Authors: Barbora Krasauskaite and Neil Rothwell
Written: April 2022
Funded by: NHS Education Scotland
Executive summary
Mindfulness based interventions (MBIs) such as Mindfulness Based Cognitive Therapy (MBCT) and Mindfulness Based Stress Reduction (MBSR) have demonstrated promising results in reducing the impact of anxiety, depression and stress. Both MBSR and MBCT are highly adaptable to a wide range of populations and can be delivered in groups remotely or face to face. MBIs may therefore be a cost-effective option to treat mental health conditions and increase choices and accessibility to treatment.
The aims of this project are to:
The main findings of this report:
Introduction
Poor mental health is a significant public health concern. It is estimated that at least one in four people in Scotland experience mental health problems in any one year (Public Health Scotland, 2021). Commonly reported mental health disorders include anxiety and depression, with the latter recognized as the leading cause of disability and burden of disease worldwide (WHO, 2021). Due to its recurrent nature, depression often becomes a life-long illness, outlining the need for evidence based treatments that are accessible and cost effective.
Mindfulness Based Cognitive Therapy (MBCT) is currently one of two psychological interventions set out in the national guidance for treatment of recurring depression (NICE, 2009). MBCT was originally adapted from Mindfulness Based Stress Reduction (MBSR) course, which is also an eight week group programme. Both courses involve daily meditation practices along with psycho-education. However, MBSR primarily focuses on stress reduction through mindful awareness, whereas MBCT incorporates modalities of cognitive therapy and targets rumination and negative thinking patterns (Keng, Smoski and Robins 2011). Both MBIs have gathered a robust body of evidence supporting their effectiveness in reducing various physical and mental health conditions.
Specifically, a recent review carried out by Zhang et al. (2021) examined the existing research evaluating the efficacy of MBIs. The review found that MBIs yielded moderate to strong effects in reducing the impact of anxiety and depression. MBIs were also helpful in managing stress, pain (including cancer- related pain), sleep and weight problems, addiction and psychosis. Further findings demonstrated promising results in the delivery of MBIs across different settings and populations, including interventions aimed at healthcare staff and in school settings.
The versatility of MBIs has also been highlighted since the start of the Covid-19 pandemic when the demand for internet-based interventions increased. A recent meta-analysis conducted by Sommers-Spijkerman, Austin and Bohlmeijer (2021) demonstrated that internet-based MBIs significantly reduced symptoms of depression, stress and anxiety. Although the analysis assessed MBCT and MBSR amongst other hybrid MBIs, the type of intervention did not appear to moderate the positive affects on mental health outcomes. This, therefore, outlines the adaptability of MBIs and the potential of improving the health and wellbeing across a diverse range of services and conditions.
Research evaluating the effectiveness of MBCT-specific interventions demonstrated positive outcomes. For instance, a systematic analysis conducted by Kuyken et al. (2019) suggested that MBCT was more effective in reducing the risk of depressive relapse within a 60 weeks follow-up when compared to control group and other active treatments (with an inclusion of antidepressant medication). In relation to longer term results, McCartney et al. (2020) examined the effects of MBCT for prevention and time to depressive relapse beyond 12 months. The results suggested that MBCT effectively reduced the risk of relapse of depression when compared to treatment as usual. There has also been a significant increase in time to depressive relapse when compared to treatment as usual or placebo. The results did not reveal any significant differences between MBCT and CBT in reducing rate or time to depressive relapse, thus suggesting that both interventions can be effectively utilized to treat recurring depression.
Methods/Data Analysis
This audit used a qualitative methodology to gain better insight into the subjective experience of different groups of individuals who took part in mindfulness based courses. These courses were delivered across eight different NHS health boards: NHS Borders, Dumfries & Galloway, Fife, Ayrshire & Arran, Grampian, Greater Glasgow & Clyde, Lanarkshire and Lothian. The other three NHS Health Boards had no qualitative data available at the time. The research design used was thematic analysis. This was utilized flexibly, in line with Braun and Clarke’s (2006) six stages inductive data analysis model.
