Pain,mindfulness,and spirituality: A randomized controlled trial comparing effects of mindfulness and relaxation on pain-related outcomes in migraineurs

Abstract

In order to examine mindfulness as an intervention for pain, 107 migraineurs, predominantly college students, were randomly assigned to brief training in standardized mindfulness, spiritualized mindfulness, and simple relaxation instructions. After 2 weeks of daily practice, participants completed the cold-pressor task while practicing their assigned technique, and their experience of the task was assessed. Among the 74 study-completers, standardized mindfulness led to significantly reduced pain-related stress relative to simple relaxation, providing modest support for the utility of mindfulness in pain management. Pain-related outcomes in the spiritualized mindfulness condition were similar to those of standardized mindfulness, though spirituality did appear to enhance mindful awareness.

Keywords

clinical health psychology complementary and alternative medicine randomized controlled trial religion spirituality

Introduction

Mindfulness training is receiving increasing attention in the literature as a potentially effective intervention for chronic pain. This study was designed to examine the utility of mindfulness in managing pain in a sample of migraineurs. We were also interested in whether spiritual engagement might enhance the effectiveness of mindfulness training, a possibility which has received little attention in the empirical literature. For this reason, in addition to providing background information on migraine and mindfulness, below we review literature relevant to the intersection of mindfulness and spirituality as well as literature on spirituality as a resource in pain management.

Migraine

Migraine headache is relatively prevalent, experienced by about 12 percent of individuals in the United States within a given year (Robbins and Lipton, 2010). Often accompanied by photophobia, phonophobia, and nausea, migraine headache can be disabling, with over half of migraineurs reporting attacks severe enough that they require bedrest (Linde, 2006; Lipton et al., 2007). Migraines have significant psychological costs as well. Rates of suicidality, depression, and anxiety are much higher among migraineurs than among the general population (Linde, 2006), and there is some evidence that onset of migraine may cause this elevated psychopathology and distress (Breslau et al., 2003).

While many migraineurs’ lives are dramatically improved through the use of pharmacological treatment (Holroyd and Penzien, 1990), there remains a substantial portion of patients for whom pharmacological therapies are ineffective or only partially effective (Borkum, 2007). Non-pharmacological treatments for migraine represent an important alternative or supplement to pharmacological treatment (Sauro and Becker, 2009)—for mitigating both pain and its accompanying distress. There is evidence to support the use of several kinds of non-pharmacological strategies in the treatment of migraine, including relaxation training, biofeedback, and coping skills training (Gauthier et al., 1996; Holroyd et al., 1995; Nicholson et al., 2011).

The appropriateness of behavioral and psychological treatments for migraine is underlined by research demonstrating that stress and negative mood are associated with maintenance of migraine headache and recurring attacks (De Benedittis et al., 1990; Martin and Teoh, 1999). Findings such as these suggest that treatments designed to help migraineurs appraise pain episodes and other stressors as less distressing—such as mindfulness training—may make migraines less frequent and mitigate the negative impact of migraines on well-being (Martin, 2010; Sauro and Becker, 2009).

Mindfulness and pain

Originally a Buddhist practice, mindfulness meditation involves the deliberate cultivation of mindfulness, often defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally” (Kabat-Zinn, 1994: 4). Mindfulness training typically begins with a breathing meditation, in which the practitioner is asked to attend to physical sensations associated with breathing. Practitioners are instructed to note thoughts, emotions, and sensations that inevitably disrupt their focus, and then return their attention to the breath. Another technique involves allowing an uncomfortable thought or sensation to become the focus, teaching practitioners to bring mindful attention to unpleasant aspects of experience. The idea is that, with regular practice, this mode of consciousness will gradually permeate the practitioner’s life and change the way she or he approaches all aspects of experience.

Mindfulness-Based Stress Reduction (MBSR) is a standardized form of mindfulness training which in many ways typifies mindfulness as practiced in a Western therapeutic context. Since the development of MBSR, a growing literature has investigated its utility in ameliorating medical symptoms and distress in chronic pain populations. While some studies are promising (e.g. Grossman et al., 2007; Sephton et al., 2007), it is not clear that MBSR reliably brings about clinically meaningful treatment effects for chronic headache sufferers (Rosenzweig et al., 2010).

Recently, researchers have been using studies of laboratory pain to allow for more tightly controlled research on the effectiveness of mindfulness for pain. Supporting the utility of mindfulness for pain, a randomized study found that pain tolerance increased in healthy participants who had completed 6 hours of mindfulness training, while those who received 2 hours of instruction in guided imagery did not demonstrate this improvement (Kingston et al., 2007). Another study of healthy participants found support for the effectiveness of brief (15-minute) mindfulness training in improving pain-related outcomes, as compared to a similarly brief guided-imagery intervention (Liu et al., 2012). The present study was designed primarily to test whether these findings in healthy participants would generalize to a sample of migraineurs.

Spirituality, mindfulness, and pain

This study also included an exploratory arm examining whether spiritual engagement enhances mindfulness. Here we define spirituality as a “search for the sacred,” where the sacred is characterized by these three qualities: transcendence, a sense of being in touch with something beyond ordinary experience; boundlessness, lacking the boundaries and limits of ordinary life; and ultimacy, the quality of being “basic and elemental” or deeply true (Pargament, 2007: 39). For example, aspects of meditation training which construe meditation as a technique to improve concentration would be considered secular. In contrast, elements which construe meditation as a way to get in touch with a transcendent reality or concept—for example, nirvana, the soul, or God—would be spiritual.

