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Effectiveness of an integrated mindfulness-based anxiety group intervention with university students… Maglio, Asa-Sophia T. 2011

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EFFECTIVENESS OF AN INTEGRATED MINDFULNESS-BASED ANXIETY GROUP INTERVENTION WITH UNIVERSITY STUDENTS WHO SELF-REPORT ANXIETY: A SMALL-N, MIXED METHOD DESIGN by ASA-SOPHIA T. MAGLIO B.A. (Hons), Simon Fraser University, 1998 M.A., The University of British Columbia, 2002  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF  DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Counselling Psychology)  THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) July 2011  © Asa-Sophia T. Maglio, 2011  ABSTRACT Anxiety is a common mental health challenge seen at a university counselling centre. The Integrated Mindfulness-based Anxiety Group (IMAG) was a 10-session therapy program designed for use at a university counselling centre to work with university students who struggle with anxiety. IMAG integrated core mindfulness components from three prominent therapy programs; mindfulness was trained through both mindfulness meditative practices and skills. A mixed-method, Small-N design study investigated the effectiveness of the IMAG. Seventeen university students grappling with self-reported anxiety participated in this study. The dependent variables of anxiety symptoms, general clinical symptoms, and mindfulness were monitored across the study. Eleven of these participants also were interviewed three to six months after the end of the IMAG. There were four data analytic strategies used to assess effectiveness and change. First, the Participant and Group Practice Analyses showed that formal meditation techniques were the top-practiced activities in both intervention and follow-up phases; it also was shown that participants making the most change were those who practiced the longest per practice day. Second, the Small-N Visual Analyses, the principle research analysis, showed very few functional relationships between the IMAG and the three dependent variables. Third, the Within-subject analyses showed many significant changes both at the intervention’s end and during follow-up, with the average effect sizes being in the medium range. Finally, the Thematic Analysis showed themes in the categories of change, challenge, and mindfulness. The Change category contained themes pertaining to (1) the types of change experienced by the participants and (2) the contexts and criteria that seemed to support change. The Challenge category contained themes about (1) the  ii  challenges related to the practices, (2) challenges related to the group, and (3) challenges related to the context of the participants. Although there were changes shown in the Within-subject analyses, the Small-N analysis provided only weak evidence, thus no effectiveness claim can be made for the IMAG. The study’s limitations as well as future research suggestions are provided. The study’s conclusions make recommendations to improve the IMAG to make it more robust and responsive to dealing with university students struggling with anxiety challenges.  iii  PREFACE The research presented in this thesis was approved by UBC's Behavioural Research Ethics Board, and the approval certificate number is H06-03675.  iv  TABLE OF CONTENTS  ABSTRACT....................................................................................................................... ii PREFACE......................................................................................................................... iv TABLE OF CONTENTS ................................................................................................. v LIST OF TABLES .......................................................................................................... xii LIST OF FIGURES ....................................................................................................... xiii ACKNOWLEDGMENTS ............................................................................................. xiv DEDICATION................................................................................................................. xv CHAPTER ONE: INTRODUCTION ............................................................................. 1 University Students and Mental Health...................................................................... 1 Anxiety and Therapy Interventions ............................................................................ 2 Mindfulness and Therapy Interventions .................................................................... 5 Rationale for the Study................................................................................................. 8 Overview of the Dissertation........................................................................................ 9 CHAPTER TWO: LITERATURE REVIEW.............................................................. 11 University or College Student .................................................................................... 11 University Student Mental Health ............................................................................ 13 University Counselling Centres ................................................................................ 17 Summary ................................................................................................................... 19 Anxiety ......................................................................................................................... 21 Anxiety Definitions................................................................................................... 21  v  Anxiety Disorders ..................................................................................................... 27 Anxiety Treatment or Intervention ........................................................................... 30 Summary ................................................................................................................... 36 Integrative Mindfulness-Based Anxiety Group Intervention ................................. 38 Mindfulness............................................................................................................... 40 Mindfulness and Health ............................................................................................ 42 Mindfulness and Anxiety .......................................................................................... 46 Mindfulness Interventions and Effectiveness ........................................................... 54 Summary ................................................................................................................... 55 Research Questions ..................................................................................................... 57 Expected Findings ....................................................................................................... 59 Conclusions .................................................................................................................. 60 CHAPTER 3: METHODOLOGY................................................................................ 62 Introduction................................................................................................................. 62 Research Design .......................................................................................................... 63 Participants.................................................................................................................. 65 Recruitment............................................................................................................... 65 Initial Brief Telephone Pre-Therapy Screen ............................................................. 66 Pre-Group Screening and Research Interview .......................................................... 66 Attrition..................................................................................................................... 67 Characteristics of the Participants............................................................................. 67 Group Composition................................................................................................... 70  vi  Procedures ................................................................................................................... 70 Pre-Group Screening Interview ................................................................................ 71 Baseline Phase .......................................................................................................... 72 Intervention Phase..................................................................................................... 72 Follow-Up Phase....................................................................................................... 78 Data Production .......................................................................................................... 79 Weekly Self-Report Questionnaires (WQ) ............................................................... 79 Scales of Measurement ............................................................................................. 80 Practice and Context Questions ................................................................................ 85 Goals ......................................................................................................................... 86 Post-Group Interview................................................................................................ 86 Data Analyses .............................................................................................................. 86 Small-N, Visual Analyses ......................................................................................... 87 Within-Subject Analyses of Variance....................................................................... 95 Qualitative Thematic Analysis.................................................................................. 98 Participant and Group Practice Analyses................................................................ 103 Summary.................................................................................................................... 104 CHAPTER FOUR: PARTICIPANT AND GROUP PRACTICE ANALYSES .... 106 Research Questions ................................................................................................... 106 Data Used in the Analyses ........................................................................................ 106 Group, Cohorts, and Individual Practice Analyses ............................................... 107 Group Practice Analysis ......................................................................................... 107 Cohort and Individual Participant Analyses ........................................................... 109  vii  Summary.................................................................................................................... 129 Individual Participant Analyses Summary.............................................................. 130 Stressful or Anxiety-causing Events Summary ...................................................... 133 Conclusions ................................................................................................................ 134 CHAPTER FIVE: SMALL-N ANALYSES RESULTS ............................................ 136 Research Questions ................................................................................................... 136 Review of the Data and Procedures of the Visual Analysis .................................. 137 Visual Analyses of the Multiple Baseline Graphs .................................................. 141 General Clinical Outcome Measure........................................................................ 141 Anxiety Measures ................................................................................................... 153 Mindfulness Measures ............................................................................................ 205 Summary of Visual Analyses ................................................................................... 281 CHAPTER SIX: GROUP-BASED ANALYSES RESULTS .................................... 284 Research Question .................................................................................................... 284 Review of the Data and Procedures of the Within-Subject Analyses .................. 284 General Clinical Outcome Measure ........................................................................ 287 Outcome Questionnaire-45.2 (OQ-45.2) ................................................................ 287 Anxiety Measures...................................................................................................... 289 Burns Anxiety Inventory (BAI) .............................................................................. 290 Penn State Worry Questionnaire- Past Week (PSWQ-PW) ................................... 291 State-Trait Anxiety Inventory- State Anxiety (STAI-S)......................................... 292 State-Trait Anxiety Inventory-Trait (STAI-T)........................................................ 294 Composite Anxiety Score (CAS)............................................................................ 295  viii  Mindfulness Measures .............................................................................................. 297 Mindful Attentional Awareness Scale (MAAS) ..................................................... 297 Five Facet Mindfulness Questionnaire- Describe (FF-D) ...................................... 298 Five Facet Mindfulness Questionnaire- Observe (FF-O) ....................................... 300 Five Facet Mindfulness Questionnaire- Nonreactivity to Inner Experience (FF-NR) ................................................................................................................................. 301 Five Facet Mindfulness Questionnaire- Non-judgment (FF-NJ)........................... 302 Five Facet Mindfulness Questionnaire- Acting with Awareness (FF-AA) ............ 304 Composite Mindfulness Score (CMS) .................................................................... 305 Summary.................................................................................................................... 306 ANOVA Significance Results ................................................................................ 306 Effect Statistics Summary....................................................................................... 307 Post-hoc Pairwise Comparisons.............................................................................. 309 Conclusions ................................................................................................................ 310 CHAPTER SEVEN: THEMATIC ANALYSIS RESULTS..................................... 311 Research Question .................................................................................................... 311 Review of the Interview Data and Procedures of the Thematic Analysis............ 311 Themes ....................................................................................................................... 313 Change Themes....................................................................................................... 313 Challenge Themes................................................................................................... 325 Mindfulness Definition Themes ............................................................................. 333 Summary ................................................................................................................. 335 Conclusions ................................................................................................................ 339  ix  CHAPTER EIGHT: DISCUSSION ............................................................................ 340 Therapeutic Effectiveness ........................................................................................ 340 Small-N Design, Visual Analyses........................................................................... 341 Group-based, Within-Subject Analyses.................................................................. 347 Summary ................................................................................................................. 349 Improvement and Strengthening of the IMAG...................................................... 350 Participant and Group Practice Analysis ................................................................ 350 Thematic Analysis .................................................................................................. 354 Synthesis of the Four Analyses ................................................................................ 358 Unique Contributions ............................................................................................... 359 Potential Anxiety Intervention for College or University Students........................ 359 Mindfulness Interventions ...................................................................................... 361 Mixed-Method Therapy-Outcome Designs for Newer Interventions..................... 363 Mindfulness Measurement...................................................................................... 364 Challenges and Limitations...................................................................................... 365 Future Exploration and Research ........................................................................... 368 Conclusions ................................................................................................................ 370 REFERENCES.............................................................................................................. 372 APPENDIX A: STUDY INTRODUCTION LETTER ............................................. 400 APPENDIX B: STUDY POSTER .............................................................................. 402 APPENDIX C: CONSENT FORM ............................................................................ 403 APPENDIX D: INITIAL BRIEF TELEPHONE CONTACT SCRIPT ................. 406  x  APPENDIX E: LIST OF MENTAL HEALTH REFERRALS AND RESOURCES ......................................................................................................................................... 408 APPENDIX F: PRE-GROUP SCREEN .................................................................... 409 APPENDIX G: POST-GROUP INTERVIEW QUESTIONS ................................. 413  xi  LIST OF TABLES Table 6.1 OQ-45.2 Means, with Standard Deviations (SD) and Sample Size (N) ..........288 Table 6.2 BAI Means, with Standard Deviations (SD) and Sample Size (N) ................290 Table 6.3 PSWQ-PW Means, with Standard Deviations (SD) and Sample Size (N).....291 Table 6.4 STAI-S Means, with Standard Deviations (SD) and Sample Size (N)...........293 Table 6.5 STAI-T Means, with Standard Deviations (SD) and Sample Size (N) ..........294 Table 6.6 CAS Means, with Standard Deviations (SD) and Sample Size (N) ...............296 Table 6.7 MAAS Means, with Standard Deviations (SD) and Sample Size (N)............297 Table 6.8 FF-D Means, with Standard Deviations (SD) and Sample Size (N) ..............299 Table 6.9 FF-O Means, with Standard Deviations (SD) and Sample Size (N) ..............300 Table 6.10 FF-NR Means, with Standard Deviations (SD) and Sample Size (N)..........301 Table 6.11 FF-NJ Means, with Standard Deviations (SD) and Sample Size (N) ...........303 Table 6.12 FF-AA Means, with Standard Deviations (SD) and Sample Size (N)..........304 Table 6.13 CMS Means, with Standard Deviations (SD) and Sample Size (N).............305 Table 7.1 Change Themes...............................................................................................314 Table 7.2 Challenge Themes...........................................................................................326 Table 7.3 Mindfulness Themes ......................................................................................333  xii  LIST OF FIGURES Figure 5.1 Outcome Questionnaire 45.2 (OQ-45.2) ......................................................142 Figure 5.2 Composite Sum Score of Anxiety Measures (CAS) ....................................154 Figure 5.3 Burns Anxiety Inventory (BAI).....................................................................164 Figure 5.4 Penn State Worry Questionnaire- Past Week (PSWQ-PW)..........................174 Figure 5.5 State-Trait Anxiety Inventory- State Anxiety (STAI-S) ...............................184 Figure 5.6 State-Trait Anxiety Inventory- Trait Anxiety (STAI-T) ..............................194 Figure 5.7 Composite Sum Score of the Mindfulness Measures (CMS)........................206 Figure 5.8 Mindfulness Attentional Awareness Scale (MAAS).....................................216 Figure 5.9 Five Factor Mindfulness Questionnaire: Acting with Awareness (FF-AA) .227 Figure 5.10 Five Factor Mindfulness Questionnaire: Describing (FF-D) ......................238 Figure 5.11 Five Factor Mindfulness Questionnaire: Nonjudgment of Experience (FFNJ)....................................................................................................................................249 Figure 5.12 Five Factor Mindfulness Questionnaire: Nonreactivity to Inner Experience (FF-NR).........................................................................................................259 Figure 5.13 Five Factor Mindfulness Questionnaire: Observing (FF-O) .......................270  xiii  ACKNOWLEDGMENTS  (1) To my dissertation committee, thank-you for your patience, support, rigor, excellence, wisdom, and compassion … (2) To the Canadian Social Science and Humanities Research Council (SSHRC), thankyou for supporting my doctoral education … (3) To Dr. Melanee Cherry, thank-you for sharing your expertise and journey … (4) To my participants, thank-you for your bravery.  xiv  DEDICATION I dedicate this work to the whale, the eagle, the bear, the wolf, and Stanley ... eternally.  xv  CHAPTER ONE: INTRODUCTION This study investigated the effectiveness of an Integrative Mindfulness-based Anxiety Group intervention (IMAG) for university students, who self-reported dealing with problematic anxiety. The IMAG (formerly the Challenging Anxiety Group [CAG]) was a long-standing group therapy intervention used at a major university counselling centre for students suffering with anxiety. This study used weekly assessments to evaluate student-client’s clinical progress across the intervention. Both reductions in anxiety and general clinical symptoms were monitored. Also, increases or acquisition of mindfulness characteristics were evaluated. Thus, this current study set out to investigate the IMAG’s effectiveness and ways to strengthen or improve the IMAG’s ability to support the student-client in dealing with anxiety and well-being concerns. The following is an introduction to this study and its aims. University Students and Mental Health University students are a goal-driven and determined group of individuals, who invest considerable time and resources into attaining a university or college education. One of the biggest challenges that can be faced by a student is mental health issues. “(S)tudents who struggled with symptoms related to depression and anxiety also tended to report struggling with academics …” (Locke et al., 2009, p. 14). These mental health issues present a burden not only for the student, but also for the university counselling centres that are charged to support the student in their pursuit of academic success (Benton, Robertson, Tseng, Newton & Benton, 2003; Gallagher, 2009). Baez (2005), a senior psychologist at a large university counselling centre, emphasized that the clinical practice with college students involves the whole person,  1  including clinical (e.g., single disorders or multiple co-existing disorders) and developmental (e.g., normative adjustment to college) challenges. Several large-scale studies (e.g., ACHA-NCHA, CSCMH, CUSC) have shown that mental health challenges encountered on university campuses are varied, and have been found to be increasing in severity, chronicity, and complexity (Benton, et al., 2003; Erdur-Baker, Barrow, Abserson, & Draper, 2006). Additionally, the increases in mental health symptoms is taking place in the context of stretched campus counselling resources (Gallagher, 2006, 2009). This is further complicated by the sparse presentation of therapeutic outcome research, specifically targeting common mental health challenges experienced by university students who are seen at a university counselling centre. Anxiety is one of these challenges that has insufficient effectiveness research for interventions regarding this unique population and this common disorder (Baez, 2005). Anxiety and Therapy Interventions Anxiety is a mental health challenge that can have both positive and detrimental effects in a student’s academic life and career. Although there are multiple ways to view anxiety, one way to define it is “(a holistic human system that) functions to warn of a potential danger situation and triggers the recruitment of internal psychological and/or external protective mechanisms” (Barlow, 1988, p. 11). Anxiety is a human process that is experienced on physiological, behavioural, psychological, emotional, and social levels. The somatic presentations can include nausea, rapid heartbeat, shallow breath, chest pressure or tightness, chills, hot flashes, muscle tension, queasiness, dry mouth, or sweating (Bourne, 2000; Sullivan, Kent, & Coplan, 2000). The cognitive aspects might be misappraisal, confusion, selective and self-focused attention, negative judgments, and  2  self-talk with themes of worry, future-based fears, and what if’s (Bourne, 2000; Pincus, Ehrenreich, & Mattis, 2008; Rachman, 2004). The affective qualities can be those of being jittery, apprehensive, uneasy, psychologically tense, nervous, distressed, overwhelmed, and/or pressured. The behavioural characteristics can be avoidance or escape (Pincus, Ehrenreich & Mattis). Bourne (1998) outlines a quality of anxiety not often discussed, which is social or contextual disconnection (e.g., separation from family, from community, from nature, from self, and from one’s higher power). Anxiety, as a potent and critical evolutionary system, can be both advantageous to the student-client, and/or it can be devastating and highly disruptive to academic and life tasks. Anxiety is a normative and protective human system that supports safety in the face of a threat of danger. It is easy to see how this could be helpful for survival. In an adaptive form, it could promote a student to study, meet imminent deadlines, and take academic tasks seriously, as not to do so would threaten safety and security as a successful student. However, this helpful system can become threatening in and of itself at high and chronic levels. Anxiety disorders are a class of discrete mental health disorders recognized in North America (e.g., DSM-IV-TR) and globally (e.g., ICD-10); each disorder has its own set of diagnostic criteria. They are described as “intense and prolonged feelings or fear and distress that occur out of proportion to the actual threat or danger. … The feelings of fear and distress interfere with normal daily functioning” (Health Canada, 2006, p. 81). Prevalence statistics in Canada show that approximately 4.7% of Canadians over the age of 15 years met the criteria for at least one of the anxiety disorders over the last 12 months, and approximately 11.5% of Canadians over the age of 15 years met the criteria for at least one anxiety disorder over their lifetime (StatsCan,  3  2002). In addition to discrete anxiety disorders, Brown and Barlow (2009) discuss a transdiagnostic dimensional model involving neuroticism/ behavioural inhibition, and low positive affect/behavioural activation, with types of avoidance strategies (i.e., behavioural and interoceptive avoidance, and cognitive and emotional avoidance) to explain dysfunctional anxiety. Although this particular model is in its genesis form, these leaders in anxiety treatment research stated that transdiagnostic models are useful in that they “may obviate the outcome of