Preconceptions, motivations and expectations
While the majority of participants had past experience of some form of psychological intervention (10/13), ranging from counselling to relaxation exercises, and five had seen a psychiatrist, only one participant had past experience of meditation. Several people in the group indicated that the chronicity of their problems with anxiety and depression was a major motivating factor for participating in the program.
"I was eh, at a stage, I still am at a stage, where I will do anything"-P1
"Because I have suffered for a lot of years with anxiety and bouts of depression"-P9
Avoiding medication was highlighted by only one of the participants as an important reason for persisting with the course.
"I didn't want anti-depressants or things like that. I wanted to take control of things myself......I was determined when I started to stick to it, to get to the end of the course and understand what the course was about. I also went into it thinking this might not help me, but I am giving it a try. I am going to see it through and it did help."-P5
A few participants mentioned the importance of commitment and self-help as an important part of recovery from depression.
" I've always had the attitude that if I don't do it nobody else can do it for me. So you know, it was there and I wanted to try it and I got the opportunity to do it. So it was a sort of self help thing"-P9
"You have got to work at these things you know......my downfall is I'm very undisciplined I don't follow things through"-P8
"(the MBCT course was) Something I could work with and something I saw myself practising out"-P6
One woman, who had struggled with severe anxiety and depression for 30 years, described having high expectations prior to starting the course and feeling disappointed afterwards.
"Because I've got severe anxiety and depression so I thought coming along to this I would be immediately cured – so I am disappointed in that"-P3
Being in a group
This was the first time that any of the participants, except one, had been in a group 'intervention'. For several people this seemed to be an important normalising process. Themes such as being understood by the group, realising that you were not alone and being able to show emotion in a safe environment, emerged as common positive aspects to being in a group.
"It was really good and I got to know other people as well, that I'm not on my own. There is other people with the same sort of problems which is good"-P10
For one man being in a group was an important turning point in his understanding of mental illness;
"Don't ask me, what I was expecting the other people to be? Raving lunatics, people with axes in their hands, I haven't a clue – but they were not....it was you, it was my next door neighbour. They weren't giggling half wits. I know that is rather narrow minded but they were ordinary everyday run of the mill people which reinforces the fact that that is what I am as well. I'm not a nut...I'm just an ordinary, everyday run of the mill person who ended up in the crap for whatever reason, and so are they. So that was another thing that was a great plus"-P1
However, not everyone found being in a group a positive experience. One man with a history of panic attacks, usually provoked in social circumstance, found the group claustrophobic. For him, the group conjured up images of an Alcoholics Anonymous meeting and he was afraid that he might become more depressed if he stayed in the group;
"I found I was a lot better than I had been when I started the course anyway, with going back to work. And things seemed to be picking up. But I found, I wouldn't say it dragged me back down, but I felt it started to almost like reawaken kind of feelings of anxiety being in close proximity to erm, so many people and just in the group that kind of thing you know"-P7
Two people talked about how the group helped them persevere with the meditation exercises.
"I think if you are on your own you would quite easily walk way and give up whereas you've got the support there and you know that everybody's sort of helping you out and you would go back in for the groups sake and try again."-P9
Several people in the group expressed relief about not having to talk about their personal problems.
"I didn't like it at first...in case I have to say what my problems were....You were under no pressure whatsoever. If you wanted to come in and not participate that night, just sit, watch and listen that was fine by him"-P6
Length of the course
While most of the group found the course enjoyable the majority of the group thought the course was too short. Although some participants commented that it was long enough to learn the basics of practice, most of the group would have liked the course to go on for another 3–4 weeks. Nine out the eleven interviewed expressed a desire for some form of follow-up and one woman spoke about feels of loss of support following completion of the course.
"I felt it was about right....... what a few of us was saying, actually at the end we wished it would continue for a wee bit longer cause we enjoyed it so much......the people I was getting up to the bus stop at night that's what they where saying, they would have loved it to have continued."-P5
"I think it could have been longer, much longer......maybe another 4 weeks on top of that would have been better."-P11
"If we even said...monthly or quarterly something like that whereby you have still got this link and you would still have each other. It's like you had this sort of support if you like and then it's just gone. So I think personally a follow up is a must"-P9
"I know meditation would be a good thing and I would enjoy it if I could get into it, it's very beneficial and I think it would have helped if it had gone on longer but it just wasn't long enough."-P3
One participant thought that some additional one-to-one sessions with the course facilitator would allow participants discuss personal problems without having to air them in front of the group.
The course exercises
There was a wide range of views on the course exercises, in particular the body-scan and walking meditation. While some participants found the body-scan a pleasurable, relaxing experience others found it a difficult practice.
