Developments in MBCT. Mark Williams University of Oxford Department of Psychiatry Oxford Mindfulness Centre

Developments in MBCT Mark Williams University of Oxford Department of Psychiatry Oxford Mindfulness Centre Collaborators: Zindel Segal, John Teasdale, Jon Kabat-Zinn Oxford Team: Melanie Fennell, Thorsten Barnhofer, Catherine Crane, Danielle Duggan, Adhip Rawal, Emily Hargus, Wendy Swift, Dhruvi Shah, Kate Brennan, Kate Muse, Adele Krusche, Ann Hackman www.mbct.co.uk www.oxfordmindfulness.org Outline of Talk Building bridges between Ancient and Modern Update on MBCT for preventing depression outcome evidence New understandings Of mindfulness and its measurement Of the effects of mindfulness on meta-cognitive awareness Of effects of experiential processing on intractable emotional / behavioural problems New directions 1

Outline of Talk Building bridges between Ancient and Modern Update on MBCT for preventing depression outcome evidence New understandings Of mindfulness and its measurement Of the effects of mindfulness on meta-cognitive awareness Of effects of experiential processing on intractable emotional / behavioural problems New directions Ancient and Modern 2

University of Oxford Famous for its ancient libraries... 3

The Oxford Mindfulness Centre (OMC) The Lobby, OMC 4

The Meditation Space... Building bridges between ancient and modern 5

Lively debate amongst Buddhist Scholars Scientist and clinicians Mindfulness teachers Definitions of mindfulness and its role Risks and benefits of bring mindfulness into secular contexts Volume 11, No 1, May 2011 Mark Williams Jon Kabat-Zinn Bhikku Bodhi Georges Dreyfus Andy Orlendzki John Dunne John Teasdale Michael Chaskelson Melanie Fennell Zindel Segal Willem Kuyken Christina Feldman Martine Batchelor Edel Maex Sharon Salzberg Mirabai Bush Saki Santorelli Paul Grossman Nicholas Van Dam Ruth Baer Rupert Gethin Jon Kabat-Zinn 6

Jacob Piet Meta-analysis of the six outcome trials A Total of 593 randomized participants 74% women; mean age = 46; age of first onset = 28 Mean baseline depression score (HAM-D) = 4.9 96% had a history of medical treatment for depression All participants were in remission Quantitative data synthesis Risk of relapse between MBCT and controls for participants with three or more previous episodes (N = 363) MBCT Control Risk Ratio Risk Ratio Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI 1.1.1 MBCT vs TAU Bondolfi 2009 9 31 10 29 9.4% 0.84 [0.40, 1.77] Godfrin 2010 12 40 32 47 19.9% 0.44 [0.26, 0.74] Ma 2004 10 28 21 27 18.2% 0.46 [0.27, 0.79] Teasdale 2000 22 55 33 50 36.2% 0.61 [0.41, 0.89] Subtotal (95% CI) 154 153 83.8% 0.55 [0.43, 0.70] Total events 53 96 Heterogeneity: Tau² = 0.00; Chi² = 2.66, df = 3 (P = 0.45); I² = 0% Test for overall effect: Z = 4.71 (P < 0.00001) 1.1.2 MBCT vs PLA Segal 2010 10 26 18 30 16.2% 0.64 [0.36, 1.13] Subtotal (95% CI) 26 30 16.2% 0.64 [0.36, 1.13] Total events 10 18 Heterogeneity: Not applicable Test for overall effect: Z = 1.54 (P = 0.12) Total (95% CI) 180 183 100.0% 0.56 [0.45, 0.71] Total events 63 114 Heterogeneity: Tau² = 0.00; Chi² = 2.90, df = 4 (P = 0.57); I² = 0% Test for overall effect: Z = 4.93 (P < 0.00001) 0.01 0.1 1 10 100 Favours MBCT Favours control 8

MBCT as alternative to Continued Antidepressants Kuyken et al., 2008 JCCP Segal et al., 2010 Arch Gen Psychiat Kuyken et al (2008) MBCT vs m- ADMs 9

Recurrence Across 18 Months Intention to Treat - Unstable Remitters 27% 28% 71% Log-rank test = 8.24, df =2, p = 0.016 Quantitative data synthesis Risk of relapse between MBCT and m-adm (N = 177) Study or Subgroup Kuyken 2008 Segal 2010 MBCT m-adm Risk Ratio Risk Ratio Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI 29 10 61 26 37 13 62 28 78.0% 22.0% 0.80 [0.57, 1.11] 0.83 [0.44, 1.55] Total (95% CI) Total events 39 50 Heterogeneity: Tau² = 0.00; Chi² = 0.01, df = 1 (P = 0.91); I² = 0% Test for overall effect: Z = 1.45 (P = 0.15) 87 90 100.0% 0.80 [0.60, 1.08] 0.01 0.1 1 10 100 Favours MBCT Favours m-adm MBCT relapse rate = 45% M-ADM relapse rate = 56% A non-significant risk reduction of 20% in favor of MBCT 10

