project report arabic mindfulness intervention project ... · pdf fileproject report arabic...

Project Report Arabic Mindfulness Intervention Project Evaluation

South Eastern Sydney Local Health District June 2016

Produced by the Multicultural Health and Mental Health Services

South Eastern Sydney Local Health District

Arabic Mindfulness Intervention Project Evaluation

Report prepared by Fatima Hamdan, Project Officer Lisa Woodland, Manager, Multicultural Health Service, South Eastern Sydney Local Heath District (SESLHD) Project team: Hend Saab, Senior Bilingual Psychologist, Mental Health Service, SESLHD Lisa Woodland, Manager, Multicultural Health Service, SESLHD Fatima Hamdan, Project Officer A/Prof Ilse Blignault, Western Sydney University SOUTH EASTERN SYDNEY LOCAL HEALTH DISTRICT District Executive Unit Locked Mail Bag 21 TAREN POINT NSW 2229

T +61 2 9540 7756 F +61 2 9540 8757 E [email protected] www.seslhd.health.nsw.gov.au Produced by: Multicultural Health Service South Eastern Sydney Local Health District Suggested citation: Multicultural Health Service, South Eastern Sydney Local Health District (2016) Arabic Mindfulness Intervention Project Evaluation Report South Eastern Sydney Local Health District, Darlinghurst, NSW. Disclaimer: Content within this publication was accurate at time of publication. This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from the South Eastern Sydney Local Health District © South Eastern Sydney Local Health District Further copies of this document can be downloaded from the SESLHD website www.seslhd.health.nsw.gov.au/multicultural_health

June 2016

mailto:[email protected]

http://www.seslhd.health.nsw.gov.au/

http://www.seslhd.health.nsw.gov.au/multicultural

Arabic Mindfulness CD Research Report June 2016 of 44

Contents

Acronyms .............................................................................................................................. 4

Acknowledgements ............................................................................................................... 4

List of Tables and Figures ..................................................................................................... 5

Executive Summary .............................................................................................................. 6

Background ........................................................................................................................... 8

Evaluation Overview .............................................................................................................11

Methodology .........................................................................................................................12

Results .................................................................................................................................17

Is the intervention culturally acceptable? .......................................................................17

Qualitative feedback ......................................................................................................19

Does the use of the Arabic Mindfulness CD improve psychological distress? ................20

Discussion ............................................................................................................................23

References ...........................................................................................................................25

Appendices ..........................................................................................................................27

Appendix 1: K10 results.................................................................................................27

Appendix 2: DASS21 Results ........................................................................................28

Appendix 3: Participant Information Sheet and Consent Form ......................................30

Appendix 4: Participant Questionnaire ...........................................................................34

Appendix 3: Participant Instructions and Activity Log Sheet ..........................................37


Acronyms

CALD Culturally and Linguistically Diverse

DASS21 Depression Anxiety and Stress Scale (21 items)

K10 Kessler Psychological Distress Scale (10 items)

LOTE Language other than English

MBI Mindfulness-based Intervention

MBSR Mindfulness-based stress reduction

MBCT Mindfulness-based cognitive therapy

NAATI National Accreditation Authority for Translators and Interpreters

NESC Non English speaking country

SESLHD South Eastern Sydney Local Health District

Acknowledgements

We would like to thank our community partner, Al Zahra Muslim Women’s Association, and our university partner, Centre for Primary Health Care and Equity, University of NSW. In particular we would like to acknowledge A/Professor Elizabeth Comino, Fakhrul Islam and Dr Julie McDonald for their support with the statistical analysis.

Special thanks also to the community members who participated in the research, for undertaking the Mindfulness intervention and for sharing their experiences.


List of Tables and Figures

Table 1: Socio-demographic characteristics of the 70 participants 12

Table 2: Health professionals seen during the previous month 14

Table 3: Frequency of use of Mindfulness post-intervention 17

Table 4: Summary of responses to knowledge and attitude questions 18

Table 5: Change in K10 category from baseline to 5 weeks to 12 weeks 27

Table 6: Change in K10 scores from baseline to 5 weeks and 12 weeks 27

Table 7: Change in DASS21 measurement from baseline to 5 weeks to 12 weeks 28

Table 8: Change in DASS21 scores from Baseline to 5 weeks and 12 weeks 29

Figure 1: Change in K10 category from baseline to 5 weeks to 12 weeks 20

Figure 2: Change in K10 score from baseline to 5 weeks to 12 weeks 20

Figure 3: Change in DASS21 categories from baseline to 5 weeks to 12 weeks 21

Figure 4: Mean change in DASS21 subscale scores from baseline to 5 weeks to 12 weeks 22


Executive Summary

As one of the most culturally diverse areas of NSW, South Eastern Sydney Local Health

District (SESLHD) has a strong commitment to providing services that are culturally

responsive. There is a large Arabic speaking community in the District, many of whom are

known to experience high levels of psychological distress, while also having poor

engagement with mental health services.

There is growing evidence for the efficacy of self-management techniques as an effective

mechanism to help people with mental health issues. In particular, Mindfulness based

interventions have been found to be effective for managing depressed moods, anxiety, stress

and rumination; and preventing relapse of depression and anxiety. In light of this, together

with the lack of self-management treatment resources for people who speak a language

other than English at home, the Arabic Mindfulness Intervention Project was established.

The project comprised two phases. The first phase was the translation of an evidence-based

Mindfulness Intervention into Arabic (CD and electronically). This was disseminated to

people from Arabic speaking backgrounds through community mental health and other

health related services.

The second phase aimed to evaluate the clinical utility and cultural acceptability of the five

week mindfulness self-management intervention in Arabic. This was the first study of its type

to be conducted both nationally and internationally with Arabic speakers.

Seventy Arabic-speaking people aged between 18 and 65 years participated in the study by

using the Arabic Mindfulness CD for five weeks, and participating in a follow-up interview at

12 weeks. Arabic translations of standardised measures: the Kessler Psychological Distress

Scale (K10) and the Depression Anxiety and Stress Scale (DASS21) were used in a pre and

post-test design at three points in time (baseline, after 5 weeks and 12 week follow-up).

Qualitative data collection methods were also used to evaluate perceptions and the

acceptability of the program to the community.

Evaluation results showed significant improvements in mental health in addition to cultural

acceptability. Clinical utility was measured through standardised self-report mental health

measures, with the K10 and the DASS21 administered at baseline, post intervention (5

weeks) and follow-up (12 weeks).

