Mindfulnessbased stress reduction in breast cancer care

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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_at_breastcancerhaven.org.uk

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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

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Being present is the essence of meditation

• Lets 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

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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 ones 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)

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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 universitys medical
  centre (Kabat-Zinn 1982)
• This later became known as MBSR.

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Interventions based on mindfulness training

• Mindfulness-Based Stress Reduction (MBSR)
• Mindfulness-Based Cognitive Therapy (MBCT)
• Mindfulness-Based Art Therapy (MBAT)

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Other interventions incorporating mindfulness
training

• Dialectical Behaviour Therapy (DBT)
• Acceptance and Commitment Therapy (ACT)
• Mindfulness-Based Relapse Prevention (MBRP)

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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

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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

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Mindfulness-Based Stress Reduction (MBSR) class
format

• Each class starts with at 45 minutes of
  mindfulness practice
• Feedback from weeks 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

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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

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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

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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-Zinns 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.

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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.

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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

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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)

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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

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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)

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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

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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)

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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)

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Mindfulness research showing improvements in
physical and psychological parameters in cancer

• Stress and mood in cancer (n109) (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 (n111) (Monti et al 2006)

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Grounded theory study of MBSR in cancer
outpatients (n13)

• Five major themes emerged (McKenzie et al 2006)
• 1) opening to change
• 2) self-control
• 3) shared experience
• 4) personal growth
• 5) spirituality

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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

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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

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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

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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.

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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 peoples 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
  dont get so many hot flushes

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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. Ive noticed that
  Im 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. Ive
  also become far more productive in many years and
  happier in my skin

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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

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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

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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?

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