have unpleasant thoughts or feelings, I try to get rid of them. It is okay to have unpleasant thoughts or feelings. Feeling anxious or depressed is something to be concerned about. If I feel pain, I dont do anything to make it go away. I dont like feeling down or sad. If I have an itch, I will do anything to scratch it. When I have a bad memory, I try to distract myself to make it go away. I dont mind feeling too hot or too cold. Its okay to be anxious. Its normal for thoughts and feelings to come and go. I harp on the negative events that happened to me that day. When something does not go as planned, I can accept the results for what they are. I feel okay with the negative experiences in my life. When I think of the accomplishments in my life, I can accept them for what they are. Events that cause pain are okay. Its okay when someone lets me down. I enjoy being with people who are different than I am.

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Awareness Acceptance

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

_____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

I feel unlucky, as if I started life out a few cards short of the deck. I become angry when I think about my past. My emotions get in the way of tasks I try to complete. I sometime have to take a day off because of my emotional state. I can feel sad, upset, or anxious and still do what I have to do. I take medication or drink alcohol to escape my feelings. It is important to control feelings like anxiety or anger. I try to distract myself when I feel unpleasant emotions. I can have negative thoughts without getting into a bad mood. I can listen to criticism openly without reacting or getting defensive. I dont let feeling afraid or depressed stop me from doing the things I want to do. I try to change my mood if I dont like it. I wish Id be able to stop thinking about things Ive said in the past. There are aspects of myself I dont want to think about. I put unwanted thoughts out of mind. I try to put my problems out of mind. There are things I try not to think about. I have thoughts I try to avoid. I try to stay busy to keep thoughts or feelings from coming to mind. It is important always to feel happy or positive. When I am standing outside and get cold, I try to do things to make myself warmer. I am comfortable with experiencing whatever emotion I'm feeling at the time. I feel like I'm flooded with emotions that I can't control. I wish I could control my emotions more easily. My emotions are too much for me to handle. If there is something I dont want to think about, Ill try many things to get it out of my mind. Whenever I feel an extreme emotion, such as sadness or anger, I try to stop it. I tell myself that I shouldnt feel sad. I tell myself that I shouldnt have certain thoughts.

_____

_____ _____ _____ _____

_____ _____ _____

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Awareness Acceptance

_____ _____ _____

_____ _____ _____

I avoid situations that will make me upset. I do not tolerate situations I cannot change. When I am outside and a cold wind blows, I do things so I wont feel cold.

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Appendix F: List of Retained Items and Expert Judges Mean Ratings

1 Very Poor

2 Poor

3 Fair AWARENESS ITEMS

4 Good

5 Very Good

Mean Rating: Awareness 4.50

Mean Rating: Acceptance 1.67

When the room is quiet, I hear sounds like a clock ticking or air coming out of the vents.

3.83 4.33 4.50

1.33 1.67 2.00

I notice when Im hungry. I notice my surroundings when walking down the street. I can tell when I feel anxious because of changes inside my body.

4.67 4.67 4.83

2.17 2.00 2.00

I am aware of what thoughts are passing through my mind. I am aware of thoughts Im having when my mood changes. During my last meal, I was aware of the texture of the food I was eating.

5.00

2.00

When talking with other people, I am aware of their facial and body expressions.

4.50

2.17

When talking with other people, I am aware of the emotions I am experiencing.

4.33

1.83

When I listen to music, I pay attention to all aspects (words, tune, rhythm).

4.83

1.83

When I shower, I am aware of how the water is running over my body.

4.33

2.00

When I am startled, I notice what is going on inside my body.

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4.33 2.17 Whenever my emotions change, I am conscious of them immediately. 4.17 2.00 When someone asks how I am feeling, I can identify my emotions easily. 4.17 1.40 I finish walking or driving a short distance and realize I did not notice the journey. 4.33 3.83 1.40 1.40 I finish a meal and realize I did not notice tasting the food. I often do not hear what someone has told me even though I was having a conversation with them. 3.83 3.83 2.00 1.60 I notice how my mood is affected by the food I eat. When my mood changes, I notice the event or the thought that caused it to change. 4.17 4.17 1.40 1.40 I do things without paying much attention. I rush through activities without paying attention to what Im doing. 4.17 4.33 4.50 4.17 4.33 1.40 1.80 1.40 2.00 2.00 I do many tasks like I am on auto-pilot. When I feel sad, I am conscious of it. I am sensitive to a change in my emotions. When I get scared, I feel my muscles tense up. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 4.50 1.83 When I walk outside on a sunny day, I notice how the sun feels on my skin. 4.50 1.67 When I walk outside, I am aware of smells or how the air feels against my face.

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3.83 1.33 Compared to most people I am very perceptive of my surroundings.

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ACCEPTANCE ITEMS Mean Rating: Awareness 2.00 Mean Rating: Acceptance 4.33

When I dont want to think of something, I try to push the thoughts out of my head.

1.67 1.67 1.67

4.33 4.67 3.83

If I have unpleasant thoughts or feelings, I try to get rid of them. It is okay to have unpleasant thoughts or feelings. Feeling anxious or depressed is something to be concerned about.

1.83

4.00

When I have a bad memory, I try to distract myself to make it go away.

1.50 1.50

4.67 4.00

Its okay to be anxious. When something does not go as planned, I can accept the results for what they are.

1.33 1.33

3.83 4.00

I feel okay with the negative experiences in my life. When I think of the accomplishments in my life, I can accept them for what they are.

1.67 1.67 1.67 1.67 2.17 1.83

3.83 4.17 4.17 4.17 4.17 4.17

Events that cause pain are okay. I take medication or drink alcohol to escape my feelings. It is important to control feelings like anxiety or anger. I try to distract myself when I feel unpleasant emotions. I can have negative thoughts without getting into a bad mood. I dont let feeling afraid or depressed stop me from doing the things I want to do.

1.67 2.00 1.67

3.83 4.17 4.00

There are aspects of myself I dont want to think about. I put unwanted thoughts out of mind. I try to put my problems out of mind.

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1.67 1.83 1.67 4.00 4.17 4.17 There are things I try not to think about. I have thoughts I try to avoid. I try to stay busy to keep thoughts or feelings from coming to mind. 1.33 1.50 1.67 4.50 4.00 4.17 It is important always to feel happy or positive. I wish I could control my emotions more easily. If there is something I dont want to think about, Ill try many things to get it out of my mind. 2.17 4.33 Whenever I feel an extreme emotion, such as sadness or anger, I try to stop it. 1.67 1.50 1.50 1.33 4.00 4.17 4.17 4.00 I tell myself that I shouldnt feel sad. I tell myself that I shouldnt have certain thoughts. I avoid situations that will make me upset. I do not tolerate situations I cannot change.

