Mindful rehabilitating: Does mindfulness-meditation make a good rehabilitation program for cognitive deficits in glioma patients?

Bachelor thesis in Cognitive Neuroscience part of the Bachelor’s degree in Psychology of Health

Department of Medical Psychology and Neuropsychology, Section Neuropsychology, Tilburg University

Author: S.C.M. Pennings ANR: 439650 Supervisor: Prof. Dr. M.M. Sitskoorn Date: 12-08-2011

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Abstract Patients with a glioma tumour can have cognitive deficits as a result of the tumour or treatment. These cognitive deficits can have a negative effect on their sense of wellbeing and their quality of life. The objective of this thesis is to investigate whether mindfulness can be used as a method to improve the cognitive deficits or to protect again cognitive decline in glioma patients. Mindfulness is defined as a state of sustained moment-to-moment awareness in which attention is being paid to all sensations, feelings and thoughts that arise with an open and non-evaluative attitude. Several studies are discussed in this thesis suggesting that mindfulness has a positive effect on attention, memory, executive functioning and verbal fluency. Furthermore several studies demonstrate a positive effect of mindfulness on measures of wellbeing. The mechanism by which mindfulness has its effect on wellbeing is mediated by changes in values and cognitive, emotional and behavioural flexibility. Furthermore neuroimaging studies demonstrate that meditation-related neuroplasticity takes place and leads to a functional reorganization of the brain. Especially the anterior cingulate cortex and prefrontal areas seem to be enhanced in meditators, suggesting an increase in attentional skills and cognitive flexibility. The clinical and neuroimaging studies discussed in this thesis provide preliminary evidence that mindfulness has a positive effect on cognition and wellbeing. Cognitive flexibility seems to play a crucial role as a mechanism by which mindfulness exerts its positive effect. Further research is needed to confirm these results. Keywords mindfulness – meditation – rehabilitation – brain tumour – glioma – cognition – attention – quality of life

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Contents

1. Cognitive deficits in brain tumour patients

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2. Method

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3. Mindfulness

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3.1 History

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3.2 Types of interventions

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3.3 The mindfulness construct

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4. Mindfulness and cognition

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4.1 Attention

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4.2 Memory

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4.3 Executive functioning

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4.4 Verbal fluency

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4.5 Mindfulness and cognition in patients with neuro(psycho)logical disorders

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5. Mechanism of mindfulness

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6. Neurobiological features of mindfulness

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6.1 EEG studies

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6.2 Neuroimaging studies

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7. Discussion

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7.1 Conclusion

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7.2 Methodological limitations

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7.3 Research proposal

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8. References

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9. Annexes

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Tabel 1: summary of the studies of the effect of mindfulness-meditation on

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cognition

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1. Cognitive deficits in brain tumour patients Being diagnosed with a brain tumour has many consequences for the daily life of the diagnosed patient. Not only do they have a physical disease, which is possibly life-threatening, but also their cognitive abilities can be affected by the brain tumour or the treatment they receive. Combined these factors can have a significant impact on the patients health related quality of life (Liu, Page, Solheim, Fox, & Chang, 2009). Glioma Gliomas are tumours in the glia cells of the central nervous system. About 40% of all brain tumours are gliomas (Grier & Batchelor, 2006). Of these gliomas about 15-20% are low-grade gliomas (Douw et al., 2009). LGG are a diverse group of tumours in the brain, brainstem, of spinal cord, with distinct characteristics, patterns of occurrence, response to treatment en survival rates. This kind of tumour is more common in relatively younger and healthier patients and the average life expectancy is ten years or more. The prognosis for patients with a LGG is better than for patients with a HGG because of the slow progress and the young age at which the disease is diagnosed (Grier & Batchelor, 2006). The physical symptoms often seen in brain tumour patients are seizures, motor and sensory deficits and increased intracranial pressure. The severity and impact of these symptoms depend on the size and location of the tumour (Gustafsson, Edvardsson, & Ahlström, 2006). In fast growing, high-grade, gliomas (HGG) the physical symptoms are paramount and therefore it is less essential to diagnose and treat cognitive deficits. In slow growing tumours, so called low-grade gliomas (LGG), the prognosis is better and life expectancy is longer and therefore cognitive deficits are of more importance (Taphoorn & Klein, 2004). Cognitive deficits The cognitive deficits and complaints often seen in brain tumour patients comprise attentional, memory, executive functioning and language deficits (Correa, DeAngelis, Shi, Thaler, Lin, & Abrey, 2007; Gehring, Aaronson, Taphoorn & Sitskoorn, 2011a) . These cognitive deficits can arise as a result of the brain tumour itself¸ or as a result of tumour-related epilepsy or the treatments used for the tumour or epilepsy (for example: surgery, chemotherapy, radiotherapy or antiepileptics). The disease might also cause psychological distress, or even feelings of anxiety or depression, which in turn also affect the cognitive abilities. Furthermore the psychological distress can negatively influence quality of life, which also has a detrimental effect on cognition. Most likely it is a combination of these primary and secondary factors that leads to the final cognitive deficits (Taphoorn & Klein, 2004; Correa et al., 2007). 4