To fully immerse with the data, the first author read and re-read the data provided by each NHS health board. Initial thoughts and comments were noted down and data codes were established. The author generated initial themes which were reviewed again. The final stages of this analysis involved naming and defining themes and writing the results up.
Population of participants
The current report focused solely on the existing qualitative data obtained and provided by eight different NHS Health Boards. The qualitative data included the feedback from mindfulness interventions delivered to either clients or staff members within the NHS (referred as ‘participants’ throughout this report) who were involved with mental health services at the time. There were over 86 responders.
This report did not include any information relating to the demographics of participants.
Characteristics of the Intervention
This report included data from both MBSR and MBCT courses. Typically, the MBSR and MBCT interventions are delivered over a course of 8 weeks, with one 2 hour session each week. Both courses include psycho-education, formal (e.g., sitting meditation, body scan, mindful movement) and informal practices (e.g., mindfulness in everyday life activities such as tooth brushing or eating). In addition to practicing in the group, participants were also assigned to complete daily home practices.
Two out of eight mindfulness courses were delivered remotely as a consequence of lockdown restrictions imposed due to Covid-19. The remaining six courses were delivered face to face. ................................................................................................
Results:
Theme 1: Perceived benefits of Mindfulness course
The current report identified several positive effects of mindfulness course training. Most commonly, participants reported an enhanced awareness and ability to recognise and interrupt unhelpful negative thinking patterns and triggers to anxiety or low mood. Participants also reported utilizing various resources (e.g., diverting attention to the present moment and identifying thoughts as mental events) to prevent rumination and further deterioration in mental health:
“I can recognise better when my mind is spiralling when I am anxious and I can quieten it better to the present moment”
“I am feeling more aware of triggers to my depressive episodes – and more awareness of my thoughts as ‘just thoughts”
In addition, participants reported greater ability to cope with stress and stressful situations. Moreover, increased awareness of one’s thoughts, emotions and feelings enabled participants to make conscious efforts to take a pause and respond in much calmer and positive ways:
“I gained much more awareness of what goes on in terms of mind & body in day to day life. This lets me have the opportunity to take a step back and do what will be helpful rather than just ‘reacting...”
Participants reported a greater sense of self-compassion:
“It helps me to treat myself as I would others and be less of a harsh critic”
Theme 2: Perceived experience of working in a group setting:
Many participants reported initial feelings of uneasiness and fear about attending mindfulness group training:
“I was worried to come to the group, worried about judgement and failing. I’m so happy to have completed the course....”
However, although feeling apprehensive at first, many participants reported that being in a group setting was helpful in normalizing their experiences and recognizing that they are not alone which is an important aspect of a healing journey. This was achieved through shared experiences and through hearing stories of others’, different views and opinions.
“I am not alone, it is okay to be down, accept it and carry on”
“...enjoyed the regular commitment of it [the course] and having other people sharing experiences. Got so much more out of it than reading a book”
Some participants reported that mindfulness group training has increased their ability to connect and respond to own and others’ emotional needs:
“I found it very helpful to practice in a group because of the shared atmosphere and feeling. I have become more aware of my feelings but also have more patience and time to listen to others. I find I am not letting my own judgments of thoughts overwhelm my overall feelings. I can cope with difficult situations better by using breathing techniques and find it easier not to be judgemental”.
Theme 3: Perceived barriers/challenges
Some perceived barriers reported by participants are worth noting. The most commonly reported challenge was attributed to difficulties to commit to regular home practice due to high amount of work this entailed:
“Homework practice is very intense and difficult to properly commit to”
Some participants reported finding the course to be too fast paced:
“Perhaps more time per session/ more sessions might have been useful, as it felt like there was an awful lot of material to get through each week”
Other barriers included difficulty incorporating mindfulness home practices into daily routine due difficulty balancing other commitments:
“There have been times it has difficult fitting a practice in during the week, working full-time and running the house.”
“I work 3 night shifts a week so I struggle with routine and that makes it difficult.”
One participant reported that when their mental health worsens, they find it difficult to continue practicing mindfulness based exercises:
“When my depression is bad… On better days I practice.”
