Mindfulness training for loneliness among Chinese college students: A pilot randomized controlled trial

Authors

  • Na Zhang,

    Corresponding author
    1. Department of Psychology, Tsinghua University, Beijing, China
    • Correspondence should be addressed to Na Zhang, Department of Family Social Science, University of Minnesota, 290 McNeal Hall, 1985 Buford Ave, St. Paul, MN 55108, USA. (E-mail: zhan3616@umn.edu).

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    • Present address: Department of Family Social Science, University of Minnesota   Twin Cities, Minneapolis, MN, USA
  • Fu-min Fan,

    1. Department of Psychology, Tsinghua University, Beijing, China
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  • Si-yuan Huang,

    1. Department of Psychology, Tsinghua University, Beijing, China
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    • Present address: Department of Psychology, San Diego State University, San Diego, CA, USA
  • Marcus A. Rodriguez

    1. Department of Psychology and Neuroscience, Duke University, Durham, NC, USA
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  • The authors wish to thank the participants for their contributions. We also thank Dr. Abigail Gewirtz, Dr. David DeGarmo, Dr. Yang Liu and the anonymous reviewers for their help in writing the manuscript. This research was supported by Hubei Key Research Laboratory of Human Development and Mental Health, Central China Normal University (Grant No. 201105).

Abstract

Loneliness has been found to predict a wide range of physical and mental health problems. It is suggested that China's One-Child Policy places young Chinese people at a particularly high risk for loneliness. Although loneliness is most prevalent in late adolescence and early adulthood, interventions have primarily targeted children or older adults with limited success. The current study examines a pilot randomized controlled trial of a mindfulness training program among Chinese college students. Participants with elevated loneliness (N = 50, ages 17–25) were randomized into either an 8-week mindfulness training or a control group. Self-reported measures of loneliness and mindfulness were administered at baseline and posttest. The training group also completed a program evaluation form and a 3-month follow-up assessment. Results provided preliminary evidence indicating that the intervention was feasible and effective at reducing loneliness among Chinese college students. Limitations and future directions were discussed.

“Loneliness and the feeling of being unwanted is the most terrible poverty.” – Mother Teresa

After nearly four decades, China abandoned the One-Child Policy in 2016. According to some, the policy created “the loneliest” generation (Hernandez & Qin, 2015) and a myriad of “social problems and personality disorders in young people” (as cited in Cameron, Erkal, Gangadharan, & Meng, 2013). Indeed, Chinese college students today report higher levels of loneliness than their American counterparts (Hawkley, Gu, Luo, & Cacioppo, 2012). This warrants cause for concern, because loneliness has been found to predict a variety of health problems (e.g., cardiovascular health risk, depression, and anxiety; Hawkley & Cacioppo, 2010; Heinrich & Gullone, 2006). Loneliness in Chinese college students has been linked to maladaptive coping styles (Li, Tang, Ming, & Zhang, 2014), lower life satisfaction (Kong & You, 2013), and suicidal ideation above and beyond depression (Li, Luo, & Wang, 2012). This study reports results from a mindfulness intervention intended to reduce loneliness among Chinese college students, today's young and educated generation—a product of the One-Child Policy (Hatton, 2013).

Loneliness has been defined as an aversive state resulting from a discrepancy between the interpersonal relationships one expects to have and those that one perceives to have (Peplau & Perlman, 1982). A cognitive element is emphasized, in which loneliness is influenced by the individual's appraisals of interpersonal relationships as being unsatisfactory (Heinrich & Gullone, 2006). Lykes and Kemmelmeier (2013) have found that the absence of interactions with family, but not friends, was more strongly associated with loneliness in collectivistic societies compared to individualistic societies. Accordingly, young Chinese people may experience increased loneliness as they leave their homes and families for college.

