International Journal of Environmental Research and Public Health Article Testing the Intermediary Role of Perceived Stress in the Relationship between Mindfulness and Burnout Subtypes in a Large Sample of Spanish University Students David Martínez-Rubio 1,2,3,† , Juan P. Sanabria-Mazo 4,5,6,7,† , Albert Feliu-Soler 4,5,6, * , Ariadna Colomer-Carbonell 4,5, * , Cristina Martínez-Brotóns 1,3 , Silvia Solé 8 , Cristina Escamilla 9 , Elisa Giménez-Fita 9 , Yolanda Moreno 10 , Adrián Pérez-Aranda 6 , Juan V. Luciano 4,5,‡ and Jesús Montero-Marín 11,‡ 1 Psicoforma Integral Psychology Center, 46001 Valencia, Spain; david@psicoforma.es (D.M.-R.); cristina@psicoforma.es (C.M.-B.) 2 Excellence Research Network PROMOSAM (PSI2014-56303-REDT), 28029 Madrid, Spain 3 Obesity Unit. QuironSalud, 46010 Valencia, Spain 4 Institut de Recerca Sant Joan de Déu, 08950 Esplugues de Llobregat, Spain; jp.sanabria@pssjd.org (J.P.S.-M.); jvluciano@pssjd.org (J.V.L.) 5 Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, 08830 St. Boi de Llobregat, Spain 6 Faculty of Psychology, Universitat Autònoma de Barcelona, 08193 Bellaterra (Cerdanyola del Vallès), Barcelona, Spain; adrian.perez@uab.cat 7 Department of Medicine, International University of Catalonia, C/Josep Trueta s/n, 08195 Sant Cugat del Vallès, Barcelona, Spain 8 Department of Nursery and Physiotherapy, Universitat de Lleida, 25198 Lleida, Spain; silviasole@infermeria.udl.cat 9 Department of Psychology, Faculty of Health Sciences, European University of Valencia, 46010 Valencia, Spain; mariacristina.escamilla@universidadeuropea.es (C.E.); elisa.gimenez@universidadeuropea.es (E.G.-F.) 10 Department of Basic Sciences, Faculty of Physical Activity and Sport Sciences, Catholic University of Valencia San Vicente Mártir, 46001 Valencia, Spain; yolanda.moreno@ucv.es 11 Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK; jesus.monteromarin@psych.ox.ac.uk * Correspondence: a.feliu@pssjd.org (A.F.-S.); a.colomer@pssjd.org (A.C.-C.); Tel.: +34-93-640-6350 (ext. 1-2540) (A.F.-S. & A.C.-C.) † Both authors contributed equally to this paper and should be considered as co-first authors. ‡ These authors share senior authorship.  Received: 5 August 2020; Accepted: 21 September 2020; Published: 25 September 2020  Abstract: The burnout syndrome is the consequence of chronic stress that overwhelms an individual’s resources to cope with occupational or academic demands. Frenetic, under-challenged, and worn-out are different burnout subtypes. Mindfulness has been recognized to reduce stress, comprising five facets (observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience). This cross-sectional study aimed to assess the relationship between mindfulness facets, perceived stress, and burnout subtypes in a sample of 1233 students of Education, Nursing, and Psychology degrees from different universities of Valencia (Spain). Structural Equation Modelling (SEM) was computed showing an adequate fit (Chi-square, CFI, TLI, RMSEA, and SRMR). Four mindfulness facets (all but observing) significantly correlated with general second-order mindfulness. Unexpected results were found: Acting with awareness facet was positively associated with frenetic subtype, while the non-reacting facet was positively associated with frenetic and under-challenged subtype. Ultimately, mindfulness facets negatively predicted the Int. J. Environ. Res. Public Health 2020, 17, 7013; doi:10.3390/ijerph17197013 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 7013 2 of 16 perceived stress levels, which in turn, predicted burnout. However, mindfulness plays different roles in the early stages of burnout syndrome (i.e., frenetic and under-challenged). Keywords: burnout; mindfulness; stress; mental health; students; university; structural equation model; cross-sectional study 1. Introduction 1.1. Stress Factor and Burnout When environmental demands overwhelm an individual’s resources, high levels of stress are perceived and threaten personal wellbeing [1,2]. Undergraduate and graduate students consistently experience elevated perceived stress due to academic, social, and financial pressures. In this regard, 50.8% of undergraduate students reported being “often” or “always” stressed [3]. Elevated levels of stress have a negative effect on mental and physical health [4]. A survey of undergraduate and graduate students found this factor to be the most usually reported impediment to academic performance [5]. Furthermore, stress is positively correlated with depression, a mental disorder that can also hamper academic performance [6]. Considering this background, student distress, along with associated anxiety and depression, has