Although mindfulness practice is often described as secular and non-conceptual (e.g. Gunaratana, 1990; Thera, 1973), others conceptualize mindfulness training as compatible with spiritual concepts (e.g. Bergemann et al., 2013; Greeson et al., 2011; Kristeller, 2010). Notably, Rosch (2007) argues that mindfulness training provides instruction not only in how to pay attention, but also what to look for. One example of a spiritual concept that practitioners of mindfulness are taught to attend to is the Buddha nature—the True or Original Self, the loving core of every being (Gunaratana, 1990; Hart, 1987). The concept of “Buddha nature” is present to some extent even in MBSR—in the form of “wholeness,” (Kabat-Zinn, 1990). In explaining wholeness, Kabat-Zinn tells readers that we are more than our suffering; “[w]e are also what was present before the scarring, our original wholeness, what was born whole,” (p. 161). He goes on to suggest that wholeness is a crucial goal in MBSR, saying, “perhaps more than anything else, the work in the stress clinic involves helping people to see and feel and believe in their wholeness,” (p. 162).

In addition to having a spiritual goal or focus, mindfulness training can also become spiritual when spiritual practices or content is used to enhance mindful awareness. For example, Nyanaponika Thera (1973) instructs practitioners to begin meditation by reciting the Threefold Refuge, a devotional practice in which the practitioner reminds himself or herself to “take refuge” in the Buddha, the Sangha (spiritual community), and the Dharma (teachings). As another example, American Buddhist teachers Goldstein and Kornfield (1987) recommend harnessing reverence for the Buddha to infuse ordinary activities with mindfulness, suggesting, “If you choose the opening of doors throughout the day, you can open each door as if the Buddha himself were to pass through with you” (p. 185). Similarly, Thich Nhat Hanh (1976/1987) uses sacred language to explain what it means to bring mindfulness into daily life: “I plant with all my heart and mind. I clean this teapot with the kind of attention I would have were I giving the baby Buddha or Jesus a bath” (p. 61).

Another reason to hypothesize that spiritual elements enhance the effectiveness of mindfulness for pain is that spiritual engagement may itself be a resource in managing pain. Three lines of research offer suggestive evidence that engaging spirituality is helpful to those with chronic pain (Rippentrop, 2005):

Research showing that many chronic pain sufferers turn to religion and spirituality to cope (e.g. Glover-Graf et al., 2007; Keefe et al., 2001);

Research demonstrating a positive association between religion/spirituality and well-being in other populations (e.g. Sawatzky et al., 2005; Hackney and Sanders, 2003; Thoresen and Harris, 2002);

Cross-sectional studies of chronic pain populations yielding positive associations between spiritual engagement and well-being indicators (e.g. Bush et al., 1999; Keefe et al., 2001; Rippentrop et al., 2005).

This suggestive evidence is complemented by results of two randomized controlled trials of mantra meditation (a technique distinct from mindfulness) showing that spiritual mantra meditation leads to improved psychological and pain-related outcomes relative to secular mantra meditation (Wachholtz and Pargament, 2005, 2008). The results of these studies shaped our hypothesis, stated below, on the effectiveness of spiritualized mindfulness relative to a standard mindfulness script.

The present study

This study was primarily designed to test whether mindfulness is effective in improving pain-related outcomes in a sample of migraineurs (hypothesis 1). We also examined the possible utility of engaging spirituality in mindfulness training (hypothesis 2).

Hypothesis 1: Standardized mindfulness (STM) training will lead to superior pain-related outcomes relative to simple relaxation instructions (R). Specifically, participants in the STM condition will report less pain and stress during the cold-pressor task and greater pain tolerance than participants in the R condition—as indexed by the amount of time they are willing to keep their hand in the cold water bath.

Hypothesis 2: Spiritualized mindfulness (SPM) training will lead to superior pain-related outcomes relative to STM. Specifically, participants in the SPM condition will report less pain and stress during the cold-pressor task and greater pain tolerance.

Method

Participants

Participants were volunteers recruited on a midwestern university campus and in the local community. Potential participants with Raynaud’s disease and other circulatory problems were screened out to avoid adverse effects these individuals could experience during the cold pressor task. In keeping with Wachholtz and Pargament (2005), atheists were not screened out, as the study was designed to be appropriate for atheists and agnostics along with religious affiliates. Also in keeping with Wachholtz and Pargament (2005), we planned to recruit and run participants until 25 to 30 participants had completed the post-test procedures in each of the three conditions. The decision to terminate recruitment procedures was made blind to results—that is, prior to data analysis.

Migraine screener

Prior to enrollment, participants were screened for migraine using the ID-Migraine screener (Lipton et al., 2003). This validated self-administered screener consists of three questions asking the respondent whether he/she experiences nausea, disability, and light sensitivity during headaches. Endorsement of two or more of these items is considered indicative of migraine. This screener was validated on a sample of primary care patients presenting for routine office visits who also reported headaches in the past 3 months (Lipton et al., 2003). After completing the screener, participants in the validation study were referred to a headache expert who interviewed them to determine whether they met criteria for migraine diagnosis. Data on the 80 percent of referred patients who completed the diagnostic interview suggested a sensitivity of 0.81, a specificity of 0.75, and a positive predictive value of 0.93 for the screener.

