In 2013, Oasis-Talk became one of a number of qualified providers of IAPT mental health services for Bristol and South Gloucestershire, delivering one-to-one support and a range of courses for NHS patients.
Included in these courses is an eight-week mindfulness programme, ‘Mindful Living’. Incorporating the core features of mindfulness-based stress reduction (MBSR) and mindfulnessbased cognitive therapy (MBCT), the course is aimed largely at people experiencing stress and/or anxiety, but with an element of relapse prevention for people with chronic depression. An additional programme, ‘Living Mindfully with Stress and Illness’, supports people living with long-term health conditions, fatigue and chronic pain.
Course participants are recruited from a number of sources. These include: self-referral to the IAPT service; referral to the IAPT service via a health professional; direct referral onto the course by counsellors or CBT therapists, following treatment; and, direct referral from other courses in the psycho-educational programme.
The course aims to:
- help participants develop the ability to ground and stabilise themselves by developing calm, non-judgmental awareness of breath, body and sensory impressions
- increase participants’ awareness of habitual patterns of thinking, feeling and reacting, and the effect that these have on mood, so that they can make conscious choices about how to respond to difficulties and challenges
- develop a calm, spacious and nonjudgmental perspective, based on kindness and self-compassion, increasing self-acceptance and the ability to ‘step back’ from unhelpful patterns of reaction
- improve mood by enhancing enjoyment of everyday aspects of life
- improve self-care by increasing awareness of behaviours that negatively impact wellbeing.
Courses follow the eight-week format typical of MBCT and MBSR programmes and are led by qualified and experienced mindfulness teachers from a variety of backgrounds, including mental health, teaching and occupational therapy, all of whom follow the good practice guidelines developed by the UK Network of Mindfulness-Based Teachers.1
The core mindfulness meditations are practised together during the sessions; these are followed by guided enquiry, to explore and reflect upon personal experience. There is also an expectation that participants will practise at home between sessions, including the development of mindfulness in daily life. We provide workbooks and guided audio links.
How the course differs from other mindfulness-based programmes
The majority of new IAPT referrals are assessed by a central triage service, rather than by Oasis-Talk. In addition, the mindfulness courses are classed as ‘low-intensity’ psycho-educational courses, despite being more in depth than other courses in this category. These factors have affected recruitment to the courses and have required modifications in how they are run. We have encountered the following challenges:
(i) Assessment and orientation: Assessors in the central triage service are trained in CBT, but very few have training in mindfulness. Referrals are also received from counsellors or CBT therapists who have a variable understanding of mindfulness. There is little scope for mindfulness teachers to carry out their own assessment and orientation sessions, as would normally be the case with mindfulness courses, so there is greater likelihood of inappropriate referrals. These may include patients with severe, enduring and complex mental health issues, who may be actively depressed rather than in recovery, or who may be too anxious to engage with the course.
(ii) Session length: Sessions are one-and-a-half hours long, rather than the two to two-and-a-half hours, common to most mindfulness courses. This means that particular care needs to be taken to maintain a balance between meditation practice and didactic content. It also means that there is less time for the guided reflection (known as ‘enquiry’) that encourages experiential learning and personal insight.
(iii) No day retreat or follow-up sessions: These are included in many mindfulness courses and can be very helpful in consolidating personal practice and providing ongoing support.
In an attempt to address these issues, assessment notes for patients referred to the courses are reviewed and contact details given to the course facilitators (most of whom are freelance), so that they can carry out a brief additional assessment and orientation by phone. The IAPT assessors have been made aware of referral criteria and contraindications through on-site presentations and written guidance notes. Session duration has been modified to two hours for the ‘Living Mindfully with Stress and Illness’ course, and we have made course participants aware of external opportunities for retreat days and follow-up sessions.
The evaluation project
Given these constraints, I wanted to carry out an evaluation of the courses, in order to answer the following questions and find out whether there are lasting benefits beyond the end of the course:
- Are course participants continuing to practise mindfulness six months after the course ends?
- If so, why did they decide to continue the practice?
- If not, why did they discontinue the practice?
- Using standard IAPT measures and qualitative feedback, have they experienced an improvement, decline or no difference in levels of anxiety and depression, and in the impact of their mood on work and routine activities?
- If participants have continued to practise mindfulness, which practices have they adopted, and how frequently?
- If they are continuing to practise, what do they feel are the main benefits of doing so?
I also wanted to see whether there was any noticeable difference in wellbeing between those who have continued, and those who have discontinued, their mindfulness practice.
Participants for the evaluation project were recruited from ‘Mindful Living’ and ‘Living Mindfully with Stress and Illness’ courses over a period of 12 months. A letter was distributed in the final week of the course, inviting course attendees to participate in the project, and obtaining their written consent.
After six months, participants were sent a pack containing an IAPT standard questionnaire and a qualitative survey on their current wellbeing and mindfulness practice, with a request to complete and return the questionnaires, whether or not they had continued to practise mindfulness.
