Mindfulness-Based Interventions in Recurrent Ovarian Cancer: A Mixed-Methods Feasibility Study

A recurrence of cancer is a traumatic and stressful experience, and a number of approaches have been proposed to manage or treat the associated psychological distress. Meditative techniques such as mindfulness may be able to improve an individual’s ability to cope with stressful life events such as cancer diagnosis or treatment. This single-arm mixed-methods study primarily aimed to determine the feasibility of using a mindfulness-based intervention in managing psychosocial distress in recurrent ovarian cancer. Twenty-eight participants took part in a mindfulness-based program, involving six group sessions, each lasting 1.5 hours and delivered at weekly intervals. The study found that the mindfulness-based intervention was acceptable to women with recurrent ovarian cancer and feasible to deliver within a standard cancer care pathway in a UK hospital setting. The results suggested a positive impact on symptoms of depression and anxiety, but further study is needed to explore the effectiveness of the intervention.


Practices
Informal mindfulness practice -"checking in and releasing tension" Teaching points Learning to release and let go of tension Relaxation is the natural state Homework Daily practice of "checking in and releasing tension" Practice log & journal (observations -thoughts, feelings, body sensations, comments) Choose specific approach/ attitude each day and explore that as you go about activities Session 2

Training attention using a Breath Awareness Practice
Learning to pay attention, noticing when the mind has wandered and simply bringing it back is central to mindfulness (Gunaratana, 2002). Mind-wandering is prevalent, is associated with being unhappy and is exacerbated by stress (Killingsworth & Gilbert, 2010). It is known to correlate with neural activity in a network of brain areas that support self-referential processing, known as the default-mode network (Brewer et al. 2011;Farb et al. 2007). Consequently, we can easily lose conscious control; amplify emotions and fall into habitual patterns of thoughts and behaviours, so exacerbating our stresses, anxieties and sadness (Williams & Penman 2011). Furthermore, it is thought that concentration-based mindfulness meditation helps "deautomise" mental processes that cloud perception of stimuli in the present moment (Lutz et al. 2008) and that this is central to the benefits of practising mindfulness, coming off automatic pilot and seeing things clearly as they are. Typically, the breath -sensations of breathing -is used to train attention (Grossman, 2010;Gunaratana, 2002). This provides an anchor to the present moment and facilitates disengaging with other mind activities such as rumination (Williams et al. 2007). As the mind becomes focused it has a calming effect, reducing stress and anxiety.

Theme & content "Gathering a scattered mind"
We know that nearly 50% of the time our mind is not where we intended it to be and when we are stressed, anxious or have low mood this increases. Furthermore, a wandering mind is not a happy mind; it has a negative bias, and can take us to dark places, caught up in rumination and proliferation. In this session we will use mindfulness to gather and focus a wandering mind; bring it back to a neutral place grounded in the present moment. "Checking in" • Practice • Discussion of how the week has been -was it possible to practice?
• Experiences of mindfulness able to share • Barriers and obstacles to practice Living on autopilot & the dangers of a wandering mind • Background of mind wandering and where it can take us • Common having survived cancer that there are anxieties, worries and how mindfulness can be used to gather the mind when it is all over the place and bring it back to focus on something neutral such as the breath • Taking control of a wandering mind • Video showing impact of mindfulness on the brain Training attention • Breath awareness • Breath used as focus of attention -it is in the present moment and considered a neutral focus • Reminder that this is not just a concentration exercise as the attitude we bring is important e.g. kindness and curiosity • If problems with the breath provoking anxiety, can use external object such as sound • Experience of the practice discussed in pairs and then open to the group Revisit Breath and breathing from first session • Power of the breath -indicator of how we are • Practices to invigorate or relax • Now introduced as an anchor to gather and calm a scattered mind. What causes you to hold your breath?
• Notice when this happens, release and let go

