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Eric Smernoff, PhD,1 Inbal Mitnik, MA,1 Ken Kolodner, ScD,2 and Shahar Lev-ari, PhD1#

Objectives: The Work is a meditative technique that

enables the identication and investigation of thoughts that
cause an individual stress and suffering. Its core is comprised
of four questions and turnarounds that enable the participant
to experience a different interpretation of reality. We assessed
the effect of The Work meditation on quality of life and
psychological symptoms in a non-clinical sample.
Design: This study was designed as a single-group pilot
clinical trial (open label). Participants (n 197) enrolled in
a nine-day training course (The School for The Work) and
completed a set of self-administered measures on three
occasions: before the course (n 197), after the course
(n 164), and six months after course completion (n 102).
Outcome Measures: Beck Depression Inventory-II (BDI-II),
Subjective Happiness Scale (SHS), Quality of Life Inventory
(QOLI), Quick Inventory of Depressive Symptomatology-Self
Report (QIDS-SR16), Outcome Questionnaire 45.2 (OQ45.2), StateTrait Anger Expression Inventory-2 (STAXI-2),
and StateTrait Anxiety Inventory (STAI).

Mental disorders, in particular depression and anxiety, are
associated with impairment in physical, social, and role
functioning, as well as in health-related quality of life. They
are also associated with increased prevalence of chronic
diseases and increased mortality and morbidity, such as in
coronary heart diseases.13 Mental disorders account for 13%
of the global disease burden, and their economic effect is

1 Center of Complementary and Integrative Medicine, Institute of

Oncology at Tel-Aviv Sourasky Medical Center, Sackler Faculty of
Medicine, Tel-Aviv University, 6 Weizmann St., Tel-Aviv 64239,
2 Department of Psychiatry and Behavioral Sciences, The Johns
Hopkins School of Medicine, Baltimore, MD
The Work Foundation, a non-prot 501 organization, partially
supported this study. The Work Foundation was not involved at
any stage of data collection, interpretation of results, or the writing of
this article.
# Corresponding author.


& 2015 Elsevier Inc. All rights reserved.

ISSN 1550-8307/$36.00

Results: A mixed models analysis revealed signicant positive changes between baseline compared to the end of the
intervention and six-month follow-up in all measures: BDI-II
(t 10.24, P o .0001), SHS (t 9.07, P o.0001), QOLI
(t 5.69, P o .0001), QIDS-SR16 (t 9.35, P o .0001),
OQ-45.2 (t 11.74, P o .0001), STAXI-2 (State) (t 3.69,
P .0003), STAXI-2 (Trait) (t 7.8, P o .0001), STAI (State)
(t 11.46, P o .0001), and STAI (Trait) (t 10.75,
P o .0001).
Conclusions: The promising results of this pilot study
warrant randomized clinical trials to validate The Work
meditation technique as an effective intervention for
improvement in psychological state and quality of life in
the general population.
Key words: The Work, meditation, psychological symptoms, quality of life
(Explore 2015; 11:24-31 & 2015 Elsevier Inc. All rights reserved.)

signicant.4 A survey held in the US between 2001 and 2003

revealed that mental disorders are highly prevalent in the
general population.5 It found that anxiety disorders were the
most common and that mood disorders were the next most
common but had the highest proportion of serious cases.5
There are various kinds of interventions aimed at improving mental state and quality of life, such as medication,
psychotherapy, physical activity, and others.1,6 The past few
decades have witnessed a growing interest in the therapeutic
efcacy of mindbody interventions. These interventions are
dened by the National Center for Complementary and
Alternative Medicine as a variety of techniques aimed to
strengthen the awareness of and affect bodily functions and
symptoms. The common tools for treatment include meditation, prayer, yoga, guided imagination, and art therapy.7
The practice of meditation has become increasingly popular
and has gained acceptance among clinicians, researchers, and
the public. Reports in the scientic literature demonstrated
the effects of meditation practices on mental health
(emotional distress, depression, anxiety, etc.),8,9 as well as
on medical conditions (cardiovascular and metabolic disorders, pain syndromes, etc.).10,11 Meditation was the rst