incomplete treatment and the necessity of repeated, sequential, and narrowly targeted courses of intervention for each DSM-IV disorder” (Brown & Barlow, 2009, p. 267). Thus, a single treatment modality can support the wellbeing and symptom reduction of many different anxiety sufferers. Anxiety treatment and interventions are numerous. Most of the major therapeutic modalities can be used to assuage anxiety symptoms and distress (DiTomasso & Gosch, 2002). However, few of these treatments have evidence of their effectiveness with reducing anxiety and its symptoms. Treatments such as Cognitive-Behavioural therapy (CBT), Behavioural Therapy (BT), and Acceptance and Commitment therapy (ACT) are the exceptions (see Pincus, Ehrenreich, & Mattis, 2008; Twohig, Masuda, Varra, & Hayes, 2005; Zinbarg, Craske, & Barlow, 2006). Bloom, Yeager, and Roberts (2004) reviewed 59 studies on evidence-based practices with anxiety disorders, and concluded that “brief cognitive-behavioral therapies generally seem to be more efficacious than brief psychodynamic therapy, support psychotherapy, or nondirective therapy” (p. 301). Thus, there are rigorously examined therapeutic interventions designed to work with anxiety that can make substantiated effectiveness statements. However, it is important to ask under which conditions and with which populations can the intervention work (Shadish et  4  al., 1997). An additional burden of clinical effectiveness is the ability to produce reliable and significant clinical outcomes in real world therapeutic clinics, and not just under hygienic and heavily controlled research contexts. The following two studies investigated the effectiveness of two group-based anxiety interventions for university students undertaken on a university campus. Damer, Latimer, and Porter (2010) adapted a cognitive-behavioural group therapy (CBGT) to deal with social anxiety on their specific university campus. Although they did find significant reductions in anxiety and its symptoms, effectiveness statements could not be made because there were no experimental controls utilized by the study. Van Ingen and Novicki (2009) examined the effectiveness of a group therapy for transdiagnostic anxiety at a university counselling center (UCC). And again, as with Damer, Latimer, and Porter, these clinician-researchers found significant differences between pre- and postmeasurements in anxiety, but could not support effectiveness statements because of challenges to internal validity caused by insufficient experimental control. Baez (2005) states that anxiety interventions specifically tailored for university students and rigorously evaluated for effectiveness with this population are few and far between. As mentioned above, the IMAG, a transdiagnostic anxiety group, works with university students self-reporting problematic anxiety. The IMAG however is unique in that its main therapeutic mechanism of change is mindfulness. To date, the IMAG does not have effectiveness evidence supporting its use with anxious university students. Mindfulness and Therapy Interventions Mindfulness (MF) is a 2500-year old strategy for mental, physical, and spiritual wellbeing, originating from the Buddhist tradition. More recently, Western psychological  5  therapeutic programs have appropriated this healing approach to deal with a variety of mental and physical health challenges (Kabat-Zinn, 2000, 2003). Mindfulness is difficult to define, but most broadly it is the cultivation of conscious attention and awareness (Brown & Ryan, 2003). Thich Nhat Hanh (1976) stated that it is “keeping one’s consciousness alive to the present reality (p. 11). Chögyum Trungpa Rinpoche (1974), a Tibetan master, discussed the practice of meditation to build mindfulness. The sheer discipline required to sit, to stay, to be present in one’s own life is “a brave attitude, a sane attitude”; he reflected that mindfulness simplifies one’s mind and slows one down. Some of the therapeutic change mechanisms cultivated through MF are: maintaining a present-moment focus; remaining open and aware of both internal and external contexts; training to relax both the mind and body; shifting to a non-judgmental and accepting stance; learning to respond, and lessen reactivity; de-identifying with mental content; and fostering a curious, open and patient attitude with the self and one’s world. Although largely disconnected from its Buddhist roots, MF in western therapy is now being used in several therapeutic programs. McKee, Zvolensky, Soloman, Bernstein, and Leen-Feldner (2007) showed significant negative correlations between anxiety indicators, and both single-factor and multi-factorial mindfulness indicators. The major mindfulness programs (i.e., Mindfulness-based Stress Reduction [MBSR: KabatZinn, 1990], Dialectic Behavioral Therapy [DBT: Linehan, 1993a], Acceptance and Commitment Therapy [ACT: Hayes, Strosahl, & Wilson,2003]) each have shown success with working with anxiety and anxiety symptoms. Kabat-Zinn and his colleagues (Kabat-Zinn & Massion, 1992; Miller, Fletcher, & Kabat-Zinn, 1995) found that MBSR was effective at reducing anxiety symptoms across the program, and at 3-month and 3-  6  year follow-ups. Tacón, McComb, Caldera, and Randolph (2003) also found significant reductions of anxiety symptoms after a MBSR group for women with heart disease. Although DBT’s mindfulness skills are being used with anxious clients (see Marra, 2004), Gratz, Tull, and Wagner (2005) warn that “there is not yet empirical support for the use of only the skills training component of DBT (separate from the other components)” (p. 148). This is challenging because as DiGiorgio (2009) found, therapists are using components of DBT without knowing the effectiveness of these separate components at reducing anxiety symptoms or supporting a client suffering with anxiety. The following intervention however is the exception. Roemer and Orsillo (2005) developed an integrative mindfulness-based approach for working with Generalized Anxiety Disorder (GAD). These authors created the Acceptance-based Behavioural Therapy for GAD, which is a 16-session program in which mindfulness activities or exercises from MBSR/MBCT, DBT, and ACT were added to a CBT-treatment for GAD. Preliminary findings on the effectiveness of this integrative approach (Roemer & Orsillo, 2005; Roemer, Orsillo, & Salters-Pedneault, 2008; Roemer, Salters-Pedneault, & Orsillo, 2006) are positive, showing significant reductions in anxiety at the end of the intervention and at 3-month follow-up. These researchers suggest that future investigations might focus using this therapy approach in different populations (Roemer & Orsillo, 2005). Additionally, they were interested in exploring the therapeutic change mechanisms actually creating the change (e.g., mindfulness). The above studies investigating the effectiveness of mindfulness-based interventions are showing positive and promising results in terms of these intervention’s  7  abilities to create significant reductions in anxiety symptoms. Toneatto and Nguyen (2007) however temper the exuberance of these findings in an exploration of MBSR effectiveness studies and the specific findings of only well-controlled studies. These researchers report, “MBSR appears to have equivocal effects on the symptoms of anxiety and depression. … Better controlled studies found no evidence for the efficacy of MBSR” (Toneatto & Nguyen, 2007, p. 264). Therefore, further investigation in the area of effectiveness of mindfulness-based interventions and their ability to create change in anxiety symptoms would be advantageous and required. Rationale for the Study Evidence-supported therapeutic effectiveness is an important quality of any therapeutic intervention (Chambless, 1999; Shadish et al, 1997). Given the demands and pressures placed on a university student, an effective anxiety intervention offered at a university counselling centre would be an advantage, not only to the student but also to the centre. The IMAG is a unique and important intervention for many reasons. First, it was designed specifically for university students dealing with problematic anxiety. Second, it can work with transdiagnostic anxiety thus can broaden the catchment of clients and increase the IMAG’s usability in an university counselling center serving a vast variety of students suffering with anxiety and other complex mental health and academic issues. Finally, IMAG’s core mechanism of change is mindfulness, which is becoming a highly used intervention approach. The IMAG’s 10-week program integrates the mindfulness techniques and skills from three well-established therapy programs to create a versatile and potent therapy program. This IMAG however has not been  8  evaluated for its effectiveness with university students who self-report problematic anxiety. For the purposes of this research, the main areas of investigation are: (1) is the IMAG effective at reducing anxiety symptoms in student-clients, and (2) is the IMAG effective at increasing the qualities of mindfulness in the student-clients. Additionally, exploring the student-clients’ experience of change (or lack thereof) in the IMAG is important to understand not only the possible change mechanisms utilized by the IMAG but also to provide insight in how to strengthen or improve the IMAG’s delivery and effectiveness. Given that therapy groups like the IMAG might increase in the future as mindfulness as a change mechanism for anxiety becomes more accepted, it is important to understand how effective it is with university students and how to make this specific group (i.e., IMAG) more potent in supporting these students in their academic tasks. Overview of the Dissertation There are a total of eight chapters comprising this dissertation research. This chapter was a general orientation to the study and its aims. The second chapter provides a more in-depth review of the current literature supporting this study as well as outlines some of the gaps in the literature that this current study addresses. The research questions guiding this study are reviewed at the end of the second chapter. The third chapter describes the research methodology being used by this study, the student-participants and the IMAG, the study’s procedures, and the four data analytic strategies being used to answer the research questions. The next four chapters present the results of the study. The fourth chapter presents the frequency and the types of skills and techniques practiced by the participants and the group. The fifth chapter presents the results from the Small-N  9  Visual Analyses. The sixth chapter presents the results from the Group-based WithinSubject Analyses. The seventh chapter presents the results from the Thematic analysis of the post-group interviews. The final chapter discusses these results in the context of the research questions, as well as the unique contributions and the limitations of this study, and future research suggestions. This final chapter included statements about the IMAG’s effectiveness, and future directions that could improve and enhance this important intervention.  !  10  CHAPTER TWO: LITERATURE REVIEW This chapter outlines the literature underlying this study. This research project explored the effectiveness of an integrative mindfulness-based anxiety intervention (IMAG) for university or college students who self-report problematic anxiety. There are three key areas of literature reviewed in this chapter. The first area of literature is university or college students and the mental health challenges that the students face. Understanding mental health challenges of students leads this review into a discussion of campus counselling centres and their role in working with student populations and their mental health challenges. The second area of literature is anxiety, which is one of the most prevalent mental health challenges within the general population as well as on the university campus. Within this topic, the clinical definitions and a component analysis are undertaken. A particular focus is placed on current popular and evidence-supported anxiety interventions. The final area of literature to be reviewed is an overview of mindfulness and mindfulness-based clinical interventions. This section includes a description of the IMAG (formerly the Challenging Anxiety Group [CAG]), the anxiety intervention explored by this current study. Additionally, definitions of mindfulness, and its respective anxiety interventions are reviewed. To end, this literature review summarizes the main rationale of the study, provides the research questions guiding this research, its expected findings, and a conclusion for the chapter. University or College Student The University of British Columbia’s homepage (www.ubc.ca) describes the life of a university or college student as involving transition, growth, and learning. University or college education requires considerable determination, achievement,  11  commitment, and possibly sacrifice. At the core of the student’s academic task is the successful completion of a program of study, which can support a future career and possibly wage-earning potential. For this, the student invests considerable personal resources into academic success. To understand Canadian university students better, the Canadian University Survey Consortium (CUSC) surveyed 11,981 undergraduate students at 31 Canadian campuses (CUSC, 2008). This report found that the average student age is 22 years, and female. At the undergraduate level, females currently outnumber males by about 2:1. About half of the students have majors in the Arts and Humanities (24%) or Social Sciences (22%), with the remaining students completing majors in Business (13%), Biological Sciences (13%), and other majors (28%). Most have full-time status (92%). Nineteen percent report being a part of an ethnic or minority group. Six percent report having children. Approximately eight percent of students have identified themselves as having a challenge or disability, with either a learning or mental health disability being most prevalent. Interestingly, the age of the average undergraduate student is within the age range of onset for many major psychological disorders (e.g., anxiety, schizophrenia, mood disorders) (APA, 2000). According to the CSCMH student health report, thirtyfive percent of students reported taking psychiatric medications at some time in their life (Locke et al., 2009); psychotropic medication may have allowed broader access to academics for a student that might not have formerly been able to manage both scholastic and mental health demands (Kitzow, 2003). In the area of work or employment, the above CUSC survey (2008) found that students spend about 33 hours a week on school-related tasks: 16 hours in class and 17  12  hours out of class. Time spent on academics however fluctuates depending on the discipline (e.g., engineering students typically spend about 44 hours on academics). Approximately 49% of students have a job, and work about 17 hours per week. Of these individuals, about 60% stated that employment has some negative consequences on their academic success. Forty-nine percent indicated that they had some debt resulting from their education; on average, students carry about $19,000 of debt, with increases in this amount as school progresses. This is important because financial strain can be associated with stress and mental health challenges (Andrew & Wilding, 2004; Eisenberg, Gollust, Golberstein, & Hefner, 2007). Thus, being successful in academics occurs in the larger context of the student’s life, which can have other responsibilities or obstacles. One of the most profound challenges to a student’s academic success is difficulty with one’s own mental health. University Student Mental Health Academic success is tied to mental health. “(S)tudents who struggled with symptoms related to depression and anxiety also tended to report struggling with academics …” (Locke et al., 2009, p. 14). Transitions, personal expectations, interpersonal challenges, and academic demands can represent psychosocial or environmental stresses, which can worsen existing mental health problems, overwhelm coping systems, and/or strain cognitive, emotional, or social resource-bases. Kessler, Foster, Sauder, and Stang (1995) found in a sample of 5877 subjects that anxiety, mood disorders, substance abuse, and conduct disorder were all significantly predictive of academic failure at the high school or university level; conduct disorder was particularly disruptive for males, and anxiety disorders created substantial obstacles for females.  13  When the prevalence of depression and anxiety in undergraduate students was 15.6%, and 13% in graduate students (Eisenberg et al., 2007), psychopathology or mental health challenges begin to appear as obstacles to success for both the student and the academic institution alike. To further understand these challenges in student populations, American College Health Associations- National College Health Assessment (ACHA, 2009) surveyed 80,121 students from 106 academic institutions across the United States and Canada. Although this largely web-based survey inquired about physical and mental health, only mental health information is reviewed here. In terms of reported health impediments to academic performance, stress was reported by 33.9% as the highest ranked health issue to impact academics; stress was reported more frequently by females (37.5%) than males (27.2%). Other mental health concerns impacting academic performance was the thirdranked sleep difficulties impacting about 25.6% of surveyed students; the sixth-ranked depression/anxiety disorder/SAD (16.1%); and the seventh-ranked relationship difficulties (15.9%). Of the top rank-ordered health problems most concerning to students over the year, depression was fourth and anxiety was seventh. Although there are broad health challenges concerning students, mental health issues are amongst the top ranked student concerns impacting academics. Taking a closer view of mental health in the above-mentioned ACHA-NCHA survey (ACHA, 2009), 14% students reported a depression at some point in their lives. Of these depression-reporting students, 32% indicated a diagnosis in the past school year, with 25% currently attending therapy, and 36% taking medication for depression. Approximately 1% attempted suicide at least once during the school year, and about 9%  14  reporting seriously considering suicide at least once. In terms of frequency of mental health difficulties, students reported feeling the following challenges over nine times in the last school year: overwhelmed (36.7%), exhausted (35.6%), sad (17.3%), hopeless (12.3%), and depressed to the point it was hard to function (8.9%). Students felt the following challenges between 5 - 8 times during the past school year: overwhelmed (25.5%), exhausted (24.5%), sad (15.5%), hopeless (11%), and depressed to the point it was hard to function (8.9%). This cross-sectional study not only emphasized the prevalence of mental health challenges in a large university sample, but also outlined the variety of psychological challenges that can be found on a campus. The next two longitudinal studies follow mental health challenges over both a semester, and across a program of study. Andrews and Wilding (2004) investigated depression and anxiety over a semester. These authors surveyed 351 undergraduate students before the semester and at the midpoint in the semester. They found that 9% of symptom-free students had depressive symptoms by the mid-point. Surprisingly, clinically significant anxiety symptoms had manifested at the semester mid-point in about 20% of prior symptom-free students. Thus, academic demands may worsen mental health over certain points in a semester. However, this was not always the case. Thirty-six percent of students with symptoms at the beginning of the semester were symptom-free by the semester mid-point. Andrews and Wilding surmise that a stable structure, rules and procedures, and predictable expectations possibly can improve a student’s psychological condition. Thus, the academic context plays a complex role in a student’s mental health; it can be an agent influencing health, and it can be an environment in which health (or dysfunction)  15  manifests. Understanding this complexity along with the uniqueness of the student’s needs is arguably important for the successful treatment of the student-client. Zivin, Eisenberg, Gollust, and Golderstein (2009) surveyed 763 university students in 2005 and again in 2007. These authors used a variety of brief screening instruments (i.e., depression, anxiety, eating disorder, self-injury, and suicidal thoughts) to assess mental health. The findings showed that over half of the students suffered from at least one mental health problem at some point in the study (i.e., either baseline or follow-up). Sixty percent of those who had elevated scores in 2005 still had similar scores in 2007. Of those students who had elevated scores at both times in the study, less that half of these students received treatment for their difficulties. This study shows not only the prevalence but also the persistence of mental health challenges in a university student population. Although mental health is important to academic success, this research warns that students are not necessarily pursuing clinical support for their challenges. When dealing with a mental health challenge, one of the main sources of support for a student is a university’s counselling centre (UCC). Benton and her colleagues (2003) reviewed a counselling centre’s archival clinical information for over 13,000 client-students over the span of 13 years. The findings of this research show that students’ mental health issues are becoming more complex, chronic, and severe. Research by Erdur-Baker, Aberson, Barrow, and Draper (2006), and Gallagher (2006, 2009) each echo this finding. “The number of students seen each year with depression doubled over the time period, while the number of suicidal students tripled and the number of students seen after a sexual assault quadrupled” (Benton, Robertson, Tseng,  16  Newton, & Benton, 2003, p. 69-70). Benton and her colleagues (2003) also showed many mental health challenges (e.g., stress and anxiety) have steeply increased over the 13 years, and have stabilized at these high levels towards the end of the study. Overall, these authors conclude that greater mental health severity and complexity in students will require more resources to meet these new demands. They also critique the availability of these resources in the community, and acknowledge that “the role of providing care (will primarily rest) in the hands of the counseling center staff” (p. 72). Thus, the student’s mental health challenges have ramifications for both the student, and the university campus trying to support the success of these students in their programs. University Counselling Centres University counselling centres (UCC) are charged with the task of helping students meet their academic goals. “(T)o assist a student to define and accomplish personal, academic, and career goals” through providing developmental, preventive, and remedial counseling (Council for the Advancement of Standards in Higher Education [CAS], 2008, p. 5) succinctly states a UCC’s goals. The National Survey of Counseling Center Directors (NSCCD) reports on the changing roles and duties of counselling centers (Gallagher, 2009). Following is some of their findings. In 2008, over 300 university counselling center directors reported that 2.6 million students were eligible for clinical services at the various UCCs, with approximately 10.4 % of students or 270, 000 students actually seeking help. This creates a ratio of 1 counsellor to 1527 students. Remarkably, many more students (32.5%) were supported through other services, such as through workshops or campus outreach. Many centers provide free services, with only 6.1% charging nominal fees for  17  personal counselling; the mean counselling centre fee was $13.00 per session (Gallagher, 2009). This would be important for students whose financial resources are being subsumed by tuition and related fees. Correspondingly, several of these directors (66.2%) also reported concerns about the growing demand for services without adequate or appropriate increases in resources from the universities (Gallagher, 2009). Although UCCs provide affordable mental health support on campuses, these services may be stretched due to said ratios, and demands of a large student body. When asked about current psychological trends, Gallagher (2009) reported that the directors have consistently reported an increase in the severity of the psychological issues being seen at the centres; 92% of directors in 2006 and 93.4% of directors in 2009 reported this pattern (Gallagher, 2006, 2009). Even with stretched resources and increases in client difficulties, many of the directors agreed that the various treatment modalities provided at their centres (e.g., eclectic/ integrative, cognitive-behavioural therapy, psychodynamic, developmental) were successful in supporting or treating most students with mental health challenges. The statement of efficacy for campus-based services is supported by the CSCMH study that used pre- and post-therapy data from over 1500 students who utilized UCC counselling services (Locke et al., 2009). This study found that students had statistically significant decreases for depressive symptoms (d=0.87), and suicidal ideation (d=0.37) over the six-weeks of treatment at a counselling centre. This finding held even for students who self-reported high levels of depressive symptoms. Impressively, “students who initially presented with a more significant history of suicidal ideation, and thus are at higher risk for a future suicidal attempt, exhibited an even more pronounced decrease in  18  suicidal ideation after treatment” (Locke et al., 2009, p. 13). Locke and colleagues concluded that UCCs play an important role in the maintenance of mental health and safety of university and college students. Although the above shows that UCC services have been found to be clinically and financially effective for students, Baez (2005), a senior psychologist at a large UCC, highlighted the lack of clinical outcome research focused on the effectiveness of clinical interventions for common mental health challenges at universities. He states: Campus based therapists wanting to know the EBT (evidence-based treatment) literature in our field would likely be disappointed by the scarcity of outcome research on the anxiety disorders in college mental health. Moreover, the majority of the existing empirical evidence in college settings is based on nonclinical samples, especially psychology student volunteers. (Baez, 2005, p. 37) Although UCCs are charged with the task of supporting a mass variety of students with progressively worsening symptoms and disorders, outcome research specifically focused at supporting counselling centres and the populations they serve is sparse. This is troubling given the scope of the mental health problems faced, and the importance of the academic success for students and institutions alike. Summary University counselling centres (UCC) play an important role in helping students achieve academic success, even in the face of mental health challenges. They are a core resource for supporting university student’s mental health. The findings above show a successful post-therapy decrease in depressive symptoms and suicidal ideation, both mental health challenges that can have devastating consequences. Thus, not only are  19  UCCs a central mental health resource for students, they can be very successful. However, therapeutic outcome research focused specifically on common mental health issues impeding university students is not always available. Huge campuses, with heterogeneous student populations, with varied health challenges sets-up university counselling centres with the overwhelming task of servicing these students and supporting their academic tasks. The directors acknowledged the increased complexity and severity of mental health problems that university students are grappling with, and they also outline stretched and inadequate resources to deal with the increasing demands being placed on UCCs by students and campus administrations. Therefore, an intervention capable of supporting a student’s successful management or assuaging of anxiety would be helpful to a university counselling centre, particularly if the intervention was able to work with a group of students simultaneously thus lessening the demands on the counselling centre staff, and increasing the service capacity of the counselling center. Gap in the literature. Baez (2005) clearly outlines a gap in the literature: the need for evidence-supported anxiety treatments for university students dealing with problematic anxiety who are seeking support from an UCC. “(S)tudents who struggled with symptoms related to … anxiety also tended to report struggling with academics …” (Locke et al., 2009, p. 14). Thus, researching the effectiveness of an anxiety group-based intervention for counselling centres would seem to be a worthwhile and supportive endeavour for both students and campuses alike. As reviewed above, there are a multitude of mental health challenges that can be found on a university or college campus, with one of the most common being anxiety.  