Due to the increased life expectancy and longer disease-free periods the emphasis in low-grade gliomas has shifted from solely treating the brain tumour and corresponding physical complaints, towards the prevention and treatment of cognitive deficits (Taphoorn & Klein, 2004; Gehring, Sitskoorn, Aaronson, & Taphoorn, 2008). As a result of the extended survival the quality of survival is becoming of great importance (Gehring et al, 2008). Results from a study performed by Gustafsson et al. (2006) suggest that mental problems have a substantial impact on quality of life and possibly a greater impact than physical problems. Cognitive deficits have a major impact on the daily lives of patients and the burden of these cognitive symptoms on their daily life is considerable, leading to a diminished quality of life and sense of wellbeing (Heimans & Taphoorn, 2002; Liu et al., 2009). Quality of life is defined by Liu, Page, Solheim, Fox en Chang (2009) as a concept that encompasses the multidimensional wellbeing of the patient and his or hers satisfaction with life. Liu et al. (2009) conclude that it is important to include quality of life in future treatment. On the one hand because of a primary effect on quality of life itself, but on the other hand because of the beneficial effects quality of life can have on the prognosis and the course of the disease. In other words, it is not just important to fight the symptoms of the disease but also to create conditions for optimal recovery by enhancing quality of life (Liu et al., 2009). Furthermore, cognitive dysfunction can also have implications on decision making processes and therefore influences the decisions regarding informed consent and other medical and lifestyle decisions (Liu et al., 2009). For these reasons mentioned it is important to not only treat the physical condition, but also the cognitive disabilities in order to diminish the social handicaps that are a result of the tumour and all its consequences (Heimans & Taphoorn, 2002). Cognitive rehabilitation Based on the results of cognitive rehabilitation in other patient populations with brain damage Gehring et al. (2008) conclude that brain tumour patients would make good candidates for cognitive rehabilitation. The improvement of cognitive functioning could possibly also have a favourable effect on fatigue, mood and quality of life. However, it is possible that an effective treatment of fatigue and mood disorders might also positively effect cognitive functioning. Gehring, Aaronson, Taphoorn & Sitskoorn describe in their review (2010) five interventions for cognitive deficits in brain tumour patients. The interventions are aimed at both treating cognitive deficits as well as preventing them from arising or deteriorating. In their review they mention two approaches often used for treating cognitive deficits; pharmacological and neuropsychological (for example cognitive rehabilitation). Cognitive rehabilitation is defined as a non-pharmacological intervention aimed at preventing or treating cognitive deficits. The five types of interventions for 5