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mindbody intervention to be widely adopted by mainstream

healthcare and incorporated into therapeutic programs in the
United States and other countries.12 Despite a lack of
consensus regarding its denition, most researchers agree
that meditation is a form of mental training, striving to
reach a state of detached observation in terms of full
awareness of the current moment without cognitive
The Work meditation technique was developed by Byron
Katie in 1986. It is based on identifying and investigating the
thoughts that cause stress and suffering. The basic assumption is
that when we believe our thoughts, we suffer, and when we do
not believe, we do not suffer. This technique does not require
any intellectual, religious, or spiritual preparation but rather a
will to deepen the level of self-awareness. The rst part of the
technique is to identify stressful thoughts in a systematic and
comprehensive way and write down the thoughts about various
situations that are perceived as stressful. The second part is a
meditative investigation of the stressful thoughts by a series of
four questions and turnarounds, which enable the participant
to experience a different interpretation of the perceived reality.13,14 The technique incorporates Deliberative thinking,
which occurs when one is consciously and intentionally
thinking about something, and Witnessing awareness, which
occurs when one observes what arises in his awareness without
trying to control or think about it.15,16 Like other psychological
models, such as Cognitive Behavioral Therapy (CBT), The
Work technique assumes that feelings (such as sadness, anger,
and pain) emerge from an attachment to a stressful thought,
which leads to behavior. This means that thought precedes
feelings and behavior and should be focused on as the primal
cause of stress and suffering. However, unlike cognitive restructuring that encourages an individual to use deliberative thinking
to answer questions, The Work uses it only for asking
questions and relies on one's witnessing awareness to listen
for a response to arise naturally from within.15 The activated
internal mental process of The Work is qualitatively different
from classical CBT as the inner wisdom associated with a
meditative state of mind is addressed rather than the
rationality.17 This process produces an essentially different
experience as its discoveries feel as an emotional insight.17
This may address the problem frequently encountered in CBT
where a client might report that he knows that the negative
thought is not true, but he nevertheless feels that it is.13,14
Additional differences from CBT relate to The Work inquiry
format of the four questions and turnarounds, which encourages an emotional perspective and limits the cognitions
inuence and credibility (e.g., Yes/No questions).18
It is estimated that The Work has been practiced by
hundreds of thousands of people in more than 30 countries.13
Several clinical trials have been initiated to assess the effect of
The Work intervention on psychological and physical
symptoms and quality of life of breast cancer survivors
(observational study NCT01244087)19 and of BRCA1/BRCA2
mutation carriers (randomized clinical trial NCT01367639).20
The current study is a preliminary investigation of the
effectiveness of The Work in a non-clinical sample of
individuals who enrolled in the techniques workshop. It

The Effects of The Work Meditation

assesses the effectiveness of the technique on participants

psychological symptoms and quality of life using wellestablished standardized assessments.

