Mindfulness-based cognitive therapy: treatment of depression and relapse prevention

Mindfulness-Based Cognitive-Behavioral Therapy: A Review

Mindfulness-based cognitive therapy (MBCT) is a form of behavior therapy aimed at treating various different disorders, most commonly major depressive disorder. It developed from an interaction between cognitive therapy and behavior therapy, which is known as cognitive behavioral therapy (CBT). It adds the component of mindfulness, which is more than simply changing what a person perceives, but how those perceptions are made. The goal of MBCT is to increase awareness of thoughts and feelings, so that a person can accurately label his thoughts and separate them from self-image or self-perception. This paper will examine MBCT including: major tenets and historical developments; conceptual and philosophical foundations; therapeutic technique; human development; personality; psychopathology; presumed mode of therapeutic action; goals for treatment; strengths and limitations of the orientation; application in diverse and multi-cultural contexts; and review and critique of the scientific evidence.

Introduction

Mindfulness-based cognitive therapy (MBCT) is a form of behavior therapy aimed at treating various different disorders. It is most commonly used to help prevent relapses of depression, though it has other applications as well, particularly in relapse prevention in substance abuse. "The focus of MBCT is to teach individuals to become more aware of thoughts and feelings and to relate to them in a wider, decentered perspective as 'mental events' rather than as aspects of the self or as necessarily accurate reflections of reality" (Teasdale et al., 2000, p.616 para. 7). MBCT derives from cognitive behavior therapy (CBT) methods, but combines newer techniques with traditional CBT methods. As the name suggests, the largest difference between MBCT and CBT is the concept of mindfulness and how developing mindfulness can increase the efficacy of therapeutic CBT interventions. This paper will examine the development of MBCT, how it is used in treating individuals, possible future applications, and the strengths and weaknesses of the therapy.

Conceptual and Philosophical Foundations

One of the interesting things about MBCT is that, while it is a psychological intervention, it has actually been used far longer than the formal profession of psychology. In many ways, cognitive therapy, particularly mindfulness, has a foundation in ancient philosophy. This is based upon the notion that emotions are neither solely internal nor solely external, but the result of the individual interacting with the world. "In recent decades there has been an unfortunate trend away from a philosophical understanding of behavior therapy to a more technique- understanding," but the background philosophy is a huge part MBCT (O'Donohue & Fisher, 2008, p.1, para.3). In fact, while this is not a new concept, MBCT brings together elements from psychology, sociology, and philosophy in a way that makes it clear that behavior and cognition are inexplicably intertwined and that the individual does not exercise sole control over the development of those processes. On the contrary, "Subjective thoughts, images, and feelings are rooted in the enduring attitudes and assumptions, or schemas that the individual develops from prior experience. Human experience is automatically filtered through these cognitive structures existing in the brain, by which input is categorized and evaluated (Laird, & Metalsky, 2008, p.35, para.1).

One of the major concepts in MBCT is the idea of kindness. While kindness may seem like an amorphous concept, and may seem like an implicit part of a therapeutic process, it is not always part of the process in other forms of therapy. Therefore, one of the defining characteristics of MBCT is that it is not a critical and negative approach. On the contrary, the "cultivation of self-compassion (as a contrast to judgments and criticism that often arise in response to clients' own thoughts and feelings) [is] an important aspect of these treatments" (Roemer, & Orsillo, 2009, p.4, para. 2).

Ideas Related to Therapeutic Technique

One of the things to keep in mind when looking at therapeutic technique is what types of disorders the therapy is most likely to be used to treat. MBCT is most likely to be used to treat depression and addiction. Moreover, it is not generally a first-line treatment. In other words, MBCT is not generally used to help someone get through a major depressive disorder or find sobriety. Instead, MBCT is frequently used as a means of relapse prevention. Therefore, the therapeutic technique is not the same as one would expect in a different type of treatment-focused intervention, because its goal is generally to prevent relapse.

