Abstract
Introduction
When cancer is advanced and life-threatening, it has both physical and psychological effects, and for many people creates existential concerns. Mindfulness as a therapeutic endeavour is widely used in psychological interventions within clinical settings. People with cancer are likely to benefit from psychological interventions. However, there appear to be few intervention studies with advanced cancer populations, potentially due to ethical, methodological, and logistical issues. The purpose of this doctoral thesis was therefore to address this gap by designing and delivering a low-burden, easily accessible mindfulness-based intervention developed by the investigator, designed to provide psychological and emotional support to patients with advanced cancer, and research the intervention’s effectiveness. The intervention is called “Coping with Cancer Mindfully” (CCM) and focuses on mindful coping skills, acquiring an acceptance stance and reflection on meaning in the patients’ life.
Methods
This study is a one group pre-post test design with a convergent parallel mixed methods approach for data analysis. Twenty adults with advanced cancer (stage III or IV) were recruited via public hospital oncology services and other cancer-related service providers in Christchurch, New Zealand. Three short questionnaires evaluated participants’ levels of mindful coping skills (Mindful Coping Scale), acceptance stance (Acceptance and Action Questionnaire – II) and meaning in their lives (Meaning in Life Questionnaire). Pre-post semi-structured interviews explored participants’ perspectives about their advanced diagnosis and how they experienced the intervention. Statistical analysis was conducted and participants’ interview responses were coded and themed. The two strands of data (quantitative and qualitative) were collected concurrently, analysed separately and the findings and results were merged in a side-by-side comparison analysis.
Results
Twenty adults participated in the study, and adherence to the CCM treatment was 100%, with 19/20 post-intervention questionnaires completed. There was variability in age and time since their advanced cancer diagnosis. At baseline, those diagnosed for longer had higher levels of acceptance but age was not related to scores on any of the measures. Results from the statistical analysis (intention to treat and completer analyses) identified moderate to large effect sizes, with improvement in participants’ mindful coping skills of awareness and constructive self-distraction, their level of acceptance and the extent of presence of meaning in life.
Findings from the thematic analysis were that at baseline, participants as a group were experiencing distress but very few had been offered psychological support. After the CCM intervention, participants’ observant awareness of their life experiences was related to a change of perspective in order to better adapt to their advanced diagnosis, and new actions, skills and attitudes were evident. Their changed perspectives were conceptualized as shifting from a position of Vulnerability in Battle to Vulnerability in Peace, with the bridge between these positions being their use of mindful coping skills, acquisition of an acceptance stance, and reflections on meaning in life. The mixed methods integrated findings were largely convergent with only minor inconsistencies, the qualitative data supported the quantitative findings regarding change in key outcomes after this intervention. The qualitative data went beyond this however, providing rich contextual information about participants’ past experiences and coping as well as rich detail about what changed and how they used the CCM intervention.
Discussion
A key finding from the merged results of this study was that although the majority of participants diagnosed with advanced cancer related experiencing emotional distress and the need to psychologically adapt to having a limited amount of time left to live, the majority were not offered psychological support. The analyses highlighted the presence and impact of vulnerability in the face of the advanced cancer, and for most participants, the absence of appropriate professional support. These findings indicated that these participants benefitted from the psychological support from the CCM intervention at this intense period in their lives - they reported investing time in reflections on meaning in life, acknowledged the support of others, pursued reconciliation with others, and undertook other subjective and fulfilling actions.
Most participants demonstrated increased psychological flexibility: they not only reflected on the uncertainties and adversities that they were living with, but took actions as well, demonstrating increased emotional strength and flexibility to manage their lives in the best ways they could during the disease course.
Results from this study suggest that a brief, individual home-delivery, low-burden, mindfulness-based intervention is a viable psychological support option that could be offered by healthcare providers to address the gap in services for patients with advanced cancer. Participants’ feedback indicates that the nature and delivery of the CCM intervention made this original mindfulness-based brief intervention a readily accessible psychological aid to assist them to better cope with their current reality, and a valuable self-management resource to help these patients cope with further adversity.
Conclusion
Based on the preliminary findings of this study, it is concluded that the participants’ perspective of their illness shifted as a result of the CCM intervention, from an initial state of vulnerability to one that encouraged and produced positive perspectives and actions in relation to the participants’ cancer experience, despite their ongoing vulnerability. These findings suggest that those with advanced cancer should be offered suitable options of psychological support that they can access at any stage post-diagnosis.