Cognition, Brain, Behavior.

An Interdisciplinary Journal
Copyright 2013 ASCR Publishing House. All rights reserved.
ISSN: 1224-8398
Volume XVII, No. 2 (June), 135-148

MINDFULNESS-BASED
STRESS REDUCTION INTERVENTION
IN ROMANIAN BREAST CANCER INPATIENTS
Csaba L. DEGI*1, Tunde SZILAGY2
1
2

Department of Social Work, Babe-Bolyai University, Cluj-Napoca, Romania

Department of Psychology, Babe-Bolyai University, Cluj-Napoca, Romania

ABSTRACT
The present study investigated the effect of a mindfulness-based intervention on
anxiety, depression symptoms, coping mechanisms and quality of life in a group of
Romanian breast cancer inpatients. The Mindfulness Based Stress Reduction
(MBSR) intervention was carried out in a group of female cancer patients,
hospitalized and treated with radiotherapy at the Institute of Oncology "Prof. Dr.
Ion Chiricuta" in Cluj-Napoca, Romania. Our results indicate that the MBSR
intervention did not reduce either negative affectivity, nor contribute to the
flexibility of cognitive processes, nor to improvements in quality of life, but it
helped reduce the isolation of patients assigned to the experimental group. This is
the first published study that investigates the MBSR intervention in oncological
settings in Romania.
KEYWORDS: breast cancer, distress, quality of life, isolation, MBSR

Cancer and its treatment bring about a series of specific problems in the life of
people involved: a diagnosis perceived as the synonym of death penalty, the shortterm and long-term consequences of the treatment (e.g. the pain) or other,
perplexing side effects (such as the amputation of the breast, nausea, hair loss as a
result of chemo- and radiotherapy), and the subsequent modification of life-style
(Szabo, 2001). Hospitalized cancer patients in Romania experience high levels of
cancer distress: 47.5% are clinically depressed, 46.7% suffer from anxiety
disorders, and 28.1% report critically low quality of life (Degi, 2011). Ethnic
minorities, particularly Hungarian and Rroma cancer patients, are most vulnerable
to depression and emotional distress (Degi, Kllay, & Vincze, 2007).

Corresponding author:
E-mail: csabadegi@gmail.com

136

C. L. Degi, T. Szilagy

In Europe, a number of 3,2 millions of people are diagnosed with cancer

every year (53% male; 47% female), which means an increase of 300,000 cases
since 2004 (Ferlay et al., 2007). Until 2020, an increase of 50% of cancer cases is
estimated, which means 16 million new patients globally and 1,030,200 new cases
in Central and Eastern Europe (553,100 male and 477,100 female) (WHO, 2005).
The annual death rate of cancer is of 1,7 million cases (56% male, 44%
female), out of which 637,000 people (359,200 male; 277.800 female) are from
Central and Eastern Europe (Ferlay Autier, Boniol, Heabue, Colombet, & Boyle,
2007; WHO, 2005). This percentage represents 15% of the Central and Eastern
European mortality. It is estimated that by 2020 cancer will have caused the death
of approximately 10,3 millions of people globally, which means an increase of 25%
of the Eastern and Central European mortality (742,800 people, of which 432,600
male and 310,200 female) (WHO, 2005).
Presently, the incidence of cancer in Romania is under the European
average rate (240.66 cases per 100,000 inhabitants, at a population of 21,5 million
vs. the European 460.12). This situation has persisted over the last two decades.
Although today the incidence of cancer is relatively moderate, cancer mortality is
increasing; having reached the European average (Romania 179.8 vs. Europe
182.79).
Patients reaction to this type of situations, their attitude towards the
disease, and coping strategies may have an effect on co-morbidity and mortality.
This effect may be linked to treatment results, or to complex mechanisms which
influence reacting forces of the body in coping with the disease (Blasco & Bayes,
1992).
Due to the fact that suffering from cancer is considered a psychosocial
condition of extreme intensity, all the factors that may reduce morbidity and
mortality should be observed with great caution. In this special category we include
factors as: the effect of the illness on emotional well-being, on social relations and
on other important aspects of life, and the coping mechanisms on which patients
rely. Moreover, cancer combines bio-psycho-social aspects which greatly differ
from those in healthy peers (e.g., oncological patients are much more sensitive).
Therefore, one should expect different outcomes when studying effects of
psychosocial factors on cancer patients and on healthy subjects (Szabo, 2001).
The large number of factors involved in cancer distress and survival may
be categorized into three major categories (Uitterhoeve Vernooy, Litjens, Potting,
Bensing, De Mulder, et al., 2004), (i) factors related to age, patients general health
condition, tumor site and stage, (ii) factors related to treatment potentials, and (iii)
economic and psychosocial factors.
Hereinafter, we shall make a presentation of psychological and
psychosocial factors that play a significant role in cancer distress and survival (such
as coping mechanisms, depression, anxiety, and social support).
Cognition, Brain, Behavior. An Interdisciplinary Journal
17 (2013) 135-148