To qualify for participation in this study, participants were required to report two migraine-type headaches in the past month, in addition to scoring positive on the screener. In light of consultation with a neurologist and researcher (Gretchen Tietjen, personal communication, 11 May, 2011), individuals reporting greater than 15 headaches per month were excluded and instead encouraged to seek individual behavioral or medical treatment.

Adherence

Over the course of their involvement in the study, participants completed a daily diary with questions assessing adherence to their assigned techniques. We planned to exclude participants who failed to complete at least 12 of the 14 daily dairies. After data collection, these criteria were changed to include participants who completed daily diaries on at least 10 of the 14 days, as participants reported intermittent technical problems with completing two of the online diaries.

Religion and spirituality

Participants were asked to provide their religious affiliation (or lack thereof), frequency of attendance at religious services, and frequency of prayer/religious meditation (see Fetzer Institute, 1999). Two items assessing self-rated religious and spiritual intensity were also used.

Headache impact

The Headache Impact Test—6-item version—(HIT-6; Kosinski et al., 2003) was used to assess migraine severity. The six items of this measure assess pain severity, role limitations due to headache, and distress due to headache. The HIT-6 has good psychometric properties (Kosinski et al., 2003; Shin et al., 2008).

Manipulation check questions and perceived efficacy

Participants were asked to indicate the frequency with which they felt connected to the sacred during their assigned technique on a 5-point Likert scale from 0 (rarely or never) to 4 (all or nearly all of the time), using the following prompt: “Thinking about your experience during your daily practice, how often did you feel connected to something transcendent, ultimate or sacred?” This item was intended to assess whether STM participants experienced their technique as more spiritual relative to the other groups. To address concerns that the participants in the R condition would find their training to be less credible, participants were also asked about their subjective experience of the technique as relaxing (“How relaxing did you find your assigned technique to be?”), helpful (“How helpful did you find your assigned technique to be?”), and consonant with their spiritual background (“How well did your assigned technique fit with your spiritual background?”), using a Likert scale from 0 (not at all) to 4 (very much).

Dependent measures¹

Cold-pressor task

At post-test, participants completed the cold-pressor task. A cold water bath was maintained at 2 °C, and water was circulated with an aquarium pump to keep temperature uniform throughout the bath. Participants were asked to keep their hand in the water bath up to the wrist “until it becomes too uncomfortable.” The time that participants kept their hands in the water was recorded. Afterwards, participants were asked to rate their experience of pain, using the following prompt: “Please indicate how painful this task was on a scale from 0 (no pain at all) to 10 (pain as bad as it could be).” They were also asked about stress experienced because of the task (“please rate how stressful this task was for you on a scale ranging from 0 [not at all] to 4 [very much].”).

Mindfulness

The Toronto Mindfulness Scale (TMS; Lau et al., 2006), a validated 13-item measure of state mindfulness, was administered to assess perceived mindfulness during the cold-pressor task. The TMS comprises two subscales: Curiosity, which reflects the degree to which a respondent maintained an attitude of curiosity toward their experience, and Decentering, which reflects how much the respondent was able to maintain a sense of self as independent of his or her thoughts/experiences.

Procedure

Participants were recruited and study procedures were run from May 2011 to April 2012. After obtaining approval from the university’s Human Subjects Review Board, fliers were posted around a midwestern university campus and the local community to recruit participants. The study was posted to the computer system that the university uses to advertise studies and to assign research participation credits (required for psychology classes). Advertisements described this study as a study of meditation and relaxation techniques for people with headaches. Interested individuals were provided with a link to a screener inquiring about migraine headaches and circulatory problems. Individuals who passed the screener were invited to attend a pre-test appointment to initiate their involvement in the intervention.

Prior to the start of the study, separate groups of research assistants were trained by the principal investigator to run pre-test and post-test procedures. Pre-test research assistants were assigned to teach sessions in a balanced manner—such that each assistant taught roughly the same number of sessions for each of the three treatment conditions. Post-test research assistants were kept blind to each participant’s assigned condition.

Participants met in groups of 2 to 10 for pre-test procedures. After providing informed consent, participants completed a survey packet consisting of demographics questions, religion and spirituality measures, and the HIT-6. Participants were then randomly assigned to one of three conditions (STM, SPM, and R) in the following way. A chart was created listing each of the three conditions in this order—STM, SPM, R—repeatedly. Ahead of their arrival at the lab, research assistants wrote first names of participants arriving for the same appointment time slot into this chart alphabetically by first name, starting with the first blank spot available in the chart. This was done to ensure that within each appointment group, participants were distributed relatively evenly into each of the three conditions.

Groups were separately trained in their assigned technique—see below for descriptions of each. At the end of each training, each group was told to practice for 20 minutes a day for the next 2 weeks. Participants received a handout outlining their assigned technique for their reference. They were also provided with this same handout via email shortly after the pre-test appointment and again a week later.

