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!

Academic summary

Easier explanation of results (for those unfamiliar with Mindfulness research)

Observations

Brief descriptions of self-compassion and mindfulness facets.

Bias

How is MBCT-Ca different to other mindfulness courses

Charts

Thesis download

Disclaimer

Copyright

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.


Summary (for those familiar with Mindfulness research)

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.


Easier explanation of results (for those not familiar with Mindfulness research)

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.


Observations

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.



Brief descriptions of self-compassion and mindfulness facets.

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.


How is MBCT-Ca different to other mindfulness courses

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.


Questionnaire References

  • 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.


Charts

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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