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Journal ArticleDOI

Participation in an Adapted Version of MBCT in Psychiatric Care

27 Jun 2012-Mindfulness (Springer US)-Vol. 3, Iss: 3, pp 218-226
TL;DR: In this article, an adapted version of MBCT was developed with nine instead of 8 weekly units, reduced duration of some exercises, and patients invited to make an active decision about continuing with the program or leaving the group after an introductory phase of the first three sessions.
Abstract: Mindfulness-based cognitive therapy (MBCT) groups are challenged by high attrition particularly in early sessions. This leads to disturbances in the composition of the groups and potential dissatisfaction. In order to support patients in their decision about participation and to accommodate the program to psychiatric patients, an adapted version of MBCT was developed with nine instead of 8 weekly units, reduced duration of some exercises, and patients invited to make an active decision about continuing with the program or leaving the group after an introductory phase of the first three sessions. 120 participants joined the program, 35 % decided to leave the program before the advanced stage started, and 50.8 % completed it. In a multiple logistic regression model, neither the degree of depression and mindfulness at onset nor sociodemographic variables could predict if participants would complete the program. The only significant predictor was the number of sessions attended in the introductory phase. In bivariate analyses, having participated in group therapies earlier strongly predicted if a person would complete sessions 1 to 3. The therapist’s assessment of the patient’s motivation and her/his predictions if the patient would leave the group preterm and if the patient would finalize the program regularly were also related to attrition. The modified version of MBCT has proved to be feasible and useful to stabilize the participants’ presence in the later sessions. Particular attention should be paid to patients who miss sessions in the introductory phase and for which the therapist recognizes low motivation or risk of dropping out.

Summary (2 min read)

Method

  • In primary care, most of the patients do not suffer from recovered depression but from active depression and often from additional psychiatric disorders like anxiety disorders, substance abuse, or personality disorders.
  • In order to lower the barrier for patients to join the course, it was divided into two parts: the introduction course consists of 3 weekly classes followed by the advanced stage (six sessions).
  • Patients who were interested in the MBCT program were offered a precourse interview after which they gave their commitment to participate in the introduction course.
  • Most of their patients were in outpatient psychiatric treatment (n087, 72.5 %), either at the outpatient CBT department (n049) or in psychiatric ambulatory practices (n038).
  • Table 2 compares the characteristics of the study sample with the two largest Table 1.

Decision about continuation

  • Advanced 4 Staying present Staying present 5 Thoughts–mood–bodyd (practice: sitting meditation (20 min); mindful walking (15 min)).
  • How can I best take care of myself 8 Early warning signsd (practice: 3-min breathing space; body scan (20 min)).

Main diagnosis (ICD-10)

  • A Data for 2007 are not available for inpatients due to changes in the clinical information system b Diagnoses according to ICD-10 unknown for externally referred patients populations from which the participants were recruited (inpatients from Psychiatric University Hospital without geriatric rehabilitation and outpatients from the CBT department) to illustrate the process of recruitment and (self-) selection.
  • A considerable proportion of the inpatients and outpatients in this study had already received CBT in a one-to-one setting before entering the MBCT program.
  • As most of the participants suffered from depressive symptoms and because MBCT was originally designed to prevent relapse in depression, the BDI (Beck et al.
  • In order to assess status and progression in mindfulness, a short form with 14 items of the German version of the FMI (short form; Walach et al.
  • Bivariate nonparametric correlations (Spearman-Rho) and χ2 tests were utilized to further elucidate the covariation of further interesting ordinal or nominal variables from the preclass interview with the completion of the introductory course or the full program.

Results

  • Overall, the MBCT program, together with the “treatment as usual” continued in parallel, resulted in reduced severity of the depressive symptoms as measured by the BDI and increased mindfulness as measured by the FMI and MAAS (Table 3).
  • The differences between the precourse measurement and the measurement at session 3, however, are all highly significant as well.
  • Completion of the introductory phase, at best having visited all three sessions, was a good predictor for finalizing the whole program in the bivariate analysis (χ2015.430, df01, p<0.001).
  • Only 17 (21.8 %) of those 78 persons who had decided to continue after the introductory phase left the group before the eighth session, and 61 (78.2 %) of the participants in the advanced stage completed the course.
  • For the finalization of the whole program, the preexisting experience with group therapies had no predictive value (χ200.899, df01, p00.343).

Discussion

  • Neither sex, age, or other demographic variables, nor the intensity of the depressive symptomatic (as measured by the BDI) or of preexisting mindfulness (as assessed by the FMI) are able to predict preterm leave from the Basel MBCT program.
  • There are significant differences between the participants in their study and those reported on in the literature.
  • Compared to most other studies in the mindfulness field, only few of the analyzed relations reached statistical significance.
  • Overall, the authors think that the study contributes to the understanding of how MBCT programs can deal with the patients’ expectations and, with not meeting all of them, gives useful evidence which subgroups of participants should be taken particular care of to reduce attrition from MBCT programs to a minimum.
  • The authors declare that they have no conflict of interest.

