To assess the duration of an episode of depression, the criteria of Frank et al

Chapter 8: The Insiders Perspective on Treatment EffectsRef: Ma, S.H. (2002) The Insiders Perspective on Treatment Effects, in: Prevention of Relapse/Recurrence in Recurrent Major Depression by Mindfulness-Based Cognitive Therapy (PhD Thesis). University of Cambridge. Chapter 8The Insiders Perspective on Treatment EffectsIn this chapter, we examine the subjects views of the impact of MBCT on them. The previous analyses have been quantitative and can be regarded as an attempt to produce an objective statement of the treatment effects of MBCT. In contrast, the following analyses are mainly qualitative and represent an attempt to get close to the subjects personal world, to take an insiders perspective (Conrad, 1987). It is hoped that the two approaches will complement each other in enhancing our understanding of the effects of MBCT in preventing relapse in depression.

8.1 METHODAs reported in Sections 4.1.1 and 4.1.2, subjects were followed up for twelve months after the completion of the treatment programme. In the last interview, after the assessment of relapse, the clinical psychologist who conducted the interview and was hitherto blind to subjects treatment condition asked the subject to reveal their treatment allocation. For subjects who were allocated to MBCT, a semi-structured interview was conducted to explore their experience of the benefits and problems brought about by the treatment programme. They were asked, Has the programme been useful to you? If the answer was in the affirmative, then they were asked, In what ways has it been useful? Can you give an example? After they gave an answer, they were asked, Anything else? until they answered in the negative. Then they were asked, Has the programme caused you any difficulties or problems? If the answer was yes, then they were asked to describe the difficulties or problems and give examples until they had covered all the difficulties or problems. Where necessary, follow-up questions were asked for clarification and elaboration of what the subject had said.

8.2 RESULTS8.2.1 Strategies of AnalysesThe analyses followed the approach of interpretative phenomenological analysis (IPA) (Smith, Jarman, & Osborn, 1999), one particular form of qualitative analysis. The aim of IPA is to explore in detail the subjects view of the topic under investigation. Thus the approach is phenomenological in that it is concerned with an individuals personal perception or account of an event. At the same time, IPA also recognises that it requires the researchers own conceptions and interpretation to make sense of the subjects personal world. Hence the term interpretative phenomenological analysis is used to signal these two facets of the approach. The transcripts of the interviews were read and re-read closely to look for themes in what the subject said. The themes were examined for connections between them. As clusters of themes emerged, they were checked back to the transcript to ensure that the connections held for the primary source material what the subject said. The themes were not selected purely on the basis of their prevalence in the subjects responses, as in the case of content analysis, which aims at recording how often a predefined concept is observed in the data set (Weber, 1990). Factors that were taken into consideration in selecting and clustering the themes included the richness of the particular responses that accentuated the themes, and how the theme helped illuminate other aspects of the account. As a master list of themes emerged, the themes were arranged in a coherent order, and further examined and compared in a search for super-ordinate themes that captured most strongly the subjects responses on that particular topic and pointed to the multiple qualitative facets of potentially significant concepts. Care was taken to ensure that each theme was represented in the verbatim transcript and not to allow the bias of the researcher to distort the selective process. This involved sustained interaction with the text, and a number of techniques (e.g. constant comparison, category splitting and category integrating) commonly associated with grounded theory (Pidgoen & Henwood, 1996). Patterns and relationships within and between the themes were explored so as to arrive at a holistic understanding of the subjects experiences. As the degree of attendance is likely to have an impact on a persons experience of the programme, the analyses of the themes in the responses of the subjects who attended four or more sessions of the MBCT programme are presented first, followed by those in the subjects who attended less than four sessions.

8.2.2Subjects who attended four or more sessions of MBCT8.2.2.1 BENEFITS OF MBCTAll thirty-five subjects answered in the affirmative to the question whether the programme had been of benefit to them. Four major themes emerged from the responses of these subjects to the questions about the perceived benefits of MBCT: Depression-Related Changes, Changes in Interpersonal Relationships, Changes in Life in General and Support from the Group. Compared to people who had relapsed, a greater proportion of people who had not relapsed reported incidents that reflected two sub-themes of Depression-Related Changes - Halting the downward spiral and Breaking old problematic patterns, and the difference was even more obvious when people whose relapses were triggered by significant life events were excluded (for details of the sub-themes and their prevalence in the sub-groups, see Appendix III). There was no obvious difference between the themes mentioned by people with three or more episodes and those with two, probably because there were only four subjects in the latter group. As it will become obvious in the following analyses, the themes are not clear-cut separate entities, but rather they interweave with each other to form a greater picture of the persons experience.

