Mindfulness-Based Cognitive Therapy

(MBCT)(Third Wave CBT)

Heather Laws, Zainab Isah & Bahire Akartürk

Introduction (1)

• MBCT is one of the main third wave CBT

o Practiced for about 20 years now

o Have their root in Buddhist traditions extending back over 2500 years

• Developed by Zindel Segal, Mark Williams and John Teasdale

• Based on Kabat- Zinn’s Mindfulness Based Stress Reduction (MBSR) programme

Introduction (2)• Mindfulness is the awareness that emerges through paying

attention on purpose, in the present moment, and nonjudgmentally to things as they are

• MBCT combines elements of CBT and MBSR

oThe cognitive aspect encourages patients to bring awareness to their thoughts and feelings NOT change them

oThe behavioural aspect includes supporting patients to mindfully complete activities to enhance their wellbeing (e.g. taking a bath, going for a walk, listening to pleasant music)

Which disorders can MBCT be used for?

• Depression

• Anxiety

• Chronic Pain

• Long Term Illness Patients (e.g. Diabetes)

• Insomnia

• Bipolar Disorders

• Anxiety Disorders

• Depressive Disorders

• Chronic Fatigue Syndrome

• Stress

• Unemployment Stress

• Cravings (e.g. Overeating)

• Low-Level Addiction (e.g. Smoking)

• And there are more added to the list every day …

Doing Mode vs. Being Mode

What is vs Ought to be Accept present moment

BEING MODEDOING MODE

MBCT

• MBCT encourages participants to adopt a distinct mode of being

o Adopt a new way of being and relating to thoughts and feelings rather than changing aspects of cognitions

o Break the cycle of rumination about past regrets or future fears and enhance self-compassion

MBCT for Relapse Prevention

Cognition(e.g.

Ruminative Thinking)

Event

Relapse

Resilience

MBCT Sessions (1)

• 8 weekly sessions for 2 hours

• A full day session in week 6

• Formal and informal meditation practices

oGuided meditation such as sitting and walking meditations

oMindful movement based on Hatha yoga

oThree minute breathing spaces

oFocused attention on daily routine activities

MBCT Sessions (2)

• Early sessions in MBCT

o focused on bringing attention to breathing or bodily sensations through guided meditation

• Later sessions

ofocused on expanding mindful awareness to mental events such as thoughts and emotions that may have been avoided previously.

• Homework is essential

oClients are required to spend about 45 minutes daily practicing mindful activities

oProvided with guided meditations to practice at home

MBCT Theoretical Justifications

•  A two-component model of mindfulness:

Self-regulation of attention (awareness):

To bring awareness to current experience - observing and attending to the changing fields of "objects" (thoughts, feelings, sensations), from moment to moment - by regulating the focus of attention".

Orientation to experience (consciousness):

To maintain a particular orientation toward one’s experiences in the present moment, which characterized by curiosity, openness, and acceptance.

Clarity of Awareness (1)• Mindfulness related to a clear awareness of one’s inner

and outer worlds in which involve thoughts, emotions, sensations, actions, or surroundings as they exist at present moment.

• In Langer’s (2002) metaphoric language, the walls, floors, and ceilings of one’s life become glass like, permitting a clearer view of the contents from attic to basement.

• Clarity is also thought to facilitate unhindered access to all of one’s relevant knowledge such as intellectual, emotional, and physical/intuitive) to aid in negotiating life situations.

Clarity of Awareness (2)• Certain phenomena can remain hidden from conscious

awareness since they represent threats to the self-concept or to aspects of self that are ego invested.

• This can be recognized by , several therapeutic interventions incorporating mindfulness training in order to encourage certain attitudes toward experience.

• For example, particularly non -judgmentality or acceptance make easier direct contact with uncomfortable realities or experiences. Thus, it is thought diminishing impulsive or defensive reactions to unsettling experiences and promote the development of insight into self, others, and the human condition (Ryan, 2005).

Flexibility of Awareness and Attention (1)

• Another key feature of mindfulness is its flexibility.

• Research suggested that mindfulness similar to a zoom lens which can move back from particular states of mind to gain a larger perspective on what is taking place (clear awareness), and can also zero in on situational details (focused attention) depends on inclination or circumstance (Cullen, 2006).

• It was found that mindfulness is strongly related to attentional control and other indicators of concentrative capacity. However, mindfulness and concentration are considered unique capacities, and some evidence supports this distinction (Dunn, Hartigan, & Mikulas, 1999).

Flexibility of Awareness and Attention (2)

• The main difference between them is that concentration entails a restriction of attention to a single interoceptive or exteroceptive object which lead to to a withdrawal of sensory and other inputs

• On the contrary, the mindful mode of processing include a voluntary, fluid regulation of states of attention and awareness. (Engler, 1986).