cognitive impairments in patients with a brain tumour that they describe are: 1) To modify and restructure the environment to help patients sustain an independent daily life without having to rely as much on their impaired cognitive abilities. 2) The patient can learn to use external aids or technology, like electronic diaries. 3) Structured strategy training can help patients to learn new internal strategies to cope with their cognitive impairments (for example, planning and pacing of activities en minimising distractions). 4) Retraining of specific cognitive skills. 5) Through psychoeducation the patient can learn how to cope with their cognitive deficits and the consequences for their daily life. Gehring et al. (2009) have investigated the effect of cognitive rehabilitation on both objective and subjective measures of cognitive functioning in glioma patients. In a randomised controlled trial they offered a cognitive rehabilitation program to a group of glioma patients while the control group was placed on a waitlist. 140 subjects with both objective cognitive deficits and subjective cognitive symptoms were randomly allocated to either the intervention condition or the waitlist condition. The treatment program consisted of six weekly two hour sessions, incorporating a cognitive retraining and a cognitive compensation training. They uses a computer program called ‘Strategy Training and C-Car (STCC), this program incorporated two training approaches: 1) a cognitive retraining that consisted a series of hierarchically organised tasks that should strengthen several aspects of attention. 2) The cognitive compensation training was aimed at learning strategies for improving attention, memory and executive functioning (Gehring et al., 2011a). Gehring et al. (2009) found a significant long term effect for the objective neuropsychological measurements of attention and verbal memory. On the subjective level they found significant short term results. Furthermore cognitive rehabilitation was shown to have a positive effect on mental fatigue in the long term. There was no significant effect found on quality of life. Gehring, Aaronson, Gundy, Taphoorn & Sitskoorn (2011b) have investigated specific patient factors that are associated with a beneficial cognitive rehabilitation. They conclude that about 60% of the participants had improved significantly six months after the rehabilitation program. Only age was found to be a significant in predicting individual improvement. Older patients reported more difficulties with the amount of strategy homework involved in the rehabilitation program (Gehring et al., 2011a). Their results are promising, however they leave room for improvement, and therefore it would be useful to investigate if other rehabilitation programs might lead to better success rates and possibly positive effects on quality of life as well. Research question

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For some time mindfulness has been emerging as a treatment method that seems to generate positive results on improving both cognitive abilities and sense of wellbeing. Glioma patients face some serious problems with their cognition as a result of their tumour and/or treatment, which in turn have a great impact on their quality of life and sense of wellbeing. In this thesis I would like to investigate if mindfulness is a suitable method to improve the cognitive abilities of LGG patients or prevent them from deteriorating. If mindfulness is shown to positively affect cognition then I would like to investigate by which mechanism mindfulness has an effect on cognition. To finish this thesis off I will put forward a research proposal to study the effect of mindfulness on cognitive deficits in glioma patients and to compare these results with the cognitive rehabilitation programs used up to now.

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2. Method Data collection The search for articles for this thesis has been performed using the search engines Pubmed and PsychINFO using combinations of the following words: “mindfulness”, “meditation”, “MBCT”, “MBST”, “Vipassana”, “Zen”, “ACT”, “DBT”, “cognitive deficits”, “cogn*”, “attention”, “memory”, “executive functioning” “rehabilitation”, “therapy”, “brain tumo(u)r”, “tumo(u)r”, “glioma”, “dementia”, “stroke”, “traumatic brain injury”, “Alzheimer” en “Parkinson”. These terms have been used in several combination using the boolean operators “AND” and “OR”. Furthermore, articles have been found using references of relevant articles and through citation indices of relevant articles on Web of Science. Inclusion en exclusion criteria Only studies performed after the year 2000 have been used for this thesis, because of the rapid developments in this research area and the poor quality of older studies. Furthermore there was a lack of consent on an operational definition of mindfulness before 2000. Articles in languages other than English have been excluded from this thesis. De articles found in this search have been manually searched for relevance to the subject of this thesis. Every article had been assessed for relevance based on title and abstract. Articles relating to mindfulness and the effect on cognition have been selected. Both studies with a clinical focus and neuro-imaging studies have been selected, for both healthy patients as well as patients with neuro(psycho)logical disorders. Studies on the effects of mindfulness in psychiatric disorders have been excluded from this thesis. Furthermore articles have been selected that provide background information for mindfulness and the mechanism by which it works. Data analysis The articles have been collected by one person in the period march-june 2011. The selected articles have been divided into three groups; articles regarding cognitive rehabilitation, clinical studies on the effect of mindfulness on cognition, and neuro-imaging studies on the effect of mindfulness on the brain. The studies have been systematically compared to each other based on design, population , method, sample size and characteristics, type of mindfulness intervention, measurements and results (see table 1). Attention has been paid to methodological qualities of the studies and more importance has been giving to methodological sound experiments. The conclusions of the studies will be discussed separately and subsequently compared to each other.