DEPRESSION-RELATED CHANGESThe first theme Depression-related Changes articulates the subjects perception of how the programme had helped them to achieve what they had hoped to learn: dealing with depression. The sentiments of Marys[footnoteRef:1] words were echoed in many others: When I first came, I could not imagine not living with depression. It was always there and if not, just about to start again. It coloured everything. And now I never thought Id be this well. [1: Names of all subjects have been changed to protect confidentiality]

Halting the Downward SpiralMany subjects typically described how they had halted the downward spiral of their dysphoric mood at a point of potential relapse, to act before it is too late, before you go down too far that dark road or path (Bonnie). In my period of unemployment, prior to the course, I would have thought, Im unemployed. I havent got a job. What on earth is going to happen, etc. etc.. And the thoughts would have had a downward spiral or decline if you like. But now I am able to have the presence of mind to check myself and say, Heh! Look! You may be unemployed but youve got your health, youve got a home, youve got food, and you are feeling okay right now so tomorrow may change but it is now that is important (Henry).

I think being aware is the biggest thing and certainly being aware of a situation, even this lump[footnoteRef:2], trying not to let it get out of control, trying to think this is not going to be necessarily bad rather than being negative at the very beginning trying not to let things snowball to a point where you cant get it back in - Its a different way of thinking. I didnt think like this before (Patricia). [2: Patricia found a lump in her breast and was waiting for a biopsy report.]

John (the MBCT therapist) said, A thought is not a fact.I thought that was a casual throwaway but it has been most helpful to meWhen I get very upset about my son, I sort of stop, especially if I feel near to tears. I just try to stop myself thinking along the inevitable track of what have I done wrong and all the rest of it. It tends to pull me up short and stop the downward spiral (Josephine).

Very often you worry about things and it spirals. It (The programme) made me take a breathing space and think, You are not getting anywhere with these thoughts (Charles).

As can be seen from the above excerpts, subjects employed different techniques, including awareness of the present, reminding themselves that thoughts are not facts and taking a breathing space, to pull themselves back from the downward spiral. We shall look more into the different skills and approaches they used in the section Ways to Change. Breaking Old Problematic PatternsSubjects often animatedly recounted how the programme had helped them to break long-standing problematic or debilitating patterns of behaviours or reactions. Before, I was a great binge eater, stuffing myself Im not doing that anymore. All of a sudden, one day, I realised that I hadnt done that for agesI was always under stress, like this last month, and I would eat. I would really stuff myself. I havent done that. There was no need for it. I would just be calm and there was no need for it (Charlotte).

Previously, on landing or in rough weather Id really get quite nervous, sweaty palms, couldnt concentrate. Id really get quite panicky inside... Flying has absolutely no worries for me at all now. And if the plane is leaping about all over the placeI just rest my hands on my legs and start concentrating on my breathing and Im completely relaxed (Kenny).

I always felt from being a child I had to put on an act. Now having done this course it has broken that pattern and it helps me to be more trusting in myself...When I talked to people, I was so eager to express ideas all the time. Im a little bit more ready to listen for a change. (Jack).

I think the biggest thing that stuck in my mind was when John (the MBCT therapist) said, Dont think about it Just do itGoing for it really, I suppose, rather than hesitatingdoing things that previously I would have thought it a bit too risky at my ageSpeaking up more at work is one of the big things and doing bolder things at work...I put my ideas and opinions forward which I wouldnt have done (Ruby).

(Talking about dealing with a car accident) Before the course, I would have exploded and afterwards thought, That wasnt sensible. Now Ive learned to think before I act which is very useful (Bonnie).

There was a time before when I knew a relationship was wrong but Id kept it going, going and going and Id have got worse; whereas now, I got strength, knew it wasnt right, so I sorted it out and got rid of it now. I would never have been able to do that before (Natalie).

Worries gnawed at me quite a lot. I used to find it difficult kind of meeting people. Before, it used to worry me: How would anyone want to know me? I was putting myself down quite a bit, but now I know Im meeting somebody, it doesnt fill me with apprehension. I dont get worked up about it (Isaac).

