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Employees’ use of mindfulness in managing occupational stress : a qualitative study Treleaven, David Allan 2006

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E M P L O Y E E S ' U S E O F M I N D F U L N E S S IN M A N A G I N G O C C U P A T I O N A L S T R E S S : A Q U A L I T A T I V E S T U D Y by David A l l an Treleaven B . A . , The University of British Columbia, 2001 A THESIS S U B M I T T E D I N P A R T I A L F U L F I L M E N T OF T H E R E Q U I R E M E N T S F O R T H E D E G R E E OF M A S T E R O F A R T S in T H E F A C U L T Y OF G R A D U A T E S T U D I E S (Counselling Psychology) T H E U N I V E R S I T Y OF B R I T I S H C O L U M B I A January 2006 © David A l l an Treleaven, 2006 ABSTRACT Research has shown Mindfulness-Based Stress Reduction ( M B S R ) to be an effective stress management intervention (Baer, 2003). Several studies (e.g., Cohen-Katz et al., 2004; Shapiro et al., 1998, 2005a) have examined the effects of M B S R on health care professionals, yet research has not clarified processes underlying the use of mindfulness in the workplace. To address the absence of empirical accounts in this domain, this qualitative study explored how employees who regularly practice meditation use mindfulness to manage occupational stress. Grounded theory methodology (Strauss & Corbin, 1998), a well-validated framework for data analysis and interpretation, was used to develop a conceptual description of mindfulness processes. Semi-structured, face-to-face interviews were conducted in Vancouver, Canada, with 10 female and 2 male employees between the ages of 26 to 58 years ( M = 42). The constant comparative method from grounded theory was used to continually test and refine emerging categories (i.e., themes). Procedures such as coding (i.e., a process used to identify concepts) and continual memoing (i.e., a written record of methodological decisions and hypotheses) were also employed to ensure a rigorous analytical process. The use of mindfulness in the workplace was associated with: (a) a heightened awareness of physical, cognitive, or emotional responses to occupational stressors; (b) a shift in awareness to internal processes (e.g., bodily sensations); and (c) a sustained attention to these internal processes. The types of stressors that precipitated a shift in awareness and specific internal processes the employees attended to distinguished the categories. Implications for research include: (a) the contribution of an initial framework of processes underlying the use of mindfulness to be tested and incorporated into future research; (b) findings that show particular stressors to significantly influence the use of mindfulness in the workplace; and (c) findings that emphasize the importance of practitioners' awareness of potential negative impacts caused by the use of mindfulness. T A B L E O F C O N T E N T S A B S T R A C T i i T A B L E O F C O N T E N T S i i i L I S T O F T A B L E S . v i L I S T O F F I G U R E S .. v i i A C K N O W L E D G E M E N T S : . . . . v i i i D E D I C A T I O N ix C H A P T E R I I N T R O D U C T I O N 1 Mindfulness, M B S R , and Occupational Stress 1 Occupational Stress-management Interventions and M B S R 2 Rationale of the Study 3 Purpose of the Study 3 C H A P T E R II L I T E R A T U R E R E V I E W 5 Meditation and Mindfulness Research 5 Meditation research 5 Meditation and mindfulness 5 M B S R 6 M B S R : Theoretical framework 6 M B S R research ....7 Summary 8 Occupational Stress Research 8 Occupational stress and stress theory 8 History of occupational-stress research 9 Occupational stress-management interventions 10 Summary 10 Meditation and M B S R as Occupational Stress-management Interventions.. 10 Meditation as an occupational stress-management intervention 10 M B S R as an occupational stress-management intervention 11 Current trends in mindfulness-based research 16 Summary.. 16 The Use of Qualitative Methodology in M B S R Research 16 The effects of M B S R on nurse practitioners 16 Other qualitative M B S R research 18 The use o f grounded theory in mindfulness-based research 20 Summary 21 iv Conclusion 21 C H A P T E R III M E T H O D 22 Qualitative Research and Grounded Theory 22 Participants 23 Data Collection and Procedures 26 Pilot study 26 Recruitment 26 Interview Protocol 26 Reflexivity 27 Data Analysis 28 Constant comparative method 29 Coding. 29 Ethical Considerations 30 C H A P T E R IV F I N D I N G S 31 Context 31 Tuning Into One's Body 33 Summary 35 Relinquishing Workplace Expectations : 35 Summary 37 Tuning Into Inner-Dialogue 37 Summary 39 Sensing Increased Time and Spaciousness 39 Summary 42 Preliminary Categories 42 Increased self-compassion 42 Connecting with others. 43 Summary 43 C H A P T E R V D I S C U S S I O N 44 Research Findings in the Context of Professional Literature 44 Tuning into the body -46 Relinquishing workplace expectations 47 Tuning into inner-dialogue 48 Sensing increased time and spaciousness 48 Preliminary categories 48 Summary 48 Rigor and Trustworthiness of the Study 48 Limitations • 49 Contributions to Research and Implications for Practice 50 Recommendations for Future Research 50 Concluding Remarks 51 R E F E R E N C E S 52 A P P E N D I X A : Interview Questions 61 A P P E N D I X B : Behavioral Research Ethics Board Certificate of Approval 63 A P P E N D I X C: Recruitment Poster 64 A P P E N D I X D : Letter of Initial Contact 65 A P P E N D I X E : Consent Form 66 A P P E N D I X F: Demographic Info Questionnaire 68 A P P E N D I X G : Letter Accompanying Interview Summary 69 A P P E N D I X H : Logic Diagram 70 LIST O F T A B L E S Table 1 v i i LIST OF FIGURES Figure 1 32 A C K N O W L E D G E M E N T S I am thankful to have been supervised by Dr. Bonnie Long, whose scholarship, patience, and professionalism set an example to which I w i l l aspire. I am also thankful to committee members Dr. Colleen Haney and Dr. Joe Lucyshyn for their insight, and to participants for their time and energy. I am grateful to my mother and father, Lorraine and Wes, for their unwavering support, and to my younger brother, Ryan, for becoming a boundless source of laughter in his old age. Thank you also to my grandparents, A l and Bea, for their continued editorial, conversational, and financial support. Finally, 1 am indebted to my dear friends, Catherine and Yaari , for sharing in the joy of awakening. D E D I C A T I O N To my first U B C professor, Dr. Stephen Straker (1942-2004) my first U B C mentor, Dr. Tom Blom (1933-2003) and my beloved grandparents, Donald Clemes (1920-2005) & Isabelle Clemes (1917-2005) each who taught me to combine curiosity with love. To live in this world you must be able to do three things: to love what is mortal; to hold it against your bones knowing your life depends on it; and, when the time comes to let it to let it go. - Mary Oliver 1 C H A P T E R I I N T R O D U C T I O N Research has shown that Mindfulness-Based Stress Reduction ( M B S R ) , a mindfulness-training program, is an effective stress-management intervention (e.g., Astin, 1997; Kaplan, Goldenberg, & Galvin, 1993; Speca, Carlson, Goodey, & Angen, 2000). A t present, several studies (e.g., Cohen-Katz et al., 2004; Shapiro et al., 1998, 2005) have examined the effects of M B S R on the well-being of health care professionals and medical and premedical students, yet research has not clarified processes underlying the use of mindfulness in managing occupational stress. In the absence of empirical, qualitative accounts regarding processes of mindfulness, the focus of the present study was a qualitative exploration of how employees with a sustained meditation practice use mindfulness to manage occupational stress. Mindfulness, MBSR, and Occupational Stress Instructions on the use of mindfulness date back 2,500 years to Siddhartha Gautama, more commonly known as the "Buddha" (Sumedho, 1992). Described as "openhearted, moment-to-moment, non-judgmental awareness" (Kabat-Zinn, 2005a, p. 24), mindfulness is commonly achieved through Buddhist meditation techniques (Astin, 1997; Hahn, 1976). Over the past 25 years, the introduction of Western-based, non-religious mindfulness programs has generated empirical interest into potential clinical applications (Dimidjian & Linehan, 2003). The most frequently cited program is M B S R , an intensive 8-week group intervention that uses meditation to teach participants how to use mindfulness (Baer, 2003). Over 60 published studies have examined M B S R as a treatment option for a variety of conditions including chronic pain, stress, fibromyalgia, and disordered eating (e.g., Astin, 1997; Kabat-Zinn, 1982, 1985; Kristeller & Hallett, 1999; Mil ler , Fletcher, & Kabat-Zinn, 1995; Randolph, Caldera, Tacone, & Greak, 1999; Reibel, Greeson, Brainard, & Rosenweig, 2001; Shapiro et a l , 1998; Speca et al., 2000; Will iams, Kollar, Reger, & Pearson, 2001). The M B S R program identified the workplace as an area where many potential stressors converge (Kabat-Zinn, 1990). In economic terms, occupational stress cost the North American industry over $150 bill ion per year since the 1990s (Wright & Smye, 1996), and an increasing amount of literature has been devoted to understanding the impact of occupational stress. According to a recent Health and Safety Canada report (Tangri, 2005), work stress costs Canadian organizations 55% of employee assistance program expenses, 40% of worker turnover, and 19% of all absenteeism. In their analysis of employee data from two demographically similar Canadian samples in 1991 (N= 21,228) and 2001 (N= 6,502), 2 Duxbury and Higgins (2001) also found that twice as many employees in the 2001 sample (27% compared to 13%) reported having a high degree of occupational stress, and that employees who had "work overload" were found to more frequently use Canada's health care system. Occupational Stress-management Interventions and MBSR In an attempt to minimize the psychological and economic impacts of work-related stress, organizations have introduced occupational stress-management interventions (Caulfield, Chang, Dollard, & Elshaug, 2004; Stien, 2001) traditionally divided into three categories: (a) primary prevention strategies addressing the source of stress, (b) secondary interventions that focus on employees' stress-management skills, and (c) tertiary approaches that treat health conditions after they emerge (Murphy, Hurrell, Sauter, & Keita, 1995). The proactive and reactive approaches represented by (a) and (c), respectively, have been combined with secondary intervention strategies that educate workers in how to manage stress. Research has commonly examined the effects of stress management interventions on workers' health (e.g., Tangri, 2005), and three approaches have dominated the literature: cognitive-behavioral skills training, progressive muscle relaxation, and meditation (Murphy et al., 1995). Mixed findings are commonly reported in this area (e.g., Kenney & Cooper, 2003), with traditional meditation programs often shown to be ineffectual compared with other approaches (Bellarosa & Chen, 1997). Three studies that used M B S R as an occupational stress-management intervention recently reported improved mental health outcomes for health care professionals (e.g., doctors, nurses, mental health workers) and students (Cohen-Katz et al., 2004; Shapiro et al., 1998, 2005), generating renewed interest into the use of meditation in the workplace (Kabat-Zinn, 2005b). Cohen-Katz.and colleagues (2004, 2005a) reported significant reductions in burnout measures for nursing practitioners who had completed the M B S R program, and Shapiro et al. (1998, 2005) found significant decreases in anxiety and depression scores (subscales of the Hopkins Symptom Checklist 90 - Revised [Derogatis, 1977]) for health care professionals and medical students who completed the M B S R program. Other writers such as Epstein (1999, 2003a, 2003b), Williamson (2003), and Scherger (2003) suggested that mindfulness may enhance medical practice by improving practitioners' attentiveness and presence, though they provided only anecdotal evidence. 3 Rationale of the Study If M B S R is to be considered an effective occupational stress-management intervention, research must clarify the processes underlying employees' use of mindfulness in managing occupational stress. Mindfulness-based research has yet to provide empirical evidence distinguishing mindfulness from potentially related processes such as relaxation and acceptance (Bishop, 2002). A s Hayes and Wilson (2003) aptly described in their discussion of current literature: There are times when technologies are so powerful that impact alone justifies their standing, but within the more normal range the progress of the field demands that technologies enter into one or more scientific accounts... and that there be some evidence for the importance of the processes and principles specified in such an account in the favorable outcomes obtained, (p. 161) Wi th mindfulness having been described as a cognitive ski l l , a collection of techniques, and a psychological process that influences outcomes (Kabat-Zinn, 2005b; Langer, 1997), ambiguity has hindered development of the account Hayes and Wilson (2003) identified. Furthermore, judging by a recently proposed operational definition of mindfulness (Bishop et al., 2004), accounts of mindfulness processes have been deductive and lack empirical evidence. Although researchers have suggested that M B S R positively impacts employees' health outcomes, attention to how mindfulness helps manage occupational stress has been lacking (e.g., Cohen-Katz et al., 2004). With M B S R expanding into the workplace (e.g., Bellarosa & Chen, 1997), research would benefit from a comprehensive account of employees' experiences using mindfulness in an occupational context. In the present study, I drew on a qualitative approach to explore employee's experiences using mindfulness to manage occupational stress. Grounded theory methodology (Strauss & Corbin, 1998) offers a well-validated framework for data analysis and interpretation and was used to develop a conceptual description of mindfulness processes. With research having largely failed to provide an account of mindfulness processes beyond anecdotal evidence (e.g., Bauer-Wu et al., 2004; Majumdar et al., 2002), a grounded theory approach to exploring employees' use of mindfulness is a needed contribution to research. Purpose of the Study A s a pre-scientific concept, mindfulness processes have been difficult to capture in research. A qualitative exploration of mindfulness would thus benefit from being anchored in a particular social context and environment. With the expansion of M B S R programs into occupational settings, exploration of workers' experiences using mindfulness to manage occupational stress provides the opportunity to develop a more refined description of mindfulness, enhancing research and practice. This study explored how employees with a sustained, long-term meditation practice use mindfulness to manage occupational stress. 5 C H A P T E R II L I T E R A T U R E R E V I E W In this study, I explore how employees use mindfulness to manage occupational stress. Researchers have examined the effects of mindfulness-based programs (e.g., M B S R ) on clinical diagnoses (e.g., chronic pain, A x i s I disorders), and have more recently included non-clinical populations such as adult employees and volunteers (e.g., Anderson, Levinson, Barker, & Kiewra, 1999; McBee, 2003; Reibel, 2001; Williams et al., 2001). However, research designs have been predominantly pre-post designs without a control group, and between-group designs using wait-list control groups (Baer, 2003). A s mindfulness-based programs expand into workplace settings, researchers have yet to provide a comprehensive account of employees' use of mindfulness in managing occupational stress. Consequently, mindfulness remains difficult to untangle from potentially confounding processes such as relaxation (Benson, 1977) and exposure (Baer, 2003). In this chapter, I detail the separate histories of mindfulness and occupational stress research, including the more recent encounter between the two. Methodological approaches used to evaluate the effectiveness of M B S R with employees are considered, including the implications of a recent attempt to operationalize mindfulness. Meditation and Mindfulness Research Meditation research. Before mindfulness became a focus of study in Western psychology, empirical research focused on physiological outcomes associated with meditation (Andresen, 2000). Reported benefits included reduced heart rate and blood pressure (Wenneberg et al., 1997), increased cerebral blood flow (Jevning et al., 1996), and decreased respiratory rate (Laurie, 1977) for medical patients. The principle method of meditation examined in this context was Transcendental Meditation (TM), a concentration-based approach that restricts attention to a single object (Andresen, 2000). After a groundbreaking 1970 publication in Science (Wallace, 1970), T M became the most widely used meditation approach in research. Similar approaches during this period included the Relaxation Response (Benson, 1977), a non-spiritual meditative technique developed at Harvard medical school to reduce sympathetic arousal and norepinephrine (i.e. neurotransmitter) receptor activity (Stien, 2001). Meditation and mindfulness. Mindfulness is described as a heightened awareness of one's moment-to-moment experience developed through specific meditation techniques (Kabat-Zinn, 2005a). A major difference between mindfulness meditation and concentration-based techniques (e.g., T M ) is their separate approaches to the redirection of attention (Baer, 2003). 