Journal of Behavioral Medicine

, Volume 34, Issue 6, pp 508–518 | Cite as

Changes in spirituality partly explain health-related quality of life outcomes after Mindfulness-Based Stress Reduction

  • Jeffrey M. GreesonEmail author
  • Daniel M. Webber
  • Moria J. Smoski
  • Jeffrey G. Brantley
  • Andrew G. Ekblad
  • Edward C. Suarez
  • Ruth Quillian Wolever


Mindfulness-Based Stress Reduction is a secular behavioral medicine program that has roots in meditative spiritual practices. Thus, spirituality may partly explain Mindfulness-Based Stress Reduction outcomes. Participants (N = 279; M (SD) age = 45(12); 75% women) completed an online survey before and after an 8-week Mindfulness-Based Stress Reduction program. Structural equation modeling was used to test the hypothesis that, following Mindfulness-Based Stress Reduction, the relationship between enhanced mindfulness and improved health-related quality of life is mediated by increased daily spiritual experiences. Changes in both spirituality and mindfulness were significantly related to improvement in mental health. Although the initial mediation hypothesis was not supported, an alternate model suggested that enhanced mindfulness partly mediated the association between increased daily spiritual experiences and improved mental health-related quality of life (indirect effect: β = 0.07, P = 0.017). Effects on physical health-related quality of life were not significant. Findings suggest a novel mechanism by which increased daily spiritual experiences following Mindfulness-Based Stress Reduction may partially explain improved mental health as a function of greater mindfulness.


Mindfulness-Based Stress Reduction Spirituality Quality of life Meditation Mediation 



This research was supported by grant K99 AT004945 from the National Center for Complementary & Alternative Medicine (NCCAM) to JMG. MJS was supported by K23 MH087754 from the National Institute of Mental Health (NIMH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health (NIH). Additional support was provided by a research infrastructure grant from the Fannie E. Rippel foundation. We thank Katie Strobush and Janna Fikkan, Ph.D., for their assistance with recruitment. We thank all of the expert Mindfulness-Based Stress Reduction program instructors at Duke Integrative Medicine (Mary Matthews Brantley, M.A., LMFT; Sasha Loring, M.Ed., LCSW; Maya McNeilly, Ph.D.; Jeanne van Gemert, M.A., M.F.A., LMBT, LPC; and Ron Vereen, M.D.) for their intellectual contributions to study design and data interpretation. Finally, we thank all of the study participants who volunteered their time to complete our survey.