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Appendix G: Results from Development Sample Analyses

Table G1 Initial Factor Loadings for Items Completed by the Development Sample Item 9. I am aware of what thoughts are passing through my mind. 10. When I have a bad memory, I try to distract myself to make it go away. 11. I am aware of thoughts Im having when my mood changes. 15. When talking with other people, I am aware of their facial and body expressions. 17. When talking with other people, I am aware of the emotions I am experiencing. 21. When I shower, I am aware of how the water is running over my body. 23. When I am startled, I notice what is going on inside my body. 25. Whenever my emotions change, I am conscious of them immediately. 26. I try to distract myself when I feel unpleasant emotions. 27. When someone asks how I am feeling, I can identify my emotions easily. .258 .562 .568 -.158 .073 .603 -.052 .634 .033 .538 .107 .653 .043 .503 .082 .579 .533 .001 Acceptance subscale .106 Awareness subscale .506

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32. There are aspects of myself I dont want to think about. 36. I try to put my problems out of mind. 37. When my mood changes, I notice the event or the the thought that caused it to change. 38. There are things I try not to think about. 40. I have thoughts I try to avoid. 42. I try to stay busy to keep thoughts or feelings from coming to mind. 46. I wish I could control my emotions more easily. 48. If there is something I dont want to think about, Ill try many things to get it out of my mind. 51. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 52. I tell myself that I shouldnt feel sad. .559 -.043 .514 -.362 .604 .626 .721 -.003 -.042 .678 .742 .668 -.081 -.003 .010 .528 .050 .013 .596 .636 .005

53. When I walk outside on a sunny day, I notice how -.134 the sun feels on my skin. 54. I tell myself that I shouldnt have certain thoughts. 55. When I walk outside, I am aware of smells or how the air feels against my face. .059 .670

-.021

.543

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Table G2 Initial Corrected Item-Subscale Correlations for Items Completed by the Development Sample ______________________________________________________________________________ Corrected Item-Subscale Awareness Items 9. I am aware of what thoughts are passing through my mind. 11. I am aware of thoughts Im having when my mood changes. 15. When talking with other people, I am aware of their facial and body expressions. 17. When talking with other people, I am aware of the emotions I am experiencing. 21. When I shower, I am aware of how the water is running over my body. 23. When I am startled, I notice what is going on inside my body. 25. Whenever my emotions change, I am conscious of them immediately. 27. When someone asks how I am feeling, I can identify my emotions easily getting tense. 37. When my mood changes, I notice the event or the thought that caused it .51 to change. 51. I notice changes inside my body, like my heart beating faster or my muscles. 53. When I walk outside on a sunny day, I notice how the sun feels on my skin. 55. When I walk outside, I am aware of smells or how the air feels against my face. .54 .46 .46 .51 .54 .53 .48 .61 Correlation .45 .49 .43

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______________________________________________________________________________ Corrected Item-Subscale Acceptance Items Correlation .48 .53 .55 .48 .63 .72 .61 .52

10. When I have a bad memory, I try to distract myself to make it go away 26. I try to distract myself when I feel unpleasant emotions. 32. There are aspects of myself I dont want to think about. 36. I try to put my problems out of mind. 38. There are things I try not to think about. 40. I have thoughts I try to avoid. 42. I try to stay busy to keep thoughts or feelings from coming to mind. 46. I wish I could control my emotions more easily.

48. If there is something I dont want to think about, Ill try many things to .67 get it out of my mind. 52. I tell myself that I shouldnt feel sad. 54. I tell myself that I shouldnt have certain thoughts. .50 .61

______________________________________________________________________________

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Table G3 Inter-item Correlations from Initial Items Completed by Development Sample

Awareness Items
Item: Item9 Item11 Item15 Item17 Item21 Item23 Item25 Item27 Item37 Item51 Item53 Item55 #9 --.35 .23 34 .25 .27 .31 .24 .36 .24 .21 .25 #11 .35 --.16 .40 .28 .37 .50 .32 .52 .21 .09 .13 #15 .23 .16 --.48 .25 .27 .16 .30 .22 .27 .25 .30 #17 .34 .40 .48 --.29 .34 40 .45 .46 .32 .28 .31 #21 .25 .28 .25 .29 --.37 .29 .26 .19 .26 .42 .47 #23 .27 .37 .27 .34 .37 --.42 .27 .35 .40 .23 .31 #25 .31 .50 .16 .0 .29 .42 --.33 .46 .24 .15 .26 #27 .24 .32 .0 .45 .26 .27 .33 --.34 .16 .24 .33 #37 .36 .52 .22 .46 .19 .35 .46 .34 --.25 .15 .22 #51 .24 .21 .27 .32 .26 .40 .24 .16 .25 --.38 .34 #53 .21 .09 .25 .28 .41 .23 .15 .24 .15 .38 --.59 #55 .25 .13 .30 .31 .47 .31 .26 .33 .22 .34 .59 ---

Acceptance Items
Item: Item10 Item26 Item32 Item36 Item38 Item40 Item42 Item46 Item48 Item52 Item54 #10 --.51 .28 .29 .24 .31 .31 .29 .47 .29 .32 #26 .51 --.20 .35 .31 .42 .37 .30 .50 .31 .32 #32 .28 .20 --.23 .49 .52 .47 .42 .37 .33 .34 #36 .29 .35 .23 --.45 .39 .37 .21 .54 .17 .28 #38 .24 .31 .49 .45 --.66 .44 .35 ..51 .29 .41 #40 .31 .42 .52 .39 .66 --.45 .45 .51 .47 .53 #42 .31 .37 .47 .37 .44 .45 --.33 .52 .36 .41 #46 .29 .30 .42 .21 .35 .45 .33 --.36 .30 .41 #48 .47 .50 .37 .54 .51 .51 .52 .36 --.26 .43 #52 .29 .31 .33 .19 .29 .47 .36 .30 .26 --.56 #54 .32 .32 .34 .28 .41 .53 .41 .41 .43 .56 ---

