Mindfulness-Based Cognitive Therapy in Primary Care: Clinical Applications and Analysis of the Five Facet Mindfulness Questionnaire (FFMQ)

Abstract: The overall objective of this thesis is to analyse the concept of mindfulness as measured by the Five Facet Mindfulness Questionnaire (FFMQ) and its clinical usefulness in primary care through group Mindfulness-Based Cognitive Therapy (MBCT). Because no Swedish version of the FFMQ was available, that became the starting point of this research project. Mindfulness came into practice in Sweden in the early 2000s as a complement to clinical treatment thanks to evidence-based treatment models developed in the United States and Great Britain including Mindfulness-Based Stress Reduction (MBSR); MBCT, Acceptance and Commitment Therapy (ACT), and Dialectical Behaviour Therapy (DBT). International researchers have been interested in analysing how mindfulness is defined and operationalized and in investigating its usefulness in clinical practice. The Swedish research has mainly focused on MBSR and its effects on stress-related illness. The aims of this thesis are therefore to examine the clinical applications of mindfulness by analysing the usefulness and effectiveness of MBCT in Swedish primary health care and the mindfulness construct measured by the FFMQ. This thesis consists of four studies. In Study I (N = 495) the aims were to (1) develop and assess the Swedish version of the FFMQ; (2) compare the psychometric properties of the Swedish FFMQ with the original version of Baer et al.; and (3) examine the overall mindfulness construct, using confirmatory factor analysis (CFA). In Study II (N = 817) the aim was to look for differences in profiles between meditators and non-meditators (325 meditators and 317 non-meditators) through analysing the FFMQ using a person-oriented approach. In Study III (N = 19) a qualitative method was used, with the aim of exploring how primary care patients with recurrent major depressive disorder (MDD) perceived the usefulness of MBCT in preventing relapse. In Study IV (N = 45) quantitative methods were used, with the aim of examining the clinical effects of MBCT in primary care (prevention of relapse in depression) and generalizability of effects. The main findings indicate that mindfulness is a multidimensional skill that can be developed with practice, and that MBCT can work as a preventative primary health care intervention for patients with MDD. Study I showed that the Swedish FFMQ (FFMQ_SWE) provides results comparable to those obtained for the original version. Cronbach’s alpha was high for all facets and the CFA showed that the Observe subscale was not a significant part of the overall self-reported mindfulness construct in a population of Swedes with little experience of meditation. In Study II the hypothesized relationship between the Observe facet and mindfulness (which we assumed to be higher among meditators), was tested and the results showed mindfulness to be related to high levels of observing and attending to experience. In Study III the thematic analysis suggested two overarching themes: “Strategies for remission” and “Personal development”. The formal and informal meditation exercises that focused on the body and the breath were described as the most important strategies for remission and the mindfulness practice helped the participants to deal with everyday stress and interpersonal functioning. In Study IV a benchmarking approach, used to compare the relapse rate in the study participants (16%) with that of patients receiving treatment as usual (TAU) (68%) in the efficacy study, revealed a large effect size. The person-centred approach, measured by the Reliable Change Index, showed that 67% of participants in the clinical group improved, none worsened, and women’s depression and anxiety improved significantly more than men’s. In conclusion, the thesis shows that the concept of mindfulness should be seen as a multidimensional skill that can change over time, and that may develop differently in various subgroups. The clinical studies showed that participants perceived meditation and yoga as most helpful in preventing the recurrence of depression. Improvement of interpersonal functioning was another prominent change after participation in MBCT. The overall results suggest that MBCT can be implemented successfully in Swedish primary care as a preventive intervention for patients with recurrent depression.