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3. Mindfulness In the last twenty years mindfulness has gained considerable interest within western psychology practices as a method for increasing awareness and attention (Bishop et al., 2004; Rapgay & Bystrisky, 2009)). Kabat-Zinn (2003) defines mindfulness as ‘the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of the moment. Each thought, feeling or sensation in the attentional field is acknowledged and accepted as it is’. 3.1 History Buddhist origin Mindfulness originates as part of the Buddhist meditation tradition and traditionally plays an important role in the Buddhist concept of Dharma, the path of human well-being. Through the use of mindfulness one can systematically train mindful attention and strengthen various aspects of mind and heart. In this way mindfulness can release the mind of suffering (Kabat-Zinn, 2003). Mindfulness derives from the the pāli word ‘sati’ which means ‘to remember’. Most likely the explanation for this - perhaps unexpected - translation can be found in the Buddhist view that once mindfulness is present memory will function as well (Chiesa & Malinowski, 2010). Although mindfulness is certainly associated with Buddhism and has been developed and cultivated within the Buddhist tradition over the past 2500 years, there is nothing particularly Buddhist nor religious about mindfulness. On the contrary, mindfulness is considered to be an inherent human capacity (Kabat-Zinn, 2003). Western psychology The former Buddhist concept of mindfulness has been adapted to create clinical applications of mindfulness and mindfulness-based approached. Kabat-Zinn developed mindfulness-based stress reduction (MBSR) in 1979 with the vision that mindfulness might help patients relieve from suffering and learn about the powerful mind-body connection. His intention was to create an effective training for medical patients to help them cope with the stress, pain and illness through the practice of meditation. This training model turned out to be mindfulness-bases stress reduction (MBSR). MBSR was first used as an treatment program for patients with chronic pain in 1982 (Kabat-Zinn, 2003). Since then the use of mindfulness had increased and MBSR¸ and other mindfulness-based interventions, are now being used not only in the treatment of chronic pain but in various neurological, psychological en psychiatrical disorders (Bishop et al, 2004). 3.2 Types of interventions There are several mindfulness meditations or mindfulness-based approached that are currently being used as a clinical application (Chiesa & Malinowski, 2011). 9

Vipassana Vipassana is an Buddhist meditation practice and is deeply rooted in the Buddhist philosophy. Vipassana is supposedly the meditation practiced by Gautama Buddha more than 2500 years ago (Chiesa, 2010a). In Vipassana meditation one learns to focus on the breath through sustained bare attention while at the same time trying to be aware of the whole body breathing in and out through the development of a general awareness (Rapgay & Bystrisky, 2009). When thoughts, feelings of sensations interfere with the bare attention some introspective awareness may be applied before returning to the focus on breathing (Chiesa & Malinowski, 2011). Vipassana meditation is usually taught in a ten-day retreat (Chiesa, 2010a) Zen Zen is, just like Vipassana, rooted in the Buddhist philosophy. There are several kinds of Zen practices depending on the level of experience. Contrary to Vipassana meditation, a novice in Zen meditation usually starts with a concentration like meditation, called ‘su-soku’, during which the novices count their breaths in a way to keep the focus on their breathing (Chiesa, 2010b; Chiesa & Malinowski, 2011). The more advanced practitioners no longer count their breaths but are simply aware of the present experience. This meditation practice is called ‘shikantanza’ (Chiesa, 2010b). Another Zen practice is meditation on a ‘koan’, an unsolvable riddle (Chiesa & Malinowski, 2011). Mindfulness-Based Stress Reduction (MBSR) MBSR is the only modern mindfulness-based intervention with clear roots in the Buddhist tradition. MBSR was first used in 1979 in a treatment program for chronic pain patients by Kabat-Zinn. KabatZinn has acknowledged that MBSR is influenced by both Vipassana en Zen meditation practices (Kabat-Zinn, 2003). However MSBR is very much a western meditation based treatment approach and has no religious component (Chiesa & Malinowski, 2011). MBSR usually consists of three different components; body scan, sitting meditation and Hatha Yoga practice (Chiesa & Malinowski, 2011). Sitting meditation involves paying attention to the perception of the body breathing (Hölzel et al. 2011). During a body scan the attention is sequentially focused through the body, starting with the head and slowly moving the focus through the body to the feet. Attention is being paid to all the sensations and feelings that arise with an open and accepting attitude (Hölzel et al. 2011; Chiesa & Malinowski, 2011). The Hatha Yoga practice involves breathing exercises, gentle stretching exercises and yoga postures, all coordinated with breathing, bringing full attention to the present-moment experience (Hölzel et al. 2011). Participants usually receive audio recordings containing guided meditation to practice mindfulness at home. Furthermore the 10