However, it is also important to keep in mind that mindfulness is a very popular self-help technique. MBCT is considered a way to help people achieve a greater degree of happiness and success in their lives, even if those people do not actually suffer from a disorder. This is an important concept to keep in mind for the practitioner who may be more comfortable with treating a disease, rather than treating an individual. MBCT can help even those people without a disorder or a diagnosis achieve a greater degree of personal satisfaction in their lives, so that treatment has to focus on improvement in "normal" lives and not just curing or fixing disorders.

Approach to Human Development

One of the misconceptions about MBCT, and a critique of CBT, behavior therapy, and cognitive therapy is that it ignores the impact of development on the human process. In fact, because of the way that CBT has been used to treat anxiety and anxiety-related disorders, some people believe that it has traditionally targeted the symptoms without examining the life behind the symptoms (Eifert et al., 2005, p.5, para.2). It is true that MCBT focuses on bringing about behavior change. However, it is not true that MBCT leaves no room for examination of underlying motivations and human development. However, the very essence of mindfulness is that it reflects how people have learned to pay attention to their internal thoughts and external surroundings. There is no way to ignore the impact of childhood and development on cognition.

"Child learning occurs as a function of repetition followed by changes or contrast in child experience" (Friman, 2008, p.557, para.4). Therefore, how one thinks is going to be a result of human development. By looking at the underlying cognitions and how they have conditioned people to focus on some elements and ignore others, MBCT does examine the impact of development on the individual.

Approach to Personality

Furthermore, some might suggest that MBCT does not focus on interpersonal relationships, and, as such is fundamentally flawed because interpersonal relationships serve as the foundation for so much that is healthy and functional in life, and also so much that is unhealthy and dysfunctional in life. As a result, it is important to realize that outside relationships will impact the efficacy of MBCT, particularly for those people who are extra-sensitive (Gardner-Nix & Kabat-Zinn, 2009, p.123, para.1). Therefore, the MBCT approach looks at self-perceptions and how those are impacted by mindfulness. Therefore, this therapy requires an examination of how present and past relationships impact thoughts. The goal is not necessarily to alter relationships in a radical way. Instead, "through seemingly subtle shifts in relationship with experience, radical new perspectives emerge" (Crane, 2009, p.65, para.1). Therefore, not only do relationships help change perception, but changes in perception help change relationships.

In addition, one of the focuses on MBCT is often to increase individual assertiveness. This is because many people see a lack of assertiveness as a reason that people have failed to function appropriately in society. Therefore, the default setting suggests that assertiveness is appropriate, and understanding this approach to personality is critical to understanding the role that personality plays in MBCT. "Implicit in the discussion of assertiveness is the suggestion that assertive behavior is the universally preferred behavioral alternative, and that assertive behavior necessarily leads to preferred outcomes" (Duckworth, 2008, p.26, para. 2). Whether or not this assumption is true is debatable, and that actually leads to some of the questions about the efficacy of MBCT as a therapeutic intervention.

Approach to Psychopathology

One of the important elements of MBCT is how it approaches psychopathology, particularly depression. While it does not ignore the disease aspect of depression, MBCT offers a very optimistic approach to the treatment of depression. Moreover, it suggests that the underlying schema of depression can be changed, so that rather than being cyclical, major depression can be turned into a disorder with only a single major episode. To understand this approach, one needs to understand how MBCT practitioners envision depression and the negative cognitions underlying depression. They understand that negative thought patterns occur, not because people want to mire themselves in negativity, but because people think that doing so will actually help them overcome their problems. "Of course, nobody broods over problems because they believe it's a toxic way of thinking. People genuinely believe that if they worry enough over their unhappiness they will eventually find a solution" (Williams et al., 2011, p.30, para. 3). By showing people that worrying does not lead to a solution, the concept is that the underlying psychopathology can be changed.