20  The next section explores the mental health challenge of anxiety and the interventions that are designed to help clients (and student-clients) deal with anxiety symptoms and/or anxiety disorders. Anxiety Anxiety is a relatively common mental health challenge on a university campus, and it can have a detrimental impact on students’ “academic performance, attendance, retention, career selection, relationship development, as well as on their physical health and general well being” (Baez, 2005, p. 35). Several authors note that anxiety is related to and can precede other mental health challenges, such as depression, substance abuse, alcoholism, and suicidal behaviour (Baez, 2005; Barlow, 1988; Marra, 2004). Anxiety also is mentioned by all of the major studies reviewed above (e.g., CSCMH, CUSC, NCMH-ACHA) as being a prevalent and persistent mental health challenge on campuses. However, as Barlow (1988) points out, without anxiety few accomplishments would be undertaken, performance of students would suffer, creativity would decrease, and motivation would be low. For many, anxiety is a normal and advantageous emotional state, which promotes safety and achievement. Thus, there seems to be a continuum of anxiety ranging from the helpful to the harmful, with both ends of the continuum being present on campuses. Anxiety Definitions Anxiety is a universal human experience, and a highly valuable system that activates in the face of a perceived threat. Bourne (2000), the author of one of the most popular anxiety workbooks, describes that an anxiety reaction can be “appropriate and reasonable” (p. 4) and continues onto say, “if you didn’t feel any anxiety in response to  21  everyday challenges involving potential loss or failure, something would be wrong” (p.4). The Yerkes-Dobson effect states that low and high arousal can both be detrimental to both physiological and psychological performance; yet optimal performance requires some moderate-range arousal (Gorbatkov, 2008). In other words, normative anxiety is adaptive in contexts where actual potential harm or threat is present, or advantageous at moderate levels in performance tasks or environments. Although anxiety can be a normative and protective process, current pressures and demands in life can increase the experience of threat in a variety of areas in a vulnerable person’s life tasks, and subsequently increase the experience of anxiety. Anxiety is seen by some to be endemic to modern times, as this century is labelled the “age of anxiety” (Bourne, 1998, p. 19). Not only can anxiety be a response to a threat, it also can become the threat at high levels. Anxiety, functional or dysfunctional, is difficult to define, and there is not much agreement in the literature on a single definition. The word anxiety arguably comes from the Latin word angh, which refers to the concept of narrowness or constriction (Barlow, 1988). However, this definition does not seem to correspond to the various ways to define it in the literature. Following are some of these definitions: “(t)he feeling of difficult to describe discomfort in anticipation of some poorly defined threatening situation” (Sullivan, Kent, & Coplan, 2000, p. 17); “a feeling of uneasy suspense, the tense anticipation of a threatening but obscure event” (Rachman, 2004, p. 26); “the occurrence of disordered stimulus evaluation as it is conditioned through the conflict of the organism with a certain environment which is inadequate for it” (Goldstein, 1939, p. 295); or, “(a) function to warn of a potential danger situation and triggers the recruitment of internal psychological and/or external protective mechanisms” (Barlow, 1988, p. 11).  22  According to these definitions, anxiety involves negative affect in response to a threat or the apprehension about a perceived threat. There are less conventional definitions. Sarbin (1968) saw anxiety as “a class of mental state words in psychology, words that seem to lead lives of their own- their status uninfluenced by empirical events or by rational argument” (p. 411). He also discussed anxiety as a reified metaphor (Sarbin, 1968). Hallam (1994) posited anxiety as a personal construct able to describe a broad range of experiential states, which could differ from person to person. Finally, Barlow (1988) added to his considerable discussion, an existential definition and purpose to include anxiety as “a higher level of existence and a greater appreciation of what it is to be alive” (p. 10). Although anxiety can mean many different things to different theorists, it is more often understood through how it is experienced. Perhaps, the narrowness and constriction found in the word can be found in the experience. Anxious experience is a holistic one. It occurs on physiological, behavioural, psychological, emotional, and social levels. The somatic presentations can include nausea, rapid heartbeat, shallow breath, chest pressure or tightness, chills, hot flashes, muscle tension, queasiness, dry mouth, or sweating (Bourne, 2000; Sullivan, Kent, & Coplan, 2000). The cognitive aspects might be misappraisal, confusion, selective and self-focused attention, negative judgments, and self-talk with themes of worry, futurebased fears, and what if’s (Bourne, 2000; Pincus, Ehrenreich, & Mattis, 2008; Rachman, 2004). The affective qualities can be jitteriness, apprehensiveness, uneasiness, psychologically tense, nervous, distressed, overwhelmed, and/or pressured. The behavioural characteristics can be avoidance or escape (Pincus et al., 2008), but the  23  response behaviours also can be effective coping and/or facing the threat. This is an important distinction because avoidance and escaping patterns can ultimately maintain the perceived threat, and sustain and even strengthen the anxious experience. Bourne (1998) outlines a quality of anxiety not often discussed, which is social or contextual disconnection. He outlines several areas of disconnection that can happen for the anxious person: separation from family, from community, from nature, from self, and from one’s higher power (e.g., God, Goddess). Thus, the anxious experience might be an orchestrated response with all of the above areas activated. Or, there may be only one or a couple of these facets activating for the anxious individual. Regardless, anxiety will expend resources, and can leave the individual feeling wired and tired. When activated, anxiety also tends to be prevalent or dominant in the subjective experience of the person, not leaving a lot of psychological resources for other systems or processes. The following is a description of the unfolding of the subjective anxious experience. Rachman (2004) described the experiential sequence of the anxious process. He discusses the anxious person’s global scanning in order to find the threat in the environment. Once a threat is detected from the global scan, “the person’s attention then focuses narrowly and intensely on the potential threat, with enhanced perceptual sensitivity and even distortion” (p. 27). This enhanced perception allows for sustained attention and focus on the threat, and according to the interpretation of the threat, may lead to a particular response to the situation (e.g., avoidance or escape). Other characteristics attributed to the anxiety process are: vulnerability, sensitivity, vigilance, selective attention, self-focused attention, interpretation/misinterpretation, and  24  consequences (i.e., avoidance and escape) that reinforce and strengthen the initial process (Rachman, 2004). Interestingly, this process can take place in an actual situation, in preparation to engage in a particular situation, or in a hypothesized situation. Anxiety can occur in preparation or in apprehension, thus can lead one to avoid the potential perceived threat. Thus, maladaptive attempts (e.g., avoidance and escape) to decrease this negative emotion can actually sustain and strengthen the anxious response through maintaining the threat. More recently, Barlow (2000) and Barlow, Allen, and Choate (2004) have investigated anxiety from within a theory of emotion. He describes an anxiety process as “a coherent cognitive-affective structure within a defensive motivational system” that has at its heart “a sense of uncontrollability focused largely on possible future threat, danger, or other upcoming potentially negative events … where the danger is present and imminent” (Barlow, 2000, p. 1249). This system brings about a state of helplessness in regards to the perceived lack of control to bring about desired outcomes (Barlow, 2000). He also discusses the etiology of anxiety from a triple vulnerability standpoint: a generalized heritable (biological) vulnerability, a generalized psychological vulnerability set up by one’s sense of control in early life, and a second, more specific psychological vulnerability where one learns to focus anxiety on situation or objects (Barlow, 2000; Suarez, Bennett, Goldstein, & Barlow, 2009). What is posited is that anxiety disorders are “essentially disorders of emotion” where “deficits of emotional regulation are found in each of the disorders … (and) maladaptive regulation strategies … contribute to the persistence of symptoms” (Brown & Barlow, 2009, p. 267). He and his colleagues  25  (Brown & Barlow, 2009; Campbell-Sills & Barlow, 2007; Moses & Barlow 2006) have forwarded an emotional regulation approach to anxiety and mood disorder treatment. In summary, anxiety is a powerful, important, and holistic human system, which can promote achievement, adjustment, and protection and safety. Anxiety announces a threat to the individual, and involves both intrapersonal and interpersonal characteristics as anxiety alerts to, focuses on, and mobilizes for action to respond to the threat. This evolutionary system produces a response to one’s environment that can be either adaptive or maladaptive. In terms of anxiety with college or university students, adaptive anxiety can promote studying or preparation, meeting deadlines, taking one’s tasks seriously and responsibly, and striving to do one’s best. Adaptive anxiety (e.g., anxiety at low or moderate levels) might be evidence of the student’s growth, learning, and achievements as they challenge and surpass the limits of who they were. Dysfunctional anxiety however can have the opposite effect. Goldstein (1939), a psychiatrist and neurologist, reflected that fear brings acuity to the senses, whereas anxiety brings paralysis. Problematic anxiety will activate a high demand and priority system in order to address or redress a threat that is not necessarily a veridical risk to the person. Thus, the actual risk is low, but the perceived threat is high. This threat activates and locks a highly consuming system that can create damage psychologically, physiologically, emotionally and/ or socially. Needless to say, it can severely interfere with the academic tasks of a university or college student. The following is a discussion of the classes of dysfunctional anxiety acknowledged by the psychological and psychiatric communities.  26  Anxiety Disorders Anxiety disorders are a cluster of psychological disorders that differ from normative anxiety in several ways: the disorders are more intense; they last longer; they are maladaptive or dysfunctional in the person’s life (Bourne, 2000). The prevalence of anxiety disorders is that approximately one in eight Canadians between the ages of 15-64 reported meeting the criteria for an anxiety disorder over their lifetime; 4.7% of Canadians met criteria for an anxiety disorder over the last 12 months (Health Canada, 2006). Anxiety disorders can be described as “intense and prolonged feelings of fear and distress that occur out of proportion to the actual threat or danger” and “the feeling of fear and distress interferes with normal daily functioning” (Health Canada, 2006, p. 80). Psychological and psychiatric communities have created several categories for discrete anxiety disorders; each disorder has its own set of criteria for the purposes of diagnosis. The Diagnostic and Statistical Manual of Mental Disorders-IV- Text Revision (DSM-IVTR: American Psychiatric Association [APA], 2000) reports on 12 disorders; International Statistical Classification of Diseases and Related Health Problems-10 (ICD10: World Health Organization [WHO], 2010) also portrays 13 disorders, however they have similar yet different symptom constellations and disorder names. The following are several DSM-IV-TR (APA) brief descriptions of these disorders and their prevalence statistics. Panic disorder. This disorder is evidenced by a persistent concern of having an unexpected panic attack (e.g., sudden onset of the feelings of apprehension and doom, combined with distressing symptoms, such as shortness of breath, tightness in the chest,  27  sweating, and shaking) (APA, 2000). In 2002, between 1.4 % - 1.9% of Canadians 15 years or older met criteria for a panic disorder over a 12-month period, with a lifetime prevalence of 1.4% – 4.6% (Health Canada, 2006, p. 83). This corresponds to the DSMIV-TR lifetime prevalence rate of 1% - 2% (APA, 2000, p. 436). Generalized anxiety disorder. This disorder is characterized by excessive anxiety and worry for at least six months (APA, 2000). There is a prevalence rate of 3% over a 12-month period, and 1% over a lifetime period (APA, 2000). Social (or performance) phobia. This disorder is characterized by extreme fear and avoidance of social and/or performance situations, where there is a possibility of being embarrassed, humiliated, or observed (APA, 2000). In 2002, between 0.9 % - 4.7% of Canadians 15 years or older met criteria for a social anxiety disorder over a 12-month period, with a lifetime prevalence of 2.6% – 9.4% (Canadian Community Health Survey as cited in Health Canada, 2006, p. 83). In a community sample, there is a prevalence rate of 3% -13% over a lifetime period (APA, 2000). Specific phobia. This disorder is evidenced by substantial and excessive fear of a specific object or situation, such as flying, heights, and animals (APA, 2000). In a community sample, the prevalence rates are between 4% - 8.8%, and over a lifetime is 7.2% - 11.3% (APA, 2000). Obsessive-compulsive disorder. This disorder is characterized by obsessive thoughts that cause marked anxiety or distress, and/or repetitive or compulsive behaviours that occur in response to an obsession or in a ritualistic way (APA, 2000). In a community sample, the 1-year prevalence rates are between 0.5% - 2.1%, and over a lifetime is 2.5% (APA, 2000).  28  Post-traumatic stress disorder. This disorder characterizes re-experiencing a past traumatic event that is accompanied by increased arousal or avoidance around the trauma event stimuli (APA, 2000). In a community sample, there was a lifetime prevalence rate of 8% (APA, 2000). Agoraphobia. This disorder presents when escaping from a situation or a place might be difficult or embarrassing, thus avoidance ensues (APA, 2000). Although there is professional agreement about this classification, there are authors that are investigating alternative ways of understanding anxiety disorders. Brown and Barlow (2009) proposed a dimensional classification system, which is based on the shared aspects of anxiety and mood disorders. These authors discuss some of the difficulties with the above classification being measurement error, diagnostic comorbidity, and challenges with “categorical threshold on the number, severity, and duration or symptoms” (p. 259). Brown and Barlow (2009) presented a higher-order dimensional model: neuroticism/behavioural inhibition, and low positive affect/behavioural activation, with types of avoidance strategies (i.e., behavioural and interoceptive avoidance, and cognitive and emotional avoidance). Although in its nascent form, these two leaders in the area of anxiety research suggest that including a dimensional understanding of anxiety could complement the existing categorical diagnosis, and help to include important therapeutic features that would be missed with the current framework. Brown and Barlow (2009) also add that a dimensional understanding promotes a possibility of “a transdiagnostic treatment protocol” (p. 266), which “may obviate the  29  outcome of incomplete treatment and the necessity of repeated, sequential, and narrowly targeted courses of intervention for each DSM-IV disorder” (p. 267). The next section reviews literature and research regarding the treatment for anxiety difficulties and clinical interventions with current anxiety disorders. Anxiety Treatment or Intervention Given the prevalence and the disruption that anxiety can cause in someone’s life, clinical treatment and intervention is important for supporting the person struggling with problematic or dysfunctional anxiety or someone dealing with one or more anxiety disorders. There is a voluminous quantity of anxiety treatment and outcome literature and research. Some of this literature is in the popular therapeutic domain, and some of it is scientific-based outcome research. The following is a cross-sectional review that discusses some current approaches to clinically working with anxiety. As outlined above, there is not a single definition of anxiety and there are a many different manners that anxiety, functional or dysfunctional, can present itself in a person’s experience. Being that anxiety is one of the most prevalent disorders in the modern time, it is not surprising that there are many ways in which a therapist could approach clinically working with an anxious person. DiTomasso and Gosch (2002) edited a book comparing how 11 different possible treatments dealt with an anxious client; these interventions were Cognitive-behavioural therapy (CBT), Problem-solving therapy, Acceptance and Commitment Therapy (ACT), Context-centered therapy, Contextual-family therapy, Adlerian therapy, Interpersonal psychotherapy, Person-centered therapy, Supportiveexpressive therapy, Psychodynamic therapy, and psychopharmacological treatment (PPT).  30  Although only a few of these therapy-types had outcome research supporting their use (eg., CBT, ACT, PPT), all of the above interventions provided a rationale for their theoretical conceptualization of anxiety, the change mechanisms behind the intervention they proposed, and the logic for the approach that the intervention would take with the client (DiTomasso & Gosch, 2002). Thus, although there may be an abundance of anxiety interventions, there are few intervention types that have evidenced their effectiveness with anxiety. This echoes the challenges outlined by Baez (2005); there are few evidenced-based anxiety interventions for use on college campuses with university students. Bourne (2000) approaches the problem of treatment slightly differently. He reviews the anxiety disorders and the popularly accepted treatments. Following is Bourne’s list of the disorders and possible corresponding interventions. •  Panic disorder: relaxation training, panic-control therapy, interoceptive desensitization, medication, lifestyle & personality changes  •  Agoraphobia: relaxation training, graded exposure, cognitive therapy, medication, assertiveness training, group therapy  •  Social/performance phobia: relaxation training, cognitive therapy, imaginal & real-life exposure, medication, social skills training, assertiveness training  •  Specific phobia: relaxation training, cognitive therapy, incremental exposure  •  Generalized anxiety disorder: relaxation training, cognitive therapy, problemsolving, distraction, medication, lifestyle & personality changes  •  Obsessive-compulsive disorder: relaxation training, cognitive training, exposure & response prevention training, medication, lifestyle & personality changes  31  •  Post-traumatic stress disorder: relaxation training, cognitive therapy, exposure therapy, medication, support groups Specific anxiety disorder interventions are the most common researched or  evidence-based interventions in the anxiety therapy literature. Bloom, Yeager, and Roberts (2004) reviewed 59 studies on evidence-based practices with anxiety disorders, and concluded that “brief cognitive-behavioral therapies generally seem to be more efficacious than brief psychodynamic therapy, support psychotherapy, or nondirective therapy” (p. 301). These authors also found that these brief therapy practices could be in either individual or group formats and be effective, but that directed programs generally had better outcome results. The following reviews two disorder specific cognitivebehavioural therapy programs, which have empirical evidence supporting the therapy program’s effectiveness. Pincus, Ehrenreich, and Mattis (2008) developed a therapy program named, Mastery of Anxiety and Panic for Adolescents. This 11-session intervention is designed to work with adolescents who struggle with anxiety and panic. The manual also provides an opportunity for the parents to be involved in their child’s treatment. The sessions covered the following areas: the introduction to intervention and the component model (i.e., feelings, thoughts, and behaviors), the physiology of panic and breathing, cognitive component covering probability over-estimation and catastrophic thinking, cognitive restructuring, interoceptive exposure, introduction to the situational exposure, safety behaviors and exposure, exposure sessions, and relapse prevention and therapy termination. Additionally, the authors of the manual review the research that supports this model. The effectiveness of this program was evaluated using a wait-list control  32  design. A total of 24 adolescents completed this program, and significant differences were found from pre-intervention to post-intervention in the areas of severity of panic symptoms, as well as in anxiety sensitivity. Interestingly, the control group means remained in the clinical range, whereas the intervention group fell to sub-clinical levels and maintained these gains at a 3-month follow-up (Pincus, May, Whitton, Mattis, & Barlow, 2008). The second program, Mastery of Your Anxiety and Worry, 2nd Edition (Zinbarg, Craske, & Barlow, 2006), focused on adults with Generalized Anxiety Disorder (GAD). This 10-session (or more if need be) covers: an introduction to the intervention and the disorder, learning to recognize anxiety, understanding anxiety’s function and purpose, learning to relax, controlling thoughts (e.g., overestimating risk, thinking the worst), learning to face fear, dealing with real life problems (e.g., time management, goal setting, and problem solving), medication options, and reviewing accomplishments and terminating the intervention. The efficacy of this program was established using a waitlist control design (Zinbarg, Lee, & Yoon, 2007). The results showed that 50% of those who completed were within one standard deviation of the non-clinical mean on four of the five indicators. Another 37.5% of the participants were within one standard-deviation on between two or three of the five indicators. Thus, these two programs show outcome evidence for a CBT approach for the disorders of panic in adolescents, and GAD in adults. As stated above, the anxiety disorder specific interventions and their corresponding research are abundant. Less available is effectiveness research with anxiety disorders in particular contexts.  33  The following reviews a treatment for social anxiety with university students. Damer, Latimer, and Porter (2010) adapted a cognitive-behavioural group therapy (CBGT) to deal with social anxiety on their specific university campus. These authors adapted the CBGT in the areas of duration (i.e., shortened therapy from 12-24 weeks, to 8 weeks), length (i.e., shortened sessions from 2.5 hours, to 1.5 hours), size (i.e., 5 members, to up to 10 members), and focus (from individualized exposure plans, to common social anxiety-inducing situations). They did report however that the treatment component of cognitive restructuring and exposure remained the same between the original and modified programs. To evaluate this adapted group, 12 student-clients completed pre- and post- measurements, and it was found that there were significant decreases in social interaction anxiety and phobia. It should be noted that there were no experimental control options utilized in this outcome evaluation. Thus, these clinicians needed to make changes to a CBGT program to fit the unique needs of their college counselling center. Although an evaluation was undertaken, no statements of effectiveness can be made given the inadequacy of the effectiveness research design. In addition to anxiety disorder specific interventions, Barlow and other authors are exploring and developing transdiagnostic anxiety treatments (e.g., Brown & Barlow, 2009; Campbell-Sills & Barlow, 2007; Eifert et al., 2009; Kabat-Zinn & Massion, 1992). Wolfe (2005) proposes a synthesis across several major psychotherapy theories (e.g., Behavioural, Psychodynamic, Social Learning, CBT, Experiential), and arrives at an integrated approach with three goals, which are “(a) reduction of symptoms, (b) analysis and modification of defenses against painful self-views, and (c) healing self-wounds” (p. 191). There is no effectiveness research for Wolfe’s model. Moses and Barlow (2006)  34  forwarded transdiagnostic anxiety treatment approach emphasizing emotional regulation as a change mechanism, and has integrated the “most salient components of the currently empirically supported individualized treatment for various specific anxiety and mood disorders” (p. 148). This approach also has three components: “(a) altering antecedent cognitive appraisals, (b) modifying emotion-driven behaviours, and (c) preventing emotional avoidance” (p. 148). Transdiagnostic anxiety approaches allow clinicians to serve a more heterogeneous population of clients who suffer from anxiety. Additionally, these approaches were integrative across several therapy programs to capture the salient and change promoting components. van Ingen and Novicki (2009) examined the effectiveness of a group therapy for transdiagnostic anxiety at a university counselling center (UCC). These authors were interested if a CBGT could work in the real life setting of a UCC, with university students struggling with anxiety; these clinician-researchers also do not distinguish across the anxiety disorders and allowed clients presenting with one or more of the disorders into the group. Although not integrative, they did allow group process to supplement the change mechanisms of the CBGT. Of the 31 clients who started, it is reported that 17 clients completed the 20 or more sessions of the CBGT. The stated goal of the research “was management, not elimination of anxiety symptoms to allow more satisfactory functioning in the participant’s daily lives” (van Ingen & Novicki, 2009, p. 246). This CBGT had the basic CBT components of exposure therapy, ritual prevention, cognitive restructuring, psychoeducation, breathing exercises, social skills training, and cognitive-behavioural  35  modification. These authors also included group process (e.g., member-member learning and support, group cohesion) as an active change mechanism in the CBGT. The results showed significant decreases found in the self-report measure between pre-group and post-group; this measure assessed issues such as general anxiety, anticipating anxiety, depressed mood, and other clinical indicators (van Ingen & Novicki, 2009). The identified shortcomings of this research were the expert anxiety therapists coleading this group making it difficult for generalizability, a single self-report measure being used to measure change, and not controlling for time. These authors suggest future research to increase internal validity by using a research design with a control, thus allowing for stronger effectiveness statements to be made. Summary Anxiety is a common mental health challenge in Canada, and on Canadian university campuses. Anxiety can occur at levels that are helpful and motivating, or it can exceed these levels to become distressing, and even disordered. Anxiety at these levels would be disruptive even detrimental to academic and general life tasks. Given the common occurrence of anxiety in the population, it is not surprising that there are many different therapeutic approaches for clinically working with anxiety. Treatments can address separate anxiety disorders, or can use a transdiagnostic anxiety approach. Additionally, treatments can utilize a single theoretical orientation (e.g., CBT) or can integrate across several orientations or programs to capture salient or core change mechanism components (e.g., Wolfe, 2005). In terms of effectiveness claims, there are different methods with which an author, clinician, or research might promote the effectiveness of a given anxiety intervention.  