Participation in the mindfulness interventions was successful in:

reducing psychological distress, as measured by the K10; the mean score decreased

from 30.5 at baseline to 26.9 (p<.001) at 5 weeks, and to 23.8 (p<.001) at 12 weeks.

reducing depression, anxiety and stress, as measured by the DASS21; from baseline

to 12 weeks, the mean score for depression decreased from 8 to 5.2 (p<.001), the

mean score for anxiety decreased from 4.3 to 2.8 (p<0.001), and the mean score for

stress decreased from 12 to 7.5 (p<.001).


In addition, the acceptability of the program was high with all participants reporting that they

saw the practice of Mindfulness as compatible with their cultural and religious practices, and

saw it as suited to their way of life. The majority (n=66; 94%) continued to practice

Mindfulness after the intervention period.

The program has been found to be effective; low cost; and suitable across a range of

settings including individual self-management, community groups and as an adjunct to

primary and specialist mental health care.

As work continues in this area, it will be a priority to explore opportunities to expand the

program and to determine whether similar outcomes can be obtained when community

members are engaged through different pathways, such as group programs. It will also be

important to test the viability of the program in different geographical regions in Sydney.

More broadly, the study suggests that there is potential for interventions such as this to

improve access to culturally appropriate mental health interventions for people from culturally

and linguistically diverse communities.


Background

Twenty six percent (26%) of the population served by South Eastern Sydney Local Health District (SESLHD) were born in a non-English speaking country (NESC) and thirty seven percent (37%) speak a language other than English (LOTE) at home (ABS, 2011). In 2011, there were 18,746 people who spoke Arabic at home in SESLHD. Arabic is the fourth most common LOTE spoken in the District.

Evidence indicates that mental health issues are highly prevalent in culturally and linguistically diverse (CALD) communities in general, with the World Health Organisation estimating that almost 50% of migrants suffer from mental health related trauma (Kljajic, 2009).

There are numerous barriers faced by people from CALD backgrounds in accessing mental health care. Both language and cultural issues are significant. Stigma associated with mental health problems represents a major barrier to seeking mental health care, disclosing symptoms and participating in treatment. In particular, there is evidence to suggest that Arabic-speaking communities in Australia underutilise mental health services (Steel et al., 2006), preferring to rely on family, family doctors, traditional healers and religious leaders (Youssef & Deanne, 2006; Tobin, 2000). They often have negative perceptions due to their experiences of seeking mental health care in their country of origin. In addition, there are service related barriers for Arabic speaking people including the lack of a culturally skilled workforce, and culturally appropriate assessment and therapy tools.

Mindfulness as a self-management intervention for mental health issues

Mindfulness is a psychological practice, based on Buddhist traditions, that has been popularised in western societies for the management of clinical problems through the work of John Kabat-Zinn who described it as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn,1994, p. 4, cited in Baer, 2003). Mindfulness is often taught through a variety of meditation exercises that allow people to manage unhelpful thoughts and distressed feelings and strengthen attentional control (Siegel, 2007; Baer, 2003). Mindfulness-based interventions (MBIs) usually incorporate meditation practice together with various cognitive and/or behavioural techniques (Mirdal, 2012).

Although there are many methodological flaws in the current literature, a recent systematic review and meta-analysis found that MBIs, such as Mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT), can significantly improve depressive symptoms, anxiety, stress, quality of life and physical functioning (Gotink et al., 2015). Accordingly, Mindfulness has become a core component of many mental health therapies and is being used increasingly within mainstream mental health settings; however, current treatment resources are almost exclusively available in the English language.

In recent times there has also been growing support for self-management interventions as an efficient means of addressing health conditions; with less, or no, reliance on contact with clinical services to achieve improved health outcomes. Systematic reviews and meta-analyses have demonstrated:

Self-management improves health outcomes with the best evidence in patients with diabetic, cardiovascular and mental health conditions (Panagioti et al., 2014).


Mindfulness self-help interventions can be learned without clinician guidance and can lead to a reduction in depression and anxiety (Cavanagh, Strauss, Forder, & Jones, 2014).

Recruitment of participants in non-clinical settings is associated with greater effectiveness of self-help interventions for depression (Gellatly et al., 2007).

Again, self-management mindfulness resources are almost exclusively available in English.

Mindfulness in Arabic speaking communities

Many spiritual traditions have practices for contemplation, silence, and direct awareness of experience, such as prayers. Expressions commonly used by Arabic speakers such as ‘Insha’Allah’ (God willing) embodies qualities such as patience, resoluteness, wisdom, compassion, serenity and non-reactivity, all of which are qualities that are embodied in Mindfulness. The Arabic word ‘sabr’ represents a calming and unconditional acceptance of what is there, here, and now, not succumbing to worry and anxiety.

There is very limited information about the use of Mindfulness with Arabic speaking communities. Only two case studies on the effectiveness of MBCT with Arabic speaking clients have been reported in the literature (Pigni, 2010). In these cases, MBI was effective in reducing psychological distress, did not clash with the clients’ cultural values; and gave them a chance to learn skills that could be useful in the future.

The Arabic Mindfulness Intervention Project in SESLHD

This two phase project was a pioneering initiative of the St George Community Mental Health Service, funded in 2012-2013, through a Multicultural Health Cultural Diversity grant from the Multicultural Health Service, SESLHD. It was based on the premise that Mindfulness-based interventions have the potential to be culturally sensitive, relevant and effective.

The aim of the first phase of the project was to develop a self-help resource and make it widely available to the Arabic speaking communities to help decrease psychological distress and improve emotional wellbeing. The resource is a translation, into formal Arabic, of the Mindfulness Skills Volume 1 CD produced by Dr Russ Harris. The resulting CD is 60 minutes in duration and contains five tracks, each taking between 15 and 30 minutes to complete.

The second phase of the project was designed to systematically test the clinical utility and cultural acceptability of the CD in the Arabic-speaking community in St George. This was the first study of its type to be undertaken both nationally and internationally with Arabic speakers.

During the first phase of the project (2012-2013), the CD was disseminated to people from Arabic speaking backgrounds through community mental health and other health related services, including private psychologists. It was informally evaluated through interviews with clients of the Mental Health Service who used the resource in conjunction with standard therapy. Clients’ feedback was positive and Mindfulness proved particularly effective when integrated with Cognitive Behaviour Therapy. Clients of Islamic and Christian faiths reported that they found Mindfulness consistent with daily religious practices and complementary to their regular reflective prayer. The tracks were also made available through the SESLHD internet site.


