MBCT is an experiential type therapy and as such the importance of practice was discussed in Chapter 1. Chapter 2 examined the use of MBCT with clients with a history of psychotic symptoms, and pointed to some potential difficulties in working with this population. In Chapter 3, the importance of ‘home-based practice’ is explored in more detail. ‘Home-based practice’ in general is espoused as an important
component of CBT-based therapies, of which MBCT is one. Because of the lack of research in this area, this chapter will explore ‘home-based practice’ in general, but will also refer specifically to ‘home-based practice’ of mindfulness skills where research exists. The evidence supporting the use of ‘home-based practice’ for clients, rates of non-compliance, possible barriers to clients completing ‘home-based practice’, and the use of interventions that aim to increase compliance are discussed.
Defining ‘home-based practice’
Previous studies use different words or phrases to refer to work undertaken by clients inbetween therapy sessions (Kazantzis, Deane, Ronan, & L’Abate, 2005). This work has been defined as “assignments that are planned therapeutic activities
undertaken by clients between sessions” (Kazantzis, et al., 2005, p.2). The variation in phrases used may in part be explained as an attempt to avoid the term ‘homework’, which can have negative connotations for clients. In this study the work clients completed between sessions is referred to as ‘home-based practice’. To aid the
readability of the literature review all instances of between session work are referred to as home-based practice. It should be noted that the focus of this research is specifically on the home-based practice of mindfulness skills that have been learnt in therapy sessions.
The theory of why home-based practice is important
Home-based practice is conceptualised as an important component in both MBCT and its related modality of CBT. Right back at the inception of CBT, Beck et al. (1979) introduced the importance of home-based practice to CBT in the original
manualised CBT description. In therapeutic CBT sessions, many skills and tools are introduced to clients, but further practice and exploration of what has been learnt in therapy is an important part of the treatment approach. Home-based practice provides an opportunity to practice what has been experienced during the therapy session, thereby extending the therapeutic experience for clients, and allowing them to generalise and experiment with what they have learnt.
MBCT, like its related modality CBT, places a large emphasis on the importance of home-based practice because this is conceptualised as necessary to maximise
possible benefits of the therapy (Vettese, Toneatto, Stea, Nguyen, & Wang, 2009) . Kabat-Zinn (1990) emphasised regular daily practice as a core aspect of mindfulness- based approaches, and likened it to building a muscle through daily physical exercise. MBCT protocol for home-based practice is 30 to 60 minutes per day during the 8-week course, with on-going practice emphasised (Segal et al., 2002). Others have spoken of the need to modify this regime depending on the specific clinical disorders that are the focus of treatment (Chadwick et al., 2005; Samuelson, Carmody, Kabat-Zinn, & Bratt, 2007). As discussed in Chapter 1, both proposed mechanisms through which MBCT are thought to work have regular practice at their core; metacognitive insight is something attained through experience, not knowledge, and, therefore, the skills necessary to develop metacognitive insight must be practised (Teasdale, 1999b); the ability to switch between different modes of mind in order to regulate information processing is also an ability that must be practised in order to develop the skill (Segal et al., 2002).
It has been noted that what constitutes mindfulness practice is itself varied and includes a diverse range of activities, such as listening to guided meditations, focusing on scanning the body for sensations and 3-minute breathing spaces (Crane et al., 2014). Also, there is no consensus whether it is the frequency or duration of mindfulness practice (or both) that is important for producing therapeutic gain (Crane et al., 2014). Further, it is not known whether there is a linear relationship between increased home- based practice and clinical outcome or if there is a threshold necessary to achieve clinical improvements (Crane et al., 2014). Given this wide variation in what constitutes mindfulness practice, it follows that measuring and assessing it may be fraught with difficulty.
It appears that home-based practice is a desirable, if not essential, component of MBCT in theory. The next section will examine the evidence regarding the proposition that home-based practice is important.
