Body-Mind-Spirit Therapy/Qigong

To examine the effect of two interventions on emotion suppression and psychological distress in patients with non-metastatic breast cancer

Each group met for eight weeks for two hours each week. There were three groups: 

1. Supportive expressive intervention model: Adapted 52-week version down to brief protocol focused on social support and interpersonal relationships, emotional expression, life priorities, fear of death, and coping skills
2. Body-mind-spirit: Sessions focused on holistic health lifestyle, including physical activities and discussions; developing resilience, normalizing traumatic experiences, looking for mutual support, promoting self-acceptance, and peace of mind; mental well-being and forgiveness 
3. Control: Social support self-help without structured programming. Self-led group discussed healthy living (diet, food, exercise) and self-care; shared worries; showed mutual support

• N = 157 (BMS, n = 51; SEG, n = 49; control, n = 57)   
• AGE: Range = 18-65 years; mean = 47.7 years
• FEMALES: 100%
• CURRENT TREATMENT: Not applicable; completion of active treatment  
• KEY DISEASE CHARACTERISTICS: Non-metastatic breast cancer

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: Hong Kong, China

PHASE OF CARE: Transition phase after active treatment

Three-arm RCT with measurement at baseline (T0), 4 months (T1), 8 months (T2), and 12 months (T3)

• Emotional suppression–Chinese Courtauld Emotional Control Scale (how often suppress anger, anxiety, and depression)
• Perceived stress–Chinese Perceived Stress Scale (how often felt stressful in past month)
• Anxiety and Depression–Chinese Hospital Anxiety and Depression Scale 
• Baseline psychological functioning–Chinese General Health Questionnaire (higher scores indicate worse health)

No difference in groups except for cancer duration, which was longer in SEG group and shorter in the BMS group (p = 0.01). There were no significant improvements in anxiety or depression. Emotion suppression: significantly decreased in the first four months for SEG and BMS with no change in control group. Perceived stress: No change in control or SEG but significant decreases in first four months in BMS group.
SEG resulted in moderate decrease in emotional suppression at 4 and 8 months, with participant perceived benefits; method is applicable for increased expression of emotions. SEG minimal effect on anxiety, depression and perceived stress. 
BMS showed no effect on anxiety and depression (d = 0.38–0.46) and little (small to medium  d = 0.07–0.2) effect on emotional suppression and perceived stress.

No significant effectiveness of the named therapies: SEG or BMS

• Small sample per group
• Risk of bias (no random assignment)
• Measurement/methods not well described
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Drop-out rate. 11.5% overall; 10.2% in SEG group and 17.5% in control group.
• Low statistical power and low-moderate effect sizes. Unclear which aspects of the abbreviated 52-week protocol were applied. Self-selection bias may be at play. Treatment adherence was not measured; participants completed seven sessions on average.

Conduct large-scale research with sufficient power to examine effectiveness of these therapies. Learn and apply these therapeutic approaches. Use full-scale 52-week protocol for expression support therapy.

To examine the effects of body-mind-spirit group therapy on anxiety, depression, and holistic well-being among women with breast cancer

Patients in the control group received standard care. Patients in the experimental group received standard care plus 10 sessions of weekly group therapy, 180 minutes per session. Therapy integrated concepts and practices, such as qigong exercises of vital energy, massage, meditation, positive thinking, group mutual support, long-term survivors’ sharing, songs, home assignments, and exercises. These activities were based on traditional Chinese medicine, the Eastern philosophies of Taoism and Confucianism, and the practice of Buddhism. The goal of the activities were to manage physical, psychosocial, and spiritual distress. Sessions included qigong exercises provided for 20 minutes each week by a qigong master and body-mind-spirit group assignments that included sharing and singing. The qigong master facilitated the first 20 minutes of each session. Then the primary investigator and co-investigators, working as mental health nurses, managed the rest of each session. Co-investigators held a 90-minute focus group interview after the last group therapy session. They conducted the interview in Mandarin and transcribed it. A bilingual researcher translated the transcription.

A coinvestigator implemented the randomization so that the patients, physician, and primary investigator were blinded to the randomization process. The primary investigator conducted groups after randomization and completion of initial surveys. Participants completed a baseline questionnaire after informed consent. After two months of intervention, participants completed a postintervention questionnaire.

• The sample was composed of 28 participants: 12 in the experimental group and 16 in the control group. 
• Mean patient age in the study was 40–60 years. In the experimental group, mean patient age was 52 years (SD = 8.3 years). In the control group, mean patient age was 46.1 years (SD = 7.8 years).
• The sample was composed of female patients with breast cancer only. Those suffering ailments in addition to breast cancer or receiving other psychotherapy were excluded.
• Patients had cancer in stages I–III. The distribution of stages in groups follows: stage I, three patients in the experimental group and three in the control group; stage II, six patients in the experimental group and eight in the control group; stage III, two patients in the experimental group and three in the control group.
• The types of surgery that patients had undergone included modified radical mastectomy, conservative surgery, and radical mastectomy, with the distribution of types in groups as follows: modified radical mastectomy, seven patients in the experimental group and nine in the control group; conservative surgery, three patients in the experimental group and five in the control group; radical mastectomy, two patients in the experimental group and two in the control group.
• One patient in the experimental group and two patients in the control group experienced relapse.

• Single site
• Outpatient setting 
• Consultation room of a cancer foundation center

• Phase of care: active treatment
• Clinical applications: late effects and survivorship

Mixed-methods design incorporating a randomized controlled trial and focus-group interviews

• Beck Depression Inventory II (BDI-II)      
• State-Trait Anxiety Inventory (STAI)
• Body-Mind-Spirit Well-being Inventory (BMSWBI)

• Pre/post-test comparison of symptoms of depression in the intervention, or experimental, group and control group showed a difference in depression improvement and body-mind-spirit well-being; the difference was not significant.
• Pre/post-test comparison of symptoms of anxiety in the intervention, or experimental, group and control group showed a significant difference (p < 0.03) in state anxiety.
• Qualitative focus group interviews revealed eight domains with subthemes. The imparting information domain had seven themes: learning about appropriate diet, learning about treatment and care of breast cancer, learning how to monitor physical condition, learning to exercise, learning to practice relaxation, learning to reframe cognitive distress, and learning to practice forgiveness.
• The interpersonal learning domain had two themes: having more interpersonal interactions and obtaining support from group members.
• The catharsis domain had three themes: understanding the impact of suppressing emotions on holistic well-being, sharing suffering with group members, and learning to use projective methods to express emotions.
• The universality domain had two themes: learning that I am not the only one who suffers from cancer and learning that personal characteristics are the common cause of cancer.
• The domains of group cohesiveness and altruism each had one theme: having a sense of belonging and using one’s own successful experience to help others, respectively.
• The existential factors domain had two themes: practicing self-love and learning to view misfortune positively.

Culturally sensitive body-mind-spirit group therapy reduced anxiety among outpatients with breast cancer.

• The study had a small sample, with fewer than 30 participants.
• The researchers were not completely blinded to the randomization process because the coinvestigator implemented it.
• Forty-nine participants were enrolled in the study, but only 28 completed the study. The drop-out rate reduces the power of the study.
• Findings may have limited generalizability beyond women ages 40–60 with stage II breast cancer.
• Longer-term follow-up to study maintenance of depression improvement are needed.

Mental health nurses who provide group therapy for patients with cancer could help to enhance quality of care in psycho-ontological nursing. Further research with older and younger women — as well as with patients in stages I, III, and relapse — are suggested.