Stability or Continuity of Attention and Awareness (1)

• Some research indicated that all human being have a capacity of mindfulness inherently. (Kabat-Zinn, 2003). However, it varies in strength.

• A rudimentary form, mindful states might be fleeting or infrequent. A fuller form mindful states are more frequent or continuous.

• The research indicated that steadiness of awareness and attention enable to eliminate opportunities for concepts, ideas, and associated emotions to be blindly or automatically tacked onto bare facts (Smith&Novak,2004).

Stability or Continuity of Attention and Awareness (2)

• Moreover, it makes easier the recognition of being caught up in conceptual thoughts or emotions rooted in past experience or anticipated futures, and the return to an awareness of what is currently taking place.

• Then, mindfulness is noticing what is present, including noticing that one is no longer present.

• Continuity of mindfulness helps to ensure that attention can move from narrow focus to broad without distraction or loss of collectedness.

Present-Oriented Consciousness

• Consciousness facilitate to widen the field awareness and enable one to see more clearly how his/her minds function.

• Consciousness is consist of series of moments of awareness of the objects that come in contact with our five senses and our mind.

• There is a metaphor which is like a motion detector connected to a light; when it is triggered, it brighten the object that is in its sense field, such as the visual field.

School

• It was evidenced that Mindfulness is effective treatment for children and young people.

• School-based interventions provided positive outcomes on wellbeing, reduce anxiety and distress as well as improving behaviour, among other areas. (Weare, 2013).

• Kuyken et al, (2013) also indicated that children using mindfulness practices more frequently reported higher wellbeing and lower stress scores.

Criminal Justice

• Mindfulness-based stress-reduction courses were administered in drug units in six Massachusetts Department of Corrections prisons in the USA.

• Evaluation assessments were held before and after each course and highly significant pre- to post-course improvements were detected on self-report measures of hostility, self-esteem, and mood disturbance.

• Improvements for women were greater than those for men, (Samuelson, et al, 2007).

Workplace

Many positive effects of Mindfulness in the workplace has also been evidenced.

These includes:

a decrease in perceived stress,

an increase in better concentration levels

an increase performance in memory tasks and multi-tasking.

Wolever ( 2012) demonstrated that mindfulness in the workplace could be an effective intervention to target ”high stress levels, sleep quality, and autonomic balance.

Evidence (1)

• It has been found that MBCT can reduce the relapse of recurrent depression by, on average, 43% (Williams et al., 2013).

• Initial trials on the effectiveness of MBCT reported significantly lower rates of relapse when participants received MBCT compared to those that received treatment as usual (TAU) (37% vs 66%) (Teasdale et al., 2000)

• Another study found a significant reduction in depressive symptoms with MBCT compared to TAU and further reduction after a one month follow- up (Kingston et al., 2007)

Evidence (2)

• Meta-analysis (Piet & Hougaard, 2011) of MBCT indicated that MBCT was effective when participants had 3 or more previous episodes of depression

• MBCT was as effective as maintenance antidepressant medication

• MBCT was more effective when combined with other treatments than when used alone

Brain Activity during MBCT

• FMRI studies have found an association between mindfulness practices and an increased activation in the prefrontal cortex and a decreased activation in the amygdala (Sipe & Eisendrath, 2012)

• Increased theta power and decreased beta power post MBCT intervention for participants with bipolar disorder (Howells, 2012)

• There is also a video to illustrate this: https://www.youtube.com/watch?v=8bxw4IYW1eE

Case Study – Binge Eating Disorder (BED)‘Sally was a married Caucasian female in her mid-50s with two

grown children living outside the home. She had a master's degree, but had not worked for several years and spent much of her time at home. She reported that she had engaged in binge eating for several years, and had once consulted her physician about it, but had been told that the problem was not serious because she was not anorexic or bulimic. For about 1 year prior to treatment, Sally had been actively dieting, and had been logging her daily food intake as part of an internet support group for dieters. She had lost 30 pounds and wanted to maintain her current weight of 122 pounds. She was 5'4" tall and had a body mass index (BMI) of 21, placing her in the normal weight range. She reported that she was engaging in moderate exercise, was eating three regular meals and fairly regular snacks each day, and was consuming a balanced, low-fat diet, except during binges. She was not involved in any other weight loss or mental health treatment program.’

Case Study - Therapy• Self-referral to MBCT

• No Major Depressive Disorder but feelings of sadness relating to children who had grown up and moved away. Some suicidal ideation when having a binge episode but no concrete plans or attempts.