"I liked the body-scan. That was the one bit that I really liked. I've got an awful lot of pain with the arthritis and when he was going through the body-scan and all that saying breathe into the pain, it was actually taking the pain away."-P3
"What I did find about the body scan when we were doing it whether at home or in here I became very aware of small itches and things like that irritated by them and really that was part of what I found quite hard to do. If it was my foot throbbing or itchy or just if I start to feel I've got to get out you know I've got to get up"-P7
One woman with a history of childhood sexual abuse found the body-scan made her aware of "horrible feelings through my body that I had never felt before". She found this exercise and the longer meditation exercises too difficult to practice at home. Despite this, she found the 3-minute breathing space a useful exercise and continued to use it regularly, three months after the course had finished. In contrast, one of the other participants with a history of childhood sexual abuse had no such problems with the body-scan and continued to practice the longer meditation practices several times a week three months after the course finished. One man had a traumatic flashback of an accident he had witnessed while doing the body-scan for the first time. This flashback, the first for a number of months, provoked considerable anxiety and claustrophobia. Another participant with severe generalised anxiety disorder found the body-scan an effective way of reducing her anxiety and found it more effective than her previous experiences using a progressive muscle relaxation technique.
"I couldn't believe the way I was feeling after doing the body-scan.....when you are doing (progressive muscle) relaxation you are sort of concentrating just on muscles or different parts of your body but it's outside your body but I felt the meditation was going inside the body.... as if I've got into the root, is probably the best way to describe it. And I can get right to the nucleus of it and I can feel it"-P9.
There was a wide variation in the amount and type of homework done, with some participants only practicing the occasional breathing space and other spending 30 minutes a day practicing meditation. One woman felt that making the time to practice the longer meditation was 'too much of a luxury' when she had 6 children at home an instead practiced mindfulness of washing the dishes and mindful walking.
"you are doing the dishes.... actually take the time, look at the shape, the shape of the dishes and the water temperature. Calm down and actually take notice of what you are doing and relaxing instead of automatically jumping, as I do, onto the next couple of things maybe for the whole day, you know.-P2.
Some participants described struggling with the meditation exercises;
"I have great difficulty in keeping on the line of the meditation, getting used to it, I had great difficulty but I still persevered and I still have great difficulty with it"-P1
"The one where you meditate sitting, I can't do it for 25–30 minutes because I've got a bad spine and I found it, I get agitated I cant sit for that length of time"-P8
Others adopted a more flexible attitude towards practice;
"Sometimes I would start doing it (the body-scan) and maybe I didn't feel myself relax. I fought against it at the start. I thought this isn't working but what I started doing was if I didn't feel that I could relax right away I would put it off and then later on go back and do it".-P5
The same participant later she describes letting go of trying to force the relaxation
"I let go of those feelings and it just all started to come naturally."-P5
Another woman described a similar process whereby her ability to sit with her anxiety depended on her own meditation skill and the degree of anxiety;
"I find it (sitting meditation) very, very good but I must say that when I am very, very anxious and uptight about something I find it very hard, very, very hard to sit with my anxiety.... that's a definitely a skill".-P11
In general, those in the group that were able to let go of expectations of results and focused simply on the meditation methods, were more likely to persist with the exercises and feel benefit from the course.
Benefits and on-going practice
Most of the course participants continued to use some of the mindfulness exercises three months after the course ended, suggesting that they found some benefit from these practices. The majority continued to use the three-minute breathing space, finding it an effective method for regaining composure in the face of difficult emotions, particularly anxiety. Five participants continued to have a regular formal meditation practice 2–3 times per week three months after finishing the course. Other participants, while not continuing formal periods of meditation, integrated mindfulness practices into ordinary activities such as walking the dog or washing the dishes. Several participants spoke about the difficulty in motivating themselves to continue practicing, after the course had ended.
In total 4 participants dropped out of the course and two of these were interviewed. One man had kept the material with the intention of one day trying it. The other, who dropped out after the first session said the course had acted as a trigger for her to engage in her own form of meditation/relaxation practice. Of the two drop outs that were unavailable for interview one had a history of alcohol abuse and dropped out after only 2 classes. The other, a woman whose husband had walked out on her half way through the 8-week program was too upset to continue with the course, had since moved out of the area.
The group described a wide range of benefits that came from the course. These included an
increased ability to relax,
a decreased tendency to jump to negative conclusions,
learning to take time out,
learning new ways of dealing with difficult emotions
greater self acceptance.
"I am able to deal with my emotions...I am not scared of things any more...I don't want to turn about and walk away from things...I'll take the time out to sit down and face up to it..."-P5
"Well I think it must have helped because I usually land up in hospital and I didn't this time...... I'm just being more relaxed about what I am thinking"-P2
"I don't panic the same, eh, I still have negative thoughts about things, I worry a lot and I always see the pessimistic point of view but I don't go into tizzies.... the course has helped. I wish I had that course years ago"-P8
"its helped me look at things in a different way...just accept it"-P3
Two participants who had been off work because of psychological difficulties believed the course had helped them get back to work. One of these participants had been out of work for almost a year because of depression and difficulty coping with stress at work. He felt the course helped him get back to work. The other participant had been off work for 9 months due to a combination of physical and psychological problems.
