Evaluating Mindfulness Based Stress Reduction: Analyzing Stories of Stress to Formulate Focus Group Questions

INTRODUCTION

The therapeutic community (TC) approach is an effective treatment for substance use disorders. TCs provide a highly-structured social learning environment in which the community is the key agent of behavioral change (DeLeon, 2000). TC residents progress through treatment in stages, each giving them more privileges, and thus more responsibility and opportunity to exercise judgment. A confrontational style of peer-based learning is an implicit component of TC treatment which most likely affects dropout by contributing to environmental stress. Dropout rates are reported to be as high as 40% within the first 30 days in therapeutic community treatment (Galanter, 1999).

Mindfulness Based Stress Reduction (MBSR) is an evidence-based mediator of stress in clinical and non-clinical settings (Bishop, 2002). MBSR programs help individuals cultivate a non-reactive, non-judgmental attitude toward objects, events, and ideas, by highlighting their impermanence, through an intentional focus on the breath and sensations in the body (Kabat-Zinn, 1990). In a 4-year behavioral therapies trial, MBSR classes were integrated into the TC program as an adjunct to treatment to reduce stress and promote retention (Marcus, Liehr, Schmitz et al., 2007). The purpose of this column is: 1) to describe conventional content analysis undertaken as first-level evaluation of MBSR incorporated into TC treatment and 2) to identify key questions for focus group discussion, the second-level evaluation.

METHOD

Using standardized guidance for expressive writing (Pennebaker, 2000), written stories of stress were collected five times over the course of a behavioral therapies trial. The primary intent of the story-gathering was to document personal change over time. Stories (n = 356) from all participants collected at the four post-MBSR intervention time points were reviewed to identify those where participants spontaneously referenced MBSR (n = 38).

This was a secondary data analysis using conventional qualitative content analysis (Hsieh & Shannon, 2005) to evaluate stories of stress which referenced MBSR. Content analysis is a systematic approach for understanding patterns of human thought by examining a unit of analysis (Graneheim & Lundman, 2004). The stories of stress referencing MBSR were the unit of analysis. Approval from the researchers’ affiliated University Institutional Review Board was obtained prior to conducting the content analysis.

Selective reduction of the texts was achieved by the researchers who independently read the stories of stress to highlight key words and phrases related to the MBSR intervention. Obvious explicit terms, such as “focus on breath” and “be in the moment” were identified as language consistent with MBSR. Initial analysis was conducted by reading the stories of stress to capture first impressions of the contribution of MBSR to TC treatment. Key words (eg: release, focus, cope) were identified through collaborative examination by the researchers. Key words were then coded and codes were defined by consensus. After completion of the coding, findings were synthesized. Trustworthiness of findings was addressed by the parallel roles of the researchers for all aspects of the analysis.

FINDINGS

Three qualities of MBSR were identified by participants in their stories of stress: utility, portability and sustainability. Utility is the usefulness of MBSR practice for calming self. The meaning of utility related to MBSR included being able “to learn a lot of tools,” for stress reduction. The utility of the MBSR tools was described as “being remarkable (in) how (they) work.” One of the tools identified by several residents was “focus on the breath” to cope with difficult situations. Being able to “feel aware of surroundings” and to “manage bad events” helped some participants to “use (MBSR) all the time, all day long.” Portability was defined as potential for transporting MBSR lessons out of the classroom to real-life experiences. Participants wrote about using MBSR for “applying what (they) have learned” in the TC community. Portability was expressed as being able to use MBSR to “cope with stressful situations” in order to “take time out whether at work, here or any place.” Sustainability referred to the potential long-range contribution of MBSR to ongoing recovery. Sustainability meant that the MBSR experience could help with goal achievement, described by one participant as being able to “use (MBSR) when I go to college” and after “I exit from the TC.”

DISCUSSION

Conventional content analysis provided insight about the value of MBSR for TC residents in this first-level evaluation of MBSR. Utility, portability and sustainability were identified as essential qualities important for integrating MBSR into TC treatment. These qualities were used as a foundation for framing key questions (Krueger, 1998) for second-level focus group evaluation.

Key questions should foster a dialogical environment which elicits the voices of focus group participants. The content analysis highlighted familiar terms and friendly language to demonstrate a thoughtful approach for conversation, a critical element for dialogue when using a focus group method (Krueger & Casey, 2000). In order to conduct successful focus groups, the facilitator must encourage participants to voice their perspectives in their unique language.

Three questions were framed around the qualities of utility, portability, and sustainability. In each of the questions, MBSR sessions are called “stress class” because this was the common terminology used by the TC population when referring to the sessions. The first question addressing utility was: How do the stress class tools, like focus on your breath, affect your thoughts, feelings and bodily sensations? The second question addressing portability was: What lessons from the stress class do you use to help you to cope with difficult TC situations? The third question addressing sustainability was: How will you use the stress class techniques to achieve your goals once you leave the TC?

CONCLUSION

Content analysis of the stories of stress provided a first-level evaluation of MBSR and prepared the research team for second-level focus group evaluation by cuing the team to appropriate language and identifying essential qualities as a foundation for formulating key questions. This content analysis approach shows promise for structuring guidance to enable focus group dialogue which resonates with participants and enables collection of meaningful evaluation data.