• Met all criteria for BED, did not meet criteria for Anorexia Nervosa or Bulimia Nervosa.

• MBCT was conducted over 8 weekly sessions and as homework Sally kept a food diary and participated in daily mindfulness exercises.

• The treatment included self-regulation of attention to increase awareness of present- moment experience without judgment or evaluation as well as cultivating a different relationship to unpleasant experiences, es- pecially those related to binge eating.

Case Study - Outcome• In preliminary sessions Sally mentioned that she did not like practicing mindfulness

exercises because of the negative emotions this brought up.

• Initially, Sally felt that a leap of faith was needed as she was unsure about the treatment but as time went on she understood the process and potential benefits.

• Results show that Sally had a substantial improvement in symptoms and an increase of mindfulness behaviours and an acceptance of internal experience. She also became more aware of the feelings that she associated with binge eating.

• Sally put on weight during treatment, but still had a healthy BMI, which could have been going back to a normal weight for her after her previous dieting.

• At follow-up Sally felt that she was happy with her weight and overall body image, an improvement from before.

• However, Sally still engaged in overeating behaviour when she was bored and in response to negative feelings. This is in line with MBCT which does not aim to change emotional affects of behaviours, but instead focuses on the acknowledgement of behaviours without acting on them.

• At her 6 month follow-up, Sally disclosed that she had stopped mindfulness exercises but was planning on starting again as she realised the benefit as her binge eating behaviours had drastically reduced.

Mindfulness Exercise

• https://www.youtube.com/watch?v=ytEFmXjWA0c

• Now, we are going to practice doing a mindfulness exercise ourselves.

The Raisin Meditation• The raisin meditation is a classic Mindfulness technique and is

widely used (Williams, Teasdale, Segal, & Kabat-Zinn, 2007).

• The exercise takes around 5 – 10 minutes to complete and should be done in a completely quiet and isolated environment with no distractions. Please turn your phones on silent!

• If you do not like raisins, the exercise can be completed with any form of food, for example chocolate or grapes.

• Please see the hand-out for the 8 steps of the meditation (holding, seeing, touching, smelling, placing, tasting, swallowing, following). Around 20 – 30 seconds should be spent on each stage.

The Raisin Meditation – Your Thoughts?

• Please now record your reactions on a piece of paper.

• How was your experience of the raisin meditation?

Limitations of MBCT (1)

• It is found that the reduction rate in relapse/recurrence with MBCT is highest if there are no antecedent life events reported as onsets of depression

That is, MBCT is effective in reducing relapse/recurrence related to autonomous and ruminative type of negative thinking patterns that are provoked internally

• BUT ineffective in reducing relapse/recurrence associated with severe life events

Limitations of MBCT (2)

• Segal et al. (2002) indicated that MBCT is particularly designed for people who have been depressed in the past but are relatively well when they start the MBCT program.

• Therefore, MBCT does not target patients who are acutely depressed since poor concentration and higher intensity of negative thinking among those patients would affect their focus and attention required to develop the core skills for MBCT.

Positives of MBCT (1)

Positives of MBCT (2)

MBCT in the NHS (1)

• MBCT is still categorised under the umbrella of CBT and so this can be confusing to some patients, although the therapy is becoming more widely recognised.

• Although the access to MBCT is currently limited in the NHS, there is ongoing work to explore how to make the therapy more widely available.

• It is currently unknown how many MBCT practitioners there are practicing in the UK and how many patients are participating in MBCT therapy but one thing is certain, the numbers for each are rapidly increasing due to empirical evidence.

• As many as 30% of GP’s are estimated to refer their patients presenting with relevant mental health issues to MBCT and patients are also allowed to ask for self-referrals.

MBCT in the NHS (2)

• A recent study (2013) has shown that 75% of GP’s now believe that prescribing medication for mental health disorders is not enough for a positive intervention.

• MBCT is recognised by NICE as being effective, especially in the treatment of recurrent depression.

• More information about the Mental Health Foundation MBCT initiative can be found here: http://bemindful.co.uk/

• There are also many private MBCT courses that you can seek to take part in yourself via this website: http://bemindful.co.uk/learn/find-a-course/

Closing Thoughts

• https://www.youtube.com/watch?v=kk7IBwuhXWM

Group Discussion

• How do you personally feel about this therapy?

• Do you think there would be any generational differences?

• How do you think ‘Third Wave CBT’ compares to ‘Traditional CBT’?

References (1)• Baer, R. A., Fischer, S., & Huss, D. B. (2005). Mindfulness-based

cognitive therapy applied to binge eating: A case study. Cognitive and Behavioral Practice, 12(3), 351-358.

