College Anxiety & Mindfulness Interventions

Abstract

During recent years, rates of anxiety in college students have increased. Young adults transitioning from high school where they were surrounded by family units and developed friendships to having independence and a lack of familiar supports face new challenges that add to the stress of needing to succeed and excel in school. Seeking help in times of need can be difficult, especially when it is unclear of who you can go to and potential feelings of embarrassment associated with sating “I need help.” To combat the stigma of needing help and/or being seen as having a mental health concern, colleges can implement mindfulness programs to help college students starting in their freshman year. By making treatment such as mindfulness readily available, the stigma of using the techniques will diminish and as students transition into more complex classes and circumstances of life, they will have a set of developed skills to manage anxiety-inducing stress.  This paper will provide an overview of what anxiety looks like for college students and mindfulness interventions that can be implemented into college programs.  

College Stress and Anxiety

 Anxiety as a college student is an increasingly recurrent issue as anxiety is if the most diagnosed and treated mental health diagnosis with several negative consequences (Bamber & Morpeth, 2019). In 2017, students reported increased rates of stress and anxiety putting them at risk for negative consequences of psychological and physical health. A national survey conducted by the ACHA found that 57% of students reported experiencing extreme levels of stress while 61% reported experiencing overwhelming anxiety for a year. A study conducted by Fidler, McGeorge, and McLaren under the supervision of Samuolis (2018) aimed to identify rates of anxiety and the characteristics of anxiety in college students. 365 college students from a liberal arts university answered an online questionnaire. Results of the questionnaire showed that 49% of participants experienced extreme stress for a year time (McLaren, Fidler, & McGeorge, 2018).  

As noted in the DSM, there are various forms of anxiety disorders that college students may experience. There are also other anxieties such as social, test, and performance anxiety that can be experienced. Although they may not be clinical diagnoses, these forms of anxiety cause distress and require coping skills to manage (Rankin, Paisley, Mulla, & Tomeny, 2018). In 2019, research investing the relationship between psychological inflexibility and stress, generalized anxiety, and somatization in college students found that situations causing psychological distress to have less of an impact on students when they have psychological flexibility (Tavakoli, Broyles, Reid, Sandoval, & Correa-Fernández, 2019). Researchers found that psychological inflexibility has a positive relationship with symptoms of anxiety in student with worrying having a stronger relationship in European-Americans than Hispanic Americans. The relationship between anxious symptomology and psychological inflexibility was the same across all races with the exception of worry. Results of the study were similar to past research that also found somatization to be linked to psychological inflexibility (Tavakoli, Broyles, Reid, Sandoval, & Correa-Fernández, 2019). 

Research on social support has found that decreased symptoms of anxiety and depression are associated with positive social supports. It has been established that as individuals develop and become more complex, the more important social supports become (Rankin, Paisley, Mulla, & Tomeny, 2018). During the transition to college, young adults are tasked with developing new social groups while being away from their primary family supports.  Past research has indicated that social supports in college leads to decreased anxiety in students and is a protective factor against feelings of hopelessness (Rankin, Paisley, Mulla, & Tomeny, 2018). When looking at social supports there is perceived quality and need for support that has to be investigated. Researchers are trying to determine whether the effects of social support are dependent upon whether the received support matches the needed support. One study, conducted by Rankin et al. (2018) examined this relationship and the effect it has on mental health outcomes. Researchers used 428 college students to test the theory that having more support will decrease symptoms of impulse control, anxiety, and depression. Results of the study suggest that when one receives moderate adequate emotional support anxiety increases. Interestingly, when adequate support increases or decreases, anxiety levels decrease (Rankin, Paisley, Mulla, & Tomeny, 2018). 

Gender and Cultural Differences

The expression of anxiety, a universal construct, is influenced by one’s gender and culture. Patricia Lowe at the University of Kansas conducted a measurement invariance study to examine how equivalent anxiety is across gender and country. Lowe’s study consisted of 1,344 undergraduate college students in the United States and Canada completing an online administered Adult Manifest Anxiety Scale (AMAS-C), which measures “physiological anxiety, social concerns/stress, test anxiety, and worry/oversensitivity” (Lowe, 2018). Participants also completed demographics and a test anxiety measure with the understanding that the study was to validate a test anxiety measure (Lowe, 2018). Data analysis showed that overall, AMAS-C scores were essentially the same across the country. The analysis further showed that compared to all males, females regardless if the country reported higher levels of “physiological anxiety, social concerns/stress, test anxiety, and worry/oversensitivity”.  When comparing the United States and Canada, student scores had no differences (Lowe, 2018). The results of this study imply that not only is anxiety a universal construct, but its expression may be universal as well.