The second phase of the project (2014-2015) comprised a research study to evaluate the cultural acceptability and clinical effectiveness of the Arabic language Mindfulness CD within Arabic speaking communities. Funding again was received through a Multicultural Health Cultural Diversity grant from the Multicultural Health Service. The project was undertaken in partnership with Al Zahra Muslim Women’s Association and statistical analysis was undertaken by the Centre for Primary Health Care and Equity, University of New South Wales.


Evaluation Overview

In order to explore the acceptability and clinical utility of the translated CD for Arabic-speaking community members the evaluation sought to answer the following questions:

Was the Arabic Mindfulness CD culturally acceptable to members of the Arabic speaking community?

Did the use of the exercises on the CD reduce psychological distress over a five week period?

Was the reduction in psychological distress maintained over a 12 week period?

Seventy people participated in the study between November 2014 and June 2015. Participants were Arabic-speaking; aged between 18 and 65 years; living in or accessing services within the St George region. All participants agreed to use the Arabic Mindfulness CD for five weeks, and to participate in a follow-up interview at 12 weeks.

Strong connections with the Arabic speaking community encouraged a high level of participation in the study with Arabic-speaking community groups and organisations engaged from the beginning through the bilingual research assistant who was a highly respected member of the community.

Ethics approval was obtained from the SESLHD Human Ethics Research Committee (reference no. 14/155). All participant related materials, including the Participant Information Sheet, Consent Form and standardised assessment measures were available to participants in both Arabic and English. Translations were undertaken by a Level 2 translator accredited by the National Accreditation Authority for Translators and Interpreters (NAATI).


Methodology

Recruitment

The 70 participants were recruited through the following channels:

1. St George Community Mental Health Service; 2. Community groups (through promotion at community events where a number of

participants registered to participate in the evaluation); 3. Word of mouth and snowballing (participants telling others about the study or

volunteering the name of a family member or friend who they thought would be interested);

4. Local Arabic speaking psychologists.

The choice of recruitment methods varied. However the success of recruitment was attributed mainly to:

The research assistant’s established connection with the Arabic speaking community;

The different methods applied in promoting and following up the study;

The use of Snowball Sampling;

The referral support provided by the St George Community Mental Health Service.

Having strong connections with the community, word-of-mouth and snowballing proved to be the most effective strategies, recruiting the highest number of participants. In all, approximately 70% of participants were recruited directly from the community. The other factors that also motivated individuals to participate in the study were:

The possession of a self-help resource they could use at any time;

The health benefits participants perceived they would get from using the resource;

The regular follow up with participants throughout the 12 weeks evaluation of the CD and provision of support and encouragement as required.

Initially, 81 people agreed to participate in the study, however 11 participants withdrew prior to the study commencing due to unexpected circumstances, overseas travel plans and other unforeseen commitments.

Participants

Socio-demographic characteristics of participants are presented in Table 1. The majority of participants were females aged between 26 and 55 years. Countries of birth reported by participants included Lebanon, Iraq, Egypt, Palestine, Syria and Senegal. Most participants spoke Arabic at home and had been in Australia for 15 years or more. Nearly all were of Islamic faith and half had no post-school qualifications (Table 1).

Participants’ use of health services was self-reported (Table 2). Most commonly, participants (51.4%) reported that they had seen their general practitioner (GP) at least once during the previous 4 week period. Four had presented to a hospital emergency department (ED) and five reported seeing a specialist other than a psychiatrist. In addition to seeing a GP, a quarter of the participants reported that they had seen a psychiatrist or psychologist during the month prior to commencement of the study. No participants reported seeing a counsellor.


Table 1: Socio-demographic characteristics of the 70 participants

n %

Age group (years)

18-25 8 11.4

26-35 19 27.1

36-45 17 24.3

46-55 15 21.4

56-65 11 15.7

Gender

Female 51 72.9

Male 19 27.1

Country of birth

Lebanon 55 78.6

Iraq 5 7.1

Egypt 4 5.7

Palestine 3 4.3

Syria 2 2.9

Senegal, West Africa 1 1.4

Years spent living in Australia

0-15 21 30.0

16-30 30 42.9

Over 30 19 27.1

Proportion of life spent in Australia

0-19% 4 5.7

20-39% 19 27.1

40-59% 22 31.4

60-79% 16 22.9

80+% 9 12.9

Language spoken at home

Arabic 48 68.6

Arabic & English 20 28.6

English 2 2.9

Religion

Christian 4 5.7

Muslim 66 94.3

Education attainment

Year 12 or less 34 48.6

Trade certificate 24 34.3

University 12 17.1


Table 2: Health professionals seen during the previous month

Health professional

n %

GP

At least one 36 51.4

None 34 48.6

Psychologist


None. 58 82.9

Psychiatrist

At least one 5 7.1

None 65 92.9

Any counselling professional*


None 53 75.7

* Psychiatrist or psychologist. No one reported seeing a counsellor

Measures

Two standardised measures of psychological distress were used. Both measures have been translated into Arabic (Transcultural Mental Health Centre, 2014; Taouk, Lovibond, & Laube, 2001)

Kessler Psychological Distress Scale (K10) - a 10 item self-report questionnaire intended to give a global measure of distress based on questions about anxiety and depressive symptoms that a person has experienced in the most recent 4 week period.

Depression Anxiety and Stress Scale (DASS21); a 21 item self-report questionnaire.

Data collection

A series of appointments were arranged for each participant at a location and time of their choice.

The first appointment involved:

Providing information about the research project and the level of involvement required from participants - written information (in Arabic and English) was provided in the form of a Participant Information Sheet;

Completing the Consent Form;

Completing a questionnaire seeking demographic characteristics including questions about participants’ use of health services, as well as acceptability and knowledge of, and attitudes to Mindfulness;

Completing the K10 and DASS21;

Providing participants with the Arabic Mindfulness CD and a 5 week activity log sheet to record when and for how long they listened to each track, comments regarding their experience of listening to the CD and other general comments.

The second appointment (arranged for 5 weeks after the initial recruitment) involved:


Completing the K10 and DASS21 questionnaires;

Collecting completed Activity Log sheets;

Arranging the 12 week follow up appointment.