Other challenges included difficulty adopting new techniques/exercises that initially felt unfamiliar and strange:
“I have struggled with meditation as it felt strange/weird but once I got into it I really enjoyed it; I will carry on doing this. I really enjoyed the body scan part of the group.”
Finally, participants reported finding their mindful journey more difficult than initially thought:
“...I found the process [practicing] harder and more emotional than expected but this made the practice more relevant”
Theme 4: Most helpful mindfulness exercise:
The most commonly reported mindfulness exercises performed included 3 minute breathing, sitting meditation, body scan and informal practices such as mindful eating:
“Body scan and sitting meditation are helpful.... 3 minute breathing and eating... helps with feeling of anxiety/stress at work”
“Body scan, 3 minute breathing, mindfulness in everyday life”
Participants reported that due to the flexibility and versatility of mindfulness exercises, they were able to easily incorporate it into their day-to-day lives. Moreover, due to a wide variety of exercises to choose from, individuals could engage in what worked best for them at the time:
“...I think it’s something everyone could benefit from. Easy practices which can be integrated into life to get the most from it.”
“....the variety in practices is good so that I can fit them in when I have less time and so I don’t have to do the ones I don’t find helpful (the body scan is not great for me)....”
Some reported that even short practices yielded positive effects:
“Even short practice can be helpful, if I really try my best to pay attention. I don’t have to focus on negative things, they come and go.”
Theme 5: Experiences of remote sessions
Two out of eight sessions were delivered remotely due to Covid-19. The qualitative feedback suggested that individuals found it challenging to adjust to this due to technological issues that occurred:
“Connectivity/technical problems – found it stressful, not computer minded so it’s more stressful”
“Worried about being asked questions just in case I am unable to work the online platform to mute/unmute myself. Some weeks found it difficult to connect to the course and this caused panic”
Participants also expressed that it was more difficult to engage and interact with others in the group due to sessions not being face to face:
“Felt there was less opportunities to talk to other people because the group was online. Would have felt more control if it was face to face, it would have enabled more conversations and learning from others’ experiences”
However, despite challenges with technology, participants were still able to benefit from the course. One participant reported that although face to face course would have been preferred, they were still able to relate and connect with others in the group:
“It helped me realize that I am not the only one going through things and it helped’
“I knew people would be expecting me every Thursday and this would make me want to get ready and show up...”
“Before the group I felt very cut off, lonely and alone. Although I don’t have many friends now due to lockdown, I feel that I can cope better”
Participants also found the course materials/content useful:
“Enjoyed the poems, relevant situations, thought provoking materials”
Other useful aspects of the remote mindfulness course included:
“[Learning about] Mindfulness in general, what it was about...”
“Realise it’s in the now, triangle of awareness, live in the now”
“Not to let external factors impact on my mood. Body scan. Lot calmer, less reactive. Protection of time for mindfulness. Flowed really well.”
One participant also outlined the benefit of “not having to travel”, which increases accessibility of the course to people living in remote areas.
Subtheme: Suggestions for future remote sessions
Participants urged clinicians to get more familiar with online tools being used during sessions:
“e.g., when noting down ideas on a power point slide”
Encouragement to use platforms that enable more interactive sessions:
“...like ‘virtual board’ where people [from the group] are able to leave anonymous comments”
“...breakout rooms would have been good because I would have liked to chat with peers to get to know them”
“...the chat function could have been utilized more”
Discussion:
This report provides qualitative evidence for the effectiveness of mindfulness based interventions across mental health services in Scotland. The key findings suggested that MBIs can 1) reduce symptoms of anxiety and depression 2) increase awareness of unhelpful negative thinking and early warning signs to prevent deterioration in mental health 3) enhance individuals’ ability to remain calm in response to stress and stressful situations 4) increase a sense of kindness and compassion towards self and others.
The current report has further outlined individuals’ experiences of attending MBIs in a group setting. The findings suggested that despite initial doubts and fears of attending a group, most participants gained from this experience. Specifically, participants reported increased ability to relate to others through shared experiences. This has helped to normalize suffering and make deeper connections with others.