The sample included individuals self-enrolled in a nine-day
workshop entitled The School for The Work at Los Angeles,
CA, USA, in November 2008. All the participants signed an
informed consent form prior to enrollment in the research study.
Due to the samples characteristics, minimal exclusion criteria of
ability to read English at a ninth grade level or higher (as judged
by successful completion of a battery of self-reported measures)
and willing to sign an informed consent were employed.
Data Collection
Each participant was assigned a number that was used on all
test materials in order to ensure condentiality. All the subjects
lled in seven self-administered questionnaires on three occasions: at the beginning of the training course (T1), at the
completion of the training course (T2), and at six months after
completing the training course (T3). The forms were returned
by mail at T3. The research staff was available at all times to
answer questions. Questionnaires were scored according to the
standard procedures of each instruments instruction manual.
Intervention Method
The participants attended a nine-day workshop guided by
Byron Katie and assisted by a staff of facilitators who were
trained in the authorized certication program at The
Institute of the Work (ITW), an international learning
center13 based in the USA. All sessions followed the
guidelines of the training manual that was developed in
order to maintain consistency in the program. This manual
is based on the instructions of Judge-your-neighbor (JYN)
worksheet (Appendix 1) and the inquiry technique detailed in
Loving what is.14 The subjects received a training manual to
serve as a guideline for performing the various forms of the
inquiry practice.
During the sessions, the participants were encouraged to explore
their stressful thoughts using The Work technique, which is based
on identifying and investigating the thoughts that cause distress and
suffering. This process is divided into two parts. The rst part is to
identify the stressful thoughts in a systematic and comprehensive way
and to write down the thoughts about various situations perceived
by the person as being stressful.
JYN worksheet is the main tool for systematically identifying
stressful thoughts in The Work technique.
The participant is instructed to think of a reoccurring stressful
situation, a situation that is reliably stressful even though it may
have only happened once and reoccurs only in your mind. Before
answering each of the questions below, allow yourselves to mentally
revisit the time and place of the stressful occurrence. The participant
then writes down all the thoughts and beliefs regarding the stressful
situation as he/she perceives them according to the worksheet

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In the second part, the participant, with or without the help

of a facilitator (a person with experience in The Work
technique), chooses the most stressful thought and investigates
it by four questions and turnarounds. Examples of stressful
thoughts are My husband doesnt listen to me, My boss
should appreciate me, and My body is too fat. The participant
then examines the selected thoughts by asking the following
questions: (1) Is it true? (2) Can I absolutely know that it is true?
(3) How do I react when I believe that thought? (4) Who would
I be without the thought? This part is meditative, and the
participant is guided to search the true and genuine answers to
the four questions with no xed agenda. Unlike deliberate
thinking in which a person consciously and deliberately thinks
about something and experiences it as if he/she created the
thought, the participant is guided to be aware of the thoughts
that come into his/her mind without trying to control or direct
them. He/She perceives himself/herself as a witness, apart from
these thoughts. Encouraging this kind of meditative ability is a
central part of The Work technique.1315
The next stage is the implementation of the turnarounds,
in which the participant experiences a different interpretation
of the reality as he/she perceives it. If the original thought was
My husband doesnt listen to me, a possible turnaround can
be I dont listen to my husband (turnaround to the other), I
dont listen to myself (turnaround to myself), or My
husband does listen to me (turnaround to the opposite).
The participant is asked to nd three genuine examples in
which the turnaround is as true as the original thought. By
doing so, the participant can understand and experience that
he/she does not have to automatically believe the thoughts
that cause stress and frustration but can choose to replace
them by other thoughts and different interpretations of
reality. By doing so, situations perceived as stressful (such as
a visit to the doctor) can become less threatening.13,14
Beck Depression Inventory-II (BDI-II) measures the level of
depressive symptoms reported by respondents, with higher
numbers indicating higher levels of depression: a score of 013
indicates minimal level of depression, 1419 mild depression,
2028 moderate depression, and 2963 severe depression.21
Quick Inventory of Depressive Symptomatology-Self Report
(QIDS-SR16) measures self-reported depressive symptoms.
Higher numbers indicate higher levels of depression.22,23
StateTrait Anger Expression Inventory (STAXI) (State)
assesses the intensity of anger as an emotional state at a
particular snapshot in time. Higher scores indicate higher
levels of anger. The mean score is 18.75 for normal adults and
23.38 for the psychiatric population. The STAXI-2 (Trait)
measures the respondents more enduring disposition to
experience anger as a personality trait. Higher scores indicate
more proclivities for anger. The mean score is 18.14 for
normal adults and 19.96 for psychiatric population.24
StateTrait Anxiety Inventory (STAI) Form measures anxiety in adults. It differentiates between State Anxiety and longstanding qualities of Trait Anxiety. Higher scores indicate
higher levels of anxiety for both measures. The mean score is
37.2 for the normal adult population for State Anxiety and
36.79 for Trait Anxiety.25


