Running Head: MINDFULNESS-BASED MEDICAL PRACTICE i Mindfulness-Based Medical Practice: A Mixed-Methods Investigation of an Adapted Mindfulness-Based Stress Reduction Program for Health Care Professionals Julie Anne Irving Department of Educational and Counselling Psychology McGill University, Montreal PhD in Counselling Psychology October 2011 A thesis submitted to McGill University in partial fulfillment of the requirements of the degree of Doctor of Philosophy in Counselling Psychology © Julie Anne Irving 2011 Running Head: MINDFULNESS-BASED MEDICAL PRACTICE ii Abstract The necessity of providing health care professionals with tangible tools to manage stress and safeguard their own well-being has become increasingly apparent. Rates of burnout in the helping professions are rising; the consequences of clinician distress for patient care have been highlighted in recent literature. Past research has examined the potential for Mindfulness-Based Stress Reduction (MBSR) to act as an adjunctive intervention for various clinical problems, including but not limited to chronic pain, for over 25 years. Presently, the applications of this program are burgeoning with health care professionals, for whom the intervention holds the promise of promoting both personal and clinical benefits. Past research has examined outcomes of MBSR in health care professionals such as burnout, empathy, perceived stress, as well as medical and psychological symptoms such as depression or anxiety. The current program of research sought to expand on existing research by examining positive psychological outcomes such as well-being, as well as potential mechanisms of change such as mindful attention, and self-compassion. Quantitative and qualitative methods were employed to provide a broad portrait of how change is experienced by health care professionals engaged in the program. This dissertation comprises three manuscripts that collectively contribute to the literature. The first manuscript provides a focused literature review, summarizing the empirical literature on MBSR for health care professionals specifically. The second manuscript utilized self-report measures to explore benefits of engaging in Mindfulness- Based Medical Practice (MBMP), an adapted version of MBSR for health care professionals which includes training in mindful communication. The program was completed by a sample of 51 physicians, psychologists, social workers, nurses, and other Running Head: MINDFULNESS-BASED MEDICAL PRACTICE iii health care professionals in two cohorts during the spring of 2008 and 2009. Findings provide initial evidence of the effectiveness of MBMP as demonstrated by significant decreases in perceived stress, and increases in mindful attention and awareness and self- compassion. Bootstrapped hierarchical regression analyses failed to reveal a moderating effect of either mindfulness or self-compassion on the negative relationship between perceived stress and well-being. The third manuscript presents a study which investigated participants’ experiences of the 8-week course through focus group interviews (n = 27). A grounded theory analysis yielded a model highlighting unique change processes for practicing health care professionals in relation to enhanced awareness of perfectionism, self-criticism, and orientation to others. Participants described achieving personal outcomes such as changes in self-care attitudes and practices, as well as implications for clinical encounters with patients. This study provides one of the first in-depth qualitative investigations of practicing health care professionals’ experiences of an MBSR program. Taken together, the three manuscripts provide a solid rationale for future research on the potential for MBSR to enrich the lives of health care professionals and the patients they serve. Running Head: MINDFULNESS-BASED MEDICAL PRACTICE iv Résumé La nécessité de fournir aux professionnels de la santé les bons outils pour gérer le stress et améliorer leur mieux-être apparaît de plus en plus criante. Le taux d'épuisement des professionnels de la santé est en hausse et les conséquences de la détresse des médecins se réflètent également auprès des soins prodigués aux patients. Cette réalité est d’ailleurs largement documentée dans les récentes publications scientifiques. Depuis plus de 25 ans, plusieurs recherches ont examiné le potentiel de Mindfulness-Based Stress Reduction (MBSR) qui consiste à prendre pleine conscience de son stress afin de le réduire. Ce programme agit comme un moyen d’intervention d'appoint devant plusieurs problèmes d'ordre clinique, incluant de façon non limitative la douleur chronique. Actuellement, la mise en application de ce programme est en plein essor auprès des professionnels des soins de santé et les résultats leur apportent des avantages à la fois personnels et médicaux. Des recherches antérieures ont examiné les résultats du MBSR auprès des professionnels de la santé atteints d'épuisement, ou de leur attitude face à la perception du stress, de l'empathie, ainsi que des symptômes médicaux et psychologiques comme la dépression ou l'anxiété. Le programme actuel de recherche a cherché à s’étendre sur la recherche existante en examinant les résultats positifs psychologiques tels que le mieux-être, ainsi que les mécanismes potentiels de changement tels que l'attention consciente et l'autocompassion. Des méthodes quantitatives et qualitatives ont servi à fournir un portrait général sur la façon dont le changement est vécu par les professionnels de la santé inscrits à ce Running Head: MINDFULNESS-BASED MEDICAL PRACTICE v programme. Cette étude est documentée en trois ouvrages qui contribuent à enrichir la publication scientifique. Le premier ouvrage met en évidence à travers la publication scientifique un résumé des publications empiriques du MBSR particulièrement pour les professionnels des soins de santé. Le second ouvrage a étudié des mesures d'auto-évaluation pour explorer les avantages de s'investir dans une version adaptée de MBSR soit le Mindfulness-Based Medical Practice (MBMP), qui comprend une formation en communication consciente. Le programme a été suivi par des médecins, psychologues, travailleurs sociaux, infirmières et autres professionnels de la santé par deux groupes au cours du printemps 2008 et 2009 (n = 51 [m1]). Les résultats ont prouvé l'efficacité de MBMP comme en témoignent la baisse significative du stress ressenti et une augmentation marquée de l'attention consciente et de l’autocompassion. Les analyses de régression hiérarchique avec un bootstrap ont omis