6 A s opposed to a firm restriction of attention in T M , mindfulness meditation encourages an . acceptance of distraction, and an attitude of curiosity towards its content (Bishop et al., 2004). This distinction between mindfulness meditation and T M has attracted individuals deterred by meditation's religious affiliation (Kabat-Zinn, 2005b). MBSR. Burgeoning interest in mindfulness-based interventions can be attributed to M B S R (Kabat-Zinn, 2005a). Originally developed in a medical setting to assist individuals with chronic pain and stress-related disorders (Kabat-Zinn, 2003), M B S R has been used to treat psychological suffering associated with chronic illness (Speca et a l , 2000), emotional and behavioral disorders (Bishop et al., 2004), and stress-reduction for healthy individuals (Grossman et al., 2004). Notably, a number of separate mindfulness-based interventions such as Mindfulness-Based Cognitive Therapy (Segal, Will iams, & Teasdale, 2002) have recent years, though M B S R remains most frequently cited (Baer, 2004). M B S R is typically conducted over 8 weeks, with groups of 20-35 participants meeting 2.5 hours weekly to practice sitting mindfulness meditation (Kabat-Zinn, 1990). Participants are offered basic psychoeducational instruction about stress, a component of M B S R that may influence positive outcomes (Bishop, 2002). Instruction includes information on "stressors" (Seyle, 1974), physiological responses to stress, and the distinction between adaptive and maladaptive stress coping strategies (Kabat Zinn, 2005b). One day-long retreat is typically held in the 6 t h week, and separate practices that encourage mindfulness (e.g., body scans, mindful stretching) are taught during the program (Baer, 2003). Participants are asked to maintain a regular sitting meditation practice of 45 minutes a day 6 days a week, an aspect considered over-demanding by some researchers (e.g., Bishop 2002). Canadian M B S R programs typically cost between $350-400 for the 8-week program, with sliding financial scales frequently offered to participants. Program costs have also been covered by provincial health care with doctor referral (e.g., http://www.meditationforhealth.cpm/refform.html). More than 16,000 medical patients have completed M B S R , and demographic characteristics regarding this group are difficult to access (Kabat-Zinn, 2005b). MBSR: Theoretical framework. In creating the M B S R program, Kabat-Zinn (1990) drew upon a number of stress models such as Hans Selye's (1974) general adaptation syndrome (GAS) , Martin Seligman's (1993) conception of optimism and health, and Richard Lazarus's (1993a, 1993b) Transactional Process theory. Lazarus's (1990) conceptualization of stress as a transactional relationship between person and environment, in particular, served as a principle component of M B S R as the subjective appraisal of external stress events (i.e., stressors) largely 7 determines one's response. Kabat-Zinn (1990) distinguished between a stress reaction (i.e., an automatic process involving inhibitory behavior and maladaptive coping strategies), and a stress response (i.e., a conscious experience utilizing healthy coping strategies). B y bringing mindfulness to a stress reaction, individuals appraise events with awareness and relaxation, theoretically leading to healthier coping strategies. Kabat-Zinn here focused on the possibility o f interrupting the unconscious internalization of inhibited stress reactions, in his view the first stage of maladaptive coping that leads to illness and disease. This proposed process underscored two general themes that entered into Kabat-Zinn's notion of how mindfulness works: quicker recovery of cognitive equilibrium and increased mental balance. A s wi l l be discussed, these themes have been more thoroughly developed in recent years, with Bishop and colleagues (2004) having proposed a two-component operational definition of mindfulness. Mindfulness is developed through sitting meditation, considered the heart of the M B S R program (Kabat-Zinn, 2005b). Meditation involves sitting in an upright posture and directing attention to a point of focus, most often the breath. When attention wanders to thoughts or emotions, individuals are instructed to observe stimuli with an attitude of acceptance and gently return to the breath (Kabat-Zinn, 1990). The consistent application of these instructions is thought to strengthen cognitive self-regulation and increase acceptance of one's moment-to-moment experience (Bishop et al., 2004). Further, the cultivation of mindfulness is believed to lead to a heightened awareness of physiological cues (e.g., increased blood pressure and pulse rate) and the transactional stress process. If individuals can attune to their experience of external stress events, Kabat-Zinn proposed, maladaptive coping strategies can be minimized and healthy ones adopted. MBSR research. A n examination of the literature related to mindfulness and meditation revealed that: (a) the majority of M B S R literature has used medical patients as participants (e.g., chronic pain patients, cancer patients), (b) male participation has been generally low ranging from 0% (Massion, Teas, Herbert, Werfheimer, & Kabat-Zinn, 1995) to 51% (Carlson et al., 2000), and (c) sample sizes have ranged from small (N= 16, Massion et al.) to moderate (N= 142, Kabat-Zinn, Lipworth, & Burney, 1985). Baer's (2003) meta-analytic review of 20 mindfulness-based studies found the mean age of participants to be 45 years, and the average sample size to be 35. Participants' race, ethnicity, education, marital status, and socioeconomic status have been notably underreported in the literature. Clinical M B S R trials have used mental health measures such as the Beck Anxiety Inventory (Beck & Steer, 1987) and physical health reports. In a study reflective of much 8 research in this area, Kristeller and Marlatt (1999) used an extended baseline design with a single group to examine the effects of M B S R on 18 binge-eating disorder patients. Participants were all women, all had graduated from high school, the average age was 46.5 years, all but one was white, and none had previous meditation experience. Pre-post measures used the Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin, 1982), self-reported binge frequency, and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock , & Erbaugh, 1961). The authors found significant B E S and B D I score reductions obtained 3-weeks prior and 3-weeks following the intervention: B E S mean scores were 31.69 (SD = 7.69) pre-treatment and 15.08 (SD = 8.12) post-treatment, and B D I mean scores 17.47 (SD =' 12.02) pre-treatment and 9.11 (SD = 6.95) post-treatment (p < .001 for both variables). Reported binges also decreased in frequency from 4.02 per week to 1.57 per week, suggesting that M B S R may have some value as an intervention component in the treatment of binge eating disorder. Notably, Kristeller and Marlatt's (1999) findings were limited by the lack of any control group and the inability to control for other potentially confounding variables (e.g., relaxation, psychoeducation). Similar studies focused on anxiety (Kabat-Zinn, 1992), chronic pain (Randolph, Caldera, Tacone, & Greak, 1999), fibro-myalgia (Kaplan, Goldenberg, & Garvin, 1993), and general medical patients (Reibel et al., 2001) have also failed to use a control group, eliminating the possibility of accounting for passage of time or comparing data with other treatment modalities. Summary. Early medical research focused predominantly on the physiological health benefits associated with meditation. With the emergence of M B S R in the 1980s, empirical research examined the effects of mindfulness meditation on physical and psychological outcomes, focused primarily on clinical populations suffering from illness and disease. The M B S R program is held in groups of 20 to 35 over 8-weeks, and uses meditation as a primary instruction technique. M B S R studies have used a variety of mental and physical health measures to report on effectiveness. In addition to a consistent lack of using control groups, failure to account for the potentially beneficial effects of psychoeducation as a treatment component remains a limitation. Occupational Stress Research Occupational stress and stress theory. The work environment is a setting where many potential stressors converge (Kabat-Zinn, 1990). The combination of financial pressure, interpersonal struggle, time constraint, and rapid technological advancement create an often chronically stressful workplace that leaves employees vulnerable to injury and disease (Alan & Cavaiola, 2000). A number of theories have considered the interaction between a person and their work environment (Vagg, Spielberger, & Wasala, 2002). French's (1973) Person-Environment Fit (PE-Fit) model conceptualized occupational stress as occurring when one's available resources could not meet the demands of the surrounding environment. This model foreshadowed Lazarus's (1991) transactional perspective that emphasized the cognitive processes involved in appraising a stressful event. Spielberger's state-trait theory (Shedletsky & Endler, 1974) recognized the importance of both PE-Fi t and cognitive appraisal, but placed more emphasis on the personality traits connected to one's emotional reaction to stress. Theories such as these created a framework for the empirical study of occupational stress and increased interest into the relationship between work stressors and strain (Vagg et al., 2002). History of occupational-stress research. Occupational-stress research dates back to the First World War (Kenny & Cooper, 2003), though the phenomenon of 'job stress' was not popularized until the 1970s (Ivancevich, Matteson, Freedman, & Phillips, 1990). Common impacts have included increased absenteeism and injury, health problems, and decreased worker productivity (Hurrell, Nelson, & Simmons, 1998; Stien, 2001; Vagg et al., 2002). Estimates from a recent US-based study reported that over one 1third o f workers find their jobs to be "stressful" the majority of the time (Murphy & Sauter, 2003), with these findings taking on added significance considering that occupational stress injuries account for 55% of employee assistance program expenses, and cost North American employers between $150 and $ 180 bil l ion dollars per year (Wright & Smye, 1996). In a large-scale American study, Goetzeland colleagues (1998) examined the economic-impacts of 10 risk factors (e.g., depression, body weight, tobacco use, exercise habits) within a working population. Multivariate regression analyses were conducted on data obtained from the health-reports of 46,026 employees aged 18 to 64 who had purchased health insurance from six major providers. Forty percent of this sample was comprised of employees aged 35 to 44, 58% were male, 83% were white, 56% were professional or managerial workers, 43% were laborer, clerical, or technical workers. The authors reported that health-care expenditures for workers who experienced high amounts of workplace stress were nearly double that of "risk free" workers (45%), with the amount tripling for workers who experienced both high stress and depression (90%). These findings emphasized the impacts of workplace stress on the health care expenditures for workers with health insurance, including the potentially exacerbating effects of depression within this population. 10 Occupational stress-management interventions. In an effort to remedy adverse effects of occupational stress, organizations introduced occupational stress-management interventions such as relaxation techniques (e.g., progressive muscle relaxation), electromyogram ( E M G ) biofeedback, and standardized meditation programs (Bunce, 1997; Giga, Noblet, Faragher, & Cooper, 2003) into the workplace. In reviewing the small amount of evidence-based research in this area, Caulfield et al. (2004) divided occupational stress-management interventions into primary approaches, designed to prevent workplace stressors from arising, secondary approaches that promote individual stress-resiliency through personal development, and tertiary approaches that treat health conditions after they emerge. Despite receiving theoretical support (e.g., Bruning & Frew, 1987), primary approaches have not been shown to be consistently effective in reducing workplace stressors, with research more often focused on secondary approaches (Murphy et al., 2003). Furthermore, with occupational stress-management interventions often initiated by private companies rather than government bodies, the challenge of effectively measuring stress outcomes is exacerbated by differing organizational objectives (Murphy & Sauter, 2003). Summary. Many potential stressors converge in work-related environments. Impacts of occupational stress have included increased worker absenteeism and illness, decreased productivity, and significant economic loss. Theories into how employees interact with their environment have been offered (e.g., PE-Fit) , and organizations have introduced occupational stress-management interventions to minimize the costs of occupational stress. Secondary approaches focused on the stress-management resources of individual employees have received the bulk of attention, with preventative, primary approaches shown to be less effective. Meditation and MBSR as Occupational Stress-management Interventions Meditation as an occupational stress-management intervention. The effectiveness of concentrative-based forms of meditation (e.g., T M ) has been studied as occupational stress-management interventions, with mixed findings commonly reported in the literature (e.g., Anderson et al., 1999; Metzger, 2003; Stein, 2001; van der Kl ink , Blonk, Schene, & van Dijk, 2001). Kolbe l l (1995) examined the effects of a meditation-based stress-management intervention in a single workplace setting for 38 United States (U.S.) employees whose age, gender, or socioeconomic status was not provided. Participants were randomly assigned to a treatment or no-treatment control group, with the treatment group meeting 20 minutes each workday for 4 weeks to learn and practice concentrative-based meditation. Measures included arithmetic subtests of the Wechsler Adult Intelligence Scale-Revised (Wechsler, 1981) to 11 evaluate cognitive functioning, scores on the Maslach Burnout Inventory (Maslach, Jackson, & Leiter, 1996) to measure employees' stress, and self-reported sick-days and physical symptoms 5 months before and following the intervention. Using a multivariate analysis of covariance ( M A N C O V A ) , no significant between-group differences were found. From these results, Kolbe l l concluded that meditation practice alone, without the support of other components such as psychoeducational instruction regarding stress, might not be an effective stress-management intervention in the workplace. In a separate study that reported similar results, Bellarosa and Chen (1997) designed a questionnaire for "stress management subject matter experts" (p. 247) to report on their opinions regarding the effectiveness and practicality of six popular occupational stress-management interventions: relaxation, physical fitness, cognitive restructuring, assertiveness training, meditation, and stress inoculation. Experts were comprised of U .S . and Canadian participants (N = 96) who worked in applied (80%) or academic (20%) settings, with 88% having conducted stress-management interventions in work-related settings. The average age of participants was 45 years (range = 27 to 67, SD not reported), and 60% were male. Questionnaires utilized a 7-Point Likert-scale to collect information regarding experts' familiarity with six common interventions (relaxation, physical fitness, cognitive restructuring, meditation, assertiveness training, and stress inoculation) and their opinions regarding the practicality and effectiveness of each. Although experts reported familiarity with meditation as an occupational stress-management intervention (M= 5.33, SD = 1.76, range = 1-7), the approach was rated last in both practicality and effectiveness. In their discussion, the authors speculated that meditation's unpopularity might have been the result of religious connotations attached to meditation. Whatever the case, the effectiveness of meditation as an occupational stress-management intervention is brought into question with such findings. MBSR as an occupational stress-management intervention. A s opposed to traditional, concentrative-based meditation programs, M B S R has offered an alternate approach to stress management in the workplace (Kabat-Zinn, 2005a). A t present, two studies (Cohen-Katz et al., 2004; Shapiro et al., 2005) have examined the effects of M B S R on the well-being of health care professionals, and another (Shapiro et al., 1998) on medical and premedical students. A handful of other articles (e.g., McBee, 2003; Scherger, 2003; Williamson, 2003) have reported on the use of M B S R in occupational settings, but offered only anecdotal accounts regarding its effectiveness. 