36  For some interventions, there is no research or effectiveness evidence provided but instead there is an appeal to clinical experience or the author’s reputation. For others, there is evaluation, but the research designs used in the assessment are not sufficient to make effectiveness statements. Finally, there are interventions for which outcome and effectiveness statements are supported by rigorous research designs capable of supporting effectiveness assertions. However, as Shadish and his colleagues (1997) point out, effectiveness evidence is most applicable if an intervention is evaluated in the particular environment and with the participant population with which it will be used. Gaps in the literature. Given the unique context of university student’s health outlined in the first section, evaluating the effectiveness of a group therapy intervention specifically tailored for university students dealing with dysfunctional or problematic anxiety would be advantageous. This would address several literature gaps. First, there is a need for well-designed effectiveness research with anxiety interventions capable of being used in the university or college counselling context (Baez , 2005; Damer, Latimer, & Porter, 2010; van Ingen & Novicki, 2009). Second, most of the well-designed anxiety effectiveness research has been completed on discrete anxiety disorders, and with carefully selected participants; it is not efficient for a busy university counselling centre to treat anxiety in this manner. Given the recency of transdiagnostic anxiety treatments (see Brown & Barlow, 2009), effectiveness statements for these interventions are less available. Thus, the even larger gap in the literature is well-designed effectiveness research on transdiagnostic or dysfunctional anxiety treatments specifically designed for university students.  37  The next section outlines the Challenging Anxiety Group, a transdiagnostic, theoretically-integrative group anxiety intervention developed and used at a university counselling centre. This type of group therapy would be helpful not only for the anxious student but also for university counselling centres that are charged with the responsibility of supporting university and college students in meeting their academic goals. Integrative Mindfulness-Based Anxiety Group Intervention The Challenging Anxiety Group therapy (CAG) for university students was a transdiagnostic anxiety intervention used at a counselling centre at a major university. Dr. Melanee Cherry, an expert anxiety therapist, developed the CAG for use with university students in a counselling centre. She believed that a transpersonal approach [sic], namely mindfulness, could supplement CBT approaches for anxiety, in particular Generalize Anxiety Disorder, which she states has a longer course (e.g., earlier onset and longer duration) and is more resistant to recovery or achieving a high end state functioning (Cherry, n.d). Cherry advocated for the use of mindfulness meditation for use with anxiety because it: develops the observing self and awareness, helps to face fear or other negative affective states, induces a state of both mental and physical relaxation, helps a here and now orientation, supports not attaching to an affective state, supports noticing impermanence of affective, cognitive, and physical states, and supports accepting the self and one’s affect states thus circumventing the need to escape or avoid. “(M)indfulness offers … a means to develop the spaciousness necessary to stay present with fear ….” (Cherry, n.d.). The CAG has mindfulness as its main mechanism of change, with multiple methods (e.g., practices, techniques, skills, perspectives) to support the student-client in developing mindfulness in their lives.  38  The CAG is a technically integrative group therapy, which integrates core mindfulness components from Mindfulness-Based Cognitive Therapy (MBCT: Segal, Williams, & Teasdale, 2002) and Dialectic Behavioral Therapy (DBT: Linehan, 1993a). From the program of MBCT, the core components of breathing practices and meditative practices (Segal, Williams, & Teasdale, 2002), and stretching and movement routines. From the program of DBT, the core components of Wise Mind skills, Mindfulness skills, Radical Acceptance, and the emotional regulation of fear and shame were incorporated (Linehan, 1993a). More recently, Cherry (personal communication) had begun to integrate some of the practices of Acceptance and Commitment Therapy (ACT: Hayes, 2005) into the CAG. From ACT, the values orientation was beginning to be added. The following are some of the advantages presented by the CAG: •  The focus population were university students who dealt with transdiagnostic anxiety; this intervention allowed for a broad catchment of students who suffered.  •  It was integrative. Thus, captured the change mechanisms across empirically supported therapy programs.  •  Has a focus on emotional regulation through the application of mindfulness techniques.  •  Promoted cognitive and meta-cognitive observation, regulation, and restructuring through the application of mindfulness techniques.  •  Trained in relaxation and breathing techniques.  •  Promoted exposure to internal contexts (e.g., cognitive, sensory, physical, and affective), and external contexts (e.g., environmental and social).  •  Promoted non-reactivity to mental and external stimulus.  39  •  Promoted present moment awareness and openness.  •  Promoted goals and goal achievement.  •  Used member to member learning and cohesion to support and normalize anxious and life experiences.  Mindfulness is at the core of CAG. For the purposes of this current research, the CAG had its name changed to the Integrated Mindfulness-Based Anxiety Group (IMAG) so that there could be greater transparency for the integrative nature of the intervention. Following is a review of mindfulness, and its expansive contributions and presence in western therapeutic programs that deal with anxiety. Mindfulness Mindfulness (MF) is difficult to define, but most broadly it is the cultivation of conscious attention and awareness (Brown & Ryan, 2003). Thich Nhat Hanh (1976) stated that it is “keeping one’s consciousness alive to the present reality (p. 11). He believes that MF should not be reserved only for meditation, but should be exercised in everyday tasks (e.g., driving to work, relating to others, and being in one’s life). At the beginning of a MF practice, there is consciousness of the breath; attention follows the breath as it enters and leaves the body (Hanh, 1976). Simply following the breath. This leads to consciousness of the body, and consciousness of one’s surroundings (Hahn, 1976). Consciousness is not evaluating and thinking; it is being non-judgementally aware of the information entering the sense doors (i.e., sight, hearing, touch, taste, and smell). MF changes “how one relates to dysfunction thought and negative affect, rather than changing eliminating the states themselves” (Breslin, Zack, & McMain, 2002, p. 281).  40  This promotes a way of living based on non-evaluative and accepting awareness of one’s experience in the moment. In addition to facilitating conscious awareness, there are certain attitudes for being with one’s experience in the moment (e.g., non-judgement, patience, seeing as new, trust in self, non-striving, acceptance, and letting go in the moment), and commitments to the breath, meditation, and the embodiment of experience (Kabat-Zinn, 1990; Kornfield, 1993; McLeod, 2002). MF is not a narrowing of attention or concentration (i.e., transcendental meditation), but promotes insight and integration of the perceptual and sensory fields (Killackey, 1998). This is a holistic approach, which addresses not only cognitive, emotional, behavioural, spiritual, social, and physiological areas, but also the gestalt of these spheres. MF is a way of being, which encourages holistic engagement of one’s experience with the present moment. Thoughts and emotions driven from the past and expectations of the future block the ability to experience today, which is experiencing this moment exactly as it is. Training the MF attitudes through a meditative practice is the mechanism for loosening the mental pervasiveness, and challenging mental and emotional automaticity (KabatZinn, 1990). It is a “self-regulation and retraining of attentional habits … to achieve a specific attentional set” (Goleman, 1976, p. 44). Attention regulation, openness to new information and experience, less reliance on pre-conceived ideas or beliefs, release of self- and other-judgment, relaxation, and self-care are some of MF’s healing pathways (Kabat-Zinn, 1990). Being alive to the present moment and its content is antithetical to pervasive, reactive, and rigid patterns of response to one’s world.  41  Chögyum Trungpa Rinpoche (1974), a Tibetan master, discussed the practice of meditation to build mindfulness. He joked that the Buddha sat and wasted his time, so sitting and wasting time is very important. He reflected that mindfulness is the basis of being. One of Chögyum Trungpa Rinpoche’s students, Pema Chödrön (2005) talked about the power of staying. Staying with the good thoughts, and the bad thoughts; staying with the good emotions, and the bad emotions. Good, bad, no problem, just stay (Chödrön, 2005). Thus, these masters discuss mindfulness and meditation as ways to train to stay, non-judgementally and with openness, in the present moment, with all that it has to offer. Awareness or consciousness has been identified by many philosophical, spiritual, and psychological traditions as being important to wellness (Wilber, 2000). Learning to heighten one’s awareness in the moment is hypothesized to help individuals “manage the capricious nature of the mind”, and can aid in “protecting one’s mental health and for raising awareness of choice in action” (Hirst, 2003, p. 365). Kabat-Zinn (2000) eloquently states, “all human beings … have … deep and life-long inner recourses for learning, growing, healing, and personal transformations. Part of (the therapist’s) job is to make available appropriate opportunities and effective vehicles for mobilizing those resources … so (the clients) can put them into service of their own health” (p. 239). Mindfulness and Health In terms of MF’s place in Western psychological healing practices, this tradition originated from a different categorical system of health and wellbeing. MF is firmly seated in Buddhism, which is considered to be the most psychological religion, or the most spiritual psychology (Walsh, 1988).  42  The Eastern perspective tends to view mental illness as extensions of the pathology of the every day. From the Eastern perspective, the roots of everyday pathology are said to be ignorance, attachment, and aversion (Goleman, 1976). Ignorance is a paucity of knowledge regarding one’s own psyche and true nature, which is good and socially concerned at its essence (Goleman, 1976; Walsh, 1988). The affect of this ignorant state can be shamelessness, remorselessness, egoism, and perplexity or the inability to decide what is in the interest of compassion and equanimity; when ignorance is present so is attachment and aversion (Goleman, 1976). Attachment constitutes the never-ending need to fulfill desires, and may present as greed, materialism, and envy. Aversion is the avoidance of anxiety and fears. Goleman (1976) states a fourth pathological factor as contraction and torpor. These contribute to “a nonadaptive, rigid inflexibility and moribund clinging to unhealthy mental states” (Goleman, 1976, p. 43). Overall, happiness is predicated, not on satisfying attachments and aversions, but on extinguishing them (Walsh, 1988). In addition to the reduction of ignorance, attachment/aversion and rigidity, Walsh (1988) discussed seven health-related attitudes that can be broken into three broad categories. The first category is arousing the mind, which is composed of effort, rapture (i.e., delight of conscious awareness), and exploration. These motivate the mind’s inquisitive and curious properties. The second category is quieting the mind, which is composed of calm, equanimity, and concentration. These encourage the mind’s reflective and still properties. The final category is MF, which is the awareness and balance of the other two categories. MF is the awareness of the sensory-field stimulus, and the metacognitive position of being aware of this awareness. With this, the qualities of MF can be  43  seen as: attention regulation (MF), openness to new information and experience (arousing), less reliance on pre-conceived ideas or beliefs (arousing), release of self- and other-judgments (quieting), relaxation (quieting), and disciplined self-care (MF). Through MF, one can monitor the state of one’s mind to bring it into equanimity, or balance. An equanimous mind is one that can engage fully with the world, yet not become embroiled with it. Although the Eastern perspective seems ostensibly incongruent with Western notions of health and illness, there is a remarkable overlap with many of the conceptual ideas in Western therapy types, such as Psychoanalysis, Existential, Cognitive, and Behavioural techniques (Walsh, 1988). Although attaining understanding of the roots of mental dysfunction may be different, there may be common roads to healing. Walsh (1988), an expert in Eastern religions and Western therapeutic practices, outlines these pathways, some of which are summarized below. •  MF “might be regarded as the refinement of the psychoanalytic ‘observing ego’” (Walsh, 1988, p. 553). The observing ego allows us to step outside and view ourselves more rationally.  •  MF’s therapeutic use of a distancing function or de-centring serves two purposes: (1) allows for greater volitional access to the 0.25 seconds between unconscious impulse and conscious action (Libet, 1985), and (2) challenges an overidentification with mental content that is by its nature capricious and not enduring.  •  MF encourages the relaxing of psychic structures, and the acceptance and nonjudgment of whatever material occurs in consciousness. This allows the  44  individual to see that thoughts are not facts, but mental events that inevitably change. •  MF pertains to how you relate to objects presenting in both your internal and external worlds. Experiencing the world with a beginner’s mind, or without preconceived notions about how it should be or how it has been in the past is an objective of MF. The beginner’s mind precludes an evaluative and judgmental stance.  •  MF acknowledges the fundamental reality of suffering, and authenticity equaling the experience and acceptance of the fullness of human experience (i.e., pain and pleasure) in the present moment.  •  Controlling the content of the mind through volition, practice, and attention/concentration is the aim of both cognitive and MF practices. These two approaches share the similarity of conditioning or training the mind.  •  MF focuses on behaviours, and how behaviours can affect the mind. Although the first step in many MF practices is quieting the mind through calming the body, the body also is a mechanism for fostering attention, awareness, and consciousness. In general, Western therapies focus on altering the impact of past on present  functioning. In contrast, Buddhist practice ignores the “emotionally loaded contents of awareness” and seeks to alter the context in which this information is presented in conscious awareness (Goleman, 1976, p. 52). The Western therapist “assumes as given the mechanisms underlying perceptual, cognitive, and affective processes, while seeking to alter them at the level of socially conditioned patterns” (Goleman, 1976, p. 52). MF  45  bypasses these patterns and targets the “control and self-regulation of the underlying mechanisms themselves” (Goleman, 1976, p. 52). In MF, therapeutic behavioural and personality change is a secondary phenomenon to the primary goal of consciously regulating mental states that define one’s reality (Goleman, 1976). Finally, Daniel Goleman (1976), a Buddhist psychoanalyst, states: Consciousness is the medium which carries the messages that compose experience. Psychotherapies are concerned with these messages and their meanings; meditation instead directs itself towards the nature of the medium, consciousness. (p. 53) Mindfulness is different yet complementary to Western approaches. Not judging and releasing mental content, training the mind to stay open to experience in the moment, slowing the impulse-to-action process, and not overly identifying with emotional or cognitive content of the capricious mind are methods of conditioning consciousness or the medium that holds negative thought and emotions, and automatic and rigid response patterns. Given the complementary nature of MF and western psychotherapies, it is not surprising the Western therapy is beginning to integrate MF into modalities of health. Mindfulness and Anxiety Mindfulness is fast becoming one of the most popular clinical approaches being used, and with a vast variety disorders and ailments. A short list of disorders that mindfulness techniques have been applied to are: binge eating disorder (Kristeller & Hallet, 1999), job stress (Cohen-Katz et al., 2005a; Shapiro, Astin, Bishop, & Cordova, 2005), stress reduction and quality of life (Roth & Robbins, 2004), substance abuse (Bowen, Chawla, & Marlatt, 2011; Breslin, Zack, & McMain, 2002; Marcus, Fine,  46  Moeller, Khan, Pitts, Swank, & Liehr, 2003), mood and stress with medical patients (Carlson, Ursuliak, Goodey, Angen, & Speca, 2001; Speca, Carlson, Mackenzie, & Angen, 2006), nurses’ burnout (Cohen-Katz et al., 2005b), academic stress (Beauchemin, Hutchins, & Patternson, 2008; Shapiro, Schwartz, & Bonner, 1998), recurrent depression (Scherer-Dickson, 2004; Segal, Williams, & Teasdale, 2002), positively influencing brain and immune functions (Davidson, et al., 2003), psoriasis (Kabat-Zinn, et al., 2003), increases in brain grey matter (Holzel, Carmody, Vangel, Congleton, & Yerramsetti, 2011), aggression (Singh et al., 2007b), schizophrenia (Davis, Strasburger, & Brown, 2007), and various difficulties in mild mental retardation (Singh, Wahler, Adkins, & Myers, 2003; Singh et al., 2007a). Additionally, there have been both quantitative and qualitative research (see Mackenzie, Carlson, Munoz, & Speca, 2007; Mason & Hargreave, 2001) completed with participants undertaking mindfulness-based programs to deal with a psychological or physical difficulty. One of the most prevalent disorders that mindfulness has been used to address is anxiety. Anxiety and its manifestation is antithetical to mindfulness and its presentation. When comparing anxiety to mindfulness, one finds these stark differences: •  Narrowing and constriction of mental states vs. opening and expansion of the mental states  •  Future orientation vs. a present orientation  •  Fleeing, avoiding, and escaping vs. staying and facing in  •  Embroiled or centered in mental content vs. an observing or de-centred stance  •  Over-identification with emotional/mental content vs. de-identification with the impermanence of emotional/mental content  47  •  Judgement of self or situation vs. non-judgement of self or situation  •  Not trusting self vs. trusting self and one’s being state  •  Intolerance of the situation vs. acceptance of the situation as it is  •  Tension and stress vs. relaxed, calm, and balanced  •  Narrowly focused attention vs. broadly focused attention  •  Automatic and habitual reaction patterns vs. situationally-based responding  •  Reactive and closed vs. curious and open Needless to say, there is an abundance of literature and research that has  investigated mindfulness-based therapy or treatment of anxiety. Brown and Ryan (2004), Carmody and Baer (2008), McKee, Zvolensky, Soloman, Bernstein, and Leen-Feldner (2007) showed significant negative correlations between anxiety indicators and both single-factor and multi-factorial mindfulness indicators, respectively. The use of mindfulness-based interventions with anxiety and anxiety disorders is plentiful: transdiagnostic anxiety (Kabat-Zinn, et al., 1992; Miller, Fletcher, & Kabat-Zinn, 1995), social anxiety (Goldin, Ramel, & Gross, 2009), anxiety reduction in medical patients (Tacón, McComb, Caldera, & Randolph, 2003), anxious children (Semple, Reid, & Miller, 2005), insomnia in anxiety disorders (Yook et al., 2008), anxiety reduction in schizophrenia (Brown, Davis, LaRocco & Strsburger, 2010; Davis, Strasburger, & Brown, 2007), general anxiety disorder (Evans et al., 2008), and depression and anxiety presentations (Finucane & Mercer, 2006). Finally, there are workbooks and manuals to support the acquisition and increase of mindfulness through various theoretical programs, such as The Mindfulness & Acceptance Workbook for Anxiety- A Guide to Breaking Free From Anxiety, Phobias & Worry Using Acceptance & Commitment Therapy (Forsyth &  48  Eifert, 2007), or Depressed and Anxious- The Dialectic Behavioural Therapy Workbook for Overcoming Depression and Anxiety (Marra, 2004). Like these workbooks, many of the above studies utilized specific mindfulnessbased or mindfulness-included programs to train and support the increase and acquisition of mindfulness in a client’s life. The following briefly outlines these main mindfulness programs, and specifically reviews anxiety research that uses these programs to increase mindfulness in the lives of the anxious participants. Mindfulness-based Stress Reduction (MBSR: Kabat-Zinn, 1990). MBSR is “a clinical program, developed to facilitate adaptation to medical illness, which provides a systematic training in MF meditation as a self-regulatory approach to stress reduction and emotion management” (Bishop, 2002, p. 71). It is an 8-10 week program that trains people in foundations of MF (i.e., the attitudes and commitment), correct breathing and sitting meditation posture, body-scan technique, yoga, walking meditation, a day of silent retreat, and generalizing the seeds of MF across one’s life. “MBSR aims to teach people to approach stressful situations ‘mindfully’ so they may respond to the situation instead of automatically reacting to it” (Bishop, 2002, p. 72). The program itself is largely psychoeducational and skill-based, with a large homework or practice commitment. Essentially, participants work up to a personal, daily practice of MF meditation and bodyscan techniques. Additionally, leaders of MBSR are expected to have a restorative and stable meditative practice of their own (Brantley, 2005). In MBSR, MF is presented as a mind-body intervention, without any evidence of its Buddhist origins. In Buddhist terms, MF is one of the paths to enlightenment; personality and therapeutic change and health are merely secondary gains to the main goal of training of a MF way of being in the  49  world. It therefore could be said that MBSR is not a stress-reduction, anxiety-reduction, or pain-reduction program at all, but a new way of being in the world. Mindfulnessbased Cognitive Therapy for Depression Relapse (MBCT: Segal, Teasdale, & Williams, 2002) uses MBSR’s meditation approaches and techniques as a basis or foundation to its own program. MBSR was one of the first mindfulness-based programs to show effectiveness outcome research with transdiagnostic anxiety. Kabat-Zinn and his colleague (1992) tested the effectiveness of the MBSR with anxiety disorders. Twenty-two participants with diagnosed anxiety completed the MBSR group. Assessments in anxiety, depression, and general and medical symptoms were taken before, during, and after the group. It was reported that the participants served as their own controls. The results showed significant reductions across the measurements, and at a 3-month follow-up. Miller, Fletcher, and Kabat-Zinn (1995) followed-up with these same participants at 3-years to see if gains were maintained. Eighteen of these same participants showed a maintenance of prior gains as reported on depression and anxiety measures. It also was shown that the majority of the participants (10 of 18) maintained their meditational practices, with 16 of 18 practicing informal techniques of mindfulness. Tacón, McComb, Caldera, and Randolph (2003) showed improvements in anxiety symptoms in female patients suffering from heart disease. A total of 20 women were randomly assigned to an experimental group and a control group. After the MBSR group, the experimental group showed significant reductions in anxiety symptoms and reductions in the tendency to suppress negative emotions. Finally, Shapiro, Schwartz, and Bonner (1998) randomly assigned 78 pre-medical or 2nd year medical students to  50  either an experimental group or a control group. The experimental group undertook the MBSR intervention while the remainder stayed on a wait-list. It was found that there was a reduction in depressive symptoms, state and trait anxiety, increases on empathy scores, and increases on a spirituality measure. Additionally, these same gains were observed when the wait-list participants entered intervention, across experimenters, and during examination periods. These authors stated that compliance to the treatment (i.e., maintaining meditative practice) was important to outcome. From these four studies, one can see that MBSR is successful in reducing anxiety symptoms in transdiagnostic groups, and that the gains that are made are maintained at during extended follow-up periods. Dialectic Behavioral Therapy (DBT: Linehan, 1993a, b). DBT is a multicomponent program that was built to treat difficult and complex mental disorders (e.g., chronically suicidal patients, multi-disordered individuals with Borderline Personality Disorder). Although DBT belongs to the family of cognitive-behavioural and behavioural therapies, it has some significant differences. Dimeff and Linehan (2001) outline the three main differences from said therapies being (1) inclusion of the dialectics of acceptance and change, (2) possessing multiple components (i.e., group skills training, individual therapy, and telephone consultation), and (3) having therapists supported through a consultation team to keep motivated and healthy. Linehan (1993a) discusses her inclusion of the dialectic orientation from her experience with meditation practices and Eastern spirituality. “The DBT tenets of observing, mindfulness, and avoidance of judgment are all derived from the study and practice of Zen meditation” (Linehan, 1993a, p. 20). One of Linehan’s multiple contributions was distilling mindfulness meditation down to sets of practical skills (e.g., Mindfulness skills, Wise Mind, and Radical  51  Acceptance); stated differently, it is “a pragmatic approach to mindfulness training that may serve as a valuable resource for clinicians who wish to teach mindfulness skills to clients with anxiety disorders” (Gratz, Tull, & Wagner, 2005, p. 148). Interestingly, DiGiorgio (2009) found in her dissertation research that DBT therapists were less likely to adhere to the full protocol of DBT when dealing with anxiety clients, and that those therapists with a non-cognitive-behavioural orientation were more likely to use the mindfulness skills