Mindfulness-based Cognitive Therapy

Mindfulness-Based Cognitive Therapy (MBCT) is a method of therapy which blends features of two disciplines:

• Cognitive therapy aims to identify and alter cognitive distortions (warped or inaccurate thoughts);
• Mindfulness is a meditative practice from Buddhism, which aims to help people identify their thoughts, moment by moment, but without passing judgement on the thoughts.

In MBCT, the patient is invited to recognize and accept feelings as they come and go instead of trying to push them away. Traditional cognitive therapy, or cognitive behavioral therapy (CBT), focuses on changing negative content of thoughts while MBCT emphasizes the process of paying attention to thoughts and feelings moment by moment and without judgment. Changing the patient's relationship to the suffering caused by negative thoughts is the key because there is no possible way to alleviate all suffering. No therapy or meditation will prevent unpleasant things from happening in our daily lives but the two practices combined may provide more objectivity from which to view these unpleasant things.

MBCT's main technique is based on the Mindfulness-Based Stress Reduction (MBSR) eight week program, developed by Jon Kabat-Zinn in 1979 at the University of Massachusetts Medical Center. Research shows that MBSR is enormously empowering for patients with chronic pain, hypertension, heart disease, cancer, and gastrointestinal disorders, as well as for psychological problems such as anxiety and panic. People often misunderstand the goal of therapy and especially mindfulness. Relaxation and happiness are not the aim, but rather a "freedom from the tendency to get drawn into automatic reactions to thoughts, feelings, and events" .^[1] Patients change the relationship to chronic pain so the pain becomes more manageable.

Mindfulness-Based Cognitive Therapy grew largely from Jon Kabat-Zinn's work. Zindel V. Segal, J. Mark G. Williams and John D. Teasdale helped adapt the MBSR program so it could be used with people who had suffered repeated bouts of depression in their lives. Currently, MBCT programs usually consist of eight-weekly two hour classes with weekly assignments to be done outside of session. The aim of this program is to enhance awareness so we are able to respond to things instead of react to them. "We can respond to situations with choice rather than reacting automatically. We do that by practicing to become more aware of where our attention is, and deliberately changing the focus of attention, over and over again".^[2] The structure of MBCT requires strong commitment and work on the clients' part but the rewards can be lasting. Patients participating in the program meet as a group on a weekly basis. The Mindful Way Through Depression is used as the patient manual for the program and contains guided Mindfulness practices on CD that are assigned as homework.^[3]

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Effectiveness of MBCT

Research is now showing the effectiveness of mindfulness in the prevention of relapse. The UK National Institute for Health and Clinical Excellence (NICE) has recently endorsed MBCT as an effective treatment for prevention of relapse. Research has shown that people who have been clinically depressed three or more times (sometimes for twenty years or more) find that taking the program and learning these skills helps to reduce considerably their chances that depression will return. In a study conducted with 145 participants, all the patients had previously recovered from depression and then relapsed. These sufferers were split randomly into groups providing different methods of treatment. Within a year, patients who were undergoing MBCT "reduced relapse from 66% (control group) to 37% (treatment group)".^[4] "Whereas most people might be able to ignore sad mood, in previously depressed persons a slight lowering of mood might bring about a potentially devastating change in thought patterns".^[5] The core skill of MBCT is to teach the ideas of recognizing these thought patterns in order to break away from the false constructs of our mind. Relapse is avoided because the onset of depression is recognized before it has fully developed. The vicious cycle is stopped before it even gets started.

Benefits of MBCT and mindfulness practice

Mindfulness meditation is a useful tool in dealing with many different scenarios. Practicing mindfulness aids patients, laypersons, and therapists. This approach to meditation focuses our attention back to the present, to what is happening right now in this exact moment. When one is mindful, the attention is focused on the present so judgment cannot be placed. Often, our pain and mental discomfort are caused by the judgment placed on the present moment and not by what is actually happening. This judgment and negative thinking is what can possibly lead to depression. MBCT prioritizes learning how to pay attention or concentrate with purpose, in each moment and most importantly, without judgment.^[6]

Segal and his partners found that "thoughts and feelings could interact with each other in a damaging, vicious spiral".^[1] Through the practice of mindfulness, we recognize that holding onto some of these feelings is ineffective and mentally destructive. Viewing things mindfully requires not turning away from any feeling but instead being open to the experience while trying not to engage defense mechanisms. All thoughts are welcomed into the mind equally so that one does not judge the thought or the self for thinking the thought. Gaining perspective on one's own thoughts allows us to escape the mental grooves and ruminative thinking that plagues us. Through mindfulness practice the spiral of negative thought is stopped before one finds herself at the bottom looking up.

