Journal of Affective Disorders 178 (2015) 46–51

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Research report

Online mindfulness-based intervention for late-stage bipolar disorder: pilot evidence for feasibility and effectiveness G. Murray a,n, N.D. Leitan a, M. Berk b,d, N. Thomas a, E. Michalak c, L. Berk d, S.L. Johnson e, S. Jones f, T. Perich g, N.B. Allen h, Michael Kyrios i a

Swinburne University, Melbourne, Australia Deakin University, Melbourne, Australia c University of British Columbia, Vancouver, Canada d University of Melbourne, Melbourne, Australia e University of California, Berkeley, Berkeley, USA f Lancaster University, Lancaster, UK g University of New South Wales, Sydney, Australia h University of Oregon, Eugene, USA i Australian National University, Canberra, Australia b

art ic l e i nf o

a b s t r a c t

Article history: Received 18 October 2014 Received in revised form 18 February 2015 Accepted 23 February 2015 Available online 5 March 2015

Objectives: People in the late stage of bipolar disorder (BD) experience elevated relapse rates and poorer quality of life (QoL) compared with those in the early stages. Existing psychological interventions also appear less effective in this group. To address this need, we developed a new online mindfulness-based intervention targeting quality of life (QoL) in late stage BD. Here, we report on an open pilot trial of ORBIT (online, recovery-focused, bipolar individual therapy). Methods: Inclusion criteria were: self-reported primary diagnosis of BD, six or more episodes of BD, under the care of a medical practitioner, access to the internet, proficient in English, 18–65 years of age. Primary outcome was change (baseline – post-treatment) on the Brief QoL.BD (Michalak and Murray, 2010). Secondary outcomes were depression, anxiety, and stress measured on the DASS scales (Lovibond and Lovibond, 1993). Results: Twenty-six people consented to participate (Age M¼46.6 years, SD ¼12.9, and 75% female). Ten participants were lost to follow-up (38.5% attrition). Statistically significant improvement in QoL was found for the completers, t(15) ¼ 2.88, 95% CI:.89–5.98, p¼.011, (Cohen's dz ¼.72, partial η2 ¼ .36), and the intent-to-treat sample t(25) ¼2.65, 95% CI:.47–3.76, (Cohen's dz ¼ .52; partial η2 ¼ .22). A non-significant trend towards improvement was found on the DASS anxiety scale (p ¼.06) in both completer and intentto-treat samples, but change on depression and stress did not approach significance. Limitations: This was an open trial with no comparison group, so measured improvements may not be due to specific elements of the intervention. Structured diagnostic assessments were not conducted, and interpretation of effectiveness was limited by substantial attrition. Conclusion: Online delivery of mindfulness-based psychological therapy for late stage BD appears feasible and effective, and ORBIT warrants full development. Modifications suggested by the pilot study include increasing the 3 weeks duration of the intervention, adding cautions about the impact of extended meditations, and addition of coaching support/monitoring to optimise engagement. & 2015 Elsevier B.V. All rights reserved.

Keywords: Mindfulness Quality of life Staging Bipolar disorder Online

1. Introduction Adding psychotherapy to medication improves outcomes in bipolar disorder (BD), but even with comprehensive treatment, 50–70% of

n

Corresponding author. E-mail address: [email protected] (G. Murray).

http://dx.doi.org/10.1016/j.jad.2015.02.024 0165-0327/& 2015 Elsevier B.V. All rights reserved.

patients relapse within a year (Miklowitz, 2008). Poor outcomes are particularly pronounced amongst people who have experienced numerous episodes (‘late stage BD’). The likelihood of relapse within a given time frame may be doubled amongst people who have experienced 10 or more episodes (Berk et al., 2011), and this group exhibits poorer quality of life (QoL) and more impaired functioning (Magalhães et al., 2012). There is also evidence that having experienced more than 12 episodes of BD predicts a negative response to

G. Murray et al. / Journal of Affective Disorders 178 (2015) 46–51

cognitive behaviour therapy (Scott et al., 2006), suggesting that a new approach to psychological intervention for late stage BD is warranted. To address this issue, our international team developed a novel adjunctive online psychological intervention designed specifically for late stage BD. ORBIT (online, recovery-focused, bipolar individual therapy) is targeted at improving subjective QoL outcomes, and draws strategies and exercises from mindfulness-based therapies to improve emotion regulation, relationship to self and sleep quality. Therapeutic content includes skills in living in the present moment to improve emotion regulation and sleep, clarifying personal values as a guide to action, and encouraging self-acceptance and self-compassion through avoiding attachment to positive and negative self-evaluations. Here, we report on a pilot investigation of ORBIT, with late stage defined conservatively as six or more BD episodes of any type. We begin by describing the potential for novel treatments targeting late stage BD, and briefly reviewing online delivery of psychological therapies for BD.