It was interesting to note that the directions of change could be quite different in the subjects: some learned to listen more (Jack) while others became more expressive (Ruby); some learned to think before they acted (Bonnie) while others became more able to take risks (Ruby); some became better able to break a relationship (Natalie) while others better able to meet people (Isaac). The apparently opposite directions of changes as reported by the subjects gave the impression that what they were learning from the programme was not dogmatic rules on how one should behave. Instead, they learned to be aware of and change the patterns of behaviours or reactions that had become excessive or rigid and were not conducive to their mental well being.

Ways to ChangeA close examination of subjects detailed description on what had helped them to halt the downward spiral and break old patterns yielded a rich mosaic of different techniques and approaches, which included

WARNING SIGNALS

being aware of the triggers and symptoms of depression

Now if the situations are getting on my nerves, Ill take that time out. A minute is quite a long time. When you do the tapes, you realise what you can actually get into a minuterecognising the warning signals thats the major thing really (Patricia).

(Talking about arguments with her husband) I remember the list[footnoteRef:3] and this will just chill just take a step back and dont go into the tirade, which would characterise the old step of a spiralIm now seeing the triggers in myself (Lorna). [3: Participants drew up a list of their warning signals of depression in Session 7 of MBCT. ]

Before the course, I wasnt really aware of the way I am now of my triggersWaiting is one of my triggersI cant bear it because as a child I spent lots of my time waiting for something awful to happen, waiting for my father to come homeWaiting is boring. Trying to pretend you are not waiting is even worse; it really agitates me. But if you wholeheartedly wait, there is only so much you can do before you think Ill go and have a drink (Sarah).

It has probably increased my inner awarenessbasically my body tells me to stop if my mind doesnt...I know Ive got to listen to my body more and this is what the mindfulness meditation helps you to doWhen I am running around like a headless chicken, I think then thats the time to take stock (Linda).

PLAN OF ACTION

planning strategies to deal with difficult situations

We had a plan to put into action[footnoteRef:4]. I know that if everything is too much or Im too tired or everything is overwhelming, it is time to step back (Bonnie). [4: Participants designed a plan of relapse prevention strategies for themselves in Session 7 of MBCT.]

My child care arrangements fell apart the day before (the follow-up meeting of MBCT). My new tactic which has come out of the course is to have three attempts at it, then give it up. I had three attempts at it and then rang up and said I couldnt come. I could have tried harder but that would have started one of a Youre no good. Youre bad slide and Ive decided not to do that anymore (Sarah).

Last week it was the third anniversary of my fathers death. The last two years before Id been really falling apart and crying my eyes out. This year, I did take time off work, so I was in a less stressful situation, but I was able to think about it, think about my father and experience feelings without letting them take me overSadness and the mess, the way things happenedAt one point, the only thing I could think about him was negative. I hated him. I couldnt stand him. I couldnt think of anything good about him, whereas now Im able to think he was good at that or that was something good that he did (Mary).

ACCEPTANCE

accepting what has happened

I dont dwell on the past in a negative wayyou see I had problems with my hip when I was eight now Im willing to accept what has happened in the past (Bonnie, who was suffering from deteriorating and incurable hip problems).

At Christmas, my husbands extended family visited us. Mindfulness helped me to cope with them. I observed how I reacted and knew That is what I am feeling now. There is no point in wishing away - I found that I really enjoyed some of the moments (Matilda).

AWARE OF THINGS AROUND ME

being aware of the present moment

Im much more appreciative of things around me, I suppose, rather than turning into my own little worldThe feel of the steering wheel, my feet on the pedal, spots and specks on windscreenyou know, the steering wheel is smooth on top and rough underneath (Rose, who used to be overwhelmed with anxious and worrying thoughts when driving to work).

It was good to notice things that I hadnt been particularly aware of Cycling to work makes me feel better. One of the things is that I have time to look at ducks as Im cycling alongand just smile at them, and things like that set you up for the day. You feel in a better frame of mind (Hazel).

Aware of the immediate things around you: the trees, the flowers, the animals, even the potatoes just the ordinary thingsI find my muscles letting go and relaxing (Josephine).

BREATHE & SLOW DOWN

taking a breathing space and slowing down My car got smashed up by a bus when I went to buy some stampsI didnt over-react at all, whereas previously I would have done. All I did was to say, Take a deep breath. Think about this. It is not the end of the world. (Bonnie).

At times when I might have got a bit stressed at work where I might have thought I had too much to do, just doing that deep breathing for three minutes, I would feel not so panickyI would just do one at a time and be mindful of each one rather than being overwhelmed by everything (Hazel).