been increasingly recognized as a public health issue in various countries (e.g., [7]). As a consequence of chronic perceived stress and highly related to poorer health [8,9], burnout syndrome is the inability to cope with chronic occupational stress and is an attempt to adapt to or protect oneself from it [10]. It is an adverse experience, comprising cognitions, emotions, and behaviors towards work, other people interacting with the individual at the workplace, and the professional role [11]. Burnout was originally conceptualized in helping professions, such as medical and other health-care professions [12]. However, it has also been observed in different types of professions and occupations [13], and also in graduate and undergraduate students. Even though students do not receive any salary, they are engaged in a structured and compulsory activities such as attending classes and completing academic assignments, which can be seen as a form of “work”; furthermore, they also experience high levels of pressure related to their studies and overwork [14,15]. Hence, students can also develop burnout [16–21]. In this sense, some systematic reviews have reported a prevalence of academic burnout in about 50% of university students [7]. Burnout syndrome comprises a state of emotional exhaustion, depersonalization, and a decreased sense of accomplishment when high levels of stress are perceived without the environmental resources needed to face the situation [22]. Exhaustion is the feeling of not being able to offer any more of oneself at an emotional level; depersonalization represents a distant attitude towards work; and decreased sense of accomplishment is the feeling of not performing tasks adequately or being incompetent. A more comprehensive definition of burnout has recently been proposed to differentiate three different clinical subtypes of the burnout syndrome [2]: (1) Frenetic, which is characterized by overload and the perception of jeopardizing one’s health to pursue worthwhile results, and is highly associated with exhaustion; (2) under-challenged, which is characterized by lack of development, defined as the perception of a lack of personal growth, together with the desire for a more rewarding occupation that better corresponds to one’s abilities, and is most strongly associated with cynicism; and (3) worn-out, which is characterized by neglect, defined as an inattentive and careless response to responsibilities, and is closely associated with inefficacy [23]. This typology emphasizes a phenomenological perspective and makes it possible to address the specific sources of subjective suffering [24], grouping distinct degrees of effort and persistence together in the same framework [25,26], which is rooted in a differential pattern of coping styles [27,28]. In this way, the burnout profiles can be ordered according to level of dedication to tasks, which affects Int. J. Environ. Res. Public Health 2020, 17, 7013 3 of 16 the way individuals manage their feelings of distress. Altering the level of dedication to tasks may be a way for individuals to exert some control over the balance between efforts and rewards [24]. This classification criterion is consistent with the idea of a developmental transition between the different burnout subtypes driven by changes in dedication and coping style (from active to passive), from more (i.e., frenetic) to less (i.e., worn-out) dedicated. Each stage of burnout also corresponds to a different pattern of perceived stress as a result of differing levels of dedication [2,23,26,29,30]. It has been observed that the frenetic burnout subtype is associated with a coping style focused on active problem solving; the under-challenged burnout subtype presents an escapist coping style based on distraction and cognitive avoidance; while the worn-out burnout subtype is related to a coping style mainly characterized by behavioral disengagement [27]. 1.2. Mindfulness In recent years, there has been increasing evidence that acknowledges the potential role of mindfulness in promoting wellbeing and reducing anxiety, depression, and academic stress across a variety of populations [31], including graduate and undergraduate students [32–37]. Mindfulness is defined as the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment [38]. This particular quality of awareness has been associated with several indicators of mental and physical health and can be developed using specific techniques (mindfulness practices) commonly delivered in mindfulness-based interventions. Mindfulness was initially considered as a one-dimensional construct, with tests yielding a single score [39]. Nonetheless, recently, a