in non-DBT work. In other words, therapists are adapting or cherrypicking core components of DBT (e.g., the Mindfulness skills) to meet the unique needs of their therapeutic environments. However, although this cherry-picking is shown to be common practice (e.g., Marra, 2004), Gratz, Tull, and Wagner (2005) warn that “there is not yet empirical support for the use of only the skills training component of DBT (separate from the other components)” (p. 148). There is however research on using DBT techniques as combined or integrated with other non-DBT techniques to deal with anxiety. Integrative mindfulness-based approach. Roemer, Salters-Pedneault, and Orsillo (2006) suggest an integrated mindfulness- and acceptance-based strategy for dealing with Generalized Anxiety Disorder (GAD). In this 16-session model, mindfulness activities or exercises from MBSR/MBCT, DBT, and ACT were added to an established CBT-treatment for GAD. These authors report instructing clients in both formal and informal mindfulness practices. The intervention is divided into two components: “the first seven sessions involve instruction in the relevant concepts, in addition to relevant experiential exercises, whereas the last nine sessions are focused on reviewing clients’ efforts to engage in valued, mindful action, obstacles encountered, and  52  plans to future action” (Roemer, Salters-Pedneault, & Orsillo, 2006, p. 55). These authors use both a case study (Roemer, Salters-Pedneault, & Orsillo, 2006), and a randomness controlled trial study (Roemer, Orsillo, & Salters-Pedneault, 2008) to show effectiveness. Following is an excerpt from this case study: Thomas was reported to end the 16 week treatment with significantly lower levels of generalized worry and anxiety, as well as lower anxiety related to social situation. He was not given any principal DSM-IV diagnoses; he was judged to have GAD in partial remission (2 of 8), social phobia in partial remission (severity of 2), and a GAF score of 78. (Roemer, Salters-Pedneault, & Orsillo, 2006, p. 65) Additionally, Roemer and Orsillo (2006) reported preliminary data regarding the treatment described above. Sixteen clients who suffered from GAD as well as other anxiety and mood disorders, underwent said-treatment and reported significant reductions in worry, anxiety, and depression on self-report measures. The large treatment effect observed at the end of the treatment also held at three months. Thus, these authors concluded that their integrated mindfulness- and acceptance-based strategy was useful for treating GAD and other additional disorders. For these authors, a future direction of research was demonstrating the success of their strategy in different populations, and also understanding the change mechanisms that were creating the change (e.g., mindfulness). Acceptance and Commitment Therapy (ACT: Hayes, Shrosahl, & Wilson, 2003). It is important to acknowledge the contributions made by ACT (Hayes, 2005) has made to the field of integrating mindfulness into anxiety treatment. Although not a large component, ACT strategies and activities (e.g., valued actions) were beginning to be  53  integrated into the CAG (Cherry, personal communication). Roemer and her colleagues (Roemer et al., 2009; Roemer & Orsillo, 2002, 2005; Roemer, Salters-Pedneault, & Orsillo, 2006) integrated key components of ACT into their work with GAD. Eifert and Forsyth (2005) have created an ACT manual to work specifically with anxiety disorders. Although there is empirical support for the use of ACT with anxiety disorders (see Twohig, Masuda, Varra, & Hayes, 2005), this effectiveness research is not covered in this review because of ACT’s limited application in the CAG. Mindfulness Interventions and Effectiveness The reviewed studies show that mindfulness as it is trained in particular programs can have a healing and health promoting effect. This statement has been supported through a variety of therapeutic outcome studies, across a variety of mindfulness-based interventions. Grossman, Niemann, Schmidt, and Walach (2004) conducted a metaanalytical investigation of 20 studies indicating that MBSR is an useful intervention for a diversity of mental and physical health challenges. “(C)onsistent and relatively strong levels of effect sizes across very different types of samples indicates that mindfulness training might enhance general features of coping with distress and disability in everyday life, as well as under more extraordinary conditions of serious disorder or stress” (Grossman, et al., 2004, p. 39). In terms of anxiety, Hofmann, Sawyer, Witt, and Oh (2010) also conducted a meta-analytic study on the effect sizes of 39 studies of mindfulness-based interventions for anxiety, and found the effects sizes to be robust and in the moderate range. These authors concluded that mindfulness-based therapies were a promising intervention for treating anxiety. Thus, the investigation into the effectiveness  54  of an integrated mindfulness-based intervention for anxiety in university students is a worthwhile endeavour. This point is accentuated by Toneatto and Nguyen (2007) who question the accepted belief that mindfulness-based stress reduction programs, in particular MBSR, are effective at reducing symptoms of anxiety and other mood disorders. Through an analysis of (1) experimental controls utilized in the outcome and effectiveness studies, (2) follow-up measurements, and (3) mindfulness and practice as a change mechanism, these authors conclude that MBSR’s effectiveness at making changes to anxiety and other mood symptoms is equivocal at best. They charge that maintenance of gains is not well established, and that the relationship between practicing mindfulness and changes in anxiety and depression were also equivocal. Thus, although MF is commonly practiced in many Western therapeutic programs or interventions, an analysis of effectiveness, not assumptions or generalizations, needs to guide IMAG’s use in college and university populations. Summary Historically, mindfulness (MF) was an Eastern spiritual and psychological practice. Due to its ability to promote healing and well-being, MF has been transported from its original context to be used in clinical and medical environments (Kabat-Zinn, 2000). MF means staying open to and aware of the present moment, and doing so with particular attitudes, such as patience, non-judgement, and curiosity. MF is currently being used in many therapeutic programs, and with a variety of medical and psychological ailments. Its popularity in clinical contexts is partially due to the reputations of these clinical programs (e.g., MBSR, MBCT, DBT, and ACT), but also  55  due to the research that is being completed to understand its effectiveness and the exact change mechanisms responsible for the clinical change that is being seen in these popular therapy programs. Along with this outcome research, authors are beginning to critique the mindfulness-based outcome research, which is not seen as unequivocally effective, nor is mindfulness as a change mechanism fully understood or accepted. At the centre of this current research is the IMAG, which is an integrative mindfulness-based intervention developed for clinical use with university students who struggle with self-reported anxiety. It integrates several core components found in these popular mindfulness-based therapy programs into one program focused on training student-client in mindfulness for the purposes of decreasing anxiety and increasing wellbeing. Gaps in the literature. There are several gaps identified in this section of the literature review. First, although mindfulness is being frequently used in clinical treatments, the effectiveness of mindfulness-based programs in treating anxiety and other psychological disorders is currently being explored and established. Additional welldesigned effectiveness research needs to be completed with mindfulness-based programs. Second, mindfulness is currently being explored primarily within full therapeutic programs (e.g., MBSR, or DBT, or MBCT). However, frequently clinicians use only selected components of these programs, without knowing these component’s effectiveness or how removing these components from their original programs will impact the initial effectiveness. It is the full programs that have effectiveness research, not its selective components. Third, it is unknown what aspects of mindfulness is creating change in these programs. MF training is complex and very involved, therefore  56  several aspects of this training could be responsible for the clinical change being evidenced. Additionally, it is unknown how mindfulness training is creating the change being observed. Finally, the IMAG is a relatively new integrative mindfulness-based anxiety group therapy for university students who self-report anxiety. Although this has been used on a university campus, its effectiveness at reducing anxiety symptoms or increasing mindfulness levels has not been explored. Research Questions Across the three main sections of this review are several identified gaps in the literature. Below are several research questions that attempt to address some of these literature gaps. These questions are divided into two main categories: (1) the effectiveness of the IMAG, and (2) the participant’s experience with the IMAG. Effectiveness of the IMAG. There are two main approaches for understanding the effectiveness of the IMAG. The first assesses change created by the IMAG across the study at the individual client, cohort, and group levels, so as to (1) understand the process of change across the study, and (2) design a research study capable of supporting effectiveness claims. The following questions each inquire about functional relationships between the IMAG and the dependent variables, which are anxiety reduction, general clinical symptom reduction, and an increase in mindfulness levels. Following are these questions: a) Is there a functional relationship between the IMAG and an increase in mindfulness, as seen by qualities of consciousness, awareness, attention, nonreactivity, and non-judgment among university or college students who self-report anxiety?  57  b) Is there a functional relationship between the IMAG and a decrease in the symptoms generally associated with anxiety (e.g., worry, physical, cognitive, affective symptoms) among university or college students who self-report anxiety? c) Is there a functional relationship between the IMAG and a decrease in general clinical symptoms in university or college students who self-report anxiety? In addition to an intrapersonal change analysis across the intervention, a more traditional method of supporting effectiveness claims, a group-based approach, was used. This approach used repeated-measures at pre-group, mid-group, end-group, and postgroup to investigate change across the IMAG. This research question was: Did the IMAG create statistically significant (!= 0.05) differences between scores on the dependent-variable measurements at pre-group, mid-group, end-group, and post-group measurements? Participant’s experience in the IMAG. The second approach inquires about the participant’s experience with the IMAG. This was guided by two discrete methods for understanding the participant’s experience. The first method was an analysis of the participant’s use of the various practices, techniques and skills taught in the IMAG. An additional question regarding the context of their practice was asked. The questions guiding this method were: a) How often and for how long did the participant’s practice the mindfulness skills and techniques taught in the intervention? b) Which mindfulness skills and techniques were practiced?  58  c) What types of stress and anxiety events confronted the participant’s on a weekly basis? Finally, a post-group interview directly explored the participant’s experiences. The participants were specifically asked about their experience in the IMAG and the change that they experienced and also the challenges that they faced while working with the IMAG. The research question guiding the exploration of the post-group interviews was: a) What themes occurred in the post-group interviews regarding the participant’s successes and struggles with anxiety, mindfulness, and the group intervention? Expected Findings Given the meta-analytic study that explored several mindfulness-based interventions’ success with creating therapeutic change (Grossman, Niemann, Schmidt, & Walach, 2004) and more specifically the meta-analytic study that explored the magnitude of change in mindfulness-based interventions for anxiety and mood disorders (Hofmann, Sawyer, Witt, & Oh, 2010), it was expected the IMAG, a mindfulness-based intervention for university students who self-reported anxiety, would be positive in that the IMAG would be successful or effective at creating the desired change. It was also expected that participants would have a positive experience with both the mindfulness practices and skills. Finally, it was expected that the participants would provide insight in terms of their experience of both their successes and their struggles in the intervention. The themes generated from the interview were expected to improve the IMAG.  59  Conclusions There are several queries presented by this literature review deserving emphasis. These points are listed below: •  University students are a unique clinical population because they have goals of academic completion and success, and these goals can be severely stressed or disrupted by mental health challenges, such as anxiety. Coping with mental health challenges is accomplished within a goal-driven and focused context. Thus, they are a unique population with unique needs.  •  There are few anxiety interventions for university students, which have welldesigned effectiveness evidence with this driven and goal-oriented population.  •  Transdiagnostic anxiety therapy groups are advantageous on university campus because of the increased service opportunities of a broader client-base; there are however fewer anxiety interventions with effectiveness evidence with this type of general anxiety treatment.  •  Although research has shown strong negative correlations between mindfulness and anxiety, and mindfulness-based programs (e.g., MBSR) have suggested evidence of effectiveness with anxiety, there are challenges to these statements based on methodological rigor of the outcome studies; therefore, the veracity of effectiveness and change mechanism claims need to be established.  •  Although there is evidence of effectiveness with full programs of (e.g., MBSR, DBT), it is unknown how effectiveness changes when core components (e.g., mindfulness formal and informal practices, and mindfulness skills) are taken and  60  integrated into a new program focused only on anxiety and mindfulness training for university students. •  It is unknown what the change mechanisms are in the effective mindfulness-based programs (e.g., mindfulness). This current study acknowledged many of these queries through evaluating the  effectiveness of an integrated mindfulness-based anxiety group intervention (IMAG, formerly known as the CAG) for university students who self-report dealing with anxiety. This current study investigated not only the effectiveness of the IMAG at reducing anxiety, but also the IMAG’s ability to increase or support student-client acquisition of MF. Additionally, this study monitored both MF skills and technique practice. But most importantly, this study explored the participant’s perspectives of not only the IMAG but also their experience of anxiety and mindfulness after their involvement in this intervention. Thus, the participant’s perspective is included into the exploration, and supports possible improvements in the IMAG’s delivery and effectiveness. Honouring the participant’s voices is another unique contribution made by this current study. The next chapter outlines the research methodology for this study.  61  CHAPTER 3: METHODOLOGY Introduction The goal of this study was to determine the effectiveness of an integrative mindfulness-based anxiety group therapy intervention (IMAG) at producing desired changes in anxiety symptoms and mindfulness characteristics of university or college students who self-reported dealing with problematic anxiety. A Small-N, mixed-method research design was utilized. This design allowed for the assessment of the therapy intervention through monitoring the application of techniques taught in the intervention; comparing pre- and post-measurements; analyzing the intrapersonal change process across the therapy intervention; and exploring the participant’s perspective of the therapy intervention. Multiple avenues of analyses permitted a broader understanding of the effectiveness of this intervention while considering the participant’s perspectives. This paragraph outlines the general content of this chapter. First, the research design section describes the conceptual approach to the study, and outlines the type of data produced to answer the research questions. The pragmatic and paradigmatic rationale for using a mixed qualitative and quantitative design is briefly reviewed. Second, recruitment strategies and participant characteristics are discussed. Third, the procedures of the study outline the various steps taken to complete the therapy intervention and to collect the data. Then, a brief session-by-session outline is provided. The data production strategies also are reviewed. The dependent variables are anxiety, mindfulness, and therapeutic outcome; the respective measurement scales for the dependent variables are reviewed. Additionally, the post-group interview protocol and procedures are outlined. Finally, the four separate sections for each of the data analytic  62  strategies are described: the Participant and Group Practice Analyses, the Analysis of Variance (ANOVA), the Visual analysis, and finally, and the Thematic Analysis. Research Design A mixed method strategy was used as a broad research approach for this study. More specifically, a quantitative, multiple-baseline Small-N design was the predominant model, with a qualitative, post-group interview accompanying this broader design. Stated differently, the Small-N design was the principle design, and the qualitative post-group interview was the complementary method (Morgan, 1998; Steckler, McLeroy, Goodman, Bird & McCormick, 1992). This approach was chosen because of the newness of this particular intervention. This design was both technically and paradigmatically consistent. It captured both changes expected by the researcher (i.e., quantitative data) and unexpected changes as they were experienced by the participants (i.e., qualitative data). Using this strategy, therapeutic change can be both observed by the researcher and experienced by the participant; it is recorded over time from a scale-based objective lens, and perspective-based subjective lens. These diverse data strategies allowed for a multidimensional analysis of change created by this mindfulness-based anxiety intervention, thus effectiveness is assessed broadly and thoroughly. A Small-N research design is well established in therapy-outcome research, particularly for newer interventions where the process of change may be less well understood or where the intervention itself may benefit from being fortified (Barlow & Hersen, 1973; Kazdin, 2011; Lucyshyn, Albin, & Nixon, 2002; Morgan & Morgan, 2003). Small-N design focused on intrapersonal change patterns created across various phases of a therapeutic intervention; it provided a window into the ongoing clinical  63  process at an individual level. The multiple baselines allowed for the determination of whether a functional relationship between the intervention and the dependent variable existed or not. Thus, “a flexible and viable scientific methodology” to explore intrapersonal change and therapeutic effectiveness was produced (Lundervold & Belwood, 2000, p. 94). Multiple visual analyses and two sets of ANOVAs are used to present the SmallN’s repeated and multiple measurements on the several scales of anxiety, mindfulness, and general clinical outcome. This approach maximized the possible assertion of a functional relationship existing; it allowed for the observation of possible change across several indicators at several points in time. Additionally, the ANOVAs provide levels of statistical significance, which are important if a statement about therapeutic effectiveness is to be widely accepted. In short, these quantitative analyses allowed for a triangulation of findings, which strengthens an assertion of change in key indicators over time. Qualitatively, the participants’ experiences of anxiety, mindfulness, and the therapy group itself were explored after the intervention through an interview. This allowed unexpected or novel experiences pertinent to the goals of the study to be located in the client’s experience. A thematic analysis (Boyatzis, 1998; Braun & Clarke, 2006; Ritchie, Spencer, & O’Connor, 2003) provided a data analysis approach, which remained flexible and open to the qualitative material as it occurred in the transcripts. This datadriven or inductive approach to analysis allowed the data to be parsed, coded, and organized according to the client’s experiences as they were expressed in postintervention interviews. Although of a different paradigm, this analysis provided another dimension to the triangulation efforts described above.  64  Participants Recruitment Three university and college campuses in a Western Canadian region were chosen to facilitate the therapy groups because of the support of the counselling centres at these campuses. Counselling centre directors were contacted for the purpose of informing about the study, and ascertaining their interest in supporting the research. Please see Appendix A for the letter to the counselling centre directors. Recruitment was undertaken on campuses where the therapy groups took place. Participants were recruited by advertisements posted at University and College Counselling Centres and their respective websites, posters distributed over campus and department email list serves, and posters hung around university and college campuses. Additionally, brief presentations about this research study were given at each of the counselling centres so staff-counsellors would be aware of the research and its aims, and could give prospective participants poster-advertisements at intake. The inclusionary criteria for the study were: (a) self-report of anxiety; (b) full or part time students; and (c) over 18 years of age. The exclusionary criteria for the study were the presence of (a) Obsessive-compulsive disorder; (b) Post-traumatic stress disorder; (c) psychosis; and (d) suicidality. Two campuses were on a 2-semester system, and one was on a 3-term system. Recruitment took place in Spring and Summer months. Please see Appendix B for the recruitment advertisement.  65  Initial Brief Telephone Pre-Therapy Screen A total of 45 individuals made initial phone contact with the study, and underwent the brief 10-minute telephone pre-screen interview. This initial screening briefly explained the research and the therapy group, and asked several questions: yes/no items about several common anxiety symptoms, prior and current therapy experience, and current school status. If the individual was still interested in participating and they met the initial criteria, a two-hour face-to-face interview was arranged. A copy of the informed consent was emailed to the individual in the time between the brief telephone screen and the pre-group interview. Please see Appendix C for the revised Informed Consent form, with the follow-up sessions. Fifteen of these individuals, after the brief telephone screens, were deemed to be not eligible, decided against participating, or couldn’t be reached by phone. An Anxiety Resource Sheet was offered to non-participating individuals with whom contact was possible. Please see Appendix D for the brief telephone pre-group screening. Please see Appendix E for the Anxiety Resource Sheet. Pre-Group Screening and Research Interview Thirty individuals continued to the two-hour, audio-recorded pre-group screening and research interview. The participants reviewed and signed the consent form at the beginning of this meeting. This interview further explored: (a) suitability for the study; (b) their experiences with anxiety and coping; and (c) their goals for the therapy group. Sections of the Anxiety Disorders Interview Schedule for DSM-IV, Adult Version (Brown, DiNardo, & Barlow, 1994) were administered for the purposes of exploring which types of anxious characteristics were present in the prospective participant’s experiences.  