Mindfulness-based Cognitive Therapy (MBCT) www.exeter-mindfulness-network.org Alison Evans March 2013 Outline What is mindfulness? What people learn in mindfulnessbased cognitive therapy Brief scan of the evidence base How mindfulness-based cognitive therapy supports learning MBCT 1
Practice: Attention/awareness What is Mindfulness? MBCT 2
Mindfulness Mindfulness means paying attention in a particular way.... - on purpose - in the present moment - non-judgementally Jon Kabat-Zinn Thinking/ Doing Mode MBCT 3
Sensing/ Being Mode Sensing/ Being Mode Thinking/ Doing Mode MBCT 4
Mindfulness-based Stress Reduction Vehicle for teaching mindfulness in the service of reducing suffering in people with chronic physical health problems Mindfulness-based Cognitive Therapy Zindel Segal, University of Toronto Mark Williams, University of Oxford John Teasdale, Formerly of the Medical Research Council Cognition and Brain Sciences Unit, Cambridge MBCT 5
The MBCT Story So Far MBSR & Stress Reduction Clinic MBCT Manual & RCTs Oxford Mindfulness Centre Mental Health Foundation Report Bangor Centre for Mindfulness Research & Practice 2004 & 2009 NICE Guideline NHS projects MBCT Formulation? MBCT 6
Kindling in Recurrent Depression First episode Second episode Third + episode (s) Stress Stress Stress Each new episode of mood disorder Relapse & MBCT s Proposed Mechanism of Change Rumination e.g., Why does this happen to me? Depressed states e.g., Self-as-weak Negative mood sadness Body states e.g., unmotivated Differential Activation Hypothesis (Lau, Segal and Williams, 2004) MBCT 7
Automaticity of Negative Thinking The patterns [of negative thinking] themselves also seem automatic, in the sense that the mind runs around some very well-worn mental grooves, or ruts, as old mental habits switch in and run off. Segal, Williams & Teasdale et al., 2002; p.67 What Participants Learn in Mindfulness-based Cognitive Therapy MBCT 8
Three Modalities of Change in MBCT 1. What the mind is processing 2. How the mind is processing it 3. The view or perspective (Teasdale & Chaskalson, 2011, Contemporary Buddhism) Doing mode Being mode MBCT 9
Being Awake (vs. automatic pilot) Intimate with experience in the present moment (vs. analysing) Allowing (vs. striving and judging) Compassionate (vs. aversion and judgement) Practice: Tiredness 1 MBCT 10
Rumination: Repetitively focussing on symptoms and possible causes of depression Judging, judging, judging. Conceptual Problem solving Discrepancy monitor Why do I feel sad? Constant comparison across states and time: ideal state (happiness) vs. feared state (depressed) Automatic, habitual The solution (rumination) is the problem: it takes over the self and exacerbates and maintains low mood Nolen-Hoeksema, 1991 Practice: Tiredness 2 MBCT 11
Anti-ruminative Direct experience Focussing on now, noting & disengaging from evaluative / comparative thinking Approaching state as a temporary weather configuration Why Mindfulness? Mindfulness training: intentionally moves out of an automatic pilot processing mode to a being mode cultivates a decentred relationship to negative thoughts/feelings turns towards the difficult: anti-avoidant steps out of ruminative thinking moves to being in the body MBCT 12
The Evidence Base Is MBCT Helpful? The Evidence Base MBCT 13
Is MBCT Efficacious? 145 people in three sites randomly allocated to Treatment as Usual (TAU) or MBCT (+TAU) Primary Outcome Variable - Relapse/recurrence to DSM IIIR Major Depression Procedural Replication N = 75, one site Same inclusion criteria and primary outcome MBCT 14
Is MBCT Efficacious? Survival for MBCT vs. Usual Care over 60 weeks of Follow-up Proportion Well Teasdale et al., 2000; Ma & Teasdale, 2004, JCCP 1.00 Relapse rates MBCT: 37% 0.5 TAU: 66% 10 20 30 40 50 60 Weeks MBCT vs. Maintenance Anti-depressant Medication to Prevent Depressive Recurrence MBCT 15
How Acceptable is MBCT? Acceptability of MBCT: Attendance at Classes Adherence with MBCT: 52/61 (85%) Attendance (weeks): 6.25/8 (SD = 2.47) median = 7 mode = 8 Kuyken, Byford, Taylor, Watkins, Holden, White et al., 2008 MBCT 16
Hours per week Willem Kuyken, University of Exeter Engagement with MBCT: Percentage of Class Homework Completed % of class homework completed X=70% (SD = 17.08) Median=77% Engagement with MBCT: Formal Mindfulness Practice at Follow-up 1 month follow-up 12 month follow-up Mean=2.62 (SD=1.94) Median=2.5 83% practising Mean=1.17 (SD=1.23) Median=1 67% practising Kuyken, Byford, Taylor, Watkins, Holden, White et al., 2008 MBCT 17
MBCT Outcome Trials: Summary First multi-centre RCTs of MBCT for depression For patients with a history of 3 episodes, MBCT halves chances of relapse compared to usual care MBCT is comparable to anti-depressant treatment in preventing relapse and superior on some secondary outcomes For patients with 2 episodes no effect on relapse Cost effective (because class-based approach): Clinician time per patient < 5 hours on average Tends to have high levels of participant engagement and satisfaction National Institutes for Clinical Excellence (NICE) Recommendation for Relapse Prevention (2009) MBCT 18
Parents, Depression & MBCT Parents in MBCT Baillie, Kuyken & Sonnenberg, 2012 Mindfulness-based Parent Training (2009-2013) 1. Does MBCT improve parent s mental health, parenting practices and children s behaviour? 2. Is MBCT for parents an accessible and acceptable intervention? Mann, Kuyken, O Mahen, Evans, Okoumunne & Ford Mindfulness in Schools Project Chris Cullen and Richard Burnett, Treatment developers and teachers Katherine Weare, Felicia Huppert, Obi Okoumunne & Willem Kuyken Research Team MBCT 19