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ORIGINAL PAPER
Participation in an Adapted Version of MBCT
in Psychiatric Care
Jörg Herdt & Bernhard Bührlen & Klaus Bader &
Corina Hänny
Published online: 27 June 2012
#
Springer Science+Business Media, LLC 2012
Abstract Mindfulness-based cognitive therapy (MBCT)
groups are challenged by high attrition particularly in early
sessions. This leads to disturbances in the composition of the
groups and potential dissatisfaction. In orde r to support
patients in their decision about participation and to accommo-
date the program to psychiatric patients, an adapted version of
MBCT was developed with nine instead of 8 weekly units,
reduced duration of some exercises, and patients invited to
make an active decision about continuing with the program or
leaving the group after an introductory phase of the first three
sessions. 120 participants joined the program, 35 % decided to
leave the program before the advanced stage started, and
50.8 % completed it. In a multiple logistic regression model,
neither the degree of depression and mindfulness at onset nor
sociodemographic varia bles could predict if participants
would complete the program. The only significant predictor
was the number of sessions attended in the introductory phase.
In bivariate analyses, having participated in group therapies
earlier strongly predicted if a person would complete sessions
1 to 3. The therapists assessment of the patients motivation
and her/his predictions if the patient would leave the group
preterm and if the patient would finalize the program regularly
were also related to attrition. The modified version of MBCT
has proved to be feasible and useful to stabilize the partici-
pants p resen ce in th e later sessions. Particular attention
should be paid to patients who miss sessions in the introduc-
tory phase and for which the therapist recognizes low moti-
vation or risk of dropping out.
Keywords Mindfulness
.
Participation
.
Attrition
.
Compliance
.
Outcomes
.
Psychiatry
Introduction
In the last two decades, mindfulness-based interventions have
been incorporated into the treatment of a variety of psycho-
logical disorders. The mindfulness-based stress r eduction
(MBSR) program developed by Kabat-Zinn (1990)consists
of 8 weekly classes of 2.5 h each plus an all-day 6-h class on a
weekend day. Mindfulness-based cognitive therapy (MBCT;
Segal et al. 2002) is an 8-week group intervention program
that integrates mindfulness training with elements of cognitive
behavioral therapy (CBT). Its purpose is the prevention of
relapse in patients who have recovered from depression.
While most of the first episodes of depression are triggered
by major life events, ruminative thinking style in reaction to
low mood appears to be relevant for relapses (Nolen-
Hoeksema et al. 2008). Previous studies have demonstrated
that MBCT, when taught to nondepressed patients with a
history of three or more episodes of depression, reduces the
rate of relapse by 50 % (Ma and Teasdale 2004; Teasdale et al.
2000). Kenny and Williams (2007) showed that even
treatment-resistant depressed patients showed good response
to the MBCT program and experienced an improvement in
depression scores. Kingston et al. (2007) applied MBCT to
patients with active depression with moderate severity and
found improvements in depression and reductions in rumina-
tion. The application of MBCT therefore was expanded to
include patients whose depression took a chronic course
(Kenny and Williams 2007).
Variations of the MBCT Program
The duration of the MBSR and MBCT prog rams was
designed to be long enough that participants could learn
the principles of mindfulness and mindfulness practice.
But for some clinical groups , such as inpatient populations,
the severity of their condition might exclude them from
J. Herdt (*)
:
B. Bührlen
:
K. Bader
:
C. Hänny
Psychiatric University Clinics Basel,
Wilhelm Klein-Strasse 27,
4012 Basel, Switzerland
e-mail: joerg.herdt@upkbs.ch
Mindfulness (2012) 3:218226
DOI 10.1007/s12671-012-0120-7