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Table G4 Descriptive Statistics of the Resulting 20 Items Awareness Items 9. I am aware of what thoughts are passing through my mind. 11. I am aware of thoughts Im having when my mood changes. 15. When talking with other people, I am aware 4.12 of their facial and body expressions. 17. When talking with other people, I am aware 3.86 of the emotions I am experiencing. 21. When I shower, I am aware of how the water is running over my body. 23. When I am startled, I notice what is going on inside my body. 25. Whenever my emotions change, I am conscious of them immediately. 27. When someone asks how I am feeling, I can identify my emotions easily. 51. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 55. When I walk outside, I am aware of smells or how the air feels against my face. 3.64 1.01 1 5 3.67 .96 1 5 3.48 .93 1 5 3.50 .82 1 5 3.01 .98 1 5 3.25 1.10 1 5 .82 2 5 .75 2 5 3.52 .80 1 5 Mean 4.13 SD .71 Min 2 Max 5

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Acceptance Items

Mean

SD .96

Min 1

Max 5

10. When I have a bad memory, I try to distract 3.00 myself to make it go away. 26. I try to distract myself when I feel unpleasant emotions. 32. There are aspects of myself I dont want to think about. 36. I try to put my problems out of mind. 38. There are things I try not to think about. 42. I try to stay busy to keep thoughts or feelings from coming to mind. 46. I wish I could control my emotions more easily. 48. If there is something I dont want to think about, Ill try many things to get it out of my mind. 52. I tell myself that I shouldnt feel sad. 54. I tell myself that I shouldnt have certain thoughts. 3.15 3.17 2.93 2.72 2.98 2.75 3.24 3.16 2.76

.79

1.15

.76 .88 .96

1 1 1

5 5 5

1.15

.89

.93 .98

1 1

5 5

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Table G5 Corrected Item-Subscale Correlations for Resulting 20 Items ______________________________________________________________________________ Corrected Item-Subscale Awareness Items 9. I am aware of what thoughts are passing through my mind. 11. I am aware of thoughts Im having when my mood changes. 15. When talking with other people, I am aware of their facial and body expressions. 17. When talking with other people, I am aware of the emotions I am experiencing. 21. When I shower, I am aware of how the water is running over my body. 23. When I am startled, I notice what is going on inside my body. 25. Whenever my emotions change, I am conscious of them immediately. 27. When someone asks how I am feeling, I can identify my emotions easily. 51. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 55. When I walk outside, I am aware of smells or how the air feels against my face. .50 .44 .50 .55 .52 .47 .60 Correlation .44 .48 .43

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______________________________________________________________________________ Corrected Item-Subscale Acceptance Items Correlation

10. When I have a bad memory, I try to distract myself to make it go away. .49 26. I try to distract myself when I feel unpleasant emotions. 32. There are aspects of myself I dont want to think about. 36. I try to put my problems out of mind. 38. There are things I try not to think about. 42. I try to stay busy to keep thoughts or feelings from coming to mind. 46. I wish I could control my emotions more easily. .53 .54 .47 .60 .61 .51

48. If there is something I dont want to think about, Ill try many things to .67 get out of my mind. 52. I tell myself that I shouldnt feel sad. 54. I tell myself that I shouldnt have certain thoughts. .49 .60

______________________________________________________________________________

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Table G6 Inter-item Correlations for the Resulting 20 Items
Item9 Item9 Item10 Item11 Item15 Item17 Item21 Item23 Item25 Item26 Item27 --.02 .35** .23** .34** .25** .27** .31** .05 .24** Item32 Item9 Item10 Item11 Item15 Item17 Item21 Item23 Item25 Item26 Item27 .08 .28** -.07 -.06 .05 .00 -.07 .02 .20** .12 Item32 Item32 Item36 Item38 Item42 Item46 Item48 Item51 Item52 Item54 Item55 --.23** .49** .47** .42** .37** -.18** .33** .34** .05 Item10 .02 ---.00 .03 -.01 .04 .08 .00 .51** .06 Item36 .08 .29** .02 .15* .09 .04 .08 .02 .35** .10 Item36 .23** --.45** .37** .21** .54** -.12 .17* .28** .05 Item11 .35** -.00 --.16* .40** .28** .37** .50** -.04 .32** Item38 .11 .24** .01 .00 .06 -.04 -.01 .05 .31** .13 Item38 .49** .45** --.44** .35** .51** -.34** .29** .41** -.01 Item15 .23** .03 .16* --.48** .25** .27** .16* -.08 .30** Item42 .19** .31** .19** .13 .13 .11 .06 .16* .37** .32** Item42 .47** .37** .44** --.33** .52** -.12 .36** .41** .18** Item17 .34** -.01 .40** .48** --.29** .34** .40** -.04 .45** Item46 .07 .29** -.02 -.03 .04 -.06 -.05 -.06 .30** .19** Item46 .42** .21** .35** .33** --.36** -.22** .30** .41** .03 Item21 .25** .04 .28** .25** .29** --.37** .29** -.07 .26** Item48 .11 .47** .02 .04 .03 .01 -.04 .01 .50** .09 Item48 .37** .54** .51** .52** .36** ---.27** .26** .43** .09 Item23 .27** .08 .37** .27** .34** .27** --.42** -.08 .27** Item51 .24** -.12 .21** .27** .32** .26** .40** .24** -.22** .16* Item51 -.18** -.12 -.34** -.12 -.22** -.27** ---.20** -.22** .34** Item25 .31** .00 .50** .16* .40** .29** .42** ---.09 .33** Item52 .13 .29** .02 -.03 .03 -.06 -.04 .01 .31** .11 Item52 .33** .17* .29** .36** .30** .26** -.20** --.56** .07 Item26 .05 .51** -.04 -.08 -.04 -.07 -.08 -.09 --.02 Item54 .05 .32** .14* -.10 -.01 .02 -.00 .09 .32** .14* Item54 .34** .28** .41** .41** .41** .43** -.22** .56** ---.05 Item27 .24** .06 .32** .30** .45** .26** .27** .33** .02 --Item55 .25** .02 .13 .30** .31** .47** .31** .26** -.07** .33** Item55 .05 .05 -.01 .18** .03 .09 .34** .07 -.05 ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

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Appendix H: Copies of Measures

114
PHLMS
Instructions: Please circle how often you experienced each of the following statements within the past week.
1. I am aware of what thoughts are passing through my mind. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

2. I try to distract myself when I feel unpleasant emotions. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

3. When talking with other people, I am aware of their facial and body expressions. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

4. There are aspects of myself I dont want to think about. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

5. When I shower, I am aware of how the water is running over my body. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

6. I try to stay busy to keep thoughts or feelings from coming to mind. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

7. When I am startled, I notice what is going on inside my body. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

8. I wish I could control my emotions more easily. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

9. When I walk outside, I am aware of smells or how the air feels against my face. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

10. I tell myself that I shouldnt have certain thoughts. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

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11. When someone asks how I am feeling, I can identify my emotions easily. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