C. L. Degi, T. Szilagy

137

For most lay persons, the term cancer suggests an incontrollable, swift
proliferation of cells, ultimately leading to slow and painful death. No wonder that
the diagnosis and the treatment of cancer are associated with high levels of
emotional distress. Alongside with the bodily symptoms caused by the illness and
its biological treatment (e.g., fatigue, pain, vertigo, hair loss) and the changes that
occur in the physical aspect, there is an array of emotional reactions, such as fear,
confusion, fury, anxiety, which emerge due to the prospects of a long and degrading
treatment and the breaking of the life trajectory (Carlson, Laura, & Marion, 2009).
Moreover, cancer is a highly stressful event from the perspective of the patients
family members as well, as they have to adapt to the shocking and uncertain
situation induced by their relatives diagnosis.
Generally, the initial shock and stress are ameliorated within a few weeks,
and the majority of cancer patients adjust to the new situation and restore their
normal level of emotional reactivity. Nevertheless, an important number of patients
keep displaying high levels of distress, and approximately 22-43% (some other
studies claim 23-49%; Mehnert & Koch, 2008) of them experience symptoms of
psychological distress, such as depression in the first 6 months after the diagnosis
(Classen, Kraemer, Blasie, Giese-Davis, & Koopman2008; Moorey & Greer 2002).
Also 18-30% of adult relatives suffer of clinical depression (Edwards & Clarke,
2004).
People seem to have an innate ability to actively avoid all the details
reminding them of the fragility of life, and being forced to face the imminence of
death may lead to an existential crisis (Lee, 2008). This phenomenon first identified
and described by Weisman and Worden (1976) refers to the exaggeration of
thoughts pondering and ruminating upon matters of life and existence, and on the
prospects of non-existence.
The theory of meaning making states that people have a kind of general or
global sense, a personalized scheme of life that is made up of beliefs and
assumptions which ensure the orderliness and meaning of human existence. These
assumptions, positive illusions - stating, for instance, that tomorrow will always
come, or that righteous people will be rewarded, etc. - are essential for mental
health, and they usually remain unquestioned until a negative life event, such as
cancer, occurs. When a person has to face cancer, his/her whole system of beliefs once ensuring his state of stability, familiarity and security - is shattered/becomes
uncertain (Lee, 2008; Halstead & Hull, 2001). This existential crisis kindles a new
search for meaning. This quest is a cognitive process in which patients strive to
assimilate the illness into their life scheme, in which virtually every aspect of life is
threatened by being forced to handle the disease. The struggle of identifying a new
meaning of life is a necessary, though emotionally difficult quest. The patients who
successfully complete this phase, experience a feeling of rejuvenation and personal
growth, a more profound appreciation of life and deeper compassion for others (this
phenomenon being referred to with the term posttraumatic growth; Tedeschi &
Cognition, Brain, Behavior. An Interdisciplinary Journal
17 (2013) 135-148