Another important finding included participants feedback related to versatility and flexibility of MBI practices. Specifically, participants indicated that even short practices were beneficial to their mental wellbeing. It was also noted that due to a wide range of MBIs exercises available, individuals could choose what was best suited to their needs. This therefore may increase a sense of control and confidence in incorporating MBIs into every day activities going forward. The most commonly performed exercises were sitting meditation, body scan, mindful movement and informal practices incorporating mindfulness into every day activities (e.g., mindful eating).
Perceived challenges/barriers included difficulty committing to home practices, busy daily schedules and worsened symptoms of depression, possibly impacting one’s functional abilities and motivation to engage. This might outline the need for further support to participants with planning at early stages of intervention to make home practice more manageable and ensure this is something they can commit to (Masheder, Fjorback and Parsons, 2020).
This report also explored the effectiveness of MBIs delivered remotely as a result of Covid-19 restrictions. The findings suggested that although there is a clear preference for face to face interactions, internet-based MBIs can be utilized effectively to help individuals with mental health problems. The key difficulties reported by participants included technological/connectivity problems among participants and clinicians. It is therefore plausible that with continuous development and improvement of online systems, internet-based MBIs could increase its effectiveness over time. This could increase accessibility to cost-effective treatments among individuals residing in remote geographical locations.
Limitations:
There are several important limitations in this audit worth noting. Firstly, pre-existing qualitative data collected from the NHS health boards were initially carried out at different time points, varying from 2018-2022. The most recent courses were delivered remotely due to Covid-19 and may not necessarily reflect the results of standard practices. The data also did not include details relating to individuals’ demographic information or diagnosis, therefore no comparisons could be made. The data also excluded information related to attendance, drop-out rates or follow-up sessions. The latter would have been useful in assessing the longer term effects of mindfulness training. Further, the data did not consistently indicate the type of intervention delivered (e.g., MBSR or MBCT). Therefore, it remains unclear what aspects of each intervention have been most or least useful within this report. The data provided by the NHS health boards often included only a small section of raw qualitative data. Some NHS boards only included data from one most recent course rather than two as originally requested. There was also very limited data for the MBIs delivered remotely. There have been several different evaluation forms and methods used across different NHS boards. This means that there were no standardised nor consistent measures to assess effectiveness of MBIs. The final analysis remains subjective as it relied on the researcher’s judgement due to the nature of this research.
Clinical Implications:
This report explored qualitative feedback related to perceived experiences of MBIs across several NHS health boards. The results suggested that MBIs can be effectively utilized to help with symptoms of anxiety, depression and stress among NHS staff and clinical populations. The report also outlined other challenges/barriers experienced including difficulty with planning and incorporating home based exercises and disengagement due to worsening in mental health. The findings also suggested that MBIs can be delivered remotely, however, further developments in technology and additional support may be needed to improve the experience of online based MBIs.
References:
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Keng, S.-L, Smoski, M.J., & Robins, C.J. (2011). Effects of mindfulness on psychological health: A review of empirical studies. Clinical Psychology Review, 31(6), 1041-1056. https://doi.org/10.1016/j.cpr.2011.04.006
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Masheder, J., Fjorback, L., & Parsons, C. E. (2020). “I am getting something out of this, so I am going to stick with it”:supporting participants’ home practice in Mindfulness-Based Programmes. BMC Psychology, 8(1). doi: https://doi.org/10.1186/s40359-020-00453-x
McCartney, M., Nevitt, S., Lloyd, A., Hill, R., White, R., & Duarte, R. (2020). Mindfulness‐based cognitive therapy for prevention and time to depressive relapse: Systematic review and network meta‐analysis. Acta Psychiatrica Scandinavica, 143(1), 6-21. doi: 10.1111/acps.13242
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Zhang, D., Lee, E. K. P., Mak, E. C. W., Ho, C. Y., & Wong, S. Y. S. (2021). Mindfulness-based interventions: an overall review. Britsih Medical Bulletin, 138(1), 41-57. https://doi.org/10.1093/bmb/ldab005