Assessment of Mindfulness Based Cognitive Therapy for Cancer (MBCT-Ca)
Please read the disclaimer!
I would like to thank the participants involved in this study for their time and effort, Paul's Cancer Support Centre for enabling it, my co-instructor there and supervisor at Bangor University for their time and everyone for their patience!
Easier
explanation of results (for those unfamiliar with Mindfulness research) Brief
descriptions of self-compassion and mindfulness facets. How
is MBCT-Ca different to other mindfulness courses Whilst
reasonable effort has been taken to ensure the accuracy of the data
and content provided here, it is presented as is, in good will. By reading or using
the information on this page, the Thesis, or that from links found here you agree
to indemnify the author, their associates and associated
organisations against any loss, cost or issue from its use. The author retains copyright. Please do not copy or distribute material, or downloaded content, without permission. Please reference this website or the Thesis when refering to its content.
Pilot study finds
new Mindfulness course for participants with cancer delivers
statistically significant improvements in several wellbeing measures
which are maintained at 3 month follow-up. Mindfulness
interventions are increasingly recognised as being beneficial in
reducing stress and increasing wellbeing. The main aims of this study
were to examine the effects of a newly developed, 8 week, mindfulness
course for the cancer context on measures of mindfulness,
self-compassion, wellbeing, stress and sleep quality. Seven,
participants were recruited, six post treatment, all female and took
part in a one arm longitudinal study. Data was collected pre, post
and at 3 months following the course completion. This was an
ethically approved Masters level research study at the University of
Bangor, Centre for Mindfulness Research and Practice in Wales. The
intervention consisted of an
8 week Mindfulness-Based Cognitive Therapy for Cancer course which
took place at a community support charity centre in London, UK;
Paul’s Cancer Support Centre in Battersea. This
pilot study of MBCT-Ca found statistically significant pre to post
improvements in measures of wellbeing, stress, overall sleep quality,
sleep latency, self compassion and facets of mindfulness of
‘non-reactivity’ and ‘observing’. It also
found changes close to statistically significant for mindfulness
facets of ‘acting with awareness’ and ‘non-judging’
and for subjective sleep quality. Only the ‘describe’
facet showed little change. Benefits in wellbeing, stress and all
mindfulness facets except for ‘describe’ were
statistically significant at 3 months after the course ended.
Improvements close to significant were found for self-compassion, with
overall sleep quality significant at a lower level, (See charts
below). The magnitude of improvements for scores of mindfulness,
wellbeing and self-compassion are notably larger (typically twice)
than larger studies
using existing Mindfulness courses to help participants with cancer.
Whilst various factors, such as experience of instructors or
participant demographics may explain this it remains worthy of note.
The analysis is limited by a small sample size, this also increases
the risk of type II errors masking some benefits. Larger studies,
with active controls,
are therefore recommended to confirm, compare and analyse results and
explore novel elements within this course. Benefits
are also reflected in very positive participant feedback reports, which were not part of the research study.
Overall, the study suggests that MBCT-Ca is a useful course for those with cancer or who have had it in the past. It would be of great interest to carers and those looking to provide or sponsor services to benefit these groups. Mindfulness
courses and therapies are increasingly recognised as being beneficial
in reducing stress and increasing wellbeing. The main aims of this
research study were to examine the effects of a newly developed
mindfulness course for people with cancer. The course is called
Mindfulness Based Cognitive Therapy for Cancer and lasts 8 weeks with
monthly follow-up sessions. The study used questionnaires to measure
mindfulness, self-compassion, wellbeing, stress and sleep quality.
Questionnaires were completed by participants before the course,
after the course and 3 months after the course finished. The study
had seven participants, six post treatment, all female. The course
consisted of an 8 week Mindfulness-Based Cognitive Therapy for Cancer
course as detailed in the book with the same title by Trish Bartley.
For more details of the book and course see the following website
http://www.trishbartley.co.uk/published-works Positive
improvements for self-compassion, wellbeing, stress, overall sleep
quality (a broad measure of sleep quality), sleep latency (how long
it takes to get to sleep) and mindfulness facets (which are explained
below) of ‘non-reactivity’ and ‘observing’
were found to be statistically significant, i.e. less than a 1 in 20
chance it was a fluke result. Positive changes were also found for
mindfulness facets of ‘acting with awareness’ and
‘non-judging’ and for subjective sleep quality (how
participants judged their own sleep quality) but with slightly less
certainty of it being not due to chance (1 in 10). (See Charts
below.) At
three months follow up after the course, statistically significant
positive changes compared to the initial pre-course level were found
for questionnaire results of wellbeing, stress and mindfulness facets
of ‘non-reactivity’, ‘observing’, ‘acting
with awareness’ and ‘non-judging’. Again there was
no change in the ‘describe’ facet. Improvements close to
significant were found for self-compassion with overall sleep quality
significant at a lower level. The
size of the improvements were better than larger scale studies with
other types of mindfulness course. However, since this study only had
relatively few participants, it may not show the complete picture. There is also a higher chance that some actual benefits were missed.