Project outcomes
A total of 82 course attendees agreed to participate in the evaluation project, and 36 replies were received (a 43.90 per cent response rate). The remainder of this article is based on those responses. Of the 36 who responded, 29 had been discharged immediately after the course without further intervention; five had gone on to attend other psycho-educational courses; one had been referred to a pain clinic, and one had been referred for individual counselling or CBT.
Twenty-nine respondents (81 per cent) stated that they were continuing to practise mindfulness; four participants (11 per cent) stated that they were no longer practising; two (6 per cent) gave a ‘yes/no’ answer, which they later clarified by saying that they only practised from time to time; and one person did not state whether or not they were practising. The majority of respondents were therefore continuing to practise mindfulness in some form, either through ‘formal’ meditation or through incorporating elements of mindfulness into their daily life activities.
Emotional wellbeing
Data from the IAPT standard measures showed that 67 per cent of respondents were experiencing lower levels of depression six months after course end (including three people who were no longer practising mindfulness). Twenty-eight per cent said they were feeling worse (including one person who was no longer practising) and six per cent showed no change. This is an encouraging result that seems to be in line with research on the benefits of mindfulness in relapse prevention for people with chronic depression.2
Of the seven people referred to further interventions, three showed a decline in their mood and four showed an improvement, so the additional support did not automatically result in a lower level of depression. Of the five people in this group who were continuing to practise mindfulness, three showed a decrease in their depression score, and two showed an increase.
Fifty-three per cent of respondents showed an improvement in their scores for anxiety (including two who were no longer practising mindfulness) while 22 per cent reported feeling worse and 25 per cent indicated no change. This suggests that mindfulness practice has an impact on anxiety, and is borne out in the results of the qualitative survey, where a number of people reported reductions in anxiety symptoms as a consequence of practising mindfulness.
In recording the impact of their mood on their work and daily living, 42 per cent reported an improvement, 36 per cent a negative impact and 22 per cent no change. This includes people no longer practising, of whom three reported a positive change, two a negative change and one no change.
Improved scores were also reported among the minority who were no longer practising mindfulness, so we cannot attribute all of the improvements to mindfulness alone. Additional factors, such as changes in life circumstances and medication, are also likely to have influenced outcomes for a number of people, whether practising or not. However, it does appear that continuing mindfulness practice has a beneficial effect on depression, anxiety and the impact of mood on daily living.
Participants were asked to complete a short survey on the impact of continuing or discontinuing mindfulness practice and, if continued, the form that their mindfulness practice takes. The results are set out below.
Reasons for continuing/discontinuing practice
The most common reasons given for continuing mindfulness practice were feeling more able to manage problematic/ negative thoughts (eight people reported this) and managing the stress of a busy life (reported by six people). Five people stated that they found the practice relaxing and calming, and a further five specifically mentioned the stabilising effect of coming back to the breath, and the ability to change perspective on their thoughts, as beneficial in managing anxiety. A further three felt that the practice helped in managing low mood (including seasonal affective disorder).
Respondents also identified increased self-care and self-acceptance, and the benefits of mindfulness in managing pain better and improving general wellbeing. A small number reported that they had found the meditation practice difficult during the course, but were confident that they would experience benefits if they continued to practise. One person stated that the course had been transformational and life-changing.
These responses are largely in line with the stated aims of the course, although there is some indication that a number of people are still using the meditation practice as a distraction or as a way of ‘fixing’ their symptoms, rather than learning to accept and live with them more easily. This may in part be due to the shorter session time, which does not allow for extended enquiry around participants’ experience of the practice. The enquiry process allows participants to better understand and integrate their experience, and to develop an open and reflective curiosity and acceptance towards both pleasant and unpleasant aspects of it.
Reasons given for discontinuing the practice were: forgetting to do it or not finding the time; feeling better and that they no longer needed it; and life crises interrupting practice. Two people felt that the course had been inappropriate for them (in one case due to the severity of their symptoms, and in another because they had tried meditation previously and felt that it was not for them). It was also felt by several people that further support, such as followup sessions, would have helped them to maintain their practice.
These responses seem to underline the importance of a thorough pre-course assessment and orientation, carried out by a trained mindfulness teacher, to ensure that those referred to the course are likely to be able to engage and to benefit from it. They also suggest that facilitators need to emphasise the value of establishing a regular meditation practice and ways of embedding mindfulness in daily life, so that mindfulness is seen as a way of life and not just a way of ‘fixing’ symptoms when they arise. It is understandable that course participants who are in emotional distress will be looking for an immediate solution, but careful preparation can help them to understand that the impact of mindfulness may not be immediate, and that it requires patience and regular practice in order to have long-term benefits.
There is also some indication that support beyond the course, in the form of follow-up sessions, a continuation course or virtual support, such as webinars and online forums, would be welcome and would encourage more people to maintain their personal practice.
