Mindfulness-Based Cognitive Therapy

A relapse prevention approach to depression

Over a century after William James penned this quote, the three developers of Mindfulness-based Cognitive Therapy (MBCT), Zindel Segal, John Teasdale and Mark Williams, were addressing a similar issue in their attempts to develop a new psychosocial intervention to reduce depressive relapse/recurrence. Their elaboration of a cognitive vulnerability model of depressive relapse (Teasdale, Segal & Williams, 1995) directed their search for ways to educate at-risk individuals to voluntarily bring back a ‘wandering attention’ from ruminative, depressive thought patterns implicated in depressive relapse. The solution led them to integrate mindfulness training as developed by Jon Kabat-Zinn and his colleagues (Kabat-Zinn, 1990) with traditional cognitive therapy (Beck, Rush, Shaw & Emory, 1979) techniques.

In this presentation, I will

• review why MBCT was developed and the theoretical rationale underlying its development;
• define mindfulness meditation;
• briefly describe the MBCT program and the evidence supporting its use in preventing depressive relapse and reducing depressive symptoms; and,
• finish by briefly discussing how clients can access MBCT and recommendations for clinicians interested in offering MBCT to their clients.

Why MBCT was developed

Despite the success of both pharmacological and psychosocial interventions in treating active episodes of Major Depressive Disorder, it remains a lifelong illness with a high risk for relapse and recurrence (Berti Ceroni, Neri, & Pezzoli, 1984; Keller, Lavori, Lewis, & Klerman, 1983; for review see Judd, 1997). For example, those who recover from an initial episode of depression have a 50% chance of a second episode and for those with a history of two or more episodes, then the relapse/recurrence risk increases to 70-80%. What is more, relatively little attention has been paid to the development of interventions specific for reducing this risk post-recovery. Such data point to effective prevention of relapse and recurrence as a central challenge in the overall management of depression.

Maintenance pharmacotherapy is the most validated and widely used approach to prevent depressive relapse / recurrence (e.g. Kupfer et al., 1992). However, the protection from this approach lasts only as long as patients continue to take their antidepressant medication. In practice, there are those who demonstrate low adherence rates to pharmacotherapy, and those who cannot tolerate antidepressant medication due to side effects (Cooper et al., 2007). By contrast, it appears that cognitive therapy as an acute treatment for depression also has long-term post-treatment effects in preventing future relapse (Blackburn, Eunson, & Bishop, 1986; Evans et al., 1992; Hollon et al., 2005; Shea et al., 1992; Simons, Murphy, Levine, & Wetzel, 1986). In the early 1990s, the data available at the time led to a growing interest in a maintenance version of cognitive therapy as a potential alternative to first-line pharmacological approaches in preventing depressive relapse. In particular, Zindel Segal was invited by the MacArthur Foundation to develop a maintenance version of cognitive therapy with the goal of reducing depressive relapse. Segal recruited John Teasdale and Mark Williams to collaborate on this project. Together, they set out to answer two key questions to guide their development of a stand alone relapse prevention treatment:

1. What are the psychological mechanisms underlying cognitive vulnerability to depressive relapse? and
2. How might cognitive therapy reduce depressive relapse?

A cognitive vulnerability model of depressive relapse

Teasdale’s (1988) differential activation hypothesis is a psychological model to explain the increased risk of relapse/recurrence with increased number of previous depressive episodes. Briefly, the differential activation hypothesis proposes that repeated associations between depressed mood and patterns of negative thinking during depressive episodes lead to a higher likelihood of reactivation of negative thinking patterns in subsequent dysphoric mood states. Specifically, it is the reinstatement of negative thinking patterns activated in dysphoric mood which can serve to exacerbate a mildly dsyphoric mood into a full blown depressive episode. Furthermore, the differential activation hypothesis postulates that this association is established during early episodes of depression and strengthened with each subsequent episode (Teasdale & Barnard, 1993; Segal, Williams, Teasdale, & Gemar, 1996). This model suggests that relapse risk might be reduced first by increasing one's awareness of negative thinking at times of potential relapse and, second, by responding in ways that allow one to uncouple from the reactivated negative thought streams.