more complex conceptualization of mindfulness emerged and has been mostly adopted in research [40]. This conceptualization proposes the existence of five distinct facets empirically derived: (1) observing (noticing internal/external experiences), (2) describing (labelling experiences with words), (3) acting with awareness (focusing attention on one’s current activity), (4) non-judging of inner experience (experiencing thoughts/feelings without judging them or criticizing oneself), and (5) non-reacting to inner experience (allowing thoughts/feelings to come and go without reacting to them or getting caught up in them). Overall, dispositional mindfulness has been found to act as a positive skill that fosters mental health [41,42] and, in the academic field, has been found in several studies to correlate with psychological wellbeing and mental health (e.g., [35,43]). To this extent, in the validation study of the Five Facet Mindfulness Questionnaire, Baer et al. [40] examined associations between mindfulness facets and related constructs in a sample of 881 American students, finding that three of the facets (acting with awareness, non-judging, and non-reacting) significantly predicted better general mental health; on the other hand, the observing facet was not clearly associated with fewer psychological symptoms. Harrington, Loggredo, and Perz [44] found an association between acting with awareness, describing, and non-judging facets and psychological wellbeing in 184 undergraduate American students. Bergin and Pakenham studied a sample of 481 Australian law school students and discovered that dispositional mindfulness moderated the effect of perceived academic stress on anxiety and depression [45]; furthermore, results indicated that higher levels of mindfulness facets (especially non-judging and acting with awareness) were related to better psychological adjustment. However, in contrast to predictions, observing was positively related to anxiety. In another study conducted with 310 American undergraduates, Bodenlos and colleagues [46] highlight that mindfulness facets differently correlated with wellbeing; in this case, the observing facet was negatively associated with physical health, and both acting with awareness and non-judging facets were positively associated with emotional wellbeing; the latter facet also correlated positively with social functioning. Results suggest that mindfulness (understood as a set of cognitive skills) could act as a personal internal resource that buffers against mental health outcomes such as academic burnout [47–49] by increasing individuals’ ability to detect the signs of academic stress through the Int. J. Environ. Res. Public Health 2020, 17, 7013 4 of 16 improvement of awareness [44] and, in turn, increases access to coping resources and helps alleviate the negative effects of academic stress [50]. Given perceived academic stress was one of the significant predictors of burnout [2], cultivating mindfulness may reduce burnout via alleviating psychological academic distress. Mindfulness facets have been found to explain the three components of burnout (exhaustion, cynicism, and inefficacy) in a study with 381 employees, even after controlling for other significant predictors such as personal traits, workplace resources, and workplace demands. More precisely, non-judging and non-reacting mindfulness facets were shown to convey the relationship between mindfulness with burnout domains [51]. Research has also explored the mediating role of stress in mindfulness and health behaviors. At the same time, a study conducted with 385 college students found that the relationship between mindfulness and health behaviors (e.g., sleep quality, physical activity, activity restriction, and binge eating) was partially mediated by stress [52]. In the same line, in another study with 427 occupational therapists, stress mediated the relationship between mindfulness components and health behaviors [53]. Similarly, a cross-sectional study of 315 soldiers identified that perceived stress fully mediated the effects of unidimensional mindfulness on mental health [54]. However, there are not many studies assessing the relationship between mindfulness facets, perceived academic stress, and burnout subtypes in university students, nor that evaluate the explanatory power of the mindfulness construct regarding the burnout subtypes. Knowing how mindfulness specific facets interact with perceived academic stress and burnout subtypes could offer clues to promote programs fostering such cognitive skills in academic settings. The possibly different connection between the mindfulness facets and each burnout subtype might provide useful information for developing programs targeting each specific profile, efficiently administered through brief [55] or online interventions [56]. 