138

C. L. Degi, T. Szilagy

Calhoun, 1996). This outcome is only possible when the limitations imposed by
cancer are incorporated into a new scheme of life, which ensures a renewed feeling
of order and meaning (Lee, 2008; Halstead & Hull, 2001)Thus, attitude to cancer
disease, type of treatment, family support and coping mechanisms (among other
crucial factors) do influence levels of distress and quality of life.
Psychosocial interventions are efficient in improving quality of life and
coping abilities, and in reducing distress and isolation in oncology patients (Dianne
& Hiroaki, 2009).
The Tacon study (2004) focalized on the following variables: anxiety,
stress, mental adjustment to cancer, and perception of control. The pre- and posttest results have shown a decrease of anxiety, adjustment to cancer, and better
perception of control (Tacon, Caldera, & Ronathan, 2004). A major limit of this
study was the lack of a control group.
Shapiro, Noah, Rachel, and Michael (1998) have found that the MBSR
intervention significantly increased self-control, cognitive and behavioral
flexibility, transparency of values, and exposure to experiences. Transparency is a
process whereby one shares feelings, values and personal thoughts with another
(Jourard, 1964). The transparency of values, the flexibility of cognition and
behavior have turned out to be mediators of the relationship between decentring and
the reduction of distress symptoms (James, Ruth, & Emily, 2009). Once again, we
have to mention the lack of a control group as one of the limitations of this study.
Another study has revealed that mindfulness is a mediator of the relationship
between meditative practices and patients well-being (James et al., 2009).
To conclude, psycho-oncology literature indicates a negative correlation
between mindfulness and distress, and a positive one between mindfulness and the
ability to act deliberately in social situations. The MBSR technique proved to be
profitable from the cost-benefit perspective of and it may facilitate self-maintenance
and self-care in the long run.
OBJECTIVES
The major aim of our study was to investigate whether a mindfulness-based
intervention can actually reduce levels of anxiety, depression and irrational
cognitions in a group of breast cancer inpatients from Romania, and whether it
improves the efficient use of coping mechanisms and quality of life. We assume
that mindfulness-based intervention leads to the reduction of anxiety and
depression, it induces a significant reduction of irrational cognitions and it helps the
amelioration of coping burdens. Thus, all these factors play an important role in the
improvement of quality of life of cancer patients.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

139

METHOD
Participants
We have applied the MBSR intervention in a group of patients with breast cancer,
hospitalized and treated with radiotherapy at the Institute of Oncology Ion
Chiricu from Cluj Napoca. We have decided to opt for breast cancer for two
reasons: first, to be able to control the gender and the type of cancer, thus increasing
the homogeneity of the group. The second reason was the high prevalence of this
cancer type, as breast tumors are among the most frequent oncology diseases.
The patients were given the opportunity to decide whether they wanted to
participate in the intervention or not. Thus, 11 women were voluntary included in
the experimental group. Those inpatients that refused to take part in the study were
asked to fill out a questionnaire with the pre- and post-test measurements: they
became members of the control group made up of 8 patients. During the first three
weeks of the MBSR intervention, two members of the experimental group
abandoned the study, thus we remained with 9 patients in the study group and 8
patients in the control group. 52% of our participants had secondary education, 73%
of the participants were married, 78% of the patients were of Romanian nationality.
Patients in our intervention were between 37-78 years old (M = 55.58, SD = 10.77).
Instruments
The Hospital Anxiety and Depression Scale (Zsigmond & Snaith, 1983) is a selfevaluation scale with 14 items, 7 of which refer to anxiety and 7 to depression.
Answer scores range between 0-3 (e.g. 0 - not at all, 1 - somewhat, 2 - occasionally,
3 - always). Highest attainable level of anxiety and depression on this scale are 21
points. A maximum of 21 points can be reached with the questions regarding
anxiety, and 21 points at the questions regarding depression (Bjelland, Dahl, Haug,
& Neckelmann, 2002). Cronbachs alpha of the scale is .82.
The Shortened Ways of Coping Questionnaire (Folkman & Lazarus, 1980;
Kopp & Skrabski, 1992) investigates the cognitive and behavioral coping strategies
of people in stressful situations. This questionnaire has 22 items (e.g., I thought
that there must be something good in everything, one must be trying to have an
optimistic approach); it includes 7 conflict solving factors: problem analysis,
decisive action, emotional-affective action, adaptation, help seeking, searching for
emotional balance, retreat/isolation. The first two factors deal with problem-focused
coping strategies (problem-focused coping, 7 points), the others are connected with
emotion-focused coping strategies (emotion-focused coping, 15 points). The
answers scores range between 0-3 (0-not characteristic at all, 1-somewhat
characteristic, 2-characteristic, 3-completly characteristic; at the problem-focused
coping a minimum of 0 and a maximum of 66 points can be reached, at the
Cognition, Brain, Behavior. An Interdisciplinary Journal
17 (2013) 135-148