How cognitive therapy reduces depressive relapse/recurrence

A growing body of literature demonstrates that treating acute depression with cognitive therapy significantly reduces subsequent relapse risk as compared to discontinuation pharmacotherapy (Blackburn et al.,1986; Evans et al., 1992; Hollon et al., 2005; Shea et al., 1992; Simons et al., 1986). With respect to designing a novel prophylactic intervention for depression, it was important to understand how cognitive therapy might reduce subsequent relapse risk. Ingram & Hollon (1986) proposed that cognitive therapy has its prophylactic effects by facilitating the individual’s ability to ‘decenter’ or ‘distance’ from their depressive thoughts thereby allowing the individual to see negative thoughts and feelings simply as passing events in the mind rather than reflections of reality.

Taken together, the answers to the two questions proposed above suggested developing a treatment that would first develop skills in becoming aware of negative thoughts and feelings that are reactivated by dysphoric mood, and second, to develop a different relationship to those thoughts and feelings in order to interrupt negative thought patterns. Moreover, the emphasis on developing a different relationship to one’s thoughts and feelings versus specifically changing thought content opened up the possibility to consider treatment approaches other than cognitive therapy. As a result, Teasdale et al. (1995) proposed an integrated treatment that combined mindfulness meditation training as taught in MBSR (Kabat-Zinn, 1990) with elements of cognitive therapy in order to help prevent the consolidation of negative thinking patterns that contribute to depressive relapse.

What is mindfulness meditation?

Meditation refers to a variety of attentional-control practices that intentionally focus attention and disengage the practitioner from unconscious absorption in thoughts and feelings. Buddhist psychology distinguishes between two distinct types of meditation: mindfulness (vipassana) and concentrative (samatha). Mindfulness, or insight, meditation refers to bringing attention to a wide range of objects (e.g. breath, body, emotions, thoughts) one at a time as they appear in awareness. It contrasts with concentrative meditation which refers to gently returning attention to a single object of meditation, be it a word (mantra), a part of the body (e.g. the tip of the nose) or an external object (e.g. candle flame).

Mindfulness refers both to a theoretical construct and to the practice of cultivating mindfulness (Germer, 2005). Mindfulness has been described as a non-elaborative, non-judgmental, present-centered awareness in which each thought, feeling or sensation that arises in the attentional field is acknowledged and accepted as it is (Kabat-Zinn, 1990; Segal, Williams, & Teasdale, 2002; Shapiro & Schwartz, 2000). More recently, Bishop et al. (2004) have operationally defined a two-component model of mindfulness: (1) the self-regulation of attention of immediate experience, thereby allowing for increased recognition of mental events in the present moment; and, (2) adopting an orientation of curiosity, openness and acceptance toward one’s experiences in each moment.

Mindfulness is typically cultivated through various meditation techniques originating from Buddhist spiritual practices (Hanh, 1976). Interestingly, the past 20 years has witnessed a surge in the clinical use of mindfulness. Much of this interest was sparked by the introduction of Mindfulness-Based Stress Reduction (MBSR) in 1979, a manualized treatment program originally developed for the management of chronic pain. More recently, mindfulness treatment programs have been integrated with cognitive therapy in two different but not mutually exclusive ways. Mindfulness-informed psychotherapy, such as Acceptance and Commitment Therapy (Hayes, Strosahl, & Wilson, 1999), uses a theoretical framework informed by insights derived from both Buddhist and Western psychology. Mindfulness-based psychotherapy explicitly educates patients in mindfulness practice although these treatments can vary in the degree to which they incorporate mindfulness meditation training practices. Dialectical Behaviour Therapy (Linehan, 1993), a treatment for borderline personality disorder, incorporates minimal formal meditation practice, the degree of which is limited, in part, by the perceived capacity or willingness of this patient group to be aware of and attend to present experience. On the other hand, MBCT (Segal et al., 2002) is an intensive mindfulness training course which is largely based on formal and informal mindfulness practices along with some cognitive therapy techniques.

