Mindfulness (2010) 1:215–226
DOI 10.1007/s12671-010-0030-5
ORIGINAL PAPER
Benefits of a 12-Week Mindfulness Group Program
for Mental Health Consumers in an Outpatient Setting
Georgie Paulik & Andrea Simcocks & Layla Weiss &
Steven Albert
Published online: 16 October 2010
# Springer Science+Business Media, LLC 2010
Abstract Stress has been shown to increase the risk of
development and relapse of mental illness, having a
detrimental effect on human physiology, psychology and
emotional well-being. Mindfulness-based techniques have
been shown to be effective in reducing levels of stress, as
well as anxiety and depression in both clinical and non-
clinical populations. The reported benefits of mindfulness-
based interventions are numerous, and in the past few
decades, several therapeutic interventions have been devel-
oped to incorporate mindfulness as a key component in the
treatment of a range of medical and psychological dis-
orders. In our study, we proposed that the integration of
three evidence-based mindfulness interventions would
result in an effective program to reduce stress, depression
and anxiety in a mixed clinical population, in a community
health setting. A group-based mindfulness program,
attended by seven participants, was piloted and the data
collected at baseline (pre-program), post-program and 12-
month follow-up were compared. Post-program results
showed that participants’ levels of depression, anxiety and
stress were significantly reduced, perceived ability to cope
increased, and that gains made were largely sustained at 12-
G. Paulik (*)
South East Sydney Illawarra Area Health NSW,
Bondi Junction Community Health Centre,
26 Llandaff Street, Bondi Junction,
Sydney, NSW, Australia 2026
e-mail: georgiepaulik@graduate.uwa.edu.au
G. Paulik
School of Psychiatry, University of South Wales,
Sydney, NSW, Australia
A. Simcocks : L. Weiss : S. Albert
South East Sydney Illawara Area Health NSW,
Sydney, NSW, Australia
month follow-up. These results add to the current research
showing the effectiveness of mindfulness for reducing
stress, anxiety and depression in both clinical and non-
clinical populations. Our study provides preliminary sup-
port for the amalgamation of Mindfulness-Based Stress
Reduction, Mindfulness-Based Cognitive Therapy and
Dialectical Behaviour Therapy in order to effectively meet
the needs of a mixed diagnostic group.
Keywords Mindfulness . Stress . Depression . Anxiety .
Community mental health . Mental illness . Coping
Introduction
It is well known that stress invokes an automatic effect on
the autonomic nervous system, and has a detrimental effect
on human physiology, psychology and emotional well-
being. If the stress response is chronically activated, it
increases the risk of development and relapse of depression,
anxiety and other mental illnesses. Psychological distress
has a major impact on people’s ability to work, study, and
manage their day-to-day activities. The Australian Institute
of Health and Welfare’s report The Burden of Disease and
Injury in Australia 2003 describes mental illness as a
leading cause of non-fatal disease burden in Australia—
mental disorders accounted for 13% of the total disease
burden in Australia, and 24% of the non-fatal burden
(Australian Institute of Health and Welfare 2008). Anxiety
and depression, alcohol abuse, and personality disorders
dominate the burden of mental disorders (Begg et al. 2007).
Alarmingly, the World Health Organisation estimates that
depression will be the number one cause of disability in
both the developed and developing worlds by 2030 (World
Health Organisation 2008).
216
Mindfulness has been defined as “the awareness that
emerges through paying attention on purpose, in the present
moment, and non-judgmentally to the unfolding of experi-
ence moment to moment” (Kabat-Zinn 2003, p.145).
Mindfulness is cultivated through several forms of medita-
tion derived from Buddhist meditative practises, whereby
thoughts, emotions, sensations and perceptions are ob-
served as mental events without any further elaboration,
judgment, pursuit or rejection (Kabat-Zinn 1990), and
without the intervention of habitual patterns of cognitive
and behavioural reactions (Bishop et al. 2004; Miller et al.
1995). Although mindfulness interventions may result in
relaxation, and the cognitive effects may be mediated in
part by a reduction in physiological arousal (Wenk-Sormaz
2005), they are not designed as relaxation or mood
management techniques. Instead, mindfulness interventions
are a form of mental training in non-judgemental observa-
tion of current conditions such as autonomic arousal,
muscle tension, habitual thought patterns and cognitive
reactivity (Baer 2003).
The reported benefits of mindfulness-based interventions
are numerous, and in the past few decades, several
therapeutic interventions have been developed to incorpo-
rate mindfulness as a key component in the treatment of a
range of medical and psychological disorders. In a review
of the outcome literature on mindfulness-based interven-
tions, Baer (2003) reports that mindfulness interventions
have led to reductions in a variety of problematic
conditions, including pain, stress, anxiety, depressive
relapse, and disordered eating.
The Mindfulness-Based Stress Reduction (MBSR) pro-
gram was the first mindfulness-based group program to
apply mindful acceptance to assist people with managing
stress and promoting mental wellness. However, several
other evidence-based therapeutic approaches have fol-
lowed, including Mindfulness-Based Cognitive Therapy
(MBCT; Segal et al. 2002), Dialectical Behaviour Therapy
(DBT; Linehan 1993), and Acceptance and Commitment
Therapy (ACT; Hayes et al. 2004), all of which also
balance acceptance and change as key themes. A brief
review of MBSR, MBCT and DBT will follow, as the
mindfulness-based intervention evaluated in our pilot study
was based around these three key approaches. ACT was not
integrated into our mindfulness-based program since it is a
more recent intervention and consequently had less empir-
ical evidence supporting its use in clinical populations at
the time our program was designed.
MBSR, the founding mindfulness-based group program,
was established by Jon Kabat-Zinn in 1979 as an outpatient
program delivered to medical patients with chronic pain,
stress-related conditions and other chronic medical con-
ditions (Miller et al. 1995; Saxe et al. 2001). MBSR aims to
assist patients in gaining a greater understanding of their
