Mindfulness-based stress reduction in breast cancer care

1. Mindfulness-based stress reduction in breast cancer care Caroline Hoffman Clinical Director and Research Coordinator Breast Cancer Haven London – Hereford – Leeds www.breastcancerhaven.org.uk cjh@breastcancerhaven.org.uk 1

2. What is mindfulness? “Mindfulness is about being fully awake in our lives. It is about perceiving the exquisite vividness of each moment. We feel more alive. We also gain immediate access to our own powerful inner resources for insight, transformation, and healing.” Professor Jon Kabat-Zinn Founder of the Centre for Mindfulness, Medicine, Health Care and Society University of Massachusetts

3. Being present is the essence of meditation Let’s bring our attention and awareness: - to sensations in the body - to the contact with the floor and chair - to the awareness of breathing - to thoughts as they come and go - to sounds: in the body, in the room, outside the room 3

5. Definitions of Mindfulness ‘Moment to moment non-judgemental awareness’ (Kabat-Zinn 2004) ‘a receptive attention to and awareness of present events and experiences’ (Ryan and Brown 2003) ‘bringing one’s complete attention to the experience occurring in the present moment, in a non-judgemental or accepting way’ Baer et al (2006) brought together definitions (Brown and Ryan 2003, Kabat-Zinn 2001, Linehan 1993, Marlatt and Kristeller 1999)

7. Mindfulness in healthcare Mindfulness-based stress reduction (MBSR) was developed by Professor Jon Kabat-Zinn at the University of Massachusetts, USA in the late 1970s Initially called stress reduction and relaxation programme (SR-RP) in the university’s medical centre (Kabat-Zinn 1982) This later became known as MBSR. 7

8. Interventions based on mindfulness training Mindfulness-Based Stress Reduction (MBSR) Mindfulness-Based Cognitive Therapy (MBCT) Mindfulness-Based Art Therapy (MBAT)

9. Other interventions incorporating mindfulness training Dialectical Behaviour Therapy (DBT) Acceptance and Commitment Therapy (ACT) Mindfulness-Based Relapse Prevention (MBRP)

10. Mindfulness-Based Stress Reduction (MBSR) MBSR was developed for people with a range of chronic, painful and stress-related conditions. MBSR - seven to ten weeks for groups of up to 30 participants who meet weekly for 1.5 -2.5 hours. It also includes a retreat day in week 6. Mindfulness home practice of 30-45 minutes per day

11. The five stages in the 8-week MBSR programme Stage I – meeting yourself – in the present moment Stage II – perception – ways of seeing Stage III – meeting the world – attachment and aversion Stage IV – self and others – in relationship - assertiveness or passive/aggressive Stage V – how that shapes our lives – how we take mindfulness into the world

13. Mindfulness-Based Stress Reduction (MBSR) class format Each class starts with at 45 minutes of mindfulness practice Feedback from week’s practice follows in groups Didactic teaching element – looks at stress reactions and management, noticing what happens in situations during the week at home or work Home practice is given for the next week

14. Mindfulness-Based Stress Reduction (MBSR) Day of Mindfulness in week 6 of programme is a day of silent retreat Practising mindfulness exercises: stretches, walking, sitting meditation, mountain meditation, talk about mindfulness Eating lunch mindfully and in silence Opportunity to share at the end of the day

15. MBSR Home Practice Mindful body scan (lying down meditation) Mindful lying stretches (like simple yoga) Mindful standing stretches Mindful sitting meditation All given via CDs for home practice There are also a Home Practice Manual with some short exercises to help raise awareness: 9 dots exercise, noting pleasant and unpleasant events, assertive versus passive-aggressive

17. Mindfulness-Based Cognitive Therapy (MBCT) An 8-week programme integrating some aspects of Cognitive Behaviour Therapy (CBT) for depression (Beck et al 1979) with components of Kabat-Zinn’s MBSR programme (Teasdale et al 2000). MBCT was created by Segal, Williams and Teasdale (1995). Aspects of CBT included in MBCT are mainly those designed to facilitate decentred views such as ‘thoughts are not facts’ and ‘I am not my thoughts’. Unlike CBT, there is little explicit emphasis in MBCT on changing the content or specific meanings of negative automatic thoughts, rather in changing the awareness towards them.

18. Mindfulness-Based Cognitive Therapy (MBCT) MBCT focuses on teaching people to become more aware of thoughts and feelings and to relate to them as ‘mental events’ from a decentred perspective, rather than as aspects of self or as true reflections of reality. It is this mechanism applied to depressive thoughts that can help prevent relapse of depression (Teasdale et al 2000). According to Kabat-Zinn (personal communication 2005), when taught well, there is a 95% overlap between MBSR and MBCT.

20. Similarities to Cognitive Behavioural Therapy (CBT) The mindfulness, cognitive and cognitive behavioural approaches share an emphasis on 1) noting sensations and thoughts without viewing them as catastrophic 2) the use of stress-inducing situations as triggers to engage new behaviours Unlike many health promotion and cognitive-behavioural approaches, mindfulness training focuses solely on cultivating inner resources and awareness of cognitive processes, identifying thoughts as ‘just thoughts’, or emotions to be ‘just emotions’. Teasdale et al (1995) proposed that cognitive therapy involves a more active ‘coping and controlling stance’ towards the thoughts and emotions that arise than does mindfulness

21. Five measurement tools for assessing mindfulness Freiburg Mindfulness Inventory (FMI) (Buchheld, Grossman and Walach 2001) Mindful Attention and Awareness Scale (MAAS) (Brown and Ryan 2003) Kentucky Inventory of Mindfulness Skills (KIMS) (Baer, Smith and Allen 2004) Cognitive and Affective Mindfulness Scale (CAMS) (Feldman, Hayes, Kumar, Greeson and Laurenceau (in press) The Mindfulness Questionnaire (MQ) (Chadwick, Hember, Mead, Lilley, Dagnan, unpublished, 2005) These show significant correlation with each other and promising psychometric characteristics (Baer et al 2006)