66  Participants also were introduced to the Weekly Questionnaire (WQ), which they completed in-full or in-part over the duration of the study. The WQ is outlined in the Procedures section below. Each participant completed one full-WQ at this pre-group interview. Please see Appendix F for the Pre-Group Screening Interview Protocol. Attrition Eight individuals who had the pre-group interview stopped their participation in the study’s Baseline Phase. The reasons were non-eligibility, scheduling conflicts, a lack of time, and a move out of region. Five participants dropped out of the study after the intervention began. These individuals participated in between one and four sessions in the Intervention Phase. The reasons for stopping were timing conflict with new job (stopped after four sessions), and a lack of fit with their expectations and needs (stopped after one to three sessions). An exit interview when possible, or email correspondence if participant initiated, confirmed their reasons for leaving the study. Referrals or support in finding resources were offered when possible to those who contacted the study and were not eligible, could not attend, or decided to stop participating. The data for these participants were sealed and not used in the study. Characteristics of the Participants Seventeen people (herein referred to as participants) continued onto complete the therapy group intervention. Four men and 13 women participated in the study. The age range for the study was 21 through 53 years of age, with a mean age of 30 years (SD=8.31). In terms of racial diversity, there were 12 European-descent, two Asiandescent (one international student), two Hispanic-descent (one international student), and  67  one African-descent participants. The English language was identified as challenging by three of the participants; however, their English was proficient enough to attend Englishbased university classes. There were 14 students who reported their school status as fulltime; three participants were in transition from school into the workplace, with one of these three participants preparing to return for graduate studies at a participating campus. Eleven participants identified their student designation as Undergraduate, one as Continuing Education, one as Honours, three as Masters, and one as a Doctoral student. In terms of programs, 12 identified as being in Liberal Arts, one in Mathematics, one in Sciences, and three in Fine Arts. Ten of the participants reported some paid employment in addition to their school programs, and seven participants did not. Two of the participants reported single-parenting responsibilities for school-aged children. One participant reported two-parenting responsibilities for a small child, as well as becoming pregnant during the study, and consequently reporting frequent “morning sickness” during the homework exercises. In order to protect their identities, the participants were assigned a number, and these numbers became their label in the study material. To further protect identity, the plural pronouns of they or their was used in place of gender specific pronouns. For the purposes of the study write-up, participants were re-assigned the labels of Participant 1, Participant 2, Participant 3, up to Participant 17. Vulnerability factors. Vulnerability factors such as caffeine-use, alcohol-use, and drug-use were present in the participants’ lives. Approximately half of the participants (9 of 17) drank caffeinated beverages daily, with two-thirds of these participants drinking about one cup a day. The remaining one-third of the caffeineconsuming participants drank between two and four cups daily. In terms of alcohol  68  consumption, just under 60% of the participants (10 of 17) drank alcohol, with a range of between one and four drinks per sitting. About half of those who drank alcohol (5 of 17) had only one drink during a sitting. In terms of frequency, again about half of those who drank alcohol (5 of 17) did so on a weekly or monthly basis. The other half drank alcohol (5 of 17) on a biweekly (e.g., out socializing with friends), or daily basis (e.g., a beer after work). Only one person mentioned using drugs (e.g., smoking marijuana occasionally). Under half of the participants (47%, or 8 of 17) mentioned regular exercise as part of a weekly routine. Anxiety characteristics. The following is a list of anxiety characteristics indicated by the participants. This study did not attempt to diagnose a participant with a particular disorder, but instead tried to understand the constellation of anxiety-based challenges that were faced. The anxiety-based challenges commonly experienced by the participants were worry, generally focused on an issue or content domain (15 of 17), panic-like activation (13 of 17), fear of social or stranger contexts (11 of 17), and fear of going out or unfamiliar places (5 of 17). Seldom did a participant experience only one of the above characteristics. Also, an emotional presentation with anger-like or irritability qualities was mentioned by over half of the participants (9 of 17). In addition to the anxiety symptoms, depressive features were reported by about half of the participants (9 of 17). Four of the 17 participants reported taking medication during the study. Several participants mentioned not wanting to take medication, which was why they chose to be in the study. During the Intervention phase, two participants decided to end a course of medication (i.e., a longer course of anti-depressants, and a PRN panic medication). During the Follow-up phase, two participants reported beginning a course of medication  69  (i.e., anti-depressants for depressive features or for anxiety reduction). Twelve of the participants had past experiences with counselling or psychotherapy. In terms of anxiety’s impact on life and school functioning, the majority of participants were in the mild to moderate range, with about a third of participants indicating more substantial interference with school or daily tasks. Group Composition All participants were placed in one of four therapy groups, with each group corresponding to a participating university or college campus. Participants attended the group at their campus, with the exception of two participants who had recently moved or lived closer to a different participating institution. The therapy groups were different in composition, size, and start dates. Group One had six participants begin, with one participant drop-out. Group Two had two participants begin, with no drop-outs. Group Three had eight participants begin, with three participants drop-out; Group Three had one participant who undertook the intervention in individual-session format due to a last minute schedule conflict. Group Four had five participants and one faculty-observer participant begin, with one participant drop-out. Three of four groups had a staggered or lagged start, with these groups starting in the mid and late summer, and the other started in the early fall. Procedures The following describes the procedures undertaken in the study. First, this section outlines the interview screening procedures. Second, there is an overview of the intervention, which is the 10-week Integrated-Mindfulness Anxiety Group program (IMAG). The ten sessions are briefly described, and the therapy leader’s training is  70  reviewed. Third, the weekly questionnaire, and the various scales used to measure the dependent variables are outlined. Finally, the qualitative material used in the study, the post-group interview, is overviewed. Pre-Group Screening Interview The participants were each interviewed in a two-hour pre-group screening. The nature of the study, and the nature of the therapy and its homework expectations were outlined at this interview. This was the first face-to-face meeting between the participant and the principle investigator/group leader, Asa-Sophia Maglio, MA, RCC. In this interview, the group leader was able to listen to participant’s experiences with anxiety and coping, build rapport, outline the expectations of the group, and set two or three goals for the participant to work on during the therapy group. The structure of this interview followed a general protocol, but also was flexible enough to allow for rapport to be built between the group participant and group leader. Please see Appendix F for this protocol. Although this pre-group screening interview was audio recorded and transcribed, it was not used in the analysis as data because this interview did not speak to or address the intervention’s effectiveness. During the Pre-Group Screening interview meeting, the participant also completed a full weekly questionnaire (WQ) containing the measurement scales used in the study, and was given between three and nine full WQs to take with them to complete over the following weeks. The number of full WQs provided at this meeting was largely an estimation of the number of weeks between this Pre-Group Screening interview and start of the their therapy group. Addressed, stamped envelopes also were provided. A full description of the WQ and its scales are given below in the Data Production section.  71  Baseline Phase The Baseline phase was the start of data collection, and lasted a total of 24 weeks, from the beginning of the study to the start of Group 4, the last group. The minimum number of weeks a participant was in Baseline phase was three weeks, with a maximum being 15 weeks. The three-week minimum created a three data-point trend line (i.e., three full WQ over three weeks) so that the participant could operate as his/her own experimental control. The average length of time in the Baseline phase was 7.6 weeks. Participants were emailed weekly to remind them to complete a full WQ. Also, they were emailed to remind them to forward the completed WQs to this researcher. Participants were notified once the start-date for their campus’s therapy group was selected. The various therapy groups had a staggered or lagged start. Group One started in Week 9 of the study; Group Two started in Week 13 of the study; Group Three started in Week 18 of the study; Group Four started in Week 23 of the study. Intervention Phase In this phase, the participants shifted to completing the partial WQs; the partial WQ is described in the Data Production section below. This following section describes both the group leader’s training, and the group therapy intervention. Group leader training. Ms. Asa-Sophia Maglio was the group leader of the Integrative Mindfulness-Based Therapy Group (IMAG) in this research. She possessed a Master of Art degree in Counselling Psychology, and has completed all of her clinical training and coursework for her Doctoral degree. She was a Registered Clinical Counsellor in good standing (RCC, #2752), and had a private therapy practice. In 2004, a  72  7-day Mindfulness-Based Stress Reduction (MBSR) training program for health professionals lead by Dr. Kabat-Zinn was attended; in 2005, 9-day training to lead MBSR programs was attended at the Center for Mindfulness at the University of Massachesetts. In 2005-2006 under supervision, Ms. Maglio twice co-led and once solo-led the Challenging Anxiety Group (CAG) with the same clinical population that was investigated in this research; in the solo-led CAG group, a faculty observer attended the group for the purposes of learning its application. In addition to the supervised training with the CAG, in 2006, Ms. Maglio co-taught a graduate course on Meditation and Stress-Reduction, and gave several educational lectures on meditation. She has had her own regular mindfulness meditation practice for the last eight years, and attends mindfulness retreats. Additionally, in 2006, she trained in Dialectic Behavioural Therapy (DBT). Ms. Maglio also has attended several pertinent workshops: Cognitive-Behavioral Therapy for panic and OCD in 2001, DBT for multi-disordered and suicidal clients in 2006, Acceptance and Commitment Therapy for Anxiety in 2007, and Mindfulness in Therapy in 2008. More recently, in 2010, she attended the 8-day Teacher Development Intensive for MBSR. And, in early 2011, she completed training in DBT Chain Analysis, DBT Validation Principles and Strategies, and DBT Mastery of Anxiety and Panic in Adolescents. Therapy group history. Following is a brief outline of the Integrative Mindfulness-based Anxiety Group therapy (IMAG), which was initially named the Challenging Anxiety Group (CAG). The prior-mentioned CAG was initially created by Dr. Melanee A.Cherry, Ph.D., LSW. During Ms. Maglio’s pre-doctoral internship, she worked with and was supervised using the CAG, which Dr. Cherry had been using for  73  university students coming to an university’s counselling centre with anxiety concerns and difficulties. The CAG was a regularly conducted and long-standing therapy group at the counselling centre. For the purposes of this research, the CAG was re-named the Integrative Mindfulness-based Anxiety Group therapy (IMAG) to make its components and application more transparent. Therapy group design. The IMAG was a ten 2-hour weekly session intervention, which integrated Mindfulness-Based Cognitive Therapy (MBCT: Segal, Williams, & Teasdale, 2002), and Dialectic Behavioral Therapy (DBT: Linehan, 1993a, 1993b). In 2005-2006, Dr. Cherry was beginning to integrate components of the Acceptance and Commitment Therapy (ACT: Hayes, 2005; Eifert & Forsyth, 2005) in the CAG; however, there was only a limited presentation of ACT in the IMAG. Additionally, when compared to the CAG, the IMAG had greater emphasis on the meditative practices found in the MBCT and Mindfulness-Based Stress Reduction (MBSR: Kabat-Zinn, 1990). Consultation and supervision was available from Dr.Cherry for this current research. A brief weekly outline of the components of the IMAG intervention follows. Session 1. The session starts with a 5-minute free write, which consisted of the participant writing anything they wanted in a provided booklet. Leader introduces herself, and participants introduce themselves and briefly discuss why they are in the group and what they want to achieve. Participants write out norms to be followed during the group. Leader over views the goals and the group. Leader briefly discusses anxiety, mindfulness, and the reasons for training in mindfulness. Leader introduces breathing  74  anatomy and introduces calming breath. Homework assignment: Calming Breath (Bourne, 2000). Exercise for 5-10 minutes x 5 per week. Session 2. The session starts with a free write. Leader and participants do a mindful movement routine; a CD of the routine is provided for homework practice. Group checks in on homework, and goal progress. Leader introduces differences in mind states: Wise Mind (Linehan, 1993b) and Being and Doing Mind (to Group 3 & 4 only) (Segal, et al., 2002). Leader teaches meditation posture, and Mindfulness Breathing Meditation (Segal, et al., 2002). Homework assignment: Breathing exercise with Wise Mind x 2 per week; Mindful Movement with CD x 2 per week; 10-minute meditation practice x 3 per week; and taking notice of mind states: Wise/Emotional/Reasonable Minds and Doing/Being Minds. Session 3. The session starts with a free write. Leader and participants do a body scan routine (Kabat-Zinn, 1990). A CD of the routine is provided for homework practice. Leader leads a 10-minute breath meditation (Segal, et al., 2002). Group checks in on homework from past session, and goal progression. Leader teaches Mindfulness “What Skills” (Linehan, 1993b). Homework assignment: Body Scan or Mindful Movement x 2 per week; 10-minutes of meditation practice x 5 per week; and practicing the What Skills. Session 4. The session starts with a free write. Leader leads mindful movement routine. Leader leads a 15-minute breath meditation (Segal, et al., 2002). Group checks in on homework from past session, and goal progression. Leader teaches Mindfulness “How Skills” (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements x 2 per week; 15-minutes of meditation practice x 5 per week; complete the nonjudgment log; and practicing the What/How Skills.  75  Session 5. The session starts with a free write. Leader leads body scan routine. Leader leads a 15-minute meditation, which includes breath and body sensations (Segal, et al., 2002). Group checks in on homework from past session, and goals progression. Leader teaches “Radical Acceptance” Skills (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements x 2 per week, 15-minutes of meditation practice with breath and body sensations x 5 per week; practicing the What/How Skills and Radical Acceptance Skills with chores or tasks that one is wilful (Linehan, 1993b). Session 6 (Group 1 & 2). The session starts with a free write. Leader leads Mindful Eating routine (Kabat-Zinn, 1990). Leader leads a 15- to 20-minute meditation, which includes breath and body sensations and sounds (Segal, et al., 2002). Group checks in on homework from past session, and goals progression. Leader reviews “Radical Acceptance” Skills (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements x 2 per week; 15- to 20-minutes of meditation practice with breathe or body sensations or sounds x 3-5 per week; and, eat one meal mindfully. Session 6 (Group 3 & 4). The session starts with a free write. Leader leads Mindful Eating routine (Kabat-Zinn, 1990). Leader leads a 15- to 20-minute meditation, which includes breath and body sensations and sounds (Segal, et al., 2002). Group checks in on homework from past session, and goals progression. Leader leads a “Physicalizing Exercise” (Hayes, 2005). Homework assignment: Body Scan/Mindful Movements x 2 per week; eat one meal mindfully; and 15- to 20-minutes of meditation practice with breath or body sensations or sounds x 3-5 per week. Session 7. The session starts with a free write. Leader teaches Mindful Walking (Kabat-Zinn, 1990). Leader leads a 20-minute meditation, which includes breath and  76  body sensations and sounds (Segal, et al., 2002). Group checks in on homework from past session, and goals progression. Leader teaches regulating Emotional Mind (Linehan, 1993b) and increasing positive emotions and events (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements/Mindful Eating/Mindful Walking x 2 per week; 20-minutes of meditation practice with breath and body sensations x 3-5 per week; practicing the What/How Skills and Radical Acceptance Skills; work on regulating Emotional Mind and positive events; and, complete an emotion identification form. Session 8. The session starts with a free write. Leader leads a 25-minute meditation, which includes breath and body sensations and sounds (Segal, et al., 2002). Group checks in on homework from past session, and goals progression. Leader teaches “emotional regulation” of fear (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements/Mindful Eating/Mindful Walking x 2 per week; 25-minutes of meditation practice with breath and body sensations x 3-5 per week; and, use the skills to work with fear as it applies to a goal from the group. Session 9. The session starts with a free write. Leader leads a 25-minute meditation, which includes breath and body sensations and sounds (Segal et al., 2002). Leader teaches Metta Meditation. Group checks in on homework from past session, and goals progression. Leader teaches “emotional regulation” of guilt and shame (Linehan, 1993b). Homework assignment: Body Scan/Mindful Movements/Mindful Eating/Mindful Walking x 2 per week; 25-minutes of meditation practice with breath and body sensations x 3-5 per week; working with a goal from the group; use the skills to work with fear, or guilt/shame as it applies to a goal; and, complete the valued living form (Hayes, 2005).  77  Session 10. The session starts with a free write. Leader leads a 30-minute meditation, which includes breath and body sensations and sounds. Leader leads Metta Meditation. Group checks in on homework from past session, and goals progression. Leader teaches a new form of goal setting using the values and skills learned over the group (Hayes, 2005). Follow-Up Phase In this phase, participants resumed completing the full WQ, but did so on a monthly basis. Many participants mentioned wanting follow-up sessions as they felt they needed more practice with the meditation and the skills taught. The data from the prior WQs also supported this assertion. Thus, two extra sessions were added at the end of the group. Follow-up I meeting. The first follow-up sessions all took place in week 42 of the study. The three Follow-up I meetings took place on their respective campuses. Seven of 17 participants attended these Follow-up I meeting. These 3-hour sessions reviewed the mindfulness skills and how the skills taught in the group could be used in reaching the participant’s goals using the goal sheets. A strong emphasis was placed on resuming their meditative practices, and using the skills in areas that they were having challenges. Commitments to formal meditative practice were made, as well as practicing the skills. Light refreshments were served. Follow-up II meeting. The second follow-up sessions all took place in week 49 of the study. Again, these meetings took place on their respective campuses. Six of 17 participants attended these Follow-up II meetings. This session used a behavioural chain analysis (Linehan, 1993a) approach to understand the participant’s difficulties, such as  78  the challenges to sitting during meditation practices or being caught up in judging thoughts. The meeting focused on problem solving in regards to the participant’s identified challenges. More individualized plans were set up to support the participant in dealing with the difficulties they presented. Light refreshments were served. Data Production This study used two main sources of data production: weekly self-report questionnaires and post-group interviews. The weekly self-report questionnaires contained several components: reporting of technique-use, stressful and anxiety events questions, series of measurement scales, and the monitoring of personal goals. The postgroup interview was an one-hour interview conducted by a research assistant. The following is an overview of these data production strategies. Weekly Self-Report Questionnaires (WQ) Two versions of the WQ were used in this research. These two questionnaires provided the data to be used in the Small-N Visual Analysis, Group-based Within-Subject Analysis, and the Participant and Group Practice Analysis. A more detailed review of these analyses and their corresponding research questions are provided in the Data Analysis section below. To review the content of these questionnaires, a full WQ version, had all of the scales of measurement and the goal achievement questions. Participants were given the full WQ when they were in the Baseline or Follow-up phases. A second version, the partial WQ, was used in the Intervention phase because of the considerable homework component. There were two forms of the partial WQ, each containing approximately half of the scales measuring the anxiety and mindfulness dependent variables. The partial WQ  79  was administered to lessen the amount of time in completing the questionnaires in the Intervention phase, and to lessen testing effects by lowering repeated measurement of some of the measures. The two forms of the partial WQ were alternated weekly in the Intervention phase. Both WQ versions monitored goal achievement. Both also had questions regarding meditation and skills practice, and stressful or anxiety-causing events experienced over the week. Both WQ versions also contained the general therapy outcome scale. Permission from either the author or the publisher was received for all scales of measurement that were not available in the public domain. Due to copyright on some of the scales, the full WQ and the partial WQ are not provided in an appendix. The following outlines the scales of measurement used in the study, as well as the practice and context questions found at the beginnings of the WQ. Scales of Measurement Mindfulness, anxiety, and general clinical outcome were the three primary dependent variables being used in the quantitative portion of the study; these three variables were measured using several scales of measurement. Multi-operationalism (Primavera, Allison, & Alfonso, 1996) or multiple measurements were used for each of the main variables. This addressed issues related to response covariance and construct validation (Lundervold & Belwood, 2000). The following describes the scales of measurement assessing the dependent variables of mindfulness, anxiety, and general clinical outcome.  80  Measures of mindfulness. The first dependent variable was mindfulness. It was operationalized as “bringing one’s complete attention to the experiences occurring in the present moment, in a nonjudgmental or accepting way” (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006, p. 27). There is discussion in the literature about whether mindfulness is a uni-dimensional or multi-dimensional construct (Leary & Tate, 2007), thus two scales were used in the study to capture these potential differences. The two scales of measurement used by the study were Mindfulness Attentional Awareness Scale (Brown & Ryan, 2003) and Five Facet Mindfulness Questionnaire (Baer et al., 2006). Following are descriptions of these scales. Mindful Attentional Awareness Scale (MAAS: Brown & Ryan, 2003). This is a 15-item self-report scale measuring the consciousness of the current moment awareness. Items are measured on a six-point rating scale (1= “almost never”, to 6=”almost always”). There is a single sum score produced ranging between 15 to 90; a higher score indicates higher levels of mindful attention and awareness. Thus, an ascending trend is optimal for this research. In the article exploring the MAAS’s development, reliability in past research with university students was alpha .92, and research reported good convergent and discriminant validity (Brown & Ryan, 2003). Mackillop and Anderson (2007) completed a large-scale study of the MAAS (N=757) in a university population, which reported uni-dimensionality and respectable reliability (!= 0.89). This is an oftencited measure in mindfulness-based research. Five Facet Mindfulness Questionnaire (FF: Baer et al., 2006). This is a 39item five factorial self-report scale, which measures mindfulness as multifaceted construct. The five facets are (a) Acting with Awareness, (b) Nonreactivity to Inner  81  Experience, (c) Observing Sensations, (d) Describing with Words, and (e) Nonjudgment of Experience. Items are measured on a five-point rating scale (1= “never”, to 5= “very often true”), with the sum scores ranging between 8 to 40 for four of the scales, and fifth scale’s sum score ranging from 7 to 35 points. Higher scores indicate a greater degree of the facet of mindfulness, thus ascending trends are optimal. Construct validity was supported (Baer, et al., 2008). In an article exploring FF’s development, reliability in past research with university students was reportedly adequate to excellent (Nonreactivity, != 0.75; Observation, != 0.83; Acting with Awareness, != 0.87; Describing, != 0.91; Nonjudgment, != 0.87), and reported respectable convergent and discriminant validity (Baer et al., 2006). This is a newer scale therefore few studies were using it as a measure, or in a repeated administration design. Measures of anxiety. The second dependent variable was anxiety. Anxiety is a complex human response to a perceived threat to one’s self or one’s wellbeing. It typically has cognitive, emotional, behavioural, and physiological characteristics, and is adaptive when this orchestrated and holistic response protects the individual from a harmful event. However, for some, this threat response occurs in the presence of nonharmful or neutral stimulus, which are perceived as threatening. This protective system becomes overly vigilant and maintains a state of readiness to respond regardless to the nature of the threat. In these last two scenarios, the protective system of anxiety becomes maladaptive, and can harm the individual. Given the multi-faceted nature of anxiety, four scales were used to assess anxiety’s various characteristics: Penn State Worry Scale- Past Week (Stöber & Bittencourt, 1998), Burns Anxiety Inventory (Burns & Eidelson, 1998), and the two scales of the State-Trait Anxiety Inventory (Spielberger, 1983; 1985).  82  Penn State Worry Questionnaire- Past Week (PSWQ-PW: Stöber & Bittencourt, 1998). This is a 15-item self-report measure of worry, which is built to be sensitive to small changes in pervasive worry over shorter durations of time. This is an adaptation to Penn State Worry Questionnaire (PSWQ: Meyer, Miller, Metzger, & Borkovec, 1990; Molina & Borkovec, 1994), which is a gold standard measure for worry. Items are measured on a seven-point rating scale (0= “rarely” to 6= “almost always”). A total score ranging from 0 to 105 is produced. The higher scores indicating greater worry, thus a descending trend is optimal for this research. In an article exploring PSWQ-PW’s development, reliability in past research with a clinically anxious population was reported as != 0.91, and had respectable convergent validity (Stöber & Bittencourt, 1998). Although the initial PSWQ has been shown to be responsive to probe or repeated measurement (Brown, Antony, & Barlow, 1992; Stöber & Bittencourt, 1998), the PSWQ-PW was specifically built so it could be given in an interval, probe, or repeated manner over shorter durations of time. Burns Anxiety Inventory (BAI: Burns & Eidelson, 1998). This is a self-report measure consisting of 33 items measuring cognitive, affective, and somatic indicators of anxiety. Items are measured using a four-point rating scale (0=“not at all” to 3=“a lot”). The range of scores is 0 to 99, with higher scores equalling higher levels of anxiety. Thus, a descending trend is optimal. The internal consistency with university students is reported as !=.94, with respectable convergent and discriminant validity reported (Burns & Eidelson, 1998). Other authors have used these scales in research requiring interval, probe, or repeated measurement (such as Persons, Roberts, & Zalecki, 2003).  83  Additionally, this scale was used in Vancouver Coastal Health’s psychological assessment battery, thus has validity in local and applied contexts. State-Trait Anxiety Inventory (STAI: Spielberger, 1983). This is a gold measure of both state and trait anxiety. This self-report measure is comprised of 40 items, 20 state-anxiety items and 20 trait-anxiety items. Thus, two sum scores are produced: trait anxiety and state anxiety. The items are measured using a four-point rating scale (1= “almost never” to 4= “almost always”). The respective ranges of these scales are 20 to 80, with higher scores suggesting higher anxiety. Descending trends are optimal. The reliabilities with university students are respectable (state-anxiety, != 0.91, and trait-anxiety, != 0.93) (Campagna & Curtis, 2007), as are validity assessments for this measure (Gaudry, Vagg, & Spielberger, 1975; Spielberger, 1985). Several researchers have used these scales in research requiring interval, probe, or repeated measurement (such as, Chaput & Tremblay, 2007; Massarini, Rovetti & Tagliaferri, 2005). Measure of general clinical outcome. The final scale is a global measure for therapeutic outcome. The Outcome Questionnaire-45.2 (OQ-45.2: Lambert et al., 1996) is designed to measure client progress through repeated measurements across the therapeutic process and at termination. This measure is widely used in counselling centres to monitor client progress (Vermeersch, Lambert, & Burlingame, 2000; Vermeersch et al., 2004). This 45-item measure has a range of 0 to 145, with higher scores suggesting higher client distress or challenge. Items are measured on a five-point rating scale (0=“never” to 4=“almost always”). This measure also has cut-off score for the clinical range (i.e., score of 64 and higher) and the non-clinical range (i.e., score of 63  84  and lower). There is a Reliable Change Index (RCI) of 14 points, such that change of 14 points in either direction is considered reliable change (Lambert et al., 2001). Internal consistency with university students for this measure’s full score is .93, and it has respectable convergent and discriminant validity (Lambert et al., 2001). This scale was developed for repeated measurement across a therapeutic process (Lambert et al., 2001). Composite scale scores. To capture the impact of the intervention on the two dependent variables, two composite scores were created: the Composite Anxiety score (CAS), and the Composite Mindfulness score (CMS). The CAS was composed of sum scores of three anxiety measures: the State-Trait Anxiety Inventory, Burns Anxiety Inventory, and Penn State Worry Scale- Past Week. The range of the CAS was from 40 to 364. The CMS was composed of the sum scores of two mindfulness measures: the Mindfulness Attentional Awareness Scale and Five Facet Mindfulness Questionnaire. The range of the CMS was 54 to 285. Practice and Context Questions There was a series of questions at the beginning of both full or partial WQ that pertained to two areas of inquiry: mindfulness practice, and stressful or anxiety-causing events. The practice of mindfulness skills and techniques were monitored using three questions. The first question pertained to the number of days in a particular week that mindfulness exercises and practices were undertaken. The second question pertained to how many minutes, on average, that a particular participant practiced in a given day. The third question asked which mindfulness skills and techniques were practiced.  