Mindfulness-based Cognitive Therapy (MBCT)

MBCT (Segal et al., 2002) consists of eight weekly two-hour group sessions plus a weekend day of meditation, typically after session six, with up to 15 recovered depressed patients. MBCT combines MBSR meditation practices such as the body scan, mindful stretching, mindfulness of breath / body / sounds / thoughts with cognitive therapy techniques such as psychoeducation about depression symptoms and automatic thoughts; exercises designed to demonstrate how the nature of one’s thoughts change with one’s mood; questioning of automatic thoughts; and, creating a relapse prevention plan. In addition, Segal et al. (2002) introduced a new meditation called the three-minute breathing space to facilitate present moment awareness in everyday upsetting situations. Finally, participants in MBCT are assigned approximately 45-60 minutes of formal and informal daily meditation practice to facilitate mindful awareness in everyday life.

The eight MBCT sessions are designed to progressively teach skills to help the individual stave off depressive relapse. The first four MBCT sessions help clients develop a foundation of mindfulness skills, in particular, the development of a non-judgmental awareness of their moment-by-moment experience. This is accomplished, in large part, via formal meditation practices (body scan; mindfulness of breath, body, sounds, thoughts) which help participants deconstruct their experience into the component elements of physical sensations and the accompanying thoughts and emotions. This awareness is complemented by a cognitive therapy exercise which is designed to teach the cognitive model. Specific awareness of depression-related experience is facilitated through psychoeducation regarding the nature of depressive symptoms and negative automatic thoughts that can occur in depression in order to facilitate one’s ability to detect experiences that might indicate potential relapse.

The second four sessions of the program are directed towards developing more flexible, deliberate responses at times of potential relapse. While participants have been implicitly practicing acceptance in their meditations in first half of the MBCT program by being encouraged to bring an open and non-judgmental awareness to their experience, acceptance is explicitly introduced in session five as a skilful first step in preventing relapse. In session six, the notion that ‘thoughts are not facts’ is explicitly introduced, in part, via a cognitive therapy exercise which demonstrates that one’s interpretations can depend on one’s mood and may not necessarily actually fit the facts of a particular situation. In session seven, participants develop specific action plans that can be utilized at the time of potential relapse. The final session is focused on preparing participants to maintain the momentum and discipline developed during the program.

Empirical Support

A recent systematic review of the few existing MBCT randomized controlled trials concluded that MBCT has an additive benefit to usual care in preventing depressive relapse for individuals with three or more previous depressive episodes (Coelho et al., 2007). More recently, MBCT was shown to be comparable to maintenance antidepressant medication in preventing depressive relapse for individual with a history of three or more depressive episodes with no difference in costs between these two treatments. Interstingly, MBCT was more effective than maintenance pharmacotherapy in improving quality of life (Kuyken et al., in press). MBCT is now included in the United Kingdom’s National Institute for Clinical Excellence Clinical Practice Guidelines for Depression (NICE Guidelines , 2004) for prevention of recurrent depression.

MBCT has also been shown to be effective in the treatment of depressive symptoms. The rational for the use of MBCT to target depression itself relies on extending the application of the cognitive vulnerability model of depressive relapse to acute depression. Thus, using MBCT to interrupt depressive, ruminative thought patterns suggests it may also be effective in reducing depressive symptoms. In fact, MBCT has been shown to reduce depressive symptoms in both randomized controlled trials (Kingston et al., 2007; Kuyken et al., in press; Williams et al, 2007; Williams, Russell, & Russell, 2008) and uncontrolled studies (Eisendrath et al., 2008; Finucane, & Mercer, 2006; Kenny, & Williams, 2007; Ree, & Craigie, 2007). Finally, there is preliminary support from an open-label pilot study of MBCT’s efficacy in reducing depressive symptoms in patients with treatment resistant depression and a history of three or more depressive episodes.

Where to learn MBCT and/or mindfulness meditation

Access to MBCT programs has been increasing as more mental health providers integrate mindfulness based approaches into mental health programs. However, access remains a potential barrier in many rural and even urban centers. In situations where a formal MBCT group program led by a trained MBCT teacher is not available, several options exist. These include MBCT trained clinicians guiding clients through consumer oriented MBCT books (e.g., The Mindful Way Through Depression; see Resources section) or having clients listen to audio recordings with guided meditation instructions (see Resources section), joining a meditation sitting group, or taking a meditation correspondence cours.