1.3. Aims and Hypotheses In this sense, the aim of this study was to assess the relationship between mindfulness facets, perceived stress, and burnout subtypes in a sample of 1233 students of Education, Nursing, and Psychology degrees from different universities of Valencia (Spain). We started with the following assumptions: All mindfulness facets but observing will be directly and negatively related with burnout dimensions (overload, lack of development, and neglect), and indirectly through the intermediary latent factor of perceived academic stress (Hypothesis 1). We also expect the mediating role of perceived academic stress to be greater in the case of overload (active coping style) and lesser in neglect (passive coping style), with intermediate levels in the lack of development (which is more prone to cognitive avoidance and shows intermediate levels of dedication) (Hypothesis 2) [27]. 2. Materials and Methods 2.1. Research Design Cross-sectional study with a convenience sample of Spanish university students. Participants were included if: (1) Aged ≥18 years, (2) college students in the field of Education, Nursing, or Psychology, (3) signed informed consent, and (4) able to understand Spanish. 2.2. Participants Study participants were Spanish university students from Education (n = 589, 47.8%), Nursing (n = 385, 31.2%), and Psychology (n = 259, 21%) degrees (n = 1233) from different universities of Valencia (Spain). They were in their first (n = 455, 36.9%), second (n = 296, 24%), third (n = 195, 15.8%), fourth (n = 237, 19.2%), or fifth (n = 49, 4%) academic course. Most of the participants were women (78.8%) between the ages of 18 and 56 (M = 22.19, SD = 5.18). More details can be found in Table 1. Available sample size was considered in according to the recommended 10:1 ratio of the number of participants to the number of the test items [57]. Int. J. Environ. Res. Public Health 2020, 17, 7013 5 of 16 Table 1. Sociodemographic and outcome variables. Sociodemographic Sample (n = 1233) Age, M (SD) 22.19 (5.18) Women, n (%) 971 (78.8) Living arrangement, n (%) Familiar residence 907 (73.6) Student residence 20 (1.6) Shared flat 176 (14.3) Living alone 38 (3.1) Living as a couple 89 (7.2) With a stable job, n (%) 188 (15.2) University degree, n (%) Psychology 259 (21.0) Nursery 385 (31.2) Education 589 (47.8) With a student grant, n (%) 309 (25.1) Academic years, M (SD) 2.30 (1.26) Mindfulness facets (FFMQ-20) Acting with awarenessM (SD) 12.57 (3.43) Non-judgingM (SD) 13.75 (3.72) ObservingM (SD) 12.66 (3.63) DescribingM (SD) 13.15 (3.27) Non-reactingM (SD) 11.81 (2.69) Perceived Stress Questionnaire (PSQ-24) 0.43 (0.17) Burnout subtypes (BCSQ-12) OverloadM (SD) 3.13 (1.29) Lack of developmentM (SD) 2.67 (1.15) NeglectM (SD) 2.21 (1.02) Note: BCSQ = Burnout Clinical Subtype Questionnaire; FFMQ = Five Mindfulness Facets Questionnaire. 2.3. Instruments 2.3.1. Sociodemographic Data The following sociodemographic characteristics of the sample were collected: Age, gender, year of study (“first”, “second”, “third”, “fourth”, “fifth”), university degree, academic year, stable relationship (“yes”, “no”), with a stable job (“yes”, “no”), living arrangement (“with family”, “student residence”, “shared flat”, “living alone”, “living as a couple”), with a scholarship grant (“yes”, “no”). 2.3.2. Measures The Spanish version of The Burnout Clinical Subtype Questionnaire, short form (BCSQ-12; [26]) is a 12-item questionnaire comprising three dimensions: (a) Overload” (e.g., “I think I invest more than is healthy in my commitment to my studies”), (b) lack of development (e.g., “I would like to study something else that would be more challenging to my abilities”), and (c) neglect (e.g., “When the results of my studies are not good at all, I stop making an effort”) in a 7-point Likert-type scale (from 1 = “completely disagree” to 7 = “completely agree”). The BCSQ-12 demonstrated high internal consistency for the three subscales in the present sample with Cronbach’s α of 0.81 (overload), 0.73 (lack of development), and 0.84 (neglect). The Spanish version of the Perceived Stress Questionnaire is a 24-item (PSQ-24) that assesses the subjective experience of perceived stressful situations and stress reactions during the last 30 days [58,59]. The participants indicate their agreement with the items in a 4-point Likert scale (from 1 = “almost never” to 4 = “almost always”). This PSQ-24 was validated in a university student sample and is able to