PUTTING THINGS IN PERSPECTIVE

seeing things in the light of the truth

Id get really fraught about not sleeping but now occasionally I dont sleep - I say, Ill sleep tomorrow night because Ill be tired. Its not such a big issue it was. It (The programme) makes you see things in the light of the truth, so it is not making it a hundred times worse (Ursula).

I think I actually get more done at work now because Im more likely to get on and do it rather thanthinking why didnt I get this and this done and everybody else thinking shes uselessjust constant things used to go through my head all the time it feels strange to talk about it now because I feel so different now. These thoughts dont go on forever, and are not as frequent either. I dont tend to give them as much importance (Mary).

It (The programme) has made me think that serious matters are not as serious as they were (Charles).

I feel that I can deal with it (worry) or cope with it and it is not the most important thing in the world (Isaac).CHANGES IN INTERPERSONAL RELATIONSHIPAs a result of participating in the programme, subjects found that they were better able to talk about their depression with their family and friends.Getting other people involved, not being frightened to say Im having a bad day (Patricia).

I wasnt prepared to admit to anyone that I was depressed. I am able to do it now. Being on the course and talking to other people and actually discussing it we were all together and I felt that I could talk. Previously I couldnt talk to my family (Bonnie).

It (The programme) brought the depression more out into the open in that it forced my wife and I to talk about it a lot moremy wife sees other people think Im ill not just a miserable git not that she thought that but you see it legitimises it as an illness and she sees me trying to do something about it (Raymond).

Subjects reported having positive feedback from their family and friends, and their relationships had improved. Some of them also mentioned that they have passed the tips on(Betty) to their family, friends and students.

My children and my partner say that since Ive been on the programme, I havent had real dips (Anna).

(Talking about shouting at her children when they were getting out of hand) I always make a point afterwards of going up and giving them a hug or a pat on the back and trying to explain why I reacted like I did and they are actually a lot betterFamily life is much, much betterwhereas before my older one wouldnt hold a conversation particularly but now hell perch himself in the kitchen and talk about different thingsMy elder child in some respects is like me and he gets off. Now I can try and say to him, Dont worry about it. Just stand back. So, its quite nice to be able to teach him a little bit of what Ive learned to help him (Patricia).

Ive noticed that people respond to me in a more forthcoming and friendly way than they used to people go by and wave now if they cant speak to me it didnt happen much before (Jack, who found himself listening more and the need to put on an act when dealing with people less pressing).

People have told me Im better at it (not getting worked up about meeting people) now. They say I look happier (Isaac).

CHANGES IN LIFE IN GENERAL

Although subjects came to the programme to learn to deal with depression, they reported changes that had permeated into their daily life, bringing about a slightly different level of being (Betty), a different outlook on life (Sophia).

Enjoying LifeSubjects commented that not only that they did not feel depressed, they were feeling a lot happier now (Mary), enjoying more what is around and feeling more positive about life.It (The programme) has helped me in enjoying life more to the fullWhat always stuck in my mind was one day when I looked at the magnolia flower and I didnt just look at it. I saw it! There is a difference between looking at something and actually seeing it! (Charlotte).

I do go and sit in the garden and look at the garden and enjoy whats there. I do take time to cuddle the cat. All these in the middle of the day when before I wouldnt have (Linda).

My whole approach to life is much more positive (Bonnie).

I have looked at the good in everything, including going to the dentist (laugh) (Matilda).

I found the awareness a bit of revelation really. That was like zooming out with a camera. You drive to work and see the two red lights in front of you and realise there is a whole panorama there. The awareness is quite stunning reallyJust experiencing the awareness technique is great (Kenny).

Feeling Empowered & ConfidentWhen subjects reflected on the changes in them, they often commented on a newly found sense of power in being able to make choices and to make a difference in their lives. Doing the course made me feel that there are skills, that I dont have to be a victim of circumstances, that I can do something, I can change the situation, I can change the way I think about it (Dorothy).

There was a real change there was a choice: you could get depressed or you could not get depressed. And Ive never felt like that before. So that is an amazing thing for me (Sarah).

It (The programme) empowers you to do something about it (the problem) Ive always believed that somehow the solution was within yourself to your problemIts all locked in yourself, but where is the key? Its given me the key. Its shown me where the lock is and how to open the safeBefore I started, I would have called it the safe. Now its more like a sliding door, which is easy to open (Charlotte).