140

C. L. Degi, T. Szilagy

emotion-focused coping a minimum of 0 and a maximum of 45 can be reached).

Cronbachs alpha of the scale is .51.
The Dysfunctional Attitude Scale (Macavei, 2006) was used to analyze
cognitive styles, especially those predisposing to depression. The scale has 40 items
(e.g., Seeking help is a sign of weakness.), with scores between 1-7 (1=totally
agree, 2=agree very much, 3=agree slightly, 4=neutral, 5=disagree slightly,
6=disagree very much, 7=totally disagree; min. 7 - max. 280). Subjects reaching a
total score between 40 and 155 have a level of malfunctioning that allows them to
normally function on a daily basis, and those who reach a total score between 156
and 280 display a level of malfunctioning which may induce problems of clinical
intensity (David, 2011). Cronbachs alpha of the scale is .83.
The Functional Assessment of Cancer Therapy-General (FACT-G 4.0)
(Webster, Odom, Peterman, Lent, & Cella, 1999) is a generic scale meant to
measure quality of life in our intervention, which takes into consideration both
information regarding the perception of disease and those regarding the evaluation
of the situation. Quality of life is divided into four health-related quality of life
domains by the FACTG 4.0, a 27-item scale: physical, social/family, emotional,
and functional well-being. A five-point Likert-type format (0=not at all to 4=very
much) was used with scale scores ranging from 0 to 108. Cronbachs alpha of the
scale is .78.
Procedure
Mindfulness is a form of self-awareness that allows being fully present in the
moment, not influenced by concurrent feelings, facilitated by a non-evaluative
focus on mental or physical reactions, sensations that may occur. Practicing
mindfulness cultivates three basic skills: decentring - clarity, attention control insight, and awareness - understanding (Whitfield, 2006). Generally, MBSR
programs are structured to 8-10 weeks of exercises, with groups ranging from 10 to
40 participants. The original protocol (Harris, 2008) prescribes an 8 week-long
intervention, but we have proposed a shortened group therapy. Considering the fact
that the patients do not spend more than 3-4 weeks in hospital, the intervention
comprised 6 meetings, one and a half hour long each.
Psychosocial aspects we have covered were: reducing the impact of stress on
physical and mental health, reducing levels of fear, of incertitude, increasing selfconfidence, developing the capacity of self-acceptance, acknowledging cognitive,
emotional and behavioral patterns and the way these affect responses to stress,
understanding the fundamental concepts of mindfulness meditation and mindful
experience, cultivating the capacity of living a meaningful life.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

141

RESULTS
In statistical analyses the Mann-Whitney test was used due to sample size and
distribution specificities. Descriptive statistics and indicators of distribution for
study variables are reported in Table 1.
Table 1.
Descriptive statistics and indicators of distribution for study variables
Anxiety
Depression
Dysfunctional attitudes
Coping skills
Quality of life