Participants were also provided with links to the online adherence diary. For the mindfulness groups only, items regarding their assigned technique were embedded within the initial two daily diaries in order to provide mindfulness participants with an opportunity to check their understanding of their assigned technique. If one of these questions was not answered correctly, the survey software directed participants to reread a section of the training script and answer the question again until they chose the correct answer (please contact the corresponding author for the complete questions).

After 2 weeks of practicing their technique on their own, participants returned individually for post-test procedures. Post-test procedures were held within 14–17 days after pre-test. Each participant was instructed to practice his/her assigned technique for 15 minutes in the lab. After 15 minutes, a research assistant returned to prompt the participant to place his/her hand in a cold water bath while still meditating or relaxing. Afterward, participants completed the TMS and two questions regarding the pain and stress experienced during the task, along with the manipulation check and perceived efficacy questions. See Figure 1 for an outline of the study design.

Meditation/relaxation training scripts

Each training session involved an introductory script to provide an overview of the technique and a guided meditation/relaxation script that described details of the technique. The differing rationales and techniques for each condition are described below. Guided portions of the R, STM, and SPM conditions were each rehearsed to last 5 minutes, 7 minutes, and 7 minutes, respectively. Guided meditation scripts for STM and SPM were based on a mindfulness-of-breathing script used by Arch and Craske (2006). The STM and SPM scripts were pilot-tested for equivalence in positive valence.

Relaxation (R)

The introductory R script explains that the intention of the technique is to relax and restore yourself. The technique is described as simply “sitting quietly with your eyes closed, relaxing your muscles and calming your mind.” The guided portion reiterates points from the introduction and instructs participants to “relax your body, releasing tension from your muscles,” to “let your worries and concerns fall away, and let your mind grow calm.”

Standardized mindfulness (STM)

The introductory STM script describes our habit of dwelling on the present or past and states that the purpose of the technique is to become “more engaged in your experience in this very moment.” The basics of the technique are explained (i.e. attending to the breath), and a rationale is given for focusing on the breath by commenting on its calming rhythm. Reflecting a secularized interpretation of the concept of wholeness, the introductory script closes with a metaphor adapted from Kabat-Zinn (2001), which compares this practice to dropping underneath the ocean’s choppy surface to more peaceful waters below, “where you may find a sense of calm and clarity even in times of stress, and grow closer to who you are.” The guided meditation portion of training reiterates these key points and provides guidance in following the breath and noting distractions.

Spiritualized mindfulness (SPM)

The introductory SPM script begins by framing the practice as aimed at cultivating spiritual connection, “feeling that you are closer to something within and around you, something more fundamental or sacred.” The script continues by briefly describing the spiritual background of the technique, explaining what the technique will be like (i.e. attending to the breath) and then elaborating on the connection between breath and spirituality across traditions. Specifically, the script states that in Christianity the Holy Spirit is sometimes referred to as the breath of God; that in Buddhist traditions the breath can be understood as representing our connection with all living beings; and that in some languages, the word for breath is the same or similar to word for spirit—for example, the word spiritual is derived from the Latin spiritus, meaning breath, life, or soul. As with STM, the introductory SPM script ends with Kabat-Zinn’s metaphor comparing the technique to dropping underneath the ocean’s surface, “where we may grow closer to a vast and sometimes wondrous reality that is always with us, even when we are not aware of it.” This wording was meant to reflect a spiritualized interpretation of the concept of wholeness. Again, as with STM, the guided meditation portion of SPM training reiterates key points from the introduction and provides guidance in following the breath and noting distractions.

Statistical analyses

All data analyses were conducted using SPSS version 20. Preliminary analyses were run to assess attrition, adherence to home-practice regimen, and sample characteristics, and to test for significant differences between conditions at pre-test. Three-way analyses of variance (ANOVAs) and post-hoc t-tests were conducted on dependent variables to assess the effect of condition, with particular attention to differences between STM and R, as well as differences between STM and SPM.

Results

A total of 107 participants attended initial training and were randomized to the STM, SPM, or R conditions. Participants who no-showed or who were unable to schedule a post-test appointment in the 4-day window allotted (14–17 days after their pre-test appointment) were by default dropped from the study. A total of 87 of the original 107 randomized participants successfully completed post-test appointments within the allowed time frame. After eliminating participants who did not complete at least 10 of the 14 daily diaries, 74 participants remained—22 in the STM condition, 25 in the R condition, and 27 in the SPM condition. There were no significant differences in attrition rates between conditions. Completers did not differ significantly from non-completers except in age: completers were younger than non-completers (p = 0.014). Analyses of completer data confirmed that research assistants trained roughly equal numbers of participants in each of the three conditions.

Pre-test sample characteristics

Pre-test frequencies, means, and standard deviations (SDs) for completers are reported in Table 1, sorted by condition. Ethnicity was found to differ significantly by condition. Note, however, that ethnicity was not included in analyses as a covariate because it did not correlate significantly with any of our outcome variables (including our manipulation check regarding connection to the sacred). This is in keeping with recommendations by Senn (1994) and Permutt (1990) that baseline variables not significantly correlated with outcomes should not be used as covariates, even if these baseline variables differ significantly between groups at pre-test. No other important differences were found on pre-test variables (including an item assessing prior experience with meditation or relaxation strategies).