participation in longer sessions. Therefore, an increasing
number of authors published abbreviated versions of the
two programs for particular clinical groups such as cancer
patients or patients with active depression (Finucane and
Mercer 2006). Finucane and Mercer (2006) shortened some
of the longer meditations and found that this form of MBCT
training was both acceptable and beneficial to the majority
of patients that suffered from active depression and anxiety.
Carmody and Baer (2 009) investigated if the number of in-
class hours in MBSR programs were related to the extent of
improvement in psychological functioning. They found no
evidence that shortened versions of the MBSR program are
less effective than the original format in reducing psycho-
logical distress and that shortened versions of the program
merit further study.
Compliance with the Program
The research on MBCT is still in its infancy, and outcome
studies are suffering from diverse methodological restric-
tions (Coelho et al. 2007). Even less is known about the
determinants of participation in MBCT groups, predictors of
attrition from the standardized group programs, and factors
that contribute to the therapeutic effects.
As regards the psychological processes, individuals with
high levels of cognitive reactivity, brooding, and depressive
rumination had a higher chance to drop out from MBCT;
although if they remained in the class, they were likely to
have the most to gain from the development of mindfulness
skills (Crane and Williams 2010). Regarding the severity of
the disorder, having a history of two rather than three or more
episodes of depression and having a history of attempted
suicide were associated with increased likelihood of dropout.
In their qualitative study, Langdon et al. (2011) found that
older people initially were less open to mindfulness than
younger participants. Previous therapeutic experience helped
to establish the practice, and perseverance and increased prac-
tice improved the motivation to continue. Mindfulness prac-
tice was generally seen as requiring effort and discipline, with
many obstacles reaching from resistance, stress, tiredness,
anxiety, and depression, over the beliefs about the effective-
ness of mindfulness to the influence of significant others.
In actual review articles (Chiesa and Serretti 201 1; Klainin-
Yobas et al. 2012; Piet and Hougaard 2011), dropout-rates are
not reported. Attrition rates reported in original articles vary
considerab ly betwee n values of 33 % (G od f rin and van
Heeringen 2010), 1517 % (Crane and Williams 2010), 10 %
(Bondolfi et al. 2010), and 1 % (Kenny and W illiams 2007).
Particularly in the first sessions, participants may be
confronted with a discrepancy of their first experiences with
meditation from what they had expected (Sears et al. 2011).
Early dropout is also identified as a common finding for
MBSR (Dobkin et al. 2012).
Attrition and Processes of (Self-)selection
Attrition rates are strongly dependent on the processes and
criteria by which patients decide to apply for participation or
by which patients are selected for participation in an MBCT
program. With very strict inclusion and exclusion criteria,
Kenny and Williams (2007) yielded a rate of 49 out of 50
(98 %) participants who completed the course. Besides certain
diagnostic criteria, only patients with long-lasting, strong,
treatment-resistant depressive symptoms were admitted; their
depressive symptoms had to be related to the presence of
ruminative thought patterns. Participants had to undergo a
clinical interview in which their motivation to use meditation
as a means to manage their me ntal health was checked.
Beyond a strong motivation, they had to be prepared to attend
all classes and to practice between classes for 1 h per day.
Substance abuse that might interfere with meditation in clear
consciousness was excluded. Nearly all participants were out-
patients referred to the program by external general practi-
tioners or psychiatrists (Kenny and Williams 2007). In their
uncontrolled trial with patients who, besides the MBCT
groups, received additional other antidepressive treatment,
highly significant reductions in depression were recorded
(Beck depression inventory (BDI) pre-MBCT: M 0 24.3,
SD0 9.8; post-MBCT: M
0 13.9, SD0 9.7, p>0.0001).
In the study by Eisendrath et al. (2008), the participants
were equally homogeneous with actual strong, treatment-
resistant depressive symptoms. Fifty-one out of 55 partic-
ipants completed the whole program consisting of eight 2-
h weekly sessions. All parti cipants ha d been outpatients,
having willingly chosen to learn MBCT, and therefore were
ascribed a potentially high motivation by the authors. Other
inclusion criteria or details of the admission process were
not reported. The patients benefited from the course; al-
though due to the single-group study design and parallel
other treatments, the effects could not be attributed to the
MBCT program alone: depression and anxiety levels de-
creased s ignific antly (BDI pretreatment: M0 23.96, SD0
10.00; posttreatment: M 0 14.61, SD0 9.28, p<0.001).
Mindfulness inc reased (Freib urg mindfulnes s invento ry
(FMI) pretreatment: M0 67.26, SD0 11.7; pos ttreat ment
M0 73.55, SD0 11.6, p<0.01). Increased mindfulness was
associated with decreas ed depression levels.
Crane and W illiams (2010) reported dropout rates of 15
17 % of patients allocated to MBCT before their fourth session,
thereof about 50 % even before the first treatment session. The
sample of outpatients was recruited as a part of a randomized
controlled trial (RCT) on MBCT delivered to patients with
bipolar disorder in remission with a history of serious suicidal
ideation or behavior. Inclusion criteria were at least one prior
episode of major depression accompanied by serious suicidal
ideation, NIMH criteria for recovery at the time of participation
(not more than 1 week of minimal depressive symptoms in the
Mindfulness (2012) 3:218226 219