Can I teach my patients mindfulness?

Before teaching mindfulness to others, Segal and his colleagues (2002) have recommended that potential MBCT instructors have recognized training in counseling, psychotherapy, or as a mental health professional; as well as specific training in cognitive therapy and running psychotherapy groups. In addition, they recommend formal MBCT teacher development training, attendance at mindfulness meditation retreats of at least seven to ten days, and a daily meditation practice. These last two recommendations derive from the assumption that an instructor teaches from their own meditation experience in order to embody the attitudes that they invite participants to practice.

The importance of the teacher’s own meditation practice is highlighted by a recent study where pychotherapists in training, who were randomly assigned to practice meditation, had greater symptom reductions in their patients as compared to the pychotherapists who were assigned to a no meditation condition (Grepmair, 2007). Based on these preliminary results, mental health clinicians may consider cultivating their own mindfulness practice in order to optimize clinical outcomes in their patients. Many options exist, including enrolling in an MBCT group themselves, participating in MBCT training retreat (see resources section), or attending a vipassana retreat.

references

• Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford Press.
• Berti Ceroni, G., Neri, C., & Pezzoli, A. (1984). Chronicity in major depression. A naturalistic perspective. Journal of Affective Disorders. 7(2), 123-132.
• Bishop, S.R., Lau, M.A., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J., Segal, Z.V., Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and Practice, 11, 230-241.
• Blackburn, I.M., Eunson, K.M., & Bishop, S. (1986). A two-year naturalistic follow-up of depressed patients treated with cognitive therapy, pharmacotherapy, and a combination of both. Journal of Affective Disorders, 10, 67-75.
• Coelho, H.F., Canter, P.H., & Ernst, E. (2007). Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. Journal of Consulting Clinical Psychology, 75(6), 1000-1005.
• Cooper, C., Bebbington, P., King, M., Brugha, T., Meltzer, H., Bhugra, D., & Jenkins, R. (2007). Why people do not take their psychotropic drugs as prescribed: results of the 2000 National Psychiatric Morbidity Survey. Acta Psychiatrica Scandinavica. 116, 47-53.
• Eisendrath, S.J., Delucchi, K., Bitner, R., Fenimore, P., Smit, M., & McLane, M. (2008). Mindfulness-based cognitive therapy for treatment resistant depression: A pilot study. Psychotherapy and Psychosomatics, 77(5), 319-320.
• Evans, J.D., Hollon, S.D., DeRubeis, R.J., Piasecki, J.M., Grove, W.M., Garvey, M.J., & Tuason, V.B. (1992). Differential relapse following cognitive therapy and pharmacotherapy for depression. Archives of General Psychiatry, 49, 802-808.
• Finucane, A., & Mercer, S.W. (2006). An exploratory mixed methods study of the acceptability and effectiveness of mindfulness-based cognitive therapy for patients with active depression and anxiety in primary care. BMC Psychiatry, 6(1), 14-28.
• Germer, C.K. (2005). Mindfulness: What is it: What does it matter? In Germer, C.K., Siegel, R.D., & Fulton, P.R. (Eds.) Mindfulness and Psychotherapy. New York: Guilford Press.
• Hahn, T.N. (1976). The miracle of mindfulness: A manual for meditation. Boston: Becon Press.
• Hayes, S.C., Strosahl, K. & Wilson, K.G. (1999). Acceptance and Commitment Therapy. New York: Guilford Press.
• Hollon, S., DeRubeis, R.J., Shelton, R.C., Amsterdam, J.D., Salomon, R.M., O’Reardon, J.P. et al. (2005). Prevention of relapse following cognitive therapy vs medications in moderate to severe depression. Archives of General Psychiatry, 62, 417-422.
• Ingram, R. E., & Hollon, S. D. (1986). Cognitive therapy of depression from an information processing perspective. In R. E. Ingram (Ed.), Information Processing Approaches to Clinical Psychology (pp. 259-281). San Diego: Academic Press, Inc.