Table 1.

Characteristics of completers.

	Total	Mindfulness	Relaxation	Spiritual mindfulness
N	74	22	25	27
Frequencies and proportion of sample
Gender
Male	13 (18%)	1 (5%)	5 (20%)	7 (26%)
Female	59 (80%)	20 (90%)	20 (80%)	19 (70%)
Ethnicity
White^*	53 (72%)	19 (87%)	20 (80%)	14 (52%) ^a
African American	6 (8.1%)	2 (9.1%)	4 (16%)	0 (0.0%)
Other^*	13 (18%)	1 (4.5%)	1 (4.0%)	11 (41%) ^a
Asian	2 (2.7%)	0 (0.0%)	0 (0.0%)	2 (7.4%)
Hispanic	6 (8.1%)	0 (0.0%)	1 (4.0%)	5 (19%)
Multiracial	4 (5.4%)	0 (0.0%)	0 (0.0%)	4 (15%)
Other	1 (4.5%)	1 (4.5%)	0 (0.0%)	0 (0.0%)
Religious affiliation
Protestant	32 (43%)	11 (50%)	10 (40%)	11 (41%)
Catholic	20 (27%)	5 (23%)	7 (28%)	8 (30%)
Jewish	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Muslim	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)
Agnostic/none/atheist	19 (26%)	6 (27%)	6 (24%)	7 (26%)
Agnostic	5 (6.8%)	3 (14%)	6 (4.0%)	1 (3.7%)
None	13 (18%)	3 (14%)	4 (16%)	6 (22%)
Atheist	1 (1.4%)	0 (0.0%)	1 (4.0%)	0 (0.0%)
Belief in God
Yes	60 (81%)	18 (86%)	22 (88%)	20 (74%)
No	5 (5.4%)	0 (0.0%)	1 (4.0%)	3 (11%)
Not sure	8 (11%)	3 (14%)	2 (8.0%)	3 (11%)
Frequency of prayer
I never pray	12 (16%)	4 (18%)	2 (8.0%)	6 (22%)
Formal ceremonies only 7 (9.5%)	1 (4.5%)	2 (8.0%)	4 (15%)
In times of stress^*	32 (43%)	10 (46%)	15 (60%)^b	7 (26%)
Regularly	21 (28%)	7 (32%)	6 (24%)	8 (30%)
Experience with relaxation or meditation
No instruction prior	45 (61%)	16 (73%)	14 (56%)	15 (56%)
Rarely practice	15 (20%)	5 (23%)	6 (24%)	4 (15%)
Sometimes practice	11 (15%)	1 (4.5%)	5 (20%)	5 (19%)
Regularly practice	2 (2.7%)	0 (0.0%)	0 (0.0%)	2 (7.4%)
University affiliation
Student	70 (96%)	20 (91%)	25 (100%)	26 (100%)
Faculty/employee^**	2 (2.7%)	2 (9.1%)	0 (0.0%)	0 (0.0%)
Means and standard deviations
Age	19.9 (3.5)	20.1 (5.4)	19.8 (2.8)	19.7 (1.7)
Self-rated religiousness	2.4 (0.99)	2.6 (1.1)	2.4 (0.88)	2.4 (1.0)
Self-rated spirituality	2.6 (1.0)	2.5 (1.0)	2.8 (1.0)	2.5 (1.1)
Service attendance in past year	27 (32)	26 (33)	25 (31)	29 (32)
Headaches per month	5.9 (3.4)	6.4 (3.2)	5.7 (3.6)	5.7 (3.5)
Headache impact score	63 (4.7)	63 (4.3)	64 (4.3)	62 (5.2)
Total mindfulness meditation/relaxation during intervention	190 (52)	193 (64)	191 (48)	186 (45)

ANOVA: analysis of variance.

Boldfaced numbers are significantly different from mindfulness condition in post hoc tests.

Significantly greater than the mindfulness condition at the 0.05 level.

Significantly greater than spiritual mindfulness condition at 0.05 level.

Three-way ANOVA by condition yielded a significant p-value. Note that a three-way ANOVA revealed that prayer use also differed significantly between conditions at pre-test, but post-hoc t-tests revealed that the variance was attributable primarily to a difference between the spiritual mindfulness and relaxation conditions, a comparison that was not of primary importance for this study. For this reason, prayer was not accounted for in subsequent analyses of effect of condition.

Although we recruited students and non-students, only two non-students completed our study. To allay concerns that these might represent outliers, we ran all ANOVAs on outcome variables with and without non-students. Calculated p-values were nearly identical (i.e. differed by < 0.01).

Manipulation check questions and perceived efficacy

No significant differences were found between conditions for subjective relaxation, subjective helpfulness, or reported fit with spirituality. Generally, participants found the technique moderately to quite a bit helpful (M = 2.59, SD = 0.98) and relaxing (M = 3.1, SD = 0.80), and reported that their technique fit with their spirituality a little bit to moderately well (M = 2.19, SD = 1.38). We are unaware of any important harms experienced by participants, though we did not specifically assess these, as relaxation/meditation interventions are generally considered safe.