Mindfulness (2010) 1:215–226
mind/body connection, and provides a means by which
patients can participate more fully in their own healing
process and gain greater insight into, and control over, their
distress (Bishop et al. 2004; Kabat-Zinn 2000, 2003).
MBSR has been shown to be effective in improving
symptoms for people with anxiety (Kutz et al. 1985; Miller
et al. 1995), personality disorders (Kutz et al. 1985) and
mood disorders (Ramel et al. 2004). MBSR was chosen as
one of the core components of our mindfulness-based
intervention because of its demonstrated effectiveness in
healing a range of presenting problems and client groups.
MBSR is also the mindfulness-based intervention on which
MBCT was founded, and thus, we felt it important to keep
these overlapping elements true to their original form (as
practised in MBSR).
MBCT (Segal et al. 2002) is a recently developed,
structured 8-week program that aims to prevent relapse of
depressive disorders. Blending mindfulness techniques
from MBSR with cognitive therapy for depression, MBCT
aims to assist patients to become aware that thoughts are
merely passing mental events, not facts. In turn, this
heightens the patient’s awareness of unhelpful thinking
patterns and prevents negative ruminations from “snow-
balling”. Current research shows that MBCT is effective in
preventing relapse where people have experienced three or
more depressive episodes (Teasdale et al. 2000, 1995). A
key feature of MBCT is the Relapse Prevention Action
Plan. In our pilot study, we incorporated relapse prevention
as a feature of the program. In keeping with our mixed-
diagnoses target population, the Relapse Prevention Action
Plan was adapted to suit a range of psychiatric diagnoses,
and presented as a “Mindfulness Action Plan”. MBCT
differs from MBSR by including education about depres-
sion, relapse prevention, and the relationship between
thoughts and feelings. Unlike MBSR, MBCT has the
additional goal of further preventing unhelpful thinking
patterns by providing a ‘freedom from the tendency to get
drawn into automatic reactions to thoughts, feelings, and
events’ (Segal et al. 2002, p. 122). We felt that these unique
features of MBCT would make a valuable contribution to
our mindfulness-based intervention, especially since we
anticipated that depression would be a common presenting
problem among our participants (based on attendance at
previous group programs offered at the Centre and, more
broadly, community mental health demographics).
DBT is a psychotherapy that combines dialectics,
cognitive behavioural therapy (CBT) and Buddhist princi-
ples (including Mindfulness, Acceptance and Change) that
was developed specifically for the treatment of borderline
personality disorder (BPD) by Marsha Linehan (1993).
Mindfulness skills are a key component of the DBT
program, with “Core Mindfulness” presented as one of the
four modules of the 12-month group program (the other
Mindfulness (2010) 1:215–226
modules being Interpersonal Effectiveness, Emotion Regu-
lation and Distress Tolerance). Mindfulness skills are
employed to help people increase their awareness of their
body sensations, thoughts and emotions with less emotional
reactivity. While MBSR and MBCT include both formal
(e.g. body scan, sitting meditation, and walking mediation)
and informal (e.g. mindfulness of daily living, such as
mindful eating, cleaning etc.) mindfulness practises, the
DBT model acknowledges that the extensive meditation
practise required under the MBSR model may be unattrac-
tive or unrealistic for some participants. DBT does not
define how often mindfulness practise should occur, but
includes some specific, brief everyday/informal practises
that can be used by anyone, anywhere, at anytime, making
it a particularly user-friendly approach. Furthermore, the
DBT approach to mindfulness was chosen for this program
due to the accessible presentation of mindfulness for clients
who have difficulty with understanding abstract concepts.
Linehan has effectively operationalised mindfulness, pre-
senting it as a series of easy-to-understand skills, namely
the “What” (Observe, Describe, and Participate) and “How”
(Non-judgementally, One-Mindfully and Effectively) skills.
DBT has been shown to be effective at helping people to
manage overwhelming emotions and tolerating distress
without losing control or acting destructively (e.g. deliber-
ate self-harm; Linehan et al. 1991). It has also recently been
conceptualized as a useful treatment for a wider range of
difficult-to-treat clients with symptoms similar to those of
BPD (Linehan et al. 2007). A further key element of the
DBT program included in the current study is the concept
of Radical Acceptance (derived from both eastern and Zen
practises and western contemplative spirituality), which
encourages letting go of fighting reality, and accepting
one’s situation as it is. When considering the objectives of
this group program, it was envisaged that the target
audience would include consumers of the mental health
service experiencing Axis II disorders, specifically those
who were either on a waiting list for the service’s existing
DBT program (for individuals with a diagnosis of BPD) or
those who did not meet entry criteria but were assessed as
requiring support. To this end, Radical Acceptance was
emphasised as an integral part of the program.
In the mental health arena, mindfulness techniques are
best known for decreasing stress (Kabat-Zinn 1990;
Schreiner and Malcolm 2008), which is strongly associated
with the development and relapse of mental illness.
Furthermore, there is evidence that shows mindfulness-
based techniques are also effective in decreasing symptoms
of anxiety (Bogels et al. 2006; Kabat-Zinn et al. 1992),
depression (Teasdale et al. 1995), bipolar affective disorder
(Miklowitz et al. 2009; Williams et al. 2008), psychosis
(Chadwick et al. 2005; Davis et al. 2007), binge eating
(Kristeller and Hallett 1999), attention-deficit hyperactivity
217
disorder (Zylowska et al. 2008), substance abuse (Brewer et
al. 2009), and suicidal behaviour (Williams et al. 2006). In
the subsequent section, we present some of the evidence for
mindfulness-based interventions in the treatment of several
different mental health disorders. The disorders that will be
examined were chosen based on the diagnoses of the
participants who took part in our mindfulness program.
Mindfulness Training and Psychosis
Only a few studies have investigated the effectiveness of