measure “global” perceived stress and two stress-related dimensions [60]: (1) “tenseness” or the perception of hurry and overdemand (e.g., “You have too many things to do”), and (2) “frustration” or the negative affective response to stress including feelings of discouragement, joylessness, and worry (e.g., “You feel discouraged”). A Cronbach’s alpha of 0.91 for the global perceived stress scale, and 0.88 for tenseness, and 0.87 for frustration subscales were found in the present study sample, indicating good internal consistency. Int. J. Environ. Res. Public Health 2020, 17, 7013 6 of 16 The Five Mindfulness Facets Questionnaire, 20-item short form (FFMQ-20; [61]) is a measure with 20 items assessing the five facets of mindfulness: Observing, describing, acting with awareness, non-judging of inner experience, and non-reactivity to inner experience. The response format is in a 5-point Likert scale (from 1 = “never or very rarely true” to 5 = “very often or always true”). The FFMQ-20 has been found to be valid and reliable to measure the experience of mindfulness [62]. Since the observing facet has shown inconsistent results in non-meditative samples, this specific mindfulness facet was not included in the present study. The internal consistency (Cronbach’s αs) of the FFMQ subscales were globally satisfactory in this sample: 0.70 (describing), 0.83 (acting with awareness), 0.81 (non-judging), and 0.57 (non-reacting). 2.4. Procedure Students were asked to voluntarily respond to the study questionnaire through an online survey (https://es.surveymonkey.com) or via paper-and-pencil format. Participants were provided with a general overview of the aims and characteristics of the study and an informed consent was obtained from all participants before they fulfilled the survey. The study was developed according to national and international standards (Helsinki and Tokyo Convention) and was approved by the Research Ethics Committee of the University of Valencia (code H1455835241950). Data were treated anonymously and were only used for the purposes of the study and thus the confidentiality of the participants included in the study was guaranteed. The study survey was made available from December 2015 to May 2016. 2.5. Data Analyses Sociodemographic data were analyzed with descriptive statistics of mean (M), standard deviation (SD), and range. Analyses were conducted with SPSS v25.0 (SPSS Inc., Chicago, IL, USA) and the MPLUS v7 packages (Múthen & Múthen, Los Angeles, CA, USA). All the tests used were bilateral and the significance level was set at α < 0.05. Structural Equation Modelling (SEM) procedure was used to investigate the impact of mindfulness facets on burnout subtypes and the intermediary role of perceived stress. SEM model was created by considering the four mindfulness facets (all but observing) with solid evidence of positive effects on mental health in non-meditative samples [63]. The four mindfulness facets were taken as exogenous variables in SEM model, global perceived stress as endogenous variable, and burnout subtypes as final outcomes. SEM analysis provides information about consistency of the hypothesized mediational model to the data. Measurement models were first tested to assess whether each latent variable was represented by its indicators. If the measurement models turned out satisfactory, then the SEM was tested. We tested the following measurement models: (a) A four-facet (without observing) hierarchical model of the FFMQ since it is recommended to exclude the observing facet in non-meditative samples [63], which provides a comprehensive view of mindfulness skills [35] and has proven its better fit (compared to the five-facet hierarchical model) in general population (e.g., [64]); (b) the bifactor model of the PSQ with two sub-factors (‘frustration’ and ‘tenseness’) with regard to one general factor (‘global perceived stress’) since it was reported to be satisfactory in a Spanish dental student sample [60]; and (c) a three-factor correlated model of the BCSQ since it showed a good fit in previous study with a Spanish sample [28]. After confirming goodness of model fit for the three scales, a SEM was computed by considering the four mindfulness facets as independent variables, global perceived stress as intermediary variable, and burnout subtypes as dependent variables. Given that factor loadings and standard errors are underestimated when using maximum likelihood estimation with categorical variables [65], we applied mean- and variance-corrected weighted least squares (WLSMV) to test the fit of the factor structures of the scales and as well as for the structural equation models. WLSMV