Generally participants reported feeling not at all to moderately connected to the sacred while practicing their assigned technique (M = 1.34, SD = 1.2). Scores on this item were found to differ between conditions with borderline significance (p = 0.074). Post-hoc tests revealed that participants in the SPM condition reported significantly greater connection to the sacred relative to those in the R condition (p = 0.038). Connection to sacred was greater in SPM group relative to the STM group, but only with borderline significance (p = 0.064). See Table 2 for means and SDs of responses on this item in each condition.

Table 2.

Means and standard deviations of outcome variables for each group.

	Mindfulness	Relaxation	Spiritual mindfulness
N	22^*	25	27^**
Time in water (sec)	83 (87)	85 (104)	97 (99)
Pain	5.7 (2.5)	6.1 (2.1)	6.0 (2.0)
Stress	1.2 (0.93)	1.8^a,b (1.1)	1.2 (0.93)
State mindfulness	24 (10.6)	26 (8.2)	31^c,d (6.5)
Connected to sacred	1.1 (1.2)	1.1 (1.3)	1.8^c,e (1.1)

Bold numbers are significantly different from mindfulness condition at 0.05 level or greater. More specific information about significant differences are denoted with superscripts.

Significantly greater than the mindfulness condition at the 0.05.

Significantly greater than spiritual mindfulness condition at 0.05 level.

Significantly greater than relaxation condition at 0.05 level.

Significantly greater than mindfulness condition at 0.01 level.

Significantly greater than mindfulness condition at 0.10 level.

For two of the participants, recorded water temperature of the cold water bath was above 34°F, violating study procedures. For this reason, data regarding time in water, pain, and stress were considered invalid for these participants. Both of these participants were in the STM condition—therefore, n for the variables pain, stress, and time in water in the mindfulness group is 20 instead of 22.

Three participants left the item regarding connection to the sacred blank. All three of these participants were in the SPM condition, meaning that n for this item is 24 in the SPM condition.

Adherence analysis

Average total reported meditation/relaxation time for completers was 190 minutes (SD = 52). Reported adherence to the meditation/relaxation regimen did not differ systematically by condition. Total reported meditation time was not significantly correlated with any outcome variables.

Effect of condition

Cold-pressor stress varied significantly by condition (F(2, 69) = 3.48; p = 0.036, $η_{partial}^{2} = 0.092$ ), as did state mindfulness (F(2, 71) = 4.67; p = 0.010; $η_{partial}^{2} = 0.123$ ²). ANOVAs for cold-pressor pain and time in water did not yield significant F-statistics (for pain, F(2, 69) = 0.228, p = 0.797, $η_{partial}^{2} = 0.007$ ; for time in water, F(2, 69) = 0.145, p = 0.866, $η_{partial}^{2} = 0.004$ ). Means and SDs can be found in Table 2.

Relaxation versus STM

Reported stress during the cold-pressor task was significantly lower in the STM condition relative to R (F(1,42) = 4.895, p = 0.032, $η_{partial}^{2} = 0.104$ , d = −0.68; 95% confidence interval (CI) for d: −1.27 to −0.088). No significant differences were found between the STM and R conditions for time in water (F(1,42) = 0.007, p = 0.935, $η_{partial}^{2} < 0.001$ , d = −0.016; 95% CI for d: −0.63 to 0.59), pain (F(1,42) = 0.432, p = 0.515, $η_{partial}^{2} = 0.010$ , d = −0.18; 95 percent CI for d: −0.74 to 0.38), or state mindfulness F(1,44) = 0.473, p = 0.495, $η_{partial}^{2} = 0.011$ , d = −0.22; 95% CI for d: −0.75 to 0.30).

SPM versus STM

State mindfulness was found to be significantly higher for the SPM condition relative to STM (U = 178.5,³ p = 0.017; $η_{partial}^{2} = 0.157$ , d = 0.85; 95% CI for d: 0.29 to 1.42). No significant differences were found between the SPM and STM conditions for time in water (F(1,44) = 0.141, p = 0.709, $η_{partial}^{2} = 0.003$ , d = 0.15; 95% CI for d: −0.47 to 0.76), pain (F(1,44) = 0.321, p = 0.574, $η_{partial}^{2} = 0.007$ , d = 0.15; 95% CI for d: −0.42 to 0.73), or stress (F(1,45) = 0.006, p = 0.939, $η_{partial}^{2} < 0.001$ , d = 0.075; 95% CI for d: −0.55 to 0.71).

Discussion

The inadequacy of pharmacological solutions, along with empirical evidence for the effectiveness of behavioral treatments for migraine, makes behavioral treatment an important substitute for or adjunct to pharmacological treatment in chronic pain populations. Mindfulness meditation is one type of behavioral treatment that has shown some promise in improving the lives of people with chronic pain conditions such as migraine. In this randomized study, we investigated whether brief mindfulness training improves pain-related outcomes among migraineurs as compared to simple relaxation instructions. Results partially supported this hypothesis.

In light of the spiritual origins of mindfulness and suggestions by mindfulness teachers that spiritual content may be helpful, we also investigated whether enhancing spiritual elements of mindfulness meditation would yield additional benefit regarding pain-related outcomes relative to a STM script. Results failed to support this hypothesis, though we did find evidence that spirituality may enhance self-report mindful awareness.