22. Research into MindfulnessMeta analysis (Baer 2003) 19 empirical studies of mindfulness-based interventions including MBSR and Mindfulness Based Cognitive Therapy (MBCT) in a variety of clinical conditions These studies had sample sizes ranging from 16-142, mean age of participants 38 – 50 years, gender range from 0 - 46%

23. Research into MindfulnessMeta analysis (Baer 2003) cont. Nine studies that used pre- and post- designs with no control group Nine used pre-post designs with Treatment as Usual (TAU) or wait-list control groups Most studies used the 8-10 week MBSR intervention or a variation tailored to the study population Two studies examined mindfulness-based cognitive therapy (MBCT)

24. Results of Meta analysis (Baer 2003) cont. When each of these 15 effect sizes was weighted by sample size, the overall effect size was 0.59 These mindfulness interventions have at least a medium-sized effects with some effect sizes falling within the large range This was seen as a conservative estimate due to poor reporting in some studies

26. Mindfulness research showing improvements in physical and psychological parameters chronic pain (Kabat-Zinn et al 1982, Kabat-Zinn et al 1985, Kabat-Zinn et al 1987), chronic lower back pain ( Morone et al 2008) fibromyalgia (Kaplan et al 1993, Grossman et al 2007) anxiety (Kabat-Zinn et al 1992, Miller et al 1995) generalised social anxiety disorder (Koszycki et al 2007) increased sense of control and reduction in psychological symptoms (Astin 1997) psoriasis (Kabat-Zinn et al 1998)

27. Mindfulness research showing improvements in physical and psychological parameters (cont.) eating disorders (Kristeller and Hallett 1999, Smith et al 2006) hot flushes in menopausal women (Carmody et al 2006) quality of life (Reibel 2001) prevention of depressive relapse (Williams et al 2001, Teasdale et al 2000) reduced symptoms after organ transplantation (Gross et al 2004) psycho-endocrine-immune response in HIV (Robinson et al 2008)

28. Mindfulness research showing improvements in physical and psychological parameters in cancer Stress and mood in cancer (n=109) (Speca et al 2000) Immune markers in cancer (Carlson et al 2007) Sleep in breast cancer (n = 63) (Shapiro 2003) Diet and PSA levels in prostate cancer (Saxe et al 2001) Distress, anxiety, depression and hostility in cancer (n=111) (Monti et al 2006)

29. Grounded theory study of MBSR in cancer outpatients (n=13) Five major themes emerged (McKenzie et al 2006) 1) opening to change 2) self-control 3) shared experience 4) personal growth 5) spirituality

31. Qualitative study of MBSR in cancer outpatients Four major themes emerged (Dobkin 2008) 1) acceptance 2) regaining and sustaining mindful control 3) taking responsibility for what could change 4) spirit of openness and connectedness

32. MBSR evaluating mood, quality of life and wellbeing (Hoffman: unpublished PhD thesis) N = 229 women with breast cancer attending Breast Cancer Haven in London Randomised, wait-list controlled study Data collected in 2005 -2006 Groups sizes from 12 – 20 A pilot group plus 13 study groups run

33. MBSR evaluating mood, quality of life and wellbeing (Hoffman unpublished) Profile of mood states (POMS), FACT-B (breast), FACT-ES (endocrine symptoms), WHO 5-item wellbeing questionnaire (WHO-5) qualitative data

35. How MBSR helped mood state ‘It has given me a very finely tuned acute awareness of how behavioural patterns are affecting my moods and causing me to feel low and depressed. I no longer feel pressurised to make drastic changes to my life that will not actually change the core/root cause. I am feeling much more positive, much calmer and in control.’ Able to feel in a calmer state. Anxiety level has dropped tremendously. Have been able to stop taking sleeping tablets. (Able) to feel more at peace and a happier state of mind. Able to calm down when stressful events occur.’ 35

36. How mindfulness has helped with pain and symptoms ‘The body scan has helped me with the chronic pain I have had over the past 18 months. I am calmer and more aware of people’s feelings’ ‘Sometimes I can relieve pain or hot flushes and change my mood by taking awareness to bits of my body’ ‘Using calming method to help avoid stress so I don’t get so many hot flushes 36

37. How mindfulness helps with work and family ‘At work (I teach adults) I have been able to see more clearly what anxieties drive my group and address them without getting stressed through greater awareness of triggers. I’ve noticed that I’m much more ‘present’ with my children. With my mother (who can be manipulative) I have stayed calm, mindful and become more assertive. Inner calm has become the norm for me, replacing a kind of restless energy I took to be creativity. I’ve also become far more productive in many years and happier in my skin’ 37

38. How mindfulness has helped with perceptions of life ‘I am mindful of how my thoughts can take up an awful amount of negative energy. It is as if I can stand back and now see the whole picture. The most positive affect has been on the ability to stand back and view situations/thoughts/events in their true context. I feel more grounded/calmer’ 38

39. Practice and Research Summary Mindfulness has exploded into western healthcare worldwide recently and is rapidly rising year on year There are a number of different approaches being adopted according to the needs of different clinical communities In breast cancer, MBSR and MBCT is used in UK There are now ways of formally measuring mindfulness Research to date is showing positive results although more rigorous research is still needed

40. Mindfulness and spirituality Mindfulness provides a way of bringing our attention and awareness to each moment Through present moment awareness, this connects us with the essence of our being Stillness, peace and joy are there all the time We just need allow the thinking mind to quieten Is this spiritual or simply humanity functioning in the most optimal way? 40