Research

2019 Pilot Groups & Literature Review

Mindfulness Course Pilot 2019

Introduction 

The Mindfulness Course is an eight-week course, which aims to guide the development of mindfulness skills by showing the participants different ways to pay attention to the present moment through meditation practices. This course was delivered by a Clinical Psychologist, who had completed specific mindfulness teacher training. Meditations included body scans, siting meditations, the 3-step breathing space, mindful walking, mindful movement, and self-compassion focused practices.

Evaluation was conducted on two groups of ten participants (twelve of whom completed the pre-treatment questionnaires and seven of whom completed both the pre-treatment and post-treatment questionnaires). The participants were given a questionnaire pack before and after the course, which included four psychometric measures: The Five Facet Mindfulness Questionnaire (FFMQ), The Perceived Stress Scale (PSS), The Hospital Anxiety and Depression Scale (HADS), and The Self-Compassion Scale (SCS).

Demographics

Eleven participants completed the demographics questionnaire. There were seven females and four males. The mean age was 61.73 years (SD=8.65) and the age range was 41 years to 73 years. Nine of the participants had cancer themselves, whilst the other two participants had a family member with cancer, so were either carers or were bereaved by cancer.

Measures

The Five Facet Mindfulness Questionnaire (Baer et al, 2006)

The FFMQ aims to measure the five elements of mindfulness: Observation, Description, Acting with awareness, Non-judgemental inner experience and Non-reactivity. The total score of the FFMQ provides an estimate of an individual’s mindfulness and self-awareness. There are 39 items which are accompanied by a 5-point scale where 1 means “never or very rarely true” and 5 means “very often or always true”. Seven participants completed the pre-course and post-course FFMQ. The mean total FFMQ score was higher after the course than before the course (Pre-mean=114.00, Pre-SD=18.20, Post-mean=133.29, Post-SD=15.90). Additionally, the means for all five subscales were higher after the course. A paired t-test found that the increase in the total FFMQ score was statistically significant at the p ≤0.01 level (t=-3.903, df=6, p=0.008). Of the five subscales two of the mean score increases were statistically significant (OPre-mean=26.43, OPre-SD=4.16, OPost-mean=30.57, Opost-SD=3.95, NJPre-mean=19.57, NJPre-SD=4.65, NJPost-mean=25.57, NJPost-SD=4.96). The Observe score was significant at the p ≤0.05 level (t=-3.442, df=6, p=0.014) and the Non-judgemental inner experience score was significant at the p ≤0.01 level (t=-4.011, df=6, p=0.008). This suggests that the course helped the participants improve their self-awareness and ability to be mindful, especially in the elements of observation and non-judgemental inner experience.

The Perceived Stress Scale (Cohen, Kamarck, and Mermelstein, 1983)

The PSS aims to measure the degree to which situations in an individual’s life are appraised as stressful. The scale contains 10 items and uses a five-point scale where 0 means “never” and 4 means “very often”. Seven participants completed the PSS both before and after the course. There was a decrease in the mean total perceived stress score after the course (Pre-mean=19.43, Pre-SD=7.50, Post-mean=14.57, Post-SD=7.55). A paired t-test found that this difference was statistically significant at the p ≤ 0.05 level (t=3.378, df=6, p=0.015). This suggests the course taught participants successful techniques for coping with their stress or with the perception of their stress.

The Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983)

The HADS was devised to measure symptoms of anxiety and depression. There are 14 items overall, 7 which measure anxiety and 7 which measure depression. The scale uses four-point scales with scores ranging from 0 to 3. Seven participants completed both the pre-course and post-course HADS. The mean anxiety score (Pre-mean=8.00 Pre-SD=3.06, Post-mean=6.57, Post-SD=2.23) and the mean depression score (Pre-mean=4.86. Pre-SD=3.80, Post-mean=4.00, Post-SD=3.00) decreased over the course period. Paired t-tests showed that these differences were not statistically significant. However, it is notable that the anxiety score fell from a ‘borderline ’case score to ‘normal’ case score according to the clinical cut off score of 8 (Zigmond & Snaith, 1983). In addition, the depression score was a ‘normal’ case score both before and after the course. Neither the anxiety mean score, or the depression mean score, were above 11 before or after the course, which is the clinical cut off score for an ‘abnormal’ case (Zigmond & Snaith, 1983).