There was also a developing sense of confidence and trust in themselves and in life.Before, I was not confident in going out by myself. People might think, What is the problem with her? Now I just get on with it (Matilda).

Becoming confident in that respectOne instance was when I was doing a display. I would have done it really small, but this last summer term I just did a great big bold thing and made a garden hanging from the ceiling with the children. Its gone half over the ceilingTo make it fun rather than boring, just which I probably would have done twelve months ago. And the staff have noticed it as well. They said how lovely and how the ideas were so colourfulAnother thing that has changed is wearing colourful clothes, like yellow, which I would never have had the courage to wearto just make a statement: This is me I am not someone in the corner anymore (Ruby).

And Jack saw the course as affirming his self-trust and spiritual faith:Its like I am going to a slightly different levelIts all bound up in this: I couldnt do these things at all if I didnt trust myself more. What we got is what God gives us, and thats all bound up in the course. Thats the core of the course really (Jack).

Taking Care Of SelfConfidence in themselves was often associated with a greater ability to take care of themselves, as they were better able to

SAY NOturn down others requests or demandsI was putting everything in for other people and nothing for me. I think thats one of the things why in the past Ive gone down, because Ive been afraid to say No. I realised listening to others in a group that it is okay to say No(Ruby).

Ive got a lot stronger in that: your life will never change until you start to say No to peopleEverybody is taking my time. I just want what I call my own holy timeI announced to my mates one weekend...I said, I need to shut off. I dont want anybody, phones. I dont want nothing. I give myself an allocated time to myself, thats what Ive learnedAt lunch time it used to always be that wherever I was, they (staff coming to ask her for help) always came to find meI remember thinking I made a safe escape taking my lunch out to the car. They came banging on the window, so I didnt get hid in the car park. Thats how bad it wasbut now Ive got it all under control(Natalie).

NOT FEEL GUILTY OR SELF-CRITICALfeel less guilty or self-criticalIve always perhaps been under the impression that taking time out to stand and stare was perhaps a waste of time; we should be doing something or reading a book. So I used to feel guilty but now Ive stopped feeling guilty. I probably do a lot less of dusting and hoovering than I did before the world still goes on (Josephine).

Looking back now, I dont think it was all my fault. There were some situations where it was made worse by others or would have been made better by others but they didnt bother because they thought it was my job to do it The guilt has gone (Patricia).

I used to be very critical of people, of myself in particularbut that feeling has goneI think I accept myself as I am more than I used to (Rose).

MAKE TIME FOR SELFmake time for nourishing oneselfI think working with the meditation, spending time allowing yourself it was a treat for meIf youve got low self-esteem, that isnt something you naturally doNow I run, three to four times a week and that is my time for me to just recoupthat is my time and it keeps me mentally well. I feel very strongly. It is something critical for me (Lorna).

Feeling Calm & RelaxedA recurrent theme in most of the subjects response was that they were feeling calmer and more relaxed. Some mentioned that their sleep had improved.It (The programme) helps me to stop and slow down whats going on in my mind and just focus on whatever is happening in that particular moment. Its been very calming (Josephine).

I think the mindfulness is useful and I find it easier to relax in stressful situation. Although I didnt do the full meditation, I sit down and relax, I still watch the breathing and relax that wayIve become a lot more relaxed (Charles).

I focused and tried to keep my mind on one thing breathing, then I managed to go to sleep and have a good evening rather than I should have done this I should have done that and all the other things that were whirling around in it (Anna).

Subjects also reported using a breathing space as a relaxation technique to blank the mind out (Dorothy) or to calm down (Ursula), although taking a breathing space is not meant to be just an escape hatch for people to retreat and relax (pg. 235, Segal, Williams, & Teasdale, 2002).

SUPPORT FROM THE GROUP

Group MembersAlmost all subjects mentioned in one way or another the usefulness of being in a group. The group has helped them

BEING UNDERSTOOD AND NOT ALONEto feel understood and not aloneWhat helped me was actually meeting people who I realised felt the same as me and I wasnt on my own (Lana).

It was nice to meet people who really understood (Josephine).

I definitely felt very good around the time of the courseIts probably a process thing - there were a group of people who were interested in me and my depression (Raymond).