12. There are things I try not to think about. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

13. I am aware of thoughts Im having when my mood changes. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

14. I tell myself that I shouldnt feel sad. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

17. Whenever my emotions change, I am conscious of them immediately. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

18. I try to put my problems out of mind. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

19. When talking with other people, I am aware of the emotions I am experiencing. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

20. When I have a bad memory, I try to distract myself to make it go away. 1 Never 2 Rarely 3 Sometimes 4 Often 5 Very Often

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MAAS Below is a collection of statements about your everyday experience. Using the 1-6 scale below, please indicate how frequently or infrequently you currently have each experience. Please answer according to what really reflects your experience rather than what you think your experience should be. 1 = almost always 2 = very frequently 3 = somewhat frequently 4 = somewhat infrequently 5 = very infrequently 6 = almost never _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ 1. I could be experiencing some emotion and not be conscious of it until some time later. 2. I break or spill things because of carelessness, not paying attention, or thinking of something else. 3. I find it difficult to stay focused on whats happening in the present. 4. I tend to walk quickly to get where Im going without paying attention to what I experience along the way. 5. I tend not to notice feelings of physical tension or discomfort until they really grab my attention. 6. I forget a persons name almost as soon as Ive been told it for the first time. 7. It seems I am running on automatic without much awareness of what Im doing. 8. I rush through activities without being really attentive to them. 9. I get so focused on the goal I want to achieve that I lose touch with what I am doing right now to get there. 10. I do jobs or tasks automatically, without being aware of what Im doing. 11. I find myself listening to someone with one ear, doing something else at the same time. 12. I drive places on automatic pilot and then wonder why I went there. 13. I find myself preoccupied with the future or the past. 14. I find myself doing things without paying attention. 15. I snack without being aware that Im eating.

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AAQ-R
Below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following scale to make your choice. 1-------------------2--------------------3----------------------4--------------------5-------------------6------------------7 never very seldom seldom sometimes frequently almost always always true true true true true true true _______ 1. _______ 2. _______ 3. _______ 4. _______ 5. _______ 6. _______ 7. _______ 8. _______ 9. I am able to take action on a problem even if I am uncertain what is the right thing to do. When I feel depressed or anxious, I am unable to take care of my responsibilities. I try to suppress thoughts and feelings that I dont like by just not thinking about them. Its OK to feel depressed or anxious. I rarely worry about getting my anxieties, worries, and feelings under control. In order for me to do something important, I have to have all my doubts worked out. Im not afraid of my feelings. I try hard to avoid feeling depressed or anxious. Anxiety is bad.

_______10. Despite doubts, I feel as though I can set a course in my life and then stick to it. _______11. If I could magically remove all the painful experiences Ive had in my life, I would do so. _______12. I am in control of my life. _______13. If I get bored of a task, I can still complete it. _______14. Worries can get in the way of my success. _______15. I should act according to my feelings at the time. _______16. If I promised to do something, Ill do it, even if I later dont feel like it.

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RRQ For each of the statements located on the next three pages, please indicate your level of agreement or disagreement by circling one of the scale categories below each statement. Use the scale as shown below. 1. My attention is often focused on aspects of myself I wish Id stop thinking about. 1 strongly disagree 2. 2 disagree 3 neutral 4 agree 5 strongly disagree

I always seem to be rehashing in my mind recent things Ive said or done. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

3.

Sometimes it is hard for me to shut off thoughts about myself. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

4.

Long after an argument or disagreement is over with, my thoughts keep going back to what happened. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

5.

I tend to ruminate or dwell over things that happen to me for a really long time afterward. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

6.

I dont waste time rethinking things that are over and done with. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

7.

Often Im playing back over in my mind how I acted in past situations. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

8.

I often find myself reevaluating something Ive done. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

9.

I never ruminate or dwell on myself for very long. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

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10. It is easy for me to put unwanted thoughts out of my mind. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

11. I often reflect on episodes in my life that I should no longer concern myself with. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

12. I spend a great deal of time thinking back over my embarrassing or disappointing moments. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

13. Philosophical or abstract thinking doesnt appeal to me that much. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

14. Im not really a meditative type of person. 1 strongly disagree 15. I love exploring my inner self. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

16. My attitudes and feelings about things fascinate me. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

17. I dont really care for introspective or self-reflective things. 1 strongly disagree 18. I love analyzing why I do things. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

19. People often say Im a deep, introspective type of person. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

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20. I dont care much for self-analysis. 1 strongly disagree 21. Im very self-inquisitive by nature. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

22. I love to meditate on the nature and meaning of things. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

23. I often love to look at my life in philosophical ways. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

24. Contemplating myself isnt my idea of fun. 1 strongly disagree 2 disagree 3 neutral 4 agree 5 strongly disagree

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FSS Psychologists have described times when people get very absorbed in an activity they're doing. They call this a "flow" experience. A flow experience occurs when you are totally involved in what you are doing, you are not aware of your surroundings, and time seems either to slow down or to pass by really quickly. You shut out the whole world because you are concentrating on the activity that you are doing. Your mind doesn't wander or think of anything but the activity that you are absorbed in. Please think back to such an experience that occurred within the past two weeks. Some people have these experiences often, while others rarely do. Do your best to identify some experience similar to what was described above, even if it is not exactly the same. Think about how you felt during the experience and answer the questions below using the rating scale. There are no right or wrong answers. Just circle the number that best matches your experience. Rating Scale: Strongly disagree 1 Disagree 2 Neither agree nor disagree 3 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 Agree 4 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 Strongly agree 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

1. I was challenged, but I believed my skills would allow me to meet the challenge. 2. I made the correct movements without thinking about trying to do so. 3. I knew clearly what I wanted to do. 4. It was really clear to me that I was doing well. 5. My attention was focused entirely on what I was doing. 6. I felt in total control of what I was doing. 7. I was not concerned with what others may have been thinking of me. 8. Time seem to alter (either slowed down or sped up). 9. I really enjoyed the experience. 10. My abilities matched the high challenge of of the situation. 11. Things just seemed to be happening automatically. 12. I had a strong sense of what I wanted to do. 13. I was aware of how well I was performing. 14. It was no effort to keep my mind on what was happening. 15. I felt like I could control what I was doing.