mindfulness-based interventions in patients with psychosis,
although favourable outcomes were observed in each.
Chadwick et al. (2005) investigated the use of mindfulness
techniques in helping people with chronic psychosis reduce
the distress associated with their positive symptoms. Their
mindfulness program specifically aimed to enable partic-
ipants to establish an accepting and neutral relationship to
their psychotic sensations so they no longer react to them
with fear and negativity. Compared to patients receiving
treatment-as-usual (TAU), the study found that the patients
attending a mindfulness group had improved clinical
functioning (namely, improved self-rated well-being, psy-
chotic symptoms, life functioning and risk—as measured
by the Clinical Outcomes in Routine Evaluation). In
another recent study, mindfulness was observed to be
successful in alleviating stress for individuals with schizo-
phrenia (Davis et al. 2007). Although this was a prelimi-
nary study with a small sample size, the findings were
positive, with participants reporting improved coping and a
reduction in stress.
Mindfulness Training and Depression
Teasdale et al. (1995) suggest that the nonjudgmental view
of one’s thoughts encouraged by mindfulness training may
interfere with ruminative patterns characteristic of depres-
sive episodes. Through acceptance-based approaches,
patients are said to learn that avoidance of experience is not
necessary in order to feel better. Mindfulness is thought to
inhibit ruminative thinking because it switches patients away
from the judgments, evaluations and striving typical of goal-
based thinking and might explain why it reduces the risk of
relapse in recurrent major depression (Teasdale et al. 2000).
MBCT was first developed to recognise and interrupt
automatic negative cognitions and minimise relapse for
clients in remission who had previously had three or more
episodes of major depressive disorder (Teasdale et al.
2000). In a number of clinical trials, MBCT has reduced
the relapse rate of depression by approximately half in
clients who have experienced recurrent depression, com-
pared to those receiving TAU (e.g. Teasdale et al. 2000).
MBCT has not only been found to reduce relapse, but also
218
reduce symptom severity in depression. Finucane and
Mercer (2006) found that following an 8-week MBCT
course, 72% of patients with active depression and anxiety
in primary care showed clinically significant improvements
on the Beck Depression Inventory. Adolescent psychiatric
outpatients have also been found to benefit from mindful-
ness training; Ree and Craigie (2007) reported on the
outcomes of an 8-week MBSR course versus TAU in
adolescent psychiatric outpatients and found that the
prevalence of a mood disorder in the MBSR group was
half of the prevalence in the TAU group. Sleep quality was
also significantly improved in the MBSR group.
Mindfulness Training and Bipolar Affective Disorder
Mindfulness has also been shown to be beneficial in the
treatment of bipolar affective disorder (BPAD). Miklowitz et
al. (2009) examined the benefits associated with an 8-week
MBCT program for BPAD patients who were between
episodes. Reductions were observed in depressive symptoms
and suicidal ideation, and to a lesser extent, manic symptoms
and anxiety. Miklowitz et al. (2009) suggest that MBCT is a
promising treatment alternative for BPAD, particularly for
managing sub-syndromal depressive symptoms, and recom-
mend further study exploring its cost-effectiveness and relapse
prevention potential. Williams et al. (2008) also explored the
effectiveness of MBCT for patients with a diagnosis of
BPAD. Their results show significant benefit of MBCT in
reducing anxiety and depression in this population. They
acknowledge that this is a preliminary study and recommend
further research on the application of MBCT to BPAD.
Mindfulness Training and Anxiety
A number of studies have investigated the effectiveness of
mindfulness for people with anxiety. According to Segal et
al. (2002), mindfulness practises enable clients to disengage
from habitual negative thought patterns (e.g. worry and
rumination) that can reinforce negative emotions. By
learning to attend to their thoughts and physiological
sensations in a non-judgemental and objective way, panic
reactions to their symptoms reduce.
Initial research into this area by Kabat-Zinn et al. (1992)
showed promising results. In their study, 22 people with
generalised anxiety disorder (GAD) or panic disorder
completed the 8-week mindfulness meditation-based stress
reduction group program. Of the 22 that participated in the
study, 20 had significantly reduced self-reported levels of
anxiety and depression at the end of the program. At 3-
month and 3-year follow-up, these gains were maintained,
as long as participants continued ongoing mindfulness
practise (Miller et al. 1995). Other more recent studies
Mindfulness (2010) 1:215–226
have also supported the benefits of mindfulness training to
reduce symptoms of anxiety in both clinical and non-
clinical populations. These include a randomised control
trial of 53 patients with social phobia (Koszycki et al.
2007), a study of 23 adults with GAD (Craigie et al. 2008),
a study of 26 psychiatric outpatients with mood or anxiety
disorders (Ree and Craigie 2007), a study of 50 non-clinical
participants (Schreiner and Malcolm 2008), a study of 102
adolescent psychiatric outpatients (Biegel et al. 2009), and
a study looking at reducing symptoms of anxiety in five
subjects with schizophrenia (Davis et al. 2007). All of these
studies reported reductions in anxiety due to participation in
a mindfulness-based intervention.
Aims of the Current Study
As reviewed, mindfulness-based interventions have shown
promise in effectively treating a range of mental health
concerns, as well as reducing distress and improving
quality of life in healthy individuals. However, the study
of mindfulness-based interventions is still in its infancy, and
most of the studies to date using a mental health sample
have set strict inclusion and exclusion criteria. Thus, it
remains unknown whether a mindfulness approach will
translate to a naturalistic outpatient setting with outcomes
equally as good. In this study, we aim to add to this important
body of work by bridging this gap in the outcome literature.
The objectives of our study were to develop an
individualised mindfulness-based stress management and
relapse prevention program for a mixed clinical community
