Psychological benefits for cancer patients and their partners participating in mindfulness-based stress reduction (MBSR)

Psycho-Oncology Psycho-Oncology 19: 1004 1009 (2010) Published online 16 November 2009 in Wiley Online Library (wileyonlinelibrary.com)..1651 Brief Report Psychological benefits for cancer patients and their partners participating in mindfulness-based stress reduction (MBSR) Kathryn Birnie 1, Sheila N. Garland 1,2 and Linda E. Carlson 1,3 1 Department of Psychosocial Resources, Tom Baker Cancer Centre, Calgary, AB, Canada 2 Department of Psychology, University of Calgary, Calgary, AB, Canada 3 Department of Oncology, University of Calgary, Calgary, AB, Canada * Correspondence to: Department of Psychosocial Resources, Tom Baker Cancer Centre, Holy Cross Site, 2202 2nd St. SW, Calgary, AB, Canada T2S 3C1. E-mail: sngarlan@ucalgary.ca Received: 18 June 2009 Revised: 8 September 2009 Accepted: 18 September 2009 Abstract Objective: Cancer patients experience many negative psychological symptoms including stress, anxiety, and depression. This distress is not limited to the patient, as their partners also experience many psychological challenges. Mindfulness-based stress reduction (MBSR) programs have demonstrated clinical benefit for a variety of chronic illnesses, including cancer. This is the first study to report MBSR participation with partners of cancer patients. Methods: This study examined the impact of an 8-week MBSR program for 21 couples who attended the program together on outcomes of mood disturbance, symptoms of stress, and mindfulness. Results: Significant reductions for both patients and partners in mood disturbance (po0.05) and the Calgary Symptoms of Stress Inventory (C-SOSI) subscales of muscle tension (po0.01), neurological/gi (po0.05), and upper respiratory (po0.01) symptoms were observed after program participation. Significant increases in mindfulness (po0.05) were also reported in both groups. No significant correlations were observed between patient and partner scores on any measures at baseline or on change scores pre- to post-intervention; however, after MBSR participation couple s scoresonthe ProfileofMoodStatesandC-SOSIwere more highly correlated with one-another. Post-intervention, partners mood disturbance scores were significantly positively correlated with patients symptoms of stress and negatively correlated with patients levels of mindfulness. Conclusions: Overall, the MBSR program was helpful for improving psychological functioning and mindfulness for both members of the couple. Several avenues of future research are suggested to further explore potential benefits of joint couple attendance in the MBSR program. Copyright r 2009 John Wiley & Sons, Ltd. Keywords: cancer; oncology; mindfulness-based stress reduction; couples; intervention A cancer diagnosis is highly distressing not only for the patient, but also for their partner, with high prevalence of emotional distress and psychiatric morbidity experienced by both [1]. Cancer patient and partner psychological experiences have a considerable impact on one another, such that when patients are distressed, partners tend to be as well [2 4]. These findings underscore the need for interventions targeted specifically at partners of cancer patients, as well as for the couple. The amount of research examining the benefits of mindfulness-based stress reduction (MBSR) for cancer patients continues to grow. A recent metaanalysis obtained an effect size of 0.48 for mental health outcomes in cancer patients [5]. Documented benefits include improved stress, mood, anxiety, depressive symptoms, quality of life, and fear of recurrence after program participation [6 8]. Caregiver involvement in an MBSR program has been associated with decreases in symptoms of stress and mood disturbance for parents of children with chronic conditions [9]. MBSR programs for caregivers and staff working with Alzheimer patients have also been qualitatively explored with selfreported decreases in stress, anxiety and somatic complaints, increased satisfaction in the caregiver role, and improved ability to cope with stress [10]. No published studies report on the impact of MBSR participation for partners of cancer patients. The current study is a preliminary exploration of MBSR participation for couples affected by cancer. In particular, it examines the program s impact on symptoms of stress, mood disturbance, and mindfulness for both cancer patients and their partners. It also begins to explore relationships between couples outcomes. Copyright r 2009 John Wiley & Sons, Ltd.

