Mindfulness-based Cognitive Therapy for Depression

Mindfulness-Based Cognitive Therapy (MBCT), a group psychotherapy developed by Zindel Segal, J. Mark Williams and John Teasdale, prevents depression relapse through a synthesis of mindfulness and cognitive therapy. The practice of mindfulness helps us to pay attention. It allows “emergent insight that is beyond thought but can be articulated through thought” (Jon Kabat-Zinn). This is a process that is compatible with cognitive therapy, which focuses on observing, describing and deconstructing thoughts and beliefs.

There are many techniques for cultivating mindfulness but mindfulness is not a technique. It helps people to become more aware of personal experience. As this awareness develops by a process of non-judgmental observation, a person can change the deeply grooved neural pathways of habitual ruminative thought and troublesome emotional reactions. MBCT emphasizes awareness of process and deemphasizes content, reducing the reinforcement of negative thoughts.

In the last quarter of the 20th Century, wide ranging studies of depression were conducted that showed: 1) depression is a wide-ranging mood disorder affecting a surprisingly highly percentage of people in the western world, 2) depression is highly likely to return after a first episode and comes back quickly, 3) the intervals between recurrences shorten over time. In the field of mental health, second and subsequent episodes are seen as a worsening of the first episode – relapses – rather than new episodes. When this concept of relapse began to be understood, anti-depressant medication began to be prescribed prophylactically to avoid relapse: to treat an acute episode (immediate treatment), to continue treatment (six months beyond the acute episode) and to maintain treatment (3-5 years beyond recovery. These are the current guidelines of the American Psychiatric Association.

These guidelines imply and assume that antidepressant medication, although suppressing symptoms, does not provide a long-term cure. Groundbreaking studies in the 1980’s indicated that medication in combination with interpersonal therapy was more beneficial to patients, in terms of relapse prevention, than the use of medication alone. These studies also showed links between specific skills taught to patients and the prevention of depression relapse. The more skills, the longer patients were able to stay well. Up until that time, a focus of depression treatment had been on the treatment of acute episodes rather than developing maintenance therapies. Important studies in the early 1990s showed that patients who started and stopped medication during and after an acute episode were significantly more likely to relapse than patients receiving cognitive therapy alone. The Seagal, Williams and Teasdale approach grew out of their study of the efficacy of cognitive behavioral as a maintenance approach.

As these important developments in the understanding of depression were taking place, mindfulness-based stress reduction (MBSR) was being developed, with great success, by Jon Kabat-Zinn at the University of Massachusetts. Participants in MBSR were finding significant relief of anxiety disorders and chronic pain. Segal, Williams and Teasdale have adapted the approaches of MBSR to their depression-relapse programs – group meetings, a high level of commitment to treatment, rigorous homework (up to an hour per day) and intensive training in mindfulness meditation.

Segal, Williams and Teasdale have found that MBCT is especially effective for relapse prevention in patients who have experienced three or more episodes of major depression prior to learning and practicing the MBCT skills. In this group, MBCT almost halved the relapse rates compared to conventional treatment. As they say in their book, “MBCT was able to help up to 12 patients in approximately the same time as it often takes to treat just one patient in conventional individual cognitive therapy for depression… we had achieved our aim of developing a new, cost-efficient way to reduce risk of relapse/recurrence of depression” in patients with three or more previous episodes of depression. Segal, et al hypothesize that their treatment is less efficient with people who have had two or fewer recurrences because MBCT treats autonomous relapse processes rather than teaching skills which are helpful in major life events. In other words, it may be that MBCT is more helpful in depression that is brought about by prolonged rumination rather than by major life events.

How does MBCT work?

The “core skill” taught by MBCT is the ability to identify and detach from the states of mind that evoke rumination and negative thinking. Rumination and negative thinking trigger more rumination and negative thinking, which triggers more rumination and negative thinking, and so on . . . this pattern of thought, of course, escalates a downward mood spiral. MBCT, primarily through the rigorous practice of mindfulness, as taught in a variety of ways, helps a patient to focus on process rather than content. This is different from the classic cognitive-behavioral focus on changing the content of negative thought. MBCT emphasizes awareness of how experience is processed.

Formal MBCT consists of 8 group meetings, over 8 weeks, with approximately 1 hour of homework each night of the 8 weeks, including mindfulness practice. Group meetings include orientation to and practice of mindfulness, discussion of homework, practice review and homework review. Homework includes classic mindfulness exercises, such as Mindfulness of Breath, Body Scan, Mindful Walking, Sitting Meditation, and others. Participants keep written records of homework and are taught traditional Cognitive Therapy concepts, such as Automatic Thoughts and the recording of the internal effects of pleasant and unpleasant events.

MBCT is rigorous and requires a high level of commitment. The stress of the rigor and commitment becomes part of the treatment. MBCT group leaders commit to a disciplined mindfulness practice themselves. Segal, et al, strongly emphasize that it is not possible to teach mindfulness practice if one does not understand the personal impact of such a commitment.

MBCT is an exciting and intense course of treatment. The mindfulness and cognitive tools that are taught are extremely thorough and helpful. Participants work hard and feel the negative and positive effects of such hard work. Because MBCT is an immersion, of sorts, in mindfulness skills, participants leave the group with a library of interventions that can be used over and over again. I believe that MBCT is especially helpful if the participants and group leaders are working together with an individual therapist to reinforce mindfulness practice and skills use beyond the lifetime of the group. Although it is a deviation from the carefully studied treatment as outlined in the Segal book, I believe MBCT groups can be enhanced with the addition of other behaviorally oriented skills, to help the patient tolerate the stress experienced in learning new ways of using the mind. An expansion of the MBCT program to include more skills may also be helpful to the patient who has experienced one or two relapses that have been triggered primarily by life events.

For more information about MBCT for depression, please feel free to contact me at . or at 415 249-9277.

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