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16. I was not worried about my performance during the event. 17. The way time passed seemed to be different than normal. 18. I loved the feeling of that performance and want to capture it again. 19. I felt I was competent enough to meet the high demands of the situation. 20. I performed automatically. 21. I knew what I wanted to achieve. 22. I had a good idea while I was performing about how well I was doing. 23. I had total concentration. 24. I had a feeling of total control. 25. I was not concerned with how I was presenting myself. 26. It felt like time stopped while I was performing. 27. The experience left me feeling great. 28. The challenge and my skills were equally at a high level. 29. I did things spontaneously and automatically without having to think. 30. My goals were clearly defined. 31. I could tell by the way I was performing how well I was doing. 32. I was completely focused on the task at hand. 33. I felt in total control of my body. 34. I was not worried about what others may have been thinking of me. 35. At times, it almost seemed liked things were happening in slow motion. 36. I found the experience extremely rewarding. 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5

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WBSI This survey is about thoughts. There are no right or wrong answers, so please respond to each of the items below. Be sure to answer every item by circling the appropriate letter beside each. A = Strongly disagree B = Disagree C = Neutral or dont know D = Agree E = Strongly agree 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. There are things I prefer not to think about. Sometimes I wonder why I have the thoughts I do. I have thoughts that I cannot stop. There are images that come to mind that I cannot erase. My thoughts frequently return to one idea. I wish I could stop thinking of certain things. Sometimes my mind races so fast I wish I could stop it. I always try to put problems out of mind. There are thoughts that keep jumping into my head. There are things that I try not to think about. Sometimes I really wish I could stop thinking. I often do things to distract myself from my thoughts. I have thoughts that I try to avoid. There are many thoughts that I have that I dont tell anyone. Sometimes I stay busy just to keep thoughts from intruding on my mind. A A A A A A A A B B B A B B B A A A A B A A B B C C C B C C C B B B C B B C C D D D C D D D C C C D C C D D E E E D E E E D D D E D D E E E E E E E E

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M-C SDS

INSTRUCTIONS: Please respond to the following items using the scale below.
1. Before voting, I thoroughly investigate the qualification of all the candidates. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

2. I never hesitate to go out of my way to help someone in trouble. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

3. I have never intensely disliked anyone. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

4. It is sometimes hard for me to go on with my work if I am not encouraged. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

5. On occasion I have had doubts about my ability to succeed in life. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

6. I sometimes feel resentful when I dont get my way. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

7. I am always careful about my manner of dress. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

8. My table manners at home are as good as when I eat out in a restaurant. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

9. If I could get into a movie without paying and be sure I was not seen I would probably do it. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

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10. On a few occasions, I have given up doing something because I thought too little of my ability. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

11. I like to gossip at times. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

12. There have been times when I felt like rebelling against people in authority even though they were right. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

13. No matter who Im talking to, Im always a good listener. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

14. I can remember plying sick to get out of something. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

15. There have been occasions when I took advantage of someone. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

16. Im always willing to admit it when I make a mistake. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

17. I always try to practice what I preach. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

18. I dont find it particularly difficult to get along with loud mouthed, obnoxious people. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

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19. I sometimes try to get even rather than forgive and forget. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

20. When I dont know something I dont at all mind admitting it. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

21. I am always courteous, even to people who are disagreeable. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

22. At times I have really insisted on having things my own way. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

23. There have been occasions when I felt like smashing things. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

24. I would never think of letting someone else be punished for my wrongdoing. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

25. I never resent being asked to return a favor. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

26. I have never been irked when people expressed ideas very different from my own. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

27. I never make a long trip without checking the safety of my car. 1 2 3 4 5 Very Strongly Agree Neither Agree Disagree Very Strongly Agree nor Disagree Disagree 28. There have been times when I was quite jealous of the good fortune of others. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

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29. I have almost never felt the urge to tell someone off. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

30. I am sometimes irritated by people who ask favors of me. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

31. I have never felt that I was punished without cause. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

32. I sometimes think when people have a misfortune they only got what they deserved. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

33. I have never deliberately said something that hurt someones feelings. 1 Very Strongly Agree 2 Agree 3 Neither Agree nor Disagree 4 Disagree 5 Very Strongly Disagree

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Appendix I: Results from the Nonclinical Sample Analyses

Table I1 PHLMS Descriptive Statistics from the Nonclinical Sample Item 1. I am aware of what thoughts are passing through my mind. 2. I try to distract myself when I feel unpleasant 2.70 emotions. 3. When talking with other people, I am aware of their facial and body expressions. 4. There are aspects of myself I dont want to think about. 5. When I shower, I am aware of how the water 3.31 is running over my body. 6. I try to stay busy to keep thoughts or feelings 3.28 from coming to mind. 7. When I am startled, I notice what is going on 3.01 inside my body. 8. I wish I could control my emotions more easily. 9. When I walk outside, I am aware of smells or how the air feels against my face. 10. I tell myself that I shouldnt have certain thoughts. 3.23 .96 1 5 3.74 .94 1 5 2.97 1.09 1 5 1.02 1 5 .92 1 5 1.15 1 5 3.15 .93 1 5 4.22 .73 1 5 .84 1 5 Mean 4.29 SD .70 Min 1 Max 5

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11. When someone asks how I am feeling, I can identify my emotions easily. 12. There are things I try not to think about. 13. I am aware of thoughts Im having when my mood changes. 14. I tell myself that I shouldnt feel sad. 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 17. Whenever my emotions change, I am conscious of them immediately. 18. I try to put my problems out of mind. 19. When talking with other people, I am aware of the emotions I am experiencing. 20. When I have a bad memory, I try to distract 3.00 myself to make it go away. 1.05 1 5 2.95 3.63 .90 .83 1 1 5 5 3.44 .86 1 5 2.81 .95 1 5 3.16 3.72 .97 .89 1 1 5 5 2.93 3.66 .86 .78 1 1 5 5 3.63 .86 1 5

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Table I2 Factor Loadings for the PHLMS Acceptance Item 1. I am aware of what thoughts are passing through my mind. 2. I try to distract myself when I feel unpleasant emotions. 3. When talking with other people, I am aware of their facial and body expressions. 4. There are aspects of myself I dont want to think about. 5. When I shower, I am aware of how the water is running over my body. 6. I try to stay busy to keep thoughts or feelings from coming to mind. 7. When I am startled, I notice what is going on inside my body. 8. I wish I could control my emotions more easily. 9. When I walk outside, I am aware of smells or how the air feels against my face. 10. I tell myself that I shouldnt have certain thoughts. 11. When someone asks how I am feeling, I can identify my emotions easily. .152 .503 .653 .022 .561 -.036 -.016 .577 -.068 .502 .585 .016 -.012 .542 .593 .110 .063 .542 .602 -.004 Subscale .090 Awareness Subscale .512