The third appointment was the 12 week follow-up and involved:

Completing the K10 and DASS questionnaires;

Completing a follow up questionnaire to determine whether participants continued listening to the CD, how many times per week they practiced Mindfulness, their acceptance and knowledge of, and attitudes to Mindfulness.

Participants had the choice of completing questionnaires in Arabic or English, however all were completed in Arabic. During the 5 week and 12 week follow-up, regular contact was made with participants to answer any queries and ensure that questionnaires would be completed within the agreed timeframe.


Data analysis

All data were translated from Arabic to English and entered into an Excel Spreadsheet. The age of participants was categorised as 18-25 years, 26-35 years, 36-45 years, 46-55 years and 56-65 years. Years spent living in Australia was categorised as 0-15 years, 16-30 years and over 30 years.

K10 scores were categorised according to recommended standards as follows:

low (10-15);

moderate (16–21);

high (22–29); or

very high (30–50) (Andrews & Slade, 2001).

A similar approach was taken with the three DASS21 subscales:

depression classified as normal (score 0–4), mild (5–6), moderate (7–10), severe (11–13), or extremely severe (14+);

anxiety as normal (0–3), mild (4–5), moderate (6–7), severe (8–9), or extremely severe (10+); and

stress as normal (0–7), mild (8–9), moderate (10–12), or severe (13–16) (Lovibond & Lovibond, 1995).

The mean changes in K10 and DASS21 scores between baseline, 5 weeks and 12 weeks, were treated as continuous variables.

Descriptive statistics were used to summarise the socio-demographic data, professional help-seeking, understanding of mindfulness, and K10 and DASS21 scores.

Differences across time were tested for statistical significance using paired t-tests. The paired t-tests examined the hypothesis that the mean change in score was zero. A p-value of 0.05 was taken to indicate a significant change in score. Independent t-tests were used to examine if age, education, proportion of life spent in Australia or use of Mindfulness (>3 time per week) were associated with a reduction in psychological distress.


Results

Is the intervention culturally acceptable?

Compliance with the intervention protocol

Seventy participants (70) completed all questionnaires required for the study. Compliance with the protocol was high with most participants completing the Mindfulness program and completing follow-up at 12 weeks. Over the five weeks of the project, participants were encouraged to use the CD at least three times a week. An analysis of the participant log indicated sixty four of seventy participants (91%) reported using the CD 15 times or more during the period.

Frequency of use of mindfulness post-intervention

66 participants (94%) reported that they used the Mindfulness program following the intervention period, and most commonly, they did this once or twice a week (Table 3).

Table 3: Frequency of use of Mindfulness post-intervention

Use of Mindfulness Follow up (12 weeks)

n %

I practise Mindfulness every week

Agree 66 94.3

Disagree 4 5.7

How many times per week do you practise Mindfulness

Do not use 4 5.7

Once to twice 40 57.2

Three times 20 28.6

Four or more 6 8.5

Knowledge of and attitudes to Mindfulness

Information on participants’ knowledge of and attitudes to Mindfulness was sought at recruitment and at 12 weeks follow up (Table 4). At 12 weeks follow up all participants (100%) agreed or strongly agreed that:

Mindfulness was compatible with their cultural and religious practices;

Mindfulness was suitable to their way of life;

Mindfulness offered practical strategies to reduce stress.

At baseline, more than half were unsure or did not think that Mindfulness would improve concentration. However, at 12 weeks follow up, all except 4 participants agreed that Mindfulness had assisted them in improving their concentration. Note: the four participants who did not agree with this statement did not use the CD after 5 weeks.


Table 4: Summary of responses to knowledge and attitude questions.

Knowledge Questionnaire Baseline

Follow up at

12 weeks

n % n %

Mindfulness is a form of meditation

Strongly Agree 30 42.9 39 55.7

Agree 40 57.1 31 44.3

Mindfulness uses the breath to improve concentration


Agree 31 44.3 51 72.9

Neither agree nor disagree 3 4.3 4 5.7

Disagree 15 21.4

Don’t know 18 25.7

Mindfulness is a type of physical activity


Agree 43 61.4 54 77.1

Neither agree nor disagree 5 7.1 6 8.6

Disagree 8 11.4

Don’t know 10 14.3

Mindfulness is compatible with existing cultural and religious practices


Agree 63 90.0 47 67.1

Disagree 1 1.4

Don’t know 1 1.4

I would be willing to learn new ways of improving my wellbeing


Agree 64 91.4 55 78.6

Neither agree nor disagree 1 1.4

Don’t know 1 1.4

Mindfulness fits in with my way of life


Agree 64 91.4 51 72.9

Neither agree nor disagree 1 1.4

Don’t know 1 1.4

Mindfulness offers practical strategies to reduce stress


Agree 65 92.9 43 61.4


Qualitative feedback

During the study, the bilingual research assistant was able to build rapport with participants and gain their trust. Participants engaged in conversations during appointments about certain issues and hardships they were experiencing in their daily lives affecting their level of stress and anxiety. Most were anticipating that the Mindfulness CD would assist them in coping with their mental health issues and improve their wellbeing.

Feedback from participants reflected their views that Mindfulness provided practical strategies to reduce stress and their willingness to learn about ways to improve their wellbeing. Comments in the activity logs indicated that the program was culturally and religiously acceptable to participants of both Christian and Islamic faiths, as illustrated below:

“Mindfulness is mentioned in a positive way in Quranic verses and certain Islamic

rituals. Mindfulness is important and is considered as part of Islamic practices. Imam Ali (pbuh) said: ‘To be mindful one hour is better that an act of worship

practised in 60 years."

(Female, 26-35 years, Muslim)

“Thank you for the opportunity to participate. This experience made me feel as if I am performing a religious act of worship.”

(Female, 26-45 years, Christian)

“….helps with dealing and coping with emotional distress and ways of not being affected by negative feelings. And this is good for the physical and mental health. It has a spiritual factor and is considered to be some form of a religious practice”


“I felt that it helped me so I don’t get distracted with thoughts while I am carrying out an activity. Especially activities that require focus such as prayers.”

(Male, 36-45 years, Muslim)

“These tracks made me accept that emotions of the past come and go. And I don’t have to combat them but rather see them as a video tape that begins and

ends.”