Among loneliness interventions, cognitive training has been found to be more effective than other strategies, including social skills training and social support groups (Masi, Chen, Hawkley, & Cacioppo, 2011). This may be because lonely individuals demonstrate maladaptive cognitive patterns, such as a bias for remembering negative interpersonal experiences (Hawkley & Cacioppo, 2010). Mindfulness-based cognitive therapy (MBCT) was developed to increase the moment-by-moment open awareness and to address these types of maladaptive thinking patterns (Segal, Williams, & Teasdale, 2001). In fact, Creswell et al. (2012) demonstrated that mindfulness-based training was effective in reducing loneliness among elders. However, to our knowledge, no studies have tested the effectiveness of MBCT's in reducing loneliness among Chinese college-aged students. Given the Chinese socio-cultural context leading to heightened risk for loneliness, our aim was to examine the feasibility and effectiveness of mindfulness training in reducing loneliness among Chinese college students.

METHODS

Participants

Participants consisted of 50 Chinese college students, aged 17–25, with elevated loneliness (Table 1).

Table 1. Sample characteristics per group
 Training group (n = 34)Control group (n = 16)
Age M (SD)20.38 (1.97)19.19 (1.17)
Male (%)52.9068.80
Education (%)  
Undergraduate73.5093.70
Graduate26.50 6.30

Procedure

Recruitment took place on campus through advertisements. Interested students completed an online loneliness measure. Students with elevated loneliness were selected if they scored above a cutoff on a loneliness scale (i.e., one standard deviation above the population average score, see Li, Jiang, & Li, 2006). They were then screened via telephone (n = 30) or in person (n = 21). Eligible participants were meditation-naïve, and not taking any kind of psychiatric medications nor receiving psychotherapy. One student was excluded due to current self-harm behaviors.

Eligible participants consented and were randomized into either the mindfulness training or control group (Figure 1). A randomization ratio of 7:3 (training: control) was used to ensure sufficient participants in the training group. This was informed by similar studies where higher attrition rates were found in training groups than in control groups. The training group received mindfulness training over the course of 8 weeks and completed assessments at baseline, posttest, and 3-month follow-up. The control group was awarded (about $10) for completion of baseline and “post-intervention” assessments.

Figure 1.

CONSORT flowchart of the study.

Intervention

The MBCT curriculum (Segal et al., 2001) was adapted by substituting the depression-related information with loneliness psychoeducation. During the 8 weekly 2-hour on-campus group sessions, participants learned theories, practiced mindfulness exercises, and discussed home practice. The study was conducted between October 2012 and March 2013.

Measures

Chinese college student loneliness scale

While our focus was not primarily to examine conceptual distinctions in the construct of loneliness across different cultural groups, it was considered preferable to use an indigenous loneliness scale (Li et al., 2006). The original scale consisted of 21 items, but in the present sample, the initial alpha at baseline was low (α = .50). An exploratory factor analysis identified five reverse-coded items with low loadings. After dropping these items, the alphas improved to .62 (baseline), .86 (posttest), and .89 (follow-up). The final scale used consisted of 16 items. Items were scored on a 5-point Likert scale ranging from 1 (never true) to 5 (always true). Higher composite score indicated greater loneliness.

Five facets mindfulness questionnaire – Chinese version

This questionnaire (Deng, Liu, Rodriguez, & Xia, 2011) included 39 items that were scored on a 5-point Likert scale. Higher composite scores indicated higher levels of trait mindfulness (α = .78 at baseline; .91 at posttest; .92 at follow-up).

Program evaluation form

One item (“I found the mindfulness training group helpful/satisfactory”) was used to assess the training group's program satisfaction. Responses were scored on a 7-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). Participants also answered three open-ended questions: (1) “What did you learn?” (2) “What were the costs/challenges?”, and (3) “What helped you to complete the program?”

Data analysis plan

In preliminary analyses, the groups were compared on gender, age, and baseline loneliness using t-tests. We also assessed whether there were differences among those participants who were retained and those who dropped out.