de révéler l’effet modérateur de pleine conscience ou d’auto compassion sur la relation négative entre le stress perçu et le mieux- être. Le troisième ouvrage a observé les expériences des participants à un cours de 8 semaines au moyen d'entrevues auprès de groupes cibles (n = 27). Une analyse théorique bien fondée a fait apparaître un modèle mettant en lumière des processus de changement particuliers chez les professionnels de la santé en fonction d’une sensibilisation accrue du perfectionnisme, l'auto-critique et de l'orientation envers les autres. Les participants ont exprimé avoir atteint certains buts personnels telle l’importance de prendre davantage soin d’eux-mêmes au niveau de l’attitude et du comportement, ainsi que durant les Running Head: MINDFULNESS-BASED MEDICAL PRACTICE vi rencontres cliniques avec les patients. Cette étude fournit une des premières enquêtes qualitatives en profondeur sur la participation des professionnels des soins de santé dans un programme MBSR. L’ensemble de ces trois ouvrages fournit une justification solide pour de futures recherches sur le potentiel de MBSR visant à enrichir la vie des professionnels de la santé et des patients qu'ils soignent. Running Head: MINDFULNESS-BASED MEDICAL PRACTICE vii Acknowledgements This document, and my progress as a doctoral student, have been supported and enriched by many mentors, friends, and family, to whom I am extremely grateful. I would like to begin by extending my deepest thanks to my doctoral co-supervisors and committee. First, Dr. Jeeseon Park, who encouraged me to pursue a dissertation topic that I feel deeply passionate about, which in turn resulted in this process being a true labor of love. I am indebted to you for your patience, kind words, thoughtful comments, and the compassionate and ethical manner which you embody and model to your students. I feel tremendously lucky to have had the opportunity to work with you during your time at McGill. I would also like to thank Dr. Marilyn Fitzpatrick for generously offering to become my co-supervisor this year, and for the invaluable contributions she has made to the preparation of this document as well as my successes as a masters and PhD student. I met Dr. Fitzpatrick on my first day of the Master’s program in Counselling Psychology. It has been a delight to have benefited from her insight, intellect, expertise, consummate professionalism, and poise over the years. I would not have been able to complete this project without her support. I would also like to acknowledge my committee member Dr. Patricia Dobkin, who has by all accounts acted as a supervisory mentor and played a key role in making these studies possible. Her contagious energy and passion for the practice of mindfulness and understanding its benefits through empirical research have been a driving force behind this project. She has gone above and beyond as a committee member, generously Running Head: MINDFULNESS-BASED MEDICAL PRACTICE viii and patiently sharing her time, energy, and expertise. Moreover, she made it possible for me to have access to data from the programs which she and her colleagues offer through McGill Programs in Whole Person Care. It has been a pleasure and an honor to work with Dr. Dobkin, her co-instructor Dr. Tom Hutchinson, as well as the administrative team and other students at the Whole Person Care such as Eileen Lavery, Nancy Gair, Angelica Tourdineau, and Jane Zhao. The support, friendship, and sense of community at the center have been invaluable. My sincerest appreciation is extended to other McGill faculty mentors who have served in a variety of supportive roles during my time as a masters and doctoral student. To Drs. Jack DeStefano, Martin Drapeau, and Ada Sinacore, thank you for your support, kindness, and advocacy over the years. Drs. Bruce Shore and Frank Dumont were instrumental in encouraging me to pursue a PhD, and their early letters of support made it possible for me to secure the funding which supported this project. Frank, your theories class and conversations with you led me to uncover a love and appreciation for the history and development of the field of psychology which has motivated me throughout this process. Bruce, working with you has been one of the highlights of my experience as a student at McGill. I cherish the friendships I have developed with you and many of the students in your lab. I attribute many of my academic successes to your influence and support. My dear friends; Anusha Kassan, Cassidy Syer, Lisa French, Katie Saunders, Lindsay Borovay, Krista Ritchie, Nika Morisano, Emily Kerner, and Emily Blake. You have each inspired me, made me laugh, and helped me persevere throughout this process; Running Head: MINDFULNESS-BASED MEDICAL PRACTICE ix it would not have been the same without having been able to share the PhD experience with you. To my family, thank you for having consistently been my greatest supporters. To my father, thank you for teaching the value of persistence and hard work. I wish that you could be here at the end of this journey to finally see it pay off. To my mother, grandmother, and Uncle Jeff, thank you for your ongoing patience, interest, and words of encouragement. You are the best family anyone could possibly ask for. To my fiancé Adam Lipper; thank you for sticking by me through the years, and tolerating my absences and anxieties, related and unrelated, to this process. Having your love and support made it possible to get through challenges that would have otherwise seemed insurmountable. I also would like to acknowledge all of the students, faculty, and staff in the Department of Educational and Counselling Psychology at McGill University. Special thanks to current and past Department Chairs, Drs. Alenoush Saroyan and Susanne Lajoie for their guidance. It has been inspiring to study and work in an environment with so many strong and accomplished women in leadership roles. I would also like to thank past and current administrative staff, Diane Bernier, Alexander Nowak, and Samantha Ryan for their kindness and helpful assistance. Additionally, thank you to my research assistants Andrea Chen, Vanessa Salvatore, and Andrea Weaver for their enthusiastic and meticulous work. Finally, I would like to thank the amazing group of individuals who volunteered to take part in this research. Their collective willingness to collaborate and openness to Running Head: MINDFULNESS-BASED MEDICAL PRACTICE x share their stories were touching and inspiring, and made this program of research possible, and an absolute pleasure to conduct.