  1. Astin, J. A. (1997). Stress reduction through mindfulness meditation. Effects on psychological symptomatology, sense of control, and spiritual experiences. Psychotherapy and Psychosomatics, 66, 97–106.PubMedCrossRefGoogle Scholar
  2. Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology Science and Practice, 10, 125–143.CrossRefGoogle Scholar
  3. Birnie, K., Speca, M., & Carlson, L. E. (2010). Exploring self-compassion and empathy in the context of mindfulness-based stress reduction (MBSR). Stress and Health, 26, 359–371.CrossRefGoogle Scholar
  4. Bohlmeijer, E., Prenger, R., Taal, E., & Cuijpers, P. (2010). The effects of mindfulness-based stress reduction therapy on mental health of adults with a chronic medical disease: A meta-analysis. Journal of Psychosomatic Research, 68, 539–544.PubMedCrossRefGoogle Scholar
  5. Carmody, J., & Baer, R. A. (2008). Relationships between mindfulness practice and levels of mindfulness, medical and psychological symptoms and well-being in a mindfulness-based stress reduction program. Journal of Behavioral Medicine, 31, 23–33.PubMedCrossRefGoogle Scholar
  6. Carmody, J., Baer, R. A., Lykins, E. L. B., & Olendzki, N. (2009). An empirical study of the mechanisms of mindfulness in a mindfulness-based stress reduction program. Journal of Clinical Psychology, 65, 613–626.PubMedCrossRefGoogle Scholar
  7. Carmody, J., Reed, G., Kristeller, J., & Merriam, P. (2008). Mindfulness, spirituality, and health-related symptoms. Journal of Psychosomatic Research, 64, 393–403.PubMedCrossRefGoogle Scholar
  8. Chiesa, A., & Serretti, A. (2009). Mindfulness-based stress reduction for stress management in healthy people: A review and meta-analysis. The Journal of Alternative and Complementary Medicine, 15, 593–600.PubMedCrossRefGoogle Scholar
  9. Delsignore, A., & Schnyder, U. (2007). Control expectancies as predictors of psychotherapy outcome: A systematic review. British Journal of Clinical Psychology, 46, 467–483.PubMedCrossRefGoogle Scholar
  10. Feldman, G., Hayes, A., Kumar, S., Greeson, J., & Laurenceau, J. P. (2007). Mindfulness and emotion regulation: The development and initial validation of the cognitive and affective mindfulness scale-revised (CAMS-R). Journal of Psychopathology and Behavioral Assessment, 29, 177–190.CrossRefGoogle Scholar
  11. Flickstein, M. (2001). Swallowing the River Ganges: A practice guide to the path of purification. Somerville, MA: Wisdom Publications.Google Scholar
  12. Gallup, G., & Johnson, B. R. (2003). New index tracks spiritual state of the union. Gallup Poll News Service. Retrieved from
  13. Gandhi, S. K., Warren Salmon, J., Zhao, S. Z., Lambert, B. L., Gore, P. R., & Conrad, K. (2001). Psychometric evaluation of the 12-item short-form health survey (SF-12) in osteoarthritis and rheumatoid arthritis clinical trials. Clinical Therapeutics, 23, 1080–1098.PubMedCrossRefGoogle Scholar
  14. Garland, S. N., Carlson, L. E., Cook, S., Lansdell, L., & Speca, M. (2007). A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Supportive Care in Cancer, 15, 949–961.PubMedCrossRefGoogle Scholar
  15. Goldstein, J., & Kornfield, J. (1987). Seeking the heart of wisdom: The path of insight meditation. Boston, MA: Shambhala Publications, Inc.Google Scholar
  16. Greeson, J. M. (2009). Mindfulness research update: 2008. Complementary Health Practice Review, 14, 10–18.PubMedGoogle Scholar
  17. Grossman, P. (2008). On measuring mindfulness in psychosomatic and psychological research. Journal of Psychosomatic Research, 64, 405–408.PubMedCrossRefGoogle Scholar
  18. Grossman, P., Niemann, L., Schmidt, S., & Walach, H. (2004). Mindfulness-based stress reduction and health benefits: A meta-analysis. Journal of Psychosomatic Research, 57, 35–43.PubMedCrossRefGoogle Scholar
  19. Harrington, A. (1999). The placebo effect: An interdisciplinary exploration. Cambridge, MA: Harvard University Press.Google Scholar
  20. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169–183.PubMedCrossRefGoogle Scholar
  21. Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling, 6, 1–55.CrossRefGoogle Scholar
  22. Kabat-Zinn, J. (1990). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness. New York, NY: Delacorte Press.Google Scholar
  23. Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life. New York, NY: Hyperion Books.Google Scholar
  24. Kabat-Zinn, J. (1999). Indra’s net at work: The mainstreaming of dharma practice in society. In G. Watson, S. Batchelor, & G. Claxton (Eds.), The psychology of awakening: Buddhism, science, and our day-to-day lives (pp. 225–249). London: Rider.Google Scholar
  25. Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156.CrossRefGoogle Scholar
  26. Kline, R. B. (2004). Principles and practice of structural equation modeling (2nd ed.). New York, NY: The Guilford Press.Google Scholar
  27. Koenig, H. G. (2008). Concerns about measuring “spirituality” in research. The Journal of Nervous and Mental Disease, 196, 349–355.PubMedCrossRefGoogle Scholar
  28. Koenig, H. G., McCullough, M. E., & Larson, D. B. (2001). Handbook of religion and health. New York, NY: Oxford University Press, Inc.CrossRefGoogle Scholar
  29. Kornfield, J. (1993). A path with heart: A guide through the perils and promises of spiritual life. New York, NY: Bantam.Google Scholar
  30. Kristeller, J. L. (2007). Mindfulness meditation. In P. M. Lehrer, R. L. Woolfolk, W. E. Sime, & D. H. Barlow (Eds.), Principles and practice of stress management (3rd ed., pp. 393–427). New York, NY: The Guilford Press.Google Scholar
  31. Kristeller, J. (2010). Spiritual engagement as a mechanism of change in mindfulness- and acceptance-based therapies. In R. A. Baer (Ed.), Assessing mindfulness & acceptance processes in clients: Illuminating the theory & practice of change (pp. 155–184). Oakland, CA: New Harbinger Publications, Inc.Google Scholar