(with only a small number of research participants it may only take
one person to have an erroneous result to affect the research,
something known as a type II error). Larger studies are therefore
recommended and will be required to confirm the findings and provide
a deeper analysis into the benefits of the course and its
unique contents. Benefits
are also reflected in very positive participant feedback reports, which were not part of the research study.
Overall, the study suggests that MBCT-Ca is a useful course for those with cancer or who have had it in the past. It would be of great interest to carers and those looking to provide or sponsor services to benefit these groups.
Overall the results
were very positive and the course is different in making explicit the
human dimension of teaching mindfulness which is often left to the
skill of mindfulness instructors. Due to the small number of
participants in the study, it is hard to get a clear picture of
exactly how beneficial the course is. For example it is harder to get
statistically significant results with a small number of participants
as the risk of what are called “Type II errors”
increases. This is erroneously finding that some measured aspect of
the course was not beneficial when actually it was, but there was not enough information to clarify the situation. This can arise, for example, if in
some cases, especially with small numbers of participants, one person in the group did not report an improvement
for that aspect, which can happen for a variety of reasons even those
unrelated to the effects of the course.
Of note, however, is
the magnitude of positive changes. Improvements in average scores for
wellbeing, self-compassion and some facets of mindfulness seemed to
be around twice that reported in other research reports for
mindfulness courses aimed at participants with cancer. Whilst a
variety of causes described in the thesis may explain away the
differences including the small number of participants, it may well
be due in part to the appropriateness of the course to its target
audience.
As a result, this is
a very interesting course for centres looking to offer evidence based
courses to those with Cancer, one that is also well received by
participants, who report its benefits in other dimensions of
their life too.
On a slightly separate note, it was not clear how valuable Denial and Positive Avoidance are as adjustment styles for participants. It would appear to be the opposite of mindful awareness, however, it may also be part of a skilful coping strategy that is quite mindful, so long as it is not harmful, since it may help participants work compassionately within their limits, maintain wellbeing and "Turn Towards" difficulties when they are more grounded. The stance of "Turning Towards" even if in a very gentle way is integral to MBCT-Ca. Denial and Positive Avoidance are discussed by Moorey and Greer in the same book (Moorey and Greer 2002, p82 and p88) that describes the cognitive model behind MBCT-Ca, and might warrant further exploration.
Further details are available from the questionnaire references section.
Self compassion
is described as the ability to hold one’s feelings of suffering
with a sense of warmth, connection and concern, to treat oneself with
care rather than harsh self-judgement, recognising that imperfection
is a shared aspect of the human experience rather than feeling
isolated by one’s failures and holding one’s experience
in balanced perspective rather than exaggerating the dramatic
storyline of suffering. Mindfulness
facets from
the five facet mindfulness questionnaire that was used.
1. Non-reactivity:
noticing thoughts and emotions without reacting automatically to
them.
2. Observing:
being aware of body sensations, the senses and emotions and how
emotions affect thoughts and behaviour.
3. Acting with
awareness: being aware of the present moment, of what one is
doing now, not being on "automatic pilot" preoccupied with
the future or past.
4. Describing:
Being able to put emotions, feelings, body sensations, beliefs,
opinions and expectations into words.
5. Non-judging:
Allowing one's thoughts and emotions to be seen without good or bad
judgements about them. Bias The
author was also one of the instructors and has previously trained
with Trish Bartley (MBCT-Ca’s creator) who was available
during the course as a supervisor. She played no part in the
research, participant selection, analysis or assessment of the
Thesis or in the creation of this web page.
Whilst
the author used to volunteer at Paul’s Cancer Support
Centre he no longer holds a position there. Specifically, the
Centre was not involved in the analysis of the data, presentation
of results, or conclusions within the Thesis. No attempt was made to skew
participant selection. Help was provided with grammar, clarity and factual errors on this webpage.
The
author has done his best to provide a fair and balanced view with
the hope it helps those assessing or trying to fund good courses
to alleviate suffering and enrich participants' lives.
In common with other
mindfulness courses, the course is deeply humane, gentle and works
with where people are, without pushing them beyond their limits;
subject to the skill and experience of the instructor! The quality of
awareness is also the same as other mindfulness courses such as “MBCT
for preventing relapse in Depression” (MBCT) and “Mindfulness
Based Stress Reduction” (MBSR). Some interesting differences
exist, however, in syllabus and attitude.