past 8 weeks), and no manic episodes for at least 6 months. One
hundred twenty-eight persons contacted the group and were
interested in participating, 83 thereof were eligible, and 15 of
these did not attend their first assessment or withdrew directly
after it (Williams et al. 2008). Thus, 60 of the 128 persons
interested (47 %) did not enter the program. The remaining 68
participants were randomized to either immediate treatment
with MBCT (n0 33) or to the waitlist (n0 35). Ten out of the
33 MBCT particip ants (30 %) dropped out of treatment (Crane
and Williams 2010 ).
Patients who participated in the RCT by Godfrin and van
Heeringen (2010) were treated at the outpatient clinic of the
University Department of Psychiatry of the University
Hospital Ghent. They had deliberately applied for participa-
tion because of their interest in the program, thus a positive
attitude towards MBCT can be assumed. Despite that, the
dropout rate of 33 % within the MBCT group was relatively
high. In the framework of RCTs, strict inclusion criteria are
defined to improve internal validity (e.g., homogeneous pa-
tient groups); this results in high participation of persons who
will potentially benefit from the treatment. After public infor-
mation through media announcements and mailings to psy-
chiatrists and general practitioners, 600 persons signaled
interest in participation in the study of Bondolfi et al.
(2010); only 142 persons remained. The main reasons for
exclusion were that participants had an ongoing acute depres-
sive episode, had less than three previous depressive episodes,
were too old or too young, were not able to discontinue the
antidepressant medication, met diagnostic criteria for a bipolar
mood disorder, and were not interested in being a research
participant. In the course of further selection interviews, addi-
tional 71 potential participants were excluded mainly because
they did not meet the diagnostic criteria. Eleven more dropped
out in the 3-month run-in phase during which mood had to
remain stable. Of the 31 participants in the MBCT program,
90 % completed the treatment.
A review of RCTs (Fjorback et al. 2011) concluded that
results are often biased due to self-selection. The participa-
tion in an MBCT program requires a certain amount of
active involvement; therefore, it is regarded worthwhile that
patients make an active decision for the treatment. In the
largest part of the existing studi es, the participants are thor-
oughly selected based on their motivation to participate and
openness to the method (e.g., Kenny and Williams 2007).
The authors therefore presume that the results from such
studies can only be generalized to persons who dispose of
interest and the necessary preconditions for participation in
an MBSR /MBCT program (Fjorback et al. 2011).
Aim of the Present Study
In order to ameliorate some of the participants difficulties
especially in the first phase of an MBCT course, a modified
version of the MBCT program was developed at the
Psychiatric University Cli nics in Basel, Switzerland in
2007 (Hänny and Bader 2008).The program consisted of
nearly all elements of the original. Besides a reduction of the
session duration to 1.5 h in recognition of the frequent
attention deficits of the target group, the main specific
feature was the introduction of an initial phase with three
sessions after which the patients were asked for an active
decision to stop or continue their participation. Depression
and mindfulness states were measured and reasons for drop-
out were monitored.
The aim of this study was to investigate the acceptability of
the adapted version of the MBCT program in routine psychi-
atric care for inpatients and outpatients with recovered or
active depressive symptoms or other psychiatric disorders.
Of special interest were the determinants of attrition from
the treatment and the characteristics of patients who continued
with the advanced course after attending the introduction part.
Method
Procedure
In primary care, most of th e patients do not suffer from
recovered depression but from active depression and often
from additional psychiatric disorders like anxiety disorders,
substance abuse, or personality disorders. These patients have
a range of ongoing symptoms like concentration deficit, loss
of interest, or psychomotor agitation, that may be a barrier to
their ability or willingness to practice mindfulness. Because of
this, we decided to adapt the original MBCT program for this
special group of patients. The sessions were shortened from 2
to 1.5 h weekly, and the duration of the longer meditations, for
example, the body scan and the guided sitting meditations,
was reduced to a maximum of 2025 min. In addition, we
extended the program from 8 to 9 weeks.
In order to lower the barrier for patients to join the
course, it was divided into two parts: the introduction course
consists of 3 weekly classes followed by the advanced stage
(six sessions). Patients who were interested in the MBCT
program were offered a precourse interview after which they
gave their commitment to participate in the introduction
course. After three sessions, they were asked if they wanted
to continue with mindfulness practice and attend the ad-
vanced stage. In giving the patients the opportunity to con-
tinue with the group course after they left or entered the
inpatient treatment, we treated inpatient and outpatient with-
in the same course. The scheme indicating the modifications
of the Basel vs. the original program as well as the scheme
for evaluation can be found in Table 1. More information is
found in Hänny and Bader (2008) and can be obtained from
the authors.
220 Mindfulness (2012) 3:218226