mental health population by integrating elements of
mindfulness-based programs which had been shown to be
effective for specific diagnostic populations (MBSR,
MBCT, and DBT). We aimed to implement this
mindfulness-based program in a community mental health
setting to assist participants in developing their own
Mindfulness Action Plan, in order to prevent relapse of
their mental illness and increase their resilience. We
hypothesised that our program would assist participants in
reducing levels of depression, anxiety and stress and
expected to see an increase in their perceived ability to cope
with stress and better manage their symptoms, thus replicating
and extending on the findings of Schreiner and Malcolm’s
2008 study—the findings of which supported the efficacy of
mindfulness-based intervention in a healthy community
sample in our mixed clinical community sample.
Our study is unique in that it was in a naturalistic setting,
with a mixed group of community patients, without
exclusion. The program was also unique in that we
integrated three evidence-based approaches (MBSR,
MBCT, and DBT) in an attempt to better meet the needs
of a diverse mental health population.
Mindfulness (2010) 1:215–226
Method
Participants
Information on the mindfulness group program was
distributed to government and non-government mental
health services located in Sydney Eastern suburbs, inviting
referrals to the program. There were no exclusion criteria.
Twelve individuals agreed to participate. Seven out of 12
participants ‘graduated’ (with the minimum attendance
requirement being eight out of the 12 sessions), with four
of those not meeting the attendance criteria dropping out
prior to completion (drop-out rate of ~33%). The diagnoses
of the participants who did not complete the program were
schizoaffective disorder, schizophrenia, BPAD, drug-
induced psychosis and BPD. With the exception of the
participant with BPD, this spread of diagnoses was similar
to the group that did complete the program: three had a
diagnosis of BPAD (one of whom had a co-morbid
diagnosis of obsessive–compulsive disorder), two had a
diagnosis of schizoaffective disorder, and two had a
diagnosis of schizophrenia. Of the seven participants who
completed the program, four were male and three were
female; three were taking a mood stabiliser, four were
taking atypical antipsychotics, one was taking a typical
antipsychotic, two were taking antidepressants, and two
were not taking any medications; all were Caucasian-
Australian; all participants’ main source of income was a
government benefit (disability support pension or NewStart),
and the mean level of education was 10.57 years (SD=1.40).
As is often typical in a community mental health setting,
there was a large spread of ages, with participants ranging
from 23 to 64 years of age (mean=42.57, SD=13.25). The
participants who did not complete the program did not differ
significantly from those that did complete the program on
any of these demographic or clinical variables, including pre-
program Depression Anxiety Stress Scales (DASS) and
coping scores (p>.05). All seven participants completed the
outcome measures at 12-month follow-up.
Measures
The DASS (Lovibond and Lovibond 1995) was adminis-
tered to obtain state measures of depression, anxiety, and
stress (stress, as measured by the DASS, is characterised by
persistent tension, irritability, and frustration). The DASS
has 42 items, each of which the participants are requested to
rate how much the statement applied to them over the past
week using a four-point scale (0=did not apply to me at all,
to 3=applied to me very much, or most of the time),
yielding a scale score range of 0–126. The DASS scales
have excellent internal consistency and good discriminant
219
and convergent validity (Brown et al. 1997; Lovibond and
Lovibond 1995).
A short questionnaire was developed by the clinicians to
assess coping, and was administered pre-program, post-
program and at 12-month follow-up. This measure asked
participants to identify their personal goals for attending the
group, rate their overall ability to cope on a ten-point scale
(with 1 representing “Terrible” and 10 being “Very Good”),
and identify three “unhelpful” and three “helpful” strategies
that they are currently using to manage their stress. The
unhelpful and helpful strategies were then grouped accord-
ing to their nature.
Procedure
‘Stress Less with Mindfulness’ is primarily based on Kabat-
Zinn’s (1990) MBSR program. The “Core Mindfulness”
module from the DBT program (Linehan 1993) has also
been integrated into our program. Linehan’s concept of
mindfulness includes a framework with tangible and
practical step-by-step ways to achieve this mind state. The
main concepts used from Linehan’s model were ‘How’ and
‘What’ skills, ‘Three Mind States’ and ‘Radical Accep-
tance’. Due to the varying cognitive abilities of our client
population in the Community Health Centre, it was thought
that they would benefit from the concrete framework that
Linehan provides. Our program also draws from MBCT for
depression (Segal et al. 2002), where relapse prevention is
an essential component of the program. Due to the different
diagnoses of our population, we included education about
stress and its relationship to mental illness (rather than
depression), specifically, its role as a risk factor in relapse
of illness. The cognitive model was also included from
MBCT, including increasing awareness and de-centring our
relationship with thoughts, feelings and sensations. This is
an important strategy for increasing resilience and stress
management for our mixed population.
The 12-week course consisted of weekly 2-h classes.
The program was conducted by two staff, an Occupational
Therapist and Psychologist, from the ESMHS Rehabilita-
tion Team. Each class began with a mindfulness practise of
between 5 and 15 min, followed by debriefing discussion.
Each session would then include discussion about key
concepts of mindfulness and stress, role play activities,
small group exercises, and a second mindfulness practise. It
is theorised that the development of effective mindfulness
skills is dependent on regular and purposeful practise
(Segal et al. 2002). Thus, each week, homework relating
to that week’s session content was given to participants,
including practical mindfulness exercises. This homework
was also forwarded to participants’ primary clinician (eg.
case manager), where possible, to reinforce the practise of
220 Mindfulness (2010) 1:215–226