  32. Kristeller, J. L., & Johnson, T. (2005). Cultivating loving kindness: A two-stage model of the effects of meditation on empathy, compassion, and altruism. Zygon®, 40, 391–408.CrossRefGoogle Scholar
  33. Maddux, J. E., Norton, L. W., & Stoltenberg, C. D. (1986). Self-efficacy expectancy, outcome expectancy, and outcome value: Relative effects on behavioral intentions. Journal of Personality and Social Psychology, 51, 783–789.CrossRefGoogle Scholar
  34. McCauley, J., Tarpley, M. J., Haaz, S., & Bartlett, S. J. (2007). Daily spiritual experiences of older adults with and without arthritis and the relationship to health outcomes. Arthritis Care & Research, 59, 122–128.CrossRefGoogle Scholar
  35. Nyklíček, I., & Kuijpers, K. F. (2008). Effects of mindfulness-based stress reduction intervention on psychological well-being and quality of life: Is increased mindfulness indeed the mechanism? Annals of Behavioral Medicine, 35, 331–340.PubMedCrossRefGoogle Scholar
  36. Park, C. L. (2007). Religiousness/spirituality and health: A meaning systems perspective. Journal of Behavioral Medicine, 30, 319–328.PubMedCrossRefGoogle Scholar
  37. Phelan, J. P. (2010). Mindfulness as presence. Mindfulness, 1, 131–134.CrossRefGoogle Scholar
  38. Plews-Ogan, M., Owens, J. E., Goodman, M., Wolfe, P., & Schorling, J. (2005). Brief report: A pilot study evaluating mindfulness-based stress reduction and massage for the management of chronic pain. Journal of General Internal Medicine, 20, 1136–1138.PubMedCrossRefGoogle Scholar
  39. Reibel, D. K., Greeson, J. M., Brainard, G. C., & Rosenzweig, S. (2001). Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population. General Hospital Psychiatry, 23, 183–192.PubMedCrossRefGoogle Scholar
  40. Rosenthal, R. (1991). Meta-analytic procedures for social research. Thousand Oaks, CA: Sage Publications, Inc.Google Scholar
  41. Rosenzweig, S., Greeson, J. M., Reibel, D. K., Green, J. S., Jasser, S. A., & Beasley, D. (2010). Mindfulness-based stress reduction for chronic pain conditions: Variation in treatment outcomes and role of home meditation practice. Journal of Psychosomatic Research, 68, 29–36.PubMedCrossRefGoogle Scholar
  42. Roth, B., & Robbins, D. (2004). Mindfulness-based stress reduction and health-related quality of life: Findings from a bilingual inner-city patient population. Psychosomatic Medicine, 66, 113–123.PubMedCrossRefGoogle Scholar
  43. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: The Guilford Press.Google Scholar
  44. Shapiro, S. L., Oman, D., Thoresen, C. E., Plante, T. G., & Flinders, T. (2008). Cultivating mindfulness: Effects on well-being. Journal of Clinical Psychology, 64, 840–862.PubMedCrossRefGoogle Scholar
  45. Shapiro, S. L., Schwartz, G. E., & Bonner, G. (1998). Effects of mindfulness-based stress reduction on medical and premedical students. Journal of Behavioral Medicine, 21, 581–599.PubMedCrossRefGoogle Scholar
  46. Singh, N. N. (2010). Mindfulness: A finger pointing to the moon. Mindfulness, 1, 1–3.CrossRefGoogle Scholar
  47. Southwick, S. M., Vythilingam, M., & Charney, D. S. (2005). The psychobiology of depression and resilience to stress: Implications for prevention and treatment. Annual Review of Clinical Psychology, 1, 255–291.PubMedCrossRefGoogle Scholar
  48. Stewart-Williams, S., & Podd, J. (2004). The placebo effect: Dissolving the expectancy versus conditioning debate. Psychological Bulletin, 130, 324–340.PubMedCrossRefGoogle Scholar
  49. Underwood, L. G. (2006). Ordinary spiritual experience: Qualitative research, interpretive guidelines, and population distribution for the daily spiritual experience scale. Archive for the Psychology of Religion, 28, 181–218.Google Scholar
  50. Underwood, L. G., & Teresi, J. A. (2002). The daily spiritual experience scale: Development, theoretical description, reliability, exploratory factor analysis, and preliminary construct validity using health-related data. Annals of Behavioral Medicine, 24, 22–33.PubMedCrossRefGoogle Scholar
  51. Vettese, L. C., Toneatto, T., Stea, J. N., Nguyen, L., & Wang, J. J. (2009). Do mindfulness meditation participants do their homework? And does it make a difference? A review of the empirical evidence. Journal of Cognitive Psychotherapy, 23, 198–225.CrossRefGoogle Scholar
  52. Wachholtz, A. B., Pearce, M. J., & Koenig, H. (2007). Exploring the relationship between spirituality, coping, and pain. Journal of Behavioral Medicine, 30, 311–318.PubMedCrossRefGoogle Scholar
  53. Wallace, B. A., & Shapiro, S. L. (2006). Mental balance and well-being. Building bridges between Buddhism and Western psychology. American Psychologist, 61, 690–701.PubMedCrossRefGoogle Scholar
  54. Walsh, R., & Shapiro, S. L. (2006). The meeting of meditative disciplines and western psychology: A mutually enriching dialogue. American Psychologist, 61, 227–239.PubMedCrossRefGoogle Scholar
  55. Ware, J. E., Kosinski, M., & Keller, S. D. (1998). SF-12: How to score the SF-12 physical and mental health summary scales. Lincoln, RI: QualityMetric Inc.Google Scholar
  56. Wigfield, A. (1994). Expectancy-value theory of achievement motivation: A developmental perspective. Educational Psychology Review, 6, 49–78.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Jeffrey M. Greeson
    • 1
    Email author
  • Daniel M. Webber
    • 1
    • 5
  • Moria J. Smoski
    • 2
  • Jeffrey G. Brantley
    • 1
  • Andrew G. Ekblad
    • 3
  • Edward C. Suarez
    • 4
  • Ruth Quillian Wolever
    • 1
  1. 1.Duke Integrative Medicine, Duke University Medical CenterDurhamUSA
  2. 2.Cognitive and Behavioral Research and Treatment ProgramDuke University Medical CenterDurhamUSA
  3. 3.Centre for Addiction and Mental HealthTorontoCanada
  4. 4.Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamUSA
  5. 5.University of Arkansas for Medical SciencesLittle RockUSA

Personalised recommendations