Participants
In total, 120 patients were treated in 14 consecutive MBCT
courses which were provided by the outpatient CBT depart-
ment of the Psychiatric University Hospital in Basel,
Switzerland. The first patient entere d the group in June
2007, the last patient reported on here started in January
2011. All interested persons underwent an orientating inter-
view. Most of our patients were in outpatient psychiatric
treatment (n0 87, 72.5 %), either at the outpatient CBT
department (n0 49) or in psychiatric ambulatory practices
(n0 38).
More than one fourth (n0 33, 27.5 %) were in inpatient
treatment at the Psychiatric University Hospital (department
for privately insured patients). Fifty-five persons (45.8 %)
were male, 65 (54.2 %) were female, the age ranged from 22
to 79 years (mean age M0 48.9 years, SD0 13.75).
The diagnostic spectrum was broad, largely representing
the relatively unfiltered access of psychiatric patients to the
program. At admission, 49 (40.8 %) of the participants were
diagnosed with a primary depressive disorder. Most frequent
diagnoses besides the depressive syndromes, of which six
were remitted, reached from anxiety disorders (17, 14.1 %),
seven (5.8 %) disorders due to psychoactive substance use,
six (5 %) personality disorders, and various less frequent
disorders. Only patients suffering from acute psychosis or
mania, current substance abuse, or severe personality disor-
ders were excluded from the program. Table 2 compares the
characteristics of the study sample with the two largest
Table 1 The adapted version of MBCT group program and evaluation scheme
Section Session Adapted MBCT program Original MBCT program
Precourse interview: anamnesis, information; baseline evaluation: BDI
a
, FMI
b
, MAAS
c
Introduction 1 Automatic pilot Automatic pilot
2 Dealing with barriers Dealing with barriers
Interim Evaluation: BDI, FMI, MAAS
3 Allowing/letting be
d
(practice: body scan (20 min); seeing meditation (10 min);
breathing space (3-min))
Mindfulness of the breath
Decision about continuation
Advanced 4 Staying present Staying present
5 Thoughtsmoodbody
d
(practice: sitting meditation (20 min); mindful walking
(15 min))
Allowing/letting be
6 Thoughts are not facts Thoughts are not facts
7 How can I best take care of myself How can I best take care of myself
8 Early warning signs
d
(practice: 3-min breathing space; body scan (20 min)) Using what has been learned to deal
with future moods
Final evaluation: BDI, FMI, MAAS, exercise protocols, patient satisfaction
9 Using what has been learned to deal with future moods
a
Beck depressions-inventar (BDI-II) (Hautzingeret al. 2006)
b
Freiburg mindfulness inventory short form (Walach et al. 2006)
c
Mindfulness attention awareness scale (German version; Michalak et al. 2008)
d
New elements
Table 2 Participants compared to populations of origin
MBCT program
sample (%)
(20072010)
Inpatient
population (%)
(20082010
a
)
Outpatient CBT
population (%)
(20072010)
Main diagnosis (ICD-10)
Unknown
b
34.2 13.8
F0 5.7 0.2
F1 5.8 13.9 0.9
F2 6.8 0.8
F3 40.8 63.4 10.7
F4 17.5 8.8 51.4
F5 1.7 0.3 11.1
F6 0.9 8.1
F7 0.3
F8 0.2
F9 0.6
Other (G,
H, I, S, Z)
2.1
Total 100 100 100
Male 45.8 43.9 37.5
Female 54.2 56.1 62.5
Age, M (SD) 48.9 (13.75) 56.1 (20.87) 37.6 (12.71)
a
Data for 2007 are not available for inpatients due to changes in the
clinical information system
b
Diagnoses according to ICD-10 unknown for externally referred
patients
Mindfulness (2012) 3:218226 221

populations from which the p articipants were recruited
(inpatients from Psychiatric University Hospital without
geriatric rehabilitation and outpatients from the CBT depart-
ment) to illustrate the process of recruitment and (self-)
selection. No valid reference data are available for the third
population of origin (outpatients treated by psychiatrists in
private practice).
Though most participants were in outpatient treatment,
the sample in the MBCT program resembles much more the
inpatient than the outpatient population. A considerable
proportion of the inpatients and outpatients in this study
had already received CBT in a one-to-one setting before
entering the MBCT program. All other treatmen ts in parallel
to MBCT were continued.
Materials
The data collection consisted of three measurements: before
entering the program, in week 2 after beginning (assessed
between sessions 2 and 3), and in week 8 (assessed between
sessions 8 and 9). Instruments used were a guidance for the
preclass interview collecting sociodemographic character-
istics, diagnoses, actual use of pharmaceuticals, and preex-
isting experience with mindfulness exercises.
Preclass interview data, besides information o n earlier
and actual treatments and meditation experience, included
the therapists assessment of the patients motivation on a
rating scale (16) and the therapists prediction if the patient
would leave the program early (yesno).
As most of the participants suffered from depressive
symptoms and because MBCT was originally designed to
prevent relapse in depression, the BDI (Beck et al. 1961;
Hautzinger et al. 2006) was used as outcome measure. The
BDI is one of the best established measures of depressive
symptomatology; 2 1 statements ref er to t he pres e nce of
typical depressive symptoms within the preceding 2 weeks.
In order to assess stat us and progression in mindfulness, a
short form with 14 items of the German version of the FMI
(short form; Walach et al. 2006; Walach et al. 2009) and the
German version of the mindfulness attention awareness
scale (MAAS; Brown and Ryan 2003;Michalaketal.
2008) were applied at the three points of measurement.
The FMI asks for openness for the experience of th e
moment, feeling ones body, returning to the experience of
the moment after absence, self-esteem, regard of ones
motives for action, unjudging view on ones mistakes and
problems, contact with ones e xperi en ces, acce pta nce of
unpleasant experiences, being friendly to oneself when
things go wrong, watching emotions without losing oneself
within them, ability to pause in difficult situations, experi-
ence of inner silence and serenity even when there is exter-
nal pain and inquietude, being impatient with ones fellows,
and the ability to smile when seeing how many difficulties
one introduces into the own life. The instrument has been
confirmed as a construct valid (significant correlation with
relevant constructs as self-awareness, dissociation, global
severity index, meditation experience in years) and a reliable
questionnaire for measuring mindfulness (Cronbachs
alpha0 0.86; Walach et al. 2006).
The MAAS consists of 15 items which cover difficulties
in being mindful in different circumstances: having a feeling
which only later becomes conscious, breaking or pouring
out things because of unattentiveness, difficulties to remain
concentrated, neglecting the experiences while being under-
way, inability to recognize feelings of distress, forgetting
names quickly, functioning automatically, rushing through
activities without really paying attention, loosing contact to
processes, doing tasks automatically, listening with only
one ear, driving to places without knowing how one came
there, ruminati ng about future or past, doing things without
attention, and eating without being conscious. Concerning
reliability and validity, the German version of the MAAS
shows indices comparable to the original scale (single factor
structure, internal consistency of Cronbachs alpha0 0.83,
associations with symptom distress and subjective well-
being (Michalak et al. 2008). The items of all three ques-
tionnaires can be integrated into one general score each.
Finally, at the last measurement, the participants were
asked to complete questions about how often they had
practiced the different forms of formal and informal medi-
tation in the last 6 weeks, how important the course was for
them, a nd if they would recomme nd it to other people.
Remarks were allowed, and as far as possible, the reasons
for dropouts were noted.
Data Analysis and Statistics
The data analysis was carried out with IBM SPSS Release
19.0.0 (International Business Machines Corp. 2011). Main
method of analys is was a multiple logistic regression of the
conceptually most relev ant variables to predict completion
of the co urse. Th e latter was d efined as participati on in
sessions 8 or 9 . Bivariate nonparametric correlations
(Spearman-Rho) and χ
2
tests were utilized to further eluci-
date the covariation of further interesting ordinal or nominal
variables from the preclass interview with the completion of
the introductory course or the full program.
Results
Overall, the MBCT program, together with the treatment as
usual continued in parallel, resulted in reduced severity of
the depressive symptoms as measured by the BDI and
increased mindfulness as measured by the FMI and
MAAS (Table 3).
222 Mindfulness (2012) 3:218226