To assess feasibility, the attendance percentage, attrition rate and satisfaction questions were examined. The qualitative data were analyzed using conventional content analysis (Hsieh & Shannon, 2005), which inductively classifies meaningful units into codes. Two coders generated a protocol, independently coded each participant's answer, and conducted agreement discussions. The final inter-coder agreement was 85%.

To assess effectiveness, repeated two-way multivariate analysis of variances (MANOVAs) were conducted on loneliness and mindfulness scores in SPSS 22.0. Missing data (mindfulness baseline, 12%; loneliness and mindfulness posttest, 14%) was handled using list-wise deletion. An additional random effect analysis of variance (ANOVA) was conducted in Mplus7.0, where missing data were handled with Full Information Maximum Likelihood. Finally, one-way ANOVAs were used to compare the effect of time on loneliness and mindfulness at baseline, posttest and follow-up within the training group.

RESULTS

Preliminary results

Baseline, posttest and follow-up scores of mindfulness and loneliness, stratified by group, are shown in Table 2. No significant differences were found between the groups on baseline loneliness, baseline mindfulness, and gender. However, significant differences were found between groups' age, t (45) = −2.68, p < .01, and education, t (46) = −2.04, p < .05. Participants in the training program tended to be older and graduate level students relative to the control group. Age and education were significantly correlated (r = .72, p < .001). In the following analyses, age and gender were treated as covariates.

Table 2. Loneliness and mindfulness composite scores: means and standard deviations
  BaselinePosttestFollow-up
  MSDMSDMSD
LonelinessTraining group 47.79 4.85 38.17 7.05 36.61 7.76
Control group 47.56 4.65 42.71 6.44
MindfulnessTraining group111.9311.09121.6217.78127.3116.81
Control group115.6015.49112.7915.02

Participants who were retained (n = 43) and those who dropped out (n = 7) were compared. No significant differences were found on gender, age, and baseline loneliness.

Feasibility of the mindfulness training

The study dropout rate was 14%. The training group participants attended 6.18 (SD = 2.04) sessions on average and indicated a high level of satisfaction, M = 6.11 (SD = 0.63).

Qualitative analyses revealed two broad conceptual themes: the benefits and challenges of the program. The percentage of participants who endorsed each code and a sample quote is presented in parentheses. The benefits codes included: (a) enhanced emotion regulation (82.14%; “I learned skills to regulate my emotions”); (b) increased self-acceptance (41.07%; “I learned self-acceptance”); (c) increased self-awareness and self-care (37.50%; “I explored my mind”); (d) interpersonal learning and social support (33.93%; “When I am in our group, I don't worry about things”); (e) less judgmental (17.86%; “A non-judgmental attitude has changed the way I see things”); and (f) a positive outlook on the future (8.93%; “I started to make optimistic plans for the future”). The challenges codes included: (a) time commitment to attend (92.86%; “It is hard to make time to come to training when I get very busy”); (b) daily regular practice (82.14%; “It is difficult to do regular practices every day”); and (c) expectations (26.79%; “I learned something but my original expectations were not fully met”).

Effectiveness of the mindfulness training

The interaction effect (time × group) on loneliness was significant, F (1, 41) = 5.10, p = .03. The effect remained significant after accounting for age and gender. Additionally, the random effect ANOVA that accounted for missing data with Full Information Maximum Likelihood yielded the same significant finding. The training group showed a greater degree of reduction on loneliness from the baseline to posttest, compared with the control group. There was a small effect size for differences in baseline loneliness between the groups (Cohen's D = .05), contrasted with a medium effect size at posttest (Cohen's D = .66).

The interaction effect (time × group) on mindfulness was significant, F (1, 41) = 13.18, p = .001. The effect remained significant after accounting for age and gender. The training group showed a greater increase in trait mindfulness from baseline to posttest compared with the control group (Table 2). There was a small effect size for differences in baseline mindfulness between the groups (Cohen's D = .29), contrasted with a medium effect size at posttest (Cohen's D = .52).