"I do the 3 minute thing when I'm at work.....and to be honest with you I feel that if I didn't do it I would have to go home, you know, I would have to leave my work"-P9
One woman who found the course especially useful, and whose depression resolved completely, described how she had discovered self-worth and joy.
"I feel more worthwhile now. I'm beginning to feel now that there is something out there for me. I'm going to go back to work as well.......My outlook has changed. The kids have even noticed it"-P5
"I had tried anti-depressants and that and I'm not really one for taking medication if I can help it and I think something like this, it doesn't make you be in control of your life, but it certainly helps and I think that is the thing, if something can help you. Whereas the anti-depressants I just felt as if I wasn't in control anymore. They made me feel different. The same problems were there. So when I stop taking the tablets I still had the emotional baggage and everything that I had stopped feeling when I started taking the pills. It was waiting for me at the end of the course whereas I feel with this, this is a different course. I've dealt with everything myself and at the end of the course they feelings are still there but I can deal with them so I would definitely feel that this is an alternative"-P5.
For one woman with generalised anxiety disorder the course gave her a method of managing her anxiety when having a medical procedure;
"I got a lot out of the body-scan. There was an incidence where I had went to the hospital for an endoscopy and you hear all the horror stories about what is going to happen and whatever and normally with things like that I would be physically shaken, you know I would be so uptight but because I had this, under my belt if you like, I thought no I've got to use it, that is what it is there for, so I did use it and I wasn't shaken and I was so proud of myself"-P9.
Several participants found their sleep improved when they practiced mindfulness meditation and one man found that mindfulness meditation techniques helped him with cope with restless legs syndrome. One woman describes how techniques learned for dealing with anxiety helped her give up smoking.
"But this time I stopped smoking...and I have still stopped and I'm sure that course helped me.... I don't know if you know anything about the patches, the last month we go on a low dose, it really is quite hard then because you are coming off the nicotine and I get really, really anxious. And I really do think if it hadn't been for that meditation that 8 weeks I maybe would have started smoking again"-P11
Learning to live in the present moment was seen as a way of letting go of anxiety and re-discovering joy. One woman, saw the course in spiritual terms:
"Because what its (meditation) actually accentuating is the five senses... taking in what your seeing, what your hearing, to when your eating something; you notice the texture. I walk my son's dog and I really had a lovely calming experience. It was a lovely day and I was watching the lovely breeze in the trees and I was watching the flowers and the river and your really more conscious of creation so I felt that the spiritual connotations were what was different,-P8
While some members of the group described very positive changes in mood and attitude as a result of completing the 8-week course, other participants found the course less helpful. One participant, who had suffered from anxiety and depression for more than 30 years, had hoped meditation would provide a 'miracle cure' and was disappointed this had not been the case. She spoke about on going family problems, expressing feelings of rejection and isolation and continued to experience high levels of anxiety. While she enjoyed the classes and found the 'thoughts and feelings' exercise very informative, at times she felt overwhelmed by the amount of new information. Importantly, she tended to conceptualise mindfulness practice in terms of relaxation alone and remained goal oriented while practicing meditation. Because of this she found herself judging her practice as successful if it induced relaxation and unsuccessful if she was tense or distracted. During the classes she found herself able to relax, but at home she spoke about becoming easily distracted by noises which she felt interfered with her practice and so in her opinion made the practices less effective.
"Nothing has got worse. Just I know meditation would be a good thing and I would enjoy it if I could get into it. It's very beneficial and I think I it would have helped if it had gone on longer but it just wasn't long enough. I have still been putting the tape on but I'm not putting into it, you know, it doesn't seem to be working, I think it's because I know I'm not coming back to the class"-P3
Another participant with posttraumatic depression and anxiety, found the course interesting but not particularly useful to him. While he found attending the group a hugely normalising experience, he found the meditation practices irritating and difficult. He spoke about becoming irritated with the audio instructions on the CD and giving up on the guided meditations early on in the course. Occasionally he meditated on sound, which he found calming, but admitted that since the course had ended this practice was diminishing. He continued to struggle with difficult emotional states and believed that while the mindfulness approach was helpful, it was only helpful to a certain degree:
"How much that degree is I couldn't quite fathom at the moment, it's not been long enough. There are so many hurdles that you've got to jump over. It's so easy to trip up, so unbelievably easy to get yourself back into the rut....I think perhaps it makes you recognise that you are on the edge of the rut quicker rather than falling into it and saying how the hell did I get here. And it gives you some methods of holding a better balance."-P1