skills. Each session began with a review of the previous
week’s content and their weekly practise engagement. The
structure of the program, and the content covered in each
session, is outlined briefly in Table 1.
All participants were given the DASS and the question-
naire on coping strategies to complete at the beginning of
the first group session (pre), at the end of the last group
session (post), and at the beginning of the 12-month follow-
up group session.
Results
Since we had insufficient power to perform repeated
measure ANOVAs due to the modest group size, a series
of three paired-sample t tests were used to compare
participants’ pre-program vs. post-program, pre-program
vs. follow-up, and post-program vs. follow-up scores on the
affective and coping measures. Scatter plots of participants’
scores on the four key measures (DASS-depression, DASS-
anxiety, DASS-stress and coping) were examined to ensure
statistical assumptions were not violated and effects were
not likely the product of outliers (these scores are presented
in a line graph in Fig. 1). For significant effects, effect sizes
were calculated using Cohen’s d, corrected using Morris
and DeShon’s (2002) equation eight (used for repeated
measures designs).
Affective Measures
Depression Paired-sample t test computed for the DASS-
depression scores revealed that participants self-reported
significantly lower levels of depression following both the
completion of the mindfulness group (t(6)=3.44, p=.014,
Cohen’s d=1.30) and at 12-month follow-up (t(6)=3.58,
p=.012, Cohen’s d=1.36) compared to pre-intervention
scores, and there was no significant difference between
their ratings of depression at post-program and at 12-month
follow-up (t(6)=0.23, p=.827; see Table 2 for means and
standard deviations). According to the recommended
diagnostic guideline (Lovibond and Lovibond 1995), six
of the seven participants moved from a more severe range
of depression at pre-program to a less severe range at post-