12 In the most comprehensive M B S R workplace study to date, Cohen-Katz and colleagues (2004, 2005a, 2005b) examined the effects of M B S R on stress and burnout in a group of nursing practitioners. Part I of this series of three publications described the development and implementation of the M B S R program for nurses, Part II presented the results of a quantitative data analysis, and Part III offered qualitative findings and implications for these results. Part I and II of this series (Cohen-Katz et al., 2004, 2005a) described implementation procedures and quantitative results. Using a randomized, wait-list control group design, the authors measured the effects of M B S R amongst a small (N= 27) sample of female nurses employed by a U.S . hospital and health network. Nurses had been employed within the health network for an average of 13 years (range = 25 to 30, SD not reported), in their current position for an average of 7 years, and worked continuously throughout the intervention. Employees' ages ranged from 32 to 60 ( M = 46), 96% were white, and the majority (62%) held a bachelor's degree. Intervention procedures closely followed the 8-week M B S R program by Kabat-Zinn (1990). Nurses were randomly assigned to a treatment (n = 14) or wait-list control (n= 13) group, and were assessed immediately prior (TI), immediately following (T2), and 3 months after (T3) the completion of the intervention. Instruments included three separate subscales of the Maslach Burnout Inventory measuring emotional exhaustion, depersonalization, and lack of personal accomplishment (Maslach et al., 1996), the Brief Symptom Inventory (Derogatis & Melisaratos, 1983) to measure nurses' psychological distress, and the Mindfulness Attention Awareness Scale (Brown & Ryan, 2003, 2004), a new instrument used to assess individuals' frequency of using mindfulness. Using independent t tests, the authors found no significant between-group differences at TI on any of the measures. A t T2 (postintervention), independent t tests on Maslach Burnout Inventory scores showed significantly lower mean emotional exhaustion scores for the treatment group compared with the control group (p = .05), though actual t scores were not reported. Similar findings were reported for the personal accomplishment subscale, with the treatment group having demonstrated significantly higher mean accomplishment scores compared with the control group (p — .014). Notably, no significant differences were identified on the depersonalization subscale of the Maslach Burnout Inventory. Within-group comparison over time revealed continued significant reductions in emotional exhaustion for the treatment group at T3 (p = .01), whereas the changes in the personal accomplishment scores were not significant at T3. 13 Nurses' psychological distress was measured using Global Severity Index (GSI) scores from the Br ief Symptom Inventory (BSI). GSI scores are calculated using a summation of all BSI responses, and are later converted in standardized t scores that are compared to a normative group (a t score > 63 indicates elevated psychological distress). Comparison of GSI scores revealed that the percentage of nurses exhibiting elevated psychological distress before the intervention decreased in both the treatment (25% to 8%) and control (54% to 30%) group. A Fisher exact test based on GSI scores revealed no statistically significant pre-post differences in the treatment or control group. Furthermore, an independent t test analyzing scores from the Mindfulness Attention Awareness Scale found no significant between-group differences at T l , and a significant increase in mean scores at T2 for the treatment group compared with the wait-list control group (p = .001). Within group analyses demonstrated that changes for the treatment group, compared with the waitlist group, remained significant at T3. Despite the small sample size for this study, findings supported the hypothesis that nurses who completed the M B S R program — compared with a control group — experienced significant reductions in emotional exhaustion and depersonalization. Limitations to this study, however, included failure to control for the experiment wise error rate, and the absence of any reports on clinical significance, effect size, repeated measured analysis, or individual differences. Shapiro et al.'s (1998) comprehensive M B S R study of U.S . medical and premedical students, although not exclusively work-related, examined the short-term effects of M B S R on students facing medical-professional stress, and is thus important to consider. The authors randomly divided a sample of 73 participants into a treatment (n = 36) and wait-list control (n = 37) group, with 56% of the sample reported as female, and 79% as white. The remaining participants were Hispanic (8%), Indian (5%), African (3%), and Asian American (3%). Fifty-two percent of participants were medical students, and 48% were pre-medical. Initial analyses used chi-square to ensure that randomization was matched for gender, race, and medical versus pre-medical status. Six principle dependant variables were measured immediately prior and following the 8-week M B S R program: an adapted version of the Empathy Construct Rating Scale (La Monica, 1981) to measure empathy, 9 subscales from the Hopkins Symptom Checklist 90 (Revised) — SCL-90-R (Derogatis, 1977) assessing psychological distress (e.g., anxiety, hostility, phobic anxiety), Subscale 4 of the SCL-90-R to' assess depression, the State-Trait Anxiety Inventory (STAI; Spielberger, Gorsuch, & Lushene, 1970) to measure state and trait 14 anxiety, and the Index of Core Spiritual Experiences (Kass, Friedman, Leserman, Zuttermeister, & Benson, 1991) to assess the degree of participants' core spiritual experiences. Participants' weekly submission of a daily journal was used as an ancillary measure, and the authors reported that 97% successfully completed this and all other instruments. The authors reported no significant between-group differences pre-intervention having used Newman-Keuls tests, and significant changes in post-intervention scores. One-way analysis of variance ( A N O V A ) demonstrated that the treatment group, compared with the control group, reported less depression F(\, 69) = 8.18,/? < .006, less state anxiety F ( l , 69) = 4.11,/? < .05, increased empathy F ( l , 69) = 4.30, p < .005, and spirituality F ( l , 69) = 5.62,p < .02 at T2. In an attempt to replicate these findings, the wait-list control group was administered the same measures before and following their later participation in the intervention, with reported results having replicated findings from the original group (lambda score: A[10,22] = .259, p< .001) . Limitations to this study included the fact that participants were students who voluntarily enrolled in a stress reduction intervention. Participants were likely interested in mindfulness and relaxation, reducing generalizability. Further, despite students not being academically evaluated and the use of confidential identification numbers, social desirability may have been a limitation. Shapiro and colleagues also suggested that teasing out the mechanisms of M B S R would enhance future research. In a more recent study intended to replicate and build upon this research, Shapiro and colleagues (2005) used a similar randomized trial design to measure the effects of M B S R on stress and burnout among a diverse group of health-care professionals. Participants were solicited through posters in a Californian Hospital that advertised a free stress management program for all health-care workers (e.g., doctors, nurses, social workers, mental health workers). After screening 51 respondents for English proficiency and age (18 years or older), the authors randomly divided a sample of 38 participants between the ages of 18 and 65 into an M B S R group (n = 18) and a wait-list control group (n = 20). Surprisingly, unlike Shapiro and colleagues' (1998) previous study using students, demographic information was not provided. Three separate measures were taken immediately prior and following the 8-week intervention in this study: 10 subscales from the Br ief Symptom Inventory (Derogatis & Malisaratos, 1983) that assessed psychological distress (e.g., anxiety, depression), emotional exhaustion and depersonalization scores from the Maslach Burnout Inventory (Maslach et al., 1996), and perceived stress scores from the Perceived Stress Scale (Cohen, Kamarck, & 15 Mermelstein, 1983). Two potential positive outcomes (life-satisfaction and self-compassion) were also assessed using the Satisfaction With Life Scale (Diener, Emmons, Larnse, & Griffen, 1985) and the Self-Compassion Scale (Neff, 2003). The authors found no significant between-group differences before the intervention and significant changes in post-intervention scores for Perceived Stress and Self-Compassion scales. One-way analysis of variance ( A N O V A ) demonstrated that compared with the control group, the treatment group ( M B S R ) demonstrated a significant reduction in perceived stress F(2, 24) = 4.40, p = .04, and more self-compassion F(2, 24) = 9.85,/J = .004. A limitation to this study was the dropout rate reported within the treatment group. O f the 18 participants randomly selected to participate in the M B S R program, 8 failed to complete the intervention. Employees' reasons for dropping-out of the program included family problems, health issues (n = 2), and insufficient time (n = 4), among other reasons. Thus, although results suggested that M B S R might have potential benefits for health care professionals, the small sample size detracted from the power of the study. Other limitations included the absence of repeated measured analysis and the fact individual differences were not accounted for. Notably, the high drop-out rate in this study raised an important issue for future occupational research: with the 44% drop-out rate from this study more than doubling the typical 20% drop-out rate for M B S R interventions (Kabat-Zinn, 1982; Shapiro et al., 1998), the authors suggested that the significant time commitment required to participate in the M B S R program may have detracted from health care workers' participation. With many health practitioners facing an already demanding schedule, the combination of a weekly 2-hour meeting with the expectation of home practice was hypothesized as an unreasonable expectation. A handful of other studies have reported on the use of M B S R in occupational environments, yet failed to produce evidence regarding the effectiveness of the intervention. McBee (2003), for example, reported on perceived benefits of using M B S R with patients and their caregivers, but offered only anecdotal evidence regarding her experiences as a clinician. Two frequently cited articles by Ronald Epstein (2003a, 2003b) similarly considered mindfulness as an important skill in developing an effective medical practice (e.g., increased attentiveness and decision-making ability), yet lacked empirical evidence to substantiate claims. Will iamson (2003) and Scherger (2003), who extended Epstein's work to include increased awareness of the healing relationship, also suffered from similar flaws. 16 Current trends in mindfulness-based research. A s pointed out by Hayes and Wilson (2003), the ability to establish a comprehensive account of mindfulness has been made difficult by a general lack of agreement about what mindfulness entails. Judging by the content of a recent issue of Clinical Psychology (2003) focused on mindfulness, research is moving towards operationalizing the concept (Bishop et al., 2004). Measures of mindfulness such as the Mindfulness Attention Awareness Scale (Brown & Ryan, 2003), for example, have been proposed to provide an empirically testable and quantifiable definition for future study. In the target article authored by a large collection of prominent mindfulness researchers (Bishop et al., 2004), two components of mindfulness were proposed: (a) self-regulation of attention, reflective of a metacognitive skil l , and (b) an orientation of curiosity and acceptance towards one's experience (Bishop et al.). Like the majority of mindfulness-based research, however, the components proposed by Bishop and colleagues are offered in absence of any empirical evidence supporting their claims, thus providing a speculative account regarding the phenomenon. Summary. The uses of concentrative-based forms of meditation (e.g., T M ) as an occupational stress-management intervention have received limited support in the literature. More recent research into the use of M B S R in the workplace, although limited, has suggested that this program may positively affect employees. Current trends in the literature suggest that mindfulness-based researchers have attempted to define the processes underlying the use of mindfulness without empirical data to support these claims. In this respect, processes involved in the use of mindfulness to manage occupational stress remain unclear. The Use of Qualitative Methodology in MBSR Research The use of qualitative methodology in M B S R research has been sparse, with findings most often reported anecdotally in support of quantitative findings. However, Cohen-Katz and colleagues' (2005) recently published qualitative findings from their 3-part series on M B S R and nursing stress and burnout has provided the first qualitative study focused primarily on mindfulness and occupational stress. The effects of MBSR on nurse practitioners. Cohen-Katz and colleagues' (2005b) qualitative study on the effects of M B S R used the same sample of U .S . female nurses (N = 27) detailed in Parts I and II of their study (Cohen-Katz et al., 2004, 2005a). Qualitative data was collected from six different sources before, during, and following the 8-week M B S R program: (a) a "Getting to Know Y o u " questionnaire that asked about common stressors, medical problems, and relaxation techniques, (b) weekly evaluation forms that obtained general 17 comments from participants regarding learning experiences and challenges, (c) final evaluation forms that asked a series of "yes" and "no" questions about the value and importance of the program to participants, (d) unsolicited emails received over the course of the program (16 emails from 7 participants), (e) interviews conducted with four participants by a hospital newsletter journalist, and (f) a focus group conducted with 7 of the 25 M B S R graduates. In total, 46 documents from these six categories were obtained. Further, demographic information specific to qualitative participants was not provided, although the all-female (100%), predominantly white (96%) sample remained unchanged from Parts I and II. Employees' ages ranged from 32 to 60 (M = 46), and the majority (62%) held a bachelor's degree In an attempt to provide structure to their qualitative analysis, the authors collaboratively developed a 32-item codebook to be used when coding any document. In a trial using five interview documents, the principal investigator (paired with a research assistant and hospital ethnographer) independently coded each of the 5 transcripts by hand using the 32 codes. A t the end of this process, it was determined that the codebook was "cumbersome" (p. 80), and a consensus process amongst the researchers reduced the original codebook to a 6-item scheme: (a) reasons for participating in the M B S R program, (b) challenges of participating in the M B S R program, (c) benefits of participating in the M B S R program, (d) impact of M B S R on relationships, (e) overall value of the course, and (f) how to maintain the practice over time. In total, Cohen-Katz et al. (2005b) coded 41 separate documents and constructed a number of sub-categories within each of the six larger categories. The category Benefits of participating in the MBSR program, for example, included-increased relaxation ("I'm feeling a greater calm and peace," p. 82), feeling more self-reliant ("I'm encouraged that I can do this and I can take of myself," p. 82), and decreased physical pain ( "My pain has improved," p. 82). For each sub-category the authors provided a sample quote, and included information as to whether the quote was obtained during or following the program. In their discussion of findings, the authors noted two themes they felt were especially important for nursing professionals: enhanced self-care and positive relationship changes. A s hypothesized in Part I of the series, the authors expected nurses at baseline to experience a high degree of stress as a result of their social and vocational care-giving role. Enhanced self-awareness developed through mindfulness, the authors suggested, enabled nurses to more effectively attend to their own needs before committing to the needs of others. Regarding the effect of M B S R on nurses' relationships, the authors highlighted comments regarding increased presence with others ("I've more to give... That 'more' is patience, presence, and caring," p. 18 82), and less reactivity ("I'm finding I 'm reacting less and stepping back and looking at the bigger picture more," p. 82). These categories, the authors felt, were important for nurses who were constantly working to help others in their occupational setting. Despite this study generating a number of interesting categories regarding the use of M B S R with nursing practitioners, some limitations must be noted. First, a positive bias is likely to have been present in data generated from three data sources (interviews, the focus group, and unsolicited emails) where participation was entirely voluntary. The 1 -hour focus group, for example, was advertised to coincide with a 1 -hour M B S R refresher course, likely drawing participants who had a positive experience of the program. The four interviews conducted by the hospital newsletter journalist were also conducted with the purpose of marketing the program, increasingly the possibility of participant bias towards the effectiveness of M B S R . Although weekly and final evaluation forms were collected from all participants and used in later analysis, limited space was provided on these forms to comment on negative experiences. In both of these circumstances, a halo effect (Thorndike, 1920) was likely to emerge as researchers expected the M B S R treatment to have a positive effect. A second limitation to this study was the lack of depth in categories generated from the various sources of texts. Although the authors' stated intention was to perform basic thematic analysis on documents gathered during the study, the lack of participants' concrete examples to elucidate themes detracted from the study. This limitation may be due in part to the fact follow-up questions could only be asked in two of the six data sources. Issues regarding processes underlying the use of mindfulness, including possible inter-relationships between themes, were also left unexplored. However, as the first published, qualitative study focused primarily on mindfulness and occupational stress, Cohen-Katz and colleagues (2005b) provided a number of themes that can be further explored in research. Other qualitative MBSR research. A s opposed to Cohen-Katz and colleagues' (2005b) recent