Citations
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Abstract: Mindfulness-based interventions (MBIs) are at a pivotal point in their future development. Spurred on by an ever-increasing number of studies and breadth of clinical application, the value of such approaches may appear self-evident. We contend, however, that the public health impact of MBIs can be enhanced significantly by situating this work in a broader framework of clinical psychological science. Utilizing the National Institutes of Health stage model (Onken, Carroll, Shoham, Cuthbert, & Riddle, 2014), we map the evidence base for mindfulness-based cognitive therapy and mindfulness-based stress reduction as exemplars of MBIs. From this perspective, we suggest that important gaps in the current evidence base become apparent and, furthermore, that generating more of the same types of studies without addressing such gaps will limit the relevance and reach of these interventions. We offer a set of 7 recommendations that promote an integrated approach to core research questions, enhanced methodological quality of individual studies, and increased logical links among stages of clinical translation in order to increase the potential of MBIs to impact positively the mental health needs of individuals and communities.

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TL;DR: Mindfulness-based cognitive therapy (MBCT) is a class-based program designed for use in the prevention of relapse of major depression as mentioned in this paper, which aims to teach participants to disengage from those cognitive processes that may render them vulnerable to future episodes.
Abstract: Mindfulness-based Cognitive Therapy (MBCT) is a class-based programme designed for use in the prevention of relapse of major depression. Its aim is to teach participants to disengage from those cognitive processes that may render them vulnerable to future episodes. These same cognitive processes are also known to maintain depression once established, hence a clinical audit was conducted to explore the use of MBCT in patients who were currently actively depressed, and who had not responded fully to standard treatments. The study showed that it was acceptable to these patients and resulted in an improvement in depression scores (pre-post Effect Size=1.04), with a significant proportion of patients returning to normal or near-normal levels of mood. (Reprinted with permission from Behaviour Research and Therapy 2007; 45:617–625)

