Mindfulness for the self‐management of negative coping, rumination and fears of compassion in people with cancer: An exploratory study

Abstract Background Cancer and its treatments have the potential to significantly impact mental health, provoking feelings of anxiety, depression, and distress, which can last long after treatment is over. One of the most rapidly emerging influences in the healthcare field is mindfulness‐based interventions (MBIs), which are designed to cultivate present moment awareness, attentional flexibility, compassion and acceptance, to reduce physical and psychological distress. However, there is limited research into the efficacy of MBIs or disease specific MBIs in shifting negative coping, ruminative thinking and fears of compassion as primary outcomes in individuals with cancer. Aims This exploratory study was designed to evaluate inter‐ and intra‐individual change in the management of negative coping, rumination and fears of compassion, following a cancer‐specific mindfulness‐based intervention. Methods and Results A single group, non‐experimental, repeated measures study of 22 participants across six cancer care centres explored the efficacy of an 8‐week Mindfulness‐Based Cognitive Therapy for Cancer (MBCT‐Ca) course. The Reliable Change Index (RCI) examined reliable clinical improvement, deterioration, or no change in individuals on the Mental Adjustment to Cancer Scale (MACS), the Ruminative Responses Scale (RRS) and the Fears of Compassion Scale (FCS). About 82% of participants (n = 18) saw an improvement in at least one measure. A significant decrease in primary outcome scores was observed in negative coping, ruminating and fears of self‐compassion. There were significant correlations between the fear of self‐compassion and depressive ruminating, fear of accepting compassion from others and showing it to others pre and post intervention. Conclusion Our findings indicate that the MBCT‐Ca programme may significantly reduce negative coping, ruminating and fears of self‐compassion improving psychological health and wellbeing in cancer survivors.