Table 1 Content and structure

of the 12-week ‘Stress Less with
Mindfulness’ program
Week 1: Introduction and orientation
Baseline (pre-test) measures completed
Week 2: What is stress?
Psycho-education on stress (“fight or flight response”, relationship between stress and mental
illness, identifying individual’s stress responses and triggers)
Week 3: Self-care and kindness to self strategies
Introduction to Mindfulness and relationship to stress
Introduction to the cognitive model
Week 4: Mindfulness: Mind states
Three (3) primary states of mind (Emotion, Rational, and Wise Mind)
Week 5: Taking hold of your mind
“WHAT” skills of mindfulness: 1. Observe 2. Describe
Week 6: Mindfulness “WHAT” skills (continued)
3. “Participate”
Week 7: Taking hold of your mind
“HOW” skills: 1. Non-judgementally 2. One-mindfully 3. Effectively
Week 8: Radical acceptance
Week 9: Problem solving:
Steps of problem solving, individualised problem solving plans
Week 10: Mindfulness and Thoughts/Cognitive Therapy:
Relationship between thinking and mood/stress/illness; separating our interpretations from
events; thoughts are not facts; mindfulness of thoughts; learning to let thoughts go
Week 11: Mindfulness Action Plan (MAP)—a mindfulness approach to relapse prevention:
Relationship between stress and relapse
Identifying early warning signs
How I know when I’m getting off track
Strategies to help prevent getting off track
Strategies for coping when I’m off track
Week 12: Closure and Evaluation (post-test measures completed)
Mindfulness (2010) 1:215–226 221