88 citations

Journal ArticleDOI
TL;DR: Chiesa et al. as mentioned in this paper discuss attrition factors, potential adverse effects of mindfulness, and populations contraindicated for mindfulness-based techniques, as well as screening tools for individuals interested in participating in mindfulness based practices and techniques.
Abstract: Mindfulness is generally regarded as a "quality of consciousness" (Brown, Ryan, & Creswell, 2007, p. 211); beyond this consensus, however, disagreement abounds. Currently, an abundance of evidence supports the benefits of mindfulness (e.g., Brown & Ryan, 2003; Eberth & Sedlmeier, 2012), with some researchers suggesting that the therapeutic benefits of mindfulness may be transdiagnostic (i.e., beneficial for a range of emotional and physical concerns as well as effective across a diversity of populations; e.g., Baer, 2007). Indeed, in such a climate of positive expectation, Ng (1999) suggested that "there may be social pressures upon the individual to experience and report benefits" (p. 203). Such fervor may have arrested a more balanced and temperate investigation of mindfulness (Brazier, 2013), and the existing evidence may be of questionable validity given a lack of conceptual and operational agreement as well as research designs of varying rigor (Chiesa & Malinowski, 2011; Goyal et al., 2014). Although the mindfulness literature undeniably suffers from the standard criticisms of modern scientific inquiry--methodological concerns, inadequate sample diversity, insufficient multicultural sensitivity, and so forth (e.g., Hickey, 2010)--this article primarily presents gaps more unique to the mindfulness literature In this pursuit, we address current conflicts and gaps within the mindfulness literature, not as an exhaustive critique, but as an aggregation of concerns in hopes of stimulating dialogue and empirical attention to those areas in need of greater clarification. First, we introduce the roots of mindfulness, as informed by the Buddhist canon. Second, we address the difficulties Western researchers continue to navigate in conceptually and operationally defining mindfulness. Third, we examine differences between two commonly conflated mindfulness practices: mindfulness meditation (MM) and mindfulness-based interventions (MBIs). Fourth, we discuss attrition factors, potential adverse effects of mindfulness, and populations contraindicated for mindfulness-based techniques. Finally, we review screening tools for individuals interested in participating in mindfulness-based practices and techniques, along with implications for practice. * What Is Mindfulness? History and Conceptual Definitions Mindfulness is a central element of Buddhist scriptures, specifically addressed in the Abhidhamma, a collection of Buddhist psychological and philosophical treatises. Foundationally, the Buddhist tradition holds that suffering is fundamental to the human condition (Hanh, 1998). However, the Buddhist tradition also contends that suffering can be overcome by means of the Four Noble Truths (suffering exists, the origin of suffering can be known, suffering can end, and the end of suffering is the Eightfold Path) and the Eightfold Path (right understanding, right thought, right speech, right action, right livelihood, right effort, right mindfulness, and right concentration; Hanh, 1998). Situated as the seventh element of the Eightfold Path, mindfulness has been traditionally understood as "an understanding of what is occurring before or beyond conceptual and emotional classification about what is or has taken place" (Chiesa, 2013, p. 256). Within the Buddhist context, the development of mindfulness is not taken as a goal itself, but as a means of reducing suffering and promoting psychological well-being (Chiesa, 2013). Therefore, right mindfulness is an important qualifier given that mindfulness has been traditionally grounded in an ethical (i.e., Buddhist) framework, which situates mindful practice as a means to a greater end. Difficulty understanding mindfulness begins with the translation of the Sanskrit word smriti or the Pali word sati. (Both Sanskrit and Pali are classical languages of India.) Smriti and sati are often translated into English as mindfulness and denote a quality of consciousness applied to internal and external phenomena such that experiences are clearly perceived, unmuddled by preconceptions and biases. …

49 citations

Journal ArticleDOI
TL;DR: In this article, the effects of MBCT on relapse/recurrence in depression were investigated and the mean time to first relapse and recurrence was 39.5 weeks and 53.7 weeks, respectively.

43 citations

Journal ArticleDOI
TL;DR: It is indicated that text messaging following inpatient treatment is feasible for some, but not for all people with depressive symptoms, and dose and ingredients of the intervention should be increased for this group of patients in a future full-size RCT.
Abstract: BACKGROUND: It has been shown that mindfulness practice can be helpful in preventing relapse from depression. However, practicing mindfulness regularly at home is often a challenge for people with depression. Mobile phone text messaging (short message service, SMS) may be a feasible approach to assist regular mindfulness home practice. OBJECTIVE: The aim of this study was to evaluate the feasibility of text message-based feedback to support mindfulness practice in people with depressive symptoms after inpatient psychiatric treatment. METHODS: Participants received a manualized group introduction to three mindfulness exercises during inpatient treatment and were randomized at hospital discharge. All participants were asked to practice the exercises daily during the 4-month follow-up period. Only participants allocated to the intervention group received reinforcing feedback via mobile phone text messages after reporting their mindfulness practice via text message. Participation rates and satisfaction with the interventions were evaluated, and effects on relevant outcomes were explored. RESULTS: Of the 176 eligible inpatients invited to participate, 65.9% (116/176) attended the introductory mindfulness group at least once, 33.0% (58/176) were willing to participate in the study, and 41 were randomized. The majority 85% (35/41) of these participants completed the study. Among the participants allocated to the intervention group (n=21), 81% (17/21) used the text message support at least once. The average number of text messages sent during the intervention period was 14 (SD 21, range 0-91). Satisfaction rates were high. Preliminary analyses of the effects of the intervention yielded mixed results. CONCLUSIONS: Findings indicate that text messaging following inpatient treatment is feasible for some, but not for all people with depressive symptoms. Modest use of the text messaging intervention and its mixed effects imply that dose and ingredients of the intervention should be increased for this group of patients in a future full-size RCT. Such a larger study should also include a process evaluation to investigate moderators of the effect of mindfulness practice and text message feedback on clinical outcome.

11 citations


Cites background or result from "Participation in an Adapted Version..."

  • ...Similar, sometimes higher, attrition rates were found in studies evaluating mindfulness-based interventions in depressed patients delivered face-to-face (49% [5]; 8-38% [2]) or via the Internet or mobile phone (57% [14]; 38% [15])....

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  • ...Although some studies evaluated mindfulness-based interventions for inpatients with psychosis or borderline personality disorder (eg, [3,4]), to our knowledge, only one study has evaluated mindfulness techniques in depressed inpatients [5]....

    [...]