“I noticed that observing in general is important in the mindfulness process. Especially observing oneself without any obstacles. It helps also with minimising

internal and external influences”

(Male, 26-45 years, Christian)

Participants’ comments from Arabic Mindfulness CD Activity Log


Does the use of the Arabic Mindfulness CD improve psychological distress?

Psychological distress was measured using the Kessler Scale (K10) and Depression, Anxiety

and Stress Scale (DASS21) at 5 weeks (completion of the intervention period) and at 12

weeks (follow-up period).

Improvements in K10 at 5 weeks and 12 weeks

Participation in the Mindfulness program was successful in decreasing psychological distress. At baseline, all participants had some degree of psychological distress and most were categorised as high or very high using the K10 scores. The proportion who were classified as having very high levels of distress decreased from 53% at baseline to 29% at 5 weeks and to 14.7 % at 12 weeks (Figure 1; Appendix 1:Table 5). The mean change in K10 scores decreased from 30.5 at baseline to 26.9 at 5 weeks and 23.8 at 12 weeks (all p<.001; Figure 2; Appendix 1: Table 6).

Figure 1: Change in K10 category from baseline to 5 weeks to 12 weeks

Figure 2: Change in K10 score from baseline to 5 weeks to 12 weeks (p<.001)

At 12 weeks follow up, the change in K10 score was significantly associated with age (p<.001); the greatest change in K10 score was observed for younger participants in the study with less change in the oldest group (aged 56-65 years). The change in K10 score was also significantly associated with educational achievement (p=.04); participants with a higher

52.9%

28.6%

14.7%

0%

10%

20%

30%

40%

50%

60%

Baseline Week 5 Week 12

Percentage of participants scoring in the Very High range on K10 (22-50)

30.526.9

23.9

0

10

20

30

40

50

Baseline Week 5 Week 12

Mean change in K10 score


education were more likely to show an improved K10 score at 12 weeks than those who completed year 12 or less.

Improvements in DASS21 at 5 weeks and 12 weeks

Depression

Participation in the Mindfulness program was successful in decreasing the prevalence of depression. At baseline 27.1% of participants were classified as severe or extremely severe on the depression sub-scale. The proportion that was classified with severe or extremely severe depression decreased to 14.2% at 5 weeks and to 10% at the 12 week follow-up point (Figure 3). At the end of the program the proportion that was classed in the normal range increased from 25.7% to 34.3% at 5 weeks and at the 12 week follow-up point this had increased to 50% (Appendix 2: Table 7).

Figure 3: Change in DASS21 categories from baseline to 5 weeks to 12 weeks

The overall change in the mean score was 2.9 points and the changes in score from baseline to 5 weeks (1.6), baseline to 12 weeks (2.9), and 5 weeks to 12 weeks (1.3) were all statistically significant (p<.0001) (Figure 4; Appendix 2: Table 9).

27.1

20.0

45.7

14.215.7

8.510.0

5.8

2.9

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

45.0

50.0

Depression Anxiety Stress

Baseline

Week 5

Week 12

Percentage of participants

scoring in the severe to

extremely severe category of

DASS21


Figure 4: Mean change in DASS 21 subscale scores from baseline to 5 weeks to 12 weeks (p<.01)

Anxiety

Participation in the Mindfulness program was successful in decreasing the prevalence of anxiety. At baseline 20.0% of participants were classified as severe or extremely severe on the anxiety sub-scale. The proportion that was classified with severe or extremely severe anxiety decreased to 15.7% at 5 weeks and to 5.8% at the 12 week follow-up point (Figure 3). At the end of the program the proportion that was classed in the normal range increased from 52.9% to 57.1%% and at the 12 week follow-up point this had increased to 67.1% (Appendix 2: Table 7).

The overall change in the mean DASS21 anxiety score was 1.6 points and the changes in score from baseline to 5 weeks (0.7), baseline to 12 weeks (1.5), and 5 weeks to 12 weeks (0.9) were all statistically significant (p<.0001) (Figure 4; Appendix 2: Table 8).

Stress

Participation in the Mindfulness program was successful in decreasing the prevalence of stress. At baseline 45.7% of participants were classified as having severe or extremely severe stress while only 10% were classified in the normal range. There was a substantial decline in the proportion that was classified as having severe or extremely severe stress to 8.5% after 5 weeks and 2.9% at the 12 week follow-up point (Figure 3). The proportion that was classified as normal increased from 10.0% at baseline to 31.4% after 5 weeks and 57.1% at the 12 week follow-up point (Appendix 2: Table 7).

The mean change in DASS21 stress score was 4.5 points and was a change of 2.9 from baseline to 5 weeks and change in score of 1.6 from 5 weeks to 12 weeks follow up. All were statistically significant at p<.0001 (Figure 4; Appendix 2: Table 8).

8

4.3

12

6.5

3.6

9.1

5.2

2.8

7.5

0

2

4

6

8

10

12

14

Depression Anxiety Stress

Baseline

5 weeks

12 weeks

Mean change in DASS21 subscale

scores


Discussion

This project sought to address the lack of resources and lack of evidence about Mindfulness interventions with Arabic-speaking communities. This research, the first of its type in the world with Arabic speakers, indicated that the Arabic Mindfulness Intervention demonstrated both cultural acceptability and clinical utility.

Participants reported that Mindfulness was compatible with their cultural and religious practices and their way of life. Most participants reported that they saw the CD as a practical way to reduce stress and found that it increased their concentration and the majority of participants (94%) continued to use the Mindfulness program following the intervention period.

Statistically significant improvements in mental health of the 70 participants were identified using the Kessler 10 (K10) and Depression, Anxiety and Stress Scale (DASS21) at 5 weeks post intervention and 12 week follow up.

The project was presented at an International Psychology conference in Dubai in October 2015. Since that time, a number of clinicians from around the world have reported using the intervention as an adjunct to their clinical practice with Arabic speaking clients. Positive feedback has been received from clinicians working with displaced and traumatised clients. This is particularly relevant to the Australian context given the large number of newly arrived refugees from Arabic speaking countries, including Syria and Iraq, who have high levels of psychological distress.

The project was a collaborative partnership. Arabic-speaking community groups and organisations were effectively engaged at the beginning through the bilingual research assistant (RA) who is a highly respected member of the community. In October 2015, during mental health month, community members and Arabic speaking health professionals were invited to attend the Arabic Wellbeing Forum. Results of the research were presented and access to mental health services and resources was promoted. The event was well attended (n=100) and positive feedback was received.