The Self-Compassion Scale (Neff, 2003)

The SCS aims to measure self-compassion by asking individuals how they typically act towards themselves in difficult times. It measures six factors: Self-kindness, Self-judgement, Common Humanity, Isolation, Mindfulness, and Over-identification. It contains 26 items and uses a five-point scale where 1 means “almost never” and 5 means “almost always”. Seven participants completed the SCS before and after the course. The mean total self-compassion score increased throughout the course (Pre-mean=2.88, Pre-SD=0.41, Post-mean=3.17, Post-SD=0.24), as did the scores on the six subscales. A paired t-test found the self-compassion score increase was not statistically significant. However, the increase in the mean score on the Self-kindness subscale (Pre-mean=2.77, Pre-SD=0.39, Post-mean=3.11, Post-SD=0.49) was statistically significant at the p ≤0.05 level (t=-2.661, df=6, p=0.037). According to the researcher the average scores for the subscales are around 3.00. This suggests that the mean score moved from below average to above average over the duration of the course.

Qualitative Feedback

Overall, the qualitative feedback was very positive with 100% of participants selecting that they found the course “Very Useful”. Words such as “worthwhile”, “enjoyable”, “helpful”, and “informative” were used to describe the course. One participant described the course as “very insightful, providing many useful life tools” whilst another explained that the course planted “the seeds of mindfulness.”

All the participants were pleased with the course facilitator with 100% of them selecting that they were “Very Happy” with the facilitator’s knowledge and skills, and 100% of them selecting that the facilitator maintained their interest “Very Well”. One individual described the facilitator as “brilliant, supportive, accepting, and non-judgemental” whilst another said that they felt like they were “in the hands of someone with expert knowledge and understanding.”Furthermore, one participant explained that the facilitator made “the subject accessible to everyone.”

Each week the participants were given a handout. When asked about these handouts 100% of them rated them as “Excellent”. The handouts were described as “very comprehensive”. One participant said that they would “continue to use the handouts” whilst another explained that they are “really good resources to revisit.”

During the course the participants were taught various different types of mediations and other practices, when asked to rate the exercises that they learnt 100% selected “Excellent”. One individual explained that they had learnt so much that they “have been able to put into practice”, whilst another stated that the exercises acted as “strategies to help in moments of need”. 

There were opportunities to talk with other course members throughout the sessions and in the breaks, 57% of participants thought that these opportunities were “Excellent” and the other 43% thought they were “Good”. One individual said the discussions “gave a sense of community” whilst another explained that “it was stimulating to have other peoples input and thoughts” about the practices. Additionally, one participant said that “everyone is included and gets the chance to contribute without feeling put on the spot”. 

Finally, the 2019 group was asked what they have learnt or how they have changed as a result of the course. One participant said they felt “empowered”, one said they were now “more patient”, and another said that they were aiming to be “a kinder calmer person”. A few participants mentioned what the course had taught them progress their mindfulness practice, e.g. the course “has really helped me begin to develop my practice”and I have learnt “how to identify thoughts/feelings/emotions and not be carried away by them, how to be present in each moment”. Four participants mentioned how the course has helped to improve their mental health, e.g. “It has been a significant part of helping me to overcome anxiety and depression” and the practices are “helpful in times of stress/anxiety”. 

Future Direction

Despite the low power for statistical analysis there were statistically significant increases in mindfulness and self-kindness, as well as a significant decrease in perceived stress following the course in the 2019 group. Additional analysis with more participants is needed to further these findings. 

References

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, 27- 45

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal of health and social behavior, 385-396.

Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and identity, 2(3), 223-250

Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta psychiatrica scandinavica, 67(6), 361-370.