• James, W. (1890). Principles of Psychology. New York: Holt.
• Judd, L. J. (1997). The clinical course of unipolar major depressive disorders. Archives of General Psychiatry, 54, 989-991.
• Kabat-Zinn, J. (1990). Full Catastrophe Living: Using the Wisdom of your Mind to Face Stress, Pain and Illness. New York: Dell Publishing.
• Keller, M.B., Lavori, P.W., Lewis, C.E., & Klerman, G.L. (1983). Predictors of relapse in major depressive disorder. Journal of the American Medical Association. 250(24), 3299-3304.
• Kenny, M.A., & Williams, J.G.M. (2007). Treatment-resistant depressed patients show a good response to mindfulness-based cognitive therapy. Behaviour Research and Therapy, 45(3), 617-625.
• Kingston, T., Dooley, B., Bates, A., Lawlor, E., & Malong, K. (2007). Mindfulness-based cognitive therapy for residual depressive symptoms. Psychology and Psychotherapy: Theory, Research and Practice, 80(2), 193-203.
• Kupfer, D.J., Frank, E., Perel, J.M., Cornes, C., Mallinger, A.G., Thase, M.E., McEachran, A.B., & Grochocinski, V.J. (1992). Five-year outcome for maintenance therapies in recurrent depression. Archives of General Psychiatry, 49(10), 769-773.
• Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E. White, K., Barrett, B., Byng, R., Evans, A. Mullan, E., & Teasdale, J.D. (In Press). Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of Consulting and Clinical Psychology.
• Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.
• National Institute for Clinical Excellence. (2004). Depression: Management of depression in primary and secondary care. Clinical Guideline 23.
• Ree, M.J., & Craigie, M.A. (2007). Outcomes following mindfulness-based cognitive therpay in a heterogeneous sample of adult outpatients. Behavioural and Cognitive Psychotherapy, 24(2), 70-86.
• Segal, Z.V., Williams, J. M. G. & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach for preventing relapse. New York: Guilford Press.
• Segal, Z.W., Williams, J.M.G., Teasdale, J..D., & Gemer, M. (1996). A cognitive science perspective on kindling and episode sensitization in recurrent affective disorder. Psychological Medicine, 26(2), 371-380.
• Shapiro, S.L., & Schwartz, G.E. (2000). Intentional systemic mindfulness: An integrative model for self-regulation and health. Advances in Mind-Body Medicine, 15, 128-134.
• Shea, M.T., Elkin, I., Imber, S.D., Sotsky, F.M., Watkins, J.T., Collins, J.F., Pilkonis, P.A., Beckham, E., Glass, D.R., Dolan, R.T., et al., (1992). Course of depressive symptoms over follow-up: Findings from the NIMH Treatment of Depression Collaborative Research Program. Archives of General Psychiatry, 49, 782-787.
• Simons, A. D., Murphy, G. E., Levine, J. L., & Wetzel, R. D. (1986). Cognitive therapy and pharmacotherapy for depression: Sustained improvement over one year. Archives of General Psychiatry, 43, 43-50.
• Teasdale, J. D. (1988). Cognitive vulnerability to persistent depression. Cognition and Emotion, 2, 247-274.
• Teasdale, J.D. & Barnard, P.J. (1993). Affect, cognition and change: re-modelling depressive thought. Hilldale, New Jersey: Lawrence Erlbaum Associates.
• Teasdale, J. D., Segal, Z. V., & Williams, J. M. G. (1995). How does cognitive therapy prevent relapse and why should attentional control (mindfulness) training help? Behaviour Research and Therapy, 33, 25-39.
• Williams, J.G.M., Alatiq, Y., Crance, C., Barnhofer, T., Fennell, M.J.V., Duggan, D.S., Hepburn, S., & Goodwin, G.M. (2007). Mindfulness-based cognitive therapy (MBCT) in bipolar disorder: preliminary evaluation of immediate effects on between-episode functioning. Journal of Affective Disorders, 107, 275-279.
• Williams, J.G.M., Russell, I., & Russell, D. (2008). Mindfulness-based cognitive therapy: further issues in current evidence and future research. Journal of Consulting and Clinical Psychology, 76(3), 524-529.

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