COUNT YOUR BLESSINGSto put their problems in perspective and appreciate their fortune/strength

One of the girls said that last Christmas was her first happy Christmas that she could remember. You think, Oh! My god! Thats awful! I probably had one unhappy one when I was depressed but Ive had lots of happy things. You just think, Im so lucky. Count your blessings and get on with it (Ursula).

It is quite amazing how people talk how youd react to something is totally different from how someone else reactsIt taught me a lot, yeah, we are all individuals, but it also taught me that perhaps I am stronger (Natalie).

Sitting with other people with similar problems, you could see it was quite a common situation to be inIt makes the problem feel smaller (Charles).

(It) was good to feel that you were making a contribution to something (Sarah).

LEARNING FROM OTHERSto learn from others sharing and feedback

Listening to how other people deal with theirs (problem) as well, their way of doing, and try a different way (Ruby).

One of the most striking moments for me in the programme was when someone else in the group was very, very resistant to the idea that they could stop doing something that was actually making them feel depressed. I sat there watching and thinking, God, its just like my mother! The idea that you could not not clean the house, the idea that you could not not see somebody, that you could not let them downI began to think, This is ridiculous, because youll just get depressedand I thought, Well, you have to apply that to yourself (Sarah).

When I came back to the course and told people there about it (the sitting meditation at home), how I felt, how Id agonised, how it had really, really hurt, pain everywhere, they were amazed and said, Why didnt you stop? I was dumbfounded because I never thought I had the choice...It opened my eyes (Charlotte).

TherapistSubjects expressed their appreciation of the therapist and mentioned in particular his beingkind and non-judgementalJohn (the MBCT therapist) was always very kind. He was much appreciated (Josephine).

John was very, very fair because he never let anyone take overHe never got cross which was quite somethingI never felt judged. I never felt there is something wrong with me because I got depressed well, it was like loving reallyI expected we would have some kind of school end evaluation, a done-well tick or a done-badly tick. It wasnt like that at allWhen John said Thank you, that was it really. It was very low key and I really, really like that (Sarah).

supportive

John was brilliant, so supportive during those weeks (when she had a relapse) (Florence).

enthusiastic

John was full of enthusiasm for what hes doing and everyone feels it. He is inspirational (Charles).

The overall fact that you and John are devoting substantial energy to doing this is extremely positive. It makes me smile. Its good for the world (Raymond).

DIFFICULTIES & PROBLEMS ENCOUNTEREDAbout forty percent of the subjects said that they had not encountered any difficulties or problems. For people who reported that they had, the problems fell into two major themes: Mindfulness-related Issues and General/Logistic Issues (for details of sub-themes and their prevalence in sub-groups, see Appendix IV).

Mindfulness-related IssuesBrought up unpleasant emotions Subjects mentioned that in meditation, unpleasant emotions associated with past significant events came up. Some coped by shoving them away, some by talking about them with their partners and some by coming to terms with them. Florence had a poignant story to tell:My brother committed suicide (ten years ago) and Id actually put it away a long time ago. But the meditation brought it all back. It was very difficult because I was giving up smoking as well at the timeI completely fell to piecesI didnt realise what it was until afterwardsI couldnt actually say it was the programme that did it, but looking back it was when all my problems (of not sleeping and feeling suicidal) began, about three to four weeks into the start of the programme. (Interviewer: When did you realise what it was?) Probably while I was in hospital, when the psychiatrist was talking about what had gone on to cause me to get so depressed and also the death of my parents (five and two years ago) now Im alone with no family and I think that part of the meditation brought that backI never grieved properly when my father died because having the money I went off to Australia. I went on a cruise and did a lot of things we couldnt afford to do beforeit just suddenly hit me when it had stopped that there was nobody there. While I was on holidays, I was fine. It was when I stopped going on holidays which was when the programme started.