Mindfulness as a resource in managing pain

Hypothesis 1: partial support. Results partially supported the hypothesis that STM participants would manage cold-pressor pain better than R participants. Pain variables analyzed in this study centered around the cold-pressor task: pain tolerance during the task (time in cold water bath), reported stressfulness of the task, and reported pain experienced during the task. Of these three, reported stressfulness of the task differed significantly between groups: the mindfulness group found the task significantly less stressful than participants in the basic relaxation condition. These modest findings are generally consistent with findings of other cold-pressor studies on effectiveness of brief mindfulness or sensory monitoring interventions, which yield modestly improved outcomes relative to distraction and other pain management strategies (Keogh et al., 2000; Liu et al., 2012; Nouwen et al., 2006).

An important concern regarding these results is that state mindfulness was not found to be significantly greater in the STM condition relative to the relaxation condition. Why might this be? One possibility is that a brief, secular mindfulness intervention may not adequately convey crucial aspects of mindfulness. Construct validity problems with the scale we used to measure state mindfulness (the TMS) may also play a role. Grossman (2008) has pointed out that there are important differences in definitions of mindfulness and that various measures of mindfulness may be indexing different facets of mindfulness. The TMS focuses on willingness to experience what is unpleasant and viewing one’s thoughts and experiences as separate from the self, while other measures of mindfulness focus on “acting with awareness,” labeling emotions and sensations, or some other aspect of mindfulness (Bergomi et al., 2012). Perhaps the mindfulness training provided here cultivates aspects of mindfulness inadequately captured by the TMS.

Also potentially concerning is the lack of association found between total reported meditation/relaxation time and outcome variables. However, these results are not inconsistent with the current literature on the importance of home practice to mindfulness interventions. Specifically, a systematic review of mindfulness programs found that, among the few studies which have evaluated adherence to a home-practice regimen, only half found support for the importance of home practice to benefits experienced over the course of a mindfulness intervention (Vettese et al., 2009).

Implications

These results suggest that clinicians with limited time for intervention may find mindfulness training modestly more helpful for migraineurs than basic relaxation. It is possible that these results generalize to other instances of acute or chronic pain—for instance, patients who are undergoing painful medical treatment, or people struggling with fibromyalgia or low back pain.

Spirituality as a resource in managing pain

Hypothesis 2: not supported. Results did not support the hypothesis that SPM would lead to better pain-related outcomes relative to STM. Interestingly, however, state mindfulness as assessed by the measure used here (the TMS) was found to be significantly higher in SPM condition relative to the STM condition. This finding suggests that spirituality may enhance mindful awareness, in particular those aspects of mindfulness assessed in the TMS—that is, non-identification of the self with internal experience and willingness to experience unpleasant sensations and feelings. The significant difference in state mindfulness found in this study suggests that a more intensive intervention may have led to significant differences in pain-related variables, as some studies have found that the TMS and similar mindfulness measures mediate improvement in clinical outcomes experienced over the course of an 8-week mindfulness intervention (Carmody and Baer, 2008; Garland et al., 2013; Lau et al., 2006).

Yet this key question remains: why did the present study fail to find the pattern of results reported by Wachholtz and Pargament (2005, 2008) in their studies of mantra meditation, which robustly favored spiritual mantras over secular mantras using similarly brief meditation interventions? The present study differs from studies by Wachholtz and Pargament (2005, 2008) in a few ways which could account for our differing results. First, it could be argued that, compared to the SPM condition of this study, the spiritual nature of Wachholtz and Pargament’s (2005, 2008) mantra meditation was more salient, as participants were instructed to meditate on phrases such as “God is love” and “God is peace.” It is challenging to incorporate spiritual content into a mindfulness script in a manner that is both maximally relevant and sensitive to differing theistic and non-theistic spiritual beliefs. Consistent with this concern, in the present study, connection to the sacred during practice was higher in the SPM condition relative to the STM condition only with borderline significance.

A second possible explanation has to do with the blinding of experimenters. In this study, experimenters running the cold-pressor task were blinded to the condition of each participant. In contrast, experimenters in studies by Wachholtz and Pargament (2005, 2008) were blinded to study hypotheses but not to condition; a pro-spiritual bias on the part of experimenters in these studies could have influenced participants in the spiritual condition to behave differently from those in the secular conditions.

A third potentially important difference is that Wachholtz and Pargament (2005, 2008) used mantra meditation instead of mindfulness meditation. It may be that mantra meditation is better suited to abbreviated training than is mindfulness meditation (Carhart and Feuille, 2012). It is also possible that the specific wording of the SPM meditation set up expectations in a manner that the spiritual mantra meditation did not. Specifically, the SPM script used here suggested that the aim was to feel closer to the sacred with more practice. The subset of participants who had high expectations regarding their connection with the sacred and were then disappointed may actually have fared better with the STM script instead (Annette Mahoney, personal communication, November 19, 2012).

Implications

These results regarding spirituality and mindfulness training indicate that spiritual content may not increase the effectiveness of brief mindfulness training for pain management. Given the lack of significant differences in pain-related outcomes between the spiritual and STM conditions, results of this study may allay concerns among the more secular-minded that adding spiritual content interferes with mindfulness training. Instead, spiritual content may be modestly helpful in achieving a state of mindful awareness, even though this may not translate to improved pain-related outcomes.