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1.2. Online therapy for bipolar disorder Worldwide, less than half of those with BD receive mental health treatment (Merikangas et al., 2011; Schaffer et al., 2006). Online delivery can overcome many barriers to access, including cost, perceived need for treatment and trust in professionals (Leitan et al., 2014). Webbased mental health programs have demonstrated immediate and long term benefits for a range of mental disorders (Griffiths et al., 2010) while being highly cost-effective (McCrone et al., 2004). Our previous work shows that online therapies are acceptable to people with BD (Krusche et al., 2013; Lauder et al., 2013; Todd et al., 2012). Although the benefits of online treatments are yet to be disseminated widely to people with BD, a number of interventions have initial research support (Barnes et al., 2007; Lauder et al., 2014; Proudfoot et al., 2007; Proudfoot et al., 2012; Smith et al., 2011; Todd et al., 2014). Existing research therefore underlines the potential of online dissemination of BD treatments, but interventions tested to date have been variants of traditional face-to-face psychosocial treatments, and none have accounted for stage of disorder.

1.1. Tailoring therapy to late stage bipolar disorder 1.3. ORBIT and the present study There is growing evidence that BD can follow a progressive course, and recognition that treatment response differs with illness stage (Berk et al., 2013; Rosa et al., 2012). Consequently, there are calls to develop stage sensitive psychosocial interventions for BD (Reinares et al., 2014). Stage-tailoring may be especially relevant for late stage BD. Existing psychotherapies address relapse prevention through early detection and forward planning, but such strategies are less effective for people who have experienced numerous episodes (Scott et al., 2006). Indeed, exhortations to prevent relapse by monitoring triggers may be detrimental to self-esteem in late stage BD where relapse can be unrelated to discernible life events (Kapczinski et al., 2008). In such cases, symptom-focussed models of routine clinical practice may be less effective than approaches that recognise the unavoidability of suffering, emphasise redefinition of life goals, and prioritise QoL or recovery outcomes (Berk et al., 2012). These priorities are consistent with socalled ‘third wave’ psychotherapies (Hayes et al., 2011), and a priori, we might expect mindfulness-based therapies specifically targeting QoL to be useful in this poorly served population. Mindfulness has two defining features – developing an awareness of present experience and a non-judgemental and accepting stance towards this experience (Kabat-Zinn, 2003). This would seem a useful skill for managing the emotion regulation challenges of BD, and there is evidence that mindfulness practices are common amongst people with BD. More than 50% of patients with BD report using meditation and spiritual practices naturalistically (Kilbourne et al., 2007), and more than half of 2,685 respondents to a public website (curetogether. com) report trying mindfulness meditation, rating it as effective as psychotherapy for BD. Furthermore, high functioning people with BD report that mindfulness and reflective practices are valuable wellbeing strategies (Russell and Browne, 2005; Suto et al., 2010). Clinical trials in BD populations have shown Mindfulness-Based Cognitive Therapy (MBCT) to reduce symptoms of anxiety, mania, depression, and suicidal ideation and improve emotion regulation, psychological well-being, positive affect, psychosocial and cognitive function (Deckersbach et al., 2012; Howells et al., 2013; Miklowitz et al., 2009; Williams et al., 2008b). While no published studies have investigated mindfulness specifically for late stage BD, Acceptance and Commitment Therapy (ACT) has been shown effective in related severe and chronic mental illness populations (Bach et al., 2012; Clarke et al., 2012; Farhall et al., 2013). Indeed, the ACT premise that suffering is an unavoidable part of life (Hayes et al., 1999) has the potential to reassure and empower a population whose disorder has proven difficult to manage (Berk et al., 2012).