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12. There are things I try not to think about. 13. I am aware of thoughts Im having when my mood changes. 14. I tell myself that I shouldnt feel sad. 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 17. Whenever my emotions change, I am conscious of them immediately. 18. I try to put my problems out of mind. 19. When talking with other people, I am aware of the emotions I am experiencing. 20. When I have a bad memory, I try to distract myself to make it go away. .513 -.070 .627 .050 .022 .673 -.008 .589 .692 -.092 .592 -.100 -.025 .565 .752 -.121 .049 .587

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Table I3 PHLMS Corrected Item-Subscale Correlations from the Nonclinical Sample Corrected Item-Subscale PHLMS Awareness Subscale Item 1. I am aware of what thoughts are passing through my mind. 3. When talking with other people, I am aware of their facial and body expressions. 5. When I shower, I am aware of how the water is running over my body. 7. When I am startled, I notice what is going on inside my body. 9. When I walk outside, I am aware of smells or how the air feels against my face. 11. When someone asks how I am feeling, I can identify my emotions easily. 13. I am aware of thoughts Im having when my mood changes. 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 17. Whenever my emotions change, I am conscious of them immediately. 19. When talking with other people, I am aware of the emotions I am experiencing. Corrected Item-Subscale PHLMS Acceptance Subscale Item 2. I try to distract myself when I feel unpleasant emotions. 4. There are aspects of myself I dont want to think about. 6. I try to stay busy to keep thoughts or feelings from coming to mind. 8. I wish I could control my emotions more easily. 10. I tell myself that I shouldnt have certain thoughts. Correlation .49 .47 .46 .45 .53 .43 .51 .34 .45 .44 .41 .38 .45 Correlation .36 .39

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12. There are things I try not to think about. 14. I tell myself that I shouldnt feel sad. 16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 18. I try to put my problems out of mind. 20. When I have a bad memory, I try to distract myself to make it go away .50 .40 .64 .48 .59

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Table I4 PHLMS Inter-item Correlations from the Nonclinical Sample
Item 1 Item1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 --.03 .23** .04 .20** -.04 .16** .04 .24** .02 Item11 Item1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 .22** -.07 .23** .11* .14** .04 .20** .05 .17** .06 Item11 Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20 --.03 .22** .09* .14** .01 .24** .14** .26** -.01 Item2 .03 ---.02 .25** .01 .35** -.08 .27** .02 .27** Item12 .06 .35** .01 .37** -.01 .40** .01 .35** -.09* .53** Item12 .03 ---.10* .36** -.08 .43** -.00 .42** .02 .33** Item3 .23** -.02 --.02 .21** .07 .15** -.07 .32** -.01 Item13 .24** -.11 .21** -.05 .27** -.07 .19** -.07 .17** -.10* Item13 .22** -.10* ---.17** .25** -.11* .37** -.07 .39** -.12** Item4 .04 .25** .02 ---.02 .31** -.00 .37** -.03 .37** Item14 -.01 .27** .01 .29** -.07 .23** -.06 .31** -.04 .34** Item14 .09* .36** -.17** ---.06 .34** -.04 .32** -.06 .30** Item5 .20** .01 .21** -.02 ---.03 .26** -.04 .34** -.06 Item15 .14** -.06 .19** -.04 .28** -.07 .33** -.09* .30** -.03 Item15 .14** -.08 .25** -.06 ---.18** .27** -.07 .30** -.10* Item6 -.04 .35** .07 .31** -.03 ---.11* .23** -.02 .26** Item16 -.02 .44** -.05 .28** -.06 .37** -.12** .29** -.14** .33** Item16 .01 .43** -.11* .34** -.18** ---.07 .42** -.03 .38** Item7 .16** -.08 .15** -.00 .26** -.11* ---.12** .25** -.04 Item17 .24** -.04 .22** .06 .17** -.04 .16** -.04 .19** -.03 Item17 .24** -.00 .37** -.04 .27** -.07 ---.09* .38** -.09* Item8 .04 .27** -.07 .37** -.04 .23** -.12** ---.03 .33** Item18 .03 .30** .03 .22** .00 .31** -.05 .23** -.02 .30** Item18 .14** .42** -.07 .32** -.07 .42** -.09* ---.06 .31** Item9 .24** .02 .32** -.03 .34** -.02 .25** -.03 ---.06 Item19 .24** .01 .29** .08 .24** .01 .24** -.02 .27** -.02 Item19 .26** .02 .39** -.06 .30** -.03 .38** -.06 ---.04 Item10 .02 .27** -.01 .37** -.06 .26** -.04 .33** -.06 --Item20 -.01 .29** .00 .19** -.03 .17** -.05 .18** -.09 .25** Item20 -.01 .33** -.12** .23** -.10* .38** -.09* .31** -.04 ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

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Table I5 Convergent Validity: Correlations of the PHLMS With Other Measures from the Nonclinical Sample Correlation with Measure AAQ Acceptance MAAS WBSI FSS RRQ Reflection RRQ Rumination PHLMS Awareness PHLMS Acceptance Note. *p < .01, **p < .001 PHLMS Acceptance .54** .32** -.52** .10 -.02 -.40** -.10 -Correlation with PHLMS Awareness .10 .21** -.03 .21** .36** -.02 --.10 Correlation with PHLMS Total .50** .40** -.43** .23** .23** -.33** .60** .74**

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Table I6 Correlations of the PHLMS with Measures of Psychopathology Before and After Controlling for Other Constructs in a Nonclinical Sample PHLMS Total Well-Being variable BDI (depression) BAI (anxiety) Zero-order correlation -.34** -.25** PHLMS Acceptance Well-Being Variable BDI (depression) BAI (anxiety) Zero-order correlation -.35** -.33** PHLMS Acceptance Subscale controlling for: social desirability -.33** -.32** AAQ Acceptance -.25** -.26** WBSI -.17** -.19** PHLMS Total controlling for: social desirability -.30** -.23**

PHLMS Awareness Well-Being variable BDI (depression) BAI (anxiety) Zero-order correlation -.08 .03 PHLMS Awareness Subscale controlling for: social desirability -.05 .04 MAAS (awareness) .01 .09 FSS -.02 .06

Note. *p < .01; **p < .001

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Appendix J: Results from the Clinical Sample Analyses

