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Mindfulness during the Perinatal Period by Amber Sedgfield BSc (Hons) PgDip MSc A thesis submitted in partial fulfilment of the requirements for the degree of Doctor of Clinical Psychology Coventry University, Faculty of Health and Life Sciences & University of Warwick, Department of Psychology May 2015 Total word count: 17,883 (excluding footnotes, quotations, tables and references) 1 CONTENTS PAGE List of Appendices 7 List of Figures 8 List of Tables 8 List of Abbreviations and Symbols 9 Acknowledgements 10 Declaration 11 Summary 12 CHAPTER 1: LITERATURE REVIEW 13 1.1 Abstract 14 1.2 Introduction 15 1.2.1 Maternal anxiety and stress 15 1.2.2 Prevalence of maternal perinatal anxiety and stress 16 1.2.3 Consequences of maternal anxiety and stress 17 1.2.4 Interventions for anxiety across the lifespan 19 1.2.5 Defining Mindfulness and Acceptance Based Interventions (MABIs) 19 1.2.6 MABIs for anxiety across the lifespan 22 1.2.7 MABIs for maternal anxiety and stress 23 1.2.8 Summary and rationale 24 1.2.9 Aims 25 2 1.3 Method 25 1.3.1 Review process 25 1.3.2 Search strategy 26 1.3.3 Eligibility criteria 27 1.3.4 Systematic study selection 28 1.3.4.1 Phase 1 28 1.3.4.2 Phase 2 29 1.3.5 Quality assessment 31 1.3.5.1 Development of a quality assessment tool 31 1.3.5.2 Quality assessment framework 31 1.3.6 Data extraction and synthesis 32 1.4 Results 33 1.4.1 Summary of reviewed studies 33 1.4.2 General study characteristics 45 1.4.2.1 Aims 45 1.4.2.2 Design 45 1.4.2.3 Recruitment 46 1.4.2.4 Sample 46 1.4.2.5 Interventions 48 1.4.2.6 Measures 49 1.4.2.7 Methods of analysis 49 1.4.3 Synthesis 1: Quantitative results 50 1.4.3.1 Anxiety 50 3 1.4.3.2 Pregnancy specific anxiety 51 1.4.3.3 Stress 52 1.4.3.4 Self-efficacy 53 1.4.3.5 Mindfulness 53 1.4.4 Synthesis 2: Qualitative themes 54 1.4.4.1 Acceptance 54 1.4.4.2 Slowing down in the present moment 55 1.4.4.3 ‘Stop and think’ a new way to respond 55 1.4.4.4 Improving interpersonal relationships 56 1.4.4.5 Greater self-awareness and building life skills 57 1.4.4.6 Greater empowerment and confidence 57 1.5 Integration of findings and discussion 58 1.5.1 Summary of methodological constraints 60 1.5.2 Limitations of the review 62 1.5.3 Clinical implications and future research recommendations 63 1.5.4 Conclusion 65 1.6 References 66 CHAPTER 2: EMPIRICAL PAPER 79 2.1 Abstract 80 2.2 Introduction 81 2.2.1 Mindfulness 82 2.2.2 Mindful parenting 84 2.2.3 Mindfulness-Based Childbirth and Parenting programme (MBCP) 86 4 2.2.4 Rationale 87 2.2.5 Aims and research question 89 2.3 Method 90 2.3.1 Design 90 2.3.2 Participants and recruitment 90 2.3.3 Procedure 93 2.3.3.1 Ethical approval 93 2.3.3.2 Interview procedure 93 2.3.4 Analysis 94 2.3.4.1 The Researcher’s position 94 2.3.4.2 Quality control 95 2.4 Results 96 2.4.1 Superordinate Theme 1: ‘Getting closer to really living’ 99 2.4.1.1 Subtheme: Enriching experiences in the moment –‘it’s 100 like being given lots of little gifts throughout the day’ 2.4.1.2 Subtheme: Grounded in present awareness 102 2.4.1.3 Subtheme: Containing the difficult through observing, 105 acceptance and letting go 2.4.1.4 Subtheme: Equanimity 108 2.4.2 Superordinate Theme 2: Greater connectedness and attunement 109 2.4.2.1 Subtheme: ‘Shared adventure…we’re doing it together’ 109 2.4.2.2 Subtheme: Parent-baby attunement 113 5 2.5 Discussion 116 2.5.1 ‘Getting closer to really living’ 116 2.5.2 Greater connectedness and attunement 118 2.5.3 Methodological considerations 120 2.5.4 Limitations and recommendations for future research 120 2.5.5 Implications for clinical practice 122 2.5.6 Conclusion 124 2.6 References 125 CHAPTER 3: REFLECTIVE PAPER 137 3.1 Introduction 138 3.2 Reflexivity 138 3.2.1 Epistemological reflexivity 139 3.2.2 Personal reflexivity 141 3.3 Parallels of life and research – my lived experience 142 3.4 From clinician to researcher 144 3.5 Lost themes 146 3.6 Conclusion 148 3.7 References 149 6 LIST OF APPENDICES APPENDIX 1: Quality assessment framework 150 APPENDIX 2: Data extraction proforma 152 APPENDIX 3: Quality assessment grid of studies 153 APPENDIX 4: Tables of descriptive statistics and effect sizes 155 APPENDIX 5: Letter of Ethical Approval from Coventry University 161 APPENDIX 6: Letter of Ethical Approval from University of Oxford 162 APPENDIX 7: Letter of invitation to participate in research 163 APPENDIX 8: Participant information sheet 164 APPENDIX 9: Consent form 168 APPENDIX 10: Interview Schedule 170 APPENDIX 11: IPA stages of analysis and coded sample of transcript 174 APPENDIX 12: Letter inviting participants to feedback on their transcript 180 APPENDIX 13: Authors instructions for the Archives of Women’s Mental 181 Health journal APPENDIX 14: Authors instructions for the Mindfulness journal 187 7 LIST OF FIGURES CHAPTER 1: LITERATURE REVIEW Figure 1. Sequential explanatory mixed methods review, adapted from 26 Harden (2010) Figure 2. PRISMA flow diagram of the study selection procedure 30 LIST OF TABLES CHAPTER 1: LITERATURE REVIEW Table 1. Illustration of the overlap of definitions of ‘mindfulness’ and 20 ‘acceptance’ based interventions Table 2. Search terms 27 Table 3. Study selection eligibility criteria 28 Table 4. Characteristics of the studies included in the review 34 CHAPTER 2: EMPIRICAL PAPER Table 1. Participant demographic information 92 Table 2. Superordinate and subthemes 97 Table 3. Identification of the similarities and differences of subthemes 98 between participants 8 List of Abbreviations and symbols Abbreviation / Definition Symbol ACT Acceptance Commitment Therapy CBT Cognitive Behavioural Therapy d Cohen’s d effect size DBT Dialectical Behaviour Therapy IPA Interpretative Phenomenological Analysis MABI Mindfulness and Acceptance Based Intervention MBCP Mindfulness Based Childbirth and Parenting MBCT Mindfulness Based Cognitive Therapy MBSR Mindfulness Based Stress Reduction NHS National Health Service 9