estimation uses the polychoric correlation matrix of the items, it is suited for ordered categorical variables and provides robust parameter estimates, standard errors, and tests of model fit [66]. In addition to the chi-square test, the following fit indices were analyzed (the values in parentheses denote goodness-of-fit standards in Int. J. Environ. Res. Public Health 2020, 17, 7013 7 of 16 accordance with Schermelleh-Engel et al. [67] using conservative and liberal cut-offs): Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI; ≥0.95 or ≥0.90), Root Mean Square Error of Approximation (RMSEA) with 90% confidence intervals (≤0.06 or ≤0.08), and Standardized Root Mean Squared Residual (SRMR). Since only 39 participants had incomplete data (3.2% of the total sample), no procedure for handling missing data was applied. 3. Results 3.1. Correlations of the Model Variables As shown in Table 2, all mindfulness facets variables showed significant correlations with burnout subtypes. Mainly, overload indicated a positive correlation with perceived stress facet (r = 0.48) and a negative with non-judging facet (r = −0.17); lack of development a positive with perceived stress facet (r = 0.18) and a negative with awareness facet (r = −0.14); and neglect a negative with awareness (r = −0.34), non-judging (r = −0.22), describing (r = −0.18), and non-reacting (r = −0.11) facets. The descriptive analyses of all the variables are presented in Table 1. Table 2. Pearson correlations among all variables in the model. 1 2 3 4 5 6 7 8 1. Awareness - - - - - - - - 2. Non-judging 0.362 * - - - - - - - 3. Describing 0.259 * 0.253 * - - - - - - 4. Non-reacting 0.091 * 0.128 * 0.176 * - - - - - 5. Perceived stress 0.292 * −0.361 * −0.229 * −0.166 * - - - - 6. Overload −0.013 −0.168 * −0.078 * −0.003 0.482 * - - - 7. Lack of development −0.143 * −0.090 * −0.002 −0.059 * 0.185 * 0.230 * - - 8. Neglect −0.338 * −0.217 * −0.176 * −0.113 * 0.245 * 0.112 * 0.311 * - Note: * p < 0.001. 3.2. Measurement Models All factorial loadings for items in each FFMQ subscale were significant (with λ from 0.195 (#18; describing facet) to 0.851 (#16; non-judging facet)). Furthermore, the four mindfulness facets significantly correlated with a general second-order mindfulness factor (from 0.295 (non-reacting facet) to 0.707 (non-judging)). Factorial loadings between items in PSQ and a general perceived stress factor were all significant and in the expected direction (with λ from 0.271 (#7) to 0.725 (#26)). Factor loadings between items and with each BCSQ subscale were also significant and showed acceptable values (with λ from 0.267 (#2) to 0.843 (#5)). According to modification indexes, correlations between the error terms of items #18 and #20 in FFMQ (describing subscale) and #2 and #8 in BCSQ (lack of development scale) were introduced in each corresponding model. The incorporation of these correlations between error terms significantly reduced the χ2 (p < 0.01). The measurement models were found to be satisfactory, showing fit indexes above standards cut-off (see Table 3 for more details). Table 3. Fit statistics for latent structure models for Five Mindfulness Facets Questionnaire (FFMQ-20), Perceived Stress Questionnaire (PSQ-24), Burnout Clinical Subtype Questionnaire (BCSQ-12), and SEM. Model χ2 df RMSEA [90% CI] CFI TLI SRMR FFMQ-20 888.676 * 99 0.082 [0.077, 0.087] 0.931 0.917 0.064 Four-facet hierarchical model [63] PSQ-24 1393.296 228 0.065 [0.061, 0.068] 0.949 0.938 0.047 Bifactor model [2] BCSQ-12 374.508 * 50 0.073 [0.066, 0.080] 0.972 0.963 0.052 Three-facet correlated model [23] SEM 4925.267 * 1222 0.050 [0.049, 0.052] 0.909 0.901 0.059 FFMQ, PSQ & BCSQ Note: * p < 0.001. RMSEA: Root Mean Square Error of Approximation; CFI: Comparative Fit Index; TLI: Tucker-Lewis Index; SRMR: Standardized Root Mean Squared Residual; SEM: Structural Equation Modelling. Effect of Perceived Stress Although chi-squared statistic was found to be significant (χ2 (1222) = 4925.267, p < 0.001), overall structural model showed an adequate fit according to liberal cut-offs (RMSEA[CI90%] = 0.050 [0.049, 0.052]; CFI = 0.909; TLI = 0.901; SRMR = 0.059). As can be seen in Figure 1, the following relationships between Int. mindfulness J. Environ. facets Res. Public Health and 2020, 17,global 7013 perceived stress with burnout subtypes were found: Overload 8 of 16 subtype was significantly (and positively) predicted by acting with awareness (γ = 0.202; p < 0.001), non-reacting (γ = 0.173; p < 0.001), and perceived stress (β = 0.714; p < 0.001); lack of development was 3.3. Structural positively Equation predicted byModel for Mindfulness non-reacting Facets (γ = 0.180; p