a b
40
45 35

DASS - Anxiety scores

40
DASS - Depression score
30
35
30 25

25 20
20 15
15
10
10
5 5
0 0
Pre Post F/U Pre Post F/U

c d
45 12
40
DASS - Stress scores

10
35
30 8

Coping
25
6
20
15 4
10
2
5
0 0
Pre Post F/U Pre Post F/U

Fig. 1 Line graph showing individual participant scores on the a DASS-Depression scores, b DASS-Anxiety scores, c DASS-Stress score and d
coping scores (N=7)

program, with the other one participant moving from the
upper end of the mild range (score=12) to the lower end of
the moderate range (score=15; see Table 3). Four partic-
ipants moved from a more severe range of depression at
post-program to a less severe range at 12-month follow-up,
two stayed in the same range (normal), and the other
returned back to the same range they began the group in
(extremely severe).
Anxiety Paired-sample t test computed for the DASS-
anxiety scores revealed that participants self-reported
significantly lower levels of anxiety at the completion of
the mindfulness group than prior to the group (t(6)=3.99,
p=.007, Cohen’s d=1.80), and there was no significant
difference between post-program anxiety scores and follow-
up anxiety scores (t(6)=0.75, p=.480). Although overall
anxiety ratings were lower at 12-month follow-up than
prior to commencing the program, this effect was not
significant (t(6)=2.16, p=.074). Group means and standard
deviations are provided in Table 2. According to the
recommended diagnostic guideline (Lovibond and Lovibond
1995), five of the seven participants moved from a more
severe range of anxiety to a less severe range, with the other
two participants remaining in the same range (normal), but
both still dropping in scores (see Table 3). At follow-up, one
participant had moved from a more severe range of anxiety

Table 2 Means and standard deviations (SD) for the participants before the program (pre), at program completion (post) and at 1-year follow-up
(N=7)

Pre Post Follow-up

Mean SD Mean SD Mean SD

DASS-Depression 57.71 24.04 24.57 21.84 13.71 13.35

DASS-Anxiety 38.29 24.99 14.57 15.95 10.57 10.94
DASS-Stress 26.57 13.00 11.43 9.73 16.14 12.65
Coping 2.86 1.46 7.14 2.34 5.29 2.93
222 Mindfulness (2010) 1:215–226

Table 3 Number of participants obtaining scores falling in the different severity ranges on the DASS (as identified by Lovibond and Lovibond
1995) before the program (pre), at program completion (post) and at 1-year follow-up (F/U; N=7)

Depression Anxiety Stress

Pre Post F/U Pre Post F/U Pre Post F/U

Normal 0 3 3 2 4 3 1 4 4
Mild 1 0 1 0 1 1 1 1 0
Moderate 1 2 2 1 1 1 1 1 2
Severe 1 2 0 0 1 0 2 1 0
Extremely severe 4 0 1 4 0 2 2 0 1

at post-program to a less severe range, four stayed in the and of the two that moved into a more severe range of stress,
same range (three in normal, one in moderate), and the other one scored in a range that was still less severe than when they
two returned back to the same range they began the group in began the group (moderate) while the other returned back to
(extremely severe). the same range they began the group in (extremely severe).

Stress Paired-sample t-test computed for the DASS-stress

scores revealed that participants self-reported significantly
lower levels of stress at the completion of the mindfulness
group than prior to the group (t(6)=3.83, p=.009, Cohen’s
d=1.51), and there was no significant difference between
post-program stress scores and follow-up stress scores
(t(6)=1.05, p=. 332). Although overall stress ratings were
lower at 12-month follow-up than prior to commencing the
program, this effect only reached significance at the p=0.10
level (t(6)=2.33, p=.059). Group means and standard
deviations are provided in Table 2. According to the
recommended diagnostic guideline (Lovibond and Lovibond
1995), six of the seven participants moved from a more
severe range of stress to a less severe range, with the other
one participant falling in the normal range at both pre- and
post-program (see Table 3). At follow-up, one participant had
moved from a more severe range of stress at post-program to
a less severe range, four stayed in the same range (normal),
Coping Strategies
Overall ability to cope was assessed by the question ‘how
would you rate your ability to cope’ on a ten-point scale,
with 1 representing “Terrible” and 10 being “Very Good”.
Paired t tests showed that participants coping ratings were
significantly higher (better able to cope) at the completion
of the program (t(6)=4.42, p=.004, Cohen’s d=1.73) and at
12-month follow-up (t(6)=2.56, p=.043, Cohen’s d=1.125)
that prior to commencing the program, and there was no
significant difference between coping ratings at post-
program and follow-up (t(6)=1.45, p=.197). See Table 2
for means and standard deviations.
As part of the coping questionnaire, participants were
asked to identify three unhelpful and three helpful coping
strategies that they regularly used. Results for the coping
strategies people found unhelpful are illustrated in Fig. 2.