Mean
6.73
6.36
141.0
28.06
72.83

SD
2.76
3.28
28.34
7.47
9.06

Skewness
-.152
.338
.337
-.227
-.534

SE
0.52
0.52
0.53
0.56
0.53

Pre and post-test statistics

Our first assumption was that mindfulness-based intervention would be efficient in
reducing anxiety and depression levels, meaning that patients who benefited from
this psychosocial intervention (experimental group) would experience, at the end of
the intervention, lower levels of anxiety and depression as compared with the
control group.
A Mann-Whitney test indicated that, there was no significant difference
between the two groups in the pre-test condition (U = 58.5, p = 0.238 - anxiety; U =
45.5, p = 0.904 - depression), according to the mean ranks of anxiety and
depression scales (experimental MR = 11.32, control MR = 8.19 - anxiety;
experimental MR = 10.14, control MR = 9.81 - depression). In the post-test scores
we did not indicate a significant difference between the two groups either (U =
41.5, p = 0.606 - anxiety; U = 17.5, p = 0.074 - depression) based on mean ranks of
the anxiety and depression scales (control MR = 8.31, experimental MR = 9.61 anxiety; control MR = 11.31, experimental MR = 6.94).
Based on these results we conclude that our first hypothesis has not been
confirmed, which means that mindfulness-based intervention did not lead to a
significant decrease of anxiety and depression in breast cancer patients (see Table
2,3).

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

142

Table 2.
Pre-test differences between study and control group (Mann-Whitney U tests)
Anxiety
Depression
Dysfunctional attitudes
Coping skills
Quality of life

Group
Study
Control
Study
Control
Study
Control
Study
Control
Study
Control

Mean rank
11.32
8.19
10.14
9.81
7.73
12.29
8.94
8.06
9.95
8.94

U
58.5

Z
1.20

p
NS

45.5

.12

NS

19.0

-1.77

NS

35.5

.36

NS

44.5

.40

NS

The second assumption was that the MBSR intervention would be efficient
in reducing irrational cognitions and that breast cancer patients who benefited from
mindfulness-based intervention would develop a more flexible attitude, compared
to the control group.
In pre-test condition a Mann-Whitney test did not reveal statistically
significant differences (U = 19.0, p = 0.085) of mean ranks for the DAS scale,
irrational cognitions, between experimental (MR = 7.73) and control group (MR =
12.29). Moreover, the U test did not highlight significant differences in post-test
either (U = 20.5, p = 0.662), when comparing mean ranks of the two groups for
DAS scale scores (control MR = 7.94, experimental MR = 6.92).
According to these results, we can state that our second hypothesis has not
been confirmed, which means that mindfulness-based intervention did not have a
significant effect on reducing patients` irrational cognitions in the experimental
group (see Table 2,3).
Table 3.
Post-test differences between study and control group (Mann-Whitney U tests)
Anxiety
Depression
Dysfunctional attitudes
Coping skills
Quality of life

Group
Study
Control
Study
Control
Study
Control
Study
Control
Study
Control

Mean rank
9.61
8.31
6.94
11.31
6.92
7.94
5.40
8.0
7.94
9.06

U
41.5

Z
.53

p
NS

17.5

-1.79

NS

20.5

-.45

NS

12.0

-1.17

NS

27.5

-.47

NS

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

143

Our third assumption was that the MBSR intervention would be efficient in
improving coping strategies, meaning that the patients who were in the
experimental group would be able, at the end of the intervention, to use more
effective coping mechanisms when dealing with cancer diagnosis and disease.
According to a Mann-Whitney test for independent samples, in the pre-test
condition there was no statistically significant difference (U = 35.5, p = 0.721)
between the experimental (MR = 8.94) and the control group (MR = 8.06)
regarding mean ranks for the coping mechanisms scale.
Similarly, results of the U test did not reveal any statistically significant
difference between the two study groups in the post-test condition (U = 12.0,
p = 0.284), in regards to mean ranks of the coping mechanisms scale for patients
who took part in the MBSR intervention (MR = 5.40), and for those who did not
(MR = 8.00). Nevertheless, we have made a more detailed analysis of all seven
coping strategies, covered by the Folkman and Lazarus Coping Questionnaire
(1980), and we have observed a marginally significant difference between the two
groups in isolation (U = 19.0, p = 0.068). Figure 1 shows the mean ranks of the
isolation subscale for the control (MR = 12.13) and experimental group in the pretest condition (MR = 7.40). Once the MBSR intervention completed, we have
noticed, a statistically significant difference (U = 10.0, p = 0.009, r = .008) when
comparing mean ranks of isolation in the control (MR = 12.25) and experimental
group (MR = 6.11).
As a conclusion, we can state that the MBSR intervention has proven
efficiency in reducing isolation coping strategies for breast cancer inpatients who
participated in the intervention group, compared to an increased use of maladaptive
coping mechanisms by members in the control group (see Figure 1).
Figure 1.
Comparing isolation coping strategies before and after MBSR intervention
experimental and control groups