participants are advised to integrate mindfulness into their daily lives, for example through the practice of mindful eating, walking, washing the dishes etcetera. The participants are stimulated to carry out these activities with mindful attention, bringing full attention to the moment to moment experience (Hölzel et al. 2011). Mindfulness-Based Cognitive Therapy (MBCT) MBCT was developed in 1990 by Segal et al. to prevent chronic depressed patients from relapsing. MBCT is based on MSBS and cognitive-behavioural therapy (CBT) (Chiesa & Malinowski, 2011). Both the Buddhist philosophy and CBT agree on the importance of self-responsibility, self-control and selfimprovement (Chiesa & Malinowski, 2011). There is no exposure just the experience of. Mindfulness is based on the flexibility of dealing with whatever comes to mind. This flexibility helps to create a tolerance to the thoughts, feelings and sensations that were previously considered threatening (Rapgay & Bystrisky, 2009). In MBCT the same techniques are used as in MBSR, namely: sitting meditation, body scan and Hatha Yoga practice. There are certain differences though. MBCT includes several techniques derived from cognitive-behavioural therapy, for example, how to deal with the risk of a depressive relapse. Also some general information about depression is given (Chiesa & Malinowski, 2011). And furthermore a fourth practice is added to the routine called the “ three minute breathing space” during which the patient learns to apply the MBCT to their daily lives. Dialectical Behavioural therapie (DBT) DBT was originally developed as a intervention for patients with a borderline personality disorder (Lynch, Chapman, Rosenthal, Kuo & Linehan, 2006). DBT is based on behavioural therapy, dialectic philosophy and the Zen tradition. In DBT the dialectic between acceptance and change is central. By trying to find a synthesis between a thesis and an antithesis the dialectic can be resolved. In other words the focus lies on trying to find the middle path, which is also a important feature of Zen Buddhism. (Chiesa & Malinowki, 2011) Acceptance and commitment therapy (ACT) ACT is usually included in mindfulness-bases interventions based on the fact that several strategies are consistent with the mindfulness approached. The main influence for ACT however is the philosophical view of contextualism. It is assumed that cognitions achieve their potency by the context in which they occur (Chiesa & Malinowki, 2011). Formal meditation 11

What most of these intervention, all except DBT and ACT, share in common is a formal meditation training as a part of the intervention. These mindfulness approaches use more or less the same technique of a sitting meditation. The practitioner of mindfulness sits on the flour, legs crossed and in a upright position, and tries to focus on either his breathing of another somatic sensation. Whenever the mind wanders off to other thoughts, feelings, worries, or sensations the person will acknowledge and accept the thought with an open and accepting attitude and then dismiss it en return to focus on the breathing (Chiesa & Malinowski, 2011). At a later stage the focus on a specific sensation becomes less important and the meditation practitioner will try to reach a state of general awareness to the stream of thoughts and distractions that arise (Bishop et al, 2004; Chiesa & Malinowski, 2011). Based on the fact that both DBT and ACT do not include any formal meditation practice it is questionable whether they really should be considered mindfulness-meditation interventions. For the sake of this thesis DBT and ACT are excluded from analysis based on the lack of a formal meditation practice. 3.3 The mindfulness construct Critical issues Both Vipassana and Zen meditation provide a clear distinction between attention (with the main focus on breathing), and awareness (the general awareness of other sensations arising). The literature on MBSR and MBCT often uses attention and awareness as identical and exchangeable concepts, describing a meditation technique that has more in common with a concentrative practices instead of mindfulness-mediation (Rapgay & Bystrisky, 2009). Based on these differences the term mindfulness-meditation can be misleading. Rapgay & Bystrisky (2009) do not agree upon the way that mindfulness has been integrated in western psychology. They claim that mindfulness has been transformed from a systematic practice based on a perceptual and cognitive model to a more general concept of ‘being present in the moment’. Their main critique comprises the fact that there seems to be little distinction between the concepts of ‘attention ‘ and ‘awareness’. This discrepancy however can be solved if one considers that concentrative meditation might lead to the development of a certain sustained attention which as the practice deepens becomes more effortless and develops into a more general awareness which is non-judging and non-striving (Chiesa & Malinowski, 2011). Furthermore Rapgay & Bystrisky (2009) argue that according to classical literature mindfulness is an active and engaged process. And not, like many popular mindfulness-based approaches claim a detached and non-reactive process. One is not supposed to detach oneself from reality but through