ORBIT is a low-intensity, brief intervention drawing on three recent conclusions in the psychosocial literature: mindfulness-based interventions are beneficial for serious mental illness (Khoury et al., 2013), treatments for BD can and should be tailored to illness stage (Berk et al., 2013), and the web has unrealised potential to economically deliver treatments for BD (Leitan et al., 2014). The intervention focuses on QoL outcomes, and are intended to augment rather than replace symptom management approaches. The aim of the present study was to assess the feasibility, potential effectiveness, and any negative effects of ORBIT in an open pilot trial.

2. Materials and methods 2.1. Inclusion criteria To maximise generalisability, inclusion criteria were broad, including self-reported primary diagnosis of BD, receiving care from a medical practitioner, access to the internet, proficient in English, and 18–65 years of age. Finally, being in late stage BD was an inclusion criterion, operationalised as self-report of six or more BD episodes (depressive, manic, hypomanic or mixed). 2.2. Sample Twenty-six people (Age M¼46.6 years, SD¼ 12.9) completed written informed consent procedures. Twelve of 16 (75%) with valid gender data were female (gender was not gathered for 10 participants due to technical error). Modal employment and marital status were 25.0% and 37.5%, respectively. Ten participants were lost to follow-up (38.5% attrition), with complete pre- and post-intervention data obtained from n¼16. 2.3. Measures Self-report measures were completed at baseline and immediately on completion of the four modules (post-test). The primary outcome variable was baseline to post-test change in subjective QoL, measured on the 12-item brief Quality of Life in Bipolar Disorder scale (QoL.BD), an instrument with sound psychometric properties (Michalak and Murray, 2010). Satisfaction with functioning is rated on a 5-point Likert scale, with higher scores representing greater satisfaction. Secondary outcomes were depression, anxiety and stress measured on the widely used Depression Anxiety and Stress Scales (DASS, Lovibond and

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Lovibond, 1993). Higher scores on the DASS scales reflect less severe problems in these areas. The inclusion criterion of self-reported primary diagnosis of BD was verified against the Mood Disorder Questionnaire (MDQ, Hirschfeld et al., 2000), operationalised in the standard MDQ screening criteria, as well as the relevant additional item from the MDQ (Has a health professional ever told you that you have manicdepressive illness or bipolar disorder?). At baseline, participants responded in writing to open questions about number of previous episodes, medication and psychosocial treatments. Recognising the importance of involving patients in the development of interventions (Schneider, 2012), participants were invited to provide written qualitative feedback on ORBIT via 23 post-test open questions. Feedback was sought on content (e.g., Did you think 3 weeks was too long/too short?), style (e.g., Which type of media did you find most engaging?), negative effects (e.g., Did the intervention have any negative influences on your life?) and overall impressions (e.g., Would you recommend ORBIT to other people with bipolar disorder?). To minimise participant burden, quantitative measures of engagement, time spent on modules, and therapeutic mechanisms, were not collected.

specialising in psychosocial issues in BD, whose members include consumers, researchers and clinicians (Michalak et al., 2012). Advertisements (video and text) describing the study aims, the intervention, and inclusion/exclusion criteria were published on the CREST.BD website, Twitter and Facebook pages (primarily accessing members of the CREST.BD network, but potentially the broader public). The ORBIT intervention site itself was not open to the public: Potential participants were invited to express interest by emailing researchers at Swinburne University, and were then sent password details to access the site. Participants completed a statement of informed consent (including confirmation that they were under the care of a medical practitioner) online before commencing the programme. Technical support was offered through the site, but the pilot version of ORBIT did not include any clinical support – participants consented to contacting their clinician or local emergency service in the event of a change in their symptoms, or increased distress. Treatment as usual continued throughout participation in the trial, but not assessed.

2.4. ORBIT

Hypothesis testing was conducted on Brief QoL.BD scores using paired sample t-test (Hsu and Lachenbruch, 2007) using both completer and intent-to-treat analyses (last observation carried forward technique, Unnebrink and Windeler, 2001). Effect size was measured using Cohen's d for paired samples (dz) (Cohen, 1988), and partial η2. Formal content analysis of participants' written responses to open questions is beyond the scope of this brief report: Trends and comments are presented to contextualize quantitative findings data and highlight possible refinements of the intervention.