Practices
Informal mindfulness practice -"checking in and releasing tension" Formal attention training using Breath Awareness Teaching points Learning to pay attention, beginning to gain more control over a wandering mind by focusing it on a neutral object such as the breath (or sound). As we focus the mind, it calms the mind. The Breath awareness practice is used to skilfully attend to mind-wandering, starting to allow things to be as they are. Learning how the breath can be a "vehicle" for directing awareness. This is used in all other practices (Killingsworth & Gilbert, 2010) Homework Daily Formal practice of attention training using Breath Awareness Informal mindfulness practice -"checking in and releasing tension" Practice log & journal (observations -thoughts, feelings, body sensations, comments) Choose specific approach/attitude each day and explore that as you go about activities

Session 3 Session 3: Reconnecting mind and body using the Body Scan Practice
Practices, such as the body scan, use body sensations as the focus of attention (Dreeben et al. 2013). Tuning into body sensations cultivates an awareness of the body-mind system. Formal practice has a significant effect on the insula (Hölzel et al. 2008;Lazar et al. 2005), which is implicated in interoceptive perception (Craig, 2003). This improvement in interoceptive perception, provides valuable information about the general state of our bodies, our stress levels, our moods and our behavioural urges (Fletcher et al. 2010). Effectively, through practice we are training to use the body as a barometer (Williams & Penman, 2011). Over time, we are able to identify personal signatures of emotions such as stress and anxiety and we can use these physiological signals from the body as an early warning system to offset emotional hijacks (Williams & Penman, 2011). The body scan is used to train familiarity of body sensations as they arise, learning to approach and explore them, effectively reducing avoidance of contacting them. This is an important therapeutic process, which is useful in conditions such as panic disorder, some form of posttraumatic stress disorder and pain (Fletcher et al. 2010).

Theme & content "Reconnecting mind & body"
Emotions are useful physiological signals unfortunately we often don't "read" them correctly and amplify them to the extent that they are overwhelming. We are subject to "emotional hijack" and they seem to be more in control of us rather than the other way around. Using mindfulness we can increase awareness of body sensations and begin to use the body as a barometer, an early warning system for emotions arising and gain more emotional control. "Checking in" • Practice • Discussion of how the week has been -was it possible to practice?
• Experiences of mindfulness able to share • Barriers and obstacles to practice Emotions

Practices
Informal mindfulness practice -"checking in and releasing tension" Body Scan

Teaching points
Reconnecting mind and body. Increasing body awareness. Identifying own physiological signatures of emotions arising and learning to interrupt them over time. "Body-mind loop"-bringing awareness to body can interrupt this and can be a different way of processing emotions Using the body as a valuable source of information -bodily maps of emotions (Nummenmaa et al. 2013) Recognising signals from your body, a personal "barometer" signalling inclement emotions, such as unhappiness, anxiety and stress before they arise (Williams and Penman, 2011) Homework Daily Formal practice of Body scan Informal mindfulness practice -"checking in and releasing tension" Practice log & journal (observations -thoughts, feelings, body sensations, comments) Herbert Benson stress trigger form

Session 4 Session 4: Increasing cognitive awareness using a practice of Breath Body Sounds and Thoughts
A formal meditation practice will be used to guide through observing sensations of breathing, bodily sensations, sounds and thoughts as they come and go without getting caught up in them.
In addition, to this practice we will use psycho-education exercises reinforcing that thoughts are just thoughts and not facts (Segal et al. 2013). Opening up to observe thoughts provides an opportunity to better understand how our mind works and how it affects us (Grossman, 2010).

Practices
Informal mindfulness practice -"checking in and releasing tension" Formal practice -Breath Body Sounds and Thoughts Informal Breathing Space

Teaching points
The key learning here is "de-centring" seeing thoughts and feelings simply as thoughts and feelings, as an observer rather than defining ourselves by them. It enables us to step back and effectively be able to relate to them rather than from them, caught up in them. We are starting to cultivate a spaciousness of mind, a wider perspective and so reducing the power of thoughts, able to see "thoughts as thoughts" and not facts. This enables us to see things more clearly as they really are and make better choices. Comparisons are seen between thoughts and sounds; they come and go and they are not "us". Over time we begin to recognise unhelpful thought patterns and learn to read and acknowledge them. They could simply signify a "weather pattern" and serve as a warning.