article, the majority of qualitative M B S R research has been supplemental and anecdotal. Majumdar et al. (2002), for example, gathered both quantitative and qualitative data in a German study that examined the physical and psychological health effects of M B S R before ( T l ) , immediately following (T2), and 3 months following (T3) the intervention. Measures included a translated version of the Hopkins Symptom Checklist (SCL-90-R; Franke, 1995) to measure psychological distress, the Freiburg Complaint List ( F B L - R ; Fahrenberg, 1994) to obtain physical symptom reports, and two semi-structured interviews regarding participants' experiences on the program. The sample was comprised of 17 women and 4 men (age, race, and 1 9 education not provided), 71% who reported chronic conditions such as hepatitis C , asthma, and gastritis, and 29% who reported no health concerns. Quantitative analysis used Cohen's effect size d and /-scores, with significant reductions reported in mean-average S CL-90 -R scores at T3 (t[21] = 0.62, p < .001, d= .49), and moderate reductions in mean-average F B L - R scores at T3 (t[21] = 20.00, p < .047, d= .52). Effect sizes were reported as moderate; consistent with the hypothesis that moderate to large effect sizes would be reported in dependant variables. Qualitative procedures used basic content analysis of text to offer general themes. Examples included a collection of participants' experiences regarding participation (e.g., " T found that it was difficult to practice when people were around'"), and perceived beneficial changes (e.g., " T began living my life more consciously'"). Although elements of qualitative findings provided support for continued research, participants' generic descriptions provided limited contribution to our knowledge of how mindfulness is used to manage stress. In a similarly designed pilot study presented in a publication of the American Psychological Oncology Society's 2004 Conference Abstracts, Bauer-Wu and colleagues (2004, in press) used both qualitative and quantitative data to explore the use of mindfulness meditation with 20 patients (5 men, 15 women, M= 51 years, SD not reported) undergoing bone marrow transplantation. Physiological (10cm visual analog scales, heart and respiratory rate) and psychological (Hospital Anxiety and Depression Scale [Desmond & MacLachlan, 2005]) measures were obtained at six time points over the course of treatment (pre-intervention and 100 days following), with the authors having used the Wilcoxon sign-rank test to demonstrate significant positive changes in the mean differences over the six time points in relaxation (1.7 to 2.6 cm,p < .0001 to .031), heart rate (-4.5 to -7.6,p < .001), and respiratory rate (-2.5 to -6.7, p < .008 to .031). Limitations to this study included failure to report on effect size or clinical significance, though findings were confined to the space limitations of the conference abstract. Basic content analysis was preformed on text obtained from patient interviews, though similar to Majumdar and colleagues (2002), theme development appeared limited and only supported quantitative findings. Patients' reportedly "articulated the value and appreciation of learning the intervention and incorporating mindfulness techniques throughout hospitalization and at home" (p. 10). Although the content of qualitative findings in this study was encouraging, the authors' emphasis on quantitative results detracted from the depth of qualitative findings. 20 The use of grounded theory in mindfulness-based research. Two qualitative studies have examined mindfulness-based interventions and illness (Brennan & Stevens, 1998; Mason & Hargreaves, 2001). Both studies reported using grounded theory techniques in data collection and analysis, though findings were limited by small sample sizes (N = 7, 6). Mason and Hargreaves (2001) interviewed 7 Mindfulness-Based Cognitive Therapy participants (5 female, 2 male, M = 43 years, SD not reported) on two separate occasions regarding their experience of depression throughout an 8-week mindfulness-based intervention. A description of each participant's diagnostic history was provided without demographic information such as race, education, and economic status. The authors displayed a strong understanding of grounded theory principles and analytic procedures, having coded participants' verbatim accounts and made extensive use of in vivo codes as suggested by Strauss and Corbin (1998). Interviews focused on participants' therapeutic processes that unfolded over the course of the M B S R program, resulting in the authors' development of a therapeutic model for M B S R and depression. Categories that emerged from analysis included the importance of pre-conditions and course expectations, discovery (i.e., a deeper personal understanding of one's situation), and acceptance (i.e., the development of an accepting attitude through mindfulness meditation). Findings were notably limited by the study's small sample size, yet the use of grounded theory with a clinical population suggested potential for further use. In a similar attempt to use grounded theory, Brennan and Stevens (1998) interviewed 6 Australian participants (no other demographic information was provided) regarding their experiences of using mindfulness meditation during oncology treatment for cancer. The authors described a number of themes that emerged from text including "the meditation effect" (i.e., an increased sense of control) and "positiveness" (i.e., increased happiness and physical energy). Although the use of grounded theory techniques in this study broke new ground in mindfulness-based research, the authors suggested that "[a]fter six interviews a number of emerging categories approached saturation" (p. 23), an assertion that slightly undermined findings. Strauss and Corbin (1998) suggested that saturation occurs when "no new information seems to emerge" (p. 136), a situation unlikely to occur in any domain after six interviews. Furthermore, textual references included in the article did not appear to support many of the proposed themes. Although the use of qualitative methods (e.g., grounded theory) has remained an emerging area within mindfulness-based research, qualitative researchers must attempt to improve rigor by achieving an adequate sample size. 21 Summary. Qualitative methods have been sparsely used in M B S R research, with Cohen-Katz and colleagues (2005b) having provided the first published qualitative article devoted to the study of mindfulness and occupational stress. The majority of qualitative M B S R research, however, has been anecdotal and has produced only general themes. The over-use of basic thematic analysis (as opposed to more sophisticated qualitative methods such as constant comparison), in addition to small sample sizes (e.g., Mason & Hargreaves, 2001) have detracted from the power of results. Furthermore, qualitative researchers have yet to explore potentially negative effects associated with the use of mindfulness. Conclusion Findings have suggested that M B S R may be an effective stress-management intervention. Although recent efforts to operationalize mindfulness may lead to a deeper theoretical understanding, research would benefit from an empirically supported account of how individuals actually use mindfulness. Furthermore, as M B S R expands into the workplace, occupational stress researchers would benefit from a description of how different workers use mindfulness to manage occupational stress. Qualitative research provides the opportunity to achieve a more adequate account of the use of mindfulness in managing occupational stress (McLeod, 2001). The constant comparison method, in particular, provides a systematic approach that enables knowledge to be constructed from text rather than imposing theories upon it (Duchscher & Morgan, 2004). In this study, I explore basic psychological and social processes that contribute to the effective use of mindfulness by asking the following question: "How do employees with a sustained meditation practice use mindfulness to manage occupational stress?" With researchers having been unable to clarify processes underlying the use of mindfulness, it is hoped that this investigation into its use in a specific environment (i.e., the work-place) yields a rich description that contributes to a more comprehensive empirical account. 22 C H A P T E R H I M E T H O D The purpose of this study is to provide a conceptual description of employees' use of mindfulness through an interpretive qualitative research design based on in-depth interviews. In this chapter, I describe the sample and report on methodological concepts and procedures that guided this research project. The following sections detail my choice of qualitative research, the use of grounded theory techniques (e.g., constant comparison), and data collection and analysis procedures. A discussion of ethical considerations concludes this chapter. Qualitative Research and Grounded Theory In this study, I used a qualitative approach to explore employee's experiences using mindfulness to manage occupational stress. This approach was chosen to clarify processes underlying the use of mindfulness in a work-related environment. Grounded theory techniques, developed by Barney Glasser and Anslem Strauss (1967), provided a structured framework for data analysis and interpretation. Strauss and Corbin (1998) recognized that "theory building" (p. 8) need not be the goal of all grounded theory research. Indeed, grounded theory techniques have been successfully used to generate conceptual descriptions without creating theory (e.g., White, Grzybowski, & Bruodo, 2004). I used grounded theory in this manner, adopting the constant comparative method to facilitate descriptive and conceptual understanding of processes involved in using mindfulness in the workplace. Furthermore, in alignment with grounded theorists such as Charmaz (2000), this study adopts a constructivist approach in providing a conceptual description of processes underlying the use of mindfulness. For this particular project, I recognize that data collection and analysis was interactive and that I have participated in the co-construction of categories. Semi-structured interviews were conducted and analyzed concurrently, affording the opportunity to continually test and refine emerging categories. Researchers have used grounded theory to examine a wide variety of issues including men's experiences of substance abuse and sexual behavior while incarcerated (Seal et al., 2004), career development of high-achieving African American women (Richie et al., 1997), and self-directed learning in breast cancer patients (Rager, 2004). Ideally, categories are 'grounded' in participant's experience of a phenomenon and are developed inductively rather than imposed by the researcher on the data (Morrow & Smith, 1995). 23 Participants Participants in this study were 10 female and 2 male employees ranging in age from 26 to 58 years (M= 42). When asked to describe their cultural background, 9 employees (75%) said they were White, 1 woman (8%) Chinese-Canadian, 1 woman (8%) Indo-Canadian, and 1 woman (8%) Iranian. Six (50%) of the employees were single and 6 (50%) of the employees were married or common-law. A l l participants were able bodied. Employees' experience with meditation ranged from 1 to 33 years (M = 12.67; SD = 10.66) and the number of meditation retreats attended over the past year (2 days or greater) ranged from 1 to 9 (M = 4.67; SD = 2.23). The employees practiced formal meditation an average of 4.67 times per week (range = 3 to 1\SD=\ .37) for an average of 37.92 (SD = 7.82) minutes (range = 30 to 50). Employees' worked an average of 41.75 (SD = 10.86) hours per week at their current job (range = 24 to 60) and had been at their current position for an average of 4.08 (SD = 4.17) years (range = 1 to 16). Employees' occupations varied significantly and included guidance counsellor, child-care provider, yoga instructor, and interior designer (see Table 1). Participants met the following inclusion criteria: (a) currently practiced meditation for 30 consecutive minutes at least three times a week, (b) had at least 1 year experience with meditation, (c) were employed at least part-time, (d) had experienced occupational stress in the past month, (e) were able to describe experiences with mindfulness coherently in English, and (f) resided in Vancouver or the Tri-City area. In order to determine whether the respondents experienced work-related stress/stressors, their awareness of physical and emotional responses to stressors (i.e., events related to their work) in the past month (e.g., anxiety, a tight stomach) was used as a meaningful indicator of occupational stress. The extent to which the stress was demanding was not addressed in screening. Rather, i f an employee described having experienced a physical or emotional reaction to what they perceived as a stressful event, their account was considered a meaningful example of "occupational stress." This approach is supported by Lazarus and Folkman's (1984) cognitive-appraisal model that emphasized the importance of an individual's appraisal of external/internal stress events (i.e., stressors). Kabat-Zinn (1990) considered the appraisal process central to M B S R theory, and indicators of stress used in mindfulness-based research have frequently used inventories that focus on participants' appraisal and response to stressful situations (e.g., Symptoms of Stress Inventory; Leckie, 1979). T A B L E 1. 24 Descriptive Information for the Sample (N= 12) Characteristic / % Age ( M = 41.50) 2 6 - 3 0 2 16.6 3 1 - 3 5 3 25.0 3 6 - 4 0 1 8.3 4 1 - 4 5 2 16.6 4 6 - 5 0 0 0.0 5 1 - 5 5 2 16.6 5 6 - 6 0 2 16.6 Ethnicity White 9 75.0 Indo-Canadian 1 8.3 Chinese 1 8.3 Iranian 1 8.3 Marital Status Single 6 50.0 Married / Common-law 6 50.0 Number of Years Meditating 0 - 5 4 33.3 6 - 1 0 2 16.6 11 - 15 2 16.6 1 6 - 2 0 2 16.6 2 1 - 2 5 0 0.0 25 + 2 16.6 Number of Meditation Periods (+30 minutes) Per Week 3 3 25.0 4 3 25.0 5 2 16.6 6 3 25.0 7 1 8.3 (table continues) 25 T A B L E 1. Characteristic / % Average Number of Minutes for Meditation Periods 3 3 0 - 4 0 7 58.3 41 - 5 0 5 41.7 Number of Meditation Retreats in the Past Year 1 - 2 3 25.0 3 - 4 5 41.6 5 - 6 2 16.6 6+ 2 16.6 Number of Hours Working Per Week 3 2 0 - 3 0 1 8.3 31 - 4 0 6 50.0 41 - 5 0 3 25.0 51 - 6 0 2 16.6 Number of Years at Current Job 3 1 - 5 10 83.3 6 - 10 1 8.3 10+ 1 8.3 Note. Percentages do not add up to 100% because of rounding errors. 3 Participants were asked to provide an estimate for each of these questions. 26 Data Collection and Procedures Pilot study. Two of my acquaintances were initially recruited to conduct pilot interviews for this study. From these interviews I learned the importance of asking for specific, work-related examples to solicit rich descriptions of processes underlying the use of mindfulness. I also found three of my interview questions to be redundant or distracting, so made appropriate changes. Because these participants met the screening criteria, and the interviews were deemed adequate, they were included in the main sample. A fellow graduate student in the Counselling Psychology program interviewed me using my revised set of questions (e.g., see Appendix A ) . From this interview I learned that (a) speaking about mindfulness practice was highly personal, (b) actual work-related examples of using mindfulness were difficult to recall, and (c) clarifying questions were helpful in attempting to provide concrete examples. A s a result of this interview, I decided to inform participants 2 days prior to their interview that I would be asking for specific, work-related examples related to their use of mindfulness. I contacted both pilot participants who agreed that prior awareness of this fact would have been beneficial to their experience as an interviewee. Further, after completing the interview protocol, I was sensitized to the importance of attentive listening, clarifying questions, and support. Recruitment. After receiving approval from the University of British Columbia (UBC) Behavioral Research and Ethics Board (see Appendix B) , I solicited three Westcoast Dharma Society events to access an experienced group of mindfulness practitioners (N = 300, 150, 20, respectively; for Recruitment Poster, see Appendix C). The Westcoast Dharma Society is a non-profit society located in Vancouver that typically holds eight meditation retreats per year at U B C . The mindfulness meditation practice taught at these events is synonymous with M B S R instruction, and has been examined in other mindfulness-based research (Cameron, 2004; Graves, 1999). Fifteen potential participants made contact with me by phone or email and were emailed an initial letter of contact (see Appendix D). Upon receiving this letter, potential participants had 3 days to decide whether they would participate in the study. Ten individuals who met inclusion criteria agreed to participate and a face-to-face interview was arranged at a private location of convenience (e.g., participants' residence, workplace, or an interview room at U B C ) . Interview Protocol. Respondents participated in face-to-face, audio-taped interviews that lasted approximately 1 to 1.5 hours. Written, informed consent was requested in person during the orientation stage of the initial interview (see Appendix E). The employees were 27 reminded that their participation was entirely voluntary and that they could withdraw at any time. The continual renewal of consent was used during data collection to ensure that participants were making informed choices regarding their participation. For example, when one employee began describing a volatile situation that involved a work colleague I could possibly have known, I verbally renewed consent by reminding the participant of my position and role. Interview questions focused on employees' experience using mindfulness to manage occupational stress. I attempted to maintain a focus on