Table J1 Total Number of Clinical Participants Diagnosed With Each Disorder Disorder Mood Disorders Bipolar I Disorder Depressive Disorder NOS Major Depressive Disorder Major Depressive Disorder with psychotic features Mood Disorder NOS Premenstrual Dysphoric Disorder Anxiety Disorders Anxiety Disorder NOS Generalized Anxiety Disorder Obsessive Compulsive Disorder Panic Disorder with Agoraphobia Posttraumatic Stress Disorder Specific Phobia Psychotic Disorders Psychosis NOS Schizoaffective Disorder Schizophrenia Adjustment Disorders Adjustment Disorder with depression 1 2.1% 2 2 2 4.2% 4.2% 4.2% 3 1 2 2 5 1 6.3% 2.1% 4.2% 4.2% 10.4% 2.1% 5 7 16 3 6 1 10.4% 14.6% 33.3% 6.3% 12.5% 2.1 Frequency Percentage

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Adjustment Disorder with mixed anxiety & depression Substance Disorders Alcohol Dependence Alcohol Dependence in Full Sustained Remission Alcohol Abuse Cannabis dependence Cocaine dependence Cocaine dependence in early Full Remission Opiate Dependence Opiate dependence in Full Sustained Remission Polysubstance dependence Polysubstance in Early Full Remission Polysubstance dependence Full Sustained Remission Substance Abuse in Remission Impulse-Control Disorders Impulse Control D/O NOS Intermittent Explosive D/O Other Attention Deficit/Hyperactivity Disorder Bereavement Pain Disorder Partner Relational Problem 1 1 1 1 2.1% 2.1% 2.1% 2.1% 1 1 2.1% 2.1% 4 1 1 1 2 1 2 1 1 1 1 1 8.7% 2.1% 2.1% 2.1% 4.2% 2.1% 4.2% 2.1% 2.1% 2.1% 2.1% 2.1% 1 2.1%

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Table J2 Descriptive Statistics for the PHLMS from the Clinical Sample Mean 1. I am aware of what thoughts are passing through my mind. 2. I try to distract myself when I feel unpleasant 2.50 emotions. 3. When talking with other people, I am aware of their facial and body expressions. 4. There are aspects of myself I dont want to think about. 5. When I shower, I am aware of how the water 3.62 is running over my body. 6. I try to stay busy to keep thoughts or feelings 2.46 from coming to mind. 7. When I am startled, I notice what is going on 3.36 inside my body. 8. I wish I could control my emotions more. easily. 9. When I walk outside, I am aware of smells or how the air feels against my face. 10. I tell myself that I shouldnt have certain thoughts. 11. When someone asks how I am feeling, I can identify my emotions easily. 3.33 1.02 1 5 2.71 1.05 1 5 3.62 .97 2 5 2.08 .95 1 4 .99 1 5 .90 1 4 1.19 1 5 2.46 1.04 1 5 3.87 .97 2 5 .96 1 5 3.70 SD .94 Min 1 Max 5

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12. There are things I try not to think about. 13. I am aware of thoughts Im having when my mood changes. 14. I tell myself that I shouldnt feel sad. 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 17. Whenever my emotions change, I am conscious of them immediately. 18. I try to put my problems out of mind. 19. When talking with other people, I am aware of the emotions I am experiencing. 20. When I have a bad memory, I try to distract 2.27 myself to make it go away. .89 1 4 2.54 3.42 1.06 .83 1 2 5 5 3.21 1.02 1 5 2.46 .94 1 5 2.92 3.52 1.13 .96 1 1 5 5 2.21 3.46 .91 .83 1 2 4 5

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Table J3 PHLMS Corrected Item-Subscale Correlations from the Clinical Sample Corrected Item-Subscale PHLMS Awareness Subscale Item 1. I am aware of what thoughts are passing through my mind. 3. When talking with other people, I am aware of their facial and body expressions. 5. When I shower, I am aware of how the water is running over my body. 7. When I am startled, I notice what is going on inside my body. 9. When I walk outside, I am aware of smells or how the air feels against my face. 11. When someone asks how I am feeling, I can identify my emotions easily. 13. I am aware of thoughts Im having when my mood changes. 15. I notice changes inside my body, like my heart beating faster or my muscles getting tense. 17. Whenever my emotions change, I am conscious of them immediately. 19. When talking with other people, I am aware of the emotions I am experiencing. .51 .49 .57 .62 .10 .27 .50 .45 Correlation .42 .25

Corrected Item-Subscale PHLMS Acceptance Subscale Item 2. I try to distract myself when I feel unpleasant emotions. 4. There are aspects of myself I dont want to think about. 6. I try to stay busy to keep thoughts or feelings from coming to mind. 8. I wish I could control my emotions more easily. Correlation .27 .27 .34 .60

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10. I tell myself that I shouldnt have certain thoughts. 12. There are things I try not to think about. 14. I tell myself that I shouldnt feel sad. 16. If there is something I dont want to think about, Ill try many things to get it out of my mind. 18. I try to put my problems out of mind. 20. When I have a bad memory, I try to distract myself to make it go away .43 .35 .44 .65 .23 .64

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Table J4 PHLMS Inter-item Correlations in the Clinical Sample
Item1 Item1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 ---.29* .28 .00 .20 .04 .33* .16 .03 -.03 Item11 Item1 Item2 Item3 Item4 Item5 Item6 Item7 Item8 Item9 Item10 .43** .03 .20 .08 .38** -.21 .34* .08 .23 .05 Item11 Item11 Item12 Item13 Item14 Item15 Item16 Item17 Item18 Item19 Item20 --.11 .28* -.05 -.06 -.02 .48** .12 .55** .03 Item2 -.29* ---.20 -.04 .34* .09 -.07 .30* .13 .17 Item12 .28* .37** -.100 .27 .22 .31* .10 .57** -.02 .39** Item12 .11 ---.24 .17 .07 .48** -.11 .41** .04 .24 Item3 .28* -.20 --.10 .07 -.11 .19 .01 .24 -.10 Item13 .33* -.32* .18 -.03 .08 -.21 .34* -.25 .49** -.32* Item13 .28* -.24 ---.07 .33* -.38** .60** -.07 .48** -.252 Item4 .00 -.04 .10 ---.25 .08 -.18 .34* -.17 .16 Item14 -.09 -.04 -.15 .21 -.10 .15 .09 .12 -.03 .16 Item14 -.05 .17 -.07 --.13 .07 .17 .20 -.03 .18 Item5 .20 .34* .07 -.25 ---.03 .27 -.04 .31* .10 Item15 .13 -.12 -.11 -.01 .01 .20 .04 -.15 .03 -.16 Item15 -.06 .07 .33* .13 ---.29* .21 .07 .04 -.21 Item6 .04 .09 -.11 .08 -.03 ---.17 .17 -.09 .29* Item16 .09 .37** .01 .16 .07 .44** -.14 .49** -.08 .51** Item16 -.02 .48** -.38** .07 -.29* ---.27* .32* -.08 .37** Item7 .33* -.07 .19 -.18 .27 -.17 ---.10 .43** .00 Item17 .21 -.21 .07 .13 .05 -.30* .32* -.28* .22 .00 Item17 .48** -.11 .60** .17 .21 -.27* ---.017 .48** -.26 Item8 .16 .30* .01 .34* -.04 .17 -.10 ---.20 .34* Item18 .12 .17 .17 .31* .17 .06 .00 .33* -.06 .07 Item18 .12 .41** -.07 .20 .07 .32* -.017 ---.09 .34* Item9 .03 .13 .24 -.17 .31* -.09 .43** -.20 ---.19 Item19 .24 .05 .20 .20 -.01 -.11 .23 .11 .33* -.04 Item19 .55** .04 .48** -.03 .04 -.08 .48** -.09 ---.37** Item10 -.03 .17 -.10 .16 .10 .29* .00 .34* -.19 --Item20 .12 .09 -.07 -.14 .08 .21 -.03 .35* -.13 .17 Item20 .03 .24 -.25 .18 -.21 .37** -.26 .34* -.37** ---