Presumed Mode of Therapeutic Action

MBCT exists in multiple modes and can even be handled in a self-help approach outside of a therapeutic setting. However, in an academic setting, MBCT is generally going to refer to a narrowly defined eight-week program that is a group intervention. The intervention is a class program. There are 8 weekly classes, which generally meet for 2 hours. Some weeks feature longer sessions. However, most of the work is done outside of the classroom setting. Participants use class materials to engage in guided meditations. The themes of the classes are: automatic pilot; dealing with barriers; mindfulness of the breath; staying present; allowing and letting be; thoughts are not facts; how can I best take care of myself; and using what's been learned to deal with future moods (MBCT.com, 2007, para.3). In addition, while MBCT may be based upon an eight-week program, it is important to realize the MBCT is not a closed-end process in many scenarios. "Having a support network is crucial to continuing along the path of practice and recovery" (Bowen et al., 2011, p.159, para.1).

Goals for Treatments

The basic overall goal of MBCT is to help change cognitions by increasing mindfulness. However, most people who seek out MBCT do so to treat a specific problem, generally depression, though it can also be useful for addiction. There are eight smaller goals of the treatment, which, when combined with one another, are thought to prevent relapse. The first goal is to help the individual become familiar with the workings of his own mind (MBCT.com, 2007, para.4). The second goal is to help the individual recognize high-risk times (MBCT.com, 2007, para. 4). The third goal is to help the individual find ways to release old habits (MBCT.com, 2007, para.4). The fourth goal is to introduce the individual to a different way of viewing self and the world (MBCT.com, 2007, para. 4). The fifth goal is to introduce the individual to a more appreciative posture, so that they can enjoy the externalities of the world (MBCT.com, 2007, para.4). The sixth goal is to encourage the person to be kind to himself (MBCT.com, 2007, para.4). The seventh goal is to reduce inner conflict (MBCT.com, 2007, para.4). The final goal is to increase individual levels of self-acceptance (MBCT.com, 2007, para.4).

Another way to view the overall treatment goal is to say that it will help the individual change his approach to tasks. Frequently, major depression is marked by fear and the unwillingness to engage in new behaviors because they seem overwhelming to the individual. MBCT encourages the individual to look at things differently, so that these perceptions change. One way to do so is by engaging in a task analysis. "A task analysis breaks a complex activity into its component parts or units so that they can be individually shaped if they are not already in the subject's repertoire, or brought under appropriate stimulus control within the chain if they are present already" (Williams & Burkholder, 2008, p.47, para.3).

Strengths and Limitations of the Orientation

MBCT has a number of strengths suggesting it may be effective for treating disorders. First, it is a relatively simple philosophy. At eight weeks, the program requires relatively little commitment, at least in terms of time. Furthermore, though it is a group intervention, because the individual drives the process through class participation and homework, the individual is largely responsible for the success of the program, which is both a strength and a limitation. However, the greatest strength of the orientation may be that it has appeal for people who have been punishing themselves because of depression or addiction issues. The MBCT practitioner does not suggest that those seeking treatment are responsible for the condition that has led them to seek treatment, and actually encourages participants to view themselves in a positive manner, regardless of externalities. In other words, they express support for the idea of unconditional positive regard for the patient. "Symptoms are thought to be maintained via cognitive and behavioral pathways, not by laziness, lack of motivation, or weakness" (Ledley et al., 2010, p.4, para.3).

While MBCT has a number of strengths, it is such a specific program that some researchers have expressed real concerns that it is too limited to bring into widespread practice.

Segal et al. expressed reservations about using MBCT to treat depression, because of how they were instructed to incorporate the therapy into their existing treatment programs. They were told that they would need to have their own mindfulness meditation practice, which seemed overzealous to them, because they simply intended to incorporate it into their practice with their patients (Segal et al., 2002, p.49-50, para. 3). In fact, this does seem to be the largest limitation of MBCT. Reviewing the available literature about MBCT, one sees a difference between how its proponents write about it when compared to other therapeutic modes. Perhaps because the approach has a distinctly spiritual feel, it almost seems religion or cult-like, which could certainly reduce its appeal for those patients that have no interest in a spiritual overtone in a therapeutic setting.