Be Here Now: Mindfulness in Cancer Care

Mindfulness based interventions (MBIs) are now well established in psychological care provision. There has been a proliferation of research investigating the efficacy, mechanisms and outcomes of MBIs in cancer care. In the broader literature on meditation practices, some attention has been given to possible risks and adverse effects, but more research specific to structured MBIs is needed. This paper (written in 2019) presents the rationale for the use of MBIs in cancer care along with considerations for establishing safe delivery practices.

Mindfulness-Based Interventions emerge in the West

From 2500-year-old origins in Buddhist culture, the last four decades have seen the emergence of Mindfulness meditation practices in the West. Trait mindfulness has been found to correlate significantly with a variety of cognitive and affective indicators of mental health and wellbeing (e.g. Brown, Ryan & Creswell, 2007). Mindfulness-Based Stress Reduction (MBSR: Kabat-Zinn, 1982), Mindfulness-Based Cognitive Therapy (MBCT: Segal, Williams & Teasdale, 2002), Acceptance and Commitment Therapy (ACT: Hayes, Strosahl & Wilson, 1999) and Dialectical Behaviour Therapy (DBT: Linehan, 1993) have become evidence-based psychological interventions in their own right. MBSR and MBCT (the focus of this paper) are both structured 8 week group programmes, including 2-2.5 hour weekly sessions, home practice and an additional silent day retreat. Key components of both programmes are sitting, walking and movement meditations designed to promote the skills and qualities of mindfulness. MBCT overtly includes cognitive techniques to address unhelpful thinking patterns (Segal et al, 2002). Both methods espouse the idea of teaching from an established and embodied mindfulness practice.

Two well-conducted Randomised Controlled Trials (RCTs) have shown that MBCT is effective in reducing depression relapse rates in participants with a history of three or more depressive episodes (Ma & Teasdale, 2004; Teasdale, Segal, Williams, Ridgewa, Sounsby & Lau, 2000). MBCT was written into the UK National Institute for Clinical Excellence (NICE) guidelines in 2004 as an evidence-based treatment for relapse prevention in depression and was given “key priority” status in 2009.

Mindfulness-Based Interventions in health and cancer care

The use of MBIs is also now well established in physical health care. Gotlink, Chu, Busschbach, Benson, Fricchione and Hunink (2015) conducted a systematic review and meta-analysis of RCTs using MBSR or MBCT in physical health contexts. They reported significant improvements in depressive symptoms, anxiety, stress, quality of life and physical functioning in the adjunct treatment of cancer, cardiovascular disease, chronic pain, depression and anxiety disorders.

Advances in medical science and the treatment of cancer means that in the 21stCentury unprecedented numbers of people are living with the effects of cancer and the effects of treatment (known as late effects). Cancer patients carry a significant burden of psychological distress, anxiety, depression and fear of cancer recurrence (FCR), with 30 to 40 percent of oncology, haematology and palliative cancer patients meeting criteria for mood, anxiety or adjustment disorder (see Mitchell et al, 2011). As well as the psychological effects there are physical effects (e.g. fatigue and pain) and the interaction between these physical and psychological domains (e.g. sleep disturbance), which impact on quality of life.