Preferred practices and practice routine
During the course, participants are taught a number of core practices, namely: the body scan; a guided breathing practice, using the breath as an anchor point for the attention; a longer seated practice, cultivating awareness of breath, body, sounds, thoughts and feelings; and gentle movement and walking, with full attention on moment-by-moment experience. They are also encouraged to practise the ‘three-step breathing space’, a short self-awareness practice that can also be used to ground and stabilise in times of difficulty; and informal ‘mindfulness in daily life’ exercises, such as completing routine tasks mindfully.
Of the formal practices, the largest number of people (23) reported practising the body scan, with nine people practising once or twice per week, four people practising two or three times a week, and three people practising daily or more than once a day. The remaining respondents said that they practised the body scan occasionally or infrequently. This was an unexpected outcome, as during the course, the body scan is often the practice that people least favour, due to its length (between 20 and 45 minutes).
Fewer people reported practising mindfulness of breathing (13), longer seated practice including awareness of body, breath, thoughts and feelings (12) or the three-step breathing space (10).
As the body scan is the earliest formal practice taught, its popularity may suggest that some people prefer to stay within their comfort zone, rather than engaging with potentially more challenging practices, where the emphasis is on developing compassionate acceptance of difficult aspects of their experience. The body scan may also feel more akin to relaxation techniques, as it is done lying down and is largely focused on developing calm and stability as a foundation for the later practices.
It is interesting to consider why so few people are practising the three-step breathing space. Due to its short duration, it is potentially much easier to integrate into daily life. However, during the course, participants often remark that they forget to include the breathing space because it is so short, and apparently this continues to be the case for many people. This could indicate that more time needs to be given in the course to exploring the value of the breathing space and ways to incorporate it into a daily routine.
There is a preference for mindful walking over more structured forms of mindful movement, perhaps because it is easier to integrate into day-to-day living.
Twenty-six of the 36 respondents are practising some form of informal ‘mindfulness in daily life’, when carrying out activities such as showering and bathing, eating, driving, gardening and swimming. Several also include other forms of meditation practice and relaxation, using apps or CDs that are not specifically mindfulness related.
Twenty-eight of those who are continuing their practice are incorporating more than one form of practice, according to their individual needs and circumstances. They therefore appear to be following the advice given at the end of the course, to ‘make the practice their own’.
While informal practice is most popular, perhaps because it is easiest to integrate into a busy lifestyle, it nevertheless appears that many people are continuing to set aside time for, and find benefit in, the longer formal practices. However, some people still appear to be confused about the difference between mindfulness and other interventions, such as relaxation. The reduced time for enquiry in course sessions could be a factor here; it is during this process that insight is often gained, and the true value of mindfulness practice can emerge.
Benefits of mindfulness and impact on mood
Fourteen of the 36 respondents said that mindfulness practice helped them to feel more in control of their thoughts and better able to cope with stressful situations. They reported an increased sense of calm, with a reduction in anxiety and rumination, improved sleep, greater ability to cope with pain, increased compassion towards self and others, and greater self-acceptance, including acceptance of fluctuating emotions.
There was a general appreciation of having a resource that they could draw on in daily life, contributing to a greater sense of empowerment. Others noted a positive change in perspective and in their appreciation of their lives, and said that they were taking more time for themselves. One person stated that they had not consumed alcohol for nine months following the course.
Of the nine people who reported that their mood had worsened in the six months after the course ended, six were continuing to practise mindfulness. Further investigation would be helpful in establishing how this group are using the practice, for example to support and develop resilience or as a means of distraction.
Conclusion
As comparison data are missing for 56 per cent of those who originally agreed to participate in the evaluation project, we have no way of telling whether they are continuing to practise mindfulness and, if so, whether they are benefitting from it. However, it is encouraging that most of the 39 people who responded are continuing to practise mindfulness in some form, whether this is formal meditation or the integration of mindfulness into daily living.
The benefits reported are in line with the aims of the course around managing anxiety, stress, depression and long-term health issues. However, it is important to acknowledge the potential impact of other factors, such as further treatment or changes in life circumstances. Further work would be required to establish the extent to which the improvements experienced can be attributed to mindfulness alone.
Nevertheless, it is encouraging to see that, even with limitations around assessment and orientation, course structure and session times, the ‘Mindful Living’ and ‘Living Mindfully with Stress and Illness’ courses are continuing to have a beneficial effect on participants several months after the end of the course.
Christine Bowles is the Courses Manager of Oasis-Talk, an IAPT primary mental health services provider in the South West. She completed initial mindfulness teacher training with the University of Bangor in 2008 and has subsequently become an accredited Breathworks mindfulness teacher. Chris has taught in excess of 60 mindfulness courses privately and with NHS patients.
References
1 UK Network of Mindfulness-based Teacher Trainers. Good practice guidance for teaching mindfulness-based courses. [Online]. UK Network of Mindfulness-based Teacher Trainers; 2010. https://www.bangor.ac.uk/ mindfulness/documents/MBA%20teacherGPG-Feb%20 10.pdf (accessed 16 April 2019).
2 Segal ZF, Williams JMG, Teasdale JD. Mindfulnessbased cognitive therapy for depression (second edition). New York: Guilford Press; 2013.