Not only is this practice helpful to laypersons but to the actual therapist doing this type of MBCT. As a therapist, mindfulness can be implemented into therapy sessions, and used as a means of self-care in the therapist's personal life. "Meditating therapists often report feeling more 'present', relaxed, and receptive with their patients if they meditate earlier in the day".^[7] Mindfulness incorporates not judging thought. By having that non-judgment, the therapist allows the patient to fully express true feelings by having that openness. "As the therapist learns to disentangle from her own conditioned patterns of thoughts that arise in the therapy relationship, the patient may discover the same emotional freedom".^[6] The concentration development from mindfulness also helps the therapist be able to stay fully engaged with the patient. The mind naturally wanders to other things but mindfulness is the answer to being unfocused. There is a degree of perspective that also comes with mindfulness meditation. This new perspective allows a therapist to see other solutions or options to a patient's problem he or she may not have been originally aware of. "Having this [perspective] enables the therapist to have some flexibility in finding a formulation that accords with the patient's understanding".^[6] As therapists help their patients come to these solutions and become more fully functioning, it may be easy to think they are powerful and all knowing. Maintaining perspective prevents therapists from 'buying their own press'.

As means of self-care, P. Fulton and his fellow authors would say "offering love and care to ourselves replenishes the physical and emotional reservoirs that are necessary to care for others" (p. 87). When looking at burn-out rates in the social service fields, one can see that self-care is absolutely necessary whether one thinks they need it or not. Meditating saturates these reservoirs so that compassionate, sincere work can continue. Also by dealing with personal suffering through this practice, therapists develop greater empathy and become more openhearted to the needs of their clients.

Depression as the inspiration of MBCT

Depression is a more serious problem than is often supposed. The World Health Organization (WHO) conducted a study and came up with the following projection for the year 2020: "of all diseases, depression will impose the second largest burden of ill health worldwide".^[1] Research shows that at any given time, ten percent of the United States has experienced this type of clinical depression in the last year alone.^[1] Women are affected at a significantly higher rate (20-25%) than men (7-12%).^[1] The people who are affected with this common mental disorder are also the least likely to get help or treatment.

Depression is a severe and prolonged state of mind in which normal sadness grows into a painful state of hopelessness, listlessness, lack of motivation, and fatigue. Depression can vary from mild to severe. When depression is mild, we may find ourselves brooding on negative aspects of ourselves or others. We may feel resentful, irritable or angry much of the time, feeling sorry for ourselves, and needing reassurance from someone. Various physical ailments can also occur that have no relation to physical illness.

Depression is classified as clinical when the episode inhibits a person's ability to accomplish routine daily tasks for at least two weeks. If suddenly 'normal' activities become difficult to do or the interest to do them is lost completely for a sustained amount of time, clinical depression could be a possibility. A change in basic bodily functions may also be experienced. The usual daily rhythms seem to go 'out of kilter'. One can't sleep, or one sleeps too much. One can't eat, or one eats too much. Others may notice that the sufferer may become agitated or slowed down. One may find that required energy for activities that used to be enjoyed is now gone. He or she may even feel that life is not worth living, and begin to develop thoughts that he or she would be better off dead.

Currently the most commonly used treatment for major depression is antidepressant medication. These medications are relatively cheap, and easy for family practitioners (who treat the majority of depressed people) to prescribe. However, once the episode has passed, and the client has stopped taking the antidepressants, depression tends to return, and at least 50% of those experiencing their first episode of depression find that depression comes back, despite appearing to have made a full recovery. After a second or third episode, the risk of recurrence rises to between 80% and 90%. Also, those who first became depressed before 20 years of age are particularly likely to suffer a higher risk of relapse and recurrence.

The main method for preventing this recurrence is the continuation of the medication, but many people do not want to stay on medication for indefinite periods, and when the medication stops, the risk of becoming depressed again returns. People are turning to new ways of helping them stay well after depression. To see what it is most helpful to do, we need to understand why it is that we may remain at high risk, even when we've recovered. Mindfulness-Based Cognitive Therapy can be used as a complementary method for treating chronic recurrent depression.

Why do we remain vulnerable to depression?

New research shows that during any episode of depression, negative mood occurs alongside negative thinking (such as 'I am a failure', 'I am inadequate, 'I am worthless') and bodily sensations of sluggishness and fatigue. When the episode is past, and the mood has returned to normal, the negative thinking and fatigue tend to disappear as well. However, during the episode an association has formed between the mood that was present at that time, and the negative thinking patterns.

This means that when negative mood happens again (for any reason) a relatively small amount of such mood can trigger or reactivate the old thinking pattern. Once again, people start to think they have failed, or are inadequate - even if it is not relevant to the current situation. People who believed they had recovered may find themselves feeling 'back to square one'. They end up inside a rumination loop that constantly asks 'what has gone wrong?', 'why is this happening to me?', 'where will it all end?' Such rumination feels as if it ought to help find an answer, but it only succeeds in prolonging and deepening the mood spiral. When this happens, the old habits of negative thinking will start up again, negative thinking gets into the same rut, and a full-blown episode of depression may be the result.

The discovery that, even when people feel well, the link between negative moods and negative thoughts remains ready to be re-activated, is of enormous importance. It means that sustaining recovery from such depression depends on learning how to keep mild states of depression from spiralling out of control.

Future of MBCT

Further research is being conducted to identify all the different uses of MBCT. Significant decreases in anxiety, depression, with a resulting increased sense well being, have been found so far. Research being conducted will evaluate MBCT as a useful technique with patients who are diagnosed with cancer or haematological illness. Mindfulness practice is being done over various cultures and demographics. Ellen Langer has been focusing on the future of mindfulness.^[8]

See also

• Dialectical behavior therapy
• Acceptance and Commitment Therapy
• Stoicism

References