Application in Diverse and Multi-Cultural Contexts

In many ways, MBCT is perfect in diverse contexts, because it focuses on the individual. Rather than asking the individual to conform to societal ideals about how they should be, but use greater attention to help determine how he wants to be. However, it would be irresponsible to suggest that different cultural contexts do not impact how a person interprets external and internal events. When one practices mindfulness, he may do so with "every intention of attending to the present-moment experience," yet biological physical, mental, and emotional response patterns, past individual memories, and ancestral memories that are transmitted through culture, all help impact how one interprets external and internal events (Smalley, & Winston, 2010, p.194, para. 2).

The real challenge is whether the group is able to support different cultural perspectives and help the individual understand how his cultural ancestral memories may be impacting his ability to attend to the present-moment experience. Take, for example, a common phenomenon in American society; a scenario in which race may or may not be a motivating factor. Non-minorities, who do not have a personal or ancestral history of race-based victimization, may believe that race is not a motivation and that people who suggest that certain events are race-based are engaged in race-baiting. However, minorities who do have personal or ancestral histories of race-based victimizations may rightfully be using those experiences to help filter their understanding of present-day events. A group facilitator who cannot understand the validity of both perspectives is going to encounter diversity issues.

In fact, CBT should be used with caution in some populations, and knowing these cautions is important for the MBCT practitioner. For example, suicidal populations do not respond to traditional CBT in the same way as other populations because of extra sensitivity to criticism and a tendency to emotional shut-down (Robins et al., 2004, p.30, para.1). This may not be a cultural issue, but it is an issue that reminds the practitioner that diverse populations have diverse needs. While MBCT is much gentler than other forms of CBT, it is important to examine the vulnerability of the population when introducing a treatment modality.

Review and Critique of the Scientific Evidence

When assessing a therapy, most people are concerned about efficacy. What is interesting about MBCT is that its efficacy is oftentimes assumed, rather than supported with empirical evidence. This is a problem, because one cannot simply assume that a therapeutic intervention is successful. Moreover, given that the underlying components of MBCT have not been proven to be effective in all scenarios, it seems reasonable to question the efficacy of MBCT. However, cognitive therapy has been demonstrated as an effective therapy for depression, as has behavior therapy. In addition, CBT has helped eliminate relapse among those treated for depression. As a result, one would anticipate that MBCT would be successful in treating depression, and related disorders such as anxiety disorders, addiction, and eating disorders.

Scientific Evidence Supporting the Application of MBCT

Given that MBCT is most frequently used to treat depression, accessing its efficacy necessarily involves an examination of whether or not it prevents relapse in patients who have suffered from a major depressive episode. The research suggests that it is effect in preventing those relapses. A study by Ma and Teasdale, provided strong support for the use of MBCT. They found that MBCT reduced "relapse/recurrence in patients with recurrent major depressive disorder who, following a reportedly adverse childhood, have experienced three or more previous episodes of depression, the first of which was relatively early in their lives" (Ma & Teasdale, 2004, p.39, para. 8). Furthermore, the study differentiated between situational depression and non-situational depression. MBCT may not prevent depression in a person experiencing a negative life event like death or divorce, because those negative life events do not generally involve repeating life-events that have previously been experienced. Instead, "MBCT is most effective in preventing relapse/recurrence that is unrelated to environmental provocation" (Ma & Teasdale, 2004, p.39, para. 8).

Furthermore, while MBCT was developed primarily to treat depression, it has been proven to be effective in treating other disorders. For example, one area where MBCT has proven useful is in anger management. While MBCT-based anger management programs may be in their development stages, they are promising. Moreover, as these programs become "increasingly sophisticated and better integrated into comprehensive psychological interventions," one expects continuing improvements in efficacy. "(Donohue et al., 2008, p.23, para.3).