Homework
Daily Formal practice of Breath, Body, Sounds and Thoughts Informal mindfulness practice -"checking in and releasing tension" Informal practice -Breathing Space

Session 5 Session 5: Practices looking at Facing difficulties & cultivating Loving Kindness
Formal mindfulness meditation practices to explicitly explore dealing with difficulties or pain, both physical and emotional, will be explored (Segal et al. 2013). Instead of getting caught up in the psychological and emotional struggle with pain and difficulties, individuals are encouraged to live alongside them, employing a more acceptance-based approach (Cusens et al. 2010). Acceptance and self-awareness are generally proposed as the mediating factors to explain how mindfulness affects pain (Baer, 2003;Shapiro et al. 2006). Harsh self-criticism is key to a wide range of mental health problems, especially depression. Through mindfulness practice kindness and friendliness can be developed, which is more supportive of healthy emotional processing and wellbeing. Kindness is transformative: this change in attitude enhances openness, creativity and happiness, while acting as an antidote to fear and guilt and reducing stress and anxiety (Williams and Penman, 2011). It helps to switch off the "aversion" pathways in the mind, which lead to exhaustion and chronic discontent and rather switching on the "approach" pathways. A formal Loving Kindness practice will be used to cultivate kindness. Theme & content "Facing difficulties" Dissatisfaction and "suffering" come from wanting things to be different. When we brace against things, push things away, we expend effort and add layers to our suffering. Mindfulness offers a different approach, a "softening" and turning towards. This acceptance and letting be allows us to deal with difficulties. Through mindfulness we can put processes into place to manage difficulties adaptively. Cultivating kindness and compassion is central to transformation in mindfulness. "Checking in" • Practice • Discussion of how the week has been -was it possible to practice?
• Experiences of mindfulness able to share • Barriers and obstacles to practice • What is working and not working?
• Have there been any shifts? Facing difficulties -pain physical and emotional • Usual strategies • Using mindfulness -turning towards, acceptance, letting be, curiosity • Reminder of the practice "checking in and releasing tension" Practice -Exploring difficulties • Breath, Body, opening up to intense sensations • Exploring, softening • Bringing difficulty to mind, body sensations, processing emotions in the body • Experience of the practice discussed in pairs and then open to the group Loving kindness -Self compassion • Cultivating kindness and equanimity towards self • Short practice of Loving kindness • Short Self compassion practice as a tool

Practices
Formal practice -Exploring difficulties Formal practice -Loving kindness Informal mindfulness practice -"checking in and releasing tension"

Teaching point
During the exploring difficulties practice we learn to "drop into" physical sensations in the body when there are strong negative thoughts and emotions around. Turning to these physical sensations helps stop mental proliferation and anchors awareness in the flux of present moment experience. We notice the natural variation, changes in intensity, and it provides one way of "riding the waves" of powerful internal experiences. In doing so, we are able to let go of fuelling them by trying to suppress or change things.

Homework
Daily Formal practice of Exploring difficulties or Loving Kindness Informal mindfulness practice -"checking in and releasing tension" Informal practice -Breathing Space Session 6 Session 6: Formal sitting practice of "choiceless" awareness As the course progresses and with practice, it becomes possible to move participants to meditate on whatever arises (Lutz et al. 2008). Over time, with continued mindfulness practice, participants will become more self-aware, which leads to better self-regulation of cognitions, emotions and behaviours (Gross, 1998 Formal practice of "choiceless" awareness Informal mindfulness practice -"checking in and releasing tension" Mindful movement Teaching points This practice of "choiceless" awareness focuses on the full range of experience and for many is considered as the formal sitting meditation of mindfulness. It cultivates acceptance of what is by simply allowing whatever arises to be our experience in this moment. Equally accepting pleasant, unpleasant and neutral. Developing a spacious quality of mind, aware of all experiences as they arise and pass away in consciousness. Recognising recurring patterns of the mind. Seeing more deeply into the nature of human experience and life. The experience of "choiceless" awareness practice parallels daily life. As we learn to notice and be with the flux in formal practice, we can bring greater awareness to flux in our daily experience.

Homework
Ongoing practice formal and informal, whatever works for you