The project has demonstrated an effective, low cost, evidence-based intervention which can be self-led or clinician-guided and used in multiple settings including:

self-management by community members;

community group settings;

adjunct to specialist mental health care;

adjunct to primary mental health care.

The intervention is highly transferable and scalable. Since its development, the intervention has been incorporated as an adjunct to specialist mental health care at St George Mental Health Service and delivered through five community groups. The CD has been loaded onto the SESLHD intranet and internet sites and can be accessed at no cost by clinicians and community members. It has also been made available to GPs providing primary health care to Arabic speaking patients.

Further work is needed to determine whether similar outcomes can be obtained when community members are engaged through group programs, run by multicultural health/community workers, and primary health care providers; both of which represent culturally appropriate contexts for members of the Arabic-speaking community in Australia.


It will also be important to replicate findings with a more diverse sample of Arabic-speakers across multiple geographical regions in Sydney and/or Australia; and explore the use of Mindfulness in the treatment of specific psychological issue such as pain, grief and trauma.

More broadly, the study suggests that there is potential for interventions such as this to

improve access to culturally appropriate mental health interventions for people from culturally

and linguistically diverse communities.


References

Australian Bureau of Statistics. (2011). Census of Population and Housing. Australian

Bureau of Statistics. Retrieved from www.abs.gov.au

Andrews, G. & Slade, T. (2001). Interpreting scores on the Kessler Psychological Distress

Scale (K10). Australian and New Zealand Journal of Public Health, 25(6), 494-7.

Baer, R. A. (2003). Mindfulness Training as a Clinical Intervention: A conceptual Empirical

Review. Clinical Psychology: Science and Practice, 10(2), 125–143.

Cavanagh, K., Strauss, C., Forder, L., & Jones, F. W. (2014). Can mindfulness and

acceptance be learnt by self-help?: A systematic review and meta-analysis of mindfulness

and acceptance-based self-help interventions. Clinical Psychology Review, 34, 118-129.

doi.org/10.1016/j.cpr.2014.01.001.

Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S., & Lovell, K. (2007). What

makes self-help interventions effective in the management of depressive symptoms? Meta-

analysis and meta-regression. Psychological Medicine, 37(9), 1217-1228.

doi.org/10.1017/S0033291707000062.

Gotink, R. A., Chu, P., Busschbach, J.J., Benson, H., Fricchione, G.L., & Hunink, M.G.

(2015). Standardised mindfulness-based interventions in healthcare: An overview of

systematic reviews and meta-analyses of RCTs. PLoS One, 16, 10(4):e0124344.

doi:10.1371/journal.pone.0124344.

Harris, R. Mindfulness Skills Vol 1, Learn "Mindfulness" Skills.

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday

life. New York: Hyperion.

Kljajic, K. (2009). Depression and anxiety in the CALD Community, Health Voices Journal of

the consumers Health Forum of Australia Issue 5. Available at:

https://www.chf.org.au/pdfs/hvo/hvo-2009-5-depression-anxiety-CALD-community.pdf

Lovibond, S.H. & Lovibond, P.F. (1995). Manual for the Depression Anxiety Stress Scales.

(2nd. Ed.) Sydney: Psychology Foundation.

Mirdal, G.M. (2012). Mevlana Jalal-ad-Din Rumi and Mindfulness. Journal of Religion and

Health, 51 (4), 1202-1215.

Panagioti, M., Richardson, G., Small, N., Murray, E., Rogers, A., Kennedy, A., Newman S., &

Bower, P. (2014). Self-management support interventions to reduce health care utilisation

without compromising outcomes: a systematic review and meta-analysis. BMC Health

Services Research,14, 356. doi: 10.1186/1472-6963-14-356.

Pigni A. (2010). A first-person account of using mindfulness as a therapeutic tool in the

Palestinian Territories. Journal of Child and Family Studies, 19(2), 152-156.

http://www.abs.gov.au/

https://www.chf.org.au/pdfs/hvo/hvo-2009-5-depression-anxiety-CALD-community.pdf


Siegel, D.J. (2007).The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being. New York: W. W. Norton & Company, .

Steel, Z., McDonald, R., Silove, D., Bauman, A., Sandford, P., Herron, J., & Minas, I.H. (2006). Pathways to the first contact with specialist mental health care. Australian and New Zealand Journal of Psychiatry, 40(4), 347 – 354. doi.org/10.1111/j.1440-1614.2006.01801.x

Taouk, M., Lovibond, P.F., & Laube, R. (2001). Psychometric properties of an Arabic version of the Depression Anxiety Stress Scales (DASS21). Report for New South Wales Transcultural Mental Health Centre, Cumberland Hospital, Sydney.

Tobin, M. (2000). Developing mental health rehabilitation services in a culturally appropriate context. Australian Health Review, 23(2), 177-184.

Transcultural Mental Health Centre. (2014). Kessler 10 (K10) Assessment Form (Arabic translation). Available at: http://www.dhi.health.nsw.gov.au/Transcultural-Mental-Health-Centre/Resources/Translations-/Kessler10/Kessler10/default.aspx

Youssef, J. & Deannie, F.P. (2006). Factors influencing mental health help-seeking in Arabic speaking communities in Australia. Mental Health, Religion and Culture, 9(1), 4-66.

http://dx.doi.org/10.1111/j.1440-1614.2006.01801.x


Appendices

Appendix 1: K10 results

Table 5: Change in K10 category from Baseline to 5 weeks to 12 weeks

K10 category Baseline 5 weeks 12 weeks

n % n % n* %

Moderate (16-21) 3 4.3 8 11.4 24 35.3

High(22-29) 30 42.9 42 60.0 34 50.0

Very high (30-50) 37 52.9 20 28.6 10 14.7

* 2 missing K10 scores at 12 weeks

Table 6: Change in K10 scores from Baseline to 5 weeks and 12 weeks

Change in scores

Variable Mean SD Paired t-test*

Mean change

(95%CI) p-value

K10

K10

(baseline) 30.5 6

K10 score (baseline) vs

K10 score (5weeks) 3.6 (2.8-4.4) <.0001

K10

(5 weeks) 26.9 4.9

K10 score (baseline) vs

K10 score (12weeks) 6.7 (5.7-7.6) <.0001

K10

(12 weeks) 23.8 4.2

K10 score (5 weeks) vs

K10 score (12 weeks) 3 (2.4-3.7) <.0001

* Paired t-test was used to explore the change in scores from baseline to 5 weeks and 12 weeks and from 5 weeks to 12 weeks