| INTRODUCTION
Cancer and its treatments do not just impact physical health and everyday functioning, they have the potential to significantly affect mental health and psychological wellbeing too, provoking feelings of anxiety, depression, and distress which can last long after treatment is over. 1,2 Individuals can experience the fear of disease recurrence more than 5 years post-treatment 3 and subsequent unresolved mental health issues in cancer survivors are known to lead to more frequent doctor and hospital visits, with associated increases in social and health care costs. 4 Evidence-based group mindfulness-based interventions (MBIs) have emerged as a viable and cost-effective option for a range of clinical conditions including cancer, chronic pain, depression, stress and anxiety, but mindfulness can often be misunderstood, difficult to define and hard to measure systematically due to its experiential nature and its many adaptations and approaches. 5,6 There is sufficient consensus, however, to suggest that the mechanisms of mindfulness encourage the individual to shift their perspective on thoughts, emotions, and sensations so that rather than ruminating over them, they are held in a non-judgemental, moment-to-moment place, encouraging awareness, equanimity and openness through intention, attention, and attitude. 7,8 The most widely researched MBI is Mindfulness-Based Stress Reduction (MBSR) 9,10 a structured 8-week group programme of mindfulness, gentle yoga, and body scans with additional home practice.
Mindfulness-Based Cognitive Therapy (MBCT) is an adaptation of MBSR and combines the MBSR curriculum with cognitive behavioural therapy techniques. 11 Multiple research studies have confirmed MBCT efficacy in managing the risk of relapse in depression compared to treatment as usual. [12][13][14] and it is recommended by the UK's National Institute for Health and Care Excellence (NICE) as a priority treatment for depression. 15,16 Traditionally, the mechanisms of change associated with MBIs have focused on equanimity, cognitive defusion, attentional flexibility and acceptance, that decouple the emotional salience and negative thinking seen in individuals suffering from depression, 17 which feels particularly relevant to those living with cancer. 18 Cancer survivors often experience emotion regulation difficulties, and the presence of low mood and ruminative thinking, together with lower levels of selfcompassion and motivation, can impact on physical, emotional, and cognitive function. 19 Systematic reviews, meta-analyses, and individual studies into MBSR and/or MBCT for cancer survivors reveal beneficial effects in reducing depression, anxiety and stress, leading to an improvement in quality of life. 20,21 Research into the efficacy of MBSR and breast cancer suggests participants reported an increased ability to cope, manage and find meaning 22 and a reduction in fear of recurrence. 23 In addition, a systematic review and meta-analysis of MBSR studies in a broader cancer population reported evidence for reliable improvements in reducing individuals' psychological distress. 24 The robust and consistent effects of MBCT and MBSR have been established for individuals with cancer however, there is less research into programmes specifically designed for individuals with the disease, such as Mindfulness-Based Cancer Recovery (MBCR) 25 and MBCT for Cancer (MBCT-Ca). 26 One study suggests MBCR is superior to supportiveexpressive group therapy in reducing mood disturbance and stress symptoms 27 and a study of MBCT-Ca suggests improvements in depression and quality of life. 28 However, to the authors' knowledge, there is currently no published study into the impact on ruminating and fears of compassion, after a cancer-specific mindfulness-based intervention.
Rumination is defined as attending to intrusive negative thoughts repeatedly, and fits broadly into three categories; brooding rumination, thought to be excessive and non-productive; depressive rumination, characterised as a focus on one's feelings of sadness; and reflective rumination, defined as being more purposeful and problemsolving. 29 The idea of self-compassion as a buffer against adversity is relatively new in psychopathology, but research in those with breast cancer suggests that it activates the resting parasympathetic nervous system and suppresses the threat system, to lower rumination and anxiety. 30 Interestingly, the differentiate with this study proposed that mindfulness was instrumental as a mechanism of change for the augmented self-compassion and lowered rumination. However, one study suggests low self-worth, negative emotions, suppression of painful thoughts and an anxious or avoidant attachment style can make engaging with mindfulness and developing self-compassion difficult for individuals with cancer and it recommended further research into interventions which focus on self-kindness to improve psychological outcomes for these patients. 31 Despite the range of physical and psychological benefits of mindfulness-based interventions, there can be limitations to mindfulness research in those with cancer. A systematic review of MBIs and RCTs in cancer cohorts suggested most interventions were variable and poorly defined, that the protocol often changed during treatment and that information was gathered sometime after the MBI had been delivered 32 In addition, the possibility of a high risk of performance and detection bias has also been reported in some patient cohorts. 33 A review of 124 RCTs in MBIs in healthcare, concluded that almost 90% reported positive results and the authors suggest this may be due to effect sizes being over-stated, selective outcome reporting, 'data dredging' and overall reporting bias. 34 Any intervention that has the potential for relieving psychological distress, also risks adverse effects 35 and there are a small number of studies reporting negative outcomes in mindfulness. 36 One study with chemotherapy patients suggested an increase in symptom distress and reduced quality of life, compared to those following a relaxation programme. 37 However, this was based on three 90-min sessions of MBCT-Ca and did not follow its established protocol. A recent review of the potential for harm in MBIs suggests this and other studies should be seen in the context of meta-analyses suggesting positive benefits for patients, including those with cancer. 38 This is not to say adverse events and negative experiences do not happen, but as most research examines group averages, meaningful deterioration in participants may be masked. The authors of the review call for researchers to examine individual-level data and suggest using the Reliable Change Index (RCI), which measures clinically significant improvements, deterioration, or no change in each participant. 39 Mindfulness should not be seen as a cheap option, it is not riskfree, nor appropriate for all, however as a targeted intervention for those struggling with the emotional effects of cancer, it can help develop psychological flexibility, wellbeing, and self-compassion. This study has been designed to assess the inter-and intra-individual impact of an 8-week MBCT-Ca programme on those who were either receiving active treatment, recovering from treatment, or in remission from cancer, with a focus on reliable change indices, on an individual level. The primary aim of the study was to examine any shift in mental adjustment to cancer, ruminating and fears of compassion after an intervention tailored to those with the disease. A secondary aim was to explore the potential relationship between these concepts.

| METHODS
This was a single group, non-experimental, repeated measures exploratory study of participants who had enrolled on an MBCT-Ca intervention at a UK charity offering free cancer support.

| Participants
There were 20 women and two men. All participants were over 45 and 64% (n = 14) had University or post-graduate qualifications.
Half worked full-time, part-time or were self-employed (n = 11), 36% were retired (n = 8) and 9% (n = 2) were unemployed or too ill to work. Most identified as white British, 68% (n = 15), with 86% (n = 19) specifying English as their main language. The majority were living with or beyond breast cancer, with other cancers including uterine/endometrial, ovarian, prostate, bowel, and kidney cancer. The stages ranged from stage 0 where the cancer is small and contained to stage 4, where it has spread from its origin to another organ. Some participants were in active treatment, others were not (Table 1).
Participants were assessed for mental adjustment to cancer, rumination, and fears of compassion pre and post the MBI.