The intervention was developed through collaboration between clinicians, consumers and researchers, and employs strategies and exercises from ACT and MBCT to target emotion regulation (via avoiding attachment to positive and negative self-evaluations), relationship to self (experiencing self as observer, commitment to valued goals despite symptoms) and sleep quality (via mindful acceptance of internal experiences). Beta testing conducted with an availability sample in Canada and Australia (N¼15) suggested that the intervention was coherent, engaging and unlikely to have negative effects. Refinements identified through beta testing included decreasing the amount of text, shortening descriptive videos, and adding downloadable information sheets. ORBIT's content is structured into four modules which were completed over 3 weeks in the pilot study: Introduction (aims of the intervention, clinical cautions), Self-acceptance (developing selfacceptance and self-compassion in the context of ongoing symptoms), Mindfulness (self as awareness, mindfulness as a tool for emotion regulation and sleep improvement via disengaging from distressing thoughts, feelings, bodily sensations), and Values and Goals (identifying personal values as a guide to action, setting valued goals). ORBIT's pedagogy is well suited to online delivery, being primarily experiential, and using multi-media tools to introduce mindfulness skills. Video and audio segments were recorded by a senior clinician (GM) and augmented by pre-existing mindfulness materials (see Acknowledgements). The importance of applying new skills in real-world situations is emphasised throughout, and facilitated through downloadable goal-setting and monitoring handouts (based on cognitive behavioural principles for generalising and exploring new behaviours). While explicitly QoL focussed, ORBIT supports management of symptoms, e.g., mindfulness is introduced as a strategy to improve QoL generally and also a prodrome identification strategy. In the form tested in the pilot study, ORBIT was entirely self-guided, participants completed modules sequentially at their own pace, and could return to previous modules across the 3 weeks of the programme. 2.5. Procedure The online intervention was ethically approved, hosted and managed through Swinburne University, Australia. To demonstrate international scalability, participants were people with BD residing in Canada. Recruitment was conducted through CREST.BD, an international, Canada-based research and knowledge exchange network

2.6. Data analysis

3. Results 3.1. Descriptive statistics At baseline, all 26 participants reported that a health care professional had given them a diagnosis of BD. On the MDQ, all participants met the criterion of at least seven symptoms (M¼11.58, SD¼1.68) several of which occurred at the same time. Two participants (7.7%) described these symptoms as causing a minor problem, and 24 (92.3%) described them as moderate or serious problems. The median number of reported episodes of mania, hypomania or depression was 16, ranging from 6 (3 manic and 3 hypomanic) to 248 (40 manic, 8 hypomanic, and 200 depressive). When asked about past drug treatments, all participants reported having used numerous psychotropic medications (‘…had so many’, ‘…others I can't remember’), including lithium in 11 cases (42.3%). Twenty-five participants (96.2%) reported receiving talk therapy at some time. Polypharmacy was also the norm for current drug regimens, with lithium most commonly reported (n¼9, 34.6%); three participants (11.5%) stated that they were not currently taking medication. None of the baseline variables were significantly associated with treatment-related change in QoL (all p values4.12). 3.2. Hypothesis testing The 16 completers did not differ from the 10 non-completers in gender, age, employment, marital status, number of episodes, MDQ score, or baseline scores on the Brief QoL.BD or DASS (all p values 4.20). Among 16 completers, QoL was improved at immediate post-test (M¼42.63, SD¼8.68) compared with pre-test (M¼39.19, SD¼9.22), t(15)¼2.88, 95% CI:.89–5.98, p¼ .011 (Fig. 1). Improvement was of moderate-large magnitude (Cohen's dz ¼.72, partial η2 ¼ .36), and exceeded the ‘one SEM’ criterion for minimally important change (de Vet et al., 2006). Eleven of 16 completers improved (68.8%). Statistically

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Fig. 1. Pre- and post-intervention mean Brief QoL.BD score. Left panel, n ¼16 completers; Right panel, N ¼ 26 intention to treat (LOCF).