Benefits of MBSR for cancer patients and partners 1005 Methods Participants The MBSR program at the Tom Baker Cancer Centre in Calgary, AB is available to any patient with a cancer diagnosis. Patients are welcome to bring a support person to the program with them. Couples eligible for the study had to be in a romantic relationship and attending the program simultaneously. Couples were excluded if either member of the couple was not English proficient or had previously taken MBSR. Both members of the couple had to attend a minimum of six program classes to be included in data analyses. Procedure Couples recruited for the study were a convenience sample enrolled in the MBSR program. Couples were told about the study during an orientation session prior to the program s first class. They completed study measures before the program start and within 2 weeks following program completion. Couples attended the MBSR program between 2000 and 2008. A total of 41 couples consented to the study and provided baseline data; 20 couples either did not complete post-data or did not attend at least six of the eight MBSR classes, leaving 21 couples with complete data in the final sample. The MBSR program in the current study generally followed the description in Speca et al. [6]. The program consisted of 8-weekly, 90-minute sessions, plus one 3 h weekend silent retreat. The retreat was increased to 6 h after January 2008. The study was approved by the Conjoint Health Research Ethics Board of the University of Calgary Faculty of Medicine. Measures The Profile of Mood States (POMS) [11] measures identifiable mood or affective states, as well as changes in mood. It includes 65 items and is rated on a Likert scale from 1 (not at all) to 5 (extremely) indicating how the participant has felt over the last week. It has six subscales: Tension/Anxiety, Depression/Dejection, Anger/Hostility, Vigor, Fatigue, and Confusion. A total mood disturbance score is calculated by summing all of the subscale scores except Vigor, for which the summed subscale score is subtracted from the total score of the other five subscales. Hence it is possible, if few of the other subscale items are endorsed and many of the Vigor items are endorsed, to receive a negative Total Mood Disturbance score. Kuder- Richardson internal consistency of the six subscales ranged from 0.84 (Confusion) to 0.95 (Depression). The Calgary Symptoms of Stress Inventory (C-SOSI) [12] is composed of 56-items assessing physical and psychological responses to stress. Items are rated on a Likert scale from 1 (never) to 5 (very frequently). A total score is obtained by summing responses from all items. It has eight subscales (Depression, Anger, Muscle Tension, Cardiopulmonary Arousal, Sympathetic Arousal, Neurological/GI, Cognitive Disorganization, and Upper Respiratory Symptoms). It has been validated in an oncology population with good convergent and divergent validity. Internal consistency (Cronbach s alpha) of the scale is reported as 0.95 (ranging from 0.80 0.92 for subscales). The Mindful Attention Awareness Scale (MAAS) [13] assesses individual differences in mindful states over time. It measures the presence or absence of attention and awareness to the present moment. The scale has 15 items and responses are scored on a Likert scale from 1 (almost always) to 6 (almost never) with higher scores depicting higher levels of everyday mindfulness. A score is obtained by summing responses from all items. The scale was shown to be valid by confirmatory factor analysis in a group of cancer patients with mixed diagnoses [14]. Internal consistency (Cronbach s alpha) of the scale was 0.87. Results Complete data was obtained for 21 couples on the POMS, 19 couples on the C-SOSI, and 16 couples on the MAAS. Demographics are reported for the larger sample of 21 couples; however, data analysis for each outcome (mood disturbance, symptoms of stress, and mindfulness) corresponds to the number of couples who provided complete data on that measure. Demographics Twenty couples were married and 1 was commonlaw; all were in heterosexual relationships. Ten (47.6%) of the patients were male and 11 (52.4%) female, with corresponding partners. They had a mean age of 62.9 years (SD 5 7.37) and a mean of 14.9 years of education (SD 5 3.60). The most common