Conditional goal setting (Crane, C, et al., 2010) refers to the tendency to view the achievement of high order goals for the self (e.g. happiness, self-worth, fulfilment) as conditional upon the achievement of lower order goals. Aim: To explore the relationship between conditional goal setting and dispositional mindfulness 31 depressed patients. 12

Participants Met full DSM-IV criteria for current major depression, or sub-threshold criteria for depression following a full episode Had a history of 3+ episodes of depression or chronic depression. Had a history of current or past suicidal ideation or behaviour. Mean age = 42 years Mean age at onset = 23 years Mean BDI = 31.2 Measures - mindfulness FFMQ (Baer et al) five subscales assessing different facets of mindfulness: describing (e.g. I am good at finding the words to describe my feelings ), non-reactivity (e.g. I perceive my feelings without having to react to them ), acting with awareness (e.g. I find it difficult to stay focused on what s happening in the present, reverse scored), non-judgement (e.g. I make judgements about whether my thoughts are good or bad ) observing (e.g. I notice how my emotions express themselves through my body ). 13

Conditional Goal Setting Two steps Step One: elicit goals things that you would like to happen or things that you would like to be true of your life in the future. Next 12 months? Step Two: conditionality assessment Conditional Goal Setting - Step Two For each goal, select which of two statements best describes yourfeelings about the goal I can only feel happy if I achieve this goal or even if I do not achieve this goal I can still feel happy rated how much do you agree with the statement, either very strongly, strongly, moderately or slightly. The ratings scored on a one to eight scale Identical ratings then made of self-worth and fulfilment conditionality Scores summed to produce an overall conditional goal setting score. Note: no overlap in items with Baer s mindfulness scale 14

Associations between total Conditional Goal Setting (CGS) score and each facet of the Five Factor Mindfulness Questionnaire (FFMQ) Describing Observing Non- Non- Acting with FFMQ judgement reactivity Awareness Total Total CGS Score -.44* -.60** -.45* -.63** -.57** -.76** Note (r bdi = -.64, p <.001), 15

Study 1: Meta-awareness of thoughts The ability of participants to recognise that their thoughts of DSH were simply thoughts, symptoms of depressed mood and transient events of the mind that were likely to pass with time. the knowledge that it was the illness talking. thoughts about tough times lead to these passive death wishes. The thoughts usually subside with rest, meditation and time... at some point, realizing that the "cortisol hours" from 4 AM to about 8 AM pass, that I always feel better sooner or later, and having a little bit of a rational mind saying that it wasn't real, that this was acting on feelings that weren't right. just thoughts, not worth holding onto. Study 2: Relapse signatures (Emily Hargus s data) Individual patterns of prodromal features that warn of onset of episode Very important for self-management (schizophrenia, bipolar disorder, suicidal behaviour) Not just whether noticed, but how we relate to them enmeshed I m not ever going to be able to sleep again with meta-awareness ( decentered ) I felt life was getting difficult, but it was my own inability to cope at that time 17

Meta-awareness of relapse signature 3 2.6 2.2 1.8 MBCT TAU 1.4 1 Pre Post Outline of Talk Building bridges between Ancient and Modern Update on MBCT for preventing depression outcome evidence New understandings Of mindfulness and its measurement Of the effects of mindfulness on meta-cognitive awareness Of effects of experiential processing on intractable emotional / behavioural problems New directions 18

Attention directed towards thinking Thinking Input Sensing Attention directed towards sensing Thinking Input Sensing 19

MODE OF SELF-FOCUS (Rawal, Williams & Park, under review) Choose a condition where self-focus most problematic Students with high eating concerns Anorexic in-patients Sample item: Step 1: Induction of processing modes (Watkins & Teasdale, 2004) the physical sensations in your body the way you feel inside how awake or tired you are Mode induction Conceptual: Think about the causes, meanings and consequences of Experiential: Focus your attention on the experience of 8 minutes 20

Step 2: Stress test for Eating Concerns Imaginary meal procedure (Shafran et al.,1999) Participants asked to imagine eating a fattening food for a period of 2 minutes. Step 3: Assess Outcome Estimate of actual weight How much do you think you weigh right now? 21

Analogue study: Pre and post stressor difference in weight estimate (in kg) for high ED group 0.3 Condition, p <.05 Mean Weight change 0.2 0.1 0-0.1-0.2-0.3 Conceptual Experiential Anorexic patients? 22

Patient study: Pre vs post stressor difference in weight estimate (in kg) 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Conceptual Experiential Filler task Anorexic Controls Outline of Talk Building bridges between Ancient and Modern Update on MBCT for preventing depression outcome evidence New understandings Of mindfulness and its measurement Of the effects of mindfulness on meta-cognitive awareness Of effects of experiential processing on intractable emotional / behavioural problems New directions 23

Anxiety Chronic depression & Bipolar Disorders 24

Accessibility Of a framework that will motivate curiosity decisive action for self-caring persistence Of practices 25

John Teasdale and Michael Chaskelson (2011) the patterns of mind that keep people trapped in emotional suffering are, fundamentally, the same patterns of mind that stand between all of us and the flowering of our potential for a more deeply satisfying way of being. 26

Thank you www.mbct.co.uk www.oxfordmindfulness.org 27