Mindfulness Therapies

Research on self-esteem, anxiety, and mindfulness provide evidence of mediation effects that self-esteem has on the association between mindfulness and anxiety (Bajaj, Robins, & Pande, 2016). To assess the effects, 417 undergraduate students answered questionnaires on mindfulness, self-esteem, anxiety, and depression in a classroom setting for 15 minutes. The study found that mindfulness is positively correlated to self-esteem and negatively related to anxiety and depression, which is similar to results of previous studies (Bajaj, Robins, & Pande, 2016). A major finding of the study was that students with higher levels of mindfulness were more likely to have greater self-esteem decreasing anxiety and depression levels. (Bajaj, Robins, & Pande, 2016). The results of this study are consistent with research suggesting that mindfulness leads to decreased anxiety. With the student population being Indian, it can also be suggested that the effects of mindfulness on anxiety are consistent across ethnicities. 

To address the need for care in college, there are various forms of mindfulness that have been tested and proven to be effective interventions to decrease student anxiety. Mindfulness techniques such as mindfulness-based stress reduction (MBSR) mediation, bibliotherapy, and Learning to Breathe (L2B) can implement courses that students can be trained to do on their own, as part of a stress management course through a counseling center, and/or integrated into the curriculum. 

Mindfulness-based Stress Reduction (MBSR) 

Mindfulness-based stress reduction has been used at a private research university for 9 years, offered through the university’s counseling center. Researchers advertised the class as a mental health stress reduction class, which consisted of mostly graduate level students. The longitudinal study found that students had decreased psychological distress (Felver, Morton, & Clawson, 2018). 

Hjeltnes et al. (2017) conducted a study investigating an MBSR intervention with college students diagnosed with social anxiety. The purpose of the study was to reduce distress while improving self-experiences. Researchers used 288 college students at the University of Bergen who received 8 weeks of MBSR treatment for 2 ½ to 3 hours per week. Students also attended a one-day seminar and completed homework daily. Students practiced mindfulness exercises including hatha yoga, sitting meditation, and body scans. Data analysis reported a significant reduction in symptoms of social anxiety and global psychological distress. Results also indicated significant increases in mindfulness, self-compassion, and self-esteem (Hjeltnes, et al., 2017). Despite having significant effects, the 8-week program is considered to be less effective than cognitive behavioral therapy (CBT) treatments (Hjeltnes, et al., 2017).

Falsafi (2016) conducted a research study comparing the effectiveness of mindfulness and yoga. Each intervention involved 75- minute sessions for 8 weeks conducted by the same teacher. For the mindfulness intervention, participants were trained on several practices including breathing exercises using meditation. The yoga participants were trained on a version of Hatha yoga, which has meditative qualities. Results from Falsafi’s study indicated that the mindfulness group had a significant increase in self-compassion, which was only worked on by the mindfulness group. Overall, results showed that both mindfulness and yoga can improve symptoms of anxiety (Falsafi, 2016).

Meditation. Meditation, a Buddhist tradition, which is the practice of opening and expanding one’s awareness of thoughts and feeling without out focusing on the purpose. There are 3 elements of meditation; intention, attention, and attitude. One study providing a 75-minute college meditation course twice a week for 15 weeks to 28 undergraduate students found that mediation helped students enhance their psychological well-being, compassion, and mindfulness. For this study, psychological well-being is defined as a reduction in depression, stress, and anxiety. Compassion was defined as an understanding that people are connected and experience their own suffering. For the study, the meditation course focused on a different concept every session including compassion and forgiveness (Crowley & Munk, 2017). 

At the end of the 15 weeks, participants experienced changes in mindfulness, psychological well-being, and compassion. Mindfulness, which is the way one pays attention and are aware of internal and external happenings, was enhanced in 86% of the participants (Crowley & Munk, 2017). Psychological well-being, which is having the ability to regulate emotional responses and reduce feelings of depression, stress, and anxiety, was increased by 96% of participants. Compassion, which is having empathy for others, was increased by 79% of the participants (Crowley & Munk, 2017). By increasing all 3 values, students decreased their focus on future stressful events. Meditation helped participants in the study gain better outlooks on life and have increased positive relationships with others (Crowley & Munk, 2017). 