Evidence that MBCT home-based practice improves outcomes
A meta analysis of 98 studies involving therapeutic mindfulness interventions aimed to evaluate whether home-based practice had an effect on clinical outcomes (Vettese et al., 2009). The studies sampled included those where mindfulness was the primary component of the therapy, such as Mindfulness Based-Stress Reduction, and MBCT, as well as other counselling programmes where mindfulness was the focus. It excluded studies where other factors as well as mindfulness were components of therapy, such as Acceptance and Commitment Therapy, and Dialectical Behavioural Therapy. The 98 studies were reviewed to analyse how home-based practice was measured and to report compliance rates with home-based practice. Twenty-four of the 98 studies were further examined as they reported the relationship between home-based practice and clinical outcomes.
Results from the meta-analysis were mixed. Of the 24 studies examined eight found a positive association between home-based practice and outcomes, and a further five found mixed results - positive associations on some of the measures but non- significance on others. Overall, 13 (54%) studies showed some kind of positive relationship between home-based practice and outcomes. However, 11 studies did not find a positive association between home-based practice and outcomes, with two of these reporting negative associations.
Studies included in the meta-analysis used a wide range of methodological approaches, including the way that home-based practice was reported and whether compliance with home-based practice was reported and these issues are discussed below. Additionally, for most of the studies reviewed, home-based practice was not the primary focus of the studies. It is unclear whether the lack of methodological focus on home-based practice meant that results were less robust (Vettese et al., 2009).
Home-based practice was monitored in a number of ways in the 98 studies, including daily or weekly self-reports and retrospective reports. Of those studies that reported how home-based practice was measured, 15 studies used self-report logs or diaries, 11 studies used retrospective reports, two used weekly self-reports and one used a daily self-report in conjunction with daily monitoring of home-based practice over the telephone. Because the studies used different methods of reporting, it is not possible to determine whether differences found in frequency of reported home-based practice reflect genuine differences or effects caused by the measurement methods themselves. No studies reported the psychometric properties of the tracking methods.
In addition to how home-based practice was monitored, there was the issue of whether participants completed the measures. Only two studies reported completion rates of the self-report logs. Completion rates varied between 69.5% (Carmody & Baer,
2008) and 97% (Carson, Carson, Gil, & Baucom, 2004). Given the discrepancy between these two studies that reported completion rates of self-report logs it can be
hypothesised that there is a range of completion rates across the studies. Failure of participants to complete the self-report of home-based practice may, therefore, result in an over or under estimation of home-based practice rates.
Of the 45.8% of studies that reported showing no positive relationship, only two studies showed an inverse relationship between levels of practice and positive
outcomes. One study that found negative results also had the smallest sample size of this meta-analysis, and, therefore, the results may be less meaningful. The other study that showed a negative relationship between practice and outcomes reviewed a 10-day intensive retreat-type of mindfulness therapy rather than the weekly programme advocated in MBCT. Since MBCT is the focus of this study this study may have little bearing on this current research.
Given the broad mindfulness inclusion criteria for this meta-analysis, the conclusions should be taken with caution when applied to the current research, which focuses exclusively on MBCT. Both the differences in method of collecting data on home-based practice and variable completion rates of self-report logs present issues.
Three recent studies found that increased levels of formal mindfulness practice were related to lower depression scores following an 8 week MBCT course (Crane et al., 2014; Hawley et al., 2014; Perich, Manicavasgar, Mitchell, & Ball, 2013). The studies were conducted in different countries - the US (Hawley et al., 2014), UK (Crane et al., 2014) and Australia (Perich et al., 2013) - and involved different populations from which the sample was drawn; two with Major Depression Disorder in remission (Crane et al., 2014; Hawley et al., 2014) and one with participants with Bipolar Disorder (Perich et al., 2013). Two studies found significant results at 12-month follow up, with
one reporting a negative correlation between days of formal mindfulness practice and depression scores (Perich et al., 2013), and the other reporting that formal home-based practice reduced the hazard of depression relapse (Crane et al., 2014). The second study did not find a direct effect, but found that increased mindfulness practice was associated with decreased rumination, which in turn was associated with decreased depressive symptoms (Hawley et al., 2014). All of these studies drew a distinction between formal and informal mindfulness practice. Formal mindfulness was defined as following guided mediations on CD lasting 40 minutes, or self-directed meditation lasting for 30- 40 minutes. Informal mindfulness was described as including mindfulness during normal routine activities and ‘noticing’ (see Chapter 1, page 9).