reliable change analyses (scale reliability measured as Cronbach's alpha), found two participants with reliable improvement (12.5%), and none with reliable deterioration. Intent-to-treat analyses (N ¼26) also indicated statistically significant improvement in QoL: t(25) ¼2.65, 95% CI:.47–3.76, p ¼.014, Cohen's dz ¼ .52; partial η2 ¼.22 (Fig. 1). Analyses of DASS scores amongst completers found a nonsignificant trend toward improvement from baseline (M¼27.00, SD¼8.03) to post-test (M¼29.60, SD¼7.89) on the anxiety (t(14)¼  2.09, p¼ .06) but not depression (M¼27.27, SD¼ 11.40, M¼30.00, SD¼8.89; t(14)¼  1.46, p¼.17) or stress scales (M¼25.47, SD¼8.19, M¼24.47, SD¼ 7.77; t(14)¼1.00, p¼.58). This pattern of findings was replicated in intent-to-treat analyses, viz., a nonsignificant trend for improvement on anxiety (M¼27.04, SD¼7.28, M¼28.54, SD¼7.31; t(25)¼  1.99, p¼ .06) but not depression (M¼26.42, SD¼ 10.37, M¼ 28.00, SD¼ 9.15; t(25)¼  1.44, p¼.16) or stress (M¼24.00, SD¼ 7.91, M¼23.42, SD¼7.58; t(25)¼.58, p¼.57). 3.3. Responses to open questions Participants were generally positive about the programme's content, structure, relevance, and effectiveness. Representative comments include, ‘I have noted that when ‘present’ I have been able to begin applying my values to my decision making’; ‘I found the guided meditations quite helpful’; ‘As I am often online anyway, this venue was both convenient and relevant’; ‘I was able to stop, ‘defuse’ and handle myself better when I felt overwhelmed’; ‘more focused, more present, living in the now, recalled many of the symbols and find them quite useful (e.g., the pendulum)’. Twelve of 16 completers (66.7%) responded that they would recommend the programme to other people with BD: ‘absolutely! I think the material is quite beneficial and good. I was already sharing some of the material and ideas with friends with similar issues.’; ‘Yes. I felt that the material was helpful especially the audio and visual portions. I think it's a good way to really think about and get in touch with your feelings, emotions and it's thought provoking’. One participant would only recommend the programme for people ‘with some self-awareness’, and one noted that ‘only minor cases’ might benefit. When asked about the format of the intervention, 8 people (50.0%) specifically mentioned their preferences for video media, and 2 (12.5%) noted videos generated bandwidth problems. Two participants (12.5%), in contrast, reported that they preferred text over video and audio media. When asked about the duration of the 3-week intervention, eight participants (50%) commented that it was insufficient, e.g., ‘when I was supposed to be applying things, I

was still trying to learn things and complete homework’, ‘I needed to work through the info slowly and take time to think about what I learned and how it relates to my life’. In response to enquiry about negative effects of the intervention, 15 participants reported that no aspect of the programme had any negative effects, but one reported that the 30 min ‘body scan’ meditation generated distress: ‘Although mindfulness was helpful in identifying the distress, it was not enough to help me cope with the emotional triggers that were released’.

4. Discussion People in the advanced stages of BD are often functionally impaired and symptomatic despite treatment. They are frequently high utilizers of services, and often receive complex treatments with increased risks. It has been argued that it is necessary to adopt models of care oriented to maximising QoL for late stage individuals, as well as to modify therapeutic goals towards those used in refractory and chronic medical disorders (Berk et al., 2012). Mindfulness-based approaches appear well suited to this need because of their emphasis on maximising QoL despite emotional challenges (Reinares et al., 2014). The present study found that a novel mindfulness intervention can be delivered effectively online with significant QoL benefits in a sample with late stage BD. Moderate to large effect-size increments in QoL were observed in both completer and intent-to-treat analyses. Supplementary analyses were underpowered, but consistent with existing research (Perich et al., 2014), suggested potential benefits for anxiety symptoms. Participant responses to open questions contextualised the quantitative findings, and identified critical refinements for ORBIT and related online interventions. Existing research into mindfulness for BD has explored face-toface delivery, predominantly of MBCT (e.g., Miklowitz et al., 2009; Williams et al., 2008a). Studies have generally shown benefits for the symptoms of BD and for associated psychological and cognitive variables, particularly anxiety and emotion regulation (see Perich et al., 2014). Relapse prevention has been tested in two randomised controlled trials (RCTs) to date: Perich et al. found no benefits for bipolar relapse (Perich et al., 2013b), Meadows et al. found decreased depressive relapse in a bipolar subset of people with recurrent depression (Meadows et al., 2014). The present findings encourage expansion of mindfulness research in BD to consider low-intensity modalities (Cavanagh et al., 2014), QoL as a key outcome and tailoring mindfulness strategies for the disorder stage (Scott et al., 2013).