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

144

C. L. Degi, T. Szilagy

The fourth assumption claims that the MBSR intervention will be efficient
in improving quality of life in breast cancer patients, meaning that the inpatients
subjected to our mindfulness-based intervention will report improved levels of
physical, social, emotional and functional well-being as compared to the control
group.
A Mann-Whitney test for independent samples, did not reveal any
significant difference (U = 44.5, p = 0.696) between mean ranks of quality of life
for the experimental (MR = 9.95) and control group (MR = 8.94), in the pre-test
condition. Similarly, according to our post-test results, there was no significant
difference (U = 27.5, p = 0.645) between mean ranks of quality of life for patients
who took part in the intervention (MR= 7.94) and for those who did not
(MR = 9.06) (see Tables 2, 3).
We can conclude that based on these results, the fourth hypothesis has not
been confirmed, meaning that our mindfulness-based intervention did not contribute
to the improvement of quality of life in participating breast cancer patients.
DISCUSSIONS
The objective of our study was to investigate the efficacy of an MBSR intervention
in a group of inpatients with breast cancer. We have used a behavioral group
therapy which belongs to the third wave, i.e. the Acceptance and Commitment
Therapy (ACT). Techniques used in this intervention were centered mainly on
cognitive flexibility, on awareness of values, on change or reduction of maladaptive
coping mechanisms such as avoidance or isolation, on acceptance of diagnosis,
focalizing on the present, on developing the ability to identify new meanings of life,
through finding or renewing values and goals in life, on restructuring behavior
based on these new values, and on the reduction of distress.
Our study was meant to be a response (by including a control group) to two
related MBSR studies, which identified significant results regarding the reduction
of anxiety, cognitive decentring, clarity of values and commitment (Tacon, Caldera,
& Ronathan, 2004; Shapiro Noah, Rachel, & Michael, 1998).
Our MBSR intervention has led to different results. We have not found
significant differences between the anxiety and depression levels of patients who
participated in the MBSR intervention and of those who did not. Also, it did not
increase cognitive flexibility in participating breast cancer patients. In other words,
our results suggest a failure in preventing patients to identify themselves with their
own suffering and helping them develop accepting, tolerant and present-focused
attitudes. This mindfulness-based intervention did not play any role whatsoever in
the improvement of quality of life of the participating cancer patients.
Still, a significant reduction of isolation in the experimental group was
observed. Based on this, we can assume partial efficiency of our MBSR
Cognition, Brain, Behavior. An Interdisciplinary Journal
17 (2013) 135-148