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The Quality of Life Inventory (QOLI) measures the overall

positive mental health and satisfaction with life. Higher
numbers indicate a better quality of life. An average score on
this measure ranges from 1.6 to 3.5, and a clinically signicant
change is denoted by a score that is either 2 standard deviations
higher than a dysfunctional clinical mean or 1 standard
deviation higher than a functional non-clinical mean.26,27
Subjective Happiness Scale (SHS) is a self-report measurement of happiness. Higher scores indicate higher levels of
happiness: the highest possible score is 7, and an average score
Outcome Questionnaire 45.2 (OQ-45.2) is a 45-item selfreport instrument, encompassing multidimensional measures
of key functional and symptomatic areas. The broad areas
assessed are symptom distress, interpersonal relations, and
social role (dissatisfaction and distress in tasks related to work,
family roles, and leisure life). This questionnaire was designed
for repeated measurements of clients progress through
therapy and has demonstrated sensitivity to change following
behavioral treatments. Higher scores indicate higher levels of
distress. A score over 63 indicates levels of distress higher than
normal. A 14-point change in either direction is signicant.29
Data Analysis
Analysis was carried out by an independent statistician using
the SAS analysis Version 9.2. A total of 463 surveys were
entered into a database, and composite scores were formed for
all of the measures of well-being/outcome measures.
To assess possible bias in the results due to missing data, we
compared those who were assessed at the end of the intervention and were followed at six months post-intervention to
those who were missing at both follow-up time points. We used
t-tests to compare continuous measures (all outcome measures
and age) for those who had at least one follow-up measure (n
168) to those with no follow-up data (n 29). No differences
were observed for any variable. We used chi-squares to compare
categorical demographic variables (gender and collapsed versions of marital status and occupation). Again, no differences
were observed. These data are not presented.
To assess changes in outcomes from baseline to follow-up,
we used mixed models (SAS PROC MIXED). A time effect
was used to model statistical differences between the baseline
(T1) and follow-up periods (T2 and T3) and to contrast the
two follow-up periods. No statistical changes were observed
from T2 (immediate post-intervention) to T3 (six-month
follow-up) for all measures. The time effect was completely
limited to T1 versus the two follow-up periods. Thus, we also
compared time 2 and time 3 as a single phase and compared
this phase to the baseline for all measures. Finally, we again
used mixed models with change scores (time 1 minus time
2; time 1 minus time 3). All methods yielded uniform results.
To ensure the appropriateness of our analysis, we plotted
distributions for all measures and changed scores. For most
variables, scale values and change scores generally approximated a normal distribution with skewness and kurtosis below
1. For the values that were not normal, transformations
succeeded in normalizing the data. Results did not differ on
transformed and untransformed data. Thus, we only present
the results on the original (untransformed) data.

The Effects of The Work Meditation

All 197 participants who were initially recruited to this study
completed the initial surveys (T1), 164 completed the surveys
immediately after the intervention (T2), and 102 completed
the surveys at the six-month follow-up after the intervention
(T3). Table 1 provides the demographic characteristics of the
participants. A total of 168 subjects completed one of the two
follow-ups. Overall, 68% were females (mean age 48.27
9.05 years) and 31% were males (mean age 46.83 12.28
years). Most of the participants were married, employed full
time, and had a college degree.
Mixed models revealed a signicant positive change in all
measures when comparing the baseline to T2 and T3
(Table 2). There were no differences in any measures from

Table 1. Demographic
(n 197)





No. (%a) or Mean (SD)

Age (years)

134 (68.37%)
62 (31.63%)

48.27 (9.05)
46.83 (12.28)

Marital status

55 (32.16%)
59 (34.50%)
41 (23.98%)
13 (7.6%)
3 (1.75%)

Employment status
Full time
Part time

73 (42.20%)
12 (6.94%)
68 (39.31%)
6 (3.47%)
14 (8.09%)

Education level
o12 Years
Good enough diplomab
High school
1315 Years
Bachelor's degree
Master's degree
Doctorate degree

1 (0.54%)
9 (4.86%)
32 (17.30%)
74 (40%)
47 (25.41%)
22 (11.89%)

SD, standard deviation.