For college students, upcoming tests, projects and/or performances are future stressful events that can cause performance anxiety. In a 2018 study conducted by Diaz, investigated the effectiveness of mediation on performance anxiety of college music students. Data analysis found that weekly meditation decreased reported performance while students who were highly self-oriented and considered to be perfectionist had increased levels of performance anxiety despite the weekly mediation. For this study there no was change dependent on what form of mindfulness was used (Diaz, 2018). 

A different study investigating the effectiveness of mindfulness on medical students in India had similar results that indicated an association between mindfulness and lower levels of anxiety, depression, and stress. The findings of this study suggest that mindfulness education should be integrated into the medical curriculum along with life skills training and cognitive behavior therapy (Sampath, Biswas, Soohinda, & Dutta, 2019)

Bibliotherapy. Bibliotherapy is a therapeutic technique that uses books and other media sources to address emotional and behavioral problems. Bibliotherapy has been proven to promote problem-solving, increase compassion, and enhance self-awareness. The technique was first used in the early 19th century and was used by Sigmund Freud. Based on evidence from psychological uses, it is recommended that non-fiction books be used in conjunction with other treatment modalities (Pehrsson & McMillen, 2007).

Using the effectiveness of bibliotherapy as delivery for self-help, Hazlett-Stevens and Oren (2016) conducted a study using 92 undergraduate and graduate students to test the effectiveness of bibliotherapy as an MBSR intervention. Participants were randomized into control or treatment groups. Participants in the treatment group received a workbook and were required to read one chapter weekly for 10 weeks. In addition to reading, participants were required to complete reflection assignments and practice mindfulness (Hazlett-Stevens & Oren, 2016). The control group completed questionnaires online weekly. When compared to a control group, participants experienced an increase in mindfulness. The bibliotherapy self-help model significantly reduced elevated anxiety and less severe symptoms of depression. The model also improved quality of life. With this study being the first randomized controlled study investigating the effectiveness of bibliotherapy, it was noted that the significant findings were based on 53% of the treatment group participants (Hazlett-Stevens & Oren, 2016)

Learning to Breathe. Learning to Breathe (L2B) is a research-based mindfulness program that was originally created for high school classrooms or group settings. L2B has versions for adolescents and college students. L2B has been evaluated in 10 published studies. L2B aims to improve wellbeing, develop stress management skills, enhance emotion regulation, strengthen attention and performance, and support prosocial behavior (Broderick, 2013).  One peer-reviewed published study evaluated the effectiveness of L2B on 109 first-year college students who attended 8 80-minute sessions over 6 weeks (Dvořáková, et al., 2017). For the purposes of the study, the creator of L2B and 2 facilitators adapted the L2B program to specifically address challenges that first-year college students face. To supplement learning outside of the classroom, participants were provided practice cards and worksheets (Dvořáková, et al., 2017). 

Researchers initially found that mindfulness sessions during the first semester of college significantly improvements in satisfaction in life, anxiety, depression, consequences of alcohol, and sleep issues (Dvořáková, et al., 2017). The program did not enhance interpersonal awareness nor intrapersonal awareness, but students who participated gave the program a high rating and stated they would recommend the program to peers as it is beneficial and meaningful (Dvořáková, et al., 2017). Researchers for the study recommended that going forward with the program it would be best used as a freshman orientation course, 6-week freshman-only class for credit, or a residential hall program (Dvořáková, et al., 2017). 

Dialectical Behavior Therapy (DBT). DBT is the result of practitioners applying behavior therapy by combining behavioral principles and social learning theory in the treatment of highly suicidal patients (Linehan & Wilks, 2015). Initially, the treatment was used to treat patients diagnosed with borderline personality disorder (BPD) and focused on problem-solving, which patients found to be invalidating. Over the years, DBT evolved and new theoretical principles such as Zen was integrated into the treatment. Today DBT is used for various diagnoses and symptomology. Treatment is no longer focused on problem-solving and now has 4 modules that teach skills for mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance (Linehan & Wilks, 2015). 