Each study collected self-report logs of home-based practice, which assessed formal practice using a binary yes/no response as to whether the participant had completed a 40 minute guided (or self-directed) mindfulness meditation. It is possible that this choice of measuring home-based practice may have resulted in over or
underestimates. Those who attempted the 40-minute mindfulness practice, but who did not complete it, may have scored themselves as either having completed or not
completed this mindfulness practice. As the studies did not account for partial completion of formal mindfulness practice, accuracy of the data would have been affected. It was not reported in any of the studies whether these incomplete formal practice sessions were monitored. Thus, it is not clear how much impact this may have had on the study.
Completion of home-based practice logs appears to be sporadic. One study reported that 67% of participants completed the self-report logs for home-based practice (Perich et al., 2013), while another reported 75% completed some practice data on each weekly practice questionnaire for 5 out of 7 weeks of measures. It is not clear whether
this lack of reporting reflected a lack of practice or simply logs not being completed by participants. This may have influenced results in a similar way to the binary choice of responding to home-based practice completion, discussed above. Additionally, those participants who complete home-based practice logs may have other traits that affected log completion behaviour, such as the ability to self-initiate directed behaviour or higher levels of motivation. These types of factors may explain the clinical outcomes noted in the studies rather than the effects of home-based practice per se.
Home-based practice is theorised to be important to gain therapeutic effects from MBCT, but there is currently limited evidence to support this assertion, although some studies indicate a positive relationship. More research is necessary to explore the relationship between home-based practice and positive outcomes. It should be noted that the above studies did not focus on samples from populations of individuals with psychotic symptoms, which are the focus of the current research. Issues affecting these particular individuals will be discussed below.
Compliance with home-based practice
Home-based practice has been theorised as an important component of MBCT. The evidence is still unclear as to whether levels of home-based practice affect clinical outcomes. If the theorised importance of home-based practice in MBCT is correct, then it is useful to know whether clients actually complete their home-based practice. This section will explore the rates of compliance with home-based practice. Since there is limited information in the specific area of compliance with home-based practice for MBCT with clients with psychotic symptoms, a broader range of studies will be
examined. Firstly, compliance with home-based practice rates in CBT will be reviewed because of the theoretical relationship between MBCT and CBT. Then, compliance with
home-based practice rates for MBCT will be discussed. Finally, compliance with home- based practice in populations with psychotic symptoms will be explored.
Levels of compliance with home-based practice for clients using CBT. While home-based practice has been conceptualised as an important component in CBT-based therapies, since the development of CBT, it has been noted that non-adherence to home- based practice protocol is a problem (Beck et al., 1979). It has been suggested that there are three forms of evidence that support the proposition that there are low levels of compliance with home-based practice in CBT (Kazantzis & Shinkfield, 2007). Firstly, research on how levels of practice affect clinical outcomes implies that levels of practice vary within clinical populations. Secondly, practitioner surveys show variable rates of compliance with home-based practice, from 20% to 97% (Kazantzis,
Lampropoulos, & Deane, 2005). Thirdly, terminology exists within the CBT framework for discussing the phenomenon of low compliance with home-based practice:
‘resistance’ (Leahy, 2012), ‘ obstacles’ (Beck, 1995), and ‘roadblocks’ (Leahy, 2003). Compliance with home-based practice is an issue that has been identified in CBT. The following section will examine whether compliance with home-based practice has also been highlighted as an issue with MBCT.
Researchexamining non-compliance with home-based practice in CBT suggests that patient motivation is subject to a cost/benefit analysis of the activity (Kazantzis & Shinkfield, 2007). The benefit or gain expected from the home-based practice activity is evaluated against the possible difficulty or distress that the home-based practice may cause. Cost and benefit may also be affected by the clients’ levels of confidence or self- efficacy, and thus others have suggested that these client characteristics also influence whether home-based practice is completed (Bandura, 1989a; Conner & Heywood- Everett, 1998).