85  The stressful or anxiety-causing events had two questions. The first question inquired if there was anything particularly stressful or anxiety-causing that occurred over the week in question. And, the second question asked the participant to comment on this stressful or anxiety-causing event. Goals There was a series of questions at the end of both full or partial WQs, which inquired about goal attainment. Due to a lack of specificity in the scale (i.e., metric) used to respond to these questions, the goal’s questions were not used in the analysis of the current study. Post-Group Interview This post-group interview was completed between three and six months after the Intervention phase ended. This audio-recorded phone interview was conducted by a research assistant to the study, and was approximately one-hour in length. The postgroup interview gave a second description of the participant’s experience and struggles with anxiety, and also explored their experiences with mindfulness and the group. The study’s research assistant, who was trained in how to ask questions and probe for informational clarity or concrete examples, administered these one-hour Skype/telephone interviews. These interviews were audio-recorded, transcribed, and identity protected. Please see Appendix G for the post-group interview questions. Data Analyses The quantitative data were entered into an Excel spreadsheet, and then transitioned into an SPSS-17.0 file. Two data files were created: the questionnaires and  86  the participant goals. Two research assistants checked these raw data files for both systematic and random errors; in total, the checks for errors were approximately 10 hours. The qualitative interview data were verbatim transcribed into a Word file, and then transitioned into a rich text format for use in ATLAS-ti (Buhr, 1995). The following outlines the four data analytic strategies used by this study. Each section begins with a recounting of the research questions guiding the particular analysis. All data were identity protected, and the participants are numbered 1 to 17. Small-N, Visual Analyses Small-N, visual analyses documented changes in the data paths of the dependent variables (DV) caused by the manipulation in an independent variable. Kratochwill and his colleagues (2010) outlined four steps for a visual analysis: (1) documentation of a predictable baseline, (2) examination of the data within each phase of the study, (3) comparison of the data from each phase with the data in the adjacent phase to see if a basic effect has occurred, and (4) integration of the results of the analyses across the phases to assess if a functional relationship (i.e., at least three effects at different points of time) has occurred. For the purposes of this study, both basic effects (i.e., DV changes in the Intervention phase) and delayed effects (i.e., DV changes in the Follow-up phase) were used to assess the presence of a functional relationship. The criteria to assess for effects and functional relationships are presented below. The visual analyses used in this study were guided by the following questions: a. Is there a functional relationship between the IMAG and an increase in mindfulness, as seen by qualities of consciousness, awareness, attention, non-  87  reactivity, and non-judgment among university or college students who self-report anxiety? b. Is there a functional relationship between the IMAG and a decrease in the symptoms generally associated with anxiety (e.g., worry, physical, cognitive, affective symptoms) among university or college students who self-report anxiety? c. Is there a functional relationship between the IMAG and a decrease in general clinical symptoms in university or college students who self-report anxiety? The 17 participants’ visual analyses were assessed at the levels of single cases, cohorts, and the total group. This approach allowed for an in-depth analysis of change across baseline, intervention, and follow-up phases. Additionally, multiple measures allowed for a broader coverage of the dependent variables, and multiple opportunities to view the process of change in the dependent variable constructs. The use of multiple measurements can strengthen the argument that change has occurred in the dependent variables in that there are more opportunities to view a functional relationship. Additionally, the visual analyses of the composite scores allows for a better assessment of change in the two main dependent variables. These composites also provide greater variability because of the increased sum scores, and allowed a consistent assessment of change in the main constructs undergirding the various scales used in the study. Further, in a multiple baseline design, the participant serves as their own control. In order for experimental control to be evidenced, there needs to be a predicted change in the dependent variable at a minimum of three different points in time, with these three  88  different changes occurring only after the manipulation of the independent variable has begun (Barlow, Nock, & Hersen, 2009). Taken together, multiple measures over multiple measurements over time, with basic effects or delayed effects demonstrated at three different points in time provides strong evidence for clinical change. Procedures. Following are the steps undertaken to accomplish the visual analyses. First, the weekly raw data were entered into a Excel spread sheet. These data were transitioned into SPSS (17.0), and the data were checked for errors and missing data. Reversed items were corrected to prepare for summing. Second, the sum scores for the weekly measurements of a particular scale of measurement were calculated. This summing occurred at the individual, cohort, and group level. Third, the weekly sum scores for a particular scale for an individual participant were placed on a multiple baseline design graph, which indicated all of the weeks of the study, the three phases of the study, and the range of scores for a scale of measurement (Please see Figures 5.1 5.13 for the multiple baseline design graphs). These graphs were created using InDesign (Adobe, 2008). However, only the individual participants’ summed scores were graphed; this was due to unequal time in the baseline phase. For the analyses of the cohorts and total group, this researcher used levels (i.e., phase mean) and the standard deviations to assess for clinical change. Fourth, to create the dependent variable composite scores, the sum scores for the weekly measurements for the respective scales of measurement were added together. For anxiety, four anxiety scales were added together at the weekly level to create a weekly measure of anxiety scales, or the weekly composite anxiety scores. For the mindfulness variable, two mindfulness scales were added together at the weekly levels to create a  89  weekly measure of mindfulness, or the weekly composite mindfulness score. Fifth, the weekly sum scores for a particular composite score for an individual participant were placed on a multiple baseline design graph, which indicated all of the weeks of the study, the three phases of the study, and the range of the composite scores (Please see Figures 5.2 and 5.7). These two respective composite score graphs were both created using InDesign (Adobe, 2008). The visual analyses described below for the respective composite scores were completed on the graphed data. Additionally, this researcher used levels (i.e., phase mean) and the standard deviations to assess for clinical change. Following are the visual criteria used to analyze for changes in the aforementioned graphed data. Visual analysis indicators and criteria. In order to determine if a basic or delayed effect occurred, the analysis used the several indicators outlined by Lundervold and Belwood (2000). First, the visual indicator was level, which is “the relative magnitude of change observed and can be assessed at any points during baseline or intervention (or follow-up)” (p. 96). The phase level was assessed using the phase mean and range; the phase mean was an average of the achieved level of the variable (i.e., scale of measurement) being measured in a particular phase, and the range was the range of data in the phase. Assessing level change from baseline directly before the intervention and directly after the intervention resembles a pre- and post-intervention design; the caveat for this assertion is the challenge of autocorrelation with serial measurement. Second, trend was the pattern of intra-phase sum scores; trends were assessed as either ascending or a consecutive increase of sum scores across the phase, or descending or a consecutive decrease of sum scores across the phase. Depending on the nature of the  90  criteria being measured, a trend can be optimal (e.g., descending for anxiety or therapy outcome, or ascending for mindfulness), non-optimal (e.g., ascending for anxiety or therapy outcome, or descending for mindfulness), or stable (e.g., no change). Additionally, this indicator assesses change in the directional pattern of sum scores across phases; shifting directionality or sum score patterns across phases also can assess phase change. Third, slope assesses the magnitude or steepness in a trend. Level, trend, and slope analyses were the bases for detecting change in the visual analysis, and supersede all other criteria used in the analyses. These three foundational criteria use the researcher’s judgement of the data and data paths to assess for change. However, additional standard-based criteria were included in the visual analyses of this current study. These additional criteria were included to increase the thoroughness and rigor of the assessment of group, cohort, or participant change. A fourth criterion used was non-overlapping data, which is an indictor of across phase change as it assesses improvement in the intervention and follow-up phases based on scores in the baseline phase. Non-overlapping analysis provides a percentage of scores in the intervention and follow-up phases that do not overlap with baseline data (Banda & Therrien, 2008). In order to assess if non-overlap has occurred, a standard of 80% (i.e., a moderate effect) was being used for this study (Banda & Therrien, 2008). Fifth, a form of clinical significance was used to assess participant change. The intervention phase mean and the follow-up phase mean were compared to a calculation of the baseline phase mean plus or minus two baseline standard deviations (i.e., !Xbl +2SDbl) (Jacobson & Truax, 1992). Clinical significance was met if the intervention or  91  follow-up phase means surpass the clinical significance level established by the baseline calculation (i.e., Xbl +- 2SDbl). The final criterion used in this study was variability (Barlow, Nock, & Hersen, 2009), which assessed changes in the standard deviation, or the amount of difference between sum scores found in the phase. Variability is important in clinical assessment because it can elucidate clinical change in the form of learning a skill (e.g., higher variability), or stabilizing or maintaining a skill (e.g., lower variability). Unlike the prior two criteria, variability as an indicator has no agreed upon standard, thus is made through a visual judgment. Determining an effect. The above six change indicators or criteria were used to assess if the IMAG had made a desired change in the various scales of measurement utilized by this study. Thus, the visual analysis entailed viewing each data path for the group, cohort, or participant, and assessing if the specific data or data path under scrutiny met first the criteria for level, trend, and slope, and second if it continued to meet the criteria of non-overlapping data, clinical significance, and variability. Although these six criteria were used to assess intra-phase and inter-phase change, a particular criterion was only reported if it was relevant to understanding the participant’s progress, or to understand if the IMAG had created an effect. An effect is the demonstration in either the intervention or follow-up phases of a clear pattern of change in the dependent variable (e.g., scales of measurement outlined above) due to a manipulation of the independent variable (i.e., IMAG). Stated differently, an effect is a desired change in data or a data path across a baseline. There are four types of effects being used in this study. Basic effects or weaker basic effects represent desired change in the intervention phase. Delay effects or weaker delayed  92  effects represent desired changes in the follow-up phase1. The specific criteria for the four effects follow. First, a basic effect was a desired change across the baseline and intervention phases in level and/or trend, with the additional criteria of non-overlapping data (>80%) and clinically significant change between baseline and intervention phases. Second, a delayed effect was a desired change across the baseline and follow-up phases in level and/or trend, with the additional criteria of non-overlapping data (>80%) and clinically significant change between baseline and follow-up phases. These two effects are a strict and thorough application of the criteria so as to lessen the possibility of Type I error. Third, a weaker basic effect was a desired change between baseline and intervention in level and/or trend, but does not meet the criteria of non-overlapping data (>80%) and/or clinical significance. Thus, moderate to minimal effectiveness would be indicated (Banda & Therrien, 2008). Fourth, a weaker delayed effect was a desired change in level and/or trend between baseline and follow-up, but does not meet the criteria of non-overlapping data (>80%) and/or clinical weaker  ___________________________________ 1. Singh and his colleagues (2007b) found that the intervention phase in a mindfulness study could act as a training phase, therefore the predicted effect might occur in the follow-up phase as a delayed effect. This current research study expected that same pattern of change occurring in follow-up. Thus, a delayed effect and a weaker delayed effect were used by this study to capture desired change that might occur after the training in intervention phase.  93  effects were a more liberal application of the criteria, which increase the practical significance. Again, moderate to minimal effectiveness would be indicated (Banda & Therrien). Although these two effects have utility in understanding the performance of the IMAG, this liberal application however increased the possibility of Type I error. Determining a functional relationship. The next step in the analysis was to determine whether a functional relationship existed between the intervention and the dependent variable. A functional relationship was established through vertical analyses across cohorts to assess for three demonstrations of effects created by the manipulation of the independent variable, and across at least three time periods (Barlow, Nock, & Hersen, 2009). For the purposes of this study, a functional relationship was established through both basic and delayed effects across the cohorts. In other words, one participant from three different cohorts needed to show basic effects or change in the intervention phase, or one participant from three different cohorts needed to show delayed effects or change in the follow-up phase. Thus, evidence of three participants’ changes at three different points of time per scale of measurement needed to be shown for a functional relationship to be present. Given this study utilized four different types of effects, there were two different types of functional relationships that could be assessed. First, a functional relationship was established through either three basic effects over three different cohorts, or three delayed effects over three different cohorts; this was the strongest evidence of a functional relationship. Second, a weaker functional relationship was established through either three basic and weaker basic effects, or three delayed and weaker delayed  94  effects; this provided a liberal application of criteria to establish a functional relationship. Thus, these two types of functional relationships allowed both a strict and a liberal application of the many indicators and criteria to answer the three research questions and understand the effectiveness of the IMAG. Within-Subject Analyses of Variance Within-subject Analysis of Variance Analysis (ANOVA) with post-hoc comparisons were used to compare pre-group, mid-group, end-group, and post-group measurements on all of the dependent variables to address the following research question: Did the IMAG create statistically significant (!= 0.05) differences between scores on the dependent-variable measurements at pre-group, mid-group, end-group, and postgroup measurements? Effect sizes ("2) for the various tests performed also were reported. If the IMAG did create statistically significant differences between the various phases of the intervention, post-hoc tests were used to determine in which phases the differences occurred. Group-based descriptive, statistical, and effect size analyses were conducted for the various dependent variable scales to account for the possibility of chance variance occurring. Statistical analyses on pre- and post-intervention scores are standard procedures for assessing the effectiveness of clinical interventions. Providing groupbased statistics in the context of a Small-N design is established by the literature as a viable way of summarizing and presenting data (e.g., Barreca et al., 2003; Crosbie, 1993). For these data, within-subject ANOVAs (SPSS 17.0) were performed at four time points in the study: in the pre-group (i.e., mean of the last three data points in the baseline  95  phase), mid-group (i.e., the data point that fell in the middle of the intervention for a particular participant, generally between 3rd and 7th session), end-group (i.e., last data point in the intervention phase) and post-group (i.e., last data point in the follow-up phase). These particular time points were chosen for the following reasons. Pre-group measurement. The pre-group measurement was chosen to be a mean of the last three data points in the baseline phase. Using the individual participant’s weekly sum scores for a particular scale or a particular composite score, the last three weeks in the baseline phase that had a sum score were averaged to create the mean used to represent the pre-group measurement. This mean score could account for a time period rather than a single point in time. It was a better indicator of the participant’s level on the various dependent measures prior to the intervention starting. All but one participant had at least three data points in the baseline phase. This participant misunderstood the directions about completing WQ in the baseline phase, so they only had one full WQ in the baseline phase; this single data point was used as the pre-group measurement for the ANOVAs for this participant. Mid-group measurement. The mid-group measurement was a single data point taken at approximately the mid-point in the intervention for the participant. Using the individual participant’s weekly sum scores for a particular scale or a particular composite score, this mid-point was generally between the 3rd and the 7th week of the intervention phase. This data point was the mid-point in the participant’s own attendance and process with the IMAG. Other reasons for allowing this range follow: some of the participants did not complete the full ten weeks of the IMAG but did not drop-out or withdraw from the study (e.g., holidays at the end of the summer precluded attendance), some of the  96  participants did not complete all questionnaires provided (e.g., they forgot; the week was heavy with school tasks and assignments; missed a session due to sickness or prior engagement), and there was a mix-up in the questionnaire sequence such that the same partial WQ was completed two weeks in a row thus one set of measures was skipped. Thus, the 3rd to 7th week range was used to capture the mid-intervention point given the unique circumstance of each participant. End-group measurement.. The end-intervention measurement was a single data point taken from the last measurement in the intervention phase. This measurement was chosen because together with a pre-group measurement would be most like the traditional and often-reported pre-post tests for clinical effectiveness. Post-group measurement. The follow-up measurement was the single data point taken from the last measurement in the follow-up phase. This measurement provides the best reference point of maintenance of gains, or long-term impact of the intervention. Due to inconsistent WQ completion in the follow-up phase, the post-group measurement occurred during varying weeks across this phase. Procedures. The said time-period measurements (i.e., pre-group, mid-group, end-group, and post-group) were entered into a SPSS (17.0) file. A research assistant checked this data for errors or missing data (-99). Assumptions of sphericity and normalcy were tested. Two sets of within-subject ANOVAs, and post-hoc pairwise comparison with a Bonferroni adjustment were completed. Also, because of unequal time-frames between measurements, the most conservative significance criteria (e.g., lower bound) were applied. The first set of ANOVAs used three-time periods, or pregroup mean, mid-group and end-group; this set contained all 17 participants. The next  97  set of ANOVAs used four-time periods, or pre-group mean, mid-group, end-group, and post-group; this set contained only 11 participants due to the fact that not all participants completed WQs in the follow-up phase. The addition of a group-based design remedies the possible challenge of Type II error in Small-N designs, which often do not offer sufficient power to detect differences in the data. Effect sizes or eta (SPSS 17.0) were reported to remedy the lower power in the design, and to provide a practical summary of the data and the differences between means. The criteria outlined by Cohen (2003) were used to determine the magnitude of the effect sizes: "2= 0.02 < 0.14 was a small effect; "2= 0.15 < 0.34 was a medium effect; and, "2 = 0.35< 0.99 was a large effect. Summary tables for descriptive statistics and summary write-ups are provided for the various measurement scales and the composite scores. Statistical significance of differences (!= 0.05) between the various time points assists the argument that the intervention created the changes in the targeted areas. This group-based analyses strategy (i.e., within-subject ANOVAs, post-hoc comparisons, and effect sizes) supported an evidence-based assertion of intervention effectiveness. Qualitative Thematic Analysis A thematic analysis using the post-group interview data was used to address the following research question: what themes occurred in the post-group interviews regarding the participant’s successes and struggles with anxiety, mindfulness, and the group? This qualitative thematic analysis used interview-based data that was collected in the follow-up phase. This interview data provided a dynamic qualitative picture of the participant’s own perspectives of their experiences of anxiety, mindfulness, the therapy  98  group, and their personal goals at the end of the intervention. Participant’s words and experiential reflections documented the changes or lack thereof. Much of the study focuses on changes in the area of anxiety and mindfulness; however this current analytic strategy allowed for unanticipated changes and challenges to be identified. Given the newness of the intervention, capturing the participant’s experience was crucial for an understanding of the intervention’s effectiveness or clinical relevance, anticipated or unanticipated. It also could support the intervention’s improvement and fortification. Thematic analysis can be defined as a systematic procedure for making inferences from text (Boyatzis, 1998; Stemler, 2001), or as a “method for identifying, analyzing, and reporting patterns (themes) in data” (Braun & Clarke, 2006). Often cited qualities of thematic analysis is that it delineates the material to be used and coded; has rules about coding and categorizing; and, has methods of checking trustworthiness and authenticity claims (Boyastzis, 1998; Stemler, 2001). For the purposes of this study, the data analysis approach was an inductive thematic analysis (Boyastzis, 1998) as it did not begin with a pre-set list of categories or themes; the categories developed from the post-group interviews were developed from the text itself. ATLAS-ti (Buhr, 1995) was used to manage the material. The following is a description of the various steps taken in these thematic analyses. Step one. The first step of analysis was an acknowledgment of the first coder’s prior knowledge of the data, the intervention, and the participants. More specifically, this coder recorded her beliefs and assumptions about the therapy group and the participant’s progress, her own experiences with anxiety and mindfulness, and her investment in the project’s success and what success meant. Possible biases or expectations that might  99  interfere with fully engaging with the data as it is were brought forth into consciousness. The points of this exercise were typed out in a list, and were referred to as coding and analysing proceeded. Additions to this list were made when a coder became aware of a bias or expectation in the ongoing process of coding or analysis. Step one addressed two of the “major obstacles to effective thematic analysis” (Boyatzis, 1998, p.12). First, it addressed projection or an over-familiarity with the phenomenon. This over-familiarity could create biases that preclude the message contained in the data, and can impact the coder’s mood/style or the individual preparedness to engage in the tasks of coding and analysis. Secondly, it also provided a method for remaining open to the data, and to new and unintended findings. Through consciousness, this method challenged pre-conceived expectations that may interfere with understanding the participant’s reflections. Step two. The second step of analysis entailed an open-coding strategy of transcribed post-group interviews. The coder thoroughly read each interview; one interview was worked with at a time. Recording units were identified. Although the coder was ultimately interested in recording units related to anxiety, mindfulness, participant goals, the IMAG, and change (e.g., progress or non-progress), she attempted to stay open to what the material had to offer. Thus, the text was parsed into recording units, which broadly fell into these said categories; however, the coder was careful to use said-categories as a guide but not a predefined code or theme list. Once a segment of text was identified as a recording unit, a code representing its content was developed and tentatively applied. The code was a tag for the content essence of the chosen segment; a single word or brief phrase that captured  100  or represented the core content or message of the chosen segment was applied. The coder tentatively applied the code to the recording unit, thus creating a tentative list of withininterview codes for a participant. If the chosen segment of text contain more than one possible code, then the unit was parse such that a single code could capture the essence of the content. Step three. This step was an extraction check. Approximately 25% of the text material was randomly chosen and given to a second coder. The second coder was given the task to code these segments with the broad categories, and place tentative codes that reflected the content of these randomly chosen interview segments. The coder and the second coder then compared (1) the choice of the segment and (2) the content of the segment. A percentage of agreement was formulated. If agreement is high in both areas (80%), then the first coder continued onto the next step. It is was not, then the first coder returned to re-select and re-code the text material. This step is then repeated until sufficiently high agreement is found. Step four. This step entailed creating themes from the codes and their corresponding text selection. Once all of the interviews were open-coded as per Step Two, the tentative codes and their respective text selections were assessed for similar content and meaning. A theme was developed to be sufficiently broad so as to capture meaning similarities within and across interviews, and yet specific enough to inform about the participants’ perspectives. The themes required a minimum of 25% participant involvement to be included (Butterfield, Borgen, Amundson, & Maglio, 2005). This process was intended to (a) reduce the number of codes in a specific category to a set of themes, and (b) create a framework of meaning and content across participants.  