Florence then related how she found the problems she experienced a blessing in disguiseThe programme did a good thing for me in a way because it brought it all up and I managed to cope with it a hard way to learnIt was only the last one (session) I didnt attend because I was in hospital. It was strange. In some ways, I felt it was helping. In some ways, it was like something to grasp, to keep a hold of, that was normal, because I kept wondering whether I should carry on going every weeksomething would tell me Ive got to go and Id turn up. I dont know what it was. Maybe it was good for me, deep down I knew it was time that all these came out and I sorted it outI just came to terms with being left without a familybut it was only going into a hospital that made me strong enough to do itthere was something in my mind that said I was going to end up here for the rest of my life if I didnt do something myselfI am feeling very good now. It doesnt really bother me now. I realise my family now is my husband. You cant worry about the ones that are gone. You cant bring them backIf you look at it logically, the programme actually probably worked in what it is meant to do help you cope with life and depression.Florences depression started about half way though the programme. After she was hospitalised and talked to a psychiatrist about possible causes for her relapse, she attributed her depression to unresolved grief brought up by meditation, although at the time when she was in the programme, she was only aware of feeling panicky and suicidal but not of grief coming up. It remained uncertain whether her attribution was one of insight or rationalisation. Nonetheless, it is not uncommon for intense emotions to come up in meditation. Other subjects also reported experiencing unpleasant emotions associated with past events in meditation and found ways to cope with them. Some worked through those memories and left them behind[footnoteRef:5]. [5: It (The programme) has allowed me to file and put away, quite happily, the loss of my four babies, something which saddened me greatly in the past (Patricia in her written assessment of MBCT immediately after the completion of the programme).]

I found I went through a period, one-third or half of the way in, where all sorts of experiences from the past were there. It was really quite a dark period really, where your felt you were. You started to wonder whether things that happened twenty or thirty years ago were still thereThere are things about the past that I had registered, but in the programme, I felt sadness, much more intense, when I was doing the meditationIm not sure I was brave enough to go through with the meditationInitially I fell asleep a lot but half way through it was quite unpleasant. (Interviewer: How did you deal with that?) Probably just pushed it back gradually, but didnt really deal with it (Kenny).

It was the sitting meditation I found really, really difficult(about thirty minutes into a silent mediation) It was like a force taking you over and that really, really freaked me out. I was so scared after the first time that happened. I almost felt like a child afraid of the darkI think that kind of made me binge again (Charlotte).

Difficulty in being still or focused Subjects often commented on the practical difficulty in doing the mindfulness exercises.I didnt get on with the yoga at all. I tended to wobble quite a lot when I was holding the poses (Mary).

I couldnt listen to hardly any of the tapes, keeping still for so long (Sophia).

Sounds stupid but I was almost as self-conscious when trying them (the exercises) on my own. It still felt strange and awkward to meI think a lot of it is down to some inhibition in me (Alex).

Not wanting to come to termsOne subject was emphatic about how disagreeable the idea of coming to terms was to her.(Talking about her fear of her parents dying one day) I dont want to come to terms with it really because I can only cope with it by not thinking about it. And in the program, a couple of the poems[footnoteRef:6] that were read out, I felt, to me, were an extremely strange choice for people who were already feeling depressed. I didnt find any solace in themThat is the sort of things that would spiral me downwards, not help meI dont want to discuss infinity and hell and how wonderful the universe is, because I cant understand it and it frightens me really because you cant imagine what infinity is, can you?Other people may disagree. They may think you have to come to terms with it but I personally feel that that doesnt help (Lana). [6: Poetry is used in MBCT as an alternative vehicle for communicating the messages of mindfulness, including acceptance and mindful living.]

It was not uncommon that MBCT participants found it difficult in keeping still and focused in doing the exercises (pg. 140, Segal et al., 2002) or in accepting the idea of coming to terms (pg. 228, ibid.). These difficulties would often provide fertile grounds for exploration in class, offering grist to the mill. Some could then learn from these difficulties and deepen their understanding and practice of mindfulness, while others may be deterred by the difficulties and stop their practice. In the case of Lana, she was quite angry and upset in her protests against what she considered as an unhelpful approach coming to terms and did not consider the acceptance aspect of mindfulness useful for her in dealing with depression.

General / Logistic IssuesSome subjects mentioned feeling that it (homework) added another pressure to my day (Lana) and not being able to do an-hour homework a day made them feel guilty (Mary). Again, this was a very common problem and the advice of Segal and colleagues (2002) in dealing with this kind of response was to let people know that the lack of homework will likely affect how much they will get out of the program, but without being critical of them (pg. 135). Given the tendency of self-blame and guilt in many people with a history of depression, it is often a challenge for the therapist to maintain a creative tension between encouraging MBCT participants to do the homework and not reinforcing their sense of failure and self-criticism. Other general or logistic issues that subjects mentioned included feeling annoyed that in the class, a member talked too much (Camilla) or used to take over andwould go on and on and on (Michelle), and that there was no time to speak about your personal problems (Joanna). One subject also expressed the feeling of not having enough support after the programme finished, as you havent got the will to go and do it (mindfulness practice); we cant do it on our own (Joanna). Joannas sentiment was echoed in a milder way by a number of subjects who said that they very much hoped that there would be regular follow-up classes, although they did not see the lack of continued support as a problem. In fact, all but five (84%) of the subjects indicated that they were still practising some mindfulness skills and the ones that people practised most were taking a breathing space and doing routine activities mindfully (Appendix V).