| Sample
Between October and December 2019, six centres running MBCT-Ca interventions consented to participate in the study. The inclusion criteria, developed in accordance with the MBCT Implementation Resources for recruitment, 40 included those living with or beyond cancer who were between 25 and 85 years old and could speak and read English. The exclusion criteria included those experiencing an acute episode of depression or anxiety, and/or who had a mental health diagnosis, were addicted to alcohol or drugs and/or had an additional acute life crisis such as a recent bereavement.
Centre heads and mindfulness teachers were not expected to recruit participants, however, interested individuals were directed to the participant information guidance and questionnaire. While supportive group therapy was considered as an alternative control for comparison, the centres were not running groups and resources were not available to create them A wait-list control would have been difficult to establish, as there was no guarantee of a later intervention and a passive, or no-control control group might be considered unethical in clinical populations. 41

| Procedure
Ethical approval was gained from a UK-based University. Courses began in January 2020 and all participants provided consent to participate prior to the intervention starting. Those providing an email were sent a consent form, participant information letter and a link to the baseline questionnaire, which was developed on Qualtrics, following a pilot study to assess its suitability for individuals already undergoing a clinically difficult experience. 42 A reminder email was sent towards the end of the course. If the follow-up questionnaire had not been returned a week after the intervention finished, a further reminder was sent.
All MBCT-Ca interventions were led by trained mindfulness teachers who followed an established protocol of eight weekly group

| Statistical analysis
Significance values were set at p < .05 and confidence intervals at

| RESULTS
Comparisons of available demographic data of those with cancer in a study evaluating the effectiveness of mindfulness on well-being in a similar setting, suggest the sample was comparable. 53 Preliminary analysis of the scored data was conducted before the full analysis, to investigate the assumptions of parametric tests, such as the assumptions of linearity, and parametric data were not violated.

| Mental adjustment to cancer and rumination
A paired samples t-test compared participants' adjustment to cancer and rumination scores before and after the mindfulness-based intervention. There were statistically significant differences in the pre- with a medium effect size (d = 0.5) ( Figure 1 and Table 2).  (Table 3).

| Intra-individual change
The Reliable Change Index (RCI) computes the standard error of measurement and the standard error of difference scores to calculate reliable change in each participant that is not likely due to an error of measurement alone (p = <.05). Jacobson and Truax 39 suggest using the following calculation: Formula key: x 1 = mean score T1. x 2 = mean score T2.     (Tables 4 and 5).

| Secondary outcomes
T A B L E 3 Wilcoxon signed-rank tests in participants (N = 22) regarding fears of expressing compassion for others, from others and for self in T1 and T2 Existing research suggests some individuals with cancer experience difficulties receiving affiliative emotions such as compassion 48 and a better understanding of this was suggested by the secondary aim of this study, which examined the relationships between the concepts of coping, rumination, and fears of compassion in cancer after the MBCT-Ca. There was a strong relationship between fears of selfcompassion and showing compassion to others or accepting it from others pre-and post-intervention, and it was also highly correlated with brooding and depressive ruminating, adding to studies suggesting rumination can contribute to an active resistance to kindness. 56 There was no statistically significant change for reflective rumination, which is traditionally considered to be more adaptive, a finding that is also consistent with existing studies. 30 This may be because mindfulness encourages a degree of reflective introspection by turning towards painful thoughts and feelings which some individuals with cancer may find challenging. 57 The significant positive associations between reflective ruminating with both depressive rumination and fears of self-compassion post-intervention suggests that reflection may have contributed to some negative affect, at least in the shortterm, which adds to existing research. 29 While reflection can lead to productive insights into adversity, it can also be associated with depressive thinking as it can draw individuals into negative ways of thinking and adversely affect mood 58 and future MBI research in those with cancer may benefit from a further exploration of this.
There are limitations to this study, including the lack of control group and the small sample size (N = 22). The numbers of those eligible to participate was potentially limited by the inclusion and exclusion criteria, changes in disease trajectory affecting commitment 59 and self-selection, suggesting a potential for low statistical power and a small effect size. 42 Participants were directed towards information about the study by centre heads and mindfulness teachers, however the coronavirus pandemic impacted the numbers responding. Of the initial 31 participants who successfully filled out the pre-course questionnaire, six failed to complete the post-course questionnaire, either because their course was cancelled due to coronavirus or they were ill, and three did not give a reason. This dropout rate is still lower than many studies into mindfulness in those with cancer which suggest attrition rates of around a third or more. 54,60,61 Despite the authors' attempts to recruit a diverse sample, another limitation of our study was the fact that our participants were predominantly female, middle-aged, white, with high levels of educational status, which reduces the generalizability of the study. Although this seems typical of many MBIs, 62

CONFLICT OF INTEREST
The authors have stated explicitly that there are no conflicts of interest in connection with this article.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.