workplace stress during interviews, however, the topic of mindfulness easily shifted into other areas of employees' lives. Having received clinical training as a counsellor, I used interview skills such as active listening, clarifying questions, and empathic reflection to facilitate this process. Immediately following the interview, participants were asked to f i l l out a Demographic Information Questionnaire (see Appendix F) and were invited to contact me with any outstanding questions or information they might have forgotten to provide. Memos containing my own observations (e.g., employees' body-language during a particular stage during an interview) were then recorded at this stage. Approximately 2 weeks following an interview, participants were emailed an interview summary (for letter accompanying interview summary, see Appendix G) and asked to ensure that their experiences were accurately captured. Three participants responded to this request by emailing to clarify or build on previous information. This process ensured that participants perceived the information as accurate, and contributed to a more comprehensive description of categories discussed by the employees. Reflexivity. The collection and interpretation of the transcribed interviews was influenced by my own exposure to meditation and mindfulness. Therefore, as the primary instrument of data collection and analysis, it was important for me to be aware of the personal values and assumptions I brought to this study. M y understanding of mindfulness has been informed by my experiences with meditation and Buddhism. Over the past 12 years I have studied under a number of teachers from different Buddhist traditions including Rigpa, Shambhala, and most recently the Insight Meditation Society (IMS). Teachers I currently study with associate themselves with the Theravada tradition, originally founded in Sri Lanka, Burma, Thailand, Laos, and Cambodia. The primary vehicle for spiritual growth in this tradition is "vipassana," or mindfulness meditation, presented as a means to greater awareness and happiness in one's life. Over the past 3 years I 28 have attended three extended retreats and maintained a formal sitting practice, providing the opportunity to continually refine my basic understanding of mindfulness. M y experience as an interviewee in this study helped clarify certain expectations I had regarding processes underlying the use of mindfulness. First, I believed that an orientation of acceptance and compassion towards oneself and others would play a key role for employees in successfully using mindfulness to manage occupational stress. From my perspective, the perfectionistic and self-critical attitude frequently seen in modern workplaces would underlie employees' experiences of occupational stress. Second, I felt the ability to pause, or to delay immediate reaction, would be an important factor in a one's reaction to a stressful event. Meditation practice enhances the ability to abstain from instant reactivity, a skill that can be especially useful during an interpersonal stress encounter. M y familiarity with meditation and mindfulness, including my experience of being interviewed with my own interview questions, increased my theoretical sensitivity (i.e., my ability to understand the subtleties involved in employees' use of mindfulness) in this study. This sensitivity, I believe, enabled me to make genuine connections with participants and create an atmosphere of understanding and safety. M y experience as an interviewee enabled me to empathize with the experience of sharing one's mindfulness practice, and sensitized me to assumptions I carried. In consideration of any cognitive tendencies towards my seeking confirmatory evidence (Cutcliffe, 2000), an active search for disconfirming evidence was used to ensure my own expectations and biases were accounted for. During each interview I asked about potential hindering effects of mindfulness in the workplace, including negative aspects of meditation practice for oneself or others. Data Analysis Data analysis incorporated approximately 190 pages of single-spaced interview transcript. I used memos throughout data analysis to ensure my familiarity with transcripts and to cross-reference particular interview segments (e.g., an employees' non-verbal emotion emphasized the importance of a particular situation). Memoing, a technique used to record my methodological decisions, hypotheses, and notes regarding emerging categories, were also used to create and cross-reference categories that emerged in this study. Following Strauss and Corbin's (1998) recommendations, memos were dated, contained headings, and included short phrases or quotes from text to ensure that employees' choice of language steered the analytic process. I transcribed all interviews verbatim, which contributed to my immersion in text, familiarity with employees' language, and ability to use "in-vivo" codes. To ensure that my 29 transcription was accurate, I re-read transcripts before beginning analysis and cross-referenced any potential errors with audiotaped recordings. Interview text was managed using A T L A S . t i (Muhr, 2005), a computer program designed to assist users in qualitative data management. Constant comparative method. Data analysis utilized the constant comparative method from grounded theory (Glasser & Strauss, 1967). Interview data was examined to uncover categories related to processes of using mindfulness in managing occupational stress. Categories were constantly compared within and across interview text to refine technical understanding and identify new categories—a process requiring my full immersion in the data. Coding. A n important element of the constant comparative method is "coding," a technique that enables researchers to break down text and understand it in a systematic way (Strauss & Corbin, 1998). Analysis began with open coding, involving a detailed examination of transcripts that allowed me to "fracture the data" (Strauss & Corbin, 1996, p. 97) and navigate interview text. Early memos (i.e., written analysis) in this area contained my own impressions and thoughts about the text, including questions for future interviews and reflections on the effectiveness of interview questions. Following open coding, I further collapsed data to make connections between categories. In this stage, the pieces shattered in open coding (components of written analysis) were slowly fit back together in a coherent manner. As suggested by Strauss and Corbin, a series of specific questions were continually asked of the data throughout this process: (a) what is the action or mechanism being described in the text? (b) what does this action represent? (c) in what context is this action being used? and (d) could this code be related to another code? I also used visual network diagrams created in A T L A S . t i (i.e., logic diagrams showing relationships between categories and codes) at this stage to illustrate how employee's conceptualized processes of mindfulness (e.g., see Appendix H). These diagrams laid a foundation for later interviews to build on the complexity of categories and contribute to my own theoretical understanding. Throughout the coding process, a continual comparison with emerging categories was conducted. A s Strauss and Corbin (1996) made clear, textual and thematic comparisons are essential to developing codes. In addition to continually refining categories by comparing and contrasting them with each new transcript, I used Strauss and Corbin's flip-flop technique to turn concepts "inside out" and obtain a fresh perspective. One employee, for example, described feeling a greater sense of detachment from the outcome of his personal projects at 30 work. Using the flip-flop technique, I asked whether "increased attachment" at work could be an appropriate avenue of exploration in the text, or during later interviews. Categorical labels were continually collapsed until major categories were selected to be compared and validated against other categories. Memos at this point focused on the refinement of categories rather than the creation of new ones, and ensuring that interviews were being conducted effectively. Rather than reaching a saturation point in the research process (i.e., no new emerging categories), I employed grounded theory techniques to contribute a conceptual description of mindfulness processes rather than attempting to develop mid-range theory. Ethical Considerations A s the collection of qualitative data from participants was potentially revealing and demanding, the following psychological risks were identified prior to recruitment: (a) possible confrontation with a perceived self-failure leading to loss of self-esteem, (b) increased self-awareness of underlying psychological and emotional issues without immediate and available support, and (c) unforeseen revelations regarding occupational stress that could lead to rash decision making or unwanted feelings. To address these risks, the following safeguards were implemented to protect participants: (a) the purpose of the research was clearly articulated prior to the study to ensure full understanding of how data would be used, (b) written permission was obtained by the participant by way of informed consent, (c) participants were reminded that their transcript was available to them on request, (d) participants were reminded they could withdraw from the study at any time, and (e) pseudonyms were used throughout the final transcript. The small size of the meditation community in Vancouver also necessitated the removal of potentially identifying or distinguishing features of participants to protect anonymity. Third-party identification (e.g., a description of a co-worker), for example, was removed in any quoted interview text. Printed material is being kept in a locked in a filing cabinet and all electronic documents are being stored in a password-protected personal computer. Data wi l l be stored for 5 years after computer files have been erased, and wi l l be destroyed by shredding after this time. Audiotapes wi l l also be demagnetized at the end of 5 years of storage. 31 C H A P T E R IV F I N D I N G S In this chapter, four main and two preliminary categories related to processes underlying participants' use of mindfulness are presented. These categories were constructed by using the constant comparative method during data collection and analysis. Prior to describing these categories, I summarize general findings, and provide further information regarding participants to contextualize results. Processes related to participants' use of mindfulness began with an awareness of a physical, cognitive, or emotional responses triggered by occupational stressors. In becoming aware of these responses, the employees shifted their attention to naturally occurring physical and psychological processes (e.g., inner-dialogue). The use of mindfulness did not directly influence outcomes (e.g., increased relaxation), but was associated with: (a) a heightened awareness of a response to a stressor; (b) a shift in awareness to internal processes (e.g., bodily sensations); and (c) an attendance to this internal process (for a conceptual diagram of this process, see Figure 1). The types of workplace stressors that precipitated a shift in awareness and the specific internal processes that were attended to by employees distinguished the categories. This contextual relationship between workplace stressors and specific internal processes was evident across participants' accounts, and is a central finding in this study. Categories frequently overlapped with each other, reflecting the complex nature of mindfulness processes. Context The environments that the employees worked within varied significantly. Participants worked from home, in traditional office settings, and in a variety of other atmospheres (e.g., a yoga studio and clients' residences). Two common factors in these settings were identified as especially meaningful in the context of using mindfulness: working at computers, and interacting with others (e.g., colleagues, clients). Most participants began meditation with the hope mindfulness could assist them in particular life domains (e.g., relationships, work-life). In contrast, the four youngest employees (26, 28, 34, and 36, respectively) said that they came to meditation during a challenging emotional period (e.g., "a tumultuous time," [Susan], a "difficult state" [Michelle]). The two employees in their twenties spoke about the importance of early domestic experiences: Bryan, for example, said that he came from a "crazy household with loud parents... and finding a quiet place was one of the few times I could feel calm." For these youngest employees, the use of W O R K E V E N T Event appraised as non-threatening Event appraised as threatening (i.e., a stressor) Emotional and/or physical response to stressor Using mindfulness, employees have a heightened awareness of their response to stressor Tuning into| one's body Relinquishing workplace expectations Employees shift their attention to co-occurring internal processes Tuning into an inner-dialogue Sensing increased time and spaciousness Increased self-compassion Connecting with others Figure 1. Generic conceptual diagram of employees' use of mindfulness constructed from findings in the current study. 33 mindfulness became an important tool in communicating with significant others (e.g., parents), and this dynamic was reflected in the examples these participants' used (e.g., interpersonal encounters). The four categories constructed from data analysis are detailed below. Specific excerpts from participants' accounts have been chosen to describe the categories, and occasional grammatical changes have been made to enhance readability. Changes were only made i f the meaning of the selected passage was not significantly altered. The order in which the four categories are described do not reflect degrees of importance. 1. Tuning into one's body. 2. Relinquishing workplace expectations. 3. Tuning into an inner-dialogue. 4. Sensing increased time and spaciousness. In addition, two categories that are considered preliminary are also described (Increased Self-compassion; Connecting with Others). Tuning Into One's Body The employees in this study described a process of tuning into their bodies in the workplace. Using mindfulness, participants became aware of physical sensations (e.g., tight shoulders, respiratory strain) associated with environmental (e.g., working at a computer for long periods of time) or interpersonal (e.g., facing an unexpected meeting with a supervisor) workplace stressors, and tuned into their bodies (i.e., directed attention to their physical state). The employees said that an awareness of their bodies led to positive outcomes such as increased physical relaxation, increased "self-care," and improved psychological states (e.g., a "state of calm"). A number of participants described tuning into their bodies while working in front of a computer. Participants' often noticed a physical strain associated with prolonged computer-work, as Blanche described: " I ' l l notice I 'm holding my shoulders, or holding my neck, or holding my stomach...And by noticing it, it gives me freedom. I can let go. Body awareness has been important for me." L i l l i an said that the process of tuning into her body allowed her to notice "physical cues" and ensure she was practicing "self-care" while working in front of her computer: I started to feel a strain on my eye and I started saying, T can't remember going to the washroom or having any water for the last 4 hours.' So that points to my health. A n d I think that the first thing would be my eye, starting to feel kind of tired. So meditation... helps me create the opportunity to feel my body. 34 Susan also spoke about tuning into her body at the computer. Having reached a stressful "crunch point" in her dissertation, "where [she] had to get things done," Susan found that tuning into her body was associated with a positive psychological outcome: "I became aware of my butt cn the chair, I became aware of my breath, and I became aware, of the senses in my body. A n d by bringing myself into my body, I brought myself into a state of calm." A n important element in this process was a shift in awareness from mind to body: " B y cueing into my body, I get out of my mind. . . and slow the process down" (Susan). Bryan described his experience of bodily awareness in the context of a co-worker he did not get along with: "When I hear his shoes down the hall, there's a change in my muscles, like , they tighten. A n d then I ' l l notice that I'm tightening." This process of awareness, Bryan said, allowed him to recognize his emotional response to his co-worker, and then increase his physical relaxation: It's being aware of what's going on in my body right after that emotion reaction. First there's a quick emotional response, like a fight or flight, and then right after that, my mind is noticing what just happened. A n d I recognize that it's my thoughts that are holding, say, my cheeks together. A n d i f I place my attention on my cheeks, it seems really silly that they're holding. A n d so then I can think, relax, and the muscle then relaxes. Michelle discussed a sense of increased relaxation that resulted from tuning into her body, feeling "less attached" to her experience, and more accepting of her situation. In an example where she was called to her supervisor's office for an unexpected meeting, she described her thoughts in response to the phone call: "I don't want this experience to happen. I don't want this moment... I'm basically worried that someone w i l l be angry with me." Feeling anxious while rushing to her supervisor's office, Michelle described the experience of tuning into her body: " A s I'm running, I'm aware of myself. I notice myself... I feel physically tense, I feel my shoulders hunch up... A n d it does help me relax somewhat. It doesn't remove the experience, but it helps me be a little less attached to it." This sense of relaxation and decreased attachment, Michelle said, allowed her to be more accepting of her emotional response and her current situation: I just cut myself a little bit o f slack. It's my conditioning... there's really nothing I can do about my response, it's basically purely physiological and I've created a whole detailed attachment to this response... If I've done a lot of meditation... [I'm] far more at ease with the situation and not so resistant to it. Like shifting focus from where I would usually be, which is in my head, to my body. Which is I think a much better gauge of a situation than my mind alone. 