8.2.3 Subjects who attended less than four sessions of MBCTNone of the six subjects who attended less than four sessions of MBCT indicated getting any benefits from the programme. Three attended one or more sessions and three attended none. In the former group, one did not respond despite our repeated attempts to contact him, one said that she dropped out because she did not want to be reminded of her past depressed experience, and the remaining one said that he discontinued because it was too far for him to travel and he found the tapes boring. In the latter group, two said that they did not join the group because they did not want to think about the unpleasant experience anymore and one said that it was because of a breakdown in childcare arrangement.8.3 DISCUSSION

The description of the subjects about their experience in halting the downward spiral was reminiscent of the latent variable Rumination-Depression found underlying the changes brought about by MBCT (Section 5.2.13). Subjects attributed their success in disengaging themselves from the spiral to their abilities to take a step back and have a wider perspective, check the self-critical thoughts and stop the tendency to ruminate. These were all the variables that loaded on the latent variable. Subjects description of halting the downward spiral maps very well onto the model that underlies the development of MBCT, the one of preventing relapse by helping people to disengage from ruminative and self-perpetuating negative thinking patterns reactivated at times of dysphoria or potential relapse (pg. 37, Segal et al., 2002).A number of the sub-themes in the Ways of Change revealed the active and flexible use of skills learned in MBCT: staying present (pg. 189, ibid.), having a wider perspective (pg. 270, ibid.), acceptance (pg. 218, ibid.), awareness of triggers and symptoms of depression (pg. 282, ibid.) and devising relapse prevention strategies (pg. 300, ibid.). The vivid examples subjects gave of their application in real life situations of what they had learned showed that they were not just repeating words or intellectual concepts picked up in the programme, but rather they had some experiential understanding of what these ideas meant and are practising and living them. The apparently opposite directions of changes in some subjects (e.g. some learned to think more and some to think less before acting) also reflected that they were using the skills of mindfulness in a well-considered and lively way to correct their own particular maladaptive patterns. Subjects detailed description of examples of changes in their ways of dealing with stress and depression revealed an intricate interaction amongst the different skills and approaches they learned in the programme. There did not seem to be any one single path to change. In addition, the benefits of the programme were not confined to coping with depression, but were found in life in general. The experience of being in a group and of the qualities of the therapist formed the context of subjects learning. A good therapeutic alliance has been found to be reliably associated with a positive therapy outcome across a range of therapies and outcome measures (Horvath & Symonds, 1991). In the case of MBCT, the therapeutic alliance has an unique significance in the sense that experiencing the qualities of mindfulness - being non-judgemental, kind and focused (pg. 4, Kabat-Zinn, 1994) - embodied in the therapist could help participants to better understand what mindfulness is and to appreciate its benefits. It is not uncommon that unpleasant emotions or memories come up in meditation (pg. 204, Mason & Hargreaves, 2001; pg. 139, Segal et al., 2002) and pose a challenge to a persons coping resources and mental well-being. The sensitivity and skilfulness of the therapist are crucial in helping the person to decide whether or what kind of help they would need in addition to or instead of mindfulness training for them to work through what has been brought up in meditation. This will be an important area of investigation for researchers and clinicians.While the findings of this qualitative study were in general consistent with those in Mason and Hargreaves (2001) in that acceptance, awareness of warning signals and staying present were identified as important areas of therapeutic changes, there was one notable exception. The experience of halting the downward spiral of depression, which features a central role in the report of many subjects in the present study, was not mentioned in the study of Mason and Hargreaves (2001). This may be due to the facts that a minority of the subjects interviewed in that study might not have suffered from major depression that met DSM-III-R criteria, and that the first depressive episode of five of the seven subjects in that study followed a significant life event (such as serious medical illness, divorce or death in the family) that happened in their thirties or beyond. All the subjects in the present qualitative study were assessed to have suffered from major depression that met DSM-IV criteria on at least two occasions, and, on average, had their first onset of depression in their twenties. It is possible that the subjects in the study of Mason and Hargreaves (2001) and the subjects in the present study came from different populations, hence the discrepancy in the findings. - 228 -

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