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active engagement with every experience one can gain insight into the links between the mental events. Operational definition In order to solve these misconceptions about mindfulness a general agreement of what mindfulness encompasses was needed. And in order for mindfulness to become fully integrated in western psychology it had to be translated into a western scientific concept, in other words an operation definition was needed (Bishop et al, 2004; Shapiro, 2009). First of all, however, it is important to realise when using the term mindfulness that mindfulness is both a process and an outcome (Shapiro, 2009). Bishop et al. have held a series of meetings in order to reach a consensus on a mindfulness definition. Their goal was to develop an operation definition of mindfulness, in which they combine the different component of mindfulness. This operation definition would make it easier to do scientific research and compare the results of different studies (Bishop et al., 2004). Bishop et al (2004) propose a two-component model of mindfulness, based on attention and acceptance. The first component encompasses self-regulation of attention by keeping the attention focused on immediate experience. Observing whatever comes to mind, whether it is thought, feelings or sensations. It is all about being present in the moment. The second component involves adopting a certain orientation to the experiences in the present moment. Bishop et al. describe this orientation as ‘characterised by curiosity, openness and acceptance’. The mindfulness practitioner needs to have an actively chosen attitude based on curiosity, openness and acceptance to whatever comes to mind and is being experienced (Bishop et al, 2004). According to Rapgay & Bystrisky (2009) the operation definition formulated by Bishop et al. is probably the most accurate representation of the Buddhist idea behind mindfulness. However they comment that Bishop et al. still do not adequately differentiate between awareness and attention. And they argue further: ‘if people do not understand the difference between these two concepts than what are they doing when they practice mindfulness’. Rapgay & Bystrisky (2009) suggest a model of classical mindfulness, in which first one develops a perceptual mode of knowing, also known as bare attention, without meanings or associations. After reaching this state one can move on to the state of introspective awareness. In this state one can distinguish between adaptive and maladaptive thoughts so as to increase the first and decrease the latter.

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Translating the concept of mindfulness into western psychology appears to be limited by the lack of differentiation in the English language between the eastern concepts of awareness and attention. It seems to me that although some authors use ‘attention’ instead of ‘awareness’ they do in fact differentiate between some general kind of open attention and a more focused attention, whereas in other instances other writers neglect the dichotomy, or the need for awareness, altogether. For mindfulness to become fully integrated in western psychology it is important to discuss and further define the operational definition of not only mindfulness, but also the concepts of attention and awareness.

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4. Mindfulness and cognition Based on the operational definition proposed by Bishop et al. in 2004 mindfulness involves several forms of attention and executive functioning. Sustained attention is needed in order to keep the focus on the sensation of breathing, attention switching is needed to bring back the attention to the present moment when it has wondered off, inhibition of elaborative processing is needed to avoid rumination on thoughts of worries outside the present moment, and non-directed attention is needed to enhance awareness (Bishop et al., 2004). 4.1 Attention Anderson, Lau, Segal, & Bishop (2007) have performed a study to test whether participation in a MBSR-program would improve attention control, as suggested by Bishop et al. (2004) in their operational definition. Eighty-six adults with no prior experience with meditation were recruited en either placed in a MBSR group or in a waitlist control group. The MSBR program consisted of formal meditation and informal practices during two hour classes over a period of eight weeks. Both groups were pre- en post-procedure tested on four attention tests, the Toronto Mindfulness Scale (TMS) and several affect and emotional well-being questionnaires. The attention tests consisted of the Vigil Continuous Performance Test, meant to measure sustained attention; a switching task to measure attention switching; the Stroop paradigm to measure inhibition of elaborate processing; and an object detection task to measure non-directed attention. At post-test the control group was asked to relax in a dim room prior to the testing while the MBSR-group was asked to do sitting meditation so they could invoke a state of mindfulness and then perform the attention tests. The two groups were comparable in age, education, marital status, and pre-test self-report measures of affect and well-being. The post-test measurements were combined and compared and showed significant and large group-differences in depression, anxiety, anger, positive affect, general rumination, anger rumination and anger sensitivity, all being more positive for the MBSR-group (F(9,53)=2.87, p