35 Many of the employees discussed tuning into their bodies in the context of workplace communication. Jay, for example, said that, " i f I 'm mindful and having a heated or difficult conversation with someone in the band, I usually focus right in on my body." Jay went on to report on how body awareness connected him with feelings that influenced his communication with others: -When I 'm mindful I 'm in touch with my body and able to experience what I 'm actually feeling. I bring attention to my body and it points me in the direction of how to handle things. I 'm sensitized to my emotions. So with Mark, I was able to feel my frustration, and then decide how I wanted to handle the conversation. A s an anthropologist, Tanya spoke about using a similar strategy when she feared an interviewee might become emotional: "I pick it up in my own body that it's going in the direction of a lot of feeling... So what do I draw on from practice? I probably relax and drop down and check into my own breath." Catherine also spoke about tuning into her body when interacting with children as a school counsellor: "I savor moments in a way that I didn't used to where I w i l l pause and just feel what's happening in my body and invite the kid to be with what's happening in their body." Summary. Participants described a process of tuning into their bodies when using mindfulness to manage environmental and interpersonal stressors at work. The employees' awareness of a physical response to a stressor (e.g., bodily tension) led them to purposefully shift their attention to their physical state. B y attending to their bodies, participants increased their internal congruency between cognition and emotion. The physical cues being sent by participants' bodies, when recognized and attended to, were an important source of information for the employees. Relinquishing Workplace Expectations Participants in this study described a relinquishment (i.e., letting go) of workplace expectations through an increased sense of detachment. Using mindfulness, the employees became aware of negative emotions (e.g., anxiety, frustration) triggered by specific expectations (i.e., beliefs about the future) related to the actions or perceptions of another workplace individual (e.g., a supervisor, subordinate, or client). Mindfulness increased participants' sense of detachment from these expectations, enabling the employees to relinquish (i.e., let go) of their importance. A s a consequence, the employees experienced a sense of ease and acceptance in relation to collaborating with colleagues and making difficult decisions at work. 36 Participants' abandonment of expectations related to others at work influenced cognitive factors such as the divestment of personal attributions. After being offered a position at work that was later withdrawn, Michelle 's expectations of her colleague resulted in her feeling betrayed and upset. B y becoming aware of these negative emotions and the expectations connected with them, Michelle described feeling more detached from her expectations and relinquishing their importance: Because of mindfulness, I was more detached from the story of being betrayed, and I could just see how I responded to it. I felt basically quite calm, and not overly reactive or upset, and I didn't make it a big something that had to do with me. A n d as a result I came up with a really good solution of how to handle it. Another employee had expectations about the impact of an event on another individual. Catherine's experience of terminating therapeutic relationships with children created an emotional response based on her expectations that clients would have less stability in their lives. The sadness that accompanied this expectation was eased through Catherine's increased detachment from this expectation, and her abandonment of this expectation at work: I think before I had a really regular practice, I would really get attached to kids. I would be really upset to let them go... A n d now, I think I feel easier about it . . . I think I have more acceptance with just letting them go. They ' l l find their way. The process of relinquishing expectations related to co-workers perceptions contributed to a sense of ease and acceptance in relation to others at work. In wanting to chastise his band-mate for continually being late, Jay sensed his attachment to beliefs about his colleague's perceptions and abandoned these expectations through increased detachment: I expected him to be on time, you know. It made me furious that he wasn't... I wanted to chastise h im. . . But when I saw it, what I was doing, I realized how much I was attached to others' perceptions of me, and realized I could just be honest and true without worrying so much. It made me more relaxed around him. Linda provided another example of this process with her expectations related to co-worker's perceptions. Having been raised in a culture where feminine assertiveness was often met with hostility, she held expectations that her assertiveness in the workplace would lead to negative judgments from colleagues. Through her mindfulness practice, Linda spoke about a sense of increasing detachment from other's perceptions, contributing to the relinquishment of associated beliefs in workplace situations: "When I think about the mindfulness practice, at least I've noticed in the last 15 years, slowly, that I worry less about how I'm going to be perceived, what people are going to think of me." 37 Relinquishment of expectations related to the successful completion of workplace tasks was described in the context of interpersonal relationships. For many participants, the desire to successfully complete a task was connected to the belief that colleague's perception would be influenced (e.g., gaining approval). For these employees, increased detachment from these beliefs was associated with an attitude of ease and acceptance that positively impacted their relationship with co-workers. Michelle spoke about her expectations in having her compositions accepted by her employer: "I used to really care whether or not I got [it], like it was such a huge deal. A n d I experienced a lot of stress i f I didn't get i t . . . like they won't believe that I'm trying." Michelle described becoming self-aware of expectations that she was imposing on herself and others at work, her detachment from these beliefs, and the relinquishment of their importance: I realized it didn't matter how I felt about the task. A s long as I was doing the task is really all that was really important, so I let go of the results... I'm either going to get it or I'm not going to get i t . . . there was no more personal attachment to it. It wasn't about me anymore. Michelle said that with this attitude, "I sort of have fun with it . . . and in my making fun with it, other people relax, too." Tanya also felt that her relinquishment of expectations related to colleagues made her easier to work with: Meditation has given me a wider sense of being... I 'm not so identified with a task.. Just an ease of relating, in relating, getting things done. Like , I often have work crews, having other people helping me with things, and people always say wow, it's really easy working with you. Summary. The employees in this study described the importance of abandoning workplace expectations related to others. Expectations about future events were accompanied by negative emotional responses related to disappointment, frustration, and despair. Participant's awareness of their emotional response created sensitivity to expectations associated with these feelings, and an abandonment of these beliefs through a sense of increased detachment. Furthermore, by relinquishing expectations related to future events, these employees experienced a greater sense of relaxation and ease in the workplace. Tuning Into Inner-Dialogue Participants described a process of tuning into their inner-dialogue (i.e., an ongoing internal commentary or inner-voice). Through the use of mindfulness, the employees became aware of negative emotions (e.g., anger) triggered by an interpersonal encounter at work, and shifted their attention to an inner-dialogue that had the following characteristics: questions 38 focused on the employees' immediate cognitive and emotional experiences, reassuring self-talk, and the use of empathy in taking an alternate perspective. Through this inner-dialogue, the employees identified a greater range of choices in how to respond to a workplace encounter. The employees' inner-dialogue was characterized by questions that focused the employees on their present momentary experience. Li l l ian , for example, spoke about her awareness of anger in an interpersonal exchange with her supervisor and the generation of questions focused on her emotions: The thing about meditation is that when I allow myself to be in that [mindfulness] state, I ask questions... So when I was triggered yesterday, I got angry. That was when my inner dialogue coming in (sic). How long do you want to stay angry? (...) How are you feeling right now? Questions related to the employees' present momentary experience also focused on expectations of self or other in relation to workplace roles. Lorraine described a circumstance when a subordinate continually vied for her attention during meetings and she experienced anger and frustration. In this circumstance, Lorraine became aware of her discomfort, tuned into a "rational voice," or "attendant," and generated questions on how to respond to the situation: For me mindfulness in this instance was a reminder of who I am in this moment, in this context. A n d then the rational mind comes in and says, O K Lorraine, how are you going tc respond to this? (...) A n d it was my being aware of my being uncomfortable, my attendant starting to say, O K Lorraine, how did you get yourself into this situation? Reassuring self-talk was described as a characteristic of the employees' inner-dialogue following an interpersonal exchange. Michelle described a situation when driving with a colleague whom she initially didn't trust: "So I'm like, what is going on right now? I'm fine, I realize. I'm totally fine. What's wrong with this girl? She's totally fine. What is my gut say? I can trust her." Inner-dialogue played a role in helping participants' connect to their experience of a situation, and decide how they wanted to respond. Kat described her reassuring self-talk in terms of a friendly voice: "Part of my meditation is this voice in my head... I have sort of a friendly, Jiminy-Cricket voice in my head that says, oh Kat, look what you're doing. I talk to myself as i f I was another person." For the majority of the employees, this process of tuning into reassuring self-talk provided enhanced self-awareness and the diminishment of negative emotions in relating to co-workers and clients. Kat described this process when she was "pissed off ' at an overweight yoga student and the importance of her kindness in communicating with her: 39 Normally I might tend to walk away and not have a lot of compassion for her... being aware that, oh look here I'm judging her, oh look here, I think she's too fat . . . [but] i f I'm in a mindful place, I w i l l talk to myself and say to myself, what a m i experiencing? (...) Let me focus on speaking to her with kindness and actually listening to what she needs. The participants' inner dialogue that focused on taking another's perspective (i.e., empathy) was described as a characteristic of the employees' self talk. Jay, for example, described this characteristic when a student of his asked to delay payment on a lesson for a third time: I was upset she even asked to pay next week because she knew money was tight, so at that point I checked in with myself. O K , you know, this is where she's at. What am I feeling right now? What w i l l help me in this situation? Y o u know, how do I want to respond? Susan provided another example of this inner-dialogue during a distressing exchange with a colleague: "Someone's reaming me out and, how am I feeling right now? .. .Okay, this person's really angry, gosh, I wonder why. . . What does this person need from me? Do they need understanding? Maybe I can help them out." Participants tuned into an inner-dialogue that generated questions concerned with taking another's perspective, contributing to a more multi-faceted perspective in deciding how to respond to an interpersonal encounter. Summary. Participants' use of mindfulness created an awareness of negative emotions related to interpersonal workplace exchanges, and shifted their attention to an inner-dialogue. Characteristics that were identified with this inner-dialogue included focusing questions related to participants' present momentary experience, reassuring self-talk, and empathic comments directed towards self and other. Each of these characteristics was manifested through a variety of questions (e.g., "How are you feeling right now?"), which was generated through participants' inner-dialogue. Notably, the employees only attended to elements of their inner-voice that helped them navigate an interpersonal exchange. Rather than attend to negative self-talk, the employees focused on positive characteristics of their inner-dialogue that provided them choices in how to respond. Sensing Increased Time and Spaciousness Employees in the present study reported an increased sense of time and spaciousness when experiencing interpersonal and workplace demands related to time (e.g., workplace deadlines). Using mindfulness in these circumstances, the employees said they experienced an increased (i.e., greater) sense of time available in a moment, and a sense of increased spaciousness (i.e., a perceived separation or distance between phenomenon such as thoughts or 40 feelings). In situations where the employees felt sensitized to their relationship with time and space (e.g., feeling pressured by a workplace deadline), the use of mindfulness changed participants' relationship with their experience of these phenomena. The employees described their altered experience of time or self-pacing (i.e., moving quickly or slowly) as central to their experience of using mindfulness. Michelle, for example, said that, "When I'm in a rush and not being aware, a moment feels like a nanosecond. I can't even fathom being aware of the moment." Michelle referred to mindfulness as "the what's-going-on ability" at work, which she later expanded upon: When it happens it feels really good because then I feel like I have a wider scope of a situation, and I realize there's much more space in a moment than what I perceived there actually was. That there's a great deal of time in a moment... If I use the "what's-going-on" saying, suddenly there's a great deal of space in a moment to assess, to be aware, to notice. During what Susan described as a stressful "crunch point where [she] had to get things done" in her dissertation, she said that using mindfulness when she felt anxious ("in a kafuffle") changed her relationship with time: I find time slows down, because when I'm in a kafuffle time is incredibly rapid. But when I go into a space of mindfulness, it slows right down.. . It just slows the whole thing down and it became a really gentle, very productive process that didn't have all this kafuffle in it. Jay commented on his experiences using mindfulness to manage stress associated with performance anxiety. He described a sense of being able to "slow everything down around [him]" and connect with his feelings when preparing to perform. A s he said, "I experience things as moving less quickly, so I 'm more able to connect in with my own feelings while also being able to continue to play." Brenda also spoke about a sense of slowing down after returning to work from a weekend meditation retreat: "I notice that I have more of an underlying feeling of being slowed down.. . I have an enhanced sense of spaciousness." Brenda also said that she felt pressured by her demanding work schedule as a school counsellor, and that mindfulness increased her sense of time: "Part of it is, I think just my perception of time.. .I 'm always worried that there's not enough time.. .So when I feel more slowed down, I have a feeling of spaciousness, like there is enough time." When she later addressed what this feeling provided her at work, Brenda commented that, "I notice and enjoy particular moments more... I w i l l have had more of what I call magical moments, which make it worthwhile doing this work." 41 A common outcome of participants' increased sense of time and spaciousness was an increased sense of choice in how to manage a stressful situation. Tanya, for example, described her experience of using mindfulness when she felt swept up in a succession of thoughts and feelings that she compared to a train: " I f I've not been sitting I 'm more apt to run with that train... [with mindfulness] it's like the train doesn't go as fast, and I have more opportunity to make a choice whether to go on it or not." Jay spoke about the way his altered relationship with time and space also affected his sense of choice when experiencing stress related to his musical career. Referring to a difficult situation when a band-mate had not appeared 10 minutes prior to a performance, Jay described his altered sense of time and space when using mindfulness: The sense of time really changed, which was also a sense of space in a way. I didn't feel I actually had to decide or do anything about it. I could take time to hear different perspectives. I could take time to check in with myself about how I wanted to respond. Then, more choices spontaneously presented themselves. Lorraine also spoke about a connection between spaciousness and choice when using mindfulness: " Y o u have the aversion, or you have the desire, and mindfulness is what allows you to have some space around that. A n d to then make a decision about how you act on it." Lorraine continued by describing how she felt mindfulness influenced one's decision-making process: "Bringing mindfulness to a situation allows you the space to make and await decision about how you respond to that experience." Participants described negative outcomes associated with their changed relationship with time in the workplace. Bryan said that when he was "regularly" using mindfulness at work, some of his co-workers experienced him to "be a little slow." Working with time-sensitive material in his administrative-support role, Bryan would often respond to co-workers "need to move something quickly and their anxiety" by slowing down and ensuring he had all the correct information. A s a result, he said, others occasionally received his response "as pushback. That I didn't want to do what I was being asked to do." Kat, who said that mindfulness enhanced her inner-dialogue, also described being slower around others at work: "When I'm in a situation interpersonally, it might take me 15 or 20 seconds to respond to the person because... I'm in dialogue with my own head." This experience of moving slowly, she continued, created financial stress in her attempt to run a yoga studio: "I just got to a point where I'm like, I 'm moving so slowly now I'm not able to make the rent anymore... So I think, yeah, it's really been bad for business." 