MBCT and MBSR are now commonly delivered to cancer patients and care giving family members. By 2006 MBIs had been established as having consistent benefits, improving psychological functioning, reducing stress, enhancing coping and wellbeing amongst cancer outpatients (see reviews by Ott, Norris & Bauer, 2006; Shennan, Payne & Fenion, 2010). Much of this research has been conducted with Breast Cancer patients (e.g. Lengacher et al, 2009; Henderson, Clemow, Massion, Hurley, Druker & Hebert, 2012). Lengacher et al (2009) conducted a RCT of MBSR with 84 Breast Cancer survivors within 18 months of medical treatment completion. Their 6-week MBSR(BC) program resulted in significant improvements in psychological status and quality of life compared with usual clinic follow-up. Matousek and Dobkin (2010) found that for 59 Breast Cancer patients offered the 8-week MBSR program, there was 91% adherence to the program and significant reduction in stress, depression, medical symptoms, as well as increased mindfulness. They go on to mention that “increases in mindfulness and sense of coherence predicted reductions in stress” (p 62), suggesting it is indeed the mindfulness, which is the active ingredient in the intervention. Würtzen, et al. (2013) found MBSR significantly reduced self-reported levels of anxiety and depression in a RCT of 336 Danish women treated for Stage I-III breast cancer. Zainal, Booth and Huppert (2013) conducted a meta-analysis of 9 published studies of MBSR in Breast Cancer and found moderate to large effect sizes for improved stress, depression and anxiety. Since that meta-analysis was published, Lengacher et al (2016) have published results from a 322 person RCT with Breast Cancer Survivors (BCSs). This demonstrated “extended improvement” (6 and 12 weeks post-treatment) for the MBSR(BC) group compared with usual care in psychological symptoms of anxiety, fear of cancer recurrence and physical symptoms of fatigue severity and fatigue interference. They used a moderation analysis to show that BCSs with the highest levels of stress at baseline experienced the greatest benefit from MBSR(BC). Haller, Winkler, Klose, Dobos, Kummel and Cramer (2017) systematically reviewed 10 studies (1079 patients in total) to create a meta-analysis of MBSR and MBCT with Breast Cancer patients. They found improvements in health related quality of life, sleep, depression and anxiety. They noted that it was the improvement in anxiety that was found to persist most strongly over 12 months post-treatment.

Looking beyond the Breast Cancer population, Carlson, Speca, Faris and Patel (2007) found MBSR program participation (by breast and prostate cancer patients) was associated with enhanced quality of life, improved sleep and decreased stress biomarkers, altered cortisol and immune patterns consistent with less stress and mood disturbance, as well as decreased blood pressure and decreased muscle tension. Johns, Brown, Beck-Coon, Monahan, Tong and Kroenke (2015) investigated Cancer-Related Fatigue with a heterogeneous sample of 35 cancer patients. Compared with waitlist control, they found a 7-week MBSR intervention was associated with reduced fatigue interference and reduced fatigue severity, reduced depression, reduced sleep disturbance and increased vitality. A study by van der Lee and Garssen (2012) delivered MBCT to patients with mixed cancer diagnoses and found improvements in fatigue (as compared to a wait-list control). Del Castanhel and Liberali (2018) reviewed 7 studies of MBSR published between 2013 and 2017. They declared that there is a moderate improvement in fatigue, but given that the statistical significance was not reached, further investigation of this particular symptom is warranted. Piet, Wurtzen and Zachariae (2012) reviewed 22 studies (total N = 1403 mixed cancer patients) of MBIs (including MBSR and MBCT) and found moderate and robust effect sizes for improvements in depression and anxiety. An unpublished qualitative analysis (Higgins, 2018) has also shown MBSR to be well received by and highly acceptable to cancer patients. It seems reasonable to conclude that the evidence for the effects of MBIs is increasingly robust.

Mechanisms of action

The mechanisms of action and neuro-biological underpinnings of MBIs are still under investigation. A meta-analysis by Fox et al (2014) found a moderate effect size for brain structure changes in meditation practitioners. Mindfulness is thought to promote clarity of awareness, non-conceptual awareness, non-discriminatory awareness, flexibility of awareness and attention (see Brown et al, 2007). “Mindfulness is not seen as antithetical to thought, but rather fosters a different relationship to it” (Brown et al, 2007, p 213). MBIs are “designed to enhance attentional stability or continuity, sensory awareness, metacognitive skills (impartial, nonreactive observation of one’s thought and feelings), and awareness of one’s behaviour in daily life”(Brown et al, 2007, p 219). Mindfulness is said to counter “experiential avoidance”, which has been implicated in anxiety and depression (Hayes et al, 1999). MBCT relapse prevention is hypothesised to interrupt the rumination that perpetuates depression (Michalak, Holz & Teismann, 2011) and train attentional control (Segal, Williams & Teasdale, 2013). There is also suggestion that Mindfulness training engenders self-compassion. Kuyken et al (2010) have shown “MBCT’s treatment effects are mediated by augmented self-compassion and mindfulness, along with a decoupling of the relationship between reactivity of depressive thinking and poor outcome. This decoupling is associated with the cultivation of self-compassion across treatment” (p 1105). Interestingly, other academic clinicians have focused on Self-Compassion as a practice and intervention in its own right (e.g. Neff & Germer 2017, Gilbert, 2010).