Percentages are based on valid (non-missing) observations.
Awarded to high school dropouts who passed an examination.

The Effects of The Work Meditation

T2 to T3. To simplify our analysis, we also performed our

analysis on change scores using a phase average of T2 and T3
(as described in the data analysis section). The results were
consistent when using change scores (T1 minus T2; T1 minus
T3) or actual values.
Depression levels decreased signicantly from the mildly
depressed category at T1 to no depression at T2 and T3.
Anxiety levels improved signicantly after the intervention,
and the values were below the norm for adult population.
The follow-up analysis of the three measures revealed a
persistent post-intervention change.
Both Anger State and Anger Trait scores decreased signicantly after the intervention, and this effect persisted six
months after the intervention. These levels fell below the
normal range. Quality of Life improved signicantly as
demonstrated in the overall positive mental health scores
both at T2 and T3. Happiness levels increased signicantly
after the intervention, reaching the higher end of the average
range. In the Outcome Questionnaire (OQ-45.2), there was a
signicant positive change in self-esteem, relationships with
others, and efciency in carrying out life tasks at T2 and T3.
Of the original 197 people whose data were collected for
baseline measurement (T1), 164 people also lled out the
questionnaires at the completion of the program (T2), and
102 lled them out six months post-intervention (follow-up
phase, T2). This represents dropout rates of 16.75% for the
intervention phase and additional 37.8% for the follow-up
phase. The sampling failures at follow-up (T3) may be
partially the result of the high processing time of the
questionnaire. Another factor leading to high dropout could
have been caused by the fact that the third measurement was
conducted via a postal survey; thus, high postage costs could
have been a deterrent. The attendance and dropout rates of
the current study are similar to those reported in previous
studies regarding non-pharmacological group interventions
for cancer patients such as psycho-social groups, support
groups, physical activity, yoga, and meditation (1050%).30,31

This pilot study assessed the effectiveness of The Work
intervention in a non-clinical sample, and its preliminary
results indicated a signicant improvement in psychological
state and quality of life after the intervention, as measured by
a range of well-established psychometric assessment tools.
This effect lasted six months after the intervention. The
selected sample represents a non-clinical cohort with depression scores within the normal range according to Becks
depression scale.21 Likewise, the StateTrait Anger scores24
and the Subjective Happiness Scale28 were not signicantly
different from the published norms. The Quality of Life
scales further conrmed that this cohort was mentally healthy
and relatively satised with their lives.32 Levels of Trait
Anxiety, which were higher than the normal population,23
decreased signicantly after the intervention, and this effect
persisted for six months after it.

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Table 2. Comparison of Outcomes for the Baseline Versus Post-Intervention (n 197) Using Mixed Models
Before Intervention (T1) After Intervention (T2) After Six Months (T3)
Mean (SD)
Mean (SD)
Mean (SD)
t Valuea
Beck Depression Inventory (BDI)
11.89 (10.42)
4.01 (5.16)
3.86 (5.29)
10.24 o.0001
Subjective Happiness Scale (SHS)
4.71 (1.37)
5.49 (1.18)
5.50 (1.21)
9.07 o.0001
Quality of Life Inventory (QOLI)
1.95 (1.1.73)
2.89 (1.17)
2.67 (1.27)
5.69 o.0001
Quick Inventory of Depressive
7.30 (4.76)
4.28 (2.90)
3.73 (2.66)
9.35 o.0001
Symptomatology-Self Report (QIDS-SR)
Outcome Questionnaire (OQ)
61.17 (24.46)
41.52 (20.58)
41.47 (22.00)
11.74 o.0001
StateTrait Anger Expression InventoryState
18.48 (5.63)
16.40 (4.28)
16.36 (4.70)
3.69 0.0003
StateTrait Anger Expression InventoryTrait
18.13 (5.53)
15.36 (4.07)
14.64 (3.78)
7.80 o.0001
StateTrait Anxiety ScaleState (STAI)
40.29 (13.05)
27.69 (8.53)
31.23 (11.28)
11.46 o.0001
StateTrait Anxiety ScaleTrait (STAI)
42.22 (11.67)
34.37 (10.88)
33.10 (10.60)
10.75 o.0001
SD, standard deviation.
The t value represents a contrast using mixed models of the baseline versus the pooled phase average of both follow-up time periods.