C. L. Degi, T. Szilagy

145

intervention, meaning that patients from the experimental group displayed

improvement of coping mechanisms, namely a significant decrease of isolation.
This result, on the one hand, contradicts outcomes of previous studies which
suggested a link between the reduction of anxiety and improvement of coping
mechanisms (e.g., Brown & Ryan, 2003). On the other hand, they are similar to the
results of several meta-analyses which evidence that psychosocial interventions are
efficient in improving coping mechanisms (Dianne & Hiroaki, 2009).
Limitations
Our study has several limitations. The first one refers to possible biases due to the
self-selection of cancer patients, as they entered the experimental group voluntarily.
Another important limitation of the study is size of the sample, the relatively small
number of subjects: 9 patients in the experimental group and 8 patients in the
control group. We do not have a representative sample, thus our results cannot be
generalized for larger samples or for other cohorts.
Another limitation concerns duration of our MBSR intervention, as in the
original protocol the intervention lasted for 8 weeks. Number of meetings and the
disproportional time interval (2 days per 1 week) between the meetings were found
to have a crucial importance, because this time interval was too short to allow more
profound and lasting changes to occur. Future studies may examine whether an 8
week-long MBSR intervention, with a different setup and a randomly distributed
sample would lead to similar or conflicting results.
We also have to mention another factor, i.e. family background and family
functioning, as they greatly influence the post-diagnosis distress of cancer patient
and of family members. Recent studies have revealed that good family functioning
goes along with lower levels of distress, namely depression and anxiety (e.g.,
Edwards & Clarke, 2004). During group sessions several perceptions on the
attitudes of the family members have been mentioned, most of them were being
negative towards cancer and its treatment alike. In the majority of couples the
husband blamed the wife for having developed breast cancer. Cancer has often been
experienced by these women as a stigma, potentially leading to the separation of the
partners. It seems that the patients and their family members subjective perception
on cancer reckons substantially, being associated with higher levels of distress. All
these factors may have contributed to the low efficacy of our intervention.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

146

CONCLUSIONS
We conclude that this MBSR intervention did not contribute to the reduction of
negative emotionality, to cognitive flexibility, nor did it improve quality of life in
breast cancer inpatients. However, it facilitated reduction of isolation among
members of the experimental group. Health and social professionals in Romania
need to be informed about the mindfulness based intervention programs in oncology
settings. Further development of psychosocial services in oncology is imperative in
Romania.
Acknowledgments
This work was supported by a grant of the Romanian National Authority for Scientific
Research, CNCS UEFISCDI, project number PN-II-RU-TE-2012-3-0011.

REFERENCES
Bjelland, I., Dahl, A. A., Haug, T. T., & Neckelmann, D. (2002). The Validity of Hospital
Anxiety and Depression Scale, Psychosomatic Research, 52(2), 69-77.
Blasco, T., & Bayes, R. (1992). Adaptation to illness in cancer patients: a preliminary report.
European Journal of Psychological Assessment, 8(3), 207-11.
Brown, W. K., & Ryan, R. M. (2003). The benefits of being present: mindfulness and its role
in psychological well-being. Journal of Personality and Social Psychology, 84,
822-848.
Carlson, L., Laura, G., & Marion, B. (2009). Mindfulness-based interventions in oncology.
In D. Fabrizio (Ed.), Clinical Handbook of Mindfulness (pp. 383-407), New York:
Springer Science.
Classen, K., Kraemer, H., Blasie, C., Giese-Davis, J., & Koopman, S. (2008). Supportiveexpressive group therapy for primary breast cancer patients: a randomized
prospective multicenter trial. Psycho-Oncology, 17, 438-447.
David, D. (2011). Tratat de psihoterapii cognitive i comportamentale. Iasi:Polirom.
Dgi, L. Cs. (2011). Aspecte psihosociale ale bolilor tumorale, evaluare i intervenie. Cluj
Napoca: Presa Universitar Clujean.
Degi, L. C., Vincze, A. E., & Kllay, . (2007). Differences in illness-related distress in
ethnically different cancer patients: Romanians, Romanian Hungarians and
Hungarians. Cognition, Brain, Behavior, 11(1), 143-158.
Dianne, L., & Hiroaki, K. (2009). Mindfulness-based stress reduction and cancer: a metaanalysis, Psycho-Oncology, 18, 571579.
Edwards, B., & Clarke, V. (2004). The psychological impact of a cancer diagnosis on
families: the influence of family functioning and patients illness characteristics on
depression and anxiety. Psycho-Oncology, 13, 562-576.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