It is also worth
commenting that MBCT-Ca presents a complex movement into teaching
itself, i.e. it is developed to faciliate instruction, group dynamics and learning and enriches themes that normally rely on skillful
instructors. It does this in a rich, clever and seamless way through
various dimensions from poetry to group theory. This is hard to
articulate however but likely to be of value to Mindfulness
instructors in general.
The following are
some differences to existing course formats, these are not
necessarily the most significant nor an exhaustive list.
1. It has a cancer
specific cognitive model, although the ruminative spiral is similar
to MBCT.
2. It addresses the
elephant in the room early, (this is about cancer).
3. It gives explicit
space for the gentle turning towards issue that might be avoided by
some instructors or feared by some participants if not handled
skilfully.
4. It includes
shorter less demanding practices.
5. It develops and
contains novel elements like the “sea of reactions” which
participants report help normalise, and legitimise, how they really
feel,
4. It includes
slight changes to common mindfulness course practices, e.g. the 3 minute
breathing space emphasises the breath in the chest and abdomen whilst the
body scan makes a point to gently include areas that may be avoided,
e.g. areas where there was treatment.
5. It includes novel
exercises such as the Body or Physical-Barometer.
6. It invites
dimensions not made so explicit in other courses such as compassion/
kindness, spaciousness, deep stillness.
7. It includes
action plans for the future and for difficult times, (similar to MBCT for
preventing relapse in depression)
8. New teaching
structures are utilised, such as the ‘four movements’
(Bartley, 2012) (Intention, Coming back, Turning towards and
Kindness), to facilitate the process of relating differently to
experience. It also contains a model that formulates MBCT-Ca, this suggests how mindfulness practice impacts on course participants, "The Three Circle" model. (Bartley, 2012, p355)
9. It has a developed consideration of the group process.
10. Qualities for
skillful teaching are also elaborated, principally around Intention,
Reflection and Practice.
As a result
engagement with the course may be higher and content more accessible.
As some new elements
have been included, some elements from typical
mindfulness syllabuses have also been dropped. For example MBSR typically has a week on
“difficult communications” and the “stress
reaction/ response cycle” is replaced with the more cancer
specific cognitive model. Also absent is the “moods, thoughts and alternative viewpoints” exercise from MBCT for Depression.
One wonders if a
slightly longer course including these elements might be helpful,
although skillful instructors might find creative ways of including
these if appropriate to their groups, either during the 8 weeks of
the course, the "all day" session or during follow up sessions.
Five Facet
Mindfulness Questionnaire :-
Baer,
R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L.
(2006). Using
self-report
assessment methods to explore facets of mindfulness.
Assessment,
13(1),
27-45. doi: 10.1177/1073191105283504 Self Compassion:- Raes,
F., Pommier, E., Neff, K. D., & Van Gucht, D. (2011).
Construction
and factorial
validation of a short form of the Self-Compassion Scale. Clinical
Psychology & Psychotherapy, 18, 250-
255. Wellbeing :- World
Health Organisation. (1998). WHO (Five) Well-Being Index (1998
version). Retrieved
from http://www.psykiatri-regionh.dk/NR/rdonlyres/ACF049D6-C94D-49B2- B34C-
96A7C5DA463B/0/WHO5_English.pdf Stress :- Lemyre,
L., Tessier, R., (2003).
Measuring
Psychological Stress. Concept, Model and Measurement
Instrument in Primary Care.
Canadian
Family Physician. 49,
1159-1160. Sleep Quality :-
Buysse,
D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer,
D. J. (1988). The
Pittsburgh Sleep Quality Index : A New Instrument for Psychiatric
Practice and Research.
Psychiatry
Research, 28, 193-213.
doi: 10.1016/0165-1781(89)90047-4
Book References
Bartley, T. (2012). Mindfulness Based Cognitive Therapy for Cancer. West Sussex: Wiley-Blackwell.
Moorey. S., & Greer, S. (2002). Cognitive Behaviour Therapy for People with Cancer. New York: Oxford University Press.
The following charts
illustrate the results for the 5 measures, Mindfulness through the
Five Facet Mindfulness Questionnaire, Self compassion via the short
version of the Self-compassion Questionnaire, Wellbeing via the WHO-5
wellbeing questionnaire, Stress via the Psychological Stress
Measure-9 and Sleep quality via the Pittsburgh Sleep Quality Index.
(Pre= pre-course
score, Post = score immediately after the MBCT-Ca Course, Follow-up =
score at 3 months after the course ended N = number of participants
data used in the analysis)
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Wishing you well Sud
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