Can mindfulness and acceptance be learnt by self-help?: A systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions
Introduction
The ‘third wave’ of behavioural and cognitive interventions has been characterised as paying greater attention to the context and function of cognitions, emotions and behaviour, and placing more emphasis on contextual and experiential processes of change (e.g. Hayes, 2004). Many third wave approaches are grounded in the idea that paying mindful attention to, and cultivating acceptance of, present moment experience can allow people to develop a more healthy relationship with their experience, which can lead to a reduction in psychological distress (cf. Hayes, Follette, & Linehan, 2011).
Acceptance and mindfulness are two closely related concepts. Mindfulness has been described as “paying attention in a particular way, on purpose, in the present moment and non-judgmentally” (Kabat-Zinn, 1994, p. 4). And, in the context of third wave approaches, acceptance refers to an openness to, and ability to remain present with, current experience. Paying mindful attention to and developing a more accepting relationship with present moment experience are thought to be helpful, because they can enable people to let go of habitual, unhelpful reactions to current experience and instead choose more helpful ways of responding. For example, when a negative thought has the function of driving ruminative processes, it may contribute to the maintenance of depression. However, when such a thought is mindfully observed and accepted, it can be experienced as a mental event that will pass, rather than a truth, and hence is less likely to lower mood and drive rumination (Segal et al., 2002, Segal et al., 2013). Consistent with this, there is growing evidence that paying attention in this particular way has positive consequences for both psychological health (Brown and Ryan, 2003, Keng et al., 2011) and physical health (Grossman, Niemann, Schmidt, & Walach, 2004) in clinical (Chiesa and Serretti, 2011, Hofmann et al., 2010, Vøllestad et al., 2012) and non-clinical (Chiesa and Serretti, 2010, Eberth and Sedlmeier, 2012, Sedlmeier et al., 2012) populations.
The potential benefits of mindfulness and acceptance underpin a range of approaches to the teaching, training and therapeutic attempts to increase mindfulness and acceptance in both clinical and community contexts. Three of the most well-established and thoroughly evaluated third wave interventions are mindfulness based stress reduction (MBSR; Kabat-Zinn, 1990), mindfulness based cognitive therapy (MBCT; Segal et al., 2002, Segal et al., 2013) and acceptance and commitment therapy (ACT; Hayes & Wilson, 1994).
In MBSR and MBCT participants are taught to develop mindfulness skills through a range of formal and informal mindfulness practices, including, amongst others, the body scan, mindfulness of the breath, body, sounds and thoughts, mindful movement and mindfulness of everyday activities. Participants are invited to follow these practices both during their eight, weekly classes and as part of the daily homework exercises.
A key aspect of the classes is the “enquiry process”, during which participants speak about their experiences of mindfulness practice and the MBCT/MBSR teacher embodies a kind, curious and present moment-focused attitude towards these experiences (Segal et al., 2002, Segal et al., 2013). This is thought to provide participants with a model of how they can relate to their experiences during mindfulness practice. MBSR and MBCT are very similar in content, but differ in that MBCT has a more specific focused on depression and negative automatic thoughts, whilst MBSR has a wider focus on stress more generally.
These interventions are associated with increased mindfulness and improved psychological well-being in non-clinical populations (Eberth & Sedlmeier, 2012), a reduction in risk of depressive relapse for people with a history of three or more episodes of depression (Ma and Teasdale, 2004, Teasdale et al., 2000), an improvement in health-related quality of life in clinical populations with physical illness (Fjorback, Arendt, Ørnbøl, Fink, & Walach, 2011) and decreases in symptoms of stress, depression and anxiety in clinical populations with psychiatric disorders (Chiesa and Serretti, 2011, Fjorback et al., 2011, Hofmann et al., 2010, Vøllestad et al., 2012). There is variability in size of the effect of mindfulness-based approaches, in part depending upon the outcome variable in question (Eberth & Sedlmeier, 2012). Moderate pre-post effects are typical, with larger effects being observed with participants with depression and anxiety disorders (Hofmann et al., 2010).