cancer diagnoses were prostate (28.6%), breast (19.0%), and colorectal (14.3%). The mean time since diagnosis was 2.03 years (SD 5 2.86) ranging from 0.12 to 11.01 years. None of the partners had ever received a cancer diagnosis. Partners had a mean age of 62.8 years (SD 5 9.34) and a mean of 14.33 years of education (SD 5 4.16). Independent samples t-tests revealed that prior to MBSR participation, patients reported significantly higher scores on the fatigue subscale of the POMS (t 5 2.00, p 5 0.05) than partners, while partners reported significantly higher scores on the sympathetic arousal subscale of the C-SOSI (t 5 2.19, po0.05). No other baseline differences

1006 K. Birnie et al. were observed between the two groups. Patients with baseline data only reported significantly higher levels of total mood disturbance prior to program participation than those who provided complete data (t 5 2.47, po0.05). No significant differences were observed between completing and non-completing partners at baseline. Impact of MBSR Repeated measures ANOVAs were conducted comparing the levels of change on the POMS, C-SOSI, andmaaspre-topost-mbsrinpatientscompared with partners. Significant main effects were seen for total mood disturbance (F(1,40) 5 4.49, po0.05) as well as for the tension/anxiety (F(1,40) 5 8.21, po0.01), depression/dejection (F(1,40) 5 3.38, po0.07), and fatigue subscales (F(1,40) 5 4.03, po0.05), with better post program funtioning for both members of the couple. A significant main effect was also seen for mindfulness (F(1,40) 5 6.10, po0.05), with both members of the couple reporting an increase in this outcome. No significant changes were observed on the C-SOSI total score (F(1, 36) 5 3.92, p 5 0.06); however, scores on the following subscales decreased significantly for both groups: muscle tension (F(1, 36) 5 10.07, po0.01), neurological/gi (F(1, 36) 5 4.78, po0.05), and upper respiratory symptoms (F(1, 36) 5 8.11, po0.01). One significant group effect was observed for sympathetic arousal (F(1.40) 5 2.98, po0.05, with partners having lower scores than patients at both assessment times. Results are reported in Table 1. To facilitate comparison and assess the magnitude of the impact of the intervention for patients and partners separately, within group effect sizes Table 1. Outcome by treatment group (ANOVA) Variable Patients Partners Pre-MBSR Post-MBSR Pre-MBSR Post-MBSR Time effect F (p) Group effect F (p) Interaction F (p) Profile Of Mood States (N 5 21) Tension/Anxiety 5.57 3.05 4.90 2.19 8.21 0.23 0.01 (7.31) (5.37) (6.49) (3.95) (0.01 ) (0.63) (0.92) Depression/Dejection 7.76 5.38 6.76 4.24 3.38 0.32 0.00 (10.29) (6.11) (7.62) (5.14) (0.07) (0.58) (0.96) Anger/Hostility 4.00 4.38 5.24 4.24 0.09 0.16 0.45 (7.05) (5.54) (5.08) (3.89) (0.77) (0.69) (0.51) Vigor 16.14 17.67 17.33 18.76 3.25 0.61 0.00 (4.45) (6.08) (5.90) (5.11) (0.08) (0.44) (0.95) Fatigue 8.86 6.62 5.81 4.81 4.03 3.09 0.59 (5.46) (5.48) (4.34) (5.35) (0.05 ) (0.09) (0.45) Confusion 2.19 0.57 1.33 0.52 3.04 0.23 0.34 (4.31) (2.99) (4.48) (3.22) (0.09) (0.64) (0.56) Total score 12.24 2.33 6.71 2.76 4.49 0.61 0.00 (31.03) (23.42) (30.46) (19.61) (0.04 ) (0.44) (0.96) Calgary Symptoms of Stress Inventory (N 5 19) Depression 5.40 4.89 4.85 2.79 2.57 0.56 1.12 (6.13) (5.39) (5.91) (4.38) (0.12) (0.46) (0.30) Anger 5.15 5.26 6.35 4.58 0.77 0.09 1.06 (4.34) (5.73) (5.25) (3.88) (0.39) (0.77) (0.31) Muscle Tension 9.05 7.32 7.35 4.47 10.07.965 0.86 (7.66) (6.90) (7.92) (5.10) (0.01 ) (0.33) (0.36) Cardiopulmonary 3.20 2.53 1.85 1.05 2.32 2.16 0.00 Arousal (4.26) (3.82) (2.74) (2.12) (0.14) (0.15) (1.00) Sympathetic 13.90 12.05 9.15 7.58 3.14 5.24 0.00 Arousal (8.14) (7.78) (5.24) (4.55) (0.09) (0.03 ) (1.00) Neurological/GI 2.55 3.47 2.25 3.84 8.11 0.00 0.74 (3.87) (2.46) (3.04) (2.91) (0.01 ) (0.98) (0.40) Cognitive 4.25 3.53 3.45 2.68 1.30 0.59 0.02 Disorganization (4.00) (3.22) (4.10) (2.71) (0.26) (0.45) (0.90) Upper respiratory 5.95 4.53 3.55 2.68 4.78 2.98 0.21 Symptoms (5.31) (4.72) (2.26) (2.83) (0.04 ) (0.09) (0.65) Total score 49.45 43.58 38.80 29.68 3.92 1.79 0.30 (35.40) (32.10) (29.27) (16.19) (0.06) (0.19) (0.58) Mindful Attention Awareness Scale (N 5 16) Total Score 4.22 4.36 4.18 4.53 6.10 0.08 1.07 (0.71) (0.65) (0.74) (0.60) (0.02 ) (0.77) (0.31) po0.05; po0.01.