C. L. Degi, T. Szilagy

147

Ferlay, J., Autier, P., Boniol, M., Heabue, M., Colombet, M., & Boyle, P. (2007). Estimates
of the cancer incidence and mortality in Europe in 2006. Annals of Oncology, 18,
581-592.
Folkman, S., & Lazarus, R.S. (1980). An analysis of coping in a middle aged community
sample. Journal of Health and Social Behavior, 21, 219- 239.
Halstead, M.T., & Hull, M. (2001). Struggling with paradoxes: The process of spiritual
development in women with cancer. Oncology Nursing Forum, 28, 1534-1544.
Harris, R. (2008). The happiness trap: How to stop struggling and start living. London:
Robinson Publishing.
James, C., Ruth, A., & Emily, L. B. (2009). An empirical study of the mechanisms of
mindfulness in a mindfulness-based stress reduction program. Journal of Clinical
Psychology, 65(6), 613-626.
Jourard, S. M. (1964). The transparent self: Self-disclosure and well-being. New York: D.
Van Nostrand Co.
Kopp, M., & Skrabski, A. (1992). Magyar lelkillapot. Budapest: Vgeken Alapitvny.
Lee, V. (2008). The existential plight of cancer: meaning making as a concrete approach to
the intangible search for meaning. Supportive Care in Cancer, 16, 779-785.
Macavei, B. (2006). Dysfunctional attitudes scale, FORM A; norms for the Romanian
population. Journal of Cognitive and Behavioral Psychotherapies, 6(2) 489-515.
Mehnert, A., & Koch, U. (2008). Psychological comorbidity and health-related quality of
life and its association with awareness, utilization, and need for psychosocial
support in a cancer register-based sample of long-term breast cancer survivors.
Journal of Psychosomatic Research, 64(4), 383-391.
Moorey, S., & Greer, S. (2002). Cognitive behavior therapy for people with cancer. Oxford:
Oxford University Press.
Shapiro, S.H., Noah, G.B., Rachel, M., & Michael, C. (1998). Psychotherapist mindfulness
and the psychotherapy process. Psychotherapy Theory, Research, Practice,
Training, 1, 8397.
Szab, K. (2001). A pszichoszocialis tnyezk szerepe a rkos megbetegedsekben. Erdelyi
Psziholgia Szemle, 2, 69-88.
Tacon, A., Caldera, Y. M., & Ronathan, C. (2004). Enhanced Psychosocial Well-Being
Following Participation in a Mindfulness-Based Stress Reduction Program Is
Associated with Increased Natural Killer Cell Activity. Journal of Alternative and
Complementary Medicine, 10, 531-538.
Tedeschi, R., & Calhoun, L. (1996). The Posttraumatic Growth Inventory: Measuring the
positive legacy of trauma. Journal of Traumatic Stress, 9(3), 455-471.
Uitterhoeve, R. J., Vernooy, M., Litjens, M., Potting, K., Bensing, J., De Mulder, P., & van
Achterberg, T. (2004). Psychosocial interventions for patients with advanced
cancer - a systematic review of the literature. British Journal of Cancer, 91(6),
10501062.
Webster, K., Odom, L., Peterman, A., Lent, L., & Cella, D. (1999). The functional
assessment of chronic illness therapy (FACIT) measurement system: Validation of
version 4 the core questionnaire. Quality of Life Research, 8, 60.
Weisman, A. D., & Worden, J. W. (1976). The existential plight in cancer: significance of
the first 100 days. International Journal of Psychiatry in Medicine, 7(1), 115.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

148

C. L. Degi, T. Szilagy

Whitfield, H. J. (2006). Towards case-specific applications of mindfulness-based cognitivebehavioural therapies: A mindfulness-based rational emotive behaviour therapy.
Counselling Psychology Quarterly, 19(2), 205-217.
WHO

Global
Action
Against
Cancer
(2005).
http://www.who.int/mediacentre/news/releases/2006/pr06/en/index.html
Zigmond, A. S., & Snaith, R.P. (1983). The hospital anxiety and depression scale. Acta
Psychiatrica Scandinavica, 67(6), 361370.

Cognition, Brain, Behavior. An Interdisciplinary Journal

17 (2013) 135-148

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.