Note. **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed).

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Table J5 Convergent Validity: Correlations of the PHLMS With Other Measures in the Clinical Sample Correlation with Measure AAQ Acceptance MAAS WBSI (thought suppression) FSS (flow) RRQ Reflection RRQ Rumination PHLMS Awareness PHLMS Acceptance Note. *p < .01, **p < .001 PHLMS Acceptance .31 .17 -.35 .28 -.07 -.43* -.13 -Correlation with PHLMS Awareness .07 .40* -.16 .41* .27 -.05 --.13 Correlation with PHLMS Total .29 .43* -.39* .52** .16 -.37* .65** .67**

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Table J6 Correlations of the PHLMS with Measures of Psychopathology Before and After Controlling for Other Constructs in a Clinical Sample PHLMS Total Well-Being variable BDI-II (depression) BAI (anxiety) Zero-order correlation -.41* -.42* PHLMS Acceptance Well-Being variable BDI-II (depression) BAI (anxiety) Zero-order correlation -.28 -.29 PHLMS Awareness Well-Being variable BDI-II (depression) BAI (anxiety) Note. *p < .01 Zero-order correlation -.25 -.27 PHLMS Awareness Subscale controlling for: social desirability -.20 -.21 MAAS (awareness) -.07 -.13 FSS -.03 -.02 PHLMS Acceptance Subscale controlling for: social desirability -.22 -.22 AAQ Acceptance -.19 -.19 WBSI -.15 -.17 PHLMS Total Score controlling for: social desirability -.34 -.34

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Appendix K: An Acceptance-Based Model of Social Anxiety Disorder

Social Situation

Predisposition (genetic and/or learned)

Physiological arousal & Cognitions related to social evaluation

Increased awareness of cognitions and physiological arousal (self-focused attention)

Experiential control/ avoidance Low levels of acceptance

Behavioral disruption

147 Vita

LEEANN CARDACIOTTO EDUCATION

2000 - 2005 1996 - 2000 Drexel University, Philadelphia, PA (formerly MCP Hahnemann University) Candidate for Doctorate in Clinical Psychology, received September 2005 Masters of Arts in Clinical Psychology, received August 2002 Franklin & Marshall College, Lancaster, PA; GPA: 3.71 Bachelor of Arts in Psychology, Minor in Sociology, received May 2000 Magna Cum Laude, Honors in Psychology

SELECTED RESEARCH EXPERIENCE

2000 - 2005 2001 - 2004 2002 - 2003 Anxiety Research & Treatment Program Drexel University, Philadelphia, PA Friend to Friend Program, Childrens Hospital of Philadelphia, Philadelphia, PA Parent-Child Project, Childrens Hospital of Philadelphia, Philadelphia, PA

SELECTED CLINICAL EXPERIENCE

2004 - 2005 2000 - 2004 2003 - 2004 2002 - 2003 2001 - 2002 2001 - 2002 Psychological Intern, Long Island Jewish Medical Center, Glen Oaks, NY Anxiety Research & Treatment Program, Drexel University, Philadelphia, PA Student Counseling Center, Drexel University, Philadelphia, PA Outpatient Psychiatry, Drexel University College of Medicine, Philadelphia, PA ADHD Clinic, Childrens Hospital of Philadelphia, Philadelphia, PA Lindens Neurobehavioral Program, Bancroft NeuroHealth, Haddonfield, NJ

SELECTED TEACHING EXPERIENCE

2004 - 2004 2003 - 2003 2004 - 2004 Course Instructor: Positive Psychology,Drexel University Course Instructor: General Psychology, Drexel University Course Instructor: General Psychology, Drexel University

SELECTED PUBLICATIONS AND PRESENTATIONS

Herbert, J.D., & Cardaciotto, L. (in press). A Mindfulness-Based Perspective for Social Anxiety Disorder. Chapter to appear in S. Orsillo & L. Roemer (Eds.), Acceptance and Mindfulness-Based Approaches to Anxiety: Conceptualization and Treatment (Kluwer/Penum). Cardaciotto, L. & Herbert, J. D. (2004). Cognitive behavior therapy for social anxiety disorder in the context of Aspergers Syndrome: A single-subject report. Cognitive & Behavioral Practice, 11, 75-81. Wilkins, V. M., Cardaciotto, L., & Platek, S. M. (2003). Uncertain what uncertainty monitoring monitors. Behavioral & Brain Sciences, 26(3), 356. Cardaciotto, L., & Herbert, J. D. (2005, November). The Development of a Bi-Dimensional Measure of Mindfulness: The Philadelphia Mindfulness Scale (PHLMS). In J. D. Herbert & L. Cardaciotto (chairs), The Conceptualization and Assessment of Mindfulness. Symposium accepted for presentation at the annual meeting of ABCT, Washington, D.C. Cardaciotto, L., Herbert, J. D., Gaudiano, B. A., Nolan, E. M., & Dalrymple, K. L. (2002, November). Treating social anxiety disorder with cognitive behavior therapy in the context of Aspergers syndrome: A single-subject report. Poster presented at the annual meeting of the Association for the Advancement of Behavior Therapy, Reno, NV. Autism SIG Annual Student Research Award, Association for the Advancement of Behavior Therapy, 2002 Phi Beta Kappa, Franklin & Marshall College, 2000 Psi Chi (National Honor Society in Psychology), Franklin & Marshall College, 1998-2000

SELECTED HONORS, DISTINCTIONS, AND AWARDS