With DBT now being considered a standalone treatment for individuals experience a multitude of symptomology, investigators, Lothes II and Mochrie (2017) assessed the effectiveness of the mindfulness skills on test anxiety reduction in college students. DBT mindfulness skills of “What” and “How” were used in conjunction with other mindfulness techniques including meditation. The study involved 16 college students enrolled in a general psychology course participate in an 8-week DBT mindfulness training using the “what” and “how” modules of the treatment. Students identified themselves as having test anxiety. The first two weeks of the program focused on meditating and doing scans of the body for 10 minutes-20 minutes. Lessons started in week 2 and continued through week 7 with each week being focused on a different skill (Lothes II & Mochrie, 2017).

 The study found evidence that suggests that the how and why skills of DBT can be effective in treating test anxiety in college students. Results of the study indicated that mindfulness DBT skills can not only reduce test anxiety but overall anxiety levels in college students (Lothes II & Mochrie, 2017). Like other studies, researchers found that the mindfulness skills training had no effect on the observed scale possibly due to students with high anxiety levels having salient cues for observations. Based on study findings it is recommended that the tested DBT skills be provided as training through a counseling center (Lothes II & Mochrie, 2017). Results of this study are an important contribution to research on DBT mindfulness as it is the first study designed to have weekly sessions for reducing test anxiety, examine the effects of the what and how skills with a college population and the first study to provide evidence of DBT’s mindfulness is an effective intervention for reducing test in anxiety in college (Lothes II & Mochrie, 2017).

Barriers to Treatment

One major barrier for college students to seek help with anxiety and other mental health concerns is a stigma. Most universities have counseling centers that students do not utilize the services of when experiencing anxiety, which is demonstrated by only 1/3 of students diagnosed with a mental disorder participating in treatment (Vidourek, King, Nabors, & Merianos, 2014). In a study examining perceived benefits and barriers to seeking mental health treatment in college students, researchers found that the largest barriers are an embarrassment, denial, and avoidance to being labeled crazy (Vidourek, King, Nabors, & Merianos, 2014). Least perceived barriers included not wanting help, not being prescribed medications, and lack of insurance (Vidourek, King, Nabors, & Merianos, 2014). Students identified that obtaining mental health treatment at counseling centers s beneficial as functioning will improve, stress is reduced, and problems are solved. 

Consistent with previous research, results indicated that females identify more benefits to treatment than males who have more stigma-based attitudes towards treatment. This finding indicates that males need more education on mental health and treatments. Despite males being less likely than females to seek treatment, there were no differences in perceived barriers to getting treatment between the genders. Females can identify the same barriers as males but are able to perceive more benefits that outweigh the barriers (Vidourek, King, Nabors, & Merianos, 2014). Researchers suggest that the studies results may be due to societal and gender norms that characterize males as needing to be strong and refrain from expressing emotions that are considered weak (Vidourek, King, Nabors, & Merianos, 2014). 

Researchers compared perceptions of benefits and barriers between races and found that minorities report lower levels of benefits to getting treatment than white students. Interestingly, non-white students were significantly less likely to perceive barriers to treatment than white students. Racial comparison is not consistent with past research that found minorities to have more positive attitudes towards seeking treatment (Vidourek, King, Nabors, & Merianos, 2014). When comparing ages and perceived barriers, researchers found evidence that freshman and sophomore students perceive significantly more barriers to treatment than juniors, seniors, and graduate students (Vidourek, King, Nabors, & Merianos, 2014). 

Similarities

Research on various forms of mindfulness have all provided evidence suggesting that college students benefit from mindfulness training in the treatment of various forms of anxiety such as PTSD. All the studies discussed within this paper have had similar results no matter what type of anxiety was being researched. Studies assessing the effectiveness of MBSR have provided evidence of its effects on social anxiety and general symptoms of anxiety (Hjeltnes, et al., 2017; Falsafi, 2016). Like MBSR, meditation studies have found it be effective in reducing general symptoms of anxiety in all college students and specifically in medical students (Crowley & Munk, 2017; Sampath, Biswas, Soohinda, & Dutta, 2019). Additionally, mediation has also been effective in the treatment of performance anxiety in musicians (Diaz, 2018). Despite studying different anxieties in students, these 2 treatment interventions yield the same effectiveness. 

Like meditation and MBSR, bibliotherapy has also been proven to be effective in the reduction of anxiety levels in college students as a self-help model (Hazlett-Stevens & Oren, 2016). L2B, a group mindfulness program with significant reductions in symptoms of anxiety has a different treatment format from bibliotherapy yet yielded similar results with first-year college students (Dvořáková, et al., 2017). The last treatment discussed, DBT, also suggests that mindfulness effectively decreases levels of anxiety (Lothes II & Mochrie, 2017). When reviewing the literature on all the listed treatments one can see that they all have a focus on improving psychological well-being, which the similar results may be attributed to. 