Benefits of MBSR for cancer patients and partners 1007 were p ffi calculated using the following formula: d 5 t (2(1-r)/N) and absolute values are reported. Effect sizes obtained using Cohen s d for patients were 0.35 for total mood disturbance, 0.16 for total symptoms of stress, and 0.21 for mindfulness. For partners, effect sizes were 0.34 for mood disturbance, 0.37 for symptoms of stress, and 0.50 for mindfulness. These represent small- to medium-sized effects for patients and medium effects for partners. Relationships between patient and partner outcomes To explore the relationships between couples outcomes, Pearson product moment correlations were conducted between patient and partner total scores pre-intervention and post-intervention, as well as on change scores (calculated as post- minus pre-scores). No corrections were made for multiple comparisons as these analyses were considered exploratory. Thus, p values of o0.05 were used as the cut-off to assess significance. No significant correlations were observed between patient and partner scores on any measure prior to MBSR participation or on calculated change scores. Postintervention, partners total mood disturbance scores were positively correlated with patients total symptoms of stress (r 5 0.457, po0.05) and negatively correlated with patients levels of mindfulness (r 5 0.499, po0.05). Hence, when patients were experiencing more stress and were less mindful, partners suffered from higher mood disturbance. Significant differences in the magnitudes of the correlations between patients and partners scores pre- to post-intervention were found for the POMS (Z 5 1.958, po0.05) and C-SOSI (Z 5 2.033, po0.05) total scores. Pre- and postprogram correlations are summarized in Table 2. Discussion Overall, the MBSR program was beneficial for both cancer patients and their partners for Table 2. Correlations for total scores. Partners Pre-Intervention Patients Post-Intervention POMS C-SOSI MAAS POMS C-SOSI MAAS Pre-Intervention POMS 0.280 0.146 0.202 C-SOSI 0.228 0.095 0.037 MAAS 0.333 0.173 0.036 Post-Intervention POMS 0.303 0.457 0.499 C-SOSI 0.330 0.397 0.500 MAAS 0.158 0.190 0.304 Correlation significant at po0.05. reducing mood disturbance and more physical symptoms of stress, as well as increasing levels of mindfulness. Effect sizes for the program s impact corroborate these findings by showing moderate effect sizes for mood disturbance for both patients and partners, as well as symptoms of stress and mindfulness for partners. This is the first study to indicate that participating in MBSR may also be advantageous for the partners of cancer patients, particularly for improving psychological well-being. Levels of mindfulness observed in the current study are higher than those reported in other oncology populations [14] and increases after MBSR participation are slightly less than in other mixed illness populations [15]. This is the first study to report on changes in mindfulness after MBSR in cancer patients and their partners as assessed by the MAAS. When compared with previous research of cancer patients attending the program alone and caregivers of children with chronic illness participating in MBSR, the current study achieved smaller improvements in both mood disturbance and symptoms of stress [6,7,9]. An unexpected characteristic of this sample was the very low mood disturbance scores at all time points. Pre-intervention scores are approximately 21 points lower than those reported in a normative adult sample [11], 4 25 points lower than similar samples of cancer patients [6,7,14], and 39 points lower than other caregivers participating in MBSR [9], indicating that this sample had unusually good mood compared with most program participants. The low mood disturbance reported in the sample compromises the generalizability of these findings. Still, significant improvements and moderate effect sizes were observed in mood disturbance, indicating the program s potential applicability for individuals who already have positive mood. Other limits to generalizability of the results include the selectivity of couples interested in the MBSR program, the older age of patients and their partners, as well as the presence of heterosexual relationships only. Interestingly, no relationships were observed when comparing