Finally, while MBCT is effective at relapse prevention in depression and addiction, there is increasing support for its efficacy in other areas. For example, in recent times its use has expanded "to other behavioral problems, including eating disorders and sexual offending" (Newring, et al., 2008, p.422, para.1). While there is not a substantial amount of empirical evidence supporting the efficacy of MBCT in these scenarios, early results are promising, which suggests that MBCT can be used in a much wider variety of scenarios than initially suspected.

Scientific Evidence Limiting the Application of MBCT

One of the limitations of MBCT is that it seems to be more specific than other group interventions and methods. For example, CBT administered by paraprofessionals has not proven as effective as professionally-administered CBT (Drossel, 2008, p.241, para.3). This means that, in order to reach maximum efficacy, MBCT needs to be administered by a professional. However, because MBCT is administered in a group setting, and sometimes in informal settings, it may be unrealistic to expect that professionals could always administer MBCT programs. In addition, there is a huge amount of self-help literature focused on MBCT. Do these self-help programs, which clearly are not administered by professionals, actually help individuals? Questions like these permeate any discussion of MBCT.

Discussion

One of the distinguishing factors of MBCT is its movement away from the diagnosis and treatment model of mental health intervention and its movement towards a more human-based approach. This reflects a broader change in CBT, which may or may not increase treatment efficacy. In fact, "regardless of terminology, a number of CBT models have emerged over the past decade that highlight efforts to accept, rather than directly change, distressing experiences, including thoughts, beliefs, feelings, memories, and sensations" (Herbert et al., 2008, p.5, para.1). MBCT is certainly one of those theories. It stresses the importance of self-acceptance and promotes a reduction in the type of inner conflict that leads to increased feelings of anxiety. However, serious questions remain about whether it is appropriate to teach people to accept distressing experiences. It is very possible that approaching some populations in this manner may actually increase, rather than decrease, symptomology.

One of the ideas that is stressed throughout MBCT literature is the role that the individual plays in the therapeutic experience. It certainly seems like MBCT would not be useful in resistant populations. Instead, target populations almost have to be willing in order to be successful in the process. "An essential part of willingness is that we are willing because having these experiences allows us to move towards something that matters to us" (Orsillo & Roemer, 2011, p.189, para.2). Therefore, not only do patients need to be willing, but they also need to be goal-oriented and understand why they are seeking therapy. What behaviors are they trying to eliminate, and why do they want to eliminate them? Understanding that those questions are not really answered in MBCT, but are more of a preface to the MBCT process, one can understand why MBCT is often used as a relapse prevention program rather than an initial treatment program.

Another interesting development in MBCT is that it is one of those interventions that are not limited to a population suffering from mental disorders. It can be used to treat people with lower levels of mental distress, who may not actually be experiencing mental illness, but who are seeking improvement in their daily lives. Moreover, MBCT can be used to treat disorders that may initially seem to be non-psychiatric disorders, such as insomnia, but many people fail to seek treatment for those types of disorders (Pigeon & Perlis, 2008, p.293, para.2).

Whether this change in treatment target is limited to MBCT is an academic question. For example, Steven Hayes believes that behavior therapy is in the process of undergoing a structural reorganization (Hayes, 2004, p.1, para.2). This reorganization may change the way that treatments are approached and the areas for which a treatment is considered effective. The emerging changes in MBCT may reflect this underlying structural reorganization.

Conclusion

MBCT has proven to be an effective treatment in many areas, particularly in relapse prevention programs. In addition, MBCT has been shown to be effective in a broad range of disorders that go outside of the initial area of depression. However, there is simply not enough empirical evidence about MBCT's efficacy in these other areas. While treatment for anxiety-based disorders has seen tremendous growth, there are areas still in need of additional study, including: validation of existing models; improving treatment efficacy; determining which mechanisms promote change; and improving dissemination of interventions (Orsillo et al., 2004, p. 66, para.1).