Fig. 2 Comparison of “unhelp-

ful strategies” used to cope with
stress pre-program, post-
program, and at follow-up
(N=7)
Mindfulness (2010) 1:215–226
Considerable changes in the identified use of drug and/or
alcohol (60% reduction), oversleeping (66% reduction),
and unhelpful thoughts (50% reduction), and inactivity/
avoidance (66% increase) were noted from pre-program to
post-program. The only unhelpful coping strategy to increase
from pre-program to post-program was inactivity/avoidance,
however this deceased back to pre-program levels at follow-
up. Participants reported a lower or same frequency of use of
all the unhelpful coping strategies, with the exception of
sleeping, at 12 month follow-up than at post-program.
As illustrated in Fig. 3, the only ‘helpful’ coping strategy
to increase in use by participants from pre- to post-program
was the employment of mindfulness strategies, which
increased by 600% (although this dropped to only 450% at
follow-up). Although it was somewhat disappointing to see
that participants had relied less on behavioural and other
therapeutic strategies (though the use of ‘other therapeutic
strategies’ had actually risen above pre-program levels at
follow-up), they reported relying less on medication and use
of mental health services (all participants reported not using
PRN medications or accessing mental health services at
program completion and at follow-up), consistent with their
self-reported improvement in their overall ability to cope.
Individual Example: Sam’s Story
Sam* is a 36-year-old man with a history of severe and
chronic schizophrenia. He regularly experiences distressing
auditory hallucinations, usually paranoid in nature. Sam
reported that this often led him to isolate himself and
severely restricted his ability to engage with others and
community life. Sam takes antipsychotic medication and
also engages in regular individual Cognitive Behavioural
Therapy with a clinical psychologist.
Sam registered for the ‘Stress Less with Mindfulness’
(SLWM) program, to assist in the alleviation of his current
Fig. 3 Comparison of “helpful
strategies” used to cope with
stress pre-program, post-
program, and at follow-up
(N=7). MH mental health
223
symptoms. After completing the 12-week SLWM program,
Sam’s DASS scores reduced significantly (from 66 pre-
group to 34 at follow-up). His perceived ability to cope
with stress also improved (increasing from 2/10 to 7/10,
where 0 was “terrible” and 10 was “very good”).
As a result of the SLWM program, Sam became more
aware of the workings of his mind. He was able to detach
himself from his auditory hallucinations, and begins to view
them as “just paranoid thoughts”, without believing them.
During the program, Sam diligently practised formal
mindfulness techniques (e.g. mindfulness of breath) for
“about 10 min each day”. He also used a particular
mindfulness technique, using his sense of smell, with great
effect. This involved smelling a specific essential oil to
bring him back to the present moment when he felt himself
“getting caught up” in his delusional thoughts. Sam learnt
to use the ‘Observe and Describe’ skill (Linehan’s model)
to dis-identify with his thoughts and see them clearly. He
described one occasion when he was out for coffee with
his mother. After approximately 2 h of being out in public,
his persecutory delusions had increased and became very
intense. Sam used ‘Observe and Describe’ skills to assist
him to realise that “thoughts are just thoughts, and not
facts”. He was then able to see his surroundings as non-
threatening and stayed out for longer, rather than returning
home immediately, which was his previous way of coping.
Sam still practises mindfulness, mostly informally,
during many activities every day and cites it as “just as
important as taking my [antipsychotic] medication”. Sam
reports that he uses mindfulness and CBT together—using
mindfulness to bring him to the present moment when he
notices he’s caught up in delusional beliefs, allowing him to
detach from these thoughts, and then use CBT techniques
to challenge these thoughts, helping him to realise that his
persecutory thoughts are actually misperceptions. He states
that the “breathing space” that mindfulness provides makes
the CBT techniques more accessible.
224
Sam reports that using mindfulness helps him to feel
empowered, and that this gives him hope that he is able to
take control of his mental health. “Meditating mindfully
brings me back to my real self and then accept myself a
little more.” (Sam)* name changed for privacy of client
Discussion
The current study provides preliminary evidence support-
ing the use of a novel mindfulness therapy—which draws
from MBSR, MBCT and DBT—administered in a group
format, for outpatient mental health consumers, with the
aim to reduce affective distress and improve perceived
ability to cope. The group was run over 12 weeks and was
attended by consumers with a range of diagnoses and
levels of affective symptom severity. The outcome data
showed that overall participants’ ratings of depression,
anxiety and stress all significantly reduced, echoing the
findings reported by Schreiner and Malcolm’s (2008)
study of a non-clinical population, and also supporting
Kabat-Zinn et al.’s (1992) study of a clinically anxious
population. Participants’ perceived ability to cope im-
proved from pre-to post-program completion. The effect
sizes of these shifts were large across the board, and the
clinical significance of this shift was further corroborated
when inspecting the shifts in clinical severity ranges on
the DASS, with most participants shifting from a more
severe range to a less severe range. In line with Miller et
al.’s (1995) findings (where 3-year post-program, the
improvements in anxiety and depression symptoms were
maintained), our program found that at 1-year follow-up,
the beneficial effects of the program had not diminished
for depression. The improvement in subjective coping
ratings had also been maintained, and although they had
lessened somewhat for stress and anxiety, these ratings
were still lower than prior to commencement of the
program, suggesting that gains were at least partially
maintained for all measures.
In addition to improving participants’ perceived ability
to cope, the mindfulness program also changed the type of
coping strategies they employed. All ‘unhelpful’ coping
strategies decreased from pre- to post-program commence-
ment, with the exception of inactivity/avoidance which
increased, although this increase had returned to pre-
program endorsement levels by follow-up. In addition, all
participants reported using mindfulness-based strategies as
one of their primary ‘helpful’ coping strategies at both post-
program and at follow-up, potentially accounting for the
maintenance of gains across the 1-year period (Miller et al.
1995). This suggests that the mindfulness strategies are not
only effective at reducing affective distress (as evidenced
by the drop in DASS scores) but are also user-friendly, as
Mindfulness (2010) 1:215–226
participants were able to continue implementing them
independently. Finally, participants reported a reduced use
of mental health-related services and PRN medication at
program completion and at follow-up, suggesting that the
program may have led to a reduction in illness-related
costs, thus warranting future studies to conclude a cost-
benefit analysis.
Although we cannot draw conclusions about the impact
of diagnosis on response to treatment due to insufficient
participant numbers, we noted that all of the participants
who had minimal or no improvements in affective scores
had a schizophrenia-spectrum disorder. Only one partici-
pant with a schizophrenia-spectrum disorder made gains
across all three affective measures and maintained these at
follow-up. The other three participants made partial gains,
some of which were maintained across the 12-month
follow-up period, others of which were not. It should be
noted however that these participants may have still
received some benefit from attending the group, since they
rated their ability to cope as being higher at post-program
and at follow-up than pre-program, and also reported a
reduction in their use of ‘unhelpful’ coping strategies and
decreased use of PRN and use of mental health facilities.
Furthermore, previous clinical trials of mindfulness-based
interventions in schizophrenia samples have shown prom-
ising results (Chadwick et al. 2005; Davis et al. 2007).
Thus, larger studies are needed to replicate this finding to
isolate the components of the program that are most
beneficial for this population.
Although numerous clinical trials have shown the
efficacy of mindfulness-based group programs in the
reduction of affective distress, most of these studies have
been highly controlled, and thus not able to ensure
effectiveness in a real-world setting. Thus, the results from
the current study are important because it provides
preliminary evidence that mindfulness-based group pro-
grams can be effective in a naturalistic setting (specifically,
a government-funded, outpatient mental health facility),
with mixed diagnoses (the current study had consumers
with a range of diagnoses, including bipolar affective
disorder, schizophrenia-spectrum disorders and obsessive
compulsive disorder), ages (the current study had an age
range of 23 to 64 years of age), and severity of illness (the
current study had pre-program DASS scores ranging from
normal to extremely severe). This adds to the preliminary
research conducted by Ree and Craigie (2007) which found
that MBCT produced significant improvements on meas-
ures of depression, anxiety and stress for participants with
large variations in symptom severity in a psychiatric
outpatient setting. Moreover, the present study showed
that mindfulness-based interventions are not only effec-
tive at reducing stress levels, but also in increasing
perceived ability to cope, reducing symptoms of anxiety
Mindfulness (2010) 1:215–226
and depression, and use of PRN medication and other
mental health services. Finally, the current study provides
preliminary support for the amalgamation of MBSR,
MBCT and DBT (specifically, the Core Mindfulness
module) into a group program targeting a mixed-
diagnostic group. Having a group program targeting a
mixed-diagnostic group has the obvious advantage of
allowing multiple clients to access treatment at the same
time, rather than via individual therapy, or several
diagnosis-specific groups.
The primary strength of our pilot study, namely that it is
set in a naturalistic setting, is also its limitation. Future
studies should use a waitlist/treatment-as-usual control
group to rule out the possibility that the participants would
have improved across this period of time regardless of
whether they were receiving an additional intervention.
Also, as is typically the case in most outpatient settings
given restriction on clinician availability, the same clini-
cians that delivered the program also administered the pre-
program, post-program and follow-up measures in the
current study. This could potentially have had a confound-
ing effect on the results since participants may want to
please the therapist. Although this may be the case, the
participants in the current study did have a large range of
severity scores at each assessment stage, and each
participant’s ratings varied across measures, which one
would not expect to see if they were entirely giving
responses to please. In keeping with other mental health
group therapy programs (e.g. Hofmann and Suvak 2006;
Oei and Kazmierczak 1997), attrition rates were high in
the current study. It is important, however, to note that
there were no significant clinical or demographic differ-
ences between the participants that did and did not
complete the program, suggesting that the strong treatment
effects found were not the product of a sampling bias.
Finally, it must be emphasised that the current study is a
preliminary study, and thus needs replication with a larger
sample size.
In conclusion, the current study found preliminary
support for the implementation of a novel mindfulness-
based group therapy in mixed-diagnostic outpatient pop-
ulations, in line with our hypothesis. The group helped
participants to feel more confident with their ability to cope
with stress, reduced their emotional distress, and reduced
their reliance on other mental health resources and
medications—possibly reducing their illness-related costs.
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