Another similarity that the majority of the studies have is the recommendation that mindfulness skills be taught as a program offered to freshman students in a group format. Researchers suggest that counseling centers and curriculums integrate mindfulness skills to help students develop skills needed to address anxieties that develop as they continue their education. Bibliotherapy can be used as a supplemental practice to the skills being taught in the group programs as the focus of this intervention is self-help (Pehrsson & McMillen, 2007).  Many of these treatment modalities can be combined such as using mediation to end class and giving a bibliotherapy assignment as part of homework. With all the treatment modalities for mindfulness being effective, it is important to identify which modality works best for what kind of student, which these studies have not assessed for. 

Limitations

 All research studies have identified limitations and one limitation that all the mentioned studies identified are the use of self-reports. When teaching mindfulness skills, researchers used self-reports to measure the subjective changes and effectiveness that students experienced (Hjeltnes, et al., 2017; Crowley & Munk, 2017; Lothes II & Mochrie, 2017). Another limitation is that most of the research conducted did not use randomization or control groups so comparative effects were only discussed in bibliotherapy, which is the first randomized controlled study of its kind (Hazlett-Stevens & Oren, 2016). The lack of a control group makes it difficult to determine if all effects of the intervention are due to the treatment itself or the benefit of attending a social group outside of class, which as previously mentioned provides needed social support that decreases anxiety (Rankin, Paisley, Mulla, & Tomeny, 2018). Lastly, most of the research on these interventions use small sample sizes making it unclear if the effectiveness of these treatments would translate when used on large college populations (Dvořáková, et al., 2017). 

Bibliotherapy as an intervention provides many benefits but has limitations within the format of the program. The biggest limitation is a high attrition rate, which may be explained by the lack of access to a therapist. In bibliotherapy treatments, individuals lack advice and support from a trained therapist leading to participants to discontinue or feel disengaged (Crowley & Munk, 2017). 

Recommendations

Being that research suggests mindfulness interventions be provided as a program to first-year college students, it is recommended that universities add mindfulness courses as part of the core curriculum that is required for all students as part of orientation. This assures that all incoming students learn and develop these effective skills for managing stress and decreasing anxiety. To help students continue to manage college stress and deal with the transition from college to adult life, schools can require a mindfulness course every year. An added potential benefit of setting up mindfulness college programs this way is, as everyone enrolled has to participate, the stigma of needing help and experiencing anxiety or other mental health concerns can potentially be diminished. College implemented programs should also have students work on identifying their own self-worth through mindfulness as it enhances self-esteem with awareness and acceptance (Bajaj, Robins, & Pande, 2016). 

Research indicates that males are less likely to engage and participate in mental health treatment suggesting that college programs should provide more education to males on what mental health is and various treatments (Vidourek, King, Nabors, & Merianos, 2014). Counseling centers and professors can provide education on what signs and symptoms are when to seek help, and helping others recognize their own need for help (Vidourek, King, Nabors, & Merianos, 2014). Colleges could incorporate lessons in sports programs to help normalize mental health and treatment like mindfulness amongst sports teams like football players. One way of doing this is to have single-sex orientation mindfulness courses that become multi-sex classes as students transition through schooling each year. 

It is important to start mindfulness programs with incoming students as younger students are less likely to know how to cope with anxiety and stressors related to transitioning into college (Vidourek, King, Nabors, & Merianos, 2014). 

Future Research

Many studies researching mindfulness-based interventions (MBIs) intertwine anxiety and stress to assess an MBI’s effectiveness. Future research should evaluate the effectiveness on the two separately as a person who is stressed can lack the ability to cope with the stress causing the person to develop anxiety as a reaction (Bamber & Morpeth, 2019).  Additional research can be done on following up with students who participated in mindfulness interventions to reduce anxiety after college to evaluate the lasting effects (Hazlett-Stevens & Oren, 2016). The current paper discussed different MBIs that have been researching, which all provided similar evidence. Further research on the differences between MBIs as anxiety treatments. The research included in this paper evaluated the effectiveness of each intervention as a standalone intervention with no comparison to another intervention. Research on the comparison of effectiveness for each intervention could be useful (Hazlett-Stevens & Oren, 2016).

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