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Attrition here was larger than the mean 23% found across self-help online programs for a range of conditions (Donkin et al., 2011), and the 26.5% found in a study of online psychoeducation for BD (Nicholas et al., 2010). Growing research into engagement and retention in online treatments (e.g., Leitan et al., 2014) suggests a number of improvements for the next iteration of ORBIT. The pilot version of ORBIT was built with prototype materials only, and lacked features of persuasive system design known to impact engagement (Kelders et al., 2012). Most importantly, people with BD would prefer to have human support for online interventions (Todd et al., 2013), and participants here suggested the inclusion of, ‘a learning community’, ‘connecting with other people participating’, ‘a point of contact to ask questions about the content’, ‘a message board of encouragement’, etc. The next iteration of the programme will therefore include email interaction with trained online coaches and moderated participant discussion boards, with benefits for engagement, support, monitoring and retention (Leitan et al., 2014). A brief intervention was adopted here to promote engagement, but a number of participants reported 3 weeks was insufficient: Modules will remain available throughout 12 months' follow-up in ORBIT's next version. There is growing recognition that psychotherapies can have negative effects (Rozental et al., In press). In the present context, there are anecdotal concerns that mindfulness meditation may be destabilising in BD, and there is a case report of mania being induced by an extended meditation retreat (Yorston, 2001). However, the largest controlled study to date found no link between mindfulness meditation and symptoms (Perich et al., 2013a), and qualitative reports suggest that people with BD choose not to meditate in highly aroused or depressed states (Chadwick et al., 2011). Here, 15 of 16 completers (93.8%) reported no negative effects of the intervention, but one reported significant distress from the longest meditation exercise (body scan). This participant reported a trauma history and a lack of social and counselling support, and therefore may exemplify a clinicallyimportant subset of patients. In future versions of ORBIT, the body scan exercise will be presented with a caution about its possible impact, and participants will receive the additional support and monitoring discussed above. The major limitation of this pilot study was the absence of a control condition, and a range of uncontrolled factors (benefits of simply participating, naturalistic variation in mood, etc.) may confound results. It is useful, then, to compare the QoL outcomes found here with a recent RCT comparing treatment as usual (TAU) with TAU plus recovery-focussed cognitive behaviour therapy for BD (Jones et al., 2015). Jones et al. found that TAU was associated with minimal change on the Brief QoL.BD (a secondary outcome, M¼ 36.73 and M¼ 38.14 at baseline and 6-month follow-up respectively), suggesting that the therapeutic effects found here are not entirely attributable to TAU. Second, improvements from the intervention of Jones et al. were of comparable magnitude to the effects found here (baseline M¼35.91, 6-month follow-up M¼42.30, d¼.47, p¼ .054), even though the therapy tested by Jones et al. was significantly more intensive (up to 18 h of face-to-face sessions with a clinical psychologist). A number of additional limitations should be noted. In the absence of a control group, observed QoL benefits cannot be attributed to the intervention (although qualitative reports suggested that specific ORBIT content was experienced as beneficial). A structured diagnostic interview was not used and the sample size was small. Estimates of ORBIT's effectiveness must also be qualified by the relatively large attrition rate – presumably, for example, non-completers would not endorse ORBIT as strongly as did completers. The small sample precluded quantitative analysis of predictors of benefits/risks of mindfulness in this modality, a topic requiring urgent attention. The sample was also self-selected on the basis of interest in a new mindfulnessbased intervention for BD and engaged altruistically with trialling a new intervention: Findings may not generalise to the broader BD population.

4.1. Conclusions Pilot testing provides preliminary evidence that ORBIT is a feasible, effective intervention for QoL in late stage BD. ORBIT now warrants full development and definitive testing as a novel, economical adjunct to symptom-management interventions which, alone, are far from satisfactory in this population. All authors have materially participated in the research and/or article preparation (roles described below). All authors have approved the final article.

Role of funding source MB is supported by a NHMRC Senior Principal Research Fellowship 1059660. LB is supported by an Alfred Deakin Postdoctoral Research Fellowship.

Conflicts of interest All authors declare no conflicts of interest.

Acknowledgements The authors would like to thank CREST.BD for supporting the project and participating in beta-testing of the intervention, study participants for their feedback on the pilot intervention, and the clinicians and academics who generously shared existing mindfulness materials for inclusion in ORBIT: Steven Hayes, Kristin Neff, Russ Harris, Joseph Ciarrochi, Jason Luoma, Joe Oliver, Naomi Goodlet, Neli Martin, Debra Kissen, Julian McNally and the RMIT counselling service.

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