Limitations and future directions

There are important limitations to this study which affect its generalizability. It is unclear whether findings for the abbreviated mindfulness training used in this study would generalize to more intensive mindfulness training typical of MBSR or other mindfulness interventions. These results may not necessarily generalize to a sample of migraine patients in a medical or psychotherapeutic setting, since most participants were undergraduates with 2–10 headaches per month and because migraine diagnosis was not verified by a health professional. It is also unclear whether these results would generalize to a sample naïve to prior experience with meditation, relaxation, or mind–body practices such as yoga or qigong, as exposure to these practices were not used as criteria for exclusion from the study. It is possible that declining to exclude such participants undermined between-condition distinctions in the nature of the technique participants were practicing, a concern that has been cited in other studies which fail to find significant effects for meditative treatments for chronic pain (e.g. Verkaik et al., 2013). Lack of follow-up is another important limitation. Other studies of meditation have found that some benefits of meditation increase even after the formal intervention phase of the study is over, as participants learn over time to engage in meditative awareness in their daily lives (Oman et al., 2008; Shapiro et al., 2008).

Most important for conclusions regarding spiritually integrated treatments, we have reason to be concerned that the SPM script was not sufficiently more spiritual than the STM script to effectively test the hypothesis that adding a spiritual component would enhance mindfulness training. Finally, the appropriateness of spirituality and mindfulness for pain management may be better tested through mindfulness interventions tailored to the experience of pain (i.e. which specifically address thoughts related to pain, such as, “this is unbearable;” see Liu et al., 2012) rather than the general mindfulness-of-breathing scripts used in the present study.

A future study could address limitations by repeating the protocol in a patient population, tailoring interventions to the experience of pain, providing more intensive mindfulness or meditation training, and/or gathering follow-up data. A future study might assess exposure to not only relaxation or meditation strategies but also other mind–body techniques, such as qigong or yoga, and possibly exclude those reporting prior instruction in these techniques. The methodology could also be improved through the use of more in-depth self-report measures of pain and stress experienced during the cold-pressor task. Additionally, it would be useful to assess recovery from pain, for instance, by measuring time until patients report cessation of pain following removal of their hand from the cold water bath (as in Cioffi and Holloway, 1993), or by taking physiological measures that reflect parasympathetic tone, such as heart-rate variability. This would address the possibility that mindful attention may help mitigate the delayed negative effects of daily hassles and pain episodes. More careful assessment of participants’ adherence to their assigned technique and quality of meditation/relaxation might also be useful. Specifically, in addition to asking participants to report on the number of minutes spent meditating/relaxing each day, a future study might ask participants to report on how they dealt with distractions and frustrations while meditating/relaxing and what participants’ perceptions were regarding the goals of their daily relaxation/meditation practice.

Finally, future studies on mindfulness and spirituality could explore the possibility that spiritual content may induce disappointment or struggle in a subset of participants and ways to mitigate this effect. A more carefully developed SPM training script might draw the distinction between a felt connection with sacred during a particular meditation session and the long-term goal of bringing the sacred closer in daily life (first Reviewer, August 6, 2013). Also, the SPM training might be improved by emphasizing that periods of perceived distance from God or spiritual “dryness” are often considered an integral part of spiritual development (e.g. De la Cruz, 1957; Kornfield’s [1993] A Path with Heart).

Conclusion

This study indicates that abbreviated mindfulness training provides benefit regarding pain-related stress among migraineurs relative to a simple relaxation script. Additionally, we found that enhancing spiritual content in mindfulness training may be useful in developing aspects of mindful awareness that have to do with non-identification of the self with internal experience and willingness to experience unpleasant sensations and feelings. However, contrary to expectations, adding spiritual content to mindfulness training was not found to provide incremental benefit regarding pain-related outcomes.

Footnotes

Acknowledgements

The authors would like to acknowledge the assistance of Nicole Chambers, Dylan Corp, Amanda Frey, Stephanie Frey, Savannah Hay, Maranda Krochmalny, Sarah Wilhelm, and Tyler Pendleton in running study protocols. (Those interested may contact the first author for the complete data set and study protocols.)

Funding

No funding external to the university.

Notes

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Pain,mindfulness,and spirituality: A randomized controlled trial comparing effects of mindfulness and relaxation on pain-related outcomes in migraineurs

Abstract

Keywords

Introduction

Migraine

Mindfulness and pain

Spirituality, mindfulness, and pain

The present study

Method

Participants

Migraine screener

Adherence

Religion and spirituality

Headache impact

Manipulation check questions and perceived efficacy

Dependent measures 1

Cold-pressor task

Mindfulness

Procedure

Meditation/relaxation training scripts

Relaxation (R)

Standardized mindfulness (STM)

Spiritualized mindfulness (SPM)

Statistical analyses

Results

Pre-test sample characteristics

Manipulation check questions and perceived efficacy

Adherence analysis

Effect of condition

Relaxation versus STM

SPM versus STM

Discussion

Mindfulness as a resource in managing pain

Implications

Spirituality as a resource in managing pain

Implications

Limitations and future directions

Conclusion

Footnotes

Acknowledgements

Funding

Notes

References

Dependent measures¹