42 Summary. Employees in this study described an increased sense of time and spaciousness when using mindfulness to manage occupational stressors related to time (e.g., workplace deadlines). In situations where the employees felt sensitized to their relationship with time and space, the use of mindfulness caused a perceptual shift that increased participants' sense of these phenomena. The use of mindfulness, in this respect, enabled participants to cognitively reframe their experience of a time-related stressor at work. Both positive (e.g., an increased sense of choice) and negative (e.g., being perceived as slow) outcomes were discussed, although negative outcomes were only associated with participants' relationship with time. Preliminary Categories Two potential categories that were constructed remain underdeveloped and amount to preliminary findings. In both categories, a small number of the employees (i.e., 2 to 3) referred to the importance of a particular process that was not reiterated by other participants after I probed for its importance. These two preliminary categories are thus presented to provide direction to future research. Increased self-compassion. Two employees in this study spoke about the importance of increased self-compassion when using mindfulness. The actual process by which participants increased their self-compassion remains unclear, yet participants spoke of becoming more gentle and accepting of themselves at work. For one participant, this process occurred through reassuring inner-dialogue: A t first I was just really mad at myself, I was like, fuck! Why don't you get it? God! You're an idiot, all the, you're in an idiot; you can't do a cast list, honestly! Honestly! A n d now I'm like, O K , I know you're not perfect... So be a little softer, be a little kinder; show a little bit o f compassion to yourself. (Michelle) Jay described his experience of increased tolerance for the unknown. His cognitive self-rumination on major life questions often caused him distress, and using mindfulness allowed him to have more tolerance for this state of mind: I guess tolerance is a word that comes up for me. I think I have more tolerance for different states of mind. Which allows me to feel more compassionate for myself, especially when I don't know what's happening, what I'm up to, who I am, what I'm supposed to be doing. (Jay) For these employees, the experience of using mindfulness was associated with a sense of increased self-compassion. 43 Connecting with others. Three participants spoke about their use of mindfulness in connecting with other individuals at work (e.g., colleagues, clients). The dynamics these employees described in using mindfulness varied, yet each found themselves experiencing greater connection to others in their workplace. Linda, for example, said, "I'm just a little... more tuned into communication with people." Catherine described a similar sense of tuning into others by noticing how present she was in her work: Because I've been meditating for a while I can notice degrees of, I can feel it in myself, the degrees of presence. Like i f I 'm tired or distracted or whatever. But I can really feel a different texture in the quality of connection and the upholding of the container for a child. Kat spoke about this experience in terms of being attuned to how others were receiving her: "Mindfulness also helps me, I think, in relating to people when I work. Because being mindful has let me see how people react to me." These employees described a connection with others in using mindfulness, yet the process through which this took place remains unclear. Summary Four main and two preliminary categories were constructed from the employees' accounts of processes related to the use of mindfulness in managing occupational stress. Categories included (a) tuning into one's body; (b) relinquishing workplace expectations; (c) tuning into an inner-dialogue; (d) sensing increased time and spaciousness; (e) increased self-compassion; and (f) connecting with others. Categories were identified by the workplace stressors that precipitated the use of mindfulness, and the internal processes that employees' became aware of. A s evident from the employees' examples, categories frequently overlapped with each other. 44 C H A P T E R V: DISCUSSION The purpose of this study was to gain a better understanding of how employees with a sustained, long-term meditation practice use mindfulness to manage occupational stress. Methods from grounded theory were used to construct categories that provided a descriptive account of processes underlying employees' use of mindfulness. The findings include the following four major categories: (a) tuning into one's body; (b) relinquishing work-related expectations; (c) tuning into an inner-dialogue; and (d) an increased sense of time and spaciousness. In addition, I identified two preliminary categories (connecting with others and increased self-compassion). Findings from this study suggest that for some employees, the use of mindfulness was associated with an enhanced awareness of physical, cognitive, or emotional responses to occupational stressors, and a shift of attention to concurrent internal processes (e.g., inner dialogue, cognitive expectations). The types of work stressors individuals were exposed to were also shown to uniquely affect what kind of internal processes the employees attended to. In this conceptual description, the use of mindfulness connects to a deployment of attention towards specific internal processes, a finding unique to the literature. Research Findings in the Context of Professional Literature In his seminal text on the MBSR program, Kabat-Zinn (1990) suggested that by bringing mindfulness to a stress reaction (i.e., an automatic process involving inhibitory behavior and maladaptive coping strategies), individuals experienced greater choice (i.e., a greater range of options) in deciding how to respond to a stressor. Findings from the current study support this notion, and further suggest that employees' attendance to particular internal processes is contextual, and that these processes may influence how individuals respond to a workplace stressor. The notion of "attention deployment" is a widely debated concept in the literature (e.g., Krohne, Pieper, Knoll, & Breimer, 2002; Siemer, 2005). Frijda (2005) described attention deployment in terms of "dimensions of variation," where an individual's orientation (e.g., world- versus self-focus) and mode of attention (e.g., analytic or detached) influences how he/she directs their attention. From Frijda's perspective, a self-focus and analytic orientation creates an experience of bodily awareness, and this experience informs where one deploys attention. This theory appears consistent with the self-focused orientation of participants in this study, as the use of mindfulness required a curiosity by participants about themselves. As the 45 employees described, the awareness of a somatic or psychological response to a workplace stressor required their subjective awareness (i.e., a self-focus), or as one participant described, "knowing when something had occurred on my internal radar" (Jay). A further question is whether attention deployment is an automatic response or a conscious process. Krohne and colleagues (2002), for example, regarded attentional change caused by physical or emotional arousal to be an autonomic process, yet Boden and Baumeister (1997) theorized that attention deployment is a regulatory cognitive strategy. Findings from the present study provide no evidence for either of these positions as participants' could not determine whether attention was consciously directed to internal processes (e.g., inner dialogue). Mindfulness itself may constitute an alternate conception of attention deployment that should be further examined in research. Categories constructed in this project overlap with findings from current qualitative mindfulness studies. For example, participants who tuned into their bodies were found more likely to practice self care, a finding consistent with Cohen and colleagues (2005b) report that enhanced self-care was a central outcome for nurses who completed the M B S R program. Cohen et al. also cited Positive relationship changes as an important theme for nurses, somewhat similar to the preliminary category Connecting with others. Although these two findings differ in terms of the components of these categories, the influence of mindfulness on interpersonal relationships should be further explored in research. In the context of theoretical articles concerned with mindfulness processes, findings from the current study elucidate particular aspects of earlier proposed models (e.g.. Bishop et al., 2004). Bishop and colleagues' two-component definition, for example, operationalized mindfulness as: (a) the self-regulation of attention, reflective of a metacognitive ski l l , and (b) the adoption of an orientation of curiosity and acceptance towards one's experience. In similar terms, Shapiro, Carlson, Astin, and Mil le r (2006) posited three components of mindfulness: (a) intention, (b) attention, and (c) attitude. The current study found that participants' attention to physical, cognitive, or emotional responses triggered by occupational stressors was a central aspect to their use of mindfulness at work. Attention is clearly an important component with theoretical accounts of mindfulness, and this study emphasizes the importance of meta-cognition (i.e., noticing a stress response) and sustained attention (i.e., attending to an internal process) as particular aspects of attention. Furthermore, as discussed in a recent article by Shapiro, Carlson, Astin, and Mi l le r (2006), the majority of mindfulness-based researchers have adopted quantitative approaches to 46 address the primary question, "Do mindfulness-based interventions work?" The current study, however, is focused on processes underlying the use of mindfulness rather than outcomes, and is therefore difficult to compare with quantitative findings. This study is unique in having examined the use of mindfulness in the context of occupational stress. Although the processes participants attended to following their awareness of a stress response were not necessarily unique (e.g., self talk), the context in which these processes occurred demonstrates the importance of particular work stressors. This relationship between workplace stressors and specific internal processes was evident across participants' accounts, and is a central finding in this study. Interpersonal workplace events, for example, were associated with specific inner processes: (a) interpersonal exchanges related to power (i.e., feeling intimidated by a supervisor) were associated with participants' tuning into bodily sensations or their inner-dialogue; (b) negative emotions (e.g., frustration) triggered by specific expectations of a co-worker were connected to an attendance to participants' relationship with their expectations; and (c) interpersonal demands related to time (e.g., workplace deadlines) were associated with participants attending to their relationship with time and space. Previous occupational research has shown interpersonal stressors as most distressing to employees, especially females (e.g., Portello & Long, 2001). In the following sections, I discuss specific categorical findings in the context of the literature related to the psychological processes involved. Tuning into the body. The employees in this study described becoming aware of physical sensations associated with interpersonal or environmental workplace stressors, tuning into their bodies (i.e., directing their attention to physical sensations), and attending to these physical sensations. This process is consistent with theoretical accounts that consider bodily awareness to be a central process of meditation practice (e.g., Rothberg, Goldstein, Kornfield, & McDonald-Smith, 1998). In his seminal text on the M B S R program, Kabat-Zinn (1990) theorized that mindfulness sensitizes and attunes practitioners to their bodies, contributing to an increased awareness of physical cues related to stressors. Participants' description of bodily awareness in this study affirms Kabat-Zinn's notion that physical cues are more likely to be recognized when mindfulness is used. Researchers from the stress-management field have also made observations about the importance of "tension sensation" in techniques such as progressive relaxation (Powell, 2004) and biofeedback (Blanchard & K i m , 2005). In these methods, individuals' are sensitized to physical sensations through personal observation (e.g., progressive relaxation) or a somatic 47 technological tool (e.g., biofeedback), with the goal of lowering arousal (i.e., managing stress) through the identification and release of physical tension. Findings from the present study suggest that participants used tension sensation in a similar way, yet did not necessarily use mindfulness to promote a cognitive shift directed towards releasing tension. Instead, processes the employees attended to following an initial shift o f attention (e.g., bodily sensations) appeared to influence the ability to manage stress. Relinquishing workplace expectations. Participants in this study described becoming aware of negative emotions (e.g., anxiety, frustration) related to specific workplace expectations (i.e., beliefs about the future). In stress and coping research, such expectations have been termed "anticipatory stressors," where cognitive rumination about a future event can elicit a significant psychological response (e.g., Ennis, Kel ly , & Lambert, 2001). O f central importance to this research is the subjective relationship one has with their expectations. Although much stress and coping research has explored the role of cognitive appraisal in relationship to anticipatory stressors (e.g., Smyth et al., 1998), findings from the current study suggest that participants' relinquishment of workplace expectations was associated with a sense of increased detachment, a process participants described as both cognitive and corporeal, especially in terms of their relationship to time and space. As the issue of attachment/detachment in Buddhist psychology is commonly described in holistic language (i.e., body-mind), the relationship mindfulness practitioners have to their expectations, including their experience of anticipatory stressors, should be explored in future research. Tuning into an inner-dialogue. Participants described tuning into their inner-dialogue (i.e., an ongoing internal commentary or inner-voice) when they became aware of negative emotions (e.g., anger) triggered by interpersonal encounters at work. Inner-dialogue, or self-talk, is a widely explored concept in stress management literature, and is commonly conceptualized as a coping strategy (e.g., Fields, 2002). In the current study, participants described tuning into a positive inner-dialogue (e.g., reassuring self-talk) when triggered by an interpersonal encounter. A s 83% of these participants were women, this finding is consistent with Tamres, Janicki, and Helgeson's (2002) meta-analytic study that found women more likely than men to engage in verbal coping strategies such as positive self-talk. Awareness of negative self-talk, a core component of Rational-Emotive Behavior Therapy theories and practices (Ellis, 1999), was absent from the employees' accounts, and could be explored in future research. Sensing increased time and spaciousness. Employees in the present study described an increased sense of time and spaciousness when mindfulness was triggered by interpersonal and 48 workplace demands related to time. The empirical study of cognitive, behavioral, and neurological processes related to spatiotemporal organization has used highly advanced experimental techniques difficult to summarize in this discussion (Alvarez & Scholl, 2005; Lupianez & Funes, 2005), yet the recent study of meditation by neurological scientists suggests this topic could receive further attention (Lehmann et al., 2006; Lutz et al., 2004). A t this stage, the employees' phenomenological