References
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Book
01 Jan 1989
TL;DR: Hosmer and Lemeshow as discussed by the authors provide an accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets.
Abstract: From the reviews of the First Edition. "An interesting, useful, and well-written book on logistic regression models... Hosmer and Lemeshow have used very little mathematics, have presented difficult concepts heuristically and through illustrative examples, and have included references."- Choice "Well written, clearly organized, and comprehensive... the authors carefully walk the reader through the estimation of interpretation of coefficients from a wide variety of logistic regression models . . . their careful explication of the quantitative re-expression of coefficients from these various models is excellent." - Contemporary Sociology "An extremely well-written book that will certainly prove an invaluable acquisition to the practicing statistician who finds other literature on analysis of discrete data hard to follow or heavily theoretical."-The Statistician In this revised and updated edition of their popular book, David Hosmer and Stanley Lemeshow continue to provide an amazingly accessible introduction to the logistic regression model while incorporating advances of the last decade, including a variety of software packages for the analysis of data sets. Hosmer and Lemeshow extend the discussion from biostatistics and epidemiology to cutting-edge applications in data mining and machine learning, guiding readers step-by-step through the use of modeling techniques for dichotomous data in diverse fields. Ample new topics and expanded discussions of existing material are accompanied by a wealth of real-world examples-with extensive data sets available over the Internet.

35,847 citations

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TL;DR: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out and a wide variety of psychiatric rating scales have been developed.
Abstract: The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations." Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15These have been well summarized in a review article by Lorr11on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific

35,176 citations


"Participation in an Adapted Version..." refers methods in this paper

  • ...As most of the participants suffered from depressive symptoms and because MBCT was originally designed to prevent relapse in depression, the BDI (Beck et al. 1961; Hautzinger et al. 2006) was used as outcome measure....

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Journal ArticleDOI

11,174 citations

Journal ArticleDOI
TL;DR: Correlational, quasi-experimental, and laboratory studies show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced self-awareness.
Abstract: Mindfulness is an attribute of consciousness long believed to promote well-being. This research provides a theoretical and empirical examination of the role of mindfulness in psychological well-being. The development and psychometric properties of the dispositional Mindful Attention Awareness Scale (MAAS) are described. Correlational, quasi-experimental, and laboratory studies then show that the MAAS measures a unique quality of consciousness that is related to a variety of well-being constructs, that differentiates mindfulness practitioners from others, and that is associated with enhanced selfawareness. An experience-sampling study shows that both dispositional and state mindfulness predict self-regulated behavior and positive emotional states. Finally, a clinical intervention study with cancer patients demonstrates that increases in mindfulness over time relate to declines in mood disturbance and stress. Many philosophical, spiritual, and psychological traditions emphasize the importance of the quality of consciousness for the maintenance and enhancement of well-being (Wilber, 2000). Despite this, it is easy to overlook the importance of consciousness in human well-being because almost everyone exercises its primary capacities, that is, attention and awareness. Indeed, the relation between qualities of consciousness and well-being has received little empirical attention. One attribute of consciousness that has been much-discussed in relation to well-being is mindfulness. The concept of mindfulness has roots in Buddhist and other contemplative traditions where conscious attention and awareness are actively cultivated. It is most commonly defined as the state of being attentive to and aware of what is taking place in the present. For example, Nyanaponika Thera (1972) called mindfulness “the clear and single-minded awareness of what actually happens to us and in us at the successive moments of perception” (p. 5). Hanh (1976) similarly defined mindfulness as “keeping one’s consciousness alive to the present reality” (p. 11). Recent research has shown that the enhancement of mindfulness through training facilitates a variety of well-being outcomes (e.g., Kabat-Zinn, 1990). To date, however, there has been little work examining this attribute as a naturally occurring characteristic. Recognizing that most everyone has the capacity to attend and to be aware, we nonetheless assume (a) that individuals differ in their propensity or willingness to be aware and to sustain attention to what is occurring in the present and (b) that this mindful capacity varies within persons, because it can be sharpened or dulled by a variety of factors. The intent of the present research is to reliably identify these inter- and intrapersonal variations in mindfulness, establish their relations to other relevant psychological constructs, and demonstrate their importance to a variety of forms of psychological well-being.

9,818 citations


"Participation in an Adapted Version..." refers methods in this paper

  • ...2009) and the German version of the mindfulness attention awareness scale (MAAS; Brown and Ryan 2003; Michalak et al. 2008) were applied at the three points of measurement....

    [...]

  • ...…in mindfulness, a short form with 14 items of the German version of the FMI (short form; Walach et al. 2006; Walach et al. 2009) and the German version of the mindfulness attention awareness scale (MAAS; Brown and Ryan 2003; Michalak et al. 2008) were applied at the three points of measurement....

    [...]

01 Jan 2005
TL;DR: Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness book.

5,362 citations


"Participation in an Adapted Version..." refers methods in this paper

  • ...The mindfulness-based stress reduction (MBSR) program developed by Kabat-Zinn (1990) consists of 8 weekly classes of 2.5 h each plus an all-day 6-h class on a weekend day....

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Frequently Asked Questions (1)
Q1. What are the contributions in "Participation in an adapted version of mbct in psychiatric care" ?

In this paper, an adapted version of MBCT with nine instead of 8 weekly units, reduced duration of some exercises, and patients invited to make an active decision about continuing with the program or leaving the group after an introductory phase of the first three sessions.