Appendix 2: DASS21 Results

Table 7: Change in DASS21 measurement from baseline to 5 weeks to 12 weeks

DASS Measures Baseline 5 weeks 12 weeks

n % n % N %

Depression

Normal (0-4) 18 25.7 24 34.3 35 50.0

Mild (5-6) 13 18.6 18 25.7 12 17.1

Moderate (7-10) 20 28.6 18 25.7 16 22.9

Severe (11-13) 8 11.4 5 7.1 7 10.0

Extremely Severe (14+) 11 15.7 5 7.1 0 0

Anxiety

Normal (0-3) 37 52.9 40 57.1 47 67.1

Mild (4-5) 12 17.1 16 22.9 16 22.9

Moderate (6-7) 7 10.0 3 4.3 3 4.3

Severe (8-9) 4 5.7 4 5.7 2 2.9

Extremely Severe (10+) 10 14.3 7 10.0 2 2.9

Stress

Normal (0-7) 7 10.0 22 31.4 40 57.1

Mild (8-9) 8 11.4 22 31.4 17 24.3

Moderate (10-12) 23 32.9 20 28.6 11 15.7

Severe (13-16) 26 37.1 5 7.1 2 2.9

Extremely Severe (17+) 6 8.6 1 1.4 0 0


Table 8: Change in DASS21 scores from baseline to 5 weeks and 12 weeks

Change in scores

Variables Mean SD Paired t-test*

Mean change

(95%CI) p-value

DASS 21

Depression

DASS21

(baseline) 8 4.6

DASS21 (baseline) vs

DASS21 (5 weeks) 1.6 (1.1-2.1) <.0001

DASS21 (5

weeks) 6.5 3.7


DASS21 (12 weeks) 2.9 (2.2-3.5) <.0001

DASS21

(12eks) 5.2 3.2

DASS21 (5 weeks) vs

DASS21 (12 weeks) 1.3 (0.9-1.7) <.0001

Anxiety

DASS21

(baseline) 4.3 4


DASS21 (5 weeks) 0.7 (0.2-1.2) 0.008

DASS21 (5

weeks) 3.6 3.3


DASS21 (12 weeks) 1.5 (0.9-2.2) <.0001

DASS21 (12

weeks) 2.8 2.5

DASS21 (5 weeks) vs

DASS21 (12 weeks) 0.9 (0.4-1.3) <.0001

Stress

DASS21

(baseline) 12 3.1


DASS21 (5 weeks) 2.9 (2.4-3.4) <.0001

DASS21 (5

weeks) 9.1 2.8


DASS21 (12 weeks) 4.5 (4.0-5.0) <.0001

DASS21 (12

weeks) 7.5 2.6

DASS21 (5 weeks) vs

DASS21 (12 weeks) 1.6 (1.2-2.0) <.0001

* Paired t-test was used to explore the change in scores from baseline to 5 weeks and 12 weeks and from 5 weeks to 12 weeks


Appendix 3: Participant Information Sheet and Consent Form

Participant Information Sheet

HREC Reference Number 14/155

Evaluation of Arabic Language

Mindfulness CD

Invitation

You are invited to participate in a research project evaluating a self-management

resource for Arabic speakers. This resource is a CD which provides training in

Mindfulness, a meditation practice to calm the mind and promote wellbeing. If you

decide to participate you may or may not experience the benefits associated with the use

of this resource.

This Participant Information Sheet/Consent Form tells you about the research project. It

explains what is involved. Knowing what is involved will help you decide if you want to

take part in the research. Please read this information carefully. Ask questions about

anything that you don’t understand or want to know more about.

Participation in this research is voluntary. If you don’t wish to take part, you don’t have to.

You will receive the best possible care from the health service whether or not you take

part.

If you decide you want to take part in the research project, you will be asked to sign the

consent section. By signing it you are telling us that you:

• Understand what you have read

• Consent to take part in the research project

• Consent to complete the questionnaires that are described

• Consent to the use of your personal and health information as described.

You will be given a copy of this Participant Information and Consent Form to keep.

What is involved?

If you agree to being involved, an Arabic speaking research assistant will contact you to

arrange a time to meet at a location and time convenient to you. You will be asked to fill

in some questionnaires. This will take approximately 30 mins. You may complete the

questionnaires in Arabic or English. The questionnaires will be strictly confidential and

the research assistant will not record your name on the questionnaires.


The questionnaires cover a range of areas including:

Non-identifying data about you including your age, your country of birth, your postcode)

Your recent use of health services including your GP, mental health services and emergency departments

Any recent feelings of low mood, anxiety or worries

Your understanding and attitude towards Mindfulness as a helpful approach to promoting feelings of calm and wellbeing

You will then be given an Arabic language Mindfulness training CD and asked to listen to

the CD three times per week for 5 weeks, and to record this on the activity log sheet. The

research assistant will contact you again at the end of the 5 week program and again

after 3 months to make another time to fill in some questionnaires. This will take

approximately 45 mins. You may complete the questionnaires in Arabic or English.

If you identify in the questionnaires or to the Arabic speaking research assistant that you

are experiencing high levels of distress, the Arabic speaking psychologist who is also a

co-principal investigator with this research, will confidentially contact you to discuss your

concerns. We do this to ensure your wellbeing and appropriate access to any supports

you may need.

Do I have to be involved?

Participation in any research project is voluntary. If you do not wish to take part, you do

not have to. If you decide to take part and later change your mind, you are free to

withdraw from the project at any stage. Your decision will not affect any care that you

receive through the service. If you do decide to take part, you will be given this

Participant Information and Consent Form to sign and you will be given a copy to keep.

Who is conducting and reviewing this research?

This research is being conducted by the Mental Health and Multicultural Health Services

of the South Eastern Sydney Local Health District (SESLHD) and has been funded by

the Multicultural Health Service. All research in Australia involving humans is reviewed

by an independent group of people called a Human Research Ethics Committee (HREC).

The ethical aspects of this research project have been approved by the HREC of

SESLHD. This project will be carried out according to the National Statement on Ethical

Conduct in Human Research (2007). This statement has been developed to protect the

interests of people who agree to participate in human research studies.


What happens when the research project ends?

The results of the project will be available through a report and may be presented at

conferences and in academic journals. Information from everyone involved will be

summarised so that no one person can be identified.