Levels of compliance with home-based practice for clients using MBCT. A meta-analysis of MBCT and home-based practice found the mean length of daily practice was reported in 11 studies (31.8 minutes per day, with a range of 5 to 58 minutes), mean weekly practice was reported by two studies (55.9 to 84 minutes), and total practice for the duration of the programme was reported by three studies (5.3, 15.8 and 30.3 hours), while 13 studies did not report length of daily practice (Vettese et al., 2009). Reporting the means of practice can obscure the variability in the group, so while it is true that some individuals may practice for more than half an hour every day, others may practice for only a few minutes, if at all.
The trajectory of change of home-based practice compliance; that is, the way change occurs over time, is not known. For instance, do all participants begin home- based practice in the first week of an MBCT programme and maintain these levels until post-intervention? Do participants incrementally increase their levels of home-based practice during the intervention, or is the trajectory of change of home-based practice erratic? These questions are significant for the design and implementation of a
programme; understanding the trajectory of change can reveal useful information about the necessary length of the intervention.
Compliance with home-based practice for clients with psychotic symptoms. Rates of home-based practice may be different for individuals with psychotic
symptoms. A literature search found no research in the area of home-based practice compliance, psychotic symptoms and MBCT.
There is research on the use of home-based practice for clients with psychotic symptoms and the related modality of CBT. Due to the lack of research on home-based practice compliance in clients with psychotic symptoms and MBCT, the research for CBT is reviewed. A survey of registered clinical psychologists working in a variety of
settings in New Zealand examined their administration of home-based practice (Kazantzis & Deane, 1999). The results of this survey highlighted that psychologists viewed home-based practice as of least importance for symptoms such as hallucinations and delusions, with 52% rating home-based practice of little or moderate importance, and only 23% rating it as of great importance. The potential barriers to clients with psychotic symptoms completing home-based practice (see section below) may also act as a deterrent to psychologists prescribing home-based practice due to expectations of low compliance. For example, the use of home-based practice for clients is
characterised as impractical: “in our clinical experience we have found that attempting to work with thought diaries and home-based practice assignments is generally not productive. This is partly because our patients are mostly unwilling/unable to do written home-based practice assignments, but also because they find it difficult to work at the abstract level of thinking about thinking” (Nelson, 1997, p.14).
A survey of 19 practicing psychologists working with clients with schizophrenia in Australia found that 61% of clients (N=38) were receiving some form of home-based practice (Deane, Glaser, Oades, & Kazantzis, 2005). Of these, 26% did not attempt the home-based practice. The other 39% of clients were not given home-based practice due to previous issues with non-compliance with home-based practice or other barriers to completion. Systematic administration has been posited as a method of increasing motivation and therefore home-based practice compliance. Despite this, only in 23% of the cases were psychologists found to be administrating the home-based practice in a systematic manner. If 26% of clients are not completing home-based practice, then in fact 74% are at least partially completing their home-based practice (Deane et al., 2005). Only 61% of clients were issued home-based practice due to the expectation of non-compliance by the other 39% of clients (Deane et al., 2005). Thus, the rate of
partial compliance of 74% reported is likely to be an over-estimation as only those who were anticipated to complete home-based practice were given it. Expectations by psychologists that their clients with psychotic symptoms may not comply with home- based practice may reduce the amount of home-based practice issued.
One study explored patient satisfaction with CBT for psychotic symptoms (Peters & Kulpers, 2006). They surveyed 65 patients with psychotic symptoms who had received CBT and asked one question specifically about home-based practice. To the question “how helpful were tasks you did between therapy?” the mean response was a score of 4.1 (out of 5, N=65, SD=0.7, range 2-5) at the end of treatment and 4.4 (out of 5, N=40, SD=0.7, range=3-5) at a 3-month follow-up. These results suggest that clients