ACT is grounded in functional contextualist philosophy and based on relational frame theory (Hayes, 2004). According to this theory, emotional distress results from ‘cognitive fusion’, in which unhelpful verbal rules and evaluative thoughts dominate the control of behaviour at the expense of contact with present-moment experience, which is avoided. These rules and evaluations drive maladaptive behaviours, for example deliberate attempts to suppress feelings, which are ineffective and so lead to further unhelpful evaluations and consequent distress. ACT aims to alleviate suffering by increasing ‘psychological flexibility’ and hence reducing cognitive fusion, experiential avoidance and maladaptive behaviours. Psychological flexibility is cultivated through teaching mindfulness and acceptance skills and encouraging commitment to behavioural change linked to clients' values. ACT employs a variety of techniques including, amongst others, exploring how experiential avoidance and cognitive control strategies can be unhelpful, using mindfulness exercises and related techniques to encourage psychological flexibility, eliciting and clarifying client values, and using metaphor to help clients grasp important concepts and ideas. ACT has been applied to a variety of conditions and client groups and has a growing evidence base for its efficacy (e.g. Bach and Hayes, 2002, Ost, 2008, Powers et al., 2009, Ruiz, 2012, Sharp, 2012, Veehof et al., 2011).
Other notable mindfulness and acceptance-based interventions include dialectical behavioural therapy (DBT) and person based cognitive therapy (PBCT), each of which also has a developing evidence base (e.g. Dannahy et al., 2011, Kliem et al., 2010, Ost, 2008, Strauss et al., 2012). These are multi-component interventions but each of them has a basis in principles of mindfulness and acceptance. Typically these interventions include, amongst other elements, a rationale and orientation toward a mindful, accepting approach to experience, the regular brief mindfulness meditation practices (usually 5–10 minute practices) and other exercises designed to promote mindfulness and acceptance in daily living both in group settings and in at home. One meta-analysis found no significant difference between the outcomes of pure mindfulness based interventions and multi-component interventions at least in the case of anxiety disorders (Vøllestad et al., 2012).
Given the measured benefits of mindfulness and acceptance based interventions, the possibility of extending their reach has recently begun to be explored. The dissemination of mindfulness and acceptance based interventions delivered in their traditional format may be limited by the availability of adequately experienced group leaders (e.g. Mental Health Foundation, 2010). Mindfulness and acceptance based interventions are typically offered in a group format, making them relatively efficient in terms of therapist input, however the resource is still quite high in comparison to many low-intensity interventions (cf. Bennett-Levy et al., 2010).
Methods to extend their reach, might include i) the dissemination of training and supervision in mindfulness and acceptance-based approaches to a wider group of health professionals and other trainers, ii) the development of briefer and/or larger group-based practices and iii) the development of “low-intensity” or self-help mindfulness and acceptance based approaches. This article focuses on the potential of guided and unguided self-help interventions that include mindfulness and/or acceptance components. We explore evidence for the effectiveness and acceptability of self-help interventions including mindfulness and acceptance elements to date, and present a roadmap for future research on this important topic.
Section snippets
What is self-help?
The term ‘self-help’ tends to be applied loosely and interchangeably with other terms such as ‘self-management’, ‘self-instruction’, ‘self-care’ or ‘psychoeducational’ interventions (Lewis et al., 2003). NICE (2004) describes self-help as “A self-administered intervention designed to treat depression [sic], which makes use of a range of books or a self-help manual that is based on an evidence-based intervention and is designed specifically for the purpose” (p. 358). In addition to books,
Does self-help work?
Most published studies of self-help have explored interventions based on the principles of cognitive behaviour therapy (CBT; cf. Bennett-Levy, Richards, & Farrand, 2010). Recent reviews and meta-analyses have indicated that both pure self-help and guided self-help may be of benefit to people experiencing common problems such as anxiety and depression (Coull and Morris, 2011, Newman et al., 2011). There is some evidence that guided self-help is more effective than pure self-help (Gellatly et
Literature search
We searched MEDLINE, ISI Web of Knowledge, PsycInfo and Cochrane Library Databases from inception until May 1st 2013 using the term ‘mindful* or acceptance’ in combination with the terms ‘self*help’, ‘*book’, ‘computer’, ‘app*’, ‘audio*’ or ‘*phone’ and “randomi*ed” or “RCT”. Reference lists and relevant journals were also searched manually to identify potentially eligible studies.
We included in our review: i) published reports of empirical studies, ii) that employed self-help mindfulness or
Results
Table 1 presents summary data from the 15 identified studies.
Discussion
Mindfulness and acceptance-based self-help resources are widely available within the public domain. This systematic review and meta-analyses summarise the empirical evidence to date regarding the effectiveness of self-help interventions that include mindfulness and/or acceptance components in teaching the skills of mindfulness and acceptance and evaluates the extent to which these interventions are associated with symptom change. Studies were found reporting on the effects of internet-based
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