What if I have questions or concerns?

If you want any further information about the study please contact the one or both of the

Principal Investigators below.

If you have any concerns or complaints about the conduct of this study you should

contact the Research Support Office of the South Eastern Sydney Local Health District

Human Research Ethics Committee on 02 9382 3587 or email

[email protected] and quote HREC Reference Number 14/155.

If you would like to use an Interpreter ring the free Translation and Interpreting

Service on 131 450

Through your involvement, we hope to improve the language specific resources available

to the Arabic speaking community and to promote the wellbeing of the community.

Yours sincerely

Hend Saab Lisa Woodland

Co-Principal Investigator Co-Principal Investigator

Bilingual Psychologist Program Manager

Community Mental Health Service Multicultural Health Service

St George Mental Health South Eastern Sydney Local Health District

9553 2500 9382 8670


Consent form

Evaluation of Arabic Language Mindfulness CD

I (name) ……………………………………………………. agree to take part in the

project.

I have read the Participant Information Sheet or someone has read it to me in a

language that I understand.

I understand the purposes, procedures and risks of the research described in the

project.

I understand that I may or may not experience the benefits associated with the use of

this resource.

I have had an opportunity to ask questions and I am satisfied with the answers I have

received.

I freely agree to participate in this research project as described and understand that

I am free to withdraw at any time during the project without affecting my future health

care.

I understand that all information I provide will be treated as strictly confidential and

I will be given a signed copy of this document to keep.


Service on 131 450

Name: ……………………………………………………………………………………

Signature: ……………………………………………………………………………….

Date: ………………………………

Witness’ name: ……………………………………………………………………......

Witness’ Signature: …………………………………………………………………….

Date: ………………………………


Appendix 4: Participant Questionnaire

Participant Questionnaire

Evaluation of Arabic Language

Mindfulness CD


This questionnaire is designed to find out some information about you and your

experience of Mindfulness. All information you provide is confidential and your name

will not be recorded on this questionnaire.

Participation is voluntary and you are free to withdraw from the project at any stage.

Your decision will not affect any care that you receive through the service.


Service (TIS) on 131 450.

Please take your time to answer the following questions.

Your participant number: ______________________________________

Some questions about you:

Q.1 Age: circle your age range 18-25 yrs 26-35 yrs 36-45 yrs 46-55 yrs 56-65 yrs

Q.2 Gender: circle your gender Male Female

Q.3 Postcode:

Q.4 Country Of Birth:

Q.5 Years Living In Australia:

Q.6 Language Spoken At Home: circle the languages you speak at home Arabic English Arabic and English Other

Q.7 Religion: circle your religion Christian Muslim Other None


Q.8 What is the highest level of education you completed? circle your answer Primary school (up to Year 7) Elementary school (up to Year 10) High school (up to Year 12) Higher education – trade qualification Higher education – university qualification

Some questions about the health services you have used recently:

Q.9 How many times have you visited the following health professionals/services in the last 4 weeks? circle your answer

1.GP

0 1 2 3 4 More than 4 times

2.Psychologist


3.Psychiatrist


4.Counsellor


5.Emergency Department or Hospital


6.Other health professional Please specify:



Some questions about your understanding of Mindfulness:

Q.10 How much do you agree or disagree with the following statements? circle your answer

1.Mindfulness is a form of meditation

Strongly disagree

Disagree Neither agree nor disagree

Agree Strongly Agree

Don’t know

2.Mindfulness is about focussing on the past and the future

Strongly disagree



Don’t know

3.Mindfulness uses the breath to improve concentration

Strongly disagree



Don’t know

4.Mindfulness is a type of physical activity

Strongly disagree



Don’t know

5.Mindfulness is compatible with existing cultural and religious practices

Strongly disagree



Don’t know

6.I would be willing to learn new ways of improving my wellbeing through Mindfulness

Strongly disagree



Don’t know

7.Mindfulness fits in with my way of life

Strongly disagree



Don’t know

8.Mindfulness offers practical strategies to reduce stress

Strongly disagree



Don’t know

Thank you for completing this questionnaire.


Appendix 3: Participant Instructions and Activity Log Sheet

Participant Instructions and Activity Log

Sheet

Evaluation of Arabic Language Mindfulness

CD


These instructions are designed to guide you through the Arabic Language Mindfulness CD

over the next 5 weeks.

You are welcome to contact the Research Assistant at any time if you have any questions or

if you are feeling worried or anxious while participating in the study. Their contact details are

attached.

Participation is voluntary and you are free to withdraw from the project at any stage. Your

decision will not affect any care that you receive through the service.

If you would like to use an Interpreter ring the free Translation and Interpreting Service (TIS)

on 131 450.

Instructions:

Please find a quiet place to listen to the tracks on the CD so you can fully concentrate. You

can listen to each tack as many times as you like.

Please listen to the tracks listed three times per week. This will take between 15 and 30

minutes each time.

Week 1: Listen to these tracks three (3) times during Week 1

Track 1 Introduction 5 mins

Track 2 Breathing exercises 12 mins

Track 4 Leaves on the Stream 12 mins



Track 2 Breathing exercises 12 mins




Track 5 The Observing Self 15 mins



Track 5 The Observing Self 15 mins

Week 5: Listen to this tracks three (3) times during Week 5

Track 3 Mindfulness of Emotions 15 mins

You may like to turn your phone off or to silent while the CD is playing.

Make sure you have enough time to listen to the whole track before commencing.

Please record the date and time that you listened to each track in the activity log sheet on the

following pages. If you listened to the track more than once, please record the date and time

of each time you listened to the track.

You may also like to record any comments you have about the track or about your

experience. You can record these in Arabic or English.


Your participant number:

Activity Log Sheet: Week 1

Date Time Comments

1st time

Track 1: Introduction Track 2: Breathing exercises Track 4: Leaves on the Stream

2nd time


3rd time


Other times





Date Time Comments

1st time

Track 2: Breathing exercises Track 4: Leaves on the Stream

2nd time


3rd time


Other times





Date Time Comments

1st time

Track 4: Leaves on the Stream Track 5: The Observing Self

2nd time


3rd time


Other times





Date Time Comments

1st time


2nd time


3rd time


Other times





Date Time Comments

1st time

Track 3: Mindfulness of Emotions

2nd time


3rd time


Other times


project report arabic mindfulness intervention project ... · pdf fileproject report arabic...

Documents