101  Once the theme was created, a title and definition for the theme was developed. The definition captures the essence of the theme’s content, a description of how to know when the theme occurs, and inclusion and possible exclusion criteria for the theme (Boyatzis, 1998). The theme was then represented by this definition and title. Step five. Once the set of themes with definitions and titles were created, the interviews were individually re-read to ensure that the themes matched the contexts of the total interview. Given the themes were developed based on de-contextualized segments, this step returned the themes back to the context of the whole interview from which segments were taken. If the theme did not match, then the segment, initial open-code, and the segment’s placement in the particular theme was re-assessed. Step six. This step was the sorting check. It used a second coder to sort the preidentified segments into their corresponding themes. This process entailed the second coder familiarizing himself with the themes and corresponding definitions and titles. Approximately 25% of the total interview segments were randomly chosen, and given to the second coder. The second coder then placed these segments into the pre-determined themes. A percentage of agreement between this placement and the actual theme was calculated. If the agreement was above 80%, then the first and second coders collaboratively resolved these differences. If the agreement was below 80% for a theme, then the first coder returned to Step Two to calibrate the theme’s definition and title. Once the theme was calibrated, the second coder was presented with the themes’ definitions and titles, including the calibrated definition and title, and a different 25% of randomly chosen segments, and then placed these segments into the themes.  102  Step seven. For each theme, exemplar interview segments were chosen to represent the participant’s words and perspectives, as they pertained to the theme’s content. Thus, the theme’s title, definition, and exemplar interview segments are used to represent the qualitative findings in Chapter 7. Step eight. Once the themes were established, higher-order abstractions were sought amongst the themes for the purposes of organizing a comprehensive framework for the theme presentation. These higher-order abstractions or higher-order groupings were created by reading the themes, and finding commonalities amongst the definitions of the themes. In addition to providing a framework for the themes, these groupings served to simplify the total number of themes presented across the interviews, and created a thematic structure to provide information from the participants on how to strengthen the IMAG. Participant and Group Practice Analyses The final analyses applied Frequency and Descriptive statistics (SPSS 17.0) to WQ questions related to (a) technique-use and (b) stress- and anxiety-events. These data were used to address the following research questions. a) What types of stress and anxiety events confronted the participant’s on a weekly basis? b) How often and for how long did the participant’s practice the skills and techniques taught in the intervention? c) Which skills and techniques were practiced? Each WQ included questions related to whether the participant practiced the techniques taught in the intervention, what they practiced, how many days they practiced,  103  and what the average duration of practice was. This analysis used frequency and descriptive statistics to assess the type, frequency, and duration of practice techniques (e.g., meditation, breathing exercises, mindfulness skills) used by the participants across the intervention and follow-up phases. This analysis entailed the raw data being coded into 14 pre-determined mindfulness practice categories, entered into an Excel spread sheet, transitioned into a SPSS (17.0) file, and checked for errors. A SPSS (17.0) Frequency and Descriptive statistics were run. Additionally, the WQ included questions related to the frequency and type of stressful and anxiety-based events that the participant encountered in the week prior to the completing of the questionnaire. Again, these answers were coded into 10 predetermined stress and anxiety categories, entered into an Excel spread sheet, transitioned into a SPSS (17.0) file, and checked for errors. A SPSS (17.0) Frequency and Descriptive statistics were run. Summaries for the individual participant, the cohort, as well as for the total group were provided. Summary This chapter overviewed the methods used in this study. It described the study design, and the logic for this design. The chapter then reviewed the process for enlisting the particular participants and these participants’ various characteristics. It continued on to describe the independent variable, or the IMAG and its sessions. It also discussed the leader’s training. The chapter then reviewed the dependent variables, and the data production processes. It overviewed the two versions of the WQ, the practice and context questions, and specific scales of measurement used to assess the three dependent  104  variables. It then continued to discuss the post-group interviews. To complete this current chapter, the four analyses and their corresponding research questions were reviewed. The results of these four analyses are outlined and reviewed in the next four chapters, with each chapter reviewing a respective analysis. Chapter 4: Participant and Group Practice Analyses outlined the practices and skills the participants used over the intervention and follow-up phases. Chapter 5: Small-N Visual Analysis examined the results of the main methodology of this study. Chapter 6: Group-Based Within-Subject Analysis, a gold standard therapy outcome research method, showed the results of the multiple ANOVAs. Finally, Chapter 7: Thematic Analysis outlined the themes developed from the post-group interviews. Taken together, these four chapters reviewed the results for the current research study.  105  CHAPTER FOUR: PARTICIPANT AND GROUP PRACTICE ANALYSES This is the first of four chapters reviewing the results. The chapter begins with the research questions guiding the analyses of the group’s, cohort’s, and participant’s mindfulness practice, as well as the types of stressors and anxiety-causing events in the participants’ week. Next is a description of data being used in this investigation. Finally, the results are presented at the group, cohort, and participant levels. A summary of the chapter is provided. Research Questions The research questions guiding these analyses were: 1. How often and for how long did the participants practice the mindfulness skills and techniques taught in the intervention? 2. Which mindfulness skills and techniques were practiced? 3. What types of stress and anxiety events confronted the participant’s on a weekly basis? Data Used in the Analyses The data to address the above were five questions the participants completed at the beginning of the full and partial weekly questionnaires (WQ). These questions were related to (a) mindfulness practices and techniques used during the week, and (b) stressful or anxiety-causing events during the week. All of the data reported upon was from the WQs that were completed by the participants, and submitted in various weeks across the study. The mindfulness-based questions inquired first about the number of practice days over the past week, and second about how many total practice minutes per day were  106  completed; ranges, averages and standard deviation are provided for the various analyses. The third question asked about which mindfulness exercises or skills were practiced. It should be noted that the mindfulness skills and techniques were taught as the intervention progressed, thus the participants had differing exposure and time to practice the various techniques. The mindfulness skills and techniques were coded as one of 14 categories. The two anxiety-causing or stress-based questions inquired if there was a particularly stressful or anxiety-causing event in the past week, and if so, what the nature of the event was. These events were coded as one of 10 categories. Group, Cohorts, and Individual Practice Analyses Both the group, and the cohort and the individual participant analyses are presented below. The group analysis is the composite of all 17 participants. The cohort analyses are the composites of the participants in a particular cohort (i.e., Cohort 1, Cohort 2, Cohort 3, and Cohort 4). This operates as an overview, and corresponds to the cohort and general assessments of the Small-N Visual analyses. The group analysis also corresponds to the within-subject ANOVAs. The individual analysis or a participant analysis also is presented. This corresponds to the Small-N Visual analyses of the respective participants; this current analysis might help identify differences between participants and their individual approaches to various practices of the intervention. Group Practice Analysis This group analysis is a summation of all participants for a particular phase. Mindfulness practice. In the intervention phase, the 17 participants reported practicing mindfulness techniques and skills between 0 to 7 days per week, with a weekly average of 4.2 days (SD: 1.6), and with a mode of 5.0 days of practice per week.  107  Mindfulness practice per day was reported between 0 to 60 minutes, with a daily average of 18.9 minutes (SD: 11.1), and mode of 20 minutes of practice in a day. During the intervention phase, the rank order list of mindfulness techniques and practices used by the participants was: (1) mindful meditation, (2) mindful movements/yoga, (3) breathing exercises, (4) body scan, (5) Radical Acceptance, (6) mindful walking, (7) What/How skills, (8) mindful eating, (9) Wise Mind skills, (10) emotional regulation, and (11) loving kindness/metta meditation. In the follow-up phase, the 12 participants who participated in this phase reported practicing mindfulness techniques or skills between 0 to 7 days per week, with a weekly average of 2.8 days (SD: 1.8), and mode of 3.0 days of practice per week. Mindfulness practice per day was reported between 0 to 60 minutes, with a daily average of 21.1 minutes (SD: 12.5), and mode of 20 minutes of practice in a day. During the follow-up phase, the rank order list of mindfulness techniques and practices was: (1) mindful meditation, (2) mindful movements/yoga, (3) body scan, (4) breathing exercises, (5) Radical Acceptance, (6) mindful walking, (7) What/How skills, (8) Wise Mind skills, and (9) loving kindness/metta meditation. Anxiety events. The participants reported stressful or anxiety-causing events across the study, or in all three phases of the study. Following is a rank order list of stressful and/or anxiety-causing events experienced by participants: (1) multiple stressful or/or anxiety-causing events, (2) school-related events, (3) work-related events, (4) family-related events, (5) social-related events, (6) relationship-related events, (7) healthrelated events, and (8) friend-related events.  108  Cohort and Individual Participant Analyses The following reports the cohort and individual participant’s experiences with mindfulness techniques and skills practice, and stressful and anxiety-causing events the individual participants confronted. Cohort 1. This is the summation of the five participants in Cohort 1 for a particular phase. Mindfulness practice. In the intervention phase, they reported practicing between 0 and 7 days per week, with a weekly average of 4.6 days (SD: 1.5), and for a reported total of 155 days of mindfulness practice. The duration of mindfulness practice per day was reported between 0 to 55 minutes, with a daily average of 17.8 minutes (SD: 9.3). The mindfulness techniques and skills reported as practiced across the intervention phase were: meditation, breathing, mindful movement/ yoga, body scan, mindful eating, Radical Acceptance, Wise Mind skills, Mindfulness skills, and mindful walking. In the follow-up phase, they reported practicing between 0 and 5 days per week, with a weekly average of 2.6 days (SD: 1.4), and for a reported total of 26 days of mindfulness practice. The duration of mindfulness practice per day was reported between 0 to 60 minutes, with a daily average of 24.2 minutes (SD: 15.8). The mindfulness techniques and skills reported as practiced across the intervention phase were: mindful movement/ yoga, meditation, Radical Acceptance, Mindfulness skills, and breathing. Anxiety events. The participants reported stressful or anxiety-causing events across the study, or in all three phases of the study. Following is a rank order list of stressful and/or anxiety-causing events experienced by Cohort 1: (1) multiple-events, (2)  109  work-related events, (3) family-related events, (4) relationship-related events, (5) socialrelated events, (6) friends-related events, and (7) health-related events. Participant 1. This participant completed four WQ in the baseline phase, six WQ in the intervention phase, and none in the follow-up phase. Mindfulness practice. In the intervention phase, Participant 1 reported practicing five of six weeks, from three to seven days per week, with a weekly average of 5.0 days (SD: 1.6), and for a reported total of 25 days of mindfulness practice. The duration of mindfulness practice per day was reported between 15 to 25 minutes, with a daily average of 20.0 minutes (SD: 3.5). There was no follow-up phase data. The mindfulness techniques and skills reported as practiced across the intervention phase were: meditation during four of the weeks, breathing exercises during three of the weeks, body scan during two of the weeks, mindful movement/yoga during two of the weeks, and mindful eating during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 1 reported five weeks containing stressful or anxiety-causing events: two weeks had work-related events; two weeks had socially-related events; and, one week had multiple stressful or anxiety-causing events. Four weeks were reported as not containing stressful or anxiety-causing events. Participant 2. This participant completed seven WQ in the baseline phase, ten WQ in the intervention phase, and none in the follow-up phase. Mindfulness practice. In the intervention phase, Participant 2 reported practicing 10 of the 10 weeks, between two to seven days per week, with a weekly average of 5.1 days (SD: 1.4), and for a reported total of 51 days. The duration of mindfulness practice  110  per day was reported between 4 to 25 minutes, with a daily average of 17.4 minutes (SD: 6.6). There was no follow-up phase data. The mindfulness techniques and skills reported as practiced in the intervention phase were: breathing exercises during eight of the weeks, meditation during five of the weeks, mindful movement/ yoga during five of the weeks, body scan during four of the weeks, mindful walking during one of the weeks, and mindful eating during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 2 reported six weeks containing stressful or anxiety-causing events: four weeks had work-related events and two weeks had multiple stressful or anxiety-causing events. Four weeks were reported as not containing any stressful or anxiety-causing events. Participant 2 reported a challenge resulting in substantial distress; towards the end of the intervention phase, they were referred to specialized treatment. Participant 3. This participant completed four WQ in the baseline phase, six WQ in the intervention phase, and five WQ in the follow-up phase. Mindfulness practice. In the intervention phase, Participant 3 reported practicing two of the six weeks, between three to six days per week, with a weekly average of 4.5 days (SD: 2.1), and for a reported total of nine days. The duration of mindfulness practice per day was reported between five to seven minutes, with a daily average of 6.0 minutes (SD: 1.4). The mindfulness techniques and skills reported as practiced across the intervention phase were: breathing exercises during two of the weeks, and Wise Mind skills during one of the weeks. During the five follow-up phase weeks reported on, Participant 3 practiced between three to five days per week, with a weekly average of 3.75 days (SD: 1.0).  111  Practice per day was reported as lasting between 15 to 20 minutes, with a daily average of 19.0 minutes (SD: 2.2). The mindfulness techniques and skills reported as being practiced in the follow-up phase were: mindful movements/yoga during five of the weeks, meditation during four of the weeks, and breathing exercises during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 3 reported two weeks containing stressful or anxiety-causing events: one week had work-related events and one week had health-related events. Two weeks were reported as not containing stressful or anxiety-causing events. Participant 3 reported two longstanding challenges, which preceded the study. Participant 4. This participant completed three WQ in the baseline phase, eight WQ in the intervention phase, and three WQ in the follow-up phase. Mindfulness practice. In the intervention phase, Participant 4 reported practicing seven of the eight weeks, between 0 to six days per week, with a weekly average of 3.5 days (SD: 1.9), and for a reported total of 28 days. The duration of mindfulness practice per day was reported between 0 to 50 minutes, with a daily average of 16.3 minutes (SD: 14.8). The mindfulness techniques and skills reported as being practiced across the intervention phase were: breathing exercises during four of the weeks, What/How skills during two of the weeks, meditation during one of the weeks, Radical Acceptance during one of the weeks, and mindful eating during one of the weeks. During the three follow-up phase weeks reported on, Participant 4 practiced between 0 and two days per week, with a weekly average of 1.0 days (SD: 1.4). The duration of the mindfulness practice per day was reported between 0 and 30 minutes, with  112  a daily average of 13.3 minutes (SD: 15.3). The mindfulness techniques and skills reported as practiced across the follow-up phase were: What/How skills during one of the weeks, meditation during one of the weeks, and Radical Acceptance during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 4 reported that all 14 weeks contained stressful or anxiety-causing events: three of the weeks had family-related events and eleven of the weeks had multiple stressful or anxiety-related events. Participant 5. This participant completed three WQ in the baseline phase, nine WQ in the intervention phase, and four WQ in follow-up phase. Mindfulness practice. In the intervention phase, Participant 5 reported practicing nine of the nine weeks, between four to six days per week, with a weekly average of 4.7 days (SD: 0.9), and for a reported total of 42 days. The duration of mindfulness practice per day was reported between 10 to 30 minutes, with a daily average of 21.1 minutes (SD: 7.4). The mindfulness techniques and skills reported as practiced across the intervention phase were: mindful movement/yoga during eight of the weeks, meditation during eight of the weeks, body scan during three of the weeks, Wise Mind skills during one of the weeks, breathing exercises during one of the weeks, and Radical Acceptance during one of the weeks. During the four follow-up phase weeks reported on, Participant 5 practiced between one to three days per week, with a weekly average of 2.3 days (SD: 1.0). The duration of mindfulness practice per day reported between 20 to 60 minutes, with a daily average of 38.8 minutes (SD: 17.5). The mindfulness techniques and skills reported as  113  practiced across the follow-up phase were: mindful movement/yoga during four of the weeks, and meditation during two of the weeks. Anxiety events. When considering the total time participating in the study, Participant 5 reported that eleven weeks contained stressful or anxiety-causing events: three of the weeks had relationship-related events, one of the weeks had school-related events, one of the weeks had work-related events, one of the weeks had family-related events, one of the weeks had friend-related events, and four of the weeks had multiple stressful or anxiety-related events. Five weeks were reported as having no stressful or anxiety-causing events present. Cohort 2. This is the summation of the two participants in Cohort 2 for a particular phase. Mindfulness practice. In the intervention phase, they reported practicing between 1 and 6 days per week, with a weekly average of 4.1 days (SD: 1.4), and for a reported total of 98 days of mindfulness practice. The duration of mindfulness practice per day was reported between 7 to 40 minutes, with a daily average of 18.3 minutes (SD: 8.9). The mindfulness techniques and skills reported as practiced across the intervention phase were: meditation, body scan, breathing, Radical Acceptance, breathing, and skills, and loving kindness meditation. In the follow-up phase, they reported practicing between 2 and 5 days per week, with a weekly average of 3.5 days (SD: 1.2), and for a reported total of 21 days of mindfulness practice. The duration of mindfulness practice per day was reported between 5 to 30 minutes, with a daily average of 20.0 minutes (SD: 10.6). The mindfulness techniques and skills reported as practiced across the Intervention phase were: mindful  114  movement/ yoga, meditation, Radical Acceptance, loving kindness meditation, and breathing. Anxiety events. The participants reported stressful or anxiety-causing events across the study, or in all three phases of the study. Following is a rank order list of stressful and/or anxiety-causing events experienced by Cohort 2: (1) work-related events, (2) school-related events, (3) multiple events, and (4) family-related events. Participant 6. This participant completed eight WQ in the baseline phase, twelve WQ in the intervention phase, and six WQ in the follow-up phase. In the intervention phase, Group 2 (Participants 6 and 7) skipped two weeks, however the participants completed questionnaires for the missed weeks. Therefore, Cohort 2 participants have twelve, not ten weeks of intervention data. Mindfulness practice. In intervention phase, Participant 6 reported practicing twelve of the twelve weeks, between two to six days per week, with a weekly average of 4.7 days (SD: 1.2), and for a reported total of 56 days. The duration of mindfulness practice per day was reported between 10 to 30 minutes, with a daily average of 17.1 minutes (SD: 8.6). The mindfulness techniques and skills that were reported as practiced across the intervention phase were: meditation during ten of the weeks, breathing exercises during six of the weeks, mindful movement/yoga during five of the weeks, body scan during four of the weeks, Radical Acceptance during one of the weeks, metta/loving kindness during one of the weeks, and mindful eating during one of the weeks. During the six follow-up phase weeks that were reported on, Participant 6 practiced between two and five days per week, with a weekly average of 3.5 days (SD:  115  1.2). The duration of mindfulness practice per day was reported between five to 30 minutes, with a daily average of 20.0 minutes (SD: 10.6). The mindfulness techniques and skills that were reported as practiced across the follow-up phase were: meditation during four of the weeks, body scan during three of the weeks, What/How skills during two of the weeks, breathing exercises during one of the weeks, Radical Acceptance during one of the weeks, and metta/loving kindness during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 6 reported thirteen weeks containing stressful or anxiety-causing events: six of the weeks had work-related events, two of the weeks had school-related events, one of the weeks had a family-based event, one of the weeks had a relationship-based event, and two of the weeks had multiple stressful or anxiety-related events. Thirteen weeks were reported to not contain stressful or anxiety-causing events. During the follow-up phase at approximately Week 45, Participant 6 reported dealing with extreme anxiety causing events, which were social, relationship, and academic in nature. These events caused a return to pre-intervention or the baseline phase levels. Participant 7. This participant completed seven WQ in the baseline phase, twelve WQ in the intervention phase, and none in follow-up phase. In the intervention phase, Group 2 skipped two weeks, however the participants (Participants 6 and 7) completed the corresponding questionnaires. Therefore, Cohort 2 participants have twelve, not ten weeks of intervention phase data. Mindfulness practice. In the intervention phase, they reported practicing twelve of the twelve weeks, between one to six days per week, with a weekly average of 3.5  116  days (SD: 1.4), and for a reported total of 42 days. The duration of mindfulness practice per day was reported between 7 and 40 minutes, with a daily average of 19.7 minutes (SD: 9.3). The mindfulness techniques and skills reported as practiced across the intervention phase were: meditation during seven of the weeks, mindful movement/yoga during seven of the weeks, body scan during six of the weeks, breathing exercises during four of the weeks, Radical Acceptance during two of the weeks, What/How skills during one of the weeks, and mindful eating during one of the weeks. Anxiety events. When considering the total time participating in the study, Participant 7 reported only one week as containing stressful or anxiety-causing events that were work-related. Eleven weeks were reported as not containing stressful or anxiety-causing events. In the intervention phase, Participant 7 reported the onset of a condition that made meditation difficult. Cohort 3. This is the summation of the six participants in Cohort 3 for a particular phase. Mindfulness practice. In the intervention phase, they reported practicing between 1 and 7 days per week, with a weekly average of 4.5 days (SD: 1.7), and for a reported total of 219 days of mindfulness practice. The duration of mindfulness practice per day was reported between 5 to 60 minutes, with a daily average of 16.7 minutes (SD: 10.6). The mindfulness techniques and skills reported as practiced across the intervention phase were: meditation, breathing, body scan, mindful movement/ yoga, Radical Acceptance, mindful walking, and mindful eating. In the follow-up phase, they reported practicing between 2 and 5 days per week, with a weekly average of 3.7