Mindfulness-based Cognitive Therapy for Depression with Long-term Conditions Is mindfulness based cognitive therapy feasible and acceptable to people with depression that co-occurs with a range of chronic physical health problems? Chris Dickens, Andy Gibson & Willem Kuyken Preventing Depression Relapse through Mindfulness-based Cognitive Therapy (MBCT) How does MBCT compare against maintenance anti-depressants in terms of: (1) Preventing depressive relapse (2) Secondary outcomes WK 40 MBCT 20
Mindfulness for Therapists WK 41 How MBCT Supports this Learning MBCT 21
Relapsing Depression: It s Like Being Dragged Over a Waterfall Julie: A Case Example Julie is a 52-year-old married woman, with a history of five episodes of depression, with onset age 35. She has 3 children, one of whom has ADHD. She works as a support worker. At orientation she was on 20mg Citalopram and had a BDI score of 10. She identified work stress and fraught family life as being key triggers. Early warning signs: disorganized, headless chicken mode, blaming Mid signs: withdrawing from others, judgmental of self and others Later: total withdrawal, questioning the value of life, suicidal MBCT 22
MBSR Programme Practicalities Individual pre-class orientation session Eight weekly group sessions plus follow-up sessions Each session 2 hours 15 mins length Group format with 8-15 in each class Home practice, up to one hour per day - mostly mindfulness practice - supported by CDs and handouts 1 teacher Themes for First Half of the Course Bringing attention to internal experience and seeing what happens Session 1 Automatic pilot Session 2 Dealing with barriers Session 3 Mindfulness of breath and body Session 4 Staying present MBCT 23
MBCT Programme Sessions 1-4 Core mindfulness practices Body scan Mindfulness of breath Mindful movement and walking Other practices Routine activities (e.g., eating raisin) Mindfulness of pleasant and unpleasant events 3-minute breathing space Other exercises Relationship between thoughts, feelings and bodily sensations The formulation of stress / depression / everyday suffering Raisin exercise (session 1) normally I chew, chew, chew, swallow. The taste was so much stronger... and I thought ahh (said with hint of curiosity) And then I went off on a tangent... MBCT 24
Body Scan (session 2) I kept falling asleep... I felt disappointed with myself. What is wrong with me? And I could see the judge. Pleasant events (session 3) There is a very close link between something that is pleasant turning in to something unpleasant. A very fine line. I could feel a warmth in my chest actually similar to anxiety. It could depend on my mind set how I interpret it. MBCT 25
Inquiry after sitting practice (session 4) it is feeling easier the more I do getting in to mindfulness- feeling in touch with my body. Sounds a bit strange. Practice Breathing Space MBCT 26
Themes for the Second Half of the Programme Application to life through understandings emerging from the practices Session 5 Allowing/ Letting be Session 6 Thoughts are not facts Session 7 How can I best take care of myself? Session 8 Using what has been learned MBCT Programme Sessions 5-8 Additional Practices Mindfulness with difficulties 3-minute coping breathing space Final practice Other exercises Thoughts and Moods Behavioural activation links between activity and mood Tuning in and responding at times of potential relapse - Developing a Relapse signature and Response/Action plan Developing a pattern of practice that is realistic and sustainable MBCT 27
Going down the spiral (session 5) I had these rambling thoughts in my head, a yak, yak, yak. I wasn t aware of it but when I took stock I realised I was lower that I thought. I did a body scan. Afterwards I felt calmer. The body and brain were more in sync than they had been all day. Breathing Space (session 6) I notice when I want to do, do, do. Ah time for a breathing space. When I enter headless chicken mode. It cuts the pattern. (Over the weeks getting to know this mode more from a bodily/felt sense, head spinning, has an image of whisking, moving to feelings of panic) MBCT 28
Taking care (session 7) Cycling to work mindfully is making a big difference. It sets my day up well. Instead of worrying about work all the way I see the beautiful trees and feel the fresh air on my cheeks. Continuing with practice (session 8) I choose what I think I need and can fit in to my day. This pattern works well for me. I enjoy stretching and the body scan reminds me of my body and posture. I do lots of little snippets of practice. I find myself mindful in the day. I look out of the window and see beauty and that has to better than yak, yak, yak. MBCT 29
(A) Noticing Direct experiential The Role of Inquiry (B) Dialogue Exploring the effects of bringing awareness to direct experience. Rebecca Crane, 2009 (C) Linking- Exploring how this learning relates to ways of being with inner and outer experiences in daily life. MBCT 30
Recovery from Depression Lewis (2002) - Sunbathing in the Rain The endless battle of judgemental voices in my head had caused me so much pain that I d go to great lengths to suppress them... I began to learn that, however many thought buses came past, I didn t have to catch any of them. I began to let the buses go by, just watching them. This was the single most important thing I learnt in this bout of depression. It seems like nothing, but its effects were huge. Ghosts can t harm you, and neither can depression unless you believe they can. 61 Questions? MBCT 31