Trait anxiety had previously been considered a stable

personality trait,25,33,34 but recent studies have shown that it
may be reduced by various interventions, including mind
body interventions.3537 Konefal and Duncan38 demonstrated
signicant reductions in trait anxiety after a 21-day training
course in Neuro-Linguistic-Programming. These reductions
were correlated with signicant increases in internal locus of
control scores. The current study did not measure locus of
control; however, this concept can be demonstrated in a key
tenet of The Work, according to which individuals take
responsibility for their own life by the active process of
meditatively questioning stressful thoughts.38
Scores of subjective happiness increased signicantly after
the intervention, and this increase persisted six months,
indicating that the change remained stable over time. These
ndings are similar to other studies that found a positive
effect of meditation on the subjective happiness of participants.39,40 A study by Davidson et al.41 demonstrated that
meditation was associated with greater activation of the left
prefrontal cortex, which is an area of the brain associated with
positive emotional experience. Schiffrin and Nelson42
examined the relationship between happiness and perceived
stress and revealed an inverse relationship between the two
measures: individuals with higher levels of perceived stress
reported being less happy than those with lower levels.
Reduction of perceived stress has been found to be
correlated to the practice of meditation in several studies.43,44
There are several limitations to this non-randomized pilot
study on a convenience sample. First, selection bias may limit the
possibility of generalizing the results to other populations and
may overestimate the benets of the intervention. In addition,
the current sample included a majority of high-educated individuals, which may further limit the generalization ability.
Second, there was no control group nor was there any randomization. Third, the dropout rate of respondents by the nal


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six-month follow-up reduced the available measures and could

produce bias in the results. However, mixed models showed that
there was no time effect between the assessments at the end of
the intervention compared to the six-month follow-up. That is,
there is no evidence of decay in the effects from the assessment at
the end of the intervention to the six-month follow-up. Further,
no baseline differences for any variable were observed for those
lost to follow-up (no follow-up assessments) compared to those
with at least one follow-up assessment. As a nal precaution to
guard against bias, we also performed a sensitivity analysis where
all subjects who were without a follow-up measurement were
assigned a baseline value for one follow-up period. Following an
intent-to-treat philosophy, this assumes no change for all those
subjects who are without follow-up data. Repeating the mixed
models analyses, the level of statistical signicance was attenuated
(as expected), but the results were still statistically signicant for
all outcomes. Fourth, while the intervention mainly focuses on
teaching and practicing The Work technique, the program
includes several other activities and provides the opportunity to
meet a range of people, forge friendships, hold informal
discussions, and take a break from daily routines. As such, we
are limited in inferring the extent to which the process of The
Work techniques was the mechanism of change as opposed to a
combination of all these various elements.
In conclusion, this pilot study presents preliminary ndings
on potentially benecial effects in a non-clinical sample following The Work intervention. Randomized clinical studies with a
control group are warranted in order to further examine the
effectiveness of the intervention in the general population. Its
effectiveness in a clinical population comprised of individuals
experiencing more severe levels of distress, such as people with
major depression, should also be investigated.


The Effects of The Work Meditation

The Effects of The Work Meditation

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