experience of having more time and space in a moment requires further investigation. Preliminary categories. Two employees in this study described experiencing increased self-compassion (i.e., becoming more gentle and accepting of themselves) when using mindfulness. The notion of self-compassion has been most prominently in articles concerned with Buddhist psychology (e.g., Neff, 2003). Although this research suggests that self-compassion may be associated with positive mental health benefits, the results from the present study are tentative and require further exploration. The second preliminary category in this study described three participants' experiences of feeling more connected with others when using mindfulness. Although the impact of interpersonal connection has been explored in domains such as adult substance abuse and professional knowledge networks (Kosterman, Hawkins, & Abbott, 2005; Sligo, Massey, & Lewis, 2005), further research regarding the effects of mindfulness on interpersonal relations is required. Summary. In the context of current literature, findings from this study showed consistency with theoretical accounts of mindfulness processes (e.g., attention deployment). The employees' use of mindfulness, however, was associated with a sensitization to a stress response (e.g., bodily sensations) rather than a process that directly affected appraisal. B y exploring the use of mindfulness in the context of the workplace, particular stressors (e.g., interpersonal power dynamics, workplace deadlines) were shown to influence internal processes the employees attended to following their awareness of a stress response. Each of the four main categories constructed from participants' accounts were related to psychological concepts that have been examined in the literature. Two preliminary categories were related to current empirical concepts yet require further exploration. Rigor and Trustworthiness of the Study Rigor in this study was addressed by using Beck's (1993) suggested combination of credibility and fittingness. To achieve credibility, participants' terminology was used to create codes and categories. Furthermore, the use of the constant comparative method allowed me to test and refine categories by returning to participant's descriptions of the phenomenon. The 49 articulation of my own ideas throughout this process was documented in memos comprising my own methodological decisions and thoughts on emerging hypotheses. These memos contributed to my ability to collect and analyze text in an open and inductive manner. Fittingness (i.e., transferability) was addressed by clearly describing the relevant demographic characteristics of the employees. I acknowledge that the sample in this study was small and predominantly female. Future studies would benefit from larger sample sizes and equal gender representation. Furthermore, as the scope and context of this study was limited by sample size, the creation of mid-range theory or substantive theory was not attempted. Instead, I generated a conceptual description (e.g., categories) of mindfulness processes in the workplace. Trustworthiness of findings centered on whether employees could accurately describe their experiences using mindfulness to manage occupational stress. Four methods for attaining trustworthiness were used: (a) I allowed participants to guide the research process by asking open-ended questions and searching for disconfirming evidence, (b) I continually checked and contrasted categories throughout data collection, (c) I used participants' language from interview text to create categories, and (d) I ensured that my own views were accounted for by identifying them prior to data collection and analysis. Although the employees discussed some of my beliefs (e.g., increased self-compassion), the final four categories differed markedly from my original assumptions. Furthermore, to enhance dependability, my thesis supervisor was employed as an external member check throughout the analytic process of this study. Aspects of this relationship included a close examination of early interview transcripts and audio-recording, supervision of data management, and feedback regarding the process of category construction. Limitations The small sample size and specific nature of this study restricts transferability of findings. The sample is predominately White, able-bodied, female employees in white collar (professional) occupations. Future studies would clearly benefit from greater diversity of participants. The four main and two preliminary categories would have been more comprehensive with additional purposeful sampling, yet the time and size constraints of this master's thesis restricted large conceptual descriptions. Furthermore, although a sample of employees who had completed the M B S R program would have created closer alignment with current M B S R literature, the attempt to develop a refined description of mindfulness required participants who had a comprehensive understanding of mindfulness. Because many M B S R 50 participants are relatively new to meditation, I sampled articulate, reflective employees who were able to contribute to a heightened explanation of mindfulness. Some participants in this study could not articulate their use of mindfulness. A s a result, the conceptual description presented in this study is offered to stimulate ideas for researchers and to serve as a foundation for future inquiry. Although the employees' were probed for specific use of mindfulness in a variety of workplace scenarios, the ability to describe processes in a refined and comprehensive manner proved to be a challenging task for some. Considering that the demographic characteristics did not differ between the few participants and the others (e.g., age, meditation experience), future research may consider using the Mindful Attention Awareness Scale (Brown & Ryan, 2003, 2004) to quantify participants' ability to use mindfulness, or use short screening interviews to ensure potential participants can adequately describe their experiences. i Contributions to Research and Implications for Practice The present study contributes a conceptual description of processes underlying the use of mindfulness to be tested and incorporated into future research. The deployment of attention to differing inner processes through the use of mindfulness presents a unique account not previously discussed in the literature. Findings suggest that employees' who use mindfulness in the workplace may be more sensitized to cognitions or physical sensations associated with a stress response (i.e., increased heart rate), and that these employees enhanced their ability to tune into inner processes that may have been co-occurring during a stress response. With mindfulness most commonly conceptualized as a process that broadly influences the appraisal process, these findings suggest that the process of mindfulness is more contextual, intricate, and dynamic then has been previously theorized. Wi th qualitative, empirical accounts into mindfulness processes just beginning to appear in the literature, researchers in this domain may benefit from a conceptual description that provides direction to future research. The finding that potential negative impacts can affect mindfulness practitioners contributes new knowledge to the field as research has entirely focused on beneficial aspects. Recommendations for Future Research The challenge to elicit a detailed account of employees' use of mindfulness highlights the importance of utilizing creative and innovative methodological approaches in research. A number of options are available to effectively obtain such an account. One promising approach is the Action-Project method developed by scholars in the counselling psychology field 51 (Young, Valach, & Domene, 2005). This method focuses on individuals' goal-directed and intentional behavior, providing a unique and suitable framework for analyzing internal processes related to the use of mindfulness. Data could be comprised of three separate sources consistent with Young and colleagues' proposed methodology as outlined in a recent article in the Journal of Counselling Psychology: (a) videotaped interviews conducted with experienced mindfulness practitioners engaged in a conversation while using mindfulness; (b) a self-confrontation interview using video playback to gather participants' internal processes (i.e., cognitions, emotions); and (c) interviewer's observations of participants during the data-collection process. Using the Action-Project method, video playback immediately following an initial interview would provide the opportunity to explore participants' internal processes of mindfulness, eliminating the obstacle of long-term recall. This approach could also be used to explore a wide range of issues related to the use of mindfulness (e.g., counselling processes, the use of mindfulness in treating anxiety, substance, or eating disorders), and would shape future research by providing a comprehensive, testable account of mindfulness processes. Furthermore, i f mindfulness programs are to be confidently adopted as mainstream workplace interventions, research must begin to clarify: (a) when and with whom mindfulness-based interventions are most beneficial; (b) potential negative impacts related to the use of mindfulness; and (c) what situations support or undermine the use of mindfulness. Concluding Remarks This study contributes a conceptual description of processes underlying the use of mindfulness in the workplace. Current literature has yet to clarify processes underlying the use of mindfulness in managing occupational stress, and this study offers new knowledge in this domain. 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A P P E N D I X A : Interview Questions 61 Research quest ion: H o w do employees w i th a sustained, consistent medi tat ion pract ice use mindfu lness to manage occupat ional stress? The f o l l ow ing leads w i l l be used to beg in our d iscuss ion o f the research quest ion. E a c h in i t ia l quest ion may be fo l l owed up wi th probes that faci l i tate explorat ion o f the phenomenon o f concern (e.g., what d rew y o u to meditat ion). The questions may not f o l l o w i n this speci f ic order, and some may be answered spontaneously. 1. Wha t d rew you to meditat ion? ( fo l low-up, i f not already answered: W h e n d id y o u begin pract ic ing?) 2. Descr ibe your invo lvement in medi tat ion practice since you first began. (Be sure to get a picture o f his/her pattern o f meditat ion pract ice over t ime - e.g., stopped, started, regular ly pract ice, intensely i nvo l ved in medi tat ion scene, etc). 3. What is it about meditat ion that keeps you pract ic ing it? (or, that y o u cont inue to make it part o f your l i fe?) . 4. W h a t di f ferences do y o u not ice i n yourse l f on days (or per iods o f t ime) when y o u pract ice medi tat ion contrasted w i th days (or per iods) w h e n you don ' t? 5. W h a t di f ferences w o u l d others (e.g., co-workers , fami ly members) not ice i n y o u on days that y o u pract ice medi tat ion contrasted w i th days when you don ' t? 6. Descr ibe your work and work envi ronment, and the c o m m o n stressors y o u face in this env i ronment ( i f no stressors are evident: what is a " g o o d " and " b a d " day (or exper ience) at work , or what was wo rk l i ke pr ior to pract ic ing medi tat ion?) 7. D i scuss a spec i f ic recent event (or day, or per iod o f t ime) when y o u feel your medi tat ion pract ice he lped y o u to manage a stressful si tuat ion at work. I f you can , tel l it l i ke a story, w i th a beg inn ing , m idd le , and an end ( i f the situation has ended). I f the prev ious quest ion does not prov ide enough detai l : I f you cou ld p rov ide a s low-mot ion replay, descr ibe the different exper iences you had before, dur ing, and after the stressful event (or day, or per iod o f t ime)? 8. ( I f appl icable) Descr ibe h o w your medi tat ion pract ice helped (or hindered) you i n this si tuat ion? 9. H o w might your response to this event have di f fered before you were prac t ic ing medi tat ion? D a v i d Tre leaven Version: March 7 ,h, 2005 page I of 2 10. C o u l d you prov ide another recent example o f a situation when you felt your medi tat ion pract ice he lped y o u successfu l ly manage a work-re lated stressor? 62 11. Are there situations when your practice doesn't work well for you (or hinders you) in work-related settings? If so, please describe. 12. What helps you remember to draw upon your practice at work? Or in preparation for your work, or after work? 13. Is there anything else you would like to tell me about your experiences with meditation? Anything I haven't asked about that I should have? The interview will end by arranging to re-contact the participant regarding the interview summary. I will invite participants to email or write me with any details they forgot to mention, and ask permission to email them if any quick questions arise. Note: to facilitate concrete responses that could provide further elaboration, follow up questions (e.g., "To get a clearer picture of. . . . , can you tell me more about ... .who/what/ when/why/how; and thoughts, behaviors, emotions - see below) will be asked throughout the interview. "I'm wondering about.... "How might that affect (thoughts, feelings, behaviors) "How would people see you.. .(think of you, emotional reaction, behave towards you) "How do people respond to you... Before and after differences/similarities Look for the unexpected too - that practicing meditation has a negative side to it. Keep the focus on work, however, work and family life do interact so don't ignore that interaction. David Treleaven Version: March 7th, 2005 page 2 of APPENDIX D: Letter of Initial Contact 65 Dear (potential participant), Thank you for your interest in my pilot study exploring the use of mindfulness in managing occupational stress. This study is being conducted as part of a master's thesis under the supervision of Dr. Bonita Long from the Department of Educational and Counselling Psychology, and Special Education at U B C . The purpose of this pilot study is to explore the research question, "How do individuals with a sustained, long-term meditation practice use mindfulness to manage occupational stress?" As a participant, you wi l l help me determine whether an interview can successfully address this question, and i f so, which questions are most effective in this regard. Depending on the direction of my research, your interview may or may not be used in the final thesis. In order to participate in this pilot study, I ask that you meet the following criteria: you have been meditating for at least a year you currently meditate three or more times a week for more than 20 minutes you experience work-related stress you feel you can describe your experience of using mindfulness to manage occupational stress - you are wil l ing to participate in this pilot study with the knowledge your contribution may not be used in the final thesis If you meet these criteria and agree to participate, a face-to-face, 1-1.5 hour audio-taped interview w i l l be arranged at a time and location of your convenience. To ensure accuracy, your interview w i l l be transcribed, summarized, and mailed to you for your approval. In case a secondary validation interview is warranted, I may request it at this time. In total, you are asked to dedicate approximately 2 hours to this project. Your participation in this study wi l l be entirely voluntary and you may refuse to participate or withdraw at any time. If you still wish to participate, please contact me in the next three days to arrange an interview time. Yours sincerely, David Treleaven M A Candidate, U B C Version: April 10th, 2005 Page 1 of 1 A P P E N D I X E : Demographic Info Questionnaire 68 In order to ensure I can accurately describe my sample, please complete the following questionnaire. A l l information wi l l remain confidential and your name w i l l not be used in the final manuscript. Y o u may decline to answer any of these questions. Name or initials: Age: Marital Status: Occupation: H o w long have you been meditating (semi-regular practice, 2-3 times a week)? On average, how many times per week do you meditate? '_ For how long do you meditate? Have you attended any meditation retreats in the past year? If so, how many? What kind of meditation do you practice? Number of hours you work per week (approximately): H o w long have you been working at your current job? Approximately how many people do you work with in your immediate working environment? On a scale of 1-10, how stressful do you consider your work environment? Approximately how many times per week do you experience negative emotions (e.g., anxiety, frustration) as a result of occupational stress? Version: March T, 2005 page 1 of 1 70 A P P E N D I X H : Example of a Logic Diagrams Showing Relationships Between Categories and Codes can't when in a hurry {1-1} $ CF:increased bodily-awareness , space between event and emotional reaction {'.-0} H CFitiire - changed relationship $ able to feel {1-0} $ tuned in {1-1} $ can feel tight {1-0} trying to get to the future {1-0} , y awareness of physical sensations {2-0} * * ^awarenessof body ^ p a c e to make decisions {1-0} j celebration of work {1-0} awareness of breath {2-3} j ^ . . . . . . Terience {1-0} y the past I {1-0} f space around aversion {1-0} 0 time as incredibly rapid {1-0} ^ catch herself in fear {1-1} £ time slows down {1-0} a huge disconnect {1-1} f j time: against speedy way of living {1-0} [ time: clashing with real-world ,0} $ spaces between events and {1-0} ^ all I can do is do my best {1-0} $ beating myself up {1-1} awareness of others {3-0} \ awareness of support {1-0} 0 acceptance and understanding of impermanance{l-0} 1} ^CFiSiaeaseed - : , A l , se /^cceriarce/iicreasedacffiptance' ^ CF:increased awarenes others/nterpersonal connecton' 0} 


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