the outcomes of each patient with outcomes of their partner for pre-intervention and change scores. This contrasts with previous research indicating strong associations between psychological outcomes for couples dealing with cancer, particularly in survivorship [2]. Promisingly, however, dissimilarity in psychological distress has been associated with beneficial physical health outcomes for couples dealing with cancer [3]. One potential explanation for this could be that patients in the study had earlier stage disease and were, consequently, not as distressed. They may have also had better social support, which is suggested by the presence of the partner in the program, and length of relationship may play a role. Unfortunately, none of these variables were assessed.

1008 K. Birnie et al. Following MBSR participation, higher mindfulness scores in patients were associated with less mood disturbance in partners, but the reverse correlation was not found. These findings suggest that partners may be particularly sensitive to the state of the patient s well-being and ability to live in the present moment. Indeed, partners mood was also associated with patients stress levels, reflecting expected directional relationships between the variables examined [14]. These findings are consistent with previous research indicating that when one member of the couple is distressed, the other is likely to be as well [2], but further refine this relationship by suggesting that patients well-being may be more important for partners mood than vice versa. Although very speculative given the small study sample size and study design, stronger correlations between patient and partner scores post-intervention than before MBSR suggest that participation in the program encourages members of a couple to become more aligned in their psychological adjustment during the cancer journey. There are several limitations to this preliminary study, the most obvious being the lack of a comparison or control group, making it impossible to conclude that the changes observed were the result of program participation. The study was also underpowered (making Type II errors possible), and we did not control for multiple comparisons to specifically avoid Type I errors. Lack of correction for multiple comparisons was due to the exploratory nature of the study, and an attempt to balance the risk of Type II errors described above. Support for the impact of MBSR participation for partners of cancer patients, particularly for the benefits of joint attendance, would be enhanced with a larger sample. No significant change in overall symptoms of stress was observed for either cancer patients or their partners although significant improvements were seen on the subscales of muscle tension, neurological and gastrointestinal symptoms and upper respiratory symptoms. This result, coupled with previous research with cancer patients alone [6,7], in other caregiver populations [9], and the small to medium effect sizes observed, suggests that statistical significance may be achieved with a greater number of couples. Interviews with couples dealing with cancer after participation in an MBSR intervention suggest that joint participation in the program may provide additional benefits not assessed in this study, such as improved class attendance or adherence to home practice [16]. Furthermore, attending the program may have some positive impact on the couples relationship. Higher levels of mindfulness have predicted greater capacities for responding to relationship stress, as well as positive perception of the relationship after conflict, all relevant in the context of cancer [17]. Poorer relationship quality can influence psychological distress of both patient and partner [4], and cause slow recovery from disease symptoms and treatment side effects [18]. Future research should include instruments designed to examine the programs impact on relationship outcomes for couples dealing with cancer. Several couples specific interventions exist for those affected by cancer; with varied outcomes reported [19]. A variation of MBSR entitled Mindfulness-Based Relationship Enhancement [20] has been designed specifically to enhance the couple relationship through mindfulness practice. 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