• Crane, R. (2009). Mindfulness-based cognitive therapy: Distinctive features. GB: Routledge Ltd.

• Cullen, M. (2006). Mindfulness: The heart of Buddhist meditation? Inquiring Mind, 22, 4–7, 28–29.

• Dunn,B.R.,Hartigan,J.A.,&Mikulas, W.L.(1999).Concentration and mindfulness meditations: Unique forms of consciousness? Applied Psychology and Biofeedback, 24, 147–165.

• Engler,J.(1986).Therapeutic aims in psychotherapy and meditation. In K. Wilber, J. Engler, & D.P. Brown (Eds.), Transformations of consciousness: Conventional and contemplative perspectives on development (pp. 17–51). Boston: MA: Shambhala.

References (2)• Hick, S. F., & Chan, L. (2010) Mindfulness-based cognitive therapy for

depression: Effectiveness and limitations. Social Work in Mental Health, 8(3), 225-237. doi:10.1080/15332980903405330 

• Howells, F., Ives-Deliperi, V., Horn, N., & Stein, D. (2012). Mindfulness based cognitive therapy improves frontal control in bipolar disorder: A pilot EEG study. BMC Psychiatry, 12, 15-15

• Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future. Clinical Psychology: Science and Practice, 10, 144–156.

• Kingston, T., Dooley, B., Bates, A., Lawlor, E., & Malone, K. (2007). Mindfulness-based cognitive therapy for residual depressive symptoms. Psychology and Psychotherapy, 80(Pt 2), 193. 

• Kuyken, W., Weare, K., Ukoumunne, O. C., Vicary, R., Motton, N., Burnett, R., ... & Huppert, F. (2013). Effectiveness of the Mindfulness in Schools Programme: non-randomised controlled feasibility study. The british journal of psychiatry, 203(2), 126-131.

References (3)• Langer, E. (2002). Well-being: Mindfulness versus positive evaluation. InSnyder, C. R.& Lopez, S. J. (Eds) Handbook of positive psychology (pp.214–230).New York: Oxford University Press.

• Ma, S.H., & Teasdale, J.D. (2004). Mindfulness-based cognitive therapy for depression: Replication and exploration of differential relapse prevention effects. Journal of Consulting and Clinical Psychology, 72(1), 31–40.

• Piet, J., & Hougaard, E. (2011). The effect of mindfulness-based cognitive therapy for prevention of relapse in recurrent major depressive disorder: A systematic review and meta-analysis. Clinical Psychology Review, 31(6), 1032-1040.

• Williams, J. M. G., Crane, C., Barnhofer, T., Brennan, K., Duggan, D. S., Fennell, M. J., ... & Russell, I. T. (2014). Mindfulness-based cognitive therapy for preventing relapse in recurrent depression: A randomized dismantling trial.Journal of consulting and clinical psychology, 82(2), 275.

• Williams, M., & Penman, D. (2011). Mindfulness: a practical guide to finding peace in a frantic world (Vol. 360). London: Piatkus.

References (4)• Williams, M., Teasdale, J., Segal, Z., and Kabat-Zinn, J. (2007). The Mindful Way

through Depression: Freeing Yourself from Chronic Unhappiness. New York: Guilford Press.

• Ryan, R. M. (2005). The developmental line of autonomy in the etiology, dynamics, and treatment of borderline personality disorders. Development and Psychopathology, 17, 987–1006.

• Samuelson, M., Carmody, J., Kabat-Zinn, J., & Bratt, M. A. (2007). Mindfulness-based stress reduction in Massachusetts correctional facilities. The Prison Journal, 87(2), 254-268.

• Segal, Z.V., Williams, J.M.G., & Teasdale, J.D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York: The Guilford Press

• Sipe, W. E. B., & Eisendrath, S. J. (2012). Mindfulness-based cognitive therapy: Theory and practice. Canadian Journal of Psychiatry. Revue Canadienne De Psychiatrie, 57(2), 63.

References (5)

• Weare, K. (2013). Developing mindfulness with children and young people: a review of the evidence and policy context. Journal of Children's Services, 8(2), 141-153.

• Wolever, R. Q., Bobinet, K. J., McCabe, K., Mackenzie, E. R., Fekete, E., Kusnick, C. A., & Baime, M. (2012). Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. Journal of occupational health psychology, 17(2), 246.

• http://bemindful.co.uk/

• http://bemindful.co.uk/learn/find-a-course/

• http://www.theguardian.com/society/2013/feb/26/mindfulness-meditation-depression-nhs

• http://www.mentalhealth.org.uk/help-information/mental-health-a-z/M/mindfulness/