Finally, within the training group, there was a significant effect of time (baseline, posttest, and follow-up) on loneliness, F (2, 87) = 26.92, p < .001. Post-hoc comparisons using the Tukey HSD test indicated that the baseline loneliness mean was significantly greater compared to posttest and follow-up means. Similarly, there was a significant effect of time on mindfulness, F (2, 82) = 7.11, p = .001. Post-hoc comparisons using the Tukey HSD test indicated that the baseline mindfulness mean was significantly lower than at follow-up (see Table 2).

DISCUSSION

This pilot study investigated the feasibility and effectiveness of mindfulness training for the reduction of loneliness among Chinese college students in a randomized controlled trial. The sample with elevated loneliness illustrated a selective preventive approach (i.e., targeting a subgroup whose risk of developing mental, emotional or behavioral problems is higher than average). The findings tentatively support the effectiveness of this approach for this population. That is, the mindfulness training group showed a greater decrease in loneliness at posttest compared with the control group.

In the study by Creswell et al. (2012), a similar training protocol (Mindfulness-Based Stress Reduction program) was found to be effective in reducing loneliness in older adults. The authors suggested that mindfulness training reduced psychological perceptions of social distress, which supports the assumption that mindfulness training addresses some of the maladaptive cognitions underlying loneliness. Unlike traditional cognitive behavior therapy, mindfulness training does not involve efforts to directly change one's thinking. Instead, it involves a non-elaborative awareness of one's thoughts and emotions (Chambers, Gullone, & Allen, 2009). In this way, mindfulness training enhances the capacities to disengage and de-identify with the perceived social threat, which leads to reduced loneliness.

Our qualitative data provided further information about the usefulness of the mindfulness training. Participants felt that they had gained self-awareness and self-acceptance, as well as non-judgmental, positive and emotionally balanced thinking. These elements are the essence of mindfulness, which helps individuals embrace aversive but sometimes unavoidable experiences (Chambers et al., 2009). Similar findings were seen in a Western adolescent sample (Monshat et al., 2013). Furthermore, participants also mentioned that they benefited from the program through the social support they received in the group. This raised the question of whether group-related social support was partially responsible for the observed outcome. Future studies may find it beneficial to further examine this question.

The attendance and attrition rate were comparable to previous studies (Liu et al., 2015). Although we found support for this intervention in terms of feasibility and participant satisfaction, further adaptations are recommended. For example, at posttest participants expressed that their expectations were not fully met. This was interesting because the “attachment” to an outcome (e.g., to feel less stress) might hinder practice and further hinder the occurrence of that outcome in mindfulness practice. Perhaps more education on the nature of mindfulness would be beneficial, and promoting the understanding that the cultivation of mindfulness requires many years of practice. It might also be useful to consider other non-traditional approaches to mindfulness training, such as online programs.

This study has several limitations. We did not control for depression and anxiety. Because cognition and emotion are intertwined (Chambers et al., 2009), decreases in loneliness could be explained by improvements in emotional functioning. Future studies should control for other psychopathological symptoms, such as depression and anxiety, when using mindfulness training to reduce loneliness.

Different incentives were offered to the two groups, which might have biased the findings. Future studies may attempt to have two groups with identical incentives. As noted earlier, the control group could participate in social activities, which would serve as an active control and facilitate the interpretation of findings.

Our findings may not be generalized to other cultural contexts. Using a large-scale sample to establish the intervention efficacy is recommended. Due to the potential problems of using Western scales in Chinese samples, we used an indigenous scale of loneliness; however, this scale yielded low alpha reliability. As the dropped items were all reversely coded items, acquiescence bias may have contributed to this problem (Weijters, Baumgartner, & Schillewaert, 2013). This warrants further research on the validation of the scale. Finally, future research may explore how to personalize the intervention according to different participant characteristics. For example, participants with low baseline mindfulness may need a higher dosage of intervention to achieve a desirable outcome.

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