In addition to the seminal texts “Full Catastrophe Living” (Kabat Zinn, 1990, revised edition in 2013) and “Mindfulness-Based Cognitive Therapy for Depression” (Segal, et al, 2002; 2nd Ed 2013), there are two key reference sources for clinicians wanting to deliver MBIs to cancer patients. Trish Bartley, in the UK, published her manual Mindfulness-Based Cognitive Therapy for Cancer (MBCT-Ca) in 2011 and followed it with Mindfulness: A kindly approach to being with cancer for patients in 2016. Bartley (2011) formulates MBCT-Ca as a three-circle model; proposing that mindfulness firstly changes the vicious cycle of anxious pre-occupation with cancer-related suffering, secondly fosters a kind, compassionate ‘turning toward’ way of relating to distress and thirdly helps people to connect with and enrich their lives. Shapiro and Carlson in Canada published The Art and Science of Mindfulness for health clinicians in 2009. Carlson and Speca followed it in 2011 with Mindfulness Based Cancer Recovery (MBCR) for cancer patients. Carlson (2017) describes MBCR as “distress management through mind-body therapies”. Her research team has compared face-to-face MBCT with internet-based MBCTe. They found that compared to treatment as usual both formats offered reduced FCR and rumination, and increased mental health related quality of life (Compen at al, 2018).

The Canadian research team has also published an article (Shellekens et al, 2017) looking at whether the mechanism of action of MBIs is in fact mindfulness or whether there are non-specific therapeutic factors, such as the experience of social support, that may contribute to the positive effects of MBIs. They examined whether change in mindfulness and/or social support mediated the effect of Mindfulness-Based Cancer Recovery (MBCR: N=69) compared to another active intervention (i.e. Supportive Expressive Group Therapy – SET: N=70), on change in mood disturbance, stress symptoms and quality of life. “MBCR participants improved significantly more on mood disturbance, stress symptoms and social support, but not on quality of life or mindfulness, compared to SET participants. Findings showed that increased social support was related to more improvement in mood and stress after MBCR compared to support groups, whereas changes in mindfulness were not. This suggests a more important role for social support in enhancing outcomes in MBCR than previously thought” (Shellekens et al, 2017, p 414). This points to the possibility that MBIs are helpful to cancer patients at a number of levels, including, but not limited to, the cultivation of the mindfulness.

Keeping cancer patients safe while learning mindfulness

Given the physical impositions of cancer on the human body, the above mentioned MBCT-Ca and MBCR programmes emphasise the importance of making sure mindfulness approaches are delivered in a safe way to their target audience, who may be quite physically and psychologically vulnerable during and after their cancer care. Many cancer patients report ongoing pain and somatic distress. The skill of mindfulness can be very useful in relating differently to pain that cannot be treated physically. As Dahl and Lundgren (2006) discuss, distraction and avoidance may be advantageous in the short term and for acute pain (e.g. during treatment), however, unwillingness to experience physical pain and distress may have the unintended consequence of fostering an increased sensitivity to, and intolerance of the states an individual seeks to avoid. There is an art to teaching mindfulness of sensations such that the participant does not feel engulfed by pain when it is present in the sensing.

References

Bartley, T. (2011). Mindfulness-Based Cognitive Therapy for Cancer. Oxford: Wiley-Blackwell.

Bartley, T. (2016). Mindfulness: A kindly approach to being with cancer. Oxford: Wiley-Blackwell.

Brown, K. W, Ryan, R. M., & Creswell, J. D. (2007). Mindfulness: Theoretical foundations and evidence for its salutary effects. Psychological Inquiry, 18(4), 211–237.

Carlson, L.E. (2017). Distress Management Through Mind-Body Therapies in Oncology. Journal of the National Cancer Institute Monogr, 52, http://dx.doi.org/10.1093/jncimonographs/lgx009

Carlson, L.E., & Speca, M. (2010). Mindfulness-Based Cancer Recovery. Oakland, CA: New Harbinger.

Carlson, L.E., Speca, M., Faris, P, & Patel, K.D. (2007). One year pre-post intervention follow-up of psychological, endocrine, and blood pressure outcomes of mindfulness-based stress reduction (MBST) in breast and prostate cancer outpatients. Brain Behavior and Immunity, 21, 1038-1049.

Compen, F., Bisseling, E., Schellekens, M., Donders, R., Carlson, L., van der Lee, M., & Speckens, A. (2018). Face-to-face and internet-based Mindfulness-Based Cognitive Therapy compared with treatment as usual in reducing psychological distress in patients with cancer: A multicentre randomised controlled trial. Journal of Clinical Oncology, 36(23), 2413-2421.

Dahl, J., & Lundgren, T. (2006). Acceptance and Commitment Therapy (ACT) in the treatment of chronic pain. In R.A. Baer (Ed.), Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (pp. 285-306). San Diego, CA: Elsevier.

Del Castanhel, F., & Liberali, R (2018). Mindfulness-Based Stress Reduction on breast cancer symptoms: systematic review and meta-analysis. Einstein Sao Paulo, 16(4): eRW4383.

Fox, K.C.R, Nijeboer, S., Dixon, M.L. Floman, J.L. Ellamil, M., Rumak, S.P., Sedlmeie, P., & Christoff, K. (2014). Is meditation associated with altered brain structure? A systematic review and meta-analysis of morphometric neuroimaging in meditation practitioners. Neuroscience and Biobehavioural Reviews, 43, 48-73.

Gilbert, P. (2010). Compassion Focused Therapy. Distinctive Features Series. London: Routledge.

Gotlink, R.A., Chu, P., Busschbach, J.J., Benson, H., Fricchione, G.L. and Hunink, M.G. (2015). Standardised mindfulness-based interventions in healthcare: an overview of systematic reviews and meta-analyses of RCTs. Plos One, 10(4), e0124344

Haller, H., Winkler, M.M., Klose, P., Dobos, G., Kummel, S. & Cramer, H. (2017). Mindfulness-based interventions for women with breast cancer: an updated systematic review and meta-analysis. Acta Oncologica, 56(12), 1665-1776.

Hayes, S.C., Strosahl, K., & Wilson, K.G. (1999) Acceptance and Commitment Therapy: An Experiential Approach to Behavior Change. New York: Guilford Press.

Henderson, V.P., Clemow, L., Massion, A.O., Hurley. T.G., Druker, S. & Hebert, J.R. (2012). The effects of mindfulness-based stress reduction on psychosocial outcomes and quality of life in early-stage breast cancer patients: A randomized trial. Breast Cancer Res Treat, 131(1), 99–109.

Higgins, M (2018). A qualitative based study of mindfulness-based stress reduction (MBSR) at Maggie’s Centre Gartnaval Glasgow. Unpublished Manuscript.

Johns, S.A., Brown, L.F., Beck-Coon, K., Monahan, P.O., Tong, Y. & Kroenke, K. (2015). Randomised controlled pilot study of Mindfulness-Based Stress Reduction for persistently fatigued cancer survivors. Psychooncology, 24(8), 885-893.

Kabat-Zinn, J. (1982). An outpatient program in behavioural medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. General Hospital Psychiatry, 4(1), 33-47.

Kabat-Zinn, J (1990). Full Catastrophe Living: using the wisdom of your body and mind to face stress, pain and illness. New York: Bantam Books.

Kabat-Zinn, J (2013). Full Catastrophe Living: using the wisdom of your body and mind to face stress, pain and illness. Revised Edition. New York: Bantam Books.

Kuyken, W., Watkins, E., Holden, E., White, K., Taylor, R.S., Byford, S., Evans, A., Radford, S., Teasdale, J.D., & Dalgleish, T. (2010). How does mindfulness-Based cognitive therapy work? Behaviour Research and Therapy, 48, 1105-1112.

Lengacher, C.A., Johnson–Mallar, V., Post–White, J., Moscoso, M.S., Jacobsen, P.B., Klein, T.W., Widen, R.H., Fitzgerald, S.G., Shelton, M.M., Barta, M., Goodman, M., Cox, C.E., & Kip, K.E. (2009). Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psychooncology, 18(12), 1261–1272.

Lengacher, C.A., Reich, R.R, Paterson, C.L., Ramesar, S., Park, J.Y., Alinat, C., Johnson-Mallard, V., Moscoso, M., Budhrani-Shani, P., Miladinovic, B., Jacobsen, P.B., Cox, C.E., Goodkam, M. & Kip, K.E. (2016). Examination of broad symptom improvement resulting from Mindfulness-Based Stress Reduction in breast cancer survivors: A randomised controlled trial. Journal of Clinical Oncology, 34(24), 2827-2834.

Linehan, M. (1993). Cognitive-behavioural treatment of borderline personality disorder. New York: Guilford.

Ma, S. H. & Teasdale, J. D. (2004). Mindfulness-based cognitive therapy for depression: replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 31-40.

Matousek, R.H. & Dobkin, P.L. (2010). Weathering storms: a cohort study of how participation in a mindfulness-based stress reduction program benefits women after breast cancer treatment. Current Oncology. 17(4), 62-70.

Michalak, J, Holz, A, & Teismann, T. (2011). Rumination as a predictor of relapse in mindfulness-based cognitive therapy for depression. Psychology and Psychotherapy: Theory, Research and Practice, 84, 230-236.

Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., & Meader, N. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. Lancet Oncology, 12, 160–174.

Neff, K. D., & Germer, C. (2017). Self-Compassion and Psychological Wellbeing. In J. Doty (Ed.) Oxford Handbook of Compassion Science, Ch. 27. Oxford University Press.

Ott, M.J., Norris, R.L. & Bauer-Wu, S.M. (2006). Mindfulness meditation for oncology patients: a discussion and critical review. Integrated Cancer Therapy, 5(2), 98-108.

Piet, J., Wurtzen, H., & Zachariae, R. (2012). The effect of Mindfulness-Based Therapy on symptoms of anxiety and depression in adult cancer patient and survivors: A systematic review and meta-analysis. Journal of Consulting and Clinical Psychology, 80(6), 1007-1020.

Schellekens, M.P.J., Tamagawa, R., Labelle, L.E., Speca, M., Stephen, J., Drysdale, E., Sample, S., Pickering, B., Dirkse, D., Savage, L.L., & Carlson, L.E. (2017). Mindfulness-Based Cancer Recovery (MBCR) versus Supportive Expressive Group Therapy (SET) for distressed breast cancer survivors: evaluating mindfulness and social support as mediators. Journal of Behavioural Medicine, 40(3), 414-422.

Segal Z. V., Williams J. M. G., & Teasdale J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: Guilford.

Segal Z. V., Williams J. M. G., & Teasdale J. D. (2013). Mindfulness-based cognitive therapy for depression Second Edition: New York: Guilford.

Shennan, C., Payne, S., & Fenion, D. (2010). What is the evidence for the use of mindfulness-based interventions in cancer care? A review. Psycho-Oncology, DOI: 10.1002/pon.1819

Teasdale, J. D., Segal, Z. V., Williams, J.M.G., Ridgeway, V. A., Soulsby, J. M. & Lau, M. A. (2000). Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. Journal of Consulting and Clinical Psychology, 68(4), 615-625.

Van der Lee, M.L. & Garssen, B. (2012). Mindfulness-based cognitive therapy reduces chronic cancer-related fatigue: a treatment study. Psychooncology, 21(3), 264-272.

Würtzen, H., Dalton, S.O., Elsass, P., Steding-Jensen, M, Karlsen, R.V., Flyger, H.L., Pedersen, A.E., Johansen, C. (2013). Mindfulness significantly reduces self-reported levels of anxiety and depression: Results of a randomised controlled trial among 336 Danish women treated for stage I-III breast cancer. Eur J Cancer, 49(6), 1365–1373.

Zainal, N.Z., Booth, S., & Huppert, F.A. (2013). The efficacy of